The therapeutic benefits of physical activity.

"Action is the antidote to despair."

--Joan Baez

In my career as a rehabilitation professional (who uses exercise, behavioral interventions, and mind-body medicine), I look back in amazement at how much we have learned and how much science continues to reveal to us about the therapeutic benefits of physical activity.

After Dr. Herm Hellerstein at Cleveland Clinic challenged his cardiology colleagues to encourage heart patients to get out of bed and resume activity as soon as possible, cardiac rehabilitation became synonymous with exercise. I first became involved in cardiac rehabilitation when we started one of the first phase III programs at Lansing (Michigan) Community College in 1977. Then I took exercise physiology courses in graduate school at Michigan State University, along with my rehabilitation and counseling courses. I remember a cardiac patient who moved to Lansing after being told by his doctor to retire and take it easy on his heart following a heart attack. Our medical director encouraged him to join our cardiac rehab program; one year later, he and his wife were winning age-group medals in 5K runs.

To work in the field of cardiac rehab, we learned how to use graded exercise (stress) tests to develop exercise prescriptions with individualized minimum and maximum target heart rates (target zones). Our clients were patients who had suffered heart problems--such as angina pectoris, heart attacks, or were post-surgical open-heart or even heart-transplant patients--and they would religiously track their target zone during their exercise sessions. We taught them to be hyper-vigilant to any type of chest discomfort or other cardiac symptoms, so they could promptly (and anxiously) report these to us for further evaluation.

Seeing Results

We began to notice that there were other benefits to these exercise sessions, in addition to conditioning. Recent heart patients who were apprehensively beginning exercise rehab sessions would be approached by more seasoned veterans and, as they exercised together, they would talk. The "rookie" rehab patient would learn that his new friend had been just like him (or her) a few weeks or months before. They would be talking to "living proof" that their ailing heart would get stronger and that they were likely to attain fitness levels beyond the "out of shape" status before their heart problem sent them to a hospital. Conversations often led to coffee after the rehab session or even potluck dinners--so they could meet one other's loved ones. In addition to this camaraderie, we observed changes in mood and elevated levels of confidence in our patients.

I noticed that after a second stress test showed them to be reconditioned, that many who discontinued rehab would later return. A grad student, who needed a research project, was given the suggestion to survey why they returned. I expected it was because their doctors wanted them to stay conditioned and keep their cardiovascular risk factors within normal limits. Instead, we learned that when they no longer had exercise as part of their weekly routine, they not only drifted away from physical activity but more importantly, to them, they noticed that they just didn't feel as good as they did when they had a regular physical activity routine.

We also began to have patients with other co-morbid conditions (and their non-cardiac-patient spouses) enjoy improvements in their health related quality of life. Type II diabetics needed less medication (even insulin), people with chronic lung problems could do more, arthritis patients were not as stiff or sore, kidney or even dialysis patients seemed to do better. We even integrated patients with strokes or closed head injuries after their physical therapy sessions ended.

More recently, physical activity has been found useful in the rehabilitation of some cancer patients by improving physiology such as lymph flow in the extremities. Dr. George Sheehan found running to be helpful between bouts of chemotherapy. Physical activity and even running have been associated with sustaining periods between relapse in Parkinson's Disease and Multiple Sclerosis.

Expert Opinions

As early as 1976, psychiatrist Thaddeus Kostrubala, in his book The Joy of Running, documented the improvements that occurred with patients suffering from depression and even psychosis when they exercised for a significant period of time. A 1996 government report confirmed Kostrubala's findings; the report, Physical Activity and Health--A Report of the Surgeon General, documented that the mental and emotional benefits of physical activity help to reduce anxiety, symptoms of depression, and even improve mood--along with the proven physical benefits in rehabilitation.

More recently, James Blumenthal et al, analyzed physical activity and depression. They concluded that "... those participants who used exercise as their method of treating major depression, did as well as those who used medication during the four-month treatment period." They went on to state that "... those who used exercise had better long-term (10 months) reduction in depression symptoms than did those who used medication." These results are important, argued the authors, because they offer patients suffering from major depression "a safe and effective treatment ... with no side effects."

It should be mentioned that, leading up to the surgeon's general report on physical activity, epidemiological evidence from Dr. Ralph Paffenbarger, Dr. Steven Blair, and others changed the paradigm from the regimented target zone with sustained aerobic exercise. Based on this evidence, the Centers for Disease Control (CDC) recommended that people try to accumulate 30 or more minutes of moderate physical activity, most days of the week--burning a minimum of 150 calories each day and a minimum of 1,000 calories per week. This new recommendation provided a more "user friendly" approach to exercise.

