Chapter 10
The psychology of exercise for clinical
populations
Exercise can be good for you even
when you are ill
Exercise was invented and used to
clean the body when it was too full of
harmful things.
Christobal Mendez, 1500–1561
(Berryman 2000).
Chapter 10: Aims
• highlight the psychological issues associated with
exercise for clinical populations
• use the American College of Sports Medicine’s
framework for classifying disease and disability
• provide examples of psychological issues for each
category in the ACSM framework
• summarise what we know in this area of exercise
psychology
• offer a guide to good practice
• provide recommendations for conducting research in
exercise psychology with clinical populations
Patients (n=70)
10.1 Flow of participants
through trial for Type 2
diabetics Kirk et al. 2004b
Baseline assessments
Physical activity (7-day recall, CSA activity monitor)
Glycaemic control (HbA1c, medication)
Cardiovascular risk factors (Body Mass Index, blood pressure, lipid profile)
Exercise consultation & standard
exercise leaflet (n=35)
Standard exercise leaflet alone
(n=35)
6 month assessment
Repeat baseline assessments
Exercise consultation & standard
exercise leaflet (n=32)
Standard exercise leaflet
alone (n=31)
12 month assessment
Repeat baseline assessments
Experimental group (n=31)
Control group (n=29)
10. 2 Increases in objectively measured physical activity
following physical activity counselling. Kirk et al. 2004b
4000000
*28% increase
Experimental group
Total activity counts/week
3500000
*15% increase
3000000
2500000
*12% decrease
*20% decrease
2000000
Control group
1500000
Baseline
6 months
12 months
10.3 Improvements in glycaemic control following physical activity
counselling. Kirk et al 2004a
Experimental group
Change from baseline to 12 months
Control group
0.34% increase
0.27% decrease
Change from baseline to 6 months
0.15%
increase
0.26% decrease
Non diabetic range 4-6%
-0.4
-0.3
-0.2
-0.1
0
0.1
0.2
Improving HbA1c (%) Deteriorating
0.3
0.4
10.4 Improvements in cardiovascular risk
factors following physical activity counselling.
Kirk et al. 2004a
Systolic blood pressure
6
Change in cholesterol (mmol/L)
Change in blood pressure (mmHg)
Total cholesterol
0.1
0.05
4
+ 5.0
mmHg
2
+ 0.04 mmol/L
0
-0.05
0
-2
-0.1
-0.15
- 6.3
mmHg
- 0.32
mmol/L
-0.2
-4
-0.25
-6
-0.3
-8
Experimental
group
Control
group
-0.35
Experimental
group
Control
group
10.5 Pilot study - exercise as
rehabilitation during breast cancer
treatment.Campbell et al. 2005
80
70
60
% change 50
40
over 12
30
weeks
20
10
0
-10
78
32
15
-1
7 day recall
of PA
1
-1
12 min walk Quality of life
test
usual care
exercise
Exercise dependence
pages 270 -277
 Confusing terminology: negative addiction,
obligatory exerciser, compulsive exerciser.
 Exercise dependence has the only stated
diagnostic criteria and so it is the preferred term
 Dependence occurs when exercise causes people
to be unable to function in personal relationships,
work life or health.
 Distinction between primary and secondary
dependence (eg secondary to eating disorders or
muscle dysmorphia)
ICD-10 classification of dependence syndrome
WHO 1993
Classification
Compulsion
Impaired
control
Withdrawal
Relief use
Tolerance
Salience
Dependence syndrome
Desire/compulsion to take the substance
Difficulty in controlling behaviour in regard to onset, termination
and level of substance taking
Physiological withdrawal states occurs when substance withdrawn
Substance used to avoid or relieve withdrawal symptoms
Increased amount of substance required to achieve effect similar to
lower dose
Increased amounts of time spent in obtaining or taking substance or
recovering from its effects.
Persistence despite awareness of harmful response
Criteria for exercise dependence
Veale, (1987). Exercise dependence. British Journal of
Addiction, 82, 735-740.
Criteria
A Narrowing of repertoire leading to a stereotyped pattern of exercise with a regular
schedule once or more daily
Impaired control
B Salience with the individual giving increasing priority over other activities to
maintain the pattern of exercise
salience
C Increased tolerance to the amount of exercise performed over the years tolerance
D Withdrawal symptoms related to a disorder of mood following the cessation of
the exercise schedule
withdrawal
E Relief or avoidance of withdrawal symptoms by further exercise
Relief
compulsion
F Subjective awareness of the compulsion to exercise
G Rapid re-instatement of the previous pattern of exercise and withdrawal
Impaired control
symptoms after a period of abstinence
Criteria for exercise dependence continued
Associated features
H Either the individual continues to exercise despite a serious physical disorder
known to be caused, aggravated or prolonged by exercise and is advised as such
by a health professional, or the individual has arguments or difficulties with
his/her partner, family, friends, or occupation
I Self-inflicted loss of weight by dieting as a means towards improving
performance
Raising awareness of exercise dependence
• Do you think exercise is compulsive for you?
