Psychological Aspects of Stair Use: A Systematic Review

Abstract

Stair use, a common lifestyle activity, is a moderate-to-vigorous physical activity that, despite often being brief in duration, may contribute to psychological health. A systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method to summarize psychological aspects related to stair use. Included studies examined at least 1 psychological outcome in relation to either objective measures of stair use, such as time or stair height, or subjective measures of, or measures related to, stair use such as perceived difficulty using stairs. A total of 22 studies met the inclusion criteria; 12 used subjective stair use measures and 10 used objective stair use measures. The limited evidence from studies using self-reports supported that (1) perceived difficulty using stairs was positively associated with increased symptoms of anxiety and depression and (2) stair use was not associated with a reduced incidence of mental illnesses such as depression, suicide, or dementia. Studies using objective measures of stair use supported that (3) elevated symptoms of anxiety and depression are negatively associated with stair use performance. Given the widespread use of stairs, there is surprisingly little data about the extent to which, and for whom, stair use influences psychological health.

‘Ascending stairs is a vigorous-intensity activity, whereas descending stairs is moderate intensity based on mean heart rate and perceived exertion responses to self-chosen, continuous stair use.’

Introduction

Stairs are an element of many homes and buildings. Consequently, stair use—walking up or down stairs—is a common lifestyle physical activity. Regular stair use is a muscle strengthening activity that requires multiple large muscle groups to be activated. Studies that have measured muscle activation using electromyography show that all the major muscle groups of the leg are activated when people walk up as well as down stairs. The pattern of activation is complex and varies as a function of health status and stair height, and whether one is ascending or descending.^1,2 Ascending stairs is a vigorous-intensity activity, whereas descending stairs is moderate intensity based on mean heart rate and perceived exertion responses to self-chosen, continuous stair use. ³

Guidelines and recommendations for health benefits of physical activity historically have promoted moderate-to-vigorous intensity activity in episodes or bouts of at least 10 minutes in part because few studies have documented the consequences of shorter exercise bouts. ⁴ The 2018 National Physical Activity Guidelines suggest that shorter bouts, such as walking up and down stairs for less than 10 minutes, are likely to contribute to improved health. ⁴ To date, interventions to increase stair use typically have occurred in worksites or public spaces, used point-of-decision prompts, ⁵ and used a physical health outcome as the dependent variable of interest. These studies and other experiments have documented multiple physical health benefits associated with stair use, including improvements in cardiorespiratory fitness, ⁶ balance and gait, ⁷ blood pressure, ⁸ adiposity, ⁹ glucose, ¹⁰ and cholesterol. ¹¹

No prior review has summarized the published research exploring relationships between stair use and psychological outcomes. Based on what is known about the psychological consequences of other modes of physical activity, ¹² regular stair use may be associated with better mental health compared with less frequent use of stairs. This article reviews the small body of existing evidence to consider associations between stair use and several psychological outcomes, most of which are related to psychological health. The general expectation among these studies was that greater stair use or ability to use the stairs would be associated with better psychological health.

Methods

Study Search

This review was conducted according to the PRISMA guidelines. ¹³ Peer-reviewed articles published prior to May 31, 2018, were identified by searching PubMed, PsycInfo, and Web of Science databases using the following search combinations: stair or “Paffenbarger Physical Activity Questionnaire” or “Walking Impairment Questionnaire” (both questionnaires ask about stair use) with 12 psychological outcomes—anxiety, depression, cognitive, cognition, dementia, fear of falling, memory, Mini-Mental State Examination, Minnesota Multiphasic Personality Inventory, mood, vitality, and Wechsler Intelligence Scales. Duplicate articles were removed. Two strategies were used to identify articles not found in the database search. First, retained articles’ reference lists were manually searched. Second, curriculum vitae and websites of first and last authors in retained articles were examined for additional publications. Third, those citing included articles were searched and relevant articles retained. Data were extracted independently by the study team and confirmed during the review process.

Study Selection

A flowchart of study selection is provided in Figure 1. To be included, articles were peer reviewed and published in English. Article abstracts were screened for evidence that the study included stair use as a type of physical activity and that a psychological outcome was included. Studies were eliminated for several reasons, including those that did not include a psychological outcome and those that did not include a stair use measure—for example, when STAIR was an acronym for a project, but stair use was not studied. The eligibility criteria were that the study included objective stair activity or subjective perceptions related to stair use ability as the independent variable and a psychological measure as an outcome.

Figure 1.

Illustration of the flow of published studies considered during the review process.

