Assessment Task 3 Written Assignment - Evaluating the usefuln.docx

Assessment Task 3: Written Assignment - Evaluating the
usefulness of evidence - Marking Rubric
HD DI CR PS NN No Attempt (Zero) Score
Paper 1:
Describe the quality of
evidence (type,
hierarchy, level,
strength & weakness)
LO2, 4
(GA4, 6, 8)
Correctly, clearly &
concisely describes
the quality of
evidence with
insightful
explanation.
Correctly describes
the quality of
evidence with clear
explanation.
Describes the quality
of evidence with good
explanation.

of evidence with
minimal explanation.
There is no description
of the quality of
evidence.
No attempt made
/20
Paper 2:
Describe the quality of
evidence (type,
hierarchy, level,
strength & weakness)
LO2, 4
(GA4, 6, 8)
concisely describes the
quality of evidence
with insightful
explanation.
Correctly describes
the quality of
evidence with clear
explanation.
of evidence with
good explanation.

of evidence with
minimal explanation.
There is no
description of the
quality of evidence.
No attempt made
/20
Identification of
strongest
evidence (paper
1 or 2)
related to the
scenario and
provides
justification
LO1,2,7
(GA2, 3, 9)
concisely identifies
the strongest
evidence related to
the scenario with
insightful explanation.
Correctly identifies
the strongest
evidence related to
the scenario with
clear explanation
Identifies the

strongest evidence
related to the
scenario with good
explanation.
Minimal explanation
and identification of
evidence related to
the scenario.
No explanation and
identification of
evidence related to
the scenario
No attempt made
/40
Sources and
Referencing
Accurate use of APA
referencing style on all
occasions in text and in
the reference list.
Accurate use of APA
referencing style on
most occasions in text
and in the reference
list
Inaccuracies with use
of APA referencing

style on some
occasions either in
text or in the
reference list
Many inaccuracies
with the APA
referencing style in
text or in the
reference list.
APA style is not used
in text or in the
reference list.
No references /10
Mechanics -
Grammar, Spelling
and Punctuation
There are no errors
with grammar, spelling
and punctuation, and
the meaning is easily
discernible. Minimal
use of direct quotes.
Kept to the word limit
There are minimal
errors with grammar,
spelling and
punctuation.
However, the meaning
is readily discernible.

Minimal use of direct
quotes. Kept to the
word limit
There are some errors
with grammar, spelling
and punctuation. The
meaning is discernible.
Minimal use of direct
quotes.
Kept to the word limit
There are errors with
grammar, spelling and
punctuation. The
errors detract, but the
meaning is discernible
with some effort. Use
of some direct quotes.
Within +/- 10% or
word limit
There are substantial
errors with grammar,
spelling and
punctuation that
detract significantly
from the meaning.
Excessive reliance on
direct quotes. More
than 10% over the
word limit.

Grammar, spelling and
punctuation are such
that the reader cannot
make sense of the
content.
/10
Grade: /100
/50
Comments:
Assessor: Date:
1
S5 Evidence Hierarchy
S6 Evidence Hierarchy
Assessment Task - Additional Resource
(Image source
https://twitter.com/munzr001/status/461407131900469248)
(Image source:
http://academicguides.waldenu.edu/healthevidence/evidencepyra
mid)

2
NHMRC Levels of Evidence
JBI Levels of Evidence
(Image source
https://twitter.com/munzr001/status/461407131900469248)
(Image source NHMRC (1999)

3
How to APA Reference Evidence Hierarchies
S5 and S6 Evidence Hierarchies
In-text (DiCenso, Bayley, & Haynes, 2009)
DiCenso, A., Bayley, L., & Haynes, R.B. (2009). Accessing pre-
appraised evidence: Fine tuning the
S5 model into a S6 model. Evidence Based Medicine, 12(4), 99-
101. Retrieved from
http://ebn.bmj.com/content/12/4/99.2.full.pdf+html
NHMR Levels of Evidence
In text (NHMRC, 1999)
National Health and Medical Research Council [NHMRC].
(2009). NHMRC additional levels of
evidence and grades for recommendations for developers of
guidelines. Retrieved from
https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/develop
ers/nhmrc_levels_grad
es_evidence_120423.pdf
JBI Levels of Evidence
In text (JBI, 2016)

Joanna Briggs Institute [JBI].(2016). The JBI approach.
Retrieved from
http://joannabriggs.org/jbi-approach.html#tabbed-nav=Levels-
of-Evidence
http://joannabriggs.org/jbi-approach.html#tabbed-nav=Levels-
of-Evidence
RESEARCH ARTICLE
A Pilot Study Examining the Effects of Kouk Sun Do on
University Students with Anxiety Symptoms
Jong-Ho Kim1*†, Heewon Yang1 & Stephen Schroeppel II2
1Department of Health Education and Recreation, Southern
Illinois University Carbondale, Carbondale, IL 62901, USA
2Department of Educational Psychology, Southern Illinois
University Carbondale, Carbondale, IL 62901, USA
Abstract
The effects of Kouk Sun Do (KSD), a mind–body exercise on
mental health in university students, were investigated
in this pilot study. University students (N = 30) with self-
reported anxiety symptoms were randomly assigned to
either the treatment group or the waiting list control group.
Eighteen participants (N = 18; seven in the treatment
group and 11 in the waiting list control group) completed a pre-
test and a post-test, and 12 participants dropped
out before or during the intervention. Ten 70-min KSD exercise
sessions were conducted three times per week over

a 4-week period. Trait anxiety, depressive symptoms and
general self-efficacy in coping with stress were measured
with the pre-test and the post-test. Qualitative data were
collected using open-ended questions regarding benefits of
KSD at the last session. A two (group) by two (time) repeated-
measure analysis of variance was used to analyse the
data. Trait anxiety and depressive symptoms decreased whereas
general self-efficacy increased over a 4-week period.
The treatment group had significantly reduced trait anxiety and
depressive symptoms compared with the control
group across time. Qualitative data provided support that the
self-induced relaxation effects of KSD may lead to
reduced anxiety. Copyright © 2012 John Wiley & Sons, Ltd.
Received 28 May 2011; Revised 21 March 2012; Accepted 27
March 2012
Keywords
mindfulness; meditation; yoga; mind–body exercise; mental
health
*Correspondence
Jong-Ho Kim, Department of Health Education and Recreation,
Southern Illinois University, Carbondale, IL 62901, USA.
†Email: [email protected]
Published online 4 June 2012 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/smi.2431
Anxiety is the most prevalent class of mental disorders
(Kessler, Berglund, Demler, Jin, & Walters, 2005) and
is highly associated with other psychiatric conditions
such as mood disorders (Hettema, Neale, & Kendler,
2001), substance abuse, avoidant behaviour (Roy-Byrne
et al., 2009) and depression (Reiter, Otto, & Pollack,
1991). People with anxiety disorders feel persistently
uneasy and anxious about the future because of their

overestimation of risks and unrealistic belief that
catastrophic events will occur to them. Individuals with
an anxiety disorder may also suffer from physical
symptoms such as muscle tension, stiffness, shortness
of breath, flushing and chills, palpitations, chest pains
and dizziness (Roy-Byrne et al., 2009). These symptoms
may interfere with physical and emotional role func-
tioning, task efficiency, performance at work or school
and social life, which deteriorates the overall quality of
life (Mendlowicz & Stein, 2000).
Mindfulness exercises, characterized as an awareness
that intentionally and non-judgmentally focuses atten-
tion to the present moment and sustains this attention
over time, have been a recently growing regimen for
Stress and Health 29: 99–107 (2013) © 2012 John Wiley &
Sons, Ltd.
psychological treatments in western culture (Miller,
Fletcher, & Kabat-Zinn, 1995; Rowa & Antony, 2005).
Research studies report that a mindfulness-based stress
reduction programme consisting of meditation and
mindful stretching has significant treatment effects on
people with a diverse set of medical and psychiatric
conditions by reducing stress, anxiety and depression
(e.g. Chang et al., 2004; Goldin & Gross, 2010; Gross
et al., 2004; Lazar, 2005; Toneatto & Nguyen, 2007).
Sudarsham Kriya Yoga, consisting of cycling yogic
breathing, yoga postures, meditation, group processes
and basic yogic knowledge, has contributed to significant
reductions in anxiety, depression and post-traumatic
stress disorder (Brown & Gerbarg, 2005). Yoga techniques
have been historically conducive to fostering well-being,
mood, attention, mental focus and stress tolerance.
Qigong, an exercise technique where movements are
synchronized with specific breathing patterns with fully
inhaling and exhaling respirations, as well as acupressure,

has lessened perceived stress and anxiety (Chow & Tsang,
2007; Griffith et al., 2008; Lee, Kang, Lim, & Lee, 2004;
Posadzki, Parekh, & Glass, 2010). Overall, mindfulness
99
The Effects of Kouk Sun Do on Mental Health J.-H. Kim, H.
Yang and S. Schroeppel
exercises may contribute to enhancing relaxation and
acceptance, which can buffer stress responses (Bear,
2010; Lazar, 2005).
Kouk Sun Do (KSD), also known as Sun-Do, is a
traditional Korean mind–body practice, which has
been practised over thousands of years but has hardly
been evaluated scientifically for efficacy. KSD is one
of a group of therapies considered to be a mindfulness
exercise, which combines characteristics of yoga, medita-
tion, Tai-Chi, Zen and martial arts (Kouk Sun Do, 2008).
KSD consists of three parts: warm-up exercises at the
beginning, the meditation exercises with a sequence of
postures in the middle and cool-down exercises at the
end. A series of stretching exercises are performed along
with some acupressure for the warm-up and cool-down
sections. The meditation exercise involves lower-
abdomen breathing through which the abdomen gently
puffs out with inhalation and moves back in with
exhalation following meditative chanting, which is
repeated every 5 s (Catabia, 2007). Also, the in-and-out
breathing exercise employs the nostrils and focuses on
the lower abdomen (Kouk Sun Do). KSD is primarily
based on lower-abdomen breathing techniques through
which a lower part of the abdomen, called lower danjeon,
the body’s energy centre, located about 2 in. below the
navel, is utilized to circulate universal life energy, ki or

qi, throughout the body (Catabia). Breathing and the
state of mind reciprocally respond. Emotional states
affect respiratory rate and depth (Brown & Gerbarg,
2009). On the contrary, slow breathing is correlated
with reduced psychological and physiological arousal
through parasympathetic activity and emotional
calmness with alertness (Brown & Gerbarg, 2005, 2009;
Cappo & Holmes, 1984). Experimental research has also
demonstrated that KSD implemented for community-
dwelling elderly has contributed to improvements in
mood and depression as well as in physical fitness of
balance, flexibility and strength at a 16-week post-
intervention in the treatment group (Lim & Hong,
2010). In brief, KSD is based on the deep-breathing
exercises and may be conducive in enhancing a state of
calmness with vigour and balance by training the mind
and the body.
University students are especially vulnerable to eleva-
tions in anxiety and depression compared with the years
preceding entry into university and their non-student
peers. Many university students may worry about their
future, as they transition into independence (Bewick,
Koutsopoulou, Miles, Slaa, & Barkham, 2010). They
may also experience rejection or disillusionment during
this period of exploration and change (Arnett, 2000).
Increasing prevalence of mental illness associated with
stress in university students is an area of alarming concern
(Bayram & Bilgel, 2008; Stallman, 2010). However, many
students with mental health problems do not tend to seek
help for their conditions, despite higher levels of anxiety
and depressive symptoms requiring treatment (Armando
et al., 2010; Eisenberg, Golberstein, & Gollust, 2007).
100
Although there have been anecdotal reports of the
psychotherapeutic effects of KSD practices, little empiri-

cal research has been conducted on KSD, which might
have a treatment effect on university students with anxi-
ety symptoms. Therefore, the purpose of this pilot study
was to examine the effects of KSD on mental health in
university students with anxiety symptoms.
Method
Participants
A total of 30 participants with medium to high levels of
self-reported anxiety symptoms at a large southwestern
university were recruited for this study. The researcher
put flyers on bulletin boards on campus and also distrib-
uted the flyers to potential participants. The only
requirement for volunteering in this study was that the
potential participants should be presently experiencing
some anxiety symptoms. The flyers also included
information such as the purpose of the study, session
schedules and titles and compensation. Since the partici-
pants were chosen on the basis of their interests in KSD
research described in the flyer, there was no particular
screening procedure and no cut-off point for anxiety
levels for the selection of participants for this study.
The participants’ mean age was 24.83 years ranging
from 18 to 46 years (SD = 9.41), and the ethnic represen-
tation in the study included nine Caucasians, six Asians,
two African Americans and one other. The participants
had moderate levels of trait anxiety (M = 44.61,
SD= 9.95) at baseline. There were no significant differ-
ences in age, gender and ethnicity as well as baseline
measures on trait anxiety, depressive symptoms and
self-efficacy in coping with stress between completers
(n = 18) and non-completers (n = 12). All treatment
group members attended five to eight out of the total

