OM SAKTHI

A STUDY ON THE EFFECTIVENESS OF FITNESS ENDURACE

EXERCISE IN DEPRESSION, ANXIETY AND QUALITY OF LIFE
SCORES IN EARLY OLD AGE PEOPLE

PROJECT WORK/CASE STUDY

Submitted to the Tamil Nadu Dr.M.G.R Medical University for

Bachelor of Physiotherapy degree examinations August 2015

Submitted By
N.SANTHIYA ,B.P.T (FinalYear)
ADHIPARASAKTHI COLLEGE OF PHYSIOTHERAPY

MELMARUVATHUR-603 319
 OM SAKTHI

ADHIPARASAKTHI COLLEGE OF PHYSIOTHERAPY

CERTIFICATE

THIS IS TO CERTIFY THIS PROJECT IS A BONAFIED

WORK DONE BY ___________________________ FINAL YEAR B.P.T,

AND SUBMITTED TO THE TAMIL NADU DR.M.G.R MEDICAL

UNIVERSITY, CHENNAI, FOR THE BACHELOR OF PHYSIOTHERAPY

DEGREE EXAMINATION –AUGUST 2015.

REG.NO:____________________________

PROJECT GUIDE PRINCIPAL

INTERNAL EXAMINER EXTERNAL EXAMINER

 ACKNOWLEDGEMENT

With the blessings of his holiness “ AMMA - ARULTHIRU

ADIGALAR’’,I take immence please in submitting this project.

It’s my privilege to thank the principal. Mr.S.NAGARAJAN.M.P.T..,

who has given me the confidence to embark on this project.

I extent my sincere gratitude to my project guide

MISS.P.SUBASRI ,M.P.T.(CARDIORESPIRATORY
SCIENCE),CRM,PGDSBSA for her helpful guidelines.

I extent my whole heartedly thanks to my parents

Mr.P.K.NAGARAJAN & Mrs.N.VALARMATHI, and my sister who has
encourage me to finish this project.

I would like to express my sincere thanks to all the staff

who have constantly encouraged me throughout this project.

I extent my sincere thanks to professionally touch for

computerizing this project successfully.

I take this opportunity to thank all my seniors, juniors and

friends for their voluntary participation in finishing this project quickly
and successfully.

N.SANTHIYA
 CONTENTS

S.NO TOPIC PAGE.NO

1 Abstract

2 Introduction

3 Aim of study

4 Need of the study

5 Review of literature

6 Design and methodology

7 Data collection

8 Result

9 Conclusion

10 References

Appendix
ABSTRACT
 ABSTRACT
AIM:
The aim of the study is to evaluate the depression, anxiety
and quality of life scores in old age people after an fitness
endurance exercise.

METHOD:

The study involved 10 sedentary early old age people who

were evaluated by using Geriatric Depression Scale, STAI trait/ strate
Scale, SF-36 Scale and then randomly allocated to 2 groups.

The Group A was treated with conventional therapy

The Group B is treated with fitness endurance exercise

programme consisting of Bicycle Ergometer 3 times a week on
alternate days for 10 weeks.

RESULT:

Comparing pre and post test values, this study found

significantly decreased scores for depression , anxiety and improve
quality of life in Group B but no changes in Group A

CONCLUSION:

From this study, it can be concluded that fitness endurance

exercise program is effective way of reducing or preventing the
functional decline associate with aging.
INTRODUCTION
 INTRODUCTION

Depression and anxiety disorders are among the most common

illnesses in the community and in primary care.

Patients with depression often have features of anxiety disorders,

and those with anxiety disorders commonly also have depression. Both
disorders may occur together, meeting criteria for both.

It can be difficult to discriminate between them but it is important

to identify and treat both illnesses, as they are associated with significant
morbidity and mortality.

Depression and anxiety are significantly prevalent causes of

physical illness , psychological impairment and mortality throughout the
world.

