healthcare

Review
Effects of Exercise Programs on Anxiety in Individuals with
Disabilities: A Systematic Review with a Meta-Analysis
Miguel Jacinto 1,2, *, Roberta Frontini 2,3 , Rui Matos 2,4 and Raul Antunes 2,3,4

1 Faculty of Sport Sciences and Physical Education, University of Coimbra, 3040-248 Coimbra, Portugal
2 Life Quality Research Centre (CIEQV), 2040-413 Rio Maior, Portugal; [email protected] (R.F.);
[email protected] (R.M.); [email protected] (R.A.)
3 Center for Innovative Care and Health Technology (ciTechCare), Polytechnic Institute of Leiria,
2410-541 Leiria, Portugal
4 School of Education and Social Sciences, Polytechnic Institute of Leiria, 2411-901 Leiria, Portugal
* Correspondence: [email protected]

Abstract: Anxiety symptoms are increasingly prevalent in individuals and may affect their quality of
life. Physical exercise (PE) has been shown to be an effective method for reducing anxiety symptoms
in the general population. The present study aimed to identify if PE programs can be a good method
to reduce anxiety symptoms in individuals with disabilities, through the methodology of a systematic
review with a meta-analysis. The PubMed, Web of Science, Scopus, and SPORTDiscus databases were
used, considering the period from 2001 to 2021. The descriptors used were: “cerebral palsy”, “motor
disability”, “physical disability”, “vision impairment”, “visual impairment”, “vision disability”,
“intellectual disability”, “mental retardation”, “intellectual disabilities”, “hearing impairment”,





 “hearing disability”, “multiple disabilities”, “physical activity”, “exercise”, “sport”, “training”, and
“anxiety”, with the Boolean operator “AND” or “OR”. The systematic review with a meta-analysis
Citation: Jacinto, M.; Frontini, R.;
was carried out in the period between May and June 2021. The Z values (Z-values) obtained to
Matos, R.; Antunes, R. Effects of
Exercise Programs on Anxiety in
test the null hypothesis, according to which the difference between means is zero, demonstrated a
Individuals with Disabilities: A Z = 2.957, and a corresponding p-value of 0.003. Thus, we can reject the null hypothesis, and affirm
Systematic Review with a that PE promotes positive effects and can be a good method or methodology for the reduction of
Meta-Analysis. Healthcare 2021, 9, anxiety symptoms of individuals with disabilities.
1047. https://doi.org/10.3390/
healthcare9081047 Keywords: anxiety; disabilities; physical exercise program

Academic Editor: Alessandro Sartorio

Received: 14 July 2021 1. Introduction

Accepted: 11 August 2021
Anxiety is characterized by the existence of apprehensive expectation or fear in in-
Published: 13 August 2021
dividuals, being one of the most prevalent psychiatric symptoms across the world [1,2].
It affects approximately one out of five individuals [3–5], regardless of gender, race, or age
Publisher’s Note: MDPI stays neutral
groups [6]. In the International Statistical Classification of Diseases and Related Health
with regard to jurisdictional claims in
published maps and institutional affil-
Problems created by the World Health Organization, tenth version (ICD-10), anxiety disor-
iations.
ders are classified in the group of mental and behavioral disorders, specifically neurotic
disorders. In turn, there is a chapter on the Diagnostic and Statistical Manual of Mental Dis-
orders [1] that contains various possible diagnoses, where anxiety disorders are presented
and described.
Anxiety symptoms are also prevalent in individuals with intellectual [7], visual [8],
Copyright: © 2021 by the authors.
hearing [9], and motor disabilities (including cerebral palsy) [10,11]. The presence of
Licensee MDPI, Basel, Switzerland.
anxiety disorders and symptoms can affect an individual’s quality of life [12], requiring the
This article is an open access article
distributed under the terms and
use of health services not only because of the disease itself, but also due to the variety of its
conditions of the Creative Commons
causes, including cardiovascular diseases and increased mortality risk [13–16].
Attribution (CC BY) license (https:// In the population without disabilities, physical exercise (PE) has been shown to be
creativecommons.org/licenses/by/ an accessible and inexpensive option to help reduce anxiety symptoms [17,18]. PE is
4.0/). characterized as a planned and systematic form of physical activity, consisting of a defined

