|
PEPonline
Professionalization
of
Exercise Physiologyonline
An
international electronic
journal
for exercise physiologists
ISSN
1099-5862
Vol
4 No 4 April 2001
|
The Role of
the Exercise Physiologist in Mental Health
Matthew G. Wattles, MS
8725 W. Wall Drive
Boise, ID 83709
Abstract. A new market
for increased employment of exercise physiologists is always important
information. And, one exciting health care field, in particular,
where more exercise physiologists should be employed is the "Behavioral
Health" sector. There is now considerable evidence that regular exercise
is a viable, cost-effective treatment for depression. When compared
to individual psychotherapy, group psychotherapy, and cognitive therapy,
exercise fairs rather well. In 1996, The Surgeon General released
a report on Physical Activity and Health. The report concluded that
exercise has a beneficial effect on relieving symptoms of depression and
anxiety and on improving mood. Evidence was also presented that exercise
may protect against the development of depression. A recent Duke
University Medical Center study from October 1999 concluded that “exercise
may be just as effective as medication and may be a better alternative
for certain patients”. The National Institute of Mental Health recognizes
exercise as a valid treatment for anxiety and depression. Preliminary
evidence also suggests that regular exercise deserves further attention
as a singular treatment for some anxiety disorders, for individuals suffering
from body image disturbance, and for the reduction of problem behavior
of developmentally disabled persons, and an adjunct in the treatment programs
for schizophrenia, conversion disorder, and alcohol dependence.
“The important thing
is
not to stop questioning”
- Albert Einstein
Introduction
Does your hospital have
a psychiatric ward or the newly politically correct version, “Behavioral
Health Center?” What types of exercise programs are offered to the
patients on an inpatient or an outpatient basis? As you will soon
read in this review of the literature, exercise is one of the most important
components of any psychological treatment program. But, unfortunately,
it isn't an integral part of every mental health program throughout the
nation? Apparently, very few of these centers offer any type of exercise
program at all. If they do it is usually a very limited session with
a recreational therapists or a nurse who might not have the qualifications
to use exercise in a prescriptive manner. The problem is that they
may offer a light stretching class or walking program without building
either into the actual treatment itself. The other reason that exercise
physiologists need to be employed by these centers as directors of the
exercise prescription is the risk of law suits due to injury to the patients.
Understanding the indications for and the contraindications of exercise
for specific populations is important to avoiding potential complications.
Admittedly, the recreation therapists will understand how to set up games
and different forms of exercise but, generally, they do not know how to
prescribe an exercise program to someone with schizophrenia. A nurse
will know how to administer a dose of Haldo IM but, again, may not know
the contraindications of an aerobic exercise bout for a patient with major
depressive disorder taking Zoloft. This is where the exercise physiologist’s
knowledge of exercise and structuring exercise programs in healthcare settings
are greatly needed. Hence, where possible and appropriate, it is
important that exercise physiologists step up to the plate and convince
the healthcare administrators that what they have to offer is not only
an integral component to treatment, but a very cost effective one as well.
Effects of Exercise on
Psychological Variables
There is now considerable
evidence that regular exercise is a viable, cost-effective treatment for
depression that compares favorably to individual psychotherapy, group psychotherapy,
and cognitive therapy, and is a necessary ingredient in effective behavioral
treatments that reduce self-reported pain in individuals with chronic pain.
For example, in
1996, the Surgeon General
released a report on Physical Activity and Health in which it was concluded
that exercise has a beneficial effect on relieving symptoms of depression
and anxiety and on improving mood. Evidence was also presented that
exercise may protect against the development of depression (1).
Similarly, the National Institute of Mental Health recognizes exercise
as a valid treatment for anxiety and depression. Preliminary evidence
indicates that regular exercise deserves further attention as a treatment
for some anxiety disorders, for individuals who suffer from body image
disturbance, and for the reduction of problem behavior of developmentally
disabled persons. Exercise is also recommended as an adjunct treatment
in the more traditional treatment programs for schizophrenia, conversion
disorder, and alcohol dependence (2).
