literature review in stress

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Annual Review of Psychology

Volume 72, 2021, review article, stress and health: a review of psychobiological processes.

Daryl B. O'Connor 1 , Julian F. Thayer 2 , and Kavita Vedhara 3
View Affiliations Hide Affiliations Affiliations: 1 School of Psychology, University of Leeds, Leeds LS2 9JT, United Kingdom; email: [email protected] 2 Department of Psychological Science, School of Social Ecology, University of California, Irvine, California 92697, USA; email: [email protected] 3 Division of Primary Care, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom; email: [email protected]
Vol. 72:663-688 (Volume publication date January 2021) https://doi.org/10.1146/annurev-psych-062520-122331
First published as a Review in Advance on September 04, 2020
Copyright © 2021 by Annual Reviews. All rights reserved

The cumulative science linking stress to negative health outcomes is vast. Stress can affect health directly, through autonomic and neuroendocrine responses, but also indirectly, through changes in health behaviors. In this review, we present a brief overview of ( a ) why we should be interested in stress in the context of health; ( b ) the stress response and allostatic load; ( c ) some of the key biological mechanisms through which stress impacts health, such as by influencing hypothalamic-pituitary-adrenal axis regulation and cortisol dynamics, the autonomic nervous system, and gene expression; and ( d ) evidence of the clinical relevance of stress, exemplified through the risk of infectious diseases. The studies reviewed in this article confirm that stress has an impact on multiple biological systems. Future work ought to consider further the importance of early-life adversity and continue to explore how different biological systems interact in the context of stress and health processes.

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Article Type: Review Article

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Literature Reviews

What is a Literature Review?

Steps for Creating a Literature Review
Providing Evidence / Critical Analysis
Challenges when writing a Literature Review
Systematic Literature Reviews

A literature review is an academic text that surveys, synthesizes, and critically evaluates the existing literature on a specific topic. It is typically required for theses, dissertations, or long reports and serves several key purposes:

Surveying the Literature : It involves a comprehensive search and examination of relevant academic books, journal articles, and other sources related to the chosen topic.
Synthesizing Information : The literature review summarizes and organizes the information found in the literature, often identifying patterns, themes, and gaps in the current knowledge.
Critical Analysis : It critically analyzes the collected information, highlighting limitations, gaps, and areas of controversy, and suggests directions for future research.
Establishing Context : It places the current research within the broader context of the field, demonstrating how the new research builds on or diverges from previous studies.

Types of Literature Reviews

Literature reviews can take various forms, including:

Narrative Reviews : These provide a qualitative summary of the literature and are often used to give a broad overview of a topic. They may be less structured and more subjective, focusing on synthesizing the literature to support a particular viewpoint.
Systematic Reviews : These are more rigorous and structured, following a specific methodology to identify, evaluate, and synthesize all relevant studies on a particular question. They aim to minimize bias and provide a comprehensive summary of the existing evidence.
Integrative Reviews : Similar to systematic reviews, but they aim to generate new knowledge by integrating findings from different studies to develop new theories or frameworks.

Importance of Literature Reviews

Foundation for Research : They provide a solid background for new research projects, helping to justify the research question and methodology.

Identifying Gaps : Literature reviews highlight areas where knowledge is lacking, guiding future research efforts.

Building Credibility : Demonstrating familiarity with existing research enhances the credibility of the researcher and their work.

In summary, a literature review is a critical component of academic research that helps to frame the current state of knowledge, identify gaps, and provide a basis for new research.

The research, the body of current literature, and the particular objectives should all influence the structure of a literature review. It is also critical to remember that creating a literature review is an ongoing process - as one reads and analyzes the literature, one's understanding may change, which could require rearranging the literature review.

Paré, G. and Kitsiou, S. (2017) 'Methods for Literature Reviews' , in: Lau, F. and Kuziemsky, C. (eds.) Handbook of eHealth evaluation: an evidence-based approach . Victoria (BC): University of Victoria.

Perplexity AI (2024) Perplexity AI response to Kathy Neville, 31 July.

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Library Services for Undergraduate Research (2024) Literature review: a definition . Available at: https://libguides.wustl.edu/our?p=302677 (Accessed: 31 July 2024).

Breastfeeding experiences of women with perinatal mental health problems: a systematic review and thematic synthesis

Hayley Billings 1 ,
Janet Horsman 1 ,
Hora Soltani 1 &
Rachael Louise Spencer 2

BMC Pregnancy and Childbirth volume 24 , Article number: 582 ( 2024 ) Cite this article

Metrics details

Despite its known benefits, breastfeeding rates among mothers with perinatal mental health conditions are staggeringly low. Systematic evidence on experiences of breastfeeding among women with perinatal mental health conditions is limited. This systematic review was designed to synthesise existing literature on breastfeeding experiences of women with a wide range of perinatal mental health conditions.

A systematic search of five databases was carried out considering published qualitative research between 2003 and November 2021. Two reviewers conducted study selection, data extraction and critical appraisal of included studies independently and data were synthesised thematically.

Seventeen articles were included in this review. These included a variety of perinatal mental health conditions (e.g., postnatal depression, post-traumatic stress disorders, previous severe mental illnesses, eating disorders and obsessive-compulsive disorders). The emerging themes and subthemes included: (1) Vulnerabilities: Expectations versus reality; Self-perception as a mother; Isolation. (2) Positive outcomes: Bonding and closeness; Sense of achievement. (3) Challenges: Striving for control; Inconsistent advice and lack of support; Concerns over medication safety; and Perceived impact on milk quality and supply.

Conclusions

Positive breastfeeding experiences of mothers with perinatal mental health conditions can mediate positive outcomes such as enhanced mother/infant bonding, increased self-esteem, and a perceived potential for healing. Alternatively, a lack of consistent support and advice from healthcare professionals, particularly around health concerns and medication safety, can lead to feelings of confusion, negatively impact breastfeeding choices, and potentially aggravate perinatal mental health symptoms. Appropriate support, adequate breastfeeding education, and clear advice, particularly around medication safety, are required to improve breastfeeding experiences for women with varied perinatal mental health conditions.

Peer Review reports

Breastfeeding is a key public health measure, conferring short- and long-term health and socio-economic benefits for women and their offspring [ 1 , 2 , 3 , 4 ]. Breastfeeding has been identified as crucial in meeting the United Nations Sustainable Development Goals for 2030 [ 5 ] with the World Health Organisation aiming for global rates of 50% exclusive breastfeeding until 6 months of age by 2025 [ 6 ]. Despite an increasing research base about what helps or hinders breastfeeding, there is a dramatic drop in breastfeeding prevalence within the first six weeks of birth, especially in high income countries [ 1 , 7 , 8 , 9 ]. The reasons given for cessation of breastfeeding suggest that few mothers gave up because they planned to, citing challenges such as physical pain [ 10 ], perceived insufficient milk supply [ 11 ], and breastfeeding not fitting in with family and/ or work life [ 12 ], and although complex physiological and psychosocial factors influence breastfeeding practices, evidence also suggests that mothers who experience postnatal depression may be at a greater risk of early breastfeeding cessation [ 13 , 14 ].

Perinatal mental health (PMH) conditions are mental illnesses which occur during pregnancy and up to a year following birth [ 15 , 16 ] and include a range of conditions such as: depression, anxiety, obsessive compulsive disorder, post-traumatic stress disorder (PTSD), tokophobia, bipolar disorder, postpartum psychosis, eating disorders and personality disorders [ 17 ]. These conditions are associated with increased morbidity and are a leading cause of maternal death in high-income countries [ 17 ]. Globally it is estimated that between 15 and 25% of women experience mental illness during the perinatal period, either as a new condition or as a reoccurrence of a pre-existing condition [ 17 ].

Breastfeeding is known to have psychological benefits, such as improving mood and protecting against postnatal depression in mothers, enhancing socio-emotional development in the child and strengthening mother-child bonding [ 13 , 14 , 18 , 19 ]. However, previous reviews of women’s experiences of breastfeeding whilst experiencing mental health conditions have focused primarily on postnatal depression (PND) [ 19 ]. No previous reviews have been identified which investigate the experiences and perspectives of women with a variety of perinatal mental illnesses with a view to improving breastfeeding health intervention strategies for women with such conditions.

This systematic review was reported in accordance with the PRISMA 2020 statement [ 20 ]. The review protocol was registered with PROSPERO in 2021 (registration number CRD42021297076 Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021297076 ). There was no requirement to deviate from this protocol during the study.

Search strategy

A literature search was undertaken for studies published from 2003 to Nov 2021. The selection of 2003 was to identify research undertaken following publication of the World Health Organisation Global Strategy for Infant and Young Child Feeding [ 21 ]. This advised that women exclusively breastfeed for six months and continue breastfeeding for two years and beyond for optimal health benefits to mother and infant.

The search was conducted using five electronic databases: Medline and CINAHL Complete (EBSCOhost), Maternity & Infant Care (Ovid), APA PsycInfo ® (ProQuest) and Web of Science Core Collection (Clarivate).

Search terms were devised according to the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework [ 22 ] (Table 1 ). Reference lists of included articles were scrutinised for possible additional studies.

Eligibility criteria

Eligible studies included:

published from 2003.

peer-reviewed articles.

published in English.

any setting.

qualitative primary research data.

participants were women experiencing mental health issues.

described experiences, perceptions, views, and opinions in relation to breastfeeding.

Study selection

Titles, abstracts, and potentially relevant full texts were screened independently by two authors against the eligibility criteria. Disagreement was resolved through discussion and consultation with a third author.

Data extraction

Data extracted included study authors, title, year of publication, country of origin, source of funding, study aims, study design, recruitment strategies, participant ethnicity, PMH condition, and study results. Two authors independently extracted data.

Quality appraisal of included studies was carried out to demonstrate rigour, using a Critical Appraisal Skills Programme (CASP) appraisal tool [ 23 ], however this was not used as an indicator for inclusion in the analysis.

Data synthesis

Thematic synthesis, a method of analysis widely used for qualitative systematic reviews, was undertaken [ 24 ]. This involved line by line coding of extracted quotations followed by development of descriptive and analytical themes. NVivo software was used to systematically code extracted data. Verbatim quotations, along with information on themes and sub-themes they were assigned to in the original study, were imported into the software. Codes and their supporting data were reviewed to identify related categories which could be grouped into broader descriptive themes. From this, overarching analytic themes were identified.

Author reflexivity was considered and addressed throughout the review with regular discussions between authors to debate and establish aspects such as definitions of mental health, use of terminology, themes, subthemes and the interplay between them.

Patient and public involvement

Once key findings were established, the project team organised two patient and public involvement events, which included ethnic minority perinatal peer supporters and a pre/postnatal peer support group with PMH experiences. Feedback from these groups showed that the themes identified by the review captured the main priorities of the groups.

The study selection process is outlined on the PRISMA [ 20 ] flow diagram (Fig. 1 ). A total of 5510 studies were retrieved. After removing duplicates ( n = 2604) and excluding articles which were not relevant following screening of title and abstract ( n = 2878), full text of the remaining 28 studies were screened. Of these, 11 studies were excluded, resulting in 17 studies being included in this review.

PRISMA flow diagram detailing study selection [ 20 ]. CINAHL – Cumulative Index to Nursing and Allied Health Literature. PRISMA flow diagram- 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. BMJ . 2021;372(71). DOI: https://doi.org/10.1136/bmj.n71

Characteristics of the studies

From the 17 included studies, four used thematic analysis, two in a qualitative study [ 25 , 26 ] and two within a mixed methods secondary analysis of existing data [ 27 , 28 ]. Six studies used phenomenological methods [ 29 , 30 , 31 , 32 , 33 , 34 ], two used an ethnographic approach [ 35 , 36 ] and three undertook a Grounded Theory approach [ 37 , 38 , 39 ]. One study used a psychoanalytically informed analysis [ 40 ] and one used comparative analysis [ 41 ].

Following CASP quality appraisal, the methodological quality of included papers was ranked as either low ( n = 3), moderate ( n = 2) or high ( n = 12), (Table 2 ).

Of the included studies, seven focused on PND, four included patients with PND and/or emotional difficulties, postnatal blues or mental distress, two focused on mood disorders, four included women previously diagnosed with severe mental illnesses, eating disorders, obsessive compulsive disorder, and/or traumatic childbirth/PTSD.

There were a total of 551 participants across the studies. Of these, 456 were married/cohabiting, 18 were single/separated, and 77 did not specify. For educational attainment, 321 participants identified as either ‘well educated’ or having studied beyond high school level. A total of 86 participants received a school education (high school or below), 14 participants had no schooling and 130 did not specify. Of the 17 studies, 15 were carried out in high-income countries and two in low-income countries (Table 3 ).

Through in-depth analysis of the data, three overarching themes: Vulnerabilities, Positive outcomes, and Challenges, emerged. These themes and associated sub themes are shown in Table 4 . The interplay among these major domains within the context of themes and subthemes are summarised in Fig. 2 .

Illustration of the interplay of themes and subthemes of the breastfeeding experiences of women with perinatal mental health problems PMH – Perinatal mental health

Theme: vulnerabilities

Expectations versus reality.

For some new mothers the reality of breastfeeding did not meet their expectations of being easy and ‘natural’, leaving them feeling unprepared and disillusioned when they experienced difficulties.

“You think you’re a completely useless mother and, you know, you should be able to know how to do this instinctively [breastfeeding] and in fact it’s probably the hardest thing I’ve ever done.” (25, p255).

Limited availability of antenatal breastfeeding advice led to mothers being unaware of the potential complexities of breastfeeding during the early days and weeks.

“Everyone make it seem like it’s natural because your body produces [milk]. It’s just something that should frequently come to you as soon as you have the baby., but it’s not like that. You had to hold the baby a certain way, you got to adjust your thing a certain way, you got to put the nipple in far enough for the baby to get it. There’s a lot to it. It’s really complicated.” (26, p5).

Self-perception as a mother

To be perceived as a ‘good mother’, by themselves and others, some women felt they must breastfeed at all costs. This perceived association of breastfeeding as the representation of ‘good mothering’, appeared to result in self-imposed pressure.

“I was so desperate to breastfeed him and I felt as if it was my, I felt as if I had some moral obligation as a mother and if I didn’t breast feed him I was badly letting him down.” (25, p255).

If these women were then unable to breastfeed, or if they faced significant breastfeeding difficulties, this sometimes led to feelings of guilt or inadequacy.

“There’s so much pressure on you to breastfeed. so you’re told that breast is best and you should do it and so when you don’t you think you are a failure and it’s what you should be doing.” (39, p322).

The opinions of family, friends and health professionals also played a significant part in the woman’s perception of her status as a ‘good mother’.

“The approval thing was a big factor. Everyone was telling me how well I’d done to keep breastfeeding. All that approval made me feel really good about myself, and that I was being a good mother to (baby). I wasn’t thinking negative thoughts about myself, I was feeling very positive really.” (35, p114).

However, for some mothers, this resulted in added pressure, causing them to hide their feelings and maintain an outward display of happiness.

“I didn’t want to talk with anybody about it, I always had to pretend that I was doing just great … I thought that wasn’t normal, that I was a bad mom who felt that way.” (37, p264).

Finding the right support could be very beneficial but some women had negative experiences of clinics or groups, undermining their self-belief.

“Daggers are drawn and everybody’s acting as if they can rule the world and the trouble is, when you’re depressed you just see that image and you think, I’m never going to be as good as this.” (39, p323).

Feelings of isolation felt by breastfeeding women were exacerbated by mental health issues, with Homewood et al. (39, p325) suggesting that breastfeeding could contribute to depression by increasing the sense of being trapped by the infant’s dependency.

“abandoned and alone … .scared all the time that something would happen to the baby…” (37, p264).

The sense of isolation was increased by the fact that seeking help could be difficult for women who were distressed because they were reluctant to reveal their negative feelings.

“I was feeling like really sad and just really isolated and really stuck!. . I just thought. . “How am I going to take care of this baby? And I am feeling so crappy!” I found it to be really hard just to reach out and admit that I was feeling the way that I was. I don’t know why I was so worried about being stigmatized, but I was. I just didn’t want that label of being a person with postpartum depression.” (32, p12) “.

Theme: positive outcomes

Bonding and closeness.

Whilst struggling with mental health issues, the experience of breastfeeding successfully could increase mothers’ positive feelings toward the baby, allowing them to enjoy time spent together and enhance their confidence.

“I used to feed her and it was the time I got a little lump in my throat and thought, oh, perhaps she’s not that bad, and I thought, this is perhaps how people feel a bit more of the time than I feel it.” (39, p323).

Some women reported that the physical aspect of breastfeeding allowed a connection that could compensate, to a degree, for the mental withdrawal caused by the depressive symptoms.

“I think [breastfeeding] helps because even if I feel like some days I’m not very connected emotionally, I know that at least I’m providing the baby with physical touch and bonding and all that. Even if I’m not mentally 100% there. So, I think it makes me feel better about myself as a mom.” (33, p641).

One mother noted that breastfeeding could reduce feelings of stress.

‘‘When I’m nursing her, I’m able to just hold her. And that just alleviates any worries, any stress that I’ve had through the day, just knowing that she needs me, that she’s finding comfort in me, that I’m able to comfort her. She’s comforting me at the same time.” (26, p5).

Sense of achievement

Achieving success with breastfeeding was a factor in mitigating some of the guilt that women with eating disorders might feel about the possible effects of their eating disorder on the baby, positively affecting their self-esteem.

“It wasn’t my instinct to want to breastfeed him but in the end I did. In some ways it made up for all the damage I thought I’d done to him because of my eating disorder.” (35, p113).

Some women who had experienced a traumatic birth perceived breastfeeding as having the potential to heal and reinforced their self-perception as a good mother.

“I would cover her up to feed her and hide her little head in the clothing. Not because of dignity, but because I did not want anyone else to see the magic and healing that was happening between us. Being able to breastfeed my daughter, despite all the odds, is my proudest achievement in life. I wear it in my soul as a badge of honor.” (29, p233).

Women described how breastfeeding was within their sphere of control whereas other aspects of motherhood were not.

“[Breastfeeding] was the one thing that I could control. . I think that it made me feel better because it was the one thing that I was successful at, as a mom, because my birth went so shitty, and everything just kind of spiraled down and my mood and everything. . .I lean on [breastfeeding] a lot. It is my thing with her that no one can take away. . .I don’t like other people doing it. I don’t even like the suggestion of other people doing it.” (32, p12).

Theme: challenges

Striving for control.

Some women with eating disorders perceived stopping breastfeeding as the only way to allow them to resume control over their body and their eating.

“I wanted my body back and I knew I wouldn’t get it back until I’d stopped breastfeeding. I knew the minute that stopped feeding him I could control my food again and that’s what I wanted. When I was feeding I needed to eat properly because he needs the nutrients.” (35, p114).

For women with obsessive compulsive disorder [ 30 ], some responded to contamination fears by breastfeeding, sometimes for much longer than planned.

“I forced myself to breastfeed for the whole of the first year because I was convinced that formula would be contaminating his body.” (30, p317).

Other women with eating disorders chose not to breastfeed in order to allow themselves to return to purging and undertaking strenuous exercise in order to lose their pregnancy weight rapidly [ 35 ].

Some still struggled between eating a ‘good’ diet to produce ‘healthy’ milk and the desire to return to their usual strategies such as restricted eating or purging.

“I didn’t need to make myself sick so often [when breastfeeding] but that wasn’t because I didn’t want to! [Laughs] I had to fight with myself all the time to control the urge. I thought breastfeeding would take that urge away but it didn’t. It eased a bit but I was still vomiting all the time I was breastfeeding.” (35, p112).

Inconsistent advice and lack of support

Women’s difficulties and lack of confidence with breastfeeding were increased by inconsistent advice from both professionals and family [ 25 ]. Mothers frequently made reference to seeking advice from healthcare professionals during the early weeks of breastfeeding but felt they were often left unsupported.

“I was alone and . the nurse often didn’t answer the buzzer, my buzzer when I was trying to breast feed and things. Again I felt so kind of, incredibly sensitive about everything, and anxious about everything, and they just weren’t there, were never there for me.” (25, p256).

Mothers described feeling pressurised by healthcare professionals to continue breastfeeding [ 35 ] and, without adequate support, women would often turn to friends or relatives for infant feeding advice [ 25 ].

Concerns over medication safety

Concerns regarding medication safety and breastfeeding [ 26 , 27 , 34 ] led some women to discount breastfeeding as an option for them.

“….I could try and breastfeed, but yeah, I decided that wasn’t—a good idea. Because it’s too hard and I wouldn’t be able to go back on my medication—right away after the baby was born. You have to wait two months, or something like that. So I thought that was dangerous— for both of us.” (34, p383).

Whilst others discontinued breastfeeding due to health concerns for the baby.

“And I had to get my wisdom teeth pulled out, so I decided to stop because they put you on antibiotics and stuff like that. So I just stopped.”(26, p5).

Some women with severe mental illness felt that due to the complexities of their mental health, breastfeeding was not considered relevant and was “de-prioritized” for other aspects of acute care [ 27 ]. Despite many mothers expressing strong preferences to continue breastfeeding, the mothers often felt that their preferences were ignored.

“Medication was an issue as I was initially given medication that specified it should not be taken while breastfeeding, when I had made my wish to breastfeed very clear.” (27, p7).

Some women felt that they needed to prompt staff to consider whether the medication they were prescribed would allow breastfeeding, or, alternatively, be given the choice to cease breastfeeding to allow them to have the most suitable medication to treat their mental health condition.

