Exercise as a Recreational Exercise as a Recreational Therapy Treatment for Therapy Treatment for

DepressionDepression

Tim Passmore, Ed.D., CTRSTim Passmore, Ed.D., CTRSWest Virginia Therapeutic West Virginia Therapeutic

AssociationAssociationAnnual ConferenceAnnual Conference

Oklahoma State UniversityOklahoma State University

8 Global Reasons 8 Global Reasons Increased Demand for OutcomesIncreased Demand for Outcomes

Eliminate poor/unnecessary practiceEliminate poor/unnecessary practice Negotiations between providers & payers Negotiations between providers & payers AccountabilityAccountability Mean for evaluation of ill (chronically)Mean for evaluation of ill (chronically) Empower consumersEmpower consumers Evaluate new service/interventionEvaluate new service/intervention Priority setting & resource allocationPriority setting & resource allocation Set, monitor & improve standardsSet, monitor & improve standards

(United Kingdom Clearing House on Health Outcomes, (United Kingdom Clearing House on Health Outcomes, 1997)1997)

The Term RecreationThe Term Recreation

Recreational Therapy/Therapeutic Recreational Therapy/Therapeutic Recreation Recreation Often not given similar consideration asOften not given similar consideration as

Other allied health professionOther allied health profession Because of the term recreationBecause of the term recreation

RegulationsRegulations Specifically state – don’t not pay or cover Specifically state – don’t not pay or cover

RecreationRecreation DiversionDiversion Maintenance Maintenance Comfort Comfort

Inpatient Psychiatric Treatment Inpatient Psychiatric Treatment FacilitiesFacilities

Section Section 20.1.2 – Services Expected to 20.1.2 – Services Expected to Improve the Condition or for Purpose of Improve the Condition or for Purpose of Diagnosis, A3-3102.1.A.2, HO-212.1A2 of Diagnosis, A3-3102.1.A.2, HO-212.1A2 of the Medicare Benefit Policy Manualthe Medicare Benefit Policy Manual Chapter 2 Chapter 2

Adjunctive Therapies – Adjunctive Therapies – Prior to July 2006Prior to July 2006 Recreational TherapyRecreational Therapy Occupational TherapyOccupational Therapy Milieu TherapyMilieu Therapy

Specific Wording of RT & OTSpecific Wording of RT & OT Replaced with term Therapeutic ActivitiesReplaced with term Therapeutic Activities

Inpatient Psychiatric Treatment Inpatient Psychiatric Treatment FacilitiesFacilities

““If the only activities prescribed for If the only activities prescribed for the patient are primarily diversional the patient are primarily diversional in nature, (i.e. to provide some in nature, (i.e. to provide some social or recreational outlet for the social or recreational outlet for the patient), it will not be regarded as patient), it will not be regarded as treatment to improve patients’ treatment to improve patients’ conditions.”conditions.”

Inpatient Psychiatric Treatment Inpatient Psychiatric Treatment FacilitiesFacilities

Adjunctive Therapies (Recreational Adjunctive Therapies (Recreational Therapy/Activity Therapy)Therapy/Activity Therapy) Expected to improve Expected to improve

Psychiatric conditionPsychiatric condition Assist with diagnosisAssist with diagnosis

Required to Provide Required to Provide Active TreatmentActive Treatment Recreational Therapy interventionsRecreational Therapy interventions

Specific interventions intended to improve Specific interventions intended to improve psychiatric conditionpsychiatric condition

Assist with diagnosisAssist with diagnosis

Inpatient Psychiatric Treatment Inpatient Psychiatric Treatment FacilitiesFacilities

Therapeutic Recreation – must followTherapeutic Recreation – must follow Physician’s OrdersPhysician’s Orders AssessmentAssessment Goals & ObjectivesGoals & Objectives Treatment PlanTreatment Plan Delivery of Services or InterventionsDelivery of Services or Interventions Documentation of Provision of Documentation of Provision of

Services/InterventionsServices/Interventions ReevaluationReevaluation Discharge Recommendations & SummaryDischarge Recommendations & Summary