Depression
A recent study (3)
suggests that exercising 3 times a week may be just as effective in relieving
the symptoms of major depression as the standard treatment of anti-depressant
medications. The researchers, from the Duke University Medical Center
study, studied 156 elderly patients diagnosed with major depressive disorder
(MDD). They assigned them to three groups: exercise, medication,
or a combination of medication and exercise. To the surprise of the researchers,
after 16 weeks all three groups showed statistically significant and similar
improvement in measurements of depression. Aerobic exercise has been found
to be more effective than placebo control conditions and no-treatment conditions
(4-6). Exercise compares favorably to individual
psychotherapy (7-9), group psychotherapy (10),
and cognitive therapy (11). Clearly, with as little
as 5 weeks of 3-weekly supervised sessions of aerobic (walk or run) or
nonaerobic exercise activity of low to moderate intensity (50% of maximum
heart rate) lasting from 20 to 60 minutes in duration, significant improvements
can be achieved with clinically depressed individuals. In addition, follow-up
assessments have indicated that treatment gains can be maintained for up
to 1 year, particularly if some level of regular activity is continued
(7, 12). Most notably, exercise therapy
has been demonstrated to be 4 to 5 times more cost-effective than traditional
treatments for depression (7, 11).
Anxiety Disorders
Benefits from exercise for
the treatment of anxiety symptoms are probably as numerous as those for
depression. In an exploratory study (13), 36 patients
with anxiety disorders, as defined in the 3rd edition of the Diagnostic
and Statistical Manual of Mental Disorders; American Psychiatric Association,
1980 (14), participated in an 8-week inpatient aerobic
exercise treatment program. While the patients were in the hospital, their
aerobic capacity increased and anxiety scores decreased significantly in
all diagnostic subcategories except social phobia which remained stable
throughout treatment. At 1-year follow-up, those with generalized anxiety
disorder and agoraphobia without panic attacks maintained their improvement;
however, patients with panic disorder with agoraphobia had lost their gains.
Developmental Disabilities
Gabler-Halle, Halle, and
Chung (15) conducted an excellent review of the literature
involving aerobic exercise and individuals with developmental disabilities.
They surveyed the representative research with respect to the effects of
exercise on several broad outcome areas. Methodologically, research in
this area has been relatively sound. Acceptable designs and documentation
of treatment parameters were often noted.
In the behavioral domain,
research has indicated that moderately vigorous exercise temporarily reduces
stereotypic and disruptive responding immediately after a bout of exercise
(16-22) and appears to improve the work performance
(23-24) of this group of individuals. Regarding the
type of exercise activity, findings indicate that participation in aerobic
activity is more effective in reducing short-term stereotypic responding
than is participation in ball-playing or leisure activities (20).
A direct positive relationship may exist between intensity of exercise
and reduction in inappropriate behavior immediately following the exercise
(25). Immediate, but relatively short-term, reductions
in stereotypic and disruptive behavior appear to occur following 45–60
min of aerobic exercise (17, 19,
22).
Schizophrenia
Results from recent pre-experimental
and case study evidence reveal that adjunctive exercise programs with schizophrenic
inpatients may improve cardiovascular functioning (26-28);
decrease self-reported symptoms of depression (27, 29);
is as effective as social skills training on ratings of general psychopathology
(26); decrease psychotic symptoms and psychomotor agitation
and improve social competence as rated by ward nurses (30);
and reduce the frequency of overt hallucinatory symptoms (31).
Somatoform Disorders
Individuals diagnosed with
somatoform disorders suffer from physical symptoms that, although suggestive
of a general medical condition, cannot be fully explained by such a condition
on medical evaluation (32). In several studies, the
impact of physical activity on this class of disorders has been examined.
Conversion disorder and
body dysmorphic disorder. The essential feature of conversion disorder
is the presence of symptoms affecting voluntary motor or sensory functioning
for which psychological factors are judged to be involved (32).
Although data have been reported on only 7 individuals (33-34),
results suggest that supervised physical exercise conducted 3 times a week
can lead to increased walking behavior and decreased dependence on a wheelchair.
The essential feature of body dysmorphic disorder is a preoccupation with
either an imagined defect in appearance or a markedly excessive concern
regarding an actual but slight physical anomaly (32).
To investigate exercise therapy for individuals scoring highly on several
measures of body image disturbance, Fisher and Thompson (35)
compared individuals randomly assigned to a 6-session cognitive–behavioral
group therapy, with individuals similarly assigned to a combined aerobic–anaerobic
exercise therapy conducted once per week for 6 weeks. Results revealed
equivalent reductions for both treatment groups when compared to a control
group on several measures of body image disturbance.
Pain disorder. Pain
disorder has two defining features: (a) Pain is the predominant focus of
clinical attention, and (b) psychological factors are judged to have an
important role in its onset, severity, exacerbation, or maintenance (32).
Fordyce et al. (36) demonstrated that pain behaviors
that would be expected to diminish on tissue healing are often maintained
by environmental rewards such as economic advantages, the relief from stress
or responsibility, and social rewards such as sympathy or attention. When
an acute pain condition persists for 6 months and longer, the amount of
time required for normal tissue healing, it then becomes diagnosed as a
chronic pain condition.
