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Walk of life

At least half an hour's walk a day is what is needed to keep health professionals at bay, new research suggests. Jane Hobden looks at the evidence

Football, badminton, swimming, golf and walking: the type of activity may differ but the effect on health, both physical and mental, is the same - exercise improves health. Yet, physical health benefits such as improvements in respiratory function are easier to measure than those involving the psyche, like confidence and self-esteem.

This poses a challenge for anyone working within mental health - how to persuade others, especially those holding the purse strings, that investing in exercise schemes for this vulnerable group of people, or research, is vital. Help is at hand, though, in the form of an increasing number of studies - many involving physiotherapists - which point to the connection between exercise and psychic health. Importantly, as well as its role in mental illness recovery, exercise addresses physical health issues either concurrent with or a result of mental disorders.

Physiotherapist Marie Donaghy is a firm proponent of the tenet that exercise has an important effect on mental health. A clinician for 19 years, and now associate dean and head of school of health sciences at Queen Margaret University College in Edinburgh, she has written extensively on exercise and mental health, particularly in relation to depression. 'There is good evidence, going back over the past 25 years, to show that there is a causal link between exercise and decreased depression,' she says. In 2002, she presented evidence to the National Institute for Health and Clinical Excellence for its guidelines on depression.

As she notes, the evidence of the link between exercise and depression is becoming even stronger with an important new study that explores levels of energy expenditure required to make a difference to health (see details below). 'Appropriate energy expenditure is vital and if exercise is conducted at too low a level of expenditure, then it will not have a positive effect on health', Professor Donaghy explains. 'All in all, it suggests that we need at least 30 minutes at a lower level of exercise intensity, such as walking, on most days of the week, or 45 minutes on fewer days of the week but at a higher intensity.'

In addition, Marie, who is chair of the allied health professions education forum in Scotland, points to the need for more research into severe mental health problems, such as schizophrenia. Commenting on clinical programmes run by physios and occupational therapists for people with severe mental illness, she says: 'Exercise clearly changes their lives.' However, evaluating what has made the difference is complex, and probably includes the influence of the environment, social interaction and physical benefits. Additional psychological benefits may include helping to give people control over their illness and symptoms.

David Carless concurs more research is needed to explore the possible benefits of sport for people with mental illness. In 2004, he and colleagues worked with the Bristol active life project, set up by physiotherapist Margot Hodgson, to explore the impact of a golf programme on people with severe and enduring mental illness. According to David, a former physical education teacher, one of the key factors of the programme's success (there was a high attendance rate of 80 per cent), was the way that activity was provided in a supportive environment in which every group member was valued. For instance, a professional golf coach was present as well as support staff, and golf venues were chosen where people were accepted as they are and a specific dress code was not required.

Now a research fellow at the Carnegie Research Institute at Leeds Metropolitan University, David is exploring avenues for funding to continue this line of research. However, as he notes: 'Unfortunately, exercise and sport are often not seen as a priority by potential funders, which is a shame as more research is desperately needed for this group of patients.' David feels there are two big questions that need to be explored. Firstly, how sport contributes to a person's life and how it can bring social inclusion, enjoyment and a sense of purpose to a group of people whose mental illness often means that they are excluded. Secondly, what sport can do to welcome people with mental illness and what it might currently be doing to exclude this group of people.

One key to running successful exercise and fitness schemes for this client group is working with fitness instructors, says superintendent physio Liz John. She is responsible for delivering a mental health service for adults, adolescents and older people with a range of problems from dementia and schizophrenia to eating disorders and addiction.

Based at the Whitchurch Hospital in Cardiff, she works with NHS-employed fitness instructors to deliver exercise programmes for inpatients and patients in the community. 'The instructors are given a comprehensive grounding in mental health issues, and often train alongside physio students.' says Liz. 'They have a crucial role in this work, carrying out a basic assessment for exercise and then setting up and delivering appropriate exercise programmes.'

Patients are encouraged to attend daily while in hospital and then to attend supported sessions held in local leisure centres, where fitness instructors take on the role of personal trainer to assist them on a one-to-one basis. 'This is essential for patients with severe and enduring mental health problems who require a lot of support.'

Bristol active life project's Margot Hodgson agrees that working across disciplines and agencies is vital if sport and exercise schemes are to succeed. People with long-term mental health conditions, such as schizophrenia and obsessive compulsive disorder, come under the care in the community banner, and are often not viewed as a priority in terms of NHS funding, she explains.

