Exercise as Medicine — The Dimensions of Addiction and Evidence-based Play

Written by Greg Dea Tuesday, April 20, 2021 FMS

How many of you have thought about training that stopped working?

The training forums do explore this a lot. I want to meta that. I want to hack the failure for training to work because the training may not be to blame. The programming may not be to blame. The assessment may not be to blame. The dimension might be what we’re missing. The dimension of addictive tendencies. To quote science writer Tabitha Powledge, “what follows is a selective and much-simplified account of some consequences of the dizzyingly complicated process of addiction” as it applies to exercise that stops working and how we can be better.

Let me describe it in the context of a non-identified client. Let’s call her JJ.

JJ has a history of addictive tendencies related to substance abuse. She was an elite runner with outstanding international potential before succumbing to addictions. Fast forward many years to a very different person dealing with chronic pain syndromes and it is becoming apparent that JJ has similar addictive difficulties with exercise. What I mean by that is this: JJ is always better by training, but then the effect of that training diminishes and she feels the tendency to not be stimulated by it anymore and has regression of chronic pain symptoms, like a come-down from a high that gets shorter after training. JJ agreed with me. I’m not a psychologist but it was a thought that we discussed. So, she went through a time with me where the movement prep I took her through was amazing for her, then she forgot to do them and wanted something else, so I took her through loaded movement involving kettlebells and dead balls etc., and she felt amazing and loved it. She once again was loving her running and then she wasn’t.

I knew JJ would do better by training with another coach closer to home who would be a coach for coaching sake, rather than a coaching clinician who she came to for help with exercise for her chronic pain. A fine line, I’m sure, but there’s benefit in the mind-set of turning up to train, versus turning up with the option to be treated.

She did so well with a StrongFirst qualified trainer initially and then the effect of being better from the training wore off after some time. Then she would come to me and we’d talk and treat and move and she’d feel great but it wouldn’t hold as long as she wanted. So she explored functional range conditioning given by a trusted friend - effectively another version of bodyweight loaded movement (wrapped up in different movements given by a different person with a different story on how effective it would be). The outcomes were desirable, JJ loved doing it and the overall effect on her well-being was very positive. It wasn’t lost on me so many of the movements were built into what JJ had been doing in the previous two years and that they were another version of what we were already doing, but because it was new, it had a new feel to it that replaced the old feel. When talking about this with JJ, she agreed with me. And currently, her “high volume” region-specific training with her StrongFirst trainer isn’t giving her what she wants, even though she feels good doing it and felt good doing it initially.

So, we proposed a plan to constantly vary her training.

Not ground-breaking stuff, right?
But I think there’s a ground-breaking way to think about it though, at least for me, and currently for JJ. Since much of the anxiety reflects her chronic pain, this new ground-breaking way to think about itreflected her personality – she said it was if I was describing her past 20 years!

The variance in training would have a different effect. Not a neuromuscular or movement effect, but a psychological effect to give her different buzzes. To meta that, we even decided this new way of varying training would lose its buzz, so we had to be prepared to go with the flow and return to previously beneficial blocks of training that don’t have variance. It would have an effect on the complex addition system involving the limbic system, the amygdala and pre-frontal cortex, the latter of which has so many benefits relating to movement, connecting back through the memory functions of the amygdala to the reward of moving.

At present, JJ is doing some yoga. Similar to other forms of exercise, yoga combines bodyweight loaded movement and time under tension with breath work and mindfulness. JJ could get these strategies with strong first style kettlebell training, or indeed any training if done well.

At present, I have suggested to JJ, and her other coach that she steps towards a training session that gives her single focus, with exertion and challenge, but leaves all else as a by-product.

For example, I might do a strength aerobics circuit with her and she walks away feeling amazing. And later I might just do technical swings, get ups, cleans and squats, with a med ball circuit for an energy system blast - and she’ll love it. And on another day I might prescribe a form of more extreme yoga that works on variations of movements that aren’t in typical yoga but that are part of any system of movement with extended time under tension with focussed breathing. I might add some strength or conditioning or technical work afterwards. In short, there are so many options to keep her buzzed from training, without losing the sensitivity of the training.

And here’s another evolution of training for JJ. She might even become desensitised to this type of variation in training and she may feel the need to simply stick to one form for a little while before she loses that buzz. I figure we can work with her in this very different way of working out that has training in it. It’s a play-it-by-ear style, but it might suit her self-reported addictive personality and physiology with addictive tendencies and often-changing effects of stimuli.

More on the Pre-Frontal Cortex 

Let me tell you about the four barriers to performing well, or in the case of JJ, being content with life. First, ill health, or bad energy, can inhibit contentment and performance. The Pre-Frontal Cortex (PFC) is implicated in working memory, decision making based on emotion (Tyborowska et al, 2016), social behaviours, and goal-directed behaviours (Duncan and Owen, 2000; Wood and Grafman, 2003 and Wood et al, 2003). Stimulating the PFC can lead to a reduction in neuropathic pain (Nardone et al, 2016). In the aftermath of a “negative stimuli”, a person with a stimulated PFC can have decreased “startle magnitudes” (Nardone, 2016). So, for a person like JJ with chronic pain, movement can be an elixir.

We want to be able to harness brain power when we aim to change behaviour. Let’s look at a simple process of how to do that.

