The anxiolytic effects of exercise: A systematic review and meta-analysis of randomized controlled trials

This study aimed to evaluate the anxiolytic effects of exercise in individuals with high anxiety or diagnosed anxiety disorders and to identify optimal exercise prescription parameters. A key methodological innovation of this work is the application of a three-level meta-analytic model, which accounts for effect-size dependency arising from multiple outcomes within studies, thereby improving the robustness and precision of the pooled estimates. A comprehensive literature search was conducted across five databases: Embase, PubMed, Cochrane Library, Web of Science, and Scopus. Inclusion criteria: (1) randomized controlled trial (RCT) design; (2) outcomes assessed using validated scales; (3) participants diagnosed with an anxiety disorder or identified as high-anxiety through validated scales; and (4) inclusion of both an intervention group and a control group, with the sole distinction between them being the addition of exercise in the intervention group. Analyses were performed using a three-level restricted maximum likelihood random-effects model. Twenty-seven randomized controlled trials involving 1447 participants were included. Exercise demonstrated a significant anxiolytic effect (Cohen’s d = -0.42, p < 0.01). Subgroup analysis indicated that comorbid chronic conditions attenuated treatment efficacy (Cohen’s d = -0.29, p < 0.01). O p timal outcomes were observed with exercise programs lasting < 12 weeks, sessions lasting 45-60 minutes, frequencies of > 3 times per week, and total weekly exercise durations of ≥ 180 minutes. In contrast, individuals without chronic conditions showed more favorable results. The most beneficial exercise regimens for this group included programs lasting < 12 weeks, sessions lasting > 60 minutes, frequencies of 3 times per week, and total weekly durations of > 180 minutes. Exercise appears to be an effective non-pharmacological intervention for alleviating anxiety symptoms. While chronic conditions may diminish the magnitude of these benefits, tailored exercise prescriptions remain promising. Nevertheless, given the heterogeneity of interventions and limited long-term follow-up across included studies, further high-quality research is needed to confirm the sustainability and generalizability of these findings. The protocol was registered in PROSPERO with the registration number CRD420251014897. • Exercise can alleviate symptoms in high anxiety or anxiety disordered patients. • A high-frequency, short-duration exercise prescription is advocated for individuals with chronic diseases. • A low-frequency, long-duration regimen is recommended for those without chronic diseases.