Of the 811 articles found during the database and other search methods, 287 duplicate articles and 474 articles that did not meet the eligibility criteria based on abstract review were excluded. After reviewing the full article text, 28 additional studies were excluded for not meeting the eligibility criteria, resulting in a final sample of 22 publications.

Data Aggregation

Studies were grouped based on objective measurement of stair use, or self-reported stair use, or perceived stair use ability.

Risk of Bias

Risk of bias for experimental or quasi-experimental studies was assessed using the guidelines in the Cochrane Handbook. ¹⁴ For observational studies, the criteria described by Agency for Healthcare Research and Quality were used. ¹⁵ Two study team members independently reviewed each study to appraise risk of bias. Three study team members discussed discrepancies and came to consensus on the ratings. Results were summarized within and across studies. Risk of bias assessments for individual studies are provided in Supplemental Table 1 (randomized controlled trials) and Supplemental Table 2 (all other studies). Across randomized controlled trials (n = 4), there was a high risk of bias because of lack of blinding to allocation (100%), assignment (75%), and outcome (100%). This is largely a result of the experimental condition including exercise that was not provided to the control groups. There was low risk of bias for randomization, missing data, and selective reporting.

Of 18 cross-sectional and longitudinal observation studies, 12 provided measures of effect size (66.7%). None of the included studies provided a priori power or sample size calculations. In general, the study questions, exposure and outcome measures, confounders, and discussion had low risk of bias in these studies (Supplemental Table 2).

Self-reported Measures of Stair Climbing

Self-reported Number of Stairs Walked and Mental Illness

The Paffenbarger Activity Questionnaire has been used in at least 2 studies that examined mental health disorders. The questionnaire includes the question, “How many flights of stairs do you climb up each day?” and defines 1 flight as equal to 10 steps. This question was used in 1 study of male Harvard alumni aged 35 to 74 years in 1962 or 1966, which examined the incident rates of physician-diagnosed depression (among 10 201 alumni) and suicide rates (among 21 569 alumni) in relation to the self-reported number of stairs climbed up. ¹⁶ Stair climbing was unrelated to the 129 suicides and the 387 bouts of depression documented during the 23- to 27-year follow-up. The authors noted that the results need to be judged, in part, in light of the relative infrequency of stair climbing. Only 16% of the man-years of physical activity experienced was contributed by men climbing 8 or more floors each day.

One study of 749 Italians, examined prospective associations between physical activity, as measured by the Paffenbarger questionnaire, and the incidence of both vascular dementia and Alzheimer disease. ¹⁷ Stair climbing was coded as high-intensity physical activity and given a metabolic equivalent of 8 METs. After a mean of 3.9 years of follow-up, there were 86 incident cases (54 Alzheimer disease, 27 dementia). There was no association between Alzheimer disease and total physical activity. There was a significantly lower risk of vascular dementia, independent of socioeconomic, genetic, and medical confounders, in those in the upper tertiles of walking, which is also measured by the Paffenbarger questionnaire, as well as moderate and total physical activity. The association for stair climbing was in the same direction as walking and the other physical activities but not statistically significant. Here, again, a factor in the results being statistically nonsignificant may be the relatively little stair climbing that was done by most of the sample.

Perceived Difficulty Walking Stairs and Symptoms of Anxiety, Depression, Confusion, and Fatigue

Stair ascent requires effort that many will avoid. Observations from shopping malls show that 94% avoid stair use and choose the escalator. ¹⁸ Stair avoidance appears most common among those carrying large bags, women, obese individuals, older adults, and those with mobility limitations. ¹⁹ A large body of research has found that limited mobility and poor physical function are associated with symptoms of poorer mental health.^20,21 Fewer studies have examined relationships between limited ability for stair climbing and mental health symptoms. Most often, this type of limited mobility has been measured by self-reported difficulty walking stairs. The studies can be categorized into those focused on older adults with a specific type of anxiety—the fear of falling while stair walking—and those studies exploring difficulty walking stairs in relation to general symptoms of either anxiety or depression or both. The substantial overlap between nonspecific anxiety and depression symptoms is well known and is thought to have both genetic and environmental underpinnings.^22-24 Thus, anxiety and depression symptoms are often considered in tandem. Elevations in anxiety and depression symptoms also can contribute to fatigue, confusion, and reduced cognitive performance, but relationships between anxiety or depression and fatigue or cognitive variables are typically weaker than associations between anxiety and depression.^25,26

Fear of Falling

Fear of falling and its potential impact on physical activity among older adults, especially those in poor physical health, is well documented.^27,28 Estimates of fall prevalence range widely from 3% to 85% and depend on age, the presence of pain or prior falls, medication use, and health status such as the presence of a hip fracture or balance problem.^29-31 Relatively little information is available about interactions among fear of falling and other psychological factors as they relate to stair use in older adults.

