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Journal of Consulting and Clinical Psychology1982, Vol. 50, No. 6, 1004-1017

Copyright 1982 by the American Psychological Association, Inc.0022-006X/82/5006-1004$00.75

Exercise Applications and Promotion in Behavioral Medicine:Current Status and Future Directions

John E. Martin and Patricia M. DubbertVeterans Administration Medical Center, Jackson, Mississippi, and

University of Mississippi Medical Center

The present article summarizes and comments on the clinical applications andpromotion of aerobic (endurance) exercise within behavioral medicine. High-lighted applications include cardiovascular risk modification, obesity, diabetes,and smoking. Particular emphasis is placed on the problem of poor adherenceto exercise programs in clinical and apparently healthy populations alike, on theidentification of the high-risk dropout, and on the modification of exercise ad-herence. Finally, preliminary findings are summarized, and recommendationsare made for future research and exercise program applications and promotion.

The topic of exercise has received consid-erable attention in recent years, both fromthe standpoint of cardiovascular risk reduc-tion and in respect to life-quality enhance-ment. Research by exercise physiologists, ep-idemiologists, and others suggests an inverserelationship between habitual physical activ-ity and cardiovascular morbidity and mor-tality (Fox, Naughton, & Haskell, 1971; Kan-nel & Sorlie, 1979; Morris, Everitt, Pollard,Chave, & Semmence, 1980; Paffenbarger,Hale, Brand, & Hyde, 1977). Additionally,exercise has been associated with importantpsychological and quality-of-life improve-ments in normal and clinical populations(Folkins & Sime, 1981; Stern & Cleary,1981).

Although the-term exercise encompassesmany forms of physical activity, in the pres-ent context it refers mainly to sustained in-creases in large muscle and cardiopulmonaryactivity, which, when performed with sum-

Preparation of this article was supported, in part, bythe Medical Research Service of the Veterans Admin-istration, Health Services Research and DevelopmentGrant 4187-003.

The authors wish to express their appreciation toLeonard H. Epstein and Neil B. Oldridge for their ex-tensive and very helpful comments on earlier versionsof this article. Appreciation is also expressed to MaryLake for her technical assistance throughout its prepa-ration.

Reprints may be obtained by writing John E. Martin,Psychology Service (116B), Veterans AdministrationMedical Center, Jackson, Mississippi 39216.

cient frequency, intensity and duration, re-sult in improved endurance (ACSM, 1978).Considerable research has accumulated doc-umenting the physiological changes that ac-company this form of exercise training (Clau-sen, 1976). In contrast, relatively little isknown about the psychological and behav-ioral effects of exercise.

Despite its demonstrated and presumedbenefits, exercise remains an experimental"therapy" in many areas of interest to clin-ical and health psychologists. In these areas,in particular, much of the evidence regardingthe clinical efficacy of exercise has accruedfrom anecdotal case studies and from cor-relational and/or flawed experimental anal-yses that fail to demonstrate a causal rela-tionship. Perhaps even more important, ex-ercise adherence is typically poor even amongthose who are likely to benefit the most. Infact, the problem of exercise adherence is notunique to clinical populations: Surveys haveindicated that roughly two thirds of Ameri-cans do not exercise regularly (Harris Poll,1978a; 1978b), and 45% may not exercise atall (Bucher, 1974). Thus far, the problem ofdemonstrating the clinical efficacy of exerciseand of changing habits of people who do notexercise properly, or at all, remains a signif-icant challenge to the health professions. Thepsychologist/behavioral medicine specialistmay be uniquely well equipped to meet thischallenge by furthering our understanding ofthe effects of exercise and of the importantbehavioral and psychological factors that re-

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EXERCISE IN BEHAVIORAL MEDICINE 1005

late to the acquisition and maintenance ofthe exercise habit.

The present review is a summary and com-mentary on the clinical applications and pro-motion of exercise within behavioral medi-cine. Given the importance of the problemof poor exercise participation and adherence,a considerable portion of the present articlewill rje devoted to the analysis and promotionof exercise behavior. Due to the volume ofstudies in some areas and to space limita-tions, only a representative sample of thestudies that have been published are dis-cussed, with the primary emphasis on thosestudies incorporating aerobic1 (endurance)exercise.

Clinical Application of ExerciseThe present section focuses on application

of exercise training to enhancement of phys-ical health and lifestyle change. The topicsdiscussed include areas of traditional interestin behavioral medicine and conditions forwhich exercise has already been shown or hasbeen suggested to have beneficial effects.

Cardiovascular Risk ModificationExercise has been employed perhaps most

extensively in the prevention and treatmentof coronary heart disease (CHD) and its se-quelae. A systematic program of aerobic ex-ercise has been shown to both improve car-diovascular efficiency (Scheuer & Tipton,1977) and modify cardiovascular risk profilesin apparently healthy, high-risk, and coro-nary patients (Clausen, 1976; Kannel & Sor-lie, 1979; Leon & Blackburn, 1977; Mann,Garrett, Farhi, Murray, & Billings, 1969;Wilhelmsen et al, 1975). For example, ex-ercise has been associated with reductions inthe harmful plasma triglycerides and LDLcholesterol and increases in the protectiveHDL cholesterol (Wood & Haskell, 1979);decreases in resting and active heart rate andblood pressure; and increases in stroke vol-ume and oxygen utilization (Clausen, 1976).

