School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET
Focused Question:
Does physical exercise decrease symptoms of depression and anxiety for adults with serious
mental illness?
Prepared By:
Jesse Vallera, OTS and Peter Wallace, OTS
School of Occupational Therapy
Touro University Nevada
874 American Pacific Drive
Henderson, NV 89014
Under the supervision of: Donna Costa, DHS, OTR/L, FAOTA Associate Professor of
Occupational Therapy, Touro University Nevada donnacosta@tun.touro.edu
Date Review Completed:
09/29/2015
Clinical Scenario:
Within the general population, many individuals experience serious mental illness pertaining
to depressive and anxiety disorders. Many of the disorders have comorbidities that manifest
such as post-traumatic stress disorder (PTSD), major depressive disorder (MDD), panic
disorder (PD), and general anxiety disorder (GAD) (Rosenbaum, Sherrington, & Tiedemann,
2015). Many of these disorders have clinically significant social and occupational
impairments that are characterized by symptoms of hyper-arousal, re-experiencing, negative
cognitions, negative mood, and avoidance (Rosenbaum, et al., 2015).
Depressive and anxiety disorders have been greatly documented in the literature. One in
17about 13.6 millionlive with a serious mental illness such as MDD, and other
comorbidities. Approximately 18.1 percent of American adults, about 42 million people, live
with anxiety disorders, such as panic disorder, obsessive-compulsive disorder (OCD),
posttraumatic stress disorder (PTSD), generalized anxiety disorder and phobias (Duckworth,
2013). These disorders emerge as stressors in specific circumstances and may exacerbate and
lead to social isolation, living alone, lack of physical exercise, behavior issues, drug abuse,

sleep problems, and general health problems. Depressive and anxiety disorders are connected
to health conditions that may impede normal routines and functions in daily occupations,
including work, play, leisure, and rest (American Occupational Therapy Association [AOTA],
2014). In addition, these symptoms could be a risk for cardiovascular health and could
contribute to further health decline (Rosenbaum et al., 2015)
In order to reduce, remediate, or prevent these disorders, occupational therapy practitioners
must plan effective interventions in clinical situations. One implication of these disorders is
physical exercise that was found to have significant impact in the literature. The Occupational
Therapy Framework Practice (OTPF) categorize physical exercise under health management
and maintenance (AOTA, 2014). Physical exercise can increase blood flow, progressive
relaxation, and reduce sleep problems (Hovland et al., 2013). Furthermore, these interventions
can improve, restore, or enhance physical function, aerobic conditioning, manage chronic
health conditions, improve functional performance, muscle performance strength and
endurance (Rosenbaum et al., 2015). Physical exercise interventions may prevent healthrelated risk factors, ensure safety, reduce the need for additional support services, and reduce
costs associated with medical needs. Finally, interventions that utilize physical exercise can
improve self-esteem, self-confidence, social participation, overall health, well-being, quality of
life, and ultimately increase independence in life occupations (Hovland et al., 2013; Kerling et
al., 2015; Rosenbaum et al., 2015; Singh et al., 2005; Wedekind et al., 2010).
Generally these interventions take place in outpatient therapy clinics and psychiatric
institutions; however, there are numerous exercise alternatives that can be more intrinsically
motivating to the client, such as sports, bicycling, ocean and aquatic activities, yoga, tai chi,
and resistance training.
This CAT paper is focused on assessing current literature to provide evidence on the
effectiveness of interventions that utilize physical activity to improve functional performance
and prevent progression of symptoms in adults with depressive disorders, anxiety disorders,
and PTSD.

Summary of Key Findings:

Summary of Levels I, II and III:
All ten of the studies included in this CAT found physical exercise intervention to be
significantly effective at reducing symptoms of anxiety and depression for people
with SMI pertaining to anxiety disorders, depressive disorders, or PTSD. All studies
utilized exercise as either primary intervention or adjunct intervention in conjunction
with traditional care (Hovland et al., 2013; Kerling et al., 2015; Rosenbaum et al.,
2015; Singh et al., 2005; Wedekind et al., 2010). Traditional care was defined as
psychotherapy and/or pharmacological treatment (Kerling et al., 2015; Rosenbaum et
al., 2015). All studies had positive results associated with the following related
outcome topics: reduction in anxiety, reduction in depression, and improvement in
quality of life.

