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Abstract

Background:

Middle-aged women often suffer from mood symptoms such as depression and anxiety, which may be associated with autonomic modulation. Stretching exercises improve joint flexibility, mood symptoms, and parasympathetic activity. However, the effects of stretching on mood symptoms and autonomic modulation in middle-aged women are unknown. Thus, this study investigated this.

Methods:

Altogether, 25 middle-aged women (51.8 ± 4.4 years) were included in this study. Each participant completed a whole-body stretching program for 25 min or a control resting period in random order on separate days. Mood symptoms, including negative or positive mood and anxiety, were assessed before and after the intervention using the Profile of Mood States-2 and the State-Trait Anxiety Inventory. Autonomic modulation was measured using heart rate variability before, immediately after, and 30 min after the intervention. A two-way repeated-measures analysis of variance was performed for comparisons. Post hoc testing was performed using the Bonferroni correction.

Results:

Mood symptoms significantly improved after stretching, especially in terms of decreasing anxiety and inducing a positive mood (p = 0.001 – 0.047). However, the autonomic modulation indices showed no significant changes immediately or 30 min after stretching under either the stretching or control conditions (p = 0.068 – 0.808).

Conclusion:

Stretching exercises improved mood symptoms, particularly anxiety and positive moods. However, the autonomic modulation was not altered. Stretching is an effective exercise for managing mood and mental health in middle-aged women.

Introduction

Middle-aged women experience menopause, which is defined as the permanent cessation of menstruation caused by a decline in ovarian follicular activity.¹ During menopausal transition, women experience various symptoms, including vasomotor symptoms such as hot flashes and night sweats, sleep disturbance, depression, anxiety, sexual dysfunction, and physical symptoms such as joint pain.² Compared with reproductive women, women in menopausal transition have reported significantly lower health-related quality of life and work productivity owing to menopausal symptoms, as well as increased health care usage and costs.³ Therefore, midlife is often perceived as a crisis for women, with menopausal symptoms negatively affecting mental and physical well-being and health.^2,4

Middle-aged women in menopausal transition are at an increased risk of mood symptoms such as depression and anxiety.^5–7 The Study of Women’s Health Across the Nation has reported higher mood symptoms in perimenopausal women than in premenopausal women (odds ratios, depression: 1.31−1.79, and anxiety: 1.56−1.61).^8,9 A meta-analysis of mood symptoms in perimenopause has also shown more severe depression and a higher risk of mood disorders in perimenopausal women than in premenopausal women.⁵ Zhao et al. examined the network structure underlying symptoms of menopause among middle-aged women in China.⁷ They have identified depression and anxiety as central symptoms, with anxiety being the most important manifestation. Furthermore, post-midlife women with mood symptoms had low autonomic modulation and high heart rate (HR), suggesting increased sympathetic activity.¹⁰ Mood symptoms reduced parasympathetic activity in women with more intense menopausal symptoms than in those with less intense symptoms.¹¹ For the improvement of quality of life in middle-aged women, reducing mood symptoms and increasing parasympathetic activity are important. Therefore, exercise interventions should be developed and implemented.

Recent research has increasingly focused on the benefits of exercise for mental health among middle-aged women.¹² In particular, exercise at moderate-to-high intensity, such as aerobic and resistance training, improves mood symptoms and autonomic modulation among middle-aged women.^13–15 However, these women commonly have low adherence to exercise because of musculoskeletal complaints, physical limitations, and lack of time owing to household and work responsibilities.¹⁶ Alternative exercise modalities should be investigated to determine their effects on mood symptoms and autonomic modulation.

Stretching is a low-intensity activity with low cost and injury risk, making it suitable for a wide range of populations.^17,18 Previous studies have indicated that stretching improves mood symptoms in inactive young adults with mood disorders^19,20 and autonomic modulation in postmenopausal or pregnant women with obesity.^21–23 Thus, stretching may also improve menopausal and mood symptoms and increase parasympathetic activity in middle-aged women.²¹,²⁴ However, these studies did not simultaneously survey mood symptoms and autonomic modulation. Investigating the effects of stretching on mood and autonomic modulation may help develop an effective and easy intervention for improving mood symptoms in middle-aged women.

This study investigated the effects of stretching on mood and autonomic modulation in middle-aged women. We hypothesized that stretching improves mood symptoms and increases parasympathetic activity in this population.

