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Physical activity on anxiety symptoms during the COVID-19 pandemic: a systematic review

Atividade física nos sintomas de ansiedade durante a pandemia de COVID-19: uma revisão sistemática

Abstracts

Abstract

This systematic review aimed to investigate the effect of physical activity on anxiety symptoms during the COVID-19 pandemic. Three databases (PubMed; Scopus and Web of Science) were searched in the period from 2020 to 2022 the following base terms were used: “Physical Activity”, Exercise, Anxiety and COVID-19. Peer-reviewed, primary studies published in English, Portuguese and Spanish using valid and reliable measures were included. Eighteen studies met the eligibility criteria, of which 17 were cross-sectional, 2 were cohort studies. The number of participants ranged from 43 to 2,301, aged between 18 and 65 years or older. A decrease in PA practice or an increase in sitting time were associated with higher levels of anxiety symptoms. Additionally, participants who did not meet PA recommendations were more likely to experience moderate to severe anxiety symptoms. The results showed that physical activity is associated with the alleviation of anxiety symptoms during confinement in the COVID-19 pandemic.

Key words:
Social Isolation; Mental Health; Lockdown; COVID-19; Angst; Physical activity


Resumo

Esta revisão sistemática teve como objetivo investigar o efeito da atividade física nos sintomas de ansiedade durante a pandemia de COVID-19. Foram pesquisadas três bases de dados (PubMed; Scopus e Web of Science) no período de 2020 a 2022 foram utilizados os seguintes termos base: “Physical Activity”, Exercise, Anxiety e COVID-19. Foram incluídos estudos primários, revisados ​​por pares, publicados em inglês, português e espanhol usando medidas válidas e confiáveis. Dezoito estudos preencheram os critérios de elegibilidade, sendo 17 transversais, 2 estudos de coorte. O número de participantes variou de 43 a 2.301, com idade entre 18 e 65 anos ou mais. Uma diminuição na prática de AF ou um aumento no tempo sentado foram associados a níveis mais elevados de sintomas de ansiedade. Além disso, os participantes que não atendiam às recomendações de AF eram mais propensos a apresentar sintomas de ansiedade moderados a graves. Os resultados mostraram que a atividade física está associada ao alívio dos sintomas de ansiedade durante o confinamento na pandemia de COVID-19.

Palavras-chave:
Isolamento Social; Saúde mental; Confinamento; COVID-19; Angústia; Atividade física


INTRODUCTION

The COVID-19 pandemic has been the target of research regarding mental health, due to the impact it has on the global health of the population11 Sepúlveda-Loyola W, Rodríguez-Sánchez I, Pérez-Rodríguez P, Ganz F, Torralba R, Oliveira DV, et al. Impact of Social Isolation Due to COVID-19 on Health in Older People: Mental and Physical Effects and Recommendations. J Nutr Health Aging. 2020;24(9):938-47. http://dx.doi.org/10.1007/s12603-020-1500-7. PMid:33155618.
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.

Recent evidence suggests that people who are kept in isolation and quarantine experience significant levels of anxiety, anger, confusion, and stress1010 Faisal RA, Jobe MC, Ahmed O, Sharker T. Mental health status, anxiety, and depression levels of Bangladeshi University students during the COVID-19 pandemic. Int J Ment Health Addict. 2022;20(3):1500-15. http://dx.doi.org/10.1007/s11469-020-00458-y. PMid:33424514.
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, as it was also seen in the influenza epidemic in 20081515 Taylor MR, Agho KE, Stevens GJ, Raphael B. Factors influencing psychological distress during a disease epidemic: Data from Australia’s first outbreak of equine influenza. BMC Public Health. 2008;8(1):347. http://dx.doi.org/10.1186/1471-2458-8-347. PMid:18831770.
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, and H1N1 in 20091616 Wang Y, Xu B, Zhao G, Cao R, He X, Fu S. Is quarantine related to immediate negative psychological consequences during the 2009 H1N1 epidemic? Gen Hosp Psychiatry. 2011;33(1):75-7. http://dx.doi.org/10.1016/j.genhosppsych.2010.11.001. PMid:21353131.
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. The first systematic review and meta-analysis on the prevalence of stress, anxiety, and depression in the general population resulting from the COVID-19 pandemic showed that the prevalence of stress, anxiety, and depression are 29.6, 31.9, and 33.7%, respectively99 Salari N, Hosseinian-Far A, Jalali R, Vaisi-Raygani A, Rasoulpoor S, Mohammadi M, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Global Health. 2020;16(1):57. http://dx.doi.org/10.1186/s12992-020-00589-w. PMid:32631403.
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, revealing that a significant portion of people is becoming mentally ill, not directly from the SARS-CoV-2 virus infection, but due to the nuisances of the pandemic in general. In a recent systematic review, it was found that the prevalence of anxiety and depression in 2020 were 32.6% and 27.6%, respectively1717 Liu X, Zhu M, Zhang R, Zhang J, Zhang C, Liu P, et al. Public mental health problems during COVID-19 pandemic: a large-scale meta-analysis of the evidence. Transl Psychiatry. 2021;11(1):384. http://dx.doi.org/10.1038/s41398-021-01501-9. PMid:34244469.
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.

One of the problems related to mental disorders during the COVID-19 pandemic was physical inactivity. Puccinelli et al.1818 Puccinelli PJ, da Costa TS, Seffrin A, de Lira CAB, Vancini RL, Nikolaidis PT, et al. Reduced level of physical activity during COVID-19 pandemic is associated with depression and anxiety levels: an internet-based survey. BMC Public Health. 2021;21(1):425. http://dx.doi.org/10.1186/s12889-021-10470-z.
http://dx.doi.org/10.1186/s12889-021-104...
showed that 30% and 23.3% of the subjects evaluated in their study (n=1853) had moderate/severe symptoms of depression and anxiety, respectively, associated with a reduction in PA. The health benefits of regular exercise are well established in the scientific literature1717 Liu X, Zhu M, Zhang R, Zhang J, Zhang C, Liu P, et al. Public mental health problems during COVID-19 pandemic: a large-scale meta-analysis of the evidence. Transl Psychiatry. 2021;11(1):384. http://dx.doi.org/10.1038/s41398-021-01501-9. PMid:34244469.
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,1919 Bartley CA, Hay M, Bloch MH. Meta-analysis: Aerobic exercise for the treatment of anxiety disorders. Prog Neuropsychopharmacol Biol Psychiatry. 2013;45:34-9. http://dx.doi.org/10.1016/j.pnpbp.2013.04.016. PMid:23643675.
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20 Ensari I, Greenlee TA, Motl RW, Petruzzello SJ. Meta-analysis of acute exercise effects on state anxiety: An update of randomized controlled trials over the past 25 years. Depress Anxiety. 2015;32(8):624-34. http://dx.doi.org/10.1002/da.22370. PMid:25899389.
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21 Jayakody K, Gunadasa S, Hosker C. Exercise for anxiety disorders: Systematic review. Br J Sports Med. 2014;48(3):3853-62. http://dx.doi.org/10.1136/bjsports-2012-091287. PMid:23299048.
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22 de Sousa RAL, Rocha-Dias I, de Oliveira LRS, Improta-Caria AC, Monteiro-Junior RS, Cassilhas RC. Molecular mechanisms of physical exercise on depression in the elderly: A systematic review. Mol Biol Rep. 2021;48(4):3853-62. http://dx.doi.org/10.1007/s11033-021-06330-z. PMid:33864590.
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-2323 Parry DA, Oeppen RS, Amin MSA, Brennan PA. Could exercise improve mental health and cognitive skills for surgeons and other healthcare professionals? Br J Oral Maxillofac Surg. 2018;56(5):367-70. http://dx.doi.org/10.1016/j.bjoms.2018.03.005. PMid:29650472.
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, which can be an important intervention in combating the negative effects of the COVID-19 pandemic on mental health2222 de Sousa RAL, Rocha-Dias I, de Oliveira LRS, Improta-Caria AC, Monteiro-Junior RS, Cassilhas RC. Molecular mechanisms of physical exercise on depression in the elderly: A systematic review. Mol Biol Rep. 2021;48(4):3853-62. http://dx.doi.org/10.1007/s11033-021-06330-z. PMid:33864590.
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,2424 Ranasinghe C, Ozemek C, Arena R. Exercise and well-being during COVID-19 - Time to boost your immunity. Expert Rev Anti Infect Ther. 2020;18(12):1195-200. http://dx.doi.org/10.1080/14787210.2020.1794818. PMid:32662717.
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,2525 de Sousa RAL, Improta-Caria AC, Aras-Júnior R, de Oliveira EM, Soci ÚPR, Cassilhas RC. Physical exercise effects on the brain during COVID-19 pandemic: links between mental and cardiovascular health. Neurol Sci. 2021;42(4):1325-34. http://dx.doi.org/10.1007/s10072-021-05082-9. PMid:33492565.
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.

