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The psychological effects of an electrical stimulation walking program for persons with paraplagia Guest, Rosalind 1995

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THE  PSYCHOLOGICAL EFFECTS OF AN ELECTRICAL STIMULATION WALKING PROGRAM FOR PERSONS WITH PARAPLEGIA  by  ROSALIND GUEST  B.SC  University of Alberta, 1985  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS  in THE  FACULTY OF GRADUATE STUDIES  Department of Counselling Psychology  We accept t h i s t h e s i s as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA August 1995 ©Rosalind Guest, 1995  In  presenting this  degree at the  thesis  in  partial  fulfilment  of  the  requirements  University  of  British  Columbia,  I agree that the  freely available for reference, and study. I further agree that copying  of  department  this thesis for scholarly or  by  his  or  her  for  |t. is  permission for extensive  understood  head of my  that  publication of this thesis for financial gain shall not be allowed without permission.  Department of  Co usv^Ml?>jj  cLt>to Cjtj  The University of British Columbia Vancouver, Canada  Date  DE-6 (2/88)  7 ^ ^Jns-u^J-^  ;  If 97 .  advanced  Library shall make it  purposes may be granted by the  representatives.  an  copying  or  my written  ii Abstract The purpose of t h i s study was to determine whether persons with spinal cord injury who p a r t i c i p a t e i n an ambulation t r a i n i n g program, using e l e c t r i c a l stimulation, experience changes i n the psychological variables of p h y s i c a l self-concept, depression, s e l f - e f f i c a c y and mood states. Participants were 12 men and 3 women of mean age 2 8.4 (SD=6.6) and mean duration of injury 4.03 years  (SD=3.14) with  spinal cord injury between T4 and T i l . Treatment consisted of ambulation t r a i n i n g 3 times weekly for 12 weeks. P r i o r to the f i r s t session p a r t i c i p a n t s were assessed on the above measures using the Tennessee Self-Concept Scale (TSCS), the Beck Depression  Inventory  (BDI), the S e l f - E f f i c a c y Scale (SES) and  the P r o f i l e of Mood States (POMS). They were reassessed at posttreatment.  Also at posttreatment  p a r t i c i p a n t s were  interviewed to document t h e i r subjective reactions to the t r a i n i n g program. Repeated measures analysis of variance indicated that changes on the TSCS and the BDI occurred i n the expected d i r e c t i o n and the changes were s t a t i s t i c a l l y s i g n i f i c a n t . The change on the POMS was not s t a t i s t i c a l l y s i g n i f i c a n t . Unexpectedly scores on the SES changed opposite to the expected d i r e c t i o n and the change was s t a t i s t i c a l l y s i g n i f i c a n t . Content analysis was performed on the interview data and responses occurring three times of greater were reported.  iii The r e s u l t s from both the objective and the subjective data are discussed as are the implications f o r future and practice.  «  research  iv Table of Contents Page ABSTRACT  i i  TABLE OF CONTENTS  iv  LIST OF TABLES  vi  LIST OF FIGURES  vii  ACKNOWLEDGEMENTS  vi i i  INTRODUCTION  1  REVIEW OF LITERATURE  4  Limitations of the data base Self-concept and exercise  4 .  5  Depression and exercise  9  Spinal cord injury and exercise  12  Conclusions  ..15  HYPOTHESIS  18  METHOD  19  Participants  19  I d e n t i f i c a t i o n of P a r t i c i p a n t s  20  Measures  21  Tennessee Self-concept Scale  21  Beck Depression Inventory..  22  P r o f i l e of Mood States  24.  S e l f - e f f i c a c y Scale  25  Procedures  2 6.  Informed Consent  26  Testing  26  Psychological Evaluation  27  V  Interviews  28  Training Protocol  29  Data Analysis  29  RESULTS  31  Pretreatment Dependent Measures  31  Correlation Matrix  31  Treatment E f f e c t s - Dependent and A n c i l l a r y Measures  34  DISCUSSION  38  Q u a l i t a t i v e Data  43  Conclusions, Limitations, and Recommendations52 REFERENCES  .  APPENDIX A  64  Description of Parastep Walking System APPENDIX B Physical Evaluation  Forms  Participant Informed Consent Form  Interview Outline APPENDIX E  65 67  APPENDIX C  APPENDIX D  60  68 70 71 73 74 76  Summary and Frequency Count of Interview Data..77  vi  L i s t of Tables Table  Page  1. I n t e r c o r r e l a t i o n between Age, Duration of Injury and Dependent Measures Pre- and Posttest  33  2. Pre- and Posttest Means and Standard Deviations of Dependent and A n c i l l a r y Measures  36  vii  L i s t of Figures Figure  Page  1. Pre- and Posttest Means and Standard Deviations of the Dependent Measures  37  viii  Acknowledgements I would l i k e to thank my committee members, Dr.  Bonita  Long, Dr. Colleen Haney, Dept.of Counselling Psychology and Ms. (UBC)  (UBC)  Chris Carpenter, Faculty of R e h a b i l i t a t i o n Medicine  for t h e i r support and encouragement i n seeing t h i s  thesis through to completion. A l l showed enthusiasm f o r the project despite the fact that i t required a l o t of longdistance communication and great f l e x i b i l i t y on t h e i r part. I am extremely g r a t e f u l for t h e i r dedication and h e l p f u l guidance. I would also l i k e to thank my husband, Dr. Jim Guest and my co-worker Dr. Jim Broton for t h e i r willingness to provide expert computer assistance at a moment's notice! Dr. John Klose provided valuable advice i n the preparation of the Data Analysis section of the manuscript. Ms.  Betty Mas  generously  helped with t r a n s l a t i o n of the dependent measures and acted as an interpretor when required and I am g r a t e f u l f o r her assistance. F i n a l l y , I would l i k e to thank the p a r t i c i p a n t s i n t h i s study for t h e i r good humor and willingness to cooperate with completing the measures and to share t h e i r experiences and insights during the  interviews.  1 Introduction The psychological e f f e c t s of exercise i n the  general  population have been much debated and studied i n recent There i s now  years.  a growing i n t e r e s t i n e f f e c t s of exercise i n special  populations. One area where research i s notably lacking i s the disabled population. Exercise plays a v i t a l r o l e i n the maintenance of physical functioning and quality of l i f e i n t h i s population, yet outside of t r a d i t i o n a l hospital and r e h a b i l i t a t i o n settings, suitably adapted exercise programs are often lacking. Research suggests that i n the general exercise may  population  have a p o s i t i v e e f f e c t on psychological health,  p a r t i c u l a r l y i n improving self-concept and s e l f - e f f i c a c y , and i n moderating or a l l e v i a t i n g symptoms of depression (e.g., Martinsen, Hoffart, & Solberg, 1989; 1984;  and  anxiety  McCann & Holmes,  Short, DeCarlo, Steffer, & Pavlain, 1984). I t would be  l o g i c a l to suppose that these same e f f e c t s might be found i n persons with d i s a b i l i t i e s . However, there i s a very l i m i t e d body of research dealing with the e f f e c t s of exercise i n t h i s population  (e.g., Horvat, French, & Henschen, 1986;  Bezzubyk, Daley, & Asu,  Valliant,  1985). In addition, the general mental  health status of persons with d i s a b i l i t i e s has not been well documented. The purpose of the present study was  to examine the  psychological e f f e c t s of exercise i n a population of adults with a s p e c i f i c d i s a b i l i t y . The population studied was  adults with  spinal cord injury, s p e c i f i c a l l y traumatic onset paraplegia.  2  Paraplegia r e s u l t s when injury occurs below the c e r v i c a l l e v e l of the spinal cord i n the thoracic or lumbar regions. The lower but not the upper extremities are affected i n paraplegia. The type of exercise undertaken was  a computerised  e l e c t r i c a l l y stimulated walking program that allows persons with paraplegia to stand and walk for short distances. The device  was  developed by a company c a l l e d Sigmedics, based i n Chicago. I t has received FDA approval and i s now being marketed throughout the United States and Europe. The system uses surface electrodes placed on muscles i n the legs and hips with the sequencing controlled v i a a battery-operated  computer u n i t . This u n i t i s  connected into a walker that has switches on the handles which allows the person to activate the necessary muscles i n the desired sequence. (See Appendix A for further description of the device.)  The l e v e l of performance achieved with the device  varies widely between i n d i v i d u a l s . The most successful walkers may  be able to use i t i n a functional way,  for example around  t h e i r house or at the o f f i c e . I t i s also possible to use i t for a c t i v i t i e s such as going out to a movie or restaurant. Other individuals may  be more limited and w i l l use i t mainly as an  exercise device i n a controlled setting. The speed of walking i s slow, the average person takes 6 to 8 minutes to walk 150 feet. The energy cost of t h i s type of exercise i s high and i t provides an intense workout, often i n the range of 80-90% of maximum heart rate. Health related benefits derived from t h i s type of exercise are currently being investigated and may  include increases i n  3 muscle mass i n the legs, improvement i n c i r c u l a t i o n and  increases  in cardiovascular f i t n e s s . Spinal cord i n j u r i e s (SCI) a f f e c t people i n the prime of l i f e , generally between 18 and 35 years of age. Eighty  percent  are male and they were often a t h l e t i c a l l y active i n d i v i d u a l s p r i o r to t h e i r injury. With advances i n management of medical problems subsequent to the injury, persons with SCI now  have an  almost normal l i f e expectancy and quality of l i f e has become an important issue. An exercise program such as the one under investigation may  have s i g n i f i c a n t physical and  psychological  benefits. In contrast to other commonly available forms of exercise, t h i s i s one of the few a c t i v i t i e s that allows  the  spinal cord injured person to leave t h e i r chair and t h i s may  have  a powerful psychological e f f e c t i n restoring a sense of normalcy to the i n d i v i d u a l , even i f the a c t i v i t y i s only of short duration and they must return to the chair afterwards. study was  The aim of t h i s  to examine these psychological e f f e c t s to determine the  u t i l i t y of such a program i n the promotion of mental health. S p e c i f i c a l l y the study examined whether the exercise program resulted i n improved scores on the Physical S e l f subscale of the Tennessee Self-Concept  Scale (Roid & F i t t s , 1988), the Beck  Depression Inventory (Beck, Rush, Shaw & Emery, 1979), the P r o f i l e of Mood States  (McNair, Lorr, & Droppleman, 1971), and  the S e l f - E f f i c a c y Scale (Sherer, Maddox, Mercandante, PrenticeDunn, Jacobs, & Rogers, 1982).  4  Review of Literature In the following sections the l i t e r a t u r e concerning  the  psychological e f f e c t s of exercise i s reviewed. As there i s such a lack of experimental research i n the disabled population, I f i r s t examine the l i t e r a t u r e concerning on self-esteem and depression  the e f f e c t s of exercise  i n the general population. These  are two of the major variables to be examined i n the current study. The studies r e l a t i n g to d i s a b i l i t y and exercise are mainly c o r r e l a t i o n a l i n nature and often make comparisons between a t h l e t i c a l l y active and inactive persons with d i s a b i l i t i e s . Only one study was  located that used an exercise intervention for  persons with d i s a b i l i t i e s . This study examined changes i n s e l f concept following stationary b i c y c l e t r a i n i n g i n a small group of persons with hemiplegia.  Hemiplegia refers to p a r a l y s i s a f f e c t i n g  one side of the body and usually occurs following a stroke. Limitations of the Data Base I t should be noted from the outset that t h i s i s an area of research that has been fraught with methodological d i f f i c u l t i e s . John Hughes (1984) undertook a comprehensive review of the l i t e r a t u r e dealing with the psychological e f f e c t s of aerobic exercise. He i d e n t i f i e d over 1000  a r t i c l e s and of these only 12  met h i s c r i t e r i a for experimental design! In the studies reviewed he found three consistent d e f i c i t s — p o o r choice of measures of psychological constructs, experimenter/subject biases, inadequate description of methods. More recent research  and has  5  attempted to address some of these problems and there has been an increase i n the number of randomized, controlled studies. trend that became apparent was  One  that there needed to be a d e f i c i t  in the variable being studied i n order for any change to be seen to take place as a r e s u l t of exercise. Self-Concept  and  Considerable  Exercise attention has  been devoted to the e f f e c t of  exercise on self-concept. (This term i s used interchangeably self-esteem  with  i n the l i t e r a t u r e . ) Sonstroem and Morgan (1989) have  developed a model that seeks to explain the pathway through which changes i n self-esteem and possibly depression may Although t h i s was  occur.  