OBM Integrative and Complementary Medicine

ISSN 2573-4393
Free Publication in 2018

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Review

Integrating Mindfulness and Physical Exercises for Medical Students: A Systematic Review

Marcus A. Henning 1, * , Tae Joo Park 2 , Fiona Moir 3 , Chris Krägeloh 4 , Christopher Mysko 5 , Jennifer Hobson 6 , Craig S. Webster 7

  1. Centre for Medical and Health Sciences Education, 1415 University of Auckland , New Zealand
  2. School of Medicine, University of Auckland, New Zealand
  3. Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
  4. Department of Psychology, School of Public Health and Psychosocial Studies, Auckland University of Technology, New Zealand
  5. School of Medicine, University of Auckland, New Zealand
  6. Learning and Teaching Management, LLS Client Services, University of Auckland, New Zealand
  7. Centre for Medical and Health Sciences Education and Department of Anaesthesiology, University of Auckland, New Zealand

*   Correspondence: Marcus A. Henning

Academic Editors: Sok Cheon Pak and Soo Liang Ooi

Special Issue: Health Benefits of Meditation

Received: May 25, 2018 | Accepted: October 10, 2018 | Published: October 26, 2018

OBM Integrative and Complementary Medicine 2018, Volume 3, Issue 4 doi: 10.21926/obm.icm.1804027

Recommended citation: Henning MA, Park TJ, Moir F, Krägeloh C, Mysko C, Hobson J, Webster CS. Integrating Mindfulness and Physical Exercises for Medical Students: A Systematic Review. OBM Integrative and Complementary Medicine  2018;3(4):027; doi:10.21926/obm.icm.1804027.

© 2018 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

Abstract

Background: The purpose of this systematic review was to appraise the empirical evidence pertaining to medical students and the integration of mindfulness and physical exercise regimens.

Methods: A systematic review was undertaken. Five databases were used to survey the salient literature.

Results: The initial search identified 353 potentially relevant articles of which 17 articles were considered for the final review. The findings indicated that the research was mainly conducted in the USA with some research originating from Europe, Canada, Jamaica, and India. In addition, a range of research designs were applied to measure or discuss the efficacy of the integrated intervention. Four key categories captured the essence of the results of our review, namely: (1) quality of evidence and research methods; (2) types of interventions; (3) measurement protocols; and (4) benefits of integrating mindfulness and physical exercises.

Conclusions: This systematic review demonstrated that when mindfulness and physical exercises are integrated there are likely to be positive health outcomes for medical students. In the studies that yielded the highest level of evidence it was clear that this combination enhanced mental health, and reduced stress levels amongst students, and the benefits may assist with interpersonal development, such as greater empathetic levels and improved interpersonal responsivity.

Keywords

Mindfulness; physical exercise; medical students; wellbeing

1. Introduction

Mindfulness is a well-established philosophy and practice that has been described by the Mental Health Foundation of New Zealand as a state of mind which involves “paying attention to what is presently occurring, with kindness and curiosity”[1]. Brown and Ryan [2] have also characterised the meditation practice of mindfulness as a “state of being attentive to and aware of what is taking place in the present”. Monitoring and paying attention to thoughts in the mind and sensations in the body combined with genuine awareness of surrounding influences in the environment are part of the skill to be developed [3].

Mindfulness meditation practices can be undertaken to achieve a more insightful state throughout the day, and mindfulness courses have been shown to enhance wellbeing [4]. Such courses are usually structured and delivered over a prescribed number of weeks (e.g., 8-weeks) [4]. They consist of weekly face-to-face group meetings plus home practice. The two courses most commonly cited and researched are Mindfulness Based Stress Reduction (MBSR) and Mindfulness Based Cognitive Therapy (MBCT) [5].

MBSR was developed by Jon Kabat-Zinn and presents a secular approach to a long standing traditional Buddhist practice. The MBSR approach is therapeutic and educational and its aim is to promote awareness of the mind and body and has a pragmatic orientation that involves developing coping strategies for dealing with toxic stress. It has several components that can include a sitting meditation, a body scan, and hatha yoga [6]. MBCT came from the development of the MBSR system and combines the principles of cognitive therapy and mindfulness often to manage the state of depression. Typically a MBCT programme utilises a seated meditation and develops awareness on mood changes, rumination, and negative thoughts [6]. MBCT is now included in the National Institute for Health and Care Excellence (NICE) guidelines in the United Kingdom as a depression relapse prevention programme [7].

Medical students are often cited as being at risk of burnout and other psychological conditions, such as anxiety, depression, and insomnia [8,9,10,11,12]. A recent meta-analysis of 77 studies concluded that depression affected almost one third of medical students [13]. Calls have been made for medical educators to address this issue, including during medical undergraduate training. Although the recent meta-analysis did conclude that medical students are at greater psychological risk than students from other courses, there were clearly benefits of mindfulness training for all health professional students. Even twenty years ago, it was known that mindfulness training reduced anxiety and increased empathy in medical students[4], which are also clearly core skills for a doctor[14]. Mindfulness training has, therefore, been applied to the medical education context [15,16,17]. In addition to its use as a therapeutic practice, the theory and application of mindfulness has been embedded in some medical curricula both formally and informally [18,19].

What is less well-known is to what extent an integrative mind-body approach, which includes both mindfulness and physical exercise regimens, is taught or researched with medical students. Despite the commonly held belief that the mindfulness exercises are generally conducted whilst in a seated posture there is a well-established connection between mindfulness approaches and physical exercise [3]. Given the lauded benefits of mind-body strategies in promoting health and ameliorating ill-health [20,21], we were interested to find out what methods were being researched and to see if these methods had proven to be effective for medical students.

