Vol.5, No.2, 222-228 (2013) Health
Effects of aquatic exercise on depression and anxiety
in ischemic stroke subjects
Felipe J. Aidar1, Nuno D. Garrido2*, António J. Silva2, Victor M. Reis2, Daniel A. Marinho3,
Ricardo Jacó de Oliveira4
15th Military State Fireman, Uberlândia, Brazil
2University of Trás-os-Montes and Alto Douro—UTAD/CIDESD, Vila Real, Portugal;
*Corresponding Author: ngarrido@utad.pt
3University of Beira Interior—UBI/CIDESD, Covilhã, Portugal
4University of Brasília—UnB, Brasília, Brazil
Received 6 December 2012; revised 5 January 2013; accepted 13 January 2013
Background: Stroke ranks third and is the lead-
ing cause of permanent disability in western
countries. Furthermore there are no treatments
for the psychosocial effects of this pathology.
Purpose: Analyse the effect of an aquatic exer-
cise program in depression and trace and state
anxiety in subjects who suffered an ischemic
stroke. Methods: Two groups were analyzed: ex-
perimental group (EG) n = 15, 50.3 ± 9.1 years;
control group (CG) n = 13, 52.5 ± 7.7 years. EG
underwent a 12-w eek aquatic exercise program.
Both groups were evaluated in pre- and post-
treatment using Beck Depression Inventory (BDI)
and Trace State Anxiety Inventory (IDATE). Wil-
coxon signed-rank and Mann-Whitn ey tests we re
used to compare moments and groups, respec-
tively. Results: The BDI scores of aquatic acti-
vities were: pre-treatment, 17.4 ± 7.7 and 16.9 ±
8.6 for the EG and CG, respectively; post-treat-
ment, 13.2 + 7 .1 and 16.4 + 7 .9 for the EG and CG,
respectively. The IDATE scores for anxiety trace
in strength training were: pre-treatment, 43.2 +
12.5 and 42.9 + 12.2 for the EG and CG, respec-
tively; post-treatment, 39.7 + 7.1 and 42.6 + 12.1
for the EG and CG, respectively. The IDATE
scores for a nxiety state in st re ngth tr ainin g were:
pre-treatment, 46.9 + 7.6 and 47.4 + 8.1 for the
EG and CG, respectively; post-treatment, 44.4 +
7.9 and 47.5 + 8.0 for the EG and CG, respectively.
Significant differences were found in pre and
post-treatment values in the EG and between
groups in the depression and trace and state
anxiety levels in post-treatment (p < 0.05). Con-
clusions: Aquatic physical activity contributes
to an improvement of the levels of depression
and anxiety in people who suffered a stroke.
Keywords: Aquatic Physical Activity; Beck
Depression I n ve n to r y ; C ardiovascular Dise ase;
Cerebrovascular Accident; Ischemic Stroke; Trace
State Anxiety Inventory
The stroke incidence has increased in recent years.
Regarding its mortality, the stroke ranks third in causes
of permanent disability, being the main cause of perma-
nent disability in western countries [1,2]. The American
Heart Association estimates that there are four million
stroke survivors in the United States and that 600.000
new cases occur annually [3]. In Brazil stroke represents
one third of deaths from circulatory diseases per year and
assumes a prominent place in conjunction with other
cardiovascular problems [4,5].
Moreover, treatments for possible negative psychoso-
cial effects of the disease are uncertain and somewhat
unreliable [6], being the most appropriate treatment di-
rected towards its systematization with accurate diagno-
sis. Moreover, action within an optimal timeframe,
within the first three hours after the stroke and with the
proper workup, is also reported [7-11]. In this sense, one
can observe a clear tendency to treatments only directed
for pharmacologic intervention. In the same way, a de-
layed intervention tends to cause more squeals and treat-
ment difficulties [12]. Indeed, the squeals may occur as a
consequence of cerebral ischemia lasting four to six
hours, producing irreversible neurological damage [13,
14]. Moreover, among adults, the stroke squeals are con-
sidered the most common causes of disability [15]. Ac-
cordingly, there is a need to continued treatment and
monitoring of people with stroke squeals [16], where the
psychosocial aspects tend to be compromised.
On the other hand, stroke is associated to cognitive
dysfunction and functional impairment, leading to diffi-
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F. J. Aidar et al. / Health 5 (2013) 222-228 223
culties in walking and interference in aspects related to
depression and social features [17]. Thus, the presence of
depression and anxiety should be appropriately treated,
where the focus of intervention should be to improve
functional aspects [18].
