Implementing cognitive behavioural aspects in treating compulsive exercise within physiotherapy

• It is concerned principally with the present and future rather than the past.
• The focus is on those factors and processes that maintain the exercise behaviour.
• It should be very much an “active” therapy, with responsibility for behaviour change residing with the patient.
  • Exposure therapy
• The therapist’s role is to provide information, guidance, support, and encouragement.
• It is essential that a trusting, collaborative relationship is established.

Aims of a cognitive behavioural approach

• To educate the patient about the cognitive view on the maintenance of compulsive exercise.
• To promote insight into the factors affecting (maintaining) the patient’s attitudes, beliefs and behaviours toward exercise.
• To educate the patient about what constitutes „healthy‟ exercise.
• To introduce the patient to the cognitive skills and strategies necessary to challenge maladaptive attitudes, beliefs and behaviours toward exercise.
• To introduce the patient to alternative (adaptive) emotion coping strategies.
• To educate the patient about relapse prevention.
  
• Negative reinforcement:
  • Compulsive exercisers experience affective withdrawal symptoms when they are unable to exercise (e.g. anxiety, depression, guilt, irritability, frustration, anger), and avoidance of these adverse symptoms is a primary maintaining mechanism for the exercise behaviour (i.e., negative reinforcement).
• Positive reinforcement:
  • Exercise is not always a dysfunctional behaviour in terms of affect regulation. It may be an adaptive way of regulating affect.
    
• Compulsivity:
  • Triggers the "OCD" cycles
    

OCD cycle

Start of a CBT approach in your physiotherapy setting

• Education and assessment
  
• Homework: monitoring
  • Monitoring is a way of recording the things that have an influence on patients’ behaviour and it can provide a detailed picture why they behave a certain way.
  • The reason to use a monitoring sheet is that it can help to examine and understand the role thoughts and feelings play in making patients to behave a certain way.
  • It makes them more aware of what they are doing and why they are doing it.
  • Monitoring is a very powerful way of helping to change behaviour that previously seemed automatic or even out of patients’ control.
    
• Mood improvement / positive reinforcement
  • This scale measures how much of a positive effect exercise has on a patient’s mood.
  • A high score:
    • A substantial mood improvement as a result of exercising -> exercise = reinforcing.
    • Susceptible to becoming psychologically dependent on exercise as a means to improve or regulate mood (see scale 2).
    • Likely difficulties to cut down or stop exercise behaviour.
  • A mid-range score:
    • A positive uplift in mood as a result of exercising, but unlikely to be psychologically dependent on exercise as a means to improve or regulate their mood.
  • A low score:
    • Exercise has little to no effect on mood: exercise is probably not a very pleasurable activity.
      
• Negative reinforcement (mood avoidance)
  • This scale measures the effect on a patient’s mood of being unable to exercise.
  • It is a measure of dependence on exercise as a means of avoiding (regulating) negative emotions (an avoidant coping mechanism).
  • A high score:
    • Exercise = a means of avoiding (regulating) a wide range of negative mood states or emotions -> a high level of psychological dependence on the mood regulatory effect of exercise.
    • Likely very difficult to cut down or stop exercise (withdrawal symptoms).
  • A mid-range score:
    • Either psychologically dependent on exercise as a means of avoiding/regulating certain specific negative mood states or „at risk‟ of developing a psychological dependence on exercise.
    • Likely quite difficult to cut down or stop exercise behaviour.
  • A low score:
    • Exercise is not used as an avoidant coping mechanism -> not psychologically dependent on exercise as a means to regulate your mood, -> able to stop or cut down exercise behaviour without suffering a negative mood state.
      
• Behavioural rigidity
  • This scale measures how rigid and repetitive exercise behaviour has become.
  • A high score:
    • Exercise behaviour (routine) has become very rigid and repetitive, and strongly predicts that a patient will have great difficulty in cutting down, stopping, or even altering their exercise behaviour.
    • Associated with the following of specific „exercise rules‟ (e.g. “I must exercise for at least xxx hours”).
  • .A mid-range score:
    • Patient would be able to cut down, stop, or alter the exercise behaviour without too much difficulty so long as it is carefully planned.
  • A low score:
    • A highly flexible approach to exercise, as they do not follow any sort of fixed routine or rules.
      
• Compulsive exercise
  • This scale measures how compulsive a patient has become about exercise.
  • A high score:
    • Exercise has become grossly over-inflated in terms of its importance, and as such a patient feels that they „have‟ to exercise.
    • Patient may hold false beliefs about the importance of exercise for your general well-being and health -> very difficult to cut down or stop your exercise behaviour.
    • Very concerned (afraid) of what may happen to them if they stop or cut down your exercise (i.e., the negative consequences).
  • This scale is one of the strongest indicators of an „unhealthy‟ approach to exercise, and as such a high or mid-range score on this scale is very likely associated with high scores on many of the other scales, especially scales 2 and 3.
    
• Weight and shape concerns
  • This scale measures how obsessional a patient has become about exercise specifically in terms of its influence on weight and shape.
  • A high score:
    • Exercise primarily for weight and shape reasons -> a very strong reciprocally reinforcing relationship between exercise and eating, attitudes, beliefs and behaviours (i.e. the exercise attitudes, beliefs and behaviours are supporting the eating disorder and vice-versa).
    • Exercise attitudes, beliefs and behaviours are a significant maintenance factor for the eating disorder, and strongly suggests that they may hold false beliefs about what constitutes appropriate and „healthy‟ exercise.
    • Even in the absence of an eating disorder, a high score on this scale would indicate an extremely un-healthy approach to exercise, due to the grossly inflated importance attributed to its influence on weight and shape.
  • A mid-range score:
    • Exercise largely for weight and shape reasons, and in the presence of an eating disorder suggests a moderately strong reciprocally reinforcing relationship between exercise and eating, attitudes, beliefs and behaviours.
  • A low score:
    • Shows that weight and shape are not primary reasons for exercise.
      
• Lack of exercise enjoyment
  • This scale measures how un-enjoyable exercise is for the patient.
  • A high score:
    • A patient does not enjoy exercise at all, and strongly suggests this patient is exercising for the wrong reasons.
  • A mid-range score:
    • Does not always enjoy exercise, they do not hate it.
  • A high or mid-range score on this scale would therefore suggest that if they have had a high score on any of the other scales, they should make efforts to re-learn what constitutes „healthy‟ and enjoyable exercise so that they may continue to exercise in a manner that improves their health and well-being.
    

The subsequent sessions

Integrate home-tasks in your multi-component physiotherapy approach

• Homework serves as both an introduction to each session and the primary education component, and should be thoroughly reviewed.
• Group discussions