Exercise & Mental Health: Review & Recommendations

For decades there has been a growing body of evidence that exercise supports improved mental health outcomes.  Numerous systematic reviews have found support for use of exercise as an intervention in psychological patients with depression, eating disorders, anxiety, & dysphoric mood all the way to Alzheimer’s & Parkinson’s disease (Byrne & Byrne 1993, DeBoer et al. 2012, Fremont & Craighead 1987, Marchant et al. 2010,  Stathapoulou et al. 2006, Yaguez et al. 2011). It is difficult to find a psychological condition that doesn’t benefit from exercise.  The lines between physical health & mental health are beginning to blur.  It seems that one may support the other.

The effectiveness of exercise interventions extends beyond these conditions to older adults and children alike (Colcombe & Kramer 2003, Tomporowski et al. 2015).  Exercise supports widespread cognitive benefits, even in healthy populations. Frequent evidence is demonstrated for improvement of executive function, proprioception, & balance, along with more qualitative measures of support, meaning, emotional expression, and identity (Best 2010, Colcombe & Kramer 2003, Mason & Holt 2012, Ritter & Low 1996, Schubert et al. 2010) The evidence is clear & pointed: exercise benefits mental health.

This is often explained by the connections between the body, brain, and mind.  We’ve seen that exercise improves microstructure of the brain (Black et al. 1990, Tian et al. 2014), leading to the development of new blood vessels.  And there is some evidence that physical actions relate to the process of thought & learning (Goldin-Meadow & Wagner 2005). More and more evidence shows that the benefits of exercise come from the plastic nature of the nervous system (Buonomano & Merzenich 1998, Cotman & Berchtold 2002, Recanzone et al. 1992), long thought to be a fixed entity in adulthood.  The brain essentially has the ability to rewire itself as part of the learning process. In fact when it comes to learning new motor patterns & skills the process is almost completely reliant on neuroplasticity (Dayan & Cohen 2011).  This plasticity was thought to exist solely in young individuals, but elderly populations appear not to lose this capacity to create new neural connections (Goble et al. 2009). It seems you can in fact teach an old dog new tricks through focused exercise & learning.

So exercise may provide a substantial benefit for mental health.  The question then arises: does it serve as an adjunct to, or replacement for traditional methods of psychological treatment?  The answer seems to be: it depends. A small body of evidence highlights the use of exercise as a replacement of traditional talk therapy in some populations.  Exercise is often less expensive per hour and provides a similar level of benefit in some cases, but not all (Fremont & Craighead 1987).  However, its benefits seem extended when used in conjunction with typical psychological interventions (Oswald et al. 2006).  

The main differentiator between exercise & cognitive interventions comes down to scope of benefit.  While traditional cognitive training has very focused improvements, there is evidence that exercise training may provide more generalized benefit for mental health (Schafer & Schumacher 2011).  Clearly exercise interventions are a powerful tool in the treatment toolkit. In fact a recent review (Ranjbar et al. 2015) calls for a multi-disciplinary team for the treatment of depression, utilizing the expertise of both the medical community and the exercise/movement community.  

However, two problems consistently arise, which this review addresses.  The first is that we need a shift from quantitative to qualitative when prescribing exercise intervention (Pesce 2012).  The second is that available literature does not provide an accurate definition of effective training methodology (DeBoer et al. 2012, Pichierri et al. 2011, Robertson et al. 2012).  We know exercise is useful, but we don’t know how to prescribe it well.

Although exercise interventions have a demonstrated benefit, it is less clear what type of exercise is most beneficial.  Aerobic exercise was presumed to be the gold standard for a long time (e.g., Robertson et al. 2012), but mounting evidence points to similar benefit from both anaerobic exercise, such as resistance training, and mindfulness-based training, such as yoga or Tai Chi (DeBoer et al. 2012, Gothe et al. 2013, Ranjbar et al. 2015, Yaguez et al. 2011).  It may be prudent to extrapolate that a range of physical activity is best. Based on the available literature this review suggests that an exercise intervention for mental health have the following characteristics:

  1. Focused attention.

  2. Proprioceptively demanding.

  3. Variation.

  4. A balance of slow & fast movement.

Each is explored below.

