Anxiety Disorders and
Exercise: The Role for
Health and Fitness
Professionals
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Justin Brown, MPhil, MS,1 Andrew T. Del Pozzi, PhD,2 and Charlie Hicks-Little, PhD1
1
Department of Exercise and Sport Science University of Utah, Salt Lake City, Utah; and 2Integrative Exercise
Physiology Laboratory, School of Kinesiology, Ball State University, Muncie, Indiana
ABSTRACT
ANXIETY DISORDERS ARE PSY-
CHOLOGICAL CONDITIONS
THAT HAVE BOTH BEHAVIORAL
AND PHYSIOLOGICAL RE-
SPONSES THAT CAN BE DETRI-
MENTAL TO HEALTH AND
QUALITY OF LIFE FOR THOSE
WHO EXPERIENCE THEM. IN
ADDITION, ANXIETY DISORDERS
SHARE FEATURES THAT DEFINE
AND SEPARATE THEM FROM
DEPRESSIVE DISORDERS. TYPI-
CAL TREATMENT INCLUDES
PRESCRIPTION MEDICATIONS
AND COGNITIVE BEHAVIORAL
THERAPY. THE PURPOSE OF
THIS ARTICLE IS TO FAMILIARIZE
THE HEALTH AND FITNESS PRO-
FESSIONAL (HFP) WITH THE
SPECIAL CONSIDERATIONS
THAT SHOULD BE ADDRESSED
WHEN WORKING WITH CLIENTS
WHO HAVE ANXIETY DISOR-
DERS. SPECIFICALLY, THE
PREVALENCE OF THE CONDI-
TION AND CLIENT RESPONSES
TO AEROBIC, RESISTANCE, AND
YOGA EXERCISE WILL BE COV-
ERED.
Address correspondence to Justin Brown,
justin@parvo.com.
41 Copyright Ó National Strength and Conditioning Association
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.
INTRODUCTION
nxiety disorders are the most
A common mental illness. They
have a 1-year prevalence of
18% (25,32) and are characterized by
intense and prolonged feelings of fear,
distress, excessive worry, preoccupa-
tion, obsessive thoughts, and appre-
hension. In addition to mental
symptoms, those who experience anx-
iety disorders also exhibit physical
symptoms, such as hypertension, ath-
erosclerosis, rapid breathing and heart-
beat, and myocardial ischemia
(2,31,33,46). Anxiety disorders can be
classified into subgroups such as gen-
eral anxiety disorder, obsessive-
compulsive disorder, post-traumatic
stress disorder, panic disorder, and
social anxiety disorder. Therefore, in
this article, we will discuss how anxiety
disorders affect the body and how
exercise with special considerations
can improve the lives of those who
experience anxiety disorders.
PHYSIOLOGY
Although anxiety disorders are consid-
ered mental or psychological disor-
ders, they can present with physical
symptoms. When exposed to danger,
stress, or fear, the body reacts by acti-
vating physiological and behavioral re-
sponses such as increased alertness,
increased cardiovascular tone, and
increased respiratory rate (9,47). When
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the threat is no longer present, the
body’s physiological processes return
to a state of homeostasis (10). In the
case of anxiety disorders, individuals
perceive continued stress that results
in prolonged deviations from homeo-
stasis (10). When the stress becomes
chronic, there is a hyperactivation of
the sympathetic nervous system and
the hypothalamic-pituitary-adrenal
axis, in addition the release of inflam-
matory mediators (46). As a result, in-
dividuals who experience anxiety
disorders report physical symptoms
such as diabetes, hypertension, irritable
bowel syndrome, trembling, shortness
of breath, chest pain or discomfort,
nausea, dizziness, and hot and cold
flashes (11,23,28,34). Treatment often
includes prescription medications and
cognitive behavioral therapy (1,23).
