Healthy Stress Management (from ACSM's Resources for the Exercise Physiologist, 2nd edition)

Abstract

Chapter 13 of ACSM's Resources for the Exercise Physiologist. Health Stress Management.

Full text

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OBJECTIVES
Healthy Stress
Management
John B. Bartholomew and Matthew Stults-Kolehmainen •AQ1•
CHAPTER
13
 To examine the effects of stress on health behaviors
(including physical activity), well-being, and physical
health.
 To evaluate the role of exercise and how it may be uti-
lized effectively to manage acute and chronic stress.
 To identify the role of other techniques and resources in
effective stress management.
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ACSM’s Resources for the Certified Exercise Physiologist • www.acsm.org
INTRODUCTION
Psychological stress is an enduring and relevant issue for the health care and fitness
professional. For instance, a wide swath of society reports being stressed, as deter-
mined by the Stress in America investigation (6). This report, published annually by
the American Psychological Association, found that during the financial crisis of
the late 2000s, this score was greater than 6 (on a 1–10 scale, with 10 being “a great
deal of stress”) (6). Although the average score has dropped to just under 5 in 2014
— indicating improving conditions — it remains a reasonably high level of stress.
This report also corroborates a large literature that has generally found stress to
negatively impact health. Specifically, stress has been linked with the common cold,
development of chronic illness, including cardiovascular disease and stroke, and
worsening of autonomic diseases, such as multiple sclerosis (MS), and premature
death (31). How stress and health are connected is complex, but likely involves the
effects of stress on motivation for and practice of health behaviors, both positive
(e.g., exercise and physical activity) and negative (e.g., illicit drug use). Exercise, on the
other hand, is typically a productive way to cope with stress, and a growing literature
indicates that exercise programs have a positive impact on perceptions of stress.
Many other stress management techniques have also been successfully utilized,
such as mindfulness meditation, biofeedback and massage. Lastly, it goes without
saying that this concept is also personally relevant because exercise professionals —
like anyone else — are not immune to the effects of stress.
Definition and Characteristics of Stress
Stress is a popular term in today’s vocabulary, used in regular, everyday language (109). People often
use the word stress to express uncomfortable situations in life, with phrases such as “I feel stressed
out” or “my job is stressful,” and the word is often used to refer to pressure or tension (109). In fact,
if you search books for these terms (https://books.google.com/ngrams; used January 13, 2017), it
is clear that use of the words “stressful” and “stressed out” are still exponentially increasing, indi-
cating a clear and continued relevance for today’s society. Likewise, “stress” ranks in the top 2,100
of English words currently used, more common than words like “actions,” “improved,” “milk,” and
“spot” (http://www.wordcount.org; used January 13, 2017).
From a scientific perspective, however, stress is defined as the process by which one responds to
an environmental demand that is perceived as threatening (109). Understanding the interaction
between the environment and the person is important — essentially, stress occurs whenever an en-
vironmental demand taxes one’s resources (68). This discrepancy between demands and resources
elicits a physiological response that compensates for the disturbance and restores equilibrium (ho-
meostasis). The specific pattern of responses may be physical (e.g., increased heart rate or blood
pressure), behavioral (e.g., increased movement, such as pacing), psychological (e.g., emotional
distress), or a combination of these reactions (109). If demands exceed resources over a long period
of time one’s well-being may be endangered, and the inability of the body to cope properly and
restore homeostasis after exposure to a stressor can result in biological or psychological damage
(119). Stress encompasses this full process — from demand to response and recovery. As such, it is
important to consider the component parts.
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3Chapter 13 Healthy Stress Management
The stimulus, or environmental demand, is known as a stressor. Stressors have a diverse set
of sources and characteristics. To start, the source of a stressor can come from within the person
(e.g., a health problem), the family (e.g., divorce), the community (e.g., crime, traffic), or the society
(e.g., civil unrest). Stressors vary in intensity, from mild (e.g., waiting in a long line) to severe (e.g.,
witnessing the 911 tragedy). Stressors differ in their time course, from infrequently to very often.
For example, chronic stress is often thought of as the steady accumulation of minor, everyday chal-
lenges, such as daily demands from clients or patients at work (90). Chronic stress could also be
described as the long-term grinding kind of stress, and some examples of this might be: poverty,
demanding jobs with long work hours, or poor relationships (133). The duration of a stressor can
also be acute, as in an immediate “fight or flight” response (e.g., seeing a snake). The duration of
the stressor is not always easy to determine. For example, a major life event, such as experiencing a
car wreck, may in itself only last seconds, but the repercussions may be long-lasting. Stressors that
are severe, occur often, and of longer duration are considered to be the most impactful and poten-
tially damaging. However, even small incidents in everyday life (i.e., daily hassles) such as giving
a speech, encountering heavy traffic, or misplacing keys can be perceived as stressful and possibly
have a larger effect as they occur consistently over time. That is, recent minor life events, major life
events, and traumatic events can add up to form cumulative adversity. Thus, any single stressor or
event may not be considered a significant disturbance in isolation, but the additive effect of these
may be damaging (130).
Importantly, not all stressors are perceived as negative; indeed, some stress is considered favor-
able and adaptive. Good stress, or eustress, is considered to be a pleasant and stimulating experi-
ence that promotes growth, development, and improvement in performance (93). An example of
this type of stress might be a marriage, addition to the family, or a job promotion (109). Conversely,
bad stress or distress is negative and more likely to be disruptive. An example of this type of stress
could include being diagnosed with an incurable illness or loss of employment. However, the
perception that an event is stressful depends entirely on the individual and his or her appraisal
process and resources needed to meet the demand. These will be addressed in the next section on
the appraisal of stress.
Appraisal of Stress
According to the transactional model of stress and coping, the impact of a stressor is largely based
on one’s cognitive appraisal of two components, namely the event’s threat (primary appraisal) and
availability of resources (secondary appraisal) (28,67,68). In primary appraisal, individuals gauge
both their susceptibility to and the severity of the threat by asking questions such as “What does
this mean to me?” and “Will I be in trouble?” The significance of a stressor is further refined by one’s
expectations of future harm and potential for achieving growth, mastery, and additional resources.
These appraisals may, therefore, result in perceptions of positive challenge instead of negative threat
(113). For example, a sedentary person starting a new exercise routine may perceive a bout of exer-
cise as unsafe and thus injurious, or he may think of it as fairly benign, fun, and challenging. With
secondary appraisal, one evaluates their resources to control and cope with the stressor to either
alter the situation or at least manage the emotional reaction. For secondary appraisal, individuals
evaluate (a) their resources available to cope with the stressor (perceived control over the threat),
(b) their emotional reaction (perceived control over feelings), and finally, (c) their ability to deal ef-
fectively with the resources concerning the burden of stress (coping self-efficacy) (51). For example,
exercise may be less threatening if a new exerciser perceives that she has adequate resources to deal
with the experience (e.g., plenty of water, time to take breaks, someone to ask for help), the ability
to manage these resources (e.g., use of a smartphone application, ability to approach someone for
guidance) and the ability to manage emotions (e.g., minimize feelings of hurt or pain). Each of
these is a part of the coping process — a process that is critical for understanding the impact of a
given demand on each person’s response.
