Psychiatric Annals

Review Article 

Physical Exercise as Medicine for Self-Injurious Behavior

Asif Ali, PhD; Muhammad Azam, PhD; Jawairiyah Mattiullah, MPhil

Abstract

Self-injurious behavior is one of the leading causes of death worldwide. Anxiety, substance abuse, posttraumatic stress disorder, trauma, depression, and personality disorders are commonly reported in patients with self-injurious behavior. The primary purpose of this article is to present a summary of research examining the effectiveness of exercise to reduce self-injurious behavior and to recommend directions for further research. Major research databases including PubMed, Scopus, Science Direct, Taylor & Francis, Google Scholar, PsycINFO, MEDLINE, and ERIC were searched for published work. Only five studies were found relevant to the topic of our interest: one retrospective case study, two cross-sectional studies, and two interventional/experimental studies. The results of interventional studies found beneficial effects of aerobic exercise for reduction in self-injurious behavior. In addition, cross-sectional studies found effectiveness of moderate to vigorous exercise for self-injury. The findings also showed that exercise appeared to reduce negative psychological conditions and improve overall psychological states in people with self-injurious behavior. [Psychiatr Ann. 2020;50(4):167–177.]

Abstract

Self-injurious behavior is one of the leading causes of death worldwide. Anxiety, substance abuse, posttraumatic stress disorder, trauma, depression, and personality disorders are commonly reported in patients with self-injurious behavior. The primary purpose of this article is to present a summary of research examining the effectiveness of exercise to reduce self-injurious behavior and to recommend directions for further research. Major research databases including PubMed, Scopus, Science Direct, Taylor & Francis, Google Scholar, PsycINFO, MEDLINE, and ERIC were searched for published work. Only five studies were found relevant to the topic of our interest: one retrospective case study, two cross-sectional studies, and two interventional/experimental studies. The results of interventional studies found beneficial effects of aerobic exercise for reduction in self-injurious behavior. In addition, cross-sectional studies found effectiveness of moderate to vigorous exercise for self-injury. The findings also showed that exercise appeared to reduce negative psychological conditions and improve overall psychological states in people with self-injurious behavior. [Psychiatr Ann. 2020;50(4):167–177.]

Self-injurious behavior and physical activity have become two important public health global concerns in recent decades. In 2015, self-injury was identified as the eighth leading cause of death among people of all age groups in United States.1 According to a report from The World Health Organization, 880,000 people died worldwide as a consequence of self-injury in 2010.2 Other estimates showed that approximately 1% of the total population and 4% of adults in the US appeared to be involved in some form of self-injurious behavior.3 The rates of self-injury are higher among youth and young adults (ages 14 to 24 years).4 Reports also indicated that 32% of the sample of undergraduate students in US engaged in self-injurious behavior at least once in their life.5 In many cases, psychological symptoms such as anxiety, stress, posttraumatic stress disorder, trauma, depression, substance abuse, and personality disorder were found to coexist with self-injurious behavior.6 Extreme situations of self-injurious behavior can lead to suicide,7 but exercise and physical activity appeared to be positively related with a wide range of physical and mental health outcomes.8 The World Health survey report showed that 23.7% of people in 47 low- and middle-income nations were inactive.9

Even though self-injurious behavior and physical activity are considered as distinct public health issues, some researchers have shown interest in exploring the relationship between these two variables. In this context, studies have shown that exercise was linked with various positive psychological outcomes, such as improvement in emotional states, and reduction in stress, anxiety, and depression.10 On the other hand, researchers have also recognized that depression, stress, anxiety,11 and negative emotional states6 were linked with self-injurious behavior. This led us to assume that if stress, anxiety, depression, and negative mood states accounted for self-injurious behavior12 and physical activity reduces these psychological conditions,13 then, hypothetically, people engaged in exercise or physical activity would exhibit reduction in self-injurious behavior. In this regard, research demonstrated that participation in physical activity and exercise was associated with better mental health and reduction in anxiety and depression.14 Evidence also documented that the mental health profile of people who exercise regularly was more satisfactory in comparison with those who did not exercise.15 These findings provided the support for the view that participation in physical activity, exercise, and sport programs may play a protective role against self-injurious behaviors.

