The effects of mindfulness training on competition-induced anxiety and salivary stress markers in elite Wushu athletes: A pilot study

Accepted Manuscript The effects of mindfulness training on competition-induced anxiety and salivary stress markers in elite Wushu athletes: A pilot study

Amir Hossien Mehrsafar, Jana Strahler, Parisa Gazerani, Mohammad Khabiri, José Carlos Jaenes Sánchez, Alireza Moosakhani, Ali Moghadam Zadeh PII: DOI: Article Number: Reference:

S0031-9384(19)30696-1 https://doi.org/10.1016/j.physbeh.2019.112655 112655 PHB 112655

To appear in:

Physiology & Behavior

Received date: Revised date: Accepted date:

4 July 2019 5 August 2019 16 August 2019

Please cite this article as: A.H. Mehrsafar, J. Strahler, P. Gazerani, et al., The effects of mindfulness training on competition-induced anxiety and salivary stress markers in elite Wushu athletes: A pilot study, Physiology & Behavior, https://doi.org/10.1016/ j.physbeh.2019.112655

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ACCEPTED MANUSCRIPT ORIGINAL ARTICLE

Title: The effects of mindfulness training on competition-induced anxiety and salivary stress markers in elite Wushu athletes: a pilot study Short title: Mindfulness affects psychobiological response to competition

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Amir Hossien Mehrsafar1, Jana Strahler2,*, Parisa Gazerani3, Mohammad Khabiri4 , José Carlos Jaenes Sánchez5, Alireza Moosakhani6, Ali Moghadam Zadeh7,**

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1. Amir Hossien Mehrsafar Department of Sport Psychology, Faculty of Sports Sciences, Faculty of Sports Sciences, University of Tehran, Tehran, Iran. Email: [email protected], [email protected]

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2. Jana Strahler Department of Psychotherapy and Systems Neuroscience, Faculty of Psychology and Sport Science, University of Giessen, Giessen, Germany. Email: [email protected], [email protected]

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3. Parisa Gazerani Department of Health Science and Technology, School of Medicine and Health, Aalborg University, Aalborg, Denmark. Email: [email protected]

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4. Mohammad Khabiri Department of Sport Psychology, Faculty of Sports Sciences, Faculty of Sports Sciences, University of Tehran, Tehran, Iran. Email: [email protected], [email protected]

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5. José Carlos Jaenes Sánchez Department of Social Anthropology, Basic Psychology & Health, Universidad Pablo de Olavide, Seville, Spain. Email: [email protected]‫‏‬ 6. Alireza Moosakhani Department of Exercise Physiology, Faculty of Sports Sciences, University of Tehran, Tehran, Iran. Email: [email protected] 7. Ali Moghadam Zadeh Department of Psychology, Faculty of Psychology and Education, University of Tehran, Tehran, Iran. Email: [email protected], [email protected]

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* Corresponding Author: Jana Strahler Research Associate, Department of Psychotherapy and Systems Neuroscience, Faculty of Psychology and Sport Science, Justus Liebig University Giessen,

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Institution Address: Faculty of Psychology and Sport Science, University of Giessen, OttoBehaghel-Strasse 10H, 35394, Giessen, Germany. Otto-Behaghel-Str. 10H 35394 Giessen Room H 123 (BION) Phone: +49 (0) 641 / 99 - 26332 Fax: +49 (0) 641 / 99 - 26309 Email: [email protected]

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** Corresponding Author: Ali Moghadam Zadeh Assistant Professor, Department of Psychology, Faculty of Psychology and Education, University of Tehran, Tehran, Iran.

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Institution Address: Faculty of Psychology and Education, University of Tehran, Jalal Al-eAhmad Avenue, Tehran, Iran. Room H 135 Tel: +98 (21) 88255031 Cell phone: +98 912 194 4254 Postal code: 14155-6456 Fax: +98 (21) 88254734 Email: [email protected], [email protected]

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The effects of mindfulness training on competition-induced anxiety and salivary stress markers in elite Wushu athletes: a pilot study Abstract Objective Due to the impact of stress and related psychophysiological responses on competitive performance,

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psychological interventions that reduce stress and may thus increase athletic performance need to be evaluated. In this pilot study, the effects of a mindfulness-based intervention (MBI) on competitive

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anxiety, self-confidence and mindfulness, and autonomic and endocrine stress responses to a

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competition in elite athletes‫ ‏‬were determined. Methods

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Twenty-six male elite Wushu athletes (N = 26) were randomly assigned to either MBI (8 weeks) or a wait-list control group. Both groups participated in three competitions at baseline, immediately post

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intervention, and at a 2-month follow-up. Athletes completed the Competitive State Anxiety Inventory-2 prior to the competitions. Saliva, from which the stress markers cortisol (sCort) and alpha-

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amylase (sAA) were determined, was collected prior to and after competitions as well as after

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awakening and in the evening of competition days. Results

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Repeated measures ANOVAs showed that the MBI group, but not the wait-list control group,

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demonstrated an increase in self-confidence and mindfulness and a decrease in competitive anxiety from baseline to post intervention (all p < .001, all ɳp ² > 0.39). The MBI group exhibited lower sCort daily levels (p = .001, ɳp ² = 0.332) and lower sCort (p = .013, ɳp ² = 0.121) and sAA responses (p = .022, ɳp ² = 0.119) to the competition after the intervention. Daily sAA was unaffected by the intervention (p = .742, ɳp ² = 0.011). These changes remained stable up to the 2-month follow-up. Conclusions The present pilot study suggested that mindfulness-based intervention might be associated with a diminished physiological and psychological stress responses to competition. Whether this in turn translates to change in performance needs to be examined in future studies with larger samples. Moreover, different sport activities need to be considered before findings can be generalized. 3

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Key words: Competitive anxiety, Salivary cortisol, Salivary alpha-amylase, Mindfulness-based

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intervention, Elite athlete.

