Physical Activity for People with Mobility Issues or Disabilities

The active living movement has encouraged all of us to be more physically active in our daily lives and to maintain or improve our health. People with disabilities or mobility issues can achieve important health benefits by being as physically active as possible.

This article outlines:

• the benefits of physical activity for people with disabilities
• the benefits of physical activity for people with mobility issues (due to a disability, health condition, age or other factors)
• ways to adapt various activities to meet special needs
• benefits of cardiovascular, strength and flexibility activities

Every Person is Unique
Although every individual is different, it’s true that some people with disabilities or mobility issues are not as active as others. If you have a disability or limited mobility – and are leading a sedentary lifestyle – you may be at greater risk of being obese, or experiencing Type 2 diabetes, high blood pressure or coronary heart disease.
For anyone with a disability or mobility issue, it’s vital to be as physically active as possible. Equally, it’s important to find ways to overcome any barriers you may face as you try to become physically active. These barriers may include affordability and/or a lack of access, transportation and information.
The Benefits of Physical Activity are RealWhether you have a short-term or long-term disability, or are experiencing mobility issues for any reason, physical activity can:

• Give you an enhanced sense of control.
• Allow you to focus on your physical abilities, not your disability or mobility issue.
• Give you more energy and strength to do things on your own, whether at home or at work, or for tasks such as grocery shopping or housework.

Participants in activity groups for people with disabilities report that these programs:

• Help them to feel they’re not alone when working towards fitness or health goals.
• Provide a social outlet where people can discuss common experiences, talk about solutions to various challenges and just have fun together.

Exercising in a social setting also increases your motivation to participate in physical activities. As you participate more, you’ll be inspired keep at it!

Canadian Sedentary Behaviour Guidelines

“Canadian children and youth spend sixty-two per cent of their waking hours in sedentary pursuits, with six to eight hours per day of screen time as the average for school-aged kids,” said Dr. Mark Tremblay, Director, Healthy Active Living and Obesity Research (HALO) at the CHEO Research Institute, and Chair of the CSEP Physical Activity Guidelines Committee. When Kids Get GoingThe good news is that reducing sedentary time can provide health benefits. According to Tremblay, lower levels of sedentary behaviour are “consistently associated with improved body composition, cardio-respiratory and musculoskeletal fitness, academic achievement and even self-esteem.”
“Generally, kids that are active are better learners,” said Brian Torrance, Director of Ever Active Schools in Edmonton, Alberta. “For instance, school kids that have had a 10-minute walk before a test arrive at the exam with their ‘neurons firing’ and are more relaxed, so test results are better.”
Torrance suggests that some schools may not be as aware of the need to reduce sedentary time as others. “Awareness at the school level about limiting sedentary behaviour definitely needs to increase, so these new guidelines are a helpful tool to boost that awareness,” he said.
Sedentary Guidelines Complement Physical Activity GuidelinesJohn C. Spence, Associate Dean, Research, at the University of Alberta’s Faculty of Physical Education and Recreation, explains that some researchers are now finding that simply being less sedentary provides health benefits, regardless of the amount of moderate or vigorous physical activity or exercise a person may do each day. “What this research shows is that just by standing for longer periods and moving around more often during the day, a person will burn several hundred more calories per day. “
But Spence and other experts are quick to add a word of caution: simply being less sedentary is only part of the solution on the road to good health.
In fact, the Canadian Sedentary Behaviour Guidelines for Children and Youth are complementary to the Canadian Physical Activity Guidelines for the same age range.

Recreation and Active Living at Major Alberta Conferences

October 2011 marks an exciting time for people and organizations from Alberta and across Canada who will be converging in the Alberta Rockies for two major conferences, both of which have strong ties to different aspects of wellness, recreation and active living.

• The first event is the 2011 International Action on Wellness Symposium, hosted by Alberta Health and Wellness, which will take place in Banff from October 11-13. The conference theme is “Building a Healthier Tomorrow Together.”
• The second is the 2011 National Recreation Summit, from October 23-26 in Lake Louise. The Summit is a joint effort between the Canadian Parks and Recreation Association (CPRA) and the Interprovincial Sport and Recreation Council (ISRC) along with federal government agencies. The event will be co-hosted by Alberta Tourism, Parks and Recreation and the Alberta Recreation and Parks Association (ARPA). The conference theme is “Recreation, Community and Quality of Life.”

Both events are intended (in different ways) to promote networking, partnerships and collaborative efforts.
For instance, one of the objectives of the 2011 Symposium is to “stimulate new partnerships and opportunities for networking and engagement between multiple sectors (within and beyond the traditional health sector) and at all levels of society that promote wellness.”
The 2011 Symposium follows on the heels of an Action on Wellness Forum hosted by Alberta Health and Wellness in 2010. Due in part to the success of the 2010 Forum, the idea of launching an international symposium gained strength.
Like the 2010 Forum, the 2011 Symposium will approach wellness from four themes: healthy eating, active living, mental well-being and addiction prevention.  More than 100 speakers will be on tap, while hundreds of attendees are expected from Alberta, Canada and around the world.
"Everyone has opportunities to be a positive influence and model healthier behaviour wherever they work, live learn and play,” said Gene Zwozdesky, Minister of Health and Wellness.  “Alberta’s first-ever International Action on Wellness Symposium will bring together wellness experts from around the world to the beautiful Banff Springs Hotel to inspire attendees and give them the tools and strategies to champion wellness in their own communities.” 

Physical Activity Impacts Overall Quality of Sleep

A nationally representative sample of more than 2,600 men and women, ages 18-85, found that 150 minutes of moderate to vigorous activity a week, which is the national guideline, provided a 65 percent improvement in sleep quality. People also said they felt less sleepy during the day, compared to those with less physical activity.
The study, out in the December issue of the journal Mental Health and Physical Activity, lends more evidence to mounting research showing the importance of exercise to a number of health factors. Among adults in the United States, about 35 to 40 percent of the population has problems with falling asleep or with daytime sleepiness.
"We were using the physical activity guidelines set forth for cardiovascular health, but it appears that those guidelines might have a spillover effect to other areas of health," said Brad Cardinal, a professor of exercise science at Oregon State University and one of the study's authors.
"Increasingly, the scientific evidence is encouraging as regular physical activity may serve as a non-pharmaceutical alternative to improve sleep."
After controlling for age, BMI (Body Mass Index), health status, smoking status, and depression, the relative risk of often feeling overly sleepy during the day compared to never feeling overly sleepy during the day decreased by 65 percent for participants meeting physical activity guidelines.
Similar results were also found for having leg cramps while sleeping (68 percent less likely) and having difficulty concentrating when tired (45 percent decrease).
Paul Loprinzi, an assistant professor at Bellarmine University is lead author of the study, which was conducted while he was a doctoral student in Cardinal's lab at OSU. He said it is the first study to examine the relationship between accelerometer-measured physical activity and sleep while utilizing a nationally representative sample of adults of all ages.
'Our findings demonstrate a link between regular physical activity and perceptions of sleepiness during the day, which suggests that participation in physical activity on a regular basis may positively influence an individual's productivity at work, or in the case of a student, influence their ability to pay attention in class," he said.
Cardinal said past studies linking physical activity and sleep used only self-reports of exercise. The danger with this is that many people tend to overestimate the amount of activity they do, he said.
He added that the take-away for consumers is to remember that exercise has a number of health benefits, and that can include helping feel alert and awake.
"Physical activity may not just be good for the waistline and heart, but it also can help you sleep," Cardinal said. "There are trade-offs. It may be easier when you are tired to skip the workout and go to sleep, but it may be beneficial for your long-term health to make the hard decision and get your exercise."

Physical Activity and Mental Health

Kim Horn has enjoyed being physically active since she was a little girl. Living on Vancouver Island, she and her friends were outside year-round. Once she started university in 2000, however, she realized that was beginning to change. “I found my daily routine became a lot more sedentary, sitting in the classroom and doing schoolwork. That can be especially bad for your energy levels in the winter,” said Horn, 23.
 “To balance it out and make sure I was healthy, I decided in my first year that I was going to make an effort to be active.”
As most of us know, physical activity is an excellent way to maintain physical health. It is also an effective way to maintain mental health. Canadians have a unique opportunity to be active outdoors. Whether gardening, hiking on trails, walking the dog, or playing sports outside, we can choose from a great number of activities.