10 KSD sessions including at least one of the final week’s
sessions and completed the post-test on the day after the
last session.
Procedure
The plan of this research project was approved by
the university’s Institutional Review Board prior to
the start of the study. Prior to taking the pre-test, the
participants completed an informed consent form.
The participants were randomly assigned to either a
treatment group or a control group. Because of the
limited number of staff and facility, the researcher
provided the sessions to the treatment group first.
Thus, the sessions were provided to the control group
after the treatment group completed their sessions.
During the session, the primary researcher verbally
explained the concepts of mind–body exercise and the
mindfulness of the lower-abdomen breathing that
would bring the awareness of the present and gratitude.
The sessions used a translated English version of a KSD
compact disc, which contained instructions to guide
the participants through the KSD exercises with
Sons, Ltd.
J.-H. Kim, H. Yang and S. Schroeppel The Effects of Kouk Sun
Do on Mental Health
background nature sounds and meditation chanting.
The principal investigator and an assistant led each
session by demonstrating KSD meditation exercise
postures and teaching the exercises and basic concepts
of KSD. To allow time for participants to become famil-

iarized with the first level of KSD exercise, a total of 10
KSD sessions were implemented over a 4-week period
in addition to an introductory session held in the first
week. On the basis of the commonly held practice
standard, the KSD sessions took place three times per
week with each session lasting approximately 70 min.
Upon the completion of the sessions, the post-test
was given to both groups. Among the treatment group,
seven participants completed the pre-test and the post-
test, whereas 11 participants in the control group
completed the pre-test and the post-test. Twelve partici-
pants (n = 12; seven in the treatment group and five in
the waiting list control group) who participated in the
last session of KSD provided their opinions through
open-ended questions for qualitative data regarding the
effects of KSD. A $30 compensation was provided to
participants who completed the pre-test and the post-test
($10 for the pre-test and $20 for the post-test). In addi-
tion, a $10 incentive was awarded to participants who
attended more than eight out of the total 10 sessions,
and a KSD compact disc was provided to participants
who completed at least six out of the total 10 sessions.
Instrumentation
Qualitative data regarding how the participants have
experienced the entire KSD exercise over a 4-week period
were collected upon the completion of the last session
through open-ended questions to which the participants
wrote answers. They are as follows: (1) What did you like
about the KSD exercise the most?; (2) What did you like
the least about the KSD exercise?; (3) What do you think
about the benefits of the KSD exercise?; and (4) What is
your overall impression about the KSD exercise? There
were no follow-up questions.

To measure quantitative aspects of the effects of the
KSD exercise programme, three different instruments
were used. The questionnaires specifically measure the
levels of trait anxiety, depressive symptoms and self-
efficacy in coping with stress of the participants. The
administration of the questionnaires were conducted
approximately 1 week prior to the first session and
after the last session. Demographic information was
also collected at the time of the administration. The
instruments are described in more detail below.
Trait anxiety
Trait anxiety was measured using the State Trait
Anxiety Inventory (STAI), which assesses general feelings
of anxiety (e.g. ‘I worry too much over something that
really doesn’t matter’) (Spielberger, Gorsuch, & Lushene,
1970). The STAI consists of 20 items ranked on a four-
point Likert scale ranging from almost never (1) to almost
always (4). Higher scores indicate higher trait anxiety.
Sons, Ltd.
The measure has been shown to have high internal
consistency, estimated by a Cronbach’s alpha greater
than .90 in a variety of samples (Novy, Nelson, Goodwin,
& Rowzee, 1993) and high test–retest reliability (r = .86)
(Spielberger, Gorsuch, & Lushene, 1970). In the present
study, Cronbach’s alpha was .91, demonstrating high
internal consistency.
Depressive symptoms
The Beck Depression Inventory (BDI-II), which
measures the severity of depressive symptoms (e.g.
pessimism, punishment feelings and irritability), was

used to measure the level of depressive symptoms of
the participants. The instrument consists of 21 items
(Beck, Steer, Ball, & Ranieri, 1996), and each item is rated
on a four-point Likert scale ranging from 0, indicating
not at all, to 3, indicating severe. Higher scores indicate
higher depressive symptoms. The measure showed high
internal consistency and high test–retest reliability
(r = .93) (Beck, Steer, & Brown, 1996). The scale’s inter-
nal consistency in the present study was satisfactory, with
a Cronbach’s alpha of .85.
Self-efficacy
General self-efficacy, which refers to a broad and
stable sense of personal belief in one’s capability of
dealing effectively with a variety of stress and adaptation
after stressful life events (Luszczynska, Scholz, &
Schwarzer, 2005), was assessed by using the general
self-efficacy (GSE) scale (e.g. ‘I can always manage to
solve difficult problems if I try hard enough’). The scale
consists of 10 items on a four-point Likert scale anchored
by not at all true (1) and exactly true (4). Higher scores
indicate higher general self-efficacy. Previous research
showed adequate internal consistencies (a = .71–.91) in
numerous studies and acceptable test–retest reliabilities
over a 1-year period (r = .55–.75) (Scholz, Dona,
Sud, & Schwarzer, 2002). The scale yielded favourable
internal consistency with a Cronbach’s alpha of .83 in
the present study.
Data analysis
From the participants’ written answers in open-ended
questions, the qualitative data were analysed with
inductively emerging themes and categorization using
grounded theory, which utilizes open coding, axial

coding and selective coding (Corbin & Strauss, 2008).
Open coding involves breaking the data into small,
meaningful units; axial coding is comprised of compar-
ing and contrasting the initial codes in the open coding
to produce grouped categories; and selective coding sorts
and integrates categories (Glaser & Strauss, 1967).
These methods were conducted by two separate
researchers to avoid any possible researcher bias, also
referred to as triangulation. More specifically, two coders
individually analysed the qualitative data on responses to
the open-ended questions by reading each response until
101
becoming familiar with the content following the
grounded theory approach. Notes were taken to figure
out key points of responses in each of the four questions
among 12 participants (open coding). The concepts were
developed through the process of the collection of codes
of similar content that allowed the data to be grouped by
comparing similarities and differences of the initial codes
in each response to the four open-ended questions (axial
coding). The themes for Questions 1, 3 and 4 were drawn
from each response through the axial coding process and
were comprehensively integrated because of the fact that
those questions addressed the participants’ overall feeling
about the KSD session that they participated in.
Responses to Question 2 were discarded because of the
myriad of responses that did not allow for any concise
data categorization (Webster-Stratton & Spitzer, 1996).
Since the categories identified in the open and axial
coding processes were mere descriptions of the qualita-

tive responses, those various types of categories needed
to be integrated to develop a theoretical framework
(selective coding). That is, a central category (i.e. self-
induced relaxation in this study), around which all other
categories are based, was identified, and a theoretical
framework (i.e. a storyline) was generated as a restatement
that relates to the central category. These three steps of
the coding process were separately conducted by two
researchers, and the two researchers reached a consensus
on the central category.
A two (group) by two (time) repeated-measure
analysis of variance was used to examine both the inter-
action and the main effects of the KSD intervention.
Effect size f using power analysis was calculated for
the interaction terms. All alpha levels were set at .05,
and all data were analysed using SPSS 17.
Results
Qualitative data
From qualitative data analysis using open coding from
grounded theory (Corbin & Strauss, 2008; Webster-
Stratton & Spitzer, 1996), 10 interrelated themes were
drawn from the responses from 12 participants who
completed the last KSD session. The identified themes
are as follows: relaxation, mind and body rejuvenation,
mind clearing, calmness, focus, alleviation of stress
and anxiety, a learned breathing technique, use of the
relaxation technique on one’s own, breathing meditation
and a new alternative to yoga. Through axial coding, two
core themes, relaxation and usefulness of the relaxation
technique in daily life, were drawn.
Relaxation

Out of 12 participants, 11 explicitly mentioned that
they experienced relaxation effects as a result of having
participated in KSD. For instance, one participant
stated, ‘I liked all the stretching involved especially after
the breathing segment. It really helped me relax and
stretch my body and mind. I always felt relaxed and
102
energized after the session.’ It is probable that the
participants’ mind–body relaxation experiences have
contributed to the reduction of their anxiety level.
Usefulness of the relaxation technique in
daily life
After participating in KSD, seven out of 12 participants
clearly reported that the breathing/stretching techniques
from KSD were applicable to daily life. According to
one participant, ‘I feel like I’m able to focus my energy
better during the day using breathing techniques
learned in session.’ The relaxation technique seems to
have been useful to the participants in daily life when
dealing with stress.
Overall, the theoretical integration drawn from
the qualitative data was boiled down to self-induced
relaxation (Margolis, 1987). This refers to individually
controlled, individually induced relaxation that does
not require external apparatuses or trained clinicians
and aims to achieve calmness and psychological
confidence, thus conducive to handling potentially
stressful and anxiety-provoking situations.
Quantitative data
According to the ratio of the skewness to its standard

error of less than 2, all the measures at baseline
followed the distribution of normality. Also, there were
no mean differences on the study variables between
the two groups at baseline. Table I illustrates the mean
differences in trait anxiety, depressive symptoms and
general self-efficacy in relation to the response scales
between treatment and control groups at pre-test and
post-test along with the interaction between time
and group.
Trait anxiety decreased over a 4-week period
[F(1, 16) = 11.24, p < .01, �2p = .41]. There was a signifi-
cant interaction between time and group, which indi-
cates that trait anxiety levels differed significantly
depending on group membership [F(1, 16) = 7.86,
p < .05, �2p = .33, f = .70]. As shown in Figure 1, the treat-
ment group had a significant reduction in trait anxiety
compared with the control group.
There was a significant difference in depressive symp-
toms on the BDI-II within-subjects factors of the two
time points, [F(1, 16) = 11.45, p < .01, �2p = .42]. As
illustrated in Figure 2, the interaction between time and
group was significant, [F(1, 16) = 12.45, p < .01,
�2p = .44, f = .88], which indicates that depressive
symptoms decreased significantly in the treatment
group compared with those in the control group over a
4-week period.
There were significant main effects of time
[F(1, 16)=6.93, p< .05, �2p =.30] and group [F(1, 16) =
8.58, p = .01] in general self-efficacy. The interaction
between time and group was not significant [F(1, 16) =
3.92, p = .065, �2p = .20, f = .50]. These results were
illustrated in Figure 3.