Materials and Methods

Participants

Altogether, 25 women aged 45–60 years (mean age: 51.8 ± 4.4 years; height: 157.0 ± 5.9 cm; weight: 52.1 ± 11.1 kg) were enrolled in this study. The exclusion criteria were a history of hormone replacement therapy and psychotropic medication used 6 months prior to the study, cardiovascular disease, diabetes, musculoskeletal problems that would limit stretching exercises, and a history of surgical menopause. All participants were required to refrain from caffeine and alcohol intake, moderate-to-vigorous physical activity for 24 h, ingesting anything (except drinking water), and smoking for at least 2 h prior to the measurement. Participants were instructed to maintain their daily lifestyle during the study period. All participants provided written informed consent before participation. The study protocol was approved by the ethics committee of our university (approval number: 22 – 76) and conducted in accordance with the Declaration of Helsinki.

Procedures

The participants visited the laboratory on three separate days. Study protocol orientation, baseline survey, and stretching exercises were conducted on day 1. Stretching or control conditions were randomly performed on days 2 and 3. Measurements were obtained from 9:00 to 17:00 at the same time of the day (± 1 h) to minimize potential diurnal variations in autonomic modulation within the participants. The stretching and control conditions were separated by >2 days.²⁵ All experimental trials were completed within a month. After the participants arrived at the laboratory room, they were instructed to sit and rest for 15 min to adapt to the environment,²⁶ and then perform the stretching or control protocol for 25 min. Mood was measured before and after the intervention (PRE and POST0, respectively), and autonomic modulation was measured before and after the intervention and 30 min after the intervention (PRE, POST0, and POST30, respectively). The room temperature was maintained at 23 ± 1°C for all measurements.

Baseline characteristics

Body composition was measured using a body composition analyzer (MC-780A-N; TANITA, Co., Japan). Weight (kg), body mass index (kg/m²), lean mass (kg), body fat percentage (%), and basal metabolic rate (kcal) were measured. Self-reported questionnaires were used to measure sociodemographic characteristics (age, alcohol consumption, smoking habits, marital status, and employment status). Total weekly physical activity level and sitting time were calculated using the International Physical Activity Questionnaire.²⁷ The menstrual status (menstrual regularity and years of menopause) was divided into three categories as follows: premenopause (regular menstrual cycle), perimenopause (irregular menstrual cycle or menopause within 2 years), and postmenopause (in menopause for >2 years).¹ Menopause symptoms were assessed using the Simplified Menopausal Index (SMI), which is a questionnaire designed to assess menopausal symptoms of Japanese women.²⁸ The SMI consists of 10 items covering vasomotor, psychological, and somatic symptoms. Symptom severity was classified as mild (0–25 points, no abnormality), moderate (26–50 points, attention to diet and exercise), or severe (51 – 100 points, recommendations to visit a menopausal clinic). The participants completed the questionnaires in a private room.

Intervention protocol

Each participant completed two 25-minute sessions consisting of either a stretching or control condition. The stretching protocol consisted of nine active stretches of the major muscles, including extension and rotation of the neck, shoulders, hips, and lower back, as described in a previous study (Fig. 1).²⁹ Each of which was performed for two sets of 30 s at the point of maximal exertion or range of motion, where the participant felt the stretch without discomfort or pain. Following each stretching exercise, a 30-second rest period was allowed. The participants were instructed to watch a video demonstration and breathe deeply while stretching.²² Stretching exercises were performed according to the instructions and supervision of a physical therapist. In the control condition, the participants sat for 25 min and were allowed to read magazines.³⁰

FIG. 1.

Whole-body active stretching program.

