An Osteopathic Approach to Mental Health Through Exercise and

AN OSTEOPATHIC APPROACH TO MENTAL
HEALTH THROUGH EXERCISE AND MOVEMENT
Stacey Pierce-Talsma DO, MS.MEd-L, FNAOME
AAO Convocation 2016, Orlando Fl.
DISCLOSURES
• The opinions offered in this presentation are of the
presenters and do not represent the opinions of the
American Academy of Osteopathy
• All materials and content are the intellectual property of
the presenter or are cited and do not infringe on the
intellectual property of any other person or entity
• The speakers do not endorse any product, service or
device with this presentation
• Dr. Pierce-Talsma has no financial disclosures
OBJECTIVES & GOALS
• Describe the results of literature on the use
of exercise in the treatment of depression &
anxiety
• Identify physiologic and psychologic
processes by which exercise and movement
may affect mood
• Explore the connections of anatomy,
physiology, posture and emotion
• Delineate how movement and exercise may
benefit patients with mood disorders
WHY EXERCISE/MOVEMENT FOR
ANXIETY & DEPRESSION?
“We should not exercise the body without the joint assistance of the
mind; nor exercise the mind without the joint assistance of the body.”
~Plato
• Variations in diagnosis
• Variations in type of exercise
• Dose of exercise
• Different methods of assessing depressive
scores
• Small sample sizes
• Source of subjects
• Exercise Location
• Variation in Age
• Health Status
• Physical activity only vs those aimed at
changing multiple health behaviors
• Lack of concealment
• Incentive
RESEARCH HAS
PROVEN TO BE
DIFFICULT
POSITIVE STUDIES
• North 1990- Meta-analysis
• Bridle et al 2012- Systematic Review and MetaAnalysis of RCT11
• Acute/Chronic exercise effective and effects may begin at the
first session
• Exercise will reduce depression severity in patients >60
• All types of health statuses had decreased depressive scores
• Decreased regardless of location
• Older subjects had a greater decrease in depression
• May only be useful with clinical depression
• Anerobic and aerobic both effective
• As effective as psychotherapy and added with psychotherapy
greatest effect
• Lawlor 2001, Sjosten 2006, Rethorst 2009- Meta-analysis
• Exercise may be effective but recommended further welldesigned trials
• “exercise treatment had significantly lower depression”
• Conn 2010- Meta-analysis on healthy adults
• Reduction of depressive symptoms in healthy adults
• Robertson 2012 systematic review and metaanalysis• Walking may be a useful adjunct for depression treatment
• Cooney et al 2013- Cochrane Database Systematic
Review (update from 2001, 2009, 2012)
• “Exercise may have a moderate sized favorable
association with depression, but because of risk of bias,
this association may be small.”
• Exercise is moderately more effective than no therapy for
reducing symptoms of depression
• Exercise is no more effective than antidepressants for
reducing symptoms of depression or psychological
therapies
• Exercise is superior to bright light therapy
NEGATIVE STUDIES
• Krogh et al 2010- Systematic Review and Meta-Analysis of RCT3
• Conclusion: (small benefit)- little evidence of a long-term beneficial effect
• + Clinical Diagnosed Depression, adults of all ages- 13 trials limited power
• DEMO 2009/DEMO II 2012/TREAD 2011/TREAD-UK 2012- RCT’s
• DEMO- aerobic exercise vs anaerobic vs relaxation (control)
• DEMO II- aerobic vs stretching- reduction in both groups- but no difference between groups
• TREAD 2011- non significant trend toward remission at 16kcal/kg/week
• TREAD 2012- (usual care vs usual care + intervention) exercise was ineffective and a more costly
strategy
• FAILED to find statistically significant antidepressant effects of exercise
• Underwood et al 2013 RCT
• Aged 65 years or older in care homes- twice weekly exercise sessions with a physiotherapist
• Exercise did not reduce depressive symptoms in elderly residents of care homes
COMPARING EXERCISE TO ANTIDEPRESSANTS
• Blumenthal et al (1999, 2007)49, 41
• 16 weeks of group exercise in older patients with MDD was as effective as Sertaline
• At 10 months the relapse rate and rates of depression was significantly lower in the exercise group than the
medication group or combination group
• 2007 study- remission rates- supervised exercise 45%, home exercise 40%, medication 47%, placebo 31%
• Dunn 2005- RCT4
• Public health does is an effective monotherapy for MDD
• Mota-Pereira et al (2011)26
• Treatment resistant MDD (pharmacotherapy vs pharmacotherapy + exercise)