These symptoms affect millions of people irrespective of

ethnicity, education, gender or income with the prevalence of
depressive disorders ranging from 5-25% and anxiety disorder
somewhat lower.
PHYSIOLOGICALY CHANGES OF AGEING:

 The nervous system, along with the endocrine system, controls and
integrates the activities of major organs and tissues. It receives and
processes sensory input from organs such as the eyes, ears and
skin, and responds through a variety of effector organs.
 The brain is extremely complex, with around 100 billion
interconnected neurons.
 There is a progressive loss of neural tissue with age usually reflected
by a gradual decline in cognitive function.
 Anatomical changes in the brain
The ageing brain gradually loses neurons and some of the supporting
neuroglial cells - it has been estimated that brain mass drops by
around 10% between the ages of 20 and 90 years. From the age of
20-60 years, neural losses are only around 0.1% per year but the
process speeds up thereafter.
 In addition, the remaining tissues display an increased concentration
of potentially harmful materials such as iron, aluminium and free
radicals.
 Aged neural tissue shows increasing pigmentation, largely due to the
deposition of a brown pigment called lipofuscin and a black pigment
called melanin.
 Lipofuscin is linked to the formation of neurofibrillary tangles
(abnormal areas of tangled neural tissue present at high densities in
Alzheimer’s disease), which are often present at low densities in aged
brain tissue, even in the absence of underlying disease.
 Loss of neurons is most apparent within the cerebral cortex. The
grooves (sulci) that mark the surface convolutions (gyri) of the
cerebral cortex are visibly deeper in brains taken from older people
significant amount of neural tissue is lost from the hippocampus an
area of the limbic system with an important role in memory and the
acquisition of skills.
 There is a gradual increase in the size of the fluid-filled chambers
(ventricles) within the brain because of a progressive loss of the cells
lining the ventricles. These expand and fill with more cerebrospinal
fluid. It has been estimated that individuals in their 90s may have
ventricles up to three times bigger than those of 20-year-olds.
 The medulla oblongata and other areas of the brain stem show
minimal neural losses compared with other regions of the brain. This
may reflect the essential role of the brain stem in life support,
controlling critical processes such as breathing, peristalsis, heart rate
and blood pressure.
 There appears to be no direct correlation between normal age-related
loss of neural tissue and decrease in intellectual function - indeed,
many people with severe dementia have normal brain mass.
 Research indicates that, as neurons are lost, those remaining show
increased plasticity, with lengthening axons and the sprouting of new
dendrites . This allows new connections (synapses) between
adjacent nerve cells to be established and may partially compensate
for age-related loss of neurons.
Changes in cerebral blood flow
 In old age, cerebral blood flow will have decreased by around 20% ,
primarily due to the loss of elasticity and lumen diameter in aged
 blood vessels . These changes are often far worse in people who
have underlying vascular disease and metabolic disorders such as
diabetes.
 In those with atherosclerosis, blood flow through smaller vessels in
the brain may become so slow that it may lead to transient ischaemic
attacks (mini strokes) which, if recurrent, can lead to vascular
dementia.
Changes in the levels of neurotransmitters
 There is an age-related decline in the synthesis of many
neurotransmitters and their receptors. These include the
catecholamines (adrenaline and noradrenalin), dopamine and
serotonin. These reductions can slow reaction, impair the processing
of information and, sometimes, increase the risk of depression.
Spinal cord changes:
 There is a gradual age-related loss of neural tissue from the spinal
cord. Up to 46% of neurons may be lost in humans over the age of
50.
 Although this appears to have little effect on spinal-cord function,
changes in the composition and shape of the cartilaginous
intervertebral discs may increase pressure on the cord and its
branching nerve roots. This often leads to a reduction in sensory
stimuli reaching the central nervous system, potentially reducing
reaction times to harmful actions such as touching a hot object.
Similarly, the conduction of nerve impulses along motor neurons
slows, adding to the reduction in muscular strength that is apparent in
old age.
 Reduced sensory and motor conduction increase the chances of
injury due to poor coordination, balance and fine motor control.
Peripheral nerve changes:
 With age the peripheral nerve cells often show a progressive
degeneration of the myelin sheath (insulatory layer around the axon).
This slows the conduction of nerve impulses by around 5-10% . In
health, this reduction in conductivity causes few problems but, in
older people with diabetes, it may contribute to and exacerbate any
pre-existing diabetic neuropathy.
 Damage to peripheral nerves is not repaired efficiently in older people
and some damaged nerves will remain unrepaired. This can
contribute to reduced sensation and motor control.
Functional changes
 In the absence of underlying disease, intellectual ability is usually
retained until at least age 80 . The gradual loss of neurons, slowing of
nerve conduction and depletion of neurotransmitters often slows the
processing of information and, as a result, some tasks may take
longer to complete in older age.
 Some functional changes are commonly experienced by older
people, including:
Loss of short-term memory: this is probably the earliest indication
of age-related changes within the brain. Unlike dementia, it tends not
to affect life skills, such as the ability to cook, but typically manifests
itself in trivial inconveniences such as forgetting an item from a
shopping list or misplacing keys.
 Loss of verbal skills: individuals over the age of 70 may
increasingly have problems in choosing appropriate words (for
example, struggling to find the correct word to finish a sentence) and
learning new language becomes increasingly difficult.
Reduced reaction times: the progressive loss of neurons, a
reduction in impulse velocity and changes within the spinal cord
typically lead to a slowing in reaction times. This can create problems
on encountering painful or harmful stimuli.
Depression: Clinical depression is more common in older people
and may be related to reduced levels of neurotransmitters such as
serotonin. Depression can often produce worrying symptoms that
mimic dementia (pseudodementia), frequently leading to great
anxiety.
 Increased activity of neuroactive drugs: because neural mass is
reduced, drugs that affect mental function may be more potent in
older people. As such, normal doses of common antidepressants and
neuroleptics may induce confusion or delirium.
Reducing the effects of ageing
 There is strong evidence that keeping mentally active can reduce
some of the age-associated problems described in this article .people
should be encouraged to engage in stimulating activities such as
socializing, reading and participating in games, which are thought to
improve cognitive function and memory as well as reducing the risk of
depression.
 It is a common misconception that ageing naturally leads to
conditions such as confusion, dementia and delirium. The human
brain has so many neurons that it has a natural built-in redundancy
 that allows it to adequately cope with the physical changes that are
associated with ageing.
 Indeed, in the absence of disease, it is possible for adequate mental
function to be retained throughout life.
AIM OF THE STUDY
 AIM OF THE STUDY

