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Aerobic Exercise Training During Pregnancy Reduces Depressive Symptoms in Nulliparous Women: a Randomised Trial

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Aerobic Exercise Training During Pregnancy Reduces Depressive Symptoms in Nulliparous Women: a Randomised Trial Robledo-Colonia et al: Exercise during pregnancy and depression Aerobic exercise training during pregnancy reduces depressive symptoms in nulliparous women: a randomised trial Angelo Fernando Robledo-Colonia, Natalia Sandoval-Restrepo, Yannier Ferley Mosquera- Valderrama, Celia Escobar-Hurtado and Robinson Ramírez-Vélez University of Valle, Cali, Colombia Question: Does supervised aerobic exercise during pregnancy reduce depressive symptoms in nulliparous women? Design: Randomised trial with concealed allocation, blinded assessors, and intention-to-treat analysis. Participants: 80 nulliparous, pregnant women attending for prenatal care at one of three tertiary hospitals in Cali, Colombia. Intervention: The experimental group completed a 3-month supervised exercise program, commencing at 16 to 20 weeks of gestation. Each session included walking (10 min), aerobic exercise (30 min), stretching (10 min), and relaxation (10 min). The control group continued usual activities and performed no specific exercise. Outcome measures: The primary outcome was symptoms of depression assessed by the Center for Epidemiological Studies Depression Scale (CES-D) at baseline and immediately after the 3-month intervention. Results: 74 women completed the study. After the 3-month intervention, the experimental group reduced their depressive symptoms on the CES-D questionnaire by 4 points (95% CI 1 to 7) more than the control group. Conclusions: A supervised 3-month program of primarily aerobic exercise during pregnancy reduces depressive symptoms. Trial registration: NCT00872365. <3PCMFEP$PMPOJB"' 4BOEPWBM3FTUSFQP/ .PTRVFSB7BMEFSSBNB:' &TDPCBS)VSUBEP$ 3BN®SF[ 7²MF[3 "FSPCJDFYFSDJTFUSBJOJOHEVSJOHQSFHOBODZSFEVDFT EFQSFTTJWF TZNQUPNT JO OVMMJQBSPVT XPNFO BSBOEPNJTFEUSJBMJournal of Physiotherapyo> Key words: Aerobic exercise, Pregnant women, Depression, Randomised trial, Physiotherapy Introduction supported the popular belief that physical activity is Depression disorders have become a widespread health associated with psychological health in pregnant women. concern throughout the world. The worldwide prevalence Guidelines from the American College of Obstetricians of depression has been estimated at 10.4% (Andrews et al and Gynecologists (Artal and O’Toole 2003) recommend 2000). During pregnancy, depression affects 10–50% of regular exercise for pregnant women, including those women, with the incidence being higher in cohorts with low who are sedentary, for its overall health benefits including socioeconomic status (De Tychey et al 2005). Depression improved psychological health. Physical activity during during pregnancy is more common among women with a pregnancy appears to be beneficial to the maternal-foetal history of depression or a family history of depression, those unit and may prevent the occurrence of maternal disorders, in single motherhood or with more than three children, such as hypertension (Yeo et al 2000, Barakat et al 2009) cigarette smokers, low income earners, teenagers, and those and gestational diabetes (Dempsey et al 2004, Callaway in unsupportive social situations (Dietz et al 2007, Yonkers et al 2010), as well as improving well-being and quality of et al 2009). The importance of prenatal intervention is life (Montoya Arizabaleta et al 2010). In addition, several highlighted by studies showing that depression is associated studies over the last decade have reported that physical with increased risk of prenatal and perinatal complications activity has few negative effects for many pregnant women (Jablensky et al 2005, Nakano et al 2004). For example, (Alderman et al 1998, Artal and O’Toole 2003, Barakat et depressed women are more likely to deliver prematurely al 2008, Barakat et al 2009). (Field 2011) and they often have neonates who require intensive care for postnatal complications including growth Pregnancy is a time of intense physical change and emotional retardation and bronchopulmonary dysplasia (Chung et al upheaval in many women (Hueston and Kasik-Miller 1998, 2001). Furthermore, although pregnant women typically Montoya Arizabaleta et al 2010). In addition to the obvious report significantly lower rates of tobacco, alcohol, and outward physical changes that accompany pregnancy, cannabis use than before pregnancy (Hotham et al 2008), significant increases in mental health problems, including depression increases vulnerability to caffeine, nicotine, drug, and alcohol use in pregnant women (De Tychey et 8IBUJTBMSFBEZLOPXOPOUIJTUPQJD Depression is al 2005, Field et al 2009). Depression is also associated common among pregnant women and is associated with failure to eat well and seek prenatal care (Yonkers et with increased risk of prenatal and perinatal al 2009). complications. Exercise is an effective therapy for depression in many other patient populations. Prenatal interventions for depressed pregnant women have included antidepressants, psychotherapy, alternative 8IBUUIJTTUVEZBEET Three months of aerobic therapies, and physical activity (Field et al 2009, Rethorst exercise training reduces the severity of symptoms of depression among pregnant women. et al 2009). In recent years, accumulating evidence has Journal of Physiotherapy 2012 Vol. 58 – © Australian Physiotherapy Association 2012. Open access under CC BY-NC-ND license. 