Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis

Abstract

Objectives:

This systematic review and meta-analysis examined the effects of exercise on individuals with alcohol use disorders (AUDs) across multiple health outcomes.

Data Sources:

PubMed, Medline, Web of Science, Scopus, Academic Search complete, Sport Discuss, and ERIC databases.

Study Inclusion and Exclusion Criteria:

Interventional studies published between 2000 and 2018 focused on evaluating the effectiveness of exercise interventions in adults with AUD.

Data Extraction:

This protocol was prepared using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols standard and the Meta-Analyses and Systematic Reviews of Observational Studies guidelines.

Data Synthesis:

Physical activity levels/fitness [VO₂ max (Oxygen Uptake) and HRmax (Maximum Heart Rate)], levels of depression, anxiety, self-efficacy, quality of life, and alcohol consumption (number of standard drinks consumed per day and per week).

Results:

The findings indicated that exercise significantly improved physical fitness as assessed by VO₂ max (standardized mean difference [SMD]: 0.487, P < .05) and HRmax (SMD: 0.717, P < .05). Similarly, exercise significantly improved mental health as assessed by quality of life (SMD: 0.425, P < .05), but levels of depression, anxiety, self-efficacy, and alcohol consumption did not change significantly. Aerobic exercise alleviated depression and anxiety symptoms more than that of yoga and mixed types. Duration of exercise also had a similar effect on anxiety and depression.

Conclusions:

Exercise can be an effective and persistent adjunctive treatment for individuals with AUDs.

Keywords

alcohol use disorder exercise physical fitness mental health number of drinking

Introduction

Alcohol use disorders (AUDs) are among the most common mental illnesses worldwide.^1,2 In the general population, the 12-month and lifetime prevalence of AUDs is 13.9% and 29.1%, respectively.³ Measured in disability-adjusted life years, 5.1% of the global burden of disease and injury is from alcohol.⁴ It is a significant health problem affecting physical, psychological, and social aspects of life.¹ Although many psychopharmacology and psychotherapy treatments are useful for the treatment of AUDs, relapse remains a significant problem.^4,5 Moreover, oral medications have the risk of addiction and potential drug–drug interactions. As a result, new adjuvant interventions are needed that help maintain abstinence and target physical and psychological conditions related to AUDs.

Physical activity is defined as “any bodily movement produced by skeletal muscles that require energy expenditure.” Exercise is “a subcategory of physical activity that is planned, repetitive, structured, and purposeful in the sense that the improvement or maintenance of one or more components of physical fitness is the objective.” (pp. 14) ⁶ Accumulated evidence from observational and laboratory-based studies supports a strong inverse relationship between physical activity and hypertension, obesity, stroke, premature mortality, metabolic syndrome, osteoporosis, cardiovascular diseases (CVDs), type 2 diabetes mellitus, breast cancer, functional health, falls, depression, and cognitive function.^7

-13 Regular physical activity is vital not only for the heart, respiration, endurance, flexibility, and neuromotor properties but also for the development and maintenance of physical fitness and psychological well-being.^14,15 Recent systematic reviews and meta-analyses have demonstrated the therapeutic effects of many different exercise approaches on mental disorders, especially depression, anxiety, schizophrenia, and substance use disorders (SUBs).^16

-20 A physically active life leads to many positive emotional changes: self-energetic feeling,²¹ prosperity,²² increased quality of life (QoL),^23,24 decreased cognitive decline, and reduced risk of dementia.^25,26

Exercise has been proposed as an adjunct treatment approach in the prevention or treatment of AUDs.^27,28 Regular exercise not only improves physical functioning but also reduces negative emotional states through various mechanisms.^29,30 Depression and anxiety symptoms are especially common among patients with AUD and often indicate poor prognosis and risk of relapse.^31,32 Regular exercise has been found to have positive effects on depressive symptoms, anxiety, and QoL.^31,33

-37 Furthermore, exercise results in significantly reduced alcohol consumption and alcohol craving.³⁸ Despite increasing evidence on the usefulness of exercise interventions in other mental disorders and SUBs, relatively little evidence exists regarding the direct impact of exercise-based interventions on the prevention of AUDs.

Hallgren et al conducted a meta-analysis involving 21 studies between 1972 and 2016 that examined exercise approaches for AUDs. Available evidence suggests that exercise has a positive effect on depression and physical fitness. The outcomes were reported in only 4 and 5 studies, respectively. However, they found no significant changes in alcohol consumption, anxiety, and self-efficacy. The analyses were limited to only 3 and 6 studies, respectively.¹⁴ A recent systematic review by Giesen et al reported that exercise could improve the level of physical and psychological functioning for individuals with AUDs. However, they observed inconsistent effects, but with a trend toward a positive effect of exercise on depression, anxiety, drinking behavior, and alcohol craving. In general, exercise was shown to be a non-harmful treatment for people with AUDs.²⁷ Another systematic review by Manthou et al indicated that exercise had a beneficial effect on alcohol consumption and abstinence rates in 6 of 11 studies examined.³⁹

These studies, however, do not include evidence from newer research.^36,40,41 Also, they did not assess the effects of the type, frequency, intensity, and duration of exercise on various health outcomes (eg, physical fitness, anxiety, and depression). In the current systematic review and meta-analysis, we investigated the impact of exercise as a treatment on individuals with AUDs by analyzing the randomized controlled trials (RCTs) and non-RCTs. Physical fitness (VO₂ max and heart rate), depression levels, anxiety levels, self-efficacy levels, QoL, and alcohol consumption were included in the current meta-analysis as treatment outcomes. Additionally, this study also included the subgroup analyses of the frequency, intensity, type, and duration of exercise on AUDs.

Material and Methods

Design

The study protocol was prepared using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols standard⁴² and the Meta-Analyses and Systematic Reviews of Observational Studies guidelines.⁴³

Inclusion and Exclusion Criteria

Types of studies

We included only interventional studies RCTs and non-RCTs and excluded cross-sectional and cohort studies reporting associations between exercise and AUD. We excluded studies that assessed only the acute effects of exercise, with measures taken directly after a single exercise bout or with an exercise program lasting <1 week. We included papers published in English and Turkish languages in peer-reviewed journals. Only studies published as a full paper were included. Studies were restricted from 2000 to 2018.

Types of setting

We did not limit the environment or country in which the interventions were implemented. Studies could contain inpatient and outpatient treatment programs, community-based interventions, public health interventions, and student populations.

Types of participants

Studies involving only adult participants (aged ≥18 years) were included. Studies involving only adult participants (aged ≥18 years) were included. Thus, studies in which participants were children or adolescents were excluded. All participants had a diagnosis of AUD based on Diagnostic and Statistical Manual of Mental Disorders (DSM)-I, DSM-II,⁴⁴ DSM-III,⁴⁵ DSM-III-R,⁴⁶ DSM-IV,⁴⁷ DSM-V,⁴⁸ the International Classification of Disease, Tenth Revision (ICD-10) ⁴⁹, the Alcohol Use Disorders Identification Test (AUDIT),⁵⁰ or guidelines of the National Institute on Alcohol Abuse and Alcoholism. We excluded studies with a heterogeneous sample consisting of AUD participants (eg, SUBs and post-traumatic disorders).

Types of interventions

All studies included exercise defined as any intervention that is planned, structured, repetitive, and purposeful.⁶ No restrictions were made regarding the intensity, length, frequency, or duration of the program. Control groups featured no treatment (eg, no treatment in a control group or waitlist control group), treatment as usual (TAU; eg, standard medical treatment or other standard practices), or active control condition with any nontherapeutic activities (eg, health education or relaxing activities).

Types of outcome measures

The studies had to evaluate at least 1 primary outcome. These include the following:

Physical activity levels/fitness (heart rate, VO₂ max, body mass index)

Levels of depression anxiety, self-efficacy, and QoL

Alcohol consumption, including the number of standard drinks consumed per day or per week or the number of heavy drinking days.

We included studies with sufficient data to achieve the standardized size in meta-analysis studies.

Data Sources

Two reviewers searched PubMed, Medline, Web of Science, Scopus, Academic Search Complete, SportDiscuss, and ERIC databases from inception to July 13, 2018. Keywords used were “alcoholism” or “alcohol” or “alcohol use disorder” or “alcohol dependence” or “alcohol-related” or “alcohol abuse” or “harmful drinking” or “hazardous drinking” and “exercise” or “aerobic training” or “physical activity” or “resistance training” or “endurance training” or “sport” or “yoga”. Also, references from these publications were manually screened to identify additional articles.

Study Selection

Following the removal of duplicates, 2 authors screened the titles and abstracts and determined the potentially eligible articles. Then, the full texts of these potentially eligible articles were reviewed, and a final list of included articles was established by consensus. Discrepancies were discussed with a researcher until an agreement was reached.