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1. Introduction Athletic competitions, particularly those including social-evaluative elements like judges and audience which pose a threat to the social and athletic self, are accompanied by increased anxiety and emotiona l stress levels (Strahler, Ehrlenspiel, Heene, & Brand, 2010; Paridon, Timmis, Nevison, & Bristow, 2017). Anxiety has been described as a negative emotional state which is characterized by restlessness,

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worriness, and a state of arousal in mind and body (Weinberg & Gould, 2018). The Multidimensiona l Theory of State Anxiety specific to sports proposes two dimensions of anxiety during a competitive

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event. Cognitive anxiety refers to negative thoughts and expectations about the competitive event and

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the evaluation of performance, whereas somatic anxiety refers to the physiological-affective components that directly affect the central nervous system (Martens, Vealey, & Burton, 1990). In

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addition to these psychological reactions, the acute response to competitive stress also involves the activation of physiological systems including the activation of the autonomic nervous system (ANS)

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with the release of catecholamines and the hypothalamic-pituitary-adrenal (HPA) axis with the secretion of cortisol. Cortisol can be reliably assessed in saliva (salivary cortisol, sCort) (Hellhammer,

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Wüst, & Kudielka, 2009) and there is current consensus that the starch-degrading salivary enzyme

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alpha-amylase (sAA) can be considered a surrogate marker for autonomic reactivity (Nater & Rohleder, 2009; Strahler, Skoluda, Kappert, & Nater, 2017).

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Numerous studies provide evidence that competition constitute a major stressor in athletes. In line with assumptions of acute stress responses to be highly adaptive (Sapolsky, Romero, & Munck,

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2000), these responses are assumed to put the athlete in an optimal state to compete and perform. Cortisol levels in elite soccer players have been shown to be elevated at the beginning of competition (Alix-Sy, Le Scanff, & Filaire, 2008). Draper et al., (2012) confirmed this peak of cortisol levels at the start of rock-climbing competitions. Time course of stress responses seem somewhat different for ballroom dancing where the highest cortisol increases were found at the end of the first round (Rohleder, Beulen, Chen, Wolf, & Kirschbaum, 2007). Previous researches employing sAA in elite athletes confirms elevated levels of this marker in response to competition (Kivlighan & Granger, 2006). For example, Capranica et al., (2017) reported that state anxiety and sAA were elevated durin g a taekwondo competition and that the sAA peak was observed at the end of the competition. Likewise, 5

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inline skating (Dehghan et al., 2019), golf and soccer (Kim, Chung, Park, & Shin, 2009), and basketball competitions significantly increase sAA (Moreira et al., 2018). Evidence of the usefulness of both sAA and sCort to evaluate athletic stress and competitive anxiety stems from studies showing a positive correlation between anxiety levels and salivary stress markers to competition in different athlete populations, e.g. tennis (Filaire, Alix, Ferrand, & Verger, 2009), archery (Lim, 2018), and even

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for coaches (Hudson, Davison, & Robinson, 2013). Further empirical support for the usefulness of sCort and sAA in sports contexts stems from research investigating important moderators of this

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association. For instance, it was shown that sCort is more pronounced in home as compared to away

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competitions (Carré, Muir, Belanger, & Putnam, 2006), when there is more audience (Agnew & Carron, 1994), or when competing as a couple as compared to a larger group (Rohleder et al., 2007).

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While this acute increase in stress system activity is useful and has often been associated with better athletic performance (Kraemer et al., 2004; Lazarus, 2000), prolonged training periods and repeated

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competitions are assumed to result in a constant wear and tear of the athlete’s body and negative health consequences (Berndt, Strahler, Kirschbaum, & Rohleder, 2012; Kuipers & Keizer, 1988).

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Beside the effects of acute changes in homonal markers, sport-related anxiety can also

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influence sport performance in either a faciltative or debilitative fashion (Strahler et al., 2010). Such effects seem to depend on the individual’s cognitive, behavioral, and physiological responses and the

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situation itself (Lazarus, 2000). A high degree of competitive anxiety experienced before and during competition has been related to decreased athletic performance (Ford, Ildefonso, Jones, & Arvinen-Barrow,

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2017). Such detrimental consequences are well documented in the literature‫(‏‬Craft, Magyar, Becker, & Feltz, 2003; Mellalieu, Hanton, & Thomas, 2009). Recently, some studies indicated that higher levels of stress markers (such as sCort and sAA) before and during competiton can have negative consequences ultimately resulting in a decline in athletic performance (Aufegger & Wasley, 2018; Lautenbach, 2017; Lautenbach, Laborde, Achtzehn, & Raab, 2014; I. S. Lim, 2016). However, there are also contrary findings which can often be traced back to the study’s design, i.e. examining non-real competitions and non-controlled settings (Lautenbach et al., 2014; Robazza et al., 2012). One assumed mechanism in this regard is that cortisol affects cognitive processes and attentional control (Lautenbach, 2017). Moreover, some studies suggest that higher level of cortisol during competition could reinforce risky 6

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behavior which may lead to more mistakes (Lautenbach, Laborde, Klämpfl, & Achtzehn, 2015) . Therefore, interventions that can reduce psycho-physiological stress and anxiety are assumed to increase athletic performance. One of the proposed interventions is mindfulness. Mindfulness is defined as “paying attention on purpose, in the present moment and nonjudgmentally to the present experience” (Kabat-Zinn,

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2003).‫‏‬Mindfulness allows an individual to review all internal and external informational input and to be able to experience the changed relationship toward normal reactions (Goldin & Gross, 2010; Scott-

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Hamilton & Schutte, 2016). The goal of the mindfulness-based intervention (MBI) is to reduce

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suffering by developing equanimity in mind and body, as well as gaining insight into mental and physical conditions that inhibit an individual’s capacity to respond pro-actively and effectively to

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everyday events (Shapiro, Wang, & Peltason, 2015). There is a rather large body of experimenta l evidence in clinical (Goldberg et al., 2018) and non-clinical (Khoury, Sharma, Rush, & Fournier,

