As a fitness professional, you undoubtedly know how prevalent anxiety is. You may know people who are living with anxiety. They may be your colleagues, your clients … heck, you might even have it yourself. Sadly, there’s only little information on fitness-based remedies that deal with anxiety reduction (except “exercise is good for you”). You’d think anxiety relief was simply a side effect of exercise, but can anxiety be treated with specific fitness programs?
Do you have clients with anxiety? Read on to learn about what exercises you can recommend to your clients to reduce their anxiety.
I’ll try to be comprehensive, but because there’s a lot to cover, some related questions are outside the article scope, such as nutrition, supplements, and a related condition, depression. For these, see my book, The Mental Health Prescription. Readers of the canfitpro blog can get the free PDF.
WHAT IS ANXIETY?
Plain old worry differs from clinically diagnosed anxiety (more accurately, Generalized Anxiety Disorder, or GAD.) According to the psychiatric diagnostic manual, DSM-5, the following criteria apply:
- Excessive worry lasting at least 6 months. “Excessive worry” happens when the worry is disproportionate to the actual risk. Sometimes, this worry is generalized, diffused, and non-specific. You can’t pinpoint the cause as “if this problem went away, so would my worry.”
- Difficulty in controlling the worry
- When at least 3 of the following symptoms occur:
- Edginess or restlessness
- Unusual fatigue
- Inability to concentrate
- Increased muscle soreness or pain
- Difficulty sleeping (whether in falling asleep, waking up throughout the night, or not feeling rested when you wake up)
- Difficulty with daily functioning at work
- Unrelated to other medical conditions, medications, drugs, alcohol consumption, or to any other mental disorder.
Because GAD is a cognitive disorder, blood tests won’t reveal GAD the way it would confirm high blood sugar, for example. GAD is diagnosed and assessed with clinical questionnaires. One of the most common of these questionnaires is the State-Trait Anxiety Inventory (STAI).
In what follows, I will be using the terms “anxiety” and “GAD” interchangeably.
HOW TO EXERCISE FOR ANXIETY REDUCTION
The research into what the optimal exercises really are is not as robust as I’d like. There are still many unanswered questions. In this section, I’ll summarize what’s known so far.
Breathing, Yoga, Cardio or Strength Training?
How awesome would it be if one study compared these four types of workouts head-to-head to settle what really is the best for anxiety? Because, unfortunately, that one comparative study is not available yet, let’s take a look at the existing research we have.
- BREATHING EXERCISES: In one four-week study, 41 GAD patients who were already on medications for at least 2 months, were asked to undergo a supervised weekly 2-hour breathing training, in addition to daily 20-minute breathing practices, on their own.
The result? 73% reported reduced anxiety and 41% actually went into remission.
- YOGA: In one study, 69 GAD sufferers completed 10 days of intense yoga, followed by 6 months of a daily 30-minute yoga practice.The result was a very large initial drop in anxiety, followed by a plateau (but no increase). This study would solidify that yoga as an exercise routine is promising for treating anxiety.
- CARDIO and STRENGTH: One 16-week study grouped 42 participants not diagnosed with GAD as follows:
- relatively low anxiety + cardio
- relatively low anxiety + strength training
- high anxiety + cardio
- high anxiety+ strength training
The result was that no group showed any reductions in their anxiety for the first 8 weeks. The reductions came in weeks 8 to 16.
However, another study has slightly conflicting results. In this study, 30 women with GAD who were on medications for anxiety, were divided into 3 groups:
1: strength training twice per week, lower body exercises only
2: cardio twice per week (cycling)
3: control group: no exercise.
The results show that after 6 weeks, 30% of the no-exercise group experienced remission of their anxiety. Cool. I can see the headlines now: “Sit on your butt. Do nothing. Anxiety gone!”
But there’s more.
In # 2 (cardio), 40% experienced remission.
In # 3 (strength training), 60% of experienced remission.
The clear winner in this study in particular, was strength training.
One study found reduced anxiety immediately after strength training, but levels rose back to baseline within 20 minutes. However, another study found that long-term strength training resulted in more stable reductions. (Unfortunately, the subjects weren’t diagnosed with GAD).
Apparently, there’s more than one way to “skin the anxiety cat.” Different kinds of exercise can help with anxiety.
Confused by these conflicting results? How do you figure out what’s best for individual clients? What’s the right exercise intensity?
EXERCISE INTENSITY FOR ANXIETY REDUCTION
Low-to-moderate. This meta-analysis found that a single bout of high-intensity strength training (over about 70% of 1RM) either causes no change or even increases anxiety. Whereas mostly moderate intensity (50-60% of 1RM) decreases anxiety. In one study, participants reported reductions in anxiety at 10% intensity.