• Is exercise the most important priority in your life?
• Is your exercise pattern very routine and rigid? Could
people ‘set their watches’ by your exercise patterns?
• Are you doing more exercise this year than you did last
year to gain that feel good effect?
• Do you exercise against medical advice or when injured?
• Do you get irritable and intolerable when you miss
exercise and quickly get back to your exercise routine if
you are forced to change it?
• Have you ever considered that you were risking your job,
your personal life or your health by overdoing your
exercise?
• Have you ever tried to lose weight just to make your
exercise performance better?
If you answered YES to most of these questions,
or if you are worried about becoming dependent
on exercise please speak to a member of staff or
follow these self- help strategies:
 use cross-training to avoid over use injuries,
remember aerobic fitness, strength and flexibility are
all important aspects of fitness
 schedule a reasonable rest period between two
bouts of exercise to prevent mental and physical
fatigue
 schedule one complete rest day each week and
notice how energetic you feel the next day
 exercise your mind by getting involved in mental and
social activities that can lower anxiety and lift selfesteem
 try to learn a stress management technique such as
relaxation, yoga, tai chi or meditation
Exercise dependence is
characterised by:
• a frequency of at least one exercise session per
day
• a stereotypical daily or weekly pattern of
exercise
• recognition of exercise being compulsive and of
withdrawal symptoms if there is an interruption
to the normal routine
• reinstatement of the normal pattern within one or
two days of a stoppage
Exercise dependence as
secondary to eating disorders
• What are the common eating disorders?
– Anorexia nervosa (body image of ‘fat’ even when
very thin, starvation, can be fatal, associated with
hyperactivity)
– Bulimia nervosa (binge eating, use of laxatives,
vomiting and exercise to ‘cleanse’, may look
normal, but feels fat)
• These eating disorders affect more women
than men
• Exercise is secondary to these conditions
• Exercise can be successfully used in
treatment programmes
Exercise dependence secondary to
muscle dysmorphia [reverse anorexia]
Pope et al (1997) Psychosomatics, 38,548-57
• Body dysmorphic disorder is a mental
illness
– eg hating a leg and wishing it to be
amputated
• muscle dysmorphia is a pathological
preoccupation with the whole body
– perception of insufficient muscularity
– lives consumed by weightlifting and other
exercise, nutrition and perhaps drug abuse
– affects both genders more common in men
Muscle dysmorphia consequences
• Profound distress about body being seen
in public
• impaired social and work functioning
• anabolic steroid and other drug abuse
• it is rare but more prevalent in the weight
training fraternity
• Diagnostic questionnaire recently
developed
• recent phenomenon- why?
Could athletes training for a
competition be exercise dependent
?
Possible answers?
• Yes
– If athletes feel compelled to train in systematic way
against medical advice, or despite personal or work
problems.
• No
– If volume of training required for performance
• Awareness needed
– Could be a pre-cursor to overtraining and so
awareness of exercise dependence needs to be
raised amongst athletes and coaches as well as
exercise leaders
Subclinical eating disorders in athletes
• What sports are most likely to create
disordered eating with a view to weight loss
or gain?
• Sports that require lean athletes: long
distance running, gymnastics, ballet
• weight category sports: judo, jockeys, boxing
• weight advantage sports: sumo wrestling
• coaches and sport scientists must be aware
of these issues and avoid poor eating
patterns becoming serious disorders
Why does exercise dependence
occur?
• No clear answer
• Suggestions include:
–
–
–
–
–
–
–
–
Obessive-compulsive disorder
‘running away’ from other problems
Low self-esteem
High anxiety levels
Addicted to ‘endorphins’etc
Sympathetic arousal hypothesis
Analogue to eating disorders
Cultural pressure
ACSM (1977) ACSM’s exercise
management for persons with chronic
diseases and disabilities
• cardiovascular and pulmonary diseases
• metabolic diseases
• immunological and haematological
disorders
• orthopaedic diseases and disabilities
• neuromuscular disorders
• cognitive, emotional and sensory disorders
Recommendations for research
with clinical populations
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•
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•
•
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•
•
Researchers should form links with medical teams dealing with specific
conditions.
Qualitative research may often provide a starting point for such research
because many of the situations do not lend themselves to standard clinical
trials.