not an empirical study, several subsequent  studies have used the model to carry out experimental research, therefore i t i s reported here. I t may for understanding how  also provide a framework  psychological changes may  take place i n the  group with SCI being studied. Sonstroem and Morgan developed t h e i r model i n response to what they viewed as s i m p l i s t i c self-esteem theory i n r e l a t i o n to exercise and the lack of  new  theory emerging from current studies. Their model contains "self-esteem  components t h e o r e t i c a l l y arranged i n d i c a t i v e of  progressive influence by exercise p a r t i c i p a t i o n . " (p.329) At the base of the model i s "physical s e l f - e f f i c a c y . " Self-conceptions at t h i s l e v e l should be the most accurate  and  the most r e a d i l y influenced by environmental i n t e r a c t i o n . Increases i n physical self-efficacy, in. r e l a t i o n to exercise would in turn bring about changes at the next l e v e l which i s "physical  6 competence"—defined as a general evaluation of the s e l f as possessing physical f i t n e s s . Increases i n physical competence i n turn lead to changes i n "physical acceptance"—defined as the degree of s a t i s f a c t i o n with various parts and processes of the body. S a t i s f a c t i o n with the body has repeatedly demonstrated strong empirical relationship with general self-regard. two constructs  These  i n turn influence o v e r a l l self-esteem. The authors  comment that: The model appears to possess p a r t i c u l a r u t i l i t y f o r studying the r e h a b i l i t a t i o n of the p h y s i c a l l y impaired. I t i s capable of assessing the manner and stages by which physical therapy a c t i v i t i e s impact on global self-esteem v i a the mediating processes of physical s e l f - e f f i c a c y and physical competence development, (p.335) Sonstroem, Harlow, Gemma, and Osborne (1991) undertook a study to t e s t t h e i r model. Participants were 145 adults i n the maintenance phase of a cardiac r e h a b i l i t a t i o n program. They completed measurement scales of self-esteem, physical competence, and s e l f - e f f i c a c y and were f i t n e s s tested on a bike ergometer. The authors performed complex s t a t i s t i c a l procedures (structural modelling analysis) to t e s t the f i t of t h e i r model. They report that " t h i s study provided support f o r the discrete l e v e l s of competence self-perceptions, t h e i r measurement and t h e i r association as proposed by the Exercise and Self-Esteem Model." (p.359) Caruso and G i l l  (1992) also used Sonstroem's model as a  basis for t h e i r study. They measured the e f f e c t s of a weight-training program and aerobic t r a i n i n g program on self-perceptions, global self-esteem, and body s a t i s f a c t i o n i n college-aged women. The study used a non-random design. T h i r t y four women volunteered from physical education a c t i v i t y classes13 weight-training, 15 aerobic, and 6 controls. Strength and physical work capacity were measured pre- and postexercise. Participants exercised three times a week for 10 weeks. The control group did fencing, v o l l e y b a l l , and bowling. Results supported the hypothesis that physical self-perceptions and f i t n e s s are enhanced by p a r t i c i p a t i o n i n an exercise program. Correlations among the various measures revealed that physical self-perceptions are s i g n i f i c a n t l y related t o o v e r a l l physical self-worth and to more general constructs such as global self-esteem. The only study that examined exercise mediated changes i n self-concept i n persons with d i s a b i l i t i e s was undertaken by Brinkmann and Hoskins i n 1979. hemiparesis  Participants had various l e v e l s o  following a stroke. A l l had completed acute phase  r e h a b i l i t a t i o n . Seven volunteers entered the study and s i x completed. Each rode a stationary bike at 70% of age predicted maximum heart rate, three times weekly for 30 minutes. Fitness t e s t i n g was performed on the b i c y c l e ergometer. Self-concept was measured using the Tennessee Self-Concept Scale (TSCS). The normative group was 626 normals. I n i t i a l t e s t i n g revealed that a l l p a r t i c i p a n t s were deconditioned and self-concept scores  8 r e f l e c t e d a devaluation of the s e l f as compared t o normals. They scored s i g n i f i c a n t l y lower on four of the s u b s c a l e s — T o t a l P, a measure of o v e r a l l self-esteem, Identity Score, Physical Self, and Personal Self. Posttraining scores for these measures showed s i g n i f i c a n t improvement and approached more normal l e v e l s . There was  also a s i g n i f i c a n t improvement i n aerobic capacity. However,  the Physical Self scores s t i l l remained s i g n i f i c a n t l y lower than normal. The authors hypothesised that the change i n self-concept was brought about by the volunteers p a r t i c i p a t i n g i n what they believed to be a p o s i t i v e action program with highly desirable outcomes and goals. This study has been discussed i n some d e t a i l due t o i t s p o t e n t i a l application to the population of people with spinal cord injury. Doyne, Ossip-Klein, Bowman, Osborn, McDougall-Wilson,& Neimeyer,(1987) measured the e f f e c t of exercise on depression. Their group published a separate study using the same group of depressed women but evaluated the e f f e c t of exercise on self-concept (Ossip-Klein, Doyne, Bowman, Osborn, McDougallWilson & Neimeyer, 1989). Thirty-two women were randomly assigned to either aerobic exercise or w e i g h t - l i f t i n g groups. Both groups demonstrated a s i g n i f i c a n t increase i n self-concept as compared to controls and there was no difference between groups. A follow-up study revealed that the changes were sustained over 1 year.  Given the changes i n the w e i g h t - l i f t i n g  (non-aerobic)  group, t h i s study points again t o the p o s s i b i l i t y of graded mastery and s e l f - e f f i c a c y changes as being responsible for the  9 changes i n self-concept, rather than simply an aerobic e f f e c t . Short, DiCarlo, S t e f f e r , and Pavlain (1984) studied the changes i n self-concept with exercise i n a group of obese men. Participants were 45 p o l i c e o f f i c e r s a l l 20-50% above ideal body weight. The study was designed to t e s t i f self-concept and physical f i t n e s s increase i n individuals matched for d i e t but exposed to i n s t r u c t i o n a l classes only or classes plus physical conditioning. The exercise group completed walk/jog a c t i v i t i e s at 80% of maximum heart rate, 45 minutes, three times weekly for 8 weeks. Self-concept was measured using the TSCS. Both groups showed an increase i n aerobic capacity but the exercise group increased s i g n i f i c a n t l y more than the controls. Both groups made s i g n i f i c a n t gains on the Physical Self subscale of the TSCS and the exercise group also had s i g n i f i c a n t increases on the Personal Self and S e l f - S a t i s f a c t i o n subscales. Interestingly both groups scored 1 standard deviation below the mean for normative groups on Physical S e l f subscale and although t h e i r scores  increased  they were s t i l l below the mean at posttest. Depression and Exercise One  of the most widely studied psychological variables i n  the exercise l i t e r a t u r e i s depression.  I t should be noted that  most of the following studies are dealing with persons who have been diagnosed as being depressed. Several of the following studies examined the e f f e c t s of aerobic exercise only, have compared i t with strengthening  others  programs. McCann and Holmes  (1984) undertook one of the f i r s t controlled studies of the  10 influence of aerobic exercise on depression. Subjects were 43 female psychology students with scores greater than 11 on the Beck Depression Inventory  (BDI)  (Beck et a l . , 1979). Participants  were randomly assigned to aerobic exercise, relaxation t r a i n i n g (the placebo condition), or no treatment. In order to control expectancies, p a r t i c i p a n t s were led to believe that the experiment involved learning how  to deal with s t r e s s . A l l  completed a 12-minute walk-run test and the BDI at pre- and posttraining. At the outset, an ANOVA on the depression  scores  revealed no difference between groups. At posttreatment, a l l groups had a s i g n i f i c a n t reduction i n depression scores.  (The  authors comment that t h i s points to the need for a control group in these type of studies.) Volunteers i n the aerobic group had a 10% increase i n aerobic capacity. S t a t i s t i c a l analysis of covariance demonstrated that the aerobic exercise group had r e l i a b l y lower depression scores than did those i n the other  two  groups. Martinsen, Medlus, and Sandvik (1985) studied 43 male and female inpatients h o s p i t a l i s e d with DSM  111 c r i t e r i a f o r major  depression. For 33 of the patients the episode of depression  had  been ongoing for greater than 6 months. A l l the patients were receiving individual psychotherapy and occupational therapy  and  23 were on t r i c y c l i c antidepressants. Prior to commencing the study, p a r t i c i p a n t s completed a submaximal V02 t e s t (a measure of aerobic conditioning) on a b i c y c l e ergometer, t h i s was  repeated  at the end of the study. Depression was measured using the BDI at  11 s t a r t , 3, 6, and 9 weeks. Participants exercised for 1 hour three times weekly at 50-70% of maximal aerobic capacity. The control group attended extra Occupational Therapy during the exercise time. Results showed that the volunteers i n the exercise group had a s i g n i f i c a n t increase i n aerobic capacity and a s i g n i f i c a n t decrease i n depression scores as compared to the control group, although depression scores did decrease i n the control group also. Further analysis revealed that the decrease i n depression score was correlated with increases i n maximum oxygen uptake. In a more recent study, Martinsen, Hoffart, and  Solberg  (1989) compared aerobic with non-aerobic exercise (weight-lifting) i n the treatment of depression. Participants were 99 inpatients, 38 men  and 61 women, at the same f a c i l i t y i n  Norway. The aerobic group performed b r i s k walking or jogging at 70% of V02 max,  the other group performed strength and  f l e x i b i l i t y t r a i n i n g . Both groups exercised three times weekly for 8 weeks. Depression was measured using the BDI and ratings by p s y c h i a t r i s t s . There was a s i g n i f i c a n t increase i n aerobic capacity i n the aerobic group. Both groups had equal mean depression scores at the s t a r t of the study and they decreased  to  the same degree i n each group at the end. These r e s u l t s are i n contradiction to the previous study where decrease i n depression was related to change i n aerobic capacity. The authors argued that the results i n t h e i r more recent study were  more r e l i a b l e  because of the larger sample size. Their conclusion was psychological mechanisms such as mastery, s e l f - e f f i c a c y ,  that and  12 response contingent p o s i t i v e reinforcement reduction i n depression  may mediate the  scores rather than purely the aerobic  conditioning e f f e c t . Spinal Cord Injury and Exercise In t h i s f i n a l section of the review some of the psychological variables related to persons with SCI are examined in a somewhat roundabout way. Two of the studies  explore  self-concept and l i f e s a t i s f a c t i o n i n SCI and the remainder are studies of the psychological p r o f i l e s of wheelchair athletes. Most of these studies use  group-comparative and c o r r e l a t i o n a l  design rather than experimental design. Together they provide some useful background information from which to proceed but the lack of studies using interventions soon becomes apparent. This section helps to j u s t i f y the need f o r more studies looking at s p e c i f i c interventions i n t h i s population. Green, Pratt, and Grigsby  (1984) administered  the TSCS to 71  persons with SCI, 49% were quadriplegic and 51% paraplegic. The mean age was 40 and the mean duration of injury was 11 years. Participants were contacted by mail, 220 packages were sent and 71 responded. This poor response rate immediately draws the conclusions into question. Student t - t e s t s were used to compare respondents' subscale means to the TSCS norm means. On s i x of the subscales, respondents had higher mean scores than d i d the norm group. Personal Self, Social Self, and Moral-Ethical S e l f were s i g n i f i c a n t l y higher. Physical Self scores were s i g n i f i c a n t l y lower than f o r the norm group and there was a s i g n i f i c a n t  13 negative c o r r e l a t i o n between scores on t h i s subscale and age at injury. Perceived independence was found to be p o s i t i v e l y and s i g n i f i c a n t l y related to Physical, Personal, Social, and Total Self scores. Overall the authors reported that t h e i r volunteers had very p o s i t i v e self-concepts although they did mention the non-random nature of t h e i r sample. They speculate that a "growth through adversity" theory may i n part explain the high scores. Estimates of the prevalence of depression i n persons with SCI vary. Craig, Hancock, and Dickson (1994) conducted a longitudinal study of depression and anxiety i n the f i r s t 2 years following spinal cord injury i n a group of 41 men and women. Depression was measured using the BDI. Assessment was performed at approximately three months post-injury, 6 months, 1 year and 2 years. Analysis revealed that about 30% of the group scored above 14 on the BDI and that those who were depressed i n i t i a l l y  showed  l i t t l e improvement by 2 years post-injury. They comment that response to SCI i s very i n d i v i d u a l . The majority were not depressed but i t cannot be assumed that those who do develop symptoms of depression w i l l necessarily improve with time. A study by Kinney and Coyle (1992) examined the perception of l i f e s a t i s f a c t i o n among persons with physical d i s a b i l i t i e s . Three hundred and forty-four persons with a v a r i e t y of d i s a b i l i t i e s were interviewed—SCI, multiple s c l e r o s i s , cerebral palsy, and blindness. Participants completed measures of depression, self-esteem, and l i f e s a t i s f a c t i o n . The authors found that l e i s u r e s a t i s f a c t i o n was the most important predictor of  14 l i f e s a t i s f a c t i o n , explaining 42% of the variance i n l i f e s a t i s f a c t i o n scores. In t h e i r discussion the authors point to the implications that these results have for designing therapeutic recreation programs for persons with d i s a b i l i t y . Super and Block (1990) investigated self-concept and need for  achievement i n men with d i s a b i l i t i e s . Participants were 95  men  aged between 18 and 40. They were divided into four groups:  d i s a b l e d - a t h l e t i c a l l y active, and inactive, able-bodied active, and inactive. A l l completed the TSCS.  ANOVA was used to t e s t the  differences between means on the TSCS. Results showed that the disabled a t h l e t i c a l l y active group had higher mean scores than the inactive group, i n fact t h e i r scores were very s i m i l a r to the able-bodied active group. In t h e i r conclusion, the authors suggest that a t h l e t i c p a r t i c i p a t i o n could have a therapeutic e f f e c t for patient populations that have a negative self-concept. In another study, V a l l i a n t , Bezzubyk, Daley and Asu (1985) measured self-esteem i n 161 a t h l e t i c adults with d i s a b i l i t i e s — d i s a b i l i t i e s included cerebral palsy, amputations, blindness, and SCI. There was also a control group of non-athletes (n=22). The athletes with d i s a b i l i t i e s were found to have higher self-esteem and to be more s a t i s f i e d with l i f e than non-athletes. A study by Horvat, French, and Henschen (1986) used the P r o f i l e of Mood States (POMS),(McNair, Lorr, & Droppleman,  1971)  to evaluate the mood states of athletes with d i s a b i l i t i e s .  They  investigated 33 men  and 62 women who were wheelchair athletes.  