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Section 25
Physical Activity and Anxiety

Question 25 | Test | Table of Contents

Introduction
The low physical fitness and poor physical health of depressed and anxious psychiatric patients and the beneficial effects of regular exercise on reduction of depressive and anxious symptoms, are important arguments for the implementation of psychomotor therapy (PMT) into treatment programmes in psychiatric hospitals.  Designing well-considered PMT programmes for these patients requires a measurement of their physical fitness.

Evaluation of cardio-respiratory fitness in psychiatric patients
Direct measurement of maximal oxygen intake by way of a maximal exercise test is the most accurate indicator of cardio-respiratory fitness. Maximal tests, however, have the disadvantage of requiring the subject’s optimal motivation to work to ‘near exhaustion’, and require the supervision of a physician and the use of expensive equipment.  In psychomotor therapy for psychiatric patients, however, submaximal measures are highly recommended for the reasons that many patients have poor physical health, low levels of fitness and physical self-concept, few experience with aerobic training, and less energy and motivation for heavy physical effort.  Salmon pointed out that, especially in this population, physiological measurements studied in a laboratory could be influenced due to pretest anxiety. Patients with an increased anxiety disposition, for example, might fear that maximal aerobic effort will provoke physiological reactions such as hyperventilation, tachycardia, dizziness or sweating, which they associate with symptoms of panic attacks.  These clinical considerations usually lead to the application of submaximal exercise tests in PMT programmes. Craft and Landers  concluded in a meta-analytic review of studies regarding the effects of exercise on clinical depression that submaximal measurements are common in psychiatric settings; 18 of 20 surveys used submaximal exercise tests. However, our previous research on the evaluation of cardio-respiratory fitness has shown that substantial numbers of patients have difficulty carrying out standard test protocols.  These patients were unable to perform the minimal work loads or dropped out before completing the tests. In the survey of van de Vliet et al. in non-psychotic psychiatric inpatients (n=166), 13.75% of female subjects without somatic diseases could not complete the Astrand-Rhyming bicycle ergometer submaximal test at the minimal work load of 50 Watts. The investigation of Knapen et al. with the World Health Organization ergocycle test, consisting of a warm-up and three consecutive 4-min stages, showed that the warm-up (50 Watts), the first work load (75 Watts) and the increments of 25 Watts per stage were too heavy for many patients. Because of these difficulties in measuring cardio-respiratory fitness of these patients, we adapted an existing test protocol to develop a clinically useful instrument.

Evaluation of the rate of perceived exertion: a valuable contribution to assessment of cardio-respiratory fitness?
A high level of perceived exertion during exercise is negatively associated with participation in physical activity. As the effort perceived by an individual increases, so too does the chance of drop-out.   For anxious and depressed patients who often suffer from fatigue and low motivation, the rate of perceived exertion during physical activity is an important parameter when designing an appropriate exercise programme.   The fatigue and recovery time after an effort are not only dependent upon physiological stressors (intensity, duration, and frequency of the training stimulus) but also upon psychosocial factors.  Psychological and social problems can cause considerable stress.

Generalized fatigue and lack of energy are typical symptoms of depressive syndrome.   The exercise tolerance of anxious patients is reduced due to the fact that they are preoccupied with physiological reactions during effort such as palpitations, perspiration, and hyperventilation.  They are focused on these bodily symptoms and associate them with serious somatic diseases (hypochondria).  These psychological factors cannot be ignored when developing a well-designed fitness programme. The evaluation of degree of perceived exertion can be derived from the psychophysiological concept of Borg.  The Borg 15 Graded Category Scale and the Borg Category Ratio 10 Scale (Borg CR 10 scale) quantify the sensations that the subject experiences during physical effort. The Borg 15 Graded Category Scale has a score range from 6 to 20 (15 grades), and the Borg CR 10 scale from 0 to 10 (10 grades). Both scales show a linear relationship with heart rate during progressive incrementally exercise (r=0.94 and r=0.88, respectively).

Method
Subjects
Twenty-nine male patients (age M=35.69 years, SD=11.52; body weight M=76.40 kg, SD=13.22; Body Mass Index M=22.24, SD=2.78) and 39 female patients (age M=35.73 years, SD=9.15; body weight M=62.63 kg, SD=13.24; Body Mass Index M=25.26, SD=3.85) took part in the study. They suffered from anxiety disorders (e.g., generalized anxiety disorder, panic disorder, acute stress disorder) and/or depressive disorders (e.g., major depressive disorder, dysthymic disorder, bipolar disorder).   All patients were hospitalized within one of three specialized treatment units of a university psychiatric hospital in Belgium. The exclusion criteria were treatment with beta-blockers, and severe cardiopulmonary, orthopaedic or neurological diseases that totally prevented exercise testing.

