Effect of juggling therapy on anxiety disorders in female patients

  • Toshihiro Nakahara1Email author,

    Affiliated with

    • Kazuhiko Nakahara2,

      Affiliated with

      • Miho Uehara1,

        Affiliated with

        • Ken-ichiro Koyama1,

          Affiliated with

          • Kouha Li1,

            Affiliated with

            • Toshiro Harada1,

              Affiliated with

              • Daisuke Yasuhara1,

                Affiliated with

                • Hikaru Taguchi1,

                  Affiliated with

                  • Sinya Kojima1,

                    Affiliated with

                    • Ken-ichiro Sagiyama1 and

                      Affiliated with

                      • Akio Inui1

                        Affiliated with

                        BioPsychoSocial Medicine20071:10

                        DOI: 10.1186/1751-0759-1-10

                        Received: 28 September 2006

                        Accepted: 01 May 2007

                        Published: 01 May 2007



                        The aim of this study was to investigate the effect of juggling therapy for anxiety disorder patients.

                        Design and Method

                        Subjects were 17 female outpatients who met the DSM-IV diagnostic criteria for anxiety disorders. Subjects were treated with standard psychotherapy, medication and counseling for 6 months. For the last 3 months of treatment, subjects were randomized into either a non-juggling group (n = 9) or a juggling therapy group (juggling group: n = 8). The juggling group gradually acquired juggling skills by practicing juggling beanbags (otedama in Japan) with both hands. The therapeutic effect was evaluated using scores of psychological testing (STAI: State and Trate Anxiety Inventry, POMS: Profile of Mood Status) and of ADL (FAI: Franchay Activity Index) collected before treatment, 3 months after treatment (before juggling therapy), and at the end of both treatments.


                        After 6 months, an analysis of variance revealed that scores on the state anxiety, trait anxiety subscales of STAI and tension-anxiety (T-A) score of POMS were significantly lower in the juggling group than in the non-juggling group (p < 0.01). Depression, anger-hostility scores of POMS were improved more than non-jugglers. In the juggling group, activity scores on the vigor subscale of POMS and FAI score were significantly higher than those in the non juggling group (p < 0.01). Other mood scores of POMS did not differ between the two groups.


                        These findings suggest that juggling therapy may be effective for the treatment of anxiety disorders.


                        Several therapies, including anxiolytics, psychotherapy, and cognitive behavioral therapy (CBT), are available for the treatment of anxiety disorders. Although little research on alternative therapy was conducted in the past, several recent studies have reported their efficacy in patients with posttraumatic stress disorder (PTSD) [1], general anxiety disorders (GAD) through herbal therapy [2], anxiety and mood disorders through several complementary therapies [3], anxiety disorders through yoga therapy [4], and anxiety disorders through meditation and relaxation [5].

                        Eye movement desensitization and reprocessing (EMDR) is an integrative psychotherapy approach that has been consistently evaluated as effective for treating several anxiety disorders, inclucing PTSD [6], panic disorders [7], and phobias [8]. Although conflicting data has been reported for the efficacy of EMDR [9], this therapy is considered to be of low to moderate level of efficacy [10]. Originally, research on this therapy found that moving the eyes rapidly in a side-to-side motion reduced disturbing thoughts and related anxiety [11]. Currently rapid eye movement methods are occasionally replaced by smooth pursuit eye movement and bilateral stimulation. Smooth pursuit eye movement, bilateral tapping and bilateral tones have been found to be as effective as rapid eye movement [12].

                        Juggling (otedama) has a 3000-year history in Jaoan [13], first appearing in the Nara and Heian Periods (8th – 9th centuries). To date, such games have continued to grow in popularity. A previous report has indicated that three-ball cascade juggling facilitates the growth of gray matter in the mid-temporal lobe [14]. And a previous report suggested that mid-temporal lobe structures may relate to explicit conditioning tasks [15]. Physical movement via meditation [5], and yoga therapy [4] may reduce anxiety through relaxation. With regards to anxiety disorders, a report suggested the involvement of the temporal lobe in the generation of panic attack [16]. This finding suggests that visual motion information and physical movement might improve the psychoneurogical network.