“I wish they had told me to stop breastfeeding rather than give me diluted medication.” (27, p6).

Others described being given contradictory information from health professionals about breastfeeding whilst taking psychotropic medication:

“Early in pregnancy, the mental health midwife said not to take fluoxetine if breastfeeding and to change to sertraline or citalopram. Next time I saw her later on and she said I could stay on fluoxetine if I was happy on it.” (27, p6).

Such conflicting advice made mothers confused and distressed. A resultant lack of confidence in healthcare professionals “ prompted some women to conduct their own research or to disregard medical advice ” (27, p6).

Perceived impact on milk quality and supply

There was a perception that women with PMH conditions would be unable to produce a sufficient quality and/or volume of breastmilk to sustain their baby nutritionally. This concern could potentially generate feelings of depression for women [ 26 ].

Some mothers perceived that their own poor nutrition could potentially cause problems with breastfeeding. This concern was often associated with eating disorders [ 26 ], food unavailability or lack of appetite due to mental ill health [ 38 , 41 ]. For women with eating disorders there was a belief that frequent cycles of binging and purging were not compatible with producing sufficient good quality breast milk. This caused some women to discount breastfeeding, and some received pressure from partners to bottle feed in the belief that the child would not receive the necessary nutrition.

“He (husband) didn’t want me to breastfeed because he thought I wasn’t eating enough to feed her (baby) properly. [.] He was on and on about me giving her the bottle. He even dragged my sister in to try and get her to talk me round.” (35, p111).

Some women with eating disorders did wish to breastfeed and commented on needing to change their eating patterns to achieve this.

“I had to eat properly when I was breastfeeding because I had a baby to think about. The baby needs nutrition. I thought whatever I eat the baby is going to get it. So I had to eat properly. Like when I was pregnant I made myself eat properly.” (35, p112).

Depression and anxiety are a common problem in the perinatal period, and pregnancy and childbirth can put women at risk of relapse or exacerbation of pre-existing mental illness [ 17 ]. Although postpartum anxiety is more prevalent than postpartum depression [ 42 ] we did not find any studies of women’s experiences of anxiety and breastfeeding. In this review there were examples of specific mental illnesses being associated with specific issues in relation to breastfeeding along with the difficulties faced by many women. Data from the included studies replicated what is already known regarding the relationship between perinatal depression and breastfeeding, that this relationship is bidirectional, with evidence of depressive symptoms contributing to worse breastfeeding outcomes and breastfeeding challenges sometimes serving as a trigger for postnatal depressive symptoms [ 43 ].

In this study it was found that, for mothers who were struggling with their mental health, the sense of achievement obtained by successful breastfeeding could boost their self-esteem and bolster the perception of themselves as a good mother [ 29 , 32 , 40 ]. These mothers found that breastfeeding could increase their mother/child bond and reinforce their confidence as a mother and felt that the closeness experienced during breastfeeding could reduce feelings of stress and compensate their baby for times when they were feeling withdrawn [ 26 , 33 , 35 , 39 ].

However, the perception that ‘good mothering’ is defined by successful breastfeeding can also result in overwhelming pressure for mothers, who may feel obliged to breastfeed despite experiencing challenges [ 44 , 45 , 46 ]. This pressure can then be further compounded by the attitudes and behaviours of healthcare professionals, family members and society in general [ 46 ]. A large proportion of the women in the included studies had a strong intention to breastfeed [ 25 , 28 , 31 , 33 , 37 ] and were often motivated to continue, despite difficulties, because of the pressure they placed on themselves to fulfil the role of the ‘good mother’. If they then had difficulties or ceased breastfeeding they often experienced feelings of guilt, inadequacy, and failure [ 25 , 27 , 40 ].

There is a wealth of literature describing the guilt and despair experienced when women’s expectations for breastfeeding to occur naturally, the desire to be a good mother, and ‘breast is best’, clash with the demands and labour-intensive workload that breastfeeding often entails [ 43 , 44 , 47 , 48 ]. A lack of antenatal education regarding potential breastfeeding challenges appears to be evident, with much of this being dedicated to the benefits of breastfeeding to both mother and baby, and although this information is important, it can provide a skewed ideal of the breastfeeding process [ 47 ]. Findings from studies by Hoddinott et al. [ 47 ] and Redshaw and Henderson [ 48 ] suggested realistic antenatal education is key to preparing women for common difficulties and suggest providing a realistic view rather than rosy pictures or patronising breastfeeding workshops with knitted breasts and dolls [ 47 ]. This lack of preparation for the challenges that frequently arise during the early days of breastfeeding can result in mothers feeling inadequate and unable to cope [ 45 , 46 ], potentially resulting in early discontinuation of breastfeeding and/or a decline in mental wellbeing.

The perception that mental health conditions can lead to insufficient or poor-quality breast milk is a common perception amongst breastfeeding women. A systematic review of breastfeeding problems by Karaçam and Sağlık, [ 49 ], found that 12 out of 34 studies referred problems such as “inadequate breastmilk/lack of breastmilk/ concern for inadequate breastmilk/thought that the baby was not satiated adequately/inadequate weight gain.” The theme was again identified by this study, particularly amongst those with eating disorders [ 29 , 35 ] and women from the two African based studies [ 38 , 41 ]. Women’s perceptions were primarily that poor mental health leads to inadequate nutritional intake (due to lack of appetite/disordered eating) and therefore impacts breastmilk volume and quality. This added burden of believing that their breastmilk may not adequately sustain their child could potentially further impact their mental health as a perceived failure [ 29 ].

For some women a sense of isolation in their role as carer, and specifically regarding breastfeeding was expressed in the included studies [ 25 , 32 , 34 ]. The sense of isolation can be magnified both by the symptoms of mental health issues and the reluctance of the mothers to reveal their condition, either pre-existing or newly emerging, to their loved ones and health professionals, worrying about what they may think [ 30 , 32 , 37 ]. This is reflected in previous research, which found stigma associated with mental ill health, compounded by a pervasive social stigma attached to being seen to ‘fail’ as a mother, leads to under-reporting of perinatal mental health issues [ 50 ]. A study of Australian women undergoing routine psychosocial assessment also found that 11.1% reported they were not always honest in the assessment and lack of trust in the midwife was the most frequent reason for non-disclosure [ 51 ]. Failure to reveal previous mental health issues may lead to inappropriate or sub-optimal advice [ 35 ].

The findings also identified that a lack of trust in the support and advice given by health professionals was also a contributing factor when considering medication safety and was stated as a reason to cease or not commence breastfeeding [ 27 , 34 ]. These inconsistencies sometimes prompted women to undertake their own research to gain answers [ 27 ], which could potentially lead to serious health consequences. The concerns held by women regarding medication safety and breastfeeding were highlighted in a Swedish study [ 52 ] which found that 57.7% of pregnant participants classed medication use during breastfeeding as harmful/probably harmful.

This lack of consistent advice regarding medication safety is largely due to a lack of high-quality evidence [ 53 ]. However, for those requiring medication during the postnatal period, clearer guidance is needed from healthcare professionals on the suitability of each type of medication when breastfeeding, and whether alternative medications can be considered so that breastfeeding can be undertaken safely without additional worry. Some women in the study felt they did not have the opportunity to make an informed choice regarding their medication and that desire to breastfeed was deprioritised over their mental health [ 27 ]. However, findings from this and previous studies have shown that when breastfeeding is successful it can improve mood and help protect against postnatal depression [ 32 , 33 , 54 , 55 ], as well as strengthen mother-child bonding [ 26 , 33 ]. It may therefore be the case that, in conjunction with suitable medication, breastfeeding may further help to boost mood and improve the overall wellbeing of the mother by providing a sense of achievement and control.

Negative attitudes towards diagnosis and treatment of perinatal mental health conditions result in women avoiding help seeking and reinforces feelings of stigma and guilt. Organisational-level factors such as inadequate resources, fragmentation of services and poor interdisciplinary communication compound these individual-level issues [ 50 , 56 ]. Structural factors (especially poor policy implementation) and sociocultural factors (for example language barriers) also cause significant barriers to accessing services for this group of women [ 50 , 56 ].

A strength of this review is the inclusion of literature regarding various mental health conditions (not purely depression) which had not been previously synthesised. This review highlights that each mental health condition may impact differently on breastfeeding experiences and merits separate investigation to inform policy and practice. The findings from this synthesis were based on a systematic literature search of five electronic databases. Inductive and in-depth analysis, using an iterative approach, allowed for immersion in the data, which strengthened the review findings.

Limitations were similar to those identified by previous studies relating to maternal mental health needs [ 57 ]. Participants were predominantly white and well educated, and studies were primarily undertaken in high income countries. This means that the findings may not be applicable to all women particularly those from low-income countries who may have different experiences and needs. None of the included studies incorporated the views and experiences of women from low socioeconomic status specifically, who are more likely to experience PMH conditions [ 47 ]. A comparison of the breastfeeding experiences of women with PMH conditions between different countries was beyond the scope of this review, however it must be acknowledged that differences are expected due to variations in culture, health systems, resource, and infant feeding attitudes.

The methods of diagnosing mental health conditions differed between studies. Some participants had a clinical diagnosis, whilst some were included based upon tools such as the Edinburgh Postnatal Depression Scale, or a self-diagnosis of distress/depression. This allowed us to increase the scope of studies included but may mean that some studies included women who may have not met the criteria for a clinal diagnosis of depression.

To ensure completeness prior to publication, the original search was again undertaken to capture any studies published between November 2021 and February 2024. The search identified two further papers which met the inclusion/exclusion criteria. Both papers supported the original themes found in the study and therefore further validated the findings. Scarborough et al. [ 58 ] reported a perceived pressure to breastfeed, mixed impact on the mental health of the mother and the mother infant bond, and challenges receiving adequate information and support. Frayne et al. [ 59 ] highlighted the importance of good communication, consistency of advice, and shared decision making for women taking psychotropic medication, and the challenges faced if these aspects were not achieved.

There is a complex dynamic relationship amongst breastfeeding intention, practice, and experiences for mothers with PMH conditions. The intensity and magnitude of positive outcomes that women describe, and the challenges experienced, are exacerbated in mothers with PMH conditions. The challenging experiences are particularly influenced by a lack of support, shame, fear of stigmatisation and additional health concerns, such as worries over medication safety.

The synthesis identified inconsistent advice from healthcare professionals, particularly in relation to medication. Further training and improved communication pathways between specialities may help enhance perinatal maternity care provision. An in depth understanding of the women’s views/needs in relation to their specific PMH condition could help enhance their experiences of infant feeding. This will help women to make informed choices about feeding, increasing their sense of control and improving self-efficacy, which could have a positive impact on their emotional and physical wellbeing, their ability to bond with their baby and their transition to motherhood.

Gaps identified through this systematic review include the need for further investigation on breastfeeding and PMH in women from minority groups, as well as a need for robust evidence and advice on medication use during breastfeeding for women experiencing perinatal mental ill health.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

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Billings, H., Horsman, J., Soltani, H. et al. Breastfeeding experiences of women with perinatal mental health problems: a systematic review and thematic synthesis. BMC Pregnancy Childbirth 24 , 582 (2024). https://doi.org/10.1186/s12884-024-06735-1

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The Effects of Stress on Physical Activity and Exercise

Associated data.

Psychological stress and physical activity (PA) are believed to be reciprocally related; however, most research examining the relationship between these constructs is devoted to the study of exercise and/or PA as an instrument to mitigate distress.

The aim of this paper was to review the literature investigating the influence of stress on indicators of PA and exercise.

A systematic search of Web of Science, Pub-Med, and SPORTDiscus was employed to find all relevant studies focusing on human participants. Search terms included “stress”, “exercise”, and “physical activity”. A rating scale (0–9) modified for this study was utilized to assess the quality of all studies with multiple time points.

The literature search found 168 studies that examined the influence of stress on PA. Studies varied widely in their theoretical orientation and included perceived stress, distress, life events, job strain, role strain, and work–family conflict but not lifetime cumulative adversity. To more clearly address the question, prospective studies ( n = 55) were considered for further review, the majority of which indicated that psychological stress predicts less PA (behavioral inhibition) and/or exercise or more sedentary behavior (76.4 %). Both objective (i.e., life events) and subjective (i.e., distress) measures of stress related to reduced PA. Prospective studies investigating the effects of objective markers of stress nearly all agreed (six of seven studies) that stress has a negative effect on PA. This was true for research examining (a) PA at periods of objectively varying levels of stress (i.e., final examinations vs. a control time point) and (b) chronically stressed populations (e.g., caregivers, parents of children with a cancer diagnosis) that were less likely to be active than controls over time. Studies examining older adults (>50 years), cohorts with both men and women, and larger sample sizes ( n > 100) were more likely to show an inverse association. 85.7 % of higher-quality prospective research (≥7 on a 9-point scale) showed the same trend. Interestingly, some prospective studies (18.2 %) report evidence that PA was positively impacted by stress (behavioral activation). This should not be surprising as some individuals utilize exercise to cope with stress. Several other factors may moderate stress and PA relationships, such as stages of change for exercise. Habitually active individuals exercise more in the face of stress, and those in beginning stages exercise less. Consequently, stress may have a differential impact on exercise adoption, maintenance, and relapse. Preliminary evidence suggests that combining stress management programming with exercise interventions may allay stress-related reductions in PA, though rigorous testing of these techniques has yet to be produced.

Conclusions

Overall, the majority of the literature finds that the experience of stress impairs efforts to be physically active. Future work should center on the development of a theory explaining the mechanisms underlying the multifarious influences of stress on PA behaviors.

1 Introduction

1.1 review of the problem.

The association between physical activity (PA), exercise, and health outcomes is well-established [ 1 , 2 ]. In the Behavioral Risk Factor Surveillance System (BRFSS) database, the number of unhealthy days reported by 175,850 adults was inversely associated with PA [ 3 ]. Those who exercise have a lower incidence of coronary events and cardiovascular disease. There is a strong inverse relation between exercise and obesity and diabetes mellitus [ 4 , 5 ]. Furthermore, those who exercise have fewer incidences of certain types of cancers [ 6 ] and more robust immune responses [ 7 ]. Interventions designed to increase PA have resulted in profound reductions in physical ailments [ 8 , 9 ]. There is a similar picture for exercise and mental health outcomes. Those who exercise suffer from less depression [ 10 ], anxiety [ 11 ], fatigue [ 12 , 13 ], and cognitive impairments [ 14 , 15 ].

Despite the well-known benefits of PA, the practice of this behavior is very low. Approximately 21.9 % of adults in the US participate in light-to-moderate leisure-time PA a minimum of five times per week, and only 11.1 % of adults engage in vigorous leisure-time PA at this same frequency [ 16 ]. According to self-report data from the BRFSS, only 48.8 % of US adults meet the minimum level of PA necessary for maintaining good health as determined by the Healthy People 2010 objectives [ 16 ].

Recent evidence suggests that one’s experience of stress may be an important impediment for achieving healthful levels of PA [ 17 , 18 ]. Despite the well-known effects of exercise on mental health outcomes, a lesser emphasis has been placed on the reverse relationship [ 19 , 20 ]. A firmly established reverse link for depression and PA suggests that a similar trend may exist for stress and PA [ 21 , 22 ]. While related to stress, depression is, nonetheless, a distinctly different construct [ 23 ]. At this time, no paper has attempted to synthesize the evidence both for and against the effects of mental stress on exercise behavior. The aim of this review is to fill this gap in the literature and to identify factors that may moderate the relationship, which may help to identify both populations vulnerable to the effects of stress and mechanisms responsible for the relationship.

1.2 Understanding Stress

There is no universal agreement on the definition of stress. McEwen [ 24 ] simply states that “Stress is a word used to describe experiences that are challenging emotionally and physiologically.” These stressors may be acute (e.g., hassles) or chronic (e.g., bereavement), small in magnitude (e.g., standing in a long line), or traumatic (e.g., violent attack) [ 25 ]. Contrary to the view of stress as an impinging stimulus, other definitions provide a glimpse into what systems are challenged and how the human organism reacts. Stress may be defined as a state of threatened homeostasis, which is counteracted by adaptive processes involving affective, physiological, biochemical, and cognitive–behavioral responses in an attempt to regain homeostasis [ 26 , 27 ]. Stress reactions are always followed by recovery processes, which may be compromised when stressors are severe, prolonged, or unaccustomed [ 28 , 29 ]. The adaptive capacity to deal with stress is one’s fitness, which when exceeded may place the individual at greater risk for disease [ 30 ]. This may be manifested in the dysregulation of active processes of adaptation, or allostasis, resulting in cumulative wear and tear of the body, also known as allostatic load [ 24 , 31 ]. Typically, this has been utilized to explain how chronic stressors relate to physiological maladaptations in middle and later life [ 32 ]; however, mounting evidence also implicates traumatic childhood experiences, stressors that have a reverberating impact for decades [ 33 , 34 ]. Therefore, stressful events appear to accumulate from the earliest days of life, and this cumulative adversity may have a profound impact on a wide range of health outcomes [ 35 ].

Lazarus and Folkman [ 36 ] provide a transactional cognitive component to stress with their concept of appraisal, which indicates that individuals only perceive stress when a challenge or event is both threatening and of such a nature that the individual is unable to cope. In this viewpoint, objective demands and subjective appraisals may differentially impact health behaviors. It is important to note, however, that some stressors may be appraised as positive [ 24 , 37 ]. Cognitive models of the stress concept have recently been overshadowed by new research on the integrated role of the brain (particularly centers of emotion and memory) as a regulator of stress processes [ 24 ].

1.3 Relationship of Stress to Health Outcomes and Behavior

Psychological stress has a deleterious effect on a wide range of physical and mental health outcomes with accumulating evidence that health practices/maladaptive behaviors may mediate these relationships [ 38 ]. Stress has been strongly implicated in the pathogenesis of coronary heart disease [ 39 ] and the incidence of acute myocardial infarctions [ 40 ]. Those under high stress are less likely to survive cardiac events [ 41 ]. Alterations in the immune system by stress are well-established [ 42 ], and those who report high levels of stress are more likely to become infected [ 43 ]. The nervous system is also compromised during times of undue stress [ 44 , 45 ]. Stress is associated with a host of mental symptoms as well, including cognitive dysfunction, dementia [ 46 ], and excessive fatigue [ 13 , 47 , 48 ]. While stress may have a direct effect on health (e.g., dysregulation of hormonal axes), indirect routes toward maladaptation also likely exist [ 49 , 50 ]. For instance, stress is related to declining physical function over time [ 51 ] and obesity [ 52 - 54 ], which contributes to cardiovascular disease. Another likely factor is impaired health/lifestyle practices and maladaptive behaviors, such as decreased exercise and PA and increased sedentarianism [ 50 ]. Furthermore, delays in recovery from exercise [ 29 ] and dampened muscular and neural adaptations are observed with chronic stress [ 55 , 56 ]. It is of no wonder that individuals under high stress are much more likely to incur greater healthcare costs [ 57 ].

1.4 Understanding Physical Activity (PA)

In contrast to the apparently debilitating effects of unremitting psychological stress, PA appears to have a salubrious effect on many health outcomes. PA is “any bodily movement produced by skeletal muscles that results in energy expenditure [ 58 ] above resting (basal) levels [ 59 ]. PA broadly encompasses exercise, sports, and physical activities done as part of daily living, occupation, leisure, and active transportation” [ 60 ]. Also implicit in this definition is that PA is a physical stressor, though not necessarily an uncomfortable one. Exercise is a behavioral subset of PA and is defined as “Physical activity that is planned, structured, and repetitive and has as a final or intermediate objective the improvement or maintenance of physical fitness” [ 58 ]. Dissimilarly, sedentarianism is “activity that involves little or no movement or PA, having an energy expenditure of about 1–1.5 metabolic equivalents (METs). Examples are sitting, watching television, playing video games, and using a computer” [ 61 ]. These definitions connote that PA behaviors are specific to a person, situation, and context. Also, they suggest that these concepts are quantified in terms of mode, frequency, duration, and intensity [ 60 ].

1.5 Beneficial Effects of PA/Exercise on Psychological Stress

When the PA and stress relationship is explored, it has typically been within the perspective of improving mental health outcomes via exercise [ 62 ]. As suggested earlier, those who exercise have lesser rates of depression, negative affectivity, and anxiety [ 10 , 11 ]. Indeed, PA and exercise have been demonstrated to promote positive changes in one’s mental health and ability to cope with stressful encounters [ 19 , 63 , 64 ]. Moreover, exercise interventions appear to improve one’s depression status [ 65 , 66 ].

