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Combined physical training associated with multidisciplinary intervention in the treatment of alcohol use disorder: a study with n of 1

O treinamento físico combinado associado à intervenção multiprofissional no tratamento do transtorno por uso de álcool: um estudo com n de 1

ABSTRACT

Objective:

Substance misuse can lead to several consequences for physical and mental health. Physical exercise is an important ally to pharmacological and psychotherapeutic treatment for substance use. However, the literature is still scarce regarding long-term interventions. Thus, this study aims to describe the acceptability and effects of combined physical training intervention (aerobic and strength).

Methods:

This study comprises an n-of-1 clinical trial that was performed with a 64-year-old male individual with alcohol use disorder. The treatment lasted 12 weeks and evaluated the association of multidisciplinary interventions on quality of life, depressive symptoms, cognitive impairment, and anxiety.

Results:

The participant improved general quality of life (12.5%), no alterations were found for depressive symptoms, there was an improvement in cognition (20%), as well a reduction in the trait (16.2%) and state (14.7%) anxiety symptoms of the participant.

Conclusions:

These findings allude to the importance of non-drug therapeutic resources such as structured physical exercise, associated with other offers in the treatment of alcohol use disorder.

KEYWORDS:
Alcohol-related disorders; alcoholism; exercise; quality of life; and mental health

RESUMO

Objetivo:

O uso de substâncias psicoativas pode levar a diversas consequências à saúde física e mental. O exercício físico é um importante aliado ao tratamento farmacológico e psicoterápico para o uso de substâncias. No entanto, a literatura ainda é escassa em relação às intervenções de longa duração. Dessa forma, este estudo objetiva descrever a aceitabilidade e os efeitos de uma intervenção de treinamento físico combinado (aeróbico e força).

Métodos:

Este estudo compreende um n-of-1 clinical trial que foi realizado com um indivíduo do sexo masculino, de 64 anos de idade, com transtorno por uso de álcool. O tratamento teve a duração de 12 semanas e avaliou a associação de intervenções multiprofissionais sobre a qualidade de vida, sintomas depressivos, comprometimento cognitivo e ansiedade.

Resultados:

O participante melhorou a qualidade de vida geral (12,5%), não foram encontradas alterações para sintomas depressivos, houve melhora na cognição (20%), bem como redução nos sintomas de ansiedade traço (16,2%) e estado (14,7%) do participante.

Conclusões:

Esses achados aludem à importância de recursos terapêuticos não medicamentosos como o exercício físico estruturado, associados às demais ofertas no tratamento para o transtorno por uso de álcool.

PALAVRAS-CHAVE:
Transtornos relacionados ao uso de álcool; alcoolismo; exercício físico; qualidade de vida; saúde mental

INTRODUCTION

The use of alcohol is associated with several physical and mental health problems, especially among middle-aged and older adults11 Fenollal-Maldonado G, Brown D, Hoffman H, Kahlon C, Grossberg G. Alcohol Use Disorder in Older Adults. Clin Geriatr Med. 2022;38(1):1-22.. The consequences of individual health abuse of alcohol are numerous, reducing overall functionality and well-being, and having clinical, family, and social repercussions. Further, substance misuse is associated with a higher risk for HIV infection, and liver diseases including hepatitis, cancer, and cirrhosis, conditions that may lead to an increased risk of premature death22 World Drug Report. United Nations publication; 2021. p. 109. Available from:. https://www.unodc.org/res/wdr2021/field/WDR21_Booklet_2.pdf:
https://www.unodc.org/res/wdr2021/field/...
. There is also high psychiatric comorbidity rates33 Choi NG, DiNitto DM. Alcohol use disorder and treatment receipt among individuals aged 50 years and older: Other substance use and psychiatric correlates. J Subst Abuse Treat. 2021;131:108445.. In Brazil, the prevalence of alcohol use disorder (AUD) among adults is 17,1%44 Silva LES, Helman B, Luz e Silva DC, Aquino ÉC, Freitas PC, Santos RO, et al. Prevalência de consumo abusivo de bebidas alcoólicas na população adulta brasileira: Pesquisa Nacional de Saúde 2013 e 2019. Epidemiol Serv Saúde [Internet]. 2022;31(spe1):e2021379. Available from: https://doi.org/10.1590/SS2237-9622202200003.especial
https://doi.org/10.1590/SS2237-962220220...
, similar to 16% of the worldwide population55 World Health Organization. Global health observatory data. 2016. Available from: http://www.who.int/gho/substance_abuse/burden/alcohol_prevalence/en/
http://www.who.int/gho/substance_abuse/b...
.