This study preferentially employed a systematic review to determine the evidence, in both the quantitative and qualitative literature, regarding the use of mindfulness and physical exercises to enhance the wellbeing of medical students. Systematic reviews require the implementation of a detailed search strategy and aim to methodologically search relevant databases and determine the quality of evidence on a particular topic [22]. This review option was preferred to a narrative review that may have a selection bias or a meta-analysis which requires a focus on the quantitative evidence to determine a summary effect size [22].

The aim of this systematic review was to appraise the quality of research evidence regarding the use of both mindfulness and physical exercises to enhance the wellbeing of medical students [23,24]. The research question was, “what is the quality of evidence establishing the efficacy for integrating mindfulness and physical exercise with respect to enhancing medical students’ wellbeing?”

2. Materials and Methods

As a systematic review, this manuscript did not require ethical approval as it contains no primary data.

2.1 Search Protocol

A literature search was conducted in five databases: the three Ovid databases Embase (1980-Present), Medline (1946-Present) and PsycINFO (1806-Present), as well as Scopus and all segments of the Cochrane Library. Three researchers (MH, TJP, JH) collaborated to identify search terms and develop search strategies that would be both sensitive enough to retrieve all relevant studies, as well as studies specific to our research focus. The key concepts mindfulness/meditation, were combined with a range of exercise related terms and modalities. The keyword medic* was included to narrow the focus to medical students. Relevant subject headings specific to each database were combined with keywords to increase the scope of the searches, for example, see Table 1 for the medical subject headings and keywords used. Search strategies were checked several times initially by TJP, then by MH and JH. One of the database search strategies, PsycINFO, is illustrated in Table 2.

Table 1 Medline subject headings and keywords.

Medline subject headings (MeSH)

Keywords

Mindfulness

Mindfulness/
Meditation/

Mindful*
Meditat*

 

Exercise

Mind-body therapies/
exp Exercise/
Yoga/
Tai Ji/

 

(Mind adj3 body)
Exercis*
Physical activit*
Sport
Sports
Taiji
Taijiquan
Tai Chi
T'aichi
T'ai chi
Walking

Swim*
Running
Jogging
Baseball Basketball
Football
Judo
Martial art*
Soccer
Tennis
Weightlifting

Medical

 

Medic*

 

Students

Students/
exp Students, health occupations/
 

 

Student*
Freshm?n
Post graduate*
Postgraduate*
Graduate
Sophmore

Intern
Interns
Trainee*

Table 2 The PsycINFO search strategy and terms used.

#

Searches

Results

1

exp EXERCISE/

23304

2

exp sports/

23398

3

exercis*.mp.

66604

4

(tai ji or taiji or taijiquan or tai chi or t'aichi or t'ai chi).mp.

525

5

yoga.mp.

2520

6

mind body therapy/

150

7

("mind and body" adj3 exercis*).mp.

51

8

(mind-body adj3 exercis*).mp.

53

9

(body-mind adj3 exercis*).mp.

9

10

("baseball" or "basketball" or "extreme sport*" or "football" or "judo" or "martial art*" or "soccer" or "swim*" or "tennis" or "weightlifting").mp.

20830

11

sports.mp.

26598

12

1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11

107566

13

mindfulness/ or meditation/

10302

14

(mindful* or meditati*).mp.

18281

15

13 or 14

18281

16

medical students/

12542

17

postgraduate students/ and medic*.mp.

100

18

exp college students/ and medic*.mp.

2614

19

((freshm?n or student* or post graduate* or postgraduate* or graduate* or under grad* or undergrad* or freshman or sophomore or trainee* or intern or interns) adj3 medic*).mp.

20395

20

16 or 17 or 18 or 19

22150

21

12 and 15 and 20

21

2.2 Type of Participants

Participants for our study were defined as university students enrolled in a medicine programme.

2.3 Types of Interventions

Interventions had to include mindfulness or mind-body based exercises that also incorporated physical exercise.

2.4 Types of Outcome Measures

Outcome measures for our study were not defined ahead of time, but were identified as the outcomes reported in the included papers (outcomes being beneficial, harmful or uncertain). The final search strategies were run in all five databases and search results were imported and collated into EndNote, a reference management program [25]. The articles were then reviewed by two researchers (MH, TJP) and duplicates were removed. The resulting studies were screened systematically by TJP and MH, first by title and then by abstract. After screening, the full texts were reviewed together by two researchers (TJP & MH) using precise inclusion and exclusion criteria as listed below:

  1. Studies must have included an empirical study or a critical review of the area.

  2. Only journal articles and conference abstracts (with sufficient data) were considered for review.

  3. Studies must have included students who were studying medicine at the time of the research in at least one of the intervention groups.

  4. The intervention must have incorporated both mindfulness-based practices and physical exercise. Studies that only used either mindfulness-based practices or physical exercise were removed.

2.5 Data Analysis

Using the aforementioned criteria, articles were first identified, then screened for eligibility and finally inclusion was confirmed for the final review of the full text. This process was documented in a flow diagram (Figure 1) and a final list of eligible articles for review were summarised (Table 3), which is consistent with PRISMA guidelines [26].

A categorisation system of key study features was applied to this list of articles. This process was predominantly inductive relying on the generation of categories, which is a version of thematic analysis [27]. In the first review round, two authors (MH, TJP) familiarised themselves with the findings of the studies being reviewed noting down initial ideas. Next, all authors reviewed the essential features of the selected articles and confirmed the final categories that best represented the ideas and conclusions emerging from the articles. The categories were checked at different stages by all authors.

