TREAD carefully with your conclusions! Exercise to treat depression – is it effective?

Depression is one of the most prevalent mental disorders in the World and the global incidence is on the rise. It is already the leading cause of disability, and the fourth leading contributor to the global disease burden according to the World Health Organisation (WHO). WHO is predicting depression to reach second place in the rankings of disability-adjusted life years calculated for all ages and both genders. At least 121 million people are thought to be affected worldwide, with this figure likely being an underestimate.

Exercise has long been thought of as a positive treatment intervention for depression, and many healthcare practitioners recommend exercise as part of a treatment strategy. However, the publication of a new paper by Chalder and colleagues in the British Medical Journal at the start of this month has caused much controversy and debate amongst physicians and patients alike.

Chalder and colleagues reported the results of a UK-based multi-centre, two-armed parallel randomised controlled trial in primary care entitled the TREAD’ study (TREAtment of Depression with physical activity).

The study participants were 361 adults aged between 18 and 69 who had consulted their primary care clinician with symptoms of depression. The intervention consisted of 3 face-to-face sessions and ten telephone calls with a trained physical activity facilitator over an 8 month period designed to offer individually-tailored support for patients to engage in physical activity, and both intervention and control groups were offered ‘usual care’ including antidepressant treatment.

The primary outcome measure was the Beck Depression Inventory score at 4 months follow-up, with secondary outcome measures of the same score at 8 and 12 months, and a self-reported measure of antidepressant use. Physical activity was measured by use of a self-reported 7-day recall diary in which individuals were requested to record 10 minute bouts of light, moderate, and vigorous physical activity, and these were subsequently converted to metabolic equivalents (METS) by multiplying by a factor thought appropriate to each level of activity. An attempt was made to check the validity of this method of data collection by comparison with accelerometry data which found a reasonable correlation between self-reported data and light-moderate physical activity, with less of a correlation at higher levels.

The group found no differences between the groups in Beck Depression Inventory scores at the four, eight or twelve month stage, and no evidence of a decrease in antidepressant use in the treatment group compared with the control group. They concluded that ‘The addition of a facilitated physical activity intervention to usual care did not improve depression outcome or reduce use of antidepressants compared with usual care alone.’

These findings sparked a number of media headlines in different sources including the Daily Telegraph newspaper, the BBC website, and the Guardian newspaper suggesting that exercise is not effective in the treatment of depression.This leap of faith in media reporting in pronouncing that exercise will not help to treat depression as a result of the findings of this trial is quite astonishing but perhaps not surprising.

The devil is, as ever, in the detail and there has been a vociferous response from clinicians and patients alike pointing out the many limitations of the study, including :

1) Questions about the accuracy of self-reported physical activity data ;

2) High drop-out rate during the trial (36.8% and 40.2% at 8 months) ;

3) Lack of a controlled physical activity intervention with doubts about the frequency, intensity, time and type of physical activity undertaken by individuals ;

4) Lack of recording of the exact nature of ‘physical activities’ that were performed by the intervention group including whether these were individual or group activities ;

5) Heterogeneity of possible diagnoses involving depressive symptomatology amongst the study groups (eg bipolar, unipolar, reactive, depressive personality disorder etc) ;

6) Lack of enough well-defined exclusion criteria ;

7) Debate about the suitability of the Beck Depression Inventory for monitoring a treatment response in patients with depression or with depressive symptomatology ;

8) Lack of availability of pre-study physiological parameters (eg VO2 max / Max HR etc) ;

9) Use of an arbitrarily-defined threshold for the ‘desired’ physical activity level ;

10) Lack of controlling for other possible bias and confounding factors (eg psychosocial issues such as alcohol use, unemployment, poverty, previous depressive illness etc).

There is a plethora of evidence for a positive treatment effect of exercise on depression. However, many studies to date have methodological limitations which makes it difficult to make firm conclusions about a treatment effect.

 A Cochrane review conducted by Mead and colleagues in 2010 included 25 relevant randomised controlled trials, many of which had methodological weaknesses, and concluded that exercise did seem to improve symptoms of depression but that the effect sizes were moderate and not statistically significant.