Fear of falling is a greater concern during stair descent compared with stair ascent. Self-reported factors potentially affecting stair use were examined in a survey of 248 adults who were largely white, highly educated, retired, and between the ages of 40 and 92 years. ³² The results showed that feelings of fatigue were a greater factor affecting stair ascent while fear of falling was a greater concern going down stairs. Although this study did not meet the inclusion criteria, the findings are of interest and are illustrated in Figure 2.

Figure 2.

The 4 most prevalent self-reported individual factors affecting stair ascent and descent reported in a sample of 248 community dwelling older adults. Adapted from Gill et al. ³²

Turning to the included studies about fear of falling, 1 study examined fear of falling and symptoms of depression in older adults. In-home interviews of community-dwelling healthy, primarily white women (67% of the sample) and men aged 65 years and older living in the St Louis area (n = 890) were conducted, and data were obtained on self-reported variables potentially associated with fear of falling. ³³ Fear of falling was greater among women and increased with age and frailty. Stepwise logistic regression found that the odds of fear of falling was increased by more than 4-fold (OR = 4.31; 95% CI = 1.95-9.54) among those who reported needing assistance to climb stairs. Need for assistance in using stairs was more strongly related to fear of falling than all but one of the factors independently associated with fear of falling—a prior fall resulting in a fracture. After adjustment for age and gender, being moderately or more fearful of falling was cross-sectionally associated with increased symptoms of depression. This cross-sectional association was observed at a 1-year follow-up, but in the separately published analysis, depression symptoms did not predict the development of greater fear of falling. ³⁴

A third study examined factors related to fear of falling and stair use in a sample of medical patients. A sample of 214 Japanese women who had undergone total hip arthroplasty were asked whether they were, or were not, afraid of falling during 9 activities of daily living. In all, 45% of the sample reported experiencing a fear of falling associated with stair use, and stair walking was the activity most commonly associated with a fear of falling. Multiple regression identified 5 independent predictors of fear of falling, including a measure of hip pain and function, history of falling, walking capacity, age, and elevated scores on the Penn State Worry Questionnaire, a trait measure of generalized pathological worry. ³⁵

One concern among all these investigations was the failure to control for the potential confounding effect of overlapping content between the fear of falling measures and the anxiety and depression measures. This potential concern appears to be a minor issue in the investigations summarized here based on our review of the item content of the questionnaires. Fear of falling was measured using questions that asked about either the severity of fear of falling (ie, very, somewhat, or not fearful)^33,34 or whether the individual experienced fear (or no fear) while completing specific activities of daily living (eg, getting in and out of bed, taking a bath or shower). ³⁵ These questions were quite distinct from the more general content of anxiety-related items on the Geriatric Depression Scale (eg, Do you often get restless and fidgety?) and Penn State Worry questionnaires (eg, I have been a worrier all my life; I worry about projects until they are done) used to assess psychological symptoms.

General Symptoms of Anxiety, Depression, Confusion, and Fatigue

Six cross-sectional studies examined associations between stair use and symptoms of anxiety and depression. These studies focused on perceived difficulty with stair use mobility. Difficulty with mobility among nonstair activities has been associated with symptoms of anxiety and depression.^21,36 The largest study in our review involved interviews of a nationally representative sample of civilian, noninstitutionalized adults in the United States (n = 142 572) using the 1994-1995 National Health Interview Survey—Disability Supplement. ³⁷ Mobility was measured with 3 questions, including whether the individual had “any difficulty walking up 10 steps without resting.” The percentage of people reporting being frequently depressed or anxious or frequently confused, disoriented, or forgetful was positively related to the level of mobility difficulty as illustrated in Figure 3. Mobility problems also were more likely among those who were older, obese, poorly educated, impoverished, African American, women, or those living alone.

Figure 3.