There is some suggestive evidence (Boyer& Kasch, 1970; Choquette & Ferguson,1973; Horton, 1981) that exercise may re-duce blood pressure in hypertensives, inde-pendent of weight or dietary sodium reduc-tions. Although blood pressure reductions

have been linked to exercise training, thisfinding must be interpreted extremely cau-tiously due to the methodological inadequa-cies of the studies and in light of the negativefindings of large-scale epidemiological andmultiple-risk-factor intervention studies(Leon & Blackburn, 1982; Taylor, Buskirk,& Remington, 1973). These conflicting re-sults may indicate differential effects of ex-ercise across various subtypes of hyperten-sives. The limited evidence available suggeststhat, in general, borderline or mild hyperten-sives might benefit the most from exerciseinterventions. Much more research is needed,however, before any definitive statementscan be made.

In addition to its potential primary andsecondary benefits in the area of CHD riskmodification, exercise has been shown to beimportant in the tertiary physical and psy-chosocial rehabilitation of the cardiac patient(Pollock & Schmidt, 1979; Stern & Cleary,1981). In coronary patients, even low-inten-sity exercise has been shown to improvepreanginal exercise and stress tolerance (Fer-guson, Cote, Gauthier, & Bourassa, 1978),to improve self-care and emotional status(Stern & Cleary, 1981), and to attenuate per-ceived exertion (Gutman, Squires, Pollock,Foster, & Anholm, 1981), whereas higher in-tensity (aerobic) exercise may reduce myo-cardial ischemia (Ehsani, Heath, Hagberg,Sobel & Holloszy, 1981). Early and sustainedphysical mobilization has been associatedwith shprter hospitalization and a more com-plete return to work, the latter relating toincreased survival rate (Wenger, 1978; 1979).Unfortunately, as in other areas of exerciseapplication, cardiac patients typically showpoor compliance to even medically pre-scribed and supervised exercise programs(Oldridge, 1979b, 1982).

1 Aerobic (endurance) exercise is used to describe re-petitive isorhythmic activities such as brisk walking, jog-ging, cycling, and swimming involving major musclegroups (e.g., legs) in which energy is derived from met-abolic processes using a constant flow of oxygen (Cooper,1968; McArdle, Katch, & Katch, 1981). For cardiovas-cular benefit these activities should occur at a minimumintensity of 60% to 65% of maximum heart rate, for aduration of 15 to 30 minutes or more, and at a minimumfrequency of three times per week (American College ofSports Medicine, 1978, 1980).

1006 JOHN E. MARTIN AND PATRICIA M. DUBBERT

Obesity

Until recently, exercise received surpris-ingly little attention as a component inweight-reduction programs. Aerobic exercisetraining has consistently been shown to pro-duce weight loss and improvement in bodycomposition (lean to fat ratio) for obese aswell as normal-weight individuals; althoughwithout concurrent dietary caloric restric-tion, changes in weight and body fat are clin-ically small (Epstein & Wing, 1980a). Theextent of behavioral (eating) compensationthat may or may not result from increasedcaloric output due to exercise remains anunsettled issue (Brownell & Stunkard, 1980;Epstein & Wing, 1980a). Bjorntorp (1976;1978) has suggested that weight and body-fatchanges achieved through exercise therapycan be predicted, as in the dietary treatmentof obesity, by the individual's pretreatmentfat-cell number. The available evidence sug-gests that individuals with increased fat-cellnumber achieve expected gains in fitnesswithout loss of body fat; therefore, exercisemay not be a good sole alternative for thetreatment of hyperplastic obesity.

Controlled studies support the hypothesisthat treatment programs that emphasize in-creased caloric expenditure as well as reducedcaloric intake produce greater average weightlosses and better maintenance (Dahlkoetter,Callahan, & Linton, 1979; Stalonas, John-son, & Christ, 1978). A number of mecha-nisms that may mediate these effects havebeen suggested: Increased activity may de-crease appetite (Bjorntorp, 1976; Mayer,Roy, & Mitra, 1956); regular exercise coun-teracts the homeostatic reduction in meta-bolic rate, which reduces the effectiveness ofcaloric-intake restriction (Brownell & Stun-kard, 1980; Thompson, Jarvie, & Lahey,1982); exercise serves as a healthful substitutefor or timeout from snacking as a copingtechnique (Epstein & Wing, 1980a); and ex-ercise may reduce stress from dieting or othersources (Foreyt, Goodrick, & Gotto, 1981).Although most obese patients seek to reduceprimarily for cosmetic reasons, weight lossesthat are cosmetically disappointing may,when combined with an exercise program,be associated with significant improvements

in cardiovascular risk indicators such as hy-pertension (Stamler et al, 1980).