Exercise 'helps mental health'

Many people with mental health problems use physical exercise to make them feel better, a survey has found. The survey by the charity Mind found that 83% of people with mental health problems looked to exercise to help lift their mood or to reduce stress.
Two-thirds said exercise helped to relieve the symptoms of depression and more than half said it helped to reduce stress and anxiety.
Some people even thought it had a beneficial effect on manic depression and schizophrenia.
Six out of ten said that physical exercise helped to improve their motivation, 50% said it boosted their self-esteem and 24% said it improved their social skills.
Mind found that people with mental health problems were more likely to get their exercise from everyday activities like walking, housework and gardening.
However, 58% did not know that GPs can sometimes prescribe exercise sessions and activities.
'Valid'
The biggest barriers that prevented people from taking part in physical exercise were motivation problems, the cost of sport and lack of confidence.
One respondent to the survey said: "I would not have recovered over the last few years without daily exercise, combined with alterations of diet."
Another said: "I still suffer from depression, anxiety and stress, but doing exercise does give relief and greatly helps me through the days."
Report author Sue Baker said: "Our survey proves, beyond any doubt, that physical activity and exercise has a valid place in the 'treatment' of mental health problems.
Gym members
"As such it deserves far more recognition and should be made more widely available."
However, she stressed that physical exercise could not prevent all mental health problems from developing, and should not be seen as a replacement for other 'treatments'.
Mind is calling for:

• More information about the availability of exercise prescriptions from GPs
• Greater access to leisure facilities for people with mental health problems
• Subsidies to leisure centres for people on limited or low incomes
• Increased provision of exercise in mental health services, for instance as part of care treatment plans

In separate research, gym users with no mental health problems were quizzed about their attitudes to exercise.
Seven out of ten gym members thought their general mental well being would suffer if they stopped exercising.
One in three reported that exercise improved their performance at work.
Mind is launching a new booklet, the Mind guide to physical activity.

Mental Health Benefits of Exercise

Do you think exercise is only good for developing a lean body, strong muscles and a strong heart?  Well, think again about Health and Fitness!  Physical activity has been shown to help with being emotionally and mentally fit also.

While the majority of fitness research efforts focus on the physical and health benefits of exercise, there is a growing body of work demonstrating that exercise promotes wellness and mental health.  Researchers at Duke University studied people suffering from depression for 4 months and found that 60% of the participants who exercised for 30 minutes three times a week overcame their depression without using antidepressant medication.  This is the same percentage rate as for those who only used medication in their treatment for depression.

You don't have to be suffering from a clinical or diagnosed Mental Illness to get substantial mental health benefits from exercise and fitness.  One study found that short workouts of 8 minutes in length could help lower sadness, tension and anger along with improving resistance to disease in healthy people.  Many people exercise to boost confidence along with reducing anxiety and stress, all of which contribute to psychological health and well-being.  So, exercise can be viewed as a preventative or wellness activity that may actually help prevent physical and emotional conditions.  By the way, even short bursts of activity help individuals feel better, which means that you don't have to spend hours at the gym to gain real mental health benefits.

Judith Easton, personal training director and instructor in mindfulness meditation at Galter Life Center in Chicago, noted one reason for the feelings of well-being that are generated during and after exercise: the body's natural release of endorphins.  These chemicals released by the brain are the body's natural painkillers and can lead to an increase in feelings of happiness.  "Exercise leads to an increase in energy and to better sleeping patterns, which may also explain why it is so helpful to people with depression.  Low energy and poor sleep are common symptoms of depression."

Clinical psychologist Eliezer Margoles, Ph.D. stated that feeling joyful and the pleasure of being in one's body is very beneficial.  He urged people to "take time out, and instead of saying no to exercise say no to something else." He also cautioned against a "punitive mindset" in which some people engage during exercise, viewing it as a task or punishment instead of a pleasure.  Instead, he recommends that you view movement as an affirmation of living and a function to maintain wellness.

Meditation and yoga, though more nontraditional, also lend themselves to using the body to achieve optimal levels of mental health.  Both "answer the need to have down time along with the need to quiet down and look within" according to Judith Easton.  This is especially important, she noted, because "in the year 2000 people absorb more information in one day than a person in the 1400s absorbed in an entire lifetime". Easton noted that "technology, including cell phones, faxes and computers, along with the mentality of moving quicker and constantly doing things, tends to lead to people forgetting that this inward focus is necessary and vital to mental health".  Yoga participants often say they feel more centered and calm, along with the physical benefits of stretching and building strength.

Elements of a successful program of physical activity

Val Mayes (2006) draws upon her experience as the executive director of the Edmonton Chamber of Voluntary Organizations to recommend affordable (preferably free) physical activity programs that are accessible, close to public transportation, and non-threatening (in the sense that no special skills are required for participation). She also maintains that the importance of appropriately trained staff who know how to support and motivate mentally ill clients (e.g., by using reinforcements such as prizes) cannot be underestimated. In terms of the psychoeducational component of such a program, she promotes the use of plain language and visual models. Another identified doorway to success is to partner with other mental health organizations: “Collaborations do bring more resources to the table and do enrich those who take part” (Mayes, 2006, PowerPoint slide 17).
Mayes (2006) and Camann (2001) both mention that a program that takes into consideration Prochaska and Diclemente’s (1992) stages-of-change model and its various facilitative processes (consciousness-raising, social liberation/societal support, dramatic relief, and stimulus control) is a step closer to success.
In harmony with that model, Camann (2001) advocates that making the program voluntary would be vital to its success. Richardson and colleagues (2005) summarize several additional factors (p. 327):

• "Programs that deliver exercise prescriptions or motivational messages in printed form or by computer are more effective than face-to-face counselling alone."
• "Participants need to set goals and self-monitor achievement in order to successfully change their behaviour — use daily paper longs, Web-based logging systems, plus objective monitoring devices such as pedometers and heart rate monitors.... Feedback is a critical component of self-monitoring and self-regulation."
• Facilitators need to take advantage of "opportunities for some individualized attention and recognition."
• "Enthusiastic, knowledgeable and supportive exercise leaders are as important as the actual exercise program."
• Decreasing the perceived risk of injury can improve attendance.

When formulating community-based interventions, it is also worthwhile to take into account "the infrastructure and social structures around individuals that greatly affect both collective and individual change" (Edwards, 2000, p. 22). Indeed, change interventions are more successful when individual, network, organizational, community and societal levels are supportive of the new program (also p. 22).

Issues of adherence

In the general population, adherence to physical activity programs drops off after six months to half of the original number of participants. It would be unreasonable to expect better from programs for mentally ill persons, who have additional barriers to regular attendance (e.g., illness exacerbation, issues surrounding autonomy/independence, increased motivational problems) (Richardson et al., 2005, p. 328). Martinsen (1993) found that if physical activity programs are integrated into psychiatric services, then the adherence rate is similar to that of the general public.

Barriers to implementing and accessing physical activity programs

The consensus in the research community that regular physical activity is fruitful in the prevention and treatment of mental illness is strengthening. Nevertheless, there are few programs that implement these research suggestions, and those that exist are often fragmented (Richardson et al., 2005). In their insightful article, "Exercise and Mental Health: It’s Just Not Psychology!" Faulkner and Biddle (2001) identified three challenges to the integration of physical activity into mental health programs:

• Mental health clinics' lack of knowledge about the therapeutic benefits of exercise
• The perceived simplicity of these programs
• An incompatibility of exercise programs with traditional treatments

During a "Mental Health and Physical Activity" workshop in Alberta (Berry, 2006), various mental-health practitioners added to that list of challenges. They argued that "quality of life, normalization of the disease, and recognition of mental illness as a chronic problem [are] key to moving forward. This group recognized that for many of these clients, obesogenic environments (i.e., environments that foster physical inactivity and poor diet) [are] a problem. They recommended emphasizing small, manageable changes. This group felt that 'the system' (i.e., policy-makers) needs to be educated on this topic and recommends forging links between researchers and practitioners and using an integrated teamwork approach" (Berry, 2006, p. 4).
Even after problems about the implementation of physical activity programs in institutional settings are settled, mentally ill people may encounter other barriers. Issues such as motivation, fear of injury, childcare support (Edwards, 2000, p. 22), transportation, available time, social support, and stigma (Berry, 2006) may need to be dealt with. Indeed, in her insightful public presentation, "Reality Check," Val Mayes (2006) identifies similar barriers that she encountered while trying to implement a diabetes prevention program for persons with chronic mental illness. One additional, emerging issue that came to her attention has to do with the changing health care system, and how it disrupted the mental health workers’ schedule to such a degree that they could not appropriately engage in the program. She concludes that staff who are overworked and stressed constitute an additional barrier, for they are not in the position to adequately support their clients' integration into new programs such as those promoting physical activity.

