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Development of aerobic fitness of individuals with substance abuse/dependence following long-term individual physical activity

Asgeir Mamena; Egil W. Martinsenb a Faculty of Teacher Education and Sport, Sogn og Fjordane University College, Sogndal b Institute of Psychiatry, University of Oslo, Oslo, Norway Online publication date: 09 June 2010

To cite this Article Mamen, Asgeir and Martinsen, Egil W.(2010) 'Development of aerobic fitness of individuals with

substance abuse/dependence following long-term individual physical activity', European Journal of Sport Science, 10: 4, 255 — 262 To link to this Article: DOI: 10.1080/17461390903377126 URL: http://dx.doi.org/10.1080/17461390903377126

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European Journal of Sport Science, July 2010; 10(4): 255262

ORIGINAL ARTICLE

Development of aerobic fitness of individuals with substance abuse/ dependence following long-term individual physical activity

ASGEIR MAMEN1 & EGIL W. MARTINSEN2 Faculty of Teacher Education and Sport, Sogn og Fjordane University College, Sogndal, and 2Institute of Psychiatry, University of Oslo, Oslo, Norway

Downloaded By: [European College of Sport Science] At: 06:51 20 August 2010

1

Abstract Thirty-three individuals with substance abuse who completed a training programme 7.5 months (s4.1) in duration were evaluated on development of aerobic power and performance on a lactate profile test using directly measured VO2max and measurement of blood lactate concentration. The group improved moderately on aerobic power (4%, sx 2, P 0.020) and on performance at the lactate threshold (running: 7%, sx 3, P 0.03; cycling: 13%, sx 5, P 0.03). The low improvement rate compared with other studies may be attributed to the use of directly measured VO2max, as indirect tests used in previous studies are prone to exaggerate the improvement. Those individuals whose aerobic fitness improved performed more of the training above threshold heart rate than those who did not improve (P 0.006), although the amount of training during the programme (315 h, sx 97 vs. 279 h, sx 89; P 0.30) did not differ significantly. The programme is the first to show that direct testing of fitness using maximal tests is feasible for this patient group. The programme is also pioneering in the use of training partners to help patients with substance abuse and dependence conduct large amounts of training.

Keywords: Health, testing, lactate threshold, running, cycling

Introduction Persons with substance abuse or dependence (whether alcohol or drugs/medication) are often in poor physical health. This may be due to both a generally unhealthy lifestyle as well as the use of intoxicating substances. The adverse effects of excessive alcohol intake on health have been studied in details for more than a century. A large intake of alcohol provides a caloric surplus that is difficult to compensate with increased energy expenditure (Orozco & de Castro, 1994). Excessive intake of alcohol over long periods is detrimental to skeletal and heart muscle (Urbano-Marquez & Fernandez-Sola, 2004), and thus contributes to lower aerobic fitness and possibly also a reduced ability to respond to training. Chronic alcoholics have a reduced amount of myoglobin in skeletal muscle and reduced maximal isokinetic muscle power (Lundin, Hallgren, Landelius, Roxin, & Venge, 1986). Rubin (1979) reported skeletal muscle loss and impaired cardiovascular

performance in persons with alcoholic cardiomyopathy. The physical effects of other forms of drug abuse/dependence have not been studied so extensively. Physical activity has been used in the treatment of alcohol abuse and dependence for more than 30 years. The interventions have mostly been of short duration, and the amount and intensity of the training have not been precisely described. Frankel and Murphy (1974) reported a 23% improvement on a step-test after 12 weeks of training (one hour a day, 5 days a week). They also found that resting heart rate was reduced by 6.5%, from 82 beats × min1 (s13) to 77 beats × min 1 (s 15). Sinyor and colleagues (Sinyor, Brown, Rostant, & Sereganian, 1982) reported an increase of 12% in maximum oxygen consumption (VO2max) assessed by the sub˚ strand/Ryhming cycle ergometer test, in a maximal A mixed-sex group of adults with problematic drinking behaviour who trained for 6 weeks. The authors also observed a 6% decrease in body fat. After an 8-week

