Depression in MSK Practice

This blog is not about how to treat depression. This blog might be for physiotherapists in orthopedic practice who want to expand their role in their patient’s lives by encouraging them to use their rehab exercises as a springboard to help them reduce their depressive symptoms overall.  Or maybe it’s for physiotherapists treating chronic pain patients who want to improve their educational interventions around exercise and mood disorders.  Or maybe this is a blog for a physiotherapist who just wants to improve the way they deliver information to patients using the psychological research to really help motivate people.

In any case, we’re going to delve into a truly humanistic approach - thinking beyond the sore joint to try to improve overall health.  Because if you’re going to build a good, satisfying family practice for yourself, if you want to really connect with patients, you have to care about the whole person.

The Story

A good patient of mine came in to see me one day. He's a middle aged guy, with a professional job. We had been working for 2 years on recovery from a major motor vehicle accident with multiple fractures. Quite tragically, shortly after this one of his parents was killed in a separate accident.  So there was quite a process going on both in his physical rehab but also his emotional and spiritual recovery.  And this particular day he told me that his doctor had just diagnosed him with depression and prescribed for him anti-depressant medication. 

“Jeff, I don’t really want to take it” he said.  It’s not that he was denying that he was depressed, he just didn’t want to treat it with medicine.  I prepare for these conversations long in advance and so when he asked me “are there any other options?” I got out my dry erase marker and my white board.

This brings up a major ethical question.  A patient asks for advice on how to treat his depression. Do we have a role to play?  When I was a young Physio I saw my professional boundaries with dark black lines. I was advised and encouraged not to step into a professional area that wasn't my expertise. After nearly 30 years in practice, I've changed my mind.  I’d like to tell you how I approached this issue with him.  But first, let’s talk about our area of speciality - exercise, and what role that plays in the management of mental health.

Exercise to treat depression

If we’re going to address this issue of mental health and how it relates to physical exercise with our patients, we've got to do two things. First, we have to possess the information. And second, we have to have a strategy to deliver it effectively.

Part 1: The Information

If you read the health and fitness section of your local newspaper, at this time of year (January) you'll find an article about mood disorders and depression.  And sure enough, just today as I'm writing this blog, that article came out in the Edmonton Journal. The health and fitness experts try to convince the public that exercise has a role to play in their mood, but I'm not going to try and convince you of this. Because you already know.

When it comes to exercise and mood disorders, the jury is not out.  The jury is definitely in. Here’s what a 2024 article in Translational Psychiatry says.

"It is well established that any level of physical activity can help prevent [1] and treat [2, 3] depression in both adults and adolescents, with a longer duration of intervention and more intense activity having a greater effect. "[4]

And here’s a systematic review published 2 weeks ago, January 2026 from the Cochrane Database:

“Exercise appears to be no more or less effective than psychological or pharmacological treatments, though this conclusion is based on a few small trials.” [5]

So the summary here is that we have good research to prove that exercise is helpful for depression and there is even small-trial evidence that it is just as effective as medicine. And importantly, there is no strong evidence to say that medication works any better than exercise.

So let’s take a few minutes on physiology here. We’re going to skim over the deep dive and just talk about some of the proposed mechanisms that might be relevant to us.

Systemic inflammation

From the journal Translational Psychiatry in 2017, we read this: 

“Systemic inflammation increases the odds of developing depression.” [6] 

And then from another psychiatry journal published in 2018,

“inhibition of inflammatory cytokines reduces depressive symptoms in patients with inflammatory conditions”  [7]

That’s interesting because we’re often seeing patients in physiotherapy with general systemic inflammation for a variety of reasons.  Because of that reality the population of people we see likely has a higher incidence of depression than the general population, especially if you add in the number of chronic pain patients who experience depression as well.  In other words we really do need to have some familiarity with mood disorders in our practices.

Generally, the medical community addresses systemic inflammation with 2 key classes of drugs:  These so-called “anti-cytokine drugs” include the general immunosuppressants (cortisone, prednisone, methotrexate), and the newly popular monoclonal antibodies; the “mAbs”.  Things like Adalimumab (which is Humira, used in RA and Crohns),or Bimekizumab which is used for psoriasis.

There are a host of other drugs in this category with equally unpronounceable names. This class of drug is actually fascinating. they are engineered antibodies that block a certain cytokine.  Generally, the physicians choose these drugs on a best-guess, trial and error basis and when the right cytokine is targeted these patients enjoy considerable relief without the heavy side effects of the prednisones and methotrexates.

So it's good to remember that patients on these classes of anti-inflammatory drugs may be reducing their risk for depression by reducing their systemic inflammation.  Although, according to the journal Lancet Psychiatry in 2020,

“It is worth noting that findings into the antidepressant effects of anti-inflammatory medication are mixed." [8]

Why is it important to understand the mechanisms behind exercise and depression?

