Exercise is Medicine for Depression

Depression can be a short-term state or a long-term clinical disorder.  Depression as a transient mood state is characterized by feeling sad, discouraged, or unhappy. These feelings generally resolve over the course of a few days or less.  Depression as a clinical condition is a psychiatric disorder where certain diagnostic criteria must be met.  The diagnosis of major depressive disorder requires psychiatric evaluation by a qualified professional. The diagnosis typically includes at least several of the following: weight loss, sleep disturbance, agitation, fatigue or loss of energy, feelings of worthlessness or guilt, diminished concentration, and possibly recurrent thoughts of death.  Major depressive disorder is distinguished from transient feelings of depression by both the severity and duration of symptoms.

It is estimated that one in five adults will suffer from major depressive disorder at some point in their life.  The incidence is higher in women.  One in four adolescents suffers from depression and this increases the risk of depression later in life.   Depression has also been linked to obesity, diabetes, and heart disease.  All of these disorders, including depression, are on the rise in the United States.   These disorders are also commonplace in outpatient physical therapy clinics where individuals are recovering from injuries.  Perhaps, the knowledge and positive habits learned in physical therapy can assist those with symptoms of depression and chronic disease.  Follow-through with a long-term exercise program can produce meaningful changes in mood, physical health, and quality of life.   All of these benefits can be achieved without the adverse effects associated with other forms of treatment.

Conventional Treatments for Depression

Antidepressant medication is the staple treatment for symptoms of depression.  Approximately half of individuals with depression will respond favorably to prescription medications without side effects.  The other half will either not respond to treatment or suffer side effects from the medications such as constipation, sleep loss, blurred vision, weight gain, fatigue, nausea, and sexual dysfunction.

Treatment may involve individual or group counseling lasting several months. Psychotherapy has been shown to be an effective long-term treatment for depression.  This form of treatment is often used in conjunction with antidepressant medication for individuals with more severe depression.   Cognitive behavioral therapy is one form of psychotherapy which aims to identify and change negative thoughts in those with depression.

Exercise as a Treatment for Depression

As a stand-alone treatment, exercise has been shown to result in moderate to large improvements in depressive symptoms.  Research has also shown no difference in outcomes when comparing exercise to cognitive behavioral therapy.  When combining the results from four studies, no differences were found between the effects of exercise and antidepressant medication.  This is not to suggest that medication and psychotherapy are ineffective.  Instead, exercise may enhance the effects of these conventional treatments for depression.  And perhaps, exercise may even be able to replace them over time.

Type and Dose of Exercise to Manage Depression

Most studies showing positive effects with exercise have included some form of aerobic exercise.  Walking, jogging, and cycling are the most commonly utilized forms of aerobic exercise.  The optimal frequency of exercise has not been determined but most studies have included exercising 3-5 times per week.  Programs with higher energy expenditures have been shown to produce greater results but positive effects can be achieved with lower intensity programs. A good starting point is to perform short walks 3 days per week.   As aerobic capacity and confidence improve, exercise should be progressed based on the American College of Sports Medicine recommendations of moderate intensity exercise performed for at least 30 minutes 5 days per week.  As aerobic capacity improves, exercise intensity and duration should be progressed in order to continue to make gains.

Tips to Increase Chances of Success

The first challenge with any exercise program is simply taking the first step.  Starting small and gradually building up the intensity, duration, and frequency is a wise approach.  Expect minor setbacks along the way and do not be discouraged when they occur.  The antidepressant effects of exercise takes time.  Be patient.   Once you begin to notice small progress in your exercise capacity and overall well-being, momentum will start to build.  The key to long-term adherence is to stay disciplined and develop habits for a lifetime.  Below are a few tips to help you on your journey.

  • Pick a form of exercise you enjoy and stick with it
  • Invest in a good pair of sneakers to exercise in
  • Pick a time of day to exercise which works best for you and make this part of your daily routine
  • Set your own goals and track your progress
  • Anticipate barriers (fatigue, work duties, bad weather, etc) and develop solutions ahead of time
  • Team up with a partner or partners and you will be more likely to stick with it
  • Do not be discouraged if you miss one session. If you fall off, get right back on the next day.
  • Take a minute and appreciate how you feel at the end of each exercise session

Let us know if you need help getting started and best of luck!

