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Summary of key paragraphs In Touch "Exercise & depression" page 17 of MPA In Touch - 2007 Issue 1

The Event Organiser's comments are in UPPER CASE BLUE

Many of us have experienced that feeling of well-being; that burst of energy after completing a bout of intense exercise. AGREED
 

Recently, there has been increasing interest in the role of exercise in the management of depression.  AGREED
 

A number of mechanisms have been proposed to explain why exercise might be beneficial for a person with depression.
 

1st: Direct physiological benefit. The release of endorphins that can follow exercise may have a positive influence on mood, energy, and feelings of well-being.  THESE BENEFITS HAVE BEEN KNOWN OF FOR A LONG TIME
 

2nd: Important social benefits from exercising.  Exercising in a group increases the possibility of social contact, and therefore could help to address the feelings of isolation and loneliness that can accompany depression. Exercise is a positive activity by society, so that a person with depression who exercises is more likely to receive positive feedback from others.  DITTO ABOVE


3rd:  Exercising often involves learning and perfecting a new skill or task. A person can feel better about themselves once they have successfully mastered the ability to do a gym program independently or achieved the aim of completing a fun run.   AGREED.  THE 'EVENT ORGANISER' HAS FIRST HAND EXPERIENCE OF PEOPLE WHO WERE INITIALLY AFRAID OF CYCLING, DEVELOPING INTO GUNGHO HO, DEVIL-MAY-CARE CYCLISTS WHO FEAR NOTHING

 

Exercise for a person with depression can have important diversional benefits.  Focussing attention and efforts onto an exercise program can help divert a person away from negative thoughts.  AGREED.  A POWERFUL TOOL
 

Lawlor and Hopker review article in the British Medical Journal in 2001 provides an excellent summary of the evidence about exercise and depression.
 

The type of exercise programs included aerobic programs, and strengthening programs, typically three times a week for eight to 12 weeks, either in a group setting or with a supervisor.  AGREE THE NEED FOR STRENUOUS, STRENGTHENING EXERCISE, WHERE -

*    PARTICIPANTS EVIDENCE IMPROVED FITNESS PERFORMANCE; AND

*    OTHERS COMMENT UPON THE IMPROVED APPEARANCE OF THE PATIENT


Nearly all of the trials reported benefits for people with depression who exercised when this was compared to doing nothing.  When the results were statistically combined across these randomised controlled trials, procedure known as meta-analysis, on average people with depression could reduce their depressive symptoms by more than seven points on the Beck Depression Inventory (out of a possible score of 63).  REDUCING BY UP TO 7 PTS OUT OF A POSSIBLE 63 IS ONLY 11.11%.  CASUAL EMPIRICISM FROM ASSOCIATING WITH HUNDREDS OF CYCLISTS, SOME OF WHOM HAVE EXPERIENCED BOUTS OF DEPRESSION DUE TO THE NORMAL STRESSES THAT HIT MOST OF US, SUGGEST A GREATER POTENTIAL BENEFIT THAN 11.11% FROM THOSE WHO HAVE SET THEMSELF A DIFFICULT CYCLING CHALLENGE AND SUCCEEDED IN THAT CHALLENGE.  ONE LADY WHO WAS IN THE GRIPS OF A MAJOR BOUT OF DEPRESSION 6 MONTHS EARLIER DUE TO A RELATIONSHIP BREAK-UP, ON ANTI-DEPRESSANTS AND SEEING HER THERAPIST, COMPLETED THE 2005 200KM AUDAX ALPINE CLASSIC IN 40O+ HEAT WHEN MANY MORE SEASONED ENDURANCE CYCLISTS BAILED-OUT BECAUSE OF THE HEALTH THREATENING CONDITIONS IN A HEAT-WAVE.  BUT THIS LADY STUCK AT IT, BECAUSE SHE HAD A POINT TO PROVE TO HERSELF  "A large contributor to this high pullout rate would have been the searing heat, it was around 42 Celsius in the sun and was not really a pleasant temperature anywhere (especially not below 1000 metres down in the valleys)."