The quality of the evidence was analysed using several methods. First, a risk of bias analysis was conducted using the Cochrane risk of bias criteria for randomised or nonrandomised control studies (Table 4a) [28,29,30,31]. Second, the Newcastle-Ottawa Scale was used to assess the quality of nonrandomised cohort studies (Table 4b) [32]. Third, the Critical Appraisals Skills Programme (CASP) checklist was applied to qualitative and descriptive studies (Table 4c) [33]. Lastly, levels of evidence were applied to all studies according to predefined criteria (Tables 4a to 4c) [23,24,34]. To further maintain the integrity of the process, analysis procedures were discussed amongst all authors and several strategies were used to establish trustworthiness in the data analysis process [35].

3. Results

3.1 Search History and Results

The initial search results from the five databases yielded a total of 353 articles (Figure 1). Seventy six duplicates were identified and in the next step we conducted a review of 277 titles and abstracts based on inclusion and exclusion criteria. The subsequent quota of articles resulted in the exclusion of 250 articles. A list of 31 articles was identified as potentially relevant by two researchers (MH, TJP). This was reduced to a final list of 17 refereed sources after appraisal of the full text. Table 3 shows the final collated list of 17 articles included in the evidence review, showing key study features such as methods, research design, key findings and conclusions.

3.2 Summary of the Articles Included for Review

Table 3 shows the country of origin as well as overall sample size. Of the 17 articles, the majority were conducted in the USA (n=10, 59%) followed by India (n=3, 18%). One article was found to be published from Norway, one from Canada, one from Jamaica and one with students from Sweden and the Netherlands (n=4, 23%). The pooled medical student sample size was 1,307 plus 112 psychology and 47 nursing students. The psychology and nursing students were compared and contrasted with medical student groups in two separate studies [36,37].

Figure 1 Search methodology flow diagram (exclusion and inclusion criteria are stated in section 2.4).

Table 3 Characteristics of the 17 studies (in alphabetical order) utilising both mindfulness meditation and exercise strategies.

Note: (1)*denotes conference abstract or poster only; (2) ethnicity details provided if available.

3.3 Categories Summarising the Literature Review

The overarching key categories that optimally condense the results of our review can be summarised as follows: (1) quality of evidence and research methods; (2) types of interventions; (3) measurement protocols; and (4) benefits of integrating mindfulness and physical exercises. It was noted that five of these studies were published as conference abstracts or posters with four categorised as IIb [38,39,40,41] and one as IV [42].

Quality of evidence and research methods. First, the Cochrane risk of bias criteria (Table 4a) were applied to the reviewed randomised or nonrandomised control studies. According to the level of evidence criteria, four articles [4,36,43,44] used category Ib evidence incorporating a randomised control trial. Two studies [4,36] were rated low risk in terms of randomisation but some areas of the research design were categorised as unclear. The two remaining studies [43,44] showed that although they mentioned using a randomisation process, there were many aspects of the design that were rated as high risk or unclear.

The latter two studies [43,44] applied a paired t-test approach to analyse the effect of the intervention excluding the use of co-factors. In contrast, the former two studies [4,36] used more sophisticated analyses incorporating several multivariate techniques, such as, the use of multivariate analysis of variance (MANOVA), regression and structural equation modelling.

Two further studies [37,45] provided evidence using a controlled feature but without randomisation (IIa). These studies were essentially prospective, nonrandomized, cohort-controlled studies and attempted to simulate comparisons between those choosing the intervention (mindfulness and physical exercises) and those choosing a similar option (the control). However, much of the design was categorised as high risk.

Second, the Newcastle-Ottawa Scale (Table 4b) was used to assess the quality of reviewed nonrandomised cohort studies. This was the most common research method and they were assigned with a level of evidence category IIb. Eight studies [38,39,40,41,42,46,47,48] used this method and analysed their data using a repeated-measures approach, such as a paired t-test or repeated-measures analysis of variance (ANOVA). Nonetheless, all these studies showed good levels of selection with reasonable outcome measures, but poor levels of comparability [32]. The study that appeared to have the greatest quality of evidence within this category was the Bond et al study [46], given they reported a good level of detail in their paper including all expected outcomes. In addition, the principal investigator, in the Bond et al study, assigned each student a unique confidential study identification number, suggesting that all researchers other than the principal investigator were blinded to the identity of each survey respondent.

Third, the CASP Checklist was used to assess the quality of reviewed qualitative studies (Table 4c). These remaining three articles [42,49,50] used qualitative or descriptive evidence and were assigned a category IV level of evidence. In one study [42] interviews were conducted with medical students to investigate their experiences with mindfulness and physical exercise programmes. In the next study [49], medical schools in the USA were surveyed to establish which types of mind-body strategies were being used across 15 Universities. In the final study [50], students were asked about the experiences when involved in a composite lifestyle and nutrition course.

Table 4a Applying the Cochrane Risk of bias criteria by levels of evidence for reviewed randomised or nonrandomised control studies.

Level of evidence

Article

Randomization

Allocation concealment

Blinding

Attrition bias

Reporting bias

Other bias

Ib: Evidence from at least one randomised controlled trial

 

Biswas (2010)

Unclear

Unclear

High risk

High risk

Unclear

Unclear

De Vibe et al (2013)

Low risk

Low risk

High risk

Unclear

Low risk

Contamination bias

Kondam et al (2016)

Unclear

Unclear

High risk

Unclear

Unclear

Unclear

Shapiro et al (1998)

Low risk

Unclear

Low risk

Low risk

Unclear

Unclear

IIa: evidence from at least one controlled study without randomisation

Rosenzweig et al (2003)

High risk

High risk

High risk

Unclear

Unclear

Unclear

Van Vliet et al (2017)

High risk

High risk

High risk

High risk

Low risk

Unclear

Table 4b Applying the Newcastle-Ottawa Scale for assessing the quality of reviewed nonrandomised cohort studies.