Sons, Ltd.
Figure 1 Trait anxiety levels of treatment and control groups at
Time 1 and Time 2
Figure 2 Depression levels of treatment and control groups at
Time 1 and Time 2
Table I. Comparison of changes in measures on major variables
in relation to the response scales used from the pre-test to the
post-test for
the participants in the treatment and control groups
Variable
Treatment Control Interaction
Pre-test Post-test Pre-test Post-test Group (2) by time (2)
M SD M SD M SD M SD �2p f p
STAI 2.21 0.57 1.80 0.54 2.25 0.47 2.21 0.40 0.33 0.70 0.013
BDI-II 0.79 0.51 0.36 0.34 0.74 0.28 0.75 0.42 0.44 0.88 0.003
GSE 2.11 0.41 2.50 0.40 1.83 0.34 1.88 0.33 0.20 0.50 0.065
Note: The interaction between time (2) and group (2) on each
measure has been displayed with effect size and significance
value.
STAI, Trait Form of the State Trait Anxiety Inventory; BDI-II,
Beck Depression Inventory; GSE, General Self-Efficacy Scale;
M, mean; SD, standard

deviation; �2p, partial eta squared; f, effect size; p,
significance value.
Do on Mental Health
Overall, a significant interaction between time
and group as well as a significant main effect of
time was found in trait anxiety and depressive
Sons, Ltd.
symptoms. Also, significant main effects of time
and group were found in general self-efficacy in
coping with stress.
103
Figure 3 General self-efficacy levels of treatment and control
groups at Time 1 and Time 2
Discussion
The purpose of this study was to investigate the effects of
the KSD mind–body exercise on university students with
self-reported anxiety symptoms. Self-induced relaxation
effects were drawn from qualitative data using open-
ended questionnaires. From the main effects of time
and the interaction between time and group, it was found
that KSD exercise, performed three times each week over
a 4-week period, may be efficacious to reduce trait anxi-
ety and depressive symptoms among university students.
In addition, the KSD intervention resulted in a trend that
may indicate enhanced self-efficacy in coping with stress.

Although the correlation between trait anxiety on STAI
and depressive symptoms on BDI-II at pre-test and
post-test was very high (Pearson correlation r = .81 to
.87), it is consistent with the previous finding showing
that the measure of trait anxiety on STAI is highly corre-
lated with depressive symptoms on BDI (Beck, Brown,
Epstein, & Steer, 1988). Also, the high correlation may
infer that anxiety is often co-morbid with depressive
symptoms (Beck, Brown, Epstein, & Steer, 1988; Brown
& Barlow, 1992; Reiter, Otto, Pollack, & Rosenbaum,
1991). Since these measures were used as outcome vari-
ables in the study, the result of high correlation between
these variables would suggest that this study confirms the
result of the previous research, demonstrating the high
co-morbidity between anxiety and depression as well as
the similarity in the measures between STAI and BDI.
One possible mechanism by which KSD meditation
serves as a catalyst to reduce anxiety is that participants
may feel a heightened sense of control against perceived
stressors and tension in one’s mind and body through
relaxation (Benson et al., 2000; Tigunait, 2008). Core
themes, extracted from the qualitative data analysis
using a grounded theory approach, were as follows:
(a) relaxation and (b) usefulness of the relaxation
technique in daily life. The findings led to integrating
104
the recurring themes into a term, self-induced relaxa-
tion (Margolis, 1987). The self-induced relaxation
may have played a mediating role between KSD and a
reduction in anxiety. Mindfulness meditation, similar
to those in KSD, activates frontal brain areas, which
induces states of focused attention, associated with
relaxation (Davanger, Ellingsen, Holen, & Hugdahl,
2010; Leite et al., 2010; Stefano, Fricchione, & Esch,
2006; Wallace & Shapiro, 2006). Qigong, another form

of mindful exercise similar to KSD, mainly composed
of five elements (visualization, meditation, relaxation,
deep breathing and target ki circulation), contributes
to a reduction in anxiety and an improvement in posi-
tive mood through relaxation (Chow & Tsang, 2007;
Lee et al., 2001). Previous research has shown that an
applied relaxation intervention is as effective as cogni-
tive therapy in the treatment of cognitive and somatic
anxiety and worry as well as generalized anxiety and
fatigue (Arntz, 2003; Ost & Breitholtz, 2000; Pawlow,
O’Neil, & Malcolm, 2003). In addition, slow breathing
with prolonged respiratory expiration leads to a reduc-
tion in psychological and physiological arousal in an
anxiety-provoking situation (Cappo & Holmes, 1984).
Therefore, self-induced relaxation may have resulted
in enhancing a personal sense of control over anxiety
in the present study (Benson et al., 2000; Posadzki
et al., 2010). Further quantitative research through a
well-calibrated measure needs to be conducted to
confirm the possible mediator, self-induced relaxation
contributing to anxiety reduction.
A limitation of the present study is the small sample
size that may have resulted in a lack of statistical power
to detect a significant difference in anxiety between
groups. However, since there were large effect sizes for
the interaction term, these results seems to be promising
for future study, which would allow investigation of the
group differences using a larger sample size. Post-test
power analyses showed that the minimum required
Sons, Ltd.

Do on Mental Health
sample sizes to obtain a power of .8 are N = 40 for trait
anxiety on STAI. All the measures on STAI, BDI-II and
GSE for the repeated-measures analysis of variance
within–between interaction in the present study demon-
strated strong power (1� b error probabilities = .995
to 1, critical F = 4.49) according to post hoc computed
achieved power analysis. In addition, this study showed
test–retest internal consistencies below .7, ranging from
.63 to .65 for GSE and BDI-II, which is often considered
as the minimally acceptable reliability for these types of
measures. Also, since the measurement was conducted
to examine the immediate effect right after the
intervention, a follow-up study appears to be necessary
to investigate the long-term effects of KSD.
This study suffered from a high attrition rate. Out of
30 participants, 12 withdrew from the programme. More
specifically, nine subjects dropped out at baseline, and
three subjects withdrew during the intervention. Among
the 12 participants, six participants reported that they
had time conflicts, and one reported she disliked the
session. The reason for withdrawing from the study is
unknown for the remaining five participants. It is also
probable that the duration of each session (about
70min) and the frequency of the sessions per week (three
times per week) may have hindered the participants from
dedication to the programme. Although there were no
significant differences between completers and non-
completers in terms of demographic information, a
future study may need to further examine participants’
personal experiences or characteristics that may impact
participation in KSD.
Participants recruited in the study were limited to
university students with self-reported anxiety symptoms.

Thus, the results may not generalize to other popula-
tions. Replication of this study must be necessary to
assess the effects of KSD in patients with anxiety
disorders in clinical settings as well as in more diverse
populations in other settings such as people with chronic
disease and the elderly with physical limitations.
Mind and body dualism is the traditionally underlying
western philosophy that has influenced principles of
science including the field of medicine. As a conse-
quence, the notion that mind and body reciprocally
interact in the context of holistic treatment may have
Sons, Ltd.
been regarded as myth or unscientific (Mehta, 2011).
However, mind and body exercises recently have been
implemented in a variety of medical and psychiatric
settings globally as alternative therapies, taking psycho-
logical, social and environmental factors dealing with
illness and health into account to optimize treatment
effects (Pieri, 2008; Toneatto & Nguyen, 2007). This
holistic approach may serve as a complementary regimen
worldwide. The notion is also in alignment with the
World Health Organization (1946), which defined that
health is not merely absence of disease, but a state of
complete physical, mental and social well-being. Also,
many studies support the influence of mind–body unity
on physical and mental health in which psychological
stress reciprocally interacts with physical health (e.g.
Gadalla, 2009; Kosuri & Sridhar, 2009; Lin & Korff,
2008; Marucha, Kiecolt-Glaser, & Favagehi, 1998).
Therefore, despite these limitations, the findings of the
present study would shed light on the efficaciousness of
KSD in aiding young adults with anxiety symptoms.
Conclusion

This pilot study revealed that the KSD intervention, held
three times per week over a 4-week period, may have
contributed to enhancing relaxation and reducing trait
anxiety and depressive symptoms in university students
with anxiety symptoms. Also, self-efficacy in coping with
stress showed significant main effects of time and group.
Self-induced relaxation found in qualitative data may
have played a mediating role between KSD exercise and
alleviations of anxiety. Overall, the results of this
study illustrated the potential of KSD as an alternative
approach to enhance mental health of university
students. Although there is little research on the issue,
more research conducted in this area with randomized
controlled trials would be desirable and useful. This
research may contribute to the literature by demonstrat-
ing that KSD, a new way of mind and body exercise, may
reduce the level of anxiety symptoms through self-
induced relaxation. In addition, this research may be
meaningful in suggesting an alternative approach in
which human potential can develop as a self-healing
agent by using mind, body and breath.
REFERENCES
Armando, M., Dario, C., Righetti, V., Saba,
R., Cavaggioni, G., Lia, C., & Nastro, P. F. (2010). De-
pressive and anxiety symptoms in a community sam-
ple of young adults and correlation with help-seeking
behavior. Clinica Therapeutica, 161(2), E25–E32.
Arnett, J. J. (2000). Emerging adulthood: A theory of
development from the late teens through the

twenties. American Psychologist, 55(5), 469–480.
Arntz, A. (2003). Cognitive therapy versus applied
relaxation as treatment of generalized anxiety
disorder. Behaviour Research and Therapy, 41(6),
633–646. DOI: 10.1016/S005-7967(02)00045.1
Bayram, N., & Bilgel, N. (2008). The prevalence and
socio-demographic correlations of depression, anxiety,
and stress among a group of university students.
Social Psychiatry and Psychiatric Epidemiology, 43(8),
667–672. DOI: 10.1007/s00127-008-0345-x
Bear, R. A. (Ed.) (2010). Assessing mindfulness and
acceptance processes in clients. Oakland, CA:
New Harbinger.
Beck, A. T., Brown, G., Epstein, N., & Steer, R. A.
(1988). An inventory for measuring clinical anxiety:
Psychometric properties. Journal of Consulting and
Clinical Psychology, 56(6), 893–897.
Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. F.