Correspondence: A. Mamen, Faculty of Teacher Education and Sport, Sogn og Fjordane University College, PO Box 133, N-6851 Sogndal, Norway. E-mail: [email protected] ISSN 1746-1391 print/ISSN 1536-7290 online # 2010 European College of Sport Science DOI: 10.1080/17461390903377126


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A. Mamen & E. W. Martinsen

training intervention (70 min three times a week), Murphy and colleagues (Murphy, Pagano, & Marlatt, 1986) reported a 12% improvement in maximal aerobic power using a sub-maximal cycle ergometer test. Palmer and colleagues (Palmer, Vacc, & Epstein, 1988) used walking exercise three times a week, which meets the minimum requirements for a graded exercise programme according to the American College of Sports Medicine, as part of the treatment of male alcoholic inpatients. They reported no improvement in physical fitness assessed ˚ strand/Ryhming cycle test after 28 days inby the A patient treatment. Sell and Christensen (1989) reported a 37% improvement in VO2max measured ˚ strand-Rhyming test in eight substance by the A abusers training twice a week for 12 weeks. The training progressed from walking 1.5 km to running 10 km. Over the same period, resting heart rate was reduced by 14%, from 82 to 72 beats × min1. Collingwood and colleagues (Collingwood, Reynolds, Kohl, Smith, & Sloan, 1991) trained a group of substance-abusing adolescents twice a week for 9 weeks. Those individuals who were less fit improved their one-mile (1609 m) running time by 23%, while those who were fit experienced no significant reduction. We are not aware of exercise intervention studies involving patients with other types of drug abuse/dependence. In previous exercise intervention studies, physical fitness has been calculated from indirect tests. These are less reliable than direct measurements from maximal tests. In particular, the use of heart rate as a criterion may inflate the effect of training (Segerstro¨ m et al., 2008). We avoided this inaccuracy by using direct measurements of aerobic power during an incremental exercise test to volitional fatigue. From a physiological perspective, training programmes should be designed on an individual basis, taking into consideration both the activity preferences of the participants and the individual heart rate training zones based on a lactate profile test or other appropriate test. To the best of our knowledge, no previous studies have used lactate threshold

performance to assess fitness in a sample of patients with substance abuse or dependence. Motivation is a tremendous challenge when helping patients with substance-related problems to exercise. In the present study, patients were assisted by lay people in their own municipalities called ‘‘training partners’’ (Skrede, Munkvold, Watne, & Martinsen, 2006), who trained together with the participants, helping them to maintain a suitable intensity and frequency of training. The aim of the study was to assess improvement in aerobic fitness in persons with substance abuse or dependence, who had undergone systematic longterm individualized training. This evaluation was based on the results from both a lactate profile test and direct measurement of VO2 during maximal treadmill running.

Methods Participants Thirty-three individuals (26 males, 7 females), who had volunteered to take part in a rehabilitation programme for people with substance abuse or dependence with additional mental disorders, served as participants. Their mean age was 31.2 years (s9.9). The mean body mass index of the group at baseline was 24.8 kg × m 2 (s4.5). The participants’ physical characteristics at baseline are given in Table I. The participants reported that they primarily used alcohol (n 15), cannabis (n 12) or other substances (n 6), but they were all mixed users. As comparisons between these groups did not reveal significant differences, except for re-test of threshold treadmill speed, we considered them as one group. Responders and non-responders Individual responses to training programmes vary, and day-to-day biological variations occur (Kuipers, Verstappen, Keizer, Geurten, & van Kranenburg, 1985). We therefore used a cut-off value for improvement in aerobic power of 0.15 litres × min1 to ensure that improvements were above the random biological

Table I. Participant characteristics at baseline (mean values with standard deviations in parentheses)

Age (years) Height (m) Body mass (kg) BMI (kg × m 2) Age abuse began (years) Length of abuse (years)