Comparison groups were e l i t e l e v e l able-bodied athletes. The POMS  15 has been widely used i n the able-bodied population t o predict a t h l e t i c success. Athletes generally demonstrate what i s known as an "Iceberg P r o f i l e " on the POMS. (Morgan, 1980) This i s characterised by low scores on the Depression, Anger, Fatigue, Tension, and Confusion subscales and a peak on the Vigor subscale. The authors analyzed the results s t a t i s t i c a l l y as well as doing a v i s u a l comparison. Male wheelchair -athletes demonstrated an Iceberg P r o f i l e very s i m i l a r to able-bodied athletes. The women also had an Iceberg P r o f i l e but i t s shape was less dramatic than the men's. The inherent design weakness of t h e i r study i s that i t was c o r r e l a t i o n a l i n nature and d i d not include a control group, however the authors recommended further research into the therapeutic value of sport and recreation f o r persons with d i s a b i l i t i e s . Conclusions This review has explored possible psychological e f f e c t s of exercise, s p e c i f i c a l l y on the variables of depression and self-esteem. Next I examined, i n a very preliminary way, the psychological status of active and inactive persons with d i s a b i l i t i e s . This was done to give some background for the present study examining the psychological e f f e c t s of a walking program for persons with paraplegia. What conclusions can be drawn from t h i s review? Dealing f i r s t of a l l with the l i t e r a t u r e concerning depression and self-esteem, conclusions must be drawn cautiously due to the wide variety of populations studied and persistent methodological weaknesses. The majority of studies  16 reviewed here did use control groups but common problems i d e n t i f i e d were lack of random assignment to groups, small sample size, and frequent a t t r i t i o n from studies. Bearing t h i s i n mind i t does appear that persons who depressed or who  are mildly to moderately  have low self-esteem, may  benefit from a regular  exercise program. Well-designed studies by Doyne et a l . (1987) and Martinsen  et a l . (1989) support t h i s conclusion.  The  mechanism by which t h i s improvement takes place i s s t i l l  not  e n t i r e l y clear. E a r l i e r research focused on possible physiological changes that occurred as a r e s u l t of aerobic exercise, a popular theory being that release of endorphins was stimulated through exercise, which brought about a f e e l i n g of well-being. This has never been f u l l y proven to occur. The more recent studies seem to point to cognitive-behavioral mechanisms as being to a large extent responsible for the changes. Many of these studies included a group that performed non-aerobic strengthening exercises as well as the t r a d i t i o n a l aerobic type and most showed equal improvement i n self-esteem and  depression.  Sonstroem and Morgan (1989) developed a model that l a i d the foundation for studying these mechanisms i n more depth. A reasonable  conclusion would appear to be that p a r t i c i p a t i o n i n  exercise programs,which provide experiences  of progress  and  success, increase the individual's sense of mastery, s e l f - e f f i c a c y , and self-acceptance which, i n turn, can lead to increases i n self-esteem and decreases i n depression. The studies reviewed i n the area of SCI and exercise allow  17 for only tentative conclusions.  The majority used group  omparative designs, often included a v a r i e t y of d i s a b i l i t i e s , and very few attempts were made to control variables. For example, some included individuals with very d i f f e r e n t d i s a b i l i t i e s such as blindness, cerebral palsy, and amputations as well as persons with SCI. These d i s a b i l i t i e s have very d i f f e r e n t  manifestations,  some are acquired, some congenital, some progressive and some s t a t i c . Therefore, the psychological status of these i n d i v i d u a l s may be quite v a r i a b l e . Even within the population of persons with SCI, l e v e l of injury, age at onset, and l e v e l of education may a l l play a r o l e i n determining  the person's psychological health.  Despite a l l t h i s , a large number of the studies appeared to support the conclusion that persons with d i s a b i l i t i e s who are a t h l e t i c a l l y active demonstrate p o s i t i v e psychological attributes when compared with able-bodied athletes and with the general population. On t e s t s such as the POMS, they tended to score higher than disabled non-athletes. The study by Green et a l . (1984), i n which the TSCS was administered SCI, indicated that Physical Self-Concept  to 70 persons with i s an area where t h i s  population tends to score lower than the norm and which might be amenable to improvement through exercise intervention v i a the mechanisms discussed e a r l i e r . P a r t i c u l a r l y i n t h i s group, small changes i n strength or aerobic capacity could lead to quite s i g n i f i c a n t changes i n l e v e l s of functional independence, which i n turn could have an e f f e c t on s e l f - e f f i c a c y cognitions and o v e r a l l self-concept.  18 Hypothesis The purpose of t h i s study was to examine the psychological e f f e c t s of an e l e c t r i c a l - s t i m u l a t i o n walking program for persons with paraplegia. The research question was: does t h i s walking t r a i n i n g have an e f f e c t on measures of self-concept,  depression,  mood states and s e l f - e f f i c a c y ? Stated formally, the hypotheses are: 1. The exercise t r a i n i n g , consisting of an e l e c t r i c a l  stimulation  walking program, w i l l r e s u l t i n improved scores between pre- and posttesting on the Physical Self subscale of the Tennessee S e l f Concept Scale. 2. The exercise t r a i n i n g w i l l result i n improved scores between pre- and posttesting on the Beck Depression  Inventory.  3. The exercise t r a i n i n g w i l l result i n improved scores between pre- and posttesting on the S e l f - E f f i c a c y Scale. 4. The exercise t r a i n i n g w i l l result i n improved scores between pre- and posttesting on the P r o f i l e of Mood States, Total Score. A l l hypotheses w i l l be tested at the p < .05 l e v e l of significance.  19 Method In t h i s study participants with SCI completed a 3-month ambulation t r a i n i n g program using functional e l e c t r i c a l stimulation. Changes i n four psychological  variables were  measured pre- and posttraining. The variables measured were: physical self-concept,  s e l f - e f f i c a c y , depression, and general  mood state. In addition, interviews were performed at the end of the t r a i n i n g period to assess the participants' reactions to the program. I t was considered reasonable to perform these interviews given the exploratory  nature of t h i s study. The aim was to gather  additional information about the participants'  subjective  experiences through content analysis of the interview  data,  participants Participants were 12 men and 3 women with SCI of traumatic onset. A l l were motor and sensory complete i n j u r i e s , i . e . , no active motor function below the l e v e l of injury and no appreciable sensory function. Injury l e v e l was between T4 and T i l . This i s a requirement for use of the device. Persons with higher injury l e v e l s tend to have inadequate hand control and balance. Injuries below T i l r e s u l t i n damage to nerve roots rather than to the cord i t s e l f and these individuals  generally  have no muscle response to e l e c t r i c a l stimulation. The mean age of participants was 28.37 (S_D,=6.6). Mean duration  of injury was  4.03 years (SD=3.14). The group was e t h n i c a l l y diverse and consisted of 7 Caucasians, 6 Latin Americans (2 from Venezuela, 1 from Chile, 1 from Argentina, 1 from Equador, and 1 from  20  Columbia), 1 African-American, and 1 West Indian. Eleven of the participants had high school l e v e l education, 3 were attending college or university, and 1 had graduate-level education. Other physical requirements for the program included adequate bone and j o i n t i n t e g r i t y as measured by x-ray and bone densitometry, f u l l lower extremity range of motion, no recent fractures or uncontrolled s p a s t i c i t y and no history of head injury or psychiatric illness. A l l potential participants were evaluated by myself, following a set format. (See Appendix B f o r evaluation forms) P r i o r to formal admission into the study they were examined by an Orthopedic surgeon who reviewed the x-rays and bone density results and also performed a b r i e f history and physical examination. I d e n t i f i c a t i o n of Participants Participants were i d e n t i f i e d using several d i f f e r e n t methods. The Miami Project maintains a computerised mailing l i s t of  a l l persons who have contacted the i n s t i t u t i o n and expressed  an interest i n the research being conducted. Persons from t h i s l i s t of potential participants with the appropriate injury l e v e l were contacted by telephone and/or l e t t e r by myself. The nature of the study was described and i f they expressed an interest they were i n v i t e d to come for a screening evaluation. This l i s t i s comprised of persons from a l l over North America as well as overseas, mainly South America. I t gives access to persons with varied socioeconomic, educational, and ethnic backgrounds. Many  21 persons with SCI tour the Miami Project and a couple heard of the study and expressed an interest i n p a r t i c i p a t i n g , at which point an evaluation was arranged. Measures The Tennessee Self-Concept Scale CTSCS). The TSCS was developed by F i t t s i n 1965  (Roid & F i t t s , 1988). I t was  first  chosen  for t h i s study for a number of reasons. F i r s t i t provides a measure of global self-concept but also measures self-concept on a number of subscales such as Family Self, Social Self, MoralE t h i c a l Self and Physical Self. Of p a r t i c u l a r interest i n t h i s study i s physical self-concept. A purely global self-concept scale would not allow access to t h i s information. Second, the TSCS has been widely used i n research, over 200 studies are published annually using t h i s scale, and a wealth of r e l i a b i l i t y and v a l i d i t y data i s available, as well as normative data. The normative data was established using a sample of 626 people of heterogeneous background. They were aged between  12-68  with an approximate balance between ethnic, socioeconomic, and educational backgrounds.  In subsequent research, the e f f e c t s of  SES, i n t e l l i g e n c e , gender, and e t h n i c i t y have been found to be small. A comprehensive  study of internal consistency was  conducted  using data from 472 responses. Cronbach alpha f o r the t o t a l score was found to be.94 and the subscales ranged between .70 and Test-retest studies were done over a 2-week i n t e r v a l and were found to be .92 f o r the t o t a l score and .80 to .91 f o r the  .87.  subscales. Standard error of measurement has been found to l i e between 3 and 6 T-score points. The widespread use of the TSCS i n counselling, educational, c l i n i c a l , and medical settings has provided substantial evidence for the v a l i d i t y of the scale as a measure of self-concept. A number of studies have compared the TSCS to other measures that would be expected to relate to the construct of self-concept, e.g., most of the TSCS scores correlate with MMPI (Butcher, Graham, Tellegen, & Kaemner, 1989)  scores i n ways that would be  expected. The TSCS has been found to correlate .75 with scores on the Coopersmith Self-Concept Scale (Coopersmith,  1981). I t has  also been shown to have a high negative c o r r e l a t i o n with the Internal-External Locus of Control Scale (Rotter, 1966), i . e . , those with high internal scores tend to have higher self-concept. In studies comparing psychiatric groups with normative group data there were s i g n i f i c a n t differences on TSCS scores. The TSCS has also been found to discriminate between d i f f e r e n t types of psychological problems e.g., delinquency, alcoholism, and drug abuse. In conclusion there i s strong evidence f o r construct, c r i t e r i o n , and convergent v a l i d i t y of the TSCS scale. The range of scores on the Physical Self subscale i s from 35 to 90 and the mean score on t h i s subscale for the normative group i s 71.8.  The higher the score the stronger one's self-concept.  Beck Depression Inventory  (BDI). The BDI was developed i n  the 1960s by Aaron Beck and has been widely used as a self-report measure of depression (Beck et a l . , 1979). The decision was made  23 to use a depression scale i n t h i s study because t h i s has been one of the areas to show s i g n i f i c a n t changes as a r e s u l t of exercise i n previous research. However, i t has been pointed out i n numerous studies that i f no depression i s present then obviously scores cannot be expected to change i n a p o s i t i v e d i r e c t i o n . I did not expect that the research participants i n t h i s study would be severely depressed, however, i t was possible that they could be experiencing symptoms of mild to moderate depression. Advantages of the BDI include i t s widespread use i n over  1900  research studies. Also i t i s easy to administer and takes only 10-15  minutes to complete. Possible disadvantages  are that the  items are very obvious, therefore i t would be easy to fake or give s o c i a l l y desirable responses i f the person wished to. The test consists of 21 items scored from 0 to 3. The possible range of scores i s 0 to 63. Total scores of.0 to 9 represent no depression, 10 to 18 mild depression, 19 to 29 moderate-severe depression, and 30 to 63 extremely Steer, 1987)  severe depression. (Beck &  The manual suggests that the BDI measures two  subscales of depression, these are cognitive-affective and somatic-performance. Internal consistency estimates range from .73 to .95. Testretest r e l i a b i l i t y i s d i f f i c u l t to measure due to the v a r i a b i l i t y of depression but range from .60 to .90 for non-psychiatric patients. For non-patients t e s t - r e t e s t r e l i a b i l i t y was  found to  be .90 over a two-week i n t e r v a l . The BDI measures s i x of the nine DSM  111 c r i t e r i a  for major depression. In studies of concurrent  24 v a l i d i t y the BDI has been found to correlate .61 with the MMPI (Butcher et a l . , 1989) 90 (Derogatis, 1977)  Depression subscale and .76 with the SCL  Depression subscale.  P r o f i l e of Mood States (POMS) (McNair et a l . , 1971). The POMS i s a 65-item, 5-point adjective rating scale which measures six i d e n t i f i a b l e mood states: Tension-Anxiety, DepressionDejection, Anger-Hostility, Vigor-Activity, Fatigue-Inertia, and Confusion-Bewilderment.  