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Review Article |

The Effect of Exercise Training on Anxiety Symptoms Among Patients:  A Systematic Review FREE

Matthew P. Herring, MS, MEd; Patrick J. O’Connor, PhD; Rodney K. Dishman, PhD
[+] Author Affiliations

Author Affiliations: Department of Kinesiology, The University of Georgia, Athens.


Arch Intern Med. 2010;170(4):321-331. doi:10.1001/archinternmed.2009.530.
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Background  Anxiety often remains unrecognized or untreated among patients with a chronic illness. Exercise training may help improve anxiety symptoms among patients. We estimated the population effect size for exercise training effects on anxiety and determined whether selected variables of theoretical or practical importance moderate the effect.

Methods  Articles published from January 1995 to August 2007 were located using the Physical Activity Guidelines for Americans Scientific Database, supplemented by additional searches through December 2008 of the following databases: Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science. Forty English-language articles in scholarly journals involving sedentary adults with a chronic illness were selected. They included both an anxiety outcome measured at baseline and after exercise training and random assignment to either an exercise intervention of 3 or more weeks or a comparison condition that lacked exercise. Two co-authors independently calculated the Hedges d effect sizes from studies of 2914 patients and extracted information regarding potential moderator variables. Random effects models were used to estimate sampling error and population variance for all analyses.

Results  Compared with no treatment conditions, exercise training significantly reduced anxiety symptoms by a mean effect Δ of 0.29 (95% confidence interval, 0.23-0.36). Exercise training programs lasting no more than 12 weeks, using session durations of at least 30 minutes, and an anxiety report time frame greater than the past week resulted in the largest anxiety improvements.

Conclusion  Exercise training reduces anxiety symptoms among sedentary patients who have a chronic illness.

Figures in this Article

Anxiety, an unpleasant mood characterized by thoughts of worry, is an adaptive response to perceived threats that can develop into a maladaptive anxiety disorder if it becomes severe and chronic.1 Anxiety symptoms and disorders are common among individuals with a chronic illness,28 yet health care providers often fail to recognize or treat anxiety and may consider it to be an unimportant response to a chronic illness.9

Anxiety symptoms can have a negative impact on treatment outcomes in part because anxious patients can be less likely to adhere to prescribed medical treatments.10,11 Personal costs of anxiety among patients include reduced health-related quality of life12 and increased disability, role impairment,13 and health care visits.14

Adequate evidence is available to justify screening for anxiety problems in primary care settings and prescribing effective treatments for those likely to benefit.9,14 While pharmacological and cognitive behavioral therapies are both efficacious in reducing anxiety,15,16 there continues to be interest in alternative therapies such as relaxation and exercise.1719

Exercise training is a healthful behavior with a minimal risk of adverse events that could be an effective and practical tool for reducing anxiety among patients.2022 Meta-analytic reviews have summarized the association between exercise and anxiety symptoms both in samples of primarily healthy adults2326 and exercise training studies of patients with fibromyalgia and cardiovascular disease, but these analyses did not focus on the best available evidence.2729

We used the results from randomized controlled trials to evaluate the effects of exercise training on anxiety. One goal was to estimate the population effect size for anxiety outcomes. A second goal was to learn whether variables of theoretical or practical importance, such as features of the exercise stimulus and the method for measuring anxiety, account for variation in the estimated population effect.

This systematic review and meta-regression analysis was conducted in a manner consistent with guidelines set forth in the QUOROM statement.30

DATA SOURCES AND SEARCHES

Articles published from January 1995 to August 10, 2007, were located using the Physical Activity Guidelines for Americans Scientific Database, developed and maintained by the Division of Nutrition, Physical Activity, and Obesity at the Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health Promotion.20 That search was supplemented by additional searches through December 2008 of the following databases: Google Scholar, MEDLINE, PsycINFO, PubMed, and Web of Science. We used the keywords “exercise,” “physical activity,” “anxiety,” “tension, “randomized trial,” and “randomized controlled trial.” Supplemental searches of the articles retrieved and those supplied by colleagues were performed manually.

STUDY SELECTION

Inclusion criteria included (1) English-language articles, (2) sedentary adult participants with a chronic illness, (3) random assignment to either an exercise intervention of at least 3 weeks or a comparison condition that lacked exercise training, and (4) an anxiety outcome measured at baseline and after exercise training.

Investigations were excluded that (1) included exercise as one part of a multicomponent intervention but did not include the additional component (eg, stress management) in a comparison condition, (2) compared exercise only with an active treatment (eg, cognitive behavioral therapy, medication, another mode of exercise), (3) focused on education promotion interventions aimed at increasing physical activity but failed to show that physical activity levels were increased, and (4) used anxiety outcome measures focused on a specific phobia. Figure 1 provides a flowchart of study selection.

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Figure 1.

Flowchart for selection of studies

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DATA EXTRACTION AND QUALITY ASSESSMENTS
Study Characteristics

Seventy-five effects were derived from 40 studies3170: 21 from patients with cardiovascular disease, 15 from patients with fibromyalgia, 10 from patients with multiple sclerosis (MS), 9 from patients with psychological disorders, 8 from patients with cancer, 4 from patients with chronic obstructive pulmonary disease (COPD), 4 from patients with chronic pain (eg, knee osteoarthritis, back pain), and 4 from patients categorized as having “other medical illnesses” (ie, obesity, lupus, and epilepsy). The mean (SD) age was 50 (10) years. The mean percentage of women was 59% (33%). Exercise training averaged 3 (1) sessions per week, 42 (22) minutes per session, and was of 16 (10) weeks’ duration. The exercise training adherence rate averaged 78% (14%). Adherence was reported for 51 of 75 (68%) of the effects.

Study Quality Assessment

Two of us (M.P.H. and P.J.O.) independently assessed study quality according to randomization methods, baseline differences between treatment groups, the quality of the anxiety outcome measure, adherence, and exercise program descriptions.

Effect Size Calculation

Effect sizes were calculated by subtracting the mean change in the comparison condition from the mean change in the experimental condition and dividing the difference by the pooled standard deviation of baseline scores.71 Effect sizes were adjusted for small sample size bias and calculated such that a decrease in anxiety resulted in a positive effect size.71 When exact means and standard deviations were not provided (n = 3), effect sizes were estimated72 from exact P values60,62 and from a figure shown in the study.70 When a standard deviation was not reported (n = 151), it was estimated from the largest other study that used the same anxiety measure.34

Data Synthesis and Analysis

Random effects models were used to aggregate mean effect size delta (Δ) and to test variation in effects according to selected moderator variables.71,73 The number of unpublished or unretrieved studies of null effect that would diminish the significance of observed effects to P > .05 was estimated as fail-safe N+.74 A 2-way (effects × raters) intraclass correlation coefficient (ICC) for absolute agreement was calculated to examine interrater reliability for the calculation of effect sizes. The initial ICC was 0.93, and discrepancies were resolved.

Primary Moderators

To provide focused research hypotheses about variation in effect size,75 6 primary moderator variables were selected (Table 1): exercise program length, session duration, and change in physical fitness20,76; type of comparison group and type of intervention used (single [exercise alone vs nonexercise comparison] vs multiple [eg, exercise + medication vs medication] interventions)77; and the time frame of anxiety report (eg, right now vs past week).23,78

Table Graphic Jump LocationTable 1. Definitions for Levels of Primary Moderators
Primary Moderator Analysis

Each primary moderator level was coded according to planned contrasts79 (P ≤ .05) among its levels when the number of effects (k) per level was at least 3. A two-way (effects × raters) mixed-effects model ICC with absolute agreement was calculated to assess interrater reliability for coding of moderator variables. The initial ICCs were at 0.92 or higher, and discrepancies were resolved. The 6 primary moderator variables and 2 interaction terms (program length × session duration and comparison group × intervention type) were included in mixed-effects multiple linear regression analysis with maximum-likelihood estimation,71,73 adjusting for nonindependence of multiple effects contributed by single studies.80 Tests of the regression model (QR) and its residual error (QE) are reported.