Graded exercise activity
(either aerobic, strength training, or a combination) has been included
as a treatment component in clinically effective behavioral treatment approaches
for chronic pain (37-39). When included as a component
in comprehensive treatment packages, regular aerobic exercise resulted
in a more rapid reduction of clinically reported pain levels over that
of another viable treatment (40). A component
analysis investigating the effective ingredients of behavioral therapy
for chronic pain revealed that, although aerobic exercise alone was ineffective,
it was a necessary ingredient of effective multicomponent behavioral treatment
(41). The best available evidence suggests that aerobic
exercise, gradually increasing from 10 to 30 min in duration and from 60
to 70% of maximum heart rate capacity, conducted 5 times weekly, can contribute
to significant reductions in self-reported pain intensity in patients suffering
from moderately severe chronic pain. However, further research is necessary
to determine the precise boundaries of treatment parameters required to
produce significant improvements. The suggested mechanisms responsible
for the effects of exercise therapy include the effects of social reinforcement
and the fact that performance of regular physical activity is incompatible
with pain and illness behavior (36).
Substance Abuse Disorders
Previous reviews found mixed
results regarding the role exercise treatments may play in therapy for
substance abuse problems. Research on exercise treatments for alcohol dependence
has not increased a great deal since the previous reviews. Only two studies
(42-43) were reported and, although both indicated some
positive effects, only Sinyor et al. reported increased abstinence rates
as a result of adjunctive exercise treatment. However, because the
methodological rigor of this study may be questioned, the status of this
finding must remain tentative.
Recent interest has been
shown in the potential for exercise to contribute to smoking cessation
treatment programs. Three early evaluations of exercise therapy indicated
that it was either ineffective (44) or possibly counterproductive
to smoking-cessation efforts in terms of increased anxiety and sleep disturbances
(45-46). However, more recently, Martin et al.
(47) reported that aerobic exercise, when combined with
behavioral counseling, was more effective than both standard education
alone and behavioral counseling combined with nicotine gum therapy on measures
of post treatment abstinence. However, this advantage was not maintained
at either 6- or 12-month follow-up assessments. Therefore, more controlled
research is required to clarify these conflicting findings.
Hypotheses Explaining
the Psychological Benefits of Exercise
It has been well documented
that exercise positively impacts psychological well being and functions
as an antidepressant (48-53). One theory is that exercise
increases the levels of brain norepinephrine and serotonin and that the
release of endogenous opiods from the pituitary gland acts as a mood enhancer
and antidepressant. Another hypothesis is the thermogenic theory, which
suggests that the increase in body temperature has a tranquilizing effect
(6, 54-57).
According to Greist and Jefferson,
"some experts believe that simply moving large muscle masses in regular
rhythmical ways is inconsistent with depression" (54).
Several psychosocial hypotheses have been presented concerning the connection
between exercise and improved perceptions of well being. Exercise and physical
activity can furnish a sense of achievement, promote feelings of personal
control, provide a channel for emotional release and reconnect one to the
play of childhood (58). The positive feelings derived
from exercise and physical activity may also be due to feelings of mastery,
self-efficacy and accomplishment of a task (59). Involvement
in physical activity has also been suggested to provide a sense of competence,
an emotional catharsis and a form of biofeedback, which teaches participants
how to regulate their emotions (6, 56-57,
60-63).
Other psychosocial mechanisms
that have been suggested include the possibility that physical activity
provides a distraction from problems, and that exercise can offer a change
of scenery and divert one's mind from anxious thoughts (58,
50, 55, 64-67).
What are the Implications?
To prevent potential ethical
and legal conflicts, clinical psychologists who have not received training
in the principles of exercise physiology might seek interdisciplinary liaisons
with physicians and exercise physiologists. The benefits of such
efforts,
particularly as further
evidence of the clinical effectiveness of exercise therapy is documented,
are a broadening of practice possibilities and a possibly expanding base
of potential referrals (2). The following is a list of
the different tasks and roles that the exercise physiologist can play in
a Behavior Health facility:
1. Work with inpatient
and outpatient staff and the medical personnel to determine which patients
would benefit most from exercise therapy.
2. Work with inpatient and
outpatient staff to develop exercise consulting, health and fitness evaluation,
exercise prescription, and exercise programs for there clients – this can
be included in an outpatient treatment plan as well. This has the
potential to attract a much broader client base and has the possibility
of being a substantial revenue generator for outpatient services.
3. Conduct individual and
group exercise sessions with patients.
4. Works in conjunction
with other health professionals in implementing patient’s treatment.