(1996). Comparison of Beck Depression Inventories-
IA and-II in psychiatric outpatients. Journal of
Personality Assessment, 67(3), 588–597.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual
for the Beck Depression Inventory-II, San Antonio, TX:
Psychological Corporation.
Benson, H., Wilcher, M., Greenberg, B., Huggins,
E., Ennis, M., Zuttermeister, P. C., & Friedman, R.
(2000). Academic performance among middle school
students after exposure to a relaxation response
curriculum. Journal of Research and Development in
Education, 33(3), 156–165.
Bewick, B., Koutsopoulou, G., Miles, J., Slaa, E., &
Barkham, M. (2010). Changes in undergraduate
students’ psychological well-being as they progress
105
through university. Studies in Higher Education, 35(6),

633–645. DOI: 10.1080/03075070903216643
Brown, T. A., & Barlow, D. H. (1992). Comorbidity
among anxiety disorders: Implications for treatments
and DSM-IV. Journal of Consulting and Clinical
Psychology, 60(6), 835–844.
Brown, R. P., & Gerbarg, P. L. (2005). Sudarshan Kriya
yogic breathing in the treatment of stress, anxiety,
and depression: Part II—Clinical applications and
guidelines. Journal of Alternative and Complementary
Medicine, 11(4), 711–717.
Brown, R. P., & Gerbarg, P. L. (2009). Yoga breathing,
meditation, and longevity. Annals of the New York
Academy of Science, 1172, 54–62. DOI: 10.1111/
j,1749-6632.2009.04394.x
Cappo, B. M., & Holmes, D. S. (1984). The utility of
prolonged respiratory exhalation for reducing
physiological and psychological arousal in non-
threatening and threatening situations. Journal of

Psychosomatic Research, 28(4), 265–273. DOI:
10.1016/0022.3999(84)90048-5
Catabia, R. (2007). Gut feelings: Daoist lower
dan-tien psychotherapy. The Empty Vessel. Retrieved
from http://www.sundo.org/media/EmptyVessel_
GutFeelings.pdf
Chang, V. Y., Palesh, O., Caldwell, R., Glasgow, N.,
Abramson, M., Luskin, F., . . . Koopman, C. (2004).
The effects of a mindfulness-based stress reduction
program on stress, mindfulness self-efficacy, and posi-
tive states of mind. Stress and Health, 20, 141–147.
DOI: 10.1002/smi.1011
Chow, Y. W. Y., & Tsang, H. W. H. (2007).
Biopsychosocial effects of qigong as a mindful
exercise for people with anxiety disorders: A
speculative review. Journal of Alternative and
Complementary Medicine, 13(8), 831–839. DOI:
10.1089/acm.2007.7166

Corbin, J., & Strauss, A. (2008). Basics of qualitative
research: Techniques and procedures for developing
grounded theory (3rd ed.). Thousand Oaks,
CA: Sage.
Davanger, S., Ellingsen, O., Holen, A., & Hugdahl,
K. (2010). Meditation-specific prefrontal cortical
activation during Acem meditation: An fMRI study.
Perceptual and Motor Skills, 111(1), 291–306.
Eisenberg, D., Golberstein, E., & Gollust, S. E. (2007).
Help-seeking and access to mental health care in a
university student population. Medical Care, 45(7),
594–601. DOI: 10.1097/MLR.obo13e31803bb4c1
Gadalla, T. M. (2009). Determinants, correlates and
mediators of psychological distress: A longitudinal
study. Social Science & Medicine, 68(12), 2199–2205.
DOI: 10.1016/j.socscimed.2009.03.040
Glaser, B. G., & Strauss, A. L. (1967). The discovery of
grounded theory: Strategies from qualitative research.

Retrieved from http://faculty.babson.edu/krollag/
org_site/craft_articles/glaser_strauss.html
Goldin, P. R., & Gross, J. J. (2010). Effects of mindfulness-
based stress reduction (MBSR) on emotion regulation
in social anxiety disorder. Emotion, 10(1), 83–91. DOI:
10.1037.a0018441
Griffith, J. M., Hasley, J. P., Liu, H., Severn, D. G.,
Conner, L. H., & Adler, L. E. (2008). Qigong stress
reduction in hospital staff. Journal of Alternative and
106
Complementary Medicine, 14(8), 939–944. DOI:
10.1089/acm.2007.0814
Gross, C. R., Kreitzer, M. J., Russas, V., Treesak, C., Frazier,
P. A., & Hertz, M. I. (2004). Mindfulness meditation
to reduce symptoms after organ transplant: A pilot
study. Alternative Therapies in Health and Medicine,
10(2), 58–66.
Hettema, J. M., Neale, M. C., & Kendler, K. S. (2001). A
review and meta-analysis of the genetic epidemiology

of anxiety disorders. The American Journal of Psychiatry,
158(10), 1568–1578.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., &
Walters, E. E. (2005). Lifetime prevalence and age of
onset distributions of DSM-IV disorders in the
national comorbidity survey replication. Archives of
General Psychiatry, 62(6), 593–602.
Kosuri, M., & Sridhar, G. R. (2009). Yoga practice in
diabetes improves physical and psychological outcomes.
Metabolic Syndrome and Related Disorders, 7(6),
515–518. DOI: 10.1089/met.2009.0011
Kouk Sun Do. (2008). In Kouk Sun Do: The art of
breathing. Retrieved from http://www.sundousa.org/
Lazar, S. W. (2005). Mindfulness research. In Christopher,
K., Germer, R. D., & Fulton, P. R. (Eds.), Mindfulness
and psychology (pp. 221–238). New York, NY:
Guilford Press.
Lee, M. S., Huh, H. J., Hong, S. S., Jang, H. S., Ryu, H.,

Lee, H. S., & Chung, H. T. (2001). Psychoneuroim-
munological effects of qi-therapy: Preliminary
study on the changes of level of anxiety, mood,
cortisol and melatonin and cellular function of
neutrophil and natural killer cells. Stress and Health,
17, 17–24.
Lee, M. S., Kang, C. W., Lim, H. J., & Lee, M. S.
(2004). Effects of qi-training on anxiety and
plasma concentrations of cortisol, ACTH, and
aldosterone: A randomized placebo-controlled pilot
study. Stress and Health, 20, 243–248. DOI:
10.1002/smi.1023
Leite, J. R., Ornellas, F. L. D. M., Amemiya, T. M.,
Almeida, A. A. D., Dias, A. A., Afonso, R., &
Kozasa, E. H. (2010). Effect of progressive self-focus
meditation on attention, anxiety, and depression
scores. Perception and Motor Skills, 110(3), 840–848.
DOI: 10.2466/PMS.110.3.840-848

Lim Y. M., & Hong, G. R. S. (2010). Effect of
16 week Kouk-Sun-Do exercise on physical
fitness, emotional state, and immunoglobulin A in
community-dwelling elders in Korea. Applied
Nursing Research, 23, 91–100. DOI: 10.1016/j.
apnr.2008.05.004
Lin, E. H. B., & Korff, M. V., on behalf of the WHO
WMH survey consortium (2008). Mental disorders
among persons with diabetes—Results from the
world mental health surveys. Journal of Psychosomatic
Research, 65, 571–580.
Luszczynska, A., Scholz, U., & Schwarzer, R. (2005).
The general self-efficacy scale: Multicultural
validation studies. The Journal of Psychology, 139(5),
439–457.
Margolis, H. (1987). Self-induced relaxation: A practical
strategy to improve self-concepts, reduce anxiety,
and prevent behavioral problems. The Clearing

House, 60(8), 355–358.
Stress and Health 29
Marucha, P. T., Kiecolt-Glaser, J. K., & Favagehi, M.
(1998). Mucosal wound healing is impaired
by examination stress. Psychometric Medicine,
60, 362–365.
Mehta, N. (2011). Mind–body dualism: A
critique from a health perspective. Mens Sana
Monographs, 9(1), 202–209. DOI: 10.4103/0973-
1229.77436
Mendlowicz, M. V., & Stein, M. B. (2000). Quality of
life in individuals with anxiety disorders. The
American Journal of Psychiatry, 157, 669–682.
Miller, J. J., Fletcher, K., & Kabat-Zinn, J. (1995).
Three-year follow-up and clinical implications of a
mindfulness meditation-based stress reduction
intervention in the treatment of anxiety disorders.
General Hospital Psychiatry, 17(3), 192–200.
Novy, D. M., Nelson, D. V., Goodwin, J., & Rowzee,

R. D. (1993). Psychometric comparability of the
State-Trait Anxiety Inventory for different ethnic
subpopulations. Psychological Assessment, 5(3),
343–349.
Ost, L. G., & Breitholtz, E. (2000). Applied relaxation vs.
cognitive therapy in the treatment of generalized
anxiety disorder. Behaviour Research and Therapy,
38, 777–790.
Pawlow, L. A., O’Neil, P. M., & Malcolm, R. J. (2003).
International Journal of Obesity, 27, 970–978.
Pieri, M. (2008). Mind–body dualism/unity in medicine
[Web log post]. Retrieved from http://serendip.
brynmawr.edu/exchange/node/2345
Posadzki, P., Parekh, S., & Glass, N. (2010). Yoga and
qigong in the psychological prevention of mental
health disorders: A conceptual synthesis. Chinese
Journal of Integrative Medicine, 16(1), 80–86. DOI:
10.1007/s11655-009-9002-2

Reiter, S. R., Otto, M. W., Pollack, M. H., &
Rosenbaum, J. F. (1991). Major depression in panic
disorder patients with comorbid social phobia.
Journal of Affective Disorders, 22(3), 171–177.
Rowa, K., & Antony, M. M. (2005). Psychological
treatments for social phobia. Canadian Journal of
Psychiatry, 50(6), 308–316.
Roy-Byrne, P., Veitengruber, J. P., Bystritsky, A.,
Edlund, M. J., Sullivan, G., Craske, M. G., ... Stein, M. B.
(2009). Brief intervention for anxiety in primary care
patients. Journal of the American Board of Family
Medicine, 22, 175–186. DOI: 10.3122/jabfm.2009.02.
080078
Scholz, U., Dona, B. G., Sud, S., & Schwarzer, R. (2002).
Is general self-efficacy a universal construct?
Psychometric findings from 25 countries. European
Journal of Psychological Assessment, 18(3), 242–251.
DOI: 10.1027/1015-5797.18.3.242

Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E.
(1970). Manual for the State-Trait Anxiety
Inventory. Palo Alto, CA: Consulting Psychology
Press.
Stallman, H. M. (2010). Psychological distress in
university students: A comparison with general
population data. Australian Psychologist, 45(4), 249–257.
DOI: 10.1080/00050067.2010.482109
Stefano, G. B., Fricchione, G. L., & Esch, T. (2006).
Relaxation: Molecular and physiological significance.
Medical Science Monitor, 12(9), HY21–HY31.
: 99–107 (2013) © 2012 John Wiley & Sons, Ltd.
http://faculty.babson.edu/krollag/org_site/craft_articles/glaser_s
trauss.html
http://faculty.babson.edu/krollag/org_site/craft_articles/glaser_s
trauss.html
http://serendip.brynmawr.edu/exchange/node/2345
http://serendip.brynmawr.edu/exchange/node/2345
Do on Mental Health
Tigunait, P. R. (2008). The journey inward a master’s
guide to relaxation. Yoga+ Joyful Living, 102, 46–51.