The treatment of people with AUD usually includes a multidisciplinary intervention with a multidisciplinary health team such as psychiatrists, nurses, and psychologists66 Lopes LLT, Silva MRS, Santos AM, Oliveira JF. Multidisciplinary team actions of a Brazilian Psychosocial Care Center for Alcohol and Drugs. Rev Bras Enferm [Internet]. 2019;72(6):1624-31. Available from: https://doi.org/10.1590/0034-7167-2018-0760
https://doi.org/10.1590/0034-7167-2018-0...
. This study took place in a specialized treatment service for addictions and also includes occupational therapists, nutritionists, and exercise science professionals. This team develops approaches in relapse prevention, emotional regulation, social skills training, motivation for treatment, nutritional education, physical exercise program, and well-being. In this way, there is evidence that exercise can reduce depressive symptoms and increase physical fitness77 Hallgren M, Vancampfort D, Giesen ES, Lundin A, Stubbs B. Exercise as treatment for alcohol use disorders: systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1058-64., as demonstrated by improvements in cardiorespiratory conditioning, resting heart rate, and muscular strength88 Giesen ES, Deimel H, Bloch W. Clinical exercise interventions in alcohol use disorders: a systematic review. J Subst Abuse Treat. 2015;52:1-9.. Regular physical exercise can also positively influence mood, decrease anxiety symptoms, improve cognitive function, and helps with alcohol cravings99 Hallgren M, Vancampfort D, Schuch F, Lundin A, Stubbs B. More Reasons to Move: Exercise in the Treatment of Alcohol Use Disorders. Front Psychiatry. 2017;8:160.. However, most of the studies evaluated only the effects of aerobic exercise, and there is limited evidence on adding up the combination of aerobic and strength exercises to a usual multidisciplinary intervention. In addition, there is a scarcity of data on the benefits of combined strength and endurance training on the mental health of older adults with alcohol dependence. Lastly, there is a paucity of interventions prescribing exercise with progressive workloads.

In this sense, this study aimed to describe the effects of combining progressive workload strength and aerobic exercises to the usual care multidisciplinary intervention in a set of outcomes. Specifically, we sought to evaluate the effects on quality of life, depression, anxiety, and cognition in one outpatient with alcohol dependence.

METHODS

This study was carried out by the Physical Education and Occupational Therapy Service and the Addictions and Forensic Psychiatry Service of the Hospital de Clínicas in Porto Alegre (HCPA). The protocol was approved by the research ethics committee of HCPA (number 4.556.680). The participant agrees to participate in this study and signs the informed consent form.

