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Physical exercise and psychological

Physical exercise and psychological

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Published by bodeadumitru9261
Physical exercise and psychological well being: a
critical review
Physical exercise and psychological well being: a
critical review

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Published by: bodeadumitru9261 on May 22, 2010
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Physical exercise and psychological well being: acritical review
Deirdre Scully, John Kremer, Mary M Meade, Rodger Graham, Katrin Dudgeon
Summary
The relation between physical exercise andpsychological health has increasingly comeunder the spotlight over recent years.While themessage emanating from physiological re-search has extolled the general advantages of exercise in terms of physical health,the equiva-lent psychological literature has revealed amore complex relation. The paper outlines theresearch evidence, focusing on the relationbetween physical exercise and depression,anxiety, stress responsivity, mood state, self esteem, premenstrual syndrome, and bodyimage. Consideration is also given to thephenomena of exercise addiction and with-drawal, and implications for exercise prescrip-tion are discussed.
Introduction
The positive role that physical exercise can playin the prevention and treatment of a range of medical conditions has received a great deal of attention over recent years, with numeroushigh profile reports supporting the popularmessage that exercise is good for you.
1–3
Inaddition, research has identified the long termprotection that regular exercise a
ords againsta plethora of somatic complaints, includingcoronary heart disease, hypertension, anumber of cancers, diabetes, andosteoporosis.
4 5
Following from these findings,recommendations for exercise regimens em-phasise the physical benefits that accompanyincreased physical activity, for example, withthe American College of Sports Medicine(ACSM) advocating that “Every US adultshould accumulate 30 minutes or more of moderate-intensity physical activity on most,preferably all, days of the week”.
6
Unfortunately, while the somatic benefitsassociated with physical exercise are well docu-mented, hard evidence to support an equiva-lent relation between exercise and psychologi-cal well being is less plentiful. Indeed, neitherthe ACSM guidelines nor many of the availableinternational public policy documents onphysical activity make specific recommenda-tions concerning exercise and mental health.Of the 17 documents reviewed by Blair
et al 
,
7
only two make mention of the psychologicalbenefits associated with physical activity.
8 9
This is true despite the fact that, when askedabout perceived health benefits of exercise,general practitioners are most likely to mentionpsychosocial benefits such as relaxation, in-creased social contact, promotion of self care,and self esteem.
10
The interview survey of Smith
et al 
10
bolstersa notion that has gained popularity both in thepopular press and the academic community,namely that the psychosocial benefits of physi-cal exercise may equal if not surpass the physi-ological benefits. The present paper aims toexamine critically the evidence presented insupport of this contention, before progressingto practical recommendations on the prescrip-tion of exercise regimens for the treatment of arange of psychological problems.
Physical activity and psychological well being
Over the last decade there have been severalextensive reviews of the exercise psychology lit-erature,whichtogethero
erpositiveifguardedsupport for the role that exercise can playin thepromotion of positive mental health.
11–13
Thisoptimism is founded on growing numbers of controlled studies which have identified thepositive e
ects of exercise, most often amongclinical populations. At the same time, cautionis expressed both in relation to the direction of causality and in the use of reductionistargumentsto interpret findings.In the wordsof Rejeski
14
“it is misguided to theorize thatexplanations for psychosocial outcomes willultimately be reduced to some physiologicalsystem (e.g.cardiac-related cortical activity) orneurochemical activity” (p 1053). Instead,what Rejeski and others maintain is thatperceived psychosocial benefits may occur inthe absence of clearly identifiable changes inphysiologicalparameters,justasitispossibletoestablish physiological changes in the absenceof any perceived psychological benefits.In a wide ranging literature review,McAuley
13
has considered the relation betweenexercise and both positive and negative psycho-logical health. In common with other reviewarticles, McAuley identifies the positive corre-lation between exercise and self esteem, self e
Y
cacy,psychologicalwellbeing,andcognitivefunctioning, and the negative correlation be-tween exercise and anxiety, stress, and depres-sion. While such information can be used tosupport the general benefits of exercise, it fallsshort of suggesting practical guidelines on howexercise may be used to alleviate particularsymptoms, and, just as significantly, whichforms of exercise are likely to be mostbeneficial in which circumstances. In addition,establishing the direction of causality hasproved di
Y
cult—that is, did psychological wellbeingprecede,follow,oroperateindependentlyfromaparticularexerciseregimen?Withthisinmind, it is unsurprising that reviewers remaincritical of the methodological limitations of much of the exercise psychology literature (seeMutrie and Biddle
11
).In a more innovatory critique of theliterature, Rejeski
14
attempted to frame thepsychosocial outcomes of exercise in terms of a
Br J Sports Med 
1998;
32
:111120 111
University of Ulster at Jordanstown, School of Leisure and Tourism, Jordanstown, Co.Antrim, NorthernIreland
D ScullyM M Meade
School of Psychology,Queens University of Belfast, Belfast,Northern Ireland
 J KremerR GrahamK Dudgeon
Correspondence to:Dr D Scully, University of Ulster, Shore Road, Jordanstown, Co. AntrimBT37 0QB, NorthernIreland.Accepted for publication9 March 1998
 
