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Physical Exercise and Yoga in Prevention and Treatment of Addictive Diseases
Karel NESPOR, M. D., Ph.D. and Borivoj PROKES, M. D. The Czech version of this paper was published in Cas. Lek. ces. 2005 (144):53-55.

Summary
Prevention of addictive diseases should be complex and systematic and it should include training of social skills, decision making skills, family intervention, etc. Similarly, effective treatment is usually long-term, systematic and complex. Physical exercise and yoga can be useful components of comprehensive prevention and treatment programs. On the other hand, competitive professional sports rather increase the number of risk factors of substance-related problems (injuries, stress, doping, one-sided strain, exhaustion, unbalanced life style, etc.). Practical experience with the use of yoga in substance dependent patients and pathological gambles are mentioned. The advantages of yoga include the integration of physical exercise and relaxation. Beside this, yoga is not competitive, does not require expensive equipment and it can be used even in patients with severe health problems. Key words: Yoga - Sport – Exercise – Addictive diseases – Prevention – Treatment

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Physical Exercise in Prevention
Best effective programs preventing alcohol and drug related problems, such as Life Skills Training Program (Botvin et al., 1995), are complex and include the training of social skills relaxation techniques, decision making, family involvement, etc. Beside this the availability of alcohol and other drugs is also important (e.g. age limits for purchasing alcohol). We are not aware of any effective preventive program based solely on physical exercise. On the other hand, physical exercise can be an useful component of complex preventive and treatment programs. It is necessary to distinguish between targeted rehabilitation exercises and recreational sports on one hand and competitive professional sports on the other (Nespor, 1994). Recreational sports and targeted physical rehabilitation seem useful whereas professional competitive sport is associated with many risk factors (tables 1 and 2). Table 1. Sports in the prevention of substance related problems - protective factors. Recreational Professional sports sports Compensation of one-sided or Usually yes Usually no insufficient physical activity. Healthy peer involvement It depends It depends Feeling „high“ in a healthy way. Yes Yes Non-pharmacological management of Yes Yes, but tough competition is anxiety and depression. often associated with anxiety. Prevention of many health problems Usually yes Usually no including painful diseases which may increase the risk of substance abuse. Immunity Improved It can be weakened by excessive physical activity. Spontaneous relaxation after exercises. Usually yes Sometimes yes, sometimes rather exhaustion. Table 2. Sports in the prevention of substance related problems - risk factors. Recreation Competitive sport al sport Doping Seldom Comparatively often Excessive stress Seldom Comparatively often Extreme exhaustion Seldom Comparatively often One-sided strain, unbalanced life-style Seldom Comparatively often Injuries Seldom Comparatively often Excessive competition causing disregard to health Seldom Comparatively often Related to the promotion of alcohol and unhealthy Seldom Comparatively often products. Related to the promotion of gambling (bookmaking) Seldom Comparatively often Alcoholic victory celebrations (sportsmen and their Seldom Comparatively often fans)

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Protective factors
Some protective factors deserve more detailed description. Compensation of one-sided or insufficient physical activity: Targeted rehabilitation and suitable recreational sports are crucially important in the prevention and treatment of many diseases. Long-term sitting at school and in front of a computer or a TV leads to e. g. painful back problems and they increase the risk of the abuse of analgesic drugs. Healthy peer involvement: The influence of peers on substance related behavior is very important especially in adolescence, but also in later stages of life. That is why the organizations with healthy life style policy and with the members refusing alcohol, tobacco and other drugs are beneficial. On the other hand, alcohol visits to pubs after trainings or matches are very risky. Non-pharmacological management of anxiety and depression: Physical exercise my decrease anxiety and depression (Leppamaki a spol., 2004, Lam a Kennedy, 2004, Cox a spol., 2004). The obvious advantage is almost instant effect. (Severe depression requires more complex approach such as the combination of pharmacotherapy, behavioral psychotherapy and life style changes.) Spontaneous relaxation after exercises: Relaxation itself and even more so in the combination with physical exercise can relieve anxiety and depression. Beside this, relaxation helps to overcome exhaustion and excessive stress. Sometimes relaxation appears spontaneously after exercise or it can be induced more easily after some kind of physical activity. Table 3. Some changes during relaxation and stress STRESS  MUSCLE TONE  RESPIRATION RATE  HEART RATE  BLOOD PRESSURE  METABOLISM  SOME HORMONES (SUPRARENAL, THYROID)  GALVANIC SKIN CONDUCTANCE  EEG WAVES FREQUENCY

RELAXATION        

Yoga in the prevention and the treatment of substance-related problems
The reasons why we use yoga in substance dependent patients include:  We often treat patients with severe physical and sometimes also mental problems. Easy and non-competitive yogic practices can be used even in them (Nešpor, 2001). E. g. the substance dependent patient with posttraumatic paraplegia took part in our sessions. At the beginning he practiced only at his wheelchair but after some time he dared to move on a mat, and he was able to practice with appropriate modifications most of the exercises.  Non-competitive nature of yoga is useful in the prevention of injuries in substance dependent patients. Many of them are injury prone because of psychological factors (lack of concentration, self-aggression) or biological factors, such as osteoporosis associated with alcohol dependence (Olszynski et al., 2004). From this point of view e. g. a football match can be rather risky affair.  Non-competitive nature of yoga protects often poor self-esteem of these patients.  Relaxation is an important part of yoga. It is general relaxation (it is interposed between more demanding practices and usually also at the end of a session), and partial relaxation during