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Coping
Coping is what people do to alleviate, eliminate, or manage stress, and this term has as many
meanings as the term stress. Coping activities are geared toward decreasing the person’s appraisal
of (or concern of) the discrepancy between the demands of the situation and the resources of
the person (113). Coping is an ongoing, dynamic process that involves continuous appraisals and
reappraisals of the shifting person–environment relationship (68). That means that coping reflects
our efforts to both manage the demands of a situation as well as our response to those demands.
In general, to neutralize or reduce stress, a person will attempt to change the environment, their
perception of it, or the meaning of the stressor. The transactional model of stress and coping
suggests that appraisals influence and predict the specific coping processes implemented during
a stressful event (68). According to the original model, coping efforts were conceptualized in two
dimensions, problem management (i.e., problem-focused coping) and emotional regulation (i.e.,
emotion-focused coping).
Problem-Focused Coping
In problem-focused coping, the person attempts to modify the nature of the stressor by either
reducing the demands of the stressful situation or expanding his or her resources to deal with it
(113). This type of coping may include actively seeking out information, talking with a profes-
sional or friend to get advice on how to handle the problem, or drawing from previous experience
and knowledge to brainstorm, weigh alternatives, and make plans — all in an attempt to resolve
the problem (51). Examples of problem-focused coping in everyday life would be negotiating an
extension on an assignment, learning a new skill (e.g., time management, assertiveness training),
making a new relationship with someone who has expertise in the problem area, or seeking out a
less stressful job (113). This type of coping is most often used when people believe that either the
personal resources or the demands of the situation are changeable (68), thereby resulting in the
perception of control and self-efficacy (51).
Emotion-Focused Coping
Emotional regulation is a more passive coping effort where the person attempts to control or
manage the emotional response to a stressful event, particularly one that is difficult to change.
In this type of coping, people engage in behaviors to distract their attention from the problem
or to simply make themselves feel better. In the 2015 Stress in America report, nearly one-half of
respondents endorsed exercise/walking to deal with stress. Respondents also endorsed listening to
music, watching TV, surfing the Internet, napping/sleeping, eating, drinking alcohol, and smoking
to manage stress (in that order). As can be seen in this list, not all emotion-focused coping would
be considered unproductive or negative. Some are positive pursuits which help a person endure a
temporary period of emotional distress. The key difference from problem-focused coping is that
the person is trying to modify their emotional response rather than dealing with the challenge.
People tend to use emotion-focused coping when they believe that the circumstances they are
facing are fixed and they cannot change their stressful condition (68). When a stressor is appraised
as uncontrollable and highly threatening, individuals often adopt disengaging or passive coping
strategies (134). One may attempt to alter thoughts about the stressful situation; denying, distanc-
ing, and avoiding the situation (51). Unfortunately, escape-avoidance behavior (e.g., hiding feelings,
refusing to think about illness or situation) has been associated with higher levels of psychological
distress and poorer quality of life (10,138). Accepting responsibility (which involves acknowledging
the role one has played in the situation and trying to make things right) and positive reappraisal
(which involves choosing to create a positive meaning from the situation, rather than a negative
meaning) are more effective techniques. Recent evidence indicates that suppressing thoughts about
One common stressor in the health and fitness setting is the stress of receiving a fitness or body
composition assessment. For some, this may be a time of excitement (e.g., eustress) about start-
ing (or completing) a training regimen. For others, facing objective data about their lack of phys-
ical conditioning may elicit feelings of threat and dread (e.g., distress). Feedback about one’s
fitness and performance may be most intimidating for individuals lacking adequate baseline
fitness and training experience. In a study investigating the response to body composition testing
with dual-energy x-ray absorptiometry (DXA), all participants responded with a decline in positive
affect (e.g., enthusiasm, high energy, alertness) (44). Clearly, seeing an image that depicts your
body fat may create a sense of displeasure for anyone. However, an increase in negative affect
(e.g., distress, anger, guilt), was only observed for overweight and obese individuals, for whom
feedback about body fat may have been a particularly threatening experience. Later research
(45) suggests that this negative emotional response may actually undermine future motivation
for exercise and diet. Specifically, those with a negative response reported eating significantly
greater amounts calorically dense and highly palatable foods in the week following testing (i.e.,
ice cream) (45). This suggests that fitness professionals must be aware of the potential of their
feedback to clients to increase stress and undermine their goals of an active, healthy lifestyle.
Sometimes, negative feedback is important, but it is just as important to help the client cope
with this information through problem-focused (e.g., choosing an appropriate exercise program)
and emotion-focused (e.g., encouragement, comparison to former clients who improved) efforts.
•AQ2•
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5Chapter 13 Healthy Stress Management
the stressful event and the experience of the event have no positive impact on coping with feelings
(142). Conversely, reappraising the emotional stimulus and using cognitive techniques like per-
spective taking are the most effective (142).
Depending on the individual and the situation, a person may be more inclined to engage either
in problem-focused or in emotion-focused coping (47,48). However, both may be necessary and
therefore will be used in combination with each other to manage emotions in the short term but
also engage in active, problem solving. Exercise, such as a short walk around the block, is an excel-
lent way to help temporarily manage distress (41). Once the person is more calm and focused, it is
easier to initiate efforts to deal with the challenge.
The Response to Stress
Stress has a combined and interrelated impact on the physiological and psychological aspects of
a person, including bodily systems, mental processes (e.g., distress, negative affect), and behaviors.
The physiological and psychological response of a person to a stressor is called strain. Strain, if
severe or prolonged, can negatively affect the functioning and health of a person, increase illness
vulnerability, and worsen disease progression and activity (90).
When an event or stimulus exceeds one’s capacity (e.g., is stressful), the body elicits an immedi-
ate response to counteract the disturbance and restore homeostatic balance. The stress response is
similar across species and is, therefore, often referred to as the general adaptation syndrome. This
response has three main stages of varied and undefined duration, although the specific response
depends on the characteristics of the individual (e.g., fitness, personality) and their appraisal,
amongst other factors. If stressors begin to accumulate — and recovery is inadequate — a person
may begin to experience excessive wear and tear or allostatic load where stress responses become
dysregulated and ineffective. The next sections will describe both the general adaptation syndrome
and allostatic load model in more detail (92).
One common stressor in the health and fitness setting is the stress of receiving a fitness or body
composition assessment. For some, this may be a time of excitement (e.g., eustress) about start-
ing (or completing) a training regimen. For others, facing objective data about their lack of phys-
ical conditioning may elicit feelings of threat and dread (e.g., distress). Feedback about one’s
fitness and performance may be most intimidating for individuals lacking adequate baseline
fitness and training experience. In a study investigating the response to body composition testing
with dual-energy x-ray absorptiometry (DXA), all participants responded with a decline in positive
affect (e.g., enthusiasm, high energy, alertness) (44). Clearly, seeing an image that depicts your
body fat may create a sense of displeasure for anyone. However, an increase in negative affect
(e.g., distress, anger, guilt), was only observed for overweight and obese individuals, for whom
feedback about body fat may have been a particularly threatening experience. Later research
(45) suggests that this negative emotional response may actually undermine future motivation
for exercise and diet. Specifically, those with a negative response reported eating significantly
greater amounts calorically dense and highly palatable foods in the week following testing (i.e.,
ice cream) (45). This suggests that fitness professionals must be aware of the potential of their
feedback to clients to increase stress and undermine their goals of an active, healthy lifestyle.