• none in control group had remission/ 26% remission in exercise group
EXERCISE FOR ANXIETY
• Petrezzullo 199151, Herring 2011 Meta-analysis
• Exercise reduces anxiety
• “Exercise training reduces anxiety symptoms among sedentary patients
who have a chronic illness”
• Broocks 1998 RCT
• Significant improvement in panic over placebo, but less effective than
clomipramine
• Cochrane review 2006 50- Meta-analysis
• Ages 11-19- Small effect in favor of decreasing depression & anxiety
scores
• Conn,V. 2010
• Statistically significant improvement in anxiety outcomes in Healthy
Adults
• Other studies23
• Acute exercise is anxiolytic
• Exercise may induce panic attacks- largely disproven- Exposure Therapy
SUMMARY
• Overall- Exercise is shown to improve
symptoms of depression and anxiety
• Exercise is better than placebo
• Exercise is equal to Sertaline
• Exercise is equal to psychotherapy
• Exercise is superior to bright light therapy
• Walking is effective for treating depression
• Exercise is a good adjunctive intervention
for CBT
• We need more studies for better data and
description of type, intensity, frequency
PHYSIOLOGIC PATHWAYS BY WHICH
EXERCISE MAY AFFECT MOOD
Monoamine Dysfunction
(Serotonin, Endorphins,
Norepinephrine)
HPA Axis Dysfunction
Neuroimmune system dysfunction
Neurogenesis Dysfunction
Other Models
Psycho-social, Behavioral, Cognitive
MONOAMINES
• Increase in response to stressors and pain
• Opioids
• B- endorphin calms the sympathetic
nervous system and provides analgesic
relief
• May stay elevated 2-3 days
• Serotonin
• increases with activity (increased
production)
• Norepinephrine and Epinephrine
• increased levels with activity (increased
release)
• Dopamine
• Increased levels with activity
HPA AXIS
• Prolonged stress can lead to increased
cortisol levels
• Early life events can lead to a persistent
sensitization of the HPA-axis
• Dysregulation related to psychiatric
disorders
• Depression usually has hyperactivity of
the HPA axis
• Exercise leads to a physiological
“toughness”
http://www.frontiersin.org/files/Articles/18322/fneur-03-00041-HTML/image_m/fneur-03-00041-g001.jpg
Physical Inactivity
NEUROIMMUNE
• Stress and Depression Elevate :
17
• IL-6, CRP, NK cell function, TNF-a
Visceral Fat Accumulation
• Hyper-reactivity of pro-inflammatory state
• Impaired T cell function
• Proinflammatory cytokines
can :
Chronic systemic Inflammation
17
• Influence monoamine metabolism
• Neuronal genesis/survival
• Decrease HPA axis sensitivity to cortisol
Insulin Resistance, Atherosclerosis,
Neurodegenerations, Tumor Growth
• Cellular neuroimmune functions
• Neuroimmune modulating effects of
Exercise
• Positively influence inflammatory, oxidative,
apoptotic and antineurogenic mechanisms
DMII, Cardiovascular disease, Depression,
Dementia, Colon Cancer, Breast Cancer42
NEUROGENESIS DYSFUNCTION
• Exercise induced VEGF-Flk-1 Signaling8
• Depression = decreased neurogenesis in hippocampus
• Exercise increases hippocampal neurogenesis- affects blood vessel density and plasticity of
neurons
• Kyneurenine metabolism12
• Kynurenine in the brain has been implicated in brain disorders and depression
• Exercise increases breakdown via KATs and reduces the amount that reaches the brain
• Stimulation of proteins to improve health and survival of nerve cells
• Exercise increases Brain-derived growth neurotrophic factor (BDNF)
• B-Endorphins and Serotonin
OTHER MODELS
• Thermogenic model
• EEG changes, gamma neuron motor
activity changes
• Endocannabinoid system excitation
• GABA
• Exercise postulated to decrease GABA
receptors increasing GABA
concentrations
• Electrocortical changes
• EEG- Alpha waves increased- more in the
frontal region associated with relaxation
PSYCHO-SOCIAL, BEHAVIORAL,
COGNITIVE
• Social Interaction
• Changes in daily routine
• Exercise releases positive
feelings
• Weight loss
• Feeling successful
• Outdoor recreation
• Increased self-efficacy
• Achievement
• Increased self esteem
• Time out
• Cardiovascular fitness
• Interruption of a maladaptive • Distraction from negative
thoughts
cognitive set
• Stress Resilience
MOVING BEYOND CARDIOVASCULAR
EXERCISE….MOVEMENT CAN CHANGE OUR SHAPE
AND STRUCTURE
“YOU SEE I BELIEVE IN SHAPES. I
BELIEVE EVERYTHING GOOD HAS A
SHAPE. SHAPES ARE THE WAY IN
WHICH WE KNOW WHO WE ARE
AND WHERE WE ARE IN OUR
UNIVERSE. SHOW ME THE SHAPES
AND FORMS A MAN GIVES TO HIS
LIFE, AND I WILL TELL YOU
WHETHER HE IS A MASTER OR
VICTIM OF THAT LIFE.”