 

It did not seem to make a difference what sort of exercise people were doing, whether it was running or walking in a group, or doing progressive resistance exercise regimen in a gym, people seemed to get the same sort of benefits.  DISAGREE.  PATIENTS WILL BENEFIT MORE FROM PARTICIPATING IN A SPORT THEY PREFER.  SOME LIKE CYCLING.  OTHERS LIKE HIKING, LAP SWIMMING OR ROWING.  THE BENEFIT IS GREATER IF PARTICIPATING IN A PREFERRED EXERCISE ACTIVITY


Four of the trials compared exercise with cognitive behaviour therapy, a common treatment approach in the management of people with depression that teaches people how to deal with their thought patterns using rational thinking.  The beneficial effect of exercise therapy was similar to the effect of cognitive behaviour therapy.  AGREED, AS IT IS CHANGING A PATTERN OF BEHAVIOUR/ROUTINE, WHICH FACILITATES BREAKING A NEGATIVE CYCLE
 

Maintaining the motivation to continue with an exercise program can be difficult for all of us and probably even more so for a person with depression. The results of the systematic review suggest that in the clinical situation making sure that patients volunteer and enter into a type of contract (such as informed consent) might contribute to adherence and a beneficial outcome.  DISAGREE.  I KNOW LOTS OF PEOPLE WHO HAVE INCORPORATED INTENSE EXERCISE THROUGHOUT THEIR LIVES BECAUSE THEY LOVE IT.  CYCLING IN A RIDE GROUP OF NEWLY FOUND POSITIVE, CONFIDENT FRIENDS PROVIDES ITS OWN IMPETUS TO TURN-UP EVERY WEEK.  IMPROVING YOUR PERSONAL BEST UP A "KOM CLIMB", LOGGING A "PERSONAL BEST", AND EVIDENCING YOUR IMPROVED "KOM CLIMB TIME" ON A CLIMB REPORT ACCESSIBLE ON THE INTERNET FOR THE RECENT CONVERT TO ROAD CYCLING AND THEIR CYCLE FRIENDS TO SEE, PROVIDES MATERIAL, TANGIBLE EVIDENCE OF IMPROVED PERFORMANCE, WITH RESULTANT ENHANCED SELF-ESTEEM


Exercise complement other treatment approaches rather than as a substitute for them.  AGREED.  HOWEVER, LONG TERM IMPROVED PERFORMANCE IN PHYSICAL SPORTS RENDERS THE PATIENT STRONGER MENTALLY AND PHYSICALLY, THEREBY REDUCING THE LIKELIHOOD OF A RECURRENCE OF DEPRESSION.   THE EVENT ORGANISER HAS EVIDENCED CYCLISTS COME OUT OF A PERIOD OF DEPRESSION TO BE MATERIALLY MENTALLY STRONGER FROM THE EXPERIENCE


What is the role of the physiotherapist?  A PHYSIOTHERAPIST CAN DEVISE A SUITABLE/SAFE EXERCISE PLAN, SUCH AS JOINING A BUSHWALKING CLUB OR CYCLING IN A RECREATIONAL RIDE GROUP FULL OF HAPPY, POSITIVE PEOPLE. 


Physiotherapists may have an important role in being part of the medical team to manage a person’s depressive symptoms.  The role of the physiotherapist goes beyond the simple prescription of an exercise program, and should include strategies that will help to improve exercise adherence and the chances of getting a beneficial outcome.  A PHYSIOTHERAPIST CAN AID SOMEONE SUFFERING DEPRESSION BY ASSISTING ESTABLISH STRATEGIES TO IMPROVE PHYSICAL FITNESS WHICH, IN TURN, ENHANCES SELF-CONFIDENCE.  IF THOSE STRATEGIES ENTAIL "POSITIVE" FEATURES, NAMELY THAT "EXERCISE IS FUN AND ENJOYABLE", THOSE STRATEGIES ARE MORE LIKELY TO BE MAINTAINED AND ENJOYED.  

 

The types of exercises that have led to beneficial effects for people with depression have been aerobic type programs and strength training programs. Although there is no evidence that one type of exercise is better than another, there is some evidence that the programs should be of sufficient intensity to lead to changes in fitness.  AGREED.  THE MORE RIGOROUS THAT THE ILL PERSON'S SKELETAL FRAME CAN HANDLE THE BETTER, AS IT IS IMPORTANT THAT THE PATIENT EVIDENCES MATERIAL IMPROVEMENT.  HOWEVER, INJURIES FROM PUSHING BEYOND THE PATIENT'S ELASTIC LIMIT (FROM OVER-DOING-IT), CAN RAPIDLY OFFSET ANY IMPROVEMENT, DUE TO THE RECOVERING PERSON SUFFERING "WITHDRAWAL SYMPTOMS" FROM NOT BEING ABLE TO CONTINUE THEIR NEW FOUND EXERCISE RELEASE.  CROSS TRAINING WITH OTHER AEROBIC SPORTS, INCL LESS INTENSIVE EXERCISES SUCH AS LAP SWIMMING WITH BI-LATERAL BREATHING TO AVOID RSI, IS IMPORTANT.


