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REVIEW ARTICLE
HSE
MARKUS GERBER & UWE PU
Institute of Exercise and Health Sciences, University of Basel, Basel, Switzerland
Abstract
Background: Understanding how exercise influences health is important in designing public health interventions. At present,
evidence suggests that there is a positive relationship between exercise and health. However, whether this relationship is
partly due to the stress-moderating impact of exercise has been less frequently investigated although more and more people
are taxed by stressful life circumstances. Methods: A comprehensive review of studies testing the potential of exercise as a
stress-buffer was conducted (including literature from 1982 to 2008). The findings are based on a narrative review method.
Specific criteria were taken into account to evaluate causality of the evidence. Results: About half of the studies reported at
least partly supportive results in the sense that people with high exercise levels exhibit less health problems when they
encounter stress. The causality analyses show that stress-moderation effects were consistently found in different samples and
with different methodological approaches. Although more support results from cross-sectional studies, exercise-based stressbuffer effects were also found in prospective, longitudinal and quasi-experimental investigations. Conclusions: This review
underscores the relevance of exercise as a public health resource. Recommendations are provided for future
research. More prospective and experimental studies are needed to provide insight into how much exercise is
necessary to trigger stress-buffer effects. Furthermore, more information is warranted to conclude which sort of
exercise has the strongest impact on the stress-illness-relationship.
Key Words: Buffer, exercise, fitness, health, physical activity, review, stress
Introduction
In industrialized countries, many people feel stressed
[1]. National health surveys show that the levels of
perceived stress have increased considerably over the
past decades [2,3]. Even children and adolescents
report high amounts of psychological stress [4].
According to the World Health Organization, stress
is among the leading causes for the global burden of
disease, entailing heavy costs both for national health
systems and the private economy [5,6].
Despite considerable heterogeneity in defining and
measuring stress, research leaves no doubt that stress
plays an important role in the aetiology of both
somatic and psychological diseases [4,711]. Human
stress regulation systems have evolved over thousands of years to deal primarily with short-term,
mostly somatic stressors. Hence, the physiological
Correspondence: Markus Gerber, Institute of Exercise and Health Sciences, University of Basel, Birsstrasse 320, CH-4052 Basel, Switzerland.
Tel: 0041 61 377 87 83. Fax: 0041 61 377 87 89. E-mail: markus.gerber@unibas.ch
(Accepted 14 September 2009)
2009 the Nordic Societies of Public Health
DOI: 10.1177/1403494809350522
802
analysis of main-effects to the investigation of interaction-effect models [18]. In this context, a multitude of cognitive, psychosocial and behavioural
variables were identified that are able to protect
against the debilitating effects of chronic stress
(i.e. hardiness, sense of coherence, mastery, optimism, self-esteem, social support) [19,20].
(4) Protection of
resources
(3) Cultivation of
resources
(1) Direct effect
Exercise
(2) Preventive
effect
Stress-event
(5) Stress-buffering
effect
Figure 1. Potential influence of exercise on the interplay between stress, resources and health [69].
Health
803
Results
Studies included in this review
Thirty-one journal articles, book sections and books
dealing with the role of exercise as a stress-buffer
were found that met all the inclusion criteria
described above. Some articles were based on the
same cohort, which reduced the number of independent datasets to 27. Detailed information about the
samples, sampling methods, research designs, control of confounding variables, measurements and
data analysis techniques and the results is provided in
Tables I to IV (separately for adolescents and adults
and studies with cross-sectional and prospective,
longitudinal or experimental design).
In sum, 12 studies fully supported the validity of an
exercise-based stress-buffer hypothesis [24,4959].
In addition, four studies showed partial support
[3,6062]. In contrast, 15 studies did not confirm
the stress-buffering hypothesis [25,6375], although
some significant interactions were found in these
studies, too [25,57,64,73,76]. This global analysis
points to a great variability regarding the potential of
exercise to buffer stress. Certainly, given the diversity
of sample characteristics, study designs and measurements, this variability is not unexpected. However,
the inconsistent findings raise the question whether
we should consider the glass as half-full or halfempty, that is to say, whether this pattern of results
(about half of the studies providing support) is to be
interpreted as good evidence in support of, or as a
basis for discounting the original hypothesis. This
question, however, must be answered with neither
nor because the presence (and consistency: see
below) of supportive findings is a necessary, but still
insufficient, condition for causality. Thus, further
criteria need to be taken into account.
