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.

Sport and Exercise Medicine – A Fresh Approach. Guest blog by Dr Richard Weiler

Sport and Exercise Medicine (SEM) has been evolving rapidly around the globe and is gaining mainstream recognition. In the United Kingdom it formally began life in 2005, when the Chief Medical Officer at the time, Liam Donaldson, pledged to develop the specialty as a commitment to the London 2012 Olympics. 2012 has arrived and the specialty of Sport & Exercise Medicine is slowly gaining a foothold in the publicly funded UK National Health Service (NHS).

In the UK, we now have an established Faculty of Sport & Exercise Medicine and a fairly comprehensive and evolving 4-year specialist training programme . There are currently about 50 specialist trainees in training across the country and about 10 doctors have become specialists in SEM in the last couple of years.

Challenging economic climates have resulted in new measures being implemented by the Government. ‘Market forces’ have been suggested as a means to ensure that funds are targeted locally and efficiently for patient needs. This has resulted in an urgent need for the fledgling SEM specialty to justify its existence and demonstrate patient benefit and cost effectiveness in order to establish new SEM services and maintain existing services. This is not easy for a specialty that has existed for only a few years. A major obstacle when speaking to those holding the funds is the lack of understanding about what SEM specialists can offer the NHS. Is it about elite sport, athletes and the Olympics or is it about exercise, gyms and running?

The truth is mostly ‘none of the above’ for the general population, so late in 2011 we published an NHS Information Document explaining what an SEM specialist offers the NHS and NHS patients. This is broadly based on education, research, musculoskeletal, sports medicine, physical activity for prevention of chronic disease and physical activity prescribed in the treatment of chronic disease (exercise medicine).

We hope that this peer reviewed NHS Information Document, endorsed by all the key UK organisations in the SEM field, will be helpful to our colleagues and fellow multidisciplinary team members both in the UK and around the world.

The rest as they say is history, or in the wise words of Master Yoda “Always in motion is the future.”

The publication involved the collaboration of too many people to thank individually, but the co-authors, whom were all SEM trainees at the time of writing, all deserve individual mention (in no particular order). Natasha Jones, Kate Hutchings, Matt Stride, Ademola Adejuwon, Polly Baker, Jo Larkin and Stephen Chew.

Dr Richard Weiler is an Honorary Consultant in Sport and Exercise Medicine based at  University College London Hospitals Foundation Trust, London, UK

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MRI scans in Sports Medicine – use or abuse?

There was an interesting article in the New York Times this week that caught my eye, thanks to an alert from our Publisher at CJSM (thanks, Paul!)

In the article by Gina Kolata, a science journalist for the New York Times, Dr James Andrews, of the Andrews Institute for Orthopaedics and Sports Medicine, was quoted as saying ‘If you want an excuse to operate on a pitcher’s throwing shoulder, just get an MRI.’

The article claims that Dr Andrews was involved in a piece of research where the pitching shoulders of 31 asymptomatic Professional Baseball pitchers were scanned using MRI, with findings of ‘abnormal shoulder cartilage’ in 90% of the shoulders, and ‘abnormal rotator cuff tendons’ in 87% of the shoulders. There was no indication as to whether or not this research was published.

Other clinicians are subsequently quoted, including Professor Bruce Sangeorzan, Vice Chairman of the Department of Orthopaedics and Sports Medicine at the University of Washington saying ‘an MRI is unlike any other imaging tool we use… It is a very sensitive tool, but it is not very specific. That’s the problem.’

In addition, Professor Christopher DiGiovanni, Sports Medicine and Orthopaedic Specialist at Brown University, is quoted as saying ‘It is very rare for an MRI to come back with the words “normal study” … I can’t tell you the last time I’ve seen it.’

Following quotes from these clinicans, the author goes on to make what some might call a leap of faith in then stating that ‘MRIs are not the only scans that are overused in medicine, but in sports medicine where many injuries involve soft tissues like muscles and tendons, they rise to the fore,’ the statement regarding ‘overuse’ having been drawn, presumably, from inferences from some of the clinicians quoted in the article.

Later on in the article, a retrospective study from 2005 by Bradley and colleagues  of 101 patients with chronic atraumatic shoulder pain is mentioned which examined the effect of pre-evaluation MRI on patient treatment and outcome, and concluded that MRI was not helpful as a screening tool for atraumatic shoulder pain before a comprehensive clinical evaluation of the shoulder.

In addition, another retrospective study from 2007 was mentioned by Tocci and colleagues who set out to prove the alternative hypothesis that rising accessibility of MRI may be resulting in it’s overuse by retrospectively reviewing 221 patients seen over a 3 month period for the treatment of a lower extremity problem. The authors concluded that ‘many of the pre-referral foot or ankle MRI scans obtained before evaluation by a foot and ankle specialist are not necessary.’

The New York Times article certainly seems to have sparked a flame of interest spreading amongst other newspaper and website authors and has been widely quoted in the few days since it has been published.