The POMS has been shown t o be a sensitive  measure of the e f f e c t s of various experimental interventions i n both normal and psychiatric populations. Internal consistency measures for a l l s i x mood scales are above .90. Test-retest r e l i a b i l i t y studies were done with a group of 100 p s y c h i a t r i c patients. Scores from intake to pretreatment ranged from .65 to .74. From intake to s i x weeks of treatment ranged from .43 to .53. The authors point out that f o r a t e s t that i s measuring mood states, which are subject to change, high t e s t - r e t e s t r e l i a b i l i t i e s would not necessarily be desirable. Concurrent v a l i d i t y was measured by comparing r e s u l t s on the POMS with the SCL-90 (Derogatis, 1977). Moderate to high correlations were found between scores on the POMS subscales and on the Somatization, Anxiety, and Depression subscales of the SCL-90. Correlation between the Tension-Anxiety subscale and the Taylor Manifest Anxiety Scale (Taylor, 1953) was .80. Results from multiple b r i e f psychotherapy  studies and controlled  outpatient drug t r i a l s have provided substantial evidence of the predictive and construct v a l i d i t y of the POMS as reported i n the  25 manual. Normative data has been compiled  for p s y c h i a t r i c outpatients  as well as for adult non-patients. The POMS can be scored by looking at each subscale separately or an o v e r a l l score c a l l e d "Total Mood Disturbance" can be generated by adding together a l l the subscales except the Vigor subscale and then subtracting the Vigor subscale. For t h i s reason i t i s possible to have a negative score on the t e s t i f l e v e l s of mood disturbance are very low and the Vigor score i s high. The possible range of scores i s from -32 to 228. The mean score for the college, non-patient normative group i s 40. In t h i s study the Total Mood Disturbance score was used. The higher the score the greater the mood disturbance. S e l f - E f f i c a c y Scale (SES). The SES i s a 22-item scale developed by Sherer et al.(1982) that measures general l e v e l s of b e l i e f i n one's own competence that are not t i e d to s p e c i f i c situations or behavior. I t consists of two sub-scales: general s e l f - e f f i c a c y and s o c i a l s e l f - e f f i c a c y . The assumption underlying the scale i s that individual differences i n past experiences or a t t r i b u t i o n s of success lead to d i f f e r e n t l e v e l s of generalized s e l f - e f f i c a c y expectations. I t has been found to be useful i n monitoring the course of progress i n c l i n i c a l interventions. The SES uses a 5-point L i k e r t scale scored from 1 to 5. The possible range of scores i s from 22 to 110 and higher scores indicate greater s e l f - e f f i c a c y . No normative data has been produced by the authors of the t e s t . The SES has f a i r l y good internal consistency with alphas of  26 .86 f o r the general sub-scale and .71 f o r the s o c i a l subscale. No t e s t - r e t e s t data was reported. I t was shown to have good c r i t e r i o n - r e l a t e d v a l i d i t y by accurately predicting that people with higher s e l f - e f f i c a c y would have greater success than those who score low i n past vocational, educational, and monetary goals. I t has also  demonstrated  concurrent v a l i d i t y by correlating s i g n i f i c a n t l y i n predicted directions with measures such as the Rosenberg Self-Esteem Scale (Rosenberg,  1979).  Procedures Informed consent. A f u l l description of t h i s study was submitted to the Investigational Review Board at the University of Miami f o r approval. Forms were also submitted to the UBC Ethics committee. Approval was received from both committees. Prior to commencing the study a l l participants completed  informed  consent forms that described the procedures to be used i n the study i n d e t a i l . (See Appendix C) Verbal explanations were also given and participants were informed of t h e i r r i g h t to withdraw at any time. Testing. Once participants completed the screening requirements, they underwent pretesting on a number of d i f f e r e n t measures p r i o r to commencing walking t r a i n i n g . The e f f e c t s of t h i s exercise on a number of d i f f e r e n t physiological functions were measured i n addition to the psychological measures. These included bone density, blood c i r c u l a t i o n to the legs, blood cholesterol and hormone l e v e l s , aerobic capacity, upper extremity  27 strength, and muscle g i r t h i n the legs. Only those r e l a t e d to the present study are discussed here. To determine i f the exercise brings about any changes i n physical f i t n e s s , a maximum V02  stress t e s t (Franklin, 1985)  was  performed p r i o r to commencing t r a i n i n g and again a f t e r 3 months. As subjects are unable to walk p r i o r to t r a i n i n g t h i s t e s t done using an arm ergometer (bicycle). V02  was  l e v e l s were measured  using a metabolic cart and EKG monitoring was also performed simultaneously to detect any abnormal cardiac response to the exercise. This t e s t i n g was performed under the supervision of a physiologist who  s p e c i a l i s e s i n cardiology.  Psychological evaluation. Psychological status was  evaluated  using four instruments: the Tennessee Self-Concept Scale, the Beck Depression Inventory, the P r o f i l e of Mood States, and the S e l f - E f f i c a c y Scale. Verbal explanations for completing  the tests  were given to each subject. Spanish t r a n s l a t i o n s were provided for any persons whose a b i l i t y to comprehend English was inadequate for completing  the tests. Diligent e f f o r t s were made  to provide translations that accurately captured the concepts being tested. A quiet area was provided for completing  the tests.  The TSCS takes about 20 minutes to complete and the others approximately  10 minutes each. Participants completed the TSCS on  one day and the others on a subsequent day. To maintain c o n f i d e n t i a l i t y , score sheets were marked only with the p a r t i c i p a n t s ' i n i t i a l s and an i d e n t i f i c a t i o n number. F i l e s were stored i n a locked cabinet. The. same t e s t s were  28  readministered following completion of 3 months of t r a i n i n g . Interviews. In order to obtain more in-depth information concerning p a r t i c i p a n t s ' reactions to the program and psychological changes experienced, individual interviews were performed following 3 months of t r a i n i n g . (See Appendix D for interview protocol.) Participants were asked to respond to a series of open-ended questions. These questions covered topics such as asking participants to describe t h e i r expectations p r i o r to commencing the program and whether or not these expectations were met. They were asked to describe any subjective physical changes noted as a r e s u l t of the exercise and also any psychological changes. To attempt to avoid bias i n the  responses  i t was emphasised that both p o s i t i v e and negative reactions are possible and that the interviewer was interested i n knowing about the f u l l range of the individual's experience. The interviews were semi-structured i n that s p e c i f i c areas were addressed. However, through use of empathic l i s t e n i n g participants were encouraged to describe t h e i r experience i n as much d e t a i l as they wished. These interviews were tape-recorded and then transcribed. Subsequently  the responses given to each of  the questions were l i s t e d separately and content analysis was performed to look for common responses. Any response that occurred three times or more, i n answer to a given question, was reported. In three cases i t was necessary to use a translator because the participant did not have an adequate l e v e l of English to comprehend the questions or to express h i s thoughts  and  29 feelings. Training protocol. The g a i t t r a i n i n g phase consists of three sessions weekly for a t o t a l of 32 sessions taking approximately 3 months to complete. Volunteers  commenced with standing  and  balance a c t i v i t i e s i n p a r a l l e l bars and then progressed to walking with a s p e c i a l l y adapted walker that connects to the stimulator unit. A l l t r a i n i n g sessions were conducted under the supervision of myself and/or my co-workers. Resting heart rate and blood pressure were monitored p r i o r too commencing the session and were reassessed  a f t e r each walk. Participants  generally performed three walks per session. The distance walked each time was  determined by the participant's a b i l i t y . Limiting  factors are fatigue of the quadriceps muscle or cardiovascular fatigue. Participants were free to withdraw from the study at any time i f they desired to do so. An Orthopedic Surgeon, a f f i l i a t e d with the Miami Project was  available on an o n - c a l l basis for the  duration of the study to evaluate any person  experiencing  problems. Apart from one i n d i v i d u a l who  had a bruised toe, no i n j u r i e s  occurred during the course of the study. Data Analysis To t e s t the hypotheses, r e s u l t s from the four psychological tests were analyzed  for differences i n the pre- and posttraining  scores using repeated measures analysis of variance. The BDI  and  SES y i e l d single scores. On the TSCS, the Physical S e l f subscale  was analyzed for posttraining changes. The POMS was analyzed as single score, the " t o t a l mood disturbance" score. In addition, the data from the V 0 2 testing was analyzed, again using a repeated measures analysis of variance to determine i f any changes i n cardiovascular fitness took place between pre- and posttraining. The audiotapes from the interviews were transcribed and content analysis was performed to look for common responses. Responses which occurred three or more times were reported.  31 Results Pretreatment Dependent Measures P r i o r to treatment, mean score on the physical self-concept scale was 67.5 (SJ2=11.25). This score l i e s approx 2/3 of a standard deviation below the mean (M=71.5) f o r the normative group (Roid & F i t t s , 1988). There was a wide v a r i a b i l i t y i n scores. Five individuals scored more than 1 standard deviation below the mean of the normative group with 3 of these scoring more than 2 standard deviations below the mean. Three individuals scored more than 1 standard deviation above the norm mean. Scores on the depression scale were also quite v a r i a b l e . The mean score at pretest was 8.5 (SD=9.24). According to the ranges of scores that have been set for l e v e l s of depression (Beck & Steer, 1987), 10 were not depressed, 2 were mildly depressed, 2 moderately  depressed, and 1 severely depressed.  Mean score on the s e l f - e f f i c a c y scale was high at pretest 95,  (S_D_=11.09) The maximum possible score on the t e s t i s 110.  This score of 95 i s i n d i c a t i v e of high l e v e l s of s e l f - e f f i c a c y . S i m i l a r l y , at pretest participants were reporting low l e v e l s of mood disturbance on the POMS. The mean score was 12.8 (S_Q=34.4). The mean t o t a l mood disturbance score f o r the normative group of college males was 40 (McNair et a l . , 1971), so the experimental group scored well below the normative mean at the outset. Correlation Matrix An examination of the c o r r e l a t i o n matrix (Table 1) showed  32 that at pretest, the physical self-concept measure was moderately negatively correlated with the depression and mood states scales, such that high physical self-concept was associated with few depressive symptoms and low l e v e l s of mood disturbance. The depression measure was strongly p o s i t i v e l y correlated with the mood states scale and strongly negatively correlated with the s e l f - e f f i c a c y scale, such that few depressive symptoms were associated with low mood disturbance and high s e l f - e f f i c a c y . The mood states scale was moderately negatively correlated with the s e l f - e f f i c a c y scale, i . e . , low mood disturbance was associated with high s e l f - e f f i c a c y . Similar relationships between the measures were observed at posttest but the correlations were not quite as strong. No c o r r e l a t i o n above .35 was noted between age or duration of injury and any of the measures.  33 Table 1 Intercorrelations Between Aae. Duration of Injury, and Outcome Measures Pre- and Posttest  Measures  TSCS Pr.  TSCS Pt. BDI  -.68 -.52  Pt.  -.72 -.59  Pt.  POMS  SES  Pr. Pt.  Pr. Pt.  Pr.  AGE Pt.  .70  Pr.  POMS Pr.  SES  Pt.  BDI  .80  -.72 -.61  .85  -.42  .43  .55  .88 .70  .72  Pr.  .47  .58 -.81 -.85 -.75 -.59  Pt.  .43  .61 -.72 -.86 -.74 -.64 .94  AGE  .04 -.22 -.35 -.23 -.23 -.17  .11 .17  DUR  .02 -.22 -.29 -.26 -.12  .05  .07  TSCS=Tennessee S e l f - Concept Scale, Physical Self BDI= Beck Depression Inventory POMS=Profile of Mood States SES= S e l f - E f f i c a c y Scale DUR= Duration of Injury Pr.= Pretest Pt.= Posttest  .18  .78  34 Treatment Effects—Dependent and A n c i l l a r y measures. Repeated measures analyses of variance (ANOVA) were performed on the dependent measures of physical self-concept, depression, s e l f - e f f i c a c y , and mood states. The change on the Physical Self subscale of the TSCS occurred i n the hypothesised d i r e c t i o n and was s i g n i f i c a n t Z(l,14) = 7.54,  p_ < .015.  statistically  (See Table 2 and Figure 1  for pre- to posttreatment means and standard deviations.) The pre- to posttreatment univariate t e s t f o r the depression scale was also s i g n i f i c a n t i n the expected d i r e c t i o n Z(l,14) = 5.42,  p <  .035.  The posttreatment mean score on the mood states scale changed i n the expected d i r e c t i o n but the change was  not  s t a t i s t i c a l l y s i g n i f i c a n t Z(l,14) = .404, p < .53. Unexpectedly the posttreatment mean on the s e l f - e f f i c a c y scale changed opposite to the hypothesised d i r e c t i o n and the change was s i g n i f i c a n t £(1,14) = 4.89,  p < .02.  As a manipulation check a repeated measures ANOVA was performed on the V02 data from pre- to posttest. There was increase i n peak V02 from 20.02 (£D.=3.27) to 23.01  an  (SJ2=3.61) and  the change was s t a t i s t i c a l l y s i g n i f i c a n t F(l,14) = 6.47,  p < .01.  A t e s t f o r c l i n i c a l significance was performed on the Physical Self subscale of the TSCS using the two-fold conservative c r i t e r i a developed by Jacobsen, F o l l e t t e , and Revenstorf.(1984)  In order to be considered for c l i n i c a l l y  s i g n i f i c a n t change, scores at pretest need to be more than 2  35 standard deviations below the mean for the normative group and to move to within 2 standard deviations of the mean by posttest. In addition, a "Reliable Change" index i s calculated by subtracting pretest from posttest scores and dividing by the standard error of the mean. A r e l i a b l e change index greater than 1.96 i s considered u n l i k e l y to occur without actual change. Based on these c r i t e r i a , 3 of the 15 participants would be considered to have demonstrated c l i n i c a l l y s i g n i f i c a n t improvement. However, i t should be noted that only 3 of the 15 p a r t i c i p a n t s scored more than two standard deviations below the normative mean at pretest. In analyzing the interview data, s i m i l a r responses occurring three times or greater i n answer to a given question were reported. (See Appendix E for summary and frequency count of the responses.) The results from the interviews are reported i n d e t a i l i n the next section.  