References

  1. Blumenthal JA, Smith PJ, Hoffman BM. Is exercise a viable treatment for depression? ACSMs Heal Fit J. 2012;16(4):14-21. doi:10.1249/01.FIT.0000416000.09526.eb.Is.
  2. Cooney G, Dwan K, Greig C, et al. Exercise for depression (Review). Cochrane Database Syst Rev. 2013;9:1-125. doi:10.1002/14651858.CD004366.pub6.www.cochranelibrary.com.

Finished Your Physical Therapy: What’s Next?

The day has come.  You’ve dedicated your time and put in the work now you and your physical therapist have decided you’re ready for discharge.  So what happens after you have completed physical therapy?

Some patients leave physical therapy feeling 100% and return to their regular active lifestyle and prior fitness routine.  In many cases, though the patients we see are ones that do not live an active lifestyle and have no prior fitness routine. Some patients may only feel 80% better and insurance benefits or financial limitations will not allow continued care. These patients, in particular, are the ones who may leave therapy feeling uneasy or unsure.  They may have many questions they are asking themselves:

  • What if I never feel 100%?
  • When will I find time to continue the home exercises on my own?
  • How long will I have to continue these exercises for?
  • What if the exercises feel like they aren’t helping me anymore?
  • Will I be disciplined enough to do them?
  • What if the pain starts to come back?
  • What if I stop doing the exercises?

Exercise After Physical Therapy

Chances are if you are asking yourself any of these questions, you may be someone who requires or would benefit from more guidance moving forward.  Ideally, you would benefit from a long-term fitness routine or group exercise program.  If you are someone who did not exercise regularly prior to staring physical therapy there is a good chance that you will not continue to do the exercise once you are done.  The intentions may be good but many people do fall short.  Some people are disciplined self-motivators but many are not.  Also, it is easy enough to say “I can’t find the time” or “life just got in the way”.   Anyone at anytime can find the excuse as to why they haven’t been able to continue with a routine.

Building Healthy Habits

Most of the time patients attend physical therapy for 2 or 3 visits a week for a few weeks, most commonly between 4 and 8 weeks.  Research says it can take 2 months or more (66 days on average) to form a new habit.  It takes repetition for the new behavior pattern to become imprinted in your neural pathways. In fact, research by Kaushal and Rhodes suggests it takes at least 4 gym sessions per week for 6 weeks to establish an exercise habit. That doesn’t mean you can’t develop an exercise habit by going less frequently; it just means it will probably take longer for it to become automatic.

If you have already been attending physical therapy 2-3 times per week DO NOT stop dedicating that time to yourself when you are done. DO NOT take a week off and decide to figure out the next step later. DO NOT lose your momentum! If you know that you are someone who needs that continued guidance and motivation ask your physical therapist to help you find the right exercise program to start with.  Depending on your fitness level, behavior characteristics and health goals there will be options that are better for some than others.  Fitness is a booming business right now and there are plenty of options out there.  Some people don’t know where to start.  Your physical therapist will have a general knowledge of what types of exercises are done at different fitness facilities, however, depending on where you live these places vary.

Local Recommendations

The physical therapists at BSR Physical Therapy have been doing the research locally here in the Manahawkin, NJ area.  We are helping to build a library of long-term fitness options for our patients.  We want you to succeed in your health goals.

Most recently Dr. Amanda Higgins, Morgan Gamble and I attended a barre class at Black Sheep Studios on LBI.  The fitness studio had a welcoming earthy vibe.  We met with one of the owners Devon who was as personable as they come and full of energy.  It only took one class to know that this is a place where you won’t get lost in the numbers as the class sizes are small and intimate and everyone called everyone else by name.  The instructors paid close attention to form and corrective technique which is a must to get the recommendation from a physical therapist.  Their instructor Wendy provides individualized programs for people with the use of pilates transformers which is a hard find in this area.  They also provide a menu of other unique exercise classes that may be the perfect fit for some of you.