In terms of psychological stress, similar patterns are observed in cross-sectional, prospective, and experimental studies. Exercise is associated with less subjective stress, a finding that has been observed in numerous populations from athletes to older adults to veterans with post-traumatic stress disorder [ 67 - 78 ]. While it is equivocal whether those who exercise have fewer life events [ 79 - 81 ], there is an association between exercise and fewer daily hassles [ 82 ]. It appears that the quantity of calories expended is most important. For instance, Aldana et al. [ 83 ] found that individuals who expend more than 3.0 kcal/kg/day in PA during leisure time were 78 and 62 % less likely to have moderate and high perceived stress, respectively. However, the intensity of exercise may play a key role as those who participated in exercise that was of a moderate intensity exhibited approximately half the amount of perceived stress as those who reported no exercise [ 83 ]. Intervention and prospective studies demonstrate that exercise and PA programs result in less perceived stress in real-world settings [ 75 , 84 – 90 ]. Randomized clinical trials have determined that exercise is an effective method for improving perceived stress, stress symptoms, and quality of life [ 91 - 95 ]. Exercise neutralizes the effects of psychological stressors on cardiac reactivity [ 96 ] and dampens stressor-evoked increases in stress hormones [ 97 ] and serotonin [ 98 ]. For instance, Throne et al. [ 99 ] found that a 16-week intervention (exercise four times per week, 40 min) improved stress reactivity in a group of fire fighters. It appears that PA, and not fitness, mollifies the effects of stress [ 64 , 100 ]; however, there is not universal agreement on this point. Those who are aerobically fit have less cardiac reactivity to stressors [ 101 - 103 ] and also better cardiovascular recovery [ 104 - 107 ]. Apart from these distinctions, a recent review concludes that exercise buffers the effects of stress on physical health [ 49 ]. For instance, exercise prevents stress-induced immunosuppression [ 108 ]. Considering the seemingly profound effects of exercise on stress, movement has been conceptualized as a method to inoculate individuals against the throes of stressful experience [ 109 ]. However, the relationship of PA with stress has not always been consistent. For instance, in two cross-lagged studies, exercise at time 1 did not predict stress at time 2 [ 20 , 110 ]. Furthermore, several studies have found no relationship between stress and exercise constructs [ 111 , 112 ] or relationships that were positive instead of negative [ 113 , 114 ].

1.6 Reciprocal Relationship of Stress and PA

The extant literature largely concludes there are relationships between stress and PA/exercise, and that PA repels the negative effects of psychological stress, but what of the relationships in the opposite direction? In other words, is stress detrimental towards the effort of adopting and maintaining exercise behavior? It has been noted extensively that a dynamic, bi-directional relationship likely exists [ 19 , 21 , 24 , 38 , 49 , 50 , 83 , 115 - 124 ], but this direction of influence is often overlooked [ 53 ]. Salmon [ 19 ] mused that the stress and PA-exercise relationships are open to interpretation, and “people who are less disturbed by stress might simply be more ready to take up exercise training” (p. 46). Zillman and Bryant [ 117 ] propose that in response to stress people will engage in unhealthy behaviors, such as poor dietary practices or a lack of exercise, as a means of emotion-focused coping. Indeed, a plethora of research links stress to increased smoking [ 125 - 127 ], use of alcohol [ 128 ], and increased substance abuse [ 27 , 129 , 130 ]. While less pernicious, stress is associated with dietary relapse [ 131 - 133 ], binge eating [ 134 ], increased caffeine consumption [ 135 ] and television viewing [ 136 , 137 ]. Studies examining composite scores of collective health behaviors, including PA, find that stress is predictive of negative health behaviors [ 138 - 143 ]. In fact, stress accounts for a substantial proportion of variance in collective health behaviors [ 143 ]. Considering the multifarious relationships between stress and behavior, it is plausible that stress is related to both PA and exercise as well.

Further evidence of this proposed relationship emanates from studies on depression and negative affect and how these factors predict PA. Negative affectivity, anxiety, anger, and distress inversely predict exercise behavior [ 21 , 144 - 148 ]. Negative affect predicts missed practices due to injury and illness, and this may be attenuated with the implementation of a stress inoculation training program [ 149 ]. Depression predicted changes in PA in women diagnosed with early-stage breast cancer [ 150 ] and was related to less PA in the Alameda County study [ 151 ]. Depressed cardiac rehabilitation patients are less likely to adhere to the exercise program; coming to fewer sessions and dropping out at high rates [ 152 ]. Concurring with these observations, a recent review of prospective studies found that depression at baseline is inversely related to measures of PA at later periods [ 22 ]. Reviews examining factors associated with increased exercise behavior and adherence have found mixed or a lack of evidence of an association between stress and PA, particularly when compared to other factors [ 153 - 161 ]. However, in every review, authors failed to amass the bulk of pertinent literature on the topic. Lutz et al.[ 20 ], in an attempt to address the bi-directional relationship of stress and exercise, determined that the relationship was stronger in the direction less often studied, underscoring the notion that stress degrades this healthful behavior. Since this time, however, no review has attempted to synthesize the diverse literature examining the effects of stress on PA. The purpose of this review, therefore, was to fill this gap by systematically identifying, classifying, and appraising the extant literature on this topic across all pertinent disciplines, including sports medicine, health psychology, health promotion and occupational health, among other areas.

2.1 Search for Publications

A search was conducted in Web of Science, SPORTDiscus and PubMed for relevant literature. The search terms utilized were “stress”, “exercise”, and “physical activity”. This yielded a large number of returns. Consequently, the search was narrowed by selecting options in each database. When possible, articles were eliminated for irrelevant fields (e.g., engineering, chemical science, etc), unoriginal data (e.g., review articles, corrections, editorials, magazine articles), non-human subjects, and text not reported in the English language. Starting with Web of Science, titles and abstracts of articles were reviewed by one of the authors (MSK) for relevance with date in descending order. To speed the search, titles containing “stress test”, “oxidative stress”, “stress fracture”, “stress incontinence”, or “urinary stress” were automatically disqualified. Abstracts were also reviewed for relevance and scanned to make sure that PA was the outcome variable of interest and stress variables were the predictors. Case-control studies that investigated PA in stressed populations were retained. After this process was completed for the first database, the inspection of results for SPORTDiscus ensued. Articles were further eliminated if they were duplicated in Web of Science. This resulted in a very small collection of additional articles. With the additional fact that the initial results from PubMed were very large, the search date range was shortened to the years 2000–2012. These returns were searched for relevance as before. Finally, all article reference lists were examined for pertinent reports. The last search for articles via database was in July 2012 (see Fig. 1 ).

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Flow chart of literature review for the effects of stress on physical activity

2.2 Study Quality Assessment

Prospective studies ( n = 55) were assessed for risk of bias with a quality assessment rating scale modeled after Rhodes and colleagues [ 162 ]. As with this former study, this instrument was developed to assess risk of bias as defined by the Cochrane Collaboration [ 163 ]. The quality scale comprised nine questions answered with a “yes” or “no” response (e.g., Did the study include a control group comparison? Was an objective measure of physical activity/inactivity used?). Low risk of bias (high quality) was deemed for studies with a score of 7–9, moderate quality and risk of bias for studies with scores between 5 and 6, and high risk of bias (low quality) for studies with a score of 4 or below (see Electronic Supplementary Material, Appendix 1 ).

3.1 The Effects of Psychological Stress on PA/Exercise: State of the Literature

The search yielded a total of 168 papers interested in the impact of stress on PA. Five studies were published in the 1980s, 37 in the 1990s, 86 in the 2000s, and 40 from 2010 to July 2012 (see Fig. 2 ). The first evidence in the scientific literature of the link between mental stress and PA was reported in the early 1980s [ 164 ] (refer to Gardell et al. [ 165 ] for an earlier study reported in Swedish). Research at this time addressed the impact of stress on a host of health-promoting and -degrading behaviors, including alcohol use, smoking, dietary practices, and PA [ 164 , 166 - 168 ], in particular in relation to their role as risk factors for cardiovascular disease. This early work was epidemiological in nature, typically cross-sectional, employing very large sample sizes [ 164 , 169 , 170 ]. Furthermore, the population of focus frequently was middle-aged adults in occupational settings [ 169 , 170 ].

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Yearly distribution of publications ( n = 168) examining the association of stress and physical activity/exercise from 1984 to 2012

Since this time, research designs have varied widely and have extended to include qualitative [ 171 - 179 ], retrospective [ 77 , 180 - 183 ], prospective [ 17 , 20 , 184 - 192 ], and experimental work [ 193 ], although most studies are cross-sectional [ 143 , 194 - 196 ]. Likewise, studies have narrowed from the examination of stress on the wider scope of health behaviors to a specific focus on the effects of stress on PA and exercise. Furthermore, stress has emerged as a central component of several theoretical models of PA behavior [ 170 , 197 - 200 ]. Most studies investigating the relationship between stress and PA have anticipated that stress would debilitate PA behavior. However, some studies have specifically approached the problem from a coping perspective, predicting enhanced PA under stress [ 168 , 188 , 201 ].

The majority of studies identified by the literature review supported the hypothesis that stress has an impact, whether negative or positive, on PA behaviors ( n = 134, 79.8 %). However, the literature is not entirely in agreement with regards to the valence of the association. The majority of studies ( n = 123, 72.8 %) provide evidence that psychological stress predicts lesser PA or exercise. Nevertheless, correlations of stress and exercise in studies supporting the association typically find no relationship greater than –0.28 to –0.42 [ 89 , 143 , 202 - 204 ]. Conversely, 29 (17.2 %) studies provide evidence of an increase in PA with stress. As might be apparent, some papers reported evidence indicating (a) an association in both a positive and negative direction; and (b) that some indicators of stress and PA were not associated, but others were in either a positive or inverse direction (see Table 1 ).

Summary of 168 studies exploring relationships between stress and indices of physical activity and exercise a

		Inverse association		No association		Positive association
			%		%		%
Studies over a single time point
Qualitative	9	9	100.0	0	0.0	4	44.4
Cross-sectional	100	67	67.0	26	26.0	14	14.0
Retrospective	5	5	100.0	0	0.0	1	20.0
Total	114	81	71.1	26	22.8	19	16.7
Studies with multiple time points
Prospective—non-objective stress	48	36	75.0	7	14.6	10	20.8
Prospective—objective stress	7	6	85.7	1	14.3	0	0.0
Total	55	42	76.4	8	14.5	10	18.2
All studies
Grand total	169	123	72.8	34	20.1	29	17.2

PA physical activity

3.2 Supporting Evidence for an Inverse Relationship Between Stress and PA

3.2.1 cross-sectional, retrospective, and qualitative studies.

Studies conducted over a single time point (cross-sectional, qualitative, and retrospective, n = 114) have established an association between stress and PA. While two-thirds (67.0 %) of cross-sectional studies reported a negative association of stress with exercise, qualitative and retrospective (where respondents self-assess changes in PA) studies unanimously find evidence of an inverse association. These studies were typically of lower quality, with the exception of one study which reported that nearly 30 % of college students who were sufficiently active in high school did not attain this level of PA when transitioning to college [ 180 ] (see Electronic Supplementary Material, Appendix 2 for more details).

Stress has been inversely related to exercise and PA behavior most frequently for employee populations (22 studies) [ 83 , 194 , 205 - 224 ], but also for individuals in community fitness programs [ 225 ], those with heart disease [ 147 , 226 ], pregnant women [ 174 ] and those in national probability samples [ 227 , 228 ]. When examining specific age groups, it is apparent that the results replicate for college-aged and young adults [ 180 , 202 , 203 , 229 - 231 ], middle-aged adults [ 143 , 167 , 232 , 233 ], and the elderly [ 195 , 234 - 237 ], but no cross-sectional data exist for children and only qualitative data exist for adolescents [ 171 ]. The relationship has been found for both genders, although several studies found that men were more vulnerable than women [ 194 , 229 , 237 , 238 ], while other studies observed the opposite trend [ 202 , 239 , 240 ]. Stress also was related to lesser PA in several minority populations [ 177 , 195 , 198 , 219 , 241 ], and ethnicity/race may interact with stress on PA [ 207 , 242 ]. However, there appears to be no moderating effect of age or education [ 196 ]. The associations appear to be true for reports of exercise [ 243 - 245 ], PA measures [ 202 , 203 ], sedentary behavior/inactivity [ 170 , 195 , 197 , 209 , 230 , 246 , 247 ] and days of sports participation [ 171 , 248 ], but little data exist for energy expenditure [ 249 ]. Stress is linked to low levels of PA in chronically stressed populations, such as military spouses [ 196 ], cancer survivors and those in treatment [ 182 , 243 , 250 ], low-income and first-time mothers [ 172 , 173 , 251 ], medical school students [ 229 , 252 ] and caregivers [ 239 , 240 , 253 - 257 ]. Several case-control studies have demonstrated that stressed populations, such as caregivers and parents of children with cancer, have lower PA and exercise behavior than matched control groups [ 239 , 240 , 254 , 255 , 258 ].

3.2.2 Prospective Studies

Directionality of the stress and PA association is evidenced by many prospective studies in which a time-lagged effect may be assessed ( n = 55) (see Table 2 ). The majority of these studies ( n = 35; 63.6 %) were rated as high quality, meaning that they were more likely to use validated instruments, control comparisons, appropriate statistical methods, and theoretical frameworks. Some studies, however, were of moderate ( n = 19) to low ( n = 1) quality (see Electronic Supplementary Material, Appendix 1 ). Many studies conducted in naturalistic settings have found evidence that stress is associated with facets of PA at a later time point [ 17 , 20 , 79 , 181 , 210 , 245 , 259 - 272 ]. For instance, in an employee population from a large food processing plant in Texas, USA, Lutz et al. [ 20 ] found that perceived stress predicted leisure time PA 2 months later. Furthermore, this association was greater than the cross-lagged relationship of exercise at time 1 on perceived stress at time 2. Likewise, in a random sample of Danish adults, those who were high in stress were 2.63 times more likely to be classified as inactive at baseline and 90 % more likely to become inactive a decade later [ 270 ]. Burton et al. [ 263 ] found that those low in emotional stress were more likely to initiate brisk PA at least three times a week than those high in stress (35.8 vs. 14.6 %). In this same study, low-stress individuals were also more likely to maintain PA over a 4-year period (69 vs. 36.4 %). On the other hand, a few studies have found no support whatsoever of a relationship [ 79 , 145 , 191 , 273 - 277 ] or evidence for a positive association of stress and PA [ 17 , 188 , 259 , 261 , 262 , 264 , 267 , 269 , 278 - 280 ] (see below for more details).

Prospective studies of all designs investigating the effects of stress on indices of physical activity