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2015) settings on the beneficial effects of MBI on psychological (Keng, Smoski, & Robins, 2011) and physiological variables‫( ‏‬for a review see Pascoe, Thompson, Jenkins, & Ski, 2017). MBI has been

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shown to reduce stress and anxiety (Chiesa & Serretti, 2009; Gotink et al., 2015; Sharma & Rush,

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2014; Vøllestad, Nielsen, & Nielsen, 2012). Likewise, there is evidence for a reduction of sCort and sAA following MBI (Brand, Holsboer-Trachsler, Naranjo, & Schmidt, 2012; Lipschitz, Kuhn, Kinney,

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Donaldson, & Nakamura, 2013). The benefits of MBI have been also studied in various sport contexts

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including springboard diving (Schwanhausser, 2009), soccer (Baltzell & Akhtar, 2014), martial arts (Trujillo-Torrealva & Reyes Bossio, 2017), and running and golf (Thompson, Kaufman, De Petrillo, Glass, & Arnkoff, 2011). A recent systematic review found positive effects for mindfulness in the sport domains, however, displayed poor internal validity (i.e. no blinding, no protocol registration, no random allocation, or no reporting via standardized checklists) of the majority of studies thereby limiting causal conclusions (Noetel, Ciarrochi, Van Zanden, & Lonsdale, 2017). Given these assumed benefits but keeping the low quality of previous reports in mind, it is not surprising that only a few studies have investigated the effect of MBI on competition-related changes in psycho-physiologica l stress markers. John et al., (2011)‫‏‬showed that MBI reduced sCort before competition but increased shooting performance in elite shooters. In a follow-up study, the authors replicated this increase in 7

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performance but showed no difference between musical intervention and MBI (John, Verma, & Khanna, 2012). In addition, (MacDonald & Minahan, 2018) demonstrated that an 8-week MBI attenuated the typical sCort increase right after awakening in wheelchair basketball players and also highlighting the effectiveness of MBI to reduce HPA axis responsiveness. To date, no study has looked at sAA with regard to the effect of MBI in athletes. The combined assessment of physiological (e.g.,

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autonomic and endocrine stress responses) and psychological (e.g., competitive anxiety profiles) responses may provide a better and multidimensional understanding of the athlete’s stress in official

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competitions.

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Main purpose of this study was to explore the effects of mindfulness training on competition induced anxiety and salivary stress markers in elite athletes. Based on previous findings, it was

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proposed that MBI might help athletes to manage their stress better during competition. MBI was expected to increase mindfulness and competition-related self-confidence, and to reduce daily and

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competitive stress reactivity in elite athletes. In this study, Wushu (Sanda style), a Chinese martial art, was used as the model for competitive stress in elite sports. In this combat sport, the stressors are

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potentially high because of their nature, that is, one on one fight with full body contact. A Sanda

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athlete must be able to use high-intensity wrestle, kicks, punches, push and pull at the same time. It was hypothesized that:

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(1) MBI would lead to reduced competitive anxiety and enhanced self -confidence and

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mindfulness before elite Wushu competitions. (2) MBI would lead to reduced daily levels of the salivary stress markers sCort and sAA in elite Wushu athletes.

(3) MBI would lead to reduced levels of salivary stress responses (sCort and sAA) to elite Wushu competitions. As research on the associations between acute physiological and emotional stress responses is unclear (Campbell & Ehlert, 2012), associations between changes in competitive anxiety, selfconfidence, mindfulness, and changes in salivary stress responses to Wushu competitions were exploratively examined.

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2. Method 2.1. Participants Twenty-six male elite Sanda Wushu‫‏‬athletes (experimental group: n= 13 and wait-list contro l group: n= 13; age: M = 25.4, SD = 2.4 years; body-mass-index: M = 23.25, SD = 3.2 kg/m²) were enrolled. All athletes were members of the Iranian national Wushu team and had a training history of

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M = 4.3, SD = 3.2 years as professional sportsmen. Participants were not taking medication and had no history of any physical illness or mental disorder. All participants were non-smokers and remained in

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healthy condition throughout the whole study. The ethics committee of the Sports Sciences Research

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Institute of Iran (SRII) approved the study protocol. All participants were informed of the study requirements and provided written informed consent. Participants did not receive credit for their

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participation. Participants in the wait-list control group received MBI after study completion.

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2.2. Intervention

The experimental group participated in an 8-week mindfulness program including arranged weekly

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one-hour workshop sessions, home meditation practice, and weekly group-based mindful-Wushu

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sessions. The purpose of the mindful-Wushu sessions was to assist participants in simulatin g mindfulness skills into their competition environment and sports practice. The mindfulness trainin g

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was performed according to the Mindfulness-based Intervention (MBI) program. The MBI was adapted from other mindfulness-intervention programs including Mindfulness-Based Stress Reduction

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(MBSR) (Kabat-Zinn et al., 1992), Mindfulness-Acceptance-Commitment (MAC) (Gardner & Moore, 2007), and Mindfulness-Based Cognitive Therapy (MBCT) (Teasdale et al., 2000). A table representing the process of the program and weekly topic lists is provided in the supplementary material. The major elements of the MBI were to provide information relevant to mindfulness practice, the discussion of home-meditation, and mindful-Wushu experience in workshop sessions. In addition, mindfulness concepts were discussed to identify how they could be best absorbed into the individuals’ weekly guided mindfulness training. The home sessions included the use of CDs provided by the MBI program. The CDs guided participants in mindfulness meditation for practicing skills such as sittin g 9

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and standing yoga and a progressive range of body scan meditations (Hamilton, Schutte, & Brown, 2016). Participants were asked to complete weekly body sensation interception forms as part of the MBI program. Participants were asked to practice the assigned 30 minutes per day home -meditation. Participants received a scheduled timetable with a workbook (including a calendar) of their exercises to tick off as they were completed. This timetable was employed as a tool to help participants keep

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track of the exercises they had done. To increase compliance, participants in the experimental group received a daily text message to remind them to do their mindfulness training. Prior each group

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session, the athletes’ workbooks were checked and the relevance of continued practices was

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emphasized again. All procedures resulted in a very low attrition rate with all athletes verifying the practice of the assigned 30 minutes per day home-meditation and n=1 athlete missing two MBI group

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sessions. All group-based mindfulness sessions were recorded and reviewed by a certified expert to

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ensure that the sessions were based on the protocol constituents.‫‏‬

2.3. Psychometric assessments

Competitive State Anxiety Inventory-2 Revised (CSAI-2R)

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2.3.1.