Toneatto, T., & Nguyen, L. (2007). Does mindfulness
meditation improve anxiety and mood symptoms?
A review of the controlled research. Canadian Journal
of Psychiatry, 52(4), 260–266.
Stress and Health 29: 99–107 (2013) © 2012 John W
Wallace, B. A., & Shapiro, S. L. (2006). Mental balance
and well-being: Building bridges between Buddhism
and Western psychology. American Psychologist,
61(7), 691–701. DOI: 10.1037/0003-066X.61.7.690
Webster-Stratton, C. W., & Spitzer, A. (1996). Parenting
a young child with conduct problems: New insights
iley & Sons, Ltd.
using qualitative methods. In T. H. Ollendick, &
R. S. Prinz (Eds.), Advances in clinical child psychology,
18, 1–62.
World Health Organization (1946). Constitution of the
World Health Organization. American Journal of
Public Health, 36, 1315–1323.
107

lable at ScienceDirect
Psychology of Sport and Exercise 20 (2015) 67e75
Contents lists avai
Psychology of Sport and Exercise
journal homepage: www.elsevier.com/locate/psychsport
Reduced emotional stress reactivity to a real-life academic
examination stressor in students participating in a 20-week
aerobic
exercise training: A randomised controlled trial using
Ambulatory
Assessment
Birte von Haaren a, *, Sascha Haertel a, Juergen Stumpp b,
Stefan Hey b,
Ulrich Ebner-Priemer a
a Institute of Sport and Sport Science, Karlsruhe Institute of
Technology, Engler-Bunte-Ring 15, 76131 Karlsruhe, Germany
b Institute for Information Processing Technologies, Karlsruhe
Institute of Technology, Engesserstrasse 5, 76131 Karlsruhe,
Germany
a r t i c l e i n f o
Article history:
Received 11 October 2014
Received in revised form
10 April 2015
Accepted 10 April 2015
Available online 21 April 2015
Keywords:
Aerobic exercise
Ambulatory Assessment

Stress reactivity
Real life
Electronic diary
Randomised controlled trial
* Corresponding author. Tel.: þ49 721 608 45724.
E-mail addresses: [email protected] (B. von Ha
(S. Haertel), [email protected] (J. Stumpp),
[email protected] (U. Ebner-Priemer).
http://dx.doi.org/10.1016/j.psychsport.2015.04.004
1469-0292/© 2015 Elsevier Ltd. All rights reserved.
a b s t r a c t
Objectives: To examine if a preventive 20-week aerobic
exercise intervention (AET) can improve
emotional stress reactivity during real-life stress.
Design: Randomised controlled trial; within-subject design.
Method: Sixty-one inactive students were randomly assigned to
a waiting control and an AET group. To
capture the situation-specific, intra-individual data in real life,
electronic diaries were used. Participants
reported their moods and perceived stress (PS) repeatedly over
two days during their daily routines pre-
and post-intervention. The pre-intervention baseline assessment
was scheduled at the beginning of the
semester, and the post-intervention assessment was scheduled at
a real-life stressful episode, an aca-
demic examination. For the aerobic fitness assessment, both
groups completed a cardiopulmonary ex-
ercise test on the treadmill before and after the intervention.
Multilevel models (MLMs) were conducted
to compare within- and between-subject associations.
Results: Significant emotional stress reactivity was evident in
both groups during all assessment periods.
However, participants in the AET group showed lower

emotional stress reactivity compared with their
control counterparts after the 20-week training programme
during the real-life stress episode (the ac-
ademic examination).
Conclusions: AET conferred beneficial effects on emotional
stress reactivity during an academic exami-
nation, which is likely an extremely stressful real-life situation
for students.
AET appears to be a promising strategy against the negative
health effects of accumulated emotional
stress reactivity.
© 2015 Elsevier Ltd. All rights reserved.
Introduction
Research in psychology has found that reactivity to daily life
stress is not only determined by a physiological response but
also
can be defined as a covariation of stress and affect (Sliwinski,
Almeida, Smyth, & Stawski, 2009). Perceived daily life
stressors,
such as excessive demands at work, have an immediate effect on
aren), [email protected][email protected] (S. Hey),
physical and emotional functioning (Van Eck, Nicolson, &
Berkhof,
1998; Zautra, Affleck, Tennen, Reich, & Davis, 2005). For
example,
the risk of depression and cardiovascular disease increases
through
the accumulated effects of daily stress (Cacioppo et al.,1998;
Carels,
Blumenthal, & Sherwood, 2000; Van Eck, Berkhof, Nicolson, &
Sulon, 1996). Enhanced emotional reactivity to real-life stress
re-
flected by Negative Affect (NA) predicts physiological
(Salovey,

Rothman, Detweiler, & Steward, 2000; Van Eck et al., 1996,
1998)
diseases and higher vulnerability to psychotic disorders (Collip
et al., 2013; Myin-Germeys, van Os, Schwartz, Stone, &
Delespaul,
2001). Patients with psychosis showed increased emotional
sensi-
tivity to smaller disturbances in daily life (Myin-Germeys,
Krabbendam, Delespaul, & van Os, 2003). In addition, the
Delta:1_given name
Delta:1_surname
Delta:1_given name
Delta:1_surname
Delta:1_given name
mailto:[email protected]
http://crossmark.crossref.org/dialog/?doi=10.1016/j.psychsport.
2015.04.004&domain=pdf
www.sciencedirect.com/science/journal/14690292
http://www.elsevier.com/locate/psychsport
B. von Haaren et al. / Psychology of Sport and Exercise 20
(2015) 67e7568
emotional component of stress reactivity plays an important role
in
future stress appraisals (Lazarus & Folkman, 1984).
Physical activity and exercise offer the potential to reduce the

risk of stress-induced mental and physical diseases (Warburton,
Katzmarzyk, Rhodes, & Shephard, 2007). Until now, the
existing
link between the health-enhancing effects of physical exercise
and
the phenomenon of stress has been mostly explained by the so-
called ‘stress-buffer hypothesis’ (Gerber & Pühse, 2009; Hamer,
2012; Sothmann, 2006; Tsatsoulis & Fountoulakis, 2006), which
is
based on the assumption that the positive health effects of
physical
activity and fitness serve as a moderator in the relationship be-
tween stress and health. In terms of stress reactivity,
researchers
have mainly examined the physiological parameters (heart rate
variability, heart rate, cortisol) of fit versus unfit individuals at
baseline and during mental stress tasks in laboratories (De Geus
&
Stubbe, 2007; Forcier et al., 2006; Gerber, 2008; Jackson &
Dishman, 2006; Sothmann, Hart, & Horn, 1991). Because
psychol-
ogy research indicates that emotional and physiological stress
reactivity may differ (Campbell & Ehlert, 2012), it is also
important
to assess emotional stress reactivity. However, existing research
that considers the association between exercise and emotional
stress reactivity has a number of limitations.
First, most studies have used laboratory-induced stress tasks,
and the results of both cross-sectional studies (Klaperski, von
Dawans, Heinrichs, & Fuchs, 2013; Rimmele et al., 2007, 2009)
and randomised controlled trials are inconsistent (Anshel, 1996;
Calvo, Szabo, & Capafons, 1996; Goldin, Ziv, Jazaieri, Hahn, &
Gross, 2013; Julian, Beard, Schmidt, Powers, & Smits, 2012;
Throne, Bartholomew, Craig, & Farrar, 2000; Zanstra &
Johnston,

2011). In a recent cross-sectional study that used the Trier
Social
Stress Tests (TSST), a laboratory stress test that is more related
to
naturalistic stressors, Klaperski et al. (2013) found greater de-
creases in mood in young women who exercised compared with
women who did not exercise in response to the TSST. Using a
similar study protocol, Rimmele et al. (2009) reported
contradic-
tory findings, namely, higher anxiety and lower mood levels in
untrained compared with trained men. Puterman et al. (2011)
found that activity levels moderated the relationship between
rumination and cortisol levels in response to acute stressors,
sug-
gesting that active people may be protected against stress-
induced
rumination. Although laboratory studies deliver important
insights
under controlled conditions, they often do not result in the same
outcomes as those from naturalistic settings (Gauvin, Rejeski, &
Norris, 1996; Wilhelm, Grossman, & Müller, 2012).
Second, previous randomised controlled trials used single
retrospective pre/post self-report measures of NA and global
measures of PS (Baghurst & Kelley, 2014; De Geus, van
Doornen, &
Orlebeke, 1993; Norris, Carroll, & Cochrane, 1992). However,
psy-
chological variables such as stress and affect are fluctuating
con-
structs that change over the course of time (Stone, Smyth,
Pickering, & Schwartz, 1996). Moreover, the patterns of
responses
to daily stressors may vary (Bolger & Schilling, 1991). Thus,
repeated real-time assessments of PS and affective states during
different situations across contexts represent the dynamic nature

of
the subjective stress experience more accurately than single pre/
post assessments (Lazarus, 2000; Poole et al., 2011; Schlotz et
al.,
2008).
Finally, the few conducted field studies are cross-sectional and
focus on the associations between acute exercise and emotional
stress reactivity in daily life (Giacobbi, Hausenblas, & Frye,
2005;
Giacobbi, Tuccitto, & Frye, 2007; Steptoe, Kimbell, & Basford,
1998). For example, Giacobbi et al. (2007) asked university stu-
dents about their daily exercise, conducted threat appraisals in
response to stressful events and assessed positive/negative
affect
via an internet platform during an examination period. During
the
most stressful days, exercise was significantly related to
increased
positive affect (PA). In addition, exercise led to decreased NA
when
events were appraised as being threatening; however, NA
increased
with accompanied exercise when events were appraised at
higher
threat levels. In another study, Giacobbi et al. (2005) showed
that
exercise and daily life events were both independently
associated
with PA. Increased levels of exercise led to increases in PA on
days
with more positive and more negative events. Steptoe et al.
(1998)
found fewer perceived stressful events on exercise days
compared
with non-exercise days among regular exercisers with low trait

anxiety and higher PA on exercise days compared with non-
exercise days. Another daily life study showed that walking
time
during the evening was inversely correlated with perceived
stress
(PS) ratings before going to sleep, and walking time during the
afternoon was inversely correlated with negatively evaluated
high
activation during the evening (Hallman & Lyskov, 2012). None
of
the studies addressed the effects of regular exercise on
emotional
stress reactivity during real life.
To date, there has been a need for inexpensive strategies that
are
easy to use and effective at preventing the development of
mental
disorders, such as depression. The potential of exercise as a
strategy
to reduce the negative effects of repeated enhanced emotional
reactivity to real-life stress is still unclear. To overcome the
short-
comings of previous studies, we conducted a randomised
controlled trial using Ambulatory Assessment. The term
“Ambula-
tory Assessment” encompasses a wide range of methods used to
study people in their natural environments, including
momentary
self-reports, ecological momentary assessments, and
observational
and physiological methods (Trull & Ebner-Priemer, 2013).
To investigate if a preventive 20-week aerobic exercise inter-
vention could lower emotional stress reactivity during real life,
we

compared the emotional stress reactivity of students who were
participating in aerobic exercise training with a control group
(CG)
pre- and post-intervention. To maximise within-subject
differences
in stress reactivity and to demonstrate the treatment effect, we
chose the following two real-life assessment periods: We set the
pre-intervention baseline assessment to the beginning of the se-
mester because we assumed that students had low stress at this
time. The post-intervention assessment was set to the end of the
semester (the examination period) and was used as the real-life
stressful episode given that academic examinations are a real-
life
demand that induces noticeable stress in students (Hazlett,
Falkin, Lawhorn, Friedman, & Haynes, 1997; Nguyen-Michel,
Unger, Hamilton, & Spruijt-Metz, 2006).
Methods
Participants
Sixty-one inactive (� 1� moderately active for 60 min/week)
male electrical engineering students (Mage ¼ 21.4, SD ¼ 1.6)
were
recruited during the semester's first week of lectures. The
sample
came from two phases (each with 30 participants) that lasted for
one winter semester (October 2011 to March 2012 and October
2012 to March 2013). After the study, participants attended a
lec-
ture on the potential of exercise to reduce stress. We addressed
only
subjects in their 3rd or 5th semesters of university studies
because
they sat for similar exams. Thus, we achieved similar conditions
during academic examinations for all participants. To recruit

par-
ticipants, we informed the students about the study during
lectures
in the first week of the semester. Interested students signed up
to
be contacted via email to receive an invitation to the study kick-
off
meeting. Every student received information about the study,
and
eligible participants who wanted to participate gave written
informed consent. Students did not receive financial
compensation,
(2015) 67e75 69
but they did receive credits in their courses if they completed
all
measurements and attended the lecture and the intervention
(experimental group).
Measures
The present study was conducted using Ambulatory Assess-
ment, which is the method used for repeated sampling of sub-
jective psychological variables in real time and in the natural
environment (Trull & Ebner-Priemer, 2013). All psychological
variables were assessed via electronic diaries, which were kept
in
the Touch Diamond 2 (HTC Germany GmbH, Frankfurt,
Germany).
Using the software MyExperience movisens Edition (movisens
GmbH, Karlsruhe, Germany), mood and stress scales were
installed on the diaries, and time stamps and intervals between
diary prompts were programmed. Participants answered the

