Feldstain, A., Lebel, S., & Chasen, M.R. (2016). An interdisciplinary palliative rehabilitation intervention bolstering general self-efficacy to attenuate symptoms of depression in patients living with advanced cancer. Supportive Care in Cancer, 24, 109–117.

To examine the effects of a palliative rehabilitation program on depression, and explore the impacts and interactions between depression, inflammation, exercise, and self-efficacy.

All patients received group physiotherapy twice a week; all patients also received as treatment plan based on assessment of individual functioning and goals that was implemented during the course of the study, including support, encouragement, feedback, and guidance to motivate patients and encourage positive change. The program was provided during an eight-week period. Study measures were obtained at baseline and at the completion of the program.

• N = 80
• AGE = Not provided
• MALES: 47.5%, FEMALES: 52.5%
• KEY DISEASE CHARACTERISTICS: Multiple tumor types existed. Patients were in stage III or IV. Breast and hematological cancers were most common.
• OTHER KEY SAMPLE CHARACTERISTICS: ECOG status of 2 or better. 21.3% were taking antidepressants.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Ottawa, Canada

• PHASE OF CARE: Late effects and survivorship
• APPLICATIONS: Palliative care

• Quasi-experimental

• C-reactive protein (CRP) as a marker of inflammation
• Six-minute walk test (6MWT)
• General Self-Efficacy Scale
• Hospital Anxiety and Depression Scale (HADS)

Completion rate for sessions was 69%. There was no change in CRP. Performance on the 6MWT increased (p < 0.001). Self-efficacy scores increased from a mean of 27.86 to 31.23 (p <  0.01). Depression scores decreased on average from 7.14 to 5.95 (p = 0.002).  Analysis showed that exercise results and self-efficacy were significant predictors of change in depression scores. Changes in the 6MWT explained 3% of the change in depression and self-efficacy explained 11%.

The multicomponent rehabilitative intervention tested here was associated with reduced depression scores. Exercise and self-efficacy were shown to be significant predictors of depression scores.

• Small sample (less than 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results
• Measurement/methods not well described
• Measurement validity/reliability questionable
• Subject withdrawals of 10% or greater 
• Almost 50% who entered the study did not complete it; about half of these were due to disease progression.
• Authors state that use of antidepressants was not correlated with change in depression scores; however, it would not necessarily be expected that scores would decline further, and there was no subgroup analysis based on use of antidepressants.
• The measure used for exercise was a measure of stamina, not exercise intensity or regularity, so their conclusions that exercise may not be as effective for depression is not necessarily accurate.
• Mean depression score changes were not at a level that was clinically significant, and floor effects of the measure at baseline are possible.
• It is not known if participants were doing any other interventions for support.

Participation in exercise has been associated with improvement in depressive symptoms, and exercising in a group setting may enhance support and its effects on self-efficacy and mood. Findings of this study, however, showed statistically significant changes in depression, but the size of these changes on the measures used was not clinically significant. Research in this area should be aimed at individuals who have clinically relevant depressive symptoms.