All (n33)

Males (n26)

Females (n7)

Responders (n20)

Non-responders (n13)

31.2 (9.9) 1.78 (0.09) 78.5 (15.6) 24.8 (4.5) B1517 25

30.8 (9.1) 1.81 (0.08) 79.9 (14.2) 24.4 (3.7) 1517 25

32.7 (13.0) 1.67 (0.03) 73.3 (20.5) 26.2 (6.8) 1517 25

31.5 (9.9) 1.79 (0.08) 73.8 (13.4) 23.0 (2.8) 1517 68

30.8 (10.2) 1.77 (0.11) 85.8 (16.5) 27.5 (5.3) 1517 25

Note: Responders improved their VO2max by more than 150 ml × kg 1 × min 1; non-responders experienced less improvement. BMIbody mass index.

Physical training of substance abusers and technical variation range. We divided the participants into responders whose aerobic power improved by 0.15 litres × min 1 (2.0 ml × kg 1 × min1) or more, and non-responders. An improvement of 0.15 litres × min1 represents an approximate 3% increase in aerobic power.


Consent The participants were informed about the programme and told that they could leave at any time without giving any reasons for doing so and without this having negative consequences for their treatment. Before starting the programme, they provided signed informed consent. The hospital administration approved the programme before implementation. As this was an intervention in the general clinical setting, a statement from the ethics review board was not necessary at the time the trial was conducted. Physical testing The physical testing included a lactate profile test on either a cycle ergometer (Monark 824E, Monark Exercise AB, Vansbro, Sweden) or a treadmill (Woodway PPS55, Woodway GmbH, Weil am Rhein, Germany). Lactate measurements were made with a LactatePro LP1710 analyser (Arkray Inc., Kyoto, Japan). The lactate profile test included several 5-min steps of increasing intensity. The lactate threshold was defined as resting blood lactate concentration1.5 mmol × l 1 (Helgerud, Ingjer, & Strømme, 1990). At the end of each work period, heart rate, 15-point rating of perceived exertion (RPE) (Borg, 1970), and blood lactate concentration were assessed. The lactate profile test continued until a blood lactate concentration of 4 mmol × l1 was reached. Step intensity increments were 2530 W for the cycle test (at 75 rev × min 1) and 0.42 m × s 1 (1.5 km × h1) for the treadmill test (1.5% inclination). After a rest period of about 20 min, the participants performed a VO2max test according to the Bruce protocol (McArdle, Katch, & Katch, 1996). The expired gases were analysed using a MetaMax I metabolic cart (Cortex Biophysik GmbH, Leipzig, Germany). Patients were tested at the beginning and at the end of the training period. Those who had used the cycle ergometer (treadmill) for the threshold test performed the re-test on the same ergometer (treadmill). Training The training was conducted individually with the assistance of ‘‘training partners’’. These were volunteers from the local municipalities who had received