questions presented on the diary screens by choosing the appro-
priate number on the presented scales using the integrated diary
touch pen.
Perceived stress
To account for work-related strains during the academic ex-
aminations, acute PS was operationalised via one item that
assessed perceived control, following earlier studies
(Fahrenberg,
Brügner, Foerster, & K€appler, 1999; Rau, 2004; Rau,
Georgiades,
Fredrikson, Lemne, & de Faire, 2001). Participants answered
the
question ‘Is the present situation under your control?’ on a 7-
point
Likert scale (1 ¼ not at all to 7 ¼ absolutely).
Mood
To assess the current mood state, we applied a short six-item
scale based on the Multidimensional Mood Questionnaire
(MDMQ;
Steyer, Schwenkmezger, & Eid, 1997) that is validated
especially for
Ambulatory Assessment (Wilhelm & Schoebi, 2007). The scale
measures three basic mood dimensions, valence (V: content-
discontent; unwell-well), calmness (C: agitated-calm; relaxed-
tense)
and energetic arousal (E: tired-awake; full of energy-without
energy),
with two items. Wilhelm and Schoebi (2007) reported within-
person (V, C ¼ 0.70; E ¼ 0.77) and between-person (V ¼ 0.92;
C,
E ¼ 0.90) reliability levels. Participants had to rate their current
moods based on the statement ‘At the moment I feel … ’ on a 7-

point
scale (0 ¼ not at all to 6 ¼ very) with opposing adjectives as
end-
points. To ensure that higher scores indicated higher values for
V, E,
and C, we recoded the three negatively pooled items into
positive
ones prior to analysis.
Aerobic capacity
Maximum oxygen consumption (VO2max) is the central
parameter for determining aerobic capacity. To be able to detect
the effects of exercise on emotional stress reactivity, an
effective
intervention reflected by significantly enhanced VO2max was
required. Thus, as a manipulation check to assess aerobic
capacity,
VO2max was determined through cardiopulmonary exercise
testing (MetaMax 3B, cortex-biophysik) on a treadmill until
exhaustion, with an initial pace of 6 km/h, a continuous slope of
1% and an increase of 2 km/h per stage every 3 min (Dickhut,
Mayer, R€ocker, & Berg, 2007). Heart rate was recorded
continu-
ously using POLAR heart rate monitors (RS800). Within a
stand-
ardised interruption of 20 s between stages, an arterial blood
sample was taken from the participants' hyperaemic earlobe into
a 20 ml end-to-end capillary to analyse blood lactate. At the end
of
each stage, participants rated their perceived exertion scores
(RPE) on the Borg Scale from 6 to 20 (Borg, 1982). All
participants
achieved a respiratory exchange ratio (RER) of � 1.1 and a
heart
rate of at least 220 beats minus age (Meyer & Kindermann,

1999),
and all were appraised as exhausted by an experienced
instructor.
Thus, for all participants, the achievement of VO2max was
assumed. The RER reflects the ratio between the amount of
carbon
dioxide produced (VCO2) and the oxygen consumed (VO2)
during
one breath.
Procedure
At the beginning of the study, participants were randomised
to a control and an aerobic exercise training (AET) group, strat-
ified by their habitual physical activity levels, which were
assessed via questionnaire (Jekauc, Wagner, Kahlert, & Woll,
2013). This study used a wait-list control group; thus, partici-
pants who were randomised to the CG received AET after the
end
of the study. We conducted the cardiopulmonary exercise
pretest
(CETpre) during the first two weeks of the study (start of the
semester) prior to the AET group intervention. After the
completion of the pretests (November 1st), the AET for the
experimental group began. After 3.5 months of AET (see Fig.
1),
we conducted the cardiopulmonary exercise post-test (CETpost)
with exactly the same procedure as the pretests. Participants
completed the post-tests prior to the exam period to avoid any
influence on their performance.
Emotional stress reactivity was assessed pre- and post-
intervention for two days each. To maximise within-subject dif-
ferences in stress reactivity and to demonstrate the treatment
effect, we chose the following two real-life assessment periods:
We set the pre-intervention baseline assessment to the

beginning
of the semester because we assumed that students had low stress
at this time. The post-intervention assessment was set to the end
of the semester (the examination period) and was used as the
real-life stressful episode given that academic examinations are
a
real-life demand that induces noticeable stress in students
(Hazlett et al., 1997; Nguyen-Michel et al., 2006). To increase
representativeness, we conducted measurements twice during
the academic examination period. The time span between the
exam and the end of data recording was restricted to at least one
and a maximum of two days. Participants chose their first mea-
surement episode (post1) during the first weeks of the exams
(weeks 2/3), and the second episode (post2) took place during
the
middle of the exams.
Participants initialised the first diary prompt of the day when
they turned on the diary after awakening. Except for the
morning
prompt, all diary prompts were initialised automatically by a
vibrating signal every 2 h with a varying incidence of the signal
of
one to 5 min to prevent participants from waiting for the signal.
Thus, all diary prompts occurred between 10 a.m. and 10 p.m. If
participants missed a signal, reminders were sent after 5, 10,
and
15 min. If participants did not answer the last reminder, the
prompt
was recorded as missing, and the next signal occurred with the
next
prompt approximately 2 h later.
Intervention
Participants in the experimental group attended a 20-week

aerobic running training course. The intervention lasted until
par-
ticipants passed both measurement times during the academic
exams. In addition to VO2max, the main outcomes of the
cardio-
pulmonary exercise test were maximum running speed, lactate
threshold and individual anaerobic threshold. Based on these,
we
calculated individual heart rate zones for each participant (zone
I:
aerobic; zone II: aerobic-anaerobic) using the software
Ergonizer®
Fig. 1. Illustration of the study design: timeline with pre- and
post-assessments of emotional stress reactivity,
cardiopulmonary exercise testing (CETpre and post) and the
duration
of the exercise intervention.
Table 1
Means and standard deviations of person characteristics and
results of the cardio-
pulmonary exercise test.
Variable Pre Post
AET CG AET CG
M (SD) M (SD)
Age 21.3 (1.5) 21.5 (1.7)
BMI 23.8 (3.5) 24.6 (4.9)
VO2maxrel (ml/kg/min) 48.5 (6.5) 49.9 (6.7) 52.8 (6.4) 47.1
(7.3)

RER 1.14 (0.1) 1.14 (0.1) 1.2 (0.1) 1.21 (0.1)
HRmax (beats/min) 199.8 (7.8) 201.8 (8.8) 197.7 (8.1) 199.8
(7.9)
Note. CG ¼ control group; AET ¼ Aerobic exercise training
group; BMI ¼ body mass
index; CET ¼ cardiopulmonary exercise testing; VO2maxrel ¼
maximal oxygen
consumption in ml per kilogram bodyweight per minute; RER ¼
respiratory ex-
change ratio; HRmax ¼ maximum heart rate.
(2015) 67e7570
(Sports medicine, Freiburg, K. R€ocker) and installed the
training
schedules and the heart rate target zones on the RS800 heart
rate
monitors. Skilled exercise science students supervised and
instructed the running groups of 7e8 people using the stand-
ardised training schedule. Participants completed the training in
a
group and wore the heart rate monitors to record their training
and
meet their individual heart rate requirements. To allow for indi-
vidual but group-based running sessions, the training sessions
took
place outdoors in an area close to the campus with fixed trails.
Training sessions took place during lunch time to allow for
short
routes and little time loss. Students had to complete two
training
sessions every week. At the beginning, running sessions lasted
approximately 30 min and included walking phases of 2 min.
Separate from the continuous increase in training duration (3
min/

week) over time, intensity was progressively increased by
adding
intervals of 3 and 4 min in zone II after week four. Compliance
with
the intervention was very good in every training group, with no
dropouts during the intervention.
Data analysis
To determine whether the aerobic exercise intervention had
successfully improved the AET group's aerobic capacity, we
con-
ducted an analysis of covariance (ANCOVA) with VO2maxrel
after
the intervention as the dependent variable (CETpost),
VO2maxrel
prior to the intervention as the covariate (CETpre) and group
(CG/
AET) as the treatment factor.
Our repeated assessments of psychological variables during the
baseline (pre) and during the exam period (post1 and post2)
resulted in data of a hierarchical structure with multiple
observa-
tions of NA and PS (level 1) nested within persons (level 2). We
applied Multilevel models (MLMs) to differentiate between
within-
subject and between-subject effects and their interactions. In
addition, MLMs allow for a different number of observations
be-
tween participants and provide model estimates even for in-
dividuals with missing data (Hoffman & Rovine, 2007). We
used
IBM SPSS Statistics 20 for Windows to estimate the effects of
the
independent variables (PS, group and interaction of PS and

group)
on the dependent variable NA. We ran MLMs for the baseline
(pre)
and both examination periods (post1 and post2).
To obtain the NA variable, we recoded the valence dimension
(V)
as follows: (0 ¼ 4; 0.5 ¼ 3.5; 1 ¼ 3; 1.5 ¼ 2.5; 2 ¼ 2; 2.5 ¼
1.5; 3 ¼ 1;
3.5 ¼ 0; 4 ¼ 0; 4.5 ¼ 0; 5 ¼ 0; 5.5 ¼ 0; 6 ¼ 0). Prior to
additional
analyses, PS was reverse coded to better illustrate NA; thus,
higher
values indicated higher PS. To account for individual
differences in
mean stress, PS was person-mean centred by subtracting the
mean
PS value across all observations per person from each
observation
of the person. Group was coded as a dummy variable as either
0 (CG) or 1 (AET group). The following equation displays the
integrated form as well as the level 1 and level 2 components of
our
model separately:
NAti ¼ Y00 þ Y10$WithinPersonperceived stress þ Y01$Group
þ u0i
þ Y11$Group$WithinPersonperceived stress þ 3ti
Level 1 : Yti ¼ b0i þ b1i$WithinPersonperceived stress þ 3ti
Level 2 : b0i ¼ Y00 þ Y01$Group þ u0i
b1i ¼ Y10 þ Y11$Group
Level 1 represents the participants' responses (subscript i) as re-

ported on the NA scale (Yti) in any given diary entry (subscript
t). Yti
is a function of the individual intercept b0i, person i's average
level
of PS, b1i, which is the effect of the within-person PS, meaning
the
increase in NA with every increase of PS, and 3ti is the residual
NA in
a situation t for a person i. Finally, b0i displays the effect of the
group
(level 2) on NA, and b1i is the effect of the cross-level
interaction
between group (level 2) and PS (level 1) on NA, that is, the
effect of
group on the extent of change in NA caused by the change in
PS.
Results
Sample characteristics
We excluded two participants from the analysis because they
did not complete all three assessments (pre, post1 and post2).
Participants in the AET and control groups did not differ in
person
characteristics or cardiopulmonary exercise testing parameters
prior to the intervention (Table 1). Aerobic capacity,
operationalised
Table 3
Means, standard deviations, and minimums and maximums of
the psychological
variables at each measurement time.
Variable AET CG