Data Extraction and Management

Two authors independently extracted data using a data collection form. Data were checked by another researcher. Table 1 shows the full data extraction table and includes author, year, number of participants in exercise and control groups, participants (eg, age, gender, and diagnosis), methods (eg, randomization), study design, interventions (exercise type, frequency, intensity, and duration), control interventions, outcomes (eg, outcomes measures), and results.

Table 1.

Summary of Included Studies.

Article	Sample Size, (n)	Age (M ± SD)	Gender (%)	Study Design	Diagnosis	Control	Experimental	Outcome measures	Results
Jensen et al., 2019, Danish	EG1: 19 EG2: 16 CG: 22	EG1: 45.6 ± 11.3 EG2: 41.1 ± 11.2 CG: 48.2 ± 11.8	Not reported	- RCT - Outpatient treatment clinic - Physical exercise	DSM diagnosis: alcohol dependence or abuse	TAU consisted of psychological and pharmacological interventions	- EG1: TAU plus group-based (GR) physical exercise - EG2: TAU plus individually based physical activity - Physical activity, which involved brisk walking or running, 24 weeks, 2 times/wk, 30 to 45 minutes each, at 80% to 90% of HRmax	- Physical capacity and VO₂ max - Running intensity and volume during training - TLFB (changes in alcohol intake)	- No significant differences in VO₂ max between 3 groups but increase for EG2 after 6-month training. - Significant reduction in training frequency for both training groups after the first month. - No significant differences in training volume and intensity between EG1 and EG2. - No significant differences in drinking outcomes between groups. - Significantly decrease in alcohol intake for all groups.
Roessler et al., 2017, Denmark	EG1: 62 EG2: 50 CG: 53	EG1: 44.8 ± 11.2 EG2: 43.8 ± 11.1 CG: 46.9 ± 11.6	EG1: 59% M EG2: 77.6% M CG: 73.6% M	- RCT - Outpatient treatment centers - Supervised and individuals AE	ICD-10 diagnosis: alcohol dependence or harmful use	- TAU - No exercise	- EG1: TAU and supervised group exercise (24 weeks 2 times/ wk, group exercise including walking or running) - EG2: TAU and individual physical exercise (24 week, least 2 times/wk, individual training program consisted of walking or running. - The intensity and duration not reported.	- ASI - TLFB - IPAQ - Physical activity levels	- At the time of the 6-month follow-up, a decrease in alcohol intake for all 3 groups (no differences). - The protective effect on drinking behavior (lower excessive drinking and higher abstinence rate) of moderate physical activity level compared to low physical activity levels, including the controls. - The amount of alcohol consumption in the intervention group decreased by for each increased exercising day.
Can Gür et al., 2017, Turkey	EG: 20 CG: 21	EG: 46.85 ± 12.07 CG: 44.33 ± 10.20	EG: 85% M CG: 81% M	- Non-RCTs - Association of Alcoholics Anonymous (AA) - AE	DSM-V diagnosis: alcohol use disorder	- TAU - No exercise	- 6 weeks, 3 times/wk, 45 to 60 min each, group aerobic exercise at 50-60% of HRmax plus CBM-based psychoeducation weekly (1 time/wk) plus incentive materials for maintaining motivation and attendance to exercise	- BDI - BAI - SES	- Statistically significant decrease in the posttest and 4-month follow-up scores of BDI between the groups. - Statistically significant improvements in the posttest scores of BAI and SES between the groups. - In the intragroup comparisons, a significant difference in favor of the posttest and 4-month follow-up test of BDI, BAI, and SES, according to the compared with the mean pretest scores. - The participation of the EG in the sessions is %98.
Gür et al., 2017, Turkey	EG: 18 CG1: 19	EG: 45.88 ± 11.10 CG: 44.42 ± 10.64	EG: 83.3% M CG: 78.9% M	- Non-RCTs - Association of Alcoholics Anonymous - AE	DSM-V diagnosis: Alcohol use disorder	- TAU - No exercise	- 6 weeks, 3 times/wk, 45 to 60 minutes each, group aerobic exercise at 50%-60% of HRmax plus CBM-based psychoeducation weekly (1 time/wk) plus incentive materials for maintaining motivation and attendance to exercise	- SF-36	- Statistically significant increase in the posttest scores of physical functioning, mental health, general health perception between the groups. - Significant increase in physical functioning, emotional role functioning, vitality, social functioning, general health perception of individuals in the experimental group
Giesen et al., 2016, Germany	EG: 14 CG: 19 hCG: 18	EG: 52.14 ± 8.08 CG: 54.63 ± 9.41 hCG: 54.11 ± 7.20	EG: 78% M CG: 73.7% M hCG: 66.7%M	- CT - Inpatient - AE	ICD-10 diagnosis: alcohol dependence	- No exercise	- 12 months, at least 2 times/wk, 60-minute exercise program: aerobic exercise (indoor and aqua cycling), functional training (strengthening, coordination, and flexibility exercise) and experience-orientated group events (eg, bicycle tour, canoeing, or other day trips). The intensity at 80% of age-estimated HRmax	- SF-36 - Physical activity level - Anthropometric data (age, weight, BMI) - Relapse rate	- Statistically significant improvements in the posttest scores for EG regarding physical functioning, mental health, general health perception, and vitality. - Significant increases in mental health and social functioning for CG, whereas vitality and emotional role functioning decreased. - Within the EG, increases to physical functioning, vitality, general health perception, and mental health values. - Within the CG, increases to mental health but decreases to vitality from T1 to T2. - Significant differences in physical activity level between 3 groups. Significant increases for EG in physical activity. - No one relapses during the observational period of 1 year for EG.
Hallgren et al., 2014, Sweden	EG: 8 CG: 6	18 years or older for both group, mean and SD not reported	Both males and females for both group, mean and SD not reported	- RCT - Pilot study - Outpatient alcohol treatment clinic - Yoga	DSM-IV diagnosis: Alcohol dependent	- TAU consisted of psychological (individuals counseling sessions with a CBT focus, 1 hour per week) and pharmacological interventions for alcohol dependence	- TAU plus 10 weeks, 1 time/wk, 1.5 hours each, group yoga sessions consisted of breathing techniques, a sequence of light physical exercise (yoga postures), meditation, and deep relaxation. - The intensity not reported	- HAD - Sheehan Disability Scale - PSS - TLFB for alcohol use status - Gammaglutamyltransferase (GT) and carbohydrate-deficient transferrin (CDT)	- Statistically nonsignificant changes in alcohol consumption, affective symptoms, quality of life, GT, and CDT parameters between groups. - But at 6-month follow-up, positive changes in alcohol consumption, affective symptoms, quality of life were reported by both groups. - Although not significant, cortisol levels had reduced more in the EG.
Brown et al., 2014, USA	EG: 26 CC: 23	EG: 43.46 ±11.5 CG1: 45.39 ± 9.99	EG: 48% F CG: 42% F	- RCT - Outpatient and day hospital care setting - AE	DSM-IV-TR diagnosis: alcohol-dependents	- 12 weeks, 15 to 20 minutes of brief advise exercising intervention plus incentives for engagement	- 12 weeks, 1 time/wk, 20 to 40 minutes each, group aerobic exercise (treadmill, elliptical machine or recumbent bicycle) at 55% to 69% of HRmax plus CBT-based exercise counseling (15-20 min) weekly plus incentives for attendance	- CES-D - STAI - SCQ - TLFB - VO₂ max	- VO₂ max increased significantly more among those adherents to AE compared to those in BA-E. - No significant difference in VO₂ max and levels of moderate exercise between AE and BA-E. - No significant differences in depression, anxiety, and self-efficacy in between AE and BA-E at the end of the 12-week treatment and 1- week follow-up. - Significant decrease in drinking days and heavy drinking days in the AE during treatment but no maintain during 12-week follow-up. - The level of exercise (ie, average minutes of weekly exercise) was related to decreases in drinking days only during the 12-week follow-up period. The level of exercise was associated with reductions in heavy drinking days both during treatment and during the 12-week follow-up.
Weinstock et al., 2014, USA	EG: 16 CG: 15	EG:21 ± 2.3 CG: 20.1 ± 1.2	EG:56.3% F CG: 73.7% F	- RCT - Pilot study - College students - Aerobic exercise	- According to AUDIT: Hazardous drinking	MET: one 50-minute session of MET focused on increasing exercise	- MET plus 8 weeks of contingency management (CM) for adhering to specific exercise activities. - The 8 structured CM sessions contained a week’s exercise activity contract. - 3 per week for 8 weeks, exercise activity. The agreement contained at 3 specific exercise activities, including walking with a pedometer, walking, or jogging on a treadmill for 15 minutes, attending an exercise class at the gym. (<40% to <60% VO₂ peak)	- BMI - YSET - TLFB	- Increased self-reported frequency of exercise in comparison to the MET for MET + CM condition. - No difference in other indices of exercise, physical fitness, and alcohol use between both groups. - Within the MET + CM, significantly increases in estimated weekly calories expended, and improved estimated VO₂ peak.
Vedamurthachar et al., 2006, India	EG: 30 CG: 30	EG: 35.6 ± 8.1 CG: 37.7 ± 7.3	EG: 100% M CG: 100% M	- RCT - Inpatient National deaddiction center	- DSM-IV diagnosis: alcohol dependents	No intervention	2 weeks, 62-65 minutes each Yoga (breathing and meditation exercises): Sudarshana Kriya Yoga (SKY; 42-45 minutes) and Yoga Nidra (20 min) The intensity not reported.	- BDI - Cortisol - ACTH - Prolactin	- Significantly lower BDI scores at the posttest in the 2 groups and a greater decrease in EG compared to CG. - Significantly lower ACTH levels after intervention in the 2 groups, a greater reduction in EG compared to CG. - Significantly lower cortisol levels for EG at post-test. - No significant increase in prolactin levels at posttest in both groups
Capodaglio et al., 2003, Italy	EG: 33 CG: 23 HG: 18	EG: 41.6±7.9 CG: 45.2 ±8.0 HG: 39.3 ± 7.7	EG: 84.8% M CG: 65.2% M HG: 72.2% M	- Non-RCTs - Inpatient, alcohol rehabilitation center - AE	DSM-IV diagnosis: alcohol dependents	Standard psychosocial therapeutic care (Cognitive Behavioral Model)	- 2 weeks, 5 times/wk, 50 minutes each exercise program: 10-minute stretching, 30-minute combined endurance training (lifting, walking, and arm-cranking) Intensity in the tests: Borg scale 4; cancel at 85% of HRmax or if Borg scale of 7 should be overreached	- HR % max - Total work capacity	- A lower work capacity compared to HG in the walking and arm-cranking test for EG and CG at test 1. - Significantly increased total work capacity in EG from test 1 to test 2 in the walking and arm-cranking test. - HR% max was higher in the patients compared to the healthy subjects at the end of the trials