The importance of physical activity in mental-health research

Considering the wealth of the research results mentioned above, it is worthwhile to mention that the growth rate of this interdisciplinary field is so great that an international, peer-reviewed journal has recently been created for this subject alone. In their inaugural editorial, the co-editors of the Journal of Mental Health and Physical Activityem> (MENPA), Adrian H. Taylor and Guy Faulkner, state that beyond the research evidence pointing at the effectiveness of physical activity in the prevention and treatment of mental illness, there are four additional reasons why physical activity should be considered a potential mental-health promotion strategy:

1. Physical activity is more cost-effective than either psychopharmacological or psychotherapeutic interventions. If appropriate, "physical activity may be a cost-effective alternative for those who prefer not to use medication or who cannot access therapy."
2. "In contrast to pharmacological interventions, physical activity is associated with minimal adverse side-effects."
3. "Physical activity can be indefinitely sustained by the individual, unlike pharmacological and psychotherapeutic treatments, which often have a specified endpoint."
4. "Physical activity stands apart from more traditional treatments and therapies for mental health problems because it has the potential to simultaneously improve health and well-being and tackle mental illness.”

This last point is especially important when one considers issues like the cardiovascular and diabetes comorbidity problems experienced by people with mental illness. For example, persons with schizophrenia tend to die not from schizophrenia, per se, but rather from comorbid cardiovascular problems — which may be directly improved through regular physical activity (Faulkner, 2006).
Physical activity plays role in the recovery of mental health. Richardson and co-authors (2005) add two further reasons why physical activity program should be included in psychiatric services:

• The opportunity for individuals with mental illness to have frequent contact with their mental health service providers. As Richardson and colleagues wrote, "...changing health behaviours can be difficult, and frequent reinforcement can play a critical role in the successful long-term adoption of regular physical activity (p. 328)."
• Specific mental illness barriers may be best addressed by people trained in the mental health field.

Exercise as it relates to specific conditions

Dementia

• Physical activity, it has been shown, is inversely associated with cognitive decline. Case-control studies tend to show a slight beneficial influence of physical activity against Alzheimer’s disease. Prospective analyses (similar to longitudinal studies) tend to show a more convincing protective effect of physical activity against Alzheimer’s as well as against all forms of dementia combined. No evidence of harmful effects from physical activity or exercise (including vigorous exercise) is evident (Laurin et al., 2005).

Depression, anxiety and stress

• Physical activity has been found to improve mental health conditions, particularly anxiety, depression and general well-being (Schmitz et al., 2004).
• Exercise has a low-to-moderate effect in reducing anxiety. Exercise training can reduce trait anxiety; single exercise sessions can reduce state anxiety. Single sessions of moderate exercise can reduce short-term physiological reactivity to brief psychosocial stressors and enhance recovery (Taylor, 2000). The strongest anxiety-reduction effects are shown in randomized controlled trials.
• Exercise decreases depression. Epidemiological evidence shows that physical activity is associated with a decreased risk of developing clinically defined depression. Experimental studies have shown that aerobic and resistance exercise may be used to treat moderate and more severe depression, usually as an adjunct to standard treatment. The anti-depressant effect of exercise can be of the same magnitude as that found for other psychotherapeutic interventions. No negative effects of exercise have been noted in depressed populations (Mutrie, 2000).
• Persons who have experienced coronary heart failure (CHF) undergo a dramatic reduction in their quality of life, which commonly causes them anxiety and depression. Clinical trials involving these patients have observed marked improvements in exercise capacity. The evidence suggests that exercise can play an important role in improving function and quality of life of patients with CHF (Lloyd-Williams & Mair, 2005).
• Aerobic exercise training has anxiolytic and antidepressant effects (Salmon, 2000).
• Habitual exercise in adolescents correlates with low depression scores (Norris et. al., 1992). A study of 16,483 university undergraduates likewise found that exercise correlated with lower levels of depression (Steptoe et al., 1997).
• In a general population sample of 55,000 a self-reported correlation between recreational physical activity and better mental health was found, including fewer symptoms of depression and anxiety (Stephens, 1988).
• Aerobic activity shown to specifically reduce depression in two well-controlled studies of 10–11 weeks of walking and running in two populations selected for exposure to stress or high anxiety (Steptoe et al., 1989; Roth et al., 1987, as cited in Salmon, 2000).
• Exercise training (in comparison to strength and flexibility training) reduced anxious mood in subjects with high anxiety. Follow-up revealed that the effect persisted over three months (Steptoe et al., 1989).
• Symptoms of anxiety and depression gradually increased over the two weeks after the cessation of regular running (Morris et al., 1990).
• Exercise therapy is significantly associated with therapeutic benefit among people with major depressive disorder, particularly if it is continued over time. It may in fact be at least as effective as standard pharmacotherapy. Participants in the exercise group were less likely to relapse then those in other groups receiving medication. Each 50-minute increment of exercise per week was associated with a 50% decrease in the risk of being classified as depressed (Babyak et al., 2000).
• Regular aerobic exercise alone is associated with clinical improvement in patients suffering from panic disorder, but one that is less than treatment with clomipramine. Depressive symptoms were also improved by exercise and clomipramine treatment (Broocks et al., 1998).
• Regular exercise can have positive effects on psychopathologic outcomes (i.e., anxiety, depression and self-esteem) in adult and non-obese child populations (N. Mutrie, 1998, and A. Steptoe, 1996, as cited in Daley et al., 2006). Obese adolescent girls who participated in aerobic exercise have lower depression scores then girls allocated to other types of exercise or to usual care (S. G. Stella, 2005, as cited in Daley et al., 2006).
• Physical activity was associated with a decreased likelihood of depression in a survey of 9,938 school-age children. Male youths were more likely to participate in physical activity and less likely to feel depressed (Goodwin, 2006).
• In a population sample of 19,288 adolescent and adult twins and their families, exercisers were found on average to be less anxious, depressed and neurotic (DeMoor et al., 2006).
• Sufficient evidence has been found for the effectiveness of exercise in the treatment of clinical depression. Exercise has a moderate reducing effect on state and trait anxiety. Aerobic and resistance exercise enhance mood states (Fox, 1999).
• Aerobic exercise training protects against the emotional and physiological consequences of stress (Salmon, 2000).
• Balance of evidence suggests that sensitivity to stress is reduced after exercise training (Salmon, 2000).
• The negative impact of life events was significantly lower among students who exercised regularly than among those who rarely exercised (Brown & Lawton, 1986).
• Adolescents who reported exercising more also self-reported less stress and depression. Adolescents in the study who were part of the high-intensity exercise group reported less perceived stress than those groups that participated in moderate-intensity exercise, flexibility training, or no exercise program at all (the control group). In the high-intensity exercise group, the relationship between perceived stress and anxiety and depression was considerably weakened after the exercise program (Norris et al., 1992).

Eating disorders

• Exercise was found to be more effective than cognitive–behavioural therapy (CBT) in reducing drive for thinness, bulimic symptoms (both binge eating and vomiting) and body dissatisfaction among subjects with eating disorders (Sundgot-Borgen et al., 2002).
• Women participating in exercise groups significantly reduced obligatory attitudes toward exercise relative to the comparison group. Moreover, anorexic women in the exercise group gained one-third more weight than those in the comparison group (Calogero & Pedrotty, 2004).
• Studies have found that exercise has a positive effect on the success of cognitive behavioural therapy (Fossati et al., 2004; Pendleton et al., 2002).

Schizophrenia

• The high incidence of obesity and other morbid conditions is strongly related to physical inactivity in this population. Existing research on the psychological benefits of exercise participation has many methodological flaws and tends to be of pre-experimental design. There is tentative evidence that participating in exercise is associated with an alleviation of negative symptoms associated with schizophrenia, such as depression, low self-esteem, and social withdrawal. There is less evidence that exercise may be a useful coping strategy for dealing with positive symptoms, such as auditory hallucinations (Faulkner, 2005).

Drug and alcohol rehabilitation

• When administered as an adjunct in alcohol rehabilitation, exercise regimens definitely have positive effects on aerobic fitness and strength. Evidence for the benefits of exercise during drug rehabilitation is less substantial. In either field of rehabilitation, the links at present between exercise and improved self-esteem, better abstinence, controlled consumption levels, and reductions in anxiety and depression are equivocal (Donaghy & Ussher, 2005).
• Physical exercise was found to be associated with health-related quality of life among persons with anxiety, affective, substance abuse or dependence disorders (Schmitz et al., 2004).

Health factors affected by exercise

Emotion and mood

Physical activity and exercise have consistently been associated with positive mood and affect. A direct relation between physical activity and psychological well-being has been confirmed in several large-scale epidemiological surveys, including in the UK, by means of various measures of activity and well-being.

• Meta-analytic evidence shows that aerobic exercise leads to a small to moderate increase in vigour; a decrease of similar magnitude in tension, depression, fatigue, and confusion; and a small decrease in anger.
• Experimental trials support a positive effect for exercise of moderate intensity on psychological well-being (Biddle, in Biddle, Fox, & Boutcher, 2000).