The percentage of 142 572 US adults reporting frequent feelings of anxiety/depression or confusion/disorientation/forgetfulness in relation to the level of mobility difficulty measured in part by difficulty in walking up 10 steps without resting. ³⁷

Associations between self-reported difficulty walking stairs and symptoms of anxiety and depression have been examined in a study of Kurdish (n = 512; mean age = 35 years), Russian (n = 467; mean age = 39 years), and Somali (n = 378; mean age = 34 years) migrants to Finland. ³⁸ As part of an interview, participants were asked, “Can you walk 0.5 km without resting?” and “Can you climb up several flights of stairs without resting?” Those reporting any difficulties in walking 0.5 km or stair climbing were considered to have mobility limitation. Anxiety and depression symptoms were measured from the Hopkins Symptom Checklist-25, and standardized cutoff scores were used to classify participants as having, or not having, severe symptoms of anxiety or depression. After adjustment for sociodemographic factors, obesity, and chronic diseases, the presence of anxiety symptoms was unrelated to mobility problems in Kurdish men and positively associated with mobility limitations in Kurdish (OR = 2.67; 95% CI = 1.41-5.04), Russian (OR = 2.98; 95% CI = 1.28-6.94), and Somali (OR = 6.41; 95% CI = 6.15-57.61) women. Analyses were not conducted with Russian or Somali men because of the small number of participants.

Relationships between depression symptoms and stair walking difficulty also were examined in a sample of 368 men and women (60% were women) aged 59 to 91 years living in Londrina, Brazil. The participants were surveyed in 2012 and asked, “Do you have difficulty walking on stairs?” ³⁹ Data were obtained on other variables potentially related to stair negotiation ability, including hand grip strength, lean body mass, and several comorbid medical conditions, including chronic obstructive pulmonary disease, depression, heart failure, and chronic lower-limb pain. Multivariate logistic regression found that for men, obesity (OR = 3.73; 95% CI = 1.24-11.29) and lower-limb pain (OR = 5.10; 95% CI = 1.96-13.29) were independently associated with stair negotiation difficulty, but the presence of comorbid depression did not reach statistical significance (OR = 4.02; 95% CI = 0.77-21.13; P = .09). Among the women, obesity (OR = 2.53; 95% CI = 1.26-5.10) and lower-limb pain (OR = 2.56; 95% CI = 1.36-4.83) also were independently associated with stair negotiation difficulty. In addition to these 2 variables, low muscle strength (OR = 2.99; 95% CI = 0.43-4.62) and elevated symptoms of depression (OR = 2.78; 95% CI = 1.10-4.70) were independently associated with stair negotiation difficulty for the women. The smaller sample size for the men and the lower rate of depression in the sample of men (4%) compared with women (17%) potentially explains the fact that the depression variable was not statistically significant for the men.

Depression symptoms associated with stair use potentially could differ between walking up stairs compared with walking down stairs. A sample of 310 healthy older adults without disability or dementia and living in Bronx County, NY, were asked 2 yes or no questions: “Do you have any difficulty climbing up stairs?” and “Do you have any difficulty climbing down stairs?” ⁴⁰ The entire sample, on average, had few symptoms of depression. Depression symptom scores were similarly higher for those who reported difficulty going up stairs as well as for those who reported difficulty going down stairs. The size of the effect was small for both the descending and ascending stair variables, with about 1 more symptom of depression among those with difficulty negotiating stairs.

Medical patients often have reduced mobility and increased symptoms of psychological distress, but such relationships for stair activity have rarely been examined. Lower levels of muscle strength, coordination, and balance are common in patients after experiencing a stroke, as is psychological distress, including increased symptoms of anxiety and depression.^41,42 One study was conducted with 75 stroke patients who could not negotiate stairs independently when admitted to the hospital. ⁴³ By the time of discharge, 33% of patients were able to negotiate stairs on their own. Those able to independently climb stairs were younger and had fewer perceptual impairments compared with those unable to climb stairs by themselves, but these 2 groups did not differ significantly in depression symptoms.

At least 1 cross-sectional study has been conducted with middle-aged, primarily Dutch, female and male office employees (n = 412). ⁴⁴ A single item assessed the frequency of daytime stair use on a continuous scale, and associations were examined with scores on a questionnaire designed to measure the need for psychological recovery from work. The items of this scale concern primarily perceptions of fatigue. The frequency of daytime stair use was significantly and negatively associated with the need for recovery after work, even after adjusting for several sociodemographic and work-related confounders (adjusted β = −1.78; P < .01).

Effects of Training

At least 1 experiment has examined the influence of exercise training on perceived stair walking difficulty, and it was conducted in a sample of patients with peripheral artery disease (PAD). PAD causes leg pain during exercise and can decrease quality of life (QOL), but little is known about the effects of stair climbing on QOL among patients with PAD. One randomized trial compared usual care (n = 14) with the effects of participation in a 12-week supervised exercise program (n = 17) in patients with PAD. ⁴⁵ The exercise program was 1 hour twice weekly and involved performing multiple exercise modalities, including a stair stepping machine. Participants were encouraged to exercise at 70% to 80% of their maximum heart rate for 30 to 40 minutes each session. Generic health-related QOL, measured by the 36-item Short Form survey (SF-36), which included symptoms of vitality and mental well-being, was unchanged. QOL specific to PAD was improved. The exercise group reported small, statistically significant improvements in perceived stair walking difficulty immediately and 1-year after the intervention, whereas the control group reported that stair walking was perceived to be more difficult at both time points. Also, exercise-induced improvements in the degree to which leg pain limited daily activities were reported compared with controls. This small trial suggests that an intervention that includes stair climbing can reduce perceived stair climbing difficulty and the degree to which leg pain is perceived to interfere with daily activities.