Study	Sample	Participants ( )	Theoretical framework or model	Study design	Stress measure(s)	PA measure(s); data transformation	Significant findings, associations, ESs	QR
Allard et al. 2011, [ ]	Public sector employees M + W Mean age 45.4 years (SD = 10.2)	3,224	Job strain Job effort– reward imbalance	Prospective 2 years PA measured twice	Copenhagen Psychosocial Q (demand–control; emotional demands; patient care emotional demands) Number of life events in last 6 months, rated by impact	1-item survey (4 responses) Binary respondent classification: inactive at follow-up considered “never spent or stopped spending more than 4 h on low intensity activity or at least 2 h on intense activity per week”	Stress events did not predict change in PA; however, stress events did predict change in BMI Less physical inactivity at follow-up predicted by higher emotional demands (OR = 0.69; 95 % Cl 0.48–0.98) and patient care emotional demands (OR = 0.73; 95 % CI 0.56–0.94) Decision latitude related to higher inactivity at follow-up (OR = 1.95; 95 % CI 1.04–3.66)	6
Bell and Lee 2006, [ ]	Random sample of young adults W only Age range 22–27 years	853	Life transitions	Prospective 4 years PA only measured at time 2	Perceived Stress Q for Young Women Transitions Q	Active Australia Survey Summed DUR of walking, moderate and vigorous activities 4-category respondent classification: no, low, moderate, or high PA	Age stopping full-time education was associated with higher stress (partial = 0.02, < 0.001) and less PA ( < 0.001, = 0.028) Age starting full-time work was associated with lower PA ( values <0.001, = 0.036) Other transitions not related to PA Note: no analysis to predict PA from perceived stress	7
Brown and Siegel, 1988 [ ]	Students in private high school, grades 7–11 W only Mean age 13 years, 10 months	364	Major life events	Prospective 8 months Two time points	Life Events Survey	DUR of 14 different activities >1×/week Measured at both time points	Life event stress at BL and not correlated with exercise at time 1 or time 2 ( = −0.03 to −0.04) No other analysis available	6
Brown and Trost, 2003 [ ]	Australian population sample W only 18–23 years at BL	7,281	Life transitions Major life events	Prospective 4 years PA measured both times	Events checklist (no validation reported)	BL and follow-up differed BL: FREQ of “vigorous” and “less vigorous” exercise multiplied by factors of 5 and 3, respectively Binary respondent classification: those above score of 15 considered “active” Follow-up: FREQ and DUR of walking, moderate and vigorous PA multiplied by factors of 3.5, 4 and 7.5, respectively Binary respondent classification: “active” defined as >600 MET min/week	Life events and transitions strongly associated with activity status at follow-up Inactivity predicted by marriage (OR = 1.46, 95 % CI 1.27–1.68), having a first baby (OR = 2.27, 95 % CI 1.90–2.59), having another baby (OR = 2.06, 95 % CI 1.70–2.51), all < 0.0001 Beginning work (OR = 1.15, 95 % CI 1.03–1.20, = 0.010). Becoming a single parent (OR = 1.32, 95 % CI 1.04–1.67, = 0.020) Return to study related to LESS inactivity (OR = 0.77, 95 % CI 0.63–0.94, = 0.009) Changing work related to LESS inactivity (OR = 0.82, 95 % CI 0.74–0.90, < 0.0001)	7
Brown et al., 2009 [ ]	Australian population sample W only 3 age cohorts: young (18–23 years), middle- aged (45–50 years), and old (70–75 years) at BL	22,595	Life transitions Major life events	Prospective 3 years PA measured both times	Norbeck Life Event Q (modified)	FREQ and DUR of walking, moderate and vigorous PA multiplied by factors of 3.5, 4 and 7.5, respectively 3-category respondent classification: “no PA” (<40 MET min/week), “low” (40–600 MET min/week), and “active” (>600 MET min/ week)	Life events and transitions associated with activity status at follow-up. Associations varied by age-cohort (see paper for details) Transitions associated with decreasing PA (all < 0.001): getting married (OR = 1.27, 95 % CI 1.10–1.46), childbirth (OR = 1.67, 95 % CI 1.43–1.95), illness (OR = 2.23, 95 % CI 1.83–2.71), surgery (OR = 1.55, 95 % CI 1.28–1.88), moving to an institution (OR = 1.97, 95 % CI 1.05–3.67) Transitions associated with increasing PA: retirement (OR = 1.52, 95 % CI 1.22–1.88, < 0.001), harassment at work (OR = 1.49, 95 % CI 1.14–1.95, < 0.01) Transitions associated with increasing PA ( values <0.05): beginning a new personal relationship (OR = 1.23, 95 % CI 1.01–1.50), changing work conditions (OR = 1.24, 95 % CI 1.04–1.48), major personal achievement (OR = 1.29, 95 % CI 1.07–1.56), death of a spouse/partner (OR = 1.55, 95 % CI 1.01–2.37), decreased income (OR = 1.20, 95 % CI 1.04–1.38)	7
Budden and Sagarin, 2007 [ ]	Working adults from diverse occupations M + W Age range 18–74 years	274	Theory of Planned Behavior	Prospective 7 days PA measured only at time 2	Spielberger Job Stress Survey	FREQ and DUR of exercise (2 items) combined into 1 composite score Binary respondent classification: exercise or no exercise	No main effect of occupational stress on PA measures = −0.10 (composite score) to −0.11 (binary score) Occupational stress did inversely relate to PBC to exercise ( = −0.16), thus relating to exercise intention and exercise behavior	7
Burton et al., 1999 [ ]	Medicare beneficiaries in Maryland, USA M + W >65 years 95.9 % of sample between 65–84 years at BL	2,507	Behavior change model	Prospective 4 years 3 time points Mutiple waves of PA data	GHQ-12 (emotional distress)	1-item survey FREQ of activities such as walking briskly, gardening, or heavy housework Binary respondent classification: those performing “brisk” PA at least 3 times a week considered “active”	There is a relationship of emotional distress measured at the last wave and PA Distress did not predict initiation of PA Moderate distress predicted maintenance of activity status over 4-year lapse of time (OR = 0.43, 95 % CI 0.28–0.67). Severe distress did not predict maintenance, however Low emotional stress, 35.8 % initiate activity, 69 % maintain; medium emotional stress, 18.0 % initiate activity, 40 % maintain; high emotional stress, 14.6 % initiate activity, 36.4 % maintain (Table 3 of study)	6
Burton et al., 2010 [ ]	Adults enrolled in university worksite 16-week intervention M + W Mean age 36.5 years (SD = 8.6)	16	Resiliency	Prospective Stress/PA intervention (open trial) No control group Measures pre/ post	Stress subscale from DASS-21	Modified AIHW Survey Total DUR of PA in previous week Time weighted by intensity factor Pedometer step counts over 7 days	Stress level improved pre-post ( = 0.013) Pedometer steps and PA survey data did not improve pre-post	6
Castro et al., 2002 [ ]	Sedentary caregivers for relatives with dementia W only Age >50 years Mean age 62.7 years (SD = 9.2)	100	Caregiving stress; stressed population	Prospective 1 year Intervention (RCT)	PSS-14 Screen for Caregiver Burden BDI TMAS	Exercise adherence Program retention Motivational Readiness for PA	BL PSS and Caregiver Burden does not predict PA adherence over 12-month period or months of program contact or total phone or mail contacts BL anxiety and depression does predict PA adherence Those who did not complete the trial had higher BL stress (mean PSS = 22.5, SD = 4.8) and spent more hours at BL in caregiving duties (mean = 100.5, SD = 41.7) than those who did complete the trial	7
Chambers et al., 2009 [ ]	Survivors of colorectal cancer M + W	978	Health stress; stressed population	Prospective 3 years post- diagnosis 4 waves of PA data	Constructed Meaning Scale (cancer threat appraisal) Brief Symptom Inventory-18 (anxiety, depression, and somatization)	Modified Active Australia survey items Total DUR of PA in previous week for walking, moderate PA, or vigorous PA. Time-weighted by intensity factor 3-category respondent categorization: inactive (0 min/week), insufficiently active (1–149 min/week), or sufficiently active (>150 min/week)	Continuous cognitive threat appraisal predicted inactive PA (OR = 0.95, 95 % CI 0.9,1.0) and insufficiently active PA (OR = 0.96, 95 % CI 0.9, 1.0). Overall model ( = 0.031) Previous anxiety predicts increase in low levels of PA (<2 h/week) (OR = 1.11, 95 % CI 1.05–1.19, = 0.004) No evidence that the distress and PA association changed over time Depression and cognitive threat did not predict increases in PA	7
Delahanty et al., 2006 [ ]	Individuals in the Diabetes Prevention Program lifestyle intervention M + W	274	None	Prospective Intervention 3 waves of PA data	Perceived Stress Q-30 Beck Depression and Anxiety Inventories	Stages of change for exercise (5 items) Modifiable Activity Q Data analyzed as: continuous PA and dichotomous [coded as meeting guidelines for PA (150 min/week)]	BL perceived stress inversely associated with PA at 3 time points: (BL, = −0.16, = 0.01; 1-year PA, = −0.18, = 0.003; 2-year PA, = −0.17, = 0.007) Similar pattern of results for anxiety and depression Stress did not independently predict PA at any time point when depression, self-efficacy, stage of change, and other factors were modeled Depression predicted PA at BL ( = 0.03) Stress did not alter the gender-PA relationship	7
Dobkin et al., 2005 [ ]	Fibromyalgia patients W only Mean age 49.2 years (SD = 8.7)	39	Behavior change theories	Prospective Intervention 3 months follow-up PA measured 3 times	WSI	Average mins of weekly stretching	Stress at BL and during the treatment were the best predictors of poor maintenance of stretching Every 1 SD increase in BL stress related to a −28.29 min change in stretching at 4, 5, and 6 months ( < 0.05) Every 1 SD increase in stress change over 3 months was related to a decline in stretching (−38.58 min) in months 4, 5, and 6 ( < 0.01) Stress did not impact weekly changes in any outcome	7
Dobkin et al., 2006 [ ]	Fibromyalgia patients W only Mean age 49.2 years (SD = 8.7)	39	Behavior change theories	Prospective Intervention 12 weeks PA measured 12 times	WSI	Daily exercise log recording exercise type, FREQ, DUR, and intensity. Energy expenditure calculated	Over 12 weeks, participants with higher BL stress reduced their aerobic exercise participation at faster rates ( = 0.02) Every 1 SD increase in stress resulted in a change of −3.19 min of aerobic exercise and −11.33 kcals of energy expenditure With interactions included in the model, stress did not impact initial participation in the aerobic exercise program Those with higher BL stress decreased energy expenditure at a higher rate ( = 0.02)	7
Dougall et al., 2011 [ ]	First-year students M + W Mean age 20.6 years (SD = 5.34) Age range 17–47 years	149	Life transition	Prospective Intervention (~13 weeks) PA measured weekly	PSS-4	1-item scale modified from Godin Leisure Time Exercise Q (DUR of strenuous activity) Approximate number of times a university fitness center was utilized Stage of change for exercise	Main effect of stress on fitness center use ( = −0.10, SE = 0.05, < 0.05) but not vigorous exercise or intention to exercise Participants with high stress in the later stages of change had more PA intention than those in earlier stages of change ( < 0.02) 3-way interaction for stress, intervention response, and time ( = 0.05). At the end of the semester, responders low in stress had higher PA 3-way interaction between stress, time, and stage of change ( = 0.09). Those in the later stages of change for exercise and low in stress had higher fitness center use initially	8
Dunton et al., 2009 [ ]	Healthy, community- dwelling adults who do not regularly exercise M + W Mean age 60.7 years (SD = 8.22) Age range 50–76 years	23	None	Prospective 2 weeks Daily diary study PA assessed at fixed intervals 4×/day	2 items: (1) problematic social interaction; (2) experience of a stressful event NA (average of ratings for: stressed, upset, lonely, annoyed, tense/anxious, sad, discouraged)	Respondents queried about whether they performed 1 of 12 activities (yes/no) and DUR if completed Data transformation: sum of mins for activities over 3.0 METs	Only 10 % of the sample reported a stressful event Stress events did not predict PA ( = 0.09) NA (subjective stress) did predict MVPA (HLM COEFF = −0.09, robust SE = 0.02, < 0.001) Within-person variance explained by NA was 0.5 %, and for stress events was 0.8 %	6
Durrani et al., 2012 [ ]	Diagnosed with hypertension in e-counseling program Individuals with anxiety or traumatic stress excluded M + W	387	None	Prospective Intervention 4 months PA assessed 2 times	PSS-10 BDI-II	HPLP-II (used to measure readiness for exercise change on a 4-point continuous scale)	BL stress ( = −0.18; = 0.001) and depression were inversely associated with BL readiness to change exercise Change in stress and depression over the 4-month intervention inversely correlated with exercise readiness post-intervention ( = −0.17; = 0.01)	7
Grace et al., 2006 [ ]	Healthcare workers from 3 worksites Pregnant W Mean age 39.5 years (SD = 7.95)	243 (201 non- pregnant)	Role strain	Prospective Case control PA measured at 3 time points	Work-Family Spillover Scale	HPLP-II (8-items for PA)	Levels of PA did not vary across groups and did not change across the pregnancy and postpartum period; however, a trend was observed for decreased inactivity during maternity leave Negative work-to-family spillover and negative family-to-work spillover was not associated with PA at BL ( = −0.07 to 0.03, NS) or at the last time point ( = −0.14 to 0.22, NS) in either the maternity group or the comparison group When returning to work (final assessment), PA was related to work-to-family spillover	8
Griffin et al., 1993 [ ]	College undergraduates M + W Mean age 18.4 years (SD = 1.22)	79	None	Naturalistic Exam stress vs. early semester (7- week period) No control group	PSS-4 items Daily Hassles and Uplifts Positive and Negative Affect Schedule Academic demands (1 item; 1–7 scale)	Wellness Inventory of the Lifestyle Assessment Q Exercise subscale items: efforts to maintain fitness over past 3 days (“I walked or biked whenever possible”; 1–6 response scale)	PSS related to exercise at start of semester ( = −0.22, < 0.05), but not at the end of the semester ( = −0.14) No association between academic demands, academic stress, hassles, or negative affect with exercise Exercise declined from low stress time of semester to finals; however, this was NS. Early semester: mean = 14.78, SD = 5.19; finals: mean = 14.64, SD = 5.78 Among subjects who experienced an increase in demands from early semester until finals, exercise decreased (but NS) Early semester: mean = 14.98, SD = 5.27; finals: mean = 14.36, SD = 5.57 Among subjects who experienced an increase in demands the week before finals (vs. early semester), exercise decreased (but NS). Early semester: mean = 15.15, SD = 5.19; finals: mean = 14.94, SD = 5.37 Exercise increased for those whose academic demands remained the same or declined during finals (NS) When controlling for BL exercise, academic demands at finals and the week before finals did not predict exercise at the second time point	7
Groeneveld et al., 2009 [ ]	Construction workers at higher risk for CVD M only Mean age 46.1 years (SD = 9.3) Age range 30–65 years	4,017	None	Prospective Intervention	Dichotomous: 12 questions regarding tiredness and stress. Scored as “yes” if 5 of 12 statements were endorsed	Binary respondent classification: participation in the lifestyle program (yes/no); dropout of program (yes/no)	35.7 % of participants were tired/stressed, while only 30.5 % of non-participants were tired/ stressed Crude OR = 1.27 (95 % CI 1.08–1.49) Relationship disappeared in multivariate models (age, smoking, type of work, symptoms) Stress had no relationship with dropout from the study (OR = 0.94, 95 % CI 0.56–1.57)	4
Ho et al., 2002 [ ]	Residents of NY metro area M + W Mean age 46 years (SD = 11) for M and 47 years (SD = 13) for W	244	Life event	Retrospective and prospective 4-month follow-up	Resident of NY after World Trade Center attack and in World Trade Center during attack Level of distress (1–10): 1 item	1 item 3-category respondent classification: exercise behavior “still abnormal”, “normalized”, or “no initial change”	Residents exercising 33 % less after attacks Those actually at the World Trade Center exercise 1.5 times less ( = 0.07) than residents not the World Trade Center 4 months later, residents of NY were exercising 13 % less	6
Hooper and Veneziano, 1995 [ ]	University employees M + W Age not reported	338	None	Prospective Intervention (20 weeks)	1 item from Wellness Q, re.: stress at home (not validated)	Binary respondent classification: exercise program starters vs. non-starters	Stress significantly discriminated starters from non-starters Non-starters: 1.34 (SD = 0.57) on stress at home Starters: 1.22 (SD = 0.44) on stress at home Both groups expressed an ability to cope with the stress	6
Hull et al., 2010 [ ]	Young adults M + W Mean age 24.1 years (SD = 1.1)	638	Life transition	Prospective 2 years PA measured 2 times	Cohabitation, marriage, parenthood transitions	Past year leisure time PA Q FREQ and DUR of every type of LTPA activity over last year completed at least 10 times Data expressed as h/week	Marriage does not impact PA in young adults Compared with those who stayed with the same number of children over the 2-year period, having a child (PA change = −3.7, SD = 6.0, = 0.01), having a first child (−3.9, SD = 5.6, = 0.02), and having a subsequent child (−3.5, SD = 6.4, = 0.02) is associated with a reduction in PA	8
Johnson- Kozlow et al., 2004 [ ]	College students M + W Mean age 24.4 years (SD = 0.06)	338	Life events	Prospective Intervention 1 year PA measured at 2 time points	Life Experiences Survey	7-day PA recall Data expressed as kcal/kg/week	44 % of sample was inactive at BL No direct relationship, but stress by time interaction was significant ( = 0.015) M with higher stress at 1 year had exercise in the exercise intervention group ( = 0.008) In the control condition, M with low stress tended to be more physically active at 1 year No relationship between stress and PA was observed for W	8
Jones et al., 2007 [ ]	Public service workers M + W Mean age 40 years (W) and 41 years (M) Age range 18–65 years	422	Job strain	Prospective diary study 4 weeks Daily PA measure	Job Content Q (Framingham version) Positive and Negative Affect Schedule Work hours	2 items: moderate and vigorous exercise (yes/no response) If “yes” response, respondents required to describe the exercise	Daily negative affect had an inverse relationship with exercise for M ( = 0.001) but not for W For M, job demand had an effect on daily exercise ( = −0.48, SE = 0.13, = −1.98, = 0.049). M in low-demand jobs showed greater reductions in PA than M in high- demand jobs There was an interaction with negative affect ( = 0.22, SE = 0.06, = 2.37, = 0.02). Negative affect also interacted with job control ( = −0.18, SE = 0.05, = −2.51, = 0.01). When combined with NA, high job control can result in less exercise Long work hours were associated with less exercise for W but not for M	7
Jouper and Hassmén, 2009 [ ]	Adults in Qigong exercise program M + W Mean age 36.5 years (SD = 17)	87	Tense- energy model	Prospective Non- intervention exercise program	Stress–Energy Scale	Exercise diary (sessions per week) Concentration on Qigong (1–10 scale, 1 item) Exercise intention	Exercise sessions negatively correlated with stress ( = −0.22, < 0.05, 1-tailed test), but there was no correlation of stress with exercise intention ( = 0.07) or concentration ( = −0.16) Stress predicted exercise session ( = 0.03)	8
King et al., 1997 [ ]	Community-dwelling adults M + W Mean age: M 56.2 years (SD = 4.1); W 57.1 years (SD = 4.3) Age range 50–65 years	269	None	Prospective Intervention RCT Home- vs. group-based exercise	PSS-14 BDI Taylor Manifest Anxiety Scale	Exercise adherence Binary respondent classification: “successful” adhering over 2 years defined as completing >66 % of prescribed workouts	Stress was a strong predictor at year 2 ( < 0.0001) Among persons assigned to either home-based program, those initially less stressed (PSS <19) were more likely to be successful than those initially more stressed (53.9 vs. 32.4 %, [1, = 173] = 7.84, < 0.01) Most successful adherers at year 2 were (a) home-based exercisers, (b) less stressed, (c) more fit, (d) less educated At year 1, the subgroup with the greatest adherence (82.4 %) comprised nonsmokers assigned to home-based exercise and reporting low stress (PSS <19) Energy but not anxiety or depression was a strong predictor of adherence	7
LeardMann et al., 2011 [ ]	US Military Service personnel M + W 41.5 % born between 1960 and 1969	38,883	None	Prospective 3–5 years PA only measured at time 2	PTSD Checklist- Civilian Version (evaluated twice)	Items from NHIS. FREQ and DUR of strength training, moderate PA and vigorous PA 5-category respondent classification PA only assessed at follow-up	Those with new-onset of PTSD symptoms are less likely to engage in moderate activity at “active” level (OR = 0.71, 95 % CI 0.60–0.84); less likely to engage in vigorous activity at “slightly active” (OR = 0.66, 95 % CI 0.49–0.89), “active” (OR = 0.58, 95 % CI 0.49–0.70), and “very active” (OR = 0.59, 95 % CI 0.46–0.76) levels; more likely to be unable to engage in strength training (OR = 2.06, 95 % CI 1.45–2.93)	6
Lutz et al., 2007 [ ]	Blue-collared workers M + W Mean age 43.6 years (SD = 9.8)	203	None	Prospective 2 months PA measured at 2 points	PSS-10	Godin Leisure Time Exercise Q PA recalled over the previous month FREQ of strenuous exercise used for analyses	In SEM analysis: (a) the stress-to-exercise model provided the best fit and was significantly different than the stability model; (b) stress and PA were not concurrently related at time 1 but were concurrently related at time 2; (c) stress at time 1 significantly predicted exercise at time 2 ( = −0.16; path COEFF = −0.13), but exercise at time 1 did not predict stress at time 2 ( = −0.03; path COEFF = −0.02)	7
Lutz et al., 2010 [ ]	Undergraduate psychology students W only Mean age 19.3 years (SD = 2.1) Age range 17–33 years	95	None	Prospective 6 weeks PA measured each week	WSI-2 scales used: stress FREQ and stress intensity	Exercise diary recorded daily FREQ, DUR, and perceived intensity of exercise were the outcome variables of interest Stages of change for exercise (each stage modeled as a dichotomous variable)	No main effects of stress events or stress intensity on exercise mins per session When exercise stages were run as dichotomous variables, the maintenance stage was a significant moderator of the stress event and exercise duration relationship ( = 0.52, SE = 0.11, (79) = 4.56, < 0.001). Similar relationship found for exercise frequency ( = 0.04, SE = 0.01, (79) = 4.12, < 0.001) and exercise intensity ( = 0.04, SE = 0.01, (75) = 2.69, < 0.001) When exercise stages were run as dichotomous variables, the maintenance stage was a significant moderator of the stress intensity and exercise duration relationship ( = 0.18, SE = 0.04, (79) = 5.00, < 0.001). Similar relationship found for exercise frequency ( = 0.012, SE = 0.003, (79) = −2.265, < 0.05) and exercise intensity ( = 0.01, SE = 0.004, (75) = 1.89, < 0.062)	6
Macleod et al., 2001 [ ]	Working Scottish adults from 27 worksites M only Mean age at first screening 48 years	5,388 (time 1); 2,595 (time 2)	None	Prospective 5 years PA measured twice	Reeder Stress Inventory (summary score, 1–8)	1-item survey for sedentary behavior (h/week) Binary respondent classification: “sedentary” defined as <3 h/week	At first screening, stress related to more sedentary behavior ( = 0.005). 26 % of high- stress group was sedentary vs. 19 % of low- stress group Sum of stress at time 1 and 2 and change in stress from time 1 to 2 not related to sedentary behavior at time 2	5
Miller et al., 2004 [ ]	Healthy young adults M + W Mean age 18.3 years (SD = 0.9)	83	None	Prospective 13 days PA measured daily	Salivary cortisol Daily ratings of subjective stress (4×/ day)	Paffenberger Activity Scale (1993) Data analyzed as mins of intense PA	Daily (cumulative) stress ratings were not associated with health behaviors, including mins of intense PA ( = −0.04)	6
Moen et al., 2011 [ ]	Best Buy corporate headquarters employees M &W Average age 32 years	659	Job strain	Prospective Stress intervention (Results Only Work Environment program) vs. control 7 months PA measured twice	Negative work-home spillover Psychological distress	Average FREQ of exercise/week over last 4 weeks	Results Only Work Environment program resulted in no changes in distress vs. control Negative work-home spillover was related to distress ( < 0.001) Those in control group decrease more in exercise overtime ( < 0.05). Thus, stress management program may help to attenuate decline in PA behavior Effect mediated by reductions in negative work- home spillover ( < 0.05)	8
Oaten and Cheng, 2005 [ ]	Introduction to Psychology students M + W Mean age 20 years Age range 18–50 years	57: 30 exam stress; 27 control	Self- regulation model	Naturalistic Exam stress vs. early semester Within-person and control group comparison	GHQ-28 (emotional distress) DASS PSS-10	PA 3-item survey: FREQ and DUR over last week “Ease” of exercise regimen (“How easy was it to fit exercise into your schedule over the last week?”) All items on 5-point scale	No difference between groups in exercise behavior at BL Those in exam stress group reported a decline in all exercise FREQ ( = 1, 26, = 71.39, < 0.001), DUR ( = 1, 26, = 35.71, < 0.001), and reported ease ( = 1, 26, = 31.24, <0.001) during exam period. No means reported The control group did not change exercise behaviors pre to post No relationship between change in perceived stress (PSS) or emotional distress (GHQ) and the change in exercise behavior. However, residuals of changes in PSS and GHQ were related to residuals of changes in exercise behavior	8
O’Connor et al., 2009 [ ]	Government workers M + W Mean age 42.6 years Age range 18–65 years	422	Diathesis- stress perspective	Prospective Diary study 4 weeks	Daily hassles: respondents reported each stressor experienced and rated each on 0–4 scale Only FREQ of hassles reported	2-item exercise survey Daily exercise participation: binary response (yes/no)	Hassles inversely related to exercise participation over time (COEFF = −0.055, SE = 0.022, = 0.013, 95 % CI 0.907–0.988) Participants with average ( = −0.064, = −2.417, < 0.05) or high ( = −0.149, = −3.93, < 0.001) levels of order (a facet of conscientiousness) exercised on days when they experienced daily hassles	6
Oman and King, 2000 [ ]	Healthy, sedentary adults M + W Mean age 56.5 years (SD = 4.3) Age range 50–65 years	173	Life events	Prospective RCT intervention 2 years	Social Readjustment Rating Scale	Exercise program adherence: (percentage of prescribed workouts completed) Stage of exercise adoption	Stress not related to adherence in the adoption phase (months 1–6) Life event and exercise adherence were associated during the maintenance phase regardless of exercise intensity or format (home- or class-based) Months 7–12: (4, 153) = 3.56, = 0.008. Months 13–18: (4, 140) = 2.52, = 0.044. Months 19–24: (4, 153) = 3.66, = 0.007	8
Payne et al., 2002 [ ]	British employees M + W Age >16 years (32 % between 35 and 44 years)	213	Job strain, Theory of planned behavior	Prospective 1-week lag (PA measured only 1×)	Karasek Job Content Q Data run as continuous and sample divided by median split on job strain	Open-ended question for exercise type and DUR: “What types of exercise did you do today and how long did you devote to each?” Exercise defined as “taking part in purposeful activity which is often structured and pursued for health and fitness benefits” Data run as continuous and dichotomous Psychological predictors of exercise intention also collected (intention, PBC, attitudes, norms, etc.)	No correlation between exercise behavior and work barriers (including work stress; = −0.08), job demands ( = −0.11), and job control ( = 0.08) Those with increased work demands have greater failure in ability to fulfill their exercise intentions (succeeded, M = 3.63, SD = 0.64; failed, M = 3.95, SD = 0.57; (1, 147) = 7.87, < 0.01, ES = 0.50) Intentions were not associated with job strain Job demands moderated the relationship between self-efficacy and the probability of being an exercise intender who actually exercised (OR = 0.93, 95 % CI 0.87–0.99) People in high-strain jobs have less exercise self- efficacy, PBC, and did less exercise at follow- up (however, they did not intend to do any less exercise)	7
Payne et al., 2005 [ ]	British employees M + W Age range 16–64 years (32 % between 35 and 44 years)	286	Job strain, Theory of planned behavior	Prospective 1-week lag (PA measured only 1×)	Karasek Job Content Q (11 items) Work barriers (hours, stress, travel)	Open-ended question for exercise type and DUR: “What types of exercise did you do today and how long did you devote to each?” Exercise defined as “taking part in purposeful activity which is often structured and pursued for health and fitness benefits” Data calculated as hours (continuous)	No direct effect of job demands ( = −0.11) or job control ( = −0.03) on exercise behavior Intention, job demands, and job control interacted but only explained 1 % more of the variance in exercise behavior Job demands and control affected exercise indirectly by lowering perceptions of perceived behavior control over exercise Job demands did not moderate the intention/ behavior relationship for exercise	7
Payne et al., 2010 [ ]	Employees M + W Age >16 years (41 % between 25 and 34 years)	42	Job strain, Theory of planned behavior	Prospective Intervention Diary study Daily for 14 days	Karasek Job Content Q Work-related affect instrument: anxiety and depression	Open-ended question for exercise type and DUR: “What types of exercise did you do today and how long did you devote to each?” Exercise defined as “taking part in purposeful activity which increases the heart rate and produces at least a light sweat and is often structured and pursued for health and fitness benefits” Data transformed to total hours of exercise/day	No main effect of job demands Demands moderated the intention/exercise relationship (COEFF = −0.10, SE = 0.01, < 0.01, OR = 1.04, 95 % CI 1.01–1.06) Anxiety and depression had no main effect on exercise and did not moderate intention- behavior relationships Note: daily planning intervention backfired (people in no intervention group were more likely to exercise)	7
Phongsavan et al., 2008 [ ]	Patients with anxiety disorders M + W Mean age 39.0 years (SD = 11.9)	73	None	Prospective 8 weeks Exercise and CBT intervention	DASS-21	Modified Active Australia survey items FREQ and DUR of PA in previous week for walking, moderate PA, or vigorous PA 3-category respondent categorization: inactive (0 min/week), insufficiently active (1–149 min/week), or sufficiently active (>150 min/week) Pedometer steps Exercise compliance vs. non-compliance	Relationship between exercise (Active Australia Survey) and stress not analyzed. Stress and pedometer steps association also not reported Those with higher mean scores on stress were more likely to drop out of the PA program, but this was not statistically significant No relationship between stress and PA program compliance	6
Reynolds et al., 1990 [ ]	10th graders from California, USA, high schools M + W Age range 14–16 years (median 15 years)	743	None	Prospective 16 months PA measured at BL, 4 and 16 months	Situational Stress Survey (scale included as appendix in article)	FREQ of 19 activities (i.e., ice skating, hiking) rated on 1–7 scale. Each rating associated with a weight to calculate a total PA score. Score represents the total number of times subject engaged in >20 min of nonstop PA (scale included as appendix in article)	At month 4, stress predicts less exercise, in W only, controlling for BMI and BL PA ( = −1.27, = 6.18, = 0.01). Stress did not predict PA at month 16 No significant correlations between stress and PA at either follow-up time point At month 4, = −0.09 At month 16, = −0.03	6
Rod et al., 2009 [ ]	Age-stratified random sample of Danish adults M + W Age range at BL 20–93 years	7,066	Allostasis	Prospective 10 years PA measured at 2 time points	2-item survey: perceived stress intensity and FREQ; combined into single score Stress only assessed at follow-up	Item inquiring about level of LTPA Binary respondent classification: active vs. inactive	Those with medium (OR = 1.19, 95 % CI 1.07–1.32) or high (OR = 2.63; 95 % CI 2.25–3.08) levels of stress were more likely to be physically inactive at BL. 12 % of the low- stress group was inactive vs. 26 % of the high- stress group Those stressed were more likely to become physically inactive during follow-up than the low-stress group (OR = 1.90; 95 % CI 1.41–2.55) Those in the high-stress group were not more likely than the low-stress group to become active (OR = 0.78, 95 % CI 0.48–1.14). Authors state “There were no differences in the proportions of inactive persons who became active during follow-up according to stress”	5
Rodriguez et al., 2000 [ ]	Nulliparous Swedish pregnant W W only Mean age 27 years (SD = 4)	350	Stressed population	Prospective 32 weeks into pregnancy PA measured at 2 time points (weeks 20 and 32)	PSS-11 (Swedish version)	Exercise FREQ (1–5 scale) and DUR over last 4 weeks Exercise type queried Data transformed into single composite score to reflect time in exercise/week	Exercise decreased from pre-pregnancy to week 20 ( < 0.001). There was no change from week 20 to week 32 Stress at week 12 correlated with exercise at week 20 ( = −0.20, < 0.05) but not week 32 ( = −0.07) Contemporaneous correlation of stress and exercise at week 32 was significant ( = −0.11, < 0.05) SEM analysis found significant path from stress at week 12 to exercise at week 20 ( = −0.20)	7
Roemmich et al., 2003 [ ]	Children Boys + girls Boys mean age 10.1 years (SD = 1.2) Girls mean age 10.1 years (SD = 1.6) Age range 8–12 years	25	None	Experimental Laboratory stressor (Trier Social Stress Test) vs. neutral control Crossover design (order randomized on 2 separate days)	Visual analogue scale for perceived stress Cardiovascular stress reactivity (median split)	Children volitionally cycled at a constant moderate intensity over a 30-min post- condition period Data analysis on DUR of cycling; energy expenditure from cycling (kcal)	Significant main effect of stress condition: lesser energy expenditure ( = 1, 23, = 14.97, < 0.001) and exercise minutes ( = 1, 23, = 7.61, < 0.001). No means for main effect reported Subjects reduced their PA by 21 % on the stress condition day Changes in perceived stress were not correlated with changes in exercise behavior ( = −0.19, > 0.35) Children with high stress reactivity had a greater decline than children with low reactivity	8
Sherman et al., 2009 [ ]	Undergraduate students M + W Mean age 20.11 years	54 (only 17 analyzed)	None	Naturalistic Self-rated most stressful final exam vs. period 2 weeks beforehand No control group	Urinary catecholamines (indicator of sympathetic system activation) 2 items: subjective appraisal of exam stress (1–4 scale)	1-item survey: DUR of exercise (min)	Note: analysis of stress and exercise was exploratory 17 participants reported exercising the night before each urine sample was collected There was a decrease in exercise DUR from the pre-test (mean = 61.18, SE = 11.94) to the post-test (mean = 30.88, SE = 7.74), (1, 16) = 5.67, = 0.03, = 0.26. Cohen’s = 0.62 Results suggest that students reduced their exercise during the midterm exam period	6
Smith et al., 2005 [ ]	Parents of a child with and without a cancer diagnosis M + W Mean age of stressed group 35.5 years (SD = 9.0) Age range 19–58 years	98	Stressed population	Case control Prospective Cancer diagnosis vs. no diagnosis 3 months PA measured twice (2 weeks after diagnosis and 3 months later)	PSS-14 Recent Life Changes Q POMS	Paffenbarger PA Q Data expressed as kcal expended/week Hours of TV viewing/week Hours of sitting/week	Overall, the stressed group reported less PA than the control group (1, 94 = 43.38, < 0.0001). Parents of cancer patients reported only 400–500 kcal/week of PA vs. 1,400–1,500 kcal/week in parents of healthy children Group × time interaction significant (1, 94 = 6.04, < 0.05). Parents of cancer patients increased their PA over time ( (48) = −2.50, = 0.01), but parents of healthy children did not change ES at time 1 = 1.71; ES at time 2 = 1.13 A group × time interaction was significant for TV viewing (1, 94 = 5.84, = 0.01). Parents of children with an illness watched more TV at time 1 but the groups were the same at time 2	9
Smith et al., 2008 [ ]	Working adults registered in Canadian National Population Health Study M + W Age range 25–60 years	3,411	Job strain Chronic stress exposure	Prospective Stress measured in 1994 PA measured in 1996	Job control subscale of Kasarek Job Content Q Wheaton Stress Q (18- item): personal, environmental, financial stress Composite International Diagnostic Interview (distress; University of Michigan revision) Household income adequacy	Survey of LTPA and sport Energy expenditure from time, DUR, and FREQ in the last 3 months PA expressed as kcal/kg/day	Those in the lowest quartile of job control had the greatest level of psychological distress Low job control measured in 1994 predicted PA in 1996 wave ( = −0.065, = −3.284, = 0.001) even when adjusted for many covariates (e.g., BMI, gender, health, back pain, education, etc.) In model comparing all stress exposures, low job control ( = −0.052, = −2.52, = 0.012) and high environmental stress ( = −0.07, = − 2.58, = 0.010) predicted PA Relationships of (a) job control and (b) environmental stress with self-rated health was mediated by PA ( values = 0.026 and 0.024, respectively)	6
Sonnentag and Jelden, 2009 [ ]	Police officers in Germany M + W (86 % M) Mean age 43.8 years (SD = 7.7)	78	Job stress Self- regulation	Prospective 5 days 2 daily measures (just after work and before bed)	Job stressor measures Situational constraints (i.e., information mishaps, communication tool failures, malfunctioning computers, etc.) Profile of Mood States—fatigue subscale	Daily recording of DUR of “sport activities” (running, cycling, swimming) and sedentary activities (watching TV, reading a newspaper, doing nothing)	Time pressure and role ambiguity did not relate to indices of sport and PA participation Situational constraints inversely related to LTPA (estimate = −0.159, SE = 0.076, = −2.106, < 0.05) Sedentary (low-effort) activities positively related to situational constraints (estimate = 0.253, SE = 0.111, = 2.275, < 0.05) Hours worked inversely related to sedentary (low-effort) activities (estimate = −0.098, SE = 0.039, = −2.513, < 0.05)	7
Steptoe et al., 1996 [ ]	College students M + W M mean age 23.0 years (SD = 3.2) W mean age = 21.8 years (SD = 2.7)	180	None	Naturalistic Exam stress vs. early semester Control group comparison	PSS-10 GHQ-28 (emotional distress)	FREQ and DUR of light, moderate, and vigorous PA, including exercise and commuting with a bicycle over last week Light PA not analyzed	Group × time interaction observed ( = 4.85, < 0.05) No difference between groups at BL PA DUR decreased between BL and exam time points of semester ( < 0.05) FREQ of exercise did not change: BL mean = 2.1 (SD = 2.1), exam mean = 1.92 (SD = 2.25); NS Note: association not influenced by social support	7
Steptoe et al., 1998 [ ]	Teachers and nurses M + W Nurses’ mean age 39.7 years (SD = 8.7) Teachers’ mean age 43.9 years (SD = 11.4)	44	None	Prospective diary study 2 weeks of highest self- rated stress vs. 2 lowest self-rated weeks of stress 8 weeks	PSS-4 Hassles and Uplifts Scale	FREQ, DUR, and type of exercise completed. Exercises classified by intensity (moderate/ vigorous or low-intensity) Assessed weekly Exercise coping (for mood regulation); 1 item taken from Reasons for Exercise Inventory	There were no significant differences in exercise FREQ or DUR with changes in perceived stress, but a trend is seen FREQ of moderate to vigorous intensity exercise decreased during stress (low stress: mean = 2.32, SD = 2.3; high stress: mean = 1.85, SD = 2.7; ES = 0.20). DUR also decreased (low stress: mean = 145.9, SD = 194.1; high stress: mean = 115.8, SD = 2.7; ES = 0.16) FREQ of light exercise decreased during stress (low stress: mean = 2.56, SD = 2.4; high stress: mean = 1.96, SD = 2.8; ES = 0.25). DUR also decreased (low stress: mean = 80.7, SD = 92.5; high stress: mean = 64.6, SD = 55.7; ES =0.17) Those who exercised to regulate mood did report more exercise, however, but this did not change with perceived stress Those who reported using exercise to cope with stress exercised more at moderate to vigorous intensity ( (1, 28) = 5.32, < 0.01) and low intensity ( (1, 26) = 4.69, < 0.01) over the entire study period, but this did not vary by stress No analysis of hassles and exercise association reported	6
Stetson et al., 1997 [ ]	Middle-aged, community-residing, already exercising on their own W only Mean age 34.8 years (SD = 11.1)	82	None	Prospective diary study Self-rated low vs. high stress weeks 8 weeks PA recorded daily	WSI: scores for stress FREQ and stress impact	Exercise History and Health Q (developed by authors, reliability >0.90, except for walking, = 0.58) FREQ and DUR for structured list of 8 activities. Subjects free to add more activities Exercise diary: daily recording of exercise plans (yes/no), actual exercise (yes/no), type, DUR (min), perceived exertion (6–20 scale), and enjoyment (1–5 scale)	69 % of sample reported exercising to cope with stress Stress FREQ associated with exercise DUR Low-stress weeks: mean = 73.56, SD = 38.10; high-stress weeks: mean = 68.06, SD = 31.47 ( < 0.05; ES = 0.14) Stress FREQ not associated with exercise FREQ, perceived intensity or number of exercise omissions Stress impact associated with exercise omissions Low-stress weeks: mean = 0.78, SD = 0.72; high-stress weeks: mean = 0.94, SD = 0.97 ( = 0.07; ES = 0.22) This indicates that high stress resulted in more cancelled preplanned exercise sessions Stress impact not associated with exercise FREQ, DUR or perceived intensity	7
Twisk et al., 1999 [ ]	Dutch adults in the Amsterdam Growth and Health Study cohort M + W 27 years at BL 29 years at follow-up	166	Life events	Prospective 2 years PA measured 2×	Everyday Problem Checklist (daily hassles) Life Event List (translated Life Event Survey) Ways of Coping Checklist	Open question, interview-based exercise survey: weekly exercise DUR and intensity over last 3 months Data expressed as METs/week	Changes in daily hassles positively related to increases in PA (standardized = 0.27, 95 % CI 0.13–0.43, < 0.01) Association moderated by coping style. Those with a rigid coping style expressed association (standardized = 0.08, 95 % CI 0.15–0.49, < 0.01). No association amongst those with a flexible coping style Type A personality interacted with daily hassles and PA. Those categorized as low (standardized = 0.50, 95 % CI 0.23–0.77, < 0.01) and high (standardized = 0.24, 95 % CI 0.03–0.45, < 0.05) in type A personality had greater PA with more hassles Life events (FREQ and subjective appraisal) did not influence PA	7
Urizar et al., 2005 [ ]	Sedentary, low income, diverse (74 % Latina) mothers W only Mean age 31.7 years (SD = 8.8)	68	Exercise barriers	Prospective Intervention 10 weeks PA measured 2×	Mother Role Q (maternal stress survey) PSS-14	Stanford 7-Day PA Recall Data expressed as kcal/kg/day Intervention program adherence: number of classes attended also reported	Maternal stress FREQ did not decrease with intervention ( = 0.06). Also, impact/intensity of stress and PSS did not change over intervention Increased PA from BL to 10 weeks was associated with decrease in maternal stress ( = −0.42, < 0.01), but maternal stress frequency over 10 weeks not related to class attendance ( = 0.01, = 0.97) Higher maternal stress frequency at BL related to less class attendance ( = −0.18, SE = 0.09, = 0.05) Higher impact/intensity of maternal stress at BL related to 10-week PA (β = −0.76, SE = 0.30, = 0.01) Perceived stress was not associated with PA or program adherence	8
Vitaliano et al., 1998 [ ]	4 groups: caregivers of spouses with Alzheimer’s vs. matched controls (both conditions split by cancer diagnosis) M + W Mean age 66.1, 54.6, 73, and 63.2 years	165 (80 caregivers)	Stressed population	Case control Prospective 15–18 months PA measured 2×	Hassles and Uplifts Scale Hamilton Depression Scale	Exercise scale inquiring about 10 different activities FREQ/week, DUR Binary respondent classification: dichotomized as active (>90 min of exercise/week) or inactive	Caregivers were more depressed ( < 0.001) and reported more hassles ( < 0.01) than the control group Caregivers had less PA than controls at both time points ( < 0.05) At time 1 among subjects without cancer, caregivers (mean = 1.2; SD = 0.74) had less PA than non-caregivers (mean =1.5; SD = 0.75; ES = 0.41) At time 2 among subjects without cancer, caregivers (mean = 0.9; SD = 0.71) had less PA than non-caregivers (mean = 1.3; SD = 0.74; ES = 0.57)	8
Wilcox and King, 2004 [ ]	Randomly selected older adults in a community fitness program M + W Mean age 70.2 years (SD = 4.1)	97	Life events	Prospective Intervention 12 months	Social Readjustment Rating Scale (modified)	Indicators of exercise adherence: (1) home-base exercise participation—daily logs with type, FREQ, DUR of exercise sessions; (2) class- based exercise participation Data calculated as average percentage of completed assigned/prescribed workouts	Number of life events (across all 3 assessments) was negatively associated with home-based exercise participation over the entire 12-month period (total sample, = − 0.17, <0.05; for W, = −0.19, = 0.07), but not class-based participation (total sample, = −0.08; W, = −0.20, = 0.06). Associations between life events and exercise participation were not significant for M Life events during months 1–6 were associated with adherence to exercise during months 7–12 for home-based exercise ( = −0.21, = 0.02) but not for class-based exercise ( = −0.04). The strongest correlation was between life events at months 1–6 and home- based exercise participation ( = −0.32, = 0.03) Subjects who experienced an interpersonal loss had lower class-based participation than those who did not (62.7 vs. 72.3 %; (94) = 1.70, < 0.05, ES = −0.38), but home-based participation rates were unaffected (ES = 0.14). Regression analysis found that interpersonal loss predicted class-based participation ( = 11.69, SE = 5.83, = 0.02) but not home-based participation Life events, particularly interpersonal loss, appear to have a negative impact on exercise in W, and this effect appears greater for class- based than for home-based exercise	8
Williams and Lord, 1995 [ ]	Community-residing older adults W only Mean age 71.6 years (SD = 5.48) Age range 60–85 years	69	None	Prospective Exercise intervention 12 months	DASS	Adherence to 12 months of exercise (assessed at 3 terms, including week 10 and at 12 months) Adherence defined as number of classes attended Binary respondent classification: exercise “continuers” vs. “non continuers”. Those who continued the exercise program after the intervention were classified as “continuers”	Adherence to the intervention was not associated with BL stress ( = 0.04), depression ( = −0.06), or anxiety ( = −0.16) Mood at 10 weeks did correlate with adherence over 12 months ( = 0.39, < 0.01) Continuing exercise after the intervention ( = 54) was predicted by depression (continuers = 2.1, SD = 3.2; non- continuers = 4.7, SD = 5.4, ES = 0.81) but not stress (continuers = 5.6, SD = 7.1; non- continuers = 8.4, SD = 8.5, ES = 0.39)	6