                        Herein, we present the first trial to investigate the therapeutic effect of juggling on anxiety disorders. We hypothesize that juggling therapy contributes to improvement in patient anxiety through changes in emotional memory processing.

                        Subjects in this study were 17 female outpatients with anxiety disorders who met the DSM-IV diagnostic criteria for 6 panic disorder (PD), 4 PTSD, 4 obsessive-compulsive disorders (OCD), and 3 GAD. No subjects had substance use, alcohol or other comorbidities. All subjects were treated with standard psychotherapy, medication and counseling. During the 6-month study period, anxiolytics and antidepressants were prescribed; however, the doses were not changed during the study. For the last 3 months of treatment, subjects were randomized into a non-juggling group (n = 9: 3 PD, 2 PTSD, 2 OCD, and 2 GAD) or a juggling therapy group (juggling group; n = 8, 3 PD, 2 PTSD, 2 OCD, and 1 GAD). Individuals in the juggling group were taught classic beanbag juggling and gradually acquired juggling skills by practicing juggling beanbags with both hands (subjects started with 2 bags, then progressed to 3 bags). They routinely exercised about 5 minutes, twice a day.

                        The difference in the therapeutic effect was estimated using scores on the State-Trait Anxiety Inventory (STAI), Profile of Mood Status (POMS), and Franchay Activity Index (FAI), collected before treatment, after 3 months of treatment (before juggling therapy), and at the end of both treatments (6 months).

                        Regarding statistical analysis, psychological test scores were compared using repeated measurement of ANOVA and post-hoc Scheffe's test. All results were considered significant at p < 0.05.

                        In accordance with the principle of the Declaration of Helsinki, we obtained the written informed consent from participants before enrollment.

                        No differences between the 2 groups were observed in any demographic characteristics. Mean ± SD age was 32.7 ± 3.2 years in the non-juggling group and 38.5 ± 3.5 in the juggling group. Duration of disease period was 18.4 ± 6.5 months and 17.0 ± 7.8 months, respectively (mean ± SD).

                        Regarding anxiety scores (state and trait subscales of the STAI, T-A (tension-anxiety) score of POMS), repeated measurement of ANOVA showed for the group (p = 0.12 and F(1,15) = 2.81, p = 0.32 and F(1,15) = 1.08, p = 0.53 and F(1,14) = 0.33, respectively), time course (p < 0.0001 and F(2,30) = 16.67, p = 0.0002 and F(2,30) = 11.8, p = 0.01 and F(2,28) = 6.23, respectively), and time course × group (p = 0.011 and F(2,30) = 5.37, p = 0.021 and F(2,30) = 5.07, p < 0.0001 and F(2,28) = 17.26, respectively). Anxiety scores in the juggling group were significantly lower than in the non-juggling group at the end of treatment (p = 0.0044, p = 0.024, p = 0.046, respectively) (Figure 1a,b,c).
                        Figure 1

                        Change of anxiety scores (mean ± SD). a) State of STAI, b) Trate of STAI, c) T-A (Tension-Anxiety) score of POMS, * p < 0.05 and ** p < 0.01 vs. controls.

                        According to the activity scores (vigor score of POMS and FAI score), repeated measurement of ANOVA showed for the group (p = 0.75 and F(1.15) = 0.10, p = 0.69 and F(1,15) = 0.17, respectively), time course (p < 0.0001 and F(2,30) = 58.40, p < 0.0001 and F(2,30) = 31.82, respectively), and time course × group (p < 0.0001 and F(2,30) = 23.08, p = 0.0011 and F(2,30) = 8.65, respectively). The activity scores of the juggling group were significantly improved in comparison with the non-juggling group.