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various practices (i. e. relaxation of the muscles which are not necessary to maintain certain posture). Earlier we found out that yogic relaxation can improve psychological state of the inpatients treated for substance dependence (Nespor and Frouzova, 1985). Relaxation decreases anxiety and depression, and also alleviates various painful problems and sleeplessness and it can thus often replace addictive medication.  Most of out patients neglected physical exercise long before their treatment. Out treatment program includes lot of psychotherapy, workshops and other activities during which patients sit on chairs. It is demanding, strains their weakened cervical and lumbar spine and causes painful problems. Yoga compensates well for this one-sided strain by suitable practices during which the spine is more or less horizontal with the floor.  Relaxation and other suitable yoga practices alleviate depression (Woolery et al., 2004). Depressive symptoms are common in substance dependent patients especially at the beginning of their treatment. Gupta and Narain (1992) compared physical exercise and yoga in patients with dysthymia. Yoga was more effective, even if both intervention groups were improved. One of the advantages of yoga is integration of physical exercise and relaxation.  There are several studies describing lower substance consumption in subjects practicing Transcendental Meditation (e g. Gelderloos et al., 1991). Unfortunately these studies have no control group that is why it can be argued that these practices may attract more people who are already ready to change their life-style. Shaffer et al. (1997) found that yoga practices are as effective as psychotherapy in patients undergoing methadone maintenance treatment. It would be interesting to know what would be the combined effect of yoga and psychotherapy. Apart from the above mentioned mechanisms, it is possible that the effects of yoga may include also social influence (the refusal of alcohol, tobacco and other drugs is common among yoga minded people).

Methodical remarks
 Our usual sessions last 30 or 45 minutes and they are divided in three approximately equal parts: 1. At the beginning we use simple yogic physical practices. 2. After that full yoga breath, possibly some other simple breathing practices, and some symbolic and positive story are introduced. 3. We end with yogic relaxation.  We use simple practices to protect the self-esteem of our patients.  The practices should be rather pleasant and should compensate for long sitting.  We often ask patients what they want to do. Their typical wishes are “something for the spine”, “a story”, “yogic laughter” or “relaxation”). These “orders” are then taken into account.  Modified yogic practices are often incorporated in other programs, such as workshops or psychotherapy groups. E.g. the “Heavenly Stretch” can be practiced with the instruction to think about the pleasures of sober life; “Chopping the Wood” may be associated with hammering down the pillars of abstinence, and “The Wings” with leaving old habits behind. Such exercises brighten the mood and enhance motivation.

Problems
Problems such us loud snoring during relaxation or small talk during practices are easily manageable. Following issue is more important. Even if most patients quite like the practices during their in-patient treatment, only the small fraction of them continues at home. It is a pity

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because full advantage of yoga appears usually only after long-term and systematic practice. We give to patients, if they wish the contacts to yoga clubs but it is clearly not enough.

Conclusion
We shall end with a slightly modified quotation by an American colleague: “Substance dependence is a chronic problem, and its treatment is successful if it is treated as a chronic problem.” Regular yoga practice can be the helpful part of long-term treatment and maintenance of substance dependent patients but it may not be easy to convince them that it is.

References
Botvin, GJ, Baker, E, Dusenbury, L, Botvin, EM: Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. JAMA, 1995 (273):1106-1112. Cox RH, Thomas TR, Hinton PS, Donahue OM: Effects of acute 60 and 80% VO2max bouts of aerobic exercise on state anxiety of women of different age groups across time. Res Q Exerc Sport, 2004 (75):165-l75. Gelderloos P, Walton KG, Orme-Johnson DW, Alexander CN: Effectiveness of the Transcendental Meditation program in preventing and treating substance misuse: a review. Int J Addict, 1991 (26):293-325. Gupta, A. K. Narain, N. J. Yogasanas in treatment of dysthymia - a double blind controlled study. World Congress of Social Psychiatry, New Delhi, 9.-13.11.1992. Lam RW, Kennedy SH: Evidence-based strategies for achieving and sustaining full remission in depression: focus on metaanalyses. Can J Psychiatry, 2004 (4): 17S-26S, suppl. 1. Leppamaki S, Haukka J, Lonnqvist J, Partonen T: Drop-out and mood improvement: a randomised controlled trial with light exposure and physical exercise. BMC Psychiatry, 2004 (11):22. Nespor, K.: The importance of sports and physical exercise in the prevention of alcohol and drug related problems in youth. Telesna vychova a sport u mladeze, 1994 (60):14-16. (In Czech) Nešpor, K.: Yoga in addictive diseases - Practical experience. Alcologia, 2001 (13):21-25. Nešpor, K., Frouzová, M.: The changes of psychological state of persons treated for substance dependence. A comparison of persons with higher and lower neuroticism. Cs. psychiatrie, 1985 (81):313-319. (In Czech) Olszynski, W. P., Shawn Davison, K., Adachi, J.D. et al.: Osteoporosis in men: epidemiology, diagnosis, prevention, and treatment. Clin Ther, 2004 (26):15-28. Shaffer HJ, LaSalvia TA, Stein JP: Comparing Hatha yoga with dynamic group psychotherapy for enhancing methadone maintenance treatment: a randomized clinical trial. Altern Ther Health Med, 1997 (3):57-66. Woolery A, Myers H, Sternlieb B, Zeltzer L: A yoga intervention for young adults with elevated symptoms of depression. Altern Ther Health Med, 2004 (10):60-63.

Address
Dr. Karel Nespor, Psychiatricka lecebna Bohnice, 181 02 Praha 8, Czech Republic. E-mail: nespor.k@seznam.cz www.drnespor.eu www.youtube.com/drnespor


				
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