The recommendations for regular PA during this pandemic period follow the standards established by the World Health Organization (WHO) and the American College of Sports Medicine (ACSM)2626 Bull FC, Al-Ansari SS, Biddle S, Borodulin K, Buman MP, Cardon G, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020;54(24):1451-62. http://dx.doi.org/10.1136/bjsports-2020-102955. PMid:33239350.
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27 Meira CM Jr, Meneguelli KS, Leopoldo MPG, Florindo AA. Anxiety and leisure-domain physical activity frequency, duration, and intensity during Covid-19 pandemic. Front Psychol. 2020;11:603770. http://dx.doi.org/10.3389/fpsyg.2020.603770. PMid:33447249.
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-2828 Twining PK. Resources for staying active during the COVID-19 pandemic. Burlington: University of Vermont; 2021. Family Medicine Clerkship Projects; 641., as there are no studies that can guide the real need for changes in current recommendations. Thus, it is not known whether social distancing, lockdown, and other physical restrictions due to the COVID-19 pandemic allowed studies on exercise to be performed following the traditional parameters recommended by international institutions. The real effects of these training programs on anxiety disorder during the pandemic period are still unclear since there is still no compilation of studies performed to date.

Therefore, the present systematic review aimed to evaluate the effects of physical activity specifically on anxiety symptoms in studies conducted during the COVID-19 pandemic. Further, the training protocols were analyzed and compared to traditional recommendations provided by the WHO and ACSM.

METHODS

Study design

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist2929 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. PLoS Med. 2021;18(3):e1003583. http://dx.doi.org/10.1371/journal.pmed.1003583. PMid:33780438.
http://dx.doi.org/10.1371/journal.pmed.1...
. Studies were included according to the Participants, Intervention, Comparison, Outcomes, and Study design (PICOS) criteria: 1): men and women over 18 years old, physically active or sedentary, with no history of joint or musculoskeletal damage, and without psychiatric illness; 2): increased physical activity or exercise; 3): sedentary subjects or active control within the exercise group; 4): Anxiety symptoms; 5): randomized and non-randomized trials and observational studies. Conference abstracts, dissertations, theses, book chapters, and studies published in non-peer-reviewed journals were not included.

Search strategy

Original studies on physical activity and anxiety symptoms during the COVID-19 pandemic were analyzed. PubMed/MEDLINE, Scopus and Web of Science databases were used, where the following Mesh terms were combined: “Physical Activity”, “Exercise”, “Anxiety”, “Angst”, “Anxiousness”, “COVID-19”, “Coronavirus” and “Sars-Cov-2”. For each database, adequacy of the search strategy was performed (Chart 1). The searches took place between February 2021 and January 2022. For each database, combinations of descriptors and terms and their respective synonyms in English were used.

Chart 1
Search strategy performed in each database.

In July 2022, the searches were updated to include studies that were published between January and July. We selected ten studies for full reading. For the analysis, only one study met the eligibility criteria3030 Al-Ajlouni YA, Park SH, Alawa J, Dodin B, Shamaileh G, Makarem N, et al. Staying Physically Active Is Associated with Better Mental Health and Sleep Health Outcomes during the Initial Period of COVID-19 Induced Nation-Wide Lockdown in Jordan. Int J Environ Res Public Health. 2022;19(2):776. http://dx.doi.org/10.3390/ijerph19020776. PMid:35055598.
http://dx.doi.org/10.3390/ijerph19020776...
. As five other studies3131 To QG, Vandelanotte C, Cope K, Khalesi S, Williams SL, Alley SJ, et al. The association of resilience with depression, anxiety, stress and physical activity during the COVID-19 pandemic. BMC Public Health. 2022;22(1):491. http://dx.doi.org/10.1186/s12889-022-12911-9. PMid:35279118.
http://dx.doi.org/10.1186/s12889-022-129...

32 Faulkner J, O’Brien WJ, McGrane B, Wadsworth D, Batten J, Askew CD, et al. Physical activity, mental health and well-being of adults during initial COVID-19 containment strategies: a multi-country cross-sectional analysis. J Sci Med Sport. 2021;24(4):320-6. http://dx.doi.org/10.1016/j.jsams.2020.11.016. PMid:33341382.
http://dx.doi.org/10.1016/j.jsams.2020.1...

33 Faulkner J, O’brien WJ, Stuart B, Stoner L, Batten J, Wadsworth D, et al. Physical activity, mental health and wellbeing of adults within and during the easing of COVID‐19 restrictions, in the United Kingdom and New Zealand. Int J Environ Res Public Health. 2022;19(3):1792. http://dx.doi.org/10.3390/ijerph19031792. PMid:35162815.
http://dx.doi.org/10.3390/ijerph19031792...

34 Galli F, Giancamilli F, Palombi T, Vitale JA, Borghi S, de Maria A, et al. Anxiety, motives, and intention for physical activity during the Italian COVID-19 Lockdown: an observational longitudinal study. Int J Environ Res Public Health. 2022;19(8):4689. http://dx.doi.org/10.3390/ijerph19084689. PMid:35457555.
http://dx.doi.org/10.3390/ijerph19084689...
-3535 Silva DTC, Prado WL, Cucato GG, Correia MA, Ritti-Dias RM, Lofrano-Prado MC, et al. Impact of COVID-19 pandemic on physical activity level and screen time is associated with decreased mental health in Brazillian adults: a cross-sectional epidemiological study. Psychiatry Res. 2022;314:114657. http://dx.doi.org/10.1016/j.psychres.2022.114657. PMid:35696934.
http://dx.doi.org/10.1016/j.psychres.202...
did not meet eligibility criteria, we could only use them for our discussion.