-Gail Godwin, Glass People
Postures Become Patterns
Can our anatomy change the shape of our emotions?
“Anatomical studies tend to
depict images that are two
dimensional, thus missing
the most important
element, emotional life. At
the same time, psychology,
which is committed to the
study of emotion, lacks an
anatomical understanding.
Without anatomy, emotions
do not exist.”9
~Stanley Keleman
Emotions
Posture Shifts
Sensorimotor
changes
“FEELINGS HAVE A
SOMATIC
ARCHITECTURE” 9
“Life make shapes. These shapes are
part of an organizing process that
embodies emotions, thoughts, and
experiences into a structure”
9
“Shape is imprinted by the challenges
and stresses of existence”
9
“Structure is slowed down Process”
Dr. Stanley Keleman
“Emotional Anatomy”
“The internal connection of all layers
gives rise to tissue consciousness, the
sum of sensations from all levels of cells
in a pattern of trillions of surfaces and
internal environments. This gives birth
to individual self-awareness”9
http://thefinchandpea.com/2013/07/31/the-art-of-science-peter-trevelyans-delicategeometry/
“WE ARE A
GEOMETRY OF
SOMATIC
CONSCIOUSNESS” 9
TENSEGRITY
• Compression and Tension
• Dynamic Element?
• Emotional Releases?
• Observing our patients
emotional posture
“a person’s physical postures are not
just “windows” or passive indicators
into emotion; instead, postures are
behaviors with stimulus properties
(social and proprioceptive) that can
have a self-regulatory role as they
affect the person’s own selfperceptions and actions.”18
ANATOMY AFFECTS
EMOTION
EMBODIED
COGNITION
• ATTITUDE- Miriam Webster
• “The Arrangement of the parts of a body
or figure: Posture”
• Slumped Vs. Upright Posture
• Effect on Confidence, metacognition
• Posture can affect direction of thoughts
• Slumped- lower self esteem and mood
and greater fear
• Influences Productivity
• Influences Memory
• Upward head tilting & Posture increased
pride
• Poor posture can leave you vulnerable to
crime
• Slumped posture led to helplessness &
lack of persistence
• Movement in a “yes” pattern produced
increased preferences
“Sometimes your joy is the source of
your smile, but sometimes your smile
can be the source of your joy”
~Thich Nhat Hanh
IPHONE, IHUNCH, IPOSTURE
• “While many of us spend hours every day using small mobile
devices to increase our productivity and efficiency, interacting
with these objects, even for short periods of time might do
just the opposite, reducing our assertiveness and
undermining our productivity.”20
• “Sitting upright may be a simple behavioral strategy
to help build resilience to stress”
• How much is our sitting- our lack of movement- our lack of a
full range of physical experience affecting our physical being,
and our emotional being
Erikdalton.com
POWER POSES
• Amy Cuddy-Ted Talk
• Expression of power through open expansive
postures
• Powerlessness through closed contractive postures
• High Power Poses
• Increase in Testosterone
• Decrease in Cortisol
• “Displays of power caused advantaged and
adaptive psychological, physiological, and
behavioral changes, and these findings
suggest that embodiment extends beyond
mere thinking and feeling to physiology
and subsequent behavioral changes.”38
• Zumba
• Tai Chi
TYPES OF MOVEMENT
• Yoga
• Pilates
• Dance
• Belly Dance
• Aerobics
• Gyrokinesis
• Martial Arts
• Dance Therapy
• http://www.adta.org/About_DMT/
• American Dance Therapy Association
“EXPANSION AND
CONTRACTION ARE THE
ESSENTIAL PUMPS OF EXISTENCE”
• Autonomic nervous system
•
•
•
•
Engagement of Breath
Physiologic postures
