AbstractThe role of expectations in psychological responses to acute resistance exercise (RE) is largely unknown. This study quantified associations between expectations regarding psychological responses to exercise and observed state anxiety and mood responses after acute RE among adults with and without Analogue Generalized Anxiety Disorder (AGAD). Acute RE was nested into week one of an eight-week RCT of RE among 56 young adults with AGAD (n = 25) and non-AGAD (n = 31). 23 young adults were randomized to the intervention group and 33 to seated quiet rest. State anxiety and mood were measured pre and 10 min-post acute RE or seated quiet rest (QR). Expectations were measured pre acute RE or QR. Spearman’s rho quantified associations between expectations and mood responses. There were no associations in the acute RE sample between expectations of psychological outcomes and experienced psychological outcomes (all rho: -0.05 to 0.16) and the QR sample (all rho: -0.07 to 0.22). The measurement of Expected Psychological Outcomes of Exercise (EPOE) was not specific to RE modality alone, possibly influencing participants’ responses. These preliminary findings suggest that post-acute RE mood responses are independent from expectations of psychological outcomes, which is paramount when promoting RE as a potential treatment/therapeutic option to improve mood. Future research should focus on expectations of psychological responses specifically to acute and chronic RE.
IntroductionElevated anxiety symptoms and disorders are prevalent and successful treatment with frontline therapies (e.g., psychotherapies and medication) is limited1. Consequently, time- and cost-effective alternative treatments are needed2. The anxiolytic effects of exercise have been established among otherwise healthy adults3, chronically-ill adults4, and adults with anxiety disorders5. Generalized Anxiety Disorder (GAD) is a debilitating chronic disorder characterized by prolonged (≥ 6 months), persistent and uncontrollable worry causing overall impairment to quality of life6. Analogue Generalized Anxiety Disorder (AGAD) is not synonymous with clinically diagnosed GAD, rather, it is symptom severity scores indicative of GAD based on empirically established cut-scores. Previous studies of acute aerobic exercise among adults with analogue, or subclinical, GAD (AGAD) found small reductions in state anxiety (Δ = 0.27) and large increases in feelings of energy (Δ = 1.09)7. Recent meta-analytic evidence supports that less well-studied resistance exercise training (RET) reduces anxiety symptoms among adults for a small effect size (Δ = 0.31)8. However, there is limited research of acute resistance exercise (RE) effects on state anxiety and mood states.Given the benefits of RE9, a better understanding of the mechanisms driving participation and response is essential to implement successful interventions. The inability to perform adequate blinding makes exercise-based interventions especially susceptible to placebo effects, because participants are aware that they are receiving a treatment10. A placebo is any sham treatment used for its psychological or psychophysiological effects, or believed to have a specific effect, but actually has no direct effect on the condition being treated11. Further, the lack of a valid exercise placebo means it is not possible to disentangle placebo effects from treatment effects in exercise interventions. However, recent advances in exercise placebo effects research have developed a measurement via an expectations questionnaire, which indicates that the contribution of placebo effects to treatment effects can be inferred by measuring expectations of psychological response to exercise10. These advances allow for the multi-directional measurement of expectations which permits participants to report positive expectations (placebo) and negative expectations (nocebo)12.Expectations, beliefs that a given behaviour will lead to a certain outcome13, are a central psychological mechanism of placebo effects and critical to consider when developing and implementing interventions for anxiety disorders14. Therefore, to attribute observed anxiety responses to the causal effects of acute RE, it is paramount to verify that improvements are not influenced by expectations15. Expectations are generated and maintained in the prefrontal cortex16; emerging neuroscientific evidence suggests that subjective factors like expectations may have physical effects on the body by activating endogenous opioids which are involved in mood regulation17. Exploring the placebo effect allows for a better understanding of how beliefs and values influence brain functions, perception, emotion, and overall health18.Thus, herein the associations between expectations regarding psychological responses to exercise and observed state anxiety and mood state responses to acute RE were quantified in an effort to examine the extent to which outcome expectations influence psychological responses to acute resistance exercise. Based on evidence that expectations directly impact psychological responses to exercise12,19, the authors hypothesized that expectations of psychological response to exercise would be associated with observed state anxiety and mood state responses to acute RE.MethodsThis trial was compliant with the checklist of the consolidated standards of reporting trials (CONSORT)20. The research experiment protocol was approved by the University’s Research Ethics Committee (EHSREC No: 2017_03_18_EHS) and was conducted in accordance with the Declaration of Helsinki, all experiments were performed in accordance with relevant guidelines and regulations.Trial designThis manuscript describes secondary analysis findings from a previously