An additional treatment for anxiety dis-
orders that is often neglected is a carefully
planned exercise program. When exer-
cise is performed 2–3 times per week,
there is an improvement in mood (11)
and a reduction in stress (12,19). Exercise
can be an inexpensive and an easy treat-
ment modality that has been shown to
increase self-confidence while promoting
feelings of satisfaction and overall well-
being. Furthermore, exercise is associated
KEY WORDS:
depression; exercise prescription; panic
 Anxiety and Exercise Prescription
with increases in circulating serotonin
and decreased perception of stress and
hypothalamic-pituitary-adrenal axis acti-
vation. The benefits of exercise clearly
indicate that it should be considered as
a treatment modality when working with
clients who have an anxiety disorder.
EXERCISE MODALITIES
Inactivity and increased sitting time are
associated with numerous diseases such
as obesity, type 2 diabetes, hypertension,
and metabolic syndrome (39,45). Indi-
viduals who are affected by an anxiety
disorder tend to have large amounts of
sedentary time and fail to meet exercise
guidelines (21,52), which puts them at an
increased risk of chronic diseases associ-
ated with low physical activity. A care-
fully designed exercise program should
include goals that are specific to improv-
ing fitness, decreasing muscle tension,
improving cardiovascular risk factors,
mood, and decreasing the negative ef-
fects of anxiety disorders (6,29,37). Exer-
cise should be carefully planned for the
client to avoid any increase in anxiety.
This will mean the health and fitness
professional (HFP) needs to have an
understanding of the specific triggers
for their client, and do their best to avoid
them, so the risk of injury due to
increased anxiety can be avoided. In
addition, it would not be unreasonable
to suggest to a client that they engage in
group activities such as fitness classes or
boot camps because it has been previ-
ously shown that the support one re-
ceives by becoming a regular member
of a group fitness setting is a leading
determinant to exercise adherence (18).
AEROBIC EXERCISE
The avoidance of physical activity and
exercise may result in the individual hav-
ing a lower fitness level and increased
fatigue on exertion, thereby inducing
a negative impact on health. It is, there-
fore, important to engage the clients
with anxiety disorders in some form of
physical activity or exercise program to
avoid the increased risks of all-cause
mortality and chronic conditions associ-
ated with a sedentary lifestyle. Reviews
of exercise and anxiety disorders demon-
strate no negative effects of aerobic
42 VOLUME 41 | NUMBER 5 | OCTOBER 2019
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exercise and suggest a decrease in state
anxiety after a workout (4,6,29). For
example, Broocks et al. (4) investigated
the efficacy of aerobic exercise, clomipr-
amine, and a placebo pill in a group of
subjects suffering from moderate to
severe panic disorder. Treatment was
randomized, and results of the study re-
vealed a significant improvement in anx-
iety scores for aerobic exercise. In
addition, patients taking clomipramine
along with aerobic exercise demon-
strated the greatest improvement in anx-
iety scores. In another study, researchers
demonstrated an improvement in mood
in patients with post-traumatic stress
syndrome after completing 30 minutes
of moderate intensity (70–75% maxi-
mum heart rate) (11). Other investiga-
tions using interval training as the
exercise mode have documented im-
provements in aerobic capacity and
lower depression scores (14,20). Those
results also demonstrated lower scores
for anxiety and insomnia; however, they
were not statistically significant. Shapiro
and Cline (40) examined the effective-
ness of meditation, exercise, or a combi-
nation of the 2 on post-traumatic
cognitions, ruminative thoughts, and
memories in young women with a his-
tory of sexual violence. They found med-
itation alone was effective at reducing
trauma-related thoughts; however, the
combination of meditation and exercise
had a synergestic effect and resulted in
a greater improvement in both and
improved feelings of self-worth (40).
In addition to reduced panic, anxiety,
and depression, exercise helps improve
coronary artery health (36). If the client’s
goals for exercise are independent of state
anxiety reduction, higher intensity aero-
bic exercise may be a better option. In the
case where the HFP prescribes higher
intensity exercise, the duration should
be decreased, keeping the volume
roughly the same, and a mode selected
in which the activity can be safely com-
pleted. Regardless of exercise intensity,
mode, or duration, the HFP should mon-
itor the client using heart rate and rating
of perceived exertion. In addition, the cli-
ent should be granted breaks during exer-
cise to accommodate low initial fitness
levels and to help ensure long-term com-
pliance (29). Using the transtheoretical
model, Findorff et al. found elderly adult
women were more likely to adopt an
exercise program if they had close con-
tact with the provider and continuous
feedback which allows for identification
of personal obstacles to exercise along
with strategies to overcome them (13).