To change behaviour and break the individual's previous patterns, we have to first get their attention. As coaches we create environments for change. When we improve the sensory environment, we set the first environment to break the undesirable patterns. After we improve the sensory environment, we create circumstances and challenges to stimulate the perception of the sensory environment. We can do that via auditory, visual or somatosensory (tactile) cues. And importantly, when we reduce pain and improve mobility, we do just that – improve the sensory environment, readying the person for our cue to get their attention, to change their behaviour. Which bring us to the second barrier to performance – blocked energy, the impairment or restrictions of mobility.

The PFC is connected to brain areas involved in processing sensory and motor inputs (Ongur & Price, 2000, Croxson et al, 2005 and Wise, 2008). This very same area of the brain plays a role in error related adjustments (Zavala et al, 2006). Also, activation of the infralimbic area of the PFC may promote behavioural strategies that involve mobilizing the body and suppress strategies that involve immobilizing the body (Halladay and Blair, 2016). What we can draw from this research is that when we involve the PFC, through play, through movement, through emotional connection to movement, we may unblock energy by improving mobility.

With enhanced mobility, we have a sensory environment better placed to receive our cues for change. In other words, we prime the person to better control their movement. Which is exactly what the third barrier to performance is about – the barrier of leaked energy. A person who initiates a movement, who has the health and mobility to do so, but is unsuccessful or inefficient with that movement is said to have leaked the energy of the signal. In other words, the software just isn’t running very well on a hardware that is capable. Luckily for us, a stimulated PFC can decrease reaction time and error rate when balancing speed and accuracy of motor skills – meaning, we can improve control of software, control of movement patterns, by stimulating the PFC (Georgiev et al, 2016; Liu and Watanabe, 2012).

The fourth barrier to performance is deficient energy, the opposite of which is what we chase with performance training – abundant energy via strength, power, endurance – supported by health and high quality movement within the first three barriers to performance. The practical way to creative movement should harness brain power, supporting science through playful training. This practical way has layers of involvement of the nervous system, progressively challenging the pre-frontal cortex, amygdala and limbic system. These layers are:

  1. Involve multiple joints within a limb, as opposed to an isolated joint;
  2. Involve multiple limbs, as opposed to a single limb;
  3. Involve multiple limbs between upper and lower body;
  4. Involve multiple limbs on opposite sides of the body;
  5. Involve movement across the midline.
  6. Involve reward, attention, planning & motivation (pre-frontal cortex)

Play involves all these.

Powledge, Tabitha M.. 1999. Addiction and the brain: The dopamine pathway is helping researchers find their way through the addiction maze. BioScience 49: 513-519. doi: 10.2307/1313471. https://doi.org/10.2307/1313471

Duncan, J. and A.M. Owen, Common regions of the human frontal lobe recruited by diverse cognitive demands. Trends Neurosci, 2000. 23(10): p. 475-83.

Wood, J. N. & Grafman, J.. 2003. Human prefrontal cortex: processing and representational perspectives. Nat Rev Neurosci 4: 139-47. doi: 10.1038/nrn1033.

Tyborowska, A., Volman, I., Smeekens, S., Toni, I. & Roelofs, K.. 2016. Testosterone during Puberty Shifts Emotional Control from Pulvinar to Anterior Prefrontal Cortex. J Neurosci 36: 6156-64. doi: 10.1523/jneurosci.3874-15.2016.

Wood, J.N., et al., Category-specific representations of social and nonsocial knowledge in the human prefrontal cortex. J Cogn Neurosci, 2003. 15(2): p. 236-48.

Nardone, R., Holler, Y., Langthaler, P. B., Lochner, P., Golaszewski, S., Schwenker, K., Brigo, F. & Trinka, E.. 2016. rTMS of the prefrontal cortex has analgesic effects on neuropathic pain in subjects with spinal cord injury. Spinal Cord doi: 10.1038/sc.2016.87.

Ongur, D. and J.L. Price, The organization of networks within the orbital and medial prefrontal cortex of rats, monkeys and humans. Cereb Cortex, 2000. 10(3): p. 206-19.

Croxson, P.L., et al., Quantitative investigation of connections of the prefrontal cortex in the human and macaque using probabilistic diffusion tractography. J Neurosci, 2005. 25(39): p. 8854-66.

Wise, S.P., Forward frontal fields: phylogeny and fundamental function. Trends Neurosci, 2008. 31(12): p. 599-608.

Zavala, B., et al., Human subthalamic nucleus-medial frontal cortex theta phase coherence is involved in conflict and error related cortical monitoring. Neuroimage, 2016. 137: p. 178-87

Halladay, L.R. and H.T. Blair, Prefrontal infralimbic cortex mediates competition between excitation and inhibition of body movements during pavlovian fear conditioning. J Neurosci Res, 2016.

Georgiev, D., et al., Continuous Theta Burst Stimulation Over the Dorsolateral Prefrontal Cortex and the Pre-SMA Alter Drift Rate and Response Thresholds Respectively During Perceptual Decision-Making. Brain Stimul, 2016. 9(4): p. 601-8.

Liu, C.C. and T. Watanabe, Accounting for speed-accuracy tradeoff in perceptual learning. Vision Res, 2012. 61: p. 107-14.


Greg is a Performance Sports Physiotherapist, with multiple Olympic medalists and world champion athletes among his clientele. He is based out of the Mornington Peninsula in the south east of Melbourne, Australia. He regularly works in professional sports in China and teaches in five countries. He has been a titled Sports Physiotherapist for 10 years and a practicing Physiotherapist since 1999. He has lived in five countries, studied and worked in eight, and travelled to over thirty to learn what the best practitioners and coaches do, systematically, in the toughest athletic environments.





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