Meta-analysis of the effects of multimodal physical therapy on improving depression

Abstract

BACKGROUND

Depression is a widespread psychological disorder that has substantial effects on public health and society. Conventional therapies include medication and psychotherapy, recent investigations have highlighted the possible advantages of multimodal treatments, such as physical therapy, for improving depression.

AIM

To perform a meta-analysis of how multimodal physical therapy can help treat depression.

METHODS

We searched for collection of articles that satisfied the inclusion and exclusion criteria, encompassing randomized controlled research-related sources. We incorporated these studies into the meta-analysis using terms such as “findings”, “intervention”, and “population attributes”. We used statistical examination to measure the total impact magnitude and evaluate study variability.

RESULTS

The encouraging aspect is that multi-modal physical therapy is being considered for its effectiveness in treating symptoms related to depression. Sensitivity analysis was conducted to identify key factors and determine their impact on quality.

CONCLUSION

Regarding treatment for depression, this meta-analysis extends the increasing number of studies demonstrating the effectiveness of multimodal physical therapy.

Key Words: Depression; Multi-modal physical therapy; Intervention; Physical therapy; Sensitivity analysis

Core Tip: This meta-analysis confirms the effectiveness of multimodal physical therapy in alleviating depressive symptoms. Multimodal physical therapy, which combines exercise with various complementary treatments, is believed to effectively reduce depressive symptoms by enhancing both physical health and psychological well-being. By combining various therapeutic approaches, it demonstrates significant potential benefits; however, sensitivity analyses highlight the necessity for additional high-quality research to strengthen the evidence.

INTRODUCTION

A statistical technique called meta-evaluation is used to combine findings from several research on a certain topic in order to provide more thorough information on the overall impact. In the context of physical therapy for treating depression, multimodal physical therapy refers to interventions that integrate diverse physical techniques such as workouts, massage, and other modalities with mental health counseling[1]. This method aims to address the physical and mental aspects of depression simultaneously. Several meta-analyses have explored the outcomes of multimodal physical therapy on depression[2]. To evaluate the efficacy of these therapies across a range of groups and situations, research usually combines data from sophisticated investigations and randomized controlled trials. Meta-analytic critiques are valuable because they can identify styles and traits that character studies might not encounter due to differences in sample sizes or methodologies[3].

The primary goal of multimodal physical therapy in treating depression is to harness the benefits of physical activity on emotional health. In particular, exercise has been studied for its antidepressant effects, which are attributed to mechanisms such as multiplied endorphin manufacturing, improved neuroplasticity, and reduced oxidative stress[4]. Combining exercise with different modalities such as cognitive-behavioral techniques or mindfulness practices can enhance typical treatment results.

Meta-analyses regularly identify moderators and mediators of treatment outcomes[5]. These can encompass elements such as the intensity and duration of therapy, affected therapy adherence, therapist competence, and particular traits of the determined samples. Understanding those nuances allows clinicians and researchers to refine treatment protocols and determine which affected populations might gain the maximum benefits from multimodal physical therapy[6]. It also investigates the quality of evidence across the included studies.

The findings of meta-analyses have suggested that multimodal physical therapy can effectively reduce depressive symptoms. For example, a meta-analysis published in an outstanding psychology journal synthesized data from more than one randomized controlled trial and determined that multimodal interventions notably reduced depression severity compared to manipulated situations[7]. This reduction in symptoms was observed across various age groups and study populations, indicating the wide applicability of such treatments.

Meta-analyses have provided compelling proof that multi-model physical therapy is a promising method for enhancing treatment effects for depression. By integrating diverse physical and mental interventions, these therapies capitalize on the synergistic effects of multiple treatment modalities[8]. Continued research and refinement of these approaches are vital for optimizing healing methods and improving the cognitive well-being outcomes for individuals suffering from depression[9].

MATERIALS AND METHODS

Protocol and registration

The search strategy and methodology were designed to yield a wide variety of research for in-depth analysis. No formal review protocol was referenced, as the search was designed to ensure comprehensive coverage of the available literature.

Eligibility criteria

Only a few studies investigating the effects of physical exercise treatments on the severity of depressive symptoms in adolescents were found in a prior review[10]. Therefore, the eligibility requirements for this review were quite wide to collect a sufficient number of research papers for meta-and subset analyses.