The aim of the study is to evaluate the depression, anxiety and quality
of life scores in old age people after fitness endurance activity.
NEED OF THE STUDY
 NEED OF THE STUDY

Depression and anxiety are the most common conditions seen in the
general medical setting, affecting millions of old age people.

Physical activity has been shown to be associated with decreased

symptoms of depression and anxiety and also improves physical health,
life satisfaction, cognitive functioning, and psychological well-being.

Though physical activities are encouraged in old age people, effects of the
exercises are short-term. Therefore in order to maintain the effect for a
longer period of time ,endurance training is more effective.
REVIEW OF LITERATURE

REVIEWS
 1. CAPURSO A(2007)

In old age, depression mainly affects those with chronic medical illness,
severe disability or mental decline. Depression in elderly worsens the
outcomes of many medical illness and increases mortality.

2. Kate B. Wolitzky-Taylor(2010)
These epidemiological studies indicate that anxiety disorders are
relatively common in late adult life, but less common than in younger
adults.

3.AHMED(2014)
Anxiety and depression are common in the elderly and
affect the quality of life

4. PETER SOLMON;(2001) stated that endurance exercise

training has antidepressant and anxiolytic effects and protects against
harmful consequences of stress.

5.ZAINAB,PEREIRA(2007)
Assessment and a quick screening of depression can be done
with the Geriatric Depression Scale. Repeated use of the same scale in a
patient would help the clinician to monitor the progress objectively.