Selected characteristics of studies mentioned in the sections “Self-reported Measures of Stair Climbing” and “Objective Measures While Stair Climbing” are summarized in Table 1.

Table 1.

Selected Characteristics of Included Studies. ^a

Reference	Country	Year	Measure of Stair Use	Psychological Measure	Study Design	Sample Size	Associations	Age	Illness Focus
Studies with subjective stair use or related measure
16	United States	1994	Number of stair flights per day	Diagnosed depression, suicide	Prospective, 23-27 years	10 201; 21 569	0; 0	35-74 Years	Depression, suicide
17	Italy	2008	Number of stair flights per day	Alzheimer disease, vascular dementia	Prospective	749	0; 0	≥65 Years	Dementia
33; 34	United States	1994	Difficulty walking stairs	Fear of falling; depression symptoms	Cross-sectional; Prospective 1-year	890; 890	+; 0	≥65 Years	None
35	Japan	2014	Difficulty walking stairs	Fear of falling	Cross-sectional	214	+	64 ± 9 Years	Total hip arthroplasty
37	United States	2001	Difficulty walking stairs	Anxiety/Depression; confusion/forgetful	Cross-sectional	142; 572	+; +	≥18 Years	None
38	Finland	2015	Difficulty walking stairs	Anxiety/Depression	Cross-sectional	1357	0 In men; + in women	18-64 Years	None
39	Brazil	2017	Difficulty walking stairs	Depression symptoms	Cross-sectional	368	0 In men; + in women	≥56 Years	None
40	United States	2008	Difficulty walking stairs	Depression symptoms	Cross-sectional	310	+ Going up stairs; + down stairs	≥70 Years	None
43	Canada	1991	Difficulty walking stairs	Depression	Prospective	75	0	Older adults	Stroke patients
44	Netherlands	2015	Day stair use frequency	Perceived fatigue	Cross-sectional	412	+	41 ± 10 years	None
45	Ireland	2013	Difficulty walking stairs	Vitality/Fatigue; mental well-being	Experimental 12-week; experimental 1-year	31	0; 0	67 ± 8	Peripheral artery disease
Studies with objective measures of stair use
3	United States	2017	10-Minute stair walk	Feelings of energy	Experimental	18	+	21 ± 1 Years	None
46	United States	2010	Stair walk time	Depression symptoms	Cross-sectional; prospective 7-year	377; 377	+; +	50 ± 5 Years	None
47	Thailand	2014	Stair ascend time; stair descend time	Depression/Anxiety	Cross-sectional	45; 45	+ Ascend; + descend	40-80 Years	Stroke
48	United States	2015	Stair walk time	Anxiety/Depression	Cross-sectional	72	+	24-85 Years	Maintenance hemodialysis
49	Canada	2005	Stair walk time	Anxiety; depression; self-efficacy	Cross-sectional	54	0 Anxiety; + depression; + self-efficacy	68 ± 9 Years	Knee osteoarthritis
51	Belgium	2012	Stair walk time	Kinesiophobia; Fatigue catastrophizing	Experimental	21	+; +	45 ± 11 Years	Chronic fatigue syndrome
52	Belgium	2013	Stair walk time	Kinesiophobia; Fatigue catastrophizing; anticipated fatigue	Cross-sectional	49	0; 0; +	39 ± 10 Years	Chronic fatigue syndrome
53	Denmark	2009	Stair walk time	Vitality/Fatigue; mental well-being; quality of life	Experimental	42	0; 0; 0	39 ± 12 Years	Blood cancer
54	Finland	1994	Stair height	Depression	Cross-sectional	205	0	80-Year-olds	None
55	Sweden	2013	Stair height	Vitality/Fatigue; role emotional; mental health	Cross-sectional	637	+; +; +	75-Year-olds	None

^a“+” Refers to a positive association between stair use and mental health outcome; 0 = no association; “−” indicates an inverse association.