As noted by Epstein and Wing (1980a),exercise may provide important benefits inthe control of energy balance, but it can onlybenefit individuals who adhere to the pro-gram. An excellent illustration of this pointis the results of an uncontrolled study byGwinup (1975), in which 11 women whoexercised 1 hour a day for l'/z years lost anaverage of 22 pounds, but 23 of the original34 subjects dropped out. Although Epsteinand Wing found little information on ad-herence to exercise by obese subjects in thebehavioral literature, investigators in theareas of cardiac rehabilitation and exercisephysiology have reported that obese subjectsmay be more likely than normals to drop outof exercise programs (Dishman & Gettman,1980; Massie & Shephard, 1971).

Diabetes

Exercise may also play an important rolein the behavioral management of diabetes.Early medical records show that exercise wasone of the oldest forms of treatment for di-abetes, and that its specific effects in diabetic-like conditions have been recognized for atleast 2,000 years. Today, regular moderateexercise is recommended to diabetics as anadjunctive treatment, along with diet and in-sulin, because of its potential to improvemetabolic control, reduce plasma insulin,and improve insulin sensitivity and glucosetolerance (Soman, Koivisto, Deibert, Felig,& DeFronzo, 1979). These exercise-mediatedchanges may, in turn, significantly reduce theoverall risk of cardiovascular disease (Rich-ter, Ruderman, & Schneider, 1981; Vranic& Berger, 1979). However, the potential ther-apeutic effect of exercise occurs only if othertherapy is already sufficient to prevent ke-tosis. It is not yet known whether regularexercise will prolong life or decrease morbid-ity in diabetics, as much of the data relevantto the beneficial effects of exercise has onlybeen collected for nondiabetics (Sherwin &Koivisto, 1981). We are not aware of anypublished studies in the psychological liter-ature evaluating the specific role of exercisetherapy or adherence to exercise programs


in diabetic populations, and this must beconsidered an important area for future re-search.

Smoking

Epidemiological studies indicate an in-verse relationship between smoking and ha-bitual physical exercise (Criqui et al., 1980),and there have been anecdotal reports thatsmokers who begin intensive aerobic trainingprograms often quit smoking (Morgan, 1981).However, the U.S. Public Health Service col-laborative study (Taylor et al., 1973) foundno significant differences in smoking quitrates between exercise and control subjectsafter 1 year. Furthermore, studies have in-dicated that smokers are far less likely to en-ter exercise programs (Massie & Shephard,1971) and that those that do are likely todrop out both early (<1 mo.; Oldridge,Wicks, Hanley, Sutton, & Jones, 1978) andlater (^2 yrs; Andrew et al., 1981).

Especially in light of these preliminarynegative findings, one must question whetherexercise alone would be an effective inter-vention, particularly in short-term treatmentprograms. It seems more likely that exercisemay, as in the treatment of obesity, work bestin combination with other effective treat-ment and maintenance interventions. Exer-cise may be particularly important for indi-viduals concerned about the risk of weightgain associated with smoking cessation (Ja-cobs & Gottenborg, 1981). Exercise may alsobe useful in reducing health risk by acceler-ating the ventilation of carbon monoxide(CO)' in those smokers consuming higherCO-yield substances who are unable or un-willing to quit (Frederiksen & Martin, 1979;Martin & Frederiksen, 1980).

Psychological EffectsSome of the potential beneficial effects of

exercise in the prevention and treatment ofcardiovascular and other health disordersmay, in fact, accrue from exercise-mediatedpsychological changes; that is, decreases indepression (Greist, Klein, Eischens, Gur-man, & Morgan, 1979; Morgan, Roberts,Brand, & Feinerman, 1970), decreases in

anxiety (Bahrke & Morgan, 1978; Morgan,1979, 1981; deVries, 1981), and improvedself-concept (Collingwood & Willet, 1971;Folkins & Sime, 1981). Unfortunately, thereis still little evidence from controlled studiesdocumenting these psychological effects, par-ticularly with behavioral medicine popula-tions. Nevertheless, the possible mediators ofthe apparent antidepressive and anxiolyticeffects of aerobic exercise are currently atopic of great interest (Sacks & Sachs, 1981).For example, exercise has been associatedwith acute changes in norepinephrine cate-cholamine levels (Dimsdale & Moss, 1980),and there is intriguing evidence that beta-en-dorphins, the body's "natural opiates," maybe liberated during exercise (Apenzeller,Standefer, Apenzeller, & Atkinson, 1980). Ithas been suggested that these effects may beresponsible for mood improvements, andcould even create a "positive addiction" tothe exercise (Apenzeller, 1981; Glasser,1976).2

The Problem of Exercise AdherenceAs the clinical efficacy of exercise for a

variety of health-related disorders is dem-onstrated, the problem of ensuring exerciseadherence becomes paramount. Studies in-dicate clearly that of those who begin an ex-ercise program, whether on their own or ina structured program, roughly one half or lesswill still be exercising after 3 to 6 months(Durbeck et al., 1972; Morgan, 1977; Tayloret al,, 1973). Relatively similar exercise ad-herence levels have been cited for apparentlyhealthy, coronary-risk, and cardiac-rehabili-tation populations (Bruce, Frederick, Bruce,& Fisher, 1976; Carmody, Senner, Malinow,& Matarazzo, 1980; Cooper, 1968; Morgan,1977; Oldridge, 1979b, 1982;,Taylor et al.,1973). Reported attrition in these types ofprograms typically ranges from approxi-mately 30% to 70% (Dishman, 1982; Frank-lin, 1978; Oldridge, 1979b; 1982). Exami-