Secondary Moderators

Secondary moderator variables were selected for descriptive, univariate analyses based on a logical, theoretical, or prior empirical relation with anxiety. They were organized into general categories of patient characteristics (eg, age, sex, and illness), characteristics of the exercise intervention (eg, adherence, exercise mode, frequency, and relative intensity), and the specific anxiety measure used (Table 2).

Table Graphic Jump LocationTable 2. Definitions for Levels of Secondary Moderators
Secondary Moderator Analysis

Mean effect sizes (Δ) and 95% confidence intervals (CIs) were computed for continuous and categorical variables using a random effects model to account for heterogeneity of moderator effects.73

Sixty-six of 75 effects were greater than zero. The distribution of the unweighted effects shown in Figure 2 was positively skewed and leptokurtic. The mean effect size Δ was 0.29 (k = 75 [95% CI, 0.23-0.36]; z = 9.06; P < .001). The fail-safe number of effects was 1525, and a funnel plot (not shown) revealed a lack of publication bias.

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Figure 2.

The distribution of the unweighted effects. Panels A-C represent a continuous forest plot. CI indicates confidence interval.

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PRIMARY MODERATOR ANALYSES

The overall multiple regression model was significantly related to effect size (QR(9) = 20.89; P = .01; R2 = 0.27; QE(65) = 56.29; P = .77). Exercise program length (β = 0.33; z = 2.55; P = .01), session duration (β = 0.27; z = 2.14; P = .03), and time frame of anxiety report (β = 0.25; z = 2.01; P = .04) were independently related to effect size. In a follow-up regression model, 2-way interactions among these variables were statistically nonsignificant (exercise program length × session duration: P = .71, exercise program length × anxiety report time frame: P = .43, and session duration × anxiety report time frame: P = .95). Planned contrasts showed a larger effect in studies in which (1) exercise training duration was 3 to 12 weeks (Δ = 0.39 [95% CI, 0.28-0.49]) compared with longer durations (Δ = 0.23 [95% CI, 0.15-0.31]; z = 2.38; P = .02), (2) the exercise session duration exceeded 30 minutes (Δ = 0.36 [95% CI, 0.27-0.44]) compared with a combination of the shorter and unspecified session durations (Δ = 0.22 [95% CI, 0.13-0.31]; z = 2.09; P = .04), and (3) the time frame of anxiety report was greater than 1 week (Δ = 0.44 [95% CI, 0.29-0.59]) compared with shorter time frames (Δ = 0.26 [95% CI, 0.19-0.33]; z = 2.78; P = .005).

SECONDARY MODERATOR ANALYSES

The number of effects (k), mean Δ effect size, 95% CI, and P value for planned contrasts of each level of primary and secondary moderators are presented in Table 3. Descriptive results for the remaining primary moderators from the overall regression model and for secondary moderators are reported as standardized regression coefficients in Table 4.

Table Graphic Jump LocationTable 3. Summary of Univariate Moderator Analysis
Table Graphic Jump LocationTable 4. Standardized Regression Coefficients for Remaining Primary and Secondary Moderators

The analysis revealed that exercise training significantly decreased anxiety scores among patients with a chronic illness. The magnitude of the overall mean effect (Δ = 0.29) is similar to the effect of exercise training on fatigue symptoms among patients (Δ = 0.37)77 and on cognitive function among older adults (g = 0.30).81

PRIMARY MODERATORS OF THE EFFECT
Exercise Program Length

Given the importance for health care providers of knowing the minimum exercise stimulus needed to improve mental health outcomes among patients,76 it is noteworthy that exercise programs of 3 to 12 weeks resulted in significantly larger decreases in anxiety (Δ = 0.39; k = 35) than programs lasting more than 12 weeks (Δ = 0.23;  = .02; k = 39). These results are generally consistent with meta-analytic reviews of the effect of exercise training on depression,82 cognitive function in older adults,81 and quality of life among patients with MS.83 These results also are comparable with the generally expected response time of pharmacological treatments of 4 to 12 weeks for individuals with anxiety.84

It is uncertain why studies with shorter program lengths had larger improvements in anxiety symptoms. One possibility is that the larger effect resulted from better adherence. A moderate inverse association was found between adherence and program length (ρ = −0.42; P = .002; k = 50). The mean (SD) adherence values for program lengths of 3 to 12 weeks (83% [11%]; k = 23) were significantly better (t(48) = 2.67; P = .01) than values for program with lengths greater than 12 weeks (73% [15%]; k = 27). A limitation, however, is that approximately one-third of the overall effects were derived from studies that did not provide information about adherence.

Exercise Session Duration

Exercise session durations greater than 30 minutes showed larger effects (Δ = 0.36; k = 40) than durations of 10 to 30 minutes (Δ = 0.22; k = 35). Better mental health outcomes with longer exercise session durations also have been found in studies of exercise training effects on cognitive function in older adults,81,85 and claudication pain reduction among patients with peripheral artery disease.86

As more data are generated, compelling evidence may emerge showing that the moderating effect of session duration is in part a function of its interactions with other relevant variables. We found that mean adherence for session durations of 10 to 30 minutes (74% [14%]; k = 24) was worse than for those lasting longer than 30 minutes (81% [13%]; k = 27), but the difference was not statistically significant (t(49) = −1.85; P = .07). There also is a potential interaction between session duration and the anxiety report time frame. While only 1 effect in the shorter session duration category used an anxiety measure with a report time frame of greater than 1 week, a report time frame of greater than 1 week was used in 23% of effects in the longer session duration category. The mean effect Δ for those studies was 0.62 (95% CI, 0.42-0.82).

Time Frame of Anxiety Report

The magnitude of the anxiolytic effects of exercise training was larger for investigations using measures with anxiety report time frames that exceeded the past week compared with investigations using measures with time frames of “past week including today” and “right now.” The present analysis may have underestimated the true effect of exercise training on anxiety because of the measurement methods used by most investigators. Although a larger mean effect was found in those studies that asked participants to report anxiety over a time frame that exceeded the prior week, approximately 80% used a shorter report time frame.

Although it is uncertain why most investigators did not use an anxiety report time frame of longer than 1 week, it may have stemmed from a misinterpretation that trait anxiety scores would be insensitive to change in response to an exercise training intervention of a few months. Trait anxiety is conceptualized as a relatively stable measure of individual differences in anxiety proneness,87 yet there is substantial evidence that trait anxiety scores are sensitive to change. Short-term interventions (up to several months) designed to reduce anxiety, including cognitive and behavioral therapies, long-term massage, and relaxation training, produce moderate-to-large reductions in trait anxiety scores.8891 These changes are consistent with data showing that genetic factors explain only 30% to 50% of the variability in trait anxiety.92 Trait anxiety also discriminates better than state anxiety among patients and samples of people without an illness, particularly among older adults.93

State anxiety responses to an intervention theoretically depend in part on individual differences in trait anxiety.87 Only 5 studies47,55,56,59,67 reported data from both state and trait subscales of the same psychometric instrument. The mean effect Δ for trait measures was 0.56 (95% CI, 0.30-0.83) compared with 0.31 (95% CI, 0.04-0.58) for state measures in these studies. Thus, a limitation to research on the effect of exercise training on anxiety outcomes conducted with people with a chronic illness is the atheoretical nature of the anxiety measurement.

In addition, a randomized controlled trial assumes a lack of systematic error across the premeasurement to postmeasurement trials. There seems to be a greater potential for systematic error associated with the use of a “right now” time frame in exercise training studies because of the greater number of variables that could change state anxiety scores on only 1 day of testing, including psychosocial stressors, circadian timing,94,95 and physical factors such as caffeine96 or light exposure.97

Theory, evidence from our analysis, and findings from related investigations support the idea that future exercise training investigations would benefit from including anxiety outcome measures with a time frame of anxiety report greater than 1 week.

SECONDARY MODERATORS

Secondary moderators were included to provide descriptive data about variables that plausibly could moderate the influence of exercise training on anxiety. There was little difference in the effect size across categories for age or sex. The effect sizes also were similar whether the exercise training did or did not meet contemporary recommendations for moderate or vigorous physical activity.98 Secondary moderator variables of special interest, type of illness and adherence, are discussed in more detail in the following 2 subsections.

