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Research Report

D. Vancampfort, PT, MSc, Faculty


of Kinesiology and Rehabilitation Sciences, Catholic University Leuven, Leuven, Belgium,
and University Psychiatric Centre,
Catholic University Leuven, Campus Kortenberg, Leuvensesteenweg 517, 3070 Kortenberg, Belgium. Address all correspondence
to Mr Vancampfort at: davy.
vancampfort@uc-kortenberg.be.

Systematic Review of the Benefits of


Physical Therapy Within a
Multidisciplinary Care Approach for
People With Schizophrenia
Davy Vancampfort, Michel Probst, Liv Helvik Skjaerven,
Daniel Catalan-Matamoros, Amanda Lundvik-Gyllensten, Antonia Gomez-Conesa,
Rutger Ijntema, Marc De Hert

Background. Although schizophrenia is the fifth leading cause of disabilityadjusted life years worldwide in people aged 15 to 44 years, the clinical evidence of
physical therapy as a complementary treatment remains largely unknown.
Purpose. The purpose of this study was to systematically review randomized

M. Probst, PT, PhD, University Psychiatric Centre, Catholic University Leuven, Campus Kortenberg,
and Faculty of Kinesiology and
Rehabilitation Sciences, Catholic
University Leuven.
L. Helvik Skjaerven, PT, MSc,
Department of Physical Therapy,
Faculty of Health and Sciences,
Bergen University College, Bergen, Norway.

controlled trials (RCTs) evaluating the effectiveness of physical therapy for people
with schizophrenia.

D. Catalan-Matamoros, PT, PhD,


Faculty of Health Sciences, University of Almeria, Almeria, Spain.

Data Sources. EMBASE, PsycINFO, PubMed, ISI Web of Science, Cumulative

A. Lundvik-Gyllensten, PT, PhD,


Division of Physical Therapy, Faculty of Health Sciences, Lund University, Lund, Sweden.

Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence


Database (PEDro), and the Cochrane Library were searched from their inception until
July 1, 2011, for relevant RCTs. In addition, manual search strategies were used.

Study Selection. Two reviewers independently determined study eligibility on


the basis of inclusion criteria.
Data Extraction. Reviewers rated study quality and extracted information about
study methods, design, intervention, and results.

Data Synthesis. Ten RCTs met all selection criteria; 6 of these studies addressed
the use of aerobic and strength exercises. In 2 of these studies, yoga techniques also
were investigated. Four studies addressed the use of progressive muscle relaxation.
There is evidence that aerobic and strength exercises and yoga reduce psychiatric
symptoms, state anxiety, and psychological distress and improve health-related quality of life, that aerobic exercise improves short-term memory, and that progressive
muscle relaxation reduces state anxiety and psychological distress.
Limitations. The heterogeneity of the interventions and the small sample sizes of
the included studies limit overall conclusions and highlight the need for further
research.

Conclusions. Physical therapy offers added value in the multidisciplinary care of


people with schizophrenia.

A. Gomez-Conesa, PT, PhD,


Department of Physical Therapy,
University of Murcia, Murcia,
Spain.
R. Ijntema, PT, MBA, Institute of
Human Movement Studies, Faculty of Health Care, HU University
of Applied Sciences Utrecht,
Utrecht, the Netherlands.
M. De Hert, MD, PhD, University
Psychiatric Centre, Catholic University Leuven, Campus Kortenberg, and Faculty of Medicine,
Catholic University Leuven.
[Vancampfort D, Probst M, Helvik
Skjaerven L, et al. Systematic
review of the benefits of physical
therapy within a multidisciplinary
care approach for people with
schizophrenia. Phys Ther. 2012;
92:1123.]
2012 American Physical Therapy
Association
Published Ahead of Print:
November 3, 2011
Accepted: August 30, 2011
Submitted: July 8, 2011
Post a Rapid Response to
this article at:
ptjournal.apta.org

January 2012

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chizophrenia is one of the most


debilitating psychiatric disorders.1 It accounts for 1.1% of
total disability-adjusted life years and
for 2.8% and 2.6% of years lived with
disability for men and women,
respectively. In addition, it is the
fifth leading cause of disabilityadjusted life years worldwide in
people who are 15 to 44 years old.2
Its lifetime prevalence and incidence range from 0.30% to 0.66%
and from 10.2 to 22.0 per 100,000
person-years, respectively.3 According to criteria in the Diagnostic
and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV),
schizophrenia comprises both positive and negative symptomatology
severe enough to cause social and
occupational dysfunction.4 Positive
symptoms reflect an excess or distortion of normal functions and
include delusions, hallucinations, and
disorganized speech and behavior.
Negative symptoms reflect a reduction or loss of normal functions and
include affective flattening, apathy,
avolition, and social withdrawal.
Mesolimbic dopaminergic hyperactivity is believed to be part of the
underlying pathology associated with
positive symptoms,5 but the pathophysiology of negative symptoms is
poorly understood. Negative symptoms therefore remain a relatively
treatment-refractory and debilitating
component of schizophrenia.6
Once the diagnosis is made, antipsychotic drugs that block dopamine D2 receptors are the main
treatment for people with schizophrenia.7 First-generation antipsychotics (eg, chlorpromazine, fluphenazine, and haloperidol) are
Available With
This Article at
ptjournal.apta.org
eTable: Excluded Randomized
Controlled Trials