6.KNUNT ENGEDAL(2005)
The spileberger state-trait anxiety inventory (STAI)-the state
scale in detecting mental disorders in geriatric patient.

7.PALUSKA SCHWENK TL(2000)

 People with depression tend to be less physically active than
non-depressed individuals, increased aerobic exercise or strength training
has been shown to reduce depressive symptoms significantly.

8.GUSZKOWSKA.M(2004)
Bicycle Ergometer using of moderate and low intensity. The
endurance training conducted for 15-30minutes and performs of 10 weeks.
This will result in reduction of anxiety and depression after single session of
exercise.

9.MORIMOTO SS(2011)
This concluded that Geriatric depression occurs in the context of
illnesses in which inflammatory processes are part of the pathogenesis.
Both aging and depression are associated with immune responses, and the
connectivity among mood-regulating structures may be modulated by
inflammatory responses.
 DEPRESSION

DEFINITION:

Depression refers to feeling of despair and hopelessness negative

shift in perception and decreased interest in activities that once
provide pleasure.

SIGNS AND SYMPTOMS ASSOCIATE WITH MILD,

MODERATE, AND SEVERE DEPRESSION:

MILD MODERATE SEVERE

 Anger  Despair  Anguish

 Anxiety Despondence  Hopelessness

 Sadness  Fearfulness  Dizziness

 Loneliness  Inadequacy  Helplessness

 Indecisiveness  Sensitivity  Insomnia

 Irritability  Excessive guilt  Worthlessness

Lethargy  Decreased self  Recurrent thought

esteem of suicide
 Decreased  Loss of appetite
concentration and weight
BEHAVIOURS ASSOCIATE WITH MILD, MODERATE &
SEVERE DEPRESSION:

MILD MODERATE SEVERE

 Frustrated  Crying  Suicide

 Difficulty planning  Decision making  Decreased

ahead problem interest in all
activities
 Sitting alone  Ruminating about  Lack of personal
past hygiene
 Obessing about  Social withdrawal  Stay in bed all
task day

CAUSES AND RISK FACTORS FOR DEPREESION:

 Loneliness
 Lack of social support
 Recent stressful life experiences
 Family history of depression
 Marital or relationship problems
 Financial strain
 Early childhood trauma or abuse
 Alcohol or drug abuse
 Unemployment or underemployment
THE BRAIN AND DEPRESSION:
 ANXIETY
DEFINITION:

Anxiety is the apprehensive anticipation of future danger

or misfortune accompanied by feeling of tension and agitation .
the anticipated danger may be real or imagined but is
experienced both physiologically and psychologically.

SIGNS AND SYMPTOMS ASSOCIATE WITH LOW,

MODERATE AND HIGH LEVELS OF ANXIETY:

LOW MODERATE HIGH

 Agitation  Abdominal  Chest pain

distress
 Apprehension  Pain  Depersonalization

 Distress  Heart palpitation  De-realization

 Irritability  Feeling  insomnia

unsteady
 motor  concentration  Dizziness
restlessness loss

 Muscle tension  Shaking  Helplessness

 Nervousness  Shortness of  Nausea

breath

 worry  fever  parasthesia

BEHAVIOURS ASSOCIATE WITH LOW, MODERATE, HIGH
LEVELS OF ANXIETY:

LOW MODERATE HIGH

 Biting lips, nails  Going to bathroom  Holding hand

frequently over heart
 Sighing heavily  Incessant talking  Reacting to
irrelevant cues
 Drumming finger  Mumbling  Throwing up
On table top
 Pacing  Over activity

 Pulling hair  Starting blankly

 Avoiding  Verbalizing pre

stressful occupations
situation

Examples of medical problems that can be linked to anxiety

include:

 Heart disease
 Diabetes
 Thyroid problems, such as hypothyroidism or hyperthyroidism
 Asthma
 Drug abuse or withdrawal
 Withdrawal from alcohol, anti-anxiety medications (benzodiazepines)
or other medications
 Irritable bowel syndrome
 Rare tumors that produce certain "fight-or-flight" hormones
 Premenstrual syndrome
RISK FACTOR FOR ANXIETY:

 Being female:

Women are more likely than men to be diagnosed with an anxiety

disorder.