Types of Illness

Exercise training reliably reduced anxiety among subsets of patients with an illness categorized as cardiovascular, cancer, chronic pain, fibromyalgia, psychological, and pulmonary. These results are generally consistent with meta-analytic reviews of the effect of exercise training on anxiety symptoms among patients with fibromyalgia,27 coronary heart disease,28 and cardiac rehabilitation.29 It is important to note that the present analysis and conclusions assume that effects attributed to exercise training among patients were not biased by confounding from unmeasured or unreported factors such as acute exercise bouts performed within a few hours of the preintervention or postintervention testing sessions.

Exercise training results in large symptom reductions among patients with panic99 and depressive disorders (ie, mean effects of 0.85 to 1.1 for patients with depression82,100). Seven of the 9 effects in the psychological category were from studies of patients with depressive disorders.3133,44 Because 5 of these 7 effects were derived from investigations using a short time frame of anxiety report, the aggregated mean for these 7 effects (Δ = 0.35) may have underestimated the true effect.

The present analysis showed that exercise training reduces anxiety among patients with cancer. This observation differs from that of others who concluded that there was weak evidence for a consistent positive effect of increased physical activity on anxiety among cancer survivors.101 Our analysis differed in that it included both patients with cancer, who exercised during treatment, and survivors who exercised following treatment.

Although anxiety is a common problem among patients with MS, it is often overlooked and poorly treated.7,102 Multiple sclerosis was the only illness for which the mean effect of exercise training was not statistically significant. Although the mean effect size of 0.19 for studies of patients with MS was comparable with the mean effect of studies of patients with cancer, the associated 95% CI for patients with MS encompassed zero. Of the 10 available effects for patients with MS, 1 study55 accounted for 6 effects. The mean for those 6 effects was small (Δ = 0.07) compared with the mean for the remaining 4 effects (Δ = 0.38).

Adherence

Exercise adherence is integral to the efficacy of exercise training. The ability to meaningfully assess the effects of the intervention decreases as dropout increases. Adherence to an exercise training program may be particularly difficult for patients during treatment.103 Exercise may be unacceptable to some patients (eg, patients with cancer) as indicated by poor adherence.104 The present findings indicated that adherence was also not a significant moderator (z = 1.75; P = .08) of the anxiolytic effect of exercise training. This finding may be due in part to a larger number of effects for which no corresponding adherence data were provided (k = 24).

FUTURE RESEARCH

Several research needs are suggested by the present findings. Needed are well-designed investigations into the effects of exercise training on anxiety that focus on individuals with an understudied illness, including those with an anxiety disorder, COPD, cancer, chronic pain, epilepsy, lupus, and MS. Also needed is better reporting of study features, especially clear and complete information about medication use and the exercise stimulus. Exercise training dose is a complex stimulus involving actual minutes of exercise in each session accumulated over all exercise sessions. Most investigators reported planned session duration as a proxy for actual time spent exercising, and only 1 study38 reported the degree to which patients complied with the prescribed exercise training during exercise sessions. Consequently, the true effect of exercise training on anxiety may be underestimated because of underexposure to the active feature of the intervention.

A better understanding of the role of exercise stimulus variables in maximizing positive mental health outcomes could be realized through investigations that (1) examine useful types of exercise that have been understudied, including resistance exercises; (2) compare different exercise training intensities and durations while controlling total energy expenditure to better understand the minimal and optimal dose necessary to elicit mental health benefits; and (3) select characteristics of the exercise stimulus to optimize program adherence and compliance with intensity and duration prescription. Findings also underscore the importance of including a valid measure of persistent anxiety to better quantify and understand the chronic effects of exercise training on anxiety symptoms.

Increasingly, efforts are being made to provide mental health treatments consistent with the available scientific evidence in primary care settings.105 The present results provide clinicians with solid evidence to recommend exercise training to patients as a means for reducing anxiety symptoms with minimal risk of adverse events. Exercise training may be especially useful for patients who prefer nonpharmacologic treatments106 because such preferences may influence the magnitude of the treatment outcomes.107 Perhaps most importantly, the results show that anxiety reduction is a favorable, adventitious outcome of exercise interventions that were designed as a primary treatment or adjuvant for medical conditions other than anxiety.

Correspondence: Matthew P. Herring, MS, MEd, Department of Kinesiology, Ramsey Center, The University of Georgia, 330 River Rd, Athens, GA 30602-6554 (mph8@uga.edu).

Accepted for Publication: October 1, 2009.

Author Contributions: Mr Herring had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Herring and O’Connor. Acquisition of data: Herring. Analysis and interpretation of data: Herring, O’Connor, and Dishman. Drafting of the manuscript: Herring. Critical revision of the manuscript for important intellectual content: Herring, O’Connor, and Dishman. Statistical analysis: Herring and Dishman. Administrative, technical, and material support: Herring. Study supervision: Herring.

Financial Disclosure: None reported.