It is evident that the increasing rate of self-injurious behaviors across all nations, age groups, and genders has dangerous consequences. This increasing rate of self-injurious behavior highlights the need for promoting understanding among health-related professionals about the use of exercise as an alternative approach to treat such behavior. Therefore, the primary purpose of this article is to summarize the hypothetical rationale examining the links of exercise/physical activity with self-injurious behavior by reviewing published work in this domain. In addition, it aims to identify gaps in existing work and present directions for further research on this topic. Self-injurious behavior was conceptualized as harming one's body deliberately in the absence of suicidal intention.16 The terms “physical activity” and “physical exercise“ are used synonymously throughout the article.

Methods

Search Strategy

Abstracts in English language were searched from major research databases including PubMed, Scopus, Science Direct, Taylor & Francis, MEDLINE, ERIC, Google Scholar, and PsycINFO, up to May 2018. The search terms were “exercise,” OR “sports participation,” OR “physical activity,” OR “athletes,” and “self-injurious behavior,” OR “self-injury,” OR “self-harm,” OR “self-mutilation,” OR “deliberate self-harm.” The relevancy of the abstracts was carefully scanned and examined by authors. Only full-length articles that were relevant to the area of interest were selected for retrieval. Studies with all kinds of research designs that were conducted on participants of any age groups, both genders, healthy and patient populations, and conducted in any country were included in the scope of this review. Only those studies that were published in peer-reviewed journals were selected. Dissertations, theses, and articles in press or published in other media were excluded from the review. The reference lists of selected full-length articles were also scanned and related articles were retrieved from reference lists. The procedure for literature search is presented in Figure 1.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram showing the procedure for literature search and selection of studies assessed the relation of exercise with self-injurious behavior.

Figure 1.

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram showing the procedure for literature search and selection of studies assessed the relation of exercise with self-injurious behavior.

Quality Assessment of the Studies

Three different appraisal tools were used to assess the quality of the time series intervention studies, cross-sectional studies, and the qualitative study. For example, quality assessment of intervention time series studies was carried out by the Single-Case Experimental Design scale developed by Tate et al.17 This is a valid and reliable rating scale consisting of 11 items that is primarily developed to assess quality appraisal of single-subject experimental research studies and is widely used in health-related research.18 Risk of bias of cross-sectional studies was evaluated using the Newcastle Ottawa Scale for cohort and case-control studies adapted for cross-sectional studies.19,20 Finally, appraisal of the qualitative case study was performed by using the Critical Appraisal Skills Programme checklist for qualitative studies.21 Based on the quality assessment of the studies, one study was identified as very good, three were classified as good, and the remaining one study was rated as fair. Full detail regarding assessment tool, scoring system, and quality rating of the included studies is presented in Table 1, Table 2, and Table 3.

Quality Assessment of Time Series Interventional Studies Based on the Single-Case Experimental Design

Table 1.

Quality Assessment of Time Series Interventional Studies Based on the Single-Case Experimental Design

Quality Assessment of the Cross-Sectional Studies Based on The Newcastle-Ottawa Scale

Table 2.

Quality Assessment of the Cross-Sectional Studies Based on The Newcastle-Ottawa Scale

Quality Assessment of the Qualitative Study Using the Critical Appraisal Skills Programme Checklist for Qualitative Studies

Table 3.

Quality Assessment of the Qualitative Study Using the Critical Appraisal Skills Programme Checklist for Qualitative Studies

Results

Study Selection, Characteristics, and Participants

From the literature search, five studies were found relevant to the topic of our interest. There were two cross-sectional studies,22,23 one qualitative case study,24 and two case studies with time series observational designs.25,26 The summary of the studies included in this review can be found in Table 4.

Evidence Describing Characteristics that Assessed Effect of Exercise on Self-Injurious BehaviorEvidence Describing Characteristics that Assessed Effect of Exercise on Self-Injurious Behavior

Table 4.

Evidence Describing Characteristics that Assessed Effect of Exercise on Self-Injurious Behavior

Among the five selected studies, one study was performed on healthy participants, one on participants with symptoms of psychological disorders such as depression and personality disorder, one with participants who were developmentaly disabled, and two studies enrolled people with a history of past episodes of self-injury. Two studies were conducted in adolescents22,24 and three in adults.23,25,26 Two studies were conducted in student populations (college/university),22,24 and one used a general population sample as participants.23 Three studies included both male and female participants,22,24 one recruited only male participants,25 and one case study was conducted using only a single female participant.26 All of the five included studies were conducted in the US (and no study was available that was conducted outside the US). All studies involved primary data, and none of the studies used secondary data for analysis.