AIHW Australian Institute of Health and Welfare, BDI Beck Depression Inventory, BMI body mass index, CBT cognitive–behavioral therapy, CI confidence interval, COEFF coefficient, CVD cardiovascular disease, DASS Depression Anxiety Stress Scale, DUR duration, ES effect size, FREQ frequency, GHQ General Health Questionnaire, HLM hierarchical linear modeling, HPLP Health Promotion Lifestyle Profile, LTPA leisure time physical activity, M men, METs metabolic equivalents, MVPA moderate to vigorous physical activity, NA negative affectivity, NHIS National Health Interview Survey, NS not significant, NY New York, OR odds ratio, PA physical activity, PBC perceived behavioral control, POMS Profile of Mood States, PSS Perceived Stress Scale, PTSD post-traumatic stress disorder, Q questionnaire, QR quality assessment rating (1–9 scale; see text), RCT randomized control trial, SD standard deviation, SE standard error, SEM structural equation modeling, TMAS taylor manifest anxiety scale, TV television, W women, WSI Weekly Stress Inventory

Studies employing diary techniques have found that exercise behavior changes in days [ 269 , 281 , 282 ] and weeks when experiencing stressful events [ 17 , 188 , 189 ] and subjective stressful states [ 265 ]. Jones et al. [ 267 ] found this was true for negative affectivity, but job strain was related to greater PA over a 4-week period. Mixed results were also discovered by Lutz et al. [ 17 ] who followed a group of 95 young women over a 6-week period. In this study, less-experienced exercisers held steady or declined in self-reported exercise frequency, intensity, and duration during weeks of greater life event stress frequency and impact. Stetson and colleagues [ 189 ] utilized the same measure of life events (the Weekly Stress Inventory [ 283 ]) and compared periods of low versus high stress among middle-aged women. They found an effect of stress frequency but not stress impact on exercise duration (effect size [ES] = 0.14) while stress impact influenced the number of planned exercise sessions that were missed (ES = 0.22). In a study with a similar data analytic approach, Steptoe et al. [ 188 ] found that exercise frequency and duration of both moderate/vigorous and low-intensity exercise decreased between two low-stress and two high-stress weeks; however, this was not statistically significant ( d values = 0.16–0.25). Unfortunately, this study suffered from high attrition, which may have masked any significant results as stressed individuals tend to dropout at higher rates.

Finally, intervention studies targeting stress [ 284 ] or exercise/health behaviors [ 89 , 124 , 204 , 281 , 285 - 287 ] have found inverse associations between stress and indicators of PA over time. For instance, Urizar et al. [ 89 ] found that PA changes over a 10-week period were moderately correlated with maternal stressors over the same period ( r = –0.42). In a particularly interesting study, Dougall and colleagues [ 286 ] were granted permission to access records of students’ use of a university fitness center. The frequency of these visits was related inversely to stress levels. Some interventions, however, have found no association [ 145 , 273 , 276 , 277 ] or that higher stress relates to greater PA [ 279 ]. Improvements in exercise readiness over time are compromised by the experience of stress [ 124 ]. Whether stress has a stronger association with adoption or continued participation of an exercise routine/PA programming is undetermined [ 184 , 278 , 288 ]. Indeed, both subjective stress and life events negatively affect adherence to exercise programming [ 89 , 184 , 204 , 287 , 289 , 290 ] and intervention attrition [ 145 ], but not all studies agree with this assessment [ 145 , 276 ]. Post-intervention PA maintenance may be affected to a greater degree by the experience of stress [ 184 , 291 ]. In an underpowered investigation, Williams and Lord found a trend in this direction, which was not significant [ 277 ].

