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UPDATED SYSTEMATIC REVIEW
The therapeutic effects of climbing: A systematic review
and meta-analysis
Lucia Gassner BSc, MSc
1,2,3
| Peter Dabnichki PhD
2
| Agnes Langer MD
4
|
Rochus Pokan MD
1
| Heidemarie Zach MD, BSc
4
| Michaela Ludwig PhD
4
|
Agnes Santer MD
4
1
Department of Sport Science, University of
Vienna, Vienna, Austria
2
School of Engineering, RMIT University,
Melbourne, Australia
3
HTA Austria - Austrian Institute for Health
Technology Assessment, Vienna, Austria
4
Department of Neurology, Medical University
of Vienna, Vienna, Austria
Correspondence
Agnes Santer, Department of Neurology,
Medical University of Vienna, Waehringer
Guertel 18-20, 1090 Vienna, Austria.
Email: agnes.santer@meduniwien.ac.at
Funding information
Completion Grant of the University of Vienna;
Hilde-Ulrichs-Foundation for Parkinson
Research, Germany; Marietta Blau grant from
the Federal Ministry of Science and Research,
Austria; Research Grant of the City of Vienna,
Austria; RMIT University Research
International Tuition Fee Scholarship,
Australia
Abstract
Objective: Several recent studies show a growing popularity of therapeutic
climbing (TC) for patients with various conditions. This could be an attempt to fill
the gap left by traditional exercises that do not always address physical, mental,
and social well-being. This review provides an overview of the physical, mental,
and social effects and safety aspects of climbing for different indications.
Literature Survey: A literature search was conducted on July 8, 2020 (update
search August 26, 2021). We searched MEDLINE via Ovid, Embase, and PubMed
and bibliographies of included studies, and we conducted a manual search.
Methodology: Two independent reviewers evaluated the quality of the studies
using appropriate Risk of Bias (RoB) tools, and the level of evidence for each
domain was graded. Study characteristics and effectiveness data for TC were
extracted and synthesized. Meta-analyses were conducted for the three dimen-
sions (physical/mental/social health), using a random-effects model.
Synthesis: A total of 112 publications were reviewed, and 22 full-text articles
were assessed regarding the eligibility criteria, of which 18 trials involving
568 patients were included. TC is safe and positively affects physical
(e.g., fitness, motor control, movement velocity, dexterity, strength), mental
(e.g., depressiveness, somatisation, psychoticism, emotion regulation, body
perception, self-esteem, fatigue), and social (e.g., social functioning, trust, com-
munication, sense of responsibility) health for individuals with neurological,
orthopedic, psychiatric, and pediatric ailments. The meta-analysis showed a
statistically significant improvement in the physical dimension favoring the
climbing group. Improvements that were not statistically significant were found
for the mental/social dimensions in the climbing group. The heterogeneity of
data was moderate/high (social/mental dimension), and for the physical dimen-
sion, data were homogenous.
Conclusions: The studies investigating TC outline its positive effects in vari-
ous patient groups. TC is a safe and effective treatment for improving physical/
mental/social well-being. This review is based on the best available evidence;
however, significant gaps remain in providing sufficiently strong evidence.
INTRODUCTION
Therapeutic climbing (TC), including sport climbing and
bouldering, has become increasingly popular in recent
years
1,2
and is performed as indoor climbing or outdoor
rock climbing.
2
In sport climbing, permanent anchors
are fixed to artificial climbing walls or rocks, affording
higher levels of protection (Figure SA1, panel A).
1
Received: 15 October 2021 Revised: 20 June 2022 Accepted: 29 July 2022
DOI: 10.1002/pmrj.12891
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permi ts use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. PM&R published by Wiley Periodicals LLC on behalf of American Academy of Physical Medicine and Rehabilitation.
PM&R. 2023;1–16. http://www.pmrjournal.org 1
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Bouldering is climbing without a rope or any other
equipment on artificial indoor walls or small rock forma-
tions at a height where climbers can safely jump off on
a crash pad (Figure SA1, panel B).
1
In contrast to recreational sport climbing and boul-
dering, TC is used as therapy in clinical practice to
treat various health problems.
3,4
It offers anaerobic
and aerobic exercise, thereby improving cardiovascu-
lar and muscle endurance.
5
Recent research has
shown multifactorial positive effects of TC on patients
with various health issues and diseases,
6
covering
physical, mental, and social health aspects.
4,6–8
This
whole-body workout significantly affects muscle
strength and endurance, body composition, balance,
flexibility, and gait.
9–11
Furthermore, it is a cognitively
challenging sport, which demands concentration.
4,11
TC requires complex cognitive problem-solving abili-
ties and is directed toward a specific goal. Reaching
this goal (mostly the route’s top) usually elicits feelings
of a successfully mastered difficult task, resulting in
improved self-efficacy, mood, and confidence.
6,11
Sport climbing, in particular, requires at least one part-
ner for belaying. As a result, climbers often train in
groups, facilitating social competence and network-
ing.
11
To summarize, TC may improve and maintain
physical fitness, cognitive and mental strength, as well
as social interactions.
This systematic review and meta-analysis focuses
on the three major dimensions, that is, physical, men-
tal, and social health, which are consistently present
in the literature and aims to produce an evidence-
based evaluation of the effectiveness of TC. We
hypothesize that TC is a safe and effective activity for
neurological, orthopedic, psychiatric, and pediatric
patients.
METHODOLOGY
The Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) statement was used as
a guideline for this review.
12
All tasks were carried out
by two independent researchers (L.G., A.S.). In case of
disagreement, discussion and consensus were fol-
lowed, or an adjudicator (H.Z.) was involved in resolv-
ing the differences.
Literature search
A literature search was conducted on July 8, 2020 (and
an additional update search was conducted on August
26, 2021) using the databases MEDLINE via Ovid,
Embase, and PubMed. The MeSH terms rock climbing,
sports psychology and sport* climb*, effect* were used
(Supplementary Material, Appendixes A and B). In
addition, a manual search was conducted in July 2020.
Eligibility criteria
This review included articles that evaluate the effective-
ness of TC interventions, which met the eligibility cri-
teria according to the PICOS scheme (i.e., Population,
Intervention, Comparison, Outcome, Study design;
Table 1).