Instruments and Procedure
The Physical Work Capacity 130 (PWC 130) and the PWC 150—the work load related to heart rate of 130 and 150 beats per minute (BPM) respectively—were determined using the submaximal incrementally Franz ergocycle test. In the test protocol of Franz the work load is increased by 10 Watts every min, starting with a work load that corresponds to the body weight. Since such a work load was not feasible for many of the patients, the first stage work load was reduced by 30 Watts for male subjects and 50 Watts for the females. At the end of each stage the heart rate was registered by means of a heart rate monitor. The pedal frequency was a steady pace of 60 rotations per min (RPM). The graded exercise test was terminated when (a) the subject reached heart rate of 150 BPM, (b) the participant showed certain symptoms making it necessary to stop the GXT test, and/or (c) the subject could no longer maintain the pedalling frequency of 60 RPM. All examinations were carried out on an electronically braked bicycle ergometer Ergo 2000. Subjects performed the first test during the first week of their treatment and the re-test after 7 days at the same hour in standardized conditions. They were requested to refrain from eating, drinking coffee or smoking during a 2-h period prior to the test. Before the examination (a) the resting heart rate was assessed after the subject had relaxed on a mat for 5 min, and (b) the test leader gave detailed information and instructions about the test protocol. After the testing participants performed a cooling-down with the same intensity in the second stage.

Results
The reliability coefficients of the PWC 130 and the PWC 150 were significant (r ranged from 0.74 to 0.90, p50.01). The differences between the means of test and re-test for these parameters were not significant.  The reliability coefficients of the Borg 130 for males (r=0.42, p50.05), Borg 130 females (r=0.48, p50.01), and Borg 150 females (r=0.58, p50.01) were significant, however relative low. The reliability coefficient of the Borg 150 males was higher (r=0.82, p50.01). There were no significant differences found between the means of test and re-test on the Borg CR 10 scale, neither for male subjects nor for females.  The smaller number subjects for the parameters PWC 150 and Borg 150 compared to the number for the PWC 130 and Borg 130 was attributed to the drop-out at the higher exercise level.

Discussion
The PWC 130 and the PWC 150, measured by means of Franz’s ergocycle test, have a moderate to good test/re-test reliability. De PWC 130 en PWC 150 are reliable parameters for developing a well-considered physical reconditioning programme and for the intra-individual evaluation of the exercise therapy. The adapted version of the Franz’s test is clinically usable considering any patient can perform up the test protocol to a heart rate of 130. This contrasts with our earlier experiences with the Astrand-Rhyming ergometer test and the World Health Organization ergocycle test.

The reliability of the Borg CR 10 Scale is considerably lower than that observed by Ljunggren & Johansson  on physically fit subjects (r=0.92). One possible explanation for the simply moderate reliability of the Borg CR 10 Scale amongst these patients is the diminished differentiation of fatigue levels resulting from the low activity level prior to the hospitalization.  At the moment of the examinations, during the first weeks of treatment in a therapeutic ward, the subjects had no specific experience with fitness training. As consequence they were not able to effectively differentiate various effort levels. Future research should determine whether patients are capable to rate perceived exertion more accurate after a period following fitness training.

According to Morgan, anxious and depressive patients make less accurate interpretations regarding bodily sensations during physical activity than healthy controls. The depressed mood and anxiety causes certain physiological reactions such as perspiration, dyspnoea, tachycardia and the linked catastrophic cognitions that influence the perceptual process.  Until now, the influence of anxiety disposition and depression on the perceived exertion has not been investigated in a sample group of psychiatric patients. Alongside these changeable emotional and cognitive factors, other factors such as low physical self-concept, fluctuating motivation, and lack of energy all influence the perception of effort and the drop-out rate at higher exercise levels.
- Knapen, J., Vliet, P. V., Coppenolle, H. V., Peuskens, J., & Pieters, G. (2003). Evaluation of cardio-respiratory fitness and perceived exertion for patients with depressive and anxiety disorders: A study on reliability. Disability and Rehabilitation, 25(23), 1312-1315. doi:10.1080/09638280310001616277




Personal Reflection Exercise #11
The preceding section contained information about evaluation of cardio-respiratory fitness and perceived exertion for patients with depressive and anxiety disorders.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Effectiveness of physical activity interventions
for improving depression, anxiety and distress:
an overview of systematic reviews

Singh, B., Olds, T., Curtis, R., Dumuid, D., Virgara, R., Watson, A., Szeto, K., O'Connor, E., Ferguson, T., Eglitis, E., Miatke, A., Simpson, C. E., & Maher, C. (2023). Effectiveness of physical activity interventions for improving depression, anxiety and distress: an overview of systematic reviews. British journal of sports medicine, bjsports-2022-106195. Advance online publication. https://doi.org/10.1136/bjsports-2022-106195

Peer-Reviewed Journal Article References:
Battalio, S. L., Huffman, S. E., & Jensen, M. P. (2020). Longitudinal associations between physical activity, anxiety, and depression in adults with long-term physical disabilities. Health Psychology, 39(6), 529–538.

Mücke, M., Ludyga, S., Brand, S., Colledge, F., Pühse, U., & Gerber, M. (2021). Associations between cardiorespiratory fitness and endocrine, autonomous, and psychological stress reactivity in male adolescents. Journal of Psychophysiology, 35(1), 23–34.

Spaderna, H., Hoffman, J. M., Hellwig, S., & Brandenburg, V. M. (2020). Fear of physical activity, anxiety, and depression: Barriers to physical activity in outpatients with heart failure? European Journal of Health Psychology, 27(1), 3–13.

QUESTION 25
Why do anxious and depressive patients make less accurate interpretations regarding bodily sensations during physical activity than healthy controls? To select and enter your answer go to Test.

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