Authors, year,
location
Kobasa et al.
1982, USA
Brown 1991,
USA
Young 1994,
USA
Zuzanek et al.
1998, USA
Carmack et al.
1999, USA
Cross-sectional (multistage
probability sampling,
controlled for age and
education)
Cross-sectional (random
sample, return rate
67.2%, controlled for
age, marital status, job
level and years of
service)
Cross-sectional (controlled
for gender)
Regression analyses
1. WSIe
2a. Profile of Mood States
2b. Health complaints
3a. Maximal fitness test
3b. Exercise (multiple items)
Regression analysis
1. LESc
2. SIRS
3a. Perceived fitness (12 items)
3b. Exercise (FDIT, 15 items)
4. Hardiness
Regression analyses
1. LESc
2a. SIRSb
2b. Health centre visits (prosp.)
3a. Exercise (TD, 15 items)
3b. Sub-maximal fitness test
Partial correlation analyses
1a. Job stress
1b. PSSd
2. Coronary heart risk factors
3. Maximal fitness test
Regression analyses
1. General stress (1 item)
2. Health perception (1 item)
3a. Exercise (general, 1 item)
3b. Exercise (TF, 22 items)
(continued )
Bivariate relationships
804
M. Gerber & U. Puhse
Employees of a university
medical centre (n 1,720,
540m, 880f, different job
levels)
Manning &
Fusilier,
1999, USA
Skirka 2000,
USA
Kaluza et al.
2001, 2002,
Germany
Lochbaum et al.
2004, USA
Regression analyses
1. LEIf
2a. Health costs
2b. Healthcare use
3. Exercise (FDT)
4a. Hardiness
4b. Social support
Regression analyses
1. OSI-2g
2a. Job satisfaction
2b. Mental well-being
2c. Physical well-being
3. Exercise (F, 1 item)
Correlation analyses
1. DHSh
2. Profile of Mood States
3. Athletes vs. non-athletes
4a. Hardiness
4b. Sense of coherence
ANCOVA and Chi2-test
1. Occupational stress
2a. Health complaints
2b. Psychological distress
2c. General well-being
2d. Backache
3. Exercise (F, 1 item)
Regression analyses
1. Social life events
2a. Depression
2b. Health complaints
3. Exercise
4a. Social support
4b. Self esteem
Regression analyses
1. PSSd
2. Health complaints
3. Strenuous exercise (F, 1 item)
4. Personality traits
Cross-sectional (random
sample, controlled for
gender, marital status,
age and income)
Stress-buffer: No support
Comment: Buffer effects found in one
cohort for 2c. Regarding 2a, exercise was a positive buffer in one
cohort, but had detrimental effects
in another.
Stress-buffer: No support
Comment: Three-way interactions
not examined.
Bivariate relationships
a
SRRS Social Readjustment Rating Scale. bSIRS Seriousness of Illness Rating Scale. cLife Experiences Survey. dPSS Perceived Stress Scale. eWSI Weekly Stress Inventory. fLEI Life
Events Inventory. gOSI-2 Occupational Stress Indicator-Version 2. hDHS Daily Hassles Scale. D Duration, F Frequency, I Intensity, T Type.
Authors, year,
location
Table I. Continued.
Regression analyses
1. SRSSa
2. SIRSb
3. Exercise (TDI, 4 items)
4a. Hardiness
4b. Social support at work
Regression analyses (a) and
ANCOVAs (b,c,d)
1. Unemployment
2a. Mental health (a,b)
2b. Health complaints (b,d)
2c. Depression (c)
2d. Self-efficacy (c,d)
3. Exercise (DF, 1 item)
4a. Social support (a)
4b. Anxiety (d)
Regression analyses
1. SRRSa
2. Somatic complaints
3. Exercise (?)
Bivariate relationships
SRRS Social Readjustment Rating Scale. bSIRS Seriousness of Illness Rating Scale. D Duration, F Frequency, I Intensity, T Type.