The authors also state to be successful
any intervention to improve exercise
compliance should be tailored to the cli-
ent’s motivational stage (30).
RESISTANCE TRAINING
Resistance training is an exercise modal-
ity that has a positive influence on mus-
cular strength, endurance, bone density,
and body composition. Like aerobic
exercise, individuals who are coping with
an anxiety disorder that partake in resis-
tance exercise training have responded
well with a decrease in anxiety (7,49),
improved mood (7,49,51), decreased
worry (3,22), decreased depression
(35,38,41,43), increased cognition (43),
and reductions in cardiovascular re-
sponses to mental stress (51). Research
has found that when state anxiety levels
are elevated before exercise, there is a re-
sulting decrease in state anxiety indepen-
dent of intensity (15). Strickland and
Smith suggest using a low- to
moderate-intensity (,70% one repetition
maximum [1RM]) load to improve feel-
ings of anxiety (44). Cavaretta et al. (8)
also suggest using lower intensity (50–
70% 1RM). However, Sjogren et al.
2006 found a light intensity of 30%
1RM was too low to reduce anxiety,
which suggests a threshold may exist
for resistance training to improve anxiety
(42). Also, longer rest periods seem to be
more effective on psychological states
than shorter rest periods (2,8). For exam-
ple, Herring et al. (22) allowed a rest inter-
val of 80 seconds between each set of
each exercise and reported no adverse
events. Comparison of intensity has dem-
onstrated high-intensity progressive resis-
tance training had a greater effect on
mental states than low-intensity progres-
sive resistance training or standard care
(pharmacotherapy and/or counseling)
from a general practitioner (41). Although
the reduction was lower for standard care
 from a general practitioner, the continued
presence of general practitioners and
mental health specialists as part of the
treatment team is recommended.
Aerobic training and resistance train-
ing are often combined in a single
exercise session. That combination of
exercise mode has demonstrated
a reduction in symptoms regardless
of exercise order (17).
YOGA
Yoga is an alternative form of exercise
consisting of various physical postures,
breathing techniques, and meditation. In-
dividuals who are dealing with an anxiety
disorder who participated in yoga have
reported reduced anxiety, mental stress,
and depression while experiencing posi-
tive swings in moods, memory, and over-
all quality of life (16,24,27,36,40,41,52,53).
Participating in yoga with or without tak-
ing medications has reportedly better
therapeutic effects than taking medica-
tions alone (16). It has been hypothesized
that breathing patterns associated with
yoga may influence autonomic function,
thereby improving emotion, stress, and
cognition (5). Although yoga is not a tra-
ditional form of exercise, it has shown
benefits for those with anxiety disorders.
Clients who are unwilling or unable to
engage in aerobic or resistance exercise
may consider yoga. Yoga and meditation
have the benefits of being low cost, can be
performed at home, and have a positive
effect on symptoms associated with
anxiety.
FLEXIBILITY
Flexibility is also an important component
of health and fitness. Poor flexibility often
results in limited range of motion, tight
muscles, and poor balance. By performing
various stretches, the goal is to improve
the client’s flexibility and further improve
quality of life. Research regarding improve-
ments in anxiety and depression scores as
a result of stretching is lacking. In a ran-
domized controlled study by Knubben
et al., (25) they found that static stretching
consisting of a 20-second stretch and 40-
second relaxation period, resulted in a 22%
reduction in anxiety scores.
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EXERCISE PRESCRIPTION
The HFP should encourage but not
force the client to participate in fitness
testing because a proper individual
assessment is paramount in developing
and implementing an exercise prescrip-
tion for any population. Changes in fit-
ness and health through exercise testing
should be used to positively increase the
client’s self-efficacy. Although those with
an anxiety disorder may be resistant to
physical activity, clients have responded
favorably to aerobic exercise, resistance
training, and yoga exercises.