Population size: Studies that enrolled individuals diagnosed with depression at the beginning and had an average participation age were appropriate for this evaluation. During structured medical interviews, the initial depressive symptoms of participants had to be identified using a positive minimum standard based on precise self-assessment scales or established scientific requirements. Studies involving patients with comorbid conditions, such as obesity, diabetes, and cancer, were excluded from this analysis.

Interventions: Studies were included that examined the effects of a physical activity regimen affected depressive symptoms. Any physical activity intervention that met this definition satisfied the treatment inclusion requirements of the overview[11].

Comparisons: Studies comparing the effects of exercise on control groups were eligible for this analysis. This review investigated alternative or supplementary physical exercise treatments for depression. Therefore, studies involving adolescents in the control group that utilized guideline-recommended treatments, such as medication and psychotherapy, for depression were excluded. This restriction was implemented to investigate the potential links between the physiological effects of exercise and the antidepressant effects of physical activity.

Outcomes: Studies were included in this analysis on the condition that they employed a continuous measure to evaluate the severity of participants’ depressive symptoms following the intervention. Since the core aim of this review was to determine the intensity of depressive symptoms, the inclusion of a continuous symptom measure was mandatory for studies to be considered eligible.

Design: We used randomized controlled studies (including cluster randomized controlled trials) in this analysis.

Search approach

The search phrases selected were intended to yield a wide variety of research for in-depth analysis. To locate relevant research in PubMed and Web pages, we employed the following search algorithm: Adolescents [Abstract/Title] Puberty OR [Title/Abstract] OR [Title/Abstract] OR girl Instead of boy* [Title/Abstract] AND (workout) [Abstract/Title] OR sport*[Abstract/Title] (Depressed) [Abstract/Title] OR “emotional symptom*”[Abstract/Title] Conversely, “emotional disorder” [Abstract/Title] OR “psychological disorder” [Abstract/Title]). We also searched using the following terms: “training through physical means” [Abstract/Title] OR “physical activity” [Abstract/Title] OR “physical effort” [Abstract/Title] It might also be “physical education” [Title/Abstract] OR in operation [Title/Abstract] OR operating [Title/Abstract] OR walking [Title/Abstract] OR cycling [Title/Abstract] OR “traits for strengthening” [Title/Abstract] or swimming [Abstract/Title]. A thorough search strategy was used in this investigation.

Assessment of the evidence’s assurance (study selection)

Using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology, we assessed the degree of confidence in the evidence included in the initial meta-analysis[12]. The GRADE system uses four categories to classify the level of confidence: Highest, average, lowest, and extremely low. Confidence in the evidence is diminished if there are one or more of the following issues: Limitations in study design, inconsistencies, indirectness, inaccuracies, and publication bias. One member of the review team provided the GRADE ratings for all reviewed studies[13].

Moderator evaluation (data collection process)

We examined the antidepressant properties of physical activity therapies mediated by either the methodological components of previous studies or the methods used for physical activity therapies. In this section, we describe the methodology for categorizing effect size estimates into subgroups to assess the influence of moderators based on the studies included in our analysis.

Procedural characteristics of current studies (data items)

Method of diagnosis for initial depression identification: Based on the research, we used the results of a self-evaluation scale or organized clinical conversations to identify symptoms of depression in adolescents. Initially, we conducted a subgroup analysis to further investigate these symptoms.

Type of experimental group: We performed a subgroup assessment depending on whether the study used an active or passive test group. Participants were classified as active if the physical activity group received psychological stimulation comparable to that of the simulated therapy group, and the untreated group was administered a placebo that did not lead to a significant improvement in cardiovascular fitness. If the members of the study group were not exposed to such experimental manipulations, they were categorized as passive participants.

Physical activity

Type of exercise: We conducted a subgroup evaluation considering whether the various exercise regimens were either standardized or game-based.