dose-response relation, a relation that had pre-viously enjoyed popularity not in the exercisepsychology but in the exercise physiologyliterature. According to Shepherd,
15
one of theprimary issues for exercise physiologists(alongside other health care professionals)centres on establishing the specific associationbetween physical activity undertaken (a prod-uct of intensity, frequency, and duration) andbiological responses (assessed by improvementin aerobic fitness or health). Despite unre-solved concerns over the application of theresearch paradigm,
15
many public policy initia-tives continue to be based on recommenda-tions derived from related research.According to Rejeski, while the dose-response relation may have heuristic value inrelation to the physiology of exercise, in termsof psychological e
ects it fails to account forthe cognitive and emotional experiences of theexerciser.Hence the complexity of the relation,in terms of both dose (activity type, frequency,intensity, and duration) and possible re-sponses, makes it di
Y
cult to envisage researchever having the potential to move fromdescriptiontoprescriptioninrelationtomentalhealth.Recent literature continues to urge cautionwhen extrapolating from the physiological tothe psychological,particularly as so few studiesare exploring the dose-response relation be-tween exercise and psychosocial outcomes.Rejeski
14
reviews only four such studies, withthe most significant conclusion derived fromthis work being that there appears to be a ceil-ing level in terms of psychosocial e
ects. Morespecifically, these studies
16 17
have suggestedthat low to moderate levels of aerobic exerciseare better than traditional demanding (anaero-bic) exercise programmes in terms of enhanc-ing mood and improving psychological func-tioning.There is greater di
Y
culty in establishingprecise guidelines with regard to the intensityand duration of exercise, partly because of methodological inconsistencies across studiesreviewed, but also reflecting on di
erencesbetween the psychological functions beingevaluated.At the level of general mental health,the literature therefore remains inconclusive asto the relation between exercise regimens andoverall psychological well being, and, with thisin mind, it is towards the specific e
ects of exercise on particular psychological functionsand conditions that attention has turned.In 1992, the International Society of SportPsychology
18
endorsed the position statementsearlier issued by the American NationalInstitute of Mental Health
19
which describedthe link between regular exercise and psycho-logical well being. Briefly, these consensusdocuments posited that particular psychologi-cal dysfunctions, most notably depression,anxiety, and stress, can benefit from involve-ment in physical activity. The evidence for asignificant and positive relation between physi-cal activity and psychological variables is takenas compelling for mentally healthyindividuals
20 21
but is seen as even stronger forthe psychiatric population.
22
This may not beunexpected—for example, given that the nor-mal population “score at the low end of depression scores and therefore, have relativelylittle room for improvement”,p 161.
23
Much of the existing literature on exercise and mentalhealth has focused on changes in anxiety,depression, mood, self esteem, and stress reac-tivity. Alongside these, for the purpose of thisreview it was decided also to examine two lessfrequently cited areas of research,those dealingwith exercise e
ects on premenstrual syn-drome (PMS) and also the relation betweenexercise and body image.
DEPRESSION
Martinsen
22
reviewed the literature dealingwith the e
ects of exercise on patients diag-nosed as su
ering from clinical depression.Initially, he found that such patients tended tobe physically sedentary and were characterisedby a reduced physical work capacity comparedwith the general population. In itself this find-ing immediately provides an argument for theintegration of physical fitness training intocomprehensive treatment programmes for de-pression, while at the same time signalling thedi
Y
culties that may be involved in implement-ing an exercise regimen with a population whoare not predisposed towards exercise.Although a number of studies stress theimportance of using aerobic exercise in thetreatment of clinical depression,
23
Martinsenfound that the antidepressant e
ects linkedwith non-aerobic exercise were equally e
ec-tive.He also found that those who continued toexercise regularly after termination of a oneyear training programme were found to havelower depression scores than those who weresedentary. In addition, the patients themselveswere found to be very much appreciative of theuse of exercise as a form of treatment and, asMartinsen states, the patients ranked exerciseas, “the most important element in compre-hensive treatment programmes for depression”(p 388).In 1990, North
et al 
24
conducted a meta-analysis based on 80 studies conducted be-tween 1969 and 1989, and included 290 e
ectsizes in their analysis. The results providedpositive support for a relation between physicalexercise and depression. In particular, it wasconcluded that acute and chronic exercisee
ectively reduced clinical depression. Allgroups of participants, regardless of gender,age, or health status, experienced the anti-depressant e
ects of exercise, with the greatestbenefits noted among those experiencingmedical or psychological care. The mode andduration of exercise were also examined and itwas found that both aerobic and non-aerobicexercise operated as e
ective antidepressants.However, the authors concede that additionalresearch should focus on the proposed psycho-therapeutic benefits of non-aerobic exercise,given that numerous studies do not concurwith this finding—for example, Folkins andSime
25
and Sachs.
26
Finally, the authors alsoexamined issues relating to length of exerciseprogramme, number of sessions, as well asintensity and frequency of exercise.Insufficient
112
Scully,Kremer,Meade,et al 
 