Measurement Instruments

Self-injurious behavior. In the five selected studies, the tools of the data collection on self-injurious behavior were either self-reported questionnaires or in the form of interviews, direct observations, and hospital records. For example, authors of two cross-sectional studies used self-reported questionnaires to assess self-injurious behavior. One study used only first part of Inventory of Statements About Self-Injury (ISAS) developed by Klonsky and Olino,27 and the authors of the second cross-sectional study used a modified version of the original Inventory of Statements about Self-Injury-Behavioral Scale.27 Both studies described validity and reliability for the instruments used. However, in the two interventional/experimental studies,25,26 the researchers recorded history of non-suicidal self-injury (NSSI) through hospital record, self-reported history, interviews, or by recording observations during treatment and baseline phases of the experiments. Lastly, in the qualitative case study conducted by Klonsky and Glenn,24 interview and a single item of a self-developed tool were used to screen the participants for the level and type of self-injurious behavior in their previous lives.

All of the five studies used valid and reliable procedures and tools for measuring self-injurious behavior in the participants. This minimized the risk of bias regarding data collection in the included studies.

Physical activity/exercise. Among the five selected studies, two cross-sectional studies administered multi-item self-reported measures of physical activity. For example, one study used the Exercise Questionnaire (EQ), a three-item self-reported questionnaire adapted from the Godin Leisure-Time EQ.28 In this instrument, participants were required to report weekly involvement in physical activity. The second cross-sectional study used a short version of the International Physical Activity Questionnaire (IPAQ) developed by Hagströmer and Sjöström.29 The short-version of this self-reported measure consisted of 7 items that measure physical activity during past 7 days. The scores obtained by this tool were converted into metabolic equivalents for further analysis. Both of the questionnaires used in the two cross-sectional studies exhibit good validity and reliability for measuring physical activity in adolescents.

However, in the two interventional/experimental studies, exercise was used as interventional strategy to evaluate its effectiveness for reduction in self-injurious behavior. Both interventional studies used jogging as the interventional treatment. None of the studies used objective measure to assess intensity of exercise. In the qualitative case study, participants provided responses regarding doing sport and exercise recreationally to cope with self-injury urge.

Although none of the studies used an objective tool to assess physical activity of the participants, self-reported measures used in the included studies are good with respect to validity and reliability and are widely used in the previous research. The valid and reliable tools and procedures used for these studies potentially contributed to minimizing the risk of bias in data collection, which further contributed to enhance the quality of these studies.

In sum, for cross-sectional studies, ISAS27 and IPAQ29 are suggested as more appropriate tools to measure self-injurious behavior and physical activity, respectively. However, for experimental and interventional studies, using ISAS in combination with hospital records, history of self-injury, and interviews would be more appropriate approaches to assess self-injurious behavior. On the other hand, objective measures of physical activity including heart rate monitors, pedometers, accelerometers, and caloric intake are suggested to use for assessing physical activity in interventional studies because these measures are thought to be more robust than that of self-reported measures of physical activity.

Relationship Between Exercise and Self-Injurious Behavior

Cross-sectional studies. In a cross-sectional study, Boone and Brausch22 examined the association between physical activity, depression, and NSSI in adolescents. Ninety-four high school students (mean age = 14.48 years; standard deviation [SD] = 0.66) and 72 undergraduate university students (mean age = 20.26 years; SD = 4.28), with 68.3% proportion of female students took part in the study. EQ, ISAS, Reynolds Adolescent Depression Scale 2nd edition (RADS-2), Center for Epidemiologic Studies Depression scale, and Exercise Motivations Inventory-2 were administered to measure frequency and level of physical activity, frequency and type of self-injurious behaviors, level of depression, subscale scores of exercise motivation, and severity of depressive symptoms, respectively. Regression analysis indicated that there was a significantly inverse relationship between episodes of NSSI and physical activity. A lower level of depression was related with decreased frequency of self-injury. People who reported greater exercise exhibited a lower rate of self-injury regardless of level of depression. In addition, decreased physical activity was related with increased frequency of self-injury and relatively higher level of depression. Specifically, adolescents engaged in exercise for improving their appearance had a higher frequency of NSSI. Moreover, results of this study highlighted that engaging in exercise for better health and well-being, rather than exercising for improving body shape, is beneficial to reduce NSSI among adolescents. In sum, the findings of this study suggested that exercise might play a protective role against NSSI in adolescents possessing symptoms of depression.