This study is an “n-of-1 clinical trial” with a 64-year-old male individual with higher education, with AUD, a design that has been increasingly widespread in the health field, intending to determine the ideal intervention for a biological specificity in each person, enhancing the results from the intervention1010 Lillie EO, Patay B, Diamant J, Issell B, Topol EJ, Schork NJ. The n-of-1 clinical trial: the ultimate strategy for individualizing medicine? Per Med. 2011;8(2):161-73.. The participant had been under treatment for over a year when we proposed the study. Our protocol is characterized by an intervention of combined aerobic and strength training associated with a multidisciplinary intervention for 12 weeks, totalizing 24 sessions. Nonetheless, the 12-week intervention protocol needed to be extended to 18 weeks to allow the participant to complete 24 combined training sessions. This period change was the consequence of the research participant’s circumstances, such as health problems and professional commitments. The exercise sessions were divided into 2 moments, 30 minutes of aerobic exercise, performed on an ergometric treadmill in a gym inside the hospital and 30 minutes of strength exercises, continuously, with no break between them. The exercise intensity progressed throughout the intervention. In strength training, a rest of 45 seconds to 1 minute was established between sets. The muscle strength exercises were prescribed using loads relative to the one repetition maximum (1 RM) values, and the aerobic exercise training progression was based on % of maximal heart rate measurement (Table 1). During strength training, six exercises were prescribed targeting the upper and lower limbs and trunk. During the combined training period, the research participant maintained contact with an outpatient clinic, participated in a motivational group, conducted by Physical Education and Nursing professionals, and participated in individual psychotherapy consultations. The quality of life was assessed using the WHOQL-BREF1111 Fleck MP, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, et al. [Application of the Portuguese version of the abbreviated instrument of quality life WHOQOL-bref]. Rev Saude Publica. 2000;34(2):178-83. questionnaire. This 24-question instrument divides them into four domains, namely: physical, psychological, social relationships, and environment, in addition to the individual’s self-perception regarding their quality of life and satisfaction with their own health. Depressive symptoms with the Beck Depression Inventory (BDI)1212 Gomes-Oliveira MH, Gorenstein C, Lotufo Neto F, Andrade LH, Wang YP. Validation of the Brazilian Portuguese version of the Beck Depression Inventory-II in a community sample. Braz J Psychiatry. 2012;34(4):389-94. questionnaire. Cognitive impairment with the Montreal Cognitive Assessment (MoCA)1313 Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695-9., the instrument has a maximum of 30 points and the cut off point for normal cognition is 26 points. Trait and state-level anxiety were assessed using the State-Trait Anxiety Inventory (STAI)1414 Biaggio ÂMB, Natalício L, Spielberger CD. Desenvolvimento da forma experimental em português do Inventário de Ansiedade Traço-Estado (IDATE) de Spielberger. Arq Bras Psicol Aplicada. 1977;29(3):31-44.. The patient was already on the usual treatment for AUD before starting the intervention and he was instructed not to perform physical activity outside the intervention protocol.

Table 1
Progressions of the intensity of aerobic training and muscular endurance

He attended an online motivational group, an advantage relapse prevention group, individual psychotherapy consultations, and a multifamily group together with his wife and other families. The questionnaires were applied by a trained exercise science professional before and after the intervention. The combined training sessions were conducted by another exercise science professional who was blinded to the test results. Data were presented with means of pre and post and percentage of change.

RESULTS

During the intervention period the research team, attentive to fluctuations in the participant’s motivation, used motivational techniques, such as educational approaches on the benefits of regular physical exercise, clarifying the process of physical conditioning, and strengthening the importance of regular practice for health gains, through words of encouragement to self-perceive in his disposition, mood, discomfort or pain. We observed improvements in the patient in the following outcomes: self-evaluation of quality of life (14.2%), in the physical domain (20.8%), in the psychological domain (13.6%), in social relationships (10%), and in the environment (6%). The assessment of the general quality of life increased by 12.5% in the WHOQOL-Bref. The differences in scores in the pre-and post-intervention assessment in the different optimized training domains are seen in Table 2. The patient was below the cutoff point for the presence of levels of depressive symptoms throughout the intervention, scoring 6 (six) in the pre-assessment and 3 (three) points after the application of the BDI. Anxiety symptoms, as measured by the STAI-S, decreased from 34 in the pre-intervention to 29 in the post-intervention points (14.7% decrease). In STAI-T, the score was 37 in the pre-intervention and decreased to 31 in the post-intervention, achieving a reduction of 16.2%. In MoCA for cognitive impairment, the participant scored 22 out of a maximum of 30 points pre-intervention, increasing to 26 points post-intervention (20% reduction).