Abbreviations: AE, aerobic exercise; ASI, The Addiction Severity Index; AUDIT, Alcohol Use Disorders Identification Test; BAI, The Beck Anxiety Inventory; BDI, The Beck Depression Inventory; BMI, body mass index; BYAACQ, Brief Young Adult Alcohol Consequences Questionnaire; CES-D, The Center for Epidemiological Studies-Depression Scale; CSQ, Client Satisfaction Questionnaire; DSM, Diagnostic and Statistical Manual of Mental Disorders; HAD, Hospital Anxiety and Depression Scale; HTGC, Hepatic Triglyceride Content; ICD-10, International Classification of Disease, Tenth Revision; IPAQ, The International Physical Activity Questionnaire; MET, motivational enhancement therapy; PSS, Perceived Stress Scale; RCT, randomized controlled trial; SCQ, The Situational Confidence Questionnaire; SD, standard deviation; SES, Self-Efficacy Scale; SF 36, The Short Form Health Survey; STAI, The Spielberger State-Trait Anxiety Inventory; TAU, treatment as usual; TLFB, Time-line-follow-back; Sheehan Disability Scale, Health-related functioning and quality of life; TLFB, The Timeline Follow Back; YSET, YMCA Submaximal Bicycle Ergometer Test; EG, Experimental Goup; CG, Control Group; HCG, Healthy Control Group.

Risk of Bias/Quality Assessment

Included studies were assessed for risk of bias using the Cochrane Collaboration’s risk of bias tool as described in the Cochrane Handbook for Systematic Reviews of Interventions.⁵¹ Two authors independently performed this assessment. In the event of disagreement regarding the evaluation of studies, a researcher was consulted. This tool assesses the risk of selection bias, performance bias, attrition bias, reporting bias, and detection bias using 12 criteria. Each item was rated as high, low, or unclear, with an explanation. The studies were rated as having a “low risk of bias” when at least 6 criteria met and the study had no serious flaws. Studies that had a severe defect or met fewer than 6 criteria were rated as having a “high risk of bias”.⁵¹ The risk of bias of the included studies is shown in Table 2.

Table 2.

Risk of Bias in Included Studies.

Author, Year	Selection Bias			Performance Bias				Attrition Bias		Reporting Bias	Detection Bias		Total: Max. 12^a
Author, Year	Adequate Random Sequence Generation	Adequate Allocation Concealment	Similar Baseline Characteristics	Adequate Participant Blinding	Adequate Provider Blinding	Similar or No Co- interventions	Acceptable Compliance	Acceptable and Described Drop-out Rate	Inclusion of an Intention-to-Treat Analysis	No Selective Outcome Reporting	Adequate Outcome Assessor Blinding	Similar Timing of Outcome Assessment	Total: Max. 12^a
Jensen et al., 2018	Yes	Unclear	Yes	No	No	Yes	Yes	No	No	Yes	Unclear	Yes	6
Roessler et al., 2017 et al., 2017	Yes	Unclear	Unclear	No	No	Yes	Yes	No	Yes	Yes	No	Yes	6
Can Gür et al., 2017	No	No	Yes	No	No	Yes	Yes	Yes	No	Yes	No	Yes	6
Gür et al., 2017	No	No	Yes	No	No	Yes	Yes	Yes	No	Yes	No	Yes	6
Giesen et al., 2016	No	No	Yes	No	No	Yes	Yes	Yes	No	Yes	No	Yes	6
Hallgren et al., 2014	Yes	No	Unclear	No	No	Yes	Yes	Yes	No	Yes	No	Yes	6
Brown et al., 2014	Yes	No	Yes	No	No	Yes	Yes	Yes	Yes	Yes	No	Yes	8
Weinstock et al., 2014	Yes	No	Yes	Unclear	No	Yes	Yes	Yes	No	Yes	No	Yes	7
Vedamurthachar et al., 2006	Unclear	No	Yes	No	No	Yes	Yes	Yes	No	Yes	No	Yes	6
Capodaglio et al., 2003	Yes	No	Yes	No	Yes	Yes	Yes	Yes	No	Yes	No	Yes	8

^a Higher scores indicate lower risk of bias.

Data Synthesis

Analyses were conducted using the comprehensive meta-analysis statistical software (version 3.3.070). The standardized mean difference (SMD) and 95% confidence intervals (CIs) were used as measures of effect size. Hedges’s g were used to evaluate the magnitude of the overall effect size with (1) SMD = 0.2 to 0.5: small; (2) SMD = 0.5 to 0.8: moderate; and (3) SMD > 0.8: large effect sizes. As a measure of heterogeneity between studies, the I ² index and Q statistic were used. The magnitude of heterogeneity was categorized as (1) I ² = 0% to 25%: low heterogeneity; (2) I ^>2 = 26% to 50%: moderate heterogeneity; (3) I ² = 51% to 75%: substantial heterogeneity; and (4) I ² = 76% to 100%: considerable heterogeneity.⁵² To investigate and adjust for publication bias, we used the Egger test.⁵³ Subgroup analyses were performed to examine differences based on the type of exercise (ie, aerobic exercise vs other), duration of exercise (≥10 weeks vs <10 weeks), frequency of exercise (1-2 times/wk vs 3-4 times/wk), and intensity of exercise (low, moderate vs high). In all analyses, P < .05 was set as statistically significant.

Results

Search Results

The literature search retrieved 1359 studies, and 1 additional study was obtained through other sources. The flow diagram of identification, screening, eligibility, and inclusion of studies is shown in Figure 1. After the deletion of duplicates, 463 studies were screened, of which 435 were rejected by reviewing the title and abstract. We then performed full-text review of the remaining 28 studies. Of them, 18 were excluded for the following reasons: the studies had acute exercise intervention,^54
-56 participants did not have a diagnosis of AUD,^57
-59 they lacked a control group,^38,60

-63 the study was still on-going,⁶⁴ the researchers used a cross-over design,^65
-67 the study included participants with SUBs,⁶⁸ or they used diagnosis guidelines that were not in line with the eligibility criteria.^69,70 Finally, 10 studies meeting our inclusion criteria were included in the present meta-analysis.^{27
-29,36,37,40,41,71
-73}

Figure 1.