published protocol21and an acute RE trial nested within a parallel RCT22.Participants Participants completed an online battery of physical activity and mood questionnaires and informed consent. Inclusion criteria were (i) age 18-40y, (ii) no medical issues that affect safe participation in RE, and (iii) not currently pregnant or lactating. For the secondary analyses reported here, data from 56 (26.7 ± 5.9y) untrained adult females (n = 35) and males (n= 21) were included. AGAD status was determined by scoring ≥ 6 on the Psychiatric Diagnostic GAD23subscale as well as scoring ≥ 45 on the Penn State Worry Questionnaire24. Figure 1 presents a flowchart of included participants (insert figure below).Fig. 1Flowchart of Included ParticipantsFull size imageAcute interventionParticipants randomized to the resistance exercise group completed a 3-week familiarization period prior to engaging in the acute bout of resistance exercise (RE). During this familiarization period, participants were introduced to the exercise protocols and gradually trained to ensure correct and safe lifting and breathing technique. A single bout of RE was used to examine the impact of acute RE and pre-condition exercise expectations on state anxiety and mood states. Consistent with the World Health Organisation25, and the American College of Sports Medicine26 guidelines, this was a fully supervised, one-on-one RET session. The session consisted of two sets of 8–12 repetitions of eight major muscle group exercises with one minute rest between sets and 2 minutes rest between exercises. The exercises included barbell squat, barbell bench, hex bar deadlift, barbell bent-over rows, dumbbell bicep curls, dumbbell lunges, dumbbell side lateral raises and abdominal crunches. The intensity was set as to allow the participant to complete 8–12 repetitions. An investigator used standardised instructions to record participant’s ratings of perceived exertion (RPE) (6–20) and muscular soreness (MS) (1–10) following each exercise27. Self-reported mood questionnaires were completed 10 minutes pre and 30 minutes post RE. Expectations of psychological response to exercise were measured following the 3-week familiarization period, 10 minutes prior to the acute RE.Control conditionParticipants randomized to the waitlist group were placed on a 3-week waiting list before their quiet rest session. Waitlist participants completed a quiet-rest (QR) control condition. Participants completed 30 min of seated QR in an empty room. As previously reported22 participants were not allowed to read or listen to music given the potential to influence mood state responses. Self-reported questionnaires were completed 10 minutes pre and 30 minutes post QR. Consistent with the RE condition, RPE and MS were taken every 5 min. Expectations of psychological response to exercise were measured following the 3-week waitlist period, 10 minutes prior to the acute QR.Primary outcomesState anxietyState anxiety was measured using the 20-item state subscale of the State-Trait Anxiety Inventory (STAI-Y1); this inventory demonstrated good internal consistency α= 0.94 (ICC = 0.92, 95%CI: 0.89 to 0.95)28. Changes in state anxiety were quantified using the delta of self-reported STAI-Y1 scores, calculated as the difference between pre-intervention and post-intervention scores. Negative change scores indicate negative responses, while positive change scores indicate positive responses.Expectations regarding psychological responses to exerciseLindheimer et al. (2020) developed the EPOES that allows the respondent to indicate both the direction and magnitude of positive and negative expectations regarding psychological responses to exercise. This allows inferences about placebo and nocebo effects to be made. Expectations regarding anxious mood, ability to relax, depressed mood and psychological well-being were measured10.Mood statesFeelings of tension, depressed mood, and total mood disturbance were measured using the five-item subscales of the 30-item Profile of Mood States – Brief Form (POMS-B)29. Changes in mood responses were quantified using the delta of self-reported POMS-B scores, calculated as the differences between pre-intervention and post-intervention scores. Negative change scores indicate negative responses, while positive change scores indicate positive responses.Statistical analysesAnalyses were performed using SPSS 28.0. Potential pre-condition differences in expectations between RE and WL/QR were quantified using Mann-Whitney U tests (see Table 3). Associations between expectations and observed state anxiety and mood state responses (pre-post change scores) to acute RE and seated quiet rest were quantified using Spearman’s rank (Rho) correlations (See Table 2). Spearman’s rank correlations were used for ordinal data that was ranked in terms of magnitude. State anxiety was matched with expectations of anxious mood; feelings of tension were matched with expectations of ability to relax; feelings of depressed mood were matched with expectations of depression; and feelings of total mood disturbance were matched with expectations of psychological well-being. Differences between pre- and post-acute state anxiety and mood state responses were quantified using paired samples t-tests and Hedges’ g effect sizes; effect sizes were calculated such that improved outcomes resulted in a positive effect size. Significance level (α) was set at 0.005 (see Table 4).ResultsTotal sampleResistance exercise Mean (SD) RPE and muscle soreness for the acute RE bout were 13.8(1.3) and 3.5(1.7), respectively (See Table 1 for participants characteristics). There were no significant pre-post differences in mood response to acute RE in the total sample (State anxiety: g = 