Authors, year,
location
Table II. Studies with adult samples and prospective, longitudinal or experimental design.
806
M. Gerber & U. Puhse
Adolescents attending
annual laboratory visits
(n 303, 50% boys, 12
24 years, 53% white,
47% black, family
hypertension
background)
Secondary school students
(n 407, 213m, 194f,
M 14.0 years)
Gogoll 2004,
Germany
Cross-sectional (non-random
sample, controlled for sex,
age and nationality)
Cross-sectional (systematic
cluster sampling, return rate
76%, controlled for gender
and perceived family
wealth)
Cross-sectional (random
sample, representative for
two German states, controlled for place of residence, sex, grade and
education)
Cross-sectional (non-random
sample, return rate 89%,
comparison of students with
the highest (n 55) and
lowest stress scores (n 55)
Regression analyses
1. Multiple objective and subjective stress indicators
2. Multiple health outcomes
3. Multiple exercise indicators
(related to youth sports)
4a. Self-esteem
4b. Family support
Regression analyses
1a. ARCSd
1b. Community stresse
2a. BMI
2b. Sum of skin folds
2c. Waist circumference
3. Exercise (FI, 1 item)
ANCOVAs
1. School-based stress
2. Health complaints
3. Exercise (F, 1 item)
4. Self-esteem
ANCOVA
1. School-based stress
2. Health complaints
3. Exercise (F, 1 item)
ANOVA
1. SRRSa
2a. SIRSb
2b. Depressed affect
3. Exercise (FDI, 4 items)
Stress-buffer: No support
Comment: Although few significant
two-way interactions were found,
the majority of the analyses did not
support a stress-buffer effect.
Similarly, the three-way-interactions generally remained
insignificant.
Stress-buffer: Partial support
Comment: Stress-buffer effect more
consistent for 1a than 1b.
Significant regression weights:
from 0.46 to 0.49.
Interaction explained between 2%
and 3% of additional variance.
Stress-buffer: No support
Comment: No significant three-wayinteraction found between stress x
exercise x self-esteem.
Bivariate relationships
SRRS Social Readjustment Rating Scale. bSIRS Seriousness of Illness Rating Scale. cHealth Behavior of School-Aged Children. dARCS Adolescent Resources Challenge Scale.
Monthly rent or mortgage in the community. D Duration, F Frequency, I Intensity, T Type.
Haugland et al.
2003, Norway
Authors, year,
location
Norris et al.
1992, UK
Rothlisberger
et al. 1997,
Switzerland
University students
(n 112, 40m, 72f,
M 18.9 years)
Authors, year,
location
Quasi-experimental (comparison
of two types of interventions
(30min/3d/wk) and one control
group, baseline, after 5 and 11
weeks and 2-months follow-up,
no baseline differences in stress,
controlled for baseline scores)
ANCOVAs
1a. LEQc
1b. PSSd
2a. SIRSb
2b. Mental health
3a. Exercise (FDI, 4 items)
3b. High intensity, n 22
3c. Moderate intensity, n 16
3d. Flexibility training, n 19
3e. Control group, n 16
ANCOVAs
1a. Daily hassles
1b. Life events
1c. Combination 1a/1b
2a. Life satisfaction
2b. Health satisfaction
3. Exercise (FDIT, 13 items,
vigorous)
4. Emotional support
Regression analyses
1. LESa
2a. Health record form
2b. Depression
2c. Anxiety
2d. Psychological functioning
3. Sub-maximal fitness test
ANCOVAs
1. LESa
2a. Health record form
2b. Health problems
2c. Depression
2d. Anxiety
2e. Health complaints
3a. Exercise: n 18
3b. Relaxation: n 19
3c. No treatment: n 18
Regression analyses
1. LESa
2. SIRSb
3. Exercise (DT, 14 items)
Table IV. Studies with adolescent samples and prospective, longitudinal or experimental design.