Level of evidence

Article

Selection

Comparability

Outcome

IIb: Evidence from at least one type of quasi-experimental study, or prospective matched cohort study

Bond et al (2013)

***

 

***

Bughi et al (2006)

***

*

**

Dutton et al (2012)

***

 

**

Gupta et al (2016)

***

 

**

Harwani et al (2013)

***

 

**

Motz et al (2012)

***

*

**

Parshad et al (2011)

***

 

**

Prasad et al (2016)

***

 

**

Table 4c Applying the CASP checklist for assessing the quality of reviewed qualitative studies.

Level of evidence

Article

Are the results of the study valid?

What are the results?

Will the results help locally?

IV: evidence from expert committee reports or opinions and⁄or clinical experience of respected authorities

Campos et al (2017)*

Valid aims, design, methodology, and data collection. Unclear details on recruitment and researcher bias.

Results and data analysis clearly stated, but ethical considerations unclear.

Implications of results unclear.

Gordon (2014)

Valid approach to collecting descriptive data for courses in operation in US universities.

Qualitative results and data analysis clearly stated from audit.

Results are valuable for designing future courses and curriculum development.

Wolf et al (1990)

Valid approach for data collection for describing the health promotion programme.

Descriptive data are analysed and summarised from audit.

Results are useful for showing the potential for future health promotion programmes.

Types of interventions. The first identified intervention that integrated mindfulness and physical exercises involved aspects of yoga practice [37,40,43,44,45,46,47,48,51]. Some of the interventions used an exclusive yoga approach [40,43,44,51], whilst other research incorporated yoga as part of a collection of activities aimed to promote wellbeing [37,45,46,47]. In the studies that researched the yoga sub-components, such as Asanas and Pranayama, the focus was on determining which aspect of the yoga practice had the greater benefit.

The second intervention involved a systems approach such as the MBSR system [52] with an embedded element of physical exercise such as mindful walking [38,39,41,42,50]. In one further article [49], the author surveyed 15 medical schools with the view to determine the prevalence and efficacy of mind-body programmes for medical students.

Measurement protocols. Different reported measurements were incorporated in the studies reviewed. Most of the studies used standardised self-report questionnaire measures to assess the efficacy of the intervention [4,36,37,39,40,41,44,45,46,47]. These measures consisted of:

  1. Stress, e.g., the Perceived Stress Scale [37,39,41,46].

  2. Empathy and self-compassion, e.g., the Jefferson Scale of Physician Empathy, Empathy Construct Rating Scale, and Self Compassion Scale [4,46].

  3. Wellbeing, e.g., The General Well Being Scale [47], the General Health Questionnaire [36], and the Self-Assessment Survey [40].

  4. Affect regulation, reflection, and interpersonal reactivity, e.g., the Positive Affect and Negative Affect Scale [37,39,41], the Trait Meta-Mood Scale [39], The Profile of Mood States [45], Groningen Reflection Ability Scale [37], and the Interpersonal Reactivity Index[41].

  5. Cognition, e.g., Addenbrooke’s Cognitive Examination-revised [41].

  6. Mindfulness, e.g., Freiburg Mindfulness Inventory [41].

Most of the self-report measurement protocols included more than one self-report measure built into the study design [4,36,37,39,41,46,53].

Three studies incorporated the use of physiological measures [43,48,51]. For example, measures included visual and auditory reaction times [43], forced vital capacity and expiratory reserve volume [48], and both systolic and diastolic blood pressure [51].

Two studies used measures that do not appear to be validated, e.g., measures of depression, anxiety, physical health and mindfulness [38] and a generalised lifestyle questionnaire [50]. The remaining data collection approaches used consisted of qualitative methods such as open ended surveys or interviews [42,49].

Benefits of integrating mindfulness and physical exercises. The key findings (Table 3) indicate the main benefits of the intervention strategies. Several studies [43,48,51] showed physiological gains in the intervention groups, e.g., Parshad et al [51] provided convincing evidence of increases in heart rate, stroke volume, cardiac output, total arterial compliance with decreases in total peripheral resistance, inter-beat interval, and ascending arterial characteristic impedance in the intervention group. The self-reported gains were widespread and included decreases in stress [38,39,42,53], improved levels of self-compassion, empathy, self-regulation [4,46], wellbeing, affect-regulation, and vigour [4,37,38,39,41,45,47,49,50,53], and finally enhanced mindfulness [4,36,39]. Nonetheless, it needs to be emphasised that in the studies that yielded the highest level of evidence [4,36] it was clear that the combination of mindfulness and physical exercise enhanced mental health, and reduced stress levels amongst students, and the benefits may assist with interpersonal development, such greater empathetic levels and improved interpersonal responsivity.

4. Discussion

Utilising a systematic review approach, this study evaluated and documented the literature on the use of mindfulness and physical exercise regimens and the impact these interventions have on the wellbeing of medical students. This study makes several contributions to the existing literature, including a novel approach to evaluating the evidence underscoring the benefits of mindfulness based interventions (MBIs) in conjunction with physical exercise regimens. Intuitively it makes sense that a mindfulness approach in conjunction with an exercise system will be more beneficial than only mindfulness or only physical exercise. We wanted to explore the evidence behind this assumption. Second, this systematic review appears to be the first review of the literature pertaining to the benefits of MBIs and physical regimens for medical students. Even though there is a vast literature on medical student burnout, stress and risk of psychopathology [10,54], and some review studies on MBIs [55], we found no such study that reviewed the purported benefits of combining MBIs and physical exercise. We do note that many MBSR systems commonly use a hatha yoga element as an adjunct system [4,6,45]; however our intent was to go further afield and consider all aspects of physical exercise given the wide array of mind-body systems that could be employed [3,20]. We now discuss our findings and consider the strengths of the claims made and the evidence provided in relation to the wider literature.

