The Power of Visualization: Imagining Yourself Doing Something Helps You Achieve Your Goal

How often have you heard an athlete say they visualize the moves they are going to make before they actually do it? Visualizing something and actually acting it out are closely connected. This process involves the activation of our motor cortex located in the frontal lobe of our brains. Our motor cortex is involved in planning, controlling, and executing voluntary movements. Basically, thinking about moving a body part or side-stepping to avoid an opponent from stealing the basketball from you activates the same areas of the motor cortex responsible for initiating that movement directly. Although thinking about a movement does not increase the amount of excitatory postsynaptic potential (EPSP) enough to reach a threshold to actually cause firing of a neuron in the brain that generates that movement, it does still activate the same region. So in short, you can think of something that activates the same region of the brain involved in movement without actually generating movement. Visualization allows us to rehearse our anticipated movements and over time primes our brain and body to more accurately and effectively execute an action. This occurs by the way of stimulating a component of the basal ganglion, the putamen (part of the striatum), a region of the brain that is involved in the rehearsal of movement. Over the course of rehearsing movements via visualization, the brain learns routine movement, making the movement more programmed and fine-tuned.

Basically, cognitive practices can get us closer and more prepared to execute a task with more success. Studies have shown us that cognitive practices are almost as effective as physical practices, and engaging in both cognitive and physical practices is even more effective than doing either one alone. Additional benefits of mental visualization include: improved attention, planning, memory, motor control, and perception. The bottom line is that the brain is receiving additional training for actual performance during imagery rehearsal. It has also been evidenced that these practices enhance motivation, self-esteem, increase states of flow, and improve motor performance. Examples include sharpening your chess skills, practicing your surgery that is coming up this week, practicing your softball swing, your forearm pass in volleyball, or your dance move, or simply working out your muscles. 

As I am writing this blog, I keep wondering if our readers are wondering how this relates to psychological well-being. Let me explain how it works. It is great to know that an athlete can use visualization to enhance his or her performance, but how could this affect someone who is not an athlete or is not planning on executing a movement?  What these studies are really teaching us is the powerful connection between our mind, body, and behavioral execution–in other words, the powerful interaction between our thoughts and our behaviors. Brain studies have now supported that idea that our thoughts produce identical mental commands as actions. Let us reflect on that statement for a second. If studies are showing that you can increase your physical health by simply thinking about it (Harvard study: Crum & Langer, E. J.), what other domains in life can you impact by simply thinking about it in a positive way? I frequently discuss with my patients the importance of positive visualization when working towards a goal, as this visualization impacts motivation and goal attainment. Therefore, if you want something to happen in your life, first you have to think about it, set your goal to achieve it, and then visualize it happening. The difficulty that many face is that we set goals and forget to do the necessary prep work that is needed to get to that goal. Part of this necessary preparation is to visualize the goal being achieved. Essentially, Henry Ford was right: “Whether you think you can, or you think you can’t–you’re right.”

Dr. Narineh Hartoonian is a Clinical Health and Rehabilitation psychologist at the Rowan Center for Behavioral Medicine. She has several years of interdisciplinary clinical and research experience in health and rehabilitation psychology and has served the needs of many individuals with chronic medical conditions and disability. Dr. Hartoonian received her Bachelor and Master of Science in Physiology from the University of California, Los Angeles (UCLA) and her Doctorate in Clinical Psychology from Loma Linda University (LLU). She has taught various graduate and undergraduate courses in the physiological sciences, health and psychobiology.


REFERENCES

  1. Crum, A. J., & Langer, E. J. (2007). Mind-set matters: Exercise and the placebo effect. Psychological Science, 18(2), 165-171.

  2. Franklin, E. N. (2013). Dance imagery for technique and performance. Human Kinetics.

  3. Gabriele, T. E., Hall, C. R., & Lee, T. D. (1989). Cognition in motor learning: Imagery effects on contextual interference. Human Movement Science, 8(3), 227-245.