Objective Measures While Stair Climbing

A small body of research has examined relationships between psychological outcomes and objective measures of stair use, such as the number of stairs traversed in a standardized time or the time required to complete a prescribed stair task. The psychological outcomes have included indicators of life quality, but the most common measures have been symptoms of anxiety, depression, and fatigue.

Time to Complete Stair Use Tasks

A longitudinal study of women (n = 377, 54.5% African American) in Michigan examined depression symptoms annually for 10 years (4 years prior to the stair use test and 6 years afterward). ⁴⁶ Stair use ability was tested as the time, in seconds, to ascend and descend 3 stairs. Stair ascension and descension, on average, took 1.4 s longer in participants with elevated depressive symptoms in the cross-sectional comparison at the time of the stair climb test (P < .05). In a longitudinal mixed-effects linear regression analysis, participants whose depressive symptoms increased with age had slower stair use speeds (regression coefficient = 0.0003; standard error = 0.0007; P < .0001).

A cross-sectional study was conducted among 45 Thai adults (75.6% male) who were 40 to 80 years of age and who had been diagnosed with a stroke within the prior year. ⁴⁷ In a cross-sectional analysis, participants completed a timed stair task on four 18-cm steps at a comfortable pace, with an average of 2 trials taken. Participants were classified as either normal or having mild or worse symptoms of depression/anxiety/stress (n = 25 with symptoms, n = 20 without). Independent samples t-tests compared the 2 groups on stair use speed. Participants with lower depression/anxiety/stress scores were able to ascend (mean difference = 0.19 s; P = .011) and descend (mean difference = 0.21 s; P = .016) faster than participants with higher scores.

Objective stair walking speed has been examined in relation to anxiety and depression in several other patient groups. A total of 72 maintenance hemodialysis patients completed a test of stair use speed and both the Beck Anxiety and Beck Depression Inventories. ⁴⁸ The subset of patients who were above cutoffs suggestive of clinically meaningful anxiety and depression on average were 4.5 s slower per 22 stairs during the test compared with those with unelevated scores on the anxiety and depression scales. In a cross-sectional study of osteoarthritis patients (59.3% women, 48.1% with bilateral osteoarthritis), 54 participants were asked to ascend 5 steps, turn around, and descend 5 steps as quickly and safely as they could. ⁴⁹ They completed self-report measures of depression, anxiety, and 4 types of self-efficacy related to arthritis, pain, function, and other. The other self-efficacy included items on fatigue, frustration, and general activity. Pearson correlation coefficients indicated that as stair use time increased, depression symptoms tended to be higher (r = 0.37, P < .001) and self-efficacy was generally lower (r = −0.68 for functional self-efficacy; r = −0.38 for other self-efficacy; both P < .001). Functional self-efficacy explained 45.7% of the variance in stair climbing time, but there were no significant associations with the other self-efficacy measures or symptoms of anxiety or depression.

Some patients with chronic fatigue syndrome (CFS) can report severe postexertional malaise even after modest exercise ⁵⁰ and, therefore, could be psychologically threatened by stair use activity. Accordingly, researchers have assessed relationships between stair use performance and measures of both anxiety and fatigue; specifically, kinesiophobia, catastrophizing about fatigue and anticipated fatigue prior to stair climbing. One study of 49 CFS patients found strong associations between the time it took to climb 2 floors of stairs and return to the starting point and both kinesiophobia (r = 0.62) and fatigue catastrophizing (r = 0.67). ⁵¹ A subsequent study of 21 CFS patients by the same research team found that slower stair use performance (on the same task) was not significantly related to kinesiophobia or fatigue catastrophizing but was associated with anticipated fatigue (r = 0.40). ⁵²

The effect of exercise training was examined in 1 small randomized controlled trial in adults undergoing allogeneic hematopoietic cell transplantation. ⁵³ A usual care control (n = 21) was compared with a multidimensional intervention involving education (daily), relaxation (twice per week), and exercise, including cycling (5 d/wk), strengthening (3 d/wk), and flexibility (5 d/wk; n = 21). The in-hospital exercise program was successful in attenuating the treatment-caused reduction in the number of steps covered in a 2-minute stair test (a mean of 86 fewer steps at the posttest for usual care compared with 25 fewer for the exercise group). However, there were no statistically significant effects of the intervention on the cancer-related QOL or psychological well-being measures. This experiment shows that an exercise intervention that excludes stair use can induce improvements in stair use. The findings also imply that such effects can occur independently of improvements in QOL and psychological health.