Sometimes, negative feedback is important, but it is just as important to help the client cope
with this information through problem-focused (e.g., choosing an appropriate exercise program)
and emotion-focused (e.g., encouragement, comparison to former clients who improved) efforts.
•AQ2•
HOW TO The Experience of Stress and Coping Associated with
Fitness Testing
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General Adaptation Syndrome
The physiologic stress response of the body was first theorized by Hans Selye (188), who later
became known as the father of stress research. Selye conducted experiments that exposed animals
to various and diverse homeostatic challenges such as heat, cold, infection, and toxic substances
and objectively measured physiological changes. The reaction to each stressor varied respectively
according to its unique characteristics, but his primary finding was an underlying nonspecific re-
sponse pattern that was consistent across the different stressors. This stereotypical response pattern
of stress was coined the general adaptation syndrome (GAS).
The GAS consists of three broad stages, each with a wide variety of nonspecific and specific re-
sponses, all working together to restore homeostasis and ensure the survival of the organism. The
first stage is called the alarm reaction, where the stressor is first recognized by the system and a fight-
or-flight response is initiated (118). The second stage is that of resistance, where a cascade of cardio-
vascular, metabolic, hormonal, and immune changes is generated as a compensatory stress reaction
(113). During this stage, some compensatory reactions may include the release of glucocorticoids (e.g.,
cortisol), the activation of the hypothalamic–pituitary–adrenal (HPA) axis, and changes in autonomic
neurotransmitters and inflammatory cytokines (92). The last stage is that of exhaustion, when the or-
ganism has depleted all biochemical substrates and additional resources and is no longer able to mount
a defense to the stressor (118). If the stressor continues and activation of these systems is extended for
a long period, the bodily systems can eventually break down and result in dysfunction of major organs
(e.g., heart or brain). In extreme situations, stress-related exhaustion has the capacity to result in death
(118). On the basis of GAS, the impact of repeated stress exposure can be problematic because indi-
viduals who remain in the resistance phase have difficulty withstanding additional challenges (118).
For example, there is evidence that those experiencing higher levels of chronic, unremitting stress have
difficulty recovering from strenuous resistance exercise, taking two to four times as long to recover as
those reporting lower levels of chronic stress (125,126) (see Exercise is Medicine Connection).
Stress and Recovery, Implications for Exercise and Adaptation
How people respond to a bout of exercise is also impacted by the
experience of stress in their lives. The stress response can essen-
tially be divided into two phases, reactivity and recovery (return to
homeostasis). The physical and metabolic stress of exercise results
in decrements of function initially. For instance, after completing a vigorous bout of resistance
training muscles that have been exercised will be fatigued and unable to generate high force. Such
a response is typically followed by quick rebound and adaptation, but these processes and the
speed of recovery can vary greatly between individuals, from 24 to 96 hours for recovery. Chronic
psychological stress includes things like changing jobs, poor performance in a class, and ending a
relationship. College students who reported higher chronic stress also had much slower recovery
from heavy resistance training (125,126). That is, even though they did the same challenging bout
of exercise — multiple repetitions on a leg press machine — they needed almost 4 days to fully
recover from the activity. In contrast, a person reporting lower stress recovered in about 1 day.
Such an effect may help to account for why some individuals respond to exercise with positive
adaptations, while others have little to no change (83). Indeed, those reporting higher chronic
stress have been shown to gain less strength over a multi-month resistance training program (16).
Some of this may be due to interference from the stress response. That is, higher cortisol levels
may undermine recovery. It may also be due to how these people cope with stress (e.g., problems
with sleep, or change in diet). Regardless, it is important for fitness professionals to be aware of the
stress of their clients and how this might impact their training.
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7Chapter 13 Healthy Stress Management
Allostasis and Allostatic Load Model
Allostasis is the ability to achieve stability through change, and the allostatic load model refers to
the rapid activation of bodily systems to cope with a stressor and restore homeostasis as effectively
and efficiently as possible (90). In regard to allostasis, all of the systems in the body are involved,
including the autonomic nervous system and HPA axis along with the cardiovascular, immune, and
metabolic systems (90). However, if the body does not compensate well and the wear and tear of
repeated stressors on the body accumulates (i.e., allostatic load), then there is an increased risk of
the development of physical ailments (91). Overactivity of the allostatic systems, where there is lim-
ited time for rest and restoration, can increase the risk of cardiovascular disease (75). Sometimes,
the body is unable to stop or shut off the stress response even after the stressor has ended. When
this occurs, the systems can be driven to exhaustion resulting in the breakdown of feedback mech-
anisms and overexposure to stress hormones such as cortisol (75). Stress, chronic and acute, minor
and severe, can have an impact on the functioning of an individual. Likewise, any accumulation of
a certain type of stressor or combination of various stressors can be damaging to one’s health (104).
This explains the link between stress and health outcomes, which are detailed in the following text.
The Effects of Stress on Health
Stress has consistently been related to poor physical and mental health (93,130). The physical changes
in response to chronic or intense stress can lead to, contribute to, or worsen life-threatening and
life-altering conditions such as myocardial infarction, stroke, cancer, or autonomic diseases. In the
Stress in America report, respondents disclosed that stress was impacting their health to such a degree
that the report was entitled “Paying with Our Health” (6). The American Institute of Stress (3) has
compiled a list of several signs and symptoms of excessive stress (Table 13.1), and this list includes
physical, emotional, and behavioral responses and conditions. Some of these symptoms are relatively
mild, such as blushing and headaches, while others are serious, such as social isolation and excessive
drug use. The American Psychological Association (4) notes that there are not always symptoms
associated with the experience of stress. For instance, some symptoms may be camouflaged by med-
ications. The following sections describe some of the most common stress-related health problems.
Digestive Issues
Ulcers, inflammatory bowel disease, and irritable bowel syndrome are all disorders in the digestive
tract that are influenced by stress (113). Ulcers are due to an increase in gastric juices and erosion of
the lining of the stomach or upper small intestine. Inflammatory bowel disease may involve inflam-
mation of the colon and small intestine, whereas irritable bowel syndrome may involve diarrhea,
constipation, and abdominal pain (113). The connection between stress and digestive tract prob-
lems has been linked to alternations in bacterial growth in the gut, but many other mechanisms
likely play a role (89).
Headaches
Intense headaches can also be a physical disorder that results from exposure to chronic stress.
The two most common recurrent headaches are migraines and tension-type headaches (72,105).
Migraines are typified by intense throbbing and pulsating sensations in the head, often accom-
panied by sensations of nausea and sensitivity to stimuli. Stress is the most common trigger for
the development of migraines but may also magnify the effects of migraines (114). Tension-type
headaches are the result of the contraction and tightening of muscles in the neck and head, which
is a common reaction of persons under stress (113). In both cases, the strain of the headache itself
is a stressor, necessitating a coping response, the selection of which may have effects on choices to
be physically active or sedentary (66).