4.1 Quality of Evidence and Research Methods

The systematic review showed a wide range of research methods being applied to this topic. In addition, the evidence hierarchy (Table 4a 4c) was spread over several groupings.

Studies analysed using the Cochrane risk of bias criteria and levels of evidence: Randomised or nonrandomised control studies. The most robust randomised control research designs were found in four cited articles (Table 4a) [36,43,44,56], and these were categorised as level Ib. In reference to the two studies with relatively lower risk of bias [4,36], we noted that mindfulness and physical exercise as a combined system has a positive impact on enhancing mental health, and reducing stress levels amongst students [4,36]. However, a gender moderation effect was identified [36], and additionally the impact of mindfulness was found to extend beyond purely personal wellbeing issues and include improved interpersonal responsivity [4].

However, the analyses used in the two remaining studies [43,44] appeared to be unidimensional. In the Biswas study [43], a paired t-test was used and in the Kondam et al study [44] a univariate ANOVA and paired t-test approach were used. In both studies a multivariate analysis would likely be more appropriate given that both studies used one independent variable (group) and several dependent variables [57]. Moreover, checking for several confounding variables in these two studies would likely have been prudent, such as age, gender, previous experience, and prior levels of fitness. This multivariate approach would have captured more explanatory variance. In reference to these two articles, caution needs to be applied to their purported benefits of mindfulness training, which related to increased attention, concentration and visual reaction time [43], and other facets of cognition (e.g., memory and visuospatial skills) [44]. Nevertheless, these studies show that different yoga systems or aspects of yoga systems will likely yield different benefits.

In the two studies [37,45], categorised as level IIa (Table 4a), both used a nonrandomised control strategy, which allowed for a quasi-experimental comparative approach. For example, Van Vliet et al [37] attempted to control for confounding variables. In the Rosenzweig et al study [45] most of the comparisons consisted of univariate approaches to analysis, which limited the validity of findings and interpretations to only pair-wise comparisons. Nonetheless, these two studies were able to generate a list of benefits associated with the intervention by using contemporaneous comparison groups [28]. The cited personal benefits attributed to the mindfulness and physical exercise regimens were decreases in total mood disturbance, personal distress, the perception of stress, tension-anxiety, and confusion-bewilderment with an increase in vigour-activity. In addition, the cited interpersonal benefits included an increase in empathic concern. These benefits resonate with those specified by the low risk randomised studies cited above [4,36].

Studies analysed using the Newcastle-Ottawa Scale checklist: Nonrandomised cohort studies. The eight articles [38,39,40,41,42,46,47,48] that used a level IIb strategy for determining the effect of the intervention can be criticised according to voluntary selection bias, lack of randomisation and offering no comparison group. However, the selection of the participants appeared to show representation of the wider community and there were demonstrable interventions yielding verifiable outcome measures [32]. In addition to the problem of comparability, a further limitation associated with these studies is that exposure to the intervention occurred by choice rather than by chance [32,34]. Therefore, reasons why the students initially engaged in the intervention likely had an impact on outcome [34]. Finally when using multiple measures only Dutton et al[38] employed a correction factor, suggesting that many of these studies ran the risk of type 1 error [58], or generating a significant effect when there is none. The quality issues attributed to these studies suggests that the results should be treated with caution.

Studies analysed using the CASP: Qualitative studies. The final three reviewed articles (Table 4c) [42,49,50], used qualitative or descriptive methods for obtaining information about the effectiveness of the intervention or in one case the prevalence of interventions in higher education in the USA [49]. The arguments concerning the strengths and weaknesses of qualitative research are well established [59], suggesting that the research findings provided in the evaluative article [42] are likely to be useful in terms of understanding and raising salient issues associated with the intervention but can’t necessarily be considered to be representative of the wider population. When we applied the CASP checklist [33], the results (Table 4c) showed that all studies had aspects of acceptable validity and each study used a different research design and method of analysis. The two studies using either a case study approach [50] or a descriptive audit approach [49] generated data that will likely be of benefit to their local communities, whilst the benefit of the findings of one study remained unclear [42].

4.2 Types of Interventions

The first intervention system highlighted in the review was the utilisation of the traditional yoga approach, which has inherent elements of both mindfulness and physical exercises within a holistic system [20]. The second system employed a more integrated and newly formed approach utilising the integration of mind and body, such as incorporating the full extent of the MBSR practice [60]. These programmatic practices focus on progressively developing mindfulness. A complete MBSR programme will often include “different forms of mindfulness meditation practice, mindful awareness during yoga postures, and mindfulness during stressful situations and social interactions” [60].

An unexpected finding was the lack of mindfulness and physical exercise regimens used with medical students that included other well-established therapeutic interventions such as Qigong, Tai Chi, Feldenkrais and Alexander technique [20]. For example, Tai Chi has been relatively well researched in the general literature heralding its benefits for students in higher education [21], although not specifically with medical students (a group purported to be at high risk of ill-health). In addition, the Webster et al [21] systematic review of Tai Chi practices in higher education reviewed articles not only in English but also in Chinese, and one of the findings was the greater number of articles in Chinese. Hence, a further search involving databases showing articles written in non-English languages may have created a greater research yield and may have included studies of Tai Chi and other mindfulness and physical exercise programmes being applied to medical students.

4.3 Measurement Protocols

Two measurement protocols were identified in the literature reviewed, namely physiological measures and self-reported measures. For example, some of the physiological measures being employed included forced vital capacity, expiratory reserve volume, peak expiratory flow rate, and maximum voluntary ventilation [48]. In addition, some of the self-reported measures included the Jefferson Scale of Physician Empathy, Cohen's Perceived Stress Scale, the Self-Compassion Scale, and the General Well Being Scale [46,47].