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The Competitive State Anxiety Inventory-2 Revised (Cox, Martens, & Russell, 2003) was used to determine competitive anxiety. The revised 17-item version from the original CSAI-2 was employed

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(Martens, Burton, Vealey, Bump, & Smith, 1990) which assess the subscales somatic anxiety (seven items; e.g., ‘‘I feel my stomach sinking’’), cognitive anxiety (five items; e.g., ‘‘I am concerned about

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performing poorly’’), and self-confidence (five items; e.g., ‘‘I’m confident at coming through under pressure’’). Answers were given on a four-point scale with the anchors (1) ‘‘Not at all’’ to (4) ‘‘Very much so’’. Higher scores on the subscales somatic and cognitive anxiety reflect higher levels of anxiety, a higher score on the self –confidence subscale indicate higher levels of self-confidence. The CSAI-2R was‫‏‬completed 15 min before each competition.

2.3.2.

Mindfulness Attention Awareness Scale (MAAS)

The Mindfulness Attention Awareness Scale (MAAS; Brown & Ryan, 2003) assesses genera l tendencies to be attentive and aware of the present-moment. The MAAS is composed of 15 questions 10

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(e.g. “I find myself listening to someone with one ear, doing something else at the same time”). Participants respond to a 6-point Likert-type scale ranging from 1 “almost always” to 6 “almost never”. High scores illustrate a higher capability to be attentive and aware of the present moment. (Brown & Ryan, 2003) reported that a high internal consistency (α = 0.82) for the MAAS along with promising convergent and discriminant validity findings. The MAAS was completed along with the

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CSAI-2R.

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2.4. Physiological assessments

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To assess sCort and sAA levels, participants provided whole saliva obtained via the passive droo l technique in a sitting position. Participants were asked to accumulate saliva for 2 minutes and to

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transfer all accumulated saliva into polypropylene vials with their head tilted forward. Saliva samples were frozen the next day at -20 ºC until analysis. Participants were instructed not to eat at least 1 hour

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before completing the sampling in order to avoid contamination of saliva with residues of food or drinks. In addition, participants should not brush their teeth at least 30 minutes before sampling in

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order to avoid blood contamination caused by microinjuries. Immediately prior sampling, participants

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should rinse their mouth thoroughly with tap water. Saliva samples were collected in all three study phases, namely baseline, post intervention, and at a 2-month follow-up‫( ‏‬BASELINE, POST, and

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FOLLOW-UP). Daily measurement time points were based on the following schedule (Filaire et al., 2009):‫ ‏‬after awakening while still in bed (08.00h), 1 h before the beginning of the match (15.00h ±

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30min), 10 min before the beginning of the match (15.50h ± 30min), 10 min after the end of the match (17.20h ± 30min), 1 h after the end of the match (18.20h ± 30min), and in the evening at 20.00h. Before biochemical procedures, all samples were thawed and centrifuged at 3000 rpm for 10 min. Salivary cortisol levels were determined by using commercially -available enzyme-linked immune‫‏‬ sorbent assay kits (Zellbio™, Germany). The detection limit of the assay was 0.1 nmol/L‫ ‏‬with intraand inter-assay‫ ‏‬coefficients of variations <8%. Levels of sAA (U/ml) were determined using a commercially available kinetic enzyme assay kit (Salimetrics, State College, PA) in compliance with the manufacturer’s protocol.‫ ‏‬Intra- and inter-assay precision for sAA was <10%. All assays were conducted in a laboratory at the Institute of Endocrinology and Metabolism, Shahid Behesht i 11

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University of Medical Sciences and Health Services, Tehran, Iran.

2.5. Procedure This study was conducted between May and September 2017 during the National Team Selection Tournament. This enabled us to study competitive conditions of similar significance as competition

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finals. In more detail, all participating athletes were competing against themselves for a spot on the team. Athletes ranking first in their weight category were allowed to take part in internationa l

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competitions. Athletes ranking second and third stayed in the national Wushu team and continued

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training until the next opportunity to qualify. The tournament was run in accordance with the rules of the International Wushu Federation (IWUF). The main tournament consisted of three officia l

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competitions throughout a period of 16 weeks. The first competition was considered the preintervention assessment (BASELINE). The second competition reflected the post-intervention phase

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(POST, i.e. about 8 weeks after the BASELINE), and the third competition was considered as a follow-up test (FOLLOW-UP, i.e. an additional 8 weeks after POST).

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Participants were randomly assigned to one of the two groups using Random Allocation

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Software: the experimental group (MBI, n = 13) and the wait-list control group (n = 13). No participant had any prior experience in any style of meditation. In order to familiar ize participants with

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MBI (all study procedures), they attended a familiarization session before participation in the 8-week intervention as well as a follow-up session. During the intervention phase, the wait-list control group

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engaged in routine training and intra-club competition while the experimental group performed MBI along with their normal training routine (i.e., bodybuilding and Wushu training for at least 5 and up to 8 sessions). During the competitions it was also possible that experimental and control athletes compete against each other. To minimize crossover effects, the experimental group was prohibited from discussing the mindfulness intervention with the wait-list control group until all study procedures were completed. Figure 1 shows the design and participants’ flow in this study. All participants underwent all study procedures.