5. Teach courses for patients
on exercise, nutrition, life-style modifications, progressive relaxation
protocols, and stress reduction techniques.
6. Assists in marketing
exercise programs throuhgout the community (e.g., seminars and presentations
at corporations and community centers), form alliance with local physicians
to secure referral patients.
7. Act as a liaison within
the community to assist patients in locating and continuing with low cost
forms of exercise (e.g., contacting health clubs to see if patients can
qualify for discounted memberships).
8. Locate and write research
grants to increase program funding. Conduct research on the benefits of
exercise on physiological variables and publish results. Some of
the doctors in these facilities may be interested in this also.
9. Possible long term goals
- Integrate Psychotherapy, exercise and nutrition programs to develop a
Behavioral Health Promotion Clinic to attract outside clientele and has
the potential of being a substantial revenue generator for hospital/center.
Exercise Therapy Program
Implementation
The following is a list
that an exercise physiologist can use to implement exercise programs in
a Behavior Health facility. This list is simply suggestions that
can be followed in setting up programs:
1. At intake, have
patients fill out a questionnaire on their exercise history. There
are several questionnaire that can be used (ParQ, Exercise attitude questionnaire,
etc).
2. Provide consultation’s
with patients on their exercise history, habits, likes, dislikes, and reasons
why. Gather other vital information from patient to include in health
history questionnaire. Conduct fitness evaluations to determine patient’s
base-line fitness levels.
3. Develop individualized
exercise prescriptions for patients based on results of information gathered
on questionnaires and during consultation and fitness evaluation and prescribe
exercise over the course of therapy.
4. Use exercise as a
venue for therapy:
(a) Work one on
one with patients demonstrating proper exercise form and techniques and
teaching strategies to increase adherence. This can be with both
inpatient and outpatient clients.
(b) Teach group exercise
sessions to inpatient.
(c) Provide follow up contact
with patients to increase adherence to their exercise programs.
(d) Provide weekly support
groups for patients to increase adherence.
5. Patient Education
classes:
(a) Instruct on
frequency, intensity, duration and mode of exercise, proper form
and techniques, and what will work best for them.
(b) Potential physical and
mental health benefits of exercise as commitment enhancement procedure.
(c) Weight loss and weight
control classes for patients (medication side effects, depression).
Nutrition education can be incorporated into with class.
(d) Strategies to assist
patients to develop behavioral self-control strategies (e.g., behavioral
contracting, stimulus control, positive reinforcement) to improve exercise
therapy adherence.
(e) Prepare patients for
recidivism and reinitiation using relapse prevention strategies.
Ideas for Funding Exercise
Therapy Programs
1. Hospital or
Center: Programs of this caliper have the potential to expand the hospitals/centers
exposure in the community and to increase revenues.
2. Patients/clients that
are able to pay for service: Develop lifestyle change programs in outpatient
with psychologists, social workers, dieticians, exercise physiologists.
This could be a huge service for the community by giving them more treatment
options and a major financial contributor to hospitals/centers.
3. Grants (Local state/city/federal
government): Hospitals/centers can use this program to improve peoples
self-esteem and
self worth. Because
of this, hospitals/centers maybe able to apply for Health and Welfare grants
to get some of their patients off public assistance and back into the workforce.
There are grants avaliable to organizations who can help assist these people
back into the work environment.
4. Research grants:
Exercise physiologists can conduct in-depth studies on the benefits of
exercise on mental health conditions. Doctor’s may also be interested in
this. Published research always brings exposure to your programs.
The National Institute of Mental Health (NIMH), National Institutes of
Health (NIH), etc., have many grant’s available to researchers in the behavioral
health realm.
5. Donations: Exercise
equipment manufactures will donate equipment if you advertise their equipment
or use them in research studies. This applies to many non-profit
hospitals/centers. Contact manufactures about possibly
donating some of their equipment.
External Sources
1. Providing a suitable
place for our patients to exercise can be as simple as providing mats for
stretching and dynabands for strength training.
2. YMCA and other health
clubs may be able to provide facilities for programming. Many hospital’s/centers
currently have Physical Therapy program contracted in YMCA’s and other
health clubs.
3. Hospital fitness center:
Facilities may be able to contract out certain hours with current hospital
fitness center or other hospital fitness centers nearby, check to see if
they have any off peak hours that you could conduct programs with patients.
Summary
The evidence is clear.
Exercise is a viable, cost-effective treatment for many behavioral health
conditions. Exercise physiologists need to be encouraged to pursue
jobs in this area of healthcare. And, equally important, the directors
and administrators of these programs need to look to exercise physiology
for qualified healthcare professionals.
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