257

basic training in applied physiology, pedagogy, and psychiatry. The partners trained on a regular basis together with the participants (Skrede et al., 2006). The results of the baseline tests were used to design an appropriate training schedule, which also met the participants’ wishes and needs. Training was conducted on an almost daily basis. The activities were varied and included jogging, cycling, cross-country skiing, swimming, canoeing, mountain hiking, climbing, strength training, and ball games. The intensity of the training was controlled by the training partner or by the participants themselves with the aid of a Polar S610 heart rate monitor (Polar Electro OY, Kempele, Finland). Statistics Descriptive data are expressed as means and standard deviations (s), except when reporting the threshold loads, where range is reported, due to the low numbers of participants who used the cycle ergometer. Changes are reported as means and standard errors (sx). The baseline versus re-test results were analysed with paired t-tests. Groups were compared using a two-sample t-test. In the few cases where the test for normality of data failed (Kolmogorov-Smirnov with Lilliefors correction), the corresponding non-parametric tests were used (Mann-Whitney-Wilcoxon rank sum test and Wilcoxon signed rank test). Changes in aerobic power were analysed with General Linear Model using training hours and percent training above threshold heart rate as fixed factors. The statistical software used included SPSS v. 16 (SPSS Inc., Chicago, IL, USA), SigmaPlot v. 10 (Systat GmbH, Erkrath, Germany), and Winks SDA v. 6.0.5 (TexaSoft, Cedar Hill, TX, USA). Results The group performed 300 h of training during the 7.5 months of the programme. The range was 350 h, so there were marked differences in training between participants. Three-quarters of the training was of a low intensity, below the heart rate at the lactate threshold. Resting blood lactate concentration was normal, 1.0 mmol × l 1 (2.6 1.5; see Methods section). Utilization of aerobic power, expressed as %HRmax at the lactate threshold, was at a level similar to untrained healthy individuals, above 70% but below 80%. The range was 31, indicating large variation in this variable. Rating of perceived exertion, assessed with Borg’s 15-point (620) scale, showed that the rating at the lactate threshold was lower than that which Seip and colleagues (Seip, Snead, Pierce, Stein, & Weltman, 1991) found at a comparable blood lactate concentration. The rating of perceived


258


exertion in the present study, 13, is considered ‘‘somewhat hard’’ on Borg’s scale. Performance on the lactate profile test, both with ergometer cycling and treadmill running, was indicative of a lowered physical fitness both at baseline and re-test. This reduced fitness level was also to some extent evident from the direct measures of aerobic power using the Bruce protocol. According to the YMCA norms (Golding, Myres, & Sinning, 1989), the males reached and remained in the ‘‘average’’ category, whereas the females were ranked ‘‘poor’’ at the first test session and increased to ‘‘below average’’ at the end. Maximal heart rate was close to the 220 age rule of thumb, 189 beats × min 1. Those who responded to the training distinguished themselves from the non-responders in doing significantly more training at high intensity (P 0.006). Baseline blood lactate concentration at the lactate threshold was significantly higher among the non-responders (P 0.02) than responders, but was still within the normal range for healthy people (1.2 mmol × l 1). Males and females differed in aerobic power, whether expressed relative to body mass or not (see Table II for details). Over the course of the training programme, body mass increased by nearly 0.5 kg for the group as a whole, raising the body mass index by 0.1 kg × m2. These changes were not statistically significant. Blood lactate concentration at the lactate threshold showed no change from baseline to re-test. Heart rate at the lactate threshold increased significantly (P B0.001), as did threshold test performance (cycling and running, both P0.03) and aerobic power (relative to body mass P 0.02, absolute P 0.01). Table III shows the difference between re-test values and baseline values. Table IV presents differences between males and females and responders and non-responders. The females were 2 years older than the males, a non-significant difference. There were no statistically significant differences between the sexes in body mass, body mass index, training period or oxygen uptake at baseline or at re-test. The baseline body mass of the non-responders was significantly higher than that of the responders (P 0.05). Furthermore, body mass index at baseline and retest was higher for the non-responders (baseline P 0.01, re-test P 0.02). An illustration of heart rate versus power is given in Figure 1. Discussion The participants experienced a small, but statistically significant improvement in VO2max. The results of the lactate profile test also improved significantly. The improvements were minor in relation to the large amount of training (300 h) undertaken