HOW LONG DO YOU NEED TO EXERCISE?
This meta-analysis found that programs longer than 16 weeks reduce anxiety the most. 10 to 15-week programs show moderate effects. Programs shorter than 10 weeks have smaller effects. So the take-away is your business tip for the day: if you offer “anxiety buster” programs, sell packages that have a duration of at least 16 weeks.
This meta-analysis found that “more is not always better.” 3-4 days per week reduces anxiety the most-less or more than 3-4 days would produce more negative results.
EXERCISE VS. OTHER THERAPIES
Diagnosed anxiety is a mental disorder that requires either medications, psychotherapy, or both. This meta-analysis that looked at 6 different studies found exercise programs with effects of “… similar magnitude of the anti-anxiolytic effects from common pharmacotherapy….” But there’s no “either/or” scenario here. Anti-anxiolytics work. Exercise programs work. Just be aware of the anxiety-reducing effects of both.
WHY DOES EXERCISE WORK?
There’s uncertainty about what specific program works best, but there’s little doubt it works. The geeks among us (like me) want to know why it works.
One theory is the distraction hypothesis: focusing on one thing distracts from the cause of the anxiety. If you’re breathing hard from exercising, you focus on the workout, and temporarily forget what’s causing the anxiety.
Another theory is the serotonin hypothesis. Serotonin is a neurotransmitter (brain chemical) that makes you feel content and relaxed. Exercise helps boost serotonin.
Angela Clow and Sarah Edmunds, authors of Physical Activity and Mental Health, propose that exercise affects brain waves. There are 4 different kinds of brain waves: (1) Beta waves are produced when awake and alert. (2) Alpha waves are produced when deeply relaxed, as when you’re lying in bed, not quite asleep, but not quite awake. (3) Delta waves are produced in early forms of sleep and (4) Theta waves are produced during deep sleep. GAD suppresses Alpha waves. Exercise boosts it.
Clow and Edmunds also suggest that “exercise raises the threshold at which anxiety is felt.” Physical arousal ranges from virtually none (as in Alpha, Delta, Theta) to a lot. GAD lowers the threshold above which there’s a sense of “anxiety”. Exercise helps raise that threshold.
As we’ve seen, exercise for anxiety reduction works in several ways. See my article on physical activity and mental health for more.
The research on exercise as a cure to anxiety is still in its infancy. There are still many unanswered questions, such as:
- What’s the minimum “dose” of exercise that reduces anxiety?
- What’s the optimum “dose” of exercise that reduces anxiety?
- Is there a best “form” of exercise? Is cycling superior to swimming, vs. running, vs. aerobics classes, vs. lifting weights?
- Are there differences between men and women?
- Are there differences between young and the elderly?
- Exercise isn’t a panacea. Can we predict who won’t benefit?
- What about cardio plus strength training? Is anxiety reduced even more? In theory, maybe, but in practice, maybe not. Synergistic? Antagonistic?
WHAT WORKS FOR YOUR CLIENTS?
We dove into the research studies on how exercise and anxiety are related. Unfortunately, we saw some conflicting results. Do you feel more confused than informed? Let’s help you figure out what works for your own clients
Remember the importance of measurements. You can’t manage what you don’t measure.
- Find an “anxiety questionnaire” online.
- Make your client fill it out.
- Start them on a program: it can be strength training, cardio, yoga, anything.
- After one workout, have them answer the questionnaire again. If the score improved, you’ve found a workable program. If their anxiety hasn’t dropped, try a different program – a different type of exercise, modified intensity, etc.
For my practice, and to see immediate results of a single workout, I have clients fill out a very quick questionnaire before the workout, and immediately after.
Try this questionnaire:
Rate feelings on a 0-5 scale (0: not felt at all; 5: felt very intensely):
Anger: 0 1 2 3 4 5
Confusion: 0 1 2 3 4 5
Sadness: 0 1 2 3 4 5
Vigor: 0 1 2 3 4 5
Fatigue: 0 1 2 3 4 5
If post-workout ratings fall, we have an effective program. If ratings worsen, try a different program. Ask the client what caused the score differences. Adjust accordingly. If there’s no clear difference, the first variable to tweak is intensity. Try a lower percentage of 1RM. Try longer breaks between sets or alternate a strength exercise with a stretch/mobility drill.
Here we are – knowing what the research says, so far. Exercise prescriptions depend on the client’s problem. This approach works great for anxiety, but maybe not for depression. To learn more about exercise for depression, download the PDF version of my The Mental Health Prescription – free for canfitpro readers. (It also goes into the nutrition side of anxiety and depression).