  4. Jeannerod, M. (1995). Mental imagery in the motor context. Neuropsychologia, 33(11), 1419-1432.

  5. Ay, K., Halaweh, R., & Al-Taieb, M. (2013). The effect of movement imagery training on learning forearm pass in volleyball. Education, 134(2), 227-239.

  6. Lacourse, M. G., Turner, J. A., Randolph-Orr, E., Schandler, S. L., & Cohen, M. J. (2004). Cerebral and cerebellar sensorimotor plasticity following motor imagery-based mental practice of a sequential movement. Journal of rehabilitation research and development, 41(4).

  7. Mulder, T., Zijlstra, S., Zijlstra, W., & Hochstenbach, J. (2004). The role of motor imagery in learning a totally novel movement. Experimental Brain Research, 154(2), 211-217.

  8. Richardson, A. (2013). Mental imagery. Springer.

Physical Activity in Multiple Sclerosis: Does it Improve Cognition?

Many individuals diagnosed with Multiple Sclerosis (MS) will tell you that they not only have to deal with the physical disabling features of MS but also with changes in cognition. Approximately 22-60% of individuals with MS report cognitive impairments in processing speed, new learning and memory, and executive functioning (organizing, problem solving, planning and execution). These difficulties can impact an individuals quality of life, their jobs, and activities of daily living. Many people with MS continue to wonder what they can do to improve their cognitive functioning.  

In a recent study I co-authored with Dr. Beier from the University of Washington School of Medicine, we looked at the relationship between physical fitness and cognitive performance in people with MS (1). A total of 88 individuals with MS participated in this controlled trial (2). Participants had a choice in what health promotion activity they wanted to engage in. In this study we focused on those participants who chose to implement an exercise practice. We wanted to see if improving overall fitness through exercise could help improve the cognitive difficulties that MS patients face during the course of their medical condition. In order to do this the participants in this study were assessed on strength, aerobic fitness and cognition before and after exercising. 

After controlling for the effects of demographic and disease characteristics (age, sex, ethnicity, education, disease activity and MS type), participants who showed improvement in either muscle strength and/or aerobic endurance also showed improvement in executive functioning (remember, this includes higher level cognitive skills such as problem solving, planning and execution, organizing etc.) after 12 weeks of exercise. 

The results of this recent study supports findings from previous research which highlight the positive relationship between physical fitness and cognitive health in people with MS (3-5). Other studies have also shown that physical activity can help improve cardiovascular fitness, range of motion, reduce fatigue, improve flexibility, decrease muscle deterioration, and improve quality of life (6-9)

Physical Activity Recommendations

In the study I presented above, participants engaged in any physical activity of their choice. Some decided to walk daily, others engaged in swimming, some increased there activity by increasing the time they spend on household chores, others engaged in more structured exercises like lifting weights at the gym.  So it is all up to you what type of physical activity you want to engage in. Whatever you decide to do just make sure it has both a strengthening and aerobic training (e.g., walking) component so you can get maximum benefits. 

There really is no prescribed formula of physical activity that would yield the best outcomes. However, there are some evidence-based guidelines that do discuss the frequency, intensity, duration and type of exercise that would increase aerobic capacity and muscle strength. Current evidence-based guidelines are recommending moderate intensity aerobic activity 2 times/week and strength training 2x/week to increases aerobic capacity and muscular strength (10). So basically suggesting that one should try to exercise for a total of 4 days a week, two of the days would be focused on walking, cycling or whatever activity that will increase your aerobic capacity, and the other 2 days would focus on activities that improve muscle strengths (e.g., lifting). Remember always consult with your physician and physical therapist before engaging in any activity.