36 Table 2 Pre- and Posttest Means and Standard Deviations of Dependent and A n c i l l a r y Measures (M=15)  Mean  TSCS Phys Self  BDI  Pre  67.4  S_D_  11.3  Mean  73.2  8.8  9.2  5.4  POMS  12.9  34.5  8.8  SES  95.0  11.1  92.3  Peak V02  20.0  3.3  23.0  TSCS = Tennessee Self-Concept Scale, Physical Self BDI = Beck Depression Inventory POMS = P r o f i l e of Mood States SES = S e l f - e f f i c a c y Scale .  Post  SD  7.1  5.9  32.5  13.2  3.6  37 Figure 1 Pre- and Posttreatment Means and Standard Deviations of Dependent Measures  Figure 1 125-  TSCS  BDI  POMS  SES  100-  o o  75-  [  I.  ^  '  o  50-  25  I  pre post pre post pre post pre post  Psychological Test  38 Discussion The purpose of the study was to determine whether p a r t i c i p a t i o n i n an e l e c t r i c a l stimulation walking program for men and women with SCI had any e f f e c t on measures of physical self-concept, depression,  s e l f - e f f i c a c y , and mood states. In  general i t can be concluded that p o s i t i v e and s t a t i s t i c a l l y s i g n i f i c a n t changes were noted i n the measures of physical s e l f concept and depression. The change i n mood states was not s i g n i f i c a n t and unexpectedly s e l f - e f f i c a c y scores decreased s i g n i f i c a n t l y from pre- to posttreatment. I hypothesized that participants would demonstrate a lowered physical self-concept on the TSCS and that the intervention would lead to an increase i n physical self-concept from pre- to posttest. This hypothesis was supported s t a t i s t i c a l l y . I t i s interesting to note however the wide v a r i a b i l i t y i n scores within the group. S p e c i f i c a l l y 5 of the 15 scored above the mean for the normative group at the outset i n d i c a t i n g that they had a healthy physical self-concept. On the other hand 5 of the participants scored more than 1 standard deviation below the mean of the normative group and of these 3 scored lower than the 16th percentile. Physical self-concept did not appear to be related to factors such as length of time post-injury or to l e v e l of injury. The heterogeneous nature of the scores for t h i s group points to the fact that physical self-concept may or may not be altered following spinal cord injury. The pretest mean for the experimental group i s s i m i l a r to that reported by Green, Pratt  39 and Grigsby (1984) who found that mean score on the Physical Self subscale for a group of 71 persons with SCI lay approximately 1 standard deviation below the mean of the normative group. Thirteen of the 15 participants increased t h e i r physical s e l f concept scores from pre- to posttest. The experimental group mean at posttest was 72.3 which places them just above the mean of the normative group, an increase of approximately 2/3 of a standard deviation. Those who commenced with the lowest scores tended to have the largest changes i n scores at posttest. Using Jacobsen, F o l l e t t e , and Revenstorf's  (1984) c r i t e r i a  for c l i n i c a l significance, 3 out of the 15 would be considered to have improved, however there were only 3 individuals who scored more than 2 standard deviations below the mean i n i t i a l l y . I t should be noted that t h i s was a "well" population being studied not a " c l i n i c a l " group. The improvement i n scores on the depression scale was also s t a t i s t i c a l l y s i g n i f i c a n t , however t h i s r e s u l t needs to be interpreted with caution. The pretest mean score was 8.8 which f a l l s within the range of no depression (range=0-9) (Beck & Steer, 1987). Two participants scored i n the mild depression range (10-18), 2 i n the moderate range (19-29), and 1 i n the severe range (30-68). Therefore, two-thirds of the group reported very minimal l e v e l s of depression whereas the other one-third experienced v a r i a b l e l e v e l s of depression. At posttest the group mean dropped to 5.5. The 2 i n the mild range dropped to no depression, the 2 i n the moderate to mild depression, and the 1  40 in the severe category to moderate depression. These results would appear to indicate that the 5 who were reporting symptoms of depression experienced a reduction i n these symptoms subsequent to the t r a i n i n g program. Although the hypothesis was supported, i d e a l l y t h i s should be r e p l i c a t e d with a larger sample size i n order to have more confidence i n the effect. Again i t i s interesting to note the v a r i a b i l i t y i n l e v e l s of depression. Time post injury does not necessarily seem to be a factor here, the 3 participants with moderate to severe l e v e l s of depression had a l l been injured within the past 2 years. However there were 3 participants reporting no depression who had also been injured within the previous 2 years. There were no s i g n i f i c a n t changes i n the mood scores from pre- to posttesting, however i t should be noted again that the group was reporting low levels of mood disturbance as compared to the normative mean for college men. Pretest mean for the group was 12.8 and the mean f o r the norm group was 40 (McNair et a l . , 1971). Eleven of the 15 participants exhibited the "Iceberg P r o f i l e " at pretest which has been reported i n the l i t e r a t u r e as being t y p i c a l of both wheelchair and able-bodied athletes (Horvat et al.., 1986). The iceberg p r o f i l e i s characterised by low scores on the Anxiety, Depression, Fatigue and Confusion subscales and a high score on the Vigor subscale. The results on the s e l f - e f f i c a c y scale are surprising. The i n i t i a l mean score was 95 out of a possible 110, indicating that  41 the participants were reporting very high l e v e l s of s e l f e f f i c a c y . Eleven of the 15 participants scored over 90 on pretest. At posttest the mean decreased to 92.3 was  the  and the decrease  s t a t i s t i c a l l y s i g n i f i c a n t . However 11 participants s t i l l  scored above 90. I t i s d i f f i c u l t to believe that the t r a i n i n g program contributed to lowered l e v e l s of s e l f - e f f i c a c y . During the interviews how  following t r a i n i n g many participants commented on  they enjoyed the challenge of the t r a i n i n g and how  i t felt  good to see the progress and increasing proficiency from week to week. The pre- to posttest c o r r e l a t i o n on the SES which i s higher than the internal consistency i s reported to be .76 t h i s t e s t was  scores was  .94  of the scale which  (Sherer et a l . 1982). This indicates that  not sensitive i n tapping the construct of s e l f -  e f f i c a c y for t h i s group. The problem may  have arisen i n  t r a n s l a t i n g the measure for those individuals whose f i r s t language was confusing  not English. The wording of the t e s t can  be  and i t i s sometimes d i f f i c u l t to determine i f the  question i s being asked i n a p o s i t i v e or negative sense. Translating the test may  have compounded the problem. I t could  also be argued that t h i s was  not the most appropriate  measure of  s e l f - e f f i c a c y to use i n t h i s s i t u a t i o n . This scale measures two subscales,  general s e l f - e f f i c a c y and s o c i a l s e l f - e f f i c a c y .  However, i n planning t h i s study, no measures of physical s e l f e f f i c a c y were found that were v a l i d for persons with spinal cord injury. They a l l contained inappropriate  items such as "I can  run  42 f a s t " or "I have good muscle tone". Sonstroem and Morgan's (1989) model of the mechanisms through which changes i n self-esteem occur as a r e s u l t of exercise t r a i n i n g was discussed i n the l i t e r a t u r e review. They hypothesized that changes i n physical s e l f - e f f i c a c y and physical competence occur as a r e s u l t of exercise which then lead to increases i n physical acceptance, which i n turn leads to improvements i n o v e r a l l self-esteem. The change i n physical s e l f concept, that i s comparable to physical self-acceptance,  was  demonstrated. However, due to the fact that participants had a high i n i t i a l score on the s e l f - e f f i c a c y t e s t and the aforementioned problems with the measure i t s e l f , increases i n physical s e l f - e f f i c a c y were not documented at posttest i n t h i s experimental group. Ideally a measure of physical s e l f - e f f i c a c y should be developed that i s v a l i d for persons with d i s a b i l i t i e s . Notwithstanding the non-random nature of the s e l e c t i o n process for t h i s study, the pretest scores on the measures do give some i n d i c a t i o n of the psychological status of a group of men  and women with paraplegia. Mean scores on the tests indicate  that o v e r a l l they were reporting low l e v e l s of depression,  high  s e l f - e f f i c a c y , and healthy mood state. Physical self-concept  was  the variable most affected i n t h i s group. A closer inspection of the i n d i v i d u a l scores reveals that approximately 25% of the group were reporting s i g n i f i c a n t symptoms of depression,  lowered  physical self-concept, and a l t e r a t i o n of mood state. The participants reporting these symptoms were a l l men  and, with  43 exception of one individual who had a low score on the TSCS, had been injured i n the previous two years. Although the number of participants i n t h i s study was small, the incidence of depression reported here supports the findings of Craig et a l . (1994) who reported that 30% of a group of men and women with SCI, injured i n the past two years, had scores above 14 on the BDI. As a manipulation check for t h i s study, changes i n V02 were measured from pre- to posttraining. The change was  statistically  s i g n i f i c a n t indicating the program did have a cardiovascular conditioning or aerobic t r a i n i n g e f f e c t .  The distance walked by  each participant was variable, from a low of 150 feet to a high of over 3000 feet. Despite t h i s , a l l participants experienced ah aerobic t r a i n i n g e f f e c t . Qualitative data Fourteen participants were interviewed following completion of t r a i n i n g and the interviews were tape-recorded. They were transcribed and subsequently the responses given to each of the questions were l i s t e d separately. Similar responses occurring three times or more i n answer to a given question was recorded. Atypical responses were also of interest. Again t h i s subjective data i s preliminary i n i t s scope yet i t reveals other facets of the individuals' reactions to the t r a i n i n g program that cannot be captured by the objective data alone. Some of the most poignant and i n s i g h t f u l of the responses deal not just with the participants' subjective experiences but with t h e i r perceptions of the attitude of the rest of society  44 towards them as individuals with a d i s a b i l i t y . For some i t seemed that one of the d r i v i n g forces behind t h e i r desire to stand walk was  and  to appear more normal i n the eyes of society and to f e e l  more accepted by that society.  This analysis i s somewhat  informal and takes the form of a discussion with each of the questions  from the interview being considered  i n sequence.  Quotations are included where appropriate. The f i r s t question asked how  the p a r t i c i p a n t o r i g i n a l l y  heard about the t r a i n i n g program. The majority of p a r t i c i p a n t s had heard about Parastep through word of mouth or through the media such as magazines or t e l e v i s i o n . Several had contacted  the  Miami Project and expressed an interest i n p a r t i c i p a t i n g i n research studies but did not know much about Parastep before they became involved i n the program. Others had had a strong desire to p a r t i c i p a t e i n a walking program for several years. Next the participants were asked to r e c a l l what t h e i r expectations were p r i o r to commencing the t r a i n i n g program. About one t h i r d stated that they did not know what to expect, that they just wanted to come and t r y i t . Another group had quite s p e c i f i c expectations,  e.g.,  they wanted to use i t as a form of exercise.  A couple of people stated that they hoped that using the Parastep and stimulating t h e i r muscles might lead to some return of function below the l e v e l of injury despite acknowledging that t h i s was  not a very r e a l i s t i c goal. One man  who  had been injured  for 9 years said: "I hoped for the ultimate, being able to throw the wheelchair away but I knew t h i s was  not r e a l i s t i c . "  45 The t h i r d question asked whether or not those  initial  expectations had been met. Eight were very pleased and f e l t that i t had met a l l t h e i r expectations. A 21-year o l d man who had been injured f o r 9 months reported: "Very much, I think I've gotten exactly what I wanted. I had a r e a l i s t i c  idea of what i t could  o f f e r , therefore, I wasn't disappointed." Three who had u n r e a l i s t i c expectations at the s t a r t were disappointed that i t d i d not give them what they hoped f o r . One woman who had expected to do well and to be able to walk f o r long distances was disappointed with the distances that she d i d achieve. I n i t i a l l y  she f e l t frustrated because she was not able  to walk as f a r as the others. She then decided to a l t e r her expectations and not to compare h e r s e l f with the others but rather to focus on the exercise benefits to her body not the distance walked. When asked t o describe the p o s i t i v e and negative aspects of the experience there were many s i m i l a r i t i e s i n the responses. On the p o s i t i v e side, the experience of standing and walking i n and of i t s e l f was b e n e f i c i a l to many. Most individuals enjoyed the strenuous nature of the exercise, which they said they were unable to achieve with other forms of exercise. They l i k e d the process of getting i n shape and reported f e e l i n g h e a l t h i e r as a r e s u l t of the exercise. Several individuals reported that the increase i n the size of t h e i r leg muscles was very p o s i t i v e f o r them. On the negative side, several p a r t i c i p a n t s had a struggle to  46 get a good step response i n i t i a l l y and t h i s led to some f r u s t r a t i o n as i t slowed t h e i r progress i n the early stages of t r a i n i n g . Those whose expectations were not met stated that t h i s was a negative aspect of the experience and led to some feelings of disappointment at the end of t r a i n i n g . When asked to describe any physical changes noted as a r e s u l t of t r a i n i n g there were again many s i m i l a r responses given. The most common response noted was an increase i n the muscle tone and bulk of the lower extremities. Many of the men reported that they had f e l t ashamed to wear shorts since t h e i r accident because they f e l t that t h e i r legs looked too t h i n , but since commencing t r a i n i n g they had taken to wearing shorts again. Other frequent answers were that breathing f e l t less r e s t r i c t e d , they generally f e l t healthier and that there had been some changes i n sensation to the lower extremities. Some developed more awareness of deep pressure and of muscle contraction i n the legs during the t r a i n i n g . Only one i n d i v i d u a l reported that he noticed very few changes as a r e s u l t of the t r a i n i n g . This was a young man who had hoped that use of the Parastep would help restore function i n h i s legs and who was disappointed when t h i s did not occur. The next question asked whether participants noted any psychological changes subsequent to the t r a i n i n g . A common response here was that the participants reported a sense of accomplishment from having seen the t r a i n i n g program through from beginning to end and watching the progress from week to week. They also reported increased feelings of well-being and s e l f -  47 confidence.  