Physical activity can have positive effects on physical
and psychosocial aspects. The practice of moderate
physical activity is likely to have a positive impact, sig-
nificantly reducing anxiety levels [19], suggesting that
the anxiolytic effects of acute exercise tend to be statis-
tically positive [20]. Similarly, strength training besides
promoting strength gains also significantly reduces anxi-
ety levels in stroke survivors [21]. Moreover, Ischemic
stroke survivors undergoing the practice of aquatic ac-
tivities showed significant improvements in levels of
quality of life when compared to survivors who were not
submitted to physical activities [6].
Apart from this, the benefits of physical activity for
people affected by stroke has been reported and linked to
improvements in standards of life quality [22], and re-
lated to rehabilitation of these patients [23].
Nevertheless, few studies have evaluated the improve-
ment in depression and anxiety in stroke patients through
aquatic physical activities.
Thus, the aim of this study was to assess the influence
of aquatic exercise on depression and anxiety in persons
with squeals due to ischemic stroke. We hypothesized
that aquatic exercise decrease depression and anxiety in
persons with squeals due to ischemic stroke.
2.1. Sample
Thirty one subjects participated in this study and were
randomly divided, 16 to the Experimental Group (EG)
and 15 to the Control Group (CG). These groups were
changed after the beginning of activities as one of the EG
subjects did not follow the program. In the CG two sub-
jects were not evaluated in post-treatment. Finally, the
EG was composed of 15 subjects, being 10 males and 5
females (and CG was composed of 13 individuals, being
9 males and 4 females). Groups’ characteristic is shown
in Table 1.
The participation in the study required previous medi-
cal clearance. As a criterion for eligibility, only subjects
who have suffered ischemic stroke for at least one year
and subjects having hemiplegia or hemiparesis. The clas-
sification was followed according to the Ranking Scale
[24,25]. In GE 6.7% of the subjects had mild disability,
66.7% moderate disability and 26.7% higher disability.
In CG 15.4% of the subjects had mild disability, 61.5%
moderate disability and 23.1% higher disability (Table 2).
There were neither asymptomatic patients nor patients
Table 1. Groups data.
Experimental group (n = 15) Mean and SD
age 50.3 9.1
age (male) 50 10.6
age (female) 50.8 7.6
sex (male/female) 10/5
Control group n = (13) Mean and SD
age 52.5 7.7
age (male) 52.3 9.0
age (female) 52.8 4.8
sex (male/female) 9/4
Ta bl e 2 . Deficit and affected side in relation to dominant and
non-dominant limb.
Experimental group* No subjects
Dominant Non-dominant
Mild disability 0 1
Moderate disability 1 9
Higher disability 1 3
Control group*
Mild disability 1 1
Moderate disability 2 6
Higher disability 0 3
*All subjects were right-handed.
with non-disabling deficit or with severe disabilities.
All subjects, after being informed about the proce-
dures, voluntarily agreed to participate in this study, and
signed a written consent to resolution 196/1996 of the
National Health Council, in accordance with the ethical
principles contained in the Declaration of Helsinki (1964,
revised in 1975, 1983, 1989, 1996 and 2000), of the
World Medical Association.
The subjects underwent a pre-treatment testing and the
experimental group (EG) began aquatic physical activi-
ties while the other group (CG) only began the activities
four months after the EG, thus serving as control group.
2.2. Instruments
2.2.1. Beck Depression Inventory
The Beck Depression Inventory (Beck Depression In-
ventory—BDI) [26,27] has been often used as a measure
of self-assessment of depression in research and clinical
practice [28], as it is validated in several countries.
The original scale consists of 21 items, including sym-
ptoms and attitudes, whose measurement ranges from 0
to 3. These items are relate to sadness, pessimism, sense
of failure, lack of satisfaction, feelings of guilt, feelings
of punishment, self-deprecation, self-accusations, suici-
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F. J. Aidar et al. / Health 5 (2013) 222-228
dal ideas, crying spells, irritability, social withdrawal,
indecisiveness, body image distortion, work inhibition,
sleep disturbance, fatigue, loss of appetite, weight loss,
somatic concerns and decreased libido.