Barlow  DH Anxiety and Its Disorders. 2nd ed. New York, NY Guilford2002;
Kuehn  BM Asthma linked to psychiatric disorders. JAMA 2008;299 (2) 158- 160
PubMed
Dahl  AAHaaland  CFMykletun  A  et al.  Study of anxiety disorder and depression in long-term survivors of testicular cancer. J Clin Oncol 2005;23 (10) 2389- 2395
PubMed
Fan  AZStrine  TWJiles  RMokdad  AH Depression and anxiety associated with cardiovascular disease among persons aged 45 years and older in 38 states of the United States, 2006. Prev Med 2008;46 (5) 445- 450
PubMed
Moffitt  TEHarrington  HCaspi  A  et al.  Depression and generalized anxiety disorder: cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Arch Gen Psychiatry 2007;64 (6) 651- 660
PubMed
Kunik  MERoundy  KVeazey  C  et al.  Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest 2005;127 (4) 1205- 1211
PubMed
Korostil  MFeinstein  A Anxiety disorders and their clinical correlates in multiple sclerosis patients. Mult Scler 2007;13 (1) 67- 72
PubMed
Roy-Byrne  PPDavidson  KWKessler  RC  et al.  Anxiety disorders and comorbid medical illness. Gen Hosp Psychiatry 2008;30 (3) 208- 225
PubMed
Stein  MBRoy-Byrne  PPCraske  MG  et al.  Functional impact and health utility of anxiety disorders in primary care outpatients. Med Care 2005;43 (12) 1164- 1170
PubMed
Tohen  MCalabrese  JVieta  E  et al.  Effect of comorbid anxiety on treatment response in bipolar depression. J Affect Disord 2007;104 (1-3) 137- 146
PubMed
Sherbourne  CDHays  RDOrdway  LDiMatteo  MRKravitz  RL Antecedents of adherence to medical recommendations: results from the medical outcomes study. J Behav Med 1992;15 (5) 447- 468
PubMed
Sareen  JJacobi  FCox  BJBelik  SLClara  IStein  MB Disability and poor quality of life associated with comorbid anxiety disorders and physical conditions. Arch Intern Med 2006;166 (19) 2109- 2116
PubMed
Kessler  RCOrmel  JDemler  OStang  PE Comorbid mental disorders account for the role impairment of commonly occurring chronic physical disorders: results from the National Comorbidity Survey. J Occup Environ Med 2003;45 (12) 1257- 1266
PubMed
Kroenke  KSpitzer  RLWilliams  JBMonahan  POLowe  B Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146 (5) 317- 325
PubMed
Allgulander  CDahl  AAAustin  C  et al.  Efficacy of sertraline in a 12-week trial for generalized anxiety disorder. Am J Psychiatry 2004;161 (9) 1642- 1649
PubMed
Mitte  K Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder. Psychol Bull 2005;131 (5) 785- 795
PubMed
Lovell  KCox  DHaddock  G  et al.  Telephone administered cognitive behaviour therapy for treatment of obsessive compulsive disorder: randomised controlled non-inferiority trial. BMJ 2006;333 (7574) 883
PubMed
Kessler  RCSoukup  JDavis  RB  et al.  The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry 2001;158 (2) 289- 294
PubMed
van der Watt  GLaugharne  JJanca  A Complementary and alternative medicine in the treatment of anxiety and depression. Curr Opin Psychiatry 2008;21 (1) 37- 42
PubMed
 Physical Activity Guidelines for Americans Scientific Database. Division of Nutrition, Physical Activity, and Obesity at the Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health: appendix F.1-3: promotion. US Department of Health and Human Services Web site. http://www.health.gov/paguidelines/report/. Accessed August 17, 2007
Stewart  ALHays  RDWells  KBRogers  WHSpritzer  KLGreenfield  S Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the medical outcomes study. J Clin Epidemiol 1994;47 (7) 719- 730
PubMed
Lavie  CJMilani  RV Adverse psychological and coronary risk profiles in young patients with coronary artery disease and benefits of formal cardiac rehabilitation. Arch Intern Med 2006;166 (17) 1878- 1883
PubMed
Long  BCvan Stavel  R Effects of exercise training on anxiety: a meta-analysis. J Appl Sport Psychol 1995;7 (2) 167- 189
PubMed10.1080/1041320950846963
McDonald  DGHodgdon  JA The Psychological Effects of Aerobic Fitness Training: Research and Theory.  New York, NY Springer-Verlag1991;
Petruzzello  SJLanders  DMHatfield  BDKubitz  KASalazar  W A meta-analysis on the anxiety-reducing effects of acute and chronic exercise: outcomes and mechanisms. Sports Med 1991;11 (3) 143- 182
PubMed
Schlicht  W Does physical exercise reduce anxious emotions? a meta-analysis. Anxiety Stress Coping 1994;6 (4) 275- 288
PubMed
Rossy  LABuckelew  SPDorr  N  et al.  A meta-analysis of fibromyalgia treatment interventions. Ann Behav Med 1999;21 (2) 180- 191
PubMed
Kugler  JSeelbach  HKruskemper  GM Effects of rehabilitation exercise programmes on anxiety and depression in coronary patients: a meta-analysis. Br J Clin Psychol 1994;33 (pt 3) 401- 410
PubMed
Puetz  TWBeasman  KMO’Connor  PJ The effect of cardiac rehabilitation exercise programs on feelings of energy and fatigue: a meta-analysis of research from 1945 to 2005. Eur J Cardiovasc Prev Rehabil 2006;13 (6) 886- 893
PubMed
Moher  DCook  DJEastwood  SOlkin  IRennie  DStroup  DF Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement: quality of reporting of meta-analyses. Lancet 1999;354 (9193) 1896- 1900
PubMed
Blumenthal  JABabyak  MAMoore  KA  et al.  Effects of exercise training on older patients with major depression. Arch Intern Med 1999;159 (19) 2349- 2356
PubMed
Blumenthal  JASherwood  ABabyak  MA  et al.  Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: a randomized controlled trial. JAMA 2005;293 (13) 1626- 1634
PubMed
Brown  MAGoldstein-Shirley  JRobinson  JCasey  S The effects of a multi-modal intervention trial of light, exercise, and vitamins on women's mood. Women Health 2001;34 (3) 93- 112
PubMed
Burnham  TRWilcox  A Effects of exercise on physiological and psychological variables in cancer survivors. Med Sci Sports Exerc 2002;34 (12) 1863- 1867
PubMed
Chang  PHLai  YShun  S  et al.  Effects of a walking intervention on fatigue-related experiences of hospitalized acute myelogenous leukemia patients undergoing chemotherapy: a randomized controlled trial. J Pain Symptom Manage 2008;35 (5) 524- 534
PubMed
Clark  DIDowning  NMitchell  JCoulson  LSyzpryt  EPDoherty  M Physiotherapy for anterior knee pain: a randomised controlled trial. Ann Rheum Dis 2000;59 (9) 700- 704
PubMed
Courneya  KSFriedenreich  CMQuinney  HAFields  ALAJones  LWFairey  AS A randomized trial of exercise and quality of life in colorectal cancer survivors. Eur J Cancer Care (Engl) 2003;12 (4) 347- 357
PubMed
Courneya  KSSegal  RJMackey  JR  et al.  Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol 2007;25 (28) 4396- 4404
PubMed
Dimeo  FCStieglitz  RDNovelli-Fischer  UFetscher  SKeul  J Effects of physical activity on the fatigue and psychologic status of cancer patients during chemotherapy. Cancer 1999;85 (10) 2273- 2277
PubMed
Dugmore  LDTipson  RJPhillips  MH  et al.  Changes in cardiorespiratory fitness, psychological wellbeing, quality of life, and vocational status following a 12 month cardiac exercise rehabilitation programme. Heart 1999;81 (4) 359- 366
PubMed
Emery  CFSchein  RLHauck  ERMacIntyre  NR Psychological and cognitive outcomes of a randomized trial of exercise among patients with chronic obstructive pulmonary disease. Health Psychol 1998;17 (3) 232- 240
PubMed
Gowans  SEdeHueck  AVoss  SRichardson  M A randomized, controlled trial of exercise and education for individuals with fibromyalgia. Arthritis Care Res 1999;12 (2) 120- 128
PubMed
Gowans  SEdeHueck  AVoss  SSilaj  AAbbey  SEReynolds  WJ Effect of a randomized, controlled trial of exercise on mood and physical function in individuals with fibromyalgia. Arthritis Rheum 2001;45 (6) 519- 529
PubMed
Gusi  NReyes  MCGonzalez-Guerrero  JLHerrera  EGarcia  JM Cost-utility of a walking programme for moderately depressed, obese, or overweight elderly women in primary care: a randomized controlled trial. BMC Public Health 2008;8231
PubMed
Jones  KDBurckhardt  CSDeodhar  AAPerrin  NAHanson  GCBennett  RM A six-month randomized controlled trial of exercise and pyridostigmine in the treatment of fibromyalgia. Arthritis Rheum 2008;58 (2) 612- 622
PubMed
Koukouvou  GKouidi  EIacovides  AKonstantinidou  EKaprinis  GDeligiannis  A Quality of life, psychological and physiological changes following exercise training in patients with chronic heart failure. J Rehabil Med 2004;36 (1) 36- 41
PubMed
Kulcu  DGKurtais  YTur  BSGulec  SSeckin  B The effect of cardiac rehabilitation on quality of life, anxiety and depression in patients with congestive heart failure: a randomized controlled trial, short-term results. Eura Med Phys 2007;43 (4) 489- 497
PubMed
Mannerkorpi  KNyberg  BAhlmen  MEkdahl  C Pool exercise combined with an education program for patients with fibromyalgia syndrome. a prospective, randomized study. J Rheumatol 2000;27 (10) 2473- 2481
PubMed
McAuley  JWLong  LHeise  J  et al.  A prospective evaluation of the effects of a 12-week outpatient exercise program on clinical and behavioral outcomes in patients with epilepsy. Epilepsy Behav 2001;2 (6) 592- 600
PubMed
Merom  DPhongsavan  PWagner  R  et al.  Promoting walking as an adjunct intervention to group cognitive behavioral therapy for anxiety disorders: a pilot group randomized trial. J Anxiety Disord 2008;22 (6) 959- 968
PubMed
Mock  VDow  KHMeares  CJ  et al.  Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncol Nurs Forum 1997;24 (6) 991- 1000