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2.6. Statistical analyses Data were checked for missing, outliers and normal distribution. While there was nothin g missing for the self-report and sCort data, sAA was not detectable during post and follow -up testing in one participant from the wait-list control group. Analyses with respect to sAA were thus based on

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n=13 participants in the intervention group and n=12 in the wait-list control group. Box-plot inspection for this data did not provide evidence for any outliers. The Kolmogorov-Smirnov normality

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test showed most variables to be normally distributed. However, several data points of sCort were not

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normally distributed. In that case, LN-transformation was employed which restored normality in most instances (except POST and FOLLOW-UP evening samples, +10 min at POST). Hypothesis testin g

show absolute values for illustrating purposes.

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concerning sCort was therefore based on LN-transformed data; however, means in text and graphs

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Keeping the pilot character of this study in mind, statistical strategies were framed around the research hypotheses. A 2x3 repeated measures ANOVA with the between-subject factor group

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(intervention, control) and the within-subject factor time (BASELINE, POST, FOLLOW-UP) was

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performed to examine intervention-related changes of competitive anxiety (CSAI-2R, individually for each subscale) and mindfulness (MAAS). Alterations of salivary markers were compared separately

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for daily profile levels (MORNING, EVENING) and competition-related changes (-1h, -10min, +10min, +1h); (1) a 2 (group: intervention, control) x 3 (phase: BASELINE, POST, FOLLOW-UP) x

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2 (MORNING, EVENING) repeated measures ANOVA was employed to examine morning-toevening slopes (thus excluding time points related to competition), and (2) a 2 (group: intervention, control) x 3 (phase: BASELINE, POST, FOLLOW-UP) x 4 (-1h, -10min, +10min, +1h) repeated measures ANOVA examined competitive stress reactivity between study phases. Greenhouse-Geisser correction was employed if Mauchly's Test of Sphericity was statistically significant. In case of a significant group by phase interaction effect, post hoc group comparisons were conducted usin g independent Student’s t test. Stress response analyses were complemented by examining area under the curve (AUC) calculation (with respect to increase) for competition samples to capture cumulative marker secretion from one hour before up to one hour after the competition. 13

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In terms of the exploratory hypothesis of whether self-report measures predict change in stress responses to the competition, stepwise regression analysis was conducted. Here, change in salivary stress markers (AUC) from BASELINE to POST was regressed on intervention-related changes in competitive anxiety and mindfulness. Difference scores, Δ, between the BASELINE and the POST phase were created to indicate intervention-related changes in AUC and self-report measures. Due to

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pronounced correlations between CSAI-2R subscales and MAAS (rPearson between 0.312 and 0.581), the backward elimination method was used (Nakagawa & Cuthill, 2007). Starting with all of the

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predictors in the model, the least significant variable was removed and the model re-fitted until only

group allocation was not considered in the models.

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significant variables (default p < 0.10 was kept for this pilot evaluation) remain in the model. Of note,

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Partial eta-squared (ɳp ²) or Hedges’s g is reported as effect size, and p < 0.05 was considered significant. To account for multiple testing, Bonferroni correction was employed, resulting in a

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performed with IBM SPSS Statistics 23.

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modified criterion of p < 0.0125 for CSAI-2R data and p < 0.025 for stress markers. All analyses were

3.1. Self-report data

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3. Results

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Groups were comparable in age (intervention: M = 24.6, SD = 2.5 years, control: M = 26.2, SD = 2.3 years; t24 = - 1.62, p = .116, gHedges = 0.666) and body-mass-index (intervention: M = 22.9, SD =

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3.4 kg/m2, control: M = 23.6, SD = 3.0 kg/m2; t24 = - 0.57, p = .572, gHedges = 0.218). Competitive anxiety and mindfulness did not differ at BASELINE (psomatic anxiety = .841, gHedges = -0.079; pcognitive anxiety = .312, gHedges = -0.405; pself-conficence = .841, gHedges = -0.582; pmindfulness = .488, gHedges = 0.276). While the wait-list control group demonstrated stable levels of these self-report measures, the intervention group showed a decrease in somatic anxiety (Fphase*group [1.8,43.6] = 15.38, p < .001, ɳp ² = 0.391), cognitive anxiety (Fphase*group [1.9,44.4] = 29.05, p < .001, ɳp ² = 0.548), and an increase in selfconfidence (Fphase*group [1.9,44.9] = 15.89, p < .001, ɳp ² = 0.398) as well as mindfulness (Fphase*group [1.8,43.1] = 26.44, p < .001, ɳp ² = 0.524). As shown in Figure 2, this change remained stable up to the 2-month follow-up (all post hoc p Student’s t test < .01 with all gHedges > |1.28|). 14

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Insert Figure 2 about here

3.2. Salivary markers 3.2.1.

Morning-to-evening slopes

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Analyses of morning-to-evening slopes demonstrated the expected decrease in sCort and increase in sAA throughout the day (sCort: Ftime[1.0, 24.0] = 1415.07, p < .001, ɳp ² = 0.983; sAA:

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Ftime[1.0, 23.0] = 664.64, p < .001, ɳp ² = 0.967). sCort overall levels were lower at POST and

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FOLLOW-UP in the intervention group (Fperiod*group [1.4, 33.6] = 11.94, p = .001, ɳp ² = 0.332) but timerelated changes were unaffected by the intervention (Ftime*period*group [1.7,40.8] = 1.51, p = .234, ɳp ² =

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0.059). Daily sAA levels and slopes where unaffected by the intervention (Fperiod*group [1.7, 38.1] = 2.65, p = .093, ɳp ² = 0.103; Ftime*period*group [1.7,39.5] = 0.26, p = .742, ɳp ² = 0.011). Figure 3 depicts the

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evening – morning differences (Δ) for each study phase between groups.

3.2.2.