2 An interesting illustration of the potential "addict-ing" effects of chronic exercise is provided by Glasser,who reported anecdotally that they were unable to gethigh-intensity exercisers (distance runners) to stop ex-ercising for any amount of money!


nation of the exercise dropout/relapse pat-tern indicates a negatively accelerated curvenot unlike that found for the negative addic-tive behaviors: The majority of dropouts/re-lapses occur within the initial 3 months, fol-lowed by continued deterioration, with at-trition leveling off between 50% and 70%after 12 to 24 months (Carmody et al., 1980;Oldridge, 1979b, 1982;Shephard, 1979). Anexcellent, well-controlled study from Finlandillustrates this disheartening situation: Ken-tala (1972) found that only 77 out of 298postmyocardial infarction patients entered arecommended exercise program; of those,only 39% remained through 5 months andonly 13% through 1 year.

Definition of Exercise Adherence

Unfortunately, it is extremely difficult toevaluate the present exercise-adherence data,due to the fact that the definitions of adher-ence vary so widely from study to study inaddition to the fact that the bulk of the stud-ies used self-selected, male high-risk or CHDsubjects enrolled in formal programs. Per-haps most confusing is the fact that many ofthe cardiac-rehabilitation studies have deter-mined overall dropout rate (e.g., Oldridge,1979a), whereas others have employed a pre-set attendance criterion to identify adherers(e.g., Mann et al., 1969). Also, most inves-tigators have reported only adherence/atten-dance to ongoing treatment programs, whileproviding little information regardingmaintenance of exercise subsequent to ter-mination of treatment—that is, some of thedropouts may actually have been exercisingon their own (Wilhelmsen et al., 1975).

Exercise Adherence Profile

Despite the difficulties inherent in properlydenning exercise adherence, it is clear thatmost people who begin an exercise programwill drop out, usually within the first 3 to 6months. Given the magnitude of the prob-lem, it is somewhat surprising that there islittle experimental research on exercise ad-herence. The existing studies consist mainlyof retrospective analyses of variables thatcharacterize the exercise nonparticipant,dropout, poor adherer, and good adherer

(Andrew & Parker, 1979; Andrew et al.,1981; Dishman & Gettman, 1980; Heinzel-mann & Bagley, 1970; Kavanaugh, She-phard, Chisholme, Qureshi, & Kennedy,1980; Massie & Shephard, 1971; Morgan,1977; Oldridge etal., 1978). Factors that havebeen found to predict exercise participationand level of adherence may be loosely sep-arated into subject factors, social/environ-mental factors, and exercise program factors(Martin, 1981).

Subject Factors

It is curious that the most obvious psy-chological predictor, one's attitude towardexercise, does not appear to predict partici-pation or later adherence. Studies have in-dicated that even the very sedentary haveextremely favorable attitudes toward per-sonal exercise (Dishman & Gettman, 1980;Morgan, 1977). One psychological factor thatdoes appear to predict attrition from an ex-ercise program is low "self-motivation," asmeasured by Dishman's self-motivation in-ventory (SMI; Dishman & Ickes, 1981; Dish-man, Ickes, & Morgan, 1980). Oldridge andassociates (Oldridge et al., 1978) have notedthat psychosocial reasons, principally "lackof motivation" are frequently cited by indi-viduals for their exercise dropout. A link mayalso exist between the maintenance of self-motivation (and, hence, exercise) and theachievement of one's exercise goals. For ex-ample, Danielson and Wanzel (1977) foundthat exercisers who failed to attain their ownexercise goals dropped out roughly twice asfast as those who did attain them.

Behavioral predictors of exercise dropoutinclude smoking (Massie & Shephard, 1971;Oldridge, 1979; Oldridge et al., 1978), inac-tive leisure-time pursuits (Oldridge, 1979a;Teraslinna, Partanen, Koskela, & Oja, 1969),Type A behavior pattern (Oldridge et al.,1978) and, curiously, poor credit rating(Heinzelmann & Bagley, 1970; Massie &Shephard, 1971). Oldridge (1979a) foundthat 80% of smokers who had inactive jobsand leisure-time pursuits and were blue collarworkers eventually dropped out of the On-tario Exercise Programs. Smoking was thesingle best predictor in the Ontario study,associated with a 59% likelihood of dropout.


Smoking has also been found to predict poorexercise-program enrollment (Massie & She-phard, 1971).

Few biological factors predict adherence(Dishman & Gettman, 1980; Morgan, 1977).Several studies, however, have related over-weight, especially high percentage of bodyfat,/ to dropout and poor adherence (Dish-man & Gettman, 1980; Massie & Shephard,1971). A combination of biological and psy-chological variables may prove much morepowerful in predicting adherence. Dishmanand Gettman (1980) have proposed a "psy-chobiologic" model, based on SMI scoresand body-composition measures, which theyclaim can correctly identify 80% of individ-uals as potential adherers or dropouts.