 Trauma:

Adults who experience a traumatic event also can develop anxiety

disorders.

 Stress due to an illness:

Having a health condition or serious illness can cause significant

worry about issues such as your treatment and your future.

 Stress buildup:

A big event or a buildup of smaller stressful life situations may trigger

excessive anxiety — for example, a death in the family or ongoing
worry about finances.

 Personality:

People with certain personality types are more prone to anxiety

disorders than are others.

 Other mental health disorders:

People with other mental health disorders, such as depression, often

experience anxiety disorder as well.

 Having blood relatives with an anxiety disorder:

Anxiety disorders can run in families.

 Drugs or alcohol:

Drug or alcohol use or abuse or withdrawal can cause or worsen

anxiety
Complications:
 Depression
 Substance abuse
 Trouble sleeping
 Digestive or bowel problems
 Headaches
 Suicide
 Poor quality of life.
DESIGN & METHODOLOGY
 DESIGN AND METHODOLOGY

Study Design:

Quasi –experimental study.

Study setting:

Out patient department,

Adhiparasakthi college of physiotherapy.

Sampling:

Convenient sampling.

Sample size:

10 subjects.

Sample criteria:

1.Inclusion criteria:

 Sex- Both male and females are included.

 Age-60-75 yrs
 Stroke
 Heart disease
 Cancer
 Diabetes
 Thyroid disorders
 Vitamin B12 deficiency
  Multiple sclerosis
 Arthritis
 Low back pain

2.Exclusion criteria:

 Taking anti depression drugs

 Taking anti anxiety drugs
 Peripheral vascular disease
 Recent injury

Duration of study: 10 weeks

Materials used:

 Bicycle Ergometer
 Sphygmomanometer

Measurement tools:

 Geriatric depression scale

 STAI(spileberger state-trait anxiety inventory) scale
 SF-36 scale
 TREATMENT PROCEDURE

ENDURANCE EXERCISE PROGRAMME:

Endurance exercise session should follow this pattern:

 warm up period
 Bicycle Ergometer training
 Cool down period

Warm up period:

 Stretching of upper and lower limb muscle

 Forward and backward bending of trunk
 Lateral bending and rotation of trunk

Bicycle Ergometer training:

After warm-up, Bicycle Ergometer exercise are

performed.

The following instructions are given before start the

exercise programme.

 The exercise should be done in a rhythmic manner without

excess strenuous to the body.
 The speed of bicycle Ergometer should be performed in gradual
manner.
 If they feel discomfort if they should inform.
  The Ergometer cycle is sub maximal intensity, rhythmically up to
20minutes being gradually increased up to maximum of 60
 Treatment protocol:
 Frequency: 3times/week.
 Intensity: submaximal
 Type: aerobic.
 Time: 20-60min

Cool - Down period:

The cool down period should last 5-10 minutes

and consist of total body movement and static stretching.

REASON FOR SELECTING BICYCLE ERGOMETER:

 Bicycle Ergometer is a base training activity and easy exercise for old
age people.
 Regular cycling strengthens leg muscles and is great for the
mobility of hip and knee joints. And also gradually improvement in the
muscle tone legs, thighs.
 To builds stamina.
 To improves cardio-vascular fitness
 To eats up calories
 In this type of exercise whole body is involved. Therefore, arm-to-leg,
feet-to-hands and body-to-eye coordination are improved.
 Any regular exercise can reduce stress and depression and improve
well being and self esteem.
BENEFITS OF ENDURANCE EXERCISE IN DEPRESSION ,
ANXIETY:

 BOOSTING ENERGY-Exercise may affect the central

monamine functioning by producing more basal free acids and
raising free tryptophan levels which could boost serotonin
synthesis by raising central nerves system availability of its
amino acids precursor.