(continued )
Stress-buffer: No support
Comment: Three-way interactions yielded non-significant
results.
Study 1:
Stress " <4 Health #
Exercise " <4 Health (2a)"
Exercise <//4 Health (2b)
Exercise <//4 Stress (1a)
Exercise " <4 Stress (1b) #
Stress-buffer: No support
Comment: Students reported
recovery from stress across all
treatment conditions.
Bivariate relationships
808
M. Gerber & U. Puhse
LES Life Experiences Survey. bSIRS Seriousness of Illnesses Rating Scale. cLEQ Life Events Questionnaire. dPSS Perceived Stress Scale. eSEM Structural Equation Modelling.
COR-E-Y Conservation of Resources Evaluation for Youth. D Duration, F Frequency, I Intensity, T Type.
a
Stress-buffer: No support
Comment: No stress-buffer effect
with cross-sectional and longitudinal analyses. Three-way
interactions yielded non-significant results.
Stress " <4 Health #
Exercise " <4 Health "
Exercise " <4 Stress #
Cross-sectional and longitudinal
(the latter with n 281 students, T2 after 1-year, dropouts
analysis on main study variables, controlled for gender,
school type, age, status and
place of residence)
Secondary and vocational
school students
(n 1,183, 537m, 646f,
M 17.16 years)
Gerber 2008,
Switzerland
Bivariate relationships
809
810
811
812
813
814
Discussion
This review supports the view that stress is negatively
associated with good health. Only one study did not
show a significant relationship between stress and
health [64]. In four studies, only some (but not all)
health indicators were negatively associated with
stress [57,62,73,75]. In all other investigations,
individuals with high stress levels reported significantly more health troubles.
Support for the validity of an exercise-based stressbuffer hypothesis was found in 16 studies. In
contrast, 15 investigations did not report significant
moderation effects. Given the status quo between
supportive and non-supportive studies, drawing a
conclusion for or against the validity of the stressbuffer hypothesis seems difficult unless other criteria
are taken into account. Accordingly, Hills [44]
quality criteria were used to obtain a more solid
and accurate interpretation of the evidence. The first
criterion was consistency, which was strongly supported. Stress-buffer effects were found among different groups of people, at different places and
moments in time and with a wide spectrum of
methodologies. From the inclusion of additional
moderator variables can be inferred that significant
relationships occurred slightly more often when
studies were conducted in North America.
Furthermore, physical fitness had a more limited
potential to balance stress-induced health complaints
compared with exercise. In turn, there is preliminary
evidence that exercise facilitates coping among at-risk
populations. The second criterion (strength of association) provided less support for a causal influence
as the magnitude of stress-buffer effects found in
most studies was relatively small. However, it must be
remembered that interaction effects are difficult to
identify and that, therefore, also small effects can be
of practical significance [86,87]. The third criterion
was specificity. However, specificity is not a strong
criterion since (i) stress has been defined as a general
adaptation syndrome and (ii) exercise influences a
myriad mental and physical diseases [22,94].
Regardless of that, moderator effects were most
often significant when health was defined as a
physical outcome. Moreover, little evidence was
found that moderator effects depend on the interplay
with other resources. As the fourth criterion (temporal sequence) was concerned, this review shows
that a bare majority of significant interactions
resulted from cross-sectional studies. In these studies, significant interactions might mean (a) that
exercisers are less affected by stress or (b) that people
who feel unaffected by stressful life circumstances are
more likely to maintain high exercise levels. However,
prospective studies also produced significant results,
especially when longer timeframes were used. The
fifth criterion (dose-response relationship) was rarely
addressed in past research. Studies provided mixed
messages about whether moderate or vigorous exercise leads to more beneficial results. To address the
sixth criterion (plausibility), we referred to studies
using a laboratory stress paradigm to find out
whether stress-buffer effects may be attributable to
biological mechanisms. However, exercise physiology
815
816
Acknowledgments
We would like to thank Dr. Dean Barker (Basel,
Switzerland) for proofreading the manuscript.
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