9 Research depression and psychosis, occur during pregnancy and in Medicine (ACSM 2009) and the American College of the immediate postpartum period (Watson et al 1984). Even Obstetricians and Gynecologists (Artal and O’Toole 2003). in normal pregnancies, women experience subtle changes that may alter their ability to carry out their usual roles and At each participating centre two health professionals, may detract from their overall health-related quality of life who volunteered, were trained to recruit and assess (Hueston and Kasik-Miller 1998, Montoya Arizabaleta et eligibility. During the recruitment period, the opportunity al 2010). Research has shown that exercise can decrease to participate in the study was offered daily to all patients depressive symptoms, yet an optimal exercise program for at the participating centres when they attended for routine treating depression has not been established. antenatal care, if they previously had been identified on the doctors’ lists as being without a chronic pathology. Therefore the research question for this study was: The participating centres were required to offer routine Does a 3-month supervised aerobic exercise program antenatal care and have facilities to allow the conduct of a decrease depressive symptoms in nulliparous pregnant supervised exercise class. women? Intervention Method Participants in the experimental group were invited to participate in three 60-min exercise classes per week, A randomised trial was conducted. Participants were starting between week 16 and 20 of gestation and continuing recruited from the prenatal care services of three hospitals for 3 months. All subjects wore a heart-rate monitor during in Cali, Colombia. Women who were interested in the the training sessions to ensure that exercise intensity was study were invited to a screening visit at one of the centres. moderate to vigorous (Ramírez-Vélez et al 2009, Ramírez- Sociodemographic data were recorded and a detailed Vélez et al 2011b). Sessions consisted of walking (10 min), physical examination was performed by a physician to aerobic exercise (30 min), stretching (10 min), and relaxation determine eligibility. After confirmation of eligibility, the (10 min). Aerobic activities were prescribed at moderate to women were randomly allocated to one of two groups: vigorous intensity, aiming for 55–75% of maximal heart rate aerobic exercise plus usual prenatal care, or usual prenatal and adjusted according to ratings on the Borg scale (Borg care only. Randomisation was performed using a permuted 1982). Adherence to the exercise program was encouraged block design with a block size of 10 and exp:con ratios of 5:5, by the physiotherapist who supervised the exercise sessions. 6:4 or 4:6. Participants in the exercise group commenced In order to maximise adherence to the training program, the program when each block was completed, allowing all sessions were: supervised by a physiotherapist and a supervised group exercise sessions comprising three to five physician, conducted in groups of three to five women, women. Baseline measures were taken the day before the accompanied by music, and performed in a spacious, air- exercise program commenced and outcomes were measured conditioned room. the day after the program was completed. The investigator responsible for randomly assigning participants to treatment The control group received no exercise intervention, did not groups did not know in advance which treatment the next attend the exercise classes, and did not take part in a home person would receive (concealed allocation) and did not exercise program. Both groups continued with their normal participate in administering the intervention or measuring prenatal care (1 session per week for 3 months) and physical outcomes. The investigators responsible for assessing activity. eligibility and baseline measures were blinded to group allocation. Participants and therapists administering the Outcome measures intervention were not blinded. The investigators responsible One day before beginning the exercise program and for outcome assessment were blinded to group allocation. immediately after the 3-month exercise period finished, All investigators received training before the trial
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