Healthcare 2021, 9, 1047. https://doi.org/10.3390/healthcare9081047 https://www.mdpi.com/journal/healthcare

Healthcare 2021, 9, 1047 2 of 12

structure and repetition, with the purpose of maintaining or improving one or more
components of physical fitness, namely, aerobic, neuromuscular capacity, balance, and
flexibility [19]. The literature reinforces that PE presents itself as an effective method for
the promotion of mental health [20–22].
Research has shown that in undiagnosed individuals, a single session of PE can
cause a reduction in anxiety symptoms [23,24]. Moreover, individuals who practice PE
have a lower risk of developing anxiety disorders compared to those who do not [25,26].
Furthermore, in diagnosed individuals, PE has also proven to be an effective method in the
treatment of anxiety [18,27].
Although the benefits of PE are clear and evident for the general population, namely,
in the reduction anxiety symptoms, the effects in the population with disabilities are still
unclear and have not been evaluated, and researchers usually direct their interests to other
variables [28–31]. It is important to understand if they are transversal to the population
with disabilities in order to promote their quality of life, related to the conceptual model
of Schalock et al. [32], being a construct divided into three dimensions: (i) Independence,
(ii) social participation, and (iii) well-being.
This is the first systematic review a with meta-analysis aimed at identifying if PE
programs can be a good method to reduce anxiety symptoms in individuals with disabilities,
answering the following question: Can an exercise PE program reduce anxiety symptoms
in individuals with disabilities?

2. Methods
2.1. Eligibility Criteria
This systematic review was constructed following the items of the PRISMA proto-
col [33] and the methodology described by Bento [34]. The protocol of this systematic
review was registered in the International Prospective Register of Systematic Reviews
(PROSPERO) International Prospective Register of Systematic Reviews, with registration
number CRD42021256218 of 2021. The PICOS strategy [35,36] is defined as follows: (i) “P”
(Patients) corresponds to participants with any type of disability, of any age, gender, ethnic-
ity, or race; (ii) “I” (Intervention) corresponds to a PE program, implemented in the referred
population, independently of the intervention time; (iii) “C” (Comparison) corresponds
to the comparison before and after the intervention or between the control group and the
intervention group; (iv) “O” (Outcome) corresponds to anxiety as the primary or secondary
variable of focus; (v) “S” (Study Design) corresponds to intervention studies, randomized
controlled trials (RCTs), or non-RCTs.

2.2. Information Sources and Research Strategies

The present study was carried out between May and June (Day 21) 2021, in English,
by searching the databases, PubMed (all fields), Web of Science, Scopus, and SPORTDis-
cus (title, abstract, and keywords), considering studies from January 2001 to June 2021.
The descriptors used were: “Cerebral palsy”, “motor disability”, “physical disability”,
“vision impairment”, “visual impairment”, “vision disability”, “intellectual disability”,
“mental retardation”, “intellectual disabilities”, “hearing impairment”, “hearing disability”,
“multiple disabilities”, “physical activity”, “exercise”, “sport”, “training”, and “anxiety”,
with the Boolean operator “AND” or “OR”, as shown in Table 1.
Healthcare 2021, 9, 1047 3 of 12

Table 1. Research strategy.

Research Number Descriptors

(“brain palsy” OR “motor disability” OR “physical disability” OR “vision impairment” OR
“visual impairment” OR “vision disability” OR “intellectual disability” OR “mental
1 retardation” OR “intellectual disabilities” OR “hearing impairment” OR “hearing disability”
OR “multiple disabilities”) AND (“physical activity” OR “exercise” OR sport* OR
“training”) AND (“anxiety” OR “phobia” OR “panic”)

2.3. Inclusion Criteria

For the selection of studies, the following inclusion criteria were considered: (i) Inter-
vention studies, RCTs, and non-RCTs; (ii) intervention studies with PE; (iii) individuals
with disabilities, of the most varied types; (iv) studies with individuals of any age group,
gender, race, or ethnicity.

