Korstjens, I., Mesters, I., May, A.M., van Weert, E., van den Hout, J.H., Ros, W., . . . van den Borne, B. (2011). Effects of cancer rehabilitation on problem-solving, anxiety and depression: A RCT comparing physical and cognitive-behavioural training versus physical training. Psychology and Health, 26(Suppl. 1), 63–82.

To examine the effects of physical therapy (PT) versus physical therapy plus cognitive behavioral therapy (CBT) interventions on problem solving, anxiety, and depression in patients with cancer

Consecutive groups of patients referred to rehabilitation centers were randomly assigned to receive either PT or PT and CBT programs for 12 weeks. PT consisted of twice weekly two-hour sessions of aerobic training, muscle-strength training, and group sports and games. CBT sessions were provided in a group format in which participants learned to apply self-management skills in striving for personal goals. Psychologists gathered self-evaluations regarding the extent to which patients adhered to the intervention protocol, and the process was evaluated via case records. Study measures were obtained at baseline, 12 weeks postrehabilitation, and three and nine months postintervention. After week 6, patients started a home-based walking program.

• A total of 147 participants were analyzed, with 132 completing rehabilitation.
• Mean age of participants was 48.8 ± 10.9.
• The sample was 16.3% male and 83.7% female.
• Of the sample, 55.8% had breast cancer, all had completed treatment at least three months prior to inclusion, and the average time since treatment was 1.7 years.
• Nearly 71% were married and living with a spouse, and 86.4% had middle to high levels of education. 
• At baseline, less than one-third had anxiety or depression scores indicating clinically relevant symptoms.

• Multisite
• Setting unspecified
• Dutch rehabilitation centers

• Transition phase after initial treatment
• Late effects and survivorship

Prospective, single-blinded, randomized, two-group trial design

• Social Problem-Solving Inventory–Revised    
• Hospital Anxiety and Depression Scale (HADS)

Overall baseline anxiety and depression scores of participants were significantly higher than those in the general Dutch population (p < 0.001). Immediately after the 12-week program, both groups showed small to moderate effect-size reduction in anxiety (0.45–0.55 [p < 0.001]) and depression (0.44–0.59 [p < 0.001]). At three and nine months, average effects, as measured by HADS score, continued to be lower than baseline, with effect sizes ranging from 0.24 to 0.4. Participants in both groups showed comparable changes in problem solving, anxiety, and depression. Subgroup analysis between those with initially higher and lower levels of distress showed no difference in changes in problem solving. Patients with higher distress, in both intervention groups, showed significant reduction in anxiety (p < 0.01) and depression (p < 0.01) at all study time points. At all measurement points, patients with lower distress at baseline showed levels of distress in keeping with those of the general population.

Study findings did not show that the addition of CBT to PT resulted in effects on problem solving, anxiety, or depression that were greater than the effects of PT alone. Findings did not support the hypothesis that the addition of CBT would be of greater benefit for individuals who had higher distress levels initially. Study findings show beneficial effects of PT on anxiety and depression.

• The study had no appropriate control group.
• Subgroup analysis was done according to overall distress levels, then compared to outcomes regarding anxiety and depression. These are different concepts and patient experiences. Subgroup analysis would have been more relevant if researchers had compared actual anxiety and depression levels to each other, respectively. 
• The study provides no information about attendance rates for sessions, the amount of exercise continued after the initial 12-week session, or adherence to the home-based walking intervention.

Findings if this study support other findings regarding beneficial effects of physical activity in a supervised group setting. Findings of this study suggest that the addition of specific CBT interventions may not increase these effects. Analysis of results in those who had high versus low levels of distress demonstrates that those with low distress do not show a benefit.