The HFP who is tasked with helping an
individual with an anxiety disorder must
consider the principles of interindividual
variability, initial values, overload, and
progression when developing a personal-
ized exercise prescription, while simulta-
neously taking into consideration the
principles of diminishing returns and
reversibility as they continually reassess
the effectiveness of their program. There
is no “one-size-fits-all” exercise prescrip-
tion for those experiencing an anxiety
disorder, but to help the HFP new to
anxiety disorders, a sample initial exercise
program can be found in Table 1.
Although individual tolerance and results
from reassessment will dictate individual
progression, a sample progression exer-
cise prescription has been provided in
Table 2. These exercise prescriptions
should in no way be considered all-
inclusive. As with any client, the HFP
needs to consider client goals, fitness level,
time constraints, and preferences. In addi-
tion, the HFP should provide guidance in
setting realistic and achievable goals and
give the client a sense of control in their
exercise program. For example, clients
who are fearful of public places or embar-
rassment may wish to begin an exercise
program gradually beginning with 2 ses-
sions per week and either increase the
number of sessions per week or the dura-
tion as they become more comfortable
with the HFP, exercise facility, and the
overall routine. Other clients may wish to
use bands, weights, and exercise videos at
home rather than exercising in public
facilities. Finally, some clients may not
enjoy aerobic exercise; in that case, the
HFP should seek out other activities that
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are compatible with the client’s interests
that promote physical activity.
SUMMARY AND PRACTICAL
APPLICATIONS
Anxiety disorders negatively impact the
health and quality of life in those who
are coping with the associated symptoms
and comorbidities of their condition. In
addition, there is a financial burden placed
on patients with an anxiety disorder.
Decreased health and increased financial
burden may worsen symptoms associated
with various anxiety disorders. Although
medications are often the primary
method of treatment, exercise should be
included in conjunction with medications
and may also be used alone depending on
the severity of the disorder and the rec-
ommendations of the medical care team.
Exercise has demonstrated a positive
impact on mood and state anxiety levels.
In addition, exercise can help reduce
other health-related risk factors. Prescrib-
ing safe and realistic exercises should be
considered an important therapeutic
modality for treating clients who have
an anxiety disorder. Proper exercise pre-
scription can help reduce symptom
severity, improve quality of life, decrease
the risk of injury, and decrease other car-
diovascular risk factors. Although exer-
cise testing is useful for exercise
prescription, clients may not wish to par-
ticipate, which could be a trigger for an
increase in anxiety. The HFP should
encourage but not force the patient to
participate in fitness testing. Changes in
fitness and health through exercise test-
ing should be used to positively increase
the client’s self-efficacy. Although those
with an anxiety disorder may be resistant
to physical activity, clients have re-
sponded favorably to aerobic exercise,
resistance training, and yoga exercises.
Exercise has demonstrated positive ef-
fects in various chronic conditions asso-
ciated with autonomic nervous system
disorders, such as chronic fatigue and
postural orthostatic tachycardia syn-
drome, including anxiety disorders. As
with any client, the HFP should obtain
a health history, list of current medica-
tions, and results of exercise testing to
develop a safe exercise plan. Based on
43
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44 VOLUME 41 | NUMBER 5 | OCTOBER 2019

Anxiety and Exercise Prescription

Table 1
Comprehensive exercise prescription for individuals with an anxiety disorder for initial 8 weeks
Mode Intensity Frequency Duration Progression Notes
Aerobic Moderate 5 40–70% HRR 3 days per week 3-min moderate intensity After 4 weeks, increase moderate
Supine cycling, or an RPE of 13–15, and following time to 5 min and add a third
recumbent bicycle low 5 30–50% HRR or 2-min low intensity, set after an additional 2 weeks
Swimming laps RPE of 7–12 3-min moderate increase moderate to 10 min
swimming with intensity, and
a kickboard, rowing 2-min low intensity
Strength/resistance 30–40% 1RM, 2 days per week; 8 weeks Increase percent 1RM by 10% Reevaluate 1RM every 8 weeks
Leg press 2 sets of 8–12 48 hours between adjust percent 1RM to new 1RM
Chest flys repetitions, or failure workouts value
Leg curl with 3-min rest Can be performed on the same
Leg extension between sets day as aerobic if time is
Bench press a concern
Row
Lat pull-down
Shoulder press
Heel raises
Abdominal crunches
Flexibility Static stretches to just Daily 4 repetitions for 10 Increase duration for each stretch
Quad stretch below pain threshold preferably after cool- seconds per stretch by 2 seconds every 2 weeks
Double knee to chest down
Trunk flex
Crossed-leg trunk
rotation
Achilles stretch
Pelvic tilt
Towel stretch
Triceps stretch
Neck rotation
Warm-up/cool-down Low intensity Before and after each 10 min Stays the same throughout. Should be in the mode you will be
workout session performing for that day.