PRISMA flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Characteristics of Included Trials and Participants

Table 1 shows an overview of trials and participants. Of the 10 included studies, 6 were RCTs and 4 used a non-RCT design. In addition, 7 studies originated from Europe (Denmark, Turkey, Germany, Sweden, and Italy),^{27,28,36,37,40,41,73} 2 from USA,^29,71 and 1 from Asia (India).⁷²

Across the 10 studies, 579 adults with AUDs were included, of whom 312 and 267 were in exercise and control conditions, respectively. Sample sizes ranged from 6 to 62 participants (median: 19.5).^28
,41 The mean age (n = 9 studies) ranged from 20.1 to 54.63 years (median: 44.6 years).^71,27 Between 26.3%⁷¹ and 100%⁷² (median: 66.7%) of patients in each study were men (n = 8 studies). Another 2 studies included men and women.^40,28 Participants in 7 studies were diagnosed with AUDs according to DSM,^{28,29,36,37,40,72,73} participants in 2 studies were diagnosed according to ICD-10,^27,41 and participants in 1 study were diagnosed according to AUDIT⁷¹. Alcohol use disorders included were alcohol dependence,^{27
-29,40,41,72,73} AUD,^36,37 hazardous drinking⁷¹ or harmful use,⁴¹ and alcohol abuse.⁴⁰

The interventions included aerobic exercise (walking, running, treadmill, elliptical machine, and recumbent bicycle; n = 4),^27,29,40,41 yoga (n = 2),^28,72 and a combination of aerobic exercise, strength training, and stretching (n = 4).^27,36,37,73 The median exercise frequency was 2 sessions/wk (range: 1-5 sessions/wk). The median duration of exercise (n = 9) was 50 to 60 minute per session, and the intensity of exercise (n = 7) was moderate at 55% to 69% of oxygen uptake. The intensity of exercise was not reported in other studies.^28,41,72 The length of exercise intervention varied from 2 to 48 weeks (median: 9 weeks).

Six studies included TAU,^{28,37,40,41,73} and 2 studies included an active control intervention.^29,71 Two studies compared the exercise group with a nontreatment control group.^27,72 Six studies included participants from outpatient treatment programs,^{28,29,36,37,40,41} 3 studies included participants from inpatient settings,^27,72,73 and 1 study involved student populations.⁷¹

Risk of Bias in Included Studies

Table 2 shows the risk of bias in the included studies. All 10 studies had a low risk of bias. The risk of selection bias was mixed; 8 studies reported similar baseline characteristic.^{27,29,36,37,40,71
-73} No studies reported blinding of participants or providers. In all studies, co-interventions and acceptable compliance were determined to have a low risk of bias. Attrition bias was mixed: 8 studies had an acceptable dropout rate,^{27
-29,36,37,71
-73} and 2 studies used an intention-to-treat analysis.^29,41 The risk of reporting bias was low. No studies blinded outcome assessors.

Outcomes

General effect sizes and heterogeneity of included studies

The result presents the pooled SMD (calculated by Hedges’s g, using a random effect model) of all the included studies.^{27
-29,36,37,40,41,71
-73} The overall effect size was 0.124 (95% CI: −0.134 to 0.382), indicating a small effect size in favor of the experimental group compared with the control group, and it was also not significant (Z = 0.943, P = .346; Figure 2). The Q test indicated medium heterogeneity among the studies, Q (22) = 80.722, P = .00, and I ² test = 72.7%, and the Egger test indicated no publication bias for all studies (β = −0.3630, P = .843).

Figure 2.

The forest plot about the effect of exercise on multiple health outcomes.

Effect of exercise on depression levels in individuals with AUD

We analyzed depression levels in individuals with AUDs after exercise intervention. The results are presented as the pooled SMD (calculated by Hedges’s g, using a random effect model) of 4 studies.^28,29,37,72 The effect size was −0.652 (95% CI: −1.585 to 0.282), indicating a large effect size in favor of the experimental group compared with the control group, and it was not also significant (Z = −1.369, P = .171; Figure 2). The Q test indicated high heterogeneity among the studies, Q (3) = 23.845, P = .000, and I ² test = 87.4%, and the Egger test indicated no publication bias for depression (β = −0.241, P = .978).

Table 3 shows the results of the subgroup analysis indicating the effect of an exercise intervention on depression. The effect types of exercise and exercise duration on depression levels in individuals with AUD were significantly different (P < .05). However, intensity and frequency of exercise did not have a significant relief on depression symptoms in AUD (P > .05).

Effect of exercise on anxiety levels in individuals with AUD

We analyzed anxiety levels in individuals with AUDs after exercise intervention. The results are presented as the pooled SMD (calculated by Hedges’s g, using a random effect model) of 3 studies.^28,29,37 The effect size was −0.276 (95% CI: −1.222 to 0.670), indicating a medium effect size in favor of the experimental group compared with the control group, and it was not significant (Z = −0.572, P = 0.567; Figure 2). The Q test indicated high heterogeneity among the studies, Q (2) = 10.664, P = .005, and I ² test = 81.2%, and the Egger test indicated no publication bias for anxiety (β = −2.92, P = .776).

The subgroup analysis found that the type, duration, and frequency of exercise had significantly different effects on anxiety symptoms in patients with AUD (P < .05), whereas the intensity of exercise did not (P > .05, Table 3).

Table 3.

Subgroup Analysis Results.^a

Analysis	Sample Size	No. of Studies	Meta-Analytic Effect Size	95% CI	Total Between		Heterogeneity	Q
Analysis	Exp/Ctrl	No. of Studies	SMD	95% CI	Q(df)	P	I	Q
Depression
Exercise type			−0.273	−0.669 to 0.123	8.352(2)	.015
Aerobic	25/23	1	0.304	−0.256 to 0.865			0%	0.00
Yoga	38/36	2	−1.115	−2.377 to 0.146			79%	4.780
Mixed	20/21	1	−0.783	−1.406 to −0.159			0%	0.00
Exercise intensity			−0.230	−1.295 to 0.835	0.00(0)	1.000
Moderate	45/44	2	−0.230	−1.295 to 0.835			84.5%	6.451
Exercise duration			−0.375	−0.898 to 0.149	5.535(1)	.019
<10 weeks	50/51	2	−1.246	−2.141 to −0.351			77.1%	4.384
10 weeks or more	33/29	2	0.078	−0.567 to 0.724			31.1%	1.453
Exercise frequency			−0.751	−1.318 to −0.184	0.055(1)	.814
1-2	63/59	3	−0.604	−1.961 to 0.754			91.5%	23.650
3-4	20/21	1	−0.783	−1.406 to −0.159			0%	0.00
Anxiety
Exercise type			−0.194	−0.582 to 0.195	10.664(2)	.005
Aerobic	25/21	1	0.463	−0.102 to 1.028			0%	0
Yoga	8/6	1	−0.402	−1.404 to 0.600			0%	0
Mixed	20/21	1	−0.938	−1.572 to −0.304			0%	0
Exercise intensity			−0.230	−1.603 to 1.143	0.00(0)	1.000
Moderate		2	−0.230	−1.603 to 1.143			90.4%	10.469
Exercise duration			−0.539	−1.041 to −0.037	4.091(1)	.043
<10 weeks	50/51	2	−0.938	−1.572 to −0.304			0%	0.00
10 weeks or more	33/29	2	0.134	−0.689 to 0.957			53.9%	2.172
Exercise frequency			−0.539	−1.041 to −0.037	4.091(1)	.043
1-2	63/59	3	0.134	−0.689 to 0.957			53.9%	2.172
3-4	20/21	1	−0.938	−1.572 to 0.304			0%	0.00
QoL
Exercise type			0.425	−0.00 to 0.849	1.169(1)	.280
Yoga	8/6	1	−0.069	−1.061 to 0.922			0%	0.000
Mixed	32/38	2	0.536	0.065 to 1.006			0%	0.902
Exercise intensity			0.536	0.065 to 1.006	0.902(1)	.342
Moderate	18/19	1	0.329	−0.306 to 0.964			0%	0.00
High	14/19	1	0.787	0.087 to 1.487			0%	0.00
Exercise duration			0.368	−0.136 to 0.871	0.039(1)	.844
<10 weeks	18/19	1	0.329	−0.306 to 0.964			0%	0.00
10 weeks or more	22/25	2	0.434	−0.392 to 1.260			47.7%	1.913
Exercise frequency			0.368	−0.136 to 0.871	0.039(1)	.844
1-2	22/25	2	0.434	−0.392 to 1.260			47.7%	1.913
3-4	18/19	1	0.329	−0.306 to 0.964			0%	0.000
Self-efficacy
Exercise type			0.387	−0.028 to 0.803	2.502(1)	.114
Aerobic	25/23	1	0.087	−0.470 to 0.645			0%	0.00
Mixed	18/19	1	0.762	0.139 to 1.385			0%	0.00
Exercise intensity			0.410	−0.251 to 1.070	0.000(0)	1.000
Moderate	43/42	2	0.410	−0.251 to 1.070			60%	2.502
Exercise duration			0.387	−0.028 to 0.803	2.502(1)	.114
<10 weeks	18/19	1	0.762	0.139 to 1.385			0%	0.00
10 weeks or more	25/23	1	0.087	−0.470 to 0.645			0%	0.00
Exercise frequency			0.387	−0.028 to 0.803	2.502(1)	.114
1-2	25/23	1	0.762	0.139 to 1.385			0%	0.00
3-4	18/19	1	0.087	−0.470 to 0.645			0%	0.00
Number of standard drinks per day
Exercise type			−0.167	−0.429 to 0.095	0.009(1)	.924
Aerobic	76/60	4	−0.170	−0.442 to 0.101			0%	1.353
Yoga	8/6	1	−0.121	−1.113 to 0.871 to			0%	0.000
Exercise intensity			−0.258	−0.602 to 0.087	0.698(2)	.705
Low	15/14	1	−0.526	−1.247 to 0.195 to			0%	0.00
Moderate	25/23	1	−0.193	−0.694 to 0.308			0%	0.00
High	16/22	1	−0.155	−0.787 to 0.476			0%	0.00
Exercise duration			−0.167	−0.429 to 0.095 to	1.099(1)	.294
<10 weeks	15/14	1	−0.526	−1.247 to 0.195 to			0%	0.00
10 weeks or more	68/51	4	−0.112	−0.394 to 0.169 to			0%	0.262
Exercise frequency			−0.170	−0.437 to 0.098	1.110(1)	.292
1-2	68/51	4	−0.144	−0.401 to 0.173			0%	0.266
3-4	15/14	1	0.526	−1.283 to 0.200			0%	0.00