Study selection criteria

Studies were included in this review after adhering to the criteria: (i) studies performed during the COVID-19 pandemic period, published in English, Portuguese or Spanish, in peer-reviewed journals; (ii) intervention studies with exercise or observational studies (screening of physical activity or exercise); (iii) sample composed of people with an assessment of “anxiety” through validated instruments.

Data screening

Each study was selected based on “Titles and Abstract.” Then, the full text was evaluated to confirm inclusion or exclusion. Title, abstract and full-text screening was performed by one reviewer and verified by three other independent reviewers (IRDDS; LFFF; EHES; EOB). Any discrepancies in the inclusion or exclusion of scientific articles were resolved in consultation with a fifth reviewer (RSMJ). The retrieved articles were cataloged, and the duplicates were removed.

Data extraction

The following information was extracted: author, year, type of study, objective, sample, instruments used, intervention, and results. Three independent reviewers extracted data. A fourth reviewer gathered the extracted information and organized the results.

Risk of bias

The Joanna Briggs Institute manual (JBI)3636 Joanna Briggs Institute. Checklist for analytical cross sectional studies. Joanna Briggs Institute Reviewer’s Manual [Internet]. Adelaide, Australia: Joanna Briggs Institute; 2017. p. 1-7. [cited 2023 January 30]. Available from: http://joannabriggs.org/research/critical-appraisal-tools
http://joannabriggs.org/research/critica...
was used to evaluate the observational/cross-sectional studies. It contains eight analytical criteria for a cross-sectional study construction. As for the evaluation of cohort studies, the Joanna Briggs Institute for cohort studies was used, which contains eleven analytical criteria for this type of study. Responses consist of “yes”, “no”, “confused”, and “not applicable” for both questionnaires. The aim of this evaluation is to estimate the methodological quality of a study and to determine the extent to which the possibility of bias has been addressed in its design, conduction, and analysis.

RESULTS

Study selection

The search resulted in 442 possible eligible studies (Figure 1). After removing 231 duplicates, 201 studies were selected for the title and abstract reading phase, resulting in forty-two studies for detailed analysis (Chart 1). A total of eighteen studies were eligible, which included seventeen cross-sectional studies and two cohort studies (Chart 2).

Figure 1
Flowchart of search strategy results.
Chart 2
Characteristics and information from observational studies.

Characteristics of the studies

The included studies were published between 2020 and 2022. A total of sixteen studies collected data between February and June 2020. In the study by Duncan et al., data were collected from April to October, while in the study by Coakley et al., data were collected from October to November 2020, with both studies collecting data in the second half of the year. In only one study, the date of data collection was not specified3939 Coakley KE, Lardier DT, Holladay KR, Amorim FT, Zuhl MN. Physical activity behavior and mental health among university students during COVID-19 Lockdown. Front Sports Act Living. 2021;3:682175. http://dx.doi.org/10.3389/fspor.2021.682175. PMid:34308346.
http://dx.doi.org/10.3389/fspor.2021.682...
,5252 Duncan GE, Avery AR, Tsang S, Williams BD, Seto E. Changes in physical activity levels and mental health during COVID-19: Prospective findings among adult twin pairs. PLoS One. 2021;16(11):e0260218. http://dx.doi.org/10.1371/journal.pone.0260218. PMid:34807944.
http://dx.doi.org/10.1371/journal.pone.0...
.

The number of participants ranged from 43 to 2,301, aged between 18 and 65 years or older. Several instruments were used to analyze the practice of PA: i) International Physical Activity Questionnaire (IPAQ), ii) Physical Activity and Sedentary Behavior Questionnaire (PASB-Q), iii) Telephone risk factor surveillance survey (Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey - VIGITEL) - physical activity section containing 5 items, iv) Physical Activity Vital Sign (PAVS), v) Godin Leisure Questionnaire (GLQ). Three studies did not use a questionnaire, but a model of questions about physical activity during the period of social isolation.

Anxiety was assessed using different scales, namely: i) General Anxiety Disorder (GAD-7 and GAD-2), ii) Depression, Anxiety and Stress Scale - Short Form (DASS-21), iii) Beck Anxiety Inventory (BAI), iv) State-Trait Anxiety Inventory (STAI), v) Self-Rating Anxiety Scale, vi) Brief Symptom Inventory (BSI) and vii) Hospital Anxiety and Depression Scale (HADS).

Risk of bias

Most observational/cross-sectional studies met the main methodological quality criteria. Some studies have demonstrated confusion in inclusion and exclusion criteria3737 Wood CJ, Barton J, Smyth N. A cross-sectional study of physical activity behaviour and associations with wellbeing during the UK coronavirus lockdown. J Health Psychol. 2022;27(6):1432-44. http://dx.doi.org/10.1177/1359105321999710. PMid:33657907.
http://dx.doi.org/10.1177/13591053219997...
,3838 Marashi MY, Nicholson E, Ogrodnik M, Fenesi B, Heisz JJ. A mental health paradox: mental health was both a motivator and barrier to physical activity during the COVID-19 pandemic. PLoS One. 2021;16(4):e0239244. http://dx.doi.org/10.1371/journal.pone.0239244. PMid:33793550.
http://dx.doi.org/10.1371/journal.pone.0...
,4040 Kua Z, Hamzah F, Tan PT, Ong LJ, Tan B, Huang Z. Physical activity levels and mental health burden of healthcare workers during COVID-19 lockdown. Stress Health. 2021. PMid:34231968.,4747 Rogowska AM, Kuśnierz C, Ochnik D. Changes in stress, coping styles, and life satisfaction between the first and second waves of the COVID-19 pandemic: a longitudinal cross-lagged study in a sample of University Students. J Clin Med. 2021;10(17):4025. http://dx.doi.org/10.3390/jcm10174025. PMid:34501473.
http://dx.doi.org/10.3390/jcm10174025...
,5151 Ozdemir F, Cansel N, Kizilay F, Guldogan E, Ucuz I, Sinanoglu B, et al. The role of physical activity on mental health and quality of life during COVID-19 outbreak: a cross-sectional study. Eur J Integr Med. 2020;40:101248. http://dx.doi.org/10.1016/j.eujim.2020.101248. PMid:33200007.
http://dx.doi.org/10.1016/j.eujim.2020.1...
. The cohort studies met all JBI criteria5252 Duncan GE, Avery AR, Tsang S, Williams BD, Seto E. Changes in physical activity levels and mental health during COVID-19: Prospective findings among adult twin pairs. PLoS One. 2021;16(11):e0260218. http://dx.doi.org/10.1371/journal.pone.0260218. PMid:34807944.
http://dx.doi.org/10.1371/journal.pone.0...
,5353 Rees-Punia E, Newton CC, Westmaas JL, Chantaprasopsuk S, Patel AV, Leach CR. Prospective COVID-19 related changes in physical activity and sedentary time and associations with symptoms of depression and anxiety. Ment Health Phys Act. 2021;21:100425. http://dx.doi.org/10.1016/j.mhpa.2021.100425. PMid:34611463.
http://dx.doi.org/10.1016/j.mhpa.2021.10...
. More details in Supplementary file 1. No studies were excluded after individual assessments, more information can be seen in the Supplementary file 1.