In another cross-sectional study, Jarvi et. al.23 investigated the association between being involved in physical activity during the previous week and NSSI (during the past 30 days) in a sample of 353 adults characterized with various psychological disorders (ie, depression, mood disorder) and partially treated in the hospital. The average age of the sample was 35.16 years (range, 18–32 years; SD = 13.6) and 49.29% of participants were female. The authors administered self-reported tools including Inventory of Statements about Self-Injury-Behavioral Scale, Center for Epidemiologic Studies Depression Scale, Generalized Anxiety Scale-7, and International Physical Activity Questionnaire to measure self-injurious behavior, depression, anxiety, and physical activity, respectively. History of NSSI behavior was assessed through three additional questions concerning past history of NSSI. The analysis of this study showed that patients who reported some history of NSSI exhibited significantly less involvement in physical activity in comparison to patients with no history of NSSI. However, the effect size remained small to medium for both vigorous physical activity and moderate physical activity for reduction in self-injurious behavior. In addition, people who had a history of NSSI exhibited significantly greater anxiety as compared to patients who reported no history of NSSI.

Effect of Exercise on Self-Injurious Behavior

Interventional/experimental studies. In a time series research study, Baumeister and Maclean25 assessed the efficacy of moderate intensity exercise (jogging) to reduce self-injurious behavior in two developmentally disabled adults who were characterized by stereotyped mannerism and self-injurious behavior. Both participants were physically normal healthy males. Their ages were 23 years and 9 years. Participants were not randomly selected and there was no control condition in this experiment. The participants performed jogging exercise for 1 hour on every afternoon for 6 weeks. The time spent exercising covered during first 2 weeks, second 2 weeks, and third 2 weeks were 1, 2, and 3 hours, respectively. The exercise was conducted under the supervision of a male staff member. Behavioral responses of both participants were recorded at 5 time points: baseline 1, 1 mile, 2 miles, 3 miles, and at baseline 2. The analysis yielded a significant reduction in the self-injurious behaviors in both participants throughout the course of the interventional period.

In a single-subject time series study, Wallenstein and Nock26 determined the effects of exercise intervention for treatment of NSSI. In this experiment, a 26-year-old overweight woman with a 13-year history of NSSI was provided with a video of 60 minutes of exercise programming asking her to self-structure an exercise program and perform it for 5 weeks with a frequency of 3 times per week. She was also instructed to perform exercise when she felt the urge for self-injury. Self-injurious behaviors were recorded during the course of the experimental period. The patient was observed for 8 weeks after the end of experimental period. The results revealed that self-injurious behavior was significantly reduced during the periods of exercise intervention compared to the non-exercise period, and that exercise remarkably reduced the urge to self-injury. Data from the follow-up interviews confirmed the consistency in improvements in psychological conditions. Overall, the results of this study provided evidence in favor of exercise intervention as treatment for NSSI. However, this study did not present details regarding intensity (vigorous, moderate, low), form (running, stretching, walking, jogging, weight training), duration (minutes, hours), time of exercise (morning, evening), and exercise setting and environment (gymnasium, outdoor). It was also not mentioned whether the exercise was performed by the patient independently or under the supervision of any professional trainer, physical educator, or physiotherapist.

Qualitative case study. In a qualitative case study, Klonsky and Glenn24 explored the effective ways to deal with urge to self-injury in an adolescent sample of 39 undergraduate college students (9 men, 30 women). All participants had some history of self-injurious behavior and most of the participants (64%) had a history of receiving treatment for certain psychiatric disorders. The mean and standard deviation of the participant's ages were 19.4 years and 2.2 years, respectively. Among the 39 participants, 35 reported that they had previously tried to resist self-injury. A list of 48 helping methods for coping with urge to self-injury were presented to 35 selected participants. They were required to rate how frequently they used a particular method in an effort to resist the urge to self-injure. They were further asked to rate how helpful they found the methods they had been using to cope with self-injury previously. Based on the participant's responses, 16 methods were identified as the most frequently used methods to deal with self-injury. Moreover, the results showed that sport and exercise ranked first, as 65.2% among those who had been previously using sport or exercise as an alternative to cope with the urge to self-injure acknowledged this method as very helpful. Other methods, such as removing self-injury means, finding a friend to share feelings, and engaging in spirituality were reported to successfully resist the urge to self-injure by 63.6%, 60.9%, and 50% of participants, respectively. Finally, findings of this study suggested that doing exercise and sport can be used as an effective means for prevention and treatment of self-injurious behaviors in adolescents.