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Cardiovascular, Metabolic Diseases and the Role of Cortisol
Unresolved, chronic stress profoundly affects the cardiovascular system, including the heart, blood
vessels, and blood itself (124). High levels of stress have been associated with abnormally enlarged
hearts and hypertension (115). These changes in the heart and blood vessels can increase cardio-
vascular reactivity to a stressor, which is considered a risk factor for the development of coronary
heart disease (84,121). Persons under stress have higher concentrations of activated platelets
(82,100) and more triglycerides, free fatty acids, and lipoproteins in the blood (76,99,141), which
promote the development of plaques in the arteries, or atherosclerosis leading to increased blood
pressure and increased likelihood of myocardial infarction and stroke (113). Corticosteroids,
specifically cortisol, are released in response to a stressful event (especially social stressors), and
1. Frequent headaches, jaw clenching, or pain 26. Insomnia, nightmares, disturbing dreams
2. Gritting, grinding teeth 27. Difficulty concentrating, racing thoughts
3. Stuttering or stammering 28. Trouble learning new information
4. Tremors, trembling of lips, hands 29. Forgetfulness, disorganization, confusion
5. Neck ache, back pain, muscle spasms 30. Difficulty in making decisions
6. Light-headedness, faintness, dizziness 31. Feeling overloaded or overwhelmed
7. Ringing, buzzing, or popping sounds 32. Frequent crying spells or suicidal thoughts
8. Frequent blushing, sweating 33. Feelings of loneliness or worthlessness
9. Cold or sweaty hands, feet 34. Little interest in appearance, punctuality
10. Dry mouth, problems swallowing 35. Nervous habits, fidgeting, feet tapping
11. Frequent colds, infections, herpes sores 36. Increased frustration, irritability, edginess
12. Rashes, itching, hives, “goose bumps” 37. Overreaction to petty annoyances
13. Unexplained or frequent “allergy” attacks 38. Increased number of minor accidents
14. Heartburn, stomach pain, nausea 39. Obsessive or compulsive behavior
15. Excess belching, flatulence 40. Reduced work efficiency or productivity
16. Constipation, diarrhea 41. Lies or excuses to cover up poor work
17. Difficulty breathing, sighing 42. Rapid or mumbled speech
18. Sudden attacks of panic 43. Excessive defensiveness or suspiciousness
19. Chest pain, palpitations 44. Problems in communication, sharing
20. Frequent urination 45. Social withdrawal and isolation
21. Poor sexual desire or performance 46. Constant tiredness, weakness, fatigue
22. Excess anxiety, worry, guilt, nervousness 47. Frequent use of over-the-counter drugs
23. Increased anger, frustration, hostility 48. Weight gain or loss without diet
24. Depression, frequent, or wild mood swings 49. Increased smoking, alcohol, or drug use
25. Increased or decreased appetite 50. Excessive gambling or impulse buying
Table 13.1 Signs and Symptoms of Excessive Stress
Source: Adapted with permission from http://www.stress.org/stress-effects/.
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9Chapter 13 Healthy Stress Management
high concentrations of cortisol in the blood over time can increase the risks of cardiovascular
disease (75,76). In addition, by blocking the uptake of glucose from the cells, high levels of corti-
sol increase insulin resistance and can lead to the development of Type 2 diabetes (76). Cortisol
also contributes to the accumulation of fat in the abdominal region, and this visceral fat is readily
released into the bloodstream. Overall, stress can have a major impact on the functioning of the
cardiovascular and metabolic systems and can lead to the development and progression of cardio-
vascular pathologies.
Immune Suppression, Cancer, and Multiple Sclerosis
The immune systems of persons exposed to chronic, severe stress are often suppressed, rendering
a person more vulnerable to infections and susceptible to contracting a disease (29). In fact, Selye
observed that animals exposed to a stressor had a reduction in the size of immune system organs,
such as the thymus gland (74,118). The sympathetic nervous system activity and the release of
cortisol after a stressful event suppress the immune system, which limits the number of lympho-
cytes that are activated in response to a viral challenge (74). For example, among mice exposed
to repeated restraint stress, there was a decrease in the production of antibodies and activation of
T cells in response to the influenza virus (120). Among humans who were exposed to the com-
mon cold virus, those who had high stress developed cold symptoms at nearly twice the rate of
who had low stress (33). Similarly, psychological stress has been correlated with a reduction in
and activity of natural killer (NK) cells, which combat cancerous tumor cells and monitor neo-
plastic (new and abnormal) growth (52,55,73). NK cell activity is considered to be important to
survival rates in certain types of cancers, specifically breast cancer (70). Experiencing major social
stressors in the previous 5 years, such as marital divorce, infidelity, quarreling, and financial prob-
lems, has been associated with an increased risk or likelihood of being diagnosed with cervical
cancer (36). There is a lack of evidence in well-controlled studies linking stress with the onset of
cancer; however, specific stressors — such as loss of social support — have been found to influ-
ence the course of cancer (133). Depression, stress, and trauma have all adversely affected disease
progression in patients with HIV, and negative beliefs and expectations about the disease and
one’s future are associated with declines in helper T cells (CD4) and the onset of AIDS (69,117).
Finally, there is a significant association between stressful life events and relapse incidence of
multiple sclerosis (MS) (96). In one study, the majority of MS relapses were associated with one
or more stressful life events occurring in the 6 weeks prior (1). Overall, the functioning of the
immune system in fighting off viruses, infections, cancer, and autonomic diseases can be severely
compromised because of stress.
Stress and Psychological Functioning
The impact of stress is not limited to the physical body. Stress can affect psychological well-being,
cognitive function, emotion (e.g., distress, negative moods), social involvement, and behavior, such
as physical activity and sedentarism (129). There are several psychological conditions that can be
influenced by chronic stress such as anxiety, depression, fatigue, insomnia, and burnout, and these
conditions can have a profound negative impact on quality of life.
Psychological Distress, Depression, and Burnout
Chronic stress has been shown to promote psychological distress and the development of psy-
chological disorders (64,133). Research studies have shown that people who report exposure to
chronic stress in their marriage, household functioning, parenting, or jobs have an increased
likelihood of being psychologically distressed (101). Chronic stress is a greater predictor of
depressive symptoms than acute stress, and if it is experienced over 2 years or more, it may lead
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to the development of depression (94). In addition, chronic stress of any type can magnify the
impact of even minimal life events on clinical depression (23). Persons who continually deal
with exposure to high levels of occupational stress can develop a psychological response called
burnout. Burnout is characterized by physical, mental, and emotional exhaustion (109). Burnout
is defined as a debilitating psychological condition brought about by unrelieved work stress,
which results in (a) depleted energy reserves, (b) lowered resistance to illness, (c) increased
dissatisfactions and pessimism, and (d) increased absenteeism and inefficiency at work (109).
Employees who experience burnout may develop a variety of symptoms, including overall job
dissatisfaction, lack of energy and insomnia, tension headaches, ulcers, and dysregulated cortisol
responses (107,109).