Outcomes TerminologyOutcomes Terminology

EffectivenessEffectiveness Effectiveness ResearchEffectiveness Research EfficacyEfficacy Evidence-based PracticeEvidence-based Practice Clinical ImportanceClinical Importance

Effectiveness/Effectiveness Effectiveness/Effectiveness ResearchResearch

EffectivenessEffectiveness How interventions work in typical clinical How interventions work in typical clinical

practicepractice Effectiveness ResearchEffectiveness Research

Compares practice or interventionsCompares practice or interventions

EfficacyEfficacy

Efficacy Efficacy Performance of interventionPerformance of intervention Controlled studyControlled study

Evidence Based PracticeEvidence Based Practice

Evidence Based PracticeEvidence Based Practice Based on best available scientific Based on best available scientific

Evidence Evidence KnowledgeKnowledge

Clinical Importance Clinical Importance

Important difference in patientImportant difference in patient OutcomesOutcomes Health StatusHealth Status Different from statistical significance Different from statistical significance

Outcomes Characteristics Outcomes Characteristics

Desired outcomes identifiedDesired outcomes identified Based on settingBased on setting Client needClient need

MeasurableMeasurable DistanceDistance Time toleratedTime tolerated ROMROM Number of Coping MechanismsNumber of Coping Mechanisms Number of Positive Self Comments Number of Positive Self Comments Etc…Etc…

Evidence Based ResearchEvidence Based Research

1970’s Early Research – Exercise & 1970’s Early Research – Exercise & DepressionDepression Reported positive outcomes of exercise Reported positive outcomes of exercise

& depression levels& depression levels 1980’s – Researchers – Compared 1980’s – Researchers – Compared

Exercise & a Combination of Exercise Exercise & a Combination of Exercise & Psychotherapy & Psychotherapy Combination – greater effect on lowering Combination – greater effect on lowering

levels of depressionlevels of depression

Evidence Based ResearchEvidence Based Research

1980’s Research1980’s Research Compared counseling & aerobic exerciseCompared counseling & aerobic exercise

Aerobic exercise had greater effect on Aerobic exercise had greater effect on depression levelsdepression levels

Later StudiesLater Studies Compared exercise & exercise in Compared exercise & exercise in

combination with pharmacotherapy & combination with pharmacotherapy & pharmacotherapy alonepharmacotherapy alone

Exercise alone was found to be as effective Exercise alone was found to be as effective as combination or pharmacotherapy aloneas combination or pharmacotherapy alone

Evidence Based ResearchEvidence Based ResearchCurrent Studies – Last 10 YearsCurrent Studies – Last 10 Years

Support earlier studiesSupport earlier studies Individuals who exercise after diagnosis Individuals who exercise after diagnosis

of depression of depression Report decreasing levels of depression Report decreasing levels of depression Maintains lower levels of depressionMaintains lower levels of depression

Studies Comparing pharmacotherapy Studies Comparing pharmacotherapy with exercisewith exercise Indicate exercise elicits similar Indicate exercise elicits similar

outcomes as medication outcomes as medication

DiagnosisDiagnosis

DepressionDepression Dysthymia Dysthymia Persistent depression that has Persistent depression that has

symptoms such as fatigue, low self-symptoms such as fatigue, low self-esteem, insomnia, and appetite esteem, insomnia, and appetite disturbances but is not severe enough disturbances but is not severe enough to amount to a psychosisto amount to a psychosis

InterventionInterventionExerciseExercise

Aerobic TypeAerobic Type TreadmillTreadmill Stationary bikeStationary bike 10 minute warm-up10 minute warm-up 45 minutes45 minutes 60% to 70% of Target Heart Rate60% to 70% of Target Heart Rate

Goal of aerobic typeGoal of aerobic type

InterventionInterventionExerciseExercise

ResistiveResistive Free WeightsFree Weights Exercise MachinesExercise Machines Exercise BandsExercise Bands Weight appropriate Weight appropriate

3 sets3 sets Weight appropriate for prescribed Weight appropriate for prescribed

repetitions repetitions 10 repetitions each set10 repetitions each set

Exercise RoutinesExercise Routines

2 types 2 types Aerobic typeAerobic type Combined aerobic type & resistiveCombined aerobic type & resistive