The Beck Inventory [26,27,29,30] allows various cut-
offs points, depending on the nature of the sample and
the study objectives. For the proposed sample “Center
for Cognitive Therapy” [31] recommends the following
cutoffs points: <10 = no depression or minimal depres-
sion; 10 to 18 = from mild to moderate depression; 19 to
29 = moderate to severe depression; 30 to 63 = severe
2.2.2. Trace State Anxiety Inventory IDATE
(St ate-T r ait Anxiety Inventory—STA I:
Form Y)
For the assessment of anxiety the Trace State Anxiety
Inventory (IDATE) [32,33] was used. The IDATE is a
self-assessment questionnaire divided in two parts: the
first assesses anxiety trait—IDATE I (referring to aspects
of personality) and the second part assesses the anxiety
state—IDATE II (referring to the systemic aspects of the
context). Each of these parts consists of 20 statements. A
score ranging from 1 to 4 is assigned to each item of both
scales and the total score can range from 20 (minimum)
to 80 (maximum). When answering the questionnaire,
the subject should consider that STATE means “as the
subject feels at that particular moment” and TRACE “as
the subject generally feels itself”. Usually the scores may
indicate a low degree of anxiety (0 - 30), medium degree
of anxiety (31 - 49) and high degree of anxiety (>50), i.e.,
the lower the score, the lower the degree of anxiety
2.3. Procedures
Questionnaires were administered before the begin-
ning of physical activity programs (pre-treatment) and
then after 12 weeks (post-treatment). Between pretreat-
ment and post-treatment EG underwent an aquatic phy-
sical activity program and the CG was not submitted to
any kind of specific physical activity.
Aquatic activities took place in a swimming pool with
25 × 12.5 m size and with an average depth of 1.5 m.
Several apparatus for the practice of water activities were
used during aquatic exercises. Activities were undertaken
twice a week in sessions lasting between 45 and 60 min-
utes in the period from 07:00 to 19:00 hours. The ses-
sions comprised 5 to 10 minute of dry land warm up ac-
tivities; 5 to 10 minutes of walking in the swimming pool
with breast level water height; 5 to 10 minutes pedaling
work out with Spaghetti; 5 to 10 minutes of climbing and
descending of pool degrees; 5 to 10 minutes of exercises
for upper and lower limbs with educational material;
breathing exercises, doing bubbles in the water; 10 min-
utes of swimming; and 5 minutes of low-intensity exer-
cise allowing calm return.
The Borg Scale of perceived exertion was used, at lev-
els comprised between 12 and 17 points [34]. The scale
was presented to the subjects at the beginning of the ac-
tivities. Subjects need to attribute a numerical value cor-
responding to their perception of effort at that particular
moment. These values were corrected till the intended
values and were readjusted during the intervention.
2.4. Statistics
Normality was determined by Shapiro-Wilk test. Since
the very low value of the N (i.e., N < 30) and the rejec-
tion of the null hypothesis (H0) in the normality assess-
ment, non-parametric procedures were adopted. Mean ±
1 standard deviation was determined for each variable.
Changes between pre and post-treatment were verified
by the Wilcoxon test for repeated measures. To compare
EG with the CG in pre and post-treatment the Mann-
Whitney test for independent samples was used. All sta-
tistical procedures were conducted with SPSS software
(v. 13.0, Apache Software Foundation, Chicago, IL,
USA). The level of significance was set at p < 0.05.
Subjects were evaluated before and after the onset of
exercise (pre and post-treatment), establishing compara-
tive data to understand the effects that the activities pro-
vided for depression and anxiety (Table 3).
The results showed a significant difference for the EG
in the variables analysed (depression, anxiety trace and
anxiety state). No significant difference was found be-
tween pre and post-treatment for the CG (p 0.05). In
the comparison between the EG and CG significant dif-
ferences were found (p 0.05) for indicators of depres-
sion and anxiety in the post-treatment (Table 4). The
results pointed towards significant differences (p 0.05)
between the EG and CG on levels of depression and
anxiety trait and state. No differences were obtained be-
tween EG and CG in pre-test.
The aim of this study was to assess the influence of
aquatic exercise on depression and anxiety in persons
with sequelae due to ischemic stroke. Main results sug-
gested that the levels of depression and anxiety in people
who suffered a stroke have decreased when involved in
an aquatic activity program during 12 weeks.
The results show that the subjects had similar levels of
depression in the pre-test and were considered moder-
ately depressed. The results corroborate other studies that
indicate that stroke is a severe disease, with high morta-
Copyright © 2013 SciRes. OPEN A CCESS
F. J. Aidar et al. / Health 5 (2013) 222-228 225
Table 3. Means (SD) in pre and post-treatment concerning
depression using the Beck depression inventory (depression)
and IDATE I and II (Anxiety trace and state) in experimental
group (EG) and control group (CG).
Pre-Test Post-Test
EG—aquatic activities (depression) 17.4 7.7 13.2 7.1*
CG (depression) 16.9 8.6 16.4 7.9
EG—strength training (anxiety trace) 43.2 12.5 39.7 7.1*
CG (anxiety trace) 42.9 12.2 42.6 12.1
EG—strength training (anxiety state) 46.9 7.6 44.4 7.9*
CG (anxiety state) 47.4 8.1 47.5 8.0
*p 0.05 (Wilcoxon test).
Ta bl e 4. Comparison of means (SD) of depression using the
Beck depression inventory and anxiety using the IDATE I and
II in EG and CG in post treatment.