Cognition
High levels of cortisol associated with long or extreme exposure to stress have been related to cogni-
tive impairment, specifically in spatial memory tasks (20,76,110). This may be because the elevated
levels of glucocorticoids (i.e., cortisol) are associated with shrinkage and toxic degeneration of the
brain’s memory center, the hippocampus, in which loss of neurons and their connectivity occurs
(77–79,85,112). Burnout symptoms (described earlier) have been associated with cognitive failures
in everyday life, increased inhibition errors, and variability in performance on attention tasks (140).
Fortunately, exercise has the opposite effect, promoting memory and cognitive performance and
delaying the onset of dementia (56).
Healthy Stress Management
Although stressful events are unavoidable in daily life, the majority of people would prefer to limit
or manage the amount of exposure to stress. Currently, there is no drug that can be taken or ritual
that can be performed to make people “immune” to stress and stressors, but there are several strate-
gies for coping and managing stress. Both cognitive and behavioral approaches exist for decreasing
the negative impact of stress. Not all strategies work for everyone, but all play a role in preventing
or reducing stress and stress reactivity.
Exercise: Breaking the Link between Stress and Health Problems
Although the bulk of this chapter has focused on the negative impact of stress, it is encouraging
that the majority of studies demonstrate that exercise may neutralize this impact (26,49,130).
For example, men who report increased levels of exercise behavior also reported fewer health
problems across all levels of reported lifetime exposure to stress (130). Likewise, a study of
college students with high stress and low levels of leisure physical activity experienced more
physical symptoms and anxiety than did those students engaging in high levels of physical
activity (47). Given this, it is important to more fully explore the relationship between exercise
and stress.
Exercise
Physical exercise is one of the most cited means of managing stress (135). This recommendation
is found in any number of news reports, magazine articles, and blogs. Why would exercise be so
effective at managing stress? As was illustrated in the earlier discussion of the GAS and the alarm
reaction, the stress response is a set of physiological changes that disrupt homeostasis as it readies
the body for action — fight or flight. Unfortunately, most stress is psychological in nature (e.g.,
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11Chapter 13 Healthy Stress Management
exams, relational problems). Not only are these generally not reduced through physical action —
they can be made worse if the action is misplaced. This mismatch between the form of stress and
the body’s reaction can lead to a long-duration disruption of homeostasis that undermines physical
and mental health. Thus, one way to think about coping with stress is to find a physical action that
can make use of the alarm reaction.
Acute bouts of exercise have been shown to effectively serve this role and reduce the stress
response. One of the best examples of this is the ability of a single bout of exercise to reduce
feelings of anxiety and other negative moods. The benefit of exercise for state anxiety is very
consistent, and occurs with nearly all forms of activity — especially those of moderate to low
intensity (43,102). Although the benefit of exercise to improve mood and reduce stress also ap-
plies to resistance exercise (14), one should be cautious with high-intensity resistance exercise.
Continuous exercise above lactate threshold has consistently been shown to reduce mood during
exercise (42), which may serve to undermine its effectiveness for stress management. A closer
examination of this effect has revealed that high-intensity exercise may increase somatic anxi-
ety during exercise, but cognitive aspects of anxiety remain unaltered and both reduce during
recovery (19).
What is especially interesting is that exercise may also be of benefit to those who are living with
chronic mental health conditions. For example, exercise is sufficient to help manage anxiety and
mood in those who are clinically depressed (15). In fact, for those with a history of depression,
as little as 15 minutes of self-selected cycle exercise was enough to improve mood (88). In addi-
tion, exercise training has been associated with reductions in clinical levels of ongoing stress (7).
Studies have shown a significant reduction in stress across a range of conditions, from panic dis-
order (22) to posttraumatic stress disorder (PTSD) (40), and in a variety of populations, including
methadone-maintained drug abusers (38). Chronic occupational stress (49) and perceived stress
(98) also improve with several months of aerobic training.
Although there is no well-accepted mechanism to explain this effect, it has been suggested
that the improvement in managing stress may be due to the ability of exercise to improve pos-
itive emotions, which in turn are reduced by sedentary behaviors (57). This, in turn, allows for
the development of other psychological resources to combat the experience of stress (57). For
example, 20 minutes of low- to moderate-intensity treadmill exercise appears to be sufficient to
reduce sensitivity to anxiety (21). Moreover, a bout of exercise, especially higher doses of activity
(either high intensity or long duration) can actually reduce a person’s physiological response
to a later stressor (53). That is, on the days that a person completes a bout of exercise, they can
expect to have less physiological response to stress for the next hour or two than if they had
been sedentary.
Interestingly, despite the benefits of exercise on perceptions of stress, the experience of stressors
impedes efforts to be physically active (129). For example, those reporting high levels of chronic
stress experience dampened responses to exercise — lower pleasure and arousal but higher rat-
ings of perceived exertion (RPE) and pain, which may be a signal of dysregulation (80,128). Not
surprisingly, those who are less habitual in their exercise routines respond to periods of stress
with less physical activity (80). In contrast, those who have strong exercise habits appear to be
resilient in the face of stress and maintain their levels of activity (80). This may be due to the use
of exercise as a form of coping. Regardless, those who are inconsistently active — and are likely to
need help from an exercise professional the most — appear to be the least likely to adhere to an
exercise program. This may impact how the exercise prescription should be presented to these in-
dividuals. For example, among highly active individuals, enjoyment is the primary motive behind
exercise, whereas only a small percentage of highly active individuals report stress management
as a reason they exercise (127). Branding exercise for its ability to enhance fun, enjoyment and
challenge may be more important than advocating its therapeutic effects on mental and physical
health (116).
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12
ACSM’s Resources for the Certified Exercise Physiologist • www.acsm.org
The most common instrument used to assess perception of chronic stress is the 10-item version
of the Perceived Stress Scale (PSS-10), which measures stress perceptions over the previous
month (30,32,34).
Brief Instructions and Tips
1. The questions in this scale ask you about your feelings and thoughts during the last month.
2. Beside each item, indicate the frequency of these feelings and thoughts (0  never, 1  almost
never, 2  sometimes, 3  fairly often, and 4  very often).
3. The best approach is to answer fairly quickly. That is, don’t try to count up the number of
times you felt a particular way that month but rather choose the option that seems like a
reasonable estimate.
4. After completing the questions, use the table called “Perceived Stress Scale Scoring” to
determine your score.
Question Never
Almost
Never Sometimes
Fairly
Often Very Often
1. How often have you been
upset because of something
that happened unexpectedly?
01234
2. How often have you felt that
you were unable to control the
important things in your life?
01234
3. How often have you felt ner-
vous and “stressed”?
01234
4. How often have you felt
confident about your ability
to handle your personal
problems?
01234
5. How often have you felt that
things were going your way?
01234
6. How often have you found that
you could not cope with all the
things that you had to do?
01234
7. How often have you been
able to control irritations in
your life?
01234
8. How often have you felt that
you were on top of things?
01234
9. How often have you been an-
gered because of things that
happened that were outside
of your control?
01234
10. How often have you felt diffi-
culties were piling up so high
that you could not overcome
them?
01234
HOW TO Rate Chronic Perceived Stress
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13Chapter 13 Healthy Stress Management
Other Modifiers or Buffers of Stress
Enhancing Social Support
Stress is typically perceived when demands outweigh resources. A key resource is social support.