Others reported that t h e i r self-concept had  improved  due to the physical changes. Several participants l i v e d alone during the study for the f i r s t time since t h e i r injury and found that t h i s increased t h e i r sense of independence by proving to themselves that they could manage alone. I t should be noted that t h i s psychological change i s not a r e s u l t of the walking i t s e l f but came as part of the whole experience. Another common theme was  that the experience of being upright led to the i n d i v i d u a l  f e e l i n g more "able". Somehow j u s t knowing that they could get out of the wheelchair whenever they wished made them f e e l better about t h e i r s i t u a t i o n . One p a r t i c i p a n t commented that he did not have to f e e l l i k e a d i f f e r e n t person any more. On the other hand, one i n d i v i d u a l reported that he continued  to f e e l depressed about  his s i t u a t i o n , that h i s attitude went up and down l i k e a r o l l e r coaster, and that he did not f e e l l i k e continuing with the exercise any more. This was  the same p a r t i c i p a n t who  reported  that he noticed very few physical changes as a r e s u l t of the exercise. Some of the most i n t e r e s t i n g responses came i n answer to the question "Why  was  i t important to you that t h i s program involved  standing and walking?"  I report some of the responses  i n d i v i d u a l l y rather than j u s t reporting what was  common i n the  responses. A couple of people mentioned that they believed that humans have a basic need and a r i g h t to stand and walk. This i s denied following spinal cord injury and using the Parastep even for l i m i t e d periods helps to f u l f i l that need and r i g h t . One male  48 participant commented: "Maybe i t s because I was given the r i g h t to walk. I screwed up and took i t away from myself and now given the chance to go again and I want to do  I'm  it."  There was also the b e l i e f that being i n the chair fundamentally altered the attitude of other people towards them, and t h i s seems to lead to a diminished sense of personal worth i n the person with a d i s a b i l i t y . (This i s i n s p i t e of the fact that they frequently recognise that the problem l i e s with others and not with themselves.)  The a b i l i t y to stand upright again seems to  help restore a sense of normalcy to the i n d i v i d u a l . A female participant who has been injured f o r 9 years reported: Man was meant to walk upright. The fact that I'm  i n a chair,  there's a d i f f e r e n t attitude from people. I know that's t h e i r problem and not mine but you s t i l l have to interact with other people and deal with i t . So t h i s gives me the a b i l i t y to a l t e r that personal body space and attitude and that's good. Standing upright and t a l k i n g to other people eye to eye instead of looking up at them was mentioned by several people as being important: You f e e l more l i k e a man.  (In the chair) I f e e l helpless  even though I'm not helpless. I mean i t s l i k e people are looking down at you a l l the time. I t s just good to have people look up at you for a change. For others what was important was just the a b i l i t y to take a break from the chair. Doing everything i n a s i t t i n g p o s i t i o n  49 seems to become very tedious for many. A woman who had been recently injured commented: When someone s i t s i n the chair a l l day long from the beginning of the day to the night i t s too d i f f i c u l t , f o r eating, for working, for washing, everything i n the chair. I'm walking i n the program I f e e l good....I see no  When  difference  with the rest of the world, I f e e l more normal. Another participant reported that standing and walking reminded him of how he used to f e e l before h i s accident: When you leave the chair you're upright and you can walk. Maybe you f e e l l i k e you f e l t before when you could walk and stand. Sometimes when you're i n the car you wish instead of bringing the chair you could at least get out of the car and j u s t walk. That's something I'm going to t r y . For another individual the importance lay i n small but s i g n i f i c a n t things that i t would allow him to do at home such as standing up and reaching into a cupboard himself instead of having to ask someone else to help, or being able to stand at the front door and greet h i s g i r l f r i e n d when she came home from work. Two male participants who had been recently injured said that they hated the wheelchair and could not accept i t . One of these individuals also worried about how the Parastep would look to others and f e l t that i t would draw negative attention to himself i f he was out i n public with i t : Even with the Parastep i t s s t i l l going to bother me because people w i l l look at you. I t ' s l i k e , look at him he's 20 and  50 he's walking with a walker. I t ' s l i k e he's got a l l these wires on h i s body, what's wrong with him? Another point that was made several times throughout the interviews, not necessarily s p e c i f i c a l l y i n answer to t h i s question, was that many individuals f e l t a c e r t a i n pressure from friends and family to do well with the walking and to be up out of the chair. I t seemed that these people cared f o r and were concerned about the person i n the chair but at the same time they sometimes had u n r e a l i s t i c expectations about what the i n d i v i d u a l would be doing once they came home with the system.  One  participant had quite a b i t of concern about returning home and reported that she had to constantly emphasize to people that she would not be throwing her wheelchair away and that she would only be able to walk for short distances at a time. F i n a l l y , several people mentioned that standing and walking was important to them because i t would help them stay i n shape i n case a treatment or cure became available: I'm not s i t t i n g i n a wheelchair l i k e most guys, moping a l l day. I'm t r y i n g to help myself, t r y i n g l i k e h e l l . I'm  trying  to keep my muscles i n shape and my bones strong, that's the most I can do. The participants were next asked how they would rate exercise with the Parastep as compared to other a c t i v i t i e s such as wheelchair racing, swimming, or w e i g h t l i f t i n g . Most people said they f e l t Parastep provided better exercise. The most common reason given was that t h i s was the only type of exercise that  51 would work the muscles below the l e v e l of the injury. A l l other forms of exercise work only the upper half of the body. Consequently, Parastep allows individuals with paraplegia to exercise at a more intense l e v e l and many participants commented that they l i k e d the high intensity of exercise and the a b i l i t y to work up a sweat. Several of the participants had also trained previously with long leg braces and they a l l said they preferred Parastep because there was less bulky equipment to put on and the gait pattern with Parastep looked more natural. However, one i n d i v i d u a l mentioned that he l i k e d the element of competition i n a c t i v i t i e s such as wheelchair racing and that he missed that with Parastep. Next the participants were asked how they f e l t  about  continuing the exercise i n the long term. Eight out of the 15 participants purchased t h e i r own units at the end of t r a i n i n g . The rest either could not afford to do so or chose not to f o r other reasons. A l l who purchased the system wanted to continue the exercise but some were a l i t t l e concerned as to how high t h e i r motivation would be once they returned home and l e f t the structured t r a i n i n g environment  and a l l the support.  Several had  already thought of some strategies to help maintain t h e i r motivation such as choosing a regular place to walk where they could time themselves and record the distance walked. Some reported that the fact that they had spent so much money on the unit would help them to stay motivated to use i t regularly. S i m i l a r l y , a couple of people had received f i n a n c i a l assistance  52 from friends and family and said that t h e i r willingness to contribute towards the cost of the system would also be a motivating  factor to continue with the exercise.  The f i n a l question put to the participants was " I f someone were to ask you whether the time and e f f o r t involved i n learning to use the Parastep were worth i t , what would you t e l l them?" The majority reported that for them, i t was worth i t . Many cautioned that a person needed a l o t of willpower and motivation to s t i c k with the program and that i t was not for the lazy. They recommended that each person would have to t r y i t f o r themselves to see i f they l i k e d i t because individual reactions vary. One person said that i t was his personal opinion that i t was not worth i t because i t did not give him what he had hoped for. Conclusions.  Limitations, and Recommendations  This study was undertaken i n order to explore the e f f e c t of an e l e c t r i c a l stimulation walking program on the variables of physical self-concept, depression,  s e l f - e f f i c a c y , and mood states  in a group of men and women with paraplegia. I t was considered a relevant and necessary study due to the lack of l i t e r a t u r e dealing with exercise interventions for persons with d i s a b i l i t i e s . I t was intended to b u i l d on the previously documented l i t e r a t u r e on the psychological e f f e c t of exercise i n the able-bodied  population.  Two of the four hypotheses were supported, i . e . , there was a s t a t i s t i c a l l y s i g n i f i c a n t increase i n physical self-concept and a s i g n i f i c a n t decrease i n depression, bearing i n mind however that  53 both pre- and posttest means on the BDI were below the cutoff score f o r mild depression. Those with the lowest self-concept and the highest l e v e l s of depression experienced the greatest improvement i n scores. There was no s i g n i f i c a n t change i n mood state. Unexpectedly the s e l f - e f f i c a c y scores showed a s t a t i s t i c a l l y s i g n i f i c a n t decrease. However on the mood states and s e l f - e f f i c a c y measures, i n i t i a l mean scores showed low l e v e l s of mood disturbance and high l e v e l s of s e l f - e f f i c a c y , therefore there was not much opportunity f o r s t a t i s t i c a l l y or c l i n i c a l l y s i g n i f i c a n t increases to take place. Several conditions were present that l i m i t the g e n e r a l i z a b i l i t y of the findings from t h i s study. To begin with, the p a r t i c i p a n t s were not randomly chosen. Individuals had to meet s p e c i f i c physical c r i t e r i a such as general health status, height and weight, j o i n t i n t e g r i t y , and f l e x i b i l i t y , i n order to be e l i g i b l e f o r inclusion. They were also i n a sense s e l f selected as the majority had already contacted our i n s t i t u t i o n , a spinal cord injury research center, and expressed an i n t e r e s t i n p a r t i c i p a t i n g i n research. I t i s possible that these individuals could be more motivated or psychologically healthy than those who did not make contact. Second, the type of exercise i s not t y p i c a l of what i s generally available. More usual exercise programs might include weight-training, swimming, or wheelchair basketball. I t could be argued that there i s p o t e n t i a l l y a stronger psychological e f f e c t from an exercise that involves "walking". The act of standing and  54 walking a f t e r being confined to a wheelchair for a number of years may  restore a sense of normalcy to the i n d i v i d u a l that  could be powerful psychologically. On the other hand, i f the person had u n r e a l i s t i c expectations  as to what the program could  o f f e r and i f i t did not meet t h e i r expectations,  i . e . , too slow,  too cumbersome, too high of an energy cost, there could be negative e f f e c t s as the person r e a l i z e d that they would not be free from t h e i r wheelchair a f t e r a l l . F i n a l l y , another possible confounding variable r e l a t e s to the nature of our i n s t i t u t i o n . I t i s a large, m u l t i - d i s c i p l i n a r y group of s c i e n t i s t s who  are working together to develop a cure  for p a r a l y s i s . I t i s possible that coming to Miami, and  being  associated with the r e h a b i l i t a t i o n side of the research, may  have  a psychological e f f e c t i n and of i t s e l f , quite apart from the exercise being undertaken. Also, many of our research  volunteers  came from out of state or out of country, and the camaderie, and friendships that were developed with other persons i n s i m i l a r situations may  have been psychologically b e n e f i c i a l .  Several design l i m i t a t i o n s are present. One  i s the lack of a  control group. Because of the non-random s e l e c t i o n process i n t h i s study i t was  decided not to include a control group, however  the lack of a control group l i m i t s the a b i l i t y to ascribe changes noted to the walking a c t i v i t y i t s e l f . The other l i m i t a t i o n i s small sample s i z e . I t was  design  not possible to study a  larger sample due to the intensive, i n d i v i d u a l i s e d nature of the t r a i n i n g , and constraints of time and  staffing.  55 Despite these factors i t was f e l t that t h i s study was s t i l l an important one to undertake, given that so l i t t l e research has been done i n t h i s area to date. Also the system i s going to become more widely available i n the next couple of years following FDA approval, and i t i s important to gain some understanding of how i t s use might a f f e c t psychological, i n addition to physical well-being. These r e s u l t s do provide some preliminary evidence that a gait t r a i n i n g program such as the Parastep may be helpful i n improving physical self-concept and reducing depression i n persons with paraplegia. I t would be i n t e r e s t i n g to o f f e r t h i s  :  t r a i n i n g to a group of people with paraplegia who had been diagnosed with depression to see i f s i g n i f i c a n t reductions i n depression occurred.  