Manipulations of the Height of a Single Stair

The association between ability to ascend stairs and depressive symptoms was assessed in a study of 80-year old Finnish adults. ⁵⁴ Participants (n = 205; 70.7% women) completed the Center for Epidemiological Studies Depression Scale and a progressive test of stair climbing, where the stair height began at 10 cm and was increased at 10-cm intervals up to 50 cm. Men performed better than women on the stair test, but more women perceived that they had the ability to negotiate stairs when asked via self-report about their physical activities of daily living (P = .017). Pearson correlation coefficients of the stair height test with depression symptoms yielded small, nonsignificant negative correlations between stair performance and depressive symptoms for both men (r = −0.16) and women (r = −0.14).

In a similar assessment of stair climbing using increasing stair heights, 75-year old Swedish adults (n = 637) completed cross-sectional assessments on a stair test and health-related QOL (vitality, social function, role emotional, and mental health scales measured by the SF-36). ⁵⁵ More men (72.0%) than women (24.7%) were able to climb the 50-cm stair height (P < .001). Stair climbing capacity was significantly associated with several subscales of the SF-36, including symptoms of vitality (r = 0.31) and mental health (r = 0.24). These small to moderate correlations between the stair test and perceptions of energy and mental well-being were similar in magnitude for men and women.

Number of Stairs Traversed During a Standardized Time

In younger adults, stair walking can increase feelings of energy based on 1 repeated-measures cross-over experiment conducted with college women caffeine-users with chronic insufficient sleep. ³ The experiment compared 10 minutes of self-paced stair use preceded by 20 minutes of seated rest to 50 mg of caffeine and a control condition of 30 minutes of seated rest. Participants traversed (up and down combined) an average of 988 stairs at a moderate-intensity heart rate (which averaged 62% of heart rate reserve), which overall was perceived as low-intensity exercise using Borg’s 6 to 20 exertion scale (mean of 11.4). A large increase in feelings of energy was reported immediately after exercise but returned to baseline when measured 20 and 40 minutes later. This transient, immediate postexercise increase in feelings of energy after stair use significantly exceeded the feelings of energy 20 minutes after consuming 50 mg of caffeine, though the energizing effects of caffeine gradually increased with the passage of time, whereas the effects of stair activity decreased. These findings need to be independently replicated before firm conclusions are drawn about the influence of stair walking on feelings of energy; however, a single bout of other types of exercise consistently and transiently improves postexercise feelings of energy. ⁵⁶

Discussion

Self-reported Stair Use and Mental Illness

There is limited evidence addressing the strength of relationships between stair use and mental health disorders. One prospective study reported nonsignificant relationships between self-reported stair walking and the development of either depression or suicide. ¹⁶ A separate prospective study showed no association between stair walking and the development of Alzheimer disease or vascular dementia. ¹⁷ Additional randomized controlled trials and larger prospective studies are needed to extend and confirm these observations, which may be biased, in part, by the limitations of self-reported stair walking, ⁵⁷ and extend what is known to include other mental health disorders such as anxiety disorders.

Fear of Falling

Fear of falling, especially when descending stairs, is common as people age and their physical function declines. Fear of falling is an important psychological factor that needs to be better understood because it is positively associated with an increased fall risk. One cross-sectional study supports the logical idea that the fear of falling is likely to be more common, intense, or bothersome among those predisposed toward general or pathological worrying and that this relationship is independent of walking capacity. ³⁵ A different cross-sectional study found that symptoms of depression were positively related to fear of falling. ³⁴ Evidence from larger prospective studies and randomized controlled trials are needed before a meaningful conclusion can be drawn about the psychological concomitants and comorbidities regarding the fear of falling down stairs. If these investigations are to yield clear results, care will need to be taken to minimize the degree to which items on measures of fear of falling overlap with items assessing psychological symptoms of anxiety and depression.

Symptoms of Anxiety and Depression

The weight of the available evidence supports an association between increased symptoms of anxiety and depression and perceived difficulty walking up stairs. Importantly, the evidence includes 1 large nationally representative sample of adults in the United States as well as samples from several other countries, including Brazilians and Kurdish, Russian, and Somali migrants to Finland.^37,38 The US study showed a dose-dependent association between anxiety/depression symptoms and the degree of perceived difficulty walking up stairs. Also, potentially notable was that the association between psychological symptoms and perceived stair use difficulty was more often statistically significant in samples of women. The available data also imply that decreases in perceived stair use difficulty that should result from increased stair use could contribute to reductions in symptoms of anxiety and depression, perhaps especially for women. A caveat is that not all the cross-sectional studies were consistent with this possibility, though null effects were found only in the 2 smallest studies. This question of whether increased stair use per se has beneficial psychological consequences has never been addressed adequately based on evidence from large randomized controlled trials designed specifically to test this idea. Only 1 small 12-week randomized trial, which used a multimodal exercise intervention that included stair stepping exercise, found that exercise training improved perceived stair walking difficulty in patients with PAD and reduced the degree to which leg pain interfered with their daily activity. ⁴⁵ Four studies found a significant positive association between perceived difficulty negotiating stairs with worse mental health outcomes.^37-40 Two of those studies found statistically significant correlations in women, but not men.^38,39 A limitation mentioned in more than 1 study was the smaller sample size in men, which potentially limited the statistical power to find a significant association.^38,39 In the 2 largest studies, stair use data were combined with, and therefore potentially confounded by, data from questions about other types of physical activity such as walking.^37,38

