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Anxiety – Physical activity improves anxiety symptoms in people with diagnosed anxiety disorders.

Evidence summary

Multiple meta-analyses have demonstrated a significant effect for physical activity reducing anxiety in the people diagnosed with anxiety disorder. A meta-analysis from 2021 looked at 13 RCTs comprising 731 adults (exercise n=376, control=355) with anxiety and related disorders found a small, bordering moderate but statistically significant effect on decreasing anxiety symptoms compared to control condition (standardized mean difference = -0.425, 95% CI -0.67 to – 0.17; I2 = 47.9%) (1). Participants had a diagnosis of an anxiety disorder and included Obsessive Compulsive Disorder (OCD), Panic disorder (PD), Post Traumatic Stress Disorder (PTSD), Generalised Anxiety disorder (GAD) and diagnosis was made via DSM or ICD criteria. This review excluded RCTs that involved exercises with meditative / breathing focus e.g., Thai Chi, Yoga, or qigong. 8 studies used aerobic exercise, two used resistance and three a combination of aerobic and resistance. Duration of intervention was from 3- 20 weeks with sessions ranging from 1 – 5 times a week lasting between 16-90 mins.

When considering the type of physical intervention, the evidence supported several types of interventions including aerobic, mindful exercise and resistance training.
Bartley et al found no significant difference on anxiety symptoms when comparing aerobic exercise intervention to non-aerobic exercise controls, however when comparing aerobic exercise to waitlist or placebo interventions there was a large effect on anxiety disorders (SMD=1.42(95%CI:0.80–2.04), z=4.5, p<0.001). (2). Resistance exercise training (RET) significantly improves anxiety symptoms, and improvements were not moderated by sex or based on features of the resistance exercise training (3).

A further meta-analysis (4) reviewed 390 participants looking at the effect of Pilates (n=201) to non-active control groups (n = 189) found a large significant reduction in anxiety symptoms (Δ = 1.29, 95%CI: 0.24, 2.33; z = 2.40, p≤0.02; N=5, n=231). 8 studies all deemed to be fair or good on the PEDro scale for risk of bias. One further meta-analysis of 14 studies compared mindful (Yoga, Thai Chi, and Qigong) to non-mindful exercises and found that mindful exercises were more effective at reducing anxiety symptoms, however this was only statistically when yoga was compared to non-mindful exercises alone (SMD = -0.45 (95% CI = – 0.81 to -0.09), p = 0.01, I2 = 82%) (5).

One systematic review and metanalysis, demonstrated a large and significant effect size in favour of reducing anxiety − 0.94 (95% CI: 0.94) with nature based physical activity and found the most effective interventions were offered for between 8 and 12 weeks, and the optimal dose ranged from 20 to 90 min. The metanalysis has also shown that exercising in nature has a large effect at developing a positive affect and reducing a negative affect. (6)

Quality of evidence
A – High

Strength of recommendation
1 – Strong

There is consistent high-quality evidence that PA significantly improves anxiety symptoms and should be considered along with usual treatments for people with anxiety disorders.

1) Ramos-Sanchez CP, Schuch FB, Seedat S, Louw QA, Stubbs B, Rosenbaum S, Firth J, van Winkel R, Vancampfort D. The anxiolytic effects of exercise for people with anxiety and related disorders: An update of the available meta-analytic evidence. Psychiatry Res. 2021 Aug;302:114046. doi: 10.1016/j.psychres.2021.114046. Epub 2021 Jun 11. PMID:34126464.
2) Bartley CA, Hay M, Bloch MH. Meta-analysis: aerobic exercise for the treatment of anxiety disorders. Prog Neuropsychopharmacol Biol Psychiatry. 2013 Aug 1;45:34-9. doi: 10.1016/j.pnpbp.2013.04.016. Epub 2013 Apr 30. PMID:23643675.
3) Gordon BR, McDowell CP, Lyons M, Herring MP. The Effects of Resistance Exercise Training on Anxiety: A Meta-Analysis and Meta-Regression Analysis of Randomized Controlled Trials. Sports Med. 2017 Dec;47(12):2521-2532. doi: 10.1007/s40279-017-0769-0. PMID: 28819746.
3) Aylett E, Small N, Bower P. Exercise in the treatment of clinical anxiety in general practice – a systematic review and meta-analysis. BMC Health Serv Res. 2018 Jul16;18(1):559. doi: 10.1186/s12913-018-3313-5. PMID: 30012142; PMCID: PMC6048763.
4) Fleming KM, Herring MP. The effects of pilates on mental health outcomes: A meta-analysis of controlled trials. Complement Ther Med. 2018 Apr;37:80-95. doi: 10.1016/j.ctim.2018.02.003. Epub 2018 Feb 13. PMID: 29609943.
5) So WWY, Lu EY, Cheung WM, Tsang HWH. Comparing Mindful and Non-Mindful Exercises on Alleviating Anxiety Symptoms: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2020 Nov 23;17(22):8692.
6) Coventry PA, Brown JE, Pervin J, Brabyn S, Pateman R, Breedvelt J, Gilbody S, Stancliffe R, McEachan R, White PL. Nature-based outdoor activities for mental and physical health: Systematic review and meta-analysis. SSM Popul Health. 2021 Oct 1;16:100934. doi:10.1016/j.ssmph.2021.100934. PMID: 34646931; PMCID:PMC8498096.