Potential Research Gaps

Overall, the results from the five studies showed the beneficial effects of exercise and physical activity for reduction or coping with self-injurious behavior. However, to date, no study has been conducted in older populations, people with decreased mobility, and in people with physical disabilities.

One possible reason for not finding any study on these populations might be that providing exercise intervention to these people is difficult due to various physical and psychological comorbidities associated with these kinds of populations. Older people in particular have a lower level of postural control, reduced balancing ability, lower neuromuscular coordination, and a remarkably lower level of physical fitness. These conditions likely make many exercise programs unsafe for older people. Assistive exercise programs in an aquatic environment are more feasible and safer for older people and people with decreased mobility as well as for people with physical disability because exercise in water provides support in controlling posture and maintaining balance. Furthermore, adaptive exercise programs can be a good choice as an intervention strategy for people with physical disability. Aquatic exercise programs have been shown to decrease anxiety and stress in an older population.30 The mental health benefits associated with aquatic exercise programs may contribute to reduce self-injurious behavior in these populations. In the future, research findings from these five preliminary studies need to be extended for older populations, people with decreased mobility, and people with physical disability.

Discussion

Overall, findings suggested that regardless of the design of the study, population, participant's characteristics, sample size, level of physical activity, exercise duration and intensity, and mode of exercise, all of the five studies included in the review demonstrated beneficial effects of physical activity and exercise for patients with symptoms of self-injurious behavior.

Among two cross sectional studies, one study reported medium effect size for frequency of physical activity on reduction of NSSI in adolescents,24 and the second study found small to medium effect for past week moderate and vigorous physical activity in adults with treatment-seeking behavior with certain psychiatric conditions.23 However, the results of this study did not show the effectiveness of low-intensity (ie, walking) physical activity to reduce self-injurious behavior in adults.

Among the two experimental studies, one study showed that self-structured exercise with the frequency of 3 days per week reduced self-injurious behavior and improved mood when compared with non-exercise periods in an adult woman with a 13-year history of NSSI and psychiatric disorders.26 In another experimental study, self-injurious behavior was remarkably reduced, and socialization and sleep was improved, because of introducing 1 hour of jogging exercise for 6 weeks in one physically healthy but developmentally disabled adult. However, this effect was limited to decreasing self-injurious behavior in the second participant.25 Among five studies, four of them showed beneficial effects of moderated and aerobic type of physical exercise for reduction in self-injurious behavior. One finding also favors vigorous physical activity for its effectiveness for self-injurious behavior. Another notable finding that emerged from the analysis is that moderate exercise also helps to reduce depressive symptoms and anxiety, improve mood and sleep, and enhance socialization in individuals with conditions of self-injurious behavior. The function of exercise to reduce negative psychological conditions, enhance mood states, and improve socialization point to the proposal that exercise may work to reduce self-injurious behavior through both psychological and sociological pathways. The positive effects of exercise in reducing self-injurious behavior are apparent for both genders. In addition, these findings are limited to advanced countries, as all of the studies were conducted in the US.

Conclusion and Areas for Future Research

Based on existing data, it can be concluded that exercise programs with moderate to vigorous intensities may be useful to reduce self-injurious behavior in children, adolescents, and adults. Although findings that emerged from these studies are promising, these findings are based on only five preliminary studies from a developed country (ie, the US). Thus, the available studies on this topic are inadequate for drawing solid conclusion regarding positive effects of exercise on self-injury. This limits the strength of the evidence in support of using exercise as an interventional strategy for patients with symptoms of self-injurious behavior. More studies are indeed needed to confirm these findings. Further studies with larger and more representative samples, methodological rigor, in diverse populations and cultures, and from varied geographical regions are suggested. Studies with longitudinal, cohort, and randomized control trials need to be conducted on this topic. The proposed mechanisms underlying the link between physical exercise and self-injurious behavior also need to be systematically assessed. Lastly, this review made important contributions to the existing literature by presenting analysis of current findings and identifying major gaps in the research area assessing association between exercise and self-injurious behavior.