PubMed
Moug  SJGrant  SCreed  GBoulton Jones  M Exercise during haemodialysis: West of Scotland pilot study. Scott Med J 2004;49 (1) 14- 17
PubMed
Nieman  DCCuster  WFButterworth  DEUtter  ACHenson  DA Psychological response to exercise training and/or energy restriction in obese women. J Psychosom Res 2000;48 (1) 23- 29
PubMed
O'Reilly  SCMuir  KRDoherty  M Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis 1999;58 (1) 15- 19
PubMed
Oken  BSKishiyama  SZajdel  D  et al.  Randomized controlled trial of yoga and exercise in multiple sclerosis. Neurology 2004;62 (11) 2058- 2064
PubMed
Paz-Díaz  HMontes de Oca  MLopez  JMCelli  BR Pulmonary rehabilitation improves depression, anxiety, dyspnea and health status in patients with COPD. Am J Phys Med Rehabil 2007;86 (1) 30- 36
PubMed
Petajan  JHGappmaier  EWhite  ATSpencer  MKMino  LHicks  RW Impact of aerobic training on fitness and quality of life in multiple sclerosis. Ann Neurol 1996;39 (4) 432- 441
PubMed
Schachter  CLBusch  AJPeloso  PMSheppard  MS Effects of short versus long bouts of aerobic exercise in sedentary women with fibromyalgia: a randomized controlled trial. Phys Ther 2003;83 (4) 340- 358
PubMed
Seki  EWatanabe  YSunayama  S  et al.  Effects of phase III cardiac rehabilitation programs on health-related quality of life in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP). Circ J 2003;67 (1) 73- 77
PubMed
Skrinar  GSHuxley  NAHutchinson  DSMenninger  EGlew  P The role of a fitness intervention on people with serious psychiatric disabilities. Psychiatr Rehabil J 2005;29 (2) 122- 127
PubMed
Sørensen  MAnderssen  SHjerman  IHolme  IUrsin  H The effect of exercise and diet on mental health and quality of life in middle-aged individuals with elevated risk factors for cardiovascular disease. J Sports Sci 1999;17 (5) 369- 377
PubMed
Stanton  JMArroll  B The effect of moderate exercise on mood in mildly hypertensive volunteers: a randomized controlled trial. J Psychosom Res 1996;40 (6) 637- 642
PubMed
Sutherland  GAndersen  MBStoov  MA Can aerobic exercise training affect health-related quality of life for people with multiple sclerosis? J Sport Exerc Psychol 2001;23 (2) 122- 135
PubMed
Tench  CMMcCarthy  JMcCurdie  IWhite  PDD'Cruz  DP Fatigue in systemic lupus erythematosus: a randomized controlled trial of exercise. Rheumatology (Oxford) 2003;42 (9) 1050- 1054
PubMed
Thorsen  LSkovlund  EStromme  SBHornslien  KDahl  AAFossa  SD Effectiveness of physical activity on cardiorespiratory fitness and health-related quality of life in young and middle-aged cancer patients shortly after chemotherapy. J Clin Oncol 2005;23 (10) 2378- 2388
PubMed
Tomas-Carus  PGusi  NHakkinen  AHakkinen  KLeal  AOrtega-Alonso  A Eight months of physical training in warm water improves physical and mental health in women with fibromyalgia: a randomized controlled trial. J Rehabil Med 2008;40 (4) 248- 252
PubMed
Tsai  JCWang  WHChan  P  et al.  The beneficial effects of tai chi chuan on blood pressure and lipid profile and anxiety status in a randomized controlled trial. J Altern Complement Med 2003;9 (5) 747- 754
PubMed
van den Berg-Emons  RBalk  ABussmann  HStam  H Does aerobic training lead to a more active lifestyle and improved quality of life in patients with chronic heart failure? Eur J Heart Fail 2004;6 (1) 95- 100
PubMed
Wand  BMBird  CMcAuley  JHDore  CJMacDowell  MDe Souza  LH Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise. Spine (Phila Pa 1976) 2004;29 (21) 2350- 2356
PubMed
Yu  CMLau  CPChau  J  et al.  A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention. Arch Phys Med Rehabil 2004;85 (12) 1915- 1922
PubMed
Hedges  LVOlkin  I Statistical Methods for Meta-analysis.  New York, NY Academic Press1985;
Rosenthal  R Parametric measures of effect size. Cooper  HHedges  LVThe Handbook of Research Synthesis. New York, NY Russell Sage Foundation1994;231- 244
Lipsey  MWWilson  DB Practical Meta-analysis.  Newbury Park, CA Sage2001;
Rosenberg  MS The file-drawer problem 1 revisited: a general weighted method for calculating fail-safe numbers in meta analysis. Evolution 2005;59 (2) 464- 468
PubMed
Rosenthal  RDiMatteo  MR Meta-analysis: recent developments in quantitative methods for literature reviews. Annu Rev Psychol 2001;5259- 82
PubMed
Dunn  ALTrivedi  MHO’Neal  HA Physical activity dose-response effects on outcomes of depression and anxiety. Med Sci Sports Exerc 2001;33 (6) ((suppl)) S587- S597
PubMed
Puetz  TWO’Connor  PJDishman  RK Effects of chronic exercise on feelings of energy and fatigue: a quantitative synthesis. Psychol Bull 2006;132 (6) 866- 876
PubMed
Wipfli  BMRethorst  CDLanders  DM The anxiolytic effects of exercise: a meta-analysis of randomized trials and dose-response analysis. J Sport Exerc Psychol 2008;30 (4) 392- 410
PubMed
Rosenthal  R Meta-analytic Procedures for Social Research.  London, England Sage Publications1991;
Gleser  LJOlkin  I Stochastically dependent effect sizes. Cooper  HHedges  LVThe Handbook of Research Synthesis. New York, NY Sage1994;339- 355
Colcombe  SKramer  AF Fitness effects on the cognitive function of older adults: a meta-analytic study. Psychol Sci 2003;14 (2) 125- 130
PubMed
Lawlor  DAHopker  SW The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. BMJ 2001;322 (7289) 763- 767
PubMed
Motl  RWGosney  JL Effect of exercise training on quality of life in multiple sclerosis: a meta-analysis. Mult Scler 2008;14 (1) 129- 135
PubMed
Davidson  JRZhang  WConnor  KM  et al.  A psychopharmacological treatment algorithm for GAD [published online October 2, 2008]. J Psycho- pharmacol
PubMed10.1177/0269881108096505
Heyn  PAbreu  BCOttenbacher  KJ The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis. Arch Phys Med Rehabil 2004;85 (10) 1694- 1704
PubMed
Gardner  AWPoehlman  ET Exercise rehabilitation programs for the treatment of claudication pain. a meta-analysis. JAMA 1995;274 (12) 975- 980
PubMed
Spielberger  CDGorsuch  RLLushene  REVagg  PRJacobs  GA Manual for the State-Trait Anxiety Inventory (Form Y).  Palo Alto, CA Consulting Psychologists Press1983;
Jorm  AF Modifiability of trait anxiety and neuroticism: a meta-analysis of the literature. Aust N Z J Psychiatry 1989;23 (1) 21- 29
PubMed
Kirkwood  GRampes  HTuffrey  VRichardson  JPilkington  K Yoga for anxiety: a systematic review of the research evidence. Br J Sports Med 2005;39 (12) 884- 891
PubMed
Manzoni  GMPagnini  FCastelnuovo  GMolinari  E Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC Psychiatry 2008;841
PubMed
Moyer  CARounds  JHannum  JW A meta-analysis of massage therapy research. Psychol Bull 2004;130 (1) 3- 18
PubMed
Clément  YCalatayud  FBelzung  C Genetic basis of anxiety like behaviour: a critical review. Brain Res Bull 2002;57 (1) 57- 71
PubMed
Kabacoff  RISegal  DLHersen  MVan Hasselt  VB Psychometric properties and diagnostic utility of the Beck Anxiety Inventory and the State-Trait Anxiety Inventory with older adult psychiatric patients. J Anxiety Disord 1997;11 (1) 33- 47
PubMed
Cameron  OGLee  MAKotun  JMcPhee  KM Circadian symptom fluctuations in people with anxiety disorders. J Affect Disord 1986;11 (3) 213- 218
PubMed
Monteleone  PMaj  M The circadian basis of mood disorders: recent developments and treatment implications. Eur Neuropsychopharmacol 2008;18 (10) 701- 711
PubMed
Alsene  KDeckert  JSand  Pde Wit  H Association between A2a receptor gene polymorphisms and caffeine-induced anxiety. Neuropsychopharmacology 2003;28 (9) 1694- 1702
PubMed
Youngstedt  SDKripke  DF Does bright light have an anxiolytic effect? an open trial. BMC Psychiatry 2007;762
PubMed
Pate  RRPratt  MBlair  SN  et al.  Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273 (5) 402- 407
PubMed
Broocks  ABandelow  BPekrun  G  et al.  Comparison of aerobic exercise, clomipramine, and placebo in treatment of panic disorder. Am J Psychiatry 1998;155 (5) 603- 609
PubMed
Mead  GEMorley  WCampbell  PGreig  CAMcMurdo  MLawlor  DA Exercise for depression. Cochrane Database Syst Rev 2008; (4) CD004366
PubMed
Schmitz  KHHoltzman  JCourneya  KSMâsse  LCDuval  SKane  R Controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiol Biomarkers Prev 2005;14 (7) 1588- 1595
PubMed
Beiske  AGSvensson  ESandanger  I  et al.  Depression and anxiety amongst multiple sclerosis patients. Eur J Neurol 2008;15 (3) 239- 245
PubMed
Courneya  KSSegal  RJGelmon  K  et al.  Predictors of supervised exercise adherence during breast cancer chemotherapy. Med Sci Sports Exerc 2008;40 (6) 1180- 1187
PubMed
Maddocks  MMockett  SWilcock  A Is exercise an acceptable and practical therapy for people with or cured of cancer? a systematic review. Cancer Treat Rev 2009;35 (4) 383- 390
PubMed
Institute of Medicine, Improving the Quality of Health Care for Mental and Substance-Use Conditions.  Washington, DC National Academies Press2005;
Yates  JSMustian  KMMorrow  GR  et al.  Prevalence of complementary and alternative medicine use in cancer patients during treatment. 1 Support Care Cancer 2005;13 (10) 806- 811
PubMed
Lin  PCampbell  DGChaney  EF  et al.  The influence of patient preference on depression treatment in primary care. Ann Behav Med 2005;30 (2) 164- 173
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

