School of Occupational Therapy

Touro University Nevada

OCCT 643 Systematic Reviews in Occupational Therapy

Critically Appraised Topic Project

EVIDENCE TABLE
Name: Jesse Vallera OTS and Peter Wallace OTS
Date: 10/08/2015
Focus Question: Does physical exercise decrease symptoms of depression and anxiety for adults with serious mental illness?

Rationale for inclusion/exclusion criteria applied to determine which articles should be included in the evidence table:
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.
Author/
Year

Study Objectives

Level/Design/
Subjects

Intervention and
Outcome Measures

Results

Study
Limitations

Implications for OT

Rosenbau
m,
Sherringt
on, &
Tiedeman
n (2014)

The effect of
exercise on
PTSD symptoms
of depression and
anxiety compared
to usual care (e.g.
psychotherapy &
pharmaceutical
interventions).

Level 1Randomized
Control Trial. 81
participants
randomly recruited
from a private
hospital (Usual care
group n=42, and
exercise group
n=39). All
participants had
confirmed
diagnosis of PTSD
by a psychiatrist.

Intervention
consisted of 12
weeks for exercising
including walking
and strength
training. There was
6 different exercises
with 3 sets of 10
reps and a 60 second
break between sets.
Intervention was
supervised by an
exercise
physiologist.
Outcomes measured
was by an assessorblind administrator.
Outcome measures
used:
Depression and
anxiety stress scale
(DASS), PTSD
Check-List Civilian
Version (PCL-C),
Pittsburgh Sleep
Quality
Index (PSQI).

Exercise group
experienced
significant
reduction in PTSD
symptoms when
compared to usual
care
(psychotherapy &
pharmaceutical
interventions),
with a mean
difference of -5.5.
95% CI, -10.5 to 0.3, P = 0.04, n =
58.

There was a
degree of
sampling bias
since the
sample was
selected from
one hospital in
Australia. The
study included
only individuals
with PTSD and
no other forms
of mental
illness that
include
depression
and/or anxiety.
Moreover, the
study did not
include
different
exercise
intensity levels.

The clinical and

community-based
practice: Walking and
strengthening
exercises can be
delivered in home
health or given as
homework with
encouragement.
Exercises can be done
in a group setting.
Program
development: Clients
could benefit from the
continuation of the
program. The sets,
reps, and duration of
exercise can be graded
up or down to
appropriately
challenge clients.
Further studies and/or
reference to other
programs may support
development.
Societal Needs:
Decreased symptoms
of anxiety and
depression enable
improved social
participation. Walking
can be done with a
partner or group to

further support social

participation.
Healthcare delivery
and policy: The
results of this trial
demonstrate the need
for regular exercise.
Interventions, like this
one, can be used to
reduce anxiety and
depression, which can
prevent future health
problems and reduce
healthcare costs.
Education and
training: Exercise
basics should be
taught in entry-level
OT education;
however, evidencebased exercise for
mental illness should
further be explored.cd
Refinement, revision,
and advancement of
factual knowledge or
theory: More studies
needed to determine
the appropriate
intensity of exercise
needed for greatest
reduction in PTSD

Fetzner & The effect of

Asmunds aerobic exercise
on (2015) (cycling) on
PTSD symptoms
of anxiety and
depression would
have a reduction.

Level 1Randomized
Control Trial n=33
(3 groups of n=11)
Primarily women in
the study (76%).
Confirmed
diagnosis of PTSD.

symptoms, anxiety,
and depression.
2 week bicycle
Exercise group
Clinically
The clinical and
intervention.
experienced
significant
community-based
3x/week for 20
significant
changes were
practice: Encouraging
minutes at 6080%
reduction of
self-reported.
group cycling may
max heart rate.
anxiety and
Individuals with increase client
Followed by 10
depression
physical
compliance with
minutes of cool
symptoms
health
exercise program.
down and stretching. (p<0.01) for both
conditions
Cycling can be
Outcome measures: anxiety and
known to coperformed on
Traumatic life
depression
occur with
stationary bike at
events checklist
outcome measures. PTSD were
home or gym, or a
(TLEC), PTSD
Significant
excluded.
street bicycle can be
checklist-civilian
reduction in PTSD Additional
used. OTs should
(PCL-C), AS index- symptoms, as
activity during
encourage clients to
3 (ASI-3), Center for measured by PCL- study was not
use a cycling means
epidemiological
C, ASI-3, and
controlled.
that provides the
studies-depression
CES-D.
Small sample
greatest outcome.
scale (CES-D).
size.
Program
development: Cycling
aerobic exercise can
be used to reduce
symptoms of PTSD;
however, more
research is needed to
determine the duration
and intensity needed
for the best outcome.
Societal Needs:
Results of this study
demonstrate a
significant decrease in