None of the reviewed studies integrated both physiological and self-reported data, which would have been useful assuming that the two tend to be complementary. Given the studies in this review reported on interventions that were aimed at heightening mindfulness [36,38], including multiple data sources, as used in other studies [61], would have improved triangulation and the credibility of the results.

One common problem with using self-reported measures to evaluate change is associated with response shift [62,63]. For example if the measurement standard changes over the pre- and post-period then the ratings could in effect reflect a shift in the standard and/or actual changes, the shift therefore, becomes a form of bias or error masking the true intervention effect. To reduce the confounding effect of response shift, Howard [62] proposes that studies integrate self-report, objective, and behavioural measures when evaluating a treatment intervention. Consistent with our statement above, combining different methods of inquiry inevitably triangulates the different aspects of reality associated with understanding a problem by creating a more complete picture of the complexities associated with measuring behavioural changes [64].

A further issue related to measurement was the use of psychometrically validated questionnaires versus untested questionnaires. Using untested questionnaires has issues associated with reliability and validity which escalates the risk of bias and prevents meaningful interferences being made.[65] However, most of the studies in this review utilised psychometrically tested self-report questionnaires [36,37,39,41,44,45,47,53,56] or well-known physiological measures [43,48,51]. With psychometrically validated instruments, inferences based on the observed scores can be more rigorously defended [65].

4.4 Benefits of Integrating Mindfulness and Physical Exercises

The research investigating the efficacy of mindfulness and physical exercise regimens has, in general, reported positive results. For example, Grossman et al[60] in their meta-analysis found that MBSR programmes are useful in ameliorating a wide range of deleterious and chronic medical conditions, and can assist with distress and disability. Nonetheless, some negative effects have been shown to be linked to mindfulness exercise programmes, such as decreased job satisfaction, and increased stress and anxiety [66].

Even though caution should be applied, other reported positive effects included increases in measures of attention, concentration, self-compassion, self-regulation, anxiety, wellbeing, mindfulness, self-care, affect regulation, and physiology.

It is also important to note that some studies did not show any significant improvements related to participating in a mindfulness and physical exercise regimen. Some of these null effects were in reference to reduced depression, and improved levels of self-control, vitality, general health, happiness, positivity, personal satisfaction, self-confidence and patience.

5. Conclusions

This systematic review demonstrates that when mindfulness and physical exercise regimens are combined there are likely to be positive outcomes which will enhance the wellbeing of medical students. A major challenge for further research in this area is to develop a unified operational definition of mindfulness [66,67]. For example, Van Dam et al [67], reported that some researchers linked mindfulness with aspects of yogic meditation whilst others aligned their definitions with a more westernised definitions related to mindfulness-based stress reduction programmes [52]. However, it is also evident the research is in its infancy.

A further challenge, identified in this review, is related to the understanding and disentangling of the specific elements and effects of integrated interventions when being applied to enhancing wellbeing in medical students. Resolving this challenge will ultimately result in more rigorous and defendable arguments related to the efficacy of mindfulness and physical exercise regimens with this student cohort.

6. Recommendations for Further Research

Future research needs to consider:

  1. More robust research methods and measurement protocols to improve credibility of findings.

  2. More refined statistical methods so that analyses can involve larger samples and more multivariate techniques to improve our understanding of the variance explained by the domains of interest.

  3. More elaborate and robust research designs to tease out the different elements of the intervention so that clearer cause and effect relationships can be determined.

  4. Further mixed-methods research so that response bias facets associated with self-report measures can be minimised.

  5. Different interventions using mind-body approaches to evaluate their effectiveness, such as the impact of Qigong, Tai Chi, and Feldenkrais.

Author Contributions

All authors contributed to the conception or design of the work analysis, and interpretation of data for the work. All authors contributed to the drafting of the work and revising it critically for important intellectual content. All authors contributed to the final approval of the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Three authors (TJP, MH, JH) were involved in the initial acquisition of the papers for review.

Acknowledgements

In reference to finalising Tables 4a to 4c, we would like to acknowledge the advice and direction provided by Dr Vanessa Jordan, Senior Research Fellow, Obstetrics and Gynaecology, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland.

Funding

This project was partially supported by the University of Auckland Summer Research Scholarship.

Competing Interests

The authors have declared that no competing interests exist.