Anxiety Disorders
Physical exercise interventions significantly reduced anxiety symptoms. Three
studies specifically studied anxiety related SMI, and all three studies reported
significant improvement in anxiety symptoms after exercise intervention for those
suffering from PTSD and various anxiety disorders, including GAD and PD (Hovland
et al., 2013; Merom et al., 2008); Wedekind et al., 2010). Two researchers, Hovland
et al. (2013) and Merom et al. (2008), compared exercise intervention to common
psychotherapy interventions, such as cognitive behavior therapy (CBT), and found
exercise to be a significant adjunct or individual intervention for anxiety disorders.
All three studies were RCTs and shared similar interventions consisting of brisk
walking and/or running.
Depression Disorders
Physical exercise interventions significantly reduced depressive symptoms for
individuals with MDD. Three studies specifically studied depression related SMI,
and all three studies reported significant improvement in depression and depressive
symptoms after exercise intervention for those suffering from MDD (Kerling et al.,
2015; Martiny et al., 2012; Singh et al., 2005). One researcher, Kerling et al. (2015),
utilized a stationary bicycle and a cross trainer/stepper for intervention, while the
other two studies utilized strength training exercises. All three studies were RCTs and
interventions were either bicycling or stepping aerobic exercise or strength training
exercises.
PTSD
Babson et al. (2015), Fetzner and Asmundson (2015), Rogers, Mallinson and Peppers
(2014), Rosenbaum, Sherrington and Tiedemann (2015) found that physical exercise
interventions significantly decreased PTSD symptoms. Sleep disorders, depression,
and anxiety frequently co-occur with PTSD, and physical exercise was found to
significantly reduce anxiety, depression, and improve sleep quality (Babson et al.,
2015; Fetzner et al., 2015; Rogers et al., 2014; Rosenbaum et al., 2015). Two studies,
Rosenbaum et al. (2015) and Singh et al. (2005), directly measured sleep quality and
reported significant decrease in sleep disturbances and an increase in sleep quality.
Rogers et al. (2014), authors of a small non-randomized pilot study, suggest that
surfing and other moderate or high intensity sports may reduce symptoms of PTSD
and help reintegrate military veterans and other PTSD suffers back into the
community as well as restore lost life occupations and life goals.
Improvement in quality of life:
Hovland et al. (2013) and Singh et al. (2005) reported significant improvement in
quality of life for groups receiving exercise intervention, as measured by the QoLI
assessment.
Commonalities among interventions:
Physical exercise interventions were commonly 30 or more minutes in duration, of
moderate intensity, and performed at least 3 days per week. Interventions included
one or more of the following: walking, brisk walking, running, bicycling, strength

training, and surfing. All of the studies utilized one or more of the following
interventions for clinical outcome measure: Beck depression inventory-II (BDI-II,
depression and anxiety stress scale (DASS-21), PTSD check-list civilian version
(PCL-C), PTSD check-list military version (PCL-M), traumatic life events checklist
(TLEC), PTSD checklist-civilian (PCL-C), AS index-3 (ASI-3), center for
epidemiological studies-depression scale (CES-D), Hamilton depression rating scale,
Montgomery-Asberg depression rating scale, Beck anxiety inventory (ADI). The
most common mutual outcome measures among the studies were: BDI-II, BAI,
DASS, and both versions of the PCL.

Summary of Level IV and V:

Level IV and V articles were excluded from this review.
Contributions of Qualitative Studies:
There were no qualitative studies included in this review.

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Bottom Line for Occupational Therapy Practice:

The clinical and community-based practice of OT:
Depression and anxiety disorders can cause mild to severe mental and physical impairments,
decreased social participation, and decreased engagement in desired occupations.
Occupational therapists (OTs) can provide skilled services to help those suffering from mental
illness to improve mental and physical function in many life occupations. Physical exercise is
an effective intervention or adjunct intervention for many mental health conditions, including
major depressive disorder, PTSD, and a variety of anxiety disorders. Research findings
support the use of physical exercise alone or in conjunction with traditional psychotherapy for
people suffering from depression and anxiety disorders (Hovland et al., 2013; Kerling et al.,
2015; Rosenbaum et al., 2015; Singh et al., 2005; Wedekind et al., 2010).
Program development:
The majority of studies utilized bicycling, brisk walking, strength training activities; however,
Rogers et al. (2014) introduced surfing as an intervention. The significant findings of the
studies analyzed suggest that the method of exercise (i.e. the frequency, duration, and
intensity) is more important than the type exercise (e.g. surfing, cycling, or running). While
any increase in physical activity may decrease symptoms of anxiety and depression,
interventions should focus on physical activities that are of moderate intensity, sustained for a