13
The selected population for the PICOS
scheme was identified in an ex-ante scoping process
by manual search. Ongoing and unpublished studies
were excluded from the search.
Study selection
Overall, 112 records were identified through database
and manual search. Abstracts were screened; poten-
tially relevant full-text papers were reviewed to check
suitability following the PRISMA diagram (Figure 1).
12
Selected outcomes
The outcomes of interest were the physical (e.g., balance,
physical functioning, muscle strength, pain), mental
(e.g., mood, self-esteem, anxiety, fatigue), and social
(e.g., trust, social functioning, communication, social
competence) effects of TC for neurological, orthope-
dic, psychiatric, and pediatric indications. For safety
TABLE 1 Eligibility criteria (PICOS)
Population Children, adolescents, and adults with
neurological, orthopedic, psychiatric, and
pediatric indications
Intervention Sport climbing, therapeutic climbing, and
bouldering
Control Physical activity, standard exercise therapy,
standard treatment, relaxation sessions,
and no treatment (e.g., waiting list)
Outcomes Physical effectiveness, e.g., balance, physical
functioning, muscle strength, and pain
Mental effectiveness, e.g., mood, self-esteem,
anxiety, and fatigue
Social effectiveness, e.g., trust, social
functioning, communication, and social
competence
Safety aspects, e.g., injuries, adverse events
Study design Controlled clinical trials, randomized controlled
trials, case studies, case series, non-
controlled trials; exclusion: systematic
reviews, meta-analyses, health technology
assessments
Setting Inpatient and outpatient care
Publication period No limitation
Languages No limitation
The PICOS (i.e., Population, Intervention, Comparison, Outcome, Study
design)
13
scheme defines the clinical question: The specific patient problem
aids in finding clinically relevant evidence in the literature.
2THE THERAPEUTIC EFFECTS OF CLIMBING
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aspects, adverse events, that is, injuries requiring
immobilization (e.g., strains, fractures, or sprains)
and/or medical attention, were analyzed. Authors used
the term TC continuously, which presents a general
term for bouldering, sport, rock, and indoor climbing
with patients.
Quality appraisal
The included studies (n =18) were assessed for qual-
ity, internal validity, and Risk of Bias (RoB). The
Cochrane Collaboration’s tool
14
and Risk Of Bias In
Non-randomized Studies of Interventions’
(ROBINS-I)
15
were used for assessing the RoB for ran-
domized controlled trials (RCTs) and controlled clinical
trials (CCTs). Joanna Briggs Institute Critical Appraisal
tools for use in Systematic Reviews
16,17
were employed
to determine the RoB of case reports/series and
non-controlled clinical trials (NCTs) (Tables SA1–SA4).
Furthermore, the level of evidence for each dimension,
that is, physical, psychological, social health, and safety
domain, was graded according to the Oxford Centre for
Evidence-Based Medicine.
18
Data extraction, analysis, and synthesis
Data retrieved from the selected trials (n =18) were
systematically extracted into study characteristics
(Table 2) and data extraction tables (Tables SA5
and SA6) using a single data extraction method with
verification by another reviewer. We extracted all data
in terms of study characteristics (author, year, study
design, number of patients, indication, comparison,
intervention type [group or individual setting], duration
of climbing intervention, RoB; Table 2), and effective-
ness (indication, methods, absolute/relative effects;
Tables SA5 and SA6). A qualitative synthesis of the
evidence was used to descriptively analyze the data.
Meta-analysis
Meta-analyses were performed to strengthen the inter-
pretation of results for the physical, mental, and social
health dimensions. We included only controlled trials in
the meta-analyses (n =12).
3–6,8,19–25
Furthermore, we
excluded articles on children
8,24
to ensure that calcula-
tions were on the same population, that is, adults,
resulting in 10 studies included in the meta-
analyses.
3–6,19–23,25
Three studies were excluded due to
missing data.
3,21,25
We contacted the authors of these
studies to obtain missing data but unfortunately they did
not respond. However, these three articles had a high or
unclear RoB, or no information was provided on which to
base a judgment about the RoB. Finally, we included
seven studies in our meta-analyses.
4–6,19,20,22,23
In the article by Dittrich et al. (2014),
19
the outcomes
of pain difference, pain intensity, functional impairment,
FIGURE 1 The PRISMA
(Preferred Reporting Items for
Systematic Reviews and Meta-
Analyses) diagram details the search
and selection process applied
12
GASSNER ET AL.3
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TABLE 2 Table of study characteristics
Author, Ref.
number Year
Study
Design
Number of
participants Indication
Comparison
group
Intervention type
a
(group
or individual setting [IS])
Duration of climbing
intervention (trial length)
Risk of Bias
Score
Dittrich M
19
2014 Quasi-
RCT
55 Chronic low back pain Waitlist Therapeutic climbing (GS) 12 sessions of 30 min (in total
6 weeks)
Unclear
Engbert K
20
2011 RCT 28 Chronic low back pain Standard exercise therapy Therapeutic climbing (GS) 4 sessions weekly of 45 min
(in total 4 weeks)
Unclear
Jolk C
40
2015 Case
series
6 Multiple sclerosis - Sports climbing (GS) 5 sessions weekly of 2 h High
Karg N
6
2020 RCT 133 Depression Home-based supervised
exercise
Bouldering (GS) 10 sessions weekly of 2 h (in
total 10 weeks)
Unclear
Kern C
21
2013 RCT 27 Multiple sclerosis n.r. Therapeutic climbing (GS) 20 sessions weekly of 2 h (in
total 6 months)
Unclear
Kim SH
5
2015 CCT 30 Lower back pain Lumbar stability mat
exercises
Therapeutic climbing (GS) 3 sessions weekly of 30 min
(in total 4 weeks)
No information
Kleinstäuber M
3
2017 CCT 40 Major depressive
disorder
Relaxation Indoor rock climbing (GS) 1 session of 2.5 h No information
Lee HS
42
2015 Case report 1 ADHD - Therapeutic climbing (IS) 12 sessions within 4 weeks High
Luttenberger K
4
2015 RCT 47 Depression Waitlist Bouldering (GS) 1 session weekly of 3 h (in
total 8 weeks)
Unclear
Mazzoni ER
8
2009 RCT 46 Children with special
needs
Waitlist Indoor wall climbing (GS) 1 session weekly of 1 h for
6 weeks
Unclear
Reiter M
38
2014 NCT 23 Anxiety and
obsessive-
compulsive
disorder
- Therapeutic climbing (n.r.) 4 sessions No information
Schinhan M
22
2016 RCT 30 Chronic low back pain No treatment Bouldering (GS) 10 sessions in 8 weeks, at
least weekly of 1 h
High
Schnitzler EE
41
2009 Case series 6 Psychosomatic disorder - Therapeutic climbing (GS) n.r. High
Schram
Christensen M
24
2017 CCT 17 Children with cerebral
palsy
Climbing for
healthy
controls
Indoor-climbing (GS) 9 sessions of 2.5 h within
17 days
No information
Stelzer EM
23
2018 RCT 47 Depression Waitlist Bouldering (GS) 1 session weekly of 3 h (in
total 8 weeks)
Unclear
Stephan MA
39
2011 Case series 4 Cerebellar ataxia - Climbing training (GS) 2–3 sessions weekly of 30–
60 min (in total 6 weeks)
High
Velikonja O
25
2010 RCT 20 Multiple sclerosis Yoga Sports climbing (GS) 1 session weekly (in total
10 weeks)
High
Wallner S
7
2010 Case series 8 Psychological disorders - Psychological climbing
(IS+GS)
Weekly for 1 year High
This table shows the study characteristics of the 18 included trials.