Social/Environmental FactorsSocial support or reinforcement both in

the home environment and during the ex-ercise has consistently been related to in-creased adherence. Heinzelmann and Bagley(1970) found that subjects with spouses whosupported their exercise habit were twice aslikely to have "good adherence" than thosewhose spouses were either neutral or negativetoward exercising, whereas Andrew et al.(1981) found that their cardiac patients with-out spouse support were three times morelikely to drop out. Oldridge et al. (1978) havenoted that family problems, as well as changeof job or residence, were cited frequently byformer exercisers as responsible for their pooradherence or dropout. Wilhelmsen and as-sociates (1975) found significantly poorerlong-term adherence in those who exercisedalone. Similarly, Massie and Shephard (1971)found that whereas only 47% of participantsin individual aerobic exercise programs wereadherent, 82% participating in group exercisewere adherent. Heinzelmann and Bagley(1970) reported that 90% of a sample of195 exercisers stated that they either didprefer or would have preferred exercisingwith others.

Program FactorsInconvenient exercise program location

has been found by many investigators to de-tract significantly from adherence to the pro-gram components and overall participation

(Andrew & Parker, 1979; Andrew et al.,1981; Bruce etal., 1976;Kentala, 1972; Mas-sie & Shephard, 1971; Morgan, 1977; Old-ridge et al., 1978; Sanne, Elmfeldt, Grimby,Rydin, & Wilhelmsen, 1973; Teraslinna etal., 1969). Another important predictor ofadherence is the overall intensity of exercise.Pollock (1977) and others (Kilbom et al.,1969; Mann et al., 1969) have found higherintensity exercise to be associated with lowerexercise adherence. These authors reportedthat approximately one half of the partici-pants in their programs developed or-thopedic injuries that necessitated discontin-uation of exercise and that many of the in-juries appeared due to excessive exerciseintensity. Along these lines, Oldridge et al.(1979a) have found that medical reasonswere cited by 22% of their coronary patientsas the primary reason for their dropout. Fi-nally, recent results from the Ontario HeartExercise Project implicate fatigue and per-ceived exertion as important factors in attri-tion (Andrew et al., 1981).

Modification of Exercise PatternsAlthough there have been suggestions as

to how to retain more exercisers and enhanceoverall adherence levels (Dishman, 1982;Franklin, 1978; Oldridge, 1977), there havebeen few data-based studies and even fewerspecific applications of behavioral technolo-gies to the analysis and modification of ex-ercise behavior in either healthy or coronarysubjects (Epstein & Wing, 1980b; Martin,1981). Studies relating to the modification ofexercise participation or adherence can becategorized according to the primary con-trolling variables targeted, including stimuluscontrol, reinforcement control, and cogni-tive/self-control.

Reinforcement control. As in most otherareas of behavioral management, many ofthe published exercise-modification studieshave focused predominantly on manipulat-ing the consequences of exercising. Severalstudies have shown the relative effectivenessof contracting and lottery procedures in im-proving short-term exercise program atten-dance (Epstein, Thompson, Wing, & Griffin,1980; Oldridge & Jones, 1981) and adher-ence (Kau & Fischer, 1974; Wysocki, Hall,


Iwata, & Riordan, 1979). For example, Ep-stein et al. (1980) compared weekly atten-dance contracts ($1.00 deposit return) withan attendance lottery and control conditionacross a 5-week (25-day) jogging program.Subjects were trained to monitor perfor-mance (speed, distance, intensity) and wereprovided feedback (e.g., resting and maximalheart rates) on a daily basis. The contractingand lottery interventions were associatedwith lower dropout and similar attendance(64%), with both clearly superior to the con-trol group (46% attendance). Wysocki et al.(1979) employed a group multiple-baselinedesign to study the effect of contracting foraerobic points3 to earn back personal itemsplaced on deposit. In the Wysocki et al.,study, 7 of the 12 subjects at least doubledtheir aerobic points earned at 10 weeks; how-ever, only 4 maintained or improved uponthis level at 1 year. Unlike the Epstein et al.study, adherence and fitness levels were notdirectly assessed. Contingency managementhas also been employed in enhancing exer-cise in the mentally retarded (Allen & Iwata,1980) and token reinforcement has beenshown to stimulate exercise in institutional-ized geriatric patients (Libb & Clements,1969).

Reinforcement control of exercise was themain focus of two of five community studiesconducted by Martin and colleagues (Martinet al., Note 1). The overall program consistedof 12 weeks of aerobic jogging/brisk walkingwith two classes per week (subjects were re-quested to exercise a third day each week ontheir own). Informant corroboration and fit-ness testing allowed validation of self-re-ported third-day and postcourse exercise-ad-herence data. In the first study (N = 33), itwas found that individualized feedback andpraise during exercise resulted in superiorprogram attendance and third-day adherencethan standard, group-based feedback/praisefollowing exercise. Three-month follow-uprevealed that 54% of the individualized praise/feedback group were still jogging, whereasonly 17% of those in the standard group hadcontinued to exercise. In Study 2 (N = 36)an attendance lottery for gift certificates, run-ning clothes, shoes, and so forth failed to addto the effectiveness of the individualized feed-back/praise procedure. The authors hypoth-

esized that the basic program of shaping,modeling, and personalized feedback and re-inforcement during exercise, administered byenthusiastic participant-therapists, was sucha powerful intervention that the tangible re-inforcement represented by the lottery wasless important to the exercisers.

