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Cognitive Behavior Therapy combined with Physical Exercise for
Adults with Chronic Diseases
Systematic Review and Meta-Analysis
Bernard P, Romain AJ, Caudroit J, Chevance G, Carayol M, Gourlan M, Needham Dancause K,
Moullec G
Assistant Professor
Department of Physical Activity Sciences, Université du Québec à Montréal
Research Center, University Institute of Mental Health at Montreal
The comorbid psychological symptoms are highly prevalent among adults with
physical chronic disease.
Depressive/anxiety disorders & high level of fatigue or pain are associated with
poor adherence rate
reduced quality of life
unhealthy health behaviors (Atlantis et al., 2013)
Two empirically validated no pharmacological treatments to alleviate psychological
symptoms in adults with chronic disease,
Physical exercise interventions Cognitive behavior therapy (CBT)
(Pedersen & Saltin 2016) (Cuijpers et al. 2016)
Physical exercise
1- Ca
Cognitive behavior therapy
1- Ca
Researchers have hypothesized an additive effect of CBT combined with
physical exercise (CBTEx) when compared to each intervention alone.
Previous RCTs with mixed results (COPD, diabetes, cancer....)
RCTs with multi-arms
VERSUS
Wait list ...
Aims
(1) to summarize the literature on the effects of CBTEx for depression, anxiety,
fatigue, and pain in adults with chronic disease
(2) to identify the potential moderators of efficacy
(3) to assess the additive effects of CBT combined with exercise on outcomes of
interest.
CBTEx versus CBT
CBTEx versus Ex
CBT versus Ex
Method
Participants
Adult with diagnosed chronic disease (e.g., COPD, diabetes, chronic fatigue, cancer…)
[World Health Organization (Alwan & Agis, 2011)]
Interventions
CBT according Cuijpers (2013) “therapy in which the therapist focuses on the impact that a patient’s
present dysfunctional thoughts affect current behaviour and functioning. CBT helps clients to evaluate, challenge,
and modify their dysfunctional beliefs ...“ 
Physical exercise (involving planned, structured, and repetitive movements )
home-based or supervised.
Control
Wait list, usual care or active control condition
Outcomes : Depression, anxiety, fatigue, or pain as a primary/secondary endpoint at post-
intervention time
Design : RCT
Exclusion criteria : Healthy participants, adults severe mental illness, counselling,
physiotherapy, relaxation, lifestyle interventions
Method
Data extraction
(i) population-related characteristics: age, proportion of women
(ii) intervention-related characteristics: length, frequency, nb of sessions, exercise type
(iii) risk of bias
(iv) total methodological quality score
Statistical analyses
‘Standardized Mean Change score using Raw score standardization (SMCR)’
(Higgins & Green, 2011)
Publication bias
Multivariate outliers
Univariate meta-regressions
.
“Metafor” package (Viechtbauer, 2010)
Results
1- Ca
Results
DEPRESSION
Chronic fatigue (6 RCTs)
Cancer (2 RCTs)
COPD (4 RCTs)
ANXIETY
Chronic fatigue (4 RCTs)
COPD(2 RCT)
Mean age = 47 years
66% women
Results
fatigue chronique (9 études)
lombalgie chronique (4 études)
MPOC (3 études)
M Age = 47 ans
66% femmes
Results
CBT
CBT targeted
Fatigue (10% RCTs)
Pain (13%)
Depression/anxiety (10%)
Group format 53% RCTs
Most CBT interventions were provided by psychologists or CBT therapists
Exercise
Supervized in 63% RCTs
‘graded exercise’ (33% RCTs)
Physiotherapist or kinesiologists
Résultats
Risk of bias
Sequence Generation
Allocation Concealment
Blinding of Outcome Assessment
Incomplete Outcome Data
1 3 5 7 9 11 13 15 17 19 21 23 25 27
Light Unclear High
Results
Results
Results
Results
Results
Discussion
VERSUS
Wait list ...
Discussion
Possible overstimated CBTEx effect for depression (Bernard et al. 2017)
« Common factors » between CBT & exercise
Therapeutic alliance
Changing expectations….
Possible contamination effect in CBT arms
CBTEx versus «partial » CBTEx
(Bishop et al. 2015) 
Conclusion
The findings do no support an ADDITIVE effect of CBTEx
For a better mental health in adults with chronic disease
« let the patient choose »
Thank you !