Quality of life

• Higher levels of physical activity were associated with greater health-related quality of life among persons with diagnosed mental disorders. Quality of life was considered across eight dimensions: vitality, social functioning, mental health, role limitations related to emotional health, those related to physical health, bodily pain, physical function, and general health. Researchers (Schmitz et al., 2004) observed a spectrum of improvements and cautiously concluded that "physical activity can be beneficial for people suffering from mental disorders."
• High-intensity aerobic exercise has shown positive effects on the well-being of adolescents (Norris et al., 1992).

Self-esteem

• Exercise is a means to promote physical self-worth and other important physical self-perceptions, such as body image. In some situations this improvement is accompanied by improved self-esteem. Physical self-worth carries mental well-being properties in its own right and should be considered one of the valuable end-points of exercise programs.
• The positive effects of exercise on self-perceptions can be experienced by all age groups, but the strongest evidence for change has been established for children and middle-aged adults.
• Several types of exercise are effective in changing self-perceptions, but most of the supporting research evidence clusters around aerobic exercise and resistance training, with the latter showing greater effectiveness in the short term (Fox, in Biddle, Fox, & Boutcher, 2000).
• Exercise showed positive effects on self-esteem, self-concept and depressive symptoms in a nonclinical sample of 399 youth (Garcia et al., 1997).
• Surveyed adolescents who reported that they exercise had significantly higher self-reported levels of self-esteem (Modrcin-Talbott et al., 1998). As depression scores decreased, their self-esteem scores increased. Lower self-esteem in this group of adolescents correlated significantly with more depression, older age, and non-participation in exercise.
• In a study by Hilyer and colleagues (1982) of 60 youthful offenders, physical fitness training was noted to reduce depression and anxiety, elevate low self-esteem, and promote a generally healthier psychological state.
• Participation in a supervised exercise-therapy program improved measures of self-esteem among obese and morbidly obese adolescents over time (Daley et al., 2006).

Social activity/sense of mastery

• Effects of exercise programs included improved body image, feelings of mastery brought about by the completion of a physically demanding program, and a variety of group dynamic effects (Norris et al., 1992).
• Benefits of an exercise program may be attributable, in part, to the social support aspects of the program (Babyak et al., 2000).
• Because solitary exercise does not improve depression (Hughes et. al., 1986), it is critically important that exercise be accompanied by social activity.
• Exercise provides the psychological benefit of self-mastery and social integration (Salmon, 2001).
• "Mastery experiences and successes with physical activity can be meaningful in improving self-esteem, particularly in the developmental stage of adolescence" (Calfas & Taylor, 1994, p. 417).

Sleep

• Individuals who exercise regularly have a lower risk of disturbed sleep, but the causal relations are less well established. Regular exercise training may improve the sleep of persons with disturbed sleep patterns, although there is no clear consensus. Acute exercise elicits a modest improvement in sleep among good sleepers; this effect is greater for longer exercise durations. The influence of acute exercise on sleep is similar for fit and unfit people. Time of day or intensity of exercise have little moderating influence (Youngstedt & Freelove-Charton, in Faulkner & Taylor, 2005).

Cognitive functioning

• Most cross-sectional studies show that older adults who are fit display better cognitive performance than those who are less fit. The association between fitness and cognitive performance is task-dependent, with tasks that are rapid and demand attention (e.g., reaction-time tasks) having the most pronounced effects. Results of intervention studies are equivocal, but meta-analysis of their findings indicates a small but statistically significant improvement in cognitive functioning among older adults who increase their aerobic fitness (Boutcher, 2000).

Introduction

Even recently, much of western medical care has treated ailments of the mind and the body as separate fields of study, in a sort of Cartesian dualism. As Timothy Smith points out, "...minds are [too often] left to psychologists and psychiatrists, whereas bodies are the business of other medical specialties and related health disciplines (Smith, 2006)." Recent research in the fields of health psychology, psychosomatic medicine, neuropsychology and behavioural medicine, however, supports the usefulness of the biopsychosocial health model.
The simple fact that mentally ill people experience increased rates of co-morbid medical conditions — and die at higher rates from them, as well — is enough to challenge the validity and usefulness of the health system’s separate silos. For instance, the mind–body connection is exemplified well by the grim reality that cardiovascular disease is the major contributor to excess mortality in people with schizophrenia (Casey & Hansen, 2003). Similarly, people with depression and anxiety are at increased risk for developing cardiovascular disease (Suls & Bunde, 2005) and vice versa: People with this physical illness are at increased risk for clinically relevant emotional disorders. Moreover, the realization that people with cardiovascular disease have a worse prognosis if they also have depression (Smith & Ruiz, 2002) strengthens our understanding of the mind–body interconnection. Evidence increasingly suggests that similar relationships exist between mood disorders and various medical ailments (Evans et al., 2005), such as with HIV/AIDS (Stringer, 2005).
Although a notable number of longitudinal and cross-sectional research studies converge on the usefulness of physical activity as a preventative strategy and adjunct treatment for mental illness, the issue still seems unsettled in the eyes of many practitioners and patrons. One reason for this may be the rather cautious and ambiguous clinical recommendations of certain studies that actually found significant positive results. For instance, in their review of 14 randomized, controlled trials concerning the effectiveness of physical activity in the management of depression, Lawlor and Hopker (2001, p. 767) found that the effect of exercise was similar to that of cognitive therapy. Yet, their conclusion was that "the effectiveness of reducing symptoms of depression cannot be determined because of a lack of good-quality research on clinical populations with adequate follow-up." Guy Faulkner is one to challenge such conclusions while at the same time addressing relevant issues about some studies' methodological weaknesses. As he wittily remarked in one of his lectures, "...the placebo effect is a boon to therapy but the bane of research" (Faulkner, 2006). Along the same line of thought, Llewelyn and Hardy (2001) reminded us that "We know psychotherapy is effective, but we also know that different and apparently contradictory theoretical approaches are approximately equally effective in outcome, but very different in content."
Understandably, it pays a researcher to be cautious; the body of research on the impacts of physical activity upon mental health has its gaps. However, as Sir Austin Bradford Hill insightfully pointed out in 1965, “… all scientific work is incomplete — whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us as a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time” (Hill, 1965, p. 299).
The basis for the Minding Our Bodies: Physical Activity for Mental Health project is that the research evidence for physical activity’s beneficial effects upon people’s physical and mental health is convincing. Physical activity has been reported to help with a wide spectrum of issues ranging from self-esteem and sense of social inclusion to clinical disorders such as schizophrenia, depression, and anxiety. Overall, there seem to be four avenues for these effects: prevention of poor mental health; improvement in mental health; treatment of mental disorders; and improvement in the quality of life of persons with mental illnesses.

Physical Activity and Mental Health Literature Review

Table of Contents

Introduction
Health factors affected by exercise
   Emotion and mood
   Quality of life
   Self-esteem
   Social activity/sense of mastery
   Sleep
   Cognitive functioning
Exercise as it relates to specific conditions
   Dementia
   Depression, anxiety and stress
   Eating disorders
   Schizophrenia
   Drug and alcohol rehabilitation
The importance of physical activity in mental-health research
Barriers to implementing and accessing physical activity programs
Elements of a successful program of physical activity
   Issues of adherence
   How much exercise is required for mental health?
Useful definitions
References

Increase Your Chances of Living Longer

Science shows that physical activity can reduce your risk of dying early from the leading causes of death, like heart disease and some cancers. This is remarkable in two ways:

1. Only a few lifestyle choices have as large an impact on your health as physical activity. People who are physically active for about 7 hours a week have a 40 percent lower risk of dying early than those who are active for less than 30 minutes a week. 
2. You don't have to do high amounts of activity or vigorous-intensity activity to reduce your risk of premature death.  You can put yourself at lower risk of dying early by doing at least 150 minutes a week of moderate-intensity aerobic activity.

Everyone can gain the health benefits of physical activity - age, ethnicity, shape or size do not matter.

Improve Your Ability to do Daily Activities and Prevent Falls

A functional limitation is a loss of the ability to do everyday activities such as climbing stairs, grocery shopping, or playing with your grandchildren.
How does this relate to physical activity? If you're a physically active middle-aged or older adult, you have a lower risk of functional limitations than people who are inactive
Already have trouble doing some of your everyday activities? Aerobic and muscle-strengthening activities can help improve your ability to do these types of tasks.

Improve Your Mental Health and Mood

Regular physical activity can help keep your thinking, learning, and judgment skills sharp as you age. It can also reduce your risk of depression and may help you sleep better. Research has shown that doing aerobic or a mix of aerobic and muscle-strengthening activities 3 to 5 times a week for 30 to 60 minutes can give you these mental health benefits. Some scientific evidence has also shown that even lower levels of physical activity can be beneficial.