^a P < .05.

Abbreviations: CI, confidence interval; Ctrl, control; Exp, experimental; QoL, quality of life; SMD, standardized mean difference.

Effect of exercise on QoL in individuals with AUD

We analyzed QoL in individuals with AUDs after exercise intervention. The results are presented as the pooled SMD (calculated by Hedges’s g, using a random effect model) of 3 studies.^27,28,36 The effect size was −0.425 (95% CI: −0.000 to 0.849), indicating a medium effect size in favor of the experimental group compared with the control group, and it was significant (Z = 1.958, P = .050; Figure 2). The Q test and I ² index indicated no evidence of heterogeneity among the studies, Q (2) = 2.071, P = .355, and I ² = 3.41%, and the Egger test indicated no publication for QoL (β = −2.75, P = .602). The subgroup analysis found that the type, duration, intensity, and frequency of exercise did not significantly affect QoL in patients with AUD (P > .05, Table 3).

Effect of exercise on self-efficacy in individuals with AUD

We analyzed self-efficacy levels in individuals with AUDs after exercise intervention. The results are presented as the pooled SMD (calculated by Hedges’s g, using a random effect model) of 2 studies.^29,37 The effect size was 0.387 (95% CI: −0.028 to 0.803), indicating a medium effect size in favor of the experimental group compared with the control group, and it was not significant (Z = 1.828, P = .068; Figure 2). The Q test indicated medium heterogeneity among the studies, Q (1) = 2.502, P = .114, and I ² test = 60%. The subgroup analysis found that the type, duration, intensity, and frequency of the exercise did not significantly affect self-efficacy in patients with AUD (P > .05, Table 3).

Effect of exercise on VO₂ max in individuals with AUD

We analyzed VO₂ max levels in individuals with AUDs after exercise intervention. The results are presented as the pooled SMD (calculated by Hedges’s g, using a random effect model) of 3 studies.^29,40,71 The effect size was 0.487 (95% CI: 0.144-0.830), indicating a medium effect size in favor of the experimental group compared with the control group, and it was significant (Z = 2.785, P = .005; Figure 2). The Q test and I ² index indicated no evidence of heterogeneity among the studies, Q (2) = 1.883, P = .390, and I ² test = 0%, and the Egger test indicated no publication bias for VO₂ max (β = −5.304, P = .442).

Effect of exercise on alcohol outcomes of consumption in individuals with AUD

We analyzed alcohol consumption in individuals with AUDs after exercise intervention (the number of standard drinks per day or per week). The results are presented as the pooled SMD (calculated by Hedges’s g, using a random effect model) of 5 studies.^{28,29,40,41,71} The effect size of the number of drinking days was −0.167 (95% CI: −0.429 to 0.095), indicating a medium effect size in favor of the experimental group compared with the control group, and it was not significant (Z = −1.248, P = .212; Figure 2). The Q test and I ² index indicated no evidence of heterogeneity among the studies, Q (4) = 1.362, P = .851, and I ² test = 0%, and the Egger test indicated no publication bias for number of drinking days (β = −0.973, P = .409).

The results are presented as the pooled SMD (calculated by Hedges’s g, using a random effect model) of 2 studies^28,71 The effect size of the number of drinking week was −0.330 (95% CI: −0.911 to 0.252), indicating a medium effect size in favor of the experimental group compared with the control group, and it was not significant (Z = −1.112, P = .266; Figure 2). The Q test and I ² index indicated no evidence of heterogeneity among the studies, Q (1) = 0.322, P = .570, and I ² test = 0%. The subgroup analysis found that type, duration, intensity, and frequency of exercise did not significantly affect alcohol consumption in patients with AUD (P > .05, Table 3).

Effect of exercise on HR max in individuals with AUD

We analyzed HRmax level in individuals with AUDs after exercise intervention. The results are presented as the pooled SMD (calculated by Hedges’s g, using a random effect model) of 1 studies.⁷³ The effect size was 0.717 (95% CI: 0.176-1.259), indicating a medium effect size in favor of the experimental group compared with the control group, and it was significant (Z = 2.596, P = .009). The Q test and I ² index indicated no evidence of heterogeneity among the studies, Q (0) = 0.00, P = 1.000, and I ² test = 0% (Figure 2).

Discussion

We conducted a systematic review and meta-analysis to examine the pooled effects of exercise (and its components including type, intensity, frequency, and duration) on multiple health outcomes, including depression, anxiety, self-efficacy, QoL, physical fitness, and alcohol consumption in individuals with AUD. This is the first study to examine the pooled treatment effects of various components of exercise interventions for AUDs across multiple health outcomes. In all, 10 controlled clinical trials met the inclusion criteria for this meta-analysis, collectively representing 579 participants with AUD who underwent exercise interventions. Overall, our results provide evidence that exercise can be considered an evidence-based treatment for AUD. The pooled data indicate that exercise was effective in increasing QoL and improving physical fitness (VO₂ max and HRmax). Although depression, anxiety, and alcohol consumption decreased and self-efficacy increased, these changes did not reach statistical significance.

VO₂ max is the maximum rate of oxygen consumption measured during incremental exercise. VO₂ max reflects the cardiorespiratory fitness of an individual, which is an essential determinant of their endurance capacity during prolonged exercise.⁵ Low levels of cardiorespiratory fitness have been associated with a markedly increased risk of early all-cause mortality and particularly due to CVD.⁷⁴ Individuals with AUDs have a 2-fold increased risk of CVD.⁷⁵ They generally have a higher risk of metabolic disorders than the general population. Metabolic syndrome and its components are associated with CVD.⁵ Exercise intervention in those with AUD is associated with a significantly better cardiometabolic risk factor profile, lower all-cause mortality, fewer CVD events, lower risk of developing physical function limitations, and lower risk of nonfatal disease. Also, exercise may be useful in preventing and treating metabolic syndrome.⁸ Hallgren et al suggested that exercise interventions should be integrated into the clinical management of individuals with AUDs.¹⁴ Studies have shown that exercise may benefit specific areas of physical fitness, including VO₂ max and HRmax.^14,15 The current findings are consistent with previously published meta-analyses and review articles investigating the effect of exercise in AUDs. In the comparison between the exercise and control groups, we found a moderate and significant effect (g = 0.487) in favor of exercise in terms of VO₂ max and HRmax. The analyses were limited to only 3 studies and 1 study, respectively. Nevertheless, these findings appear clinically important due to a high prevalence of metabolic disorders and CVD risk in AUDs.

Quality of life is a key outcome in the management of chronic diseases, including AUDs. Individuals with AUD typically report a significantly lower QoL than the general population.⁷⁶ Exercise training in patients with AUD has consistently shown to improve QoL.³⁶ The present meta-analysis found a significant treatment effect on QoL of approximately half a standard deviation for exercise compared with control conditions (g = 0.425). The analyses were limited to only 3 studies. Nevertheless, heterogeneity was recorded (I ² = 3.41%), indicating considerable consistency for the positive effect of exercise on QoL. The subgroup analysis revealed that the type, intensity, duration, and frequency of exercise induce similar beneficial effects on QoL in individuals with AUD. Thus, exercise should be incorporated into daily life as a critical step toward a healthy lifestyle.