References

  1. Rockett IR, Caine ED. Self-injury is the eighth leading cause of death in the United States: it is time to pay attention. JAMA Psychiatry. 2015;72(11):1069–1070. doi:10.1001/jamapsychiatry.2015.1418 [CrossRef] PMID:26374953
  2. Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095–2128. doi:10.1016/S0140-6736(12)61728-0 [CrossRef] PMID:23245604
  3. Kerr PL, Muehlenkamp JJ, Turner JM. Nonsuicidal self-injury: a review of current research for family medicine and primary care physicians. J Am Board Fam Med. 2010;23(2):240–259. doi:10.3122/jabfm.2010.02.090110 [CrossRef] PMID:20207935
  4. Klonsky ED. Non-suicidal self-injury: an introduction. J Clin Psychol. 2007;63(11):1039–1043. doi:10.1002/jclp.20411 [CrossRef] PMID:17932979
  5. Vanderhoff HA, Lynn SJ. The assessment of self-mutilation. J Threat Assess. 2001;1(1):91–109. doi:10.1300/J177v01n01_07 [CrossRef]
  6. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007;27(2):226–239. doi:10.1016/j.cpr.2006.08.002 [CrossRef] PMID:17014942
  7. Runeson B, Haglund A, Lichtenstein P, Tidemalm D. Suicide risk after nonfatal self-harm: a national cohort study, 2000–2008. J Clin Psychiatry. 2016;77(2):240–246. doi:10.4088/JCP.14m09453 [CrossRef] PMID:26301588
  8. Lubans D, Richards J, Hillman C, et al. Physical activity for cognitive and mental health in youth: a systematic review of mechanisms. Pediatrics. 2016;138(3):e20161642. doi:10.1542/peds.2016-1642 [CrossRef] PMID:27542849
  9. Atkinson K, Lowe S, Moore S. Human development, occupational structure and physical inactivity among 47 low and middle income countries. Prev Med Rep. 2015;3:40–45. doi:10.1016/j.pmedr.2015.11.009 [CrossRef] PMID:26844185
  10. Rebar AL, Stanton R, Geard D, Short C, Duncan MJ, Vandelanotte C. A meta-analysis of the effect of physical activity on depression and anxiety in non-clinical adult populations. Health Psychol Rev. 2015;9(3):366–378. doi:10.1080/17437199.2015.1022901 [CrossRef] PMID:25739893
  11. Hawton K, Kingsbury S, Steinhardt K, James A, Fagg J. Repetition of deliberate self-harm by adolescents: the role of psychological factors. J Adolesc. 1999;22(3):369–378. doi:10.1006/jado.1999.0228 [CrossRef] PMID:10462427
  12. Nitkowski D, Petermann F. [Non-suicidal self-injury and comorbid mental disorders: a review]. Fortschr Neurol Psychiatr. 2011;79(1):9–20. doi:10.1055/s-0029-1245772 [CrossRef] PMID:21104583
  13. O'Neal HA, Dunn AL, Martinsen EW. Depression and exercise. Int J Sport Psychol. 2000; 31(2):110–135.
  14. Paluska SA, Schwenk TL. Physical activity and mental health: current concepts. Sports Med. 2000;29(3):167–180. doi:10.2165/00007256-200029030-00003 [CrossRef] PMID:10739267
  15. Raglin JS. Exercise and mental health. Beneficial and detrimental effects. Sports Med. 1990;9(6):323–329. doi:10.2165/00007256-199009060-00001 [CrossRef] PMID:2192422
  16. Muehlenkamp JJ. Self-injurious behavior as a separate clinical syndrome. Am J Orthopsychiatry. 2005;75(2):324–333. doi:10.1037/0002-9432.75.2.324 [CrossRef] PMID:15839768
  17. Tate RL, McDonald S, Perdices M, Togher L, Schultz R, Savage S. Rating the methodological quality of single-subject designs and n-of-1 trials: introducing the Single-Case Experimental Design (SCED) Scale. Neuropsychol Rehabil. 2008;18(4):385–401. doi:10.1080/09602010802009201 [CrossRef] PMID:18576270
  18. Wendt O, Miller B. Quality appraisal of single-subject experimental designs: an overview and comparison of different appraisal tools. Educ Treat Child. 2012;35(2):235–268. doi:10.1353/etc.2012.0010 [CrossRef]
  19. Herzog R, Álvarez-Pasquin MJ, Díaz C, Del Barrio JL, Estrada JM, Gil Á. Are healthcare workers' intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review. BMC Public Health. 2013;13(1):154. doi:10.1186/1471-2458-13-154 [CrossRef] PMID:23421987
  20. Wells GA, Shea B, O'Connell D, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed March 2, 2020.
  21. Critical Appraisal Skills Programme. CASP checklist: 10 questions to help you make sense of qualitative research. https://casp-uk.net/wp-content/uploads/2018/03/CASP-Qualitative-Checklist-2018_fillable_form.pdf. Accessed March 2, 2020.
  22. Boone SD, Brausch AM. Physical activity, exercise motivations, depression, and nonsuicidal self-injury in youth. Suicide Life Threat Behav. 2016;46(5):625–633. doi:10.1111/sltb.12240 [CrossRef] PMID:26970091
  23. Jarvi SM, Hearon BA, Batejan KL, Gironde S, Björgvinsson T. Relations between past-week physical activity and recent nonsuicidal self-injury in treatment-seeking psychiatric adults. J Clin Psychol. 2017;73(4):479–488. doi:10.1002/jclp.22342 [CrossRef] PMID:27391124
  24. Klonsky ED, Glenn CR. Resisting urges to self-injure. Behav Cogn Psychother. 2008;36(2):211–220. doi:10.1017/S1352465808004128 [CrossRef] PMID:29527120
  25. Baumeister AA, MacLean WE Jr, . Deceleration of self-injurious and stereotypic responding by exercise. Appl Res Ment Retard. 1984;5(3):385–393. doi:10.1016/S0270-3092(84)80059-4 [CrossRef] PMID:6517577
  26. Wallenstein MB, Nock MK. Physical exercise as a treatment for non-suicidal self-injury: evidence from a single-case study. Am J Psychiatry. 2007;164(2):350–351. doi:10.1176/ajp.2007.164.2.350a [CrossRef] PMID:17267807
  27. Klonsky ED, Olino TM. Identifying clinically distinct subgroups of self-injurers among young adults: a latent class analysis. J Consult Clin Psychol. 2008;76(1):22–27. doi:10.1037/0022-006X.76.1.22 [CrossRef] PMID:18229979
  28. Godin G, Shephard RJ. A simple method to assess exercise behavior in the community. Can J Appl Sport Sci. 1985;10(3):141–146. PMID:4053261
  29. Hagströmer M, Oja P, Sjöström M. The International Physical Activity Questionnaire (IPAQ): a study of concurrent and construct validity. Public Health Nutr. 2006;9(6):755–762. doi:10.1079/PHN2005898 [CrossRef] PMID:16925881
  30. Katsura Y, Yoshikawa T, Ueda SY, et al. Effects of aquatic exercise training using water-resistance equipment in elderly. Eur J Appl Physiol. 2010;108(5):957–964. doi:10.1007/s00421-009-1306-0 [CrossRef] PMID:19960351