 LIFTING MOOD AND RELIEVING DEPRESSION, ANXIETY-

Exercise releases endorphins, powerful chemicals in brain that
energize spirits and make feel good.

 RELIEVE PAIN-Exercise leads to a beta-endorphin surge into

the blood stream to calm the sympathetic nervous system
and provide analgesic relief from pain associate with sternous
exercise.

 IMPROVING SLEEP: Even short burst of exercise in the

morning or afternoon can help regulate sleep pattern.

 SHARPENING OF BRAIN POWER: Exercise release endorphin

that make feel better also help concentrate and feel mentally
sharp for task at hand. Exercise also stimulates the growth of
new brain cells and helps prevent age related decline.

 Increase in self esteem: Regular activity is an investment in

mind, body when it becomes habit, it can faster sense of self
worth and make feel strong and powerful, improve sense of
well being.
DATA COLLECTION
 DATA COLLECTION

S.No GDS STAI

Pre -test Post-test Pre-test Post-test

1 14 10 54 41

2 08 06 50 38

3 11 08 56 49

4 09 04 40 36

5 09 07 45 43

6 10 07 53 49

7 11 08 55 48

8 12 08 60 54

9 10 07 59 50

10 10 06 57 48

Total 104 71 529 56

Mean 10.4 7.1 52.9 45.6

SF-36 SCALE
RESULT
RESULT
CONCLUSION

CONCLUSION
 From this study, it can be concluded that fitness endurance
exercise program is effective way of reducing or preventing the
functional decline associate with aging.

Therefore endurance exercise training program can be in corporate in

the treatment of geriatric population to lead a healthy physical life.
REFERENCE

REFERENCE
 “Primer on geriatric care”, D.E.Rosenblatt &V.S.
Natarajan,First edition(2002)Page No- 7,8,9,347.

 “The management of anxiety”,Diana keable, second edition

1997. Page. No- 4, 5.

 “Physical rehabilitation”,fifth edition,susano’s sullivan

Page. No- 38,39,45,46,47,389.

 “Therapeutic exercise therapy”,carolin kishner,fifth edition,

Page.No-250

 “Primer on geriatric care”, D.E.Rosenblatt &V.S

 Natarajan,first edition(2002)-Geriatric depression scale
 “Physical rehabilitation”fifth edition,susano’s sullaivan-SF-36
scale
APPENDICES
 APPENDICES
ASSESSMENT PROFORMA:
Name:

Age:

Gender:

Occupation:

Address:

Chief complaints:

Past medical history:

Family and social history:

Investigation:

Diagnosis:

OBJECTIVE ASSESSMENT:

Vital signs:

Higher function assessment:

Level of consciousness:

Orientation:
Comprehension and perception:

Cranial nerve integrity:

OBSERVATION:

Body built

Attitude of limb

ON PALPATION

Warmth

Muscle tone

ON EXAMINATION

Motor evaluation:

Joint integrity:

Muscle tone:

Sensory assessment:

Reflexes:

Voluntary control assessment:

Balance:

Gait pattern:

Bladder and bowel:

Co-ordination:
Functional assessment:

Measurement tool:

Geriatric Depression Scale: Short Form

Choose the best answer for how you have felt over the past week:
1. Are you basically satisfied with your life? YES / NO
2. Have you dropped many of your activities and interests? YES / NO
3. Do you feel that your life is empty? YES / NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time? YES / NO
6. Are you afraid that something bad is going to happen to you? YES / NO
7. Do you feel happy most of the time? YES / NO
8. Do you often feel helpless? YES / NO
9. Do you prefer to stay at home, rather than going out and doing new
things? YES / NO
10. Do you feel you have more problems with memory than most? YES /
NO
11. Do you think it is wonderful to be alive now? YES / NO
12. Do you feel pretty worthless the way you are now? YES / NO 13. Do
you feel full of energy? YES / NO
14. Do you feel that your situation is hopeless? YES / NO
15. Do you think that most people are better off than you are? YES / NO
Answers in bold indicate depression. Score 1 point for each bolded answer.
A score > 5 points is suggestive of depression.
A score ≥ 10 points is almost always indicative of depression.
A score > 5 points should warrant a follow-up comprehensive assessment.