Main findings

Observational studies

Marashi et al.3838 Marashi MY, Nicholson E, Ogrodnik M, Fenesi B, Heisz JJ. A mental health paradox: mental health was both a motivator and barrier to physical activity during the COVID-19 pandemic. PLoS One. 2021;16(4):e0239244. http://dx.doi.org/10.1371/journal.pone.0239244. PMid:33793550.
http://dx.doi.org/10.1371/journal.pone.0...
and Coakley et al.3939 Coakley KE, Lardier DT, Holladay KR, Amorim FT, Zuhl MN. Physical activity behavior and mental health among university students during COVID-19 Lockdown. Front Sports Act Living. 2021;3:682175. http://dx.doi.org/10.3389/fspor.2021.682175. PMid:34308346.
http://dx.doi.org/10.3389/fspor.2021.682...
in their respective studies, found that people who reported decreased PA practice or increased sitting time experienced higher levels of anxiety symptoms3838 Marashi MY, Nicholson E, Ogrodnik M, Fenesi B, Heisz JJ. A mental health paradox: mental health was both a motivator and barrier to physical activity during the COVID-19 pandemic. PLoS One. 2021;16(4):e0239244. http://dx.doi.org/10.1371/journal.pone.0239244. PMid:33793550.
http://dx.doi.org/10.1371/journal.pone.0...
,3939 Coakley KE, Lardier DT, Holladay KR, Amorim FT, Zuhl MN. Physical activity behavior and mental health among university students during COVID-19 Lockdown. Front Sports Act Living. 2021;3:682175. http://dx.doi.org/10.3389/fspor.2021.682175. PMid:34308346.
http://dx.doi.org/10.3389/fspor.2021.682...
. PA has an association on reducing state and trait anxiety4242 Antunes R, Rebelo-Gonçalves R, Amaro N, Salvador R, Matos R, Morouço P, et al. Higher physical activity levels may help buffer the negative psychological consequences of coronavirus disease 2019 pandemic. Front Psychol. 2021;12:672811. http://dx.doi.org/10.3389/fpsyg.2021.672811. PMid:33967927.
http://dx.doi.org/10.3389/fpsyg.2021.672...
,4343 Peterson JA, Chesbro G, Larson R, Larson D, Black CD. Short-term analysis (8 weeks) of social distancing and isolation on mental health and physical activity behavior during COVID-19. Front Psychol. 2021;12:652086. http://dx.doi.org/10.3389/fpsyg.2021.652086. PMid:33815233.
http://dx.doi.org/10.3389/fpsyg.2021.652...
. Indeed, it was found that vigorous PA4848 Xiang YT, Zhao YJ, Liu ZH, Li XH, Zhao N, Cheung T, et al. The COVID-19 outbreak and psychiatric hospitals in China: Managing challenges through mental health service reform. Int J Biol Sci. 2020;16(10):1741-4. http://dx.doi.org/10.7150/ijbs.45072. PMid:32226293.
http://dx.doi.org/10.7150/ijbs.45072...
had a negative and significant correlation with trait anxiety4343 Peterson JA, Chesbro G, Larson R, Larson D, Black CD. Short-term analysis (8 weeks) of social distancing and isolation on mental health and physical activity behavior during COVID-19. Front Psychol. 2021;12:652086. http://dx.doi.org/10.3389/fpsyg.2021.652086. PMid:33815233.
http://dx.doi.org/10.3389/fpsyg.2021.652...
, whereas low-intensity PA was not associated to reducing anxiety symptoms.

In addition, some studies have shown that the duration and frequency of PA practice are important for reducing anxiety levels2727 Meira CM Jr, Meneguelli KS, Leopoldo MPG, Florindo AA. Anxiety and leisure-domain physical activity frequency, duration, and intensity during Covid-19 pandemic. Front Psychol. 2020;11:603770. http://dx.doi.org/10.3389/fpsyg.2020.603770. PMid:33447249.
http://dx.doi.org/10.3389/fpsyg.2020.603...
,3030 Al-Ajlouni YA, Park SH, Alawa J, Dodin B, Shamaileh G, Makarem N, et al. Staying Physically Active Is Associated with Better Mental Health and Sleep Health Outcomes during the Initial Period of COVID-19 Induced Nation-Wide Lockdown in Jordan. Int J Environ Res Public Health. 2022;19(2):776. http://dx.doi.org/10.3390/ijerph19020776. PMid:35055598.
http://dx.doi.org/10.3390/ijerph19020776...
,4646 Schuch FB, Bulzing RA, Meyer J, Vancampfort D, Firth J, Stubbs B, et al. Associations of moderate to vigorous physical activity and sedentary behavior with depressive and anxiety symptoms in self-isolating people during the COVID-19 pandemic: a cross-sectional survey in Brazil. Psychiatry Res. 2020;292:113339. http://dx.doi.org/10.1016/j.psychres.2020.113339. PMid:32745795.
http://dx.doi.org/10.1016/j.psychres.202...
,5050 Jacob L, Tully MA, Barnett Y, Lopez-Sanchez GF, Butler L, Schuch F, et al. The relationship between physical activity and mental health in a sample of the UK public: A cross-sectional study during the implementation of COVID-19 social distancing measures. Ment Health Phys Act. 2020;19:100345. http://dx.doi.org/10.1016/j.mhpa.2020.100345. PMid:32834833.
http://dx.doi.org/10.1016/j.mhpa.2020.10...
. The minimum duration of activity and weekly frequency with some effectiveness were 30 min and 3 times a week, respectively2727 Meira CM Jr, Meneguelli KS, Leopoldo MPG, Florindo AA. Anxiety and leisure-domain physical activity frequency, duration, and intensity during Covid-19 pandemic. Front Psychol. 2020;11:603770. http://dx.doi.org/10.3389/fpsyg.2020.603770. PMid:33447249.
http://dx.doi.org/10.3389/fpsyg.2020.603...
,4545 Haider S, Smith L, Markovic L, Schuch FB, Sadarangani KP, Sanchez GFL, et al. Associations between physical activity, sitting time, and time spent outdoors with mental health during the first COVID-19 lockdown in Austria. Int J Environ Res Public Health. 2021;18(17):9168. http://dx.doi.org/10.3390/ijerph18179168. PMID: 34501758.
http://dx.doi.org/10.3390/ijerph18179168...
. Schuch et al.4646 Schuch FB, Bulzing RA, Meyer J, Vancampfort D, Firth J, Stubbs B, et al. Associations of moderate to vigorous physical activity and sedentary behavior with depressive and anxiety symptoms in self-isolating people during the COVID-19 pandemic: a cross-sectional survey in Brazil. Psychiatry Res. 2020;292:113339. http://dx.doi.org/10.1016/j.psychres.2020.113339. PMid:32745795.
http://dx.doi.org/10.1016/j.psychres.202...
found that practicing 15 minutes or more of vigorous PA/day provides a lower chance of presenting anxiety symptoms when compared to those who perform 30 minutes or more of moderate PA/day4646 Schuch FB, Bulzing RA, Meyer J, Vancampfort D, Firth J, Stubbs B, et al. Associations of moderate to vigorous physical activity and sedentary behavior with depressive and anxiety symptoms in self-isolating people during the COVID-19 pandemic: a cross-sectional survey in Brazil. Psychiatry Res. 2020;292:113339. http://dx.doi.org/10.1016/j.psychres.2020.113339. PMid:32745795.
http://dx.doi.org/10.1016/j.psychres.202...
. Reduced PA practice may have indirect effects on anxiety, as demonstrated in the study by Lewis et al, in which the decrease in PA increased the symptoms of insomnia and, consequently, anxiety4444 Lewis R, Roden LC, Scheuermaier K, Gomez-Olive FX, Rae DE, Iacovides S, et al. The impact of sleep, physical activity and sedentary behaviour on symptoms of depression and anxiety before and during the COVID-19 pandemic in a sample of South African participants. Sci Rep. 2021;11(1):24059. http://dx.doi.org/10.1038/s41598-021-02021-8. PMid:34911984.
http://dx.doi.org/10.1038/s41598-021-020...
. Haider et al.4545 Haider S, Smith L, Markovic L, Schuch FB, Sadarangani KP, Sanchez GFL, et al. Associations between physical activity, sitting time, and time spent outdoors with mental health during the first COVID-19 lockdown in Austria. Int J Environ Res Public Health. 2021;18(17):9168. http://dx.doi.org/10.3390/ijerph18179168. PMID: 34501758.
http://dx.doi.org/10.3390/ijerph18179168...
demonstrated that individuals who spend more than 60 min/day outdoors and who managed to maintain a moderate to vigorous level of PA were more likely to have high mental well-being, without depression and anxiety symptoms4545 Haider S, Smith L, Markovic L, Schuch FB, Sadarangani KP, Sanchez GFL, et al. Associations between physical activity, sitting time, and time spent outdoors with mental health during the first COVID-19 lockdown in Austria. Int J Environ Res Public Health. 2021;18(17):9168. http://dx.doi.org/10.3390/ijerph18179168. PMID: 34501758.
http://dx.doi.org/10.3390/ijerph18179168...
.

