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Evidence-Based Complementary and Alternative Medicine
Volume , Article ID , pages
http://dx.doi.org/.//
Research Article
Mindful Walking in Psychologically Distressed
Individuals: A Randomized Controlled Trial
M. Teut,1E. J. Roesner,1M. Ortiz,1F. Reese,1S. Binting,1S. Roll,1H. F. Fischer,1,2
A. Michalsen,1,3 S. N. Willich,1and B. Brinkhaus1
1Institute for Social Medicine, Epidemiology and Health Economics, Charit´
e-Universtit¨
atsmedizin Berlin,
Luisenst raße 57, 10117 Berlin, Germany
2Department of Psychosomatic Medicine, Charit´
e-Universtit¨
atsmedizin Berlin, 10117 Berlin, Germany
3Immanuel Krankenhaus, Abteilung f¨
ur Naturheilkunde, 14109 Berlin, Germany
Correspondence should be addressed to M. Teut; michael.teut@charite.de
Received May ; Accepted July
Academic Editor: Gregory L. Fricchione
Copyright © M. Teut et al. is is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background. e aim of this randomized, controlled study was to investigate the eectiveness of a mindful walking program in
patients with high levels of perceived psychological distress. Methods. Participants aged between and years with moderate to
high levels of perceived psychological distress were randomized to sessions of mindful walking in weeks (each minutes
walking, minutes mindful walking, minutes discussion) or to no study intervention (waiting group). Primary outcome
parameter was the dierence to baseline on Cohen’s Perceived Stress Scale (CPSS) aer weeks between intervention and control.
Results. Seventy-four participants were randomized in the study; ( female, . ±. years) were allocated to the intervention
and ( female, . ±. years) to the control group. Adjusted CPSS dierences aer weeks were −. [% CI: −.; −.]
(mean . [.; .]) in the intervention group and −. [−.; .] (mean . [.; .]) in the control group, resulting in a
highly signicant group dierence (𝑃 < 0.001). Conclusion. Patients participating in a mindful walking program showed reduced
psychological stress symptoms and improved quality of life compared to no study intervention. Further studies should include an
active treatment group and a long-term follow-up.
1. Background
General psychological distress and stress-related diseases are
considered to be an important health issue in Western soci-
eties. A recent survey with a representative sample showed
that between % and % of the adult German population
reported symptoms of marked psychological distress in the
last months, the frequency of chronic stress being higher
among women than men [,]. Another survey suggests
that up to % of the German population feels distressed
frequently, up to % most of the time []. It is also assumed
that the share of workers who experience stress and psycho-
logical trouble due to their working conditions is increasing.
In a recent German survey, one-h of employees felt
overburdened on work; % reported that they experienced
an increase of stress and work pressure in the last years [].
Whereas a certain level of stress is generally considered to be
of benet to improve performance, continuous stress aects
physical and mental health [,].
In several studies, mindfulness training and physical
exercise have demonstrated eects in reducing symptoms
of psychological distress [,]. Mindfulness training is
a treatment strategy derived from Buddhist mindfulness
meditation practice. It is described as the tendency to
encounter moment-to-moment experiences without being
lost in unhelpful or distressing thoughts triggered by the
experience []. e most commonly studied mindfulness
training program is mindfulness-based stress reduction
(MBSR) that has demonstrated eects not only a wide range
of mental and physical disorders, but also on stressed healthy
people [,]. A direct relationship between physical exercise
and prevention or improvements of health has not only
been established for many somatic diseases, but seems also
plausible for psychological distress [].
Evidence-Based Complementary and Alternative Medicine
For the future, it is an important public health issue to
develop and evaluate simple and cost-eective nonpharma-
cological therapies for the general population to prevent and
treat individuals with acute or chronic psychological distress.
Hypothetically it could be a good concept to combine
mental and physical stress reduction strategies, especially
if the combined exercise program would be easy to learn
and run on low costs. Up to date, a combination between
walking exercise and mindfulness has not been systematically
evaluated. erefore, we developed an easy to follow training
program that combines mindfulness with walking. e aim
of this randomized, controlled study was to investigate the
eectiveness of mindful walking in patients with high levels
of subjectively perceived psychological distress.
2. Methods
2.1. Design. is study was designed as an open, single-center
randomized controlled trial including two parallel groups.
All study participants gave their written informed consent
before inclusion. e study was carried out at the outpatient
clinic for Complementary and Alternative Medicine (CAM)
at Charit´
eUniversit
¨
atsmedizin Berlin, Germany. e mindful
walking training was performed in the surrounding streets
and parks.