Measurements of mood symptoms

Mood symptoms were assessed using the Profile of Mood States-2 Adult (POMS) short version and the State-Trait Anxiety Inventory (STAI). The POMS is a 35-item standardized questionnaire that is a short version adapted from the original 65-item questionnaire. The POMS is an efficient and reliable tool for assessing mood state.³¹ The reliability of the Japanese version of this instrument was demonstrated for seven POMS subscales: anger–hostility, confusion–bewilderment, depression–dejection, fatigue–inertia, tension–anxiety, and vigor–activity (VA).³² Participants rated the extent to which they felt each adjective at the time of evaluation on a 1–5 Likert scale (1 = not at all to 5 = extremely). The total mood disturbance (TMD) score was calculated by subtracting the VA score from the sum of scores on the other subscales. The TMD and VA scores were selected to observe changes in negative and positive moods, respectively. The lower the TMD score and higher the VA score, the better the mood. The STAI consists of 40 items, 20 of which are allocated to each state-and trait-anxiety subscale.³³ The 20 state anxiety items comprise an anxiety present score (indicating a negative mood state) and an anxiety absent score (indicating a positive mood state), with 10 items each. This questionnaire has been proven to have internal reliability.³⁴ All items are rated on a 4-point Likert scale ranging from 1 to 4. The total, anxiety-present, and anxiety-absent scores for state anxiety were calculated. The higher the score, the greater the anxiety. The total trait anxiety score was calculated at baseline. A cutoff score of 43–53 can detect moderate symptoms of trait anxiety in Japanese women.³⁵

Assessment of autonomic modulation

Autonomic modulation was assessed using heart-rate variability (HRV). HRV was measured through R–R intervals at rest for 10 min using an electrocardiogram (ECG) (Bittium Faros™ 18, Bittium, Inc., Finland) with a sampling rate of 1 kHz. The recommended duration for short-term recording is 5 min³⁶ to ensure the comparability of results across studies and laboratories. Moreover, before measurements, the participants were instructed to sit quietly for 5 min. Acclimatization of the recording environment was necessary to prevent potential anxiety and to increase attention to respiration and HR when participants were informed that the recording starts.²⁶ After disinfecting with alcohol, the electrode and sensor were positioned on the medial side of the right coracoid process, while the other two electrodes were placed on the medial side of the left coracoid process and left lower rib. The participants sat on a chair with their knees flexed at 90°, both feet on the floor, hands resting on their thighs, and palms facing upward. This position was recommended to avoid any potential interoceptive effects that could occur if the participants felt their radial pulse with their palms facing downward.²⁶ They were instructed to close their eyes and breathe spontaneously without speaking or moving during the measurement.

For the HRV indices, 10 min of ECG signals was recorded, and the last 5 min was used for analysis. ECG signals were imported into the Kubios HRV scientific software (version 4.0, Kubios Oy, Inc., Finland) for the processing and derivation of HRV indices. Established guidelines were followed to calculate HRV from ECG signals.³⁶ The automatic correction was used to detect artifacts. Any files with >5% artifacts were immediately excluded.³⁷ The HRV indices calculated were mean HR, root mean square of successive differences (RMSSD), and high-frequency power (HF; band ranging from 0.04 to 0.15). HRV indices were selected based on the physiological and statistical understanding of parasympathetic activity.³⁷

Statistical analysis

The sample size was calculated using the G*power 3.1 software (Heinrich Heine University, Düsseldorf, Düsseldorf, Germany). With the model for repeated measures analysis of variance (ANOVA), at least 17 participants were required (medium effect size = 0.25, α = 0.05, 1-β = 0.8).

The Shapiro–Wilk test was conducted to assess data distribution. Logarithmic transformation was performed for the RMSSD and HF because these variables were not normally distributed. A two-way repeated-measures ANOVA was performed to determine the effects of stretching on mood symptoms and HRV indices with condition (stretching and control) and time (PRE, POST0, and POST30) factors. The Bonferroni correction was used for post hoc comparisons. The effective size was determined using partial eta-squared values (η_p²) for repeated measures. An alpha level of 0.05 indicated statistical significance in all comparisons. Statistical analyses were performed using the SPSS version 26 software (IBM, Armonk, NY, USA).

Results

Baseline characteristics

Table 1 presents the baseline characteristics of the participants. Of the participants, 64.0%, 28.0%, and 8.0% practiced low, moderate, and vigorous physical activity, respectively. The menstrual status was premenopausal in 28.0%, perimenopausal in 36.0%, and postmenopausal in 36.0% of the women. The participants had mild (28.0%), moderate (52.0%), or severe (20.0%) menopausal symptoms. The average trait anxiety score was 44.4 ± 12.1 points, indicating moderate symptoms.

Table 1.