Focus groups convened by CDC showed that the term "exercise" was averse to many people and that use of the term "physical activity" better communicated the new paradigm, which de-emphasized intensity and gave patients more "choices" such as:

* easy guidelines to follow after their physical therapy or rehabilitation sessions ended or were no longer covered by insurance;

* exercising longer rather than harder;

* breaking physical activity into shorter episodes so that 30 minutes are accumulated throughout the day;

* using a variety of recreational, avocational, or household activities to burn calories, such as gardening or mowing the lawn;

* and being more physically active throughout the week rather than three times per week.

Walking was finally recognized as a powerful rehabilitation tool that is more "universally" available to those with limited insurance and/or limited access to a healthcare or fitness facility. Walking is an activity easily performed just about anywhere--such as the local mall--in the company of a supportive family member or friend likely to provide positive feedback to the person on the road to recovery. This mindset recognized that the real "power" of physical activity is not exercising once or twice a week, even if it is aerobic. Regular, moderate physical activities are a much more effective strategy for the recovery and maintenance of functional capacity for those who have had an acute or chronic medical condition. For a severely deconditioned person, the option of being able to start rehabilitation with lowered intensity and duration makes physical activity less intimidating.

Mind-Body Connections

It is intriguing that studies in mind-body medicine and neurochemistry indicate that physical activity seems to stimulate the brain to produce neurotransmitters and other chemicals that bring about a reduction of depression as well as an improvement in mood and an increase of positive emotions. Endorphins causing "runners high" have been well documented. We seem to see improved production of serotonin. Many antidepressants are SSRI's or Serotonin Selective Reuptake Inhibitors that try to maintain serotonin in the brain, but they may also cause significant side effects. More recent research on oxytocin shows that it is not only found in males, it seems to be produced during physical activity in which friendships and "bonding" occurs, such as experienced by patients in cardiac rehabilitation sessions. Oxytocin has not only found to enhance positive feelings of trust it is also a potent antidote for stress.

In conclusion, beginning in the 1970's we had mounting evidence of the physical benefits of physical activity and initially had antidotal evidence for the emotional benefits. In more recent years, an increasing body of evidence points to mental health benefits that promote an even more successful outcome for patients who participate in exercise as part of their rehabilitation. We are now beginning to understand, from a neuro-physiological point of view how physical activity improves the health-related quality of life of patients.

In my experience, many patients respond poorly to serious illness or injury because they feel they have "lost control" of their lives; they become depressed and passive "victims" to their health conditions. A therapeutic or rehabilitation program that includes exercise helps the patient re-establish a sense of control over his or her life again. The Lance Armstrong Foundation recognizes this problem and works to promote programs that help cancer patients regain a healthy identity.

Most health professionals agree that patients who are not depressed and who have a more positive outlook demonstrate closer adherence to therapeutic regimes, improved prognosis, and better outcomes. As a result, they consume fewer healthcare dollars. Physical activity should no longer be seen as a possible option; it is essential to the "best practices" in medicine for rehabilitation as well as prevention in healthy populations.

REFERENCES

Martins, AS, et al. Hypertension and Exercise Training Differentially Affect Oxytocin and Oxytocin Receptor Expression in the Brain. Hypertension. 2005 October; 46(4), Part 2 Supplement: 1004-1009.

Moberg KU, et al. The Oxytocin Factor: Tapping the Hormone of Calm, Love, and Healing. Da Capo Press, 2003.

Ornish, D. Love and Survival. Harper Collins Publishers, 1999.

Pert, CB. Molecules of Emotion. Simon & Shuster, 1997.

Physical Activity & Health-A Report of the Surgeon General (S/N 017-023-00196-5). U.S. Supt. of Documents, 1996.

Taylor, SE, et al. Biobehavioral Responses to Stress in Females: Tend-and-Befriend, Not Fight-or-Flight. Psychological Review. 2000;107(3):411-429.

by John D. McPhail, MA, CRC, LPC, ABMPP

John McPhail is a Certified Rehabilitation Counselor, Licensed Professional Counselor, and Board Certified Fellow of the American Board of Medical Psychotherapists and Psychodiagnosticians. He is an adjunct professor in Psychiatry at Michigan State University's medical school.