Table 2
The score for Quality of Life through WHOQOL-BREF

DISCUSSION

This study found improvements in all assessed outcomes. Regarding depressive symptoms, the questionnaire did not classify the patient as a depressed individual. In quality of life, the differences in scores in the pre-and-post-intervention assessment in the different domains are apparently clinically significant1515 Kiluk BD, Fitzmaurice GM, Strain EC, Weiss RD. What defines a clinically meaningful outcome in the treatment of substance use disorders: reductions in direct consequences of drug use or improvement in overall functioning? Addiction. 2019;114(1):9-15.. In the trait and state anxiety questionnaires, the participant had a decrease in both levels when comparing the pre-and post-intervention responses. These findings are in agreement with results of the studies mentioned in the meta-analysis77 Hallgren M, Vancampfort D, Giesen ES, Lundin A, Stubbs B. Exercise as treatment for alcohol use disorders: systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1058-64.. The changes reached about 15% in both types of anxiety, which demonstrates substantial improvement induced by a protocol of 24 sessions of combined training associated with multidisciplinary interventions. One study suggests cutoffs between 39-40 points to detect significantly relevant anxiety problems1616 Addolorato G, Ancona C, Capristo E, Graziosetto R, Di Rienzo L, Maurizi M, et al. State and trait anxiety in women affected by allergic and vasomotor rhinitis. J Psychosom Res. 1999;46(3):283-9.; however, another study1717 Kvaal K, Ulstein I, Nordhus IH, Engedal K. The Spielberger State-Trait Anxiety Inventory (STAI): the state scale in detecting mental disorders in geriatric patients. Int J Geriatr Psychiatry. 2005;20(7):629-34. considered 54-55 a cutoff point closer to reality in older adults and that it decreases the incidence of false positives. Combined training as an intervention for anxiety symptoms is scarce among selected studies in systematic reviews77 Hallgren M, Vancampfort D, Giesen ES, Lundin A, Stubbs B. Exercise as treatment for alcohol use disorders: systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1058-64.,1818 Stonerock GL, Hoffman BM, Smith PJ, Blumenthal JA. Exercise as Treatment for Anxiety: Systematic Review and Analysis. Ann Behav Med. 2015;49(4):542-56..

Thus, combined training associated with multidisciplinary interventions may have contributed to a slight reduction in anxiety symptoms, helping the patient to remain below the cutoff point for the presence of symptoms during the intervention period55 World Health Organization. Global health observatory data. 2016. Available from: http://www.who.int/gho/substance_abuse/burden/alcohol_prevalence/en/
http://www.who.int/gho/substance_abuse/b...
. Although the literature already supports these antidepressant and anxiolytic effects in alcohol users, this case study suggests that combined training associated with multidisciplinary interventions can reproduce these effects. In addition, it has been shown that people with depressive and anxiety symptoms have elevated inflammatory markers and physical exercise is a protective factor in reducing these markers1919 Schuch FB, Vasconcelos-Moreno MP, Borowsky C, Zimmermann AB, Wollenhaupt-Aguiar B, Ferrari P, et al. The effects of exercise on oxidative stress (TBARS) and BDNF in severely depressed inpatients. Eur Arch Psychiatry Clin Neurosci. 2014;264(7):605-13..

The research participant also showed significant improvement in the cognitive domain, reaching almost a 20% reduction in the total score. As already seen in the results, in the pre-intervention moment, the participant scored for “mild cognitive impairment” and after the combined training protocol associated with multidisciplinary interventions, its score changed to the category “without cognitive impairment” (26 is suggested as the cutoff point for normal cognition)1414 Biaggio ÂMB, Natalício L, Spielberger CD. Desenvolvimento da forma experimental em português do Inventário de Ansiedade Traço-Estado (IDATE) de Spielberger. Arq Bras Psicol Aplicada. 1977;29(3):31-44.. This finding converges with evidence that physical exercise stimulates brain neuroplasticity and may improve cognitive performance77 Hallgren M, Vancampfort D, Giesen ES, Lundin A, Stubbs B. Exercise as treatment for alcohol use disorders: systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1058-64..