Abbreviations: ADHD, attention deficit hyperactivity disorder; CCT, controlled clinical trial; GS, group setting; h, hour(s); IS, individual setting; min, minute(s); n.r., not reported; NCT, non-controll ed clinical trial; RCT,
randomized controlled trial; Ref., reference.
Levels of evidence
18
: 2b ([Quasi-]RCTs, CCTs); 4 (case series, NCTs); 5 (case reports).
a
The interventions were all conducted indoor in a climbing hall, even if not mentioned specifically.
4THE THERAPEUTIC EFFECTS OF CLIMBING
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and subjective physical and psychological health state
had to be excluded due to missing data. Furthermore,
for the outcomes regarding trunk force, only levels of
significance were reported (such as p< .05) for the
intervention and control group rather than exact p
values.
19
According to the Cochrane handbook,
26
we
used a conservative approach and took the pvalues at
the upper limit (e.g., for p< .05 and p> .05, we took
p=.05). In the article by Schinhan et al. (2016),
22
only
one outcome (i.e., functional status) could be included
because data were missing for all other outcomes. In
addition, in Stelzer et al. (2018),
23
the outcome of phys-
ical activity (number of steps) was excluded due to
missing data. If applicable, only the primary (not sec-
ondary) outcome measurement was included in the
analyses. If data were not reported in Δmean (stan-
dard deviation [SD]),
5,19,22
we imputed and added
these missing values.
26,27
In total, we calculated three
meta-analyses for each health dimension (physical,
mental, and social health).
For the RoB table in the meta-analysis, only three
items of the ROBINS-I for CCTs could be transferred to
the Review Manager. These were “bias selection of
participants into the study”(selection bias), “bias due
to missing data”(attrition bias), and “bias in selection
of the reported results”(reporting bias).
A random-effects model was chosen, and meta-
analyses were performed using Review Manager 5.4
(The Nordic Cochrane Centre, The Cochrane Collabo-
ration, Copenhagen, Denmark). For continuous vari-
ables, the standardized mean difference of the change
scores (T1-T0) between the two groups was calculated,
as the included articles used different outcomes mea-
surements. A significance level of .05 was chosen, and
the confidence intervals (CIs) and pvalues were
reported.
DISCUSSION
The present systematic review aims to assess the
safety and effectiveness of TC by synthesizing the cur-
rently available evidence regarding physical, mental,
and social health. The included evidence consisted of
18 trials (n =568, range: 1–133 patients) with unclear
to high RoB. There was a consistent message that TC
improves physical, mental, and social health for neuro-
logical, orthopedic, psychiatric, and pediatric diagnostic
groups. The results are quite variable, which may be
due to the variety of different outcome measures used
(Tables SA5 and SA6).
Physical effectiveness
Physical feeling, fitness, motor control, and strength as
well as velocity, dexterity, range of motion and alpha-
wave activation may improve due to TC; disk protru-
sions may be reduced in size. Balance improved for
psychological disorders and cerebellar ataxia after
TC. In contrast, balance did not improve in patients with
multiple sclerosis (MS), which may be because abnor-
malities in balance are common in MS; even with mini-
mal clinically assessable impairments, patients with MS
often show balance deficits.
28
A discrepancy was observed in individuals with
back pain, where TC relieved pain only in some trials.
In one of these studies, quality of life (QoL) focusing on
pain did not improve, but QoL focusing on physical
functioning improved. Exercise can also increase pain,
which may be explained by changes in central nervous
system (CNS) function promoted by muscle fatigue.
29
Spasticity improved in those with MS measured by the
Expanded Disability Status Scale (EDSS) pyramidal
function score but not rated by the Modified Ashworth
Scale. The EDSS is a standard measure of disability in
MS clinical research
30
; therefore, the results of this
study can be seen as reliable.
Outcomes of physical activity (number of steps)
measured using FitBit Zip accelerometers improved in
individuals with depression after eight TC sessions
23
but not in individuals with back pain in daily life activi-
ties using questionnaires even after 16 sessions.
20
This
shows that TC has potent effects on psychological con-
ditions, which aligns with a meta-analysis investigating
the effectiveness of physical activity on depression.
31
Furthermore, the FitBit Zip is validated for monitoring
physical activity.
32
Based on the conducted meta-analysis on the
dimension of physical health, a statistically significant
improvement could be found, favoring the climbing
group. The heterogeneity of data (I
2
) was 3%, which
shows homogeneity of data
33
and, therefore, reliable
results.
Mental effectiveness
Depressiveness, obsessive–compulsive behavior, somati-
zation, paranoid ideation, psychoticism, and emotional
regulation may improve due to TC. Furthermore, improved
vitality, mental health, body perception, self-esteem,
fatigue, and positive/negative affect could be observed.
Attention may improve due to TC for Attention-
Deficit/Hyperactivity Disorder (ADHD), anxiety, obsessive-
compulsive disorders, and psychological disorders, but not
for MS. Cognitive dysfunction is reported in 40% to 60% of
patients with MS and negatively affects attention.