3 X’s per week3 X’s per week 10 to 15 minute warm-up period10 to 15 minute warm-up period 45 minutes45 minutes

Discharge RecommendationsDischarge Recommendations

Continue Exercise RoutineContinue Exercise Routine Locate post discharge facility to Locate post discharge facility to

exerciseexercise CommercialCommercial

Senior Citizen CenterSenior Citizen Center Community CenterCommunity Center Exercise FacilityExercise Facility

Exercise in the community/at homeExercise in the community/at home Not recommended – due to Not recommended – due to

IsolationIsolation Reasons causing diagnosis Reasons causing diagnosis

Data & AnalysisData & Analysis

21 patients21 patients 11 assigned to combined exercise group11 assigned to combined exercise group 10 assigned to aerobic type exercise group10 assigned to aerobic type exercise group

Completed Beck Depression Inventory Completed Beck Depression Inventory atat AdmissionAdmission DischargeDischarge 6 week post discharge6 week post discharge 12 week post discharge12 week post discharge

Instrument Beck Depression Instrument Beck Depression InventoryInventory

ScaleScale Measures reported levels of depressionMeasures reported levels of depression 0 to 630 to 63 See next slideSee next slide

Instrument Beck Depression Instrument Beck Depression InventoryInventory

Below 4  = Possible denial of depressionBelow 4  = Possible denial of depression FakingFaking Below usual scoresBelow usual scores

05 - 09   Considered normal05 - 09   Considered normal 10 - 18   Mild to Moderate depression10 - 18   Mild to Moderate depression 19 - 29   Moderate to Severe depression19 - 29   Moderate to Severe depression 30 - 63   Severe Depression30 - 63   Severe Depression Over 40  Significantly above severe depressionOver 40  Significantly above severe depression

Suggests possible exaggeration of depressionSuggests possible exaggeration of depression Possibly characteristic of borderline personality Possibly characteristic of borderline personality

disorders. Significant levels of depression are still disorders. Significant levels of depression are still possible (Groth-Marnat, 1990).possible (Groth-Marnat, 1990).

ResultsResultsComparision of BDI Scores Arithmetic Means

30.4

34.18

7.9

10.45

12.1 12.27

15.2 15

0

5

10

15

20

25

30

35

40

1Admission Discharge 6 Week 12 Week

Ari

thm

eti

c M

ea

ns

Aerobic

Combined

ResultsResultsAdmissionAdmission

90% of the 11 Combined Subjects90% of the 11 Combined Subjects Scored in range of clinical depressionScored in range of clinical depression

100% of the 10 Aerobic Subjects100% of the 10 Aerobic Subjects Scored in the ranges of clinical Scored in the ranges of clinical

depressiondepression

ResultsResultsDischargeDischarge

80% of Combined Group80% of Combined Group No presences of depressionNo presences of depression Two had scores of 17Two had scores of 17

Had decreases in depression scores of 31 Had decreases in depression scores of 31 points & 19 pointspoints & 19 points

100% of Aerobic Group100% of Aerobic Group No presences of depressionNo presences of depression

Results Results 6 Week Post Discharge6 Week Post Discharge

Between groups Between groups No significant differenceNo significant difference

In adherenceIn adherence In depression scoresIn depression scores

Both Groups Both Groups Significant difference – between those Significant difference – between those

who continued & those who did notwho continued & those who did not

ResultsResults12 Week Post Discharge12 Week Post Discharge

Between GroupsBetween Groups No significant differenceNo significant difference

In adherence In adherence In depression scoresIn depression scores

Both GroupsBoth Groups Significant difference – between those Significant difference – between those

who continued & those who did notwho continued & those who did not

Contact InformationContact InformationParticipate in ResearchParticipate in Research

Tim Passmore, Ed.D., CTRSTim Passmore, Ed.D., CTRS

Assistant ProfessorAssistant Professor

School of Applied Health & EducationalSchool of Applied Health & Educational

Psychology - Leisure Studies ProgramPsychology - Leisure Studies Program

Oklahoma State UniversityOklahoma State University

(405) 744-1811(405) 744-1811

tim.passmore@okstate.edutim.passmore@okstate.edu