The lifetime odds of having any mood disorder in individuals with AUD are 1.5 times than that in the general population.³ Also, alcohol exposure causes metabolic changes that increase the risk of mood disorders.⁷⁷ Studies have reported the antidepressant effects of exercise intervention^13,78; individuals who are physically active throughout their life have a reduced risk of experiencing a depressive episode.⁷⁹ The current meta-analysis found that exercise intervention nonsignificantly decreases anxiety and depression symptoms. However, subgroup analysis found that the type of exercise—aerobic exercise, yoga, or mixed exercise—affected depression and anxiety levels differently in individuals with AUD. Aerobic exercise alleviated the depression and anxiety symptoms more than yoga and mixed types (Table 3), probably because frequent aerobic exercise reduces symptoms of depression more than lower-energy exercise.⁸⁰ However, the number of studies included in our analysis was too low to definitively conclude whether exercise reduces depression and anxiety symptoms in individuals with AUD. Giesen et al reported that exercise shows inconsistent positive effects on anxiety and mood management.²⁷ Therefore, well-designed RCTs are urgently required to elucidate the effect of exercise on depression and anxiety symptoms in individuals with AUD. Another potential factor influencing the effectiveness of exercise intervention seems to be the total length of the exercise intervention. The American College of Sports Medicine recommends that an exercise intervention should last at least 12 weeks to obtain adequate beneficial effects on the cardiopulmonary function, which is an important factor for patients with AUD.⁷⁴ In the current meta-analysis, the subgroup analysis indicated a significant difference in the depression and anxiety levels in terms of exercise duration. Individuals with AUD who exercised ≥10 weeks had lower levels of depression and anxiety than those who exercised <10 weeks, thus pointing to an inverse relationship between exercise duration and depression and anxiety levels. Long-term exercise interventions may improve depression and anxiety in individuals with AUDs.

The current meta-analysis showed that exercise showed a nonsignificant increase in self-efficacy. This finding was limited by only 2 studies. However, the result should be interpreted with caution because of the small sample size. Similarly, although there was no significant change in alcohol consumption, measured by the number of standard drinks consumed per day and per week, the direction of change favors the exercise group. A recent meta-analysis by Hallgren et al did not find statistically significant changes in alcohol consumption.¹⁴ Giesen et al reported that exercise had a positive effect on drinking behavior, but this effect was inconsistent.¹⁵ Manthou et al indicated that exercise might reduce alcohol consumption.³⁹ Nevertheless, there are promising hints toward the acute effect of exercise on reducing alcohol drinking behavior in previous studies. Although this meta-analysis provides evidence on the benefits of exercise for QoL and physical fitness, we did not find a clear effect of exercise on alcohol consumption and self-efficacy. Our analyses were limited to 5 studies. Therefore, future research should focus on the development of exercise programs that will have a greater influence on drinking behavior.

The present study had several limitations. First, the effect sizes were small. Caution should be taken when interpreting the present results as considerable heterogeneity was present. Second, only published interventional studies in English and Turkish from 2000 to 2018 were included. Third, there are various tools for evaluating the main outcomes in the literature.

Conclusions

Our results provide strong evidence that exercise can be an effective adjunctive therapy for individuals with AUD. An exercise intervention not only significantly increased QoL (g = 0.387), VO₂ max (g = 0.487), and HRmax (g = 0.717) in these individuals but also reduced depression, anxiety, and alcohol consumption and increased self-efficacy. While the type and duration of exercise affect depression and anxiety symptoms differently, effects of the type, frequency, intensity, and duration of exercise on QoL and self-efficacy are similar. Although these results generally support having exercise as a part of AUD treatment, there is a need for more highly controlled trials to further clarify the effect of the exercise intervention on patient outcomes. Future research should focus on the development of exercise programs that will have a greater influence on different health-related parameters.

Additionally, current benefits of exercise on physical fitness and multiple mental health indicators underline that health and sports professionals need to actively promote exercise in individuals with AUD during and following addiction programs. This meta-analysis contributes to this research area through its focus on the development and evaluation of exercise interventions for individuals with AUD.

So What

What is already known on this topic?

As individuals with alcohol use disorders (AUDs) have a risk of cardiovascular disease, metabolic syndrome, depression, and anxiety, the findings suggest that exercise interventions should be integrated into the clinical management (preventing and treating) of those with AUDs.

What does this article add?

This paper presents evidence that exercise intervention is effective in improving physical fitness and mental health in individuals with AUD. Improving multiple health outcomes may prevent relapse in patients with AUDs.

What are the implications for health promotion practitioners or research?

There is a need for more highly controlled trials to determine the effect of the exercise intervention on patient outcomes. Future research should focus on the development of exercise programs that will have a greater influence on different health-related parameters. The findings may be adopted in other patient populations.

Supplemental Material

Supplemental Material, sj-docx-1-ahp-10.1177_0890117120913169 - Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis

Supplemental Material, sj-docx-1-ahp-10.1177_0890117120913169 for Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis by Fatih Gür and Ganime Can Gür in American Journal of Health Promotion

Supplemental Material

Supplemental Material, sj-docx-2-ahp-10.1177_0890117120913169 - Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis

Supplemental Material, sj-docx-2-ahp-10.1177_0890117120913169 for Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis by Fatih Gür and Ganime Can Gür in American Journal of Health Promotion

Supplemental Material

Supplemental Material, sj-pdf-1-ahp-10.1177_0890117120913169 - Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis

Supplemental Material, sj-pdf-1-ahp-10.1177_0890117120913169 for Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis by Fatih Gür and Ganime Can Gür in American Journal of Health Promotion

Footnotes

Acknowledgments

The authors thank Dr. Emine YILMAZ (University of Bingol) for data checked.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Fatih GÜR is in research assistant at Pamukkale University Faculty of Sport Science, Denizli, Turkey. Ganime CAN GÜR is in PhD at Department of Nursing, Pamukkale University Faculty of Health Science, Denizli, Turkey.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ganime CAN GÜR, PhD

Supplemental Material

Supplementary material for this article is available online.

References

Rehm

Anderson

Barry

, et al. Prevalence of and potential influencing factors for alcohol dependence in Europe. Europe Addict Res. 2015;21(1):6–18. doi:10.1159/000365284.

Wittchen

Jacobi

Rehm

, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol. 2011;21(9):655–679. doi:10.1016/j.euroneuro.2011.07.018.

Grant

Goldstein

Saha

, et al. Epidemiology of DSM-5 alcohol use disorder results from the national epidemiologic survey on alcohol and related conditions III. JAMA Psychi. 2015;72(8):757–766. doi:10.1001/jamapsychiatry.2015.0584.

Maisto

Connors

Zywiak

. Alcohol treatment, changes in coping skills, self-efficacy, and levels of alcohol use and related problems 1 year following treatment initiation. Psychology Addict Behav. 2000;14(3):257–266. doi:10.1037/0893-164X.14.3.257.

McLellan

Lewis

O’Brien

Kleber

. Drug dependence, a chronic medical illness implications for treatment, insurance, and outcomes evaluation. J Am Med Assoc. 2000;284(13):1689–1695. doi:10.1001/jama.284.13.1689.

World Health Organization (WHO). Global strategy on diet, physical activity and health. https://www.who.int/dietphysicalactivity/pa/en/.2019.

Pescatello

Arena

Riebe

Thompson

. Book Reviews. Local Gov Stud. 2005;31(4):511–526. doi:10.1080/03003930500157457.

Garber

Blissmer

Deschenes

, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–1359. doi:10.1249/MSS.0b013e318213fefb.

Bart

Verkindre

. Physical activity and public health. Rev Des Mal Respir. 2001;18(2 Suppl):1423–1434. doi:10.1249/mss.0b013e3180616b27.

10.

Asano

Sales

Browne

RAV

, et al. Acute effects of physical exercise in type 2 diabetes: a review. World Journal of Diabetes. 2014;5(5):659.

11.

Golbidi

Mesdaghinia

Laher

. Exercise in the metabolic syndrome. Oxid Med Cell Longev. 2012;2012:349710. doi:10.1155/2012/349710.

12.

Kim

Kang

Park

. A meta-analysis of aerobic exercise interventions for women with breast cancer. Western J Nurs Res. 2009;31(4):437–461. doi:10.1177/0193945908328473.

13.

Kvam

Kleppe

Nordhus

Hovland

. Exercise as a treatment for depression: a meta-analysis. J Affect Disord. 2016;202:67–86. doi:10.1016/j.jad.2016.03.063.