PTSD symptoms, such

as anxiety and
depression.
Decreasing symptoms
help increase social
participation and
engagement in desired
occupations. Cycling
can also be performed
in a group setting,
which further supports
social participation.
Healthcare delivery
and policy: Aerobic
exercise may represent
an adjunct to
traditional
psychotherapy
protocols, with
immediate and longterm mental and
physical health
benefits.
Education and
training: Exercise
basics should be
taught in entry-level
education.
Evidence-based
exercise for mental
illness should further
be explored.

Babson,
Heinz,
Ramirez,
Puckett, ,
Irons,
BonnMiller, &
Woodwar
(2015)

Study effects of
exercise (cycling)
on PTSD
symptoms of
anxiety and
depression
among veterans.

Level II
Nonrandomized,
two group design.
The participants
(n=217) was selfselected. Military
veterans with
diagnosis of PTSD
(All males with a
mean age of 52.18).

Intensity of cycling
was measured in
distance (miles).
Outcome measures:
Beck Depression
Inventory-II (BDIII), PTSD ChecklistMilitary Version
(PCL-M), and PSQI.

Independent
sample t-tests
demonstrated that
individuals
who engaged in
the cycling group
reported
significantly lower
depression
symptoms, as
measured with the
BDI-II.

Participants
were selfselected to
participate. No
randomized
assignments.
Participants
were enrolled in
treatment for
varying
amounts, with
only distance of
time without a
standardized
engagement in
exercise
intervention.

Refinement, revision,
and advancement of
factual knowledge or
theory: More studies
needed on the
intensity of exercise
needed for significant
reduction in anxiety
and depression.
The clinical and
community-based
practice: Cycling
exercise can be
delivered in home
health and group
settings using a
stationary bike or a
street bike.
Program
development: Clients
could benefit from
continuation of
program. Cycling
duration, as measured
by mileage can be
graded up or down to
appropriately
challenge clients.
Further studies and/or
reference to other
programs may support
development.

Societal Needs:
Decreased symptoms
of anxiety and
depression enable
improved social
participation. Cycling
can be done with a
group to further
support social
participation.
Healthcare delivery
and policy: Further
research should be
considered as there is
a need to understand
the most effective
intensity for
interventions. Cycling
exercise was
associated with
reduction in PTSD
symptoms and
increase in sleep
quality, which can
improve health and
reduce further
healthcare costs.
Education and
training: Basic
exercise,
contraindications, and
measuring of vital
signs is taught in

Rogers,
Mallinson
,&
Peppers
(2014)

The purpose was

to determine if a
5-session, 5-wk
community-based
occupational
therapy
intervention
would reduce
PTSD and
depressive
symptoms.

Level-2, pretest
posttest cohort
design (pilot study).
n=11
24- 30 y/o military
veterans diagnosed
with PTSD.

Five 4-hr sessions

5x/wk. Active
experience of
surfing and social
participation. Each
session had an
introductory
presentation, two
surf lessons,
reflection, and group
discussion. Outcome
measures: PTSD
checklist-military
(PCL-M), Major
depressive index
(MDI).

Results suggest
that a sportsoriented OT
intervention has
potential as an
adjunct
intervention for
veterans with
PTSD. Significant
reduction of
anxiety and
depression
symptoms
(P=0.01)

Small sample
size. Self-report
measures for
depression.
About half
receiving more
than one
treatment for
PTSD.

entry-level OT
education; however,
evidence-based
exercise for mental
illness should further
be explored.
Refinement, revision,
and advancement of
factual knowledge or
theory: More studies
needed to determine
the appropriate
duration of exercise
needed for greatest
reduction in PTSD
symptoms, anxiety,
and depression.
The clinical and
community-based
practice: Surfing
interventions must
occur in the ocean or
wave pool, and many
people do not have
access to these
resources.
Program
development: Results
suggest that a sportsoriented OT
intervention has
potential for treatment
of PTSD symptoms.