References

  1. Mental health foundation of New Zealand. Mindfulness 2016 [Available from: http://www.mentalhealth.org.nz/home/our-work/category/21/mindfulness?gclid=CNPkjJnH5c0CFdgsvQodGNk
    HIQ.
  2. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Pers Soc Psychol. 2003; 84: 822. [CrossRef]
  3. Henning MA, Krägeloh CU, Webster C. Mindfulness and Taijiquan. Annals of Cognitive Science [Internet]. 2017; 1: [1-6]. Available from: http://scholarlypages.org/Articles/cognitive-science/the_scientific_pages_of
    _cognitive_science-tspcs-1-001.pdf.
  4. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med. 1998; 21: 581-599. [CrossRef]
  5. Fjorback LO, Arendt M, Ørnbøl E, Fink P, Walach H. Mindfulness‐based dtress reduction and mindfulness‐based cognitive therapy–a systematic review of randomized controlled trials. Acta Psychiatr Sand. 2011; 124: 102-119. [CrossRef]
  6. Marchand WR. Mindfulness-based stress reduction, mindfulness-based cognitive therapy, and Zen meditation for depression, anxiety, pain, and psychological distress. J Psychiatr Pract. 2012; 18: 233-252. [CrossRef]
  7. The National institute for health and care excellence. Depression in adults: recognition and management London, United KingdomOctober, 2009 [updated April, 2018. Available from: https://www.nice.org.uk/guidance/cg90/chapter/1-guidance#continuation-and-relapse-prevention.
  8. Eller T, Aluoja A, Vasar V, Veldi M. Symptoms of anxiety and depression in Estonian medical students with sleep problems. Depress Anxiety. 2006; 23: 250-256. [CrossRef]
  9. Wolf TM, Scurria PL, Webster MG. A four-year study of anxiety, depression, loneliness, social support, and perceived mistreatment in medical students. J Health Psychol. 1998; 3: 125-136. [CrossRef]
  10. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med. 2006; 81: 354-373. [CrossRef]
  11. Dunn LB, Iglewicz A, Moutier C. A conceptual model of medical student well-being: promoting resilience and preventing burnout. Acad Psychiatry. 2008; 32: 44-53. [CrossRef]
  12. Rotenstein LS, Ramos MA, Torre M, Segal JB, Peluso MJ, Guille C, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. Jama. 2016; 316: 2214-2236. [CrossRef]
  13. Puthran R, Zhang MW, Tam WW, Ho RC. Prevalence of depression amongst medical students: a meta‐analysis. Med Educ. 2016; 50: 456-468. [CrossRef]
  14. Epstein RM. Mindful practice. Jama. 1999; 282: 833-839. [CrossRef]
  15. Hassed C, De Lisle S, Sullivan G, Pier C. Enhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle program. Adv Health Sci Educ. 2009; 14: 387-398. [CrossRef]
  16. Moir F, Henning M, Hassed C, Moyes SA, Elley CR. A peer-support and mindfulness program to improve the mental health of medical students. Teach Learn Med. 2016; 28: 293-302. [CrossRef]
  17. Wong V, Chen J. Mindfulness practice in medical students. In: Henning MA, Krägeloh CU, Dryer R, Moir F, Billington R, Hill AG, editors. Wellbeing in higher education: Cultivating a healthy lifestyle among faculty and students. London, United Kingdom: Taylor & Francis Ltd; 2018. p. 94-106.
  18. Moir F, Fernando Iii AT, Kumar S, Henning M, Moyes SA, Elley CR. Computer Assisted Learning for the Mind (CALM): the mental health of medical students and their use of a self-help website. NZ Med J. 2015; 128: 51-58.
  19. Moir F, Yielder J, Sanson J, Chen Y. Depression in medical students: current insights. Adv Med Educ Pract. 2018; 9: 323. [CrossRef]
  20. Henning MA, Lyndon M, Hawken S, Webster C. Mind-Body Processes. In: Henning MA, Henning MA, Krägeloh CU, Dryer R, Moir F, Billington R, et al., editors. Wellbeing in higher education: Cultivating a healthy lifestyle among faculty and students. London, United Kingdom: Taylor & Francis Ltd; 2018. 7-19. [CrossRef]
  21. Webster CS, Luo AY, Krägeloh C, Moir F, Henning M. A systematic review of the health benefits of Tai Chi for students in higher education. Preventive Medicine Reports. 2016; 3: 103-112. [CrossRef]
  22. Uman LS. Systematic reviews and meta-analyses. J Can Acad Child Adolesc Psychiatry. 2011; 20: 57.
  23. Jensen LS, Merry AF, Webster CS, Weller J, Larsson L. Evidence‐based strategies for preventing drug administration errors during anaesthesia. Anaesthesia. 2004; 59: 493-504. [CrossRef]
  24. Merry A. Conducting Clinical Trials. The Journal of Extra-Corporeal Technology. 2006; 38: 71.
  25. Clarivate Analytics. EndNote 2017 [Available from: https://endnote.com/product-details.
  26. PRISMA. PRISMA: Transparent reporting of systematic reviews and meta-analyses 2015 [Available from: http://www.prisma-statement.org/.
  27. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008; 8: 45. [CrossRef]
  28. Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, et al. GRADE guidelines: 4. Rating the quality of evidence—study limitations (risk of bias). J Clin Epidemiol. 2011; 64: 407-415. [CrossRef]
  29. Richards L. Guidelines for systematic reviews. Am J Occup Ther [Internet]. 2017. Available from: https://ajot.submit2aota.org/journals/ajot/forms/systematic_reviews.pdf.
  30. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The cochrane collaboration’s tool for assessing risk of bias in randomised trials. Bmj. 2011; 343: d5928. [CrossRef]
  31. Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions (Version 5.1.0) 2011 [Available from: https://handbook-5-1.cochrane.org/front_page.htm.
  32. Wells G, Shea B, O'Connell D, Peterson J, Welch V, Losos M, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses Canada: The Ottawa Hospital Research Institute; 2018 [Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp.
  33. Critical Appraisals Skills Programme. CASP checklist2018. Available from: https://casp-uk.net/wp-content/uploads/2018/03/CASP-Qualitative-Checklist-Download.pdf.
  34. Elamin MB, Montori VM. The hierarchy of evidence: from unsystematic clinical observations to systematic reviews. Neurology: Springer; 2012. p. 11-24.
  35. Krefting L. Rigor in qualitative research: The assessment of trustworthiness. Am J Occup Ther. 1991; 45: 214-222. [CrossRef]