3.2.3 Prospective Evidence of Changes in PA Behaviors During Objective Conditions of Stress

In rare instances, prospective studies have employed designs to compare a period of objective stress (i.e., final examinations) with a less stressful period [ 185 , 187 , 191 , 192 ], to compare a stressed and non-stressed population over time [ 186 , 190 ], or to manipulate a laboratory stressor compared to a control condition [ 193 ]. These studies were typically of high quality (rating ≥7), with one exception [ 185 ] (see Table 2 ). Of these seven studies, six discovered a statistically significant effect of stress on exercise and/or PA.

Final examinations are naturalistic stressors which have been studied opportunistically to assess temporal associations of stress and PA behaviors. Examinations are also objectively stressful, typically endure over a longer time frame (as opposed to a discrete conflict) and provide greater ecological validity than laboratory-induced stressors. Oaten and Cheng [ 192 ] and Steptoe et al. [ 187 ] assessed students during a baseline period near the beginning of a semester and also during final examinations. Control groups were assessed at the end of the semester but not during examinations. Both studies found declines in duration of exercise/PA compared to controls, but Oaten and Cheng [ 192 ] also found declines in exercise frequency and the perceived ease of exercise. Final examinations are not uniformly stressful over an entire examination period. In an attempt to capture the most stressful point of this time frame, Sherman et al. [ 185 ] measured exercise in a group of 17 students 14 days before their most stressful final examination (as determined by self-rating of anticipated strain). Their exploratory analysis found that exercise decreased on the day of the examination compared with 14 days earlier ( d = 0.62; η 2 = 0.23). In a less rigorous design, Griffin et al. [ 191 ] found that exercise decreased for those college students experiencing increased demands during examination stress; however, the changes were not significant. Nevertheless, there was a significant correlation between stress and exercise at baseline. The lack of a significant finding at the second time point may be related to the fact that this study was confounded by a high dropout rate.

Two longitudinal, case-control studies agree that stress has an influence on PA. Smith et al. [ 186 ] found that parents of a child who had just received a cancer diagnosis reported lower weekly PA and more television viewing post-diagnosis than parents of a healthy child (approximately a 1,000 kcal difference). The size of the effect post-diagnosis was 1.71 (Cohen’s d ) and 3 months later was 1.13, indicating a large effect. Vitaliano et al. [ 190 ], studying caregivers and matched controls both with and without a cancer diagnosis, found that caregivers were higher in stress indicators, as expected, and also lower in reported exercise frequency at two time points. When comparing the caregivers and controls without cancer, the effect sizes (Cohen’s d ) were 0.41 and 0.57.

The study by Roemmich et al. [ 193 ] is exceptional in that it identified that a single, acute interpersonal stressor causes reductions in PA. Children participated in two experimental conditions, the order of which was randomized within subjects. The experimental condition was a strong interpersonal stressor, where the child prepared and delivered a videotaped speech on a social topic. The control condition was a passive reading activity. After each condition, children were provided the opportunity to be active on a cycle ergometer or remain sedentary. Results indicated that after the stressor condition, both energy expenditure and total exercise minutes decreased. In fact, PA decreased by 21 % during the stress condition; however, changes in perceived stress were not related to changes in exercise behavior ( r = –0.19). Furthermore, those children who had high autonomic stress reactivity had even greater reductions in these exercise variables. Altogether, these results indicate that acute and transient life stressors have a negative impact on PA in humans.

3.2.4 Factors that may Influence Prospective Associations Between PA and Stress

The relationship of PA and stress may vary based on several factors. Therefore, results were further broken down by gender, age, sample size, study quality, and whether the study focused specifically on clinical populations or cohorts of employees. Levels of these factors with >80 % of studies finding evidence of an inverse association were deemed as more likely to be negatively affected by stress. Per this cutoff, studies examining older adults (>50 years; 80.0 %), cohorts with men and women and larger sample sizes ( n > 100; 82.1 %), as well as studies of higher quality (≥7 on a 9-point scale; 85.7 %) were more likely to show an inverse association. Other factors, such as whether a study’s subject pool comprised employees or a clinical population, did not clearly differentiate the literature (see Electronic Supplementary Material, Appendix 3 ).

3.3 Contrary Evidence for an Association Between Stress and PA

Despite this evidence, some studies have found no association whatsoever between stress and PA. In fact, 34 studies in this review found no effect of stress on PA outcomes and several more found marginal or conflicting results [ 79 , 127 , 145 , 166 , 169 , 191 , 200 , 205 , 273 - 277 , 292 - 312 ]. These studies frequently had less rigorous designs [ 166 ], smaller samples sizes [ 273 , 303 ], and very poor measures of PA/exercise and/or psychological stress [ 297 , 308 , 310 ]. Stress management interventions have failed to demonstrate a concurrent increase in subjective and objective markers of PA [ 273 ], and stress did not appear to affect compliance with exercise programming [ 276 ]. As mentioned above, eight prospective studies did not find a relationship. For instance, Grace et al. [ 274 ], examining a group of pregnant women over three time periods during and after pregnancy, found no relationship of role strain or pregnancy (a major life event) with PA.

3.4 Evidence that Stress may Increase PA

Speaking to the point of positive influences of stress, 29 studies found that stress predicts an increase in PA behavior [ 3 , 17 , 81 , 164 , 168 , 171 , 172 , 175 , 183 , 251 , 253 , 254 , 256 , 259 , 262 , 264 , 267 , 269 , 278 - 280 , 313 - 320 ], ten of which were prospective (see above). Other studies found trends in this direction [ 169 , 191 ]. Lutz et al. [ 17 ] found that this was only the case for habituated exercisers. Brown et al. [ 262 ] found that some life events were associated with increased PA, including distressing harassment, beginning a new close personal relationship, retirement, changing work conditions, major personal achievement, death of a spouse/partner, and income reduction. Seigel et al. [ 183 ] reports that in a random sample of young Swedish women, 22.0 % were likely to increase PA, 60.1 % were likely to be unaffected, and only about 16.5 % of respondents were likely to decrease PA with the experience of stress.

3.5 Life Transitions, Major Events, and Trauma

A substantial portion of the literature focused on specific events, life transitions, or distinct experiences of trauma. As noted above [ 262 ], some life experiences result in enhancement of PA behavior. Nevertheless, this same study found that exercise declines for women for some types of events, including the birth of one’s first or second baby or grandchild, having a child with a serious illness or disability, beginning work outside the home, major personal illness or injury, major surgery, or moving into an institution [ 262 ]. Death of a spouse was deleterious for PA in older women [ 204 ]. Transitioning from high school to college or leaving college and entering the workforce full-time is also predictive of a decline in PA [ 180 , 260 , 321 ]. Fan et al. [ 200 ] found that being a victim of violence, harassment, or other threats was not related to PA. This is contradicted by evidence that exercise behavior substantially declined for New Yorkers after the trauma of the 9/11 attacks [ 181 ]. In contrast, the experience of Hurricane Katrina in the USA has been associated with heightened levels of PA [ 313 ].

4 Discussion

4.1 summary.

The majority of the literature finds an inverse association of stress and PA behaviors. The current search uncovered 168 studies reported in the English language exploring these relationships in humans. This demonstrates a high level of interest in the topic for the last two decades, with an apparent acceleration in research production in the area. The literature provided ample support for an association between stress and PA (79.8 %), and of the studies identified, 72.8 % supported the hypotheses that higher stress is associated with lesser exercise and/or PA. Prospective studies with objective markers of stress, one indicator of study quality, nearly unanimously agreed (six of seven studies, 85.7 %) with this conclusion. Studies examining older adults (>50 years), cohorts with men and women, and larger sample sizes ( n > 100) as well as studies of higher quality (≥7 on a 9-point scale) were more likely to show an inverse association. Other factors, such as whether a study’s subject pool comprised employees or a clinical population, did not clearly differentiate the literature finding inverse relationships between stress and PA and the literature finding a null association. Interestingly, 17.2 % of prospective studies found evidence that stress was predictive of greater PA and exercise behavior, and qualitative studies were particularly equivocal in regards to the valence of the association. While these findings cannot be labeled definitively as anomalies, it is clear that stress exerts a generally negative influence on PA.

The review of the literature found many life events and transitions that resulted in changed PA [ 3 , 260 , 262 ]. This specific area of inquiry has garnered substantial interest, with two review articles already published identifying specific life events that relate to perturbations in PA [ 322 , 323 ]. One recent review determined that five life changes were associated with change in PA: employment status, residence, relationships, family structure, and physical status [ 322 ]. Marriage and remarriage are often, but not always, associated with declines in fitness while divorce is associated with gains in fitness, at least in men [ 266 , 324 ]. Chronic disease diagnosis can be very stressful [ 325 ] and a vast literature connects the diagnosis of cancer [ 182 , 243 , 264 , 315 , 326 - 328 ] and HIV [ 329 ] with changes in PA. However, only a few studies gauge how mental stress associated with these conditions relates to changes in PA [ 182 , 264 ], and none were able to objectively capture PA before a diagnosis. Another criticism of this approach is that many of the above events may be interpreted as being positive in nature. However, from a classic life stress perspective, any type of event or transition that causes dramatic changes to one’s life can result in concomitant changes in behavior and health [ 330 ]. Alternatively, being inundated with minor nuisances may also weaken one’s attempts for healthy behavior—perhaps to a similar degree as the experience of a small number of major life events [ 17 , 189 ]. A familiar example includes holiday periods, when many people exercise less and eat more [ 331 ]. Given that most humans experience change frequently, clarification is needed to discern the specific conditions under which an event or series of events may perturb PA.

As might be expected, not all studies found an association between stress and PA. However, several studies suggest that the association may be indirect or masked by factors that moderate the relationship, such as exercise stage of change [ 17 , 332 , 333 ]. For instance, Lutz et al. [ 17 ] found that that women in the habit of exercising, in other words, at a higher stage of change, exercised more during times of stress. Conversely, infrequent exercisers were less active during periods of strain. This finding was supported by Seigel et al. [ 183 ], who found that young women who increased activity with stress were more avid exercisers. One’s stage of change for exercise, however, is not itself related to indicators of stress [ 243 , 334 ]. Budden and Sagarin [ 210 ] found no association between exercise and occupational stress, but did find that stress related to perceived behavioral control for exercise, which in turn predicted exercise intention. Intention was predictive of actual exercise behavior. Payne et al. [ 333 ] found a similar pattern of results in a group of 286 British employees. Clearly, the influence of stress varies by individual attributes, which in some cases may obscure simple associations between stress and PA.

4.2 Clinical Implications

Stress interferes with the engagement of activity for the majority of people, which has important theoretical, practical, and clinical significance for professionals in the health and exercise fields. This is especially true given that the experience of stress (a) is widely prevalent; (b) has repercussions for a wide range of health issues; and (c) is reported as a growing problem in developed countries around the globe [ 18 ]. On the second assertion, it is well-known that a link exists between stress and the development of depression, cardiovascular disease, and many other health endpoints [ 50 ]. Convincing evidence is emerging that such links are moderated by PA [ 49 , 53 ], with some data indicating that the connection is contingent on changes to this behavior [ 212 ]. With all of these facts in mind, health policies should include provisions for integrated prevention and treatment of chronic stress and its behavioral and medical sequela. Before this progress can materialize, however, the well-identified associations between stress and health-promoting behavior must be more recognized within the community of PA researchers, practitioners, and other advocates.

At this time, action must be taken to advance PA interventions by interweaving effective stress management techniques. Simply arousing knowledge of stress is not sufficient [ 335 ]. First, practitioners should measure objective and subjective measures of stress for each individual. This effort will help to identify those at risk for the effects of stress. Working with an interdisciplinary team, such as psychologists and therapists, will help to promote careful interpretation of these data and will provide the resources to more carefully attune to the client’s stressors and associated constrains, barriers, and needs [ 336 ]. Furthermore, practitioners should be mindful of stress vulnerability across stages of change and refine prescriptions accordingly to magnify adherence and to prevent relapse and dropout [ 184 , 189 ]. For people contemplating a new exercise regimen, stress may interfere with attempts to initiate PA, and this may translate to an inability to reach healthful levels of exercise [ 184 , 189 ]. On the other hand, those habituated to exercise exhibit resilience in the face of stress [ 17 , 183 ]. In addition to exercise habits, it is worthwhile to identify individuals’ coping style. Some people use exercise to deal with stress (exercise approach) while others become distracted and succumb to the lure of less healthful behaviors (exercise avoidance). This emphasizes further that prescriptions should be tailored to the individual [ 60 ]. Stress differentially impacts various populations and interventions must be modified accordingly [ 232 , 337 ]. As an example, Urizar et al. [ 89 ] suggests that specific coping strategies should be addressed for mothers based on family constraints, including social support, problem solving, reframing cognitions, and strategies to balance motherhood with the need to care for oneself. Relapse prevention counseling is an example of a technique that incorporates stress management [ 331 , 338 ] and is a recommended intervention for stressed populations [ 184 ].

The content of these programs should be comprehensive. Identifying high-risk situations ahead of time is an important strategy [ 331 , 339 ], and those who can predict stressors are typically better able to diminish losses potentially associated with them [ 340 ]. Teaching stressed individuals the importance of exercise as a method to emotionally cope, plus the problem-focused skills to cope with stress aside from exercise, is a dual priority [ 119 , 341 ]. As exercise is a complex behavior for the newly active, requiring much planning, resources should be put in place to assist the stressed individual with the creation of primary and contingency plans. On this note, interventions that are more flexible and ‘user-friendly’ are necessary to help clients re-engage with stress-derailed PA regimens [ 154 ]. Much has been made of the stress-impulsivity connection and, consequently, a full complement of self-regulation strategies would likely be useful [ 129 , 282 , 342 ]. Simply continuing to exercise on a regular basis is a method to build self-control [ 88 ], and it is difficult to obviate well-established and reinforcing habits. Lastly, and perhaps most important, there is evidence that combining an exercise intervention with stress management can result in increased exercise during times of stress or prevent relapse [ 149 , 279 , 343 ]. Such practice has been successfully employed with alcohol and other drug treatments [ 344 , 345 ]. Mindfulness-based stress reduction (MBSR) is a highly effective technique to promote stress reduction, and enhancing aspects of this program, such as mindful walking, may be an ideal avenue for intervention [ 346 ]. In summary, creating interventions to target stress and coping skills may help to facilitate greater PA and, ultimately, improved health outcomes.

4.3 Exercise as a Stressor

From a practical standpoint, exercise and the associated actions required to accomplish it may simply be burdens or minor stressors themselves. For many people, structured exercise is highly inconvenient (“one more thing to do” [ 189 , 347 ]) during periods of greater strain [ 348 ]. As an example, women who work long hours feel unable to exercise due to many demands on their time, interference from family obligations, and other barriers [ 196 ]. Similarly, teenagers in the midst of household conflict find it difficult to plan for sports participation [ 171 ]. It has been noted that planning for exercise but then missing it due to stress-related circumstances may degrade exercise self-efficacy and add further frustration and dissatisfaction [ 159 ]. Langlie [ 349 ] found that during times of stress, individuals feel a lack of control and perceive maintaining health behaviors as costly. Consequently, for those who view exercise as a disruption, an inconvenience or another demand on their time, it is not a stretch to predict that exercise will decrease with stress. This may be particularly true when starting a new exercise routine [ 204 , 347 ]. Indeed, Holmes and Rahe [ 330 ] suggest that any perturbation of one’s normal daily routine constitutes a stressor. Several studies have considered the potential social stress of PA participation [ 350 - 354 ]. For instance, inactive people are more sensitive to criticism of their bodyweight and fitness, more readily embarrassed, and may derive less affective pleasure and reinforcement from exercise [ 355 ], all of which may result in exercise avoidance, particularly when already in a state of mental stress. The perceived threats of comparison and competition, as well as the anticipation of an exhaustive effort may be much less tolerated under these conditions [ 122 , 356 ]. All of these sources of additional stress should be considered in intervention design. Unfortunately, making one’s PA routine more convenient, such as exercising at home, does not necessarily mean that it will result in better adherence to exercise regimens. For instance, King and associates [ 184 , 204 ] found that life events equally degraded adherence to a home-based or class-based exercise program.

The above discussion should impress upon the clinician and researcher that exercise is itself a mental [ 85 , 356 - 361 ] and physical stressor [ 362 - 366 ]. In short, the stress of exercise may in some circumstances interact with psychological stress to dampen PA behavior. Indeed, exercise might by typified as a self-inflicted stressor, often intentionally undertaken with a goal of attaining health and fitness. While such experiences are generally considered adaptive, not all outcomes are positive in nature. From a physical standpoint, for instance, there is always risk of injury [ 309 , 367 ], which is magnified under conditions of stress [ 368 ] and may result in missed exercise participation. Exercise undertaken in unaccustomed volumes can elevate glucocorticoids and stunt physical processes, such as neurogenesis [ 369 ]. Ultimately, at very high levels exercise may result in deleterious outcomes, such as unexplained underperformance syndrome. This outcome may be exacerbated by the experience of mental stressors and, likewise, may result in additional sensations of stress [ 370 ]. Indeed, increased exercise over a period of days or weeks can contribute to negative shifts in one’s mood [ 371 ] and increased perceived stress [ 372 ]. A recent study found that poor muscular recovery was associated with self reports of chronic stress [ 29 ]. As sensations related to muscle damage likely result in impaired PA [ 373 ], it is possible that stress may affect exercise behavior by magnifying unpleasant sensations associated with exercise.

4.4 Significance of Literature Finding a Positive Association Between Stress and PA

Findings that stress may elicit increases in PA behavior should not be considered happenstance and may explain studies with null findings [ 17 ]. Castro and associates [ 145 ] found that women who were anxious at baseline had better adherence to an exercise program over 12 months, and a similar result was found for colorectal cancer patients [ 264 ]. Johnson-Kozlow et al. [ 279 ] implemented an exercise intervention for a group of students in which stress management was a central feature. It should not be surprising then that with burgeoning stress men increased PA in this study. Health behaviors, such as exercise or recreational park use, may actually improve after a major life event, such as the death of a spouse with Alzheimer’s, simply because barriers for behavior are removed [ 374 , 375 ]. Moreover, such observations are consistent with theories that predict changes in behavior in either direction with stress [ 183 , 330 , 376 , 377 ]. For instance, resiliency researchers have long stressed that adversity may spur some individuals to higher levels of functioning [ 376 , 377 ]. Seigel et al. [ 183 ] suggests a nomenclature for these disparate responses, referring to increased PA with stress as behavioral activation and weakened PA as behavioral inhibition , responses that appear to vary by traits of the individual. The rebound hypothesis of stress and PA proposed by Griffin et al. [ 191 ] posits that stress can result in a degraded PA response followed within days or weeks by a compensatory uptick in PA. Specifically, these researchers speculate that people may overdo healthy behaviors, such as exercise, to compensate for poor attention to health during the stressful period.

In the face of stress, one may elect to obviate feelings of displeasure by engaging in exercise, a form of emotion-focused coping [ 62 , 168 , 378 ]. Indeed, exercise may result in enhanced feelings of pleasure and is widely accepted as a tool for stress management [ 118 , 201 , 379 - 381 ]. Stetson et al. [ 189 ] found that 69 % of their sample of women exercised to relieve stress. Qualitative research indicates that individuals will use low to moderate intensity exercise (i.e., walking) as a method to regulate emotions [ 173 , 293 ]. Interestingly, despite the expectation that PA will lessen displeasure, exercise enjoyment appears to be affected during weeks of stress [ 189 ]. Nevertheless, people who believe that exercise is a useful method for stress reduction are more likely to engage in a moderate or greater level of exercise [ 225 , 318 ]. Those who exercise to cope with stress report higher exercise behavior than those who do not cope by exercising [ 188 ]. Stress management as a motive for exercise has been found for several populations [ 178 , 382 - 386 ]. However, a large sample of highly active fitness enthusiasts reported that stress management ranked far below other sources of motivation, such as exercise enjoyment [ 387 ].

These issues decry the general lack of understanding of the relationship between coping with stress and PA. Exercise behavior declines on days when individuals use more emotion-focused coping [ 201 ], but in general the use of positive coping behaviors is related to greater PA [ 250 , 300 ]. The general coping style of the individual may account for these differences, as people with rigid coping styles tend to increase PA behavior with increased stress [ 280 ], although this finding is challenged by other data [ 150 ]. Moos and Schaefer [ 388 ] state that “Among self-efficacious individuals, engaging in PA can be described as a task-oriented way of dealing with stressful events using a behavioral-approach coping style. Alternatively, engaging in PA may be used to avoid life stressors among less self-efficacious individuals.” This suggests that exercise may serve to both deal with and steer away from stress, and the strategy utilized may vary by one’s self-efficacy for exercise. This may be particularly salient for those who are exercise dependent [ 389 , 390 ] and for those who compensate for stress-induced overeating by exercising [ 183 , 391 - 393 ]. These phenomena add an extra layer of complexity to any analysis of stress and exercise and may account for weak relationships observed by many studies.

4.5 Limitations of the Literature: Methodological Considerations

Several limitations in the stress literature have been discerned by this review, particularly as identified by the quality assessment rating (Electronic Supplementary Material, Appendix 1). The most obvious is the limited amount of experimental evidence. The use of control groups should be utilized, as changes in PA are frequently due to other factors, such as a change in seasons [ 331 , 394 ]. Examination and holiday stressors coincide with more averse weather in many latitudes, which is perhaps the greatest limitation in this area of research. Cross-sectional studies cannot provide indication of the direction of influence. Does stress impact exercise directly, or do inactive individuals self-select more stressful environments [ 170 ]? Such a possibility implies that other factors may be responsible for the association. Nevertheless, more than 50 studies in this review utilized a prospective design, which allays some concern.