14.

Hallgren

Vancampfort

Giesen

Lundin

Stubbs

Exercise as treatment for alcohol use disorders: Systematic review and meta-analysis. Br J Sports Med. 2017;51(14):1058–1064. doi:10.1136/bjsports-2016-096814.

15.

Giesen

Deimel

Bloch

. Clinical exercise interventions in alcohol use disorders: a systematic review. J Subst Abuse Treat. 2015;52:1–9. doi:10.1016/j.jsat.2014.12.001.

16.

Wipfli

Rethorst

Landers

. The anxiolytic effects of exercise: a meta-analysis of randomized trials and dose-response analysis. J Sport Exercise Psy. 2008;30(4):392–410. doi:10.1123/jsep.30.4.392.

17.

Wang

Zhou

. Impact of physical exercise on substance use disorders: A meta-analysis. PLoS ONE. 2014;9(10). doi:10.1371/journal.pone.0110728.

18.

Weinstock

Farney

Elrod

Henderson

Weiss

. Exercise as an adjunctive treatment for substance use disorders: rationale and intervention description. J Subst Abuse Treat. 2017;72:40–47. doi:10.1016/j.jsat.2016.09.002.

19.

Schuch

Vancampfort

Richards

Rosenbaum

Ward

Stubbs

Exercise as a treatment for depression: a meta-analysis adjusting for publication bias. J Psychiatr Res. 2016;77:42–51. doi:10.1016/j.jpsychires.2016.02.023.

20.

Gorczynski

Faulkner

. Exercise therapy for schizophrenia. Cochrane Database Syst Rev. 2010;(5):CD004412. doi:10.1002/14651858.CD004412.pub2.

21.

Puetz

TW.

Physical activity and feelings of energy and fatigue: Epidemiological evidence. Sports Med. 2006;36(9):767–780. doi:10.2165/00007256-200636090-00004.

22.

Yau

. Tai Chi exercise and the improvement of health and well-being in older adults. Med Sport Sci. 2008;52:155–165. doi:10.1159/000134296.

23.

Conn

Hafdahl

Brown

. Meta-analysis of quality-of-life outcomes from physical activity interventions. Nurs Res. 2009;58(3):175–183. doi:10.1097/NNR.0b013e318199b53a.

24.

Gillison

Skevington

Sato

Standage

Evangelidou

. The effects of exercise interventions on quality of life in clinical and healthy populations; a meta-analysis. Soc Sci Med. 2009;68(9):1700–1710. doi:10.1016/j.socscimed.2009.02.028.

25.

Yaffe

Fiocco

Lindquist

, et al. Predictors of maintaining cognitive function in older adults: The Health ABC Study. Neurology. 2009;72(23):2029–2035. doi:10.1212/WNL.0b013e3181a92c36.

26.

Paterson

Warburton

DER

. Physical activity and functional limitations in older adults: a systematic review related to Canada’s Physical Activity Guidelines. Int J Behav Nutri Physl Act. 2010;7(1):38. doi:10.1186/1479-5868-7-38.

27.

Giesen

Zimmer

Bloch

. Effects of an exercise program on physical activity level and quality of life in patients with severe alcohol dependence. Alcohol Treat Q. 2016;34(1):63–78. doi:10.1080/07347324.2016.1113109.

28.

Hallgren

Romberg

Bakshi

Andréasson

. Yoga as an adjunct treatment for alcohol dependence: a pilot study. Complement Ther Med. 2014;22(3):441–445. doi:10.1016/j.ctim.2014.03.003.

29.

Brown

Abrantes

Minami

, et al. A preliminary, randomized trial of aerobic exercise for alcohol dependence. J Subst Abuse Treat. 2014;47(1):1–9. doi:10.1016/j.jsat.2014.02.004.

30.

Buchowski

Meade

Charboneau

, et al. Aerobic exercise training reduces cannabis craving and use in non-treatment seeking cannabis-dependent adults. PLoS ONE. 2011;6(3):e17465. doi:10.1371/journal.pone.0017465.

31.

Gill

Womack

Safranek

. Does exercise alleviate symptoms of depression? J Fam Pract. 2010;59(9):530–531.

32.

Suter

Strik

Moggi

. Depressive symptoms as a predictor of alcohol relapse after residential treatment programs for alcohol use disorder. J Subst Abuse Treat. 2011;41(3):225–232. doi:10.1016/j.jsat.2011.03.005.

33.

Perraton

Kumar

MacHotka

. Exercise parameters in the treatment of clinical depression: a systematic review of randomized controlled trials. J Eval Clin Pract. 2010;16(3):597–604. doi:10.1111/j.1365-2753.2009.01188.x.

34.

Carek

Laibstain

Carek

. Exercise for the treatment of depression and anxiety. Int J Psy Med. 2011;41(1):15–28. doi:10.2190/PM.41.1.c.

35.

Dinas

Koutedakis

Flouris

. Effects of exercise and physical activity on depression. Irish J Med Sci. 2011;180(2):319–325. doi:10.1007/s11845-010-0633-9.

36.

Gür

Can Gür

Okanlı

. the effect of the cognitive-behavioral model-based psychoeducation and exercise intervention on quality of life in alcohol use disorder. Arch Psychiatr Nurs. 2017;31(6):541–548. doi:10.1016/j.apnu.2017.07.005.

37.

Can Gür

Okanli

The effects of cognitive-behavioral model-based intervention on depression, anxiety, and self-efficacy in alcohol use disorder. Clin Nurs Res. 2019;28(1):52–78. doi:10.1177/1054773817722688.

38.

Brown

Abrantes

Read

, et al. Aerobic exercise for alcohol recovery: Rationale, program description, and preliminary findings. Behav Modif. 2009;33(2):220–249. doi:10.1177/0145445508329112.

39.

Manthou

Georgakouli

Fatouros

Gianoulakis

Theodorakis

Jamurtas

. Role of exercise in the treatment of alcohol use disorders (review). Biomed Rep. 2016;4(5):535–545. doi:10.3892/br.2016.626.

40.

Jensen

Nielsen

Ekstrøm

Roessler

. Physical exercise in the treatment of alcohol use disorder (AUD) patients affects their drinking habits: a randomized controlled trial. Scand J Public Health. 2019;47(4):462–468. doi:10.1177/1403494818759842.

41.

Roessler

Bilberg

Søgaard Nielsen

Jensen

Ekstrøm

Sari

Exercise as adjunctive treatment for alcohol use disorder: a randomized controlled trial. PLoS One. 2017;12(10):e0186076. doi:10.1371/journal.pone.0186076.

42.

Moher

Liberati

Tetzlaff

J AD

. Supporting Figure 4. Flow diagram of studies included in the Records identified through PubMed and ISI Web of Knowledge Additional records identified through other sources Records excluded Full-text articles assessed for eligibility qualitative synthesis. PRISMA Statement. 2009;6(2009):10000 97. doi:10.1371/journal.pmed1000097.

43.

Stroup

Berlin

Morton

Olkin

Williamson

GD RD

. MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies. JAMA. 2000;283(15):2008–2012.

44.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (2nd edn.). Washington, DC: American Psychiatric Association; 1968. doi:http://dx.doi.org.lrc1.usuhs.edu/10.1176/appi.books.9780890425596.

45.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (3rd edn.) Washington, DC: American Psychiatric Association; 1980. doi:10.1016/B978-1-4377-2242-0.00016-X.

46.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (3rd Ed. Revised). Washington, DC: American Psychiatric Association; 1987.

47.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. (4rd Ed. Revised). Washington, DC: American Psychiatric Association; 2000.

48.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing; 2013. doi:10.1176/appi.books.9780890425596.744053.

49.

WHO. ICD-10 classification of mental and behavioral disorders. Diagnostic criteria for research. Geneva, Switzerland: World Heal Organ Geneva; 1993.

50.

Saunders

Aasland

Babor

Fuente

De La

Jr Grant

. Development of the alcohol use disorders identification test (audit): who collaborative project on early detection of persons with harmful alcohol consumption-ii. Addiction. 1993;88(6):791–804. doi:10.1111/j.1360-0443.1993.tb02093.x.

51.

Furlan

Pennick

Bombardier

Van Tulder

, 2009 Updated method guidelines for systematic reviews in the Cochrane back review group. Spine. 2009;34(18):1929–1941. doi:10.1097/BRS.0b013e3181b1c99f.

52.

Higgins

JPT

Thompson

Deeks

Altman

. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–560. doi:10.1136/bmj.327.7414.557.

53.

Egger

Smith

Schneider

Minder

. Bias in meta-analysis detected by a simple, graphical test measures of funnel plot asymmetry. BMJ. 1997;315(7109):629–634. doi:10.1136/bmj.315.7109.629.