Societal Needs: The

intervention includes
social participation
with focused group
processing.
Intervention was
suggested to support
transition from
military to civilian life
for those with PTSD.
Healthcare delivery
and policy: Surfing
intervention is
suggested to reduce
anxiety and
depression, which can
prevent future deficits
and reduce healthcare
costs. However, it is a
very specialized form
of exercise and leisure
activity which can
make delivery and
policy problematic.
Education and
training: Therapists
wishing to specialize
in surfing
interventions should
be experienced enough
in this setting to
adequately care for
patients.

Merom,
Phongsav
an,
Wagner,
Chey,
Marnane,
Steel, &
Bauman
(2008)

The purpose of
this study was to
examine the
effectiveness of
walking exercises
on improvement
of anxiety
symptoms of
various anxiety
disorders. Since
depression and
stress are
generally
comorbid with
anxiety,
depression and
stress were
measured and
considered as
well.

Level 1 Randomized
Control Trial
N=142, GAD
N=49, Panic
disorder, N=62,
social phobia n=31.
Participants were
recruited from a
free-of-charge
outpatient anxiety
clinic located in
South Western
Sydney Australia.

Refinement, revision,
and advancement of
factual knowledge or
theory: More studies
are needed to if
surfing and social
participation for
exercise can reduce
anxiety and depression
disorders/symptoms.
Moderate intensity
Significant decline Participants
The clinical and
exercise, such as
in anxiety,
were recruited
community-based
brisk walking, which depression, and
from the same
practice: Results
was delivered and
stress were found
clinic and may
provide evidence to
monitored by an
for exercise
not fully
support existing
exercise trainer.
groups. Depression represent the
recommendations that
Session were 30
p = 0.001, in
intended
moderate intensity
minutes 5x/wk.
anxiety score of p population. Use exercise (brisk walk)
Groups were
= 0.002, and stress of self-report
intervention reduce
sufficiently active,
score of p = 0.022 physical activity depression symptoms.
moderately, inactive,
measures (e.g.
A brisk or moderate
>150 minutes, > 30
walking
walk would be most
mins, and less than
distance) is
appropriate in home
30 mins per week.
another
health setting or as
potential bias.
homework for client.
Assessments:
Clients can be
Depression Anxiety
encouraged to
Stress Scale (DASSparticipate in walking
21). Australia
groups as well.
Questionnaire
Program
protocol
development: Clients
questionnaire.
may benefit from the
continuation of the

intervention program.
Walking distance and
intensity can be
graded up or down to
appropriately
challenge clients.
Societal Needs:
Decreased symptoms
of anxiety can increase
social participation
and physical health.
Walking can be done
with a partner or group
to further support
social participation.
Healthcare delivery
and policy: The study
demonstrates the need
for exercise
interventions or
adjunct intervention
for to reduce
symptoms of anxiety,
depression, and stress.
Education and
training: Basic
exercise science and
vital signs for
monitoring are taught
in entry-level OT
education; however,
evidence-based
exercise for mental

illness should be
explored further.
Desired client
activities should
always be considered,
and the COPM can be
utilized in goal
planning.
Refinement, revision,
and advancement of
factual knowledge or
theory: More studies
are needed to
determine the
appropriate intensity,
duration, and
frequency of exercise
programs.

Hovland,
Nordhus,
Sjb,
Gjestad,
Birknes,
Martinsen
,&
Pallesen
(2013)

To compare
physical exercise
to CBT as
treatment for PD
anxiety, and
assess
controlled longterm and
clinically
significant
effects.

Level 1 Randomized
Control Trial
The study was
randomized and
recruited through
advertisements in
the local press.
N=36, Two groups
of 18 were
randomly selected
from a pool of 141

Aerobic exercise
delivered and
monitored by an
exercise trainer
(physiotherapy,
psychiatric nurse).
Both treatments ran
for 12 weeks, CBT
and PE.
Day 1 focused on
increasing aerobic
fitness, and sessions

Physical exercise
(PE) significantly
reduced anxiety
and depression
symptoms. The
Beck anxiety and
depression p
values were not
reported. A
significant effect
of time from
baseline to the 12month follow-up

One limitation
is the therapist
ratings were not
blinded and is
considered
small, it applies
to two scales,
which were also
responded to by
way of
participant selfreport. It is

