Effectiveness and acceptability of exercise treatments for adults with anxiety disorders: a systematic review and network meta-analysis

Background: Anxiety disorders are persistent, functionally impairing conditions with high societal burden. In contrast, anxiety symptoms are elevated anxiety meeting scale thresholds (not formal diagnoses). While exercise is recognised as a complementary intervention for anxiety, the most effective mode of exercise for anxiety disorders remains unclear. Objective: To evaluate the effectiveness and acceptability of exercise treatments for adults with anxiety disorders via network meta-analysis. Methods: Systematic review and frequentist network meta-analysis were conducted, searching five databases (MEDLINE, EMBASE, PsycINFO, CENTRAL, SPORTDiscus) up to 1 March 2025. Treatments assessed included aerobic exercise, mind-body exercise (MBE), resistance training (RT), stretching, multicomponent exercise, cognitive-behavioral therapy, psychoeducation, waitlist control, usual care and placebo. Risk of bias was assessed using the Cochrane Risk of Bias Tool 2.0 (RoB 2.0). Outcomes included anxiety severity reduction (for effectiveness) and all-cause discontinuation rates (for acceptability). Results: 30 RCTs (1421 participants) were included: four had low risk, 19 some concerns and seven high risk. For combined anxiety conditions (anxiety disorders and symptoms), RT was most effective (standardised mean difference (SMD) -0.80, 95% CI -1.24 to -0.36, SUCRA 78.7%), followed by MBE (SMD -0.78, 95% CI -1.12 to -0.44, SUCRA 77.8%). For anxiety disorders, RT was most effective (SMD -0.79, 95% CI -1.18 to -0.40, SUCRA 78.5%) and MBE for anxiety symptoms (SMD -0.84, 95% CI -1.48 to -0.20, SUCRA 77.9%). No acceptability differences across treatments; network meta-regression showed diagnosis status did not alter effects. Conclusions: Both resistance exercise and MBE may be effective for anxiety disorders, with moderate certainty evidence. Acceptability remains unclear. Prospero registration number: CRD42024561238.