Recommendations for Physical Activity

When the practice of PA was analyzed according to the WHO and ACSM recommendations as parameters, we found that most of the populations studied did not meet the minimum recommendations for health benefits. Still, for those who were active, with the beginning of the pandemic and social restrictions, there was a decrease in PA levels. Al-Ajlouni et al.3030 Al-Ajlouni YA, Park SH, Alawa J, Dodin B, Shamaileh G, Makarem N, et al. Staying Physically Active Is Associated with Better Mental Health and Sleep Health Outcomes during the Initial Period of COVID-19 Induced Nation-Wide Lockdown in Jordan. Int J Environ Res Public Health. 2022;19(2):776. http://dx.doi.org/10.3390/ijerph19020776. PMid:35055598.
http://dx.doi.org/10.3390/ijerph19020776...
found that participants who did not meet the WHO guidelines had a higher prevalence of moderate to severe anxiety symptoms.

Among the studies analyzed, only the study by Duncan et al, did not meet any of the minimum recommendations of physical Activity5252 Duncan GE, Avery AR, Tsang S, Williams BD, Seto E. Changes in physical activity levels and mental health during COVID-19: Prospective findings among adult twin pairs. PLoS One. 2021;16(11):e0260218. http://dx.doi.org/10.1371/journal.pone.0260218. PMid:34807944.
http://dx.doi.org/10.1371/journal.pone.0...
. There were variations in compliance with the recommendations in the studies before and during social isolation. The studies by Haider et al.4545 Haider S, Smith L, Markovic L, Schuch FB, Sadarangani KP, Sanchez GFL, et al. Associations between physical activity, sitting time, and time spent outdoors with mental health during the first COVID-19 lockdown in Austria. Int J Environ Res Public Health. 2021;18(17):9168. http://dx.doi.org/10.3390/ijerph18179168. PMID: 34501758.
http://dx.doi.org/10.3390/ijerph18179168...
, Meira et al.2727 Meira CM Jr, Meneguelli KS, Leopoldo MPG, Florindo AA. Anxiety and leisure-domain physical activity frequency, duration, and intensity during Covid-19 pandemic. Front Psychol. 2020;11:603770. http://dx.doi.org/10.3389/fpsyg.2020.603770. PMid:33447249.
http://dx.doi.org/10.3389/fpsyg.2020.603...
and Wood et al.3737 Wood CJ, Barton J, Smyth N. A cross-sectional study of physical activity behaviour and associations with wellbeing during the UK coronavirus lockdown. J Health Psychol. 2022;27(6):1432-44. http://dx.doi.org/10.1177/1359105321999710. PMid:33657907.
http://dx.doi.org/10.1177/13591053219997...
obtained the highest percentages of the sample meeting the recommendations before social isolation, being 89%, 86.9% and 82.58%, respectively. These percentages were reduced to 76.3%, 65.6% and 51.6% during social isolation, respectively. Even with the efforts of the WHO and ACSM with illustrative publications for people to remain physically active, many individuals decreased the level of physical activity over the period of social isolation and other restrictions, as can be seen in more detail in the Chart 3.

Chart 3
Changes in Physical Activity during the COVID-19 pandemic

DISCUSSION

The present systematic review investigated the effect of exercise and PA on anxiety symptoms during the COVID-19 pandemic. Main findings revealed that exercise and PA are important factors for reducing anxiety levels, and that greater intensity, duration, and frequency were related to greater effects. Vigorous-intensity activities4646 Schuch FB, Bulzing RA, Meyer J, Vancampfort D, Firth J, Stubbs B, et al. Associations of moderate to vigorous physical activity and sedentary behavior with depressive and anxiety symptoms in self-isolating people during the COVID-19 pandemic: a cross-sectional survey in Brazil. Psychiatry Res. 2020;292:113339. http://dx.doi.org/10.1016/j.psychres.2020.113339. PMid:32745795.
http://dx.doi.org/10.1016/j.psychres.202...
or longer duration5050 Jacob L, Tully MA, Barnett Y, Lopez-Sanchez GF, Butler L, Schuch F, et al. The relationship between physical activity and mental health in a sample of the UK public: A cross-sectional study during the implementation of COVID-19 social distancing measures. Ment Health Phys Act. 2020;19:100345. http://dx.doi.org/10.1016/j.mhpa.2020.100345. PMid:32834833.
http://dx.doi.org/10.1016/j.mhpa.2020.10...
were more effective for this result than moderate-intensity activities.