34
In addi-
tion, other studies have failed to show a clear benefit and
draw firm conclusions regarding positive effects on atten-
tion for MS.
34
After four sessions, self-worth improved in anxiety/
obsessive-compulsive disorders, but not in children
with special needs after six sessions or longer. In
GASSNER ET AL.5
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contrast, physical activity such as TC is associated with
increased self-worth in healthy children.
35
Patients with MS improved cognitive fatigue after 20
sessions. After 1 year of TC, cognitive endurance
improved for psychological disorders, but not in chil-
dren with cerebral palsy after nine sessions. Cerebral
palsy is often associated with cognitive disabilities;
even if cognition did not improve due to TC, motor
activity leads to better mental health and improves cog-
nitive performance for cerebral palsy.
36
Furthermore,
study results confirm that the length of intervention may
play an essential role in the effectiveness of cognition.
A mismatch is observed regarding anxiety for those
with depression: In two studies,
4,6
TC positively affected
anxiety, whereas another study
23
did not find any effect,
even though the numbers of sessions were similar. Cop-
ing with anxiety improved in those with psychological
disorders after 1 year of climbing, which shows that the
length of intervention may be a determining factor.
Self-efficacy improved in individuals with depression
in one study
4
but not in another one,
23
even if the
authors of both studies investigated 47 patients climb-
ing for eight sessions and measured with the FERUS
questionnaire (Questionnaire for the Assessment of
Ressources and Self-management skills). In contrast,
self-efficacy improved in children with special needs
after only six sessions. This may be because children
with special needs report lower self-efficacy compared
to healthy controls.
37
Based on the conducted meta-analysis on the
dimension of mental health, a difference that was not
statistically significant was found. However, a tendency
of improvements favoring the climbing group was
observed. The heterogeneity of data (I
2
) was 75%,
which shows a high data heterogeneity.
33
Therefore,
this result needs to be interpreted with caution.
Social effectiveness
TC positively affected social functioning, trust, commu-
nication, and sense of responsibility.
7,20,38
Interper-
sonal sensitivity improved in those with depression
after eight, 3-hour sessions
23
but not after ten, 2-hour
sessions.
6
For psychological disorders, social compe-
tences improved after weekly climbing for 1 year,
7
but
not interpersonal sensitivity in individuals with depres-
sion
4
and children with special needs
8
after eight and
six sessions, respectively.
These findings show that a longer duration of ses-
sions and the length of the climbing intervention may
be important for positively influencing social heath. The
longest included study where social effectiveness was
observed was weekly TC for a whole year.
7
Based on the conducted meta-analysis on the
dimension of social health, a difference that was not
statistically significant was found. However, a tendency
of improvements favoring the climbing group could be
observed. The heterogeneity of data (I
2
) was 45%,
which shows moderate data heterogeneity.
33
There-
fore, this result needs to be interpreted with caution.
Safety
This review demonstrated that TC is a very safe full-body
workout, even if commonly mistaken as an extreme
sport. Adverse events such as a sprained wrist, not
directly from climbing, and blisters on the hands were
reported. No serious adverse events could be observed
during or after TC. Climbing can be seen as a safe activ-
ity, provided that belaying techniques are performed
properly.
2
Sport climbing and bouldering are not danger-
ous, as perceived in the public opinion: The injury rates
per 1000 hours of indoor climbing and sport climbing are
very low (0.079 and 0.2 injuries, respectively) compared
to football (31 injuries per 1000 hours).
2
TC can be seen
as a social fun sport with mental and physical challenges.
Limitations
The findings reported in this systematic review and
meta-analysis need to be interpreted with caution, as
only studies with high, unclear RoB or no information
on which to base an RoB judgment were found. None-
theless, eight RCTs were included, analyzing 379 par-
ticipants, which is a substantial number.
Another limitation is that TC interventions were per-
formed and described heterogeneously across the
studies, rendering them hard to compare. The use of
aggregated data, like in systematic reviews, always
implies a certain loss of detailed qualitative information
required for accurately interpreting the findings. How-
ever, we are convinced that the reported results provide
a valid impression of the effectiveness of TC for the
respective diagnostic groups. The small numbers of
included participants across the trials (1 to 133 partici-
pants) could influence the occurrence of adverse
events; notwithstanding, in total, a high number of
568 participants were assessed.
Perspective
To our knowledge, this review is the first to show that
TC is safe and may holistically improve physical, men-
tal, and social health for neurological, orthopedic, psy-
chiatric, and pediatric participants. TC can tackle
issues of, for example, physical functioning/fitness,
pain, mental strength, depression, and social compe-
tence, and can provide an active social environment.
This multi-faceted activity is of interest to health spe-
cialists and clinical researchers. It is crucial to broaden
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the spectrum of treatments for different diagnostic
groups, improve QoL, and involve social interactions.
More robust trials designed with higher methodological
quality are needed to investigate TC in a holistic quanti-
tative approach.
IN DEPTH ASSESSMENT OF PUBLISHED
LITERATURE (“EVIDENCE”)
Study characteristics
Table 2provides an overview of study characteristics. The
evidence consists of 18 studies (n =568, range: 1–133
patients) meeting the inclusion criteria, including eight
RCTs,
4,6,8,20–23,25
one quasi-RCT,
19
three CCTs,
3,5,24
four
case series,
7,39–41
one case report,
42
and one NCT.
38
Studies were published between 2009
8,41
and 2020,
6
including 1
42
to 133
6
participant(s). The effectiveness of
TC was investigated for MS,
21,25,40
depression,
3,4,6,23
cer-
ebellar ataxia,
39
chronic low back pain,
5,19,20,22
psychoso-
matic disorders,
41
anxiety/obsessive–compulsive
disorder,
38
psychological disorders,
7
ADHD,
42
and chil-
dren with cerebral palsy
24
and special needs
(i.e., developmental/physical/emotional/behavioral
challenges).
8
As comparative interventions, yoga,
25
standard exer-
cise therapy,
20
relaxation,
3
lumbar stability mat
exercises,
5
and home-based supervised exercises
6
were
considered; other authors used waitlist groups,
4,8,19,23
climbing for healthy controls,
24
or no-treatment groups.
22
One study did not report the benchmark comparison.