Stimulus control. Antecedent control overphysical activity has been demonstrated inseveral studies. Brownell, Stunkard, and Al-baum (1980) increased stair climbing byposting a clever cartoon sign by an escalator/stairway showing a healthy heart coaxingpeople to use the stairs rather than the es-calator. Wankel and Thompson (1977) foundthat telephone prompts to health-club drop-outs successfully increased attendance andmaintenance if they recorded positive rea-sons for returning. In a follow-up study(Thompson & Wankel, 1980) female health-club members who were led to believe thattheir activity preferences helped determinetheir prescribed exercise program had supe-rior attendance to those members who weretold that their preferences were not consid-ered.

Cognitive/self-control. Several studies haveemployed self-management strategies (in-cluding stimulus control, self-contracting andgoal setting, self-reward, and/or other cog-nitive techniques) in the modification of ex-ercise behavior. Perhaps the first reportedapplication of self-control procedures in thisarea was by Turner, Polly, and Sherman(1976), who used self-monitoring, self-re-ward, and self-punishment (self-contracting)in a fitness-improvement program for ayoung adult woman. Fitness improvementswere documented through 5 months to val-idate self-reports of aerobic points earned.Oldridge and Jones (1981) found that cardiacpatients who signed an agreement to com-plete the exercise program had better adher-ence than those who did not. Keefe and Blu-menthal (1980), using a multiple baselineacross subjects design, evaluated the effectsof a self-control-based exercise program onthree adult overweight males. The training

3 The Cooper aerobic point system (Cooper, 1977) isa nicely flexible gauge of exercise participation, as wellas fitness, and has been employed by others for moni-toring adherence in addition to fitness tracking.


program involved a very gradual shapingprocedure in which subjects set easily attain-able goals, with self-reinforcement for meet-ing these goals. At the 2-year follow-up, allsubjects reported they were still exercising,and all scored in the excellent fitness cate-gory. It is interesting that all subjects reportedthey no longer relied on the self-control pro-cedures because they found the exercise itselfto be rewarding.

Five studies conducted by Martin et al.(Note 1) involved systematic evaluation ofthe effects of cognitive/self-control proce-dures on exercise adherence. The exerciseprogram was similar in structure to that de-scribed previously, and in some cases self-control strategies were tested as a part of thesame studies. In four of the studies, exercise-goal selection was manipulated and programattendance and overall exercise adherencewere examined. In the first study (N = 33)subjects were assigned progressive exercisegoals based on distance (e.g., jog 1 mile) ortime (e.g., jog 15 minutes). Although the ex-ercise adherence of subjects receiving dis-tance-based goals did not differ from that ofsubjects receiving time-based goals, time-based goals were associated with better ad-herence than distance-based goals in subjectswho did not receive individualized feedback/reinforcement (i.e., "special attention") dur-ing running. In the next study (N = 36), flex-ible exercise goal setting by the participantwas associated with better attendance and 3-month maintenance than fixed (by instruc-tor) exercise goal setting. In a subsequentstudy (N= 16), flexible goal setting wasfound to be superior, regardless of when itwas introduced. The final goal-setting study(N = 27) evaluated the effects of proximal(weekly) exercise-goal selection by partici-pants vs. distal (every 6 weeks) exercise-goalselection. Consistent with the previous goal-setting results, the more flexible distal goal-setting procedure was associated with supe-rior attendance (82% vs. 71%) and overalladherence.

In a more recent study (N = 16), Martinet al. (Note 1) evaluated the effects of twocognitive strategies on exercise behavior.Subjects trained to use distraction/dissocia-tion during running; that is, think pleasant,coping thoughts, set small mental goals, and

"go slowly and smell the flowers," exhibitedsuperior attendance (77%) and 3-day/weekexercise adherence (78%) than subjectstrained to "associate" by focusing on bodilysensations and challenging goals ("be yourown coach"; 62% and 51%, respectively).These results as well as the other exercise-modification studies must be considered pre-liminary, however, and only suggestive of theimportant variables that may control exerciseadoption and maintenance.

Conclusions and Future Directions

The present review has chronicled the ap-plications and modification of exercise withinbehavioral medicine. At the present time, webelieve the following conclusions are war-ranted.

1. The evidence strongly suggests thataerobic exercise may be beneficial in thetreatment and/or prevention of a variety ofhealth disorders, although not always be-cause of the physiological effects of exercise.However, we frequently do not know whattypes of exercise or how much will be re-quired to produce the desired clinical effects(i.e., the exercise dose-response curve).