Strengthen Your Bones and Muscles

As you age, it's important to protect your bones, joints and muscles. Not only do they support your body and help you move, but keeping bones, joints and muscles healthy can help ensure that you're able to do your daily activities and be physically active.  Research shows that doing aerobic, muscle-strengthening and bone-strengthening physical activity of at least a moderately-intense level can slow the loss of bone density that comes with age.
Hip fracture is a serious health condition that can have life-changing negative effects, especially if you're an older adult. But research shows that people who do 120 to 300 minutes of at least moderate-intensity aerobic activity each week have a lower risk of hip fracture.
Regular physical activity helps with arthritis and other conditions affecting the joints. If you have arthritis, research shows that doing 130 to 150 (2 hours and 10 minutes to 2 hours and 30 minutes) a week of moderate-intensity, low-impact aerobic activity can not only improve your ability to manage pain and do everyday tasks, but it can also make your quality of life better.

Build strong, healthy muscles. Muscle-strengthening activities can help you increase or maintain your muscle mass and strength. Slowly increasing the amount of weight and number of repetitions you do will give you even more benefits, no matter your age.

Reduce Your Risk of Some Cancers

Being physically active lowers your risk for two types of cancer: colon and breast. Research shows that:

• Physically active people have a lower risk of colon cancer than do people who are not active.
• Physically active women have a lower risk of breast cancer than do people who are not active.

Reduce your risk of endometrial and lung cancer. Although the research is not yet final, some findings suggest that your risk of endometrial cancer and lung cancer may be lower if you get regular physical activity compared to people who are not active. 
Improve your quality of life. If you are a cancer survivor, research shows that getting regular physical activity not only helps give you a better quality of life, but also improves your physical fitness.

Reduce your risk of Type 2 Diabetes and Metabolic Syndrome

Regular physical activity can reduce your risk of developing type 2 diabetes and metabolic syndrome. Metabolic syndrome is a condition in which you have some combination of too much fat around the waist, high blood pressure, low HDL cholesterol, high triglycerides, or high blood sugar. Research shows that lower rates of these conditions are seen with 120 to 150 minutes (2 hours to 2 hours and 30 minutes) a week of at least moderate-intensity aerobic activity. And the more physical activity you do, the lower your risk will be.

Reduce Your Risk of Cardiovascular Disease

Heart disease and stroke are two of the leading causes of death in the United States. But following the Guidelines and getting at least 150 minutes a week (2 hours and 30 minutes) of moderate-intensity aerobic activity can put you at a lower risk for these diseases. You can reduce your risk even further with more physical activity. Regular physical activity can also lower your blood pressure and improve your cholesterol levels.

To lose weight and keep it off

To lose weight and keep it off: You will need a high amount of physical activity unless you also adjust your diet and reduce the amount of calories you're eating and drinking. Getting to and staying at a healthy weight requires both regular physical activity and a healthy eating plan. The CDC has some great tools and information about nutrition, physical activity and weight loss. For more information, visit Healthy Weight.

To maintain your weight

To maintain your weight: Work your way up to 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorous-intensity aerobic activity, or an equivalent mix of the two each week. Strong scientific evidence shows that physical activity can help you maintain your weight over time. However, the exact amount of physical activity needed to do this is not clear since it varies greatly from person to person. It's possible that you may need to do more than the equivalent of 150 minutes of moderate-intensity activity a week to maintain your weight.

Control Your Weight

Looking to get to or stay at a healthy weight? Both diet and physical activity play a critical role in controlling your weight. You gain weight when the calories you burn, including those burned during physical activity, are less than the calories you eat or drink. For more information see our section on balancing calories. When it comes to weight management, people vary greatly in how much physical activity they need. You may need to be more active than others to achieve or maintain a healthy weight.

If you have a chronic health condition

If you have a chronic health condition such as arthritis, diabetes, or heart disease, talk with your doctor to find out if your condition limits, in any way, your ability to be active. Then, work with your doctor to come up with a physical activity plan that matches your abilities. If your condition stops you from meeting the minimum Guidelines, try to do as much as you can. What's important is that you avoid being inactive. Even 60 minutes a week of moderate-intensity aerobic activity is good for you.

Physical Activity and Health

If you're not sure about becoming active or boosting your level of physical activity because you're afraid of getting hurt, the good news is that moderate-intensity aerobic activity, like brisk walking, is generally safe for most people.
Start slowly. Cardiac events, such as a heart attack, are rare during physical activity. But the risk does go up when you suddenly become much more active than usual. For example, you can put yourself at risk if you don't usually get much physical activity and then all of a sudden do vigorous-intensity aerobic activity, like shoveling snow. That's why it's important to start slowly and gradually increase your level of activity.

Some studies haveSome studies have found that exercise boosts activity found that exercise boosts activity

Some studies have found that exercise boosts activity in the brain's frontal lobes and the hippocampus. We don't really know how or why this occurs. Animal studies have found that exercise increases levels of serotonin, dopamine and norepinephrine. These neurotransmitters have been associated with elevated mood, and it is thought that antidepressant medications also work by boosting these chemicals.
Exercise has also been found to increase levels of "brain-derived neurotrophic factor" (BDNF). This substance is thought to improve mood, and it may play a role in the beneficial effects of exercise. BDNF's primary role seems to be to help brain cells survive longer, so this may also explain some of the beneficial effects of exercise on dementia.
The bottom line is that most of us feel good after exercise. Physical exercise is good for our mental health and for our brains. Someday we will understand it all better -- but we can start exercising today.
_{Sources:
John Briley. "Feel Good After a Workout? Well, Good for You." The Washington Post, Tuesday, April 25, 2006.
James A. Blumenthal, et al. "Effects of Exercise Training on Older Patients With Major Depression." Archives of Internal Medicine, October 25, 1999.
Michael Babyak, et al. "Exercise Treatment for Major Depression: Maintenance of Therapeutic Benefit at 10 Months." Psychosomatic Medicine, September/October 2000}

How Does Exercise Improve Mental Health?

We know that exercise has positive effects on the brain. Researchers at Duke University demonstrated several years ago that exercise has antidepressant properties. Other research has shown that exercise can improve the brain functioning of the elderly and may even protect against dementia. How does exercise improve mental health?
One theory for some of the benefits of exercise include the fact that exercise triggers the production of endorphins. These natural opiates are chemically similar to morphine. They may be produced as natural pain relievers in response to the shock that the body receives during exercise. However, researchers are beginning to question whether endorphins improve mood. Studies are showing that the body's metabolism of endorphins is complex, and there are likely additional mechanisms involved in the mental health effects of exercise.

How active do I need to be?

You should aim to do 30 minutes of moderate exercise five times a week. It may sound like a lot, but it isn’t as daunting as it first appears.
Moderate exercise means being energetic enough so you:

• breathe a little heavier than normal, but aren’t out of breath
• feel warmer, but don’t end up hot and sweaty.

You don’t have to leap in at the full amount.

• Build up slowly at a pace that suits you
• You don’t have to do a solid half hour either. Find three ten-minute slots each day if that suits you – or two quarter hours.

Exercise and Mental Health

Physical activity is also good for your mental health. Experts believe that exercise releases chemicals in your brain that make you feel good. Regular exercise can also boost your self-esteem and help you concentrate, sleep, look and feel better.
 "When I left the gym that morning I felt as if someone had given me a million pounds – it was the sense of achievement."
Being active doesn’t have to mean going to the gym, taking up jogging or wearing lycra. There are lots of ways to be active - and they don’t need to cost much money.
As well as releasing natural chemicals that improve your mood and make you feel happier, having an active lifestyle can do more to help your mental health.
Taking part in physical activities offers many opportunities. It’s a great way to meet people. And it can be a chance to give yourself a well-deserved break from the hustle and bustle of daily life – to find some quiet time.
Leading an active life can help raise your self-worth and improve your confidence. It can help you feel valued – and value yourself.
Exercise and physical activity can provide something worthwhile in your life. Something that you really enjoy, that gives you a goal to aim for and a sense of purpose.
Here are a few of the benefits:

Physical activity and mental health

Physical activity is an important public health tool used in the treatment and prevention of various physical diseases, as well as in the treatment of some psychiatric diseases such as depressive and anxiety disorders. However, studies have shown that in addition to its beneficial effects, physical activity can also be associated with impaired mental health, being related to disturbances like "excessive exercise" and "overtraining syndrome". Although the number of reports of the effects of physical activity on mental health is steadily increasing, these studies have not yet identified the mechanisms involved in the benefits and dangers to mental health associated with exercise. This article reviews the information available regarding the relationship between physical activity and mental health, specifically addressing the association between exercise and mood.