Here are some more specific tips to get you started*

1.    Set daily goals- The likelihood of completing an activity is higher if the goal is actually written down on paper. So set daily goals and do your best to complete it!
2.    Prepare– Pick a cool, well-ventilated area, wear loose clothing and always have water with you.
3.   Get proper shoes– Since stability could potentially be an issue for some people with MS, you will want to invest in some tennis shoes that will help maximize balance. 
4.    Track activity– If you have a pedometer or even an iPhone use it to track your level of activity. Studies show that those who use activity tracking end up walking or exercising more. Unless you are in a wheelchair this is an effective way to built up your exercise program and can even be helpful in keeping you moving when you are at home. 
5.   Pace your activity-Don’t dive into a challenging workout. The likelihood of drop-out is higher when you take on something difficult and get discouraged because you were unable to complete it. Also, recommendations state that you should start with 10 minutes/day and build up to 40 minutes gradually. 
6.   Do your activity in intervals– As many of you know fatigue and weakness will come on quickly. Take frequent breaks if needed. 
7.   Talk to your Physician– Be sure to consult with your provider before starting any exercise program. You insurance will likely cover the initial cost of seeing a physical therapist (PT) so take advantage of consulting with a PT who can help you tailor your exercises and improve your technique. 

*Always consult with your physician and physical therapist before starting any exercise program.

This study was presented to the European Committee for Treatment and Research in Multiple Sclerosis (ECTRMS), October 4, 2013, Copenhagen, Denmark and Published in Archives of Physical Medicine and Rehabilitation March, 4, 2014. 

About the Authors:

Dr. Narineh Hartoonian is a Clinical Health and Rehabilitation psychologist at the Rowan Center for Behavioral Medicine. She has several years of interdisciplinary clinical and research experience in health and rehabilitation psychology and has served the needs of many individuals with chronic medical conditions and disability. Dr. Hartoonian received her Bachelor and Master of Science in Physiology from the University of California, Los Angeles (UCLA) and her Doctorate in Clinical Psychology from Loma Linda University (LLU). She has taught various graduate and undergraduate courses in the physiological sciences, health and psychobiology.


Dr. Meghan Beier  is a Rehabilitation Psychologist and Clinical Researcher at the University of Washington Medicine Multiple Sclerosis Center. Dr. Beier obtained her Ph.D. from Yeshiva University, and completed a 2-year Multiple Sclerosis rehabilitation research fellowship in the Department of Rehabilitation Medicine at the University of Washington School of Medicine, which was funded by the National Multiple Sclerosis Society. Her research and clinical focus is the cognitive and emotional symptoms common to multiple sclerosis. 

Dr. Beier is also the author of the Multiple Sclerosis and Anxiety blog published on April 22, 2015. Click on the link if you are interested in finding out more about how to screen for anxiety and resources that are available to you. 

REFERENCES 

1.   Beier, M., Bombardier, C. H., Hartoonian, NMotl, R., Kraft, G. (2014) Is improved physical fitness associated with improved cognition in multiple sclerosis? Archives of Physical Rehabilitation and Medicine. DOI: 10.1016/j.apmr.2014.02.017 

2.   Bombardier CH, Cunniffe M, Wadhwani R, Gibbons LE, Blake KD, Kraft GH. The efficacy of telephone counseling for health promotion in people with multiple sclerosis: a randomized controlled trial. Arch Phys Med Rehabil 2008;89:1849-56.

3.   Motl RW, Sandroff BM, Benedict RH. Cognitive dysfunction and multiple sclerosis: developing a rationale for considering the efficacy of exercise training. Mult Scler 2011;17:1034-40. 

4.   Prakash RS, Snook EM, Erickson KI, et al. Cardiorespiratory fitness: a predictor of cortical plasticity in multiple sclerosis. Neuroimage 2007;34:1238-44. 

5.   Sandroff BM, Motl RW. Comparison of ActiGraph activity monitors in persons with multiple sclerosis and controls. Disabil Rehabil 2013; 35:725-31. 

6.   Prakash RS, Snook EM, Motl RW, Kramer AF. Aerobic fitness is associated with gray matter volume and white matter integrity in multiple sclerosis. Brain Res 2010;1341:41-51. 