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Insert Figure 3 about here

Competition slopes and AUC

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The competition resulted in pronounced increases of sCort in all study phases (Ftime[1.4, 34.2] = 50.18, p < .001, ɳp ² = 0.676; Ftime*phase[4.1, 97.4] = 3.20, p = .016, ɳp ² = 0.118). Overall levels and

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response slopes differed between the groups (Fphase*group [1.4,34.2] = 27.60, p < .001, ɳp ² = 0.535; Ftime*phase*group [4.1, 97.4] = 3.31, p = .013, ɳp ² = 0.121). In more detail, Figure 4A indicates less pronounced responses in the intervention group at POST and FOLLOW-UP. The subsequent analysis of AUCs confirmed this group difference between study phases (Fphase*group [1.9,46.1] = 5.27, p = .009, ɳp ² = 0.180; Figure 4B). Post hoc analyses demonstrated that the intervention group had a lower competition-related output of sCort at all‫ ‏‬time points; however, the most pronounced occurred at POST and FOLLOW-UP (pBASELINE = .024, gHedges = 0.944; pPOST = .002, gHedges = 1.365; pFOLLOW-UP < .001, gHedges = 2.409). Each competition additionally led to a significant increase in sAA (Ftime[1.6, 37.5] = 21.44, p 15

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< .001, ɳp ² = 0.482; Ftime*phase[3.7, 85.0] = 5.43, p = .001, ɳp ² = 0.191). Similar to sCort findings, sAA levels and reactivity slopes were less pronounced in the intervention group at POST and FOLLOW-UP (Fphase*group [1.6,37.5] = 16.67, p < .001, ɳp ² = 0.420; Ftime*phase*group [3.7,85.0] = 3.12, p = .022, ɳp ² = 0.119; Figure 4C). This was confirmed by the subsequent comparison of AUC scores (Fphase*group [1.7,39.5] = 5.88, p = .008, ɳp ² = 0.204; Figure 4D) and related post hoc analyses indicatin g

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a similar competition-related sAA output during BASELINE (p = .441, gHedges = 0.307) but lower output at POST (p = .001, gHedges = 1.440) and at FOLLOW-UP testing (p = .039, gHedges = 0.871) in the

Regression analyses

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3.2.3.

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intervention group.

The regression analysis with backward elimination demonstrated that Δ cognitive anxiety was the only

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remaining relevant predictor (βstandardized = 0.376, t = 1.99, p = .059) explaining 10.5% (R² corrected) of the variance in Δ sCort AUC. Though, the final model was not significant, F[1,24] = 3.95, p = .059. In

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terms of Δ sAA AUC, the significant predictor Δ self-confidence (βstandardized = -0.674, t = -4.38, p

Insert Figure 4 about here

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4. Discussion

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< .001) could explain 43.1% (R² corrected) of the variance, F[1,23] = 19.15, p < .001.

4.1. Summary of main findings The purpose of the present study was to determine the changes connected to a mindfulness-based intervention of psychophysiological responses to competition in elite athletes, here male Wushu athletes. The main findings of this report were that mindfulness scores increased from baseline to post intervention and the 2-months follow up in the intervention group while scores remained stable in the wait-list control group not participating in any mindfulness training. Morning to evening slopes of the physiological markers sCort and sAA were not affected by the 8-week MBI, except daily sCort levels which were significantly lower at post and at follow up in the intervention group. Competitions were 16

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related to increases in sCort and sAA. This stress response was reduced after the MBI. The wait-list control group, however, demonstrated stable stress responses. Exploring possible predictors of this change in stress marker output, cognitive anxiety and self-confidence predicted sCort and sAA reactivity, respectively. 4.2. Integration of findings

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The intervention effectively increased the elite Wushu athletes’ mindfulness state prior to competition. This is in line with various previous studies showing that MBI is related to enhanced mindfulness in

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elite and non-elite athletes (Aherne, Moran, & Lonsdale, 2011; Gross et al., 2018; Noetel et al., 2017;

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Thompson et al., 2011). The increase in mindfulness described in the present report highlights the feasibility of this such an intervention in Wushu athletes during a period of repeated competitions. In

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particular, MBI allows the athlete to train mindfulness techniques while they are experiencin g sensations (e.g. nervousness) and thoughts (e.g. subjective distress). It is assumed that this enables the

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athlete to observe naturally occurring competitions non-judgmentally and non-reactively thereby increasing performance (Hamilton et al., 2016). Indeed, the present findings indicated that engaging in

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MBI during an actual competition period is related to an increase in competitive mindfulness in elite

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Wushu athletes. Whether this increase in mindfulness, however, may have changed perception of the

remains to be proven.

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competition and, thus, results in better performance was not investigated in the present study and

In terms of psychological responses to competition, the Wushu athletes participating in a

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mindfulness intervention demonstrated greater increases in self-confidence compared to the nonintervention controls. In accordance with previous results, these findings suggest that MBI positively influences self-confidence. In line with our results, Kaufman, Glass, & Arnkoff (2009) showed that the sport self-confidence of golfers and archers increased following a mindfulness intervention similar to ours. This positive effect has been also documented in non-sport populations (Singh & Kaur, 2008). Mindfulness permits athletes to be able to regulate thoughts and emotions (related to challenges and abilities) to enter awareness and act with awareness in competitive situations. This state may prevent self-critical thoughts and reflect true reality (Pepping, O’Donovan, & Davis, 2013). It is also possible that MBI supports athletes to have an open and non-judgmental approach to thoughts and feelings, 17

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which prevents athletes from being involved in unpleasant judgmental thoughts about the self (rivals, fans, coaches, etc.) (Gardner & Moore, 2017). As‫ ‏‬self-confidence is directly related to athletic performance and since sources and types of self-confidence are different in each individual and sport (Hays, Maynard, Thomas, & Bawden, 2007), more research is warranted to determine the efficacy of MBI on an athlete's self-confidence and performance.

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The 8-week mindfulness intervention was related to a significant reduction of the Wushu athlete’s competitive anxiety (cognitive and somatic) during post and follow up testing. This finding is

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consistent with previous research showing decreased sport-related anxiety after MBI. For instance,

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MBI was associated with a decrease in somatic anxiety in archers (Kaufman et al., 2009). Likewise, De Petrillo, Kaufman, Glass, & Arnkoff (2009) showed that sport anxiety was decreased followin g

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four weeks of MBI in runners. Overall, cognitive and somatic anxiety reduction were associated with enhanced mindfulness scores in different athlete populations (Röthlin, Birrer, Horvath, & Holtforth,

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2016; Hamilton et al., 2016).