Flexibility of the Autonomic nervous system
Savasana- parasympathetic effects
• Release of muscle tension and Mind chatter
• Brings attention to the here and now
• Stress can activate the limbic system causing muscular
tension
• Ayurvedic perspective
• Solar plexus
FORWARD FOLDS
• Cooling
• Introverted
• Introspective
• Protective
• Create length and space in the
spine
• Humility, surrender, letting go
• Activate the 2nd Chakra
BACKBENDS
• Excitatory
• Extroverted
• Opening
• Open and exposed fears
• New perspectives
GROUNDING
• Redirects energy
• Stability
• Connection
• Support
• Foundation
• Used for all other elements
of motion
I
N
V
E
R
S
I
O
N
S
• Core engagement
• New perspectives
• Upending
relationship with
gravity
• Focus
• Confidence
• Autonomic
changes
• Releases ego
BALANCING
• Mental discipline
• Strength, flexibility,
proprioception
• Working through anxiety
• Dealing with falling
RESEARCH ON YOGA AND MOOD
• Kirkwood 2005 55- Yoga for Anxiety- A systematic review
• 8 studies, all positive results, methodological issues, no recommendation possible
• Cramer 201366 Yoga for Depression: A systematic Review and Meta-Analysis
• 12 studies, methodological drawbacks, yoga can be an ancillary treatment option
OTHER
• Improvement in mood, Decreased anxiety, Increase in GABA levels35
• Yoga improved mood immediately after the sessions in 113 psychiatric inpatients
• Yoga improved mood and increased morning cortisol in 28 young adults who practiced a 5 week Iyengar yoga class
FINAL THOUGHTS
How to prescribe exercise and address barriers to use
DOSE RESPONSE AND SAFETY
• The DOSE Study
• “Public health dose (PHD) of exercise is
an effective monotherapy for mild to
moderate MDD”4
• Scores reduced by 47%4
• This is comparable to CBT and
medication (36% and 42%
respectively)4
• 17.5 kcal/kg/week divided by 3 days =
Public Health Dose
• No Difference 3 day a week vs 5 day a
week
• >30 minutes of moderate intensity on
most days of the week
• Anxiety meta-analysis7
• High and moderate intensity better than low intensity
• No difference in weekly or total dose of physical
activity
• Supervised physical activity
• Very little research on the type, frequency, duration,
supervised or unsupervised
• “UK National Institute for Health and Clinical Excellence
recommends structured exercise 3 times a week for 10-14
weeks for the treatment of mild to moderate depression”
• Cooney et al. Exercise for Depression14
• Only 7 trails reported adverse events
• None reported an increase in adverse events associated
with exercise
BARRIERS TO EXERCISE
Barriers
Low motivation
Lack of ability
or
confidence
Lethargy and
fatigue from
depression
Fear- anxiety,
BMI, body
physique
awareness
• Positives
• Most viewed exercise as an acceptable
treatment
• Sense of purpose
• Autonomy
• Long term treatment without
“dependence”
• Combatted by
• Medications to help improve movement
• Activity Diary
• Motivational messaged- printed or by
computer
• Time of day
• Use of motivational interviewing
• Flexibility in exercise strategy
• Social support
• Behavioral Techniques
A SPE CI AL T H ANK S TO AL L
MY B E AUT I FUL FR I E NDS I N
MOV E ME NT !!
Amelia Bueche DO
• “This Osteopathic Life”, -Ashland Oregon
• MamaTriDoc
Leanna Garbus OMS V
• Yogi Extraordinaire!
•
Anecia Trickey & her beautiful daughter
Sophia
• RYT yoga teacher
• Alexandra Peters
• yoga teacher extrodinarire
• Sean Eshraghi
• Weight lifter – motivator!!- Beast Mode!!
[The] processes of Life must be
kept in motion.
A.T. Still
—Philosophy of Osteopathy
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