2. Many of the exercise studies within thearea of behavioral medicine are methodolog-ically flawed to the extent that it is not pos-sible to separate the specific effects of exercisefrom the nonspecific ones. For example, fewstudies have reported physiological measuresthat would quantify the exercise-training ef-fect, if any, and its relationship to clinicalchange. It is possible that in a number of theproblem areas (e.g., depression, anxiety,smoking) exercise has no direct effects, butrather some positive cognitive and behav-ioral side effects such as improved self-effi-cacy and increased adherence to life-style orother health-behavior changes. Certainly,these potential side effects are of great interestto the psychologist and should, therefore, becarefully studied in future investigations ofthe clinical efficacy of exercise.

3. Even in areas in which the clinical ef-ficacy of some form of exercise therapy hasbeen relatively well established (such as car-diovascular risk reduction and obesity), theoverall effectiveness of exercise remains indoubt because of the problems of adherence.


Although researchers have used different cri-teria to define dropouts and adherence, it isclear that many recruits are lost, especiallyin the early stages of the exercise program,and most of those who remain more than afew weeks will eventually relapse.

4. The current lack of standardized or evenof well-specified definitions of exercise ad-herence, nonadherence, and dropout makescross-study comparisons and conclusions dif-ficult or impossible. Actual exercise partici-pation may be better or worse in some of thesubject populations or program types, butthis is difficult to determine because of thedifferent criterion measures used and the lackof appropriate follow-up.

5. The preliminary studies on the modi-fication of exercise behavior indicate thatvarious interventions, including stimuluscontrol, reinforcement control, and self-con-trol procedures, can improve exercise adher-ence, but the effects appear to be temporaryfor most. Few studies have focused on themaintenance side of exercise adoption.

These conclusions prompt us to offer thefollowing suggestions as to the most impor-tant questions to be addressed in future re-search by psychologists in this area.

1. What is the relationship between im-provements in cardiovascular fitness and thebehavioral and psychological/cognitivechanges attributed to exercise? We believethat physiological measures must be pre-sented to validate and quantify the impactof adherence to any experimental exercise-training program. Assessments must be con-ducted under standardized conditions andthe dependent measures selected with careto avoid confounding by other variables.

2. How should exercise "adherence" bedefined? We propose that percentage of over-all adherence, the observed adherence of anindividual compared with a preset criterionfor ideal performance, be adopted as the stan-dard method of reporting adherence. In ourstudies, for example, we are now comparingthe individual's frequency of aerobic exercisesessions in a given week with the ideal stan-dard of three per week. Weekly adherencecan then be averaged across subjects or canbe averaged for an individual or group ofsubjects over a period of time. An ideal ad-

herence definition might also take into ac-count the minimal exercise duration, inten-sity, and frequency necessary to produce adesired effect. If cardiovascular fitness is tar-geted, then adherence might be stated as thepercentage of sessions in which 60% to 65%maximum heart rate is achieved for at least15 to 30 minutes (ACSM, 1978). It is alsoimportant that exercise outside the programbe considered in some manner, since somedropouts report continued exercising on theirown (Wilhelmsen et al, 1975). In any event,it is vital that adherence and dropout be de-fined precisely in all future studies.

3. What factors control exercise partici-pation and adherence: (a) Initially, when andhow an individual decides whether to beginan exercise program; (b) within the contextof an ongoing program, such as a community,clinical rehabilitation program, or a courseat a college or other institution; and (c) afterthe intensive treatment program has ended?Without a doubt, exercise participation andadherence (however defined) across all pop-ulations has typically been disappointing.This is not so surprising in light of the com-plexity of the behavior changes required tosuccessfully initiate and maintain an exerciseprogram or increases in routine activity. Itis not yet clear that we can accurately identifythose most likely to drop out or adherepoorly. A variety of exercise dropout profileshave been proposed, but many predictionsare based on self-report data that may notaccurately reflect the true reasons for poorexercise participation or attrition. Further,once the "high risk" dropouts can be iden-tified, it remains to be shown whether anyspecial treatment can "save" these high-riskindividuals. It can be argued that our effortsmight now best be directed to ensuring thesuccessful long-term adherence of those whoare more likely to remain in treatment.

The research indicates that both stimuluscontrol and reinforcement procedures can atleast temporarily enhance adherence duringthe initial weeks of an ongoing program.Whether these procedures have meaningfulimpact on long-term adherence, or mainte-nance of the exercise program, is a separatequestion, that will require longer term exper-imental studies and follow-up than have usu-


ally been reported. The literature from suchareas as the treatment of obesity, for exam-ple, consistently shows that the measurableimpact of these manipulations almost in-variably disappear by the 6-month or 12-month follow-up.

We believe that far too little attention hasbeen directed toward the cognitive/psycho-logical/social variables controlling exerciseadherence. The enjoyment or aversiveness ofeach exercise session may be strongly influ-enced by the individual's interpretations ofbodily sensations accompanying the exerciseand perceived success in achieving personalgoals. These subjective evaluations may, inturn, continually erode or enhance the in-dividual's probability of engaging in the ex-ercise behavior, depending on their Quality(cf. Andrew et al., 1981). We also believethat, for the exercise habit to be maintained,there must be a high ratio of enjoyable ex-perience, sensations, and cognitions to thoseof neutral, or especially of an aversive,quality.