@PaquitoBernard
bernard.paquito@uqam.ca
http://archipel.uqam.ca/id/eprint/10922

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Cognitive Behavior Therapy combined with Physical Exercise for Adults with Chronic Diseases Systematic Review and Meta-Analysis

  • 1. Cognitive Behavior Therapy combined with Physical Exercise for Adults with Chronic Diseases Systematic Review and Meta-Analysis Bernard P, Romain AJ, Caudroit J, Chevance G, Carayol M, Gourlan M, Needham Dancause K, Moullec G Assistant Professor Department of Physical Activity Sciences, Université du Québec à Montréal Research Center, University Institute of Mental Health at Montreal
  • 2. The comorbid psychological symptoms are highly prevalent among adults with physical chronic disease. Depressive/anxiety disorders & high level of fatigue or pain are associated with poor adherence rate reduced quality of life unhealthy health behaviors (Atlantis et al., 2013)
  • 3. Two empirically validated no pharmacological treatments to alleviate psychological symptoms in adults with chronic disease, Physical exercise interventions Cognitive behavior therapy (CBT) (Pedersen & Saltin 2016) (Cuijpers et al. 2016)
  • 6. Researchers have hypothesized an additive effect of CBT combined with physical exercise (CBTEx) when compared to each intervention alone. Previous RCTs with mixed results (COPD, diabetes, cancer....) RCTs with multi-arms VERSUS Wait list ...
  • 7. Aims (1) to summarize the literature on the effects of CBTEx for depression, anxiety, fatigue, and pain in adults with chronic disease (2) to identify the potential moderators of efficacy (3) to assess the additive effects of CBT combined with exercise on outcomes of interest. CBTEx versus CBT CBTEx versus Ex CBT versus Ex
  • 8. Method Participants Adult with diagnosed chronic disease (e.g., COPD, diabetes, chronic fatigue, cancer…) [World Health Organization (Alwan & Agis, 2011)] Interventions CBT according Cuijpers (2013) “therapy in which the therapist focuses on the impact that a patient’s present dysfunctional thoughts affect current behaviour and functioning. CBT helps clients to evaluate, challenge, and modify their dysfunctional beliefs ...“  Physical exercise (involving planned, structured, and repetitive movements ) home-based or supervised. Control Wait list, usual care or active control condition Outcomes : Depression, anxiety, fatigue, or pain as a primary/secondary endpoint at post- intervention time Design : RCT Exclusion criteria : Healthy participants, adults severe mental illness, counselling, physiotherapy, relaxation, lifestyle interventions
  • 9. Method Data extraction (i) population-related characteristics: age, proportion of women (ii) intervention-related characteristics: length, frequency, nb of sessions, exercise type (iii) risk of bias (iv) total methodological quality score Statistical analyses ‘Standardized Mean Change score using Raw score standardization (SMCR)’ (Higgins & Green, 2011) Publication bias Multivariate outliers Univariate meta-regressions . “Metafor” package (Viechtbauer, 2010)
  • 11. Results DEPRESSION Chronic fatigue (6 RCTs) Cancer (2 RCTs) COPD (4 RCTs) ANXIETY Chronic fatigue (4 RCTs) COPD(2 RCT) Mean age = 47 years 66% women
  • 12. Results fatigue chronique (9 études) lombalgie chronique (4 études) MPOC (3 études) M Age = 47 ans 66% femmes
  • 13. Results CBT CBT targeted Fatigue (10% RCTs) Pain (13%) Depression/anxiety (10%) Group format 53% RCTs Most CBT interventions were provided by psychologists or CBT therapists Exercise Supervized in 63% RCTs ‘graded exercise’ (33% RCTs) Physiotherapist or kinesiologists
  • 14. Résultats Risk of bias Sequence Generation Allocation Concealment Blinding of Outcome Assessment Incomplete Outcome Data 1 3 5 7 9 11 13 15 17 19 21 23 25 27 Light Unclear High
  • 21. Discussion Possible overstimated CBTEx effect for depression (Bernard et al. 2017) « Common factors » between CBT & exercise Therapeutic alliance Changing expectations…. Possible contamination effect in CBT arms CBTEx versus «partial » CBTEx (Bishop et al. 2015) 
  • 22. Conclusion The findings do no support an ADDITIVE effect of CBTEx For a better mental health in adults with chronic disease « let the patient choose »