Disarrangements resulting from the COVID-19 pandemic have had a negative impact on individuals mental health, such as, increasing the incidence of symptoms of anxiety and depression1212 Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912-20. http://dx.doi.org/10.1016/S0140-6736(20)30460-8. PMid:32112714.
http://dx.doi.org/10.1016/S0140-6736(20)...
,5555 Ornell F, Schuch JB, Sordi AO, Kessler FHP. “Pandemic fear” and COVID-19: mental health burden and strategies. Br J Psychiatry. 2020;42(3):232-5. http://dx.doi.org/10.1590/1516-4446-2020-0008. PMid:32267343.
http://dx.doi.org/10.1590/1516-4446-2020...
. Because of locomotion restrictions, an increase in sitting time and sedentary behavior5656 Stanton R, To QG, Khalesi S, Williams SL, Alley SJ, Thwaite TL, et al. Depression, anxiety and stress during COVID-19: Associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults. Int J Environ Res Public Health. 2020;17(11):4065. http://dx.doi.org/10.3390/ijerph17114065. PMid:32517294.
http://dx.doi.org/10.3390/ijerph17114065...
were major reasons for the reduction of exercise and physical Activity5757 Ammar A, Brach M, Trabelsi K, Chtourou H, Boukhris O, Masmoudi L, et al. Effects of COVID-19 home confinement on eating behaviour and physical activity: results of the ECLB-COVID19 international online survey. Nutrients. 2020;12(6):1583. http://dx.doi.org/10.3390/nu12061583. PMid:32481594.
http://dx.doi.org/10.3390/nu12061583...
in a large portion of the population, even in those who were already physically active. Time spent using screens and general sedentary behavior5858 Hallgren M, Nguyen TTD, Owen N, Vancampfort D, Smith L, Dunstan DW, et al. Associations of interruptions to leisure-time sedentary behaviour with symptoms of depression and anxiety. Transl Psychiatry. 2020;10(1):128. http://dx.doi.org/10.1038/s41398-020-0810-1. PMid:32366824.
http://dx.doi.org/10.1038/s41398-020-081...
,5959 Allen MS, Walter EE, Swann C. Sedentary behaviour and risk of anxiety: a systematic review and meta-analysis. J Affect Disord. 2019;242:5-13. http://dx.doi.org/10.1016/j.jad.2018.08.081. PMid:30170238.
http://dx.doi.org/10.1016/j.jad.2018.08....
are risk factors associated with increased anxiety5353 Rees-Punia E, Newton CC, Westmaas JL, Chantaprasopsuk S, Patel AV, Leach CR. Prospective COVID-19 related changes in physical activity and sedentary time and associations with symptoms of depression and anxiety. Ment Health Phys Act. 2021;21:100425. http://dx.doi.org/10.1016/j.mhpa.2021.100425. PMid:34611463.
http://dx.doi.org/10.1016/j.mhpa.2021.10...
.

Physical activity is considered a positive mediator of anxiety6060 Schuch FB, Stubbs B, Meyer J, Heissel A, Zech P, Vancampfort D, et al. Physical activity protects from incident anxiety: a meta-analysis of prospective cohort studies. Depress Anxiety. 2019;36(9):846-58. http://dx.doi.org/10.1002/da.22915. PMid:31209958.
http://dx.doi.org/10.1002/da.22915...
,6161 Pelletier L, Shanmugasegaram S, Patten SB, Demers A. Self-management of mood and/or anxiety disorders through physical activity/exercise. Health Promot Chronic Dis Prev Can. 2017;37(5):149-59. http://dx.doi.org/10.24095/hpcdp.37.5.03. PMid:28493659.
http://dx.doi.org/10.24095/hpcdp.37.5.03...
and even an individual with generalized anxiety disorder can sustain high levels of PA, for example by activating compensatory mechanisms6262 Eysenck MW, Derakshan N, Santos R, Calvo MG. Anxiety and cognitive performance: attentional control theory. Emotion. 2007;7(2):336-53. http://dx.doi.org/10.1037/1528-3542.7.2.336. PMid:17516812.
http://dx.doi.org/10.1037/1528-3542.7.2....
and regulatory systems of the sympathetic and parasympathetic systems, regulating the stress response through the hypothalamic-pituitary-adrenal (HPA) axis6363 Anderson E, Shivakumar G. Effects of exercise and physical activity on anxiety. Front Psychiatry. 2013;4:27. http://dx.doi.org/10.3389/fpsyt.2013.00027. PMid:23630504.
http://dx.doi.org/10.3389/fpsyt.2013.000...
, in addition stimulating the brain-derived neurotrophic factor (BDNF), which can balance the neurobiological responses to stress6464 Kandola A, Vancampfort D, Herring M, Rebar A, Hallgren M, Firth J, et al. Moving to beat anxiety: epidemiology and therapeutic issues with physical activity for anxiety. Curr Psychiatry Rep. 2018;20(8):63. http://dx.doi.org/10.1007/s11920-018-0923-x. PMid:30043270.
http://dx.doi.org/10.1007/s11920-018-092...
in cortical and limbic regions of the brain, such as in the hippocampus, where in the BDNF Val66Met polymorphism (which decreased BDNF expression and signaling) has been associated with reduced hippocampal volume and executive function, increased susceptibility to anxiety, and depressive behaviors6565 Duman RS. BDNF, 5-HT, and anxiety: identification of a critical periadolescent developmental period. Am J Psychiatry. 2017;174(12):1137-9. http://dx.doi.org/10.1176/appi.ajp.2017.17101084. PMid:29191031.
http://dx.doi.org/10.1176/appi.ajp.2017....
. In addition, the positive effect of physical activity includes increased blood flow to the hippocampus and an increase in size, as well as decreased neuro-inflammation6666 Mahalakshmi B, Maurya N, Lee SD, Kumar VB. Possible neuroprotective mechanisms of physical exercise in neurodegeneration. Int J Mol Sci. 2020;21(16):5615. http://dx.doi.org/10.3390/ijms21165895. PMid:32824367.
http://dx.doi.org/10.3390/ijms21165895...
, an increase in neuroprotection, and overpowering the negative effects of anxiety6767 Mucci N, Giorgi G, Ceratti SDP, Fiz-Pérez J, Mucci F, Arcangeli G. Anxiety, stress-related factors, and blood pressure in young adults. Front Psychol. 2016;7:1682. http://dx.doi.org/10.3389/fpsyg.2016.01682. PMid:27840615.
http://dx.doi.org/10.3389/fpsyg.2016.016...
,6868 Salari N, Hosseinian-Far A, Jalali R, Vaisi-Raygani A, Rasoulpoor S, Mohammadi M, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Global Health. 2020;16(1):57. http://dx.doi.org/10.1186/s12992-020-00589-w. PMid:32631403.
http://dx.doi.org/10.1186/s12992-020-005...
.