There may well be various stages (cf. Dish-man, 1982) of establishing and maintainingthe exercise habit, much as in other operantbehaviors, each requiring different optimalcontingencies and, perhaps, types of rein-forcement. As the literature illustrates, welose most would-be exercisers in the early andmiddle acquisition stages. The importanceof determining the key stages in the acqui-sition of the exercise habit is exceeded onlyby the need to tailor a treatment package tdthose requirements. For example, it may bebest to begin with a single exercise behavior,establish it in a single environment, and thenestablish it in other environments (i.e., stim-ulus generalization). Subsequently, a varietyof other exercise behaviors may be intro-duced, at first in a single environment (re-sponse generalization), and then in manyenvironments (stimulus and response gen-eralization). The latter steps may provide thefoundation for effective maintenance of theexercise habit.

At this point, however, one of the mostimportant tasks facing behavioral medicine/health pyehologists studying exercise and ex-ercise adherence is the development of pow-erful treatment "packages"—suitable for in-

dividual tailoring—that will produce accept-able adherence to both home and institu-tional/structured exercise programs. Thisoptimal package for ensuring adequate ex-ercise adherence may need to vary accordingto the type of program; that is, community/prevention or cardiac rehabilitation, andeven to the makeup of the participants; thatis, male, female, smoker, overweight, and soforth. Unfortunately, much of the data onexercise adherence come from primarilymale-dominated, cardiac, or high-risk pa-tient programs. As in the treatment of obesity(Stuart, 1980), we have not yet incorporatedall we know to provide an optimal treatmentpackage. In the case of exercise, the optimaltreatment package should probably includea very convenient location (e.g., neighbor-hood-based programs), group-based, lowerintensity exercise with enthusiastic partici-pant therapists, ample modeling, feedbackand social reinforcement, flexible, partici-pant-influenced exercise goalsetting, and ex-tensive family/social involvement. The pro-gram should also be tailored to individualneeds, for example, personal health goals/limitations, body composition, skill level,need for social approval versus independentpursuit of goals, and desire for variety orcompetition versus comraderie (Oldridge,1977; 1982). Choice, either perceived or ac-tual, appears to be important to adherenceto exercise (Thompson & Wankel, 1980) aswell as other behaviors (Kirschenbaum, To-marken, & Ordman, in press). In respect tothe overly competitive individual (e.g., TypeA), we recommend that very highly compet-itive activities be allowed only in addition toa more relaxed, enjoyable fitness training/maintenance program.

By emphasizing the development of opti-mal programmed exercise interventions, wedo not wish to deemphasize the potential im-portance of strategies designed to increaseroutine activities, which may themselveshave significant health benefits (Morris et al.,1980) and/or may serve as an effective firststep in shaping exercise in the extremely sed-entary. Brownell and Stunkard (1980) havesuggested two useful categories of exercisebehavior that may have important implica-tions for adherence: programmed (special)


activities, including sports and exercises thatoccur in scheduled sessions (e.g., jogging, ten-nis, swimming), and routine (regular) activ-ities, which can readily be incorporated intodaily living (using stairs instead of elevators,walking instead of driving short distances).Routine activities have the advantage of re-quiring no special equipment, places, ortimes. There is evidence from at least onecontrolled study (Epstein, Wing, Koeske,Ossip, & Beck, in press) supporting Brownell& Stunkard's (1980) hypothesis that adher-ence is superior for routine activity increasesresulting in similar long-term fitness andweight change.

No matter how optimal the exercise-ad-herence treatment package, it will likely beinsufficient to ensure maintenance once theprogram ends or if the participant must with-draw (e.g., move). Thus, special maintenanceprocedures or relatively permanent environ-mental changes must be empirically vali-dated and implemented to insure that theexercise is continued and the gains are notwasted. Merely extending treatment willprobably not be as effective as the use of gen-eralization training or special proceduressuch as continued self-monitoring, periodicprogram contact/feedback (e.g., newsletter,"crisis" phone line) and relapse-preventiontraining. Changing the environment, such asenhancing environmental cues for exercisingor implementing participatory, noncompet-itive exercise programs in the schools (cf.Cooper et al., 1975), may be especially ef-fective methods of predetermining exercisemaintenance. However, very few data areavailable and this must be considered anideal area of research. Finally, more researchcan be devoted to the initial stage of exerciseadoption, recruitment. The marketing of ex-ercise/health programs can draw from ad-vertising research, from the relatively recentresearch on health marketing as conductedby health psychologists (Frederiksen, Solo-mon, & Brehony, in press; Martin & Prue,in press) and from the data on the antecedentcontrol of exercise and physical activity (e.g.,(Wankel & Thompson, 1977).

Reference Note1. Martin, J. E., et al. The behavioral control of exercise

in sedentary adults: Studies 1 through 6. Manuscriptsubmitted for publication, 1982.

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Received February 23, 1982 ,Revision received May 11, 1982 •

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