during the programme. Those individuals whose aerobic power did not improve had trained with a lower intensity than those who increased their VO2max. Since Frankel and Murphy (1974) published their report on physical fitness in a group of alcoholics more than 35 years ago, several training intervention studies have been reported for abusers of alcohol (Collingwood et al., 1991; Murphy et al., 1986; Palmer et al., 1988; Sell and Christensen, 1989; Sinyor et al., 1982). These studies indicate that alcoholics do respond to physical training. Most interventions have been of a short duration, with training sessions 25 times a week. The degree of improvement reported in previous studies has generally been 2040%, compared with 4% in the present study. This discrepancy can in part be explained by the lower initial fitness in previous studies (VO2max: 3036 vs. 40 ml × kg 1 × min1 in our study). The step test used by Frankel and Murphy (1974) is prone to a learning effect, so their 23% improvement may partly have been due to such an effect. Several studies (Palmer et al., 1988; Sell & Christensen, 1989; Sinyor et al., 1982) have used the ˚ strand/Ryhming ergometer bicycle test (A ˚ strand & A Ryhming, 1954), a test that is also subject to inaccuracies. Segerstro¨ m et al. (2008) showed that the improvement in aerobic power due to a fitness programme for type II diabetic women was 8% ˚ strand/Ryhming test (P B according to the indirect A 0.005), but only 0.7% (n.s.) with directly measured VO2max. Their initial values were somewhat lower than in our baseline data, and diabetics may be special in their response to exercise (Segerstro¨ m et al., 2008), but this finding is in line with that which Israel (1982) found in untrained individuals. The 37% improvement in oxygen uptake that Sell and Christensen (1989) found in their small group of substance abusers may therefore partly be an artefact of the method of testing. It is, however, noteworthy that the eight participants in that study greatly improved their physical training performance, from walking 1.5 km to running 10 km non-stop in 12 weeks. Among previous studies, only Palmer et al. (1988) did not report an improvement in fitness. This may be due to the low-intensity training (walking) used, in combination with the relatively short duration (28 days) of the project. Total training time appears to have been less than 10 h (nine sessions of 50 min training, of which 10 min was the warm-up and another 10 min the cool-down). The proportions of high- (at or above heart rate at the lactate threshold) and low- (below heart rate at the lactate threshold) intensity exercise for the group as a whole appears to be in accord with common training principles for endurance training, with most training in the low region of the intensity scale


Table II. Selected results for the group as a whole, by sex, and for non-responders and responders (means and standard deviations unless otherwise stated) All (n 33) Baseline Training (h) Low-intensity training (%) BLCLT (mmol × l 1) Utilization (%HRmax) RPELT

Males (n 26)

Females (n7) Re-test

Baseline

301 (94) 74 (15)

Re-test

Baseline

257 (84) 76 (17)

Re-test

Non-responders (n 14) Baseline

313 (95) 73 (14)

Re-test

Responders (n19) Baseline

281 (86) 82 (12)

Re-test 316 (100) 68 (14)

2.6 (0.3)

2.5 (0.3)

2.4 (0.2)

2.5 (0.2)

2.6 (04)

2.5 (0.3)

2.7 (0.4)

2.5 (0.3)

2.4 (0.2)

2.5 (0.3)

72 (7)#

75 (7)

73 (6)

77 (6)

71 (7)

74 (8)

73 (7)

76 (8)

71 (7)

74 (8)

13 (2)

12 (2)

13 (1)

13 (2)

13 (2)

13 (2)

13 (2)

13 (2)

12 (2)

99 (159)*§

116 (216)*

64 (28)*

87 (13)*

106 (142)*

122 (216)*

102 (91)*

103 (83)*

97 (159)*

125 (197)*

vLT (m × s 1), incl. 1.5% VO2max (ml × kg 1 × min1) VO2max (litres × min 1)

2.11 (1.14)*§

2.29 (1.74)*

1.90 (0.48)*

2.02 (1.00)*

2.17 (1.05)*

2.38 (1.53)

2.13 (1.13)*

2.10 (0.99)*

2.09 (0.99)*

2.43 (1.59)*

40 (10)

29 (7)#

31 (6)#

40 (9)

42 (10)

36 (10)

35 (9)

39 (9)

43 (9)

3.07 (0.77)

2.13 (0.63)#

2.22 (0.61)#

3.15 (0.58)

3.30 (0.64)

2.99 (0.68)

2.85 (0.71)

2.89 (0.76)

3.23 (0.79)

HRmax (beats × min §

1

)

38 (10)

§

2.93 (0.72)

§

189 (15)

189 (13) #

183 (13)

182 (12)

191 (15)

191 (13)

187 (17)

187 (14)

192 (13)

191 (12)

*Range, PB0.05 between baseline and re-test, PB0.05 between males and females, P B0.05 between responders and non-responders. Note: HRmax maximum heart rate, BLCLT blood lactate concentration at the lactate threshold, RPELT rating of perceived exertion at the lactate threshold, PLT power output at the lactate threshold, vLT velocity at the lactate threshold.