Depression 13.2 7.1* 16.4 7.9
Anxiety trace 39.7 7.1* 42.6 12.1
Anxiety state 44.4 7.9* 47.5 8.0
*p 0.05 (Mann-Whitney test).
lity and high rates of recidivism [35-39], showing that
sequels tend to be definitive [40-42]. The same type of
results could be expected if the subjects had used drugs
for this purpose. However, there was no pharmacological
support, which can be considered as a positive result. In
the study of Simis and Nitrini [43], where pharmacol-
ogical support was used, after three months of follow up,
patients who initially had mild depressive symptoms
began to have higher values, where treatment was asso-
ciated with improved mood, memory and attention.
A prospective study with 3525 subjects, aged between
65 and 84 years, in several Italian cities, showed that
older people tend to an increased risk of depression
caused mainly by declining physical condition [44], thus
corroborating the results of this study where inactive
people tend to have an increased rate of depression. In
contrast, a study that examined 9374 patients who un-
derwent surgery in 69 hospitals in North America, has
shown that depression is not only associated with a rela-
tively active life, but to other associated factors [45].
Similarly, in a study that evaluated 101 patients, with
chronic symptomatic disease at neuromuscular level, it
was observed the relationship of physical dysfunction
with depression and anxiety. Two years after the diagno-
sis, these patients had increased the levels of depression
that could be associated with different types of dysfunc-
tions in relation to pathology [46], converging with our
results, where inactivity could cause an increase in de-
pression levels.
Yet, research has shown that symptoms of depression
and disability are closely related, when studying moder-
ate physical activities and the association between signs
of depression and disability, with 645 subjects aged 65
years or more [47]. Physical activity had a modifier ef-
fect in symptoms of depression and proved to be a factor
of change on disability matters. Even moderate and in-
tense physical activity lead to a significant decrease in
symptoms of depression, assuming that physical activi-
ties are an effective means to reduce the signs of depres-
sion [47]. Therefore, regular exercise tends to improve
the quality of life, the ability to work and leisure, and
reduces the incidence of new strokes and the consequent
decrease in physical ability [48]. The evidence point out
that physical activity is the best way to reduce stress in
people with disabilities and a tendency for improve-
ments in social and emotional aspects for those who
practice it regularly [49]. In a research conducted in Bra-
zil, depression following stroke was analyzed, noting that
this long-term psychosocial status proved to be very im-
portant in victims of cerebrovascular events [50]. When
trying to identify what caused the maintenance of high
levels of depression, it was pointed out that depression
was significantly higher in women and it was associated
with work issues, educational level, low social activity,
functional cognitive problems and dependence on some-
one else, and still the prevalence of other pathologies
associated with the stroke [50]. For anxiety, the results
suggest that aquatic physical activities were an important
factor in reducing anxiety levels. Corroborating with this,
in a study involving 104 patients, the levels of anxiety
and depression after stroke were compared four months
after the event, where 23% of subjects presented high
levels of anxiety and 19% presented high levels of de-
pression, where anxiety levels remained high even after
four months after the stroke [51]. These results are simi-
lar to the results in our study in the control group, which
even after three months of the stroke subjects showed no
improvement in anxiety levels. In an investigation where
71 patients with confirmed history of stroke were studied,
it was demonstrated that the absence of movement could
increase levels of anxiety [52], indicating that immobi-
lizing patients after stroke, tends to increase the negative
aspects of the pathology and further contributes to
worsen the symptoms of anxiety and irritability. Fure [53]
reported that in patients affected by stroke in Norway, the
emotional factor may be neglected after an event and that
anxiety exceeds normal levels in 20% - 30% of patients.
Yet 10% - 15% of patients had an emotional imbalance,
and 50% - 70% of patients had reduction of initiatives
and increased fatigue, and that the treatment was only
pharmacological, with no evidence of the success of me-
dical intervention. On the other hand, the beneficial ef-
fects of exercise are well documented, but physical ac-
tivity can increase levels of anxiety as well. In assessing
Copyright © 2013 SciRes. OPEN A CCESS
F. J. Aidar et al. / Health 5 (2013) 222-228
the relationship of physical activity and anxiety in 3289
subjects, Conn [54] noted that some activities could re-
duce anxiety in healthy adults; however, there could be a
direct relationship between casual increased anxiety and
physical activities.
The intervention of this study was to simulate what
was preconized by Subirats Bayego et al. [55], where the
benefits of physical activity tend to encompass stroke
among other diseases, being the benefits associated with
moderate aerobic exercise for at least 30 minutes, 5 days
a week or vigorous exercise for at least 20 minutes 3
days a week.
The results of this study suggest that the practice of
aquatic physical activity tends to promote improvements
in the levels of depression and anxiety in people who
suffered an Ischemic Stroke.
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