7.   Motl RW. Physical activity and irreversible disability in multiple sclerosis. Exerc Sport Sci Rev 2010;38:186-91.

8.   Motl RW, Arnett PA, Smith MM, Barwick FH, Ahlstrom B, Stover EJ. Worsening of symptoms is associated with lower physical activity levels in individuals with multiple sclerosis. Mult Scler 2008;14:140- 2.

9.   Motl RW, Weikert M, Suh Y, Dlugonski D. Symptom cluster and physical activity in relapsing-remitting multiple sclerosis. Res Nurs Health 2010;33:398-412.

10.  Latimer-Cheung, A. E., Martin Ginis, K. A., Hicks, A. L., Motl, R. W., Pilutti, L. A., Duggan, M., . . . Smith, K. M. (2013). Development of evidence-informed physical activity guidelines for adults with multiple sclerosis. Arch Phys Med Rehabil, 94(9), 1829-1836 e1827. doi: 10.1016/j.apmr.2013.05.015

Exercise and Endorphins

Did you know that there is no such thing as a bad exercise? There are only bad applications of those exercises.  A properly prescribed exercise routine should build you up, not break you down.

An important aspect exercise is the increase in the synthesis and secretion of endorphins into our blood stream.  We all have these neat feel-good neurochemicals just waiting to be released.  Virtually any form of exercise, from weight training to yoga, can act as a trigger point in the production of endorphins in your body, which, in turn, can improve mood states. (1) Mood states are dependent on endorphin synthesis and secretion. (2-4) It has been suggested that exercise strengthens the secretion of endorphin reducing symptoms related to anxiety and depression. (5) Two of the most common factors leading to the release of endorphins are stress and pain. According to the endorphins hypothesis, exercise augments the release of endogenous opioids in the brain when pain in experienced, leading to euphoria. (6)

Exercise is a form of physical stress, which we apply to our bodies in systematic ways. The second component, “pain”, is a very important factor when it comes to choosing the right exercise for you. Pain due to exercise can be placed into two categories and it is important to distinguish between the two types of pain in order to maintain safety. Are your muscles “screaming” or are they “singing?” Muscles that are “screaming” can be described experiencing as sharp, shooting, burning, or radiating pain. Muscles will scream during exercise when forced to move in a manner in which they have not been properly trained to do so. This could be due to using too much weight, doing too many repetitions or jumping into a routine without the proper warm-up and guidance. Any activity that makes you wince and want to stop immediately should not be ignored or worked through. Similarly, pain that interrupts your activities of daily living such as sleeping is also abnormal. Muscles that are “singing” tend to be working in conjunction with other muscles. Muscles work much better when they are integrated with the body, not isolated from other muscles. (7) The more muscles, joints, and planes of motion you exercise in, the happier your body will be. There is a healthy amount of soreness one should feel after performing a new or strenuous bout of exercise. This soreness is referred to as delayed onset muscle soreness (DOMS). The soreness is usually felt 24 to 72 hours after exercise. (8) DOMS can be greatly reduced or prevented by gradually increasing the intensity of a new exercise routine.

Questions to ask before getting started

When you first start your exercise program, you should set realistic goals for yourself.  Write out a routine that is easy to follow and maintain for the first 4-weeks.  When you start feeling comfortable with your routine, then you can start varying your exercise times and activities.

1.     What physical activities do I enjoy? Exercising should be fun. If you enjoy the outdoors, include activities which will take place outside. If you do better in a structured setting, sign up for group classes. Joining a group exercise class is a great way to share the gift of fitness with those around you. Or you can exercise with a close friend or your partner. This is another way to benefit from the physical activity and emotional comfort, knowing that others are supportive of you.

2.     Do I have time to start a new exercise program? We can all find time in our busy days to exercise. Make your exercise routine a priority. Schedule your exercise routine on your calendar just like you would for a dentist or doctor’s appointment.