2.4. Exclusion Criteria

Likewise, the following exclusion criteria were considered: (i) Studies published
before 2001; (ii) studies that were not published in English or Portuguese; (iii) studies
that do not describe the intervention protocol; (iv) studies in which the intervention is not
just PE.

2.5. Data Extraction Process

The research was carried out independently by two investigators, via the ENDNOTE
X7 software (Clarivate, London, United Kingdom) and duplicated articles were eliminated.
In the first phase, articles were excluded based on the reading of the titles and abstract.
In the second phase, which consisted of a complete reading of the articles, those that did
not meet the eligibility criteria were excluded, and the study sample consisted of four
articles. The results at all phases were compared by the researchers (M.J. and R.A.). One of
the researchers (M.J.) exported the relevant information from the articles and inserted them
into Table 2 (authorship, year of publication, country, objectives, participants, type of study,
assessment instruments, duration/frequency, exercises and intensities, and main results).

2.6. Methodological Quality Assessment

To assess the quality of each study, the Downs and Black scale was used [37]. This scale
consists of 27 items, scored with “one value” or “zero” for various parts of each article.
The quality of each study was assessed by two investigators (M.J. and R.A.), independently,
and they were compared and discussed to reach a consensus. When a consensus was not
possible, a third investigator was available to collaborate (R.F.). The scale was divided into
several score ranges, corresponding to the following quality levels: Excellent (26–28); good
(20–25); fair (15–19); and poor (≤14). However, as six questions (questions 8, 11, 12, 15, 16,
and 27) were not applicable to all studies, they were removed. Once modified, the scale
had a maximum of 20 points compared to the original.

2.7. Statistical Analysis

A meta-analysis was performed using Comprehensive Meta-analysis Version 3.0
statistical software (Biostact, Inc, Englewood, United States of America). The difference
in means was calculated based on information on the pre- and post-intervention means,
the number of participants, and the standard deviation, using the randomized effects model
to measure the effect size, with a 95% confidence interval (CI), magnitude effects, and
level of statistical significance (p < 0.05). Heterogeneity was assessed using the chi-square,
Cochran Q statistic, Higgin I squared (I2 ), and Tau square tests (T2 ). The homogeneity was
verified by the asymmetry of the funnel-shaped scatter plot [38], and it was considered
without publication bias when the graph had an inverted funnel [39].
Healthcare 2021, 9, 1047 4 of 12

3. Results
3.1. Selection of Studies
By searching the various databases, 330 studies were identified. In the first phase,
after the elimination of duplicate articles and based on the titles and abstracts (eliminating
articles that did not correspond to scientific publications, with an experimental method-
ology, with the implementation of a PE program, and evaluating its impact on anxiety
symptoms), a sample of six studies with relevant potential for the study were identified for
the next phase. Considering the eligibility criteria and the complete reading of the articles,
a sample of four studies constituted the full analysis (two articles were excluded, in which
the intervention was not with physical exercise or was not only with physical exercise).
Figure 1 represents a PRISMA flowchart of this systematic review.

Figure 1. PRISMA flow diagram.

Healthcare 2021, 9, 1047 5 of 12

Table 2. Characteristics of the four studies.