OTHER VARIABLES ASSOCIATED WITH MENTAL HEALTH

Positive mood . The Surgeon General’s Report also mentions the possibility of exercise improving mood. Unfortunately the area of increased positive mood as a result of acute and chronic exercise has only recently been investigated and therefore there are no meta-analytic reviews in this area. Many investigators are currently examining this subject and many of the preliminary results have been encouraging. It remains to be seen if the additive effects of these studies will result in conclusions that are as encouraging as the relationship between exercise and the alleviation of negative mood states like anxiety and depression.
Self-esteem . Related to the area of positive mood states is the area of physical activity and self-esteem. Although narrative reviews exist in the area of physical activity and enhancement of self-esteem, there are currently four meta-analytic reviews on this topic (Calfas & Taylor, 1994; Gruber, 1986; McDonald & Hodgdon, 1991; Spence, Poon, & Dyck, 1997). The number of studies in these meta-analyses ranged from 10 studies (Calfas & Taylor, 1994) to 51 studies (Spence et al., 1997). All four of the reviews found that physical activity/exercise brought about small, but statistically significant, increases in physical self-concept or self-esteem. These effects generalized across gender and age groups. In comparing self-esteem scores in children, Gruber (1986) found that aerobic fitness produced much larger effects on self-esteem scores than other types of physical education class activities (e.g., learning sports skills or perceptual-motor skills). Gruber (1986) also found that the effect of physical activity was larger for handicapped compared to nonhandicapped children.
Restful sleep . Another area associated with positive mental health is the relationship between exercise and restful sleep. Two meta-analyses have been conducted on this topic (Kubitz, Landers, Petruzzello, & Han, 1996; O’Connor & Youngstedt, 1995). The studies reviewed have primarily examined sleep duration and total sleep time as well as measures derived from electroencephalographic (EEG) activity while subjects are in various stages of sleep. Operationally, sleep researchers have predicted that sleep duration, total sleep time, and the amount of high amplitude, slow wave EEG activity would be higher in physically fit individuals than those who are unfit (i.e., chronic effect) and higher on nights following exercise (i.e., acute effect). This prediction is based on the “compensatory” position, which posits that “fatiguing daytime activity (e.g., exercise) would probably result in a compensatory increase in the need for and depth of nighttime sleep, thereby facilitating recuperative, restorative and/or energy conservation processes” (Kubitz et al., p. 278).
     The sleep meta-analyses by O’Connor and Youngstedt (1995) and Kubitz et al. (1996) show support for this prediction. Both reviews show that exercise significantly increases total sleep time and aerobic exercise decreases rapid eye movement (REM) sleep. REM sleep is a paradoxical form in that it is a deep sleep, but it is not as restful as slow wave sleep (i.e., stages 3 and 4 sleep). Kubitz et al. (1996) found that acute and chronic exercise was related to an increase in slow wave sleep and total sleep time, but was also related to a decrease in sleep onset latency and REM sleep. These findings support the compensatory position in that trained subjects and those engaging in an acute bout of exercise went to sleep more quickly, slept longer, and had a more restful sleep than untrained subjects or subjects who did not exercise. There were moderating variables influencing these results. Exercise had the biggest impact on sleep when: (a) the individuals were female, low fit, or older; (b) the exercise was longer in duration; and (c) the exercise was completed earlier in the day (Kubitz et al., 1996).

EXERCISE AND DEPRESSION

Depression is a prevalent problem in today’s society. Clinical depression affects 2–5% of Americans each year (Kessler et al., 1994) and it is estimated that patients suffering from clinical depression make up 6–8% of general medical practices (Katon & Schulberg, 1992). Depression is also costly to the health care system in that depressed individuals annually spend 1.5 times more on health care than nondepressed individuals, and those being treated with antidepressants spend three times more on outpatient pharmacy costs than those not on drug therapy (Simon, VonKorff, & Barlow, 1995). These costs have led to increased governmental pressure to reduce health care costs in America. If available and effective, alternative low-cost therapies that do not have negative side effects need to be incorporated into treatment plans. Exercise has been proposed as an alternative or adjunct to more traditional approaches for treating depression (Hales & Travis, 1987; Martinsen, 1987, 1990).
     The research on exercise and depression has a long history of investigators (Franz & Hamilton, 1905; Vaux, 1926) suggesting a relationship between exercise and decreased depression. Since the early 1900s, there have been over 100 studies examining this relationship, and many narrative reviews on this topic have also been conducted. During the 1990s there have been at least five meta-analytic reviews (Craft, 1997; Calfas & Taylor, 1994; Kugler et al., 1994; McDonald & Hodgdon, 1991; North, McCullagh, & Tran, 1990) that have examined studies ranging from as few as nine (Calfas & Taylor, 1994) to as many as 80 (North et al., 1990). Across these five meta-analytic reviews, the results consistently show that both acute and chronic exercise are related to a significant reduction in depression. These effects are generally “moderate” in magnitude (i.e., larger than the anxiety-reducing effects noted earlier) and occur for subjects who were classified as nondepressed, clinically depressed, or mentally ill. The findings indicate that the antidepressant effect of exercise begins as early as the first session of exercise and persists beyond the end of the exercise program (Craft, 1997; North et al., 1990). These effects are also consistent across age, gender, exercise group size, and type of depression inventory.
     Exercise was shown to produce larger antidepressant effects when: (a) the exercise training program was longer than nine weeks and involved more sessions (Craft, 1997; North et al., 1990); (b) exercise was of longer duration, higher intensity, and performed a greater number of days per week (Craft, 1997); and (c) subjects were classified as medical rehabilitation patients (North et al., 1991) and, based on questionnaire instruments, were classified as moderately/severely depressed compared to mildly/moderately depressed (Craft, 1997). The latter effect is limited since only one study used individuals who were classified as severely depressed and only two studies used individuals who were classified as moderately to severely depressed. Although limited at this time, this finding calls into question the conclusions of several narrative reviews (Gleser & Mendelberg, 1990; Martinsen, 1987, 1993, 1994), which indicate that exercise has antidepressant effects only for those who are initially mild to moderately depressed.
     The meta-analyses are inconsistent when comparing exercise to the more traditional treatments for depression, such as psychotherapy and behavioral interventions (e.g., relaxation, meditation), and this may be related to the types of subjects employed. In examining all types of subjects, North et al. (1990) found that exercise decreased depression more than relaxation training or engaging in enjoyable activities, but did not produce effects that were different from psychotherapy. Craft (1997), using only clinically depressed subjects, found that exercise produced the same effects as psychotherapy, behavioral interventions, and social contact. Exercise used in combination with individual psychotherapy or exercise together with drug therapy produced the largest effects; however, these effects were not significantly different from the effect produced by exercise alone (Craft, 1997).
     That exercise is at least as effective as more traditional therapies is encouraging, especially considering the time and cost involved with treatments like psychotherapy. Exercise may be a positive adjunct for the treatment of depression since exercise provides additional health benefits (e.g., increase in muscle tone and decreased incidence of heart disease and obesity) that behavioral interventions do not. Thus, since exercise is cost effective, has positive health benefits, and is effective in alleviating depression, it is a viable adjunct or alternative to many of the more traditional therapies. Future research also needs to examine the possibility of systematically lowering antidepressant medication dosages while concurrently supplementing treatment with exercise.