Apart from issues of design, there are also issues with measurement. First, stress may impact the recall of exercise behavior as opposed to exercise behavior itself, with activity being over- or understated [ 395 ]. Objective measures of PA, therefore, are greatly needed, and only a few cross-sectional studies have employed such markers [ 249 , 258 ]. Furthermore, most subjective measures do not capture the full complexity of the behavior, including occupational and commuting activity [ 308 ]. To illustrate this point, Fredman et al. [ 254 ] found that caregivers have greater self-reported total PA than non-caregivers but lower leisure time PA. Moreover, many papers do not inquire about exercise intensity, although it is equivocal as to whether intensity is impacted to the same degree as frequency or duration [ 17 , 229 , 241 , 251 ]. It is possible that an individual may shift intensity as the priority for fitness, typically achieved with greater exercise effort, gives way to a greater emphasis on stress management [ 173 ]. When athletes are specifically asked what mental factors prevent them from giving 100 % effort in practice, they typically list life events, school demands, and other stressors [ 396 ]. Lastly, it is unfortunate that nearly 50 % of prospective studies did not utilize pre-tested PA/exercise measures, with some relying on simple dichotomous measures of exercise behavior [ 210 , 219 , 263 ].

The measurement of stress appears to play an important role in the stress–exercise literature. Measures of stress varied greatly in the studies reviewed, which parallels the multiplicity of stress definitions employed. Studies in this analysis were divided nearly evenly on whether they focused on subjective (i.e., perceived) or objective (e.g., life events, daily hassles) measures of stress, and several studies have also specifically focused on chronically stressed populations [ 173 , 186 , 190 , 196 , 251 ]. Studies employing measures of life stress sometimes include both positive and negative life events with no differentiation [ 280 ], whereas others have focused exclusively on negative experiences [ 184 ]. Any challenging experience will tax the human organism at varying degrees, but many studies have favored a summation of life events without considering the weighted impact or magnitude of each individual event [ 25 , 184 ]. Exercise has been observed to serve as coping during transient stressors [ 168 , 397 , 398 ] and even when experiencing a major life event [ 175 , 184 ]. Other dimensions of the stress process may also be salient, such as the predictability of the event or an individual’s perceived ability to cope with the stressor [ 36 ]. One must also consider the type (e.g., social, financial) and controllability of stress, all of which may influence whether exercise is utilized as a coping device. On days when stress is perceived as controllable, exercise increases [ 201 ]. Animal models demonstrate that different types of stressors (i.e., social defeat vs. open field stress) result in either habituation or non-habituation of PA [ 399 ]. Indeed, social stress resulted in a significant decline in PA amongst children in the only experimental study to date [ 193 ]. Lastly, it is important to note that no research specifically focused on cumulative adversity, a construct associated with many health behaviors [ 125 , 128 ].

A tertiary area of concerns lies in temporal aspects of stress research. From a measurement perspective, assessments of stress and PA are often mismatched, with one measure inquiring about stress over a given period (e.g., the last month; Perceived Stress Scale [PSS]) and the other inquiring about PA over a different period of time (e.g., the last year, Modifiable Activity Questionnaire [MAQ]) [ 124 , 191 , 259 , 286 , 295 ]. Prospective studies, while an improvement over cross-sectional ones, do not always gauge stress and PA at each time point [ 268 , 279 ]. This is important to determine bi-directional associations of stress and PA. Diary studies have provided considerable improvement in this respect, while also being less affected by stress-related memory deficits [ 17 , 189 ]. Most research has failed to look at relationships in both a concurrent/contemporaneous and time-lagged manner [ 245 ]. While it is possible that stress has a weak relationship with PA at any given point of time, a much stronger relationship likely exists between stress and (a) PA at a future time, (b) PA change scores [ 17 , 124 , 189 ], and/or (c) more qualitative measures including exercise adoption, maintenance [ 184 , 199 ] and intervention adherence. The Physical Activity Maintenance (PAM) model [ 199 ] argues that stress most relates to relapse, and a plethora of evidence looking at other health behaviors would support this notion [ 129 ]. A cross-lagged analysis would help to determine which direction of influence is stronger between stress and PA, but only one report has undertaken such an analysis [ 20 ].

Sample characteristics are germane to the study of stress. It is frequently difficult to recruit truly stressed subjects for research studies, which results in a response or selection bias [ 400 ]. Consequently, a constrained range or low level of stress scores (i.e., not enough variability in stress) may obscure any true effect [ 191 , 275 , 303 ]. Those who drop out of studies tend to have higher stress and anxiety, which could also mask any potential effects [ 188 ]. Several studies finding an inverse trend of a stress–PA association have been underpowered [ 277 ], while others are overpowered, detecting trivial associations [ 260 , 268 , 270 , 272 , 316 ]. Studies with large samples of inactive participants (or conversely all active subjects) may not have enough variability in exercise measures to detect an effect [ 273 ].

Finally, it should be noted that this review has limitations. Only three databases were searched. Moreover, the search in PubMed was truncated and did not extend before the year 2000. However, these are not likely substantive issues considering (a) the numerous studies discovered; (b) the retrieval of few unique investigations in successive database searches; and (c) the linear distribution of papers across time ( Fig. 2 ). Additionally, this is the first review of its kind; therefore, this analysis adds considerable insight into an area that has produced a large quantity of data. Despite this abundance, the current body of work has not been featured well in reviews summarizing psychosocial influences on PA, necessitating the current report [ 153 - 160 ].

4.6 Future Directions

Possibilities abound for future research in this area. Currently, evidence demonstrating the efficacy of an exercise–stress management intervention is scant. Nevertheless, initial reports are promising [ 192 ]. Interventions could be optimized if stress–PA relationships could be titrated. For instance, Oman and King [ 184 ] discerned that an increase in major life events, specifically from three to four, did not result in a proportional decline in exercise adherence. This type of research represents an important area of future inquiry and could be coordinated to additionally identify the factors that potentially protect one from, or make one vulnerable to, the effects of stress. Risk factors might include race/ethnicity, family background or individual characteristics, such as lifetime adversity and disadvantaged experiences [ 34 , 35 ]. These latter two constructs are also indicators of stress, which serve as a reminder that stress instrumentation could be enhanced in future research by incorporating a lifespan perspective. Triangulating self-report measures with participant interviews and corroborating evidence from persons close to study participants would provide a strong advancement to stress measurement [ 401 ].

Apart from one experiment [ 193 ], there has been a lack of studies manipulating stress to assess the effect of such experiences on PA behaviors. It must be noted, however, that experimental exposure to stress is difficult, if not unethical, to implement. Measuring PA opportunistically during periods of objectively rated low and high stress, such as final examinations or other naturalistic stressors, provides stronger evidence [ 185 , 187 , 192 ]. The model demonstrated by Stults-Kolehmainen and Bartholomew [ 29 ], in which populations are screened for both very low and very high levels of chronic perceived stress, is an example of a quasi-experimental design that could be employed. Ecological Momentary Assessment (EMA) is one technique to measure stress and PA in real time, resulting in less vulnerability to stress-related failures in the recall of behavior and emotion [ 154 , 265 , 402 ]. Prospective studies should sample more frequently to minimize the effects of stress on memory and cognition, factors that in themselves may moderate the stress and exercise relationship [ 403 ].

These investigations may help to describe shifts in the relationship as individuals progress from sedentary behavior to exercise adoption, maintenance, and periods of relapse. The area of exercise habituation seems very promising [ 17 , 183 ], as it is likely that novice exercisers are more susceptible to the effects of impulses, lack self-control, and are not resilient to the physical, emotional, and social stressors of exercise itself [ 351 ]. Furthermore, as individuals habituate to exercise there are likely concomitant changes in fitness, a potential moderator with minimal emphasis thus far [ 229 ]. Other moderators may be genetic (i.e., polymorphisms in genes regulating energy expenditure), physiological (e.g., adrenal sensitivity, muscle activation), health-related (e.g., illness, symptoms), personality-related (e.g., conscientiousness, neuroticism, perfectionism, type B, sensation-seeking [ 141 , 142 , 269 , 404 - 407 ]), social/environmental [ 232 ], and related to coping style, though few studies have measured the extent to which individuals use exercise to cope with stress. Researchers may look to the nutrition literature as a similar bifurcation occurs when individuals are exposed to stressors: either more consumption or less or even fasting [ 168 , 408 ]. This work has revealed mechanisms underlying the stress and caloric intake relationship, such as cortisol reactivity [ 134 , 409 - 411 ]. Experimental models in this area are more sophisticated, which points to a need in the current literature reviewed. Hopefully this progress will help to determine the individual factors that may hasten declines in health-promoting behavior when stressed or, in a few cases, spur more activity.

The above discussion underscores the central need for additional models and a theoretical framework that describe the non-linear, bi-directional and dynamic nature of stress and PA relationships [ 20 , 290 ]. At this time, theoretical models of stress and behavior are largely lacking or are specialized to particular contexts (e.g., worksites, urban life) [ 170 , 200 ]. Links between stress, coping style, perceptions of energy and fatigue, energy expenditure (including spontaneous PA and non-exercise activity thermogenesis [NEAT]) and metabolism, amongst other factors (e.g., conscientiousness) should be integrated into conceptual models explaining obesity and physical health. Models specifically examining recovery from stressors [ 29 , 170 , 282 ] and sedentary behavior [ 170 , 173 , 193 , 195 , 209 ] would be useful, as stress is linked to these outcomes. Finally, it should be noted that psychosocial stress and exercise interact during PA itself, a third area of inquiry that will likely inform the complex confounding of these two factors [ 350 , 412 , 413 ].

5 Conclusion

This review is the only manuscript, to the best of our knowledge, that has attempted to synthesize the diverse literature on the association of stress and PA/exercise in the reverse direction of influence. This emerging focus stands in contrast to the vast number of studies that have almost exclusively emphasized the anxiolytic and anti-depressant effects of exercise. The current analysis concludes that stress and PA are associated in a temporal manner. More specifically, the experience of stress influences PA, and the great majority of studies indicate an inverse relationship between these constructs. In other words, stress impedes individuals’ efforts to be more physically active, just as it negatively influences other health behaviors, such as smoking, alcohol, and drug use. Interestingly, a smaller number of studies suggest a positive association between stress and PA. While seemingly contradictory, these data are consistent with theories that predict changes in behavior in either direction with stress. The utility of exercise as a coping or stress management technique is notable and may explain this finding. Resiliency research suggests that some individuals thrive under conditions of stress; therefore, future research is needed to understand why some individuals are immune to changes in PA in the face of stress while others become inactive. Few studies employ rigorous experimental designs, which would strengthen this area of inquiry. Nevertheless, available prospective data is of moderate to high quality. Data identifying moderators of the relationship between stress and exercise would help to improve the design of interventions targeted towards at-risk populations, such as older adults. Future empirical research in this area could be guided by a theory of stress and PA, which is lacking at this time.

Supplementary Material

Acknowledgments.

National Institute of Health grants UL1-DE019586 and PL1-DA024859 supported the preparation of this manuscript. The authors would like to extend appreciation to the late Rafer Lutz, Ph.D. for his thorough and thoughtful critiques of this manuscript just before his passing in 2012. Dr. Lutz’s work made a special contribution to advances in this literature.

Electronic supplementary material The online version of this article (doi:10.1007/s40279-013-0090-5) contains supplementary material, which is available to authorized users.

The authors declare no conflict of interest.

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Phenotypic, metabolic and genetic adaptations of the ficus species to abiotic stress response: a comprehensive review.

1. Introduction

Click here to enlarge figure

2. Adaption of the Ficus Species to Tropical Environment

3. the responses of ficus to abiotic stress, 3.1. the responses of ficus to heat stress, 3.2. the responses of ficus to drought stress, 3.3. the responses of ficus to flood stress, 3.4. the responses of ficus to oxidative stress, 3.5. the responses of ficus to saline-alkali stress, 4. the adaptive genes and molecular mechanism of ficus relating to abiotic stress, 5. potential application of ficus genes in genetic breeding, 6. conclusions, author contributions, conflicts of interest.

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Latin Name	Level	GenBank	Release Date	Genome Size	References
Ficus carica	Chromosome	GCA_009761775.1	December 2019	333.4 Mb	[ ]
Ficus microcarpa	Chromosome	GCA_025413485.1	September 2022	426.6 Mb	[ ]
Ficus hispida	Chromosome	GCA_025413025.1	September 2022	369.8 Mb	[ ]
Ficus religiosa	Scaffold	GCA_024759925.1	August 2022	406.1 Mb	[ ]
Ficus erecta	Contig	GCA_008635985.1	September 2019	595.8 Mb	[ ]

Species	Response	Stress	References
Hemiepiphytic Ficus	Morphology, behavior, physiology	Heat, drought	[ , , ]
Ficus carica L.	Morphology, behavior, physiology	Heat, drought, salt	[ , , , , , ]
Ficus chartacea var. torulosa	Physiology	Heat	[ ]
Ficus tinctoria	Physiology	Drought	[ ]
Ficus racemosa	Physiology	Drought	[ ]
Ficus deltoidea	Physiology	Drought	[ ]
Ficus septica	Physiology	Drought	[ ]
Ficus benjamina L.	Physiology, cytology	Drought	[ ]
Ficus orthoneura	Morphology	Drought	[ ]
Ficus microcarpa	Physiology, morphology	Drought, oxidative	[ , ]
Ficus concinna	Molecular mechanisms	Drought	[ ]
Ficus ssp.	Morphology	Flood	[ ]
Ficus tikoua	Viability	Flood	[ ]
Ficus crytophylla	Behavior	Flood	[ ]
Ficus squamosa	Behavior	Flood	[ ]
Ficus religiosa L.	Physiology	oxidative	[ ]
Hemiepiphytic Ficus	Morphology, behavior, physiology	Heat, drought	[ , , ]

Stress	Responses
Heat stress	Morphology	Stomatal closure and leaf abscission.
	Physiology	Decreased photosystem activity; reduced photosynthetic rate; increased transpiration rate; elevated levels of IAA, ROS, MG, and lipid peroxidation.
	Cytology	Reduced chlorophyll synthesis.
	Molecular	Inactivation of heat-sensitive proteins; synthesis of heat shock proteins.
Drought stress	Morphology	Regulated leaf temperature, increased leaf abscission, reduced stomatal conductance; decreased root hydraulic conductance (Lp); and unchanged leaf turgor pressure.
	Physiology	Decreased photosynthetic and transpiration rates; accumulation of dry matter; reduced glutamine; enhanced non-photochemical quenching (NPQ); activation of cyclic electron flow (CEF) and increased isoprene emission rate.
	Cytology	Reduced chlorophyll synthesis and damaged thylakoid structure.
	Molecular	Increased transcription of POD2, POD4, Cn-ZnSOD2, and Mn-SOD1; decreased transcription of APX1.
Flood stress	Morphology	Seed dispersal via water; reduced stomatal conductance; formation of aerial prop roots.
	Physiology	Nutrient imbalance; accumulation of ROS; decreased photosynthetic rate; increased ethylene production.
	Cytology	Damaged membrane integrity.
	Molecular	Increased ADH activity and proline content.
Oxidative stress	Morphology	Decreased antioxidant capacity during senescence.
	Physiology	Increased hydrogen peroxide and malondialdehyde levels, increased POX activity; and lipid peroxidation.
	Cytology	Decreased cell viability in adventitious roots; damage to the cell wall and plasma membrane.
	Molecular	Ascorbate-glutathione (AsA-GSH) pathway.
Salt stress	Morphology	Reduced stomatal conductance.
	Physiology	Decreased photosynthetic rate; increased sucrose and d-sorbitol; downregulated glycolytic metabolism.
	Cytology	Decreased chlorophyll content; altered cell wall composition.
	Molecular	Increased transcription of carbohydrate transport genes; overexpression of ROS signaling proteins and proline synthesis coding genes.

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Yuan, S.; Yin, T.; He, H.; Liu, X.; Long, X.; Dong, P.; Zhu, Z. Phenotypic, Metabolic and Genetic Adaptations of the Ficus Species to Abiotic Stress Response: A Comprehensive Review. Int. J. Mol. Sci. 2024 , 25 , 9520. https://doi.org/10.3390/ijms25179520

Yuan S, Yin T, He H, Liu X, Long X, Dong P, Zhu Z. Phenotypic, Metabolic and Genetic Adaptations of the Ficus Species to Abiotic Stress Response: A Comprehensive Review. International Journal of Molecular Sciences . 2024; 25(17):9520. https://doi.org/10.3390/ijms25179520

Yuan, Shengyun, Tianxiang Yin, Hourong He, Xinyi Liu, Xueyan Long, Pan Dong, and Zhenglin Zhu. 2024. "Phenotypic, Metabolic and Genetic Adaptations of the Ficus Species to Abiotic Stress Response: A Comprehensive Review" International Journal of Molecular Sciences 25, no. 17: 9520. https://doi.org/10.3390/ijms25179520

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Stress Management Interventions for Nurses: Critical Literature Review

Affiliation.

1 Mayo Clinic.
PMID: 31014156
DOI: 10.1177/0898010119842693

Background: The nursing literature contains numerous studies on stress management interventions for nurses, but their overall levels of evidence remain unclear. Holistic nurses use best-available evidence to guide practice with self-care interventions. Ongoing discovery of knowledge, dissemination of research findings, and evidence-based practice are the foundation of specialized practice in holistic nursing. This literature review aimed to identify the current level of evidence for stress management interventions for nurses. Method: A systematic search and review of the literature was used to summarize existing research related to stress management interventions for nurses and recommend directions for future research and practice. Results: Ninety articles met the inclusion criteria for this study and were categorized and analyzed for scientific rigor. Various stress management interventions for nurses have been investigated, most of which are aimed at treatment of the individual versus the environment. Contemporary studies only moderately meet the identified standards of research design. Issues identified include lack of randomized controlled trials, little use of common measurement instruments across studies, and paucity of investigations regarding organizational strategies to reduce nurses' stress. Conclusion: Future research is indicated to include well-designed randomized controlled trials, standardized measurement tools, and more emphasis on interventions aimed at the environment.

Keywords: burnout; nurse; resilience; stress management; systematic review.

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Case report
Open access
Published: 06 September 2024

Dentatorubral-pallidoluysian atrophy: a case report and review of literature

Xin Chen 1 ,
Wenwen Xiang 1 ,
Lijun Xu 1 ,
Jiahao Zhao 1 ,
Qing Ke 1 , 2 ,
Zhipeng Liu 1 &

Journal of Medical Case Reports volume 18 , Article number: 429 ( 2024 ) Cite this article

Metrics details

Dentatorubral-pallidoluysian atrophy is a rare autosomal dominant neurodegenerative disease. It is a rare disease in the world. Therefore, sharing clinical encounters of this case can deepen global awareness and understanding of the disease.

Case presentation

The patient was a 34-year-old male of Han nationality who was unmarried. The patient was admitted owing to weakness of the left lower limb with walking instability for 2 months and aggravation for 1 month. There was no dizziness, headache, numbness of limbs, convulsions, nausea, vomiting, abdominal pain, ataxia, nausea, vomiting, or abdominal pain. No nausea, vomiting, diarrhea, abdominal distension, tinnitus, hearing loss, fever, cough, expectoration. Personal history: worked in Cambodia 5 years ago, worked in Dubai 3 years ago, engaged in computer work, smoking or drinking habits. The patient was unmarried. Family history: the mother had symptoms similar to walking unsteadily (undiagnosed). Positive signs include a wide-base gait with a rotatory nystagmus that jumps upward in both eyes. Bilateral finger-nose instability test was quasi-positive, rapid alternating test was negative, and eye closure tolerance test was positive. Tendon reflexes were active in both upper limbs and hyperreflexia in both lower limbs. Stability of the heel, knee, and tibia. Genetic testing showed that the number of repeats in the dentatorubral-pallidoluysian atrophy ATN1 gene was 18 and 62, and the (CAG)n repeat sequence in the ATN1 gene was abnormal, with a repeat number of 62, and the patient was a pathogenic variant. The patient was diagnosed with dentatorubral-pallidoluysian atrophy. Dentatorubral-pallidoluysian atrophy remains a progressive neurodegenerative disease with no effective treatment. At present, the proband is taking 5 mg of buspirone three times a day, which has been reported to improve the symptoms. The patient was followed up for 6 months after taking buspirone, and there was no significant improvement in the temporary symptoms. At present, there are few cases of dentatorubral-pallidoluysian atrophy, and the characteristics of nystagmus in this disease have not been proposed in the past. This case reported the unusual presentation of nystagmus.

Dentatorubral-pallidoluygur atrophy is a rare neurodegenerative disease with autosomal dominant inheritance. To the best of our knowledge, our present case report is the first case report of dentatorubral-pallidoluygur atrophy with specific nystagmus. We describe the special eye shake and its positive signs to increase dentatorubral-pallidoluysian atrophy clinical positive signs.