I t would also be i n t e r e s t i n g to compare the  changes i n self-concept with other more conventional exercise programs such as w e i g h t - l i f t i n g or swimming. Clearly the interview data brought out the fact that there are some important psychological issues involved i n standing and walking f o r a person who i s paralysed that go much beyond the exercise i t s e l f . According to the respondents, these included the sense of freedom from the chair, and improved sense of self-worth from the a b i l i t y to stand and interact with others at eye l e v e l , as well as the , s a t i s f a c t i o n that came from seeing the muscles below the l e v e l of the injury working again. These may have been some of the factors that led to the documented increases i n physical self-concept i n t h i s study. However i t i s also possible that other types of  56 exercise programs would lead to improvement i n physical s e l f concept, p a r t i c u l a r l y i f individuals had been sedentary p r i o r to commencing a t r a i n i n g program. The interview data provided a perspective and  depth to the  p a r t i c i p a n t s ' experiences not captured by the objective data. Although subjective i n nature and therefore not generalizable i t helps to give a window on what the a b i l i t y to stand and walk, however limited, means to a person who  i s paralysed. There are  several observations that can be made of which health professionals who work with persons with spinal cord injury should be aware. F i r s t , although many of these participants stated that they had been able to accept having to use a wheelchair they s t i l l reported that they have a desire to stand upright, and they f e e l that t h i s i s a basic human need. Despite the fact that the wheelchair i s s t i l l the most energy e f f i c i e n t and fastest means of mobility, and the inherent l i m i t a t i o n s of a walking system such as the Parastep, the act of standing and walking seems to i n some way restore a sense of normalcy to the i n d i v i d u a l . The knowledge that they can be free of the chair even for  short periods, and that they can stand and interact with  other people eye to eye, seem to be two of the ways i n which t h i s takes place. Another factor s p e c i f i c to walking systems that use e l e c t r i c a l stimulation, i s that they restore a sense of connection with the lower h a l f of the body that i s v i s i b l e to the i n d i v i d u a l yet at the same time cut o f f from them. Many  57 respondents commented on how  good i t was  to see the leg muscle  size increasing, to see the leg swinging and taking steps and to have some sense, however vague, of the muscles contracting below the l e v e l of the injury. Perhaps the conclusion from t h i s i s that a person with spinal cord injury may  f e e l more whole i f he or she  has some means to maintain a sense of connection with the paralysed portion of the body, and to meet the need of and walking i n whatever way  standing:  possible.  On the negative side there were a couple of i n d i v i d u a l s who were disappointed when they r e a l i s e d the l i m i t a t i o n s to the walking with the Parastep. They had hoped that i t would allow for a more natural, less energy-consuming g a i t or that use of the system would restore permanent function to the muscles below the l e v e l of the injury. One possible way  to prevent t h i s  disappointment would be to have potential p a r t i c i p a n t s f i l l out a questionnaire p r i o r to t r a i n i n g that s p e c i f i c a l l y asked about expectations  of the walking program. In t h i s way,  unrealistic  expectations  could be more f u l l y addressed p r i o r to t r a i n i n g ,  thus helping to reduce the l i k e l i h o o d of disappointment. Although a comprehensive verbal description of what the Parastep could could not do was  and  given to each p a r t i c i p a n t p r i o r to t r a i n i n g ,  some individuals obviously did not f u l l y absorb everything they were t o l d or perhaps chose to deny the r e a l i t y of the information. The r e s u l t s from t h i s study have several implications for counselling practice and theory. F i r s t , counsellors working with  58 c l i e n t s with spinal cord injury should be aware that psychological status post-injury i s quite v a r i a b l e . Those most recently injured i n t h i s study tended to be the ones with the highest l e v e l s of depression and the greatest a l t e r a t i o n i n physical concept, however, there were equal numbers of participants with recent i n j u r i e s reporting no symptoms of depression or lowered physical self-concept. Second, a counsellor working with a c l i e n t who  i s i n the  process of adjusting to l i v i n g with a spinal cord injury should know that reaching a point of accepting the r e a l i t y of the wheelchair and retaining a strong desire to stand and walk are not necessarily mutually exclusive. Many of the p a r t i c i p a n t s i n t h i s study reported that they had accepted having to use a wheelchair but that use of the Parastep helped to f u l f i l t h e i r desire to stand and walk. These issues should be  explored  i n d i v i d u a l l y with c l i e n t s because again, due to the v a r i a b i l i t y of responses, what may  meet the needs of one person may  only  serve to f r u s t r a t e another. F i n a l l y , based on the r e s u l t s from t h i s study and from the l i t e r a t u r e , counsellors exploring l i f e s t y l e issues with t h e i r c l i e n t s can recommend p a r t i c i p a t i o n i n exercise a c t i v i t i e s both as a means of maintaining  physical health and for promoting  optimal mental health. In terms of counselling theory, several recommendations can be made f o r research. F i r s t , there i s a need for more studies examining the psychological e f f e c t s of exercise programs for  59 persons with d i s a b i l i t i e s . There are many d i f f e r e n t exercise interventions that could be used and a wide v a r i e t y of persons with physical d i s a b i l i t i e s who might benefit from such interventions. Sonstroem and Morgan's (1989) model provides a useful framework from which to proceed i n terms of determining the mechanism through which psychological changes take place. Ideally some instruments should be developed and validated to measure physical s e l f - e f f i c a c y disabilities.  specifically  for persons with  60  References Beck, A., & Steer, R. (1987). Beck Depression Inventory Manual. San Antonio: The Psychological Corporation, Harcourt Brace Publishing. Beck, A., Rush, A., Shaw, B., & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guildford Press. Brinkmann, J . , & Hoskins, T. (1979). Physical conditioning and altered self-concept i n r e h a b i l i t a t e d hemiplegic patients. Physical Therapy, 59(7), 859-865. j  Butcher, J . , Graham, J . , Tellegen, A., & Kaemner, B. (1989).  MMPI-2 content scales. Minneapolis: University of Minnesota Press. Caruso, C , & G i l l , D. (1992). Strengthening physical self-perceptions through exercise. Journal of Sports Medicine and Physical Fitness, 32(4)  f  416-427.  Coopersmith, S. (1981). Self-esteem Inventories manual. Palo Alto, CA: Consulting Psychologists Press. Craig, A., Hancock, K., & Dickson, H. (1994). A longitudinal investigation into anxiety and depression i n the f i r s t two years following a spinal cord injury. Paraplegia 22: 675-679. Derogatis, L. (1977). SCL-90-R. Administration, scoring and i  procedures manual. Baltimore: C l i n i c a l Psychometric Research. Doyne, E., Ossip-Klein, D., Bowman, E., Osborn, K., McDougall-Wilson, I., & Neimeyer, R. (1987). Running vs. w e i g h t - l i f t i n g i n the treatment of depression. Journal of  61 Consulting and C l i n i c a l Psychology, 5 5 ( 5 ) . 748-754. Franklin, A. (1985). Exercise testing, t r a i n i n g and arm ergometry. Sports Medicine 2: 100-119. Green, B., Pratt, C ,  & Grigsby, T. (1984). Self-concept  among persons with long-term spinal cord injury. Archives of Physical Medicine and Rehabilitation, 65. 751-754. Horvat, M.,  French, R.,  & Henschen, K. (1986). A comparison  of the psychological c h a r a c t e r i s t i c s of male and female able-bodied and wheelchair athletes. Paraplegia, 24, 115-122. Hughes, J . (1984). Psychological e f f e c t s of habitual aerobic exercise: A c r i t i c a l review. Preventive Medicine, 13, 66-78. Jacobsen, N., F o l l e t t e , W.,  & Revenstorf, D. (1984).  Psychotherapy outcome research: Methods f o r reporting v a r i a b i l i t y and evaluating c l i n i c a l significance. Behavioral Therapy, 15, '336-352. Kinney, W.,  & Coyle, C. (1992). Predicting l i f e s a t i s f a c t i o n  among adults with physical d i s a b i l i t y . Archives of Physical Medicine and Rehabilitation. 73, 863-869. Martinsen E., Hoffart, A., & Solberg, 0. (1989). Comparing aerobic with non-aerobic forms of exercise i n the treatment of depression: A randomised t r i a l . Comprehensive Psychiatry, 3 0(4)p 324-331. Martinsen, E., Medlus, A., & Sandvik, K. (1985). E f f e c t s of aerobic exercise on depression: A controlled study. B r i t i s h Medical Journal, 291, 109. j McCann, L. , & Holmes, D. (1984). Influence of aerobic j  62 exercise on depression. Journal of Personality and S o c i a l Psychology, 46(5)  f  1142-1147.  McNair, D., Lorr, M., & Droppleman, L. (1971). Manual for p r o f i l e of mood states. San Diego, CA: Educational and I n d u s t r i a l Tests. Morgan, W. (1980). Test of champions. Psychology Today, 92108. Ossip-Klein, D., Doyne, E., Bowman, E., Osborn, K., McDougall-Wilson, I., & Neimeyer, R. (1989). E f f e c t s of running and w e i g h t - l i f t i n g on self-concept i n c l i n i c a l l y depressed women. Journal of Consulting and C l i n i c a l Psychology, 57(1), 158-161. Roid, G., & F i t t s , W. (1988). The Tennessee  Self-Concept  Scale. Los Angeles: Western Psychological Services. Rosenberg, M. (1979). Conceiving  the s e l f . New York: Basic  Books. Rotter, J . (1966). Generalised expectancies f o r i n t e r n a l versus external control of reinforcement.  Psychological  Monographs 80. (1, Whole No. 609). Sherer, M., Maddox, K., Mercandante, B., Prentice-Dunn, S., Jacobs, B., & Rogers, R. (1982). The s e l f - e f f i c a c y scale: Construction and v a l i d a t i o n . Psychological Reports, 51, 663-671. Short, M., DiCarlo, S., S t e f f e r . , & Pavlain, K. (1984). E f f e c t s of physical conditioning on self-concept of adult obese males. Physical Therapy, 64(2), 194-198. Sonstroem, R., Harlow, L., Gemma, L., & Osborne, S. (1991). Tests of s t r u c t u r a l relationship within a proposed exercise and  I  63 self-esteem model. Journal of Personality Assessment, 56(2), 348-364. Sonstroem, R.,  & Morgan, W.  (1989). Exercise  and  self-esteem: Rationale and model. Medicine and Science i n Sports and Exercise, 21(3), 329-337. Super, J . , & Block, J . (1990). Self-concept and need for achievement of men  with physical d i s a b i l i t i e s . Journal of General  Psychology, 119(1), 73-80. Taylor, J . (1953). A personality scale of manifest anxiety. Journal of Abnormal Social Psychology, 40. 285-290. V a l l i a n t , P.,  Bezzubyk, I., Daley, L., & Asu, M.  (1985).  Psychological impact of sport on disabled athletes. Psychological Reports, 56, 923-929.  APPENDIX A Description of Parastep  Parastep Clinical Programs at Rehabilitation Institutions Sigmedics, Inc. currently provides Parastep Programs through collaboration w i t h physicians and physical therapists at leading rehabilitation institutions and hospitals across the U n i t e d States, Europe and M i d d l e East. The staff of Sigmedics serves as a support arm for the clinics' professional staff and Parastep users. Professional educational programs are provided by Sigmedics' clinicians to participating physicians and physical therapists. In addition, ongoing technical and service support for healthcare professionals and users is provided.  The Parastep* I System enables appropriate spinal cord injured patients to stand and take steps. The Parastep I is not intended for all patients. Patients must generally be in good health and have the ability to demonstrate adequate trunk control and balance to maintain an upright posture. The Parastep I is contraindicated for individuals with severe scoliosis and osteoporosis as well as a variety of other conditions. A prescribed period of physical therapy training is necessary for the safe and effective use of the Parastep I. For complete information on the Parastep I, including indications, contraindications, warnings, precautions and adverse effects, contact Sigmedics, Inc., at One Northfield Plaza, Suite 410, Northfield, Illinois 60093-3016, (708) 501-3500. C A U T I O N . Federal l a w restricts this device to sale by or on the order of a licensed physician.  Sigmedics, Inc. Sigmedics, Inc. designs, manufactures and markets rehabilitation products which help improve the quality of life for those who are neurologicallv impaired. For further information, contact:  SIGMEDICS, INC. One Northfield Plaza, Ste 410, Northfield, IL 60093, U.S.A. Tel: (708) 501-3500  Fax:(708)501-3404  A non-invasive system for standing and taking steps The Parastep System has been s h o w n to be a safe and effective means to enable standing and short distance w a l k i n g by people w h o have sustained a spinal cord injury. A s a functional neuromuscular stimulation (FNS) device, it comes from the medical engineering sciences k n o w n as neuroprosthetics. The Parastep System is a F N S modality p r o v i d e d as an alternative to traditional bracing and other orthotic approaches to long term rehabilitation management of spinal cord injury. Candidates for The Parastep System are spinal cord injured individuals for w h o m standing and gait training is indicated following evaluation by medical professionals.  Control of paralyzed muscle for limited ambulation It has long been accepted in rehabilitation medicine that prolonged inactivity has extensive deleterious physiological consequences. Few question the benefits of standing after spinal cord injury. The use of functional electrical stimulation by i n d i v i d u als w i t h neurological impairments has been s h o w n to be therapeutically effective for retarding and reversing muscular atrophy; increasing local b l o o d flow i n stimulated muscle; and increasing the range of motion at inactive joints. The Parastep affords the user the ability to activate h i s / h e r o w n muscles and stand and bear weight on the long bones of the legs when and where the i n d i v i d u a l desires to do so, whether at home or in the workplace. The Parastep System, when used in an approved program of long-term spinal cord injury management, w i l l enable the i n d i v i d u a l to stand and walk short distances. Users of the system report that the Parastep improves emotional and psychological well-being by enhancing self-esteem and morale.  