period of 30 minutes or more, and performed at least three times per week to be considered
evidence-based. To increase client adherence to intervention OTs should work with clients to
develop interventions that utilize physical activities that are intrinsically motivating to the
client.
Societal Needs:
People with SMI experience anxiety and depressive symptoms that cause clinically significant
social and occupational impairments. Use of exercise interventions can reduce anxiety and
depressive symptoms, which can ultimately improve social participation, social performance,
and satisfaction in life occupations (Hovland et al., 2013; Rogers et al., 2014; Singh et al.,
2005).
Healthcare delivery and policy:
These interventions usually take place in outpatient therapy clinics and psychiatric institutions.
There are numerous exercise alternatives that can be more intrinsically motivating to the client
and that can have a significant impact on the location, time, duration, or other factors to
consider in delivering OT interventions. It is important to collaborate with the client,
caregivers, doctors, PTs, nursing, and other healthcare disciplines to facilitate exercise
interventions that are optimal for the client. Physical exercise may prevent development of
future health problems and reduce associated healthcare costs. Furthermore, these
interventions can be participating in meaningful occupations, leisure, and health management
and maintenance.
Education and training of OT students:
Occupational therapy students (OTS) should receive education in basic exercise science to
educate clients about the health benefits of physical exercise intervention and proper body
mechanics. An OTS should identify appropriate assessments to determine the clients goals,
performance barriers, and how to implement a client-centered approach to exercise
interventions. In addition, OTS should provide education for the clients individual
precautions and contraindications to conduct a safe environment for their interventions.
Refinement, revision, and advancement of factual knowledge or theory:
Further research should be conducted to explore exercise that occurs in activities that are
intrinsically motivating to the client (e.g. sports, leisure occupations, etc.) Many themes
emerged within the literature in regards to limitations such as small sample size, specific
conditions, and specific diagnoses for each population. However, important clinical
implications emerged as well regarding evidence-based key findings that could potentially
provide more opportunities in occupational therapy exercise interventions. In the future,
effective interventions could utilize cost-effectiveness and generalizability in a variety of
contexts to client.

Review Process:

McMaster Critical Review Forms was selected to review each critically appraised
article
Authors reviewed the McMaster Critical Review Form for each study for inclusion
criteria and reliability
Authors constructed an evidence table that included ten articles for review and
critically appraised each studys objectives, designs, outcome measures, results,
limitations, and implications for occupational therapy practice.

Procedures for the Selection and appraisal of articles:

Inclusion Criteria:

Peer-reviewed scientific literature published in English with full-text and references

available.
Level 1 or level 2 evidence (Randomized control trials, control trials, or cohort design).
Published 2005 or later.
Serious mental illnesses pertaining to anxiety, depression, and PTSD.
Adult participants (age 18 or older).
Studies meeting all of the above criteria and representing the focus question.

Exclusion Criteria:

Articles published prior to 2005.

Pediatric population
Non-peer reviewed research literature published in non-English.
Serious mental illnesses other than anxiety, depression, and PTSD.

Search Strategies:
Categories
Patient/Client Population
Intervention

Outcomes

Key Search Terms

Adults, PTSD patients, Mental Illness, Military Veterans,
major depressive disorder, Anxiety disorder, mental health.
Physical activity, physical exercise, exercise, running,
jogging, cycling, weight lifting, weight training, strength
training, resistance training, aerobic exercise, exercise
intervention, sports intervention.
Anxiety, Depression, PTSD, PTSD symptoms, Quality of
Life

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Databases and Sites Searched

CINAHL, PubMed, ProQuest, PsycInfo, Medline, Google Scholar
Quality Control/Peer Review Process:

Focus question was developed by two occupational therapy students with refinement
by course instructor Donna Costa, DHS, OTR/L, FAOTA Associate Professor of
Occupational Therapy, Touro University Nevada.
Focused question, literature review, evidence table, articles, and critically appraised
topic (CAT) were reviewed by course instructor with appropriate feedback and
comments to ensure accuracy and thoroughness of CAT.
CAT was completed by students after revisions to evidence table that considered all
feedback and comments given by the course instructor.

Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:

Level of
Evidence
I
II
III
IV
V
Other

Study Design/Methodology of Selected Articles

Systematic reviews, meta-analysis, randomized
controlled trials.
Two groups, nonrandomized studies (e.g., cohort,
case-control)

Qualitative Studies
TOTAL:

Number of Articles
Selected
8
2
0
0
0
0
10

Limitations of the Studies Appraised:

Levels I, II, and III
Several studies included in the review had small sample sizes, limited
generalizability, and interventions that may only be limited to a very specific
population.