Assessment Instru-
Author, Year, Country Aims Participants Type of Study Duration/Frequency Exercises and Intensity
ments/Technique
Groups A and B:
Throwing balls to different
targets; technical and
(A) Competition boccia tactical exercises; training
group without and competition games.
professional supervision Groups A and B: Strength
State–Trait Anxiety
(N = 9); (B) training (2 × week;
Effects of Boccia on Inventory; 16 weeks;
N = 43; professionally 60 min/session).
Barak et al. [40] psychosocial outcomes State–Trait Anxiety Groups A and B trained
AA: 45.60 ± 10.95 supervised competition All groups participated in
Israel in persons with severe and Trait Anxiety 3 × week;
y;multiple disabilities. bocce (N = 7); (C) a rehabilitation program.
disabilities. Scale (36–38)—self- 90 min/session.
recreational/leisure Recreational participants
reports.
bocce were included in the
(N = 14); and (D) control training that emphasized
(N = 13). tactics (2 × week), but not
in the games and not in
one specific training
schedule.
Zung Self-Rating
Anxiety Scale (Zung,
1971)—self-
Investigating the effects completion scale Individual or paired
of a 12-week exercise Experimental study; adapted for DID movements using different
N = 27 (♂= 16; ♀= 11); 12 weeks;
Carraro and Gobbi [41] program on anxiety random groups: Training (Lindsay & Michie, equipment (balls, ropes,
AA: 40.1 ± 6.2 2 × week;
Italy states in a group of (N = 14) and control 1988); dumbbells, etc.), group
y;mild-to-moderate ID. 60 min/session.
adults with intellectual (N = 13). Trace State Anxiety cooperative situations, and
disability. Inventory Form Y adapted games.
(STAI-Y (Spielberg,
1989)—self-
completed;
Healthcare 2021, 9, 1047 6 of 12

Table 2. Cont.

Assessment Instru-
Author, Year, Country Aims Participants Type of Study Duration/Frequency Exercises and Intensity
ments/Technique
Phase-divided PE
program:
1st phase: Exercises to
Evaluating the efficacy familiarize participants
of an introductory mini Non-randomized Assessment and with equipment (ball,
tennis program as a controlled experimental Information Rating wooden paddles, and
N = 24; 24 weeks;
Hardoy et al. [42] therapeutic study; Profile—anxiety racket);
AA: 27.25 ± 8.45 y; 2 × week;
Italy aid in the psychosocial division of groups: subscale (Bouras, N. 2nd phase: Development
mild ID. 180 min/session.
rehabilitation of Training (N = 12) and and Drummond, C. of coordination skills
participants affected by control (N = 12). 1989) (oculo-manual, general
mild-to-moderate ID. dynamics, and
temporal-spatial skills);
3rd phase: Learning basic
tennis techniques.
Rhythmic aerobic exercises
Quasi-experimental
Investigating the effect were performed (20 min);
N = 30 ♀; study; Zung Self-Rating 8 weeks;
Salehpoor et al. [43] of exercise on the anxiety strength exercises
A: 15–21 y; random groups: Training Anxiety Scale (1997)— 3 × week;
Iran of adolescents with (20 min)—exercise with
mild ID. (N = 15) and control self-completion. 60 min/session.
intellectual disabilities. dumbbells, ropes, and
(N = 15).
balls.
A, age; AA, average age; ID, intellectual disability; Exer, exercise/s; min, minutes; N, participants; y, years; ♂, male; ♀, female.
Healthcare 2021, 9, 1047 7 of 12

3.2. Origin
Two of the studies selected for full analysis were from the Asian continent [40,43] and
the two others were from the European continent [41,42], with Italy being the country that
has published the most studies on this subject.

3.3. Participants
The study of Barak [40] recruited participants with multiple disabilities, with the other
three studies having a sample of individuals with intellectual disabilities only. Using an
experimental methodology in all studies, there was a sum of 124 participants, 53 of whom
were part of the control group. The participants were in the age group of young people
and adults.

3.4. Assessment Instruments/Technique

All authors used a scale to assess anxiety symptoms. The scales were applied through
self-reports or self-completion, with the exception of the study of Hardoy [42], where the
methodology used is not clear.