M (SD) Min Max M (SD) Min Max
Pre
PS 2.06 (0.66) 1.40 3.40 2.20 (0.82) 1.34 4.00
NA 0.23 (0.42) 0.00 1.30 0.26 (0.49) 0.0 1.50
E 3.81 (1.04) 1.95 5.30 3.60 (1.13) 1.48 5.16
V 4.36 (0.82) 2.70 5.41 4.35 (0.91) 2.48 5.51
C 4.42 (0.78) 2.83 5.38 4.47 (0.90) 2.47 5.63
Post1
PS 2.27 (0.58) 1.57 3.37 2.43 (0.56) 1.62 3.41
NA 0.17 (0.35) 0.00 1.10 0.34 (0.39) 0.09 1.26
E 4.11 (0.84) 2.58 5.22 3.89 (1.02) 2.02 5.28
V 4.39 (0.74) 2.80 5.38 4.23 (0.71) 2.79 5.20
C 4.35 (0.68) 3.02 5.27 4.27 (0.73) 2.93 5.29
Post2
PS 2.24 (0.61) 1.67 3.33 2.51 (0.59) 1.59 3.62
NA 0.22 (0.30) 0.00 0.93 0.35 (0.43) 0.00 1.24
E 4.23 (0.79) 2.65 5.25 3.87 (0.98) 2.03 5.19
V 4.33 (0.62) 3.12 5.18 4.22 (0.77) 2.85 5.35
C 4.21 (0.64) 2.95 5.12 4.25 (0.73) 2.97 5.34
Note. PS ¼ perceived stress; Pre ¼ baseline; Post1 ¼ first
academic exam assess-
ment; Post2 ¼ second academic exam assessment; V ¼ valence;
E ¼ energetic
arousal; C ¼ calmness; NA ¼ negative affect.
(2015) 67e75 71
via VO2maxrel, increased by 8.7% from pre-to post-
intervention in
the AET group and decreased by 5.6% in the CG (Table 1). The
ANCOVA revealed significance for the factor group,

VO2maxrel: F(1,
56) ¼ 59.8, p < .001, h2 ¼ 0.52, indicating a strong effect
(Cohen,
1988) of the intervention on aerobic capacity.
Compliance
At the baseline (pre), there were 28 missing data points (2.7%);
at post1, 94 out of 960 data points were not answered (9.7%
missing); and at post2, 80 out of 944 data points were missing
(8.5%). We had data that indicated that during the examination
period, students in general woke up later than 11 a.m. and
missed
the first prompt; thus, we appraised compliance as being good
in
the present study.
For our analysis, 944 NA and PS data points were available at
pre,
post1 and post2. Except for the two students who were
withdrawn
from the analyses, data from both measurement times during the
examination period were available for each participant.
Uncondi-
tional NA models revealed that average NA was 0.24 at pre,
0.25 at
post1 and 0.28 at post2. Intraclass coefficients were s ¼ 0.02
for
pre, s ¼ 0.41 for post1 and s ¼ 0.21 for post2, indicating that
intra-
individual variation caused 98%, 59% and 79% of the variance,
respectively.
Emotional stress reactivity at baseline
Descriptively, participants of the CG reported slightly higher PS

at baseline (pre) compared with the AET group, while values of
NA
were similar between the groups (Table 3). The MLMs revealed
that
higher PS (level 1) significantly predicted higher NA, whereas
neither the group (level 2) nor the cross-level interaction of
group � PS predicted NA at baseline (Table 2). Thus, emotional
stress reactivity was evident at baseline, but did not differ
between
the groups.
Emotional stress reactivity during academic examinations
Descriptively, the participants' average PS ratings increased
from baseline to post1 during exams, and the increase was
similar
in both groups (see Table 3). Although PS was similar during
both
exam periods (post1 and post2) in the AET group, it increased
further from post1 to post2 in the CG. In contrast to the similar
baseline NA levels in both groups, the CG showed higher NA at
post1 and post2, whereas the AET group rated slightly lower
NA at
post1 compared with baseline and similar NA compared with
baseline at post2. MLMs of the within-subject effects (level 1)
revealed that PS (person-mean centred) significantly predicted
NA (Table 2). Conditions of higher PS than the person mean
related
to higher NA ratings, and thus emotional stress reactivity was
evident.
Table 2
Results of the multilevel models for NA as the dependent
variable at every measuremen
Model negative affect

Variable Pre Post1
b SE t b
Intercept 0.25*** 0.04 5.86 0.33***
PS 0.21*** 0.03 7.24 0.24***
Group �0.02 0.06 �0.46 �0.16
PS � group �0.05 0.04 �1.17 �0.11*
Note. PS ¼ perceived stress; Pre ¼ Baseline; Post1 ¼ first
academic exam assessment; P
*p < .05. ***p < .001.
Between-subject effects revealed that during both episodes of
academic exams (post1 and post2), the coefficients for the pre-
dictor group (level 2) were negative and higher compared with
the
baseline findings. These results descriptively indicated that
AET
group participants had lower NA at post1 and post2 (see Table
2)
compared with the CG. However, group affiliation did not
signifi-
cantly predict NA during the exams.
In the next step, we added the cross-level interaction between
group and PS to the model. This interaction significantly
predicted
NA. NA values differed between groups, especially when
partici-
pants perceived stress that was higher than their person-specific
means. Table 2 shows that the coefficient for the group � PS
interaction was negative (variable coded as control group ¼ 0),
indicating that the AET group reacted with less NA in situations
of
higher PS during the exams and thus had lower emotional stress
reactivity (Fig. 2). Although this interaction did not predict NA

at
baseline, it was a significant predictor of NA at post1. At post2,
the
cross-level interaction of group � PS was again a significant
pre-
dictor of NA (Table 2; Fig. 2). Thus, after the 20-week aerobic
ex-
ercise intervention, AET group participants showed lower
emotional stress reactivity to both academic episodes (post1 and
post2). At post2, the coefficient for the group � PS interaction
in the
model was higher compared with post1 (Table 2), descriptively
indicating a larger effect of the group � PS interaction at post2
(Fig. 2).
t time.
Post2
SE t b SE t
0.08 3.93 0.35*** 0.08 4.60
0.03 7.89 0.38*** 0.03 10.75
0.11 �1.35 �0.13 0.11 �1.19
0.05 �2.33 �0.18*** 0.05 �3.55
ost2 ¼ second academic exam assessment.
Fig. 2. Emotional stress reactivity (predicted values) by group
at baseline (pre) and at
both examination periods (post1 and post2). NA ¼ negative
affect.
(2015) 67e7572

Secondary analyses
Descriptively, the mean values of the three mood dimensions
valence, calmness and energetic arousal showed different
charac-
teristics in the AET group versus the CG during the non-
stressful
and examination periods. Mean valence was similar between
baseline and both stress periods (post1 and post2) in the
AETgroup.
In addition, valence was higher compared with the CG during
both
examination periods (Table 3), but the MLMs did not reveal sig-
nificance for the predictor group (Table 2). Although the result
was
not statistically significant, mean energetic arousal was even
higher
in the AET group compared with the CG during the stressful
period
(Table 3). Descriptively, the decrease in calmness from baseline
to
post1 was lower in the AET group than the CG (Table 3).
To analyse the effects of the group � PS interaction on
energetic
arousal, calmness and valence, we calculated single models for
each
of the three dimensions. Because higher values indicated higher
calmness, energetic arousal and valence, the interpretation is
more
complex. PS significantly predicted valence, calmness and
energetic
arousal at all times of measurement (Table 4). Thus,
participants
who rated as having lower PS had higher valence, calmness and
energetic arousal ratings. In addition, the analyses revealed a

marginally significant effect of the group � PS interaction on
valence at post1, which achieved significance at post2 (see
Table 4).
The results indicate that under increased PS, the experimental
group rated greater valence than did the CG. In addition, at
post1,
the group � PS interaction significantly predicted calmness.
Under
increased PS, the experimental group rated more calmness than
did
the CG (Table 4), although this result was not confirmed at
post2.
No significant group � PS interaction was found for energetic
arousal.
Discussion
In the present study, we were able to show that a preventive 20-
week aerobic exercise intervention can lower emotional stress
reactivity to real-life stress. NA did not differ significantly
between
participants in the AET and control groups during the exams.
This
was illustrated by the non-significance of group as a predictor
in
both statistical models during the stressful episodes. However,
the
MLMs revealed a significant cross-level interaction of group
(con-
trol versus AET) and PS on the output NA. The interaction was
not
significant prior to the exercise intervention, which means that
stress reactivity did not differ between groups at baseline. In
contrast, the interaction was significant during the academic
exams
after the aerobic exercise intervention. In conditions of higher

PS,
AET participants rated lower NA and thus had reduced
emotional
stress reactivity. The significant reduction in stress reactivity
was
identified at both episodes during the exams (post1 and post2),
with a descriptively higher coefficient at post2. Thus, we
confirmed
our results of the reduced stress reactivity of the AET group at
two
different assessment times. Our results are consistent with those
from recent cross-sectional laboratory studies that found lower
decreases in mood among trained compared with untrained men
in
response to the TSST (Klaperski et al., 2013).
Because research shows that the accumulated effects of
enhanced emotional reactivity (enhanced NA) increase the risk
for
physical and mental disorders (Cacioppo et al., 1998; DeLongis,
Folkman, & Lazarus, 1988; Myin-Germeys et al., 2003; Van Eck
et al., 1998), these results are relevant for prevention because
they
support the hypothesis that exercise buffers stress-induced
health
risks (Gerber & Pühse, 2009; Hamer, 2012). Participants in the
AET
group had lower NA during conditions of high PS, and thus they
may benefit in the long term from a lower accumulation of NA
in
response to daily life stress. As a consequence, exercise appears
to
be a promising prevention strategy for reducing accumulated
enhanced emotional reactivity to the considerable stresses in
real
life. Clinical psychology treatments aim to reduce the effects of

stressors that are already present. Exercise training serves as a
strategy to influence the effects of stressors before they occur
(Salmon, 2001). In addition, exercise is a popular, easily
accessible
low-cost application for reducing NA and a successful add-on to
psychological treatments.
Our secondary analyses revealed that the interaction of PS and
group did not show a persistent pattern in predicting the
different
mood dimensions valence, calmness and energetic arousal. The
re-
sults for the valence dimension (marginally significant at post1
and
significant at post2) indicated improved emotional reactivity.
Whereas the valence of mood was more positive in the AET
group,
the results showed a more complex picture for calmness and en-
ergetic arousal. An interesting finding was that the reactivity of
the
calmness dimension was only evident at post1. The non-
significant
interaction of group � PS at post2 raises the question of
whether
exercise's effects on calmness decrease over periods of
prolonged
Table 4
Results of the multilevel models for the three mood dimensions
as the dependent variables at every measurement time.
Variable Pre Post1 Post2
b SE t b SE t b SE t

