Review articleAn examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis
Introduction
Anxiety disorders are pervasive mental health conditions and are currently the leading cause of global years lived with disability (Lopez et al., 2006, Baxter et al., 2014). Anxiety disorders (AD) such as generalized anxiety disorder (GAD), panic disorder (PD), and phobias, as well as closely related stress related disorders such as post-traumatic stress disorder (PTSD), are associated with a considerable range of deleterious impacts upon the individual, including lower quality of life (Mendlowicz and Stein, 2000), comorbid mental illness (Hofmeijer-Sevink et al., 2012) and elevated cardiovascular disease and associated premature mortality (Roest et al., 2012, Batelaan et al., 2016). Moreover, the societal and financial impacts are profound across the Western and Developing World (Chisholm et al., 2016).
Pharmacological agents such as selective serotonin reuptake inhibitors (SSRIs) and various forms of cognitive behavioral therapy (CBT) are the frontline treatments for people with anxiety/stress disorders (Hofmann and Smits, 2008, de Vries et al., 2016). Nevertheless, about a third of patients do not respond to SSRIs and CBT (Hofmann and Smits, 2008, de Vries et al., 2016). In addition, availability of those treatment options is scarce in developing world. In some stances, waiting times for psychotherapy can be lengthy (up to 12 months), resulting in a poor prognosis and more entrenched symptoms.
Exercise might be an alternative for subjects with AD unwilling to initiate medication or psychotherapy, or for subjects from regions where frontline resources are unavailable. There is evidence showing exercise can improve anxiety symptoms in people without established anxiety disorders (Conn, 2010, Herring et al., 2014, Rebar et al., 2015), including those with general chronic illness (Herring et al., 2010). However, the evidence for the anxiolytic effects of exercise in people with a diagnosis anxiety/stress disorders is equivocal and has considerable limitations. To date, one prior meta-analysis has investigated the potential benefits of exercise in people with a diagnosis of AD (Bartley et al., 2013) that concluded, that currently there is insufficient evidence to recommend aerobic exercise for their treatment. However, further investigation is now required due to more recent evidence (Gaudlitz et al., 2015, Powers et al., 2015, Rosenbaum et al., 2015) on the topic and methodological shortcomings with this prior analysis. First, exercise was compared to control conditions with established efficacy for anxiety such as mindfulness and non-aerobic physical activity, thus increasing the likelihood of a type II error. Second, no meta-regression investigated potential mediators despite the significant heterogeneity. Third, no trial with patients with anxiety/stress disorders such as PTSD was reviewed. Overall, the anxiolytic impact of exercise in comparison to usual treatment and the factors which may influence this impact, have yet to be examined. Given also the increased attention to the filed since the implementation of the above review, an update is essential.
We conducted a meta-analysis of exercise RCTs versus control conditions (including treatment as usual/ wait list/ TAU) among people with a diagnosis of an anxiety and/or a stress-related disorder. The specific aims of the current review were: (1) to evaluate the effects of exercise on anxiety symptoms in people with anxiety/stress disorders, (2) to identify moderators through meta-regression analyses, including sample characteristics (gender and age) and exercise intervention variables (length of the trial, frequency, dropout) that could impact the effects of exercise on anxiety symptoms; and (3) to evaluate the magnitude of the symptom reduction in control groups (control group response) of the included trials.
Section snippets
Methods
This systematic review is in line with the PRISMA statement (Moher et al., 2009) and the MOOSE guidelines (Stroup et al., 2000).
Search results
Following the removal of duplicates from the searches, 3999 entries were considered at the title and abstract level. From 62 full texts, six studies (Broocks et al., 1998, Herring et al., 2012, Gaudlitz et al., 2015, Powers et al., 2015, Rosenbaum et al., 2015) had met the inclusion criteria for the meta-analysis. A summary of the search results including reasons for exclusion are presented in Fig. 1.
Characteristics of included trials and participants
Across the 6 studies, 262 adults with anxiety/stress disorders were included, of whom 132 and
Discussion
Our data suggest that exercise should be considered an evidenced-based option for anxiety symptoms among people with anxiety/ stress related disorders. Specifically, when compared to control conditions, exercise has an effect size in the medium range. Whilst these findings suggest that exercise could be considered as an evidence-based treatment form for patients with anxiety disorders, one should note the limited number of reviewed trials (six). In addition, most of these trials were identified
Conclusion
In conclusion, our data suggests that exercise is seen as an effective intervention in improving anxiety symptoms in people with anxiety and stress-related disorders. However, the small number of trials should be considering in the interpretation of these results, and more high quality trials are required. Given the wider benefits of exercise on wellbeing and cardiovascular markers, we suggest that exercise should be considered an important treatment option among this population.
Declaration of interest
None to declare from any author.
Funding
This article received no specific funding.
Acknowledgement
We would like to thank Dr. Dafna Meron for sending us additional data.
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