Regardless of the methodological limitations of the TREAD study, given the complicated nature of depression, together with the wider bio-psycho-social associated factors, perhaps a controlled trial to investigate the effects of physical activity on depression is not the correct approach to take, and certainly it looks like few conclusions can be taken from this trial and effectively translated into clinical practice.

If exercise is an effective intervention for some forms of depression then the optimum time, type, frequency, and intensity still remains unknown.

In addition, we are still unsure of the possible mechanisms for a treatment effect of physical activity and exercise on depression. These are complicated and may be divided into physiological and psychological mechanisms including:

1) Physiological – monoamine hypothesis, endorphin hypothesis, regulation of hypothalamo-pituitary axis ;

2) Psychological – distraction, self-efficacy, mastery and social interaction hypotheses.

There may, of course, be a combination of mechanisms involved.

CJSM would like to hear your thoughts about physical activity and exercise as a treatment for depression. In addition, we would like to hear your thoughts about study limitations in general, and issues related to the translation of knowledge into clinical practice.

In the meantime, here are a few blog links mentioning the TREAD study you might want to check out :

1) The lay scientist – Martin Robbins (UK)

2) The ‘Mind’ blog (UK)

3) Scientific American blog (US)

4) depression blog (US)

5) Science Media Centre (NZ)

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1) Chalder M et al. 2012. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. BMJ 2012 344:e2758

2) Baxter H et al. 2010. Physical activity as a treatment for depression: the TREAD randomised trial protocol. Trials 11: 105

3) Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Exercise for depression. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD004366. DOI: 10.1002/14651858.CD004366.pub4.

Back to the iPad – explaining spinal conditions to your patients using iSpineCare

Regular blog readers will recall previous posts describing a range of different anatomy applications for the iPhone and iPad, useful for both learning anatomy and for patient education. A particular favourite of mine thus far has been the 3D4Medical series of Apps discussed in a previous blog post, describing anatomy and pathology of various joints in the body, but these have not included an app designed specifically to cover just anatomy and pathology of the spine to date.

Anatomate-Apps (anatomical animation applications) is a Australian Company founded in 2009  by Dr John Hart, in order to develop iTunes applications designed by clinicians involved in the assessment and treatment of patients with spinal conditions, for use as patient education tools.

The over-riding idea is that patients who are given visual and spoken information in the form of interactive digital media during the consultation may experience an improved quality of care overall, as they are better informed about their condition(s) in a way that they can easily understand, and can then go on to make better informed decisions about their subsequent care.

Whilst there are some patients and clinicians such as myself who undoubtedly welcome these applications for use during the consultation, there are other patients and clinicians who will prefer a more traditional approach. Nevertheless, it is hard to argue against the view that the use of applications designed for patient education on the new iDevices is likely to significantly increase in the future, and I for one am using these more and more in my patient consultations to good effect.

iSpineCare is the first spinal anatomy and patient education application for iDevices that I have come across with such a comprehensive and accurate description of spinal anatomy and pathology. Constituting a hefty download at around 1.7GB of information on iPhone or iPad, the application consists of a main menu with folders relating to cervical and lumbar spinal anatomy, movements, and pathologies together with a folder of conservative care options and an exercise library folder.

Navigating through the different sections is easy and quick, and takes you to a context-specific menu which contains links to a series of movies which can be paused, rewound, or fast-forwarded to different points of interest, together with an image library of key stills from the movies allowing for prolonged discussion around particular points of interest. In addition, a pdf document linked to each movie is presented giving a more detailed explanation of different topics.

Another bonus is the availability of medical imaging alongside the individual movies. This section contains a series of x-rays, CT scans and MRI scans and has interactive labels  and reports to help to explain the images further to patients. This section may also be useful for junior clinicians to assist with learning about spinal pathology from a visual perspective.

The quality of the images and in particular the movies is outstanding, with crystal-clear animations allowing for easy recognition of the relevant spinal anatomy and pathologies. Some of the movies have voice-overs explaining salient points, whereas others are animation-only allowing for the clinician to talk the patient through the particular points of interest important for that individual patient to be aware of and focus on during the consultation. In addition, there is a section where particular images can be added to a list of the user’s favourite movies allowing for quick access to a particular user’s most often-used animations.