21
The duration of the TC intervention was heterogeneous
and varied from a single session
3
to 1-year regular train-
ing.
7
Other authors applied, respectively, 4,
38
5,
40
6,
8
8,
4,23
9,
24
10,
6,22,25
12,
5,19,42
16,
20
and 20 sessions.
21
In
one study, patients climbed 12 to 18 sessions
(on average, 15 sessions),
39
and another study did not
report trial length and duration of intervention.
41
Effectiveness
Table 3provides an overview of the effectiveness of
TC. Physical effectiveness was assessed in 348 partici-
pants (7 RCTs of 15 studies), mental effectiveness in
522 participants (8 RCTs of 14 studies), and social
effectiveness in 332 patients (5 RCTs of 7 studies).
Statistical numbers for (non-)significant effects can be
found in Tables SA5 and SA6.
Physical effectiveness
Back pain
TC improved functional impairment (before intervention
start àafter intervention [6 weeks]), pain difference,
and static/dynamic trunk force after climbing twice a
week for 6 weeks in individuals with lower back pain.
19
General health and physical functioning improved after
four weekly climbing sessions
20
and after three weekly
sessions
5
within 4 weeks. TC positively affected pain
severity (decrease over time), functional status, and
disk protrusions after 10 sessions
22
and muscle activi-
ties (erector spinae, rectus abdominis, external oblique)
after three sessions/week for 4 weeks.
5
TC did not
improve the subjective physical health state, pain inten-
sity, functional impairment (after intervention à
3 months after intervention),
19
and pain severity in the
time course between the climbing and control group.
22
Activities of the internal oblique muscle,
5
physical role
limitations, body pain,
5,20
and activities of daily living
20
did not improve in patients with lower back pain.
Multiple sclerosis
Patients diagnosed with MS showed improvements in
(physical) fatigue, that is, increased endurance, after
20 climbing sessions within 6 months
21
and knee
extensor isometric muscle strength (both legs and
weak leg) after five sessions.
40
Spasticity measured by
the EDSS pyramidal function score was reduced, but
not when rated by the Modified Ashworth Scale after
10 weeks of climbing.
25
For MS, TC positively affected
physical functions after 10 sessions.
26
No effects on
executive function,
25
balance, and isometric muscle
strength in the knee extensors (strong leg, strong-weak
difference between both legs)
40
were found after TC.
Cerebral palsy
Children with cerebral palsy improved climbing perfor-
mance, functionality (measured by the sit-to-stand-
test), muscular coherence, ankle joint range of motion
and strength, and pinch grip rate-of-force-development
of the least affected hand.
24
Climbing speed, function-
ality (measured by the Romberg test), hand/pinch
strength, ankle dorsiflexion, and ankle joint stiffness did
not improve after nine sessions of TC.
24
Cerebellar ataxia
After two to three sessions a week within 6 weeks, par-
ticipants with cerebellar ataxia improved movement
velocity, symmetric movement speed, and motor con-
trol.
39
Two of four climbing patients improved balance
while remaining stable for the other two.
39
Manual dex-
terity improved (left: n =3, right: n =2), and remained
stable (left: n =1, right: n =1) post climbing.
39
Other indications
After six sessions, children with special needs improved
climbing height but not athletic competence and climbing
difficulty.
8
Balance and gross/fine motor skills, and physi-
calfeelingimprovedforpsychological disorders after
weekly climbing for 1 year.
7
Furthermore, physical activity
(number of steps) improved in participants with
GASSNER ET AL.7
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TABLE 3 Outcomes: overview of effectiveness of therapeutic climbing
Effectiveness of therapeutic climbing
Number of
participants Indication Comparison Sessions
Physical effectiveness (level of evidence 2b
a18
)
* Pain difference, functional impairment (change in climbers
T1 àT2)
b
, static and dynamic trunk force
19
x Subjective physical health state, pain intensity, functional
impairment (change in climbers T2 àT3)
c19
55 Chronic low back
pain
Waitlist group 12
* Pain severity (decrease over time: resting position,
fingertip-floor-distance, in motion), functional status, disc
protrusion
22
x Pain severity (in the time course between the 2 groups:
resting position, in motion)
22
30 Chronic low back
pain
No treatment 10
* Muscle activities (erector spinae, rectus abdominis,
external oblique), quality of life (physical functioning,
general health)
5
x Muscle activities (internal oblique), quality of life (role
limitation (physical), bodily pain)
5
30 Lower back pain Lumbar stability mat
exercises
12
* General health, physical functioning
20
x Role limitations (physical), bodily pain, activities of daily
living
20
28 Chronic low back
pain
Standard exercise
therapy
16
* Isometric muscle strength (knee extensors) in both legs
and weak leg
40
x Balance, isometric muscle strength (knee extensors) in
strong leg and (relative) strong-weak difference
40
6 Multiple sclerosis - 5
* Fatigue, physical fatigue
21
27 Multiple sclerosis n.r. 20
* Spasticity (EDSSpyr), physical functions
25
x Spasticity (MAS), executive function
25
20 Multiple sclerosis Yoga group 10
* Climbing performance (route fraction, hand errors),
functionality (sit-to-stand), muscular-muscular
coherence (finger pinch), ankle joint (range of motion,
strength), pinch grip rate-of-force-development (least
affected hand)
24
x Climbing speed, functionality (Romberg), hand strength,
pinch strength, ankle dorsiflexion, ankle joint
(stiffness)
24
17 Children with
cerebral palsy
Climbing for healthy
controls
9
* Climbing height
8
x Climbing difficulty, athletic competence
8
46 Children with
special needs
Waitlist group 6
* Movement velocity, symmetric movement speed, balance
(n =2), manual dexterity (left side (n =3), right side
(n =2)), motor control
39
x Unchanged balance (n =2), stable dexterity (left side
(n =1), right side (n =1))
39
4 Cerebellar ataxia - 15
* Balance, gross/fine motor skills, physical feeling
7
8 Psychological
disorders
- Weekly for 1 year
* Physical activity (number of steps)
23
47 Depression Waitlist group 8
* General fitness
38
23 Anxiety and
obsessive-
compulsive
disorder
-4
* Muscle tone, (Self-)motivation
41
6 Psychosomatic
disorder
- n.r.