Energy levels: We performed a subgroup analysis based on whether the studies included minimal, moderate, or robust intensive physical activity. The recommendations were followed for operationalizing sessions of physical exercise at low, moderate, or high intensity. Current standards recommend that teenagers participate in moderate-to-intense physical exercise for a minimum of 60 minutes each day. We also combined medium- and high-intensity physical activity and compared it with moderately strenuous activity to determine whether the antidepressant advantages of medium-to-severe exercise outweigh those of low-energy activity.

Environment: We performed a subgroups analysis based on whether the study participants received supplementary psychiatric therapies, medication, or control treatment in addition to taking part in physical activity.

Duration of therapy with physical activity: The frequency of weekly workouts, the length of each workout, the number of weeks of intervention, and the overall duration of the exercise therapy were all examined using meta-regression to determine their temporal components and their potential to affect results.

Bias evaluation risk

The potential for bias in the included studies was assessed using the physical therapy evidence databases (PEDro) assessment system. The PEDro rating system comprises the following nine items: Experts rated each of the nine included studies. If the study’s complete text made it apparent that the conditions of each item had been fulfilled, it was assigned a low probability of bias. We classified a study having a significant possibility of bias if the full-text publication did not explicitly state that the standards were met. The experts evaluated the included studies using the PEDro magnitude scale.

Measurements of outcomes and data extraction

We retrieved data on the type of release, methodology, population characteristics, outcome measures, treatment details, and control group details following the intervention. Data were also included on measurements and assessment duration following the conclusion of treatment[14]. If a publication lacked sufficient details for study evaluation or presented data exclusively in graphical form, we contacted the study’s authors to request additional information. Data were merged according to the described processes if an encompassed study examined the impact of multiple exercise medications with a test group, and if those exercise therapies were comparable in terms of the moderating influences investigated in this study.

Statistical analysis (summary measures)

The main meta-analysis investigated how physical activity interventions affect the intensity of depressive symptoms in adolescents. This was accomplished by computing the bias-adjusted Hedges’g standardized mean deviation (SMD) for each study between the physical activity and control groups post-intervention. The aggregated SMD size was interpreted according to Cohen’s classification. SMD values were considered to represent modest, moderate, and high impact sizes. To enhance comprehension, the pooled SMD was also converted into Beck Depression Inventory scores.

Synthesis of results

Physical activity has an antidepressant effect when expressed by negative SMD values. By computing Higgins’ statistic, we quantified study inconsistencies. The Higgins’ values were considered to represent a small, moderate, or substantial amount of between-study variability.

Additional analyses

Using meta-regression and subgroup analyses, we investigated the potential moderating effects of the identified factors[15]. In each included trial, the variance in dropout rates between the exercise and control groups served as a proxy for assessing treatment feasibility. The Mantel-Haenszel method was used to pool the risk-difference data by incorporating random effects.

RESULTS

Study selection

The PRISMA diagram in Figure 1 summarizes the selection procedure. Eight studies were ultimately identified and incorporated into the subjective summary of this study. Nevertheless, one of the eight studies lacked the necessary data for a meta-analysis, and the author of that study declined to respond to our request for data. As a result, seven studies that included information from 400 adolescents with depression were included in the main meta-analysis.

Figure 1 PRISMA flowchart.

Study characteristics

The features of the investigations comprising this review’s quantitative synthesis are presented in Table 1[16-23]. The eight studies that comprised the qualitative evaluation included 491 individuals with depression. The sample sizes varied from 24 to 100. Only female participants were enrolled in two studies, whereas only male participants were enrolled in one study. The only depression treatment administered to participants in six of the eight studies was physical activity. These studies were conducted in educational settings. In the remaining four studies, individuals received physical therapy in addition to psychological treatment and medication. The types of physical activity used in the investigations differed greatly. An ergometer was used for three studies that implemented a cycling intervention. Three studies used sports-related activities including volleyball, badminton, and football. Walk/run methods were used in two studies.

Table 1 Features of the studies included in this review’s quantitative synthesis.