Flowchart for selection of studies

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

The distribution of the unweighted effects. Panels A-C represent a continuous forest plot. CI indicates confidence interval.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Definitions for Levels of Primary Moderators
Table Graphic Jump LocationTable 2. Definitions for Levels of Secondary Moderators
Table Graphic Jump LocationTable 3. Summary of Univariate Moderator Analysis
Table Graphic Jump LocationTable 4. Standardized Regression Coefficients for Remaining Primary and Secondary Moderators

References

Barlow  DH Anxiety and Its Disorders. 2nd ed. New York, NY Guilford2002;
Kuehn  BM Asthma linked to psychiatric disorders. JAMA 2008;299 (2) 158- 160
PubMed
Dahl  AAHaaland  CFMykletun  A  et al.  Study of anxiety disorder and depression in long-term survivors of testicular cancer. J Clin Oncol 2005;23 (10) 2389- 2395
PubMed
Fan  AZStrine  TWJiles  RMokdad  AH Depression and anxiety associated with cardiovascular disease among persons aged 45 years and older in 38 states of the United States, 2006. Prev Med 2008;46 (5) 445- 450
PubMed
Moffitt  TEHarrington  HCaspi  A  et al.  Depression and generalized anxiety disorder: cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Arch Gen Psychiatry 2007;64 (6) 651- 660
PubMed
Kunik  MERoundy  KVeazey  C  et al.  Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest 2005;127 (4) 1205- 1211
PubMed
Korostil  MFeinstein  A Anxiety disorders and their clinical correlates in multiple sclerosis patients. Mult Scler 2007;13 (1) 67- 72
PubMed
Roy-Byrne  PPDavidson  KWKessler  RC  et al.  Anxiety disorders and comorbid medical illness. Gen Hosp Psychiatry 2008;30 (3) 208- 225
PubMed
Stein  MBRoy-Byrne  PPCraske  MG  et al.  Functional impact and health utility of anxiety disorders in primary care outpatients. Med Care 2005;43 (12) 1164- 1170
PubMed
Tohen  MCalabrese  JVieta  E  et al.  Effect of comorbid anxiety on treatment response in bipolar depression. J Affect Disord 2007;104 (1-3) 137- 146
PubMed
Sherbourne  CDHays  RDOrdway  LDiMatteo  MRKravitz  RL Antecedents of adherence to medical recommendations: results from the medical outcomes study. J Behav Med 1992;15 (5) 447- 468
PubMed
Sareen  JJacobi  FCox  BJBelik  SLClara  IStein  MB Disability and poor quality of life associated with comorbid anxiety disorders and physical conditions. Arch Intern Med 2006;166 (19) 2109- 2116
PubMed
Kessler  RCOrmel  JDemler  OStang  PE Comorbid mental disorders account for the role impairment of commonly occurring chronic physical disorders: results from the National Comorbidity Survey. J Occup Environ Med 2003;45 (12) 1257- 1266
PubMed
Kroenke  KSpitzer  RLWilliams  JBMonahan  POLowe  B Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007;146 (5) 317- 325
PubMed
Allgulander  CDahl  AAAustin  C  et al.  Efficacy of sertraline in a 12-week trial for generalized anxiety disorder. Am J Psychiatry 2004;161 (9) 1642- 1649
PubMed
Mitte  K Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder. Psychol Bull 2005;131 (5) 785- 795
PubMed
Lovell  KCox  DHaddock  G  et al.  Telephone administered cognitive behaviour therapy for treatment of obsessive compulsive disorder: randomised controlled non-inferiority trial. BMJ 2006;333 (7574) 883
PubMed
Kessler  RCSoukup  JDavis  RB  et al.  The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatry 2001;158 (2) 289- 294
PubMed
van der Watt  GLaugharne  JJanca  A Complementary and alternative medicine in the treatment of anxiety and depression. Curr Opin Psychiatry 2008;21 (1) 37- 42
PubMed
 Physical Activity Guidelines for Americans Scientific Database. Division of Nutrition, Physical Activity, and Obesity at the Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health: appendix F.1-3: promotion. US Department of Health and Human Services Web site. http://www.health.gov/paguidelines/report/. Accessed August 17, 2007
Stewart  ALHays  RDWells  KBRogers  WHSpritzer  KLGreenfield  S Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the medical outcomes study. J Clin Epidemiol 1994;47 (7) 719- 730
PubMed
Lavie  CJMilani  RV Adverse psychological and coronary risk profiles in young patients with coronary artery disease and benefits of formal cardiac rehabilitation. Arch Intern Med 2006;166 (17) 1878- 1883
PubMed
Long  BCvan Stavel  R Effects of exercise training on anxiety: a meta-analysis. J Appl Sport Psychol 1995;7 (2) 167- 189
PubMed10.1080/1041320950846963
McDonald  DGHodgdon  JA The Psychological Effects of Aerobic Fitness Training: Research and Theory.  New York, NY Springer-Verlag1991;
Petruzzello  SJLanders  DMHatfield  BDKubitz  KASalazar  W A meta-analysis on the anxiety-reducing effects of acute and chronic exercise: outcomes and mechanisms. Sports Med 1991;11 (3) 143- 182
PubMed
Schlicht  W Does physical exercise reduce anxious emotions? a meta-analysis. Anxiety Stress Coping 1994;6 (4) 275- 288
PubMed
Rossy  LABuckelew  SPDorr  N  et al.  A meta-analysis of fibromyalgia treatment interventions. Ann Behav Med 1999;21 (2) 180- 191
PubMed
Kugler  JSeelbach  HKruskemper  GM Effects of rehabilitation exercise programmes on anxiety and depression in coronary patients: a meta-analysis. Br J Clin Psychol 1994;33 (pt 3) 401- 410
PubMed
Puetz  TWBeasman  KMO’Connor  PJ The effect of cardiac rehabilitation exercise programs on feelings of energy and fatigue: a meta-analysis of research from 1945 to 2005. Eur J Cardiovasc Prev Rehabil 2006;13 (6) 886- 893
PubMed
Moher  DCook  DJEastwood  SOlkin  IRennie  DStroup  DF Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement: quality of reporting of meta-analyses. Lancet 1999;354 (9193) 1896- 1900
PubMed
Blumenthal  JABabyak  MAMoore  KA  et al.  Effects of exercise training on older patients with major depression. Arch Intern Med 1999;159 (19) 2349- 2356
PubMed
Blumenthal  JASherwood  ABabyak  MA  et al.  Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: a randomized controlled trial. JAMA 2005;293 (13) 1626- 1634
PubMed
Brown  MAGoldstein-Shirley  JRobinson  JCasey  S The effects of a multi-modal intervention trial of light, exercise, and vitamins on women's mood. Women Health 2001;34 (3) 93- 112
PubMed
Burnham  TRWilcox  A Effects of exercise on physiological and psychological variables in cancer survivors. Med Sci Sports Exerc 2002;34 (12) 1863- 1867
PubMed
Chang  PHLai  YShun  S  et al.  Effects of a walking intervention on fatigue-related experiences of hospitalized acute myelogenous leukemia patients undergoing chemotherapy: a randomized controlled trial. J Pain Symptom Manage 2008;35 (5) 524- 534