data relating to the latter two elements yieldedno firm conclusions, but the meta-analysis didsuggest that the greatest improvements indepression were found after 17 weeks of exercise (albeit that e
ects were found fromfour weeks onwards). Likewise, it was sug-gested that the greater the number of exercisesessions the greater the decrease in depression.A recent narrative review
27
has criticised themeta-analysis of North
et al 
on methodologicaland interpretative grounds, urging that theirconclusions and recommendations should beviewed with caution. In contrast, Morgan
27
issympathetic towards a monograph reviewingthe psychological e
ects of aerobic fitnesstraining.
28
Paradoxically, many of the conclu-sions of both studies are identical, in thatdepression was reduced after aerobic exercisefor men and women, all adult age groups,across survey and experimental studies, andthe e
ects were greatest among clinical sam-ples.Finally, a recent paper by Nicolo
andSchwenk
29
attempts to integrate current re-search with a view to providing physicians withpractical guidelines for exercise prescription asan adjunct to other forms of psychotherapy.Despite acknowledging that no research basedguidelines exist for recommending exercisetype, frequency, intensity, and duration, theauthors invoke prescriptions suggested byHill
30
which basically concur with thoseproposed by the ACSM.
98
Such programmesadvocate aerobic exercise conducted at 60– 70% of maximal heart rate,for 30–40 minutes,twice to five times a week.In conclusion, on the basis of existing litera-ture, it seems safe to accept that physical exer-cise regimens will have a positive influence ondepression, with the most powerful e
ectsnoted among clinical populations. Limited evi-dence would also suggest that aerobic exerciseis most e
ective, including activities such aswalking, jogging, cycling, light circuit training,and weight training,and that regimens extend-ing over several months appear to yield themost positive e
ects.
ANXIETY
To date, there have been over 30 publishedreviews dealing with the anxiolytic e
ects of exercise and physical activity. One review
31
concludes that regardless of anxiety measurestaken (trait or state, behavioural, self report,physiological), or exercise regimen invoked(acute
v
chronic),the results point to a consist-ent link between exercise and anxiety reduc-tion. Furthermore, a meta-analysis
32
specifi-cally examining studies that distinguishbetween those who are coping with stress andthose who are not concluded that aerobic exer-cise training programmes were e
ective inreducing anxiety, particularly among thoseexperiencing chronic work stress. Their overalle
ect sizes were comparable with those foundby other meta-analyses of the exercise-stressliterature, as well as other forms of psycho-therapy used to reduce anxiety.
33
Finally,recentresearchinthisarea
34 35
hasrefutedcriticismsof earlier studies that imply that anxiety reductionafter exercise represents no more than amethodological artefact
36
; instead, the e
ectdoes appear to be real and substantial.At the same time, explicating the variablesthat mediate the relation between exercise andanxiety reduction has proved problematic, atask made doubly di
Y
cult because so few stud-ies specify levels of intensity, duration, and/orlength of exercise programme. To date, it canbe inferred that most research studies haveinvolved aerobic exercise, with the few studiesexamining non-aerobic activities—for exam-ple, strength/flexibility training—actuallyshowing slight increases in anxiety. Althoughfurther research is obviously needed, it doesappear that aerobic activity is more beneficialfor anxiety reduction.No consensus of opinion emerges fromexisting reviews and meta-analyses on the levelof exercise intensity and its duration. Forexample, Landers and Petruzzello
31
reportconflicting results from a large number of stud-ies. Some suggest low intensity exercise (walk-ing, jogging at 40–50% of maximal heart rate),while others argue that moderately intensiveexercise (50–60% of maximum heart rate) isbetter, and yet others argue that high intensityactivity (70–75% of maximum heart rate) ismost beneficial.
37
Given this lack of consensus,a sensible compromise position in relation toprescription appears to be that originallyproposed by Franks and Jette.
38
That is, for theindividual to work with an adjustable level of intensity,chosen by him/herself in consultationwith a physician. This solution is especiallyattractive in the light of the goal settingliterature which argues that self selected goalsreceive greater commitment from the partici-pant.The duration of individual training sessionshas been considered across individual studies,with somewhat surprising results.According torecent research,even a single,five minute exer-cise bout may be su
Y
cient to induce ananxiolytic e
ect.
31 35 37
In terms of the length of training programmes, both clinical and non-clinical studies have shown that the largestanxiolytic e
ects are noted when programmeshave run from 10 to 15 weeks or even longer,with smaller e
ects observed for programmeslasting less than nine weeks.In conclusion, the literature unequivocallysupports the positive e
ects of exercise onanxiety, with short bursts of exercise appearingto be su
Y
cient, and, in addition, the nature of the exercise does not appear to be crucial. Aswith depression, the most positive e
ects arenoted among those who adhere to programmesfor several months.
STRESS RESPONSIVITY
A related literature has considered how exer-cise may protect against stress, althoughwhether this should be regarded as psychologi-cal or physiological research is questionable.This aside, the available research suggests thatincreases in physical condition or improved fit-ness are likely to facilitate the individual’scapacity for dealing with stress. In reviewingthis work,
39
a distinction has been made
Exercise and psychological well being 
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