* Brain waves
42
1 ADHD - 12
Mental effectiveness (level of evidence 2b
18
)
* Depression, anxiety, self-efficacy, active/passive coping,
obsessive–compulsive behavior
4
x Phobic anxiety, self-verbalisation, concentration
4
47 Depression Waitlist group 8
* Depression, anxiety, subjective body image, global self-
esteem
6
x Coping
6
133 Depression Home-based
supervised
exercise
program
10
(Continues)
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TABLE 3 (Continued)
Effectiveness of therapeutic climbing
Number of
participants Indication Comparison Sessions
* Depression (SCL-90-R, t-test), phobic anxiety, active/
passive coping (t-test), somatisation, hostility, paranoid
ideation, psychoticism, hope
23
x Anxiety, self-efficacy, self-verbalization, active/passive
coping (u-test), depression (SCL-90-R, u-test; BDI-II)
23
47 Depression Waitlist group 8
* Depressiveness, negative (group x time) and positive
affect, coping emotions
3
x Negative affect (group)
3
40 Major depressive
disorder
Relaxation group 1
* Vitality (before vs after intervention), mental health (before
vs after intervention)
20
x Vitality (climbers vs controls after intervention), role
limitations (emotional), mental health (climbers vs
controls after intervention)
20
28 Chronic low back
pain
Standard exercise
therapy
16
* Subjective general health state
19
x Subjective psychological health state
19
55 Chronic low back
pain
Waitlist group 12
* Self-efficacy
8
x Global self-worth
8
46 Children with
special needs
Waitlist group 6
x Cognitive/psychological tests
24
17 Children with
cerebral palsy
Climbing for healthy
controls
9
* Cognitive fatigue
21
27 Multiple sclerosis n.r. 20
* Fatigue, impact of fatigue on cognitive functions
25
x Attention span, mood, impact of fatigue on psychosocial
function
25
20 Multiple sclerosis Yoga group 10
* Attention span
42
1 ADHD - 12
* Attention regulation, emotion regulation, hedonism,
closeness-distance, self-worth
38
23 Anxiety and
obsessive-
compulsive
disorder
-4
* Self-esteem, frustration tolerance, body perception,
concentration and attention, coping with anxiety,
problem-solving strategies, cognitive endurance
7
8 Psychological
disorders
- Weekly for 1 year
Social effectiveness (level of evidence 2b
18
)
* Trust, social competence, clarity in communication, sense
of responsibility
7
8 Psychological
disorders
- Weekly for 1 year
* Trust in others/control, relationship between closeness and
distance
38
23 Anxiety and
obsessive–
compulsive
disorder
-4
* Social functioning (before vs after intervention)
20
x Social functioning (climbers vs controls after
intervention)
20
28 Chronic low back
pain
Standard exercise
therapy
16
x Interpersonal sensitivity, social support
4
47 Depression Waitlist group 8
* Interpersonal sensitivity
23
x Social support
23
47 Depression Waitlist group 8
x Interpersonal sensitivity
6
133 Depression Home-based
supervised
exercise
program
10
x Social competence
8
46 Children with
special needs
Waitlist group 6
Abbreviations: ADHD, attention deficit hyperactivity disorder; BDI-II, Deck depression inventory; EDSSpyr, EDSS pyramidal functions score; MAS, Modified
Ashworth Scale; n.r., not reported; SCL-90-R, Symptom checklist-90-R; vs, versus.
This table presents an overview of the effectiveness outcomes of therapeutic climbing in terms of physical, mental and social aspects. For further information on
outcome measures and pvalues, please refer to Tables A5 and A6 in the Appendix.
Levels of evidence
18
: 2b ([Quasi-]RCTs, CCTs); 4 (case series, NCTs); 5 (case reports).
*, statistically significant effects in favor of the climbing group; x, not statistically significan t effects.
a
Individual cohort study including low-quality RCT.
b
T1 àT2: immediately before intervention start àimmediately after intervention (6 weeks).
c
T2 àT3: immediately after intervention à3 months after intervention.
GASSNER ET AL.9
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depression after eight sessions,
23
and general fitness
enhanced in participants with anxiety/obsessive-
compulsive disorders after four sessions.
38
TC positively
affected muscle tone and (self-)motivation for psychoso-
matic disorders
41
and alpha-wave activation for ADHD.
42
A meta-analysis on the dimension of physical health
was conducted. Four studies reported on physical
health with 143 analyzed participants across stud-
ies.
5,19,20,22
As depicted in Figure 2, the pooled statisti-
cally significant standardized mean difference of the
change scores between the two groups across
the studies was .37 (95% CI .23 to .52; p< .001). The
low level of heterogeneity (I
2
=3%) indicates that
homogeneity of the data can be assumed.
Mental effectiveness
Depression
In participants with depression, TC positively affected
depressiveness.
3,4,6
A discrepancy could be observed as
depression measured using the Symptom Checklist 90-R
(SCL-90-R) yielded significant effects, but not when mea-
sured by the Beck Depression Inventory.
23
Anxiety
4,6
improved after 10 and 8 sessions, respectively, whereas
in another study, no effects could be observed after eight
sessions.
23
Some authors reported improved phobic
anxiety
23
; in contrast, others did not detect any improve-
ments
4
after eight sessions. Active/passive coping
4,23
and emotional coping
3
improved after eight and one
session(s), respectively, whereas one study found no
effects on coping after 10 sessions.
6
Positive affect
improved after one session of TC.
3
Participants with
depression showed improved self-efficacy after eight
sessions,
4
but another study reported no improvements.
23
Furthermore, obsessive–compulsive behaviors,
4
somati-
zation, hostility, paranoid ideations, psychoticism, and
hope
23
improved after eight TC sessions. After 10 ses-
sions, subjective body image and global self-esteem
improved.
6
Self-verbalization
4,23
and concentration
4
did
not show positive changes after eight sessions in partici-
pants with depression.
Back pain
Participants with back pain showed improved vitality and
mental health after 16 sessions
20
and subjective general
and psychological health state
19
after 12 sessions.
Multiple sclerosis
For MS, TC positively affected fatigue after 10 ses-
sions
25
and cognitive fatigue after 20 sessions.
21
The
effect of fatigue on cognitive functions improved after
10 sessions but not on psychosocial functions.
25
Fur-
thermore, mood and attention span did not change after
10 TC sessions in participants with MS.
25
Other indications
TC positively affected the self-efficacy of children with
special needs but not their global self-worth after six ses-
sions.