User Independence and Control Available u p o n physician prescription, the Parastep, a compact and lightweight system, consists of the f o l l o w i n g components: j • A microcomputercontrolled functional neuromuscular stimulation unit  Sqrgdts..  • A battery activated power pack w i t h recharger • The Paratester™, a unit for pretesting system operation and cable integrity • Surface a p p l i e d electrodes • Power and electrode cables • A control and stability walker w i t h finger activated control switches • Physical therapy training at an approved clinical site • Full technical and service support Reusable electrodes are easily applied and removed. Set-up is usually performed i n less than 10 minutes. f The user controls the system by initiating c o m mands to the microcomputer-controlled stimulator. The stimulator unit activates electrical impulses to the lower extremities to enable standing and walking. The user initiates commands either through a userfriendly keypad on the stimulator unit or v i a control switches mounted on an electronically adapted walker. The walker provides balance and stability to the user while standing and w a l k i n g . The stimulator is powered by eight A A - N i C a d batteries and is housed in a lightweight waistpack.  APPENDIX B Sample Evaluation Form  c « » a itf  _  fES system PATIENT N A M E  Physical Therapy Assessment  101 DATE  INSTTTUTION  Pre-trainino AssessmentWusculo-Skeletal Evaluation Is the user without signs of joint instability at hip, knee or ankle which precludes standing or stepping? _ - - '.—. _ Is the user without signs of soft tissue inflammation related to stress or over use? Skin  Does the user's skin tolerate stimulation?  yes  Qp.  iQ 2Q  • •  3Q  |~T  Upper Extremity Strength Is strength adequate to enable a patient to lift his body weight out of a chair and into a standing walker?  -  *Q  Is the patient able to stand using one arm for support?  sQ  Q  Can the patient maintain upright stance with minimal upper extremity effort?  «Q  ||  Does the patient display protective extension reactions?  7Q  Q  Trunk Control and Balance Q  Does the patient display protective equilibrium reactions?  »Q  Q  Does the patient demonstrate an adequate sense of balance?  «Q  Q  Is spatial orientation adequate?  _  10 Q  Is awareness of posture accurate?  Q | |  Lower Extremity FES Force Production Is FES muscle power sufficient to maintain locked knees while full weight bearing in standing double support? (A grade of fair+ with FES MMT)  Q  Can the patient detect quadriceps fatigue and properly adjust stimulus intensity?  " ED  C  Circulatory Adjustment Do heart rate and blood pressure respond appropriately to upright stance?  [~|  Do heart rate and blood pressure return to resting levels within 5 min after standing?  []]  Posture Is standing posture erect with less than 20% of body weight bom by the upper extremities?  Q  Fatigue/Recovery Can the patient stand for a minimum of three minutes?  17 Q  Does the patient recover standing capability reasonably soon (5-10 min) after fatigue?  u  Q Q  I have evaluated the above individual and determined (him/her) to be a candidate (or the Parastep functional electrical stimulation program to maximize (his/her) ambulatory potential.  "Q  Q  FT  SIGNATURE Submit this form to the medical monitor arior to the initiation of oarasteo training 7  P A R A S T E P * F E S System PATIENT NAME  Medical Acceptance Evaluation  tot DATE  INSTITUTION  Medical Criteria:  no.  1.  Status six months post recovery spinal cord injury and restorative surgery (I any)  2.  Stable orthc-neuro-metaboBc systems  3.  Intact tower motor units (L1 and bo low)  4.  Without history of long bone fractures, severe osteoporosis, hip or knee degenerative joint disease  • • a •  «• -•  Clinical Criteria: 1.  •  o  „  Does the patient demonstrate and express appropriate motivation and commitment to the therapeutic program?  Is sufficient range of motion available at all extremity articulations?  _  a  .7.  Is muscle and joint stability available for weight bearing at upper and lower extremities?  «(  _..  |  Does the patient demonstrate appropriate muscle contractile response to Functional Electrical Stimulation (FES)?  _  Is motor hyper activity sufficiently controlled to allow safe independent upright stance?  »[~|  Does the patient demonstrate adequate learning abPity to successfully employ the  PARASTEP S Y S T E M ? 7.  1 0 Q  _  Does sensory perception of electrical stimulus allow sufficient level required for muscular contraction? n| |  Functional Criteria: 1.  Is F E S muscular force at the hip and knee sufficient for required function?  2.  Does the patient respond to upright positions and with adequate hemodynamic and ventilatory responses?  «| |  „  «  3.  Is the patient independent in all transfers?  4.  Does the patient demonstrate adequate standing tolerance to perform biped activities?  5.  .  _  Q  i«|  |  is  Q  Does the patient demonstrate adequate balance and control skills to maintain an upright supported posture independently ?  6.  Does the patient demonstrate adequate hand and finger control to manipulate system controls?...  Exclusionary Criteria: 1.  Cardiovascular disease or pulmonary insufficiency  2.  Epilepsy  3.  Pregnancy  4.  5. 6. 7. 8. 9.  _  [~~J  1 (  »•  Severe scoliosis  »• »• »•  Osteoporosis related fractures... Skin disease at stimulation sites. Irreversible contracture Morbid obesity Vision or hearing impairments which interfere with training.  a  10. Autonomic Dysreflexia  2  I have evaluated the above individual and determined (him/her) to be a candidate for the Parastep functional electrical stimulation program to maximize (hisAier) ambulatory potential  | 7  • • • •  • • •  • • • • •  • • • • • • •  • • • • • |  1I  •  • MD  Slgratftaeo&'O]  Sut?mit  (hjs forrn  to the medical monitor prior to the initiation of  oarasten  traininn  APPENDIX C Informed Consent Form  THE  UNIVERSITY  OF  BRITISH  COLUMBIA  Department of Counselling Psychology Faculty of Education 5780 Toronto Road Vancouver, B . C . Canada V 6 T 1L2 Tel: (604) 822-5259 Fax: (604) 822-2328  Informed Consent Purpose. The purpose o f t h i s study i s t o determine the p s y c h o l o g i c a l changes t h a t take p l a c e as a r e s u l t of s p i n a l cord i n j u r e d p a r a p l e g i c s p a r t i c i p a t i n g i n a walking system t r a i n i n g program. We have shown t h a t p a r a p l e g i c s can l e a r n to stand and take steps u s i n g a walking system which s u p p l i e s neuromuscular s t i m u l a t i o n (NMS) t o d r i v e the muscles of the lower e x t r e m i t i e s . We have been s t u d y i n g the changes i n p h y s i c a l f i t n e s s t h a t take place and are now i n t e r e s t e d i n examining whether any p s y c h o l o g i c a l changes occur. Procedures: To p a r t i c i p a t e i n t h i s study you must f u l f i l l the following c r i t e r i a : be 18-45 years of age, have been discharged from i n i t i a l h o s p i t a l i s a t i o n at l e a s t s i x months, and have a s p i n a l cord i n j u r y from t h o r a c i c vertebrae 4-12. A l l volunteers w i l l be evaluated to determine: i f the p a s s i v e range of motion movements i n the lower e x t r e m i t i e s are w i t h i n normal l i m i t s , j o i n t i n t e g r i t y of the h i p s , knees and ankles and bone d e n s i t y of the head of t h e femur. Before commencing the study you w i l l be asked t o complete four p s y c h o l o g i c a l q u e s t i o n n a i r e s . These q u e s t i o n n a i r e s are designed to measure s e l f - c o n c e p t , general mood s t a t e s , depression and " s e l f - e f f i c a c y " - which measures how c o n f i d e n t you f e e l about your a b i l i t y t o s u c c e s s f u l l y l e a r n new t a s k s . The r e s u l t s w i l l be kept s t r i c t l y c o n f i d e n t i a l . Any questions or concerns you have regarding these q u e s t i o n n a i r e s w i l l be addressed. On completion of 3 2 s e s s i o n s of t r a i n i n g you w i l l be asked t o complete the same t e s t s again. In a d d i t i o n t o the s e l f - r e p o r t measures, f o l l o w i n g the completion of t r a i n i n g , an i n t e r v i e w w i l l be conducted with you i n which you w i l l be asked to respond to s e v e r a l questions regarding your experiences d u r i n g the t r a i n i n g process. T h i s i n t e r v i e w w i l l be tape-recorded and subsequently analysed. Following a n a l y s i s the tapes w i l l be destroyed. Therapy and M o d a l i t i e s : I f s e l e c t e d to p a r t i c i p a t e i n t h i s study you w i l l begin with l e g t r a i n i n g to b u i l d up the strength of the quadriceps muscle. Once i t has been determined t h a t the quadriceps are s t r o n g enough to support the body i n an u p r i g h t p o s i t i o n f o r a t l e a s t f i v e minutes, standing w i l l begin. The goal w i l l be to achieve the a b i l i t y t o take steps f o r 150 f e e t o r greater w i t h i n 32 s e s s i o n s . I t w i l l take approximately 12 weeks to complete the 32 s e s s i o n s at a frequency of three times a week.  APPENDIX D Interview Protocol  Appendix Interview Protocol A general o r i e n t a t i o n t o the interview w i l l be given i n i t i a l l y , explaining the purpose f o r doing the interview and  emphasizing  that the interviewer i s interested i n learning about a l l aspects of the p a r t i c i p a n t ' s experience, including both p o s i t i v e and negative r e a c t i o n s and t h a t a wide range of reactions are possible. C o n f i d e n t i a l i t y of responses w i l l also be s t r e s s e d and p a r t i c i p a n t ' s w i l l be assured that i n the f i n a l a n a l y s i s , o n l y common themes i n responses w i l l be reported and no i n d i v i d u a l w i l l be i d e n t i f i e d by name.  1. Can you describe f o r me how  and why you became interested i n  learning to use the Parastep walking system? 2. Try to think back to the beginning of the program and describe for me what your expectations were, i . e . what d i d you hope to achieve by p a r t i c i p a t i n g i n t h i s program? 3. Now  that you' re nearing the end of the program do you  feel  that those expectations were met? I f not, how was the experience d i f f e r e n t to what you expected? 4. Can you describe f o r me the p o s i t i v e and negative aspects of this  experience?  5. Do you f e e l i n any way  d i f f e r e n t p h y s i c a l l y now  as compared to  when you s t a r t e d the program? Please describe. 6. How  about mentally or p s y c h o l o g i c a l l y , has anything changed  for you over the l a s t few months? Please describe.  7. How do you f e e l about: c o n t i n u i n g t h i s t y p e o f e x e r c i s e i n t h e l o n g - t e r m a f t e r t h i s program ends? 8. How would y o u r a t e t h i s  form o f e x e r c i s e i n comparison t o  o t h e r a c t i v i t i e s t h a t a r e a v a i l a b l e t o you such as swimming, weight-lifting 9.  o r wheelchair  racing?  Can you e x p l a i n t o me whether o r not i t was i m p o r t a n t t o you  that t h i s p a r t i c u l a r  e x e r c i s e program i n v o l v e d s t a n d i n g and  walking. 10. I f so c a n y o u d e s c r i b e why i t i s important t o you t o be a b l e t o stand  and walk?  11. I f someone e l s e were t o ask you whether t h e time and e f f o r t i n v o l v e d i n l e a r n i n g t h i s a c t i v i t y were worth i t , what would you tell  them?  "75"  APPENDIX E Summary and Frequency Count of Interview Data  Summary and Frequency Count of Interview Data 1. Can you describe f o r me how you became interested i n learning to use the Parastep walking system? Frequency 7 6  Word of mouth or through the media Had contacted Miami Project and expressed i n t e r e s t i n p a r t i c i p a t i n g i n research and was t o l d about the walking program  2. Try to think back to the beginning of the program and describe for me what your expectations were p r i o r to s t a r t i n g , i . e . , what d i d you hope to achieve by p a r t i c i p a t i n g i n t h i s program? 3 5  Did not know what to expect Had s p e c i f i c expectations, e.g., to use i t as a ,. form of exercise Hoped i t might lead to return of function  3  3. Now that you're nearing the end of the program do you that those expectations were met? I f not how was the experience d i f f e r e n t to what you expected? 8  Expectations were met  3  Expectations were not met  feel  4 . Can you describe f o r me the p o s i t i v e and negative aspects of the experience? 4 3 3 3 3 3  j  Positive The experience of standing and walking The strenuous exercise The process of getting i n shape and f e e l i n g healthier The increase i n s i z e of the leg muscles Negative I n i t i a l d i f f i c u l t y getting a good step response was f r u s t r a t i n g Expectaions were not met  5. Do you f e e l i n any way d i f f e r e n t p h y s i c a l l y now to when,you started? Please describe.  as compared  10 3 6 3  Increase i n s i z e and tone of the leg muscles Breathing f e e l s less r e s t r i c t e d Generally f e e l s h e a l t h i e r Noticed some changes i n sensation below the l e v e l of the injury, e.g. increased awareness of muscle contraction or deep pressure  6. How  about mentally or psychologically, has  anything  changed? 8  Sense of accomplishment from completing the training Increased f e e l i n g of well-being and s e l f confidence Improved self-concept due to the physical changes Increased sense of independence from l i v i n g alone during the study Feel more "able" knowing that they have the a b i l i t y to get out of the chair  8 3 3 4  7. Can you explain to me why  i t was  important to you that t h i s  exercise program involved standing and walking? Responses reported i n d i v i d u a l l y for t h i s question. 8. How  would you rate t h i s form of exercise i n comparison to  other a c t i v i t i e s such as swimming, w e i g h t - l i f t i n g or wheelchair 5  racing? Better, because i t works the muscles below the l e v e l of the injury Better because the exercise i s more intense Better than long leg braces  7 3 9. How  do you f e e l about continuing t h i s exercise i n the long-  term? 7 3  Would l i k e to continue the exercise Would l i k e to continue but has some concerns about maintaining motivation l e v e l  10. I f someone else were to ask you whether the time and e f f o r t involved i n learning t h i s a c t i v i t y were worth i t what would you t e l l them? 7  Yes i t was d e f i n i t e l y worth i t  I t s worth i t but a person needs a l o t of willpower and motivation to stay with the t r a i n i n g program  

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