3.     Am I ready for change? With exercise come a number of changes. Number one, you will feel better about yourself. The second change, you will look better. And you will make new friends as you embark on your exercise journey. Exercise does not have to be monotonous.  Make sure to add variety to your workouts. Exercise should be fun!

4.     Do I have physical conditions that limit my choice of exercise? Our number one reason for not working out is, “I am not in shape.” We all have to start somewhere. You can do it. If you need help getting started, ask. Enlist the help of a professional if you need help. There are plenty of qualified Personal Trainers with a variety of training options to get you started. Have them help you set up a game plan to get you going.

5.     What goals do I have in mind? Your exercise routine should prepare your body for the activities you perform on a daily basis. Think in terms of, how this exercise will help me participate in a specific sport, run, walk, daily chores, play with my kids, etc.

6.     How often should I exercise? The goal is to work out 4 to 5 times per week. Each exercise bout should last a minimum of 30 minutes. If you have not worked out in over 6 months start with exercising last at least 20 to 30 minutes, three times a week.

7.     Which exercises should I start with? Start with bodyweight exercises. As you feel more comfortable and are able to get through the exercises with ease, only then should you add external weight to your workout. Make sure you are able to go through the full range of motion and do so in a safe and effective manner. Remember that starting an exercise routine is about setting yourself up to succeed not fail. Work on your strengths and slowly build up your areas of weakness. Before you know it, you will have those feel good endorphins going and you will be well on your way to a healthy mind, body and spirit. 

Sample Exercises

Common Lunge Matrix

  Sagittal Plane

Frontal Plane

 Transverse Plane

Uncommon Lunge Matrix

3D UE DUMBELL MATRIX

Hip to Shoulder

Common

 Uncommon

Sagittal Plane

Frontal Plane

  Transverse Plane

Marko Sanchez, CSCS
Certified Strength and Conditioning Specialist

Marko Sanchez  is a graduate of the University of California Los Angeles (UCLA) where he earned his undergraduate degree in Physiological Science. Since returning home from Los Angeles, Marko has worked in various physical therapy settings as a physical therapy aide, personal trainer, and sports performance coach. Marko received his Certified Strength and Conditioning Specialist certification from the National Strength and Conditioning Association (NSCA) in 2001. He is a student of the training and conditioning system developed by internationally renowned physical therapist, Gary Gray, known as the “Father of Function.”

Function Factory’s mission is to work with health-minded individuals to help them achieve their potential, whether it is recovering from an injury, reaching fitness goals, or generally improving their wellness.  At Function Factory, they employ a personalized, whole body approach to exercise that fits your lifestyle.  


REFERENCES

1. Dinas PC, Koutedakis Y, Flouris AD (2011). “Effects of exercise and physical activity on depression”. Ir J Med Sci 180 (2): 319–325.

2. Fichna J, Janecka A, Costentin J, Do Rego JC (2007) The endomorphin system and its evolving neurophysiological role. Pharmacol Rev 59(1):88–123

3. Stein DJ, van Honk J, Ipser J, Solms M, Panksepp J (2007) Opioids: from physical pain to the pain of social isolation. CNS Spectr 12 (9):669–670, 672–664

4. Vaccarino AL, Olson GA, Olson RD, Kastin AJ (1999) Endog- enous opiates: 1998. Peptides 20(12):1527–1574

5. Cox RH (2002) Sport psychology: concepts and applications. McGraw-Hill Publishers, St. Louis, MO

6. Grisel JE, Bartels JL, Allen SA, Turgeon VL (2008) Influence of beta-endorphin on anxious behavior in mice: interaction with EtOH. Psychopharmacology (Berl) 200(1):105–115

7. McFarland, M.D.. Cosgarea, Andrew, M.D..”What is the difference between “good” pain and “bad” pain?” Johns Hopkins Medicine Web. 05 Jan. 2014

8. Nosaka, Ken (2008). “Muscle Soreness and Damage and the Repeated-Bout Effect”. In Tiidus, Peter M. Skeletal muscle damage and repair. Human Kinetics. pp. 59-76