8
After nine TC sessions, cognitive/psychological
FIGURE 2 Physical health dimension: forest plot of the results and risk of bias of the individual studies. Note that the full risk of bias
assessment is available in the Appendix. CI, confidence interval; IV, inverse variance; SD, standard deviation
10 THE THERAPEUTIC EFFECTS OF CLIMBING
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tests did not yield positive effects in children with cere-
bral palsy.
24
Improved attention span could be observed
in participants with ADHD
42
; improved attention, emotion
regulation, hedonism, closeness-distance and self-worth
for anxiety/obsessive-compulsive disorders were found
after four TC sessions.
38
Furthermore, self-esteem, frus-
tration tolerance, body perception, concentration/atten-
tion, coping with anxiety, problem-solving strategies, and
cognitive endurance ameliorated after 1 year of TC in
participants with psychological disorders.
7
A meta-analysis on the dimension of mental health
was conducted. Four studies reported on mental health
with 255 analyzed participants across studies.
4,6,20,23
As depicted in Figure 3, the pooled statistically non-
significant standardized mean difference of the change
scores between the two groups across the studies was
.11 (95% CI .31 to .09; p=.03). However, high het-
erogeneity was found (I
2
=75%), since the dimension
of mental health covers a variety of possible outcomes.
Social effectiveness
TC improved trust, social competence, clarity in com-
munication and the sense of responsibility in
participants diagnosed with psychological disorders
performing TC once a week for 1 year.
7
Trust in
others, control, and the relationship between close-
ness and distance improved after four sessions of
TC for anxiety/obsessive-compulsive disorders.
38
Furthermore, TC positively affected the social func-
tioning of those with chronic low back pain (before
vs. after intervention) but not social functioning
(climbers vs. controls after intervention) after
16 sessions.
20
Interpersonal sensitivity improved in 47 participants
with depression after eight, 3-hour sessions,
23
but not
in 133 patients after ten, 2-hour sessions.
6
TC did not
affect social competence such as interpersonal sensi-
tivity in participants with depression
4
and children with
special needs.
8
Furthermore, no effect could be found
on social support in participants with depression after
8 weeks of TC training.
4,23
A meta-analysis on the dimension of social health
was conducted. Four studies reported on social health
with 255 analyzed participants across studies.
4,6,20,23
As depicted in Figure 4, the pooled statistically non-
significant standardized mean difference of the change
scores between the two groups across the studies was
.19 (95% CI .49 to .11; p=.21; I
2
=45%).
FIGURE 3 Mental health dimension: forest plot of the results and risk of bias of the individual studies. Note that the full risk of bias
assessment is available in the Appendix. CI, confidence interval; IV, inverse variance; SD, standard deviation
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Safety
Two incidents occurred in 47 analyzed participants.
One child with cerebral palsy accidentally sprained the
wrist in a collision during warm-up (CCT
24
). One partici-
pant with chronic low back pain reported blisters on her
hands; others described muscle aches in their upper
extremities and back muscles after TC interventions
(RCT
22
). No other adverse events or side effects were
reported in the total population of 568 participants. We
could not conduct a meta-analysis on safety aspects.
Length of intervention
Regarding a suggestion for what length may be needed
to observe certain effects, we considered only studies
with no high RoB. We could find that general fitness
improved in the physical dimension after four climbing
sessions. After 6 to 10 sessions, climbing performance
and height, functionality, muscular-muscular coher-
ence, range of motion, strength, and physical activity
improved. And after 11 to 20 sessions, general health,
pain difference, static and dynamic trunk force, muscle
activities, (physical) fatigue, functional impairment, and
physical functioning were ameliorated.
Considering the mental dimension of TC, after one to
five sessions, depressiveness, self-worth, negative and
positive affect, attention regulation, coping emotions,
and emotional regulation improved. After 6 to 10 ses-
sions, anxiety, self-efficacy, active/passive coping,
obsessive-compulsive behavior, body image, somatiza-
tion, psychoticism, and hope were ameliorated. And after
11 to 20 climbing sessions, general and mental health
state, vitality, cognitive fatigue, and QoL improved.
In the social dimension, relationship and trust
improved after 4 sessions, interpersonal sensitivity after
8 sessions, and social functioning after 16 climbing
sessions. To conclude, depending on the length of the
intervention, different outcomes may improve
due to TC.
Effects presented according to the specific
indication, climbing intervention type,
intensity, and amount of sessions
Different types of climbing, intensity, and amount of
sessions affect various populations differently. Addres-
sing these concerns, Table 4provides an overview of
physical, mental, and social effects in relation to the
indication, climbing intervention type, intensity, and
amount of sessions, sorted by indication. Suggesting
for which populations climbing may yield optimal bene-
fits, this table shows that climbing is especially effective
in participants with back pain, MS, and depression.