Quality Assessment of Time Series Interventional Studies Based on the Single-Case Experimental Design

Appraisal Item Study
Baumeister et al.25 Wallenstein and Nock26
Clinical history was specified. Must include age, sex, etiology, and severity Yes Yes

Target behaviors. Precise and repeatable measures that are operationally defined; specify measure of target behavior Yes No

Design 1: three phases. Study must be either A-B-A or multiple baseline Yes Yes

Design 2: baseline (pretreatment phase). Sufficient sampling was conducted Yes Yes

Design 3: treatment phase. Sufficient sampling was conducted Yes Yes

Design 4: data record. Raw data points were reported Yes No

Observer bias: Inter-rater reliability was established for at least one measure of target behavior Yes No

Independence of assessors Yes No

Statistical analysis No Yes

Replication: either across participants, therapists, or settings Yes Yes

Evidence for generalization No No

Total score 9 6

Overall quality rating Good Fair

Quality Assessment of the Cross-Sectional Studies Based on The Newcastle-Ottawa Scale

Study Selection of the Groups Comparability of the Groups Outcome of Interest Quality Score Out of 10 Quality Rating
Sample Representation Sample Size Nonrespondents Ascertainment of the Exposure Confounding Factors are Controlled Assessment of the Outcome Statistical Test
Boone and Brausch22 * * * * * * * 7 Good

Jarvi et al.23 * * * * * * * 8 Good

Quality Assessment of the Qualitative Study Using the Critical Appraisal Skills Programme Checklist for Qualitative Studies

Study Checklist Number from the CASP Quality Score Out of 10 Quality Rating
1 2 3 4 5 6 7 8 9 10
Aim Clearly Stated Qualitative Approach Appropriateness Study Design Suitability Appropriate Recruitment Strategy Data Collection Adequacy Relationship Between Researcher and Participants Potential Ethical Adequacy Data Analysis Sufficiency Findings Clearly Stated Scientific Value of Research
Klonsky and Glenn24 * * * * * - * * * * 9 Very good