The clinical and

community-based
practice of OT:
The study was
conducted in settings in
a psychiatric inpatient
facility. However, other
settings could be utilized
such as home health or
outpatient.
Program development:

Clients improved
physical exercise

participants that
met desired criteria.
Power analysis was
performed to
determine sample
size of 32 or greater
participants.

consisted of 60
minutes of longdistance
walking/running
outdoors in steep
terrain with
interval exercises
performed at the end
of sessions
Day 2 focused on
increasing muscular
strength through
circuit training. The
circuit
consisted of 9
different exercises
that were performed
for 60 seconds, with
a 15-second break
between each
exercise and a 2minute break
between each circuit.
Session durations
increased
from 30 to 45
minutes
On day 3, exercises
that varied in
intensity were
performed, including
sports and games
with elements of

was p < .01.

The physical
exercise-group
walked
significantly
longer than the
CBT group, p =
.039.

unclear what
impact a more
physically
demanding test
could have on
treatment
outcome.
Power analysis
indicated that a
sufficient
number
of patients in
the present
study, certain
non-significant
effects might
have been
significant
if a larger
sample size had
been used. Even
though CBT is
considered an
evidence-based
treatment for
PD, the lack of
a no treatment
control group in
the present
study limits the
ability to draw
conclusions
regarding the

(brisk walk) and CBT

for interventions that
reduce anxiety and
depression symptoms.
Societal Needs: This
study can implement
many activities in
community settings and
participate for people
who have serious mental
illness.
Healthcare delivery
and policy: Walking
and general health
practices can improve
and reduce health-risk
factors to prevent further
health decline.
Education and training
of OT students: OT
can used CBT training
and combine the CBT
for types of exercise so
that clients can improve
their health status and
self-efficacy.
Refinement, revision,
and advancement of
factual knowledge or
theory:

Further research could

be conducted to
expand knowledge of

competition. These
exercises lasted
approximately
60 minutes. All
sessions were
preceded by an
introduction, warmup exercises and
stretching,
and ended with a
short debriefing.

Wedekin
d,
Broocks,
Weiss,
Engel,
Neubert,
&
Bandelow
(2010)

To compare drug
with exercise
and/or no
medication with
relaxation.
Regular aerobic
exercise
(running) has
been shown to be

Level 1 Randomized
Control Trial, 10week, controlled,
parallel group, pilot
study. A total of 75
outpatients with
panic disorder with
or without

Assessments:
Beck Anxiety
Inventory
Beck Depression
Inventory
The Quality of Life
Inventory
Panic Attack Scale
Bodily sensitivity
Agoraphobia
Cognitions
Questionnaire
45 minute running
exercise 3 times
every week for 10
weeks. Once
weekly, patients had
a training session
with their trainer at a
local sports ground.

Physical exercise
(PE) significantly
reduced anxiety
and depression
symptoms.
Beck Anxiety
Inventory (BAI).
Patients from all 4

overall
effectiveness.

this specific
population and other
types of exercise,
duration, and levels.

A limitation is
that it is not
possible to
establish true
double-blind
conditions
with regards to
the exercise and

The clinical and

community-based
practice of OT: The
setting that conducted
this study for medication
and physical exercise are
typically used in
outpatient, home health,
inpatient, and cardio
gyms.

superior to a pill
placebo in the
treatment of
panic disorder.
Combined drug
and exercise
treatment has not
been investigated
in randomized
controlled
studies.

agoraphobia (DSMIV and ICD-10)

received either (1)
exercise plus
paroxetine 40
mg/day (n=21), (2)
relaxation plus
paroxetine (n=17),
(3) exercise plus
pill placebo (n=20),
or (4) relaxation
plus pill placebo
(n=17). The
assignment was
done by the hospital
pharmacist, with
three of six
consecutively
randomized patients
receiving either
placebo or
paroxetine in
identical capsules;
investigators
and patients were
blinded for the
pharmacological
treatment regime.

Assessments:
Beck Anxiety
Inventory
Beck Depression
Inventory
Panic Agoraphobia
scale
HAMA
MADRS

treatment groups
showed a
statistically
significant
improvement in
BAI scores over
the treatment
period
(P <0.0001).
Patients receiving
paroxetine
treatment
improved
significantly better
than those under
placebo (p <0.05).
Beck Depression
Inventory (BDI).
Patients from all 4
treatment groups
showed a
statistically
significant
improvement in
BDI scores over
the treatment
period (p<0.0001).

relaxation
condition.
Both exercise
and relaxation
have the
reputation of
being helpful in
psychiatric
disorders, and
the patients
expectations
may have
contributed to
the high effect
sizes in both
groups.
Significant
discrepancies
between
clinician and
patient selfratings.