Her solution was to link up with Bristol City Council which applied for sports and disability funding on her behalf (NHS employees are not allowed to apply for this funding, she notes). This union is a big success: 'We can plug into funding opportunities and get access to their sports development officers and the local sports council as well as appropriate sports facilities. The council also benefits because it needs to show it is helping people with mental and physical disabilities, and its problem is often accessing these groups of people.'

Marie Donaghy is also a strong believer in working across agencies and professions. She would like to see better joined up thinking by local authorities, voluntary and statutory agencies working together with health professionals to promote better exercise opportunities for people with mental health problems. Physios also need to work closely alongside occupational therapists, technical assistants and exercise professionals, as well as GPs and nurses, in developing this work. In addition, strengthening links with clinical psychologists is important. While cognitive behavioural therapy is a valuable tool in treating mental illness, it is also an expensive resource and there are not enough clinical psychologists working in this field, she notes. And with evidence showing that exercise can in some cases be as effective as therapy, physios can support the work that clinical psychologists are doing.

'As allied health professionals driving this work forward, we need to be open and flexible to different ways of working. We must also offer a range of schemes that meet the needs of all users, for instance, those who want to exercise alone as well as those exercising in groups, and provide them with enough information based on the evidence so that they understand how to measure their activity levels. Only then can we say that we are delivering the best possible service to this vulnerable group of people.'

Further information

  • Dunn AL, Trivedi MH, Kampert JB, Clark CG and Chambliss HO [2005]. 'Exercise treatment for depression: efficacy and dose response', American Journal of Preventive Medicine, 28(1), 1-8.
  • Faulkner G and Taylor A [2005]. Exercise, health and mental health: emerging relationships, Routledge, New York. This book addresses key questions including: can a sedentary lifestyle have an adverse effect on mental health? Does exercise help people cope better with mental health problems? What research is needed on the role of exercise for promoting mental health?
  • Everett T, Donaghy M, and Feaver S [2003]. Interventions for mental health: an evidence-based approach for physiotherapists and occupational therapists, Butterworth Heinemann, Edinburgh.

Marrying psyche and soma

For patients with dementia in Swindon, a walking group has proved to be a popular weekly outing - and one which clearly benefits them, as senior physio Clare Leonard explains. 'In addition to being good for physical activity , it stimulates them mentally and there's also a big social dimension to it. Patients often arrive flat, but during the course of the walk they brighten up considerably and talk and laugh much more. Clearly they find it very enjoyable.'

The scheme, which Clare set up a year ago within Avon and Wiltshire mental health partnership, involves a one to two hour walk in Swindon's Coate Water - a well-known waterpark and beauty spot - followed by tea at a local café. It is attended each week by four or five patients living within the community, sometimes their carers, and two members of staff. Patients are collected and transported home by taxi after the walk.

Good levels of support are vital for this patient group, both during any activity, and in terms of getting to and from the venue, points out Clare. There is also a shorter walk for those who may not want to walk as far. A physical activity group is also available for patients newly diagnosed with dementia, and their carers. The six to eight week programme of exercise classes is run by a physiotherapist and qualified exercise instructor.

Physio Andrew Clyne, also based at the trust, runs weight management classes in Swindon for people with mental health problems. People can self-refer on to the classes, which combine an hour of education and discussion with an hour-long walk. The classes have been effective: over a period of a year, two thirds of the people trying to lose weight did so.

Two years ago, Andrew conducted research for his MSc focusing on weight management with mental health patients. It has shaped his clinical approach. 'I learned that each individual's motivation was unique, and varied as much as the side effects to the medication. Where we used to set joint goals for the group, I now spend longer setting individual goals with each client, in order to ensure that their priorities are reflected in the programme.'

Another project close to Andrew's heart is Swindon Rovers - a self-help football team for people with mental health problems. Set up by ex-professional footballer and service user Steve Holmes, the team is funded by the Football Association and run by fitness professional Michael Allatt, supported by NHS physios. Team members self-refer and come along for two outdoor training sessions a week, as well as participating in local Football Association mental health league matches. 'The men taking part clearly get great satisfaction out of playing football and improving their skills, and this can only bring gains to their mental health', says Andrew.

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