Physical training of substance abusers

13 (2)

PLT (W)

259

260


Table III. Changes in training parameters compared with baseline values (n 33) Mean difference

95% confidence interval

P

0.4 0.1 0.0 3 8 17 0.19 2 0.14

1.7 to 2.4 0.6 to 0.8 0.2 to 0.1 3 to 4 4 to 11 2 to 32 0.02 to 0.36 0 to 3 0.03 to 0.24

0.73 0.77 0.35 B0.001 B0.001 0.03 0.03 0.02 0.01

Body mass (kg) BMI (kg × m 2) BLCLT Utilization (%HRmax) HRLT (beats × min1) PLT (W) vLT (m × s 1) VO2max (ml × kg 1 × min1) VO2max (litres × min 1)


Note: BMIbody mass index, HRmax maximum heart rate, BLCLT blood lactate concentration at the lactate threshold, HRLT heart rate at the lactate threshold, PLT power output at the lactate threshold, vLT velocity at the lactate threshold.

(Fiskerstrand & Seiler, 2004). Some of the training recorded as being above the threshold limit in the final parts of the programme may actually have been below it, as heart rate at the lactate threshold did increase significantly at re-test. The improvements in maximal aerobic power were modest for the group as a whole. However, if we look at the responders alone, their progress was closer to that reported in other exercise intervention studies, with an improvement of 11%. The blunted results for the sample as a whole are due to the nonresponders, who instead of improving aerobic power experienced an approximate 4% reduction. Among responders, 32% of training was high-intensity training above threshold heart rate, compared with only 18% among non-responders. This fits well with Wenger and Bell (1986), who stated that training intensity was the most influential factor for training progress. The increase in aerobic power that was observed in the present as well as in previous studies shows that the adaptation process is not entirely blunted by substance abuse, and that substance abusers can endure high training volumes and high-intensity training without adverse effects. This is important knowledge, because it opens up the

possibility for the use of more, and intense, training in the rehabilitation of substance abusers, as has been advocated for cardiac patients (Wisløff, Ellingsen, & Kemi, 2009). To broaden the concept of physical fitness, this study also reports changes in lactate profile for substance abusers. The lactate threshold definition was a ‘‘delta method’’; resting blood lactate concentration1.5 mmol × l1, as suggested by Helgerud et al. (1990) using a Roch 640 analyser. Different lactate analysers can report differently (Medbø, Mamen, Holt Olsen, & Evertsen, 2000), but Buckley and colleagues (Buckley, Bourdon, & Woolford, 2003) claim that the results of the ‘‘delta method’’ are influenced to a lesser extent by the specific lactate analyser used. Blood lactate concentration at the lactate threshold in the present study (Table II) was 2.5 mmol × l 1, giving a normal resting concentration of 1 mmol × l 1. This is an interesting finding, as hyperlactataemia may be seen in alcoholics without an elevated blood alcohol concentration (Kreisberg, 1980). Performance at the lactate threshold was by and large comparable with the level of aerobic power and below the average in the normal population found in

Table IV. Differences between females and males and non-responders and responders Females vs. males

Age (years) Training period (months) Height (m) Body mass, baseline (kg) Body mass, re-test (kg) BMI, baseline (kg × m 2) BMI, re-test (kg × m 2) D rVO2max (%) D aVO2max (%)

Non-responders vs. responders

Mean difference


P

Mean difference


P

2.0 2.6 0.14 6.6 9.0 1.8 0.9 3.4 1.0

6.7 to 10.6 0.8 to 6.6 0.20 to 0.07 20.2 to 7.0 21.7 to 3.6 2.1 to 5.6 2.7 to 4.4 5.1 to 12.0 8.9 to 10.8