Exercise for Optimal Brain Health

It seems as though the benefits of an active lifestyle have long been known (Voss, Nagamatsu, Liu-Ambrose, & Kramer, 2011):

“A strong body makes the mind strong.” – Thomas Jefferson

“If we could give every individual the right amount of nourishment and exercise, we would have found the safest way to health.” – Hippocrates

There is strong link between physical activity and physical health. In fact, getting out and moving has been shown to decrease the risk for cardiovascular disease, osteoporosis, diabetes as well as both colon and breast cancer (Kelley, 1998; Laaksonen et al., 2005; Lee, 2003; Shiroma, 2010).  But many may not be aware of the impact exercise has on brain functioning (Hillman et. al., 2008; Voss et al., 2011), and more importantly, the type and duration of exercise needed to positively impact brain health.  

Studies have shown that when school-age children engage in physical activity they demonstrate improved cognitive performance. These children showed improvement in IQ, perceptual skills and achievement. They also performed better on tests of verbal and mathematical skills. Those children who exercised regularly also demonstrated higher levels of development and increased academic readiness (Sibley & Etnier, 2003). This exercise-related improvement was not found in young adults (potentially due to the fact that cognitive health peaks during this period of development; Salthouse, 2006), which means that it is important for children to get regular exercise because they can not simply make up for what they have missed as they get older.  

Research indicates that older adults who maintain a healthy diet and exercise plan as well as remain socially and intellectually engaged have better cognitive functioning than their peers who do not (Karp et al., 2006). In fact, for those who have been diagnosed with early Alzheimer’s disease, a combination of aerobic and strength training has shown to improve performance in a number of areas including speed of information processing, visual and spatial memory, planning and inhibition when compared to those who engage in only one type of exercise or the other. In this study short bouts of exercise of 30 minutes or less had very little impact on cognitive functioning in this population (Colcombe, S. & Kramer A.F., 2003).

In addition to improving how people think, exercise has also been shown to improve how people feel. Physical activity has been show to improve both anxiety and depression (Davis et al., 2010; Krogh, et al., 2011; Rimer, 2012; Cooney et al. 2013).

Once we understand the benefits of exercise, the next natural question then becomes how much do we need to do in order to get these benefits? The first key is to focus on the type of activity that you are doing. We now know that combining strength training with aerobic activity has the highest impact on brain function/health (Colcombe & Kramer, 2003; Colcombe, 2006). We also know that aerobic exercise (running, walking, swimming etc.) is better than simply stretching and toning when it comes to improving brain functioning (Colcombe, 2004). Resistance or strength-training alone (e.g., lifting weights) has only been shown to improve memory when the duration of the program is at least six months but does not seem to have a positive impact on any other areas of cognitive functioning (Tsutsumi et al., 1997; Kimura, 2010).

In order to maximize the benefits of any physical exercise program the duration should be at least six months or more and each session should be 31-45 minutes in length as shorter sessions have not been found to be as helpful for improving brain health (Colcombe & Kramer, 2003). Remember to check in with your doctor prior to starting any exercise program, especially if you have not exercised in a long time or have health concerns.

Take Home Message:

1)    Type: combined strength training with aerobic activity

2)    Session Duration: 31-45 minutes

3)    Duration: 6 Months +

Nar Blog Size.jpg

Dr. Narineh Hartoonian is a Clinical Health and Rehabilitation psychologist at the Rowan Center for Behavioral Medicine. She has several years of interdisciplinary clinical and research experience in health and rehabilitation psychology and has served the needs of many individuals with chronic medical conditions and disability. Dr. Hartoonian received her Bachelor and Master of Science in Physiology from the University of California, Los Angeles (UCLA) and her Doctorate in Clinical Psychology from Loma Linda University (LLU). She has taught various graduate and undergraduate courses in the physiological sciences, health and psychobiology.