Fetzner and Asmundson (2015) had small sample size and potential bias due to
significant changes being self-reported and not controlling additional physical activity
during study.
Babson et al. (2015) had no random assignment and participants were self-selected to
participate
Hovland et al. (2013) lacked non treatment group, which limits the ability to draw
conclusions regarding the overall effectiveness of both interventions.
Rogers et al. (2014) had a small sample size and possible contamination due to nearly
half of the participations receiving more than one treatment for PTSD.

Rosenbaum et al. (2014) selected all participants from one hospital in Australia, so
some members of the intended PTSD population may have been less likely to be
included.

Levels IV and V
Level IV and V articles were excluded from this review.
Other
There were no qualitative studies or other studies included in this review.

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05

Articles Selected for Appraisal:

Babson, K. A., Heinz, A. J., Ramirez, G., Puckett, M., Irons, J. G., Bonn-Miller, M. O., &
Woodward, S. H. (2015). The interactive role of exercise and sleep on veteran recovery
from symptoms of PTSD. Mental Health and Physical Activity, 8, 15-20.
Fetzner, M. & Asmundson J. (2015). Aerobic exercise reduces symptoms of posttraumatic
stress disorder: A randomized controlled trial, cognitive behaviour therapy, 44:4, 301313, DOI: 10.1080/16506073.2014.916745
Hovland, A., Nordhus, I. H., Sjb, T., Gjestad, B. A., Birknes, B., Martinsen, E. W., &
Pallesen, S. (2013). Comparing physical exercise in groups to group cognitive

behaviour therapy for the treatment of panic disorder in a randomized controlled

trial. Behavioural and cognitive psychotherapy, 41(04), 408-432.
Kerling, A., Tegtbur, U., Gtzlaff, E., Kck, M., Borchert, L., Ates, Z., ... Kahl, K. G. (2015).
Effects of adjunctive exercise on physiological and psychological parameters in
depression: A randomized pilot trial. Journal of affective disorders, 177, 1-6.
Martiny, K., Refsgaard, E., Lund, V., Lunde, M., Srensen, L., Thougaard, B., ... & Bech, P.
(2012). A 9-week randomized trial comparing a chronotherapeutic intervention (wake
and light therapy) to exercise in major depressive disorder patients treated with
duloxetine. Journal of Clinical Psychiatry, 73(9), 1234.
Merom, D., Phongsavan, P., Wagner, R., Chey, T., Marnane, C., Steel, Z., Bauman, A. (2008).
Promoting walking as an adjunct intervention to group cognitive behavioral therapy for
anxiety disordersA pilot group randomized trial. Journal of Anxiety Disorders,
22(6), 959-968. doi: 10.1016/j.janxdis.2007.09.010
Rogers, C. M., Mallinson, T., & Peppers, D. (2014). High-Intensity sports for posttraumatic
stress disorder and depression: Feasibility study of ocean therapy with veterans of
Operation Enduring Freedom and Operation Iraqi Freedom. American
Journal of Occupational Therapy, 68, 395404.
http://dx.doi.org/10.5014/ajot.2014.011221
Rosenbaum, S., Sherrington, C., & Tiedemann, A. (2015). Exercise augmentation compared
with usual care for posttraumatic stress disorder: a randomized controlled trial. Acta
Psychiatrica Scandinavica, 131(5), 350-359.
Singh, N.A., Stavrinos, T.M., Scarbek, Y., Galambos, G., Liber, C., & Fiatrone-Singh, M.A.
(2005). A randomized controlled trial of high versus low intensity weight training
versus general practitioner care for clinical depression in older adults. Journal of
Gerontoloty: Medical Sciences, 60A, 768776.
Wedekind, D., Broocks, A., Weiss, N., Engel, K., Neubert, K., & Bandelow, B. (2010). A
randomized, controlled trial of aerobic exercise in combination with paroxetine in the
treatment of panic disorder. The World Journal of Biological Psychiatry, 11(7), 904913.

Other References:
Duckworth, K. (2013). Mental illness facts and numbers. Retrieved from
http://www2.nami.org/factsheets/mentalillness_factsheet.pdf

Adapted from AOTA Evidence-Based Literature Review Project/7 CAT Worksheet.5-05