Another section of movies under the folder ‘Conservative Care’ offers a number of movies describing back-safe ways of performing everyday duties such as gardening, shopping and typing. There are also movies offering advice on a variety of lifestyle topics.

Finally, there is an ‘Exercise Library’ folder with several sub-folders offering animations describing a series of exercises for different purposes including cervical flexibility exercises and core stability exercises.

The overall package is very slick, well thought-out, and accurate in the descriptions of spinal pathologies and anatomical features. Stand-out points are the quality of the animations and the wide range of animations available. An internet connection is not necessary for the app to run, as all of the animations are downloaded embedded within the main app.

Anatomate-Apps also offers other similar applications describing spinal surgery (iSpineOperations) and pain management (iSpinePainManagement), and there are some smaller-sized applications offering information focussed on some particular aspects of spinal pathologies and operations for those who don’t need the larger apps.

As a Sport and Exercise Medicine Physician, I would have liked a little more emphasis on some of the conditions more commonly seen in my patient population including symptomatic spondylolysis, and cervical ‘stingers’ and ‘burners.’  However, most common pathologies are well represented and I can see iSpineCare and iSpinePainManagement becoming an important part of my clinical practice in the future.

Anatomate-Apps are available on the iTunes Apps store, and a video review of iSpineCare highlighting some of its features is available from the App show iPad edition on the link below.

The Larks and the Owls – chronotypes and desynchronosis. Time for an individual approach with MEQ-SA analysis?

The practical management article in this month’s edition of the Clinical Journal of Sport Medicine by Charles H Samuels highlights a difficult problem facing athletes and their support staff that is commonly encountered during air travel, that of the issue of jet lag. Samuels makes the point about the difference between travel fatigue and jet lag (desynchronosis), defining the former as a  constellation of physical, psychological and environmental factors that impact over time on an athlete’s capacity to recover and perform, and the latter being defined as a number of symptoms occurring following travel between time zones.

The key to the understanding of these concepts lies within the study of Chronobiology – the field of biological science that examines cyclical phenomena in living organisms and their adaptation to solar and lunar rhythms. Human beings are normally diurnal creatures, usually being active in the day and sleeping at night. However, as many night and shift-pattern workers will attest, many of us are required to adapt to different patterns of activity and sleep as part of our everyday lives. Some of us are able to cope with these pattern shifts better than others, whereas extremes of sleep-activity outside the normal range may cause a person difficulty in participating in normal work, school and social activities.

Flight travel over different time zones presents a challenge for the individual as the body seeks adjusts its circadian rhythms to these different  zones. A number of different modalities may be used in order to prevent athletes developing jet-lag, including the use of melatonin, preflight adjustment to travel, timed light exposure and avoidance, and changes in training schedules. However, it is interesting to observe that some individuals seem to suffer from jet lag more than others, and that there is variability in the efficacy of preventative and treatment strategies for desynchronosis amongst athletes.

Why is it that some of us seem to cope better with time zone changes and shift pattern working? Perhaps the answer lies in an individual’s chronotype.

Sleep researchers refer to ‘Larks’ as individuals who naturally wake up in the morning, contrasting with the ‘Owls’ who wake up and go to sleep late. These groups are also described as being comprised by individuals with ‘morning-ness’ and ‘evening-ness’ tendencies. Most people lie somewhere in between. However, there are some interesting differences between the groups with some researchers going as far as to suggest that disease processes may be directly influenced by morning-ness and evening-ness. This news feature in Nature, published in 2009, discusses some of these concepts in greater detail for those readers who may be interested to know more.

Horne & Ostberg in 1976 presented a self-assessment morningness-eveningness questionnaire and this has been modified by others to produce an MEQ-SA. Those of you who may wish to objectively assess your lark-ish and owl-ish tendencies can find the modified MEQ-SA questionnaire and scoring table here. 

It is unclear which factors contribute to an individual’s chronotype, as there seems to be no clear correlation to gender, ethnicity, or socio-environmental factors. However, perhaps chronotype variation may go some way to explaining why there is such variability in the effect of different preventative strategies for jet-lag between individuals. If so, then the assessment of an individual’s chronotype may form an important part of an overall primary preventative strategy for travelling athletes and support staff, which may be best conducted as part of an individual approach rather than a team approach.