REFERENCES

Sibley, B. A. & Etnier, J. L. The relationship between physical activity and cognition in children: a meta- analysis. Ped. Exerc. Sci. 15, 243–256 (2003).

Colcombe, S. & Kramer, A. F. Fitness effects on the cognitive function of older adults: a meta-analytic study. Psychol. Sci. 14, 125–130 (2003).

Colcombe, S. J. et al. Cardiovascular fitness, cortical plasticity, and aging. Proc. Natl Acad. Sci. USA 101, 3316–3321 (2004).

Colcombe, S. J. et al. Aerobic exercise training increases brain volume in aging humans. J. Gerontol. A Biol. Sci. Med. Sci. 61, 1166–1170 (2006).

Cooney, G. M., Dwan, K., Greig, C. A., Lawlor, D. A., Rimer, J., Waugh, F. R., …Mead, G. E. (2013). Exercise for depression. Cochrane Database Syst Rev, 9, CD004366. doi: 10.1002/14651858.CD004366.pub6

Davis JC, Marra CA, Beattie BL, Robertson MC, Najafzadeh M, Graf P, Nagamatsu LS, Liu-Ambrose T. Sustained cognitive and economic benefits of resistance training among community-dwelling senior women: a 1-year follow-up study of the Brain Power study. Arch Intern Med 170: 2036–2038, 2010.

Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: exercise effects on brain and cognition. Nat. Rev. Neurosci. 2008;9:58–65.

Karp, A. et al. Mental, physical, and social components in leisure activities equally contribute to decrease dementia risk. Dement. Geriat. Cogn. Disord. 21, 65–73 (2006

Kelley GA. Exercise and regional bone mineral density in postmeno- pausal women: a meta-analytic review of randomized trials. Am J Phys Med Rehabil 77: 76 –87, 1998.

Kimura K, Obuchi S, Arai T, Nagasawa H, Shiba Y, Watanabe S, Kojima M. The influence of short-term strength training on health- related quality of life and executive cognitive function. J Physiol An- thropol 29: 95–101, 2010.

Krogh J, Nordentoft M, Sterne JA, Lawlor DA. The effect of exercise in clinically depressed adults: systematic review and meta-analysis of randomized controlled trials. J Clin Psychiatry 2011;72:529-38.

Laaksonen DE, Lindström J, Lakka TA, Eriksson JG, Niskanen L, Wikström K, Aunola S, Keinänen-Kiukaanniemi S, Laakso M, Valle TT, Ilanne-Parikka P, Louheranta A, Hämäläinen H, Rastas M, Salminen V, Cepaitis Z, Hakumäki M, Kaikkonen H, Härkönen P, Sundvall J, Tuomilehto J, Uusitupa M; and study Fdp. Physical activity in the prevention of type 2 diabetes: the Finnish diabetes prevention study. Diabetes 54: 158 –165, 2005.

Lee IM. Physical activity and cancer prevention–data from epidemio- logic studies. Med Sci Sports Exerc 35: 1823–1827, 2003.

Rimer, J., Dwan, K., Lawlor, D. A., Greig, C. A., McMurdo, M. Mor-ley, W., & Mead, G. E. (2012). Exercise for depression. Cochrane Database of Systematic Reviews, 7

Shiroma EJ, Lee IM. Physical activity and cardiovascular health: lessons learned from epidemiological studies across age, gender, and
race/ethnicity. Circulation 122: 743–752, 2010.

Salthouse, T. A. & Davis, H. P. Organization of cognitive abilities and neuropsychological variables across the lifespan. Develop. Rev. 26, 31–54 (2006).

Tsutsumi T, Don BM, Zaichkowsky LD, Delizonna LL. Physical fitness and psychological benefits of strength training in community dwelling older adults. Appl Human Sci 16: 257–266, 1997

Voss MW, Nagamatsu LS, Liu-Ambrose T, Kramer AF. Exercise, brain, and cognition across the lifespan. J. Appl. Physiol. 2011;111:1505–13

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