The lowest engagement in PA was seen in the study by Lesser and Nienhuis, with 36.6% 4949 Lesser IA, Nienhuis CP. The impact of COVID-19 on physical activity behavior and well-being of Canadians. Int J Environ Res Public Health. 2020;17(11):3899. http://dx.doi.org/10.3390/ijerph17113899. PMid:32486380.
http://dx.doi.org/10.3390/ijerph17113899...
of participants meeting the recommendations proposed by the WHO or ACSM, while the highest engagement was observed in the study by Haider et al.4545 Haider S, Smith L, Markovic L, Schuch FB, Sadarangani KP, Sanchez GFL, et al. Associations between physical activity, sitting time, and time spent outdoors with mental health during the first COVID-19 lockdown in Austria. Int J Environ Res Public Health. 2021;18(17):9168. http://dx.doi.org/10.3390/ijerph18179168. PMID: 34501758.
http://dx.doi.org/10.3390/ijerph18179168...
, with 76.3%, both during the lockdown4545 Haider S, Smith L, Markovic L, Schuch FB, Sadarangani KP, Sanchez GFL, et al. Associations between physical activity, sitting time, and time spent outdoors with mental health during the first COVID-19 lockdown in Austria. Int J Environ Res Public Health. 2021;18(17):9168. http://dx.doi.org/10.3390/ijerph18179168. PMID: 34501758.
http://dx.doi.org/10.3390/ijerph18179168...
. Such a discrepancy shows how much people diverged in the ways to keep themselves active according to the location. The non-commitment of all participants to the minimum PA recommendations may be one of the factors related to some divergent results, in studies that did not show differences in the anxiety profile in individuals who performed PA1919 Bartley CA, Hay M, Bloch MH. Meta-analysis: Aerobic exercise for the treatment of anxiety disorders. Prog Neuropsychopharmacol Biol Psychiatry. 2013;45:34-9. http://dx.doi.org/10.1016/j.pnpbp.2013.04.016. PMid:23643675.
http://dx.doi.org/10.1016/j.pnpbp.2013.0...
,5151 Ozdemir F, Cansel N, Kizilay F, Guldogan E, Ucuz I, Sinanoglu B, et al. The role of physical activity on mental health and quality of life during COVID-19 outbreak: a cross-sectional study. Eur J Integr Med. 2020;40:101248. http://dx.doi.org/10.1016/j.eujim.2020.101248. PMid:33200007.
http://dx.doi.org/10.1016/j.eujim.2020.1...
,6969 Larun L, Nordheim LV, Ekeland E, Hagen KB, Heian F. Exercise in prevention and treatment of anxiety and depression among children and young people. Cochrane Database Syst Rev. 2006;(3):CD004691. PMid:16856055.,7070 Ibrahim A, Chong MC, Khoo S, Wong LP, Chung I, Tan MP. Virtual group exercises and psychological status among community-dwelling older adults during the COVID-19 pandemic—a feasibility study. Geriatrics (Basel). 2021;6(1):16. http://dx.doi.org/10.3390/geriatrics6010031. PMid:33810155.
http://dx.doi.org/10.3390/geriatrics6010...
. Overall, participants who meet recommended PA guidelines are less likely to experience greater anxiety than those who do not5353 Rees-Punia E, Newton CC, Westmaas JL, Chantaprasopsuk S, Patel AV, Leach CR. Prospective COVID-19 related changes in physical activity and sedentary time and associations with symptoms of depression and anxiety. Ment Health Phys Act. 2021;21:100425. http://dx.doi.org/10.1016/j.mhpa.2021.100425. PMid:34611463.
http://dx.doi.org/10.1016/j.mhpa.2021.10...
,7171 López-Bueno R, Calatayud J, Ezzatvar Y, Casajús JA, Smith L, Andersen LL, et al. Association between current physical activity and current perceived anxiety and mood in the initial phase of COVID-19 confinement. Front Psychiatry. 2020;11:729. http://dx.doi.org/10.3389/fpsyt.2020.00729. PMid:32793013.
http://dx.doi.org/10.3389/fpsyt.2020.007...
.

Evidence from a systematic review conducted by Wolf et al.7272 Wolf S, Seiffer B, Zeibig JM, Welkerling J, Brokmeier L, Atrott B, et al. Is physical activity associated with less depression and anxiety during the COVID-19 pandemic? A rapid systematic review. Sports Med. 2021;51(8):1771-83. http://dx.doi.org/10.1007/s40279-021-01468-z. PMid:33886101.
http://dx.doi.org/10.1007/s40279-021-014...
suggests that people who regularly perform PA with greater volume and frequency and maintain a stable PA routine have fewer symptoms of depression and anxiety. For example, those who reported the most total time spent in moderate to vigorous PA were 12 to 32% less likely to experience depressive symptoms and 15 to 34% less likely to experience anxiety7272 Wolf S, Seiffer B, Zeibig JM, Welkerling J, Brokmeier L, Atrott B, et al. Is physical activity associated with less depression and anxiety during the COVID-19 pandemic? A rapid systematic review. Sports Med. 2021;51(8):1771-83. http://dx.doi.org/10.1007/s40279-021-01468-z. PMid:33886101.
http://dx.doi.org/10.1007/s40279-021-014...
.

The study conducted by Kim et al.7373 Kim SY, Jeon SW, Lee MY, Shin DW, Lim WJ, Shin YC, et al. The association between physical activity and anxiety symptoms for general adult populations: an analysis of the dose-response relationship. Psychiatry Investig. 2020;17(1):29-36. http://dx.doi.org/10.30773/pi.2019.0078. PMid:31856560.
http://dx.doi.org/10.30773/pi.2019.0078...
found that compared to the sedentary group (0-600 METs-min/week), individuals who achieved 600-6000 METs-min/week had a significantly lower risk of anxiety. After stratifying the data by sex, optimal PA ranges were 600 to 9,000 METs-min/week for men, but 1,200 to 3,000 METs-min/week for women. Furthermore, engagement in more than 6,000 METs-min/week was found to be not associated with higher risk of anxiety symptoms, suggesting a specific PA dose-response regardless of the type of activity practiced. In this sense, a cross-sectional study, which reported that people who were not practicing PA during COVID-19 confinement presented a higher level of stress, anxiety, and depression, highlighting the importance of home physical training to reduce the impacts of physical inactivity due to confinement measures, due to the pandemic situation on mental health7474 Narici M, Vito G, Franchi M, Paoli A, Moro T, Marcolin G, et al. Impact of sedentarism due to the COVID-19 home confinement on neuromuscular, cardiovascular and metabolic health: Physiological and pathophysiological implications and recommendations for physical and nutritional countermeasures. Eur J Sport Sci. 2021;21(4):614-35. http://dx.doi.org/10.1080/17461391.2020.1761076. PMid:32394816.
http://dx.doi.org/10.1080/17461391.2020....
.

As identified by the self-reports of participants in the studies addressed, the specifications of PA in terms of frequency and duration were crucial to reduce anxiety during the COVID-19 pandemic. In fact, other studies and institutions advocate the practice of frequent and prolonged PA. Both WHO and ACSM have recommended at least 150 minutes per week of moderate to vigorous PA and, during the COVID-19 pandemic, have suggested people to maintain their usual levels of PA. As observed in Chart 3, there was a reduction in the practice of PA due to social restrictions. Evidence supports the importance of regular PA practice in the prevention and treatment of chronic diseases, cognitive decline, improvement of the immune system and increased longevity7575 Chow LS, Gerszten RE, Taylor JM, Pedersen BK, van Praag H, Trappe S, et al. Exerkines in health, resilience and disease. Nat Rev Endocrinol. 2022;18(5):273-89. http://dx.doi.org/10.1038/s41574-022-00641-2. PMid:35304603.
http://dx.doi.org/10.1038/s41574-022-006...
. The COVID-19 pandemic reinforced the relevance of PA for physical and mental health, mainly because of PA reduction and increased sedentary behavior, especially due to social isolation protocols7676 Trabelsi K, Ammar A, Masmoudi L, Boukhris O, Chtourou H, Bouaziz B, et al. Globally altered sleep patterns and physical activity levels by confinement in 5056 individuals: ECLB COVID-19 international online survey. Biol Sport. 2021;38(4):495-506. http://dx.doi.org/10.5114/biolsport.2021.101605. PMid:34937958.
http://dx.doi.org/10.5114/biolsport.2021...
. Physical inactivity and sedentary behavior were related to the most severe outcomes of COVID-197777 Sallis R, Young DR, Tartof SY, Sallis JF, Sall J, Li Q, et al. Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients. Br J Sports Med. 2021;55(19):1099-105. http://dx.doi.org/10.1136/bjsports-2021-104080. PMid:33849909.
http://dx.doi.org/10.1136/bjsports-2021-...
, especially for the elderly who presented themselves as a risk group7878 Jiménez-Pavón D, Carbonell-Baeza A, Lavie CJ. Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: special focus in older people. Prog Cardiovasc Dis. 2020;63(3):386-8. http://dx.doi.org/10.1016/j.pcad.2020.03.009. PMid:32220590.
http://dx.doi.org/10.1016/j.pcad.2020.03...
. The low-cost and low-risk nature of PA shows that it should be implemented in public policies during pandemics.