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effective in the management of psychotic symptoms but often lead to


motor side effects. In the past 15
years, so-called second-generation
agents (eg, amisulpride, aripiprazole,
olanzapine, quetiapine, and risperidone) that less frequently cause
motor side effects have been introduced for symptom management.
Although second-generation antipsychotics are as effective as firstgeneration agents in managing positive symptoms, their promise of
greater efficacy against negative
and cognitive symptoms has not
been borne out.8 Many people with
schizophrenia continue to have persistent symptoms and relapses, particularly when they fail to adhere
to prescribed medication regimens.
This situation underlines the need
for multimodal care, including psychosocial therapies, as an adjunct
to antipsychotic medications to help
alleviate symptoms and to improve
adherence, functional outcomes,
and health-related quality of life.9
Research on psychosocial approaches
to treatment for people with schizophrenia has yielded incremental evidence of the efficacy of cognitive
behavioral therapy, social skills training, family psycho-education, assertive community treatment, and supported employment.79 Additional
research is needed to examine the
aspects of therapeutic modalities
that work and to identify the synergistic effects of combinations of
interventions. Recently, there has
been interest in the relative effectiveness of physical therapy interventions in multidisciplinary treatment
for people with schizophrenia.10
The International Organization of
Physical Therapy in Mental Health
(formerly the International Council
of Physiotherapy in Psychiatry and
Mental Health) stated that in the
multidisciplinary care of people with
schizophrenia, physical therapy is
intended to improve physical and
mental health and health-related

Number 1

quality of life.11 For people with


schizophrenia, an enhanced ability
to cope with disease symptoms
tends to improve health-related quality of life.12 Numerous physical therapy interventions are potentially
effective in improving physical and
mental health and health-related
quality of life. The techniques most
commonly used in daily clinical practice are aerobic and strength exercises, relaxation training, and basic
body awareness exercises.10,13
People with schizophrenia, who are
more likely to be less physically
active than people in the general
population14,15 and are consequently
at high risk for chronic medical conditions associated with physical inactivity,16,17 have the same physical
health needs as other people who
are sedentary. For example, metabolic and cardiovascular diseases
have become a major concern in
people with schizophrenia.18 People
with schizophrenia are 1.5 to 2 times
more likely to be overweight, their
risk for diabetes and hypertension is
2-fold higher, and dyslipidemia is 5
times more prevalent in people with
schizophrenia than in people in the
general population.19 The excess
morbidity from cardiovascular diseases results in increased premature
mortality2 or 3 times as high as
that in the general population.20,21
The mortality gap translates to a
shortening of life expectancy by 13
to 30 years compared with that in
the general population22,23 and is still
widening.24,25 A previous systematic
review of physical activity with or
without diet counseling concluded
that lifestyle interventions are feasible and effective in reducing weight
and improving the obesity-related
cardiometabolic risk profile in people with schizophrenia.26
Beneficial mental health effects from
physical therapy interventions also
have been reported. For example,
earlier systematic reviews indicated
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Multidisciplinary Care for People With Schizophrenia


that aerobic exercise reduces negative and positive symptomatology
and alleviates secondary symptoms,
such as depression, low self-esteem,
and social withdrawal.2730
The conclusions of these systematic reviews, however, were mainly
based on data from uncontrolled
trials, and the findings, therefore,
should be interpreted with caution.
More recently, a meta-analysis of
aerobic exercise31 indicated that regular physical activity is possible for
people with schizophrenia. Aerobic
exercise can have beneficial effects
on both the physical and mental
health and the well-being of people
with schizophrenia, although there
is currently insufficient evidence to
support or refute the use of aerobic
and strength exercises as a complementary intervention.31 To our
knowledge, no systematic reviews of
relaxation training and basic body
awareness exercises are available.
The question of whether aerobic and
strength exercises, relaxation training, and basic body awareness exercises are effective additions to the
multidisciplinary management of
schizophrenia, therefore, remains
largely unanswered. Thus, the purpose of this systematic review was to
evaluate the methodological quality
of and summarize the evidence from
randomized controlled trials (RCTs)
examining the effectiveness of these
physical therapy interventions in the
multidisciplinary management of
schizophrenia.

Method
Data Sources and Searches
A literature search was conducted
according to the search strategy of
Dickersin et al.32 No restrictions
were made regarding the language of
publication. EMBASE, PsycINFO,
PubMed, ISI Web of Science, Cumulative Index to Nursing and Allied
Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro),
and the Cochrane Library were
