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

RESEARCH HAS PROVEN TO BE

DIFFICULT

• 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

POSITIVE STUDIES

• North 1990- Meta-analysis

• Acute/Chronic exercise effective and effects may begin at the

first session

• 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 well-

designed trials

• “exercise treatment had significantly lower depression”

• Conn 2010- Meta-analysis on healthy adults

• Reduction of depressive symptoms in healthy adults

• Bridle et al 2012- Systematic Review and Meta-

Analysis of RCT11

• Exercise will reduce depression severity in patients >60

• Robertson 2012 systematic review and meta-

analysis-

• 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

NEUROIMMUNEPhysical Inactivity

Visceral Fat Accumulation

Chronic systemic Inflammation

Insulin Resistance, Atherosclerosis, Neurodegenerations, Tumor Growth

DMII, Cardiovascular disease, Depression, Dementia, Colon Cancer, Breast Cancer42

• Stress and Depression Elevate17:

• IL-6, CRP, NK cell function, TNF-a

• Hyper-reactivity of pro-inflammatory state

• Impaired T cell function

• Proinflammatory cytokines can17:

• Influence monoamine metabolism

• Neuronal genesis/survival

• Decrease HPA axis sensitivity to cortisol

• Cellular neuroimmune functions

• Neuroimmune modulating effects of Exercise

• Positively influence inflammatory, oxidative, apoptotic and antineurogenic mechanisms

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

• Weight loss

• Outdoor recreation

• Achievement

• Time out

• Interruption of a maladaptive

cognitive set

• Exercise releases positive

feelings

• Feeling successful

• Increased self-efficacy

• Increased self esteem

• Cardiovascular fitness

• Distraction from negative

thoughts

• 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?

“FEELINGS HAVE A SOMATIC

ARCHITECTURE”9

“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

“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”

“WE ARE A GEOMETRY OF

SOMATIC CONSCIOUSNESS”9

“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-delicate-

geometry/

TENSEGRITY

•Compression and Tension

•Dynamic Element?

•Emotional Releases?

•Observing our patients

emotional posture

ANATOMY AFFECTS EMOTION

“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 self-

perceptions and actions.”18

EMBODIED COGNITION

“Sometimes your joy is the source of

your smile, but sometimes your smile

can be the source of your joy”

~Thich Nhat Hanh

• 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

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

TYPES OF MOVEMENT• Zumba

• Tai Chi

• 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 201366Yoga 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

• 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

Barriers

Low motivation

Lack of ability

or

confidence

Lethargy and

fatigue from

depression

Fear- anxiety,

BMI, body

physique

awareness

A SPECIAL THANKS TO ALL MY BEAUTIFUL FRIENDS IN

MOVEMENT!!

Amelia Bueche DO

• “This Osteopathic Life”, -Ashland Oregon

• MamaTriDoc

Leanna Garbus OMS V

• Yogi Extraordinaire!

• AneciaTrickey & 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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