Valence model
Intercept 4.35*** 0.11 39.73 4.23*** 0.15 27.38 4.22*** 0.16
26.69
PS 0.44*** 0.04 9.76 0.45*** 0.05 9.28 0.59*** 0.05 12.78
Group 0.01 0.15 0.19 0.16 0.21 0.74 0.11 0.22 0.48
PS � group �0.00 0.07 �0.01 �0.13 0.07 �1.84 �0.24*** 0.07
�3.59
Calmness model
Intercept 4.46*** 0.12 36.01 4.29*** 0.17 24.54 4.25*** 0.17
24.99
PS 0.49*** 0.04 11.34 0.50*** 0.05 10.50 0.50*** 0.05 10.31
Group �0.04 0.17 �0.20 0.06 0.25 0.23 �0.03 0.24 �0.12
PS � group 0.03 0.06 0.48 �0.25*** 0.07 �3.50 �0.09 0.07
�1.23
Energetic arousal model
Intercept 3.57*** 0.13 27.45 3.89*** 0.13 28.63 3.85*** 0.14
26.76
PS 0.19*** 0.06 3.20 0.13* 0.06 2.08 0.33*** 0.06 5.12
Group 0.21 0.18 1.16 0.18 0.19 0.96 0.36 0.20 1.77
PS � group �0.06 0.08 �0.66 �0.00 0.10 �0.03 �0.03 0.09
�0.29
Note. PS ¼ perceived stress; Pre ¼ baseline; Post1 ¼ first
academic exam assessment; Post2 ¼ second academic exam
assessment.
*p < .05. ***p < .001.
(2015) 67e75 73
stress. More research is needed to explain the interplay of stress
and
exercise regarding the mood dimensions valence, energetic
arousal

and calmness, for example, to explain the higher energetic
arousal of
the AET participants observed during the academic
examinations.
In the present study, we were able to improve the aerobic ca-
pacity of previously inactive students after a 20-week AET by
8.7%
on average, with high intra-individual variability (SD 12%). De
Geus
and Stubbe (2007) stated that the average improvement in
VO2max
in long-term training studies was approximately 14% after four
months of training. Research shows that VO2max improvement
in
response to aerobic exercise training differs greatly (by 0e40%)
depending on target group, baseline vagal tone, age, gender,
training load and genetic disposition (Hautala, Kiviniemi, &
Tulppo,
2009). Although the present study showed VO2max
improvements
lower than the 14% change, the results are statistically
significant.
Furthermore, the AET group showed significantly reduced
emotional stress reactivity compared with the CG.
Based on the present results, people may profit from regular
exercise, especially when PS is higher. Interestingly, people do
not
use exercise during stressful times but prefer to spend more
time in
suboptimal low-effort activities such as watching television
(Sonnentag & Jelden, 2009). There needs to be further
examination
of the effects on long-term health of exercising compared with
low-

effort activities during real-life stress.
We do not know exactly which factors contributed to the
reduced emotional reactivity to real-life stress among
participants
who attended the 20-week AET. Earlier studies have argued that
it
is not the effects of regular exercise adaptations but potentially
the
aggregated positive effects of acute exercise on mood, reduced
tension and elevated beta-endorphins that lead to reduced stress
(Reed & Buck, 2009; Salmon, 2001). The results of the present
study
suggest that people profit not only from general mood enhance-
ment but also from lower NA, especially in situations of higher
demand. Salmon (2001) stated that the particular value of
exercise
might be its controllability. Although repeated exposure to un-
controllable stressors may also lead to adaptations, they can be
achieved much more quickly through controllable stressors
(Maier
& Seligman, 1976). The present study operationalised acute
stress
appraisal through perceived control. Participants in the experi-
mental group may have had lower emotional stress reactivity
because they perceived more control even in situations of severe
stress. Therefore, one explanation for the emotional benefit of
regular exercise would be the adaptations to exercise as the
repeated but controllable stressor. The potential of regular
exercise
to reduce stress reactivity and increase self-control was investi-
gated in an intervention study by Oaten and Cheng (2005).
Exer-
cisers showed significant improvement in self-regulatory
capacity,
decreased PS and emotional distress, and enhanced health

behav-
iours compared with the CG. Interestingly, in an additional
study
with a non-exercise intervention to increase self-control in
prepa-
ration for upcoming exams, the authors reported increased
physical
activity in the experimental group who participated in a self-
control programme (Oaten & Cheng, 2006).
Although our study revealed interesting findings regarding the
effect of aerobic exercise on emotional stress reactivity in real
life,
some critical aspects have to be discussed. First, the results of
the
present study are not representative because we used a sample
of
young, healthy students with rather low levels of NA and mild
levels of PS. Participants enrolled in the study voluntarily, and
thus
students with severe stress may not have participated. However,
as
we learned from previous studies that analysed exerciseemood
associations, lower baseline values indicated higher effects
(Reed &
Buck, 2009) and high baseline levels may lead to ceiling effects
(Gauvin et al., 1996). However, we found significant results,
and
thus we are optimistic that the effects may be reproducible in a
more representative sample.
Second, although we asked participants to rate PS repeatedly
throughout the day, we very likely missed some severely
stressful
moments. Therefore, using a combined protocol (integrating
event-

based and time-based sampling strategies as well as physiology-
triggered assessments) may be an even more suitable method for
future studies (Shiffman, 2007) because PS ratings can thereby
be
initialised during situations of higher stress.
Finally, there are variables we did not control for that could
also
have influenced NA and PS; context information such as social
contacts, activities and location as well as social support and
per-
sonality are a few of these variables. Future studies should
analyse
how these variables counteract or moderate the effects of
exercise
on emotional reactivity during real-life stress.
Conclusion
The present study revealed relevant results that suggest that
exercise is an effective prevention strategy for buffering against
(2015) 67e7574
stress-induced negative health effects. In addition, we depicted
how Ambulatory Assessment benefits research on the
stresseexercise association. Even during the examination period,
some participants perceived very low levels of stress and at
other
times, different students experienced more or less stress,
indicating
inter- and intra-individual variability. Negative affect values
were
on average above the mean of the NA scale, and thus, the

averaged
pre-/post-single assessments, such as were used in earlier
studies,
would not have yielded the present findings. The situation-
specific
and repeated assessments of the interactions between the predic-
tor group and PS, and the dependent variable NA allowed us to
detect more complex results.
We used two assessment episodes during the exams and were
able to confirm the results for both points in time. Thus, we
could
strengthen our results by confirming the results at two different
times and to illustrate increased representativeness. The present
study showed that it is worth analysing intra- and inter-
individual
effects when analysing intervention effects. Future studies
should
investigate in more detail how individuals at different fitness
levels
react in situations of different stress severity and contexts and
how
the impacts of acute and regular exercise interact regarding
emotional reactivity to stress in real life. Furthermore, it will be
interesting to identify the factors that are responsible for
success-
fully reducing emotional stress reactivity through aerobic
exercise.
Therefore, more studies that use Ambulatory Assessment to
eval-
uate the effects of regular exercise on both physiological and
emotional stress reactivity are needed. In addition, continuously
monitoring physical activity can capture the influences of the
cir-
cular associations between physical activity and stress in real-
life

settings (Bussmann, Ebner-Priemer, & Fahrenberg, 2009).
Acknowledgements
The authors would like to thank W. Schlotz for his support with
the statistical analyses.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.psychsport.2015.04.004.
References
Anshel, M. H. (1996). Effect of chronic aerobic exercise and
progressive relaxation
on motor performance and affect following acute stress.
Behavioral Medicine, 21,
186e196. http://dx.doi.org/10.1080/08964289.1996.9933757.
Baghurst, T., & Kelley, B. C. (2014). An examination of stress
in college students over
the course of a semester. Health Promotion Practice, 15,
438e447. http://
dx.doi.org/10.1177/1524839913510316.
Bolger, N., & Schilling, E. A. (1991). Personality and the
problems of everyday life:
the role of neuroticism in exposure and reactivity to daily
stressors. Journal of
Personality, 59, 355e386. Retrieved from
http://www.ncbi.nlm.nih.gov/
pubmed/1960637.
Borg, G. (1982). Psychophysical bases of perceived exertion.
Medicine and Science in
Sports and Exercise, 14, 377e381. Retrieved from
http://www.ncbi.nlm.nih.gov/
pubmed/7154893.

Bussmann, J. B. J., Ebner-Priemer, U. W., & Fahrenberg, J.
(2009). Ambulatory activity
monitoring. European Psychologist, 14, 142e152.
http://dx.doi.org/10.1027/1016-
9040.14.2.142.
Cacioppo, J. T., Berntson, G. G., Malarkey, W. B., Kiecolt-
Glaser, J. K., Sheridan, J. F.,
Poehlmann, K. M., et al. (1998). Autonomic, neuroendocrine,
and immune re-
sponses to psychological stress: the reactivity hypothesis.
Annals of the New
York Academy of Sciences, 840, 664e673.
http://dx.doi.org/10.1111/j.1749-
6632.1998.tb09605.x.
Calvo, M. G., Szabo, A., & Capafons, J. (1996). Anxiety and
heart rate under psy-
chological stress: the effects of exercise-training. Anxiety,
Stress, and Coping, 9,
321e337. http://dx.doi.org/10.1080/10615809608249409.
Campbell, J., & Ehlert, U. (2012). Acute psychosocial stress:
does the emotional
stress response correspond with physiological responses?
Psychoneur-
oendocrinology, 37, 1111e1134.
http://dx.doi.org/10.1016/j.psyneuen.2011.12.010.
Carels, R., Blumenthal, J., & Sherwood, A. (2000). Emotional
responsivity during
daily life: relationship to psychosocial functioning and
ambulatory blood
pressure. International Journal of Psychophysiology, 36, 25e33.
Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/10700620.

Cohen, J. (1988). Statistical power analysis for the behavioral
sciences (2nd ed.).
Hillsdale: Erlbaum.
Collip, D., Wigman, J. T. W., Myin-Germeys, I., Jacobs, N.,
Derom, C., Thiery, E., et al.
(2013). From epidemiology to daily life: linking daily life stress
reactivity to
persistence of psychotic experiences in a longitudinal general
population study.
PLoS One, 8, e62688.
http://dx.doi.org/10.1371/journal.pone.0062688.
De Geus, E., van Doornen, L., & Orlebeke, J. (1993). Regular
exercise and aerobic
fitness in relation to psychological make-up and physiological
stress reactivity.
Psychosomatic Medicine, 55, 347e363. Retrieved from
http://www.ncbi.nlm.nih.
gov/pubmed/8416085.
De Geus, E., & Stubbe, J. (2007). Aerobic exercise and stress
reduction. In G. Fink
(Ed.), Encyclopedia of stress. New York: Elsevier Academic
Press.
DeLongis, A., Folkman, S., & Lazarus, R. S. (1988). The impact
of daily stress on health
and mood: psychological and social resources as mediators.
Journal of Person-
ality and Social Psychology, 54, 486e495. Retrieved from
http://www.ncbi.nlm.
nih.gov/pubmed/3361420.
Dickhut, H. H., Mayer, F., R€ocker, K., & Berg, A. (2007).

Sportmedizin für €Arzte. K€oln:
Deutscher €Arzteverlag.
Fahrenberg, J., Brügner, G., Foerster, F., & K€appler, C.
(1999). Ambulatory assessment
of diurnal changes with a hand-held computer: mood, attention
and mor-
ningnesseeveningness. Personality and Individual Differences,
26, 641e656.
http://dx.doi.org/10.1016/S0191-8869(98)00160-3.
Forcier, K., Stroud, L. R., Papandonatos, G. D., Hitsman, B.,
Reiches, M.,
Krishnamoorthy, J., et al. (2006). Links between physical
fitness and cardio-
vascular reactivity and recovery to psychological stressors: a
meta-analysis.
Health Psychology, 25, 723e739.
http://dx.doi.org/10.1037/0278-6133.25.6.723.
Gauvin, L., Rejeski, W. J., & Norris, J. L. (1996). A naturalistic
study of the impact of
acute physical activity on feeling states and affect in women.
Health Psychology,
15, 391e397. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/8891718.
Gerber, M. (2008). Exercise and stress reactivity: a review.
Deutsche Zeitschrift für
Sportmedizin, 59, 168e174. Retrieved from
http://www.zeitschrift-sportmedizin.
de/fileadmin/externe_websites/ext.dzsm/content/archiv2008/heft
07_08/Artikel
Gerber.pdf.
Gerber, M., & Pühse, U. (2009). Review article: do exercise and

Assessment Task 3 Written Assignment - Evaluating the usefuln.docx

Assessment Task 3 Written Assignment - Evaluating the usefuln.docx

Recommended

Recommended

More Related Content

Similar to Assessment Task 3 Written Assignment - Evaluating the usefuln.docx

Similar to Assessment Task 3 Written Assignment - Evaluating the usefuln.docx (20)

More from davezstarr61655

More from davezstarr61655 (20)

Recently uploaded

Recently uploaded (20)

Assessment Task 3 Written Assignment - Evaluating the usefuln.docx