ANXIETY REDUCTION FOLLOWING EXERCISE

It is estimated that in the United States approximately 7.3% of the adult population has an anxiety disorder that necessitates some form of treatment (Regier et al., 1988). In addition, stress-related emotions, such as anxiety, are common among healthy individuals (Cohen, Tyrell, & Smith, 1991). The current interest in prevention has heightened interest in exercise as an alternative or adjunct to traditional interventions such as psychotherapy or drug therapies.
     Anxiety is associated with the emergence of a negative form of cognitive appraisal typified by worry, self-doubt, and apprehension. According to Lazarus and Cohen (1977), it usually arises “...in the face of demands that tax or exceed the resources of the system or ... demands to which there are no readily available or automatic adaptive responses” (p. 109). Anxiety is a cognitive phenomenon and is usually measured by questionnaire instruments. These questionnaires are sometimes accompanied by physiological measures that are associated with heightened arousal/anxiety (e.g., heart rate, blood pressure, skin conductance, muscle tension). A common distinction in this literature is between state and trait questionnaire measures of anxiety. Trait anxiety is the general predisposition to respond across many situations with high levels of anxiety. State anxiety, on the other hand, is much more specific and refers to the person’s anxiety at a particular moment. Although “trait” and “state” aspects of anxiety are conceptually distinct, the available operational measures show a considerable amount of overlap among these subcomponents of anxiety (Smith, 1989).
     For meta-analytic reviews of this topic, the inclusion criterion has been that only studies examining anxiety measures before and after either acute or chronic exercise have been included in the review. Studies with experiment-imposed psychosocial stressors during the postexercise period have not been included since this would confound the effects of exercise with the effects of stressors (e.g., Stoop color-word test, active physical performance). The meta-analysis by Schlicht (1994), however, included some stress-reactivity studies and therefore was not interpretable.
     Landers and Petruzzello (1994) examined the results of 27 narrative reviews that had been conducted between 1960 and 1991 and found that in 81% of them the authors had concluded that physical activity/fitness was related to anxiety reduction following exercise and there was little or no conflicting data presented in these reviews. For the other 19%, the authors had concluded that most of the findings were supportive of exercise being related to a reduction in anxiety, but there were some divergent results. None of these narrative reviews concluded that there was no relationship.
     There have been six meta-analyses examining the relationship between exercise and anxiety reduction (Calfas & Taylor, 1994; Kugler, Seelback, & Krüskemper, 1994; Landers & Petruzzello, 1994; Long & van Stavel, 1995; McDonald & Hodgdon, 1991; Petruzzello, Landers, Hatfield, Kubitz, & Salazar, 1991). These meta-analyses ranged from 159 studies (Landers & Petruzzello, 1994; Petruzzello et al., 1991) to five studies (Calfas & Taylor, 1994) reviewed. All six of these meta-analyses found that across all studies examined, exercise was significantly related to a reduction in anxiety. These effects ranged from “small” to “moderate” in size and were consistent for trait, state, and psychophysiological measures of anxiety. The vast majority of the narrative reviews and all of the meta-analytic reviews support the conclusion that across studies published between 1960 and 1995 there is a small to moderate relationship showing that both acute and chronic exercise reduces anxiety. This reduction occurs for all types of subjects, regardless of the measures of anxiety being employed (i.e., state, trait or psychophysiological), the intensity or the duration of the exercise, the type of exercise paradigm (i.e., acute or chronic), and the scientific quality of the studies. Another meta-analysis (Kelley & Tran, 1995) of 35 clinical trial studies involving 1,076 subjects has confirmed the psychophysiological findings in showing small (–4/–3 mm Hg), but statistically significant, postexercise reductions for both systolic and diastolic blood pressure among normal normotensive adults.
     In addition to these general effects, some of these meta-analyses (Landers & Petruzzello, 1994; Petruzzello et al., 1991) that examined more studies and therefore had more findings to consider were able to identify several variables that moderated the relationship between exercise and anxiety reduction. Compared to the overall conclusion noted above, which is based on hundreds of studies involving thousands of subjects, the findings for the moderating variables are based on a much smaller database. More research, therefore, is warranted to examine further the conclusions derived from the following moderating variables. The meta-analyses show that the larger effects of exercise on anxiety reduction are shown when: (a) the exercise is “aerobic” (e.g., running, swimming, cycling) as opposed to nonaerobic (e.g., handball, strength-flexibility training), (b) the length of the aerobic training program is at least 10 weeks and preferably greater than 15 weeks, and (c) subjects have initially lower levels of fitness or higher levels of anxiety. The “higher levels of anxiety” includes coronary (Kugler et al., 1994) and panic disorder patients (Meyer, Broocks, Hillmer-Vogel, Bandelow, & Rüther, 1997). In addition, there is limited evidence which suggests that the anxiety reduction is not an artifact “due more to the cessation of a potentially threatening activity than to the exercise itself” (Petruzzello, 1995, p. 109), and the time course for postexercise anxiety reduction is somewhere between four to six hours before anxiety returns to pre-exercise levels (Landers & Petruzzello, 1994). It also appears that although exercise differs from no treatment control groups, it is usually not shown to differ from other known anxiety-reducing treatments (e.g., relaxation training). The finding that exercise can produce an anxiety reduction similar in magnitude to other commonly employed anxiety treatments is noteworthy since exercise can be considered at least as good as these techniques, but in addition, it has many other physical benefits.

Mental health

Mental health as discussed in this paper by Dr. Daniel Landers, a leading authority on this topic, focuses on conditions sometimes considered to be illness states (i.e., pathological depression) as well as conditions that limit wellness or quality of life (i.e., anxiety, low self-esteem). To aid the reader, some basic terms used in this paper are outlined in the boxes below.

Physical Activity and Mental Health

he RCPsych is grateful to Professor Adrian Taylor, School of Sport and Health Sciences, University of Exeter, for writing this leaflet. Produced by the RCPsych's Public Education Editorial Board. Series Editor: Dr Philip Timms.

 

© January 2009. Royal College of Psychiatrists. This factsheet may be downloaded, printed out, photocopied and distributed free of charge as long as the RCPsych is properly credited and no profit is gained from its use. Permission to reproduce it in any other way must be obtained from the Head of Publications. The College does not allow reposting of its factsheets on other sites, but allows them to be linked to directly.

 

For a catalogue of public education materials or copies of our leaflets contact: Leaflets Department The Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG.  Telephone: 020 7235 2351 x259

Charity registration number 228636

Getting down to it

Any physical activity needs to be something that you can do regularly. But lots of things can stop you, especially if you feel depressed. You may feel that you:

• don't have the energy
• don’t feel confident enough
• don’t know anybody to exercise with
• don’t have the right clothes
• can’t afford it
• just aren’t the ‘exercise or sporty type’
• won't feel any differenrt for doing it.

Exercise can be about playing sport or doing hard-core exercise – if you want that. For other people, it is just about being more physically active and sitting around less. It doesn’t have to be hard – but try to do something every day. 

Some things aren't expensive – walking is free and jogging just needs a pair of trainers (cheap ones are fine). If you have a bike already, try cycling to work (or for any regular journey) – you may even save some money. 

But don’t overdo it!

If you haven’t been active for a while, doing too much when you start can make you more tired – particularly if you also have a health problem (including depression) that makes you tired. One day you may have the energy to be really active but feel completely exhausted the next.

Whatever you choose to do, start with something easy – like walking round the block. Build your level up gradually, perhaps by just doing a minute or two more – or a few metres more - each day. Try to do something most days, even if you feel tired.

Start by working out how much you do already – you can use a pedometer to show you how many steps you take every day. Or you could keep a diary for a few days of how long you spend doing active things. Then set yourself some goals. Make sure they are:
S – Specific (clear)
M – Measurable – you will know when you’ve achieved them
A – Achievable – you can achieve them
R – Relevant – they mean something to you
T - Time-based – you set yourself a time limit to achieve your goals.

They need to be things you can see yourself doing – and take pride in, so you feel good about yourself. You may be able to do it on your own, or with some help from others.

Nobody’s perfect. You will have setbacks when you can’t meet a short term goal, or just feel too tired to do anything. Recognise it when it happens, but don’t worry about it. Tomorrow is another day and short term setbacks don’t matter in the bigger picture of your longer-term goals. And, if you need to, do ask someone else to give you a hand. 

What's the downside?

Not much.  If you are normally very active, you may get depressed if, for any length of time, you can't exercise because of an injury. If this does happen, you can carry on with exercises using those parts of your body that are not injured. This will help you to keep fit, feel more in control and keep in touch with other people. It can help to set yourself targets – both for the next few days and longer, for the next weeks or months. 

Some people with eating disorders use exercise to lose too much weight.

Some athletes (such as those in weight-related sports like horse racing, boxing and gymnastics) are more likely to develop eating disorders.

Physical exercise can cause injuries and some health problems – but you are much more likely to get ill if you don't keep active. If in doubt, ask your doctor.

How well does exercise work for depression?

For mild depression, physical activity can be as good as antidepressants or psychological treatments like cognitive behavioural therapy (CBT).

It can certainly be harder to get active when you are depressed. But being active lifts your mood and gives you a sense of being in control and in touch with other people.

In some areas in the UK, GPs (family doctors) can prescribe exercise.

Exercise and Coping

If you are active you will probably find it easier to deal with life’s problems and challenges. So - if those problems stop you from regularly exercising, it’s worth remembering that finding time for exercise may well help you to deal with such problems.

Exercise can also help you to cope better by improving how you feel about yourself and getting you together with other people.

Eating and energy levels

Caffeine and high energy snacks will boost your energy quickly  - but after an hour or so you will probably feel more tired than you did before. A short walk will boost your energy level for much longer.

When should I exercise?

As regularly as you can. There will be days when you just don’t feel like exercise – you may feel tired or be too busy or anxious about something. If you keep to your routine and exercise at times like this, you will almost certainly feel better. Why?

If you are tired, exercise tends to give you energy. If you are worried, it can take your mind off your concerns for a while. Even if you can’t 'exercise', a 15 minute walk can help you to clear your mind and relax. You may find it helpful to listen to music at the same time.

It’s best not to do too much in the evening. Being active will generally help you to sleep but, if you exercise late in the evening, you may find it difficult to settle.

How much exercise is enough for me?

• Firstly – any exercise is better than none.
• BUT a moderate level of exercise seems to work best.
• This is roughly equivalent to walking fast, but being able to talk to someone at the     same time.
• You need to do about 30 minutes of moderate physical exercise on at least 5 days of every week. This can be done in one 30 minute session or broken up into shorter 10 or 15 minute sessions. 
• This can not only lower the risk of heart disease, diabetes and cancer, but also seems to help depression – so you get a double benefit.
• Don’t start suddenly - build more physical activity into your life gradually, in small steps.