SELF–EVALUATION QUESTIONNAIRES STAI FORM Y-1

NAME__________________________DATE________________
AGE_____________________________GENDER - M F

1. I feel calm

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

2. I feel secure

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

3. I am tense

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

4. I feel strained

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

5. I feel at ease

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

6. I feel upset

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

7. I am presently worrying over possible misfortunes

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

8. I feel satisfied

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

9. I feel frightened

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

10. I feel comfortable

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

11. I feel self-confident

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

12. I feel nervous

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

13. I am jittery

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

14. I feel indecisive

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

15. I am relaxed

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

16. I feel content

 1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

17. I am worried

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

18. I feel confused

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

19. I feel steady

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

20. I feel pleasant

1. Not at all 2. Somewhat 3. Moderately so 4. Very much so

FORM Y-1 NOT AT ALL SOMEWHAT MODERATELY VERY
SO MUCH SO
1. 4 3 2 1
2. 4 3 2 1
3. 1 2 3 4
4. 1 2 3 4
5. 4 3 2 1
6. 1 2 3 4
7. 1 2 3 4
8. 4 3 2 1
9. 1 2 3 4
10. 4 3 2 1
11. 4 3 2 1
12. 4 3 2 1
13. 1 2 3 4
14. 1 2 3 4
15. 4 3 2 1
16. 1 2 3 4
17. 1 2 3 4
18. 4 3 2 1
19. 1 2 3 4
20. 4 3 2 1
APPENDIX-4

SF-36 QUESTIONNAIRE

Name:____________________ Ref. Dr:___________________

Date: _______
ID: _______________ Age: _______ Gender: M / F

Please answer the 36 questions of the Health Survey completely,

honestly, and without interruptions.

GENERAL HEALTH:

1.In general, would you say your health is:

1.Excellent 2.Very Good 3.Good 4.Fair 5.Poor

2.Compared to one year ago, how would you rate your health in
general now?
 1.Much better now than one year ago
2.Somewhat better now than one year ago
3.About the same
4.Somewhat worse now than one year ago
5.Much worse than one year ago

LIMITATIONS OF ACTIVITIES:

The following items are about activities you might do during a typical
day. Does your health now limit you in these
activities? If so, how much?

3.Vigorous activities, such as running, lifting heavy objects,

participating in strenuous sports.
1.Yes, Limited a lot Yes,2. Limited a Little No,3. Not Limited at all

4.Moderate activities, such as moving a table, pushing a vacuum

cleaner, bowling, or playing golf
1.Yes, Limited a Lot Yes,2. Limited a Little No,3. Not Limited at all
5.Lifting or carrying groceries
1.Yes, Limited a Lot Yes, 2.Limited a Little No, 3.Not Limited at all
6.Climbing several flights of stairs
1.Yes, Limited a Lot Yes, 2.Limited a Little No,3. Not Limited at all
7.Climbing one flight of stairs
1.Yes, Limited a Lot Yes,2. Limited a Little No, 3.Not Limited at all
8.Bending, kneeling, or stooping
 1.Yes, Limited a Lot Yes,2. Limited a Little No,3. Not Limited at all
9.Walking more than a mile
1.Yes, Limited a Lot Yes,2. Limited a Little No,3. Not Limited at all
10.Walking several blocks
1.Yes, Limited a Lot Yes, 2.Limited a Little No,3. Not Limited at all
11.Walking one block
1.Yes, Limited a Lot Yes,2. Limited a Little No, 3.Not Limited at all
12.Bathing or dressing yourself
1.Yes, Limited a Lot Yes, 2.Limited a Little No, 3.Not Limited at all

PHYSICAL HEALTH PROBLEMS:

During the past 4 weeks, have you had any of the following problems
with your work or other regular daily activities as
a result of your physical health?
13.Cut down the amount of time you spent on work or other
activities
1. Yes 2. No
14.Accomplished less than you would like
1. Yes 2.No
15.Were limited in the kind of work or other activities
1. Yes 2.No
16.Had difficulty performing the work or other activities (for
example, it took extra effort)
1. Yes 2.No

EMOTIONAL HEALTH PROBLEMS:

During the past 4 weeks, have you had any of the following problems
with your work or other regular daily activities as
a result of any emotional problems (such as feeling depressed or
anxious)?