There is no doubt that there are a number of factors that could lead MRI scans to become overused as an investigation in the assessment of patients seen by Sports Medicine clinicians. These could include improved accessibility to MRI scanners, reduced cost for examinations, inadequate clinician history taking and / or examination skills, laziness on the part of clinicians in performing an appropriate assessment, financial incentives, patient pressure for scans, and defensive medical practice.

However, any clinician worth their salt surely recognises the need for an excellent history, targeted clinical examination, formulation of a differential diagnosis and appropriate investigation on the basis of these.

They would also surely realise issues regarding the sensitivity and specificity of MRI scans for detecting lesions, and the fact that the natural history of some lesions detected by MRI scans that have hitherto been undetectable is not well known, limiting the conclusions that can be drawn from some scans relating to treatment and prognosis.

In addition, the limitations of MRI scanning as a screening tool should also be known by responsible clinicians, although there is no doubt in my mind that some colleagues are using MRI scanning in a non-evidence based way for screening and that this may ultimately lead to unnecessary procedures and psychosocial harm.

I don’t agree with the quote from Dr Andrews implying that if one wants to operate on a pitcher’s shoulder then all one needs to do is order an MRI scan – good surgeons operate on patients, not scans, and should surely follow the time-honoured approach I have highlighted above.

The article by Kolata in the New York Times presents little if any evidence that MRI scans are indeed overused in Sports Medicine, and it is my opinion that the views of a few individuals plus a couple of retrospective studies don’t really form a convincing argument to support the inference in the title of author’s article, that MRIs are indeed overused in Sports Medicine.

It’s interesting that our Specialty was targeted in this article.

Is this a thinly-veiled attack on Sports Medicine clinicians?

What do our readers think?

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Home or away? Making decisions on the location of medical and surgical care of the elite athlete

I was at the UK Faculty of Sport and Exercise Medicine’s Annual Meeting today, held at the wonderfully-titled ‘Worshipful Society of Apothecaries’ Hall in Blackfriars, London. The Society and the Hall share a very interesting history, the Society itself being the largest of the Livery companies of the City of London with members originating from the Guild of Pepperers, and subsequently members of the Grocers’ company formed back in the Twelth Century. During their history, Society Members challenged the dominance of the Royal College of Physicians, and they can boast a number of previous Licentiates including Elizabeth Garrett Anderson who was the first woman to gain a medical qualification in the UK.

It was in this unique setting that an interesting debate was held during the meeting concerning the question ‘Which is the best location for the medical and surgical care of the elite athlete – home, or away?‘ Should an athlete be sent abroad for treatment, for example, surgical intervention, or should they be kept at home for such treatment?

The cases for and against ‘home’ treatment for athletes were put forward by two Internationally renowned Professors of Orthopaedic Surgery, both well known in the World of Sport Medicine. The arguments were related to issues of practice in the UK, considered to be the ‘home’ Country in this debate. Both arguments focussed on the perceived quality of care that could be provided in different Countries. The ‘home treatment’ case centred around a feeling that UK Orthopaedic surgeons are just as good if not better than their overseas colleagues, well-trained, and working within a strong clinical governance framework. The arguments for the ‘away’ case included the perception that a superior ‘whole package’ of care might be offered overseas, with better provision of rehabilitation. It was also put forward that some overseas surgeons might have a better reputation than their UK counterparts due to stronger marketing and self-promotion, and that perhaps UK surgeons reflect the generally reserved stereotype of the British people, thus making athletes more likely to seek treatment from overseas practitioners.

What struck me during the debate and subsequent questioning was the focus on clinical competence and provision of rehabilitation, and the importance of the perception of the quality of these by clinicians and athletes who are their patients. Whilst these are no doubt very important points for consideration, there are other issues to consider in a decision for ‘home’ versus ‘away’ care.

One such important issue that stands out for me is the provision of psychosocial support during a peri-operative or rehabilitation period. I have previously been involved in the care of several professional sports participants, living outside of their home Countries, who wished to return home for an operative procedure so that they could be near their families during at least the early part of their rehabilitation period. Whilst this may not seem important to some in the decision to provide the best quality of care, perhaps we are sometimes too hasty to forget the importance of such support for some athletes undergoing sometimes invasive and temporarily-debilitating procedures. It is perhaps not as easy to measure the value of immediate support from family and friends to athletes as it is to measure outcomes such as time to return to sport, but should that deter us from taking such support into account in making decisions for ‘home’ versus ‘away’ care?

If we are to entertain the concept of patient choice and a bio-psycho-social model of practice as Sports Medicine Clinicians, then surely the ideal is to form a therapeutic alliance with our patients, making joint decisions about their care not only on the basis of the provision of the perceived best treatment available, but also on the basis of patients’ needs which are often complex in nature. It’s not all about what we might think is ‘best care’ – just ask your patient what else they think is important for them!

CJSM would like to hear your views on the case for  ‘home’ versus ‘away’ care, and your thoughts on shared decision making.

(Picture of Apothecarie’s Hall, Blackfriars, in 1831 at Wikimedia Commons)

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