When social resources are low, stressors may be particularly dire. In contrast, evidence indicates
that social support has a buffering effect on the harmful physical and mental effects of stress expo-
sure (136). It also enhances well-being and health, regardless of stress levels (18). People typically
seek out and rely on help and comfort from friends, neighbors, classmates, coworkers, significant
others, and health professionals, including fitness professionals (123,139).
Four types or functions of social support exist (59):
 Emotional support — the provision of empathy, love, trust, and caring (e.g., actively listening to
concerns)
 Instrumental support — the provision of tangible aid and services that directly meet a need (e.g.,
providing services at no additional cost to client when they are experiencing a traumatic stressor)
 Informational support — the provision of advice and information concerning the problem (e.g.,
understanding why an issue is causing significant stress)
 Appraisal support — the provision of information useful for self-evaluation purposes such as
constructive feedback and affirmation (e.g., helping client brainstorm possible solutions to a
problem)
Perceived Stress Scale Scoring
PSS scores are obtained by reversing responses (e.g., 0  4, 1  3, 2  2, 3  1 and 4  0) to
the four positively stated items (items 4, 5, 7, and 8) and then summing across all scale items.
Item Your response (0–4) Reverse score needed? Final item score
1 No
2 No
3 No
4 Yes
5 Yes
6 No
7 Yes
8 Yes
9 No
10 No
Grand total score 
Interpretation and Normative Values
The scores can range from 0 to 40, and higher scores reflect a higher level of perceived
stress. High scores on the PSS-10 questionnaire have been associated with increased dif-
ficulty in making lifestyle changes, such as adopting physical activity, and increased sus-
ceptibility to stress-induced illness (129). Men in the United States have an average score
of about 12 and women have an average of about 14, but scores significantly vary by
race or ethnicity (i.e., African Americans average about 15), age (i.e., people 29 years and
younger have the highest reported stress) and education (i.e., less educated people are
more stressed) (30,34).
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ACSM’s Resources for the Certified Exercise Physiologist • www.acsm.org
All types of support may be offered by a fitness professional. However, given the situation and
client, some types of support are more important and appropriate than others. The matching
hypothesis suggests that social support is most beneficial when it meets the needs caused by a
stressful event (35). Consider this real life scenario. A patient of a clinical exercise physiologist
(CEP) experienced traumatic flooding of his home midway through a training phase. The CEP
provided an ideal amount of social support; expressing empathy and genuine concern, placing the
training sessions on hold (with no penalty) and providing tips on maintaining fitness when stay-
ing out of town. Social aspects of exercise (e.g., walking with a friend) were emphasized. Later, the
CEP provided feedback on reinitiating a serious routine once the client was ready. A referral was
also made to a social worker, who provided additional assistance, helped the client to strengthen
existing relationships, expand their social network and develop new relationships, and get in-
volved in a self-help group. All of these actions improved social support resources (54,59,113,132)
and helped the client to manage their experience of a stressful event without sacrificing their
health goals.
The mechanism for how social support improves health and well-being is not clear. Social
support may improve coping responses by reducing uncertainty and unpredictability about a
stressful situation. This would, in turn, promote a greater sense of personal control and the use of
problem-focused coping methods (54). It may also be that social support merely relieves some of
the stressor-related demands through a sharing of the burden. Regardless, the many forms of social
support are an important contributor to the ability of people to cope with stress.
Improving Personal Control and Self-Efficacy
As alluded to earlier, another psychosocial factor that modifies the evaluation of stress is personal
control (9,95,137). There is evidence that people who have a strong sense of personal control
experience less of a negative response, or strain, with stressors, compared with those who feel they
have no control over their lives (93,131). Individuals who believe that they personally have control
over their lives are considered to have an internal locus of control. On the other hand, individuals
who believe that their lives are dictated by forces outside of themselves, such as destiny, fate, or
faith, have an external locus of control (107,111). These two areas of control have a major impact
on health and health practices. For instance, those with a more internal sense of control are more
persistent in their exercise behavior. Based on how it may impact health, sense of personal control
may be further divided into four different types (113):
1. Informational control — when a person can glean knowledge about the stressful event and the
potential consequences of the situation
2. Cognitive control — when a person can use thought processes and strategies to manipulate and
modify the impact of the stressor
3. Decisional control — when a person can choose between different courses of action
4. Behavioral control — when a person can take concrete action to reduce the impact of stress
When people perceive that they have a good sense of control they feel like they are able
to effectively make decisions and execute a plan of action to produce the outcome desired
(86,113). This points to another aspect of personal control, self-efficacy, which is the belief or
conviction that one can successfully execute the behavior required to produce the outcomes
desired (11). When encountering a challenging situation, a person will actively evaluate his or
her ability (i.e., efficacy) to properly execute behaviors and determine if they think that they
can be successful in handling an activity (108). Generally speaking, people who are highly
efficacious show less psychological and physiological strain in the face of a stressor than
those who are less efficacious (12,13,58). Goal setting and preplanning for stressors are use-
ful strategies help to boost self-efficacy to regulate one’s behaviors in the face of demanding
situations (50).
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15Chapter 13 Healthy Stress Management
Nonexercise Techniques for Reducing Stress
Although it is critical for the exercise professional to understand the role of exercise as a stress man-
agement tool, there are numerous nonexercise techniques that are also successful in helping people
cope with stress, reduce arousal and promote relaxation (103). These include progressive muscle
relaxation, deep breathing, biofeedback, meditation, mindfulness, and massage (among many oth-
ers). Each of these areas takes months to years of persistent practice to master, and several, such as
massage, have their own certifications and credentialing. However, aspects of each technique may
be learned within a short period of time, and thus has utility for the exercise professional. Various
techniques may also be combined to suit different people and needs (61). To incorporate stress
management techniques into a fitness program, one might begin with time during the cool down
and stretching period after exercise when the focus is on relaxation and recovery (87,124).
Diaphragmatic Breathing and Body Scans
Breathing exercises are the easiest and fastest methods to induce the relaxation response, with capability
to relieve symptoms of stress and anxiety, including headaches, muscle tension, irritability, and fatigue
(39). Diaphragmatic breathing, or breathing from the stomach (as opposed to the chest) is superior for
the experience of these benefits. This consists of deep breaths into the lungs and exhaling as the dia-
gram contracts and relaxes. Beginners to this practice first must become aware of their normal breath-
ing habits, often while lying down with one hand on the abdomen and another on the chest. Usually
a body scan is also employed, where a person consciously examines the entire body, usually starting at
the toes and upward toward the scalp. Once awareness has been achieved, the practitioner can assume a
“dead man” pose, lying with arms and legs spread and palms facing upward, scanning the body for ten-
sion and relaxing. Then one may focus the attention on the breath, breathing in through the nose and
out through the mouth slowly and in a rhythmic fashion. Even short bouts of diaphragmatic breathing
can provide immediately stress relief. Practice over a longer period (i.e., 30–60 minutes) in the recovery
period of exercise has even been shown to decrease free radical production and cortisol (87).