17.Cut down the amount of time you spent on work or other

activities
1.Yes 2. No
18.Accomplished less than you would like
1.Yes 2. No
19.Didn't do work or other activities as carefully as usual
1.Yes 2. No

SOCIAL ACTIVITIES:

20.Emotional problems interfered with your normal social

activities with family, friends, neighbors, or groups?
1.Not at all 2.Slightly 3.Moderately 4.Severe 5. Very Severe

PAIN:

21.How much bodily pain have you had during the past 4
weeks?
1.None 2.Very Mild 3. Mild 4.Moderate 5.Severe 6. Very Severe
22.During the past 4 weeks, how much did pain interfere with
your normal work (including both work outside the
home and housework)?
1.Not at all 2.A little bit 3.Moderately4. Quite a bit 5.Extremely

ENERGY AND EMOTIONS:

These questions are about how you feel and how things have been
with you during the last 4 weeks. For each
question, please give the answer that comes closest to the way you
have been feeling.
23.Did you feel full of pep?
1. All of the time
2. Most of the time
3. A good Bit of the Time
4. Some of the time
5. A little bit of the time
6. None of the Time
24.Have you been a very nervous person?
1. All of the time
2. Most of the time
3. A good Bit of the Time
4. Some of the time
5. A little bit of the time
6. None of the Time
25.Have you felt so down in the dumps that nothing could cheer
you up?
1. All of the time
2. Most of the time
3. A good Bit of the Time
 4. Some of the time
5. A little bit of the time
6. None of the Time
26.Have you felt calm and peaceful?
1. All of the time
2. Most of the time
3. A good Bit of the Time
4. Some of the time
5. A little bit of the time
6. None of the Time
27.Did you have a lot of energy?
1. All of the time
2. Most of the time
3. A good Bit of the Time
4. Some of the time
5. A little bit of the time
6. None of the Time
28.Have you felt downhearted and blue?
1. All of the time
2. Most of the time
3. A good Bit of the Time
4. Some of the time
5. A little bit of the time
6. None of the Time
29.Did you feel worn out?
1. All of the time
2. Most of the time
 3. A good Bit of the Time
4. Some of the time
5. A little bit of the time
6. None of the Time
30.Have you been a happy person?
1. All of the time
2. Most of the time
3. A good Bit of the Time
4. Some of the time
5. A little bit of the time
6. None of the Time
31.Did you feel tired?
1. All of the time
2. Most of the time
3. A good Bit of the Time
4. Some of the time
5. A little bit of the time
6. None of the Time
SOCIAL ACTIVITIES:

32.During the past 4 weeks, how much of the time has your
physical health or emotional problems interfered with
your social activities (like visiting with friends, relatives, etc.)?
1. All of the time
2. Most of the time
3. Some of the time
4. A little bit of the time
 5. None of the Time

GENERAL HEALTH:

How true or false is each of the following statements for you?

33.I seem to get sick a little easier than other people
1.Definitely true 2. Mostly true 3. Don't know4. Mostly false
5.Definitely false
34.I am as healthy as anybody I know
1.Definitely true 2. Mostly true 3.Don't know 4.Mostly false
5.Definitely false
35.I expect my health to get worse
1.Definitely true 2. Mostly true 3.Don't know 4.Mostly false
5.Definitely false
36.My health is excellent
1.Definitely true 2. Mostly true 3.Don't know 4.Mostly false
5.Definitely false