3.5. PE Program
The PE programs were different, with no trend regarding the training methodology
used. However, we can observe Boccia modality training [40], mini tennis [42], and exer-
cises with different dynamics [41], as well as combined strength and aerobic training [43].
The PE focused on a modality [40,42] consisting of a first phase with exercises to
familiarize the participants with the equipment and, in a second phase, with the technical
and tactical drills. Barak [40] prescribed another phase with competition games, while
Hardoy [40] prescribed one phase with the development of coordination skills. The central
phase of the Carraro and Gobbi’s [41] and Salehpoor’s [43] studies consisted of individual
or paired movements using different equipment (balls, ropes, dumbbells, etc.), group
cooperative situations, and adapted games.
The programs duration varied between 8 and 24 weeks. The weekly frequency varied
between two and three times and the training sessions duration varied between 60 and
180 min.

3.6. Quality of Studies

The methodological quality of the studies was assessed as poor to good. No stud-
ies were excluded due to low-quality scores. The study with the highest quality was
Salehpoor’s [43], while the study with the lowest quality assessment was developed by
Barak [40]. The quality ratings are shown in Table 3.

3.7. Results of the Interventions

Table 3 shows the results of the PE programs on anxiety symptoms in individuals
with disabilities.
Healthcare 2021, 9, 1047 8 of 12

Table 3. Results of the interventions on anxiety symptoms.

Intervention Group Control Group Methodological

Quality
Pre-Test Post-Test Pre-Test Post-Test
Assessment instru- Intervention Intervention Intervention Intervention Intervention Intervention
Barak et al. ments/technique A B C A B C 25.76 ± 10.34 25.25 ± 10.90
Poor
[40]
Anxiety State 23.55 ± 5.38 27.00 ± 10.27 30.07 ± 4.61 20.55 ± 7.69 21.28 ± 5.82 30.07 ± 7.93
Trait Anxiety 24.44 ± 8.95 26.00 ± 10.68 30.50 ± 5.01 NE 25.38 ± 10.35 NE
Carraro and Trait Anxiety 59.9 ± 2.9 38.1 ± 2.5 59.8 ± 4.3 57.2 ± 4.3
Good
Gobbi [41]
Zung Self-Rating
33.86 ± 1.99 25.00 ± 1.62 33.46 ± 1.94 31.62 ± 1.94
Anxiety Scale
Assessment and
Hardoy et al. Information Rating
3.2 ± 1.8 2.3 ± 1.3 2.8 ± 2.3 2.8 ± 2.3 Fair
[42] Profile Anxiety
Subscale
Salehpoor Zung’s Anxiety
43.15 ± 0.96 36.60 ± 1.10 43.75 ± 1.19 45.91 ± 1.46 Good
et al. [43] Scale (1997)
NE, not evaluated.
Healthcare 2021, 9, 1047 9 of 12

Taking into account the objectives of this systematic review, we found that all studies
that assessed anxiety had a decrease in its (anxiety) levels, through the implementation of
PE programs.
Figure 2 presents the meta-analysis results.

Figure 2. Summary of the descriptive and inferential statistics of the results of each study and the
overall effect size of the effect on the anxiety symptoms in individuals with disabilities.