A limitation of the study was concerning the abstinence control of the participant, as no abstinence monitoring technique was applied throughout the study, such as the use of a breathalyzer. Although the participant had an extensive history of alcohol abuse, his social condition favors treatment adherence and collaborates with a good performance in most tests, since he demonstrates to have broad family support and good income, facilitating access to psychotherapy, means of leisure, and social interaction. Therefore, the sample in question physiologically represents an individual with AUD. However, his family and social support are far from the reality of the majority of the population that seeks treatment for AUD in the Health Unic System. It is important to emphasize that the results obtained in the study cannot be extrapolated to other patients, but it is presented as a possibility of a protocol since it proved to be effective and can serve as a model for different patients with AUD. Moreover, the results obtained from the instruments take into account all the multidisciplinary interventions that the patient received, along with factors such as medication use, time of abstinence, and family and work relationships. On the other hand, this report demonstrates the expected outcomes in a real-life scenario.

This study suggests that the combined training protocol associated with multidisciplinary interventions can improve quality of life, alleviate anxiety symptoms and improve cognitive performance in people with AUD. Since this activity can disseminate the substitution of pleasures and routine structuring, needs to be linked to the logic of relapse prevention.

CONCLUSIONS

Considering the benefits observed in the participant’s mental health and cognitive function, it is recommended that combined aerobic and strength training be encouraged and incorporated as a complementary strategy to treatment already established for people with AUD. The professional must be aware of the necessary adaptations according to each patient’s profile, considering the disorder’s peculiarities.

  • REGISTRATION OF STUDY APPROVAL
    HCPA Ethics and Research Committee with Opinion of approval under nº 4,556,680.

ACKNOWLEDGMENTS

We would like to thank Hospital de Clínicas de Porto Alegre, the Additions and Forensic Psychiatric Service, the Physical Education and Occupational Therapy Service, and Multidisciplinary Residency Commission for all their technical support for the development of this research. This study did not receive financial support from any public institution or private company.