That's an interesting question. Some people might argue that it doesn't really matter if someone understands underlying mechanisms as long as they just change their behavior. As it turns out, some research group went ahead and studied this.  Here’s the summary from a 2024 peer-reviewed article:

“Explaining the mechanisms underlying the beneficial effect of exercise on mental health, and the links between them may help persuade people that exercise is worthwhile for them” (9)

In my experience, it depends on the person. Part of the reason we ask unscripted questions with our patients (things like what do you do for fitness and fun, and what kind of post secondary background do you have) is that we're trying to learn more about them so we know how to connect with them. And when you have those patients who are deeply interested in biology and mechanisms and answers, then when we explain mechanisms to them it helps them feel more confident that we know what we're talking about. They’re more likely to listen to us.   And when we have folks who aren't into that at all, just skip it and tell them what they need to do, not what they need to know.

What type of exercise?

Today's Edmonton Journal article did a great job of summarizing the research on this.  They cite a number of modes of exercise that help improve mood, including

“aerobic exercise, walking, running, swimming, cycling… But weight training has also shown promise.”

Here's a systematic review published in June 2025 that reports 

“Interventions were significantly associated (at the 5% significance level) with changes in depression scores when delivered in either the aerobic mode, resistance mode, or mixed mode." (10)

One brief thought on mechanisms

We are not going to delve here into the role that serotonin and dopamine play on mood disorders. But I’ll note here that some of the research reports that

“fewer than half of people respond to SSRIs and only about 1/3 have symptom remission from their first pharmacological treatment and still fewer going to remission after switching to a second medication.”

One study talks about an alternative to SSRIs (selective serotonin re-uptake inhibitors) which would include medications that enhance dopamine transmission. However, according to the Journal of Psychopharmacology,

“with the exception of bupropion [11], trials using dopaminergic agents have had limited success, likely due to the mechanistic heterogeneity of depression which may render a one-size-fits-all treatment approach ineffective." [12].

So just a side note, here, that is such a universal statement… "The lack of homogeneity in a condition may render a one-size-fits-all treatment ineffective." The authors are applying that principle here to the use of a class of medication for depression, but can you see how this applies to so much of what we do?

For example, teaching a post-op protocol to all patients regardless of their age, fitness, specific impairments?  Can you see how prescribing the same six exercises for SI joint problems for every patient has limited success? I'm just going to put in a plug here for hyper specialized exercise programs for our patients. Never a month goes by without me inventing some new exercise that I've never used before in order to meet the needs of one of my patients. I hope you find excitement in that kind of creative thinking yourself. (Here's a blog on creative exercise prescription. And here's one on the folly of rehab protocols.)

Part 2: The Delivery

A favourite cartoon of mine is a physiotherapist in a white lab coat handing a sheet of paper to a dour looking patient, and the physio is saying “I’m now going to give you a list of exercises that you’ll never do.”  The humour in this cartoon is the resignation in the physio’s presentation.  He’s given up.  He's not even trying to motivate his patient.  It makes me laugh, and it’s a motivator to me - if I ever start feeling that way, I'm retiring.

This is one of the most important soft skills we need when we are in family practice - the ability to motivate patients to comply with the treatment we are prescribing.  And for this we need to dip into the psychological research - we need to know how to communicate the message when we’re asking a person to make a change in their life.

Information does not always motivate people.  Knowing exercise is good for you and helps you feel better and last longer in life does not cause everyone to get on the bike.  In fact, we don’t need more research on whether or not exercise is good, we need research on why people don’t do it.  And somehow, sometimes we choose the strategy of just providing information to our patients.  “Give these exercises a try. They should help.”  That’s about as boring a delivery as I could imagine.  That’s barely above “Here’s some exercises you’ll never do.”

Chip and Dan Heath authored the book Switch:  How to change when change is hard.  This book is full of gems of information. I think every one of us in clinical practice should read it.   Here are some of the techniques they describe when it comes to motivating patients:

1. Find the feeling.  Our emotional brain needs a feeling - a sticky message - something that stirs our dreams a bit.  This is where you really need to know your patient because you need to connect with them. And one way you can do this is to write for them a "postcard from the future." You might say something like "Here's what I'm envisioning you saying next year: A year ago I used to be in pain and I was depressed. And I can't believe how hard I had to work to get out of that but I'm so glad I did.”  That kind of conversation sparks hope in the patient. I used to be somebody not coping very well. Just saying those words out loud is a hopeful thing.