0.07, p = 0.74; Tension: g=−0.13, p = 0.53; Depressed mood: g = 0.15, p = 0.48; Total mood disturbance: g = 0.29, p = 0.16) (See Table 4). Mean (SD) change scores for anxiety were: −0.52(7.3); Tension: 0.35(2.6); Depressed mood: −0.22(1.4); Total mood disturbance: −3.7(12.5) (See Table 5).Table 1 Participant’s baseline characteristics.Full size tableQuiet restMean (SD) RPE and muscle soreness for the acute QR were 6.1(0.3) and 1.0(0.2) respectively (See Table 1). There were significant pre-post differences in most measures (State anxiety: g = 0.60, p = 0.001; Tension: g = 0.54, p = 0.003; Depressed mood: g = 0.69, p = 0.001) (See Table 4). There was no significant difference for Total mood disturbance (g = 0.45, p = 0.01). Mean (SD) change scores for anxiety were: −3.15(5.2); Tension: −0.97(1.7); Depressed mood: −1.12(1.57); Total mood disturbance: −2.87(6.2) (See Table 5).Resistance exercise and expectationsThere were no significant associations between expectations and acute mood response in the RE sample (State Anxiety: rho: 0.13, p = 0.54; Tension: rho: 0.04, p = 0.85; Depressed Mood: rho: 0.16, p = 0.45; Total Mood Disturbance: rho: −0.05, p = 0.82) (See Table 2).Table 2 Associations between expected psychological responses to exercise and observed response to acute RE and QR.Full size tableQuiet rest and expectationsThere were no significant associations between expectations and acute mood response in the quiet rest sample (State Anxiety: rho:0.14, p = 0.42; Tension: rho: −0.07, p = 0.69; Depressed Mood: rho:0.22, p = 0.23; Total Mood Disturbance: rho: 0.10, p = 0.58) (See Table 2) There were no significant differences in pre-condition exercise expectations between RE and quiet rest (See Table 3; all p > 0.33).Table 3 Pre-Condition exercise expectations (Median and IQR) by group.Full size tableTable 4 Hedges’ g effect size and 95%CI for differences in mood responses pre and post an acute bout of resistance exercise in the total sample.Full size tableTable 5 Mean change scores in mood States (Mean and SD).Full size tableDiscussionThese secondary analyses addressed the potential associations between expected psychological responses and observed responses to acute RE and QR. Pre-condition exercise expectations of psychological responses were not associated with actual state anxiety and mood state responses for either acute RE or QR. To the authors’ knowledge, this is the first study to account for the demand characteristics of expected psychological responses, outside of pain, to exercise on observed responses to acute RE and QR. While these findings indicate no associations between expectations and responses, it is important to consider that behavioural interventions, including exercise, face challenges in accounting for psychological expectations, as exercise is impossible to conceal15. Herein, participants were aware that they were receiving RE, as exercise cannot be double blinded, so there was potential for observed state anxiety and mood responses to acute RE to be influenced by expectations of psychological responses to exercise. The lack of observed associations reinforces that changes in state anxiety and mood states following acute RE appear to be directly linked to the exercise bout/stimulus.Present findings indicate that state anxiety was not improved after acute resistance exercise (Δ = 0.07, 95%CI: −0.33 to 0.46), as reflected in mean change scores (M=−0.52(SD ± 0.3). Previous literature noted that acute RE typically results in slight reductions or, in some cases, a transient increase in anxiety symptoms30,31. Additionally, participants had no experience of structured RET, which has the potential to impact their post exercise reporting, as untrained individuals are less likely to report psychological benefit32. Conversely, there were moderate-to-large effect size reductions in the QR group (Δ = 0.60, 95%CI: 0.24 to 0.99), as observed in mean change scores (M=−3.15(SD ± 5.2). Interestingly, the expectation that acute exercise would reduce anxious mood was not associated with actual reductions in state anxiety to acute resistance exercise, despite participants reporting a mean expectation of a slight decrease in anxious mood pre-acute resistance exercise. Higher levels of anxiety were not associated with more negative expectancies as hypothesised by Gyurcsik et al.33. The present results are consistent with previous evidence from acute aerobic exercise trials, which found that expectations of anxiolytic benefits of acute exercise were not reflective of actual psychological responses12. These findings highlight the actual anxiolytic responses to acute RE independent of expectations of anxiety response.Similarly, there were no improvements in mean mood state after an acute bout of resistance exercise, which differs from previous research which found that acute aerobic exercise was effective in improving mood state responses34. However, in the quiet rest group there was a large improvement in state anxiety (Δ = 0.60, 95% CI: 0.24 to 0.99), a moderate improvement in tension (Δ = 0.54, 95%CI: 0.18 to 0.92) and a moderate improvement in depressed mood state (Δ = 0.69, 95% CI: 0.32 to 1.06). These findings are consistent with previous studies which concluded that quiet rest has similar effects as exercise on state anxiety due to transitory reduction in blood pressure and time away from potential sources of stress35,36,37,38. The expectation that acute exercise would reduce negative and increase positive mood outcomes was not associated with actual mood responses for any mood outcomes (See Table 2). One potential explanation for the lack of association could be that because the participants’ expectations for improvement was positive, when this expectation was not