54.

Georgakouli

Manthou

Fatouros

, et al. Effects of acute exercise on liver function and blood redox status in heavy drinkers. Exp Ther Med. 2015;10(6):2015–2022. doi:10.3892/etm.2015.2792

55.

Coiro

Casti

Saccani Jotti

, et al. Adrenocorticotropic hormone/cortisol response to physical exercise in abstinent alcoholic patients. Alcohol: Clin Exp Res. 2007;31(5):901–906. doi:10.1111/j.1530-0277.2007.00376.x.

56.

Jamurtas

. Beta endorphin and alcohol urge responses in alcoholic patients following an acute bout of exercise. J Addict Res Therapy. 2014;05(03):194. doi:10.4172/2155-6105.1000194.

57.

Reddy

Dick

Gerber

Mitchell

. The effect of a yoga intervention on alcohol and drug abuse risk in veteran and civilian women with posttraumatic stress disorder. J Altern Complem Med. 2014;20(10):750–756. doi:10.1089/acm.2014.0014.

58.

Patten

Vickers

Martin

Williams

. Exercise interventions for smokers with a history of alcoholism: exercise adherence rates and effect of depression on adherence. Addict Behav. 2003;28(4):657–667. doi:10.1016/S0306-4603(01)00280-5.

59.

Werch

Moore

DiClemente

Owen

Jobli

Bledsoe

. A sport-based intervention for preventing alcohol use and promoting physical activity among adolescents. J Sch Health. 2003;73(10):380–388. doi:10.1111/j.1746-1561.2003.tb04181.x.

60.

Brown

Prince

Minami

Abrantes

. An exploratory analysis of changes in mood, anxiety and craving from pre- to post-single sessions of exercise, over 12 weeks, among patients with alcohol dependence. Ment Health Phys Act. 2016;11:1–6. doi:10.1016/j.mhpa.2016.04.002.

61.

Roessler

Bilberg

Jensen

Kjaergaard

A-S

Dervisevic

Nielsen

. Exercise as treatment for alcohol dependence. Sport Sci Rev. 2013;22(3-4):205–216. doi:10.2478/ssr-2013-0010.

62.

Abrantes

Blevins

Battle

Read

Gordon

Stein

. Developing a Fitbit-supported lifestyle physical activity intervention for depressed alcohol dependent women. J Subst Abuse Treat. 2017;80:88–97. doi:10.1016/j.jsat.2017.07.006.

63.

Weinstock

Petry

Pescatello

Henderson

. Sedentary college student drinkers can start exercising and reduce drinking after intervention. Psy Addict Behav. 2016;30(8):791–801. doi:10.1037/adb0000207.

64.

Hallgren

Andersson

Ekblom

Andréasson

. Physical activity as treatment for alcohol use disorders (FitForChange): study protocol for a randomized controlled trial. Trials. 2018;19(1):106. doi:10.1186/s13063-017-2435-0.

65.

Ussher

Sampuran

Doshi

West

Drummond

. Acute effect of a brief bout of exercise on alcohol urges. Addiction. 2004;99(12):1542–1547. doi:10.1111/j.1360-0443.2004.00919.x.

66.

Bichler

Niedermeier

Frühauf

, et al. Acute effects of exercise on affective responses, cravings and heart rate variability in inpatients with alcohol use disorder—a randomized cross-over trial. Ment Health Phys Act. 2017;13:68–76. doi:10.1016/j.mhpa.2017.10.002.

67.

Taylor

Cullen

. Acute effect of exercise on alcohol urges and attentional bias towards alcohol related images in high alcohol consumers. Ment Health Phys Act. 2013;6(3):220–226. doi:10.1016/j.mhpa.2013.09.004.

68.

Yeltepe Ercan

Yargiç

İL

Karagözoglu

. Alkol ve madde bağımlılığı tedavisi gören yetişkinlerde düzenli egzersizin kaygı, depresyon ve yaşam kalitesine etkisi. Anadolu Psikiyatri Derg. 2016;17(1):33–41. doi:10.5455/apd.174887.

69.

Houghton

Hallsworth

Thoma

, et al. Effects of exercise on liver fat and metabolism in alcohol drinkers. Clin Gastroenterol Hepatol. 2017;15(10):1596–1603. doi:10.1016/j.cgh.2017.05.001.

70.

Sareen

Kumari

Gajebasia

. Yoga: a tool for improving the quality of life in chronic pancreatitis. World J Gastroenterol. 2007;13(3):391–397. doi:10.3748/wjg.v13.i3.391.

71.

Weinstock

Capizzi

Weber

Pescatello

Petry

. Exercise as an intervention for sedentary hazardous drinking college students: a pilot study. Ment Health Phys Act. 2014;7(1):55–62. doi:10.1016/j.mhpa.2014.02.002.

72.

Vedamurthachar

Janakiramaiah

Hegde

, et al. Antidepressant efficacy and hormonal effects of sudarshana kriya yoga (SKY) in alcohol dependent individuals. J Affect Disord. 2006;94(1-3):249–253. doi:10.1016/j.jad.2006.04.025.

73.

Capodaglio

Vittadini

Bossi

, et al. A functional assessment methodology for alcohol dependent patients undergoing rehabilitative treatments. Disabil Rehabil. 2003;25(21):1224–1230. doi:10.1080/09638280310001608573.

74.

Thompson

Arena

Riebe

Pescatello

. ACSM’s new preparticipation health screening recommendations from ACSM’s guidelines for exercise testing and prescription, ninth edition. Curr Sports Med Rep. 2013;12(4):215–217. doi:10.1249/JSR.0b013e31829a68cf.

75.

Vancampfort

, et al. The prevalence of metabolic syndrome in alcohol use disorders: a systematic review and meta-analysis. Alcohol and alcoholism. 2016;51(5):515–521.

76.

De Maeyer

Vanderplasschen

Broekaert

. Quality of life among opiate-dependent individuals: a review of the literature. Int J Drug Policy. 2010;21(5):364–380. doi:10.1016/j.drugpo.2010.01.010.

77.

McEachin

Keller

Saunders

McInnis

. Modeling gene-by-environment interaction in comorbid depression with alcohol use disorders via an integrated bioinformatics approach. BioData Min. 2008;1(1):2. doi:10.1186/1756-0381-1-2.

78.

Hallgren

Vancampfort

Schuch

Lundin

Stubbs

. More reasons to move: exercise in the treatment of alcohol use disorders. Front Psychiatry. 2017;8:160. doi:10.3389/fpsyt.2017.00160.

79.

Dishman

Sui

Church

Hand

Trivedi

Blair

. Decline in cardiorespiratory fitness and odds of incident depression. Am J Prev Med. 2012;43(4):361–368.

80.

Saeed

Antonacci

Richard

B. Exercise, yoga, and meditation for depressive and anxiety disorders. Am Fam Physician. 2010;81(8):981–986.

Supplementary Material

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Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis

Abstract

Objectives:

Data Sources:

Study Inclusion and Exclusion Criteria:

Data Extraction:

Data Synthesis:

Results:

Conclusions:

Keywords

Introduction

Material and Methods

Design

Inclusion and Exclusion Criteria

Types of studies

Types of setting

Types of participants

Types of interventions

Types of outcome measures

Data Sources

Study Selection

Data Extraction and Management

Risk of Bias/Quality Assessment

Data Synthesis

Results

Search Results

Characteristics of Included Trials and Participants

Risk of Bias in Included Studies

Outcomes

General effect sizes and heterogeneity of included studies

Effect of exercise on depression levels in individuals with AUD

Effect of exercise on anxiety levels in individuals with AUD

Effect of exercise on QoL in individuals with AUD

Effect of exercise on self-efficacy in individuals with AUD

Effect of exercise on VO2 max in individuals with AUD

Effect of exercise on alcohol outcomes of consumption in individuals with AUD

Effect of exercise on HR max in individuals with AUD

Discussion

Conclusions

So What

What is already known on this topic?

What does this article add?

What are the implications for health promotion practitioners or research?

Supplemental Material

Supplemental Material, sj-docx-1-ahp-10.1177_0890117120913169 - Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis

Supplemental Material

Supplemental Material, sj-docx-2-ahp-10.1177_0890117120913169 - Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis

Supplemental Material

Supplemental Material, sj-pdf-1-ahp-10.1177_0890117120913169 - Is Exercise a Useful Intervention in the Treatment of Alcohol Use Disorder? Systematic Review and Meta-Analysis

Footnotes

Acknowledgments

Declaration of Conflicting Interests

Funding

ORCID iD

Supplemental Material

References

Supplementary Material

Effect of exercise on VO₂ max in individuals with AUD