Ref.	Study format	Sample	Measurement	Results
Singh et al[16]	Randomized controlled trial	128119 participants	Edinburgh Postnatal Depression Scale	For a wide variety of adults, including the general population, individuals with documented psychological disorders, and those with chronic illnesses, physical activity was very useful for reducing symptoms of depression, anxiety, and psychological distress
Laird et al[17]	Randomized controlled trial	4016 individuals	Epidemiological Studies Depression Scale	Investigated whether in older adults with and without chronic illnesses if achieving lower physical activity thresholds could be helpful for public health programs aimed at lowering the incidence of depression
Philippot et al[18]	Randomized controlled trial	52 adolescent patients	Hospital Anxiety and Depression Scale	The effectiveness of that treatment method has been demonstrated by the reduction in depressed symptoms displayed by teenage patients with depression who undergo organized workout as an additional treatment as part of their overall psychological care
Zhou et al[19]	Randomized, placebo-controlled, and double-blinded trial	84 patients	Montgomery-Asberg Depression Rating Scale	According to the experiment, promethazine administered intraoperatively can help neurosurgery patients who have moderate-to-severe depression symptoms without compromising safety
Arsh et al[20]	Randomized controlled trial	1363 patients	Hamilton Depression Scale	While exercise can successfully lessen the intensity of depression symptoms, it does not appear to have a significant impact on glycemic management
Recchia et al[21]	Randomized controlled trial	2441 participants	Validated depression scales	In young people and adolescents, physical activity therapies can be utilized to lessen depressive symptoms
Noetel et al[22]	Randomized controlled trial	14170 participants	Beck Depression Inventory, Hamilton Depression Rating Scale	Assurance for jogging or walking was inadequate, and it was extremely low for additional therapies
Loi et al[23]	Randomized controlled trial	212 patients	Geriatric Depression Scale-15	For care givers of individuals with dementia, a physical activity intervention might not be as helpful in reducing signs of depression as it would be for other types of caretakers

Bias risk evaluation

Each included study explained how participants were recruited and whether they met the eligibility requirements. Out of 36 studies with full-text available that were assessed for eligibility, 22 studies were excluded not suffering, additional health problems, and no measurements. Subsequently, ten studies were included for further review. One study lacked point estimates, variance measurements, and between-group assessments. The risk of bias each study is shown in Figure 2, while the risk of bias in various types of research is shown in Figure 3. Therapists and participants were not blinded in any of the included investigations.

Figure 2 Bias risk in each study.

Figure 3 Risk of bias in various types of research.

Moderator evaluation

In this section, we explain how the impact size estimates from the included studies were divided into subgroups.

Procedural characteristics of the current studies

Method of diagnosis for initial depression identification: Collectively, information from research utilizing a structured clinical interview process to identify depression at baseline revealed a significant effect. A small-to-moderate effect was observed when data from trials that used a self-report scale for the initial diagnosis of depression were combined. The impact sizes in each of these categories did not differ significantly.

Type of testing group: A modest antidepressant effect was noted upon pooling data from studies that compared physical activity with a physically active control group. A moderate-to-large impact of antidepressants was obtained by combining data from trials that included a passive control group. Table 2 shows the results of the moderator evaluation of the procedural characteristics.

Table 2 Moderator evaluation of procedural characteristics.

Procedural characteristics	Number of participants	Impact size estimates	95%CI	SMD	P values	Variability	Meta-regression
Method of initial depression diagnosis
Organized clinical conversation	112	6	-2.23 to -0.53	-0.92	P = 0.0003	Q = 4.16, P = 0.4, df = 2, T2 = 0, I2 = 0%	Q-between = 4.43, df = 1, P = 0.1
Self-report scale	335	9	-0.81 to -0.53	-0.54	P = 0.0019	Q = 12.18, P = 0.11, df = 9, T2 = 0.0025, I2 = 34.9%
Type of testing group
Active group	130	8	-0.85 to 0.33	-0.47	P = 0.1674	Q = 3.73, P = 0.62, df = 6, T2 = 0, I2 = 0%	Q-between = 3.72, df = 1, P = 0.19
Passive group	315	10	-0.94 to -0.45	-0.79	P = 0.006	Q = 13.55, P = 0.04, df = 8, T2 = 0.0804, I2 = 51.8%

CI: Confidence interval; SMD: Standardized mean deviation.

Physical activity

Type of exercise: A subgroup evaluation showed approximately the same magnitude of effects between examiners applying an established exercise treatment without sports characteristics and examiners using game-based physical activity.