Program development:

Recommendations that
physical exercise
intervention reduces
anxiety and
depression, and
medication and
exercise combined had
better outcomes.
Societal Needs:
If both medication and
physical exercise are
improve for the clients
quality of life and wellbeing then more
occupations can be
improve and social
participation can be
fulfilled.
Healthcare delivery
and policy: Depending
on the clients medical
insurance and proper
community resources,
the client can utilized
and conduct
cardiopulmonary
exercise and improve
occupational
performance.
Education and training
of OT students:

Although OT students
cannot administer
medication, students can
provide medication
management and
implement variety of
physical activities.
Refinement, revision,
and advancement of
factual knowledge or
theory:

Further research
would be
recommended to use
different method of
medication and other
types of exercise to
increase or decrease a
clients abilities.
Singh,
Stavrinos,
Scarbek,
Galambos
, Liber, &
FiatroneSingh
(2005)

The authors
hypothesized that
high intensity
progressive
resistance
training (PRT)
would be more
effective than
either low
intensity PRT or
standard care by
a general
practitioner (GP)
in depressed

Level 1 Randomized
Control Trial
N=60, 3 groups
with n=20, and 6
dropouts.
Participants were
recruited through
42 individual GPs
in the Central
Sydney area.
Communitydwelling patients
over 60 years of

The HIGH group

underwent a regimen
of supervised high
intensity PRT of the
large muscle groups,
3 days per week for
8 weeks. Exercise
machines included
chest press, upright
row, shoulder press,
leg press, knee
extension,
and knee flexion.

Physical exercise
(PE) significantly
reduced depression
symptoms. GDS
reduction p<0.001
and HRSD scales
p< 0.0132.
ANOVA was
used.

The elderly
depressed
patients seen in
general practice
who may have
multiple
comorbidities
that limit
effective
participation in
aerobic exercise
at these
intensities.
Thus, the

The clinical and

community-based
practice of OT: High

intensity resistance
training is superior to
low intensity
resistance training or
usual care by a GP in
older
community-dwelling
adults with clinical
depression.
Program development:

elderly persons,
and that high
intensity PRT
would provide
superior benefits
in quality of life,
sleep quality, and
self-efficacy.

age. Participants
were blind to the
investigators
hypotheses.
Participants
included in the
study were aged 60
years; power
analysis was
performed. The
study was
randomized for
eight weeks and
blinded to
psychiatrist who
performed all
outcome measures
at baseline.

The LOW group

underwent low
intensity resistance
using the exact same
regimen, except they
were trained at 20%
1RM and not
progressed,
although perceived
exertion was
assessed at each
session. Each
session lasted
approximately 60
minutes and
was followed by 5
minutes of
stretching.
Assessments:
EPQ, self-efficacy
scale, Quality of life,
HRS depression.
Participants received
a letter and a
Geriatric Depression
Scale (GDS) (13) to
complete if
interested.

combination of
better efficacy
and a similar
safety profile
compared to
low intensity
resistance
exercise, and
feasibility
in a broader
range of
patients than
moderate-high
intensity
aerobic
exercise,
suggests that
this may be the
preferred
mode of
exercise
treatment for
this patient
group.

The results provide

evidence to support
existing
recommendations that
physical exercise
intervention reduces
depression, and high
intensity is suggested
to be more effective.
Societal Needs: PRT
can increase client
occupational
performance and to
fulfill community
activities and social
participation.
Healthcare delivery
and policy: PRT can
increase the clients selfefficacy and cause
preventative future
health complications.
Education and training
of OT students: OT
students can implement
PRT exercise activity to
increase clients quality
of life through healthy
life practices.
Refinement, revision,
and advancement of
factual knowledge or

theory: Future research

is recommended to try
new avenues PRT
exercises for healthy,
safe interventions.

Martiny,
Refsgaard
,Lund,
Lunde,
Srensen,
Thougaar
d & Bech
(2012)

This study was to

investigate
whether a new
chronotherapeuti
c intervention
combining with
exercise to
induce a rapid
response and
remission in
major depressive
disorder.