Progressive Muscle Relaxation
Progressive muscle relaxation is a technique that teaches people how to focus on certain muscle
groups and alternatively contract and relax these muscles, focusing on the sensation of relaxation
(39,60). This helps the individual to identify areas of the body that tighten and hold tension when
they are under stress (e.g., jaw clamps shut, shoulders tighten up, and fingers cramp). Once iden-
tified, feelings of tension can be targeted and neutralized. With practice, whenever a person feels
tension rising in these areas, they can stop what they are doing for 5–10 minutes, breathe deeply,
tighten (5–7 s) and relax the affected muscles (20–30 s), repeat systematically, and then return to
their work (39,133). Researchers have postulated that progressive muscle relaxation may addition-
ally promote feelings of calmness and generate pleasant thoughts in the individual, which counter-
act negative feelings and thoughts associated with stress (103).
Biofeedback
Biofeedback is a method of increasing control over bodily processes, such as heart rate, muscle
tension, or sweating, in response to a stressor (37,133). Biofeedback has been useful in treating
stress-related health problems, such as chronic muscle tension headaches (25). The procedure
involves attaching sensors to the body that provide immediate biophysiological feedback on how
a person’s body is responding to a stressor (i.e., seeing fluctuations in heart rate or electrodermal
activity). This process helps patients to recognize when their body is engaged in a stress response.
Individuals are then encouraged to modify their bodily response to the stressor. For instance, one
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16
ACSM’s Resources for the Certified Exercise Physiologist • www.acsm.org
may be asked to slow down a speeding heart rate by blocking out all sounds and breathing deeply
until the heart rate reduces and returns to normal. This practice helps individuals gain awareness
of and attain voluntary control over their bodily response to a stressor.
Massage
Massage is the external application of pressure to muscles and tendons that can range from smooth, light
pressure to deep kneading motion, depending on technique, the purpose of the massage and individual’s
preference. Deep tissue massage has been an effective method for reducing stress, muscle tension, pain,
and asthma symptoms, and has been shown to boost immune function (46,113). The deep tissue massage
is the application of forceful, penetrating pressure that is applied to the muscles and joints by a trained
massage therapist. Breast cancer patients in the earlier stages of the disease have shown positive results
after 3 weeks of massage therapy, such as a decrease in anxiety, depression, and anger and an improvement
in mood (55). These patients also showed a boost in their dopamine and serotonin levels and number of
NK immune cells and lymphocytes, which could potentially promote a better and faster recovery (55).
Meditation and Prayer
Meditation is an exercise of the mind in which the individual actively focuses on calming and quieting
the body while keeping the mind alert (109). There are several forms of meditation: (a) mantra med-
itation focuses on sounds and phrases, and the same word or verse is repeated over and over again
to promote concentration; (b) yantra meditation uses a visual image, and the person focuses on that
image to eradicate distracting thoughts from the mind; and (c) transcendental meditation incorporates
breathing, visualization, relaxation, and repetition (109). Transcendental meditation has been shown to
reduce stress and improve mental and physical health by decreasing blood pressure, heart rate, respira-
tory response, and stress hormone production (17,81). Use of meditation has also been associated with
improved lactate recovery after exercise (122). An alternative to meditation is the practice of prayer,
which has been associated with facets of recovery from illness and improved health outcomes (2).
Mindfulness
Mindfulness is the discipline of paying attention to the present moment in a deliberate (purposeful)
and nonjudgmental manner (63). It is especially useful during periods of stress, when the mind often
dwells on and is clouded by past experiences, current frustrations and hurts, and potential dire con-
sequences. The practice of mindfulness is useful for restoring the mind-body connection, bolstering
emotional balance, and enhancing functioning at work and in relationships (24). By being in the
present moment, without worry about the future or preoccupation with the past, one may observe
automatic emotions and behaviors with greater clarity and perspective. This permits development
of a deeper awareness about thoughts and feelings, body sensations, and habitual stress reactions,
which in turn encourages more healthy choices about health behaviors (63). Mindfulness is more
effective than relaxation practices for reducing ruminations and distracting thoughts, enhancing
positive states of mind (61), and increasing sense of control (8). To facilitate these changes, practi-
tioners practice acceptance, trust, patience, nonjudgment, having a beginner’s mind (i.e., curiosity),
nonstriving, and letting go (63) even during daily activities like putting on one’s workout clothes,
walking into the gym, and preparing the postworkout meal. Mindfulness can also be performed
during physical exercise, such as walking, by focusing more on (a) the present-moment experience
of moving, (b) bodily sensations (such as sweating, the heart rate, breathing), and (c) emotional re-
actions to such perceptions (such as excitement, fear, pain) (106). Some of these exercise sensations
and emotions are uncomfortable, but these would be observed and approached with openness and
self-compassion and not judged or avoided. Furthermore, attention is not paid to goals, striving and
competition, which can detract from the experience and render exercise less enjoyable.
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17Chapter 13 Healthy Stress Management
Yoga and Martial Arts
Some individuals may experience greater stress management with exercise programs that incorpo-
rate breath control, mindful movements and meditative practices. Yoga and martial arts, such as tai
chi and qigong incorporate all of these elements. Mindful exercise practices have been shown to
promote numerous health benefits, such as increases in positive emotions, dampened cortisol and
cardiovascular reactivity, and lower inflammatory responses to stress (27,62,71,97). Research indi-
cates that those who regularly practice yoga have substantially reduced serum interleukin 6 levels
(one of the primary inflammatory cytokines) compared with novice yoga attendees (65). Sessions
of yoga, tai chi, or other martial arts performed routinely are effective for reducing symptoms of
stress and improving sense of well-being (27,71,97).
Referring a Client or Patient to a Psychologist (Reviewed by Lydia R. Malcolm,
PhD, University of Miami)
Exercise professionals, such as personal trainers, often find themselves as confidants to their
clientele. Consequently, conversations about stressful experiences are quite common. Although
these are to be expected, occasionally a client may deal with stress poorly or in an inappropriate
manner. They may (a) display a number of symptoms, such as those in Table 13.1; (b) communi-
cate feelings of distress, worry, anxiety or other mental health problems; or (c) verbally expresses
a need for support. Under such conditions, referral to a mental health professional may be advis-
able. When referring a client make sure to be empathetic. Consider using language outlined in
Table 13.2. The American Psychological Association provides a number of resources, including
a mental health professional locator (http://locator.apa.org/), if a referral is accepted. Most im-
portantly, if a person is suicidal or discuss hurting themselves in any way, get professional help
immediately.
Step Action Suggested Remark
1 Start by broaching the topic with a
general observation.
“You seem to have a lot of stress.”
2 Normalize the context. “I see a lot of people who are dealing with ______ [fill in the
blank].”
3 Emphasize strengths. “It’s good that you are doing some healthy things, such as exer-
cising [and anything else you know they are doing] to help you
manage this situation”
4 Suggest that they seek out addi-
tional support.
“I know some of my clients have found that getting some extra
support to help with [stress, sadness, anxiety, grief, etc.] has
been helpful.”
5 Obtain permission to make a
referral.
“Would you like me to make a recommendation?”
6 If they deny needing additional help
keep the option available for future
need.
“It sounds like now might not be a good time for you to go
to therapy. You can always contact me at a later date for the
information.”