                        Scores on the depression, anger-hostility, subscales of POMS, repeated measurement of ANOVA showed for the group (p = 0.33 and F(1,15) = 1.07, p = 0.53 and F(1,15) = 0.41, respectively), time course (p < 0.0001 and F(2,30) = 72.86, p < 0.0001 and F(2,30) = 24.76, respectively), and time course × group (p < 0.0001 and F(2,30) = 40.26, p = 0.023 and F(2,30) = 4.27, respectively). Depression and anger-hostility scores were significantly lower in the juggling group than in the non-juggling group at the end of the treatment (p = 0.0074, p = 0.026, respectively).

                        In contrast, scores on the confusion and fatigue subscales of the POMS, repeated measurement of ANOVA showed for the group (p = 0.31 and F(1,15) = 1.11, p = 0.79 and F(1,15) = 0.07, respectively), time course (p < 0.0001 and F(2,30) = 33.67, p < 0.0001 and F(2,30) = 94.84, respectively), and time course × group (p = 0.80 and F(1,15) = 0.22, p = 0.80 and F(1,15) = 0.23, respectively). At the end point these scores did not significantly differ between the groups (p = 0.213, p = 0.813, respectively).

                        In the present study, we found that anxiety scores in the juggling group were reduced more significantly than those in the non-juggling group. This finding suggested that juggling therapy may reduce anxiety through a visual motion information processing network such as EMDR. Eye movement was reported to reduce anxiety-causing memories or reduce the vividness of such memories [17], and faster resolution may have been obtained with regards to anxiety and emotional distress in the juggling group than in the non-juggling group. The activity of the ACC and lateral prefrontal cortex (PFC) is changed in individuals with higher anxiety levels [18], and the dorsal region of ACC is related to interoceptive awareness [19]. Thus, improvement on anxiety scores through juggling may have resulted from such changes in emotional memory processing and local brain activation [20].

                        On the other hand, juggling therapy or similar body work therapy may have facilitated changes in the patient's condition through relaxation. Body work therapy like yoga [4], meditation and relaxation [5] are reported to be effective in emotional control. Disrupted attentional control over the threat of anxiety was reported [21], therefore the body sensation associated with juggling therapy may have helped attenional focus control and assisted the homeostatic process such as EMDR [20]. Since mood scores such as confusion and fatigue were not improved, juggling therapy may have a specific and limited influence on the activity of the brain, among other alternative therapies.

                        Several limitations of this study must be identified. Firstly, because the number of participants was small, we used a broad definition of anxiety disorders. But a report indicated that anxiety disorder may have overlapping pathologies [22]. Secondly, as the therapeutic effect was estimated using only psychological testing without assessing brain function. Hypo- rather than hyper-activation of the PFC has been reported in PTSD patients during the verbal fluency test [23]. Therefore, further research using NIRS, fMRI, PET, and/or SPECT is required to examine the brain sites responsible for the therapeutic effect of juggling.

                        In conclusion, we demonstrated the anxiolytic effect of juggling therapy in patients with anxiety disorders. Juggling therapy could be performed easily in combination with other forms of therapy for patients with increased anxiety levels.



                        This study was supported by research grants from the Japanese Ministry of Health, Labor and Welfare, the Japanese Ministry of Science, and Kagoshima University FSRC project. We extend our appreciation to the staff and patients of Yoshimura Hospital for their support.

                        Authors’ Affiliations

                        Department of Behavioral Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, and Department Psychosomatic Medicine, Respiratory and Stress care Center, Kagoshima University Hospital
                        Health Art Clinic Kumamoto