Unfortunately, there is currently a paucity of literature on chronotype analysis in elite athletes in relation to jet-lag prevention representing an opportunity for further research in this area.

Are any readers using chronotype analysis as part of a jet-lag prevention strategy? CJSM would like to know.

References –

Samuels, Charles H. 2012. Jet Lag and Travel Fatigue: A Comprehensive Management Plan for Sport Medicine Physicians and High-Performance Support Teams. Clin.J.Sport Med. 22(3): 268-273

Phillips, Melissa Lee. 2009. Of owls, larks and alarm clocks. Nature 458 

Horne JA & Ostberg O.1976. A self-assessment questionnaire to determine morningness-eveningness in human circadian rhythms. Int. J. Chronobiol. 4(2):97-110 


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Next generation of anatomy apps for learning and patient education here NOW!!

Regular readers of the blog may remember the previous post on anatomy applications (apps) back in June last year, when I presented my top 5 anatomy apps on the Apple apps store for both learning anatomy and educating patients.

For those of you who need a quick reminder, apps from the Apple store are computer programs that work on several Apple-platform mobile devices including iPads, iPhones and the iPod touch, with certain apps and features within apps being available only on certain devices, limited only by hardware and next generation development issues. For example, the iPad 2 has an integrated camera whereas the first generation device had none. The value of anatomy apps lies both within clinician and patient education.

The next generation of anatomy apps are now available from 3D4Medical, running on both first and second generation iPads. There are updates for both of the Skeletal System and Muscle System Pro Nova apps (now in their 3rd editions), and new dedicated apps for the hip joint, knee joint and shoulder joint which include the complete anatomy of these regions including musculoskeletal anatomy, nervous system and vascular anatomy.

I am pleased to say that there has been a significant improvement to the existing apps which were already excellent in quality. Now, they are simply outstanding in many ways. The quality of the visuals has not gone unnoticed by Apple themselves who have showcased some of the apps on their latest TV adverts. The images really are stunning when seen on the iPad.

Both Skeletal and Muscle System Pro Nova III apps come with a new interface which allows for simpler navigation. Images can be more easily manipulated than before for different viewing angles allowing for simpler rotation, single finger-swipe cuts for coronal, saggital and transverse views, and a double-tap zoom feature. This allows you to get to the images you really want to see much quicker than before. There is a hint feature to help you to get to grips with the new graphical interface features which can be turned off once you get used to these. Pin Media labels are more extensive, and these are now spoken to allow users to hear the correct pronunciation of each anatomical feature.

The pin labels themselves now come with additional media, such as animations of anatomical movements or further images. There are also linked public notes which allows for users to read notes made by other users of the apps in the public domain. The images can be easily annotated, and shared with patients or other people who may wish to view them by email and social media via twitter and Facebook.

The new dedicated apps are perhaps the ones of most interest to clinicians, for the first time including all of the relevant anatomy of the regions to give a clear picture of the entire anatomy from surface to bone. The clarity of images within these apps is outstanding, and the animations are especially helpful for explaining how certain muscles produce certain movements to patients. Structures such as the subacromial bursa in the shoulder can easily be visualised, and when combined with the animations showing movement at the shoulder joint, it is much easier than before to explain to patients how impingement of this structure can occur under the subacromial arch.

You can check out the new features in the Knee Pro Nova video below (will only show on standard site).

Having used the earlier apps during my patient consultations as an educational tool, I have now started to use these new apps and have found them easier to use both in the consulting room and at the training ground than the previous incarnations. Patients seem to gain a better understanding of the anatomy relevant to their injuries or conditions when seeing the visuals, and the multimedia content really helps to bring functional anatomy to life.

Perhaps future additions to the series might include videos specifically related to pathologies. Examples might be video image of an inflamed bursa impinging under the subacromial arch, a ruptured anterior cruciate ligament in real time, or the dynamic anatomy of a snapping hip. For now, however, these apps give clinicians an extremely powerful set of tools for patient education, and for learning anatomy.

For further information on 3D4Medical’s new apps, see the 3D4Medical website, or check out videos of the other apps on youtube via these links :

Shoulder Pro

Hip Pro

Skeletal System Pro III (Nova Series)

Muscle System Pro III (Nova Series)

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