PubMed
Clark  DIDowning  NMitchell  JCoulson  LSyzpryt  EPDoherty  M Physiotherapy for anterior knee pain: a randomised controlled trial. Ann Rheum Dis 2000;59 (9) 700- 704
PubMed
Courneya  KSFriedenreich  CMQuinney  HAFields  ALAJones  LWFairey  AS A randomized trial of exercise and quality of life in colorectal cancer survivors. Eur J Cancer Care (Engl) 2003;12 (4) 347- 357
PubMed
Courneya  KSSegal  RJMackey  JR  et al.  Effects of aerobic and resistance exercise in breast cancer patients receiving adjuvant chemotherapy: a multicenter randomized controlled trial. J Clin Oncol 2007;25 (28) 4396- 4404
PubMed
Dimeo  FCStieglitz  RDNovelli-Fischer  UFetscher  SKeul  J Effects of physical activity on the fatigue and psychologic status of cancer patients during chemotherapy. Cancer 1999;85 (10) 2273- 2277
PubMed
Dugmore  LDTipson  RJPhillips  MH  et al.  Changes in cardiorespiratory fitness, psychological wellbeing, quality of life, and vocational status following a 12 month cardiac exercise rehabilitation programme. Heart 1999;81 (4) 359- 366
PubMed
Emery  CFSchein  RLHauck  ERMacIntyre  NR Psychological and cognitive outcomes of a randomized trial of exercise among patients with chronic obstructive pulmonary disease. Health Psychol 1998;17 (3) 232- 240
PubMed
Gowans  SEdeHueck  AVoss  SRichardson  M A randomized, controlled trial of exercise and education for individuals with fibromyalgia. Arthritis Care Res 1999;12 (2) 120- 128
PubMed
Gowans  SEdeHueck  AVoss  SSilaj  AAbbey  SEReynolds  WJ Effect of a randomized, controlled trial of exercise on mood and physical function in individuals with fibromyalgia. Arthritis Rheum 2001;45 (6) 519- 529
PubMed
Gusi  NReyes  MCGonzalez-Guerrero  JLHerrera  EGarcia  JM Cost-utility of a walking programme for moderately depressed, obese, or overweight elderly women in primary care: a randomized controlled trial. BMC Public Health 2008;8231
PubMed
Jones  KDBurckhardt  CSDeodhar  AAPerrin  NAHanson  GCBennett  RM A six-month randomized controlled trial of exercise and pyridostigmine in the treatment of fibromyalgia. Arthritis Rheum 2008;58 (2) 612- 622
PubMed
Koukouvou  GKouidi  EIacovides  AKonstantinidou  EKaprinis  GDeligiannis  A Quality of life, psychological and physiological changes following exercise training in patients with chronic heart failure. J Rehabil Med 2004;36 (1) 36- 41
PubMed
Kulcu  DGKurtais  YTur  BSGulec  SSeckin  B The effect of cardiac rehabilitation on quality of life, anxiety and depression in patients with congestive heart failure: a randomized controlled trial, short-term results. Eura Med Phys 2007;43 (4) 489- 497
PubMed
Mannerkorpi  KNyberg  BAhlmen  MEkdahl  C Pool exercise combined with an education program for patients with fibromyalgia syndrome. a prospective, randomized study. J Rheumatol 2000;27 (10) 2473- 2481
PubMed
McAuley  JWLong  LHeise  J  et al.  A prospective evaluation of the effects of a 12-week outpatient exercise program on clinical and behavioral outcomes in patients with epilepsy. Epilepsy Behav 2001;2 (6) 592- 600
PubMed
Merom  DPhongsavan  PWagner  R  et al.  Promoting walking as an adjunct intervention to group cognitive behavioral therapy for anxiety disorders: a pilot group randomized trial. J Anxiety Disord 2008;22 (6) 959- 968
PubMed
Mock  VDow  KHMeares  CJ  et al.  Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. Oncol Nurs Forum 1997;24 (6) 991- 1000
PubMed
Moug  SJGrant  SCreed  GBoulton Jones  M Exercise during haemodialysis: West of Scotland pilot study. Scott Med J 2004;49 (1) 14- 17
PubMed
Nieman  DCCuster  WFButterworth  DEUtter  ACHenson  DA Psychological response to exercise training and/or energy restriction in obese women. J Psychosom Res 2000;48 (1) 23- 29
PubMed
O'Reilly  SCMuir  KRDoherty  M Effectiveness of home exercise on pain and disability from osteoarthritis of the knee: a randomised controlled trial. Ann Rheum Dis 1999;58 (1) 15- 19
PubMed
Oken  BSKishiyama  SZajdel  D  et al.  Randomized controlled trial of yoga and exercise in multiple sclerosis. Neurology 2004;62 (11) 2058- 2064
PubMed
Paz-Díaz  HMontes de Oca  MLopez  JMCelli  BR Pulmonary rehabilitation improves depression, anxiety, dyspnea and health status in patients with COPD. Am J Phys Med Rehabil 2007;86 (1) 30- 36
PubMed
Petajan  JHGappmaier  EWhite  ATSpencer  MKMino  LHicks  RW Impact of aerobic training on fitness and quality of life in multiple sclerosis. Ann Neurol 1996;39 (4) 432- 441
PubMed
Schachter  CLBusch  AJPeloso  PMSheppard  MS Effects of short versus long bouts of aerobic exercise in sedentary women with fibromyalgia: a randomized controlled trial. Phys Ther 2003;83 (4) 340- 358
PubMed
Seki  EWatanabe  YSunayama  S  et al.  Effects of phase III cardiac rehabilitation programs on health-related quality of life in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP). Circ J 2003;67 (1) 73- 77
PubMed
Skrinar  GSHuxley  NAHutchinson  DSMenninger  EGlew  P The role of a fitness intervention on people with serious psychiatric disabilities. Psychiatr Rehabil J 2005;29 (2) 122- 127
PubMed
Sørensen  MAnderssen  SHjerman  IHolme  IUrsin  H The effect of exercise and diet on mental health and quality of life in middle-aged individuals with elevated risk factors for cardiovascular disease. J Sports Sci 1999;17 (5) 369- 377
PubMed
Stanton  JMArroll  B The effect of moderate exercise on mood in mildly hypertensive volunteers: a randomized controlled trial. J Psychosom Res 1996;40 (6) 637- 642
PubMed
Sutherland  GAndersen  MBStoov  MA Can aerobic exercise training affect health-related quality of life for people with multiple sclerosis? J Sport Exerc Psychol 2001;23 (2) 122- 135
PubMed
Tench  CMMcCarthy  JMcCurdie  IWhite  PDD'Cruz  DP Fatigue in systemic lupus erythematosus: a randomized controlled trial of exercise. Rheumatology (Oxford) 2003;42 (9) 1050- 1054
PubMed
Thorsen  LSkovlund  EStromme  SBHornslien  KDahl  AAFossa  SD Effectiveness of physical activity on cardiorespiratory fitness and health-related quality of life in young and middle-aged cancer patients shortly after chemotherapy. J Clin Oncol 2005;23 (10) 2378- 2388
PubMed
Tomas-Carus  PGusi  NHakkinen  AHakkinen  KLeal  AOrtega-Alonso  A Eight months of physical training in warm water improves physical and mental health in women with fibromyalgia: a randomized controlled trial. J Rehabil Med 2008;40 (4) 248- 252
PubMed