Why does exercise work?

We are not yet exactly sure. There are several possibilities:

• Most people in the world have always had to keep active to get food, water and shelter. This involves a moderate level of activity and seems to make us feel good. We may be built – or “hard wired” - to enjoy a certain amount of exercise. Harder exercise (perhaps needed to fight or flight from danger) seems to be linked to feelings of stress, perhaps because it is needed for escaping from danger.     
• Exercise seems to have an effect on certain chemicals in the brain, like dopamine and serotonin. Brain cells use these chemicals to communicate with each other, so they affect your mood and thinking.
• Exercise can stimulate other chemicals in the brain called “brain derived neurotrophic factors”. These help new brain cells to grow and develop. Moderate exercise seems to work better than vigorous exercise.
• Exercise seems to reduce harmful changes in the brain caused by stress.

What might work for me?

Activity should:

• Be enjoyable – if you don’t know what you might enjoy, try a few different things
• Help you to feel more competent, or capable. Gardening or DIY projects can do this, as well getting you more active.
• Give you a sense of control over your life – that you have choices you can make (so it isn’t helpful if you start to feel that you have to exercise). The sense that you are looking after yourself can also feel good.
• Help you to escape for a while from the pressures of life.
• Be shared.  The companionship involved can be just as important as the physical activity.

What happens if you don’t do very much?

Some people can get away with doing very little and live to a ripe old age – but most of us can’t. Broadly speaking, the less you do, the more likely you are to end up with:

• low mood / depression
• tension and worry.

 If you keep active, you are:

• less likely to be depressed, anxious or tense
• more likely to feel good about yourself
• more likely to concentrate and focus better
• more likely to sleep better
• more likely to cope with cravings and withdrawal symptoms if you try to give up a habit such as smoking or alcohol
• more likely to be able to keep mobile and independent as you get older
• possibly less likely to have problems with memory and dementia.

So - don’t worry about not doing enough – get started by building a bit more physical activity into your daily life now. Even a small change can boost your morale, give you a sense of achievement and help you to feel better in yourself.

Why bother with exercise?

To work properly, your body needs regular exercise - and most of us feel good when we are active.

Until the last 100 years or so, you had to be quite active to just live your everyday life. Now, in modern Western societies, so much of what we used to do is done by machines. We drive cars, so we walk less, vacuum cleaners make cleaning easy, and washing is done by a machine. At work we may not even have to move around in the office - it’s enough to sit at the computer. It doesn’t help that modern high-energy foods make us put on too much weight – or that, (in the West at least) food has never been cheaper or easier to buy.

So how can you start to get more active, day to day? You may be turned off by the word ‘exercise’ because:

• I’ve never done it
• I wasn’t good at sports at school
• I would feel silly
• Other people would make fun of me
• It won’t help unless it hurts - ‘No pain, no gain’ 
• It’s sweaty and uncomfortable
• I’m too tired
• I would rather do something else
• It’s expensive
• I think it will make me feel worse
• I don’t have anyone to do it with
• I don’t know where, when or how to start.

But - it doesn't have to be about running around a track or working out in a gym. It can just be about being more active each day – perhaps just walking more, or taking the stairs rather than the lift. If medical problems stop you from doing one thing, there may be others that you can do.

Physical Activity and Mental Health

This leaflet is for anyone who wants to know:

• how being active can make you feel better
• how exercise can help depression
• how active you need to be to feel better
• how to get more active safely.

Introduction

Exercise keeps our hearts and bodies healthy. But how?

We often talk about the mind and body as though they are completely separate – but they aren't. The mind can’t function unless your body is working properly – but it also works the other way. The state of your mind affects your body. 

So – if you feel low or anxious, you may do less and become less active – which can make you feel worse. You can get caught in a harmful cycle:

Definition of autism about to change

Conor Doherty is turning 16 in a few weeks, but there won't be a party with friends to celebrate, as with most teens his age, and getting a driver's licence simply will be out of the question.

The Fredericton youth is autistic and, since his diagnosis at age two, has required a host of special care, including assistants to help him with school work and other activities.

At Leo Hayes High School, he has a teacher assistant who instructs him in a cubicle separate from the other students so that he can focus on the material. Otherwise, he'd have difficulty attending public school.

"He doesn't have the ability to interact with people in a significant way . . . He requires 24/7 adult supervision," said his father Harold Doherty, a labour lawyer.

But now, after years of struggling to find the kind of help his son needs, Doherty's concerned that aide may soon be in jeopardy because of proposed changes to the definition of autism. It could make it more difficult for people who would no longer meet the criteria to access health, education and other special services that experts say improve their ability to socialize and to learn.

"As I read it, there's a good chance that people like my son will not be diagnosed (with autism) in the future," said Doherty, who was part of an effort to get early-intervention services and training for teaching assistants in the New Brunswick school system for students with autism.

An expert panel appointed by the American Psychiatric Association has proposed new criteria for the definition of autism as part of its work to revise the Diagnostic and Statistical Manual of Mental Disorders, the first major updating since 1994. The D.S.M., as it's widely known, is the standard reference used by clinicians and researchers to diagnose and classify mental-health disorders worldwide.

While the final decisions about the criteria are still months away, a preliminary analysis of the proposed changes was presented last week at a meeting of the Icelandic Medical Association. The presentation sparked a debate among medical and research professionals, as well as the public, about how the proposed diagnosis criteria would affect people.

Dr. Fred R. Volkmar, director of the Child Study Center at the Yale School of Medicine and an author of the analysis of the proposal, told the New York Times that the changes would narrow the diagnosis so much that effectively, it could end the autism surge that has occurred in recent years and it would exclude many of those now diagnosed with milder forms of autism, called Asperger's disorder, or "pervasive developmental disorder not otherwise specified."

"We would nip it in the bud," he said.

But experts working on the American Psychiatric Association's panel for the new definition — a group from which Volkmar resigned — disagrees about the effects of the proposed changes, according to the Times.

Catherine Lord, a member of the committee overseeing the revisions, told the American newspaper that the goal was to ensure that autism was not used as a "fallback diagnosis" for those with an intellectual disability or aggression.

According to the American Psychiatric Association, the Neurodevelopment Work Group that has proposed the new definition has recommended a new category called autism spectrum disorder that effectively, would replace several previously separate diagnoses, including autistic disorder, Asperger's disorder, childhood disintegrative disorder and pervasive developmental disorder, not otherwise specified.

"The proposal asserts that symptoms of these four disorders represent a continuum from mild to severe, rather than a simple yes or no diagnosis to a specific disorder," states a news release from the association.

Dr. Senthil Damodharan, a Regina-based child psychiatrist who diagnoses children with autism, told the New Brunswick Telegraph-Journal that the manual is "highly influential" because it is often the first book of reference used by physicians in Canada.

He believes replacing the four categories with one disorder, autism spectrum disorder, is a positive move that's based on "current research findings" and he doesn't share the concerns raised by some other professionals, advocates and parents about the revised definition being too narrow.

"I welcome this revised criteria because it's much more consistent with what we see in our practice and it reflects the current research findings," he said.

Damodharan, a member of the Canadian Psychiatric Association, said the label is just one part of the assessment and he hopes that there will be other categories to identify children with other impairments.

"They may end up with a different label, like social communication disorder," he said. "There are different kinds of labels being proposed now. (But) a child with clear autism, I don't think it's going to matter."

He said that under the current definition for autism, a person can be diagnosed with the disorder if that person has demonstrated six or more behaviours in three areas, including social impairment, language and communication impairment and restricted interests (repetitive or limited interests.) The new definition would require that a person would have to demonstrate three deficits in social interaction and communication and at least two repetitive behaviours.

Damodharan hopes that any changes will not spark a movement to change previous diagnoses, but that it will only inform new diagnoses.

"Hopefully, the final outcome will reflect the clinical needs," he said.

But Doherty, the Fredericton father, fears that a change to the definition of autism will mean a step backward for people with the disorder.

To help illustrate his son's "serious intellectual and behavioural challenges," Doherty said the teen worked himself into a frenzy over the weekend as he continually replayed a clip on a video to the point where he bit himself in the hand.

"He has the occasional meltdown and it has a pretty serious effect," he said. "He'll hit himself on the head with his hand and do things repeatedly . . . He's inclined to engage in obsessive behaviour and we have to stop it because it gets out of control."

Doherty is anxious to see what the new definition will look like and how it might affect his son.

He believes, based on the proposed definition, that "there will be fewer people with intellectual disabilities diagnosed with autism after this."

A change will impact peoples' lives, but the extent of that impact isn't yet known, Doherty said.