Energy levels: A subgroup evaluation showed statistically significant variance in the accumulated effect, including physical activity at low, medium, and high intensities. When small-scale physical activity studies were combined, the overall effect size was low. After combining information from trials that employing moderate levels of exercise, a significant impact size was found. When data from research using intense physical activity interventions were included, the impact magnitude was high.

Environment: Subgroup analysis revealed a small-to-moderate effect size of antidepressants, derived from studies that incorporated physical activity or control group treatments in conjunction with psychological interventions and/or medication within a clinical context. The pooled effect size of studies exclusively examining physical exercise and an educational setting as a no-treatment control group therapy was found to be medium to large. No statistically significant differences in impact sizes were observed across the groupings.

Duration of therapy with physical activity: The meta-regression analysis results showed no connection between any component related to the length of the exercise sessions and the effects of antidepressants (session duration, weekly session count, total number of weeks, and overall extent). Table 3 presents the results of the moderator analysis on physical activity characteristics.

Table 3 Moderator analysis on physical activity characteristics.

Physical activity characteristics	Number of participants	Impact size estimates	95%CI	SMD	P values	Variability	Meta-regression
Type of exercise
Exercise treatment without sports	287	11	-0. 94 to -0.25	-0.65	P = 0.001	P = 0.24, df = 10, Q = 9.34, T2 = 0.0317, I2 = 8.5%	Between Q = 0, P = 0.01, df = 1
Game-based physical activity	195	5	-0.204 to -0.21	-0.67	P = 0.1015	P = 0.02, df = 4, Q = 8.64, T2 = 0.1565, I2 = 70.9%
Energy levels
Low	145	5	-0.56 to 0.34	-0.09	P = 0.5455	P = 0.95, Q = 0.46, df = 1, T2 = 0, I2 = 0%	Between Q = 7.72, P = 0.02, df = 1
Medium	185	6	-0.37 to -0.56	-0.96	P = 0.0002	Q = 5.7, P = 0.20, df = 2, T2 = 0.0745, I2 = 34.9%
High	135	6	-0.96 to -0.23	-0.74	P = 0.0056	Q = 3.23, P = 0.65, df = 5, T2 = 0, I2 = 0%
Environment
Physical exercise and educational atmosphere	201	8	-0.87 to -0.07	-0.58	P = 0.0157	Q = 4.14, P = 0.75, df = 6, T2 = 0, I2 = 0%	Between Q = 0.95, P = 0.29, df = 1
Physical activity	245	8	-3.03 to -0.18	-0.74	P = 0.00475	Q = 13.45, P = 0.03, df = 6, T2 = 0.1423, I2 = 67.3%
Duration of therapy with physical activity
Session duration	-	-	-	-	-	-	Q-balance = 0.46, P = 0.36, df = 1, R2 = 0%
Weekly session count	-	-	-	-	-	-	Q-balance = 0.06, P = 0.65, df = 1, R2 = 0%
Total number of weeks	-	-	-	-	-	-	Q-balance = 0.44, P = 0.53, df = 1, R2 = 0%
Total duration	-	-	-	-	-	-	Q-balance = 0.001, P = 0.01, df = 1, R2 = 0%

CI: Confidence interval; SMD: Standardized mean deviation.

Analyzing how physical activity treatment affects the rate of charge remission

Out of the ten studies included in this analysis, only two assessed the dropout rate to assess the depression medication benefits of exercise treatment among adolescents with depression. The recovery rate data from the two studies were not evaluated quantitatively because the statistical power was insufficient[24]. Here, we present the findings from the two trials that provided qualitative information on remission rates. After treatment, remission was achieved in 31% of those enrolled in the control group, 50% of those in the whole-body vibration exercise group[25].

Evaluation of exercise treatment acceptance

Each study subjected to quantitative evaluation disclosed treatment discontinuation. The physical exercise group had an average departure rate of 9.01% [95% confidence interval (CI): 8.06-10.96]. The median departure rate in the control groups was 13.49% (95%CI: 11.37-14.6). Between the exercise and control groups, we could not find significant variance in the risk of dropout (k = 11, RD = -0.04, 95%CI: -0.09 to 0.04, P = 0.30).