Baseline Characteristics

Characteristics	Mean (SD) or n (%)
Age (years)	51.8 (4.4)
BMI (kg/m²)	21.0 (3.4)
Body fat percentage (%)	25.8 (7.4)
Lean mass (kg)	35.8 (3.6)
Basal metabolic rate (kcal)	1091.9 (143.1)
Alcohol habits (more than 3 times per week) Yes/No	2 (8.0) / 23 (92.0)
Smoking habits (Every day or sometimes per week) Yes/No	1 (4.0) / 24 (96.0)
Marital status: Currently married/Never married	23 (92.0) / 2 (8.0)
Employment status: Yes, full or part time job/No paid employment	16 (64.0) / 9 (36.0)
Physical activity level (per week) Vigorous/Moderate/Low Average of sitting time per week (h)	2 (8.0) / 7 (28.0) / 16 (64.0) 5.93 (2.96)
Menstrual status Pre-menopause/Peri-menopause/Post-menopause	7 (28.0) / 9 (36.0) / 9 (36.0)
Menopausal symptoms Total SMI score Mild/Moderate/Severe	35.2 (16.1) 7 (28.0) / 13 (52.0) / 5 (20.0)
Trait Anxiety^a Total score Total score Moderate-severe trait anxiety^b	44.4 (12.1)13 (52.0)

Trait Anxiety score was calculated using the trait anxiety subscales of STAI.

Moderate-to-severe trait anxiety was defined with an STAI score >43 points.

BMI, body mass index; SD, standard deviation; SMI, Simplified Menopausal Index; STAI, State Trait Anxiety Inventory.

Changes in mood symptoms

For the POMS-TMD, which assesses negative mood states, no significant condition × time interaction was identified (p = 0.067; η_p² = 0.133); however, a significant main effect of time was observed (p < 0.001) (Table 2). POMS-TMD scores were lower at POST0 than at PRE in the stretching and control conditions (p < 0.001 and p = 0.001, respectively). A significant condition × time interaction was observed for POMS-VA, indicating a positive mood state (p = 0.004; η_p² = 0.293). POMS-VA scores were higher at POST0 than at PRE in the stretching condition (p = 0.047) but lower at POST0 than at PRE in the control condition (p = 0.012).

Table 2.

Change in Mood Symptoms

Variables (points)	Condition	PRE	POST0	p value
POMS: TMD	Stretching	−0.32 (9.36)	−7.00 (7.43)^a	Interaction: 0.067 Main effect: Time < 0.001 Condition: 0.068
	Control	0.60 (8.40)	−3.56 (6.59)^a
POMS: VA	Stretching	8.04 (5.30)	9.60 (5.00)^a	Interaction: 0.004Main effect:Time: 0.547Condition: < 0.001
	Control	7.44 (4.60)	6.40 (5.03)^a	Interaction: 0.004Main effect:Time: 0.547Condition: < 0.001
STAI: total	Stretching	34.16 (7.69)	29.56 (6.69)^a	Interaction: 0.005Main effect:Time < 0.001Condition: 0.003
	Control	34.48 (7.65)	33.36 (7.78)	Interaction: 0.005Main effect:Time < 0.001Condition: 0.003
STAI: anxiety present	Stretching	11.68 (1.87)	10.44 (0.75)^a	Interaction: 0.679Main effect:Time < 0.001Condition: 0.077
	Control	11.96 (1.99)	10.88 (1.11)^a	Interaction: 0.679Main effect:Time < 0.001Condition: 0.077
STAI: anxiety absent	Stretching	22.48 (6.87)	19.12 (6.31)^a	Interaction: 0.003Main effect:Time: 0.001Condition: 0.009
	Control	22.52 (7.00)	22.48 (7.16)	Interaction: 0.003Main effect:Time: 0.001Condition: 0.009

Values are mean (standard deviation).

indicates a significant difference from PRE (p < 0.05).

POMS, Profile of Mood States-2 Adult Short; SD, standard deviation; TMD, POMS, Profile of Mood States-2 Adult Short; POST0, post intervention; PRE, pre intervention; SD, standard deviation; STAI, State Trait Anxiety Inventory; TMD, total mood disturbance score; VA, vigor-activity score.

A significant condition × time interaction was observed for the STAI-total and STAI-anxiety absent, which expressed total anxiety or positive mood states (p = 0.005, η_p² = 0.286; p = 0.003, η_p² = 0.319, respectively) (Table 2). The STAI-total and STAI-anxiety absence scores were lower at POST0 than at PRE in the stretching condition (p < 0.001) but not in the control condition (p = 0.185 and p = 0.948, respectively). No significant condition × time interaction was observed for STAI-anxiety present, which indicated a negative mood state (p = 0.069; η_p² = 0.007). However, a significant main effect of time (p < 0.001) was observed. STAI anxiety precent scores were lower at POST0 than at PRE in both the stretching and control conditions (p = 0.002 and p = 0.003, respectively).