Attention

As a society we’re largely distracted from our bodies and our movements.  Even when we do go to the gym, TV monitors and music compete for the attention of our nervous system, much to the detriment of our movement.  Evidence suggests that when distracted by external stimuli, motor performance suffers (Johansen-Berg & Matthews 2002, Schafer & Schumacher 2011).  And body awareness is linked to both proprioceptive ability & memory (Goble et al. 2010).

Mindfulness in therapy protocols has been shown to have tremendous benefit for depression, anxiety, and psychological distress (Bohlmeijer et al. 2010 & Kabatt-Zinn 2003).  Mindfulness-based exercises such as yoga, Tai Chi, and Feldenkrais Awareness Through Movement all demonstrate success in improving mental health (Gothe et al. 2013 & Kolt & McConville 2000).  Attention and focus must be staples in an effective mental health exercise intervention.

Proprioceptive Demand

Proprioception is the body’s ability to identify where it is in space & sense the effort required in movement.  It is closely linked to our sense of balance. Mounting evidence points to the improvement of cognitive outcomes including executive function, working memory, and psychological health from bouts of proprioceptively demanding activities (Adamovich et al. 2001, Alloway & Alloway 2015, Best 2010, Goble et al. 2012, Kiepe et al. 2012, Marchant et al. 2010, Schubert et al. 2010).  These activities range from tree climbing & dance, to balance training & “cognitive-focused exercise”. What becomes clear is that these activities introduce a novel challenge to participants, who are forced to use their active sense of proprioception to navigate the activity.  Rather than the rote movements of traditional aerobic/anaerobic exercise, these new movements challenge greater use of one’s mind, possibly leading to aforementioned neuroplastic changes.

Variation

Many of the benefits of exercise have been demonstrated to stem from neuroplastic changes, and complexity appears to promote these changes (Carey et al. 2005).  More so than repetition, variation facilitates the learning process. It appears that learning, not merely doing drives the formation of new synapses in the brain (Black et al. 1990 & Schilling et al. 2003).  In the world of exercise training variation often comes down to environmental factors, including the size/shape/texture of objects, terrain used for training, and the like.  In fact there is evidence to support the notion that multisensory environments, those providing variation, facilitate the learning process (Seitz & Dinse 2007). It seems safe to extrapolate that these variations would in turn support neuroplastic changes.

Fast & Slow

Part of this benefit is drawn from the prior three principles, however, the balance of fast & slow movement carries the mental health effects farther.  Faster movement evokes the known influence of aerobic and anaerobic movement, and slow movement draws on a lesser known principle of physiology, the Weber-Fechner Law (Hecht 1924).  This law states that as magnitude of stimulus increases, the ability to differentiate changes in stimulus decreases. A common metaphor is this: imagine being in a dark room with one candle lit.  It becomes instantly apparent when a second candle is lit. However, in a room with 1,000 candles burning, the 1,001st candle is harder to identify. As the magnitude of stimulus increases, we are less able to discern differences.  In the context of exercise we see that the greater the speed of a movement, the less able we are to notice sensations in the body. This can play a crucial role in the learning of a new motor pattern, which as we have seen is critical to the neuroplastic process.

Exercise interventions have a fundamental role in management and treatment of mental health.  The structural and neuroplastic effects of exercise makes it a powerful complement to traditional psychological & cognitive therapies, and its low implementation cost makes it appealing to providers and participants alike.  Although the available literature is consistent in touting the benefits of exercise for mental health, little work has been done to effectively codify the qualities that are most successful. However, this review posits that the qualities leading to most marked improvement are: attention, proprioceptive demand, variation, and a balance of slow & fast movements.  When designing exercise interventions for cognitive health, it is crucial to keep these guidelines in mind and to explore a wide range of movement options for patient benefit.


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Chandler StevensComment