  36. De Vibe M, Solhaug I, Tyssen R, Friborg O, Rosenvinge JH, Sørlie T, et al. Mindfulness training for stress management: A randomised controlled study of medical and psychology students. BMC Med Educ. 2013; 13. [CrossRef]
  37. Van Vliet M, Jong M. Long-term benefits from a mind-body medicine skills course on perceived stress and empathy among medical and nursing students. J Altern Complement Med. 2016; 22: A14.
  38. Dutton M, Prashar A, Romero G, Talley J, Amri H, Haramati A, et al. Mind-Body Medicine Skills training for self-care and emotional well-being in medical students. BMC Complement Altern Med [Internet]. 2012; 12(Suppl 1):[O49 p.]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3373743/.
  39. Motz K, Graves K, Gross C, Saunders P, Amri H, Harazduk N, et al. Impact of a mind-body medicine skills course on medical students' perceived stress, mindfulness and elements of emotional intelligence. BMC Complement Altern Med. 2012; 12: O19. [CrossRef]
  40. Prasad L, Varrey A, Sisti G. Medical students' stress levels and sense of well being after six weeks of Yoga and meditation. Evid Based Complement Alternat Med. 2016; 2016: 9251849. [CrossRef]
  41. Harwani N, Motz K, Graves K, Amri H, Harazduk N, Haramati A. Effect of a mind-body medicine skills course on perceived stress and empathy in medical students. Explore. 2013; 9: 328-329. [CrossRef]
  42. Campos MS, Archibald D, Burns J, Koszycki D, MacLean H, Duchesne V, et al. Exploring the benefits of a mandatory mindfulness workshop for third-year medical students in family medicine. Can Fam Physician. 2017; 63 S12.
  43. Biswas DA. Effects of short term yoga training on pulmonary & reaction time in students of rural medical institution. JIMSA. 2010; 23: 71-72.
  44. Kondam AG, Nagadeepa W, Jagan N, Jyothinath K, Suresh M, Chandrasekhar M. The effect of yoga in improved cognitive functions in medical students: A comparative study. National Journal of Physiology, J Pharm Pharmacol. 2017; 7: 38-42. [CrossRef]
  45. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med. 2003; 15: 88-92. [CrossRef]
  46. Bond AR, Mason HF, Lemaster CM, Shaw SE, Mullin CS, Holick EA, et al. Embodied health: the effects of a mind-body course for medical students. Med Educ Online. 2013; 18: 1-8. [CrossRef]
  47. Bughi SA, Sumcad J, Bughi S. Effect of brief behavioral intervention program in managing stress in medical students from two Southern California Universities. Med Educ Online. 2006; 11: 4593. [CrossRef]
  48. Gupta M, Jain S, Kumar V. Effect of Raja Yoga meditation on pulmonary functions of young obese medical students. Indian J Public Health. 2016; 7: 1-4. [CrossRef]
  49. Gordon JS. Mind-body skills groups for medical students: reducing stress, enhancing commitment, and promoting patient-centered care. BMC Med Educ [Internet]. 2014; 14:[198 p.]. Available from: https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-14-198.
  50. Wolf TM, Randall HM, Faucett JM. A health promotion program for medical students: Louisiana State University Medical Center. Am J Health Promot. 1990; 4: 193-202. [CrossRef]
  51. Parshad O, Richards A, Asnani M. Impact of yoga on haemodynamic function in healthy medical students. WIMJ. 2011; 60: 148-152.
  52. Kabat‐Zinn J. Mindfulness‐based interventions in context: past, present, and future. Clin Psychol Sci Pract. 2003; 10: 144-156. [CrossRef]
  53. Prasad L, Varrey A, Sisti G. Effect of yoga & meditation on medical students' stress levels & sense of well being prior to exams. Obstet Gynecol. 2016; 127: 52S. [CrossRef]
  54. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among US medical students. Ann Intern Med. 2008; 149: 334-341. [CrossRef]
  55. Daya Z, Hearn JH. Mindfulness interventions in medical education: A systematic review of their impact on medical student stress, depression, fatigue and burnout. Med Teach. 2017: 1-8.
  56. Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based stress reduction for health care professionals: results from a randomized trial. Int J Stress Manag. 2005; 12: 164. [CrossRef]
  57. Field AP. Discovering statistics using SPSS : And sex, drugs and rock’n’roll. 4th ed. London: SAGE; 2013.
  58. Lachlan K, Spence PR. Corrections for type I error in social science research: A disconnect between theory and practice. JMASM. 2005; 5: 23. [CrossRef]
  59. Choy LT. The strengths and weaknesses of research methodology: Comparison and complimentary between qualitative and quantitative approaches. ‎IOSR-JHSS. 2014; 19: 99-104. [CrossRef]
  60. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits: A meta-analysis. J Psychosom Res. 2004; 57: 35-43. [CrossRef]
  61. Henning MA, Sollers J, Strom JM, Hill AG, Lyndon MP, Cumin D, et al. Junior doctors in their first year: Mental health, quality of life, burnout and heart rate variability. Perspect Med Educ. 2014; 3: 136-143. [CrossRef]
  62. Howard GS. Response-shift bias: A problem in evaluating interventions with pre/post self-reports.Eval Rev. 1980; 4: 93-106. [CrossRef]
  63. Carver CS, Scheier MF. Scaling back goals and recalibration of the affect system are processes in normal adaptive self-regulation: understanding ‘response shift’phenomena. Soc Sci Med. 2000; 50: 1715-1722. [CrossRef]
  64. Sandelowski M. Focus on research methods combining qualitative and quantitative sampling, data collection, and analysis techniques. Res Nurs Health. 2000; 23: 246-255. [CrossRef]
  65. Morgado FF, Meireles JF, Neves CM, Amaral AC, Ferreira ME. Scale development: ten main limitations and recommendations to improve future research practices. Psicol-Reflex Crit . 2018; 30: 3. [CrossRef]
  66. Jamieson SD, Tuckey MR. Mindfulness interventions in the workplace: A critique of the current state of the literature. J Occup Health Psychol. 2017; 22: 180. [CrossRef]
  67. Van Dam NT, van Vugt MK, Vago DR, Schmalzl L, Saron CD, Olendzki A, et al. Mind the hype: A critical evaluation and prescriptive agenda for research on mindfulness and meditation. Perspect Psychol Sci. 2018; 13: 36-61. [CrossRef]