REFERENCES

  • 1
    Fenollal-Maldonado G, Brown D, Hoffman H, Kahlon C, Grossberg G. Alcohol Use Disorder in Older Adults. Clin Geriatr Med. 2022;38(1):1-22.
  • 2
    World Drug Report. United Nations publication; 2021. p. 109. Available from:. https://www.unodc.org/res/wdr2021/field/WDR21_Booklet_2.pdf:
    » https://www.unodc.org/res/wdr2021/field/WDR21_Booklet_2.pdf
  • 3
    Choi NG, DiNitto DM. Alcohol use disorder and treatment receipt among individuals aged 50 years and older: Other substance use and psychiatric correlates. J Subst Abuse Treat. 2021;131:108445.
  • 4
    Silva LES, Helman B, Luz e Silva DC, Aquino ÉC, Freitas PC, Santos RO, et al. Prevalência de consumo abusivo de bebidas alcoólicas na população adulta brasileira: Pesquisa Nacional de Saúde 2013 e 2019. Epidemiol Serv Saúde [Internet]. 2022;31(spe1):e2021379. Available from: https://doi.org/10.1590/SS2237-9622202200003.especial
    » https://doi.org/10.1590/SS2237-9622202200003.especial
  • 5
    World Health Organization. Global health observatory data. 2016. Available from: http://www.who.int/gho/substance_abuse/burden/alcohol_prevalence/en/
    » http://www.who.int/gho/substance_abuse/burden/alcohol_prevalence/en/
  • 6
    Lopes LLT, Silva MRS, Santos AM, Oliveira JF. Multidisciplinary team actions of a Brazilian Psychosocial Care Center for Alcohol and Drugs. Rev Bras Enferm [Internet]. 2019;72(6):1624-31. Available from: https://doi.org/10.1590/0034-7167-2018-0760
    » https://doi.org/10.1590/0034-7167-2018-0760
  • 7
    Hallgren M, Vancampfort D, Giesen ES, Lundin A, Stubbs B. Exercise as treatment for alcohol use disorders: systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1058-64.
  • 8
    Giesen ES, Deimel H, Bloch W. Clinical exercise interventions in alcohol use disorders: a systematic review. J Subst Abuse Treat. 2015;52:1-9.
  • 9
    Hallgren M, Vancampfort D, Schuch F, Lundin A, Stubbs B. More Reasons to Move: Exercise in the Treatment of Alcohol Use Disorders. Front Psychiatry. 2017;8:160.
  • 10
    Lillie EO, Patay B, Diamant J, Issell B, Topol EJ, Schork NJ. The n-of-1 clinical trial: the ultimate strategy for individualizing medicine? Per Med. 2011;8(2):161-73.
  • 11
    Fleck MP, Louzada S, Xavier M, Chachamovich E, Vieira G, Santos L, et al. [Application of the Portuguese version of the abbreviated instrument of quality life WHOQOL-bref]. Rev Saude Publica. 2000;34(2):178-83.
  • 12
    Gomes-Oliveira MH, Gorenstein C, Lotufo Neto F, Andrade LH, Wang YP. Validation of the Brazilian Portuguese version of the Beck Depression Inventory-II in a community sample. Braz J Psychiatry. 2012;34(4):389-94.
  • 13
    Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695-9.
  • 14
    Biaggio ÂMB, Natalício L, Spielberger CD. Desenvolvimento da forma experimental em português do Inventário de Ansiedade Traço-Estado (IDATE) de Spielberger. Arq Bras Psicol Aplicada. 1977;29(3):31-44.
  • 15
    Kiluk BD, Fitzmaurice GM, Strain EC, Weiss RD. What defines a clinically meaningful outcome in the treatment of substance use disorders: reductions in direct consequences of drug use or improvement in overall functioning? Addiction. 2019;114(1):9-15.
  • 16
    Addolorato G, Ancona C, Capristo E, Graziosetto R, Di Rienzo L, Maurizi M, et al. State and trait anxiety in women affected by allergic and vasomotor rhinitis. J Psychosom Res. 1999;46(3):283-9.
  • 17
    Kvaal K, Ulstein I, Nordhus IH, Engedal K. The Spielberger State-Trait Anxiety Inventory (STAI): the state scale in detecting mental disorders in geriatric patients. Int J Geriatr Psychiatry. 2005;20(7):629-34.
  • 18
    Stonerock GL, Hoffman BM, Smith PJ, Blumenthal JA. Exercise as Treatment for Anxiety: Systematic Review and Analysis. Ann Behav Med. 2015;49(4):542-56.
  • 19
    Schuch FB, Vasconcelos-Moreno MP, Borowsky C, Zimmermann AB, Wollenhaupt-Aguiar B, Ferrari P, et al. The effects of exercise on oxidative stress (TBARS) and BDNF in severely depressed inpatients. Eur Arch Psychiatry Clin Neurosci. 2014;264(7):605-13.

COMBINED PHYSICAL TRAINING ASSOCIATED WITH MULTIDISCIPLINARY INTERVENTION IN THE TREATMENT OF ALCOHOL USE DISORDER: A STUDY WITH N OF 1


SPENT 2019 Checklist: Recommended items to address in a clinical trial protocol and related documents* * It is strongly recommended that this checklist be read in conjunction with the SPIRIT 2013 Explanation & Elaboration for important clarification on the items. Amendments to the protocol should be tracked and dated. The SPIRIT checklist is copyrighted by the SPIRIT Group under the Creative Commons “Attribution-NonCommercial-NoDerivs 3.0 Unported” license.

Publication Dates

  • Publication in this collection
    28 Aug 2023
  • Date of issue
    2023

History

  • Received
    21 Mar 2023
  • Accepted
    12 June 2023
Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro Av. Venceslau Brás, 71 Fundos, 22295-140 Rio de Janeiro - RJ Brasil, Tel./Fax: (55 21) 3873-5510 - Rio de Janeiro - RJ - Brazil
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