Objective Measures of Stair Negotiation Time

Evidence from 4 cross-sectional studies supports that both subsamples of community-dwelling adults and medical patients who reported elevated symptoms of anxiety and/or depression took longer to complete a stair task versus subsamples with less severe symptomology.^46-49 A causal link was not supported by the only training study we are aware of, which failed to show improvements in psychological outcomes following an exercise intervention that improved performance in a 2-minute stair task. ⁵³ However, the intervention, conducted with cancer patients, was small and included other components that can influence psychological symptoms (ie, education, relaxation). Two small studies of patients with CFS found relationships between stair use time and kinesiophobia, fatigue catastrophizing, and anticipated fatigue.^51,52 Independent replication of these findings with CFS patients is needed before broader conclusions can be drawn.

Experiments Involving Manipulations of the Height of a Single Stair

In both studies of stair height, there was a trend toward better mental health with ability to climb greater stair heights among older adults (75 and 80 years). Causality could not be inferred because both studies were cross-sectional. Furthermore, there were no differences in the association between stair height and mental well-being between men and women. In the Finnish study, women perceived greater ability to negotiate stairs, but that did not correspond to lower depressive symptom scores on the Centers for Epidemiological Studies—Depression Scale. ⁵⁴ These observations need to be independently replicated and extended to broader groups to better understand the potential validity of using tests that manipulate stair height as a marker for future changes in mental health.

Acute Response to Stair Use of a Specified Duration

One experiment found that 10 minutes of self-paced stair use among young adult sleep-deprived women transiently increased their feelings of energy. This observation is consistent with other investigations showing that the interruption of 6 hours of sitting with hourly bouts of 5 minutes of moderate-intensity level treadmill walking contributes to greater feelings of energy. ⁵⁸ More research is needed to examine potential moderators of this effect, such as age, health, and baseline level of energy.

Conclusions and Limitations

Surprisingly, this review found only a small body of research that has examined relationships between psychological health and stair use. The weight of the evidence from studies using self-report supports that perceived difficulty using stairs is usually linked to greater depression and anxiety symptoms, and 2 studies suggest that the effect may be strongest among women. The evidence did not show that greater self-reported stair use was related to a reduced incidence of depression, suicide, or dementia. With regard to the studies that used objective measures of stair use, the weight of the evidence supports that elevated symptoms of anxiety and depression were usually associated with worse performance on stair use tasks.

The paucity of studies, diversity of approaches, and study limitations temper the breadth and strength of the conclusions. First, the majority of the studies were cross-sectional, and therefore, causation cannot be inferred. Second, all the studies reviewed involved brief bouts of stair use (from a single stair step up to 10 minutes of stair climbing). The psychological consequences of brief bouts of physical activity are poorly understood, and most of the evidence stems from studies involving at least 20 minutes of physical activity.^57,59,60 Third, a number of included studies had small sample sizes, particularly when data were stratified by gender or disease condition.^3,39,40,45 Fourth, about half of the samples involved older adults or individuals with a disease that limited their ability to navigate stairs; thus, it is unknown if these associations generalized to healthy or younger adults. Fifth, an unmeasured variable could contribute to false conclusions; for example, ill-health could be contributing to anxiety/depression symptoms as well as perceived difficulty using stairs or poor stair performance. Finally, there are several different methods to measure stair use. This variability in measurement may limit an assessment of effects on psychological outcomes, especially self-reported measures that combined stair use questions with other related types of physical activity, such as was done in the largest of the studies reviewed. ³⁷

Stair walking, as a physical activity modality, may be a low-cost strategy for increasing physical activity levels especially in more urban areas where multifloor buildings are prevalent. Given the importance of lifestyle physical activity to health, there is an urgent need for research that would give greater insight into both the effects of stair use on psychological health and the psychological variables that contribute to stair avoidance and stair use.