met their post exercise mood reflected this discrepancy. The lack of associations between expectations and observed state anxiety and mood state responses to acute RE contrasts with some recent evidence for aerobic exercise; Boot et al. (2013) reported that positive psychological expectations of exercise responses were associated with greater improvements in anxiety and overall mood.It is important to explore the potential influence of expectations as it is an important advance toward explaining heterogeneity in responses to exercise treatments, in whom exercise treatments are most effective, and how the modifiable factor of expectations may be manipulated to enhance exercise engagement and response39,40. More recent consensus and recommendations from Beedie et al.39 suggest that, where possible, research methods should be implemented to consider and/or control for placebo effects that may explain the variance in response to exercise treatments and interventions. Future trials should replicate and expand the current findings by using mode specific expectations (i.e., expectations for responses to resistance exercise), exploring changes in expectations, and additional mechanisms of placebo effects (e.g. priming expectations, placebo control groups).These present findings should be interpreted in the context of potential limitations. Firstly, the measurement of expected psychological responses to exercise was not specific to the modality of RE only and, the timing of the administration of the questionnaire, after three-weeks of RE familiarization, could have influenced both the participants and reporting of expectations and response to RE. Secondly, a lack of additional post-exercise measurement limits the ability to determine if there were changes in actual state anxiety and mood state responses which may have appeared after the 10-min post-exercise measurement. Finally, the small sample size may have limited the detection of resistance exercise effects on mood changes and, subsequently, associations between expectations and psychological responses.A single bout of resistance exercise did not improve state anxiety or mood states. These psychological responses were not associated with expected psychological responses. These results suggest that positive and negative psychological responses to acute resistance exercise appeared to be independent of the potential placebo effects created by expectations of psychological response. However, this lack of associations plausibly may be attributed to the absence of psychological improvements observed in the resistance exercise group. This interpretation is consistent with findings from Lindheimer et al.12 who also found a lack of association but also noted the absence of mood improvements. It could be suggested that the lack of psychological improvements may underlie the failure to detect meaningful associations. Accounting for expected psychological responses to exercise as a potential mechanism of actual psychological responses to RE strengthens the notion that post-exercise state anxiety and mood state responses can be attributed to the exercise bout, which is paramount when promoting RE as a potential treatment or therapeutic option to improve mental health.
Data availability
The authors confirm that the data supporting the findings of this study are available within the article.
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Download referencesFundingNone.Author informationAuthors and AffiliationsDepartment of Physical Education and Sport Sciences, University of Limerick, Limerick, IrelandJennifer M. Rice, Mark Lyons & Matthew P. HerringPhysical Activity for Health Research Centre, University of Limerick, Limerick, IrelandJennifer M. Rice & Matthew P. HerringHealth Research Institute, University of Limerick, Limerick, IrelandJennifer M. Rice & Matthew P. HerringPublic Health Sciences, Penn State College of Medicine, Pennsylvania, USABrett R. GordonWilliam S. Middleton Memorial Veterans Hospital, Wisconsin, VA, USAJacob B. LindheimerSport and Human Performance Research Centre, University of Limerick, Limerick, IrelandMark LyonsPESS, University of Limerick, Castletroy, Limerick, IrelandJennifer M. RiceAuthorsJennifer M. RiceView author publicationsYou can also search for this author inPubMed Google ScholarBrett R. GordonView author publicationsYou can also search for this author inPubMed Google ScholarJacob B. LindheimerView author publicationsYou can also search for this author inPubMed Google ScholarMark LyonsView author publicationsYou can also search for this author inPubMed Google ScholarMatthew P. HerringView author publicationsYou can also search for this author inPubMed Google ScholarContributionsJ.R: Conceptualization, Methodology, Formal Analysis, Writing – Original Draft, Writing – Review & Editing, Visualization; B.G: Conceptualization, Methodology, Investigation, Data curation, Writing – Original Draft, Writing – Review & Editing, Visualization; J.L: Conceptualization, Writing – Original Draft, Writing – Review Editing, Visualization, Supervision; M.L: Conceptualization, Writing – Original Draft, Writing – Review Editing, Visualization, Supervision; M.H: Conceptualization, Writing – Original Draft, Writing – Review Editing, Visualization, Supervision, Project administration. All authors made substantial contributions to conception and design, data analysis, and preparation of the manuscript. All authors have read and approved the final version of the manuscript and agree with the order of presentation of the authors.Corresponding authorCorrespondence to
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KeywordsResistance exercisePsychological expectationsPlacebo effectGeneralized anxiety disorderAnxiety