Explore a variety of programmes such as home-, community- and hospitalbased or combinations of these.
Both researchers and practitioners should operate with a model of
behaviour change to guide them.
Activity must be recorded before and after any exercise programme or
intervention.
Report the uptake for any exercise programme from the potential client
population.
Investigate motivations and barriers to exercise in each patient group as a
whole and also for those who have taken up the offer or completed an
exercise programme.
Record and report (via a register or via contact) adherence at regular
intervals
Report adherence to exercise prescription as a percentage of target in as
many ways as possible
Key point:
• It is important to apply principles of
exercise psychology to clinical
populations because quality of life is an
important outcome from exercise and
long-term adherence is beneficial to
these patient groups.
Key point:
• The long-term goal for exercise
specialists working with patient
populations is to assist them in
becoming independent exercisers.
Key point:
• Maintaining regular activity after
supervised hospital-based programmes
is difficult for cardiac rehabilitation
patients and requires urgent attention
from exercise psychology research.
Key point:
• Treating obesity and preventing weight
gain through physical activity requires
two or three times more activity (for
example, up to ninety minutes) than the
amount of activity required for health.
This is a challenge for participants and
exercise psychologists.
Key point.
• Exercise psychology could help
construct a movement education
programme for those suffering from
back pain that increases patients
confidence that they can move in a
pain-free way.
Key point
• Schizophrenic patients report benefit
from exercise and further research on
this patient group should explore what
kind of exercise and what dose of
exercise is best.
Key point:
• Evidence suggests that problem
drinkers can benefit from exercise
programmes in terms of physical
outcomes. However, evidence for
mental health benefits or any
advantage to reducing alcohol intake is
weaker.
Key point:
• Dependence is a potentially serious
negative consequence from exercise.
However, there is no known prevalence
of this problem.
Key point:
• Physical activity and exercise affect
how we think and feel – this is known
as the somatopsychic process.
Exercise- associated mood alterations: A
review of interactive neurobiologic mechanism”
LaForge, R. (1995).Medicine, Exercise, Nutrition and Health,
4, 17-32
• Best review of neurobiological mechanisms
• Integrates processes
• All mechanisms overlap in structure and function
and in terms of neuro-atomic pathways
• Latest imaging technologies will enhance what is
happening in the exerciser’s brain
Plausible mechanisms:
Neurobiological processes involved
in positive mood
Opponent process theory
Opioids
Monoamines
Neocortical activation
Thermogenic changes
HPA axis
Synergistic conclusion
La Forge
“ The mechanism is likely an extraordinary
synergy of biological transactions,
including genetic, environmental, and
acute & adaptive neurobiological
processes. Inevitably, the final answers
will emerge from a similar synergy of
researchers and theoreticians from
exercise science, cognitive science and
neurobiology”
Chapter 10: Conclusions 1
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Patients in almost all categories of disease and disability could
benefit from exercise. There are few contraindications.
Knowledge about adherence and psychological outcomes is
incomplete. The area of cardiac rehabilitation offers the most
information on adherence.
Good short-term adherence (4-12 weeks) can be achieved from
supervised programmes of exercise
Some populations, such as those in drug rehabilitation or those
with HIV + status, even short-term adherence may need special
support systems.
Long term adherence (12 months - 4 years) is poor and not well
documented.
Home-based walking programmes seem to offer the best hope for
long term adherence but other modalities must be explored.
Very little is known about the level of exercise in clinical
populations.
Chapter 10: Conclusions 2
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Drop-out from exercise programmes is associated with factors to do with the
programme and factors to do with the person and his/her circumstances
Motivations for exercise are clearly to do with improved health.
Barriers to exercise are similar to non-clinical populations (e.g., lack of time) but
also include issues to do with the particular disease state.
Cognitive behavioural strategies can be effective and the use of a counselling
approach should be encouraged in all clinical settings.
Psychological outcomes are often mentioned anecdotally but are rarely measured
in exercise programmes or interventions. The potential psychological benefits
range from increasing a person’s sense of confidence, control and self-esteem,
improving mood, increasing social opportunities, improving cognitive function, and
improving quality of life.
There is a need for raising awareness in some medical teams concerning the role
of exercise, the potential psychological benefits and the need to assist patients
with adherence to exercise.
Exercise dependence is a potentially harmful outcome from exercise but the
prevalence is not known. Exercise dependence secondary to eating disorders or
muscle dysmorphia may be more common than primary exercise dependence
There is no clear consensus about the mechanisms that could explain the
psychological benefits experienced from physical activity. New technology may
offer greater understanding of this topic in the near future