Evidence Describing Characteristics that Assessed Effect of Exercise on Self-Injurious Behavior

Study Sample Design PA Measures SIB Measures Analysis Results/Findings
Wallenstein and Nock26 A 26-year-old overweight woman with 13-year history of NSSI Intervention study with time series design A self-structured exercise program (60- minute workout video 3 times per week for 5 weeks and exercised in response to self-injury urges at any time SIB was recorded by researcher during baseline and follow-up. During the intervention, participant completed the assessment form concerning mood and self-injurious urges (both on 0–9 scales) and behaviors Mean and standard deviation SIB was decreased to 0.37 times per week during the intervention period Frequency of SIB was significantly lower during experimental phase (M = 0.29, SD = 0.49) in comparison with nonexperimental phases ([M = 2.20, SD = 0.45] t = 6.93, df = 10, P < 0.001). Moreover, analysis of mood ratings showed an increase from before exercise (M = 2.23, SD = 0.86) to after (M = 4.77, SD = 1.48) exercise (t = 7.56, df = 50, P < 0.001). When the participant exercised in direct response to self-injurious thoughts, exercise acutely reduced her urge to self-injure, from before (M = 3.00, SD = 1.87) to after (M = 0.15, SD = 0.38) exercise in every single instance (t = 5.38, df = 24, P < 0.001)
Baumeister and MacLean25 Two developmentally disabled males characterized by SIB (age 23 and 19 years) Time series observational design 6-week jogging in-tervention First 2 weeks: (1 hour jogging to 1 mile distance) 2nd and 3rd weeks: 2 and 3 miles, respectively. SIB was recorded by three observers in 30-second intervals during baseline and experimental phases Percentage of SIB in terms of 30-second observation interval SIB decreased in both participants over the course of the intervention period
Boone and Brausch22 167 high school and undergraduate students (Mean age = 17.37 years, range of 14–25 years) Cross-sectional design <list-item>

Exercise Questionnaire

</list-item><list-item>

Exercise Motivations Inventory-2

</list-item>
Inventory of statements about self-injury Linear regression The regression model was significant and explained 5.3% of the variance in NSSI frequency, F (1, 159) = 8.84, P < .01. An increase in frequency of physical activity was related with a decrease in frequency of self-injury (beta = −0.23, P < .01)
Jarvi et al.23 353 treatment-seeking adults age 18 to 72 years Mean age of 35.16 ± 13.6 years Cross-sectional design International Physical Activity Questionnaire Inventory of statements about self-injurybehavioral scale Independent-samples t tests, ANCOVA Significant between-group differences emerged for two of the four categories of physical exercise First, participants with recent NSSI (M = 60.89, SD = 99.11) engaged in significantly less PA than those without a history of NSSI (M = 112.74, SD = 269.08) for total minutes of past-week vigorous PA, t (340.15) = 2.63, P = .01 (mean difference = 51.84, 95% CI = 12.99 to 90.70, Cohen's d = .26) Second, participants with recent NSSI (M = 58.33, SD = 92.17) engaged in significantly less physical activity than those without a history of NSSI (M = 103.82, SD = 283.09) for total minutes of past-week moderate physical activity, t (344.86) = 2.26, P = .03 (mean difference = 45.49, 95% CI = 5.86 to 85.11, Cohen's d = .23)
Klonsky and Glenn24 2,776 undergraduates screened 39 students (30 women, 9 men; mean age 19.4 ± 2.2 years) found positive for SIB and who participated in an interview Retrospective qualitative study Structured interview Self-developed questionnaire Retrospective self-report measure concerning participation in sport and exercise Structured interview Self-developed questionnaire Retrospective self-report measure concerning urge to self-injury Percentages Mean and SD 65.2% of the participants reported participation in sports and exercise programs as a helpful method to cope with urge to self-injury
Authors

Asif Ali, PhD, is an Associate Professor, Department of Physical Education and Sports Sciences, Government College University Lahore. Muhammad Azam, PhD, is an Assistant Professor, Department of Physical Education and Sports Sciences, Government College University Lahore. Jawairiyah Mattiullah, MPhil, is a Doctoral Scholar, Department of Education, The Islamia University of Bahawalpur.

Address correspondence to Asif Ali, PhD, Department of Physical Education and Sports Sciences, Government College University Lahore, 54000, Punjab, Pakistan; email: goraya128@hotmail.com.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20200302-02

Sign up to receive

Journal E-contents