   
   

2. Script the critical moves.  Our rational brain needs specific direction.  Vague bits of advice (like vague home exercise programs) are weak.  We’re at our best when we give very clear written advice on exactly what we're asking them to do, and for how long and at what frequency.  You’ve heard that saying “exercise is medicine”? Do you prescribe exercise as if it’s medicine?  Do you specify the exact dose? It’s more likely your patient will perform four 20 minute walks around the neighborhood this coming week than if you encourage them to get out and walk more.

   
   

3. Tweak the environment.  Sometimes our patients know exactly what to do and they're motivated to do it but the environment they're in presents an obstacle to them. This keeps them from getting going. Again, here's where we need to know them and ask them some questions and find out what those obstacles might be. If we're asking our patient to get their heart rate up for 20 minutes at a time, five times per week, then we need to ask them what modality they'd like to use. They're going to tell us what equipment they have at home, what they like doing, what they hate doing. In fact, we might use the motivational interviewing technique where we ask them if you had to get your heart rate up, what's the easiest way to do that for you? Once we have them figure out what is the quickest and easiest path to get themselves more active, we've tweaked their environment. We've removed obstacles to make it easier for them.

Here's the summary: script the critical moves: Be specific in your prescription of exactly what you want them to do. Then find the feeling: Use your knowledge of them as a person to create a motivational, emotional message for them.  And finally, tweak the environment: Help them find a path with fewer obstacles to help them succeed.

The end of the story

So how did I deal with my patient, the one who expressed hesitation to go on medication for his depression? First I gave him the information. Then I delivered a strategy.

I got out my white board and I wrote up a simple chart for him to understand. 

I drew a circle with PAIN in the top half and DEPRESSION in the bottom half.  I explained to him that often times the two are related, and improving either of those symptoms is helpful for the other. I then drew a few arrows off the pain side of the circle, reminding him what we were doing to treat this; massage, modalities and exercise.

Then I drew three arrows off the depression side of the circle. I wrote in medication, psychotherapy, and exercise. I explained to him that these were the three most common strategies for treating depression. I told him that his doctor had offered him one of those three: Medication. Unfortunately, his doctor didn't give him other options as well.

Isn't this a common finding? Patients are sometimes frustrated when their doctor prescribes a medication for a chronic condition like pre-diabetes, depression, high blood pressure, and they don't provide any information on lifestyle strategies rather than medication?

So in this case, I just reminded him that the research tells us that exercise may be no better and no worse than the other two treatments for depression.  And so if he wanted to follow his doctors advice to treat his depression, he had more options than just medication.

As it turns out, I had been working with him for a long time to try and encourage him to come up with a regular fitness strategy that would recondition his spine.  The key impairment that was keeping him in pain was a massive endurance deficit in his spine, and he needed to finally find that regular routine of strengthening that had eluded him for 2 years.

So I used this new diagnosis of depression as a way of encouraging him to consider using exercise both to manage his pain, to improve his fitness, and to improve his mood.  On the whiteboard, I drew a circle around “exercise” on both the pain side, and the depression side.  “Let’s kill 2 birds with one stone, shall we?”

So, that’s the information he needed.  Next was the strategy - to motivate him, to script the critical moves, and to tweak the environment.  Let’s look at how I applied all 3 in this case.

Find the Feeling

I said to him something like this.  “Look, you’ve gone through a terrible couple of years.  You still haven’t recovered.  But I envision a day where you say to your wife "do you know, I used to have pain and I used to be blue all the time, but when I started that regular exercise back in winter 2026, and stuck with it until spring came, that really helped me turn a corner.”  It’s so important to have the skill of looking someone in the eye and saying words like this to motivate them, to encourage them, to give them a vision of what they can do.  If you find this awkward, it’s time to start practicing.

Script the Critical Moves

Next step is to script the critical moves for him.  I did this by prescribing.  And for this I use a sheet I call Exercise is Medicine. It's got a lot of information on one side and a specific prescription on the other side. I've got a copy of this available on the website. It's free to download and use if you're interested.*

Essentially, I gave him a specific number of minutes per day and a specific number of sessions per week and we worked together to find a specific modality that he would enjoy using. In this case, he chose an exercise bike.  So he went home that day with a sheet of paper that I asked him to put on his fridge as a reminder every day of what he needed to do. And then I gave him a 16 session challenge: because I asked him to exercise four times per week for four weeks and he was seeing me again in one month, I asked him to keep track of all 16 sessions so he could show up next time and we could celebrate that win.

Tweak the Environment

The final challenging thing is to consider what obstacles were going to get in his way of completing this plan.  Again, this took quite a bit of motivational interviewing. I asked him what time of day he was most likely to find easy to exercise. I asked him where exactly the bike was that he was planning on using, because if it took another step to drive to the gym to get on that bike, that's one more obstacle that perhaps he didn't need.   In essence, I didn't tell him exactly what to do here, but I did ask him the questions that would help him arrive at his own decisions on how to make this plan easier to execute.