Patients were allocated to treatment groups by a ran-
domization with a : ratio. e random allocation sequence
was generated using SAS . soware (SAS Institute Inc.,
Cary, NC, USA). Aer signing the informed consent form
and completing the baseline assessment questionnaires, the
subjects were centrally assigned to intervention or control
group by an independent study nurse on the telephone line.
Allocation was concealed according to the randomization list.
e study was reviewed and approved by the Ethics
Committee of the Charit´
eUniversit
¨
atsmedizin, Berlin, Ger-
many (EA// - ..). e study was registered at
ClinicalTrials.gov (NCT).
2.2. Participants. Participants were recruited through adver-
tisements in local daily newspapers. Study information and
prescreening were undertaken by phone by a study nurse and
a student of health science. Eligible subjects that reported
a high level of psychological distress were invited for a
personal consultation with a study physician for information,
informed consent, and the assessment of inclusion or exclu-
sion. Inclusion criteria were
(i) men and women between and years,
(ii) increased level of psychological distress (visual analog
scale > mm; range: – mm, higher values indi-
cating more stress).
Exclusion criteria were
(i) regular walking training in the last weeks (at least
one regular training session per week),
(ii) psychopharmacological drugs,
(iii) regular mindfulness training (at least one regular
training session per week),
(iv) other CAM treatments against stress in the last
weeks,
(v) acute diseases or chronic disease at baseline,
(vi) inability to walk.
e visual analogue scale for the detection of increased level
of psychological distress was mainly chosen for practical
reasons—VAS assessment is easily and quickly done.
2.3. Study Intervention. e intervention protocol was devel-
oped in a consensus process including a mindfulness-based
stress reduction trainer, a sports therapist, and two medical
doctors. Subjects allocated to the intervention group received
sessions of -minute mindful walking training within four
weeks. Each training group consisted up to individuals.
e intervention was delivered by two sports therapists
that were also trained in mindfulness-based stress reduction
techniques. Each session was structured as follows:
(i) meeting at a dened meeting point and greetings (
minutes);
(ii) walking to a park ( minutes);
(iii) gymnastic exercises to warm up and short walking
instructions ( minutes);
(iv) walking ( minutes);
(v) mindful walking ( minutes). Participants were
instructed to mindfully observe and focus on their
bodily sensations while walking remaining focused
on their moment-to-moment experiences without
being lost in unhelpful or distressing thoughts trig-
gered by the experience. If this was experienced
as a problem, the participants were instructed to
focus their awareness on their breath while in- and
exhaling,
(vi) a feedback round was used to share and discuss the
experiences ( minutes),
(vii) walking ( minutes),
(viii) gymnastic exercises ( minutes),
(ix) walking back to the meeting point ( minutes).
Participants of the intervention group were encouraged and
advised to keep on exercising for themselves aer completing
the -week program.
Participants allocated to the control group received no
mindful walking training in the -week duration of the study
(waiting list group). ey were only sent study questionnaires
aer and weeks by postal service and had no consulta-
tions with the study physicians between baseline and week
.
Aer the trial was completed, all subjects of the control
group were oered the previously intervention in the above
described manner for free.
2.4. Outcome Measures. Patients completed standardized
questionnaires including outcomes at baseline and aer and
weeks. As a primary outcome measure, we dened the
Evidence-Based Complementary and Alternative Medicine
Assessed for eligibility
(n = 168)
Enrollment
Randomized
(n=74)
Allocated to walking group
(n=36)
Allocated to control group
(n=38)
Lost to follow-up
(n=0)
Withdrawn
(n=6)
Lost to follow-up
(n=0)
Withdrawn
(n=5)
Analyzed
(n=36)
Excluded from analysis
(n=0)
Analyzed
(n=38)
Excluded from analysis
(n=0)
Excluded (n=94)
- Inclusion criteria not met (n=46)
- Refused to participate (n=18)
- Not reached for appointment (n=28)
- Other reasons (n=2)
F : Trial ow chart.
change to baseline of the score of Cohen’s Perceived Stress
Scale (CPSS) [] aer weeks. e CPSS consists of items
including current levels of experienced and perceived stress.
As secondary outcomes, we dened CPSS aer weeks, the
subjective levels of psychological stress of the last week on a
VAS (– mm, higher scores indicate higher levels of stress)
[] and health-related quality of life (QoL) by the SF-
questionnaire [] (higher scores indicate higher QoL) aer
and weeks. Sociodemographic data of all participants was
assessed at baseline. Adverse events were monitored by the
mindful walking trainers throughout the study.
2.5. Statistical Analysis. e study was designed to detect
a dierence of the primary outcome parameter (dierence
between CPSS score to baseline) of points between inter-
vention and control group with a power of % including a
dropout rate of approximately %. erefore, we included
participants per group.
Data analysis is based on intention-to-treat population.
Missing values were replaced by last observed value (last value
carried forward). Primary and secondary outcome parame-
ters were analyzed with analysis of covariance (ANCOVA),
adjusted for the respective baseline value, two-sided with a
signicance level of %. e ANCOVA models were used to
calculate adjusted dierences with % condence intervals.
All statistical analyses were conducted in R .. [].
3. Results
Participants were included in the study from February to May
. Study intervention and followups were completed by
September . A total of subjects were screened for
eligibility; could not be included. e main reason for
noninclusion was not meeting the inclusion criteria mainly
due to the subject reporting a perceived level of stress below
mm on the VAS (Figure ). Seventy four patients were
randomized with allocated to the intervention, to the
control group. Five participants of the intervention group
andfromthecontrolgroupdecidedtoterminatethestudy
intervention program before their individual study end for
several reasons: lost his house in a re (𝑛=1), moving out
of the city (𝑛=1), disease (𝑛=1), not explained (𝑛=2)
in the intervention group and job-related stress (𝑛=1), not
explained (𝑛=5) in the control group.
At baseline, the SF- Mental Component Score was
signicantly higher at baseline in the control group (36.3 ±
10.2)thanintheinterventiongroup(31.7 ± 8.8), all
other characteristics showed comparable values (Table ). e
mean age of the participants was 52.3 ± 8.6 (SD) in the
intervention and 49.5 ± 8.8 in the control group at baseline.
Participants were in both groups predominantly women. e
perceived stress intensity in the last week on the VAS can
be considered as elevated at baseline in both groups (71.3 ±
13.1mm in the study intervention and with 70.7 ± 12.4 in
Evidence-Based Complementary and Alternative Medicine
T : Baseline characteristics of participants in both study groups.
Mindful walking intervention
(𝑛 = 36) No intervention control
(𝑛=38)
Age (mean ±SD) . ±. . ±.
Gender (male, %) (.%) (.%)
Body mass index (mean ±SD) . ±. . ±.
Level of perceived psychological distress on visual analogue scale
(mean ±SD)∗∗ . ±. . ±.
Cohen’s Perceived Stress Scale (mean ±SD)∗∗ . ±. . ±.
Quality of life: SF-—physical component score (mean ±SD)∗. ±. . ±.
Quality of life: SF-—mental component score (mean ±SD)∗. ±. . ±.
Expectation of improvement (𝑛, %) (.%) (.%)
∗Higher values indicating better QoL, ∗∗lower values indicating less distress.
0
5
10
15
20
25
30
35
40
45
50
55
60
412
Week s
Intervention
Control
CPSS: adjusted means (95% CI)
P < 0.001 P = 0.031
F : Adjusted means and % condence intervals of Cohen’s
Perceived Stress Scale (CPSS) at and weeks with 𝑃values
comparing mindful walking with no intervention (lower values
indicating less psychological distress).
the control group). SF- Mental Component Score values
in both groups were below the reported German average of
thepopulationwhereasthePhysicalComponentScorewas
comparable to the German average (both 50.0 ± 10.0)[].
Adjusted CPSS dierences to baseline aer weeks as
primary outcome parameter were . [% CI −.; −.]
(mean . [.; .]), in the intervention group and −.
[−.; .] (mean . [.; .]) in the control group, result-
ing in a statistically signicant group dierence (𝑃 < 0.001)
(Table ,Figure ). Twelve weeks aer baseline and weeks
aer study intervention, CPSS remained still signicant (𝑃=
0.031) between study groups with a dierence to baseline of
−. [ −.; −.] in the intervention group and −. [−.;
−.] in the control group.
Signicant group dierences were also found aer
weeksfortheVASdierencetobaselinewith−. [−.;
−.] (mean . [.; .]) mm in the intervention group
compared to −. [−.; −.] (mean . [.; .]) mm
Intervention
Control
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
412
Weeks
VAS: adjusted means (95% CI)
P = 0.010 P = 0.562
F : Adjusted means and % condence intervals of per-
ceived psychological dist ress on VAS (– mm) at and weeks
with 𝑃values comparing mindful walking with no intervention
(lower values indicating less psychological distress).
(𝑃 = 0.010) in the control group but not aer weeks
(Table ,Figure ).
An improvement in the quality of life was observed for
the SF- Mental Component Score aer weeks with a
dierence of . (.; .) versus . (−.; .) (𝑃 < 0.001)
and weeks with a dierence of . (.; .) versus .
(−.; .) (𝑃 = 0.021) but not for the Physical Component
Score (Table ,Figures,and). Signicant group dierences
in favor of the study intervention were observed for the SF-
scales mental health, vitality, emotional role function, and
social role function aer weeks but only for the emotional
role function aer weeks (Ta b le ).
Five participants of the intervention group reported that
they kept on practicing the exercises regularly between and
weeks whereas participants reported noncontinuous or
irregular practice. No serious adverse events were observed
during the study.
Evidence-Based Complementary and Alternative Medicine
T : Outcome measures at weeks and weeks (means and % condence intervals adjusted for respective baseline value).
Outcomes
Adjusted dierences
to baseline
(% CI)
mindful walking
𝑛=36
Adjusted dierences
to baseline
(% CI) control
(no intervention)
𝑛=38
Adjusted means
(% CI)
mindful walking
𝑛=36
Adjusted means
(% CI) control
(no intervention)
𝑛=38
𝑃value
At 4 weeks
Cohen’s Perceived Stress
Scale ( items)∗∗ −. (−.; −.) −. (−.; .) . (.; .) . (.; .) <.
Visual analogue scale
(– mm)∗∗ −. (−.; −.) −. (−.; −.) . (.; .) . (.; .) .
SF-—mental component
score∗. (.; .) . (−.; .) . (.; .) . (.; .) <.
SF-—physical
component score∗. (−.; .) −. (−.; .) . (.; .) . (.; .) .
SF-—vitality scale∗. (.; .) . (−.; .) . (.; .) . (.; .) .
SF-—physical
functioning scale∗. (−.; .) −. (−.; −.) . (.; .) . (.; .) .
SF-—bodily pain scale∗. (−.; .) −. (−.; .) . (.; .) . (.; .) .
SF-—general health
perceptions scale∗. (.; .) −. (−.; .) . (.; .) . (.; .) .
SF-—physical role
functioning scale∗. (.; .) . (−.; .) . (.; .) . (.; .) .
SF-—emotional role
functioning scale∗. (.; .) −. (−.; .) . (.; .) . (.; .) .
SF-—social role
functioning scale∗. (.; .) . (−.; .) . (.; .) . (.; .) .
SF-—mental health
scale∗. (.; .) . (−.; .) . (.; .) . (.; .) <.
At 12 weeks
Cohen’s Perceived Stress
Scale∗∗ −. ( −.; −.) −. (−.; −.) . (.; .) . (.; .) .
Visual analogue scale∗∗ −. (−.; −.) −. (−.; −.) . (.; .) . (.; .) .
SF-—mental component
score∗. (.; .) . (−.; .) . (.; .) . (.; .) .
SF-—physical
component score∗. (−.; .) . (−.; .) . (.; .) . (.; .) .
SF-—vitality scale∗. (.; .) . (.; .) . (.; .) . (.; .) .
SF-—physical
functioning scale∗. (−.; .) −. (−.; .) . (.; .) . (.; .) .
SF-—bodily pain scale∗. (−.; .) . (−.; .) . (.; .) . (.; .) .
SF-—general health
perceptions scale∗. (.; .) . (−.; .) . (.; .) . (.; .) .
SF-—physical role
functioning scale∗. (.; .) . (.; .) . (.; .) . (.; .) .
SF-—emotional role
functioning scale∗. (.; .) . (−.; .) . (.; .) . (.; .) .
SF-—social role
functioning scale∗. (.; .) . (.; .) . (.; .) . (.; .) .
SF-—mental health
scale∗. (.; .) . (−.; .) . (.; .) . (.; .) .
Abbreviations: ∗higher values indicating better QoL, ∗∗lower values indicating less distress.
Evidence-Based Complementary and Alternative Medicine
Intervention
Control
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
412
Weeks
SF-36 physical CS: adjusted means (95% CI)
P = 0.492 P = 0.989
F : Adjusted means and % condence intervals of SF-
Physical Component Score at and weeks with 𝑃values
comparing mindful walking with no intervention (higher values
indicating higher QoL).
Intervention
Control
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
412
Weeks
SF-36, mental CS: adjusted means (95% CI)
P < 0.001 P = 0.021
F : Adjusted means and % condence intervals of SF-
Mental Component S core at and weeks with 𝑃values comparing
mindful walking with no intervention (higher values indicating
higher QoL).
4. Discussion
In this study, statistically signicant dierences for CPSS,
VAS, and SF- Mental Component Score were observed
comparing mindful walking program to a no-treatment
control group (waiting group) aer weeks. Aer weeks
from intervention start and weeks aer end of active
treatment, the group dierences were less marked, but CPSS
and SF- Mental Component Score still showed a signicant
group dierence. No serious adverse events were observed.
Mindful walking might be a useful new treatment strategy
to reduce subjectively perceived symptoms of stress. In
Germany, the normal charge for participation in an exercise
classasthisisEuroperhourandparticipant(US).e
whole intervention costs Euros ( US) per participant.
Our study does not allow us to conclude if the combination
of walking and mindfulness is superior to walking or mind-
fulness alone, but it denitely is a low-cost and easy to learn
and implement exercise program.
Ourdatasuggeststhatitisnecessarytocontinuously
practice mindful walking to obtain the best eects. However,
only participants of the intervention group kept on practic-
ing regularly aer the end of the intervention period although
it was recommended to continue practicing.
Strengths of this study include the use of highly experi-
enced therapists, a conrmatory design, and a comparably
high number of participants.
However, there are some limitations which need to be
discussed. A limitation of this study is the open design. Due to
the nature of this trial, a blinding of the participants or study
team was not possible. Also, this design makes it impossible
to assess which components of the intervention were eective
in reducing the stress. Possible eectors could have been exer-
cise (walking), mindfulness practice, participating in a group,
the expectation of improvement ( of subjects in both
groups expected improvements) (Table ), the suggestion that
theprogrammayreducestress,orthereceivedattention
through study personnel.
In addition, a design with a no-treatment control group
imitates the situation of a patient who is asking himself:
“Should I try this treatment or better do nothing and wait?”
But this model does not answer the question about the
best treatment or the most eective component. Another
limitation is the low number of males participating. It is thus
unclear whether the results of this trial are valid also for a
male population. Generally a higher percentage of female
participants do practice mind body therapies []andwere
also observed in an earlier study investigating the role of
mindfulness in stress reduction [].
To the best of our knowledge, this is the rst ran-
domized trial evaluating a mindful walking program for
the treatment of perceived general psychological distress.
ere are not many stress reduction programs combining
exercise with mindfulness practice or relaxation. Michalsen
et al. [] recently reported the results of a three-armed
study where Iyengar yoga eectively reduced distress and
improved related psychological and physical outcomes in
seventy-two females. e practice of yoga consists of physical
movements with isometric muscle strengthening, stretching,
andexibility,combinedwithamentalfocusandanemphasis
on mindfulness of body movements and consideration of
breathing patterns. Other stress reduction programs showing
positive results and combining exercise with mindfulness
practice are Tai Chi []andQiGong[,].
In this study, the exercise component consisted only of
walking, which is easier to practice than yoga exercises, but
misses the specic stretching and exibility component. On
the other hand, walking improves cardiovascular tness and
therefore might especially be valuable for individuals showing
cardiovascular risk proles.
Evidence-Based Complementary and Alternative Medicine
Further studies about mindful walking in psychologically
distressed individuals should compare the eects of the
intervention with other active stress-reducing interventions.
Comparing with a control arm delivering only guided walks
(without a mindfulness component) and also a no-treatment
control arm would allow to determine the eects of walking
alone and additional mindfulness.
Another subject for research could evaluate gender-
specic eects with the research question aimed to determine
if mindful walking is also eective in men because the small
percentage of men who participated in the trial allows no
answer for this question.
5. Conclusion
Our results indicate that a -week mindful walking program
might be a helpful tool to reduce subjectively perceived
psychological distress compared to no intervention.
Conflict of Interests
e authors declare that they have no conict of interests.
Authors’ Contributions
Study concept and design: M. Teut, E. J. Roesner, B.
Brinkhaus. Organisation and data management: E. J. Roesner,
M.Teut,B.Brinkhaus,S.Binting.Developmentofinterven-
tion:E.J.Roesner,F.Reese,M.Teut,B.Brinkhaus.Delivering
intervention:E.J.Roesner,F.Reese.Statisticaldesignand
analysis:S.Roll,F.Fischer.Interpretationanddiscussionof
data:M.Teut,E.J.Roesner,F.Fischer,S.Roll,B.Brinkhaus,
S. N. Willich, A. Michalsen. Draing the paper: M. Teut, B.
Brinkhaus. All authors read, commented on, and approved
the nal paper.
Acknowledgments
e authors gratefully acknowledge the work of their study
nurseMargitCree,themedicaldoctorsBirgitLochbrunner
and Ileni Donachie, and their medical students Katharina
Gloger and Jenny Pistol for their great support to realize this
study.
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