Previous studies have highlighted that MBI is related to improved stress management

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techniques (MacDonald, Oprescu, & Kean, 2018) and decreased worries and physiological arousa l

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(Delgado et al., 2010). In this context, it is suggested that MBI helps athletes to face challenges and stressors by providing a self-regulatory process in competition (Josefsson et al., 2017). By gaining the

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ability to reappraise competitive challenges, athletes should be enabled to simultaneously evaluate psychological re-activity and regulate their physiological arousal response. It is asserted that the MBI

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may help Wushu athletes to reduce their perception of anxiety before competition, to sustain nonjudgmental awareness during a competitive situation, and to experience a greater level of positive state of mind and act (Desrosiers, Vine, Klemanski, & Nolen‐Hoeksema, 2013; Hewett, Ransdell, Gao, Petlichkoff, & Lucas, 2011). Based on this assumption, the present report also considered physiologica l stress markers. Results indicated that there was no significant difference between the groups in sCort and sAA morning-to-evening slopes in all study phases. By contrast, overall sCort levels‫ ‏‬appeared reduced in the intervention group. This is the first study to report on salivary stress markers in Wushu athletes participating in MBI during a competition period. Previous studies on the effects of MBI on sCort and sAA are rather controversial with some studies showing decreased levels (Carlson, Speca, 18

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Faris, & Patel, 2007; Duchemin, Steinberg, Marks, Vanover, & Klatt, 2015; Rosenkranz et al., 2013) while others report unchanged levels in the MBI groups (Flook, Goldberg, Pinger, Bonus, & Davidson, 2013; Lynch, Gander, Kohls, Kudielka, & Walach, 2011). Two recent meta-analyses reported small to moderate effect size for the sCort diurnal slopes (Heckenberg, Eddy, Kent, & Wright, 2018; Sanada et al., 2016). It should be noted that morning-to-evening slopes were collected on the

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days of competition in the present study. Thus, anticipation of the upcoming competition may have affected morning levels (Powell & Schlotz, 2012; Thorn, Hucklebridge, Evans, & Clow, 2009). A

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reduction of these levels after participating in MBI can be interpreted in the context of better stress

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management (MacDonald et al., 2018). While the present study is the first to indicate reduced sCort (but unchanged sAA) following MBI in elite Wushu athletes during a competition period, future

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studies need to additionally determine diurnal slopes of salivary stress markers on days without competitions and employ a more frequent sampling scheme. This would allow for a more thorough

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investigation of awakening responses or bedtime levels. The collection of samples on non-competition days would enable the exclusion of anticipatory stress. Additionally, examining associations with

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measures of sleep quality and quantity will help to evaluate sleep parameters as predictors of athletes’

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well-being and performance.

Previous literature documented a negative association between sCort and sAA responses to the

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stress of competition and sports performance (Lautenbach et al., 2014; Lim, 2018; Lim, 2016). The results of the competitive stress reactivity slope showed that sCort levels were lower at post

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intervention and follow-up testing in the experimental group when compared to baseline. Similarly, this reduction in stress reactivity was true for sAA. The wait-list control group showed comparable stress response profiles throughout testing. This lack of habituation and strong biological stress responses to repeated competitions in the controls fits in well with research in other competitive sports such as ballroom dancing (Rohleder et al., 2007). Here, competitive ballroom dancing competitions consistently increased sCort without habituation. The result that MBI may have been associated with reduced neuroendocrine stress reactivity is in line with previous studies in other athlete populations (John et al., 2011; MacDonald & Minahan, 2018). It is assumed that mindfulness reduces stress-related HPA-axis activation which then results in 19

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prohibition of or normalized cortisol production and release from the adrenal cortex (Creswell & Lindsay, 2014). Studies have also shown that‫ ‏‬mindfulness may be able to diminish periphera l physiological stress response cascades in the ANS (Creswell, 2014). Notably, there might be two ways of ANS activity modulation by mindfulness. The first way is through decreasing sympathetic nervous system activation and the second way assumes counter-regulatory systems known to change ANS

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activity. In other words, enhanced activity in the parasympathetic nervous system, which can inhibit sympathetic nervous system fight-or-flight stress responses via the vagus nerve, has been proposed to

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underlie MBI’s beneficial effects on autonomic activity (Creswell, 2017; Tang, Hölzel, & Posner,

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2015). The present study is the first to evaluate the effect of MBI on competitive sAA reactivity. Previous studies reported that MBI is related to decreased basal and daily level sAA in non-sports

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populations (Duchemin et al., 2015; Lipschitz et al., 2013; Miodrag, Lense, & Dykens, 2013). In addition, Studies provided some evidence that an inverse association exists between non-reactivity,

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that is perceiving emotions and feelings without reacting to them, and insula activation and a down regulation of the left amygdala activation during stressful situation (Paul, Stanton, Greeson, Smoski,

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& Wang, 2012). With regard to the insula’s role in regulating emotions and autonomic functions, non-

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reactivity may decrease the following emotional responses.‫ ‏‬Likewise, the sympathetic response to stress is prohibited by the insula activation (Brefczynski-Lewis, Lutz, Schaefer, Levinson, &

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Davidson, 2007; Tang et al., 2015). MBI is related to increased emotional regulation and consistency by strengthening prefrontal cognitive control mechanisms that down-regulate the amygdala activation

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(Tang et al., 2015; Zeidan, Martucci, Kraft, McHaffie, & Coghill, 2013). It may be reasonable to assume that MBI decreases the negative affect (as shown for somatic and cognitive anxiety in the present study) and sympathetic reactivity to competition and related demands in Wushu athletes. 4.3. Strengths and Limitation The present study has a number of strengths. First, the experiment was conducted in elite Wushu athletes in competitive situations. This expands studies in non-athlete populations and shows the feasibility of MBI in elite combat sports athletes. The multidimensional stress assessment, i.e. measuring psychological and physiological stress markers, is another strength. In addition, stressinduced levels of physiological stress were examined in addition to basal levels. Here, competitions 20