EMPHASIS ON APPRAISAL OF QUALITY,
SYNTHESIS OF INFORMATION, AND
ANALYSIS/COMPARISON OF RESULTS
AND CONCLUSIONS
Search results and selection
The literature search resulted in 112 records (PRISMA
diagram, Figure 1). The abstract screening revealed
that 90 publications did not meet inclusion criteria. As a
result, 22 full-text articles were further assessed for eli-
gibility. Language was not limited during the search
process, but full-text articles not published in German,
English, and Spanish were excluded. Four records
were not eligible and were excluded with reason
(i.e., study protocol, congress abstracts, language),
resulting in 18 trials (568 patients) eligible for evidence
synthesis. The update search resulted in 18 hits, which
FIGURE 4 Social health dimension: forest plot of the results and risk of bias of the individual studies. Note that the full risk of bias
assessment is available in the Appendix. CI, confidence interval; IV, inverse variance; SD, standard deviation
12 THE THERAPEUTIC EFFECTS OF CLIMBING
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TABLE 4 Effects presented according to the specific indication, climbing intervention type, intensity, and amount of sessions
Reference Indication Intervention type Intensity Sessions High risk of bias
Physical effectiveness (level of evidence 2b
a18
)
19
Chronic low back pain Therapeutic climbing 12 sessions for 30 min (in total
6 weeks)
12
22
Chronic low back pain Bouldering 10 sessions in 8 weeks, at
least weekly for 1 h
10 X
5
Lower back pain Therapeutic climbing 3 sessions weekly for 30 min
(in total 4 weeks)
12
20
Chronic low back pain Therapeutic climbing 4 sessions weekly for 45 min
(in total 4 weeks)
16
40
Multiple sclerosis Sports climbing 5 sessions weekly for 2 h 5 X
21
Multiple sclerosis Therapeutic climbing 20 sessions weekly for 2 h (in
total 6 months)
20
25
Multiple sclerosis Sports climbing 1 session weekly (in total
10 weeks)
10 X
24
Children with cerebral
palsy
Indoor-climbing 9 sessions for 2.5 h within
17 days
9
8
Children with special
needs
Indoor wall climbing 1 session weekly for 1 h for
6 weeks
6
39
Cerebellar ataxia Climbing training 2–3 sessions weekly for 30–
60 min (in total 6 weeks)
15 X
23
Depression Bouldering 1 session weekly for 3 h (in
total 8 weeks)
8
41
Psychosomatic disorder Therapeutic climbing n.r. n.r. X
7
Psychological disorders Psychological climbing Weekly for 1 year Weekly for 1 year X
38
Anxiety and obsessive-
compulsive disorder
Therapeutic climbing 4 sessions 4
42
ADHD Therapeutic climbing 12 sessions within 4 weeks 12 X
Mental effectiveness (level of evidence 2b
18
)
4
Depression Bouldering 1 session weekly for 3 h (in
total 8 weeks)
8
6
Depression Bouldering 10 sessions weekly for 2 h (in
total 10 weeks)
10
23
Depression Bouldering 1 session weekly for 3 h (in
total 8 weeks)
8
3
Major depressive
disorder
Indoor rock climbing 1 session for 2.5 h 1
5
Lower back pain Therapeutic climbing 3 sessions weekly for 30 min
(in total 4 weeks)
12
20
Chronic low back pain Therapeutic climbing 4 sessions weekly for 45 min
(in total 4 weeks)
16
19
Chronic low back pain Therapeutic climbing 12 sessions for 30 min (in total
6 weeks)
12
21
Multiple sclerosis Therapeutic climbing 20 sessions weekly for 2 h (in
total 6 months)
20
25
Multiple sclerosis Sports climbing 1 session weekly (in total
10 weeks)
10 X
8
Children with special
needs
Indoor wall climbing 1 session weekly for 1 h for
6 weeks
6
42
ADHD Therapeutic climbing 12 sessions within 4 weeks 12 X
38
Anxiety and obsessive–
compulsive disorder
Therapeutic climbing 4 sessions 4
7
Psychological disorders Psychological climbing Weekly for 1 year Weekly for 1 year X
(Continues)
GASSNER ET AL.13
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did not match the PICOS scheme and were excluded
from the analysis.
Risk of bias assessment
Tables SA1–SA4 show that RoB varied from
unclear
4,6,8,19–21,23,38
to high,
7,22,25,39–42
or some authors
provided insufficient information
3,5,24
to rate the RoB.
The main detected issues were bias in outcomes mea-
surement and unclear reporting of the site(s)/clinic(s)
demographic information. Further issues were unclear
inclusion criteria, reporting of participants’demographics
and clinical information, invalid methods for identifying
conditions, inappropriate statistical analysis, discontinu-
ous inclusion of participants, conditions not assessed in
a standard/reliable way, and outcomes/follow-up results
not reported clearly.
Levels of evidence
The physical, psychological, social, and safety dimen-
sions have scientific evidence level 2b, that is, individ-
ual cohort studies and low-quality RCTs.
18
CONCLUSION
The available evidence supports the established pragmatic
view that TC can be considered a safe and effective activ-
ity. TC brings improvements in certain physical, mental,
and social health aspects for various participants. It offers
a potent non-pharmaceutical complement and alternative
to some disease-specific therapies. However, there is little
evidence regarding the size of the effects reported in vari-
ous studies. Yet, the strength of the available evidence is
low due to a scarcity of high-quality trials and increased
RoB in primary studies, pointing to a need for high-quality
research on the long-term effects and follow-ups.
ACKNOWLEDGMENTS
We would like to thank information specialist Tarquin
Mittermayr, MA, for his support in the systematic liter-
ature search and Gregor Goetz, MSSc MPH, for his
help regarding the meta-analyses. The study was
supported by the Hilde-Ulrichs-Foundation for Parkin-
son’s Research, Germany. LG was endorsed by the
Marietta Blau grant from the Federal Ministry of Sci-
ence and Research, Austria; the Research Grant of
the City of Vienna, Austria; the Completion Grant of
the University of Vienna; the RMIT University
Research Training support fund, Australia; and the
RMIT University Research International Tuition Fee
Scholarship, Australia.
DISCLOSURE
The authors declare they have no conflicts of interest.
ORCID
Lucia Gassner https://orcid.org/0000-0002-7734-
0682
Agnes Santer https://orcid.org/0000-0001-7647-8914
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TABLE 4 (Continued)
Reference Indication Intervention type Intensity Sessions High risk of bias
Social effectiveness (level of evidence 2b
18
)
7
Psychological disorders Psychological climbing Weekly for 1 year Weekly for 1 year X
38
Anxiety and obsessive-
compulsive disorder
Therapeutic climbing 4 sessions 4
20
Chronic low back pain Therapeutic climbing 4 sessions weekly for 45 min
(in total 4 weeks)
16
23
Depression Bouldering 1 session weekly for 3 h (in
total 8 weeks)
8
Abbreviations: ADHD, attention deficit hyperactivity disorder; h, hour(s); min, minute(s); n.r., not reported.
This table presents physical, mental and social effects in relation to the indication, climbing intervention type, intensity, and amount of sessions in the published
studies.
a
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14 THE THERAPEUTIC EFFECTS OF CLIMBING
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SUPPORTING INFORMATION
Additional supporting information can be found online
in the Supporting Information section at the end of this
article.
How to cite this article: Gassner L, Dabnichki P,
Langer A, et al. The therapeutic effects of
climbing: A systematic review and meta-analysis.
PM&R: The Journal of Injury, Function and
Rehabilitation. 2023;1‐16. doi:10.1002/pmrj.
12891
16 THE THERAPEUTIC EFFECTS OF CLIMBING
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