Conclusion

We're not always fortunate enough to follow our patients from their initial injury right through to regaining their life back. That often takes years. In a true family practice Physiotherapy setting, you probably do follow your patients on a regular basis over the years, but if you work in a program clinic of some sort you might not.

In any event, we're at our best when we consider our patients as the whole person that they are, and we understand when they have a mood disorder and help to educate them on what options they have to address that. Everyone acknowledges exercise is as powerful as medicine.

How we deliver that message to our patients may determine whether or not they take that advice.

*To access the document Exercise is Medicine, follow the login prompt at the top right of the webpage. Once you register as a Memeber of the Physiotherapy Guild (it's free), you'll be granted access to a variety of downloadable documents that will help you in your practice.

References

[1] Schuch FB, Vancampfort D, Firth J, Rosenbaum S, Ward PB, Silva ES, et al. Physical activity and incident depression: a meta-analysis of prospective cohort studies. Am J Psychiatry. 2018;175:631–48. doi: 10.1176/appi.ajp.2018.17111194.

[2] Morres ID, Hatzigeorgiadis A, Stathi A, Comoutos N, Arpin-Cribbie C, Krommidas C, et al. Aerobic exercise for adult patients with major depressive disorder in mental health services: a systematic review and meta-analysis. Depress Anxiety. 2019;36:39–53. doi: 10.1002/da.22842.

[3] Bailey AP, Hetrick SE, Rosenbaum S, Purcell R, Parker AG. Treating depression with physical activity in adolescents and young adults: a systematic review and meta-analysis of randomised controlled trials. Psychol Med. 2018;48:1068–83. doi: 10.1017/S0033291717002653.

[4] Hird EJ, Slanina-Davies A, Lewis G, Hamer M, Roiser JP. From movement to motivation: a proposed framework to understand the antidepressant effect of exercise. Transl Psychiatry. 2024 Jul 4;14(1):273. doi: 10.1038/s41398-024-02922-y. PMID: 38961071; PMCID: PMC11222551.

[5] Clegg AJ, Hill JE, Mullin DS, Harris C, Smith CJ, Lightbody CE, Dwan K, Cooney GM, Mead GE, Watkins CL. Exercise for depression. Cochrane Database Syst Rev. 2026 Jan 8;1(1):CD004366. doi: 10.1002/14651858.CD004366.pub7. PMID: 41500513; PMCID: PMC12779368.

[6] Bell JA, Kivimäki M, Bullmore ET, Steptoe A, MRC ImmunoPsychiatry Consortium, Carvalho LA. Repeated exposure to systemic inflammation and risk of new depressive symptoms among older adults. Transl Psychiatry. 2017;7:e1208. doi: 10.1038/tp.2017.155.

[7] .Kappelmann N, Lewis G, Dantzer R, Jones PB, Khandaker GM. Antidepressant activity of anti-cytokine treatment: a systematic review and meta-analysis of clinical trials of chronic inflammatory conditions. Mol Psychiatry. 2018;23:335–43. doi: 10.1038/mp.2016.167

[8] Husain MI, Chaudhry IB, Husain MO, Hodsoll J, Ansari MA, Naqvi HA, et al. Minocycline and celecoxib as adjunctive treatments for bipolar depression: a multicentre, factorial design randomised controlled trial. Lancet Psychiatry. 2020;7:515–27. doi: 10.1016/S2215-0366(20)30138-3

[9] Hird EJ, Slanina-Davies A, Lewis G, Hamer M, Roiser JP. From movement to motivation: a proposed framework to understand the antidepressant effect of exercise. Transl Psychiatry. 2024 Jul 4;14(1):273. doi: 10.1038/s41398-024-02922-y. PMID: 38961071; PMCID: PMC11222551.

[10] (Banyard H, Edward KL, Garvey L, Stephenson J, Azevedo L, Benson AC. The Effects of Aerobic and Resistance Exercise on Depression and Anxiety: Systematic Review With Meta-Analysis. Int J Ment Health Nurs. 2025 Jun;34(3):e70054. doi: 10.1111/inm.70054. PMID: 40432290; PMCID: PMC12117297.)

[11] Maron E, Eller T, Vasar V, Nutt DJ. Effects of bupropion augmentation in escitalopram-resistant patients with major depressive disorder: an open-label, naturalistic study. J Clin Psychiatry. 2009;70:1054–6. doi: 10.4088/JCP.08l04477.

[12] Argyropoulos SV, Nutt DJ. Anhedonia revisited: is there a role for dopamine-targeting drugs for depression? J Psychopharmacol. 2013;27:869–77. doi: 10.1177/0269881113494104.