Level I
Randomized
Control Trial
In all, 100 patients
were screened and
75 patients were
included,
with 37 patients
randomized to the
wake therapy group
and
38 to the exercise
group.

A study was
randomly assigned
to a 9-week
chronotherapeutic
intervention using
wake therapy, bright
light therapy, and
sleep time
stabilization (n = 37)
or a 9-week
intervention using
daily exercise (n =
38). The 17-item
Hamilton
Depression Rating
Scale was the
primary outcome
measure, and the
assessors were
blinded to patients
treatment allocation.
Outcome Measures:
HDRS,
MorningnessEveningness
Questionnaire 33
score

Baseline-adjusted
estimated mean
scores on
the HDRS-17 by
study week. A
statistically
significant
reduction in scores
in the wake
therapy group as
compared
to the exercise
group was seen in
the whole of the
continuation
phase (p = .0004).

The moderate
sample size is a
limitation.
Another
limitation is that
the inclusion
of mainly
treatmentresistant
patients, the
authors cannot
generalize
results to the
larger group of
nontreatmentresistant
patients.

The clinical and

community-based
practice of OT:

Recommendations that
physical exercise
intervention will
reduces depression
with high intensity
activity. The setting
would be home health,
outpatient, inpatient or
other areas of
cardiopulmonary
settings.
Program development:

There were superior

response and
remission rates
obtained by the wake
therapy patients and
thus the intervention
would have a
continuation of
wake/exercise
outcomes.

Exercise program of
30 minutes
minimum duration
with the
Physiotherapist.
With the obtained
results, a power
above 80% was
achieved with the
included 75 patients
on the basis of
HDRS17 scores.

Societal Needs: When

depression and anxiety
are reduced then
participants can fulfill
community activities
and social participation.
Healthcare delivery
and policy: May reduce
medical insurance costs
for physical activity.
However, artificial
sunlight device could
potentially cost more.
Education and training
of OT students:
OT students can
implement
wake/exercise activities
so clients or patients can
provide healthy lifestyle
choices.
Refinement, revision,
and advancement of
factual knowledge or
theory:

The study has

implications for rapid
antidepressant efficacy
in chronobiological
interventions and
possible effects in
exercise as well.p

Kerling,
Tegtbur,
Gtzlaff,
Kck,
Borchert,
Ates, Von
Bohlen,
Frieling,
Hper,
Hartung,
Schweige
r, & Kahl
(2015)

The study
examine patients
were receiving an
exercise program
as an adjunct for
an inpatient
treatment that
will benefit
physiological and
psychological
outcomes.

Level I
Randomized
Control Trial
42 participants, 22
one group and 20 in
other. 42 inpatients
with moderate to
severe depression
(Major Depression
Disorder) were
randomized for
weekly exercise
training and
compared to normal
treatment.

Intervention:
Consists of three
time per week of 45
minutes of moderate
intensity exercise for
six weeks. Exercise
includes 25 minutes
workout bicycle
with
6070 revolutions
per minute. 20
minutes on a cross
trainer, stepper
Outcome measures
used: MontgomeryAsberg Depression
Rating Scale
(MADRS) and the
Beck Depression
Inventory-2 (BDI-2).

Significant
reduction of
depressive
symptoms was
p=0.037 after six
weeks.

The major
limitation of the
study was the
small sample
size. Another
limitation
applies to the
psychometric
properties of the
physical activity
assessment tool
used for the
amount of
physical activity
screening
before entering
the study.

The clinical and

community-based
practice of OT: This

would be feasible to
improve quality of life
and completing
occupations. The
setting would be home
health, outpatient,
inpatient or other areas
of cardiopulmonary
settings.

Program development:

The results provide

evidence to support
existing
recommendations that
physical exercise
intervention reduces
depression
Societal Needs: When
depression and anxiety
are reduce then
participants can fulfill
community activities
and social participation.
Healthcare delivery
and policy: May reduce
medical insurance costs
for physical activity.

Education and training

of OT students:
OT students can
implement intervention
with physical exercise to
improve quality of life
for clients.
Refinement, revision,
and advancement of
factual knowledge or
theory: Further research
is required to explore
intervention methods to
gain value with
bicycling and other type
of exercise to reduce
depression and anxiety
symptoms.