According to a study conducted with Australians who underwent three data collection periods (April, July, and August 2020), people participating in at least 150 minutes of moderate or vigorous physical activity per week had significantly higher resilience scores than those not participating in PA. As resilience is a response to persistent stressors, like the COVID-19 pandemic7979 Fitzgerald DA, Nunn K, Isaacs D. Consequences of physical distancing emanating from the COVID-19 pandemic: an Australian perspective. Paediatr Respir Rev. 2020 Sep;35:25-30. http://dx.doi.org/10.1016/j.prrv.2020.06.005.
http://dx.doi.org/10.1016/j.prrv.2020.06...
, it can vary based on what individuals are capable of coping with8080 Sturman ED. Coping with COVID-19: resilience and psychological well-being in the midst of a pandemic. J Soc Clin Psychol. 2020;39(7):39. http://dx.doi.org/10.1521/jscp.2020.39.7.561.
http://dx.doi.org/10.1521/jscp.2020.39.7...
. Interventions that aim to minimize psychological distress can be designed with an understanding of resilience and its changes over time8181 Vinkers CH, van Amelsvoort T, Bisson JI, Branchi I, Cryan JF, Domschke K, et al. Stress resilience during the coronavirus pandemic. Eur Neuropsychopharmacol. 2020;35:12-6. http://dx.doi.org/10.1016/j.euroneuro.2020.05.003. PMid:32446705.
http://dx.doi.org/10.1016/j.euroneuro.20...
,8282 Schetter CD, Dolbier C. Resilience in the context of chronic stress and health in adults. Soc Personal Psychol Compass. 2011;5(9):634-52. http://dx.doi.org/10.1111/j.1751-9004.2011.00379.x. PMid:26161137.
http://dx.doi.org/10.1111/j.1751-9004.20...
.

Mental health and well-being are associated with the behaviors we adopt throughout life, so PA has been a positive way to maintain mental health during periods of social isolation3333 Faulkner J, O’brien WJ, Stuart B, Stoner L, Batten J, Wadsworth D, et al. Physical activity, mental health and wellbeing of adults within and during the easing of COVID‐19 restrictions, in the United Kingdom and New Zealand. Int J Environ Res Public Health. 2022;19(3):1792. http://dx.doi.org/10.3390/ijerph19031792. PMid:35162815.
http://dx.doi.org/10.3390/ijerph19031792...
. A study comparing the effects of isolation in New Zealand and the United Kingdom found that the as more PA practiced and the less sedentary behavior, the better the perception of well-being and the lower the DASS-9 score3232 Faulkner J, O’Brien WJ, McGrane B, Wadsworth D, Batten J, Askew CD, et al. Physical activity, mental health and well-being of adults during initial COVID-19 containment strategies: a multi-country cross-sectional analysis. J Sci Med Sport. 2021;24(4):320-6. http://dx.doi.org/10.1016/j.jsams.2020.11.016. PMid:33341382.
http://dx.doi.org/10.1016/j.jsams.2020.1...
,3333 Faulkner J, O’brien WJ, Stuart B, Stoner L, Batten J, Wadsworth D, et al. Physical activity, mental health and wellbeing of adults within and during the easing of COVID‐19 restrictions, in the United Kingdom and New Zealand. Int J Environ Res Public Health. 2022;19(3):1792. http://dx.doi.org/10.3390/ijerph19031792. PMid:35162815.
http://dx.doi.org/10.3390/ijerph19031792...
.

It is worth mentioning that the prevalence of anxiety and depression may vary in these surveys, due to the methodological heterogeneity between the studies. Wu et al.8383 Wu T, Jia X, Shi H, Niu J, Yin X, Xie J, et al. Prevalence of mental health problems during the COVID-19 pandemic: a systematic review and meta-analysis. J Affect Disord. 2021;281:91-8. http://dx.doi.org/10.1016/j.jad.2020.11.117. PMid:33310451.
http://dx.doi.org/10.1016/j.jad.2020.11....
found that the prevalence of anxiety ranged from 6.3% to 87.5% in 53 studies with seven populations (I2 = 99.6%), and the point prevalence of depression ranged from 3.1% to 87.3% among 48 studies and seven populations (I2 = 99.6%)8383 Wu T, Jia X, Shi H, Niu J, Yin X, Xie J, et al. Prevalence of mental health problems during the COVID-19 pandemic: a systematic review and meta-analysis. J Affect Disord. 2021;281:91-8. http://dx.doi.org/10.1016/j.jad.2020.11.117. PMid:33310451.
http://dx.doi.org/10.1016/j.jad.2020.11....
. The I2 values presented in both studies, above 99%, show the degree of heterogeneity that exists.

These are the main limitations of this systematic review which, in addition to the disparity in the data of the analyzed studies, could not provide sufficient quantitative information to conduct a meta-analysis. Finally, the absence of experimental studies limits us to cautious statements about the level of PA and anxiety. If, on the one hand, vigorous and moderate intensity as well as continuous frequency of at least three times weekly can mitigate anxiety, on the other hand, light exercise may not have the same effect. Nevertheless, the observational nature of the analyzed studies, which were the majority in this systematic review, makes it impossible to establish cause-and-effect relationship.

CONCLUSION

Despite the positive consequence of physical activity for the reduction of anxiety symptoms during the COVID-19 pandemic, the results of the present systematic review are still inconclusive. However, it is worth mentioning the importance of intensity, session duration and weekly frequency, which, in some studies, showed better effects in more active individuals, suggesting a proportional dose-response relationship of physical activity on anxiety. The higher the intensity and frequency of PA, the lower the risk of developing anxiety symptoms. Taking part in vigorous physical activity for at least 15 minutes per day may relieve anxiety symptoms.

SUPPLEMENTARY MATERIAL

Supplementary material accompanies this paper.

Supplementary File 1: Free access in https://osf.io/ykz6v/

This material is available as part of the online article from http://www.scielo.br/rbcdh

  • How to cite this articleDavid IR, Barbosa EO, Felício LFF, Leao LL, Souza EHE, Paula AMB, Silva FO, Machado FSM, Monteiro-Junior RS. Physical activity on anxiety symptoms during the COVID-19 pandemic: a systematic review. Rev Bras Cineantropom Desempenho Hum 2023, 25:e91715. DOI: https://doi.org/10.1590/1980-0037.2023v25e91715
  • COMPLIANCE WITH ETHICAL STANDARDS
  • Funding

    This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. This study was funded by the authors.
  • Ethical approval

    This research is in accordance with the standards set by the Declaration of Helsinki

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Publication Dates

  • Publication in this collection
    21 July 2023
  • Date of issue
    2023

History

  • Received
    02 Nov 2022
  • Accepted
    07 June 2023
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