However, even during
resistance training, you should
perform an aerobic warm-up
and cool-down

1RM 5 1 repetition maximum; HRR 5 heart rate reserve; RPE 5 rating of perceived exertion; min 5 minute.
Copyright © National Strength and Conditioning Association. Unauthorized reproduction of this article is prohibited.

Table 2
Second 8-week exercise prescription for individuals with anxiety disorders

Mode Intensity Frequency Duration Progression Notes

Aerobic Low 5 30–40% HRR or an 3 days per week 30-min moderate intensity After 4 weeks, increase intensity
Supine cycling, RPE of 7–12, to heavy and decrease duration
recumbent bicycle moderate 5 40–70% by 5 min
Swimming laps HRR or an RPE of
swimming with 13–15, and
a kickboard, rowing heavy 5 65–80% HRR or
an RPE of 16–19
Strength/resistance 50–70% 1RM, 2 days per week; 8 weeks Increase percent 1RM by 10% Reevaluate 1RM every 8 weeks
Leg press 2 sets of 8–12 48 hours between adjust percent 1RM to new 1RM
Chest flys repetitions, or failure workouts value
Leg curl with 3-min rest Can be performed on the same
Leg extension between sets day as aerobic if time is
Bench press a concern
Row
Lat pull-down
Shoulder press
Heel raises
Abdominal crunches
Flexibility Static stretches to just Daily 4 repetitions for 20 Increase duration for each stretch
Quad stretch below pain threshold preferably after cool- seconds per stretch by 2 seconds every 2 weeks
Double knee to chest down until 2 min in duration per
Trunk flex stretch is reached.
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Crossed-leg trunk
rotation
Achilles stretch
Pelvic tilt
Towel stretch
Triceps stretch
Neck rotation
Warm-up/cool-down Low intensity Before and after each 10 min Stays the same throughout. Should be in the mode you will be
workout session performing for that day.
However, even during
resistance training, you should
perform an aerobic warm-up
and cool-down

Following the second 8 weeks, all assessments should be performed and intensity reevaluated to ensure that participants continue to progress within their exercise program.

1RM 5 1 repetition maximum; HRR 5 heart rate reserve; RPE 5 rating of perceived exertion; min 5 minute.
45
 Anxiety and Exercise Prescription
the scientific literature, light-intensity
exercise is preferred because of the state
anxiety response compared with moder-
ate- and high-intensity exercise. Multiple
modalities can be incorporated to
improve aerobic capacity, strength, bone
density, body composition, and flexibility.
The HFP should use informed judgment
when prescribing exercise and carefully
consider frequency, intensity, duration,
and progression. A carefully prescribed
exercise program will alternate heavy
and light training days to help prevent
injuries while improving health and
decreasing state anxiety.
Conflicts of interest and source of funding:
The authors report no conflicts of interest
and no source of funding.
Justin Brown
works at Parvo-
Medics, Inc.
Andrew T. Del
Pozzi is an assis-
tant professor at
Ball State
University.
Charlie Hicks-
Little is an Asso-
ciate Professor in
the Department
of Physical Ther-
apy and Athletic
Training and
Director of the
Sports Medicine
Research Laboratory at the University
of Utah.
46 VOLUME 41 | NUMBER 5 | OCTOBER 2019
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