0.65 0.13 B0.001 0.33 0.16 0.37 0.61 0.42 0.85

0.1 1.1 0.02 10.7 8.6 4.0 3.2 14.0 17.8

7.3 to 7.1 1.8 to 4.0 0.08 to 0.05 0.0 to 21.4 1.8 to 18.9 1.1 to 6.9 0.5 to 5.9 19.0 to 9.1 22.8 to 12.9

0.99 0.45 0.65 0.05 0.10 0.01 0.02 B0.001 B0.001

Note: Negative values indicate larger values for the males and responders. rVO is VO2 relative to body mass, aVO2 is absolute VO2 in L/min.

Physical training of substance abusers Non-responder 180 Subject 7 Training hours: 500 Training below HRLT: 50% PLT1: 209 W HRLT1: 137 PLT2: 248 W HRLT2: 144

160 140 120 100 80 Subject 21 Training hours: 300 Training below HRLT: 90% PLT1: 158 W HRLT1: 154 PLT2: 144 W HRLT2: 156

0

50

100

150

200

250

300 0

50

100

150

200

250

60

HR (bpm)

BLC (mmol•L-1)

Responder 6,0 5,5 5,0 4,5 4,0 3,5 3,0 2,5 2,0 1,5 1,0 0,5 0,0

261

40 20

0 300

Power (W)

Power (W) Baseline

Re-test


Figure 1. Lactate profile test results for a responder and a non-responder. Blood lactate concentration (BLC) and heart rate (HR) are shown on the y-axis, ergometer cycle power on the x-axis. LT1baseline, LT2re-test. A right shift of the lactate curve is evident for the responder; the non-responder show a small leftward shift.

our laboratory. The degree of improvement was higher on this submaximal test compared to the maximal test results: 10% vs. 4%. The reduced concentration of myoglobin and content of type II muscle fibres, which is often seen in individuals with long-term alcohol abuse, could be potentially more destructive for maximal physical performances than sub-maximal ones. Non-responders decreased the threshold speed by 3%, while the responders significantly increased it by 16%. As the non-responders did not have a longer history of abuse than the responders (Table I), this difference in development is probably more related to training intensity than biological deterioration caused by toxic agents. Other factors necessary for an increase in fitness are adequate nutrition and time to rest between sessions. We do not have precise data on these variables, and we therefore cannot say whether the groups differed on these aspects. The final interesting observation in this study is the use of ‘‘training partners’’ (Skrede et al., 2006). The training load in this study was many times larger than that reported in previous studies. As Martin and Dubber (1982) stated, training programmes used in corrective therapy should be group organized and have enthusiastic therapists. It is therefore reasonable to attribute the high training compliance to the effect of having a ‘‘personal trainer’’ who guided the training.

improvements compared with previous research in this field of study. Implications for clinical practice and future research The health benefits associated with exercise are not entirely dependent on improvement in physiological variables. The level of physical activity in this programme was impressive and must have been important for both physical and mental health, in spite of limited physiological changes. This programme is the first to show that it is possible to train individuals with substance abuse/dependence over a long period with a high training load. The unique use of training partners, who trained together with the participants, may explain why the programme was so successful in training adherence. Future intervention studies including control groups are needed. Conclusion The participants experience a moderate but statistically significant increase in aerobic power and threshold performance. Those with the highest gains also performed the most high-intensity training. Maximal testing of fitness was a feasible way to document progress in this group of patients with substance abuse or dependence.

Acknowledgements Limitations and strengths of the study The sample size was small, the design was simple, and a control group was not included. This limits our ability to draw conclusions. The use of precise physiological measurements and maximal tests are

The authors are indebted to Atle Skrede and Harald Munkvold at Førde Regional Hospital, Department of Psychiatry, for their excellent conduction of the project and teaching of the training partners. We also are indebted to the participants and the training partners.

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