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were investigated thereby enhancing the ecological validity of this study. The physiological markers covered the two main stress axes, the ANS and the HPA, and saliva collections allows to non invasively measure for both stress axes without the requirement for more expensive and complicated or bothersome (e.g. venous blood collection) methods. The results of the present study should be interpreted with some caution according to severa l

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limitations. Due to the nature of elite sports, the sample size in the present study was only n=26. This limits statistical power and increases the risk of type II error, i.e. not detecting an effect although there

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is one. In addition, this study focused on elite male Wushu athletes. Future research with larger

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samples and extending onto other athlete groups can build upon the present findings. Thus, studies including women, athletes from other sports, and athletes on different competitive levels will have to

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demonstrate to what extent the present findings can be generalized. What we were not able to contro l was whether athletes in the intervention group compete against athletes in the control group. It cannot

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be ruled out that controls perceived this as particularly stressful and may thus show enhanced stress reactivity. Including qualitative methods (e.g. interview) to obtain more detailed information about

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experiences, attitudes, program challenges, facilitators and reflections of the individual athlete, may

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complement outcome and mediator or moderator assessments in future studies. Moreover, only CSAI2R and MAAS were employed to assess state competitive anxiety and mindfulness. Due to time

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constraints before the competition, it was not possible to use extend psychological assessments. Future studies may broaden their assessment tools to obtain further information (e.g. perceived stress, sport

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injury anxiety, etc.) about psychological stress profiles of elite athletes. What could not be addressed was the impact of MBI on actual competitive performance (administrative restrictions). Future studies should consider final results to evaluate the effectiveness of MBI on standardized performance (Lautenbach et al., 2014). With respect to other important outcome measures, the two major stress axes, i.e. the ANS and the HPA, were concomitantly measured but there are other stress-responsive systems that are worth investigation. For instance, inflammatory markers might be of particular interest as these have been shown to be elevated with increased training load and with the ongoin g competitive season (Lee et al., 2017) but may be reduced by MBI (Creswell et al., 2016; Hoge et al., 2018). In terms of confounding factors, athletes are not only influenced by competitive stress (which 21

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may be chronic) but also by having sequential travel, suffer from sleep disturbances or burnout, injuries, or high intensity training that emaciates the body during a league period or a tournament with a large number of competitions. In that respect, the competitive period was pretty narrow and the stability and generalizability of effects remains to be demonstrated. As MBI was applied as group sessions only, conclusions could not be made about additional advantages of MBI in individua l

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sessions. Moreover, conducting studies comparing MBI’s effectiveness with the efficacy of interventions through smartphone applications (e.g. Smiling Mind app), other cognitive-behaviora l

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interventions (e.g. Acceptance-Commitment therapy and Rational Emotive Behavior Therapy) or brain

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stimulation techniques (e. g. Transcranial Direct Current Stimulation) is highly warranted.

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4.4. Conclusion

Present findings represent preliminary support for the beneficial use of mindfulness based intervention

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for elite Wushu athletes during competitive periods. An 8-week mindfulness based intervention was associated with decreased competitive anxiety, stress-related physiological markers, and enhanced

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self-confidence and competitive mindfulness in elite Wushu athletes. The results of this study suggest

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MBI to be an effective tool in reducing the stress of competition. Future studies could extend the present findings by including women, by including other athlete groups, and by examining athlete’s

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performance as a further outcome.

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Role of the funding source This study was supported by Iran’s National Elite Foundation (INEF). INEF had no role in the execution of the study, collection, management, analysis and interpretation of the data and preparation, review or approval of the manuscript.

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Acknowledgments Our special thanks goes to Dr. David L. Lipschitz for his guidance during this study,‫‏‬and the coaches

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and athletes who participated in this study.

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The authors report no conflicts of interest.

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Conflicts of interest

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Figure captions Figure 1. Study phases and participant flow throughout testing. MBI = mindfulness -based intervention group, control = wait-list control group, CSAI-R2 = Competitive State Anxiety Inventory-2 Revised, MAAS = Mindfulness Attention Awareness Scale, Saliva = passive drool sample at six time points : awakening, -1h, -10min, +10min, +1h in relation to start of competition, evening (for more details see

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text), sAA = salivary alpha-amylase.

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Figure 2. Competitive anxiety (A: somatic anxiety, B: cognitive anxiety, C: self -confidence) and

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mindfulness (D) before, after and following (2 months later) an eight -week mindfulness trainin g program (or non-intervention control, both n=13) as measured by the Competitive State Anxiety

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Inventory-2 Revised and the Mindfulness Attention Awareness Scale, respectively. Means and

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standard errors are shown. * p Student’s t test for two samples < 0.01.

Figure 3. Morning-to-evening changes (Δ, means and standard error) of salivary cortisol (A) and

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alpha-amylase (B) before, after and following (2-months later) an eight-week mindfulness trainin g

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program (or non-intervention control, both groups n=13 for cortisol, n=12 for alpha-amylase in contro l condition). We also collected morning and evening samples on a non-competition day (“reference”).

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Figure 4. Competition-related changes of salivary cortisol (A, B depicts area under the curve with respect to increase [AUC]) and alpha-amylase (C, D depicts AUC) before, after and following (2months later) an eight-week mindfulness training program (or non-intervention control, both groups n=13 for cortisol, n=12 for amylase in control condition). Error bars in A and C are omitted for clarity. *p Student’s t test for two samples < 0.01, # p Student’s t test for two samples < 0.05.

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competition salivary alpha-amylase (U/ml)

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Highlights 

Changes related to an 8-week mindfulness-based intervention (MBI) program in elite athletes are presented.

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MBI was related to enhanced self-confidence and mindfulness.

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MBI was related to a reduction in competitive anxiety in elite athletes.

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Competition-related output of physiological stress markers was reduced after MBI.

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MBI-related change in self-confidence predicted stress marker reduction.

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Figure 1

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