Table 13.2 Suggested Remarks When Making a Referral to a Mental
Health Professional
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18
ACSM’s Resources for the Certified Exercise Physiologist • www.acsm.org
The Case of Terry
Narrative
Terry is a 55-year-old African American woman was referred to an integrated health center in a mid-sized urban
city by her primary care physician. She is in the obese category for body mass index (BMI) even after numerous
attempts to lose weight. She also continues to smoke 5–6 times a day, despite repeated warnings from her doctor.
She works full time and teaches elementary students at a local urban magnet school. Her job requires long hours at
work, grading on the weekends, and can be very stressful. She suffers from mild depression (diagnosis is depressive
disorder not otherwise specified), which has minimally improved since her husband died 3 years ago. In particular,
she reports that she has difficulty experiencing pleasure from things she used to enjoy. She has a good relationship
with her adult daughter, who lives locally.
Before her husband became sick, she reported that she and her husband were very active hikers and walked
daily. During her last attempt to be physically active, she maintained a personal training program (mostly resistance
training, 2 times a week) for 8 weeks until her apartment was broken into, disrupting her routine. She finished a
12-week program, but with great struggle. She has been inactive for about a year. Fortunately, she is metabolically
healthy (e.g., normal cholesterol and blood sugar), and her only other complaint is some mild symptoms of arthritis.
She has no family history of cardiovascular disease.
Based on her clinical intake and interest to lose weight and increase fitness, she was assigned to a licensed psy-
chologist and exercise physiologist (ACSM EP-C) for further evaluation, risk stratification and treatment. At intake,
she reported that her goals were to lose 15 pounds (returning to weight 3 years ago; approximately 165 lb), increase
fitness, improve her mental well-being, and maintain independence going into retirement.
Health Fitness Examination
Screening Tools and Outcome Measures:
PSS-10: Terry scored 20 (see box earlier for an interpretation)
Centers for Epidemiology Depression Scale (Revised): Terry scored 19 and did not meet or exceed the cut-off for
major depression based on other criteria.
Risk Stratification: Moderate (i.e., obesity, smoking, sedentarism, age)
Vitals
Age: 55 years; resting HR: 64 bpm; 66 bmp (second visit); resting BP: 119/63 mm Hg; 124/64 mm Hg (second
visit); height: 64 inches; weight: 178.5; 180.8 (second visit); BMI: 30.6; 31.0 (second visit)
Cardiorespiratory Fitness and Body Composition
YMCA Submaximal Cycle Ergometer Test predicted aerobic capacity  29 mL  kg1  min1, 45th percentile for
age and gender.
Body fat estimated with bioelectrical impedance (Tanita model TBF  300 WA)  40.0%; 39.8% (second visit)
Waist circumference  99.5 cm; 99.0 cm (second visit)
Hip circumference  110.4 cm; 109.5 cm (second visit)
Submitted by Karyn Gunnet-Shoval, PHD
Terry is a middle-aged woman attempting to lose weight. Her chief complaint
is chronic stress, and she has a history of mild depression. She was referred to
an integrated health center by her primary care physician (PCP) to meet with
a licensed psychologist and an American College of Sports Medicine (ACSM)
Certified Exercise PhysiologistSM (EP-C).
•AQ3•
FPO
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19Chapter 13 Healthy Stress Management
References
1. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed. Philadelphia (PA): Lippincott
Williams & Wilkins; 2014.
2. Carek PJ, Laibstain SE, Carek SM. Exercise for the treatment of depression and anxiety. Int J Psychiatry Med. 2011;41(1):15–28.
3. Lavie CJ, Milani RV, O’Keefe JH, Lavie TJ. Impact of exercise training on psychological risk factors. Prog Cardiovasc Dis. 2011;53(6):464–70.
4. Stults-Kolehmainen M, Malcolm LR, DiLoreto J, Gunnet-Shoval K, Rathbun EI. Psychological interventions for weight management: a
primer for the allied health professional. ACSM Health Fitness J. 2015.
QUESTIONS
 What testing and outcome measures may be appropriate in this case besides health fitness testing?
 Are there indications for use of exercise in clients with chronic stress and mild depression?
 How might an exercise program be structured and what resources may be needed for a client, such as Terry?
SUMMARY
The APA’s Stress in America reports from 2007 and 2015 demonstrate that stress continues
to be a problem in American society (5,60). Whether a person feels stressed or not, stress
is an everyday facet of life that must be managed. The perception of an event as stressful
greatly depends on the person and his or her perceived resources to deal with the stressors.
Situations that are perceived to be stressful may result in a variety of physical and mental
symptoms, including burnout, fatigue, headaches, gastrointestinal problems, muscular pain,
and greater risk for infections. Long-term chronic stressors can increase the risk of cardio-
vascular disease, heart attacks, stroke, and cancer. Contrary to popular belief, stress is not
always negative. Stress can act as a positive challenge that encourages individuals to rise to
the occasion and possibly even face their fears or anxieties. This chapter has offered and ex-
plained a wide variety of methods for buffering and decreasing the negative impact of stress
on the individual. Some tactics and strategies focus on changing the psychological percep-
tion of a stressor, and others on decreasing the physiological response to a stressor. Exercise
interventions are primarily an example of the latter, and only 10–15 minutes of moderate
aerobic activity, such as a brisk walk, may provide stress-relieving benefits (41). A challenge
for the health and fitness professional is to minimize the psychological toll of exercise itself,
which may be perceived as yet another task added to an already full plate. Indeed psycholog-
ical stress is associated with impaired efforts to be physically active (129). Perhaps by focus-
ing on an individual’s preferences and maximizing their exercise enjoyment, the full benefits
of exercise may be realized. Another strategy would be prescribing exercise regimens with
additional meditative qualities, such as mindful walking, yoga, or tai chi (97). A multifaceted
approach to stress and exercise may magnify results but does require the exercise practi-
tioner to be more mindful of the complex attributes of the stress experience.
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20
ACSM’s Resources for the Certified Exercise Physiologist • www.acsm.org
STUDY QUESTIONS
1. Understanding stress: What is stress? How is stress different from stressors? Are all stressors bad?
What are some examples of good stress? What is the feeling of being stressed out and how does
it relate to distress?
2. Why are some people apparently immune to stress when they encounter a demanding situation?
Explain the two coping mechanisms that can be implemented to minimize the impact of stress.
Exercise is which of these?
3. Discuss the consequences of stress on the development and progression of disease and evidence
that exercise may buffer this relationship.
4. Before encountering a stressful event, how can a person can prepare himself or herself to ideally
handle the event and avoid becoming stressed? Discuss some of the strategies for weakening the
impact of stress.
5. What are examples of healthy stress management? Discuss three techniques or approaches for
handling and decreasing perceived stress, the potential benefits of each, and how they might be
integrated into a fitness program.
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21Chapter 13 Healthy Stress Management
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QUERIES:
AQ1: Please confirm author names and correct order.
AQ2: Please confirm if changing “dual emission x-ray absorptiometry (DXA)” to dual-energy
x-ray absorptiometry (DXA)” is correct as per web search.
AQ3: Please confirm if the supplied expanded form of the abbreviation used is correct.
ACSM-RCEP2_CH13.indd 1 1/31/17 2:42 PM