This place is one of many that can help you stay on track.  We want to see you succeed with your health and fitness long term.  Let us help you transition from physical therapy to fitness.

-Dr. Amy McMahon

 

Movement Patterns are King, Not Isolated Muscles or Joints

The traditional medically oriented examination occurs with a patient on a treatment table focusing on the isolated area of pain. Even worse, a static image such as an MRI may be taken to determine the “cause of the problem”. These types of examination procedures provide only limited information for any professional seeking to develop a treatment plan. The human body does not function on an examination table or in an MRI tube. Movement occurs from a complex interaction of the nervous system with our muscles and joints.

In order to determine an accurate diagnosis and arrive at the best treatment plan, whole patterns of movement should be the focus. A baseball player experiencing pain during the late cocking phase of throwing should be examined throwing a ball in this position. A football player experiencing pain or giving way in the ankle should be examined in the same functional position which recreates his symptoms. This sure seems like common sense, but it is not always common practice.

The Area of Pain is Often Not the Cause

Many times, problems in the hip can lead to pain in the back. Problems in the upper back can lead to pain in the shoulder. And, problems in the ankle can contribute to pain in the knee. I could go on and on with examples of what is typical in an outpatient physical therapy clinic. In order to uncover the cause of pain or poor movement, whole movement patterns must be assessed and treated.  For individuals with pain in the front of their knee, isolated treatments to the knee rarely provide substantial relief. Assessing movement patterns such as an overhead squat, step down, or running is often the key to determining the corrective course of action.

Movements, Not Parts

Assessing and treating movement patterns, not isolated body parts, is the key to a speedy and long-lasting recovery. It is very common for limited mobility in the upper back and hips to lead to abnormal motion in the low back. Movement compensations in the low back then manifest as “disc problems” under an MRI. Treating the “disc” is rarely successful in alleviating these types of problems.

Pain Changes Movement

Sustaining a previous injury increases the risk for future injury. Spraining an ankle in middle school can contribute to knee pain in high school. This is because pain or injury changes the way we move. Individuals with previous history of ankle sprains have been shown to demonstrate delayed activation of their glute muscles and difficulty balancing on one leg several years later. If these compensations are not identified and corrected, movement patterns are changed and injury risk increases.

The human body will follow the path of least resistance in order to perform a task.  The nervous system will choose to perform the most efficient pattern of movement from an energy standpoint. The body will attempt to conserve energy during movement in case it needs it later during a crisis. However, the most efficient pattern of movement is often not the optimal pattern of movement.

Using the same example of an individual with a previous ankle sprain, we often see asymmetrical weight shifting during exercises such as a squat or deadlift. The asymmetrical weight shift will allow the body to lift the weight at that moment in time.  However, with continued compensation of movement, asymmetrical training stresses will be applied leading to suboptimal performance and the potential for further injury.

Muscles Do Not Have Memory

Pain alters the way our nervous system organizes patterns of movement. Muscles do not have memory. The brain stores patterns of movement and then signals muscles to execute what is believed to be the most efficient pattern. With repeated performance of compensatory movement patterns, the abnormal becomes the new normal. The asymmetrical squat is now programmed in the central nervous system and remains long after any injury has healed. The nervous system is very complex and we do not completely understand how this works. However, we do know these patterns can be reprogrammed and corrected with appropriate movement training by skilled professionals.

Optimal Movement is Individual

There is no single best way for all individuals to move.  We are all structurally built differently. One person’s hip socket may be oriented facing slightly downward. Another person’s hip socket me be more outward facing. These structural differences will change positioning of the body during movements such as a squat or lunge. Attempting to teach all individuals to move in exactly the same fashion is unreasonable and has the potential to increase risk for injury. All movements, exercises, and exercise programs should be individualized based on the findings from a detailed assessment by a skilled professional.

Conclusion

We should be looking past the isolated area of pain and uncover the true cause of the problem by assessing whole functional movement patterns. This type of assessment identifies subtle problems with movement which we may be unaware of. Once you are made aware of these compensations, you can start to address them. Correcting the problem will take conscious effort and require coaching from a skilled professional.  Once you are able to perform the movement correctly and automatically, it is time to increase the load and strengthen the movement pattern.