                        1. Bradley R, Greene J, Russ E, Dutra L, Westen D: A multodimentional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry 2005, 2:214–227.View Article
                        2. Miyasaka LS, Atallah AN, Soares BG: Valerian for anxiety disorders. Cochrane Database Syst Rev 2006, 4:CD004515.PubMed
                        3. Deng G, Cassileth BR: Integrative Oncology: Complementary Therapies for pain, Anxiety, and Mood Disturbance. CA Cancer J for Clinicians 2005, 55:109–116.View Article
                        4. Gupta N, Khera S, Vempati RP, Sharma R, Bijlani RL: Effect of yoga based lifestyle intervention on state and trait anxiety. Indian J Physiol Pharmacol 2006, 50:41–47.PubMed
                        5. Krisanaprakornkit T, Krisanaprakornkit W, Piyavhatkul N, Laopaiboon M: Meditation therapy for anxiety disorders. Cochrane Database Syst Rev 2006, 1:CD004998.PubMed
                        6. Shapiro F, Vogelmann-Sine S, Sine LF: Eye movement Desensitization and reprocessing: treating trauma and substance abuse. Journal of Psychoactive drugs 1994, 4:379–391.
                        7. Goldstein AJ, de Beurs E, Chambless DL, Wilson KA: EMDR for panic disorder with agoraphobia: Comparison with waiting list and credible attention-placebo control conditions. J of Counseling and Clinical Psychology 2000, 68:947–956.View Article
                        8. De Jough A, Ten Broeke E, Renson MR: Treatment of specific phobias with eye movement desensitization and reprocessing (EMDR): Protocol, empirical status, and conceptional issues. J Anxiety Disorders 1999, 13:69–85.View Article
                        9. Katon WJ: Panic disorder. New Engl J Med 2006, 354:2360–2367.View ArticlePubMed
                        10. McCabe S: EMDR: Implication of the use of reprocessing therapy in nurcing practice. Perspectives in psychiatry care 2004, 3:104–114.View Article
                        11. Shapiro F: Eye movement desensitization: A new treatment for post-traumatic stress disorder. Journal of Behavior Research and Experimental Psychiatry 1989, 20:211–217.View Article
                        12. Shapiro F: Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford 1995.
                        13. Gillen B: "Remember the Force Hassan! Delving Deeper into Juggling Hieroglyphics" Juggling in ancient Egyptian carvings. Includes some references to anthropologists who have written generally about ball play in Ancient Egypt. Juggler's World 1986, Summer:9–10.
                        14. Dragansky B, Gaser C, Busch V, Schuierer G, Bogdahn U, May A: Changes in gray matter induced by training. Nature 2004, 22:311–312.View Article
                        15. Morris JS, Ohman A, Dolan RJ: Conscious and unconscious emotional learning in human amygdala. Nature 1998, 393:467–470.View ArticlePubMed
                        16. Sazar M, Carlen PL, Wennberg R: Panic attack semiology in right temporal lobe epilepsy. Epileptic Disord 2003, 2:93–100.
                        17. Ohtani T, Matsuo K, Kato T, Kato N: Hemodynamic response to emotional memory recall with eye movement. Neurosci Lett 2005,380(1–2):75–9.View ArticlePubMed
                        18. Bishop S, Duncan J, Brett M, Lawrence AD: Prefrontal cortical function and anxiety: controlling attention to threat-related stimuli. Nature neuroscience 2004, 7:184–188.View ArticlePubMed
                        19. Critchley HD, Wiens S, Rotshtein P, Ohman A, Dolan RJ: Neural systems supporting interoceptive awareness. Nature neuroscience 2004, 7:189–195.View ArticlePubMed
                        20. Corrigan FM: Psychotherapy as assisted homeostasis: activation of emotional processing mediated by the anterior cingulated cortex. Medical Hypotheses 2004, 6:968–973.View Article
                        21. Mathews A, Mackintosh B: A cognitive model of selective processing in anxiety. Cognit Ther Res 1998, 22:539–560.View Article
                        22. Paul AC, Scott LR: Neural circuitry of Anxiety: Evidence from Structural and Functional Neuroimaging Studies. Psychopharmacology Bulletin 2003, 4:8–25.
                        23. Matsuo K, Taneichi K, Matsumoto A, Ohtani T, Yamasue H, Sakano Y, Sakaki T, Sadamatsu M, Kasai K, Iwanami A, Asukai N, Kato N, Kato T: Hypoactivation of the prefrontal cortex during verbal fluency test in PTSD: a near-infrared spectroscopy study. Psychiatry Research 2003, 1:1–10.View Article

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