DISCUSSION

The examination of the literature primarily shows the alleviation of symptoms of depression through physical activity among adolescents. It is also well supported by the evidence regarding exercise in relation to the alleviation of depressive symptoms, especially in conjunction with psychological interventions or medication. According to the investigation, sports and organized exercise programs are two examples of physical activities that have been shown to be beneficial for mental health. Subgroup evaluations revealed that moderate-intensity physical activity had the most significant impact. However, the duration of therapy did not show a clear correlation with the treatment outcomes. The risk of bias in studies was notable, especially due to lack of blinding. The evidence suggests that healthcare providers should consider incorporating physical activity into treatment plans for adolescents with depression. The findings are relevant for users, as they demonstrate that physical activity can serve as a beneficial complementary treatment. These findings highlight the significance of supporting physical activity programs in mental health efforts for policymakers. Although more research is required to improve and optimize its application, the review’s overall findings indicate that physical exercise is a viable strategy for controlling teenage depression. This meta-analysis has some limitations affecting causal inference. First, significant heterogeneity in intervention protocols (e.g., exercise types, intensities, adjunct therapies) complicates attributing observed effects to specific components of multimodal physical therapy. Second, residual confounding from unmeasured variables (e.g., lifestyle factors, genetic predispositions) may bias outcomes despite randomized designs, undermining causal conclusions. Third, short follow-up periods in included studies restrict insights into long-term causal relationships between interventions and sustained depression reduction. While blinding challenges and publication bias also pose concerns, these three limitations most directly impact the validity of causal claims. Future research should prioritize standardized interventions, rigorous control of confounders, and extended follow-ups to strengthen causal inferences.

CONCLUSION

Multimodal physical therapy, integrating exercise with other therapies, is considered to help alleviate depressive symptoms through improvements in both physical and mental conditions. This option offers a supplementary route of treatment, alongside the standard methods of drug and psychotherapy. According to the findings of this meta-analysis, physical activity therapy can be useful as an alternative form of therapy for adolescents with depression to reduce the intensity of their symptoms. Nevertheless, caution should be used when interpreting these findings. The level of certainty in the evidence was limited because of concerns regarding the methodology and accuracy of the research. Key limitations include heterogeneity in intervention protocols (e.g., variations in exercise types, intensities, and adjunct therapies), which complicates causal attribution to specific components; residual confounding from unmeasured variables (e.g., lifestyle factors, genetic predispositions) that may bias outcomes despite randomized designs; and short follow-up durations in included studies, limiting insights into long-term efficacy. According to moderator analyses, adolescents with depression should engage in moderate physical exercise to reduce their symptoms. The research also highlights the need for standardized intervention protocols to reduce variability and improve causal inference. Future research should prioritize extended follow-ups, rigorous control of confounders, and harmonized intervention designs to strengthen conclusions.

To further advance the understanding of multimodal physical therapy in depression management, future studies should prioritize longitudinal designs to evaluate sustained effects. Prospective cohort studies, such as those that track participants over extended periods, are suggested to better reveal the long-term effects of multimodal physical therapy on depression. These studies could capture fluctuations in depressive symptoms, adherence to physical activity regimens, and interactions with concurrent treatments (e.g., pharmacotherapy). Additionally, integrating biomarkers (e.g., inflammatory markers, neuroplasticity indices) and neuroimaging techniques may elucidate the biological pathways linking physical activity to emotional health. For example, multimodal neuroimaging techniques have been used to study the relationship between neurotransmitter function and symptoms in movement disorders, which could provide insights into similar mechanisms in depression. Research should also explore optimal intervention protocols, such as dose-response relationships, modality combinations, and personalized approaches, to maximize efficacy. Comparative effectiveness trials could assess how multimodal physical therapy synergizes with emerging therapies like digital mental health tools. For instance, a recent study developed a multimodal digital measurement system to assess depression, demonstrating the potential of combining different digital modalities to improve detection and monitoring. Finally, expanding studies to underrepresented groups (e.g., individuals with comorbidities, varying socioeconomic backgrounds) and real-world clinical settings will enhance generalizability. Addressing these gaps will inform evidence-based guidelines and refine implementation strategies for integrating physical therapy into holistic depression care.