Tsai  JCWang  WHChan  P  et al.  The beneficial effects of tai chi chuan on blood pressure and lipid profile and anxiety status in a randomized controlled trial. J Altern Complement Med 2003;9 (5) 747- 754
PubMed
van den Berg-Emons  RBalk  ABussmann  HStam  H Does aerobic training lead to a more active lifestyle and improved quality of life in patients with chronic heart failure? Eur J Heart Fail 2004;6 (1) 95- 100
PubMed
Wand  BMBird  CMcAuley  JHDore  CJMacDowell  MDe Souza  LH Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise. Spine (Phila Pa 1976) 2004;29 (21) 2350- 2356
PubMed
Yu  CMLau  CPChau  J  et al.  A short course of cardiac rehabilitation program is highly cost effective in improving long-term quality of life in patients with recent myocardial infarction or percutaneous coronary intervention. Arch Phys Med Rehabil 2004;85 (12) 1915- 1922
PubMed
Hedges  LVOlkin  I Statistical Methods for Meta-analysis.  New York, NY Academic Press1985;
Rosenthal  R Parametric measures of effect size. Cooper  HHedges  LVThe Handbook of Research Synthesis. New York, NY Russell Sage Foundation1994;231- 244
Lipsey  MWWilson  DB Practical Meta-analysis.  Newbury Park, CA Sage2001;
Rosenberg  MS The file-drawer problem 1 revisited: a general weighted method for calculating fail-safe numbers in meta analysis. Evolution 2005;59 (2) 464- 468
PubMed
Rosenthal  RDiMatteo  MR Meta-analysis: recent developments in quantitative methods for literature reviews. Annu Rev Psychol 2001;5259- 82
PubMed
Dunn  ALTrivedi  MHO’Neal  HA Physical activity dose-response effects on outcomes of depression and anxiety. Med Sci Sports Exerc 2001;33 (6) ((suppl)) S587- S597
PubMed
Puetz  TWO’Connor  PJDishman  RK Effects of chronic exercise on feelings of energy and fatigue: a quantitative synthesis. Psychol Bull 2006;132 (6) 866- 876
PubMed
Wipfli  BMRethorst  CDLanders  DM The anxiolytic effects of exercise: a meta-analysis of randomized trials and dose-response analysis. J Sport Exerc Psychol 2008;30 (4) 392- 410
PubMed
Rosenthal  R Meta-analytic Procedures for Social Research.  London, England Sage Publications1991;
Gleser  LJOlkin  I Stochastically dependent effect sizes. Cooper  HHedges  LVThe Handbook of Research Synthesis. New York, NY Sage1994;339- 355
Colcombe  SKramer  AF Fitness effects on the cognitive function of older adults: a meta-analytic study. Psychol Sci 2003;14 (2) 125- 130
PubMed
Lawlor  DAHopker  SW The effectiveness of exercise as an intervention in the management of depression: systematic review and meta-regression analysis of randomised controlled trials. BMJ 2001;322 (7289) 763- 767
PubMed
Motl  RWGosney  JL Effect of exercise training on quality of life in multiple sclerosis: a meta-analysis. Mult Scler 2008;14 (1) 129- 135
PubMed
Davidson  JRZhang  WConnor  KM  et al.  A psychopharmacological treatment algorithm for GAD [published online October 2, 2008]. J Psycho- pharmacol
PubMed10.1177/0269881108096505
Heyn  PAbreu  BCOttenbacher  KJ The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis. Arch Phys Med Rehabil 2004;85 (10) 1694- 1704
PubMed
Gardner  AWPoehlman  ET Exercise rehabilitation programs for the treatment of claudication pain. a meta-analysis. JAMA 1995;274 (12) 975- 980
PubMed
Spielberger  CDGorsuch  RLLushene  REVagg  PRJacobs  GA Manual for the State-Trait Anxiety Inventory (Form Y).  Palo Alto, CA Consulting Psychologists Press1983;
Jorm  AF Modifiability of trait anxiety and neuroticism: a meta-analysis of the literature. Aust N Z J Psychiatry 1989;23 (1) 21- 29
PubMed
Kirkwood  GRampes  HTuffrey  VRichardson  JPilkington  K Yoga for anxiety: a systematic review of the research evidence. Br J Sports Med 2005;39 (12) 884- 891
PubMed
Manzoni  GMPagnini  FCastelnuovo  GMolinari  E Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC Psychiatry 2008;841
PubMed
Moyer  CARounds  JHannum  JW A meta-analysis of massage therapy research. Psychol Bull 2004;130 (1) 3- 18
PubMed
Clément  YCalatayud  FBelzung  C Genetic basis of anxiety like behaviour: a critical review. Brain Res Bull 2002;57 (1) 57- 71
PubMed
Kabacoff  RISegal  DLHersen  MVan Hasselt  VB Psychometric properties and diagnostic utility of the Beck Anxiety Inventory and the State-Trait Anxiety Inventory with older adult psychiatric patients. J Anxiety Disord 1997;11 (1) 33- 47
PubMed
Cameron  OGLee  MAKotun  JMcPhee  KM Circadian symptom fluctuations in people with anxiety disorders. J Affect Disord 1986;11 (3) 213- 218
PubMed
Monteleone  PMaj  M The circadian basis of mood disorders: recent developments and treatment implications. Eur Neuropsychopharmacol 2008;18 (10) 701- 711
PubMed
Alsene  KDeckert  JSand  Pde Wit  H Association between A2a receptor gene polymorphisms and caffeine-induced anxiety. Neuropsychopharmacology 2003;28 (9) 1694- 1702
PubMed
Youngstedt  SDKripke  DF Does bright light have an anxiolytic effect? an open trial. BMC Psychiatry 2007;762
PubMed
Pate  RRPratt  MBlair  SN  et al.  Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273 (5) 402- 407
PubMed
Broocks  ABandelow  BPekrun  G  et al.  Comparison of aerobic exercise, clomipramine, and placebo in treatment of panic disorder. Am J Psychiatry 1998;155 (5) 603- 609
PubMed
Mead  GEMorley  WCampbell  PGreig  CAMcMurdo  MLawlor  DA Exercise for depression. Cochrane Database Syst Rev 2008; (4) CD004366
PubMed
Schmitz  KHHoltzman  JCourneya  KSMâsse  LCDuval  SKane  R Controlled physical activity trials in cancer survivors: a systematic review and meta-analysis. Cancer Epidemiol Biomarkers Prev 2005;14 (7) 1588- 1595
PubMed
Beiske  AGSvensson  ESandanger  I  et al.  Depression and anxiety amongst multiple sclerosis patients. Eur J Neurol 2008;15 (3) 239- 245
PubMed
Courneya  KSSegal  RJGelmon  K  et al.  Predictors of supervised exercise adherence during breast cancer chemotherapy. Med Sci Sports Exerc 2008;40 (6) 1180- 1187
PubMed
Maddocks  MMockett  SWilcock  A Is exercise an acceptable and practical therapy for people with or cured of cancer? a systematic review. Cancer Treat Rev 2009;35 (4) 383- 390
PubMed
Institute of Medicine, Improving the Quality of Health Care for Mental and Substance-Use Conditions.  Washington, DC National Academies Press2005;
Yates  JSMustian  KMMorrow  GR  et al.  Prevalence of complementary and alternative medicine use in cancer patients during treatment. 1 Support Care Cancer 2005;13 (10) 806- 811
PubMed
Lin  PCampbell  DGChaney  EF  et al.  The influence of patient preference on depression treatment in primary care. Ann Behav Med 2005;30 (2) 164- 173
PubMed

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