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Introduction

Dentatorubral-pallidoluysian atrophy (DRPLA) is a rare autosomal dominantly inherited degenerative disorder of the nervous system in which cerebellar ataxia and epilepsy as well as dementia are more common. Spinocerebellar ataxia (SCA) is a group of inherited neurodegenerative disorders that are highly heterogeneous clinically and genetically; DRPLA is a type of SCA, and DRPLA is a type of polyglutamine-polyQ disorder. The DRPLA gene ATN1 is located on chromosome 12p13.31, and in the ATN1 gene, the abnormal amplification of the CAG repeat sequence leads to the development of DRPLA. Early genetic presentation occurs in DRPLA, and it has been reported in literature that DRPLA is more prone to paternal transmission [ 1 ]. This disease has been reported most frequently in Japan, followed by Portugal, Spain, South Korea, and Venezuela, and is quite rare in China; a literature search revealed more than 30 cases both at home and abroad [ 2 ]. The clinical features, imaging, ophthalmoplegia characteristics, and gene mutation characteristics of a patient with adult-onset DRPLA, in which ataxia was the first symptom, are reported and analyzed herein. DRPLA is an extremely rare neurological disease. As clinicians, we cannot miss any opportunity to learn. Therefore, we report a patient with DRPLA to deepen the diagnosis and understanding of this disease, and we are the first to report the characteristics of nystagmus in DRPLA.

The patient was a 34-year-old Han Chinese man who was unmarried. The patient was admitted owing to weakness of the left lower limb with walking instability for 2 months and aggravation for 1 month (first visit: 1 September 2023; no follow-up. The patient presented with left lower extremity weakness without any obvious triggers, occasional choking or coughing while drinking water, unsteady walking with involuntary rightward turning of the head, and aggravated symptoms of unsteady walking in September, with no dizziness, headache, numbness of the limbs, convulsion, nausea, vomiting, abdominal pain, or ataxia. There was no nausea, diarrhea, abdominal distension, tinnitus, hearing loss, fever, cough, or sputum. Personal history: history of work in Cambodia 5 years ago, history of work in Dubai 3 years ago, computer worker, smoking or alcohol habit, and unmarried; family history: mother has similar symptoms of unsteady walking (undiagnosed). There is no particular history of medical and social psychological diagnoses, and no relevant diagnosis and treatment measures have been given before.

Physical examination on admission: temperature: 36.5 ℃, pulse: 68 beats/minute, respiration: 18 breaths/minute, blood pressure: 124/85 mmHg. Cardiopulmonary physical examination revealed no obvious abnormalities in the abdomen. Physical examination of the nervous system showed clear consciousness, wide-base gait, no aphasia, normal comprehension, insight, memory, calculation, and orientation. The double palpebral fissures were large, without drooping eyelids. No visual defects were noted with hand coarse testing. Eye movements were full without gaze palsy, and nystagmus was observed with eyes jumping in rotation. The pupils were equal in size and round, 2.5 mm in diameter, sensitive to direct and indirect light reflex bilaterally, and accommodative reflex was present. Double flank pain touch was symmetric and normal, and the jaw reflex was not elicited. Bilateral frontal lines and nasolabial grooves were symmetric and deep, with no deviation at the tooth angle. Binaural hearing was coarse but normal. Sound was clear, the soft palate elevated bilaterally, the uvula was midline, and the gag reflex was symmetric. Bilateral head turning and shrugging were symmetrical and strong, with no atrophy of the sternocleidomastoid and trapezius muscles. The tongue was midline, with no muscle atrophy or beam fibrillation. Limb joint position sense, motion sense, and tuning fork vibration sense were normal. Grade 5 moderate limb muscle strength with muscle tension was observed. Muscle atrophy and hypertrophy were not seen. Bilateral finger-nose tests were unstable, rapid rotational movement was negative, and Romberg sign was positive. Tendon reflexes were active in both upper limbs and hyperreflexia in both lower limbs. Hoffmann sign, Rosolimo sign, and palmochin reflex were negative bilaterally. Babinski sign was negative bilaterally, and the neck was soft. Kirschner’s sign and Buchner’s sign were negative.

Routine blood sampling after admission was unremarkable.

Routine cerebrospinal fluid examination, biochemistry, bacterial smear examination, virus II, bacterial culture, and cerebrospinal fluid immunoglobulin G were not abnormal; anti-neuronal cell profile 16 tests were negative (cerebrospinal fluid, serum). Thiobarbituric acid tissue based assay (TBA) test (cerebrospinal fluid): no positive signals were detected; TBA test (serum): weakly positive signals were detected in the hippocampus area, coloring in neuronal cells, and the cerebellar area showed an abnormal signal, coloring within the Purkinje neuronal cells.

The 3-hour video electroencephalogram (EEG) monitoring suggested the following: abnormal EEG, abnormal epileptiform discharges, and diffuse.

Magnetic resonance suggested mild bilateral cerebellar atrophy with multiple abnormal signals in the brainstem and mild atrophy of the cervical spinal cord with multiple abnormal signals in the cerebral white matter (Fig. 1 ).

Magnetic resonance imaging of the head and cervical spine of the proband with dentatorubral-pallidoluysian atrophy (4 September 2023). A White matter lesions in bilateral cerebral hemispheres; B mild atrophy of the cervical spinal cord; C multiple contralateral abnormal signals in the brainstem; D abnormal “cross” signals in the dorsal pons; E widening of partial sulci in the cerebellar hemispheres and mild cerebellar atrophy

Electroconvulsive nystagmography revealed bilateral upward jumping with twisting nystagmus from the upper pole of the eyeball to the left ear (Fig. 2 ) (of nystagmus electricity figure video visible supplementary material video).

Abnormal results of electronystagmography in the proband

The genetic disease candidate gene panel + dynamic mutation gene test results were as follows: 18 and 62 DRPLA ATN1 gene repeats and abnormal amplification of the (CAG)n repeat sequence in the ATN1 gene with 62 repeats. The patient had a disease-causing mutation (Fig. 3 ). The patient was diagnosed with DRPLA.

Genetic disease candidate gene panel + dynamic mutation gene detection results for the proband

Therapy: idebenone at 30 mg three times a day and mecobalamin at 0.5 mg three times a day were given to the patient from the first day of hospitalization. The patient was hospitalized for a total of 9 days, during which oral medication was administered daily as prescribed. After discharge, the patient continued to take both drugs orally, and the dosage was consistent with that during hospitalization. The patient was followed up for 10 months after discharge. During our telephone follow-up, the patient reported that his walking symptoms had improved.

DRPLA is an extremely rare neurological disease. Compared with previous literature, we are unique in that we report the nystagmus features of DRPLA, which have not been reported in previous literature. The patient developed symptoms of ataxia at the age of 34 years with a specific nystagmus: bilateral saccadic nystagmus with the upper pole of the eyeball twisted toward the left ear. In addition, oral idebenone (30 mg three times a day) and mecobalamin (0.5 mg three times a day) for 10 months helped the patient to walk unsteadily. This has not been mentioned in previous literature.

DRPLA is a subtype of spinal cerebellar ataxia (SCA) that is similar to other polyglutamine disorders and is characterized by similar gene dynamics [ 3 ]. The causative gene of DRPLA is located in the 12p13.31 region, and the elongation of the polyglutamine chain (PloyQ) is associated with an abnormal amplification of the repetitive sequence of CAG. In PloyQ, there is a specific protein, the atrophin-1 protein, and when this protein accumulates within the neuron, causing cytotoxicity, the neuron then degenerates and dies [ 4 , 5 ]. DRPLA has been associated with the disruption of protein‒protein interactions, in which amplified polyQ bundles play a crucial role, and dysregulation of gene expression [ 6 ]. The main clinically characterized symptoms of DRPLA are ataxia and cognitive decline. A summary of Chinese cases revealed that DRPLA disease is extremely rare in the Chinese population [ 7 ], and the incidence and age of onset of the disease do not differ significantly by sex, but the clinical manifestations are characterized by different ages of onset of the disease [ 8 ]. In China, the typical clinical features of adult-type cases of DRPLA are ataxia, cognitive decline, and involuntary movements, whereas epilepsy and myoclonic seizures are more common in juvenile-type clinical cases. In this case, the patient was 34 years old, an adult, with ataxia and unsteady walking as the first symptom, accompanied by rapid involuntary head rotation to the right, and upward jumping rotational nystagmus in both eyes was observed on examination. On admission, the patient’s imaging suggested cerebellar atrophy and multiple abnormal signals in the brainstem; genetic testing confirmed that the number of repeats of the CAG sequence of the ATN1 gene in the preexisting patient was 18/62, which was consistent with the diagnosis of DRPLA.

A review of this case revealed that the clinical presentation characteristics of patients with adult-type DRPLA lacked specificity, and genetic testing was the basis for confirming the diagnosis, suggesting that although DRPLA is relatively rare in China, the detection of the number of CAG repeats in the ATN1 gene should not be ignored in addition to focusing on the characteristics of cerebellar atrophy in patients who are considered for investigating the etiology of ataxia. It is worth noting that previous studies did not mention nystagmus signs in patients with DRPLA, but the examination of the present patient revealed bilateral upward rotational nystagmus, suggesting that binocular upward rotational nystagmus may be a sign characteristic of DRPLA; therefore, the nystagmus signs of patients should also be considered when diagnosing patients with DRPLA.

DRPLA is a rare genetic neurodegenerative disease, its clinical features are extremely complex, and some patients’ clinical symptoms lack specificity, which makes it easy to miss and misdiagnose. To further understand this disease and improve its diagnosis and treatment, we reviewed the relevant literature both at home and abroad and summarized the basic status of this disease.

Clinical manifestations: DRPLA can occur at all ages, with 31 years as the average age and no significant difference in sex [ 9 ]. On the basis of the age of onset and clinical features, DRPLA is categorized into juvenile (< 20 years old), early adult (20–40 years old), and late adult (> 40 years old) subtypes, and the main manifestations of DRPLA in each age group are cerebellar ataxia and dementia [ 1 , 10 ]. The age of onset is 15–19 years, and juvenile patients with DRPLA usually present with epilepsy, myoclonus, and mental retardation, with epilepsy as the first symptom and rapid progression of the disease. Adult-onset DRPLA has an age of onset of approximately 38–43 years, with cerebellar ataxia, dementia, involuntary movements, and psychiatric abnormalities as common clinical manifestations and sometimes head tremors and vision problems [ 6 ]. Ataxia and cognitive decline are usually the first symptoms and need to be differentiated from other subtypes of SCA, as well as Huntington’s disease and spinal medullary myasthenia gravis [ 11 , 12 ]. Epilepsy is less common in patients with adult-onset DRPLA, but a few cases have been reported [ 13 ] (Table 1 );

Imaging: cranial magnetic resonance imaging (MRI) is an important test for diagnosing DRPLA, which commonly shows progressive atrophy of the brainstem and cerebellum and extensive cerebral white matter lesions on T2-weighted (T2W) or fluid–attenuated inversion recovery (FLAIR) sequences. Patient age and the number of CAG repeats are two independent factors affecting the severity of brainstem and cerebellar atrophy, and changes in the volume of the brainstem and cerebellum may be important indicators of disease progression. Cerebral white matter lesions, which are significant MRI features of DRPLA, are widely distributed in the cerebrum, brainstem, thalamus, and cerebellum in patients with DRPLA, and among them, cerebellar white matter lesions are a prominent feature of MRI in patients with DRPLA, especially at disease onset. Cerebellar white matter lesions are one of the prominent MRI features of DRPLA, especially in older patients [ 14 ], and have been reported in both juvenile and adult patients, with the adult type being the most common. The mechanism by which cerebellar white matter lesions occur in DRPLA has not yet been clarified, and several studies have shown that cerebellar white matter lesions in DRPLA are not related to ischemia-induced hypoperfusion; rather, they may originate from the disease process of DRPLA itself, which involves the accumulation of aberrant proteins resulting in the absence of axons or myelinated fibers. However, it is worth noting that the severity of cerebral white matter lesions did not significantly correlate with the duration of the disease or the number of CAG repeats in patients but was positively correlated with the age of the patients examined, suggesting that cerebral white matter lesions may not only be related to the disease itself but also be affected by other unknown factors, such as failure of the relevant compensatory mechanisms owing to aging, which needs to be further investigated [ 14 , 15 , 16 ].

Gene mutation: the ATN1 gene is located on chromosome 12p13.31 and encodes the atroph-1 protein, a transcriptional corepressor widely expressed in the central nervous system. There is an unstable CAG repeat queue in this gene, encoding polyglutamine, and DRPLA is the result of abnormal amplification of the CAG repeat queue. Currently, it is believed that the number of CAG repeats in normal individuals is usually 6–35, and individuals carrying 35–47 CAG repeats show incomplete outgrowth and usually have mild clinical manifestations, while those with more than 48 CAG repeats have a complete outgrowth phenotype. The number of CAG repeats is negatively correlated with age of onset and positively correlated with disease severity. The average number of CAG repeats in juvenile patients with DRPLA is 68 (range: 63–79), that in early adult patients with DRPLA is 64 (range: 63–69), and that in late adult patients DRPLA is 63 (range: 48–67) [ 4 , 9 , 17 ]. DRPLA is similar to other PolyQ disorders in that the phenomenon of early onset of genetic predisposition occurs in PolyQ disorders, with the age of onset advancing from generation to generation and with symptoms appearing earlier and earlier in the same lineage. The age of onset is advanced, and symptoms worsen from generation to generation, which may be related to the erratic amplification of the CAG repeat cohort, which is more pronounced in patrilineal transmission [ 1 , 9 , 18 ], but follow-up of the present prediagnostic patient did not have similar clinical manifestations among the families of the prediagnostic patient (follow-up of the prediagnostic patient’s parents, grandparents, and maternal grandparents).

Diagnosis and treatment: the clinical diagnosis of DRPLA mainly relies on clinical manifestations, imaging examinations, family history, and ethnic history. There are no standardized criteria. DRPLA should be considered a possible cause of disease when the patient’s relevant history and examinations meet the following criteria:

Clinical manifestations vary according to the age of onset, with patients under 20 years of age mainly presenting with epilepsy, myoclonus, and ataxia, while patients over 20 years of age mainly present with ataxia, athetosis, involuntary movements, cognitive decline, mental behavioral abnormalities, and so on;

Imaging shows atrophy of the brainstem and cerebellum and widely distributed cerebral white matter lesions in the cerebrum, cerebellum, brainstem, thalamus, and and other parts of the brain;

There is a family history of the disease, which is consistent with the characteristics of autosomal dominant inheritance, but there are also some DRPLA cases without a family history, and the absence of a family history does not exclude the diagnosis of DRPLA. Clinical patients suspected of having DRPLA should improve genetic testing, and DRPLA confirmation criteria for genetic testing for abnormal amplification of the ATN1 gene CAG repeat sequence, which is generally greater than 48 [ 7 , 9 ], should be met. DRPLA is still a progressive neurodegenerative disease, and there is no effective treatment [ 9 ]. Moreover, the progression of the disease cannot be stopped, and symptomatic treatment is still needed. This patient received 30 mg of idebenone orally three times a day during hospitalization. Mecobalamin was administered orally at 0.5 mg three times a day. The patient was hospitalized for a total of 9 days and received both drugs daily according to the prescribed dose. After discharge, the patient continued to take both drugs orally and regularly, with doses consistent with those during hospitalization. Patients were followed up for 10 months after discharge. During the follow-up, the patient reported that walking symptoms had improved.

In summary, we report a case of a patient with dentate nucleus red nucleus pallidus globus pallidus atrophicus who began with unsteady walking, with specific nystagmus double upturns accompanied by signs of nystagmus twisting of the upper pole of the eye toward the left ear. Through a literature review, we discussed in detail the clinical presentation and diagnostic criteria of patients with dentate nucleus red nucleus pallidus globus pallidus atrophicus and emphasized the patient’s specific nystagmus, cranial magnetic resonance, family history, and genetic testing for definitive diagnosis and early detection to improve quality of life. Additionally, we learned that the age of onset of DRPLA disease in the same family line advances from generation to generation, and symptoms worsen from generation to generation and are more pronounced in paternal transmission. However, following the present case of the preexisting patient, among the family, his mother had similar symptoms of unsteady walking, but owing to the complexity of the family environment of the preexisting patient, it was not possible to perform a genetic test on his mother.

Availability of data and materials

The datasets during the current study available from the corresponding author on reasonable request.

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Acknowledgements

We thank the reviewers for their valuable comments and suggestions.

Funding was acquired through Jiangxi Provincial Natural Science Foundation, award number: 20212BAB206046; the Recruitment Program of Experts of Jiangxi Province, award number: jxsp2023102164; The Science and technology plan of Jiangxi Health Committee, award number: 202210573; and National Natural Science Foundation incubation project of the Second Affiliated Hospital of Nanchang University, award number: 2021YNFY12007.

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Xin Chen, Wenwen Xiang, Lijun Xu, Jiahao Zhao, Ye Yu, Qing Ke, Zhipeng Liu & Li Gan

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XC reviewed the literature and wrote the initial manuscript drafts; WX, LX, JZ, YY, QK, ZL, and LG managed the patient, reviewed the literature, and completed the manuscript. Both authors read and approved the final manuscript.

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Correspondence to Li Gan .

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Given the patient’s extended residence in another province and the inconvenience of walking, telephone contact was maintained with the patient and his father, and the patient agreed to allow us to publish his case.

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Chen, X., Xiang, W., Xu, L. et al. Dentatorubral-pallidoluysian atrophy: a case report and review of literature. J Med Case Reports 18 , 429 (2024). https://doi.org/10.1186/s13256-024-04745-3

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A physics-informed machine learning model for global-local stress
Therefore, the input shape is 1 × 80 × 3. Note that for laminates with less than 80 plies, zero values are applied to the respective rows and columns. The output shape is an 80 × 80 stress field for the net section plane, for every 2D stress component given 2D loadings, as generated by FE simulations. Therefore, the output shape is 80 × 80 ...
Breastfeeding experiences of women with perinatal mental health
Despite its known benefits, breastfeeding rates among mothers with perinatal mental health conditions are staggeringly low. Systematic evidence on experiences of breastfeeding among women with perinatal mental health conditions is limited. This systematic review was designed to synthesise existing literature on breastfeeding experiences of women with a wide range of perinatal mental health ...
The Effects of Stress on Physical Activity and Exercise
The majority of studies identified by the literature review supported the hypothesis that stress has an impact, whether negative or positive, on PA behaviors (n = 134, 79.8 %). However, the literature is not entirely in agreement with regards to the valence of the association.
(PDF) A Literature Review on Stress and Coping ...
Methods. This is a systematic review of studies conducted from 2000 to 2015 on stress and coping strategies in nursing students. CINAHL, MEDLINE, PsycINFO and PubMed were the primary databases for ...
IJMS
The Ficus genus, having radiated from the tropics and subtropics to the temperate zone worldwide, is the largest genus among woody plants, comprising over 800 species. Evolution of the Ficus species results in genetic diversity, global radiation and geographical differentiations, suggesting adaption to diverse environments and coping with stresses. Apart from familiar physiological changes ...
Stress Management Interventions for Nurses: Critical Literature Review
Method: A systematic search and review of the literature was used to summarize existing research related to stress management interventions for nurses and recommend directions for future research and practice. Results: Ninety articles met the inclusion criteria for this study and were categorized and analyzed for scientific rigor.
Dentatorubral-pallidoluysian atrophy: a case report and review of
Through a literature review, we discussed in detail the clinical presentation and diagnostic criteria of patients with dentate nucleus red nucleus pallidus globus pallidus atrophicus and emphasized the patient's specific nystagmus, cranial magnetic resonance, family history, and genetic testing for definitive diagnosis and early detection to ...
A scoping review of the literature exploring experiences in the trans
IntroductionIn an effort to address disproportionate levels of poor mental health, stigma, and discrimination outcomes experienced by the Australian trans and gender diverse population, gender affirming care has become an important part of state government health priorities. One form of this affirming care is chest binding, and despite its historic use in the trans community, little is known ...

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A Systematic Literature Review of Work Stress

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Breastfeeding experiences of women with perinatal mental health problems: a systematic review and thematic synthesis

Conclusions

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Study selection

Data extraction

Data synthesis

Patient and public involvement

Characteristics of the studies

Theme: vulnerabilities

Self-perception as a mother

Theme: positive outcomes

Sense of achievement

Theme: challenges

Inconsistent advice and lack of support

Concerns over medication safety

Perceived impact on milk quality and supply

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The Effects of Stress on Physical Activity and Exercise

Conclusions

1 Introduction

1.2 Understanding Stress

1.3 Relationship of Stress to Health Outcomes and Behavior

1.4 Understanding Physical Activity (PA)

1.5 Beneficial Effects of PA/Exercise on Psychological Stress

1.6 Reciprocal Relationship of Stress and PA

2.1 Search for Publications

2.2 Study Quality Assessment

3.1 The Effects of Psychological Stress on PA/Exercise: State of the Literature

3.2 Supporting Evidence for an Inverse Relationship Between Stress and PA

3.2.2 Prospective Studies

3.2.3 Prospective Evidence of Changes in PA Behaviors During Objective Conditions of Stress

3.2.4 Factors that may Influence Prospective Associations Between PA and Stress

3.3 Contrary Evidence for an Association Between Stress and PA

3.4 Evidence that Stress may Increase PA

3.5 Life Transitions, Major Events, and Trauma

4 Discussion

4.2 Clinical Implications

4.3 Exercise as a Stressor

4.4 Significance of Literature Finding a Positive Association Between Stress and PA

4.5 Limitations of the Literature: Methodological Considerations

4.6 Future Directions

5 Conclusion

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2. Adaption of the Ficus Species to Tropical Environment

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Stress Management Interventions for Nurses: Critical Literature Review

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Dentatorubral-pallidoluysian atrophy: a case report and review of literature

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