The sum of the effects was 1.875, which means that individuals from the intervention
group presented approximately 1.9 times more probability to report improvements when
compared to the control group. The range of confidence for the difference in means was
0.632 (lower limit) to 3.117 (upper limit), which means that the raw mean difference, in
the universe of studies, may fall somewhere in this range. On the contrary, this range
did not include a zero difference, which means that the true difference of means (true
difference in means) is a value other than zero. The Z values (Z-values) obtained to test the
null hypothesis, according to which the difference of means was zero, demonstrated by
Z = 2.957, with a corresponding p-value of 0.003. Therefore, the null hypothesis can be
rejected, according to which PE does not affect the anxiety of individuals with disabilities.
The obtained value of Q was 69,291 with six degrees of freedom and a p-value <0.01.
Thus, we can reject the null hypothesis that the true effect size is the same in all studies.
On the contrary, the true effect size varied from study to study. In this meta-analysis,
the I2 value obtained was 91,341, which means approximately 91% of the variance in the
observed effects reflects the variance of true effects. T2 corresponds to the variance of
the true magnitude of the effects (true effect sizes) among that studies that, in this study,
presented a value of 2.482. The value of T, on the contrary, refers to the standard deviation
of the true magnitude of the effects, and in the present meta-analysis equaled 1.576.
In addition, the Egger test was carried out (Figure 3), which proposes to test the null
hypothesis according to which the intercept is equal to zero in the population. In Figure 2,
the intercept is 1,077,080, the 95% confidence interval is (615,969, 1,538,192), with t = 6.00445
and gl = 5. The recommended p-value (two-tailed) is 0.00184. Thus, there is statistical
evidence of the existence of publication bias. This reflects those smaller studies (which
appear toward the lower) are more likely to be published if they show effects greater than
the average, making them more likely to meet the criterion of statistical significance.
Healthcare 2021, 9, 1047 10 of 12

Figure 3. Funnel scatter plot to check publication bias.

4. Discussion
This systematic review with a meta-analysis aimed to identify if PE programs can be a
good method to reduce anxiety symptoms in the population with disabilities.
Intervention with a combination of factors (physical involvement, experience of skills
improvement, and social relationships) [37,39] could have an anxiety-reducing effect.
On the contrary, training with a modality not only promotes physical fitness and abilities
such as accuracy, but also strategic planning, mental toughness, comprehensive learn-
ing processes, and social exchange [36,39]. Although the methodologies were different,
socialization proved to be an important element for the success of PE programs.
It was observed that all interventions had positive effects at the level of the studied
variables. In addition to the physical benefits, PE is an affordable and inexpensive option
to reduce anxiety symptoms in the general population [17,18] and, as evidenced by our
systematic review with a meta-analysis, in the population with disabilities.
Institutions/organizations/clubs that provide support to the target population should
take into account the results of this study, namely, at the moment of planning strategies and
interventions for individuals with disabilities. In addition to promoting physical fitness,
PE reduces anxiety symptoms, being an asset to improving quality of life.
The present systematic review with a meta-analysis found only four studies that met
the eligibility criteria, which may have limited the results and conclusions of this study.
Therefore, the results should be considered with caution. At the same time, three of the
four studies included only included individuals with intellectual disabilities. This fact is an
indicator of the need to continue to implement PE programs among the population with
disabilities, in its various types, and to understand the effect that these programs can have,
not only in terms of physical health, but also mental health. Future studies should also
evaluate the impact of PE on reducing anxiety symptoms in different gender or age groups.
Moreover, the mechanisms involved in reducing anxiety symptoms must continue to be
investigated in order to better prescribe a PE program for individuals with disabilities.

5. Conclusions
Taking into account the results shown in this systematic review with a meta-analysis,
PE is a good method for reducing anxiety symptoms in individuals with disabilities, as well
as a good method to promote their quality of life.

Author Contributions: Conceptualization, M.J., R.F., R.M., and R.A.; methodology, M.J., R.F., and
R.A.; software, M.J.; validation, M.J., R.F., and R.A.; formal analysis, M.J., R.F., R.M., and R.A.;
investigation, M.J. and R.A.; resources, M.J. and R.A.; data curation, M.J.; writing – original draft
preparation, M.J.; writing—review and editing, M.J., R.F., R.M., and R.A.; visualization, M.J., R.F.,
R.M., and R.A.; supervision, M.J., R.F., R.M., and R.A.; project administration, M.J. All authors have
read and agreed to the published version of the manuscript.
Healthcare 2021, 9, 1047 11 of 12

Funding: This research was supported by the Portuguese Foundation for Science and Technology,
I.P., grant/award number UIDB/04748/2020.
Data Availability Statement: Additional data are available upon request to the corresponding author.
Conflicts of Interest: The authors have no conflict of interest to disclose.

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