If doing an aerobic program then the intensity should be at least 55 per cent of maximum heart rate for 20-60 minutes for three to five days a week; while a strength training program should be at an intensity of 60-80 per cent of one repetition maximum for one to three sets of eight-12 repetitions two to three times a week (ACSM 1998).  AGREED.  REGULAR ROAD CYCLING PROVIDES THIS WITH MUCH LESS WEAR AND TEAR THAN SAY JOGGING.


The venue where the exercise program takes place should also be given some thought.  One of the beneficial aspects of exercise is the increased social contact that can occur. This does not necessarily mean that exercise has to be done in a group setting but should include opportunities for incidental social contact, such as exercising in a community gymnasium.  CYCLING THE 31 DIFFERENT 100KM AVE ROUTES IN MUGGACCINOS RIDE CALENDAR AMONGST A DIVERSE ARRAY OF ADULTS AND VISITING >30 CAFES AT NOSH STOPS AT CAFES AT SATELLITE OUTPOST ON THE PERIMETER OF GREATER SYDNEY AND ILLAWARRA ENABLES MARVELLOUS MENTAL THERAPY.


Strategies to improve exercise adherence may include ensuring that the person chooses to exercise, selecting a form of exercise that the person wants to do, being clear about the expected benefits, and establishing a contract with the person where they make the commitment to participate. 

"establishing a contract with the person where they make the commitment to participate" HAS A NEGATIVE CONNOTATION. 

ANYONE RECOMMENDING AND ENCOURAGING AN EXERCISE ACTIVITY NEEDS TO BE SUCCESSFUL AT THAT ACTIVITY AND HIGHLY POSITIVE ABOUT THE MERITS OF SUCH A PROGRAMME.  THE ENCOURAGER NEEDS TO PROMOTE THE ENJOYABLE ASPECTS UNDERTAKEN AMIDST SIMILAR MINDED ADULTS WHO EXHIBIT A POSITIVE ATTITUDE.


Strategies for regular review are also important. This could take the form of periodically supervising the session, monitoring progress, and self review for the person by providing them with a log book where they can track their progress.  THE ABILITY TO LOG KOM CLIMB TIMES ON REPORTS ON THE INTERNET AND READ HUMOROUS POST-RIDE WRAP-UPS IN THE LOCAL BICYCLE GROUP'S NEWSLETTER CAN REPLACE "REGULAR REVIEW".


There is evidence that aerobic and strengthening exercise programs can reduce symptoms in people with depression but exercise should not be a substitute for other treatments.  A LARGE PERCENTAGE OF ADULTS EXPERIENCE SOME FORM OF DEPRESSION DURING THEIR LIVES WHICH USUALLY OCCURS FOLLOWING A PROLONGED PERIOD OF STRESS WITHOUT EXPERIENCING MANY RELAXING/ENJOYABLE RELEASES AND/OR FAVOURABLE MILESTONES, PARTICULARLY IF THEIR IMMUNE SYSTEM AND RESISTANCES ARE LOW. 

TREATMENT NEEDS TO STRENGTHEN THE DEPRESSED PERSON IN BOTH MIND AND BODY. TRADITIONAL MEDICATIONS MAY BE NEEDED IN THE SHORT TERM TO SETTLE AND IMPROVE THE PATIENT’S EMOTIONS.  HOWEVER, A RIGOROUS EXERCISE ACTIVITY IN A SOCIAL, TEAM ENVIROMENT WILL INVARIABLY STRENGTHEN BOTH MIND AND BODY OVER THE LONG TERM WHERE THE PERSON BELIEVES THEY ARE MENTALLY AND PHYSICAL TOUGHER AFTER HAVING RECOVERED FROM THE TEMPORARY MENTAL ILLNESS.

Physiotherapists can play an important role in the team by prescribing a suitable exercise program that meets the needs of the person with strategies to maximise adherence.  AGREED.  HOWEVER, A MORE COST EFFECTIVE LONGER TERM SUPPORT MECHANISM IS A WELL ADMINISTERED RECREATION BICYCLE GROUP OR HIKING CLUB.