Changes In HRV Indices

No significant condition × time interaction was observed for the parasympathetic activity indices (RMSSD: p = 0.361, η_p² = 0.042; HF: p = 0.499, η_p² = 0.029; HR:p = 0.482, η_p² = 0.030) (Table 3). However, time had a significant effect on HR (p < 0.001). HR was lower at POST0 and POST30 than at PRE in both the stretching (p < 0.001 and p = 0.001, respectively) and control conditions (p = 0.003 and p < 0.001, respectively).

Table 3.

Change in HRV Indices

Variables	Condition	PRE	POST0	POST30	p value
RMSSD (ms)	Stretching	3.12 (0.50)	3.21 (0.42)	3.31 (0.59)	Interaction: 0.361Main effect:Time: 0.030Condition: 0.065
	Control	3.33 (0.49)	3.39 (0.57)	3.4 (0.53)	Interaction: 0.361Main effect:Time: 0.030Condition: 0.065
HF (ms)	Stretching	5.27 (1.01)	5.29 (0.83)	5.50 (1.14)	Interaction: 0.499Main effect:Time: 0.302Condition: 0.040
	Control	5.61 (0.92)	5.73 (1.05)	5.72 (1.05)	Interaction: 0.499Main effect:Time: 0.302Condition: 0.040
HR (bpm)	Stretching	68.68 (8.20)	65.52 (8.49)^a	65.48 (8.05)^a	Interaction: 0.482Main effect:Time < 0.001Condition: 0.641
	Control	67.96 (7.21)	65.56 (7.99)^a	64.52 (7.71)^a	Interaction: 0.482Main effect:Time < 0.001Condition: 0.641

Values are mean (standard deviation).

indicates a significant difference from PRE (p < 0.05).

HF, high-frequency power; HR, mean heart rate; POST0, immediate after intervention; POST30, 30 minutes after intervention; PRE, pre intervention; RMSSD, root mean square of successive differences.

Discussion

This study demonstrates the acute effects of active stretching exercises on mood symptoms and autonomic modulation in middle-aged women. Mood symptoms, particularly anxiety and a positive mood state (POMS-VA and STAI-anxiety absent score), improved only after stretching. By contrast, negative mood states (POMS-TMD and STAI-anxiety present score) increased significantly after the intervention in both the stretching and control conditions. Autonomic modulation did not change immediately or 30 min after stretching. Acute decreases in HR were observed immediately and 30 min after the intervention in both the stretching and control conditions.

The positive acute effects of active stretching on anxiety and mood in middle-aged women described in this study are consistent with those observed in several previous studies that examined different populations.^19,20 Brinsley et al. have reported that a single 30-minute stretching session had a greater effect on improving depressive mood than other exercises, including yoga and aerobic exercise.²⁰ Another study compared the acute effects of different exercise intensities in people with major depressive disorder and has reported that low-intensity exercise had the largest effect size for improving mood symptoms compared with moderate-or high-intensity exercise.³⁸ To explain the acute effects of low-intensity exercise on mood symptoms, the self-efficacy hypothesis proposes that engaging in and completing an exercise task can improve mood and self-confidence.²⁰ This hypothesis may be an important mechanism explaining the effects of stretching on mood symptoms. In addition, the mental health benefits of acute exercise may be attributed to placebo effects.^39,40 Therefore, stretching, which is categorized as a low-intensity exercise, is potentially effective in improving mood symptoms associated with menopausal transition in middle-aged women.

Furthermore, psychophysiological indices other than HRV such as arterial stiffness, electroencephalographic activity, and endocrine system activity may be associated with an increase in positive emotions after stretching.^25,41,42 Stretching increases electroencephalography associated with positive mood, leading to a state of relaxation.²⁵ Endocrine system activity, particularly cortisol, serotonin, and oxytocin levels, may be associated with positive mood⁴³ and plays a role in menopausal depressive symptoms.² Moreover, cortisol levels in patients with diabetes decrease with stretching rather than with yoga.²⁹ Therefore, the stretching-induced effect on promoting a positive mood in middle-aged women with mood symptoms should be further investigated to explore the physiological mechanisms using other psychophysiological indicators. Contrary to our initial hypothesis, parasympathetic activity did not change after stretching, as evaluated by the RMSSD and HF. A possible explanation is that the baseline characteristics may have influenced the changes in autonomic modulation with stretching. Several previous studies have shown an acute stretching effect on autonomic modulation, and these studies included different participants, such as resistance-trained men with low flexibility levels, pregnant women, and healthy young men.^22,44,45 Moreover, studies involving women with mood disorders and inactive men have reported no changes in autonomic modulation after stretching.^19,20 Therefore, the effects of stretching may differ depending on the baseline characteristics, including physical activity level, age, and severity of mood symptoms. Thus, future subgroup analyses should be based on the severity of menopausal symptoms and baseline activity levels.

HR significantly decreased immediately and 30 min after both the stretching and control conditions. A meta-analysis of the effects of stretching on cardiovascular responses has demonstrated that stretch-induced effects are primarily related to decreased arterial stiffness, which is reflected in HR reduction.⁴² In addition, stress-induced activation of cardiovascular responses, such as increased HR, has been associated with the induction of positive emotions.^46,47 Therefore, stretching-induced HR reduction may be a physiological mechanism involved in promoting a positive mood. In addition, HR also decreased in the control condition, which may have been attributable to the 30-minute sitting period.

Limitations

This study had some limitations that should be addressed. First, although we performed measurements at the same time of day for each participant (±1 h), the measurement time varied. Therefore, HRV may have been affected by the circadian rhythm. HRV measurement is sensitive to confounding factors,²⁶ which may have affected autonomic activity in within-participant conditions. Second, menstrual status was not monitored based on serum hormone levels. According to the well-known Stages of the Reproductive Aging Workshop,¹ menopausal transition is assessed based on menstrual regularity and hormonal changes, including decreased systemic estradiol levels and increased follicle-stimulating hormone levels. Lastly, the baseline characteristics of the participants, including menopausal status, mood, and physical activity levels, may have influenced the results. Studies involving more middle-aged women, considering their baseline characteristics, need to be conducted in the future.

Clinical implications

Acute mood benefits can be obtained from stretching exercises in middle-aged women. People with mood disorders are physically inactive and prefer low-intensity exercise.^48,49 Furthermore, middle-aged women with menopausal or mood symptoms engage in minimal physical activity.^50,51 More than half of the middle-aged women in our study had moderate or severe menopausal symptoms and moderate trait anxiety and were physically inactive (Table 1). Stretching is an effective exercise for managing mood and mental health in middle-aged women with mood symptoms and/or physical inactivity. Furthermore, middle-aged women with inactivity or time constraints can incorporate active stretching into their health routines, making it convenient to improve mental health.

Conclusion

Stretching exercises improved mood symptoms in middle-aged women, particularly by decreasing anxiety and inducing a positive mood state. However, autonomic modulation did not change after stretching. Stretching is effective for middle-aged women with mood disorders.

Footnotes

Acknowledgment

The authors express their gratitude to all the participants who participated in this study.

Authors’ Contributions

M.K., Y.K., T.I., S.K., H.T., and M.S. designed and implemented the study. M.K. and M.S. collected data. Y.K., T.I., and H.T. supervised statistical analyses. S.K., F.A.S., and Y.E. contributed interpretation of data. All authors drafted the article, conducted critical review for the article, and approved the final article.

Author Disclosure Statement

The authors report no potential conflicts of interest.

Funding Information

This research was supported by JST SPRING under Grant Number JPMJSP2119.

Abbreviations Used

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The Effects of Active Stretching Exercise on Mood and Autonomic Modulation in Middle-Aged Women

Abstract

Background:

Methods:

Results:

Conclusion:

Introduction

Materials and Methods

Participants

Procedures

Baseline characteristics

Intervention protocol

Measurements of mood symptoms

Assessment of autonomic modulation

Statistical analysis

Results

Baseline characteristics

Changes in mood symptoms

Changes In HRV Indices

Discussion

Limitations

Clinical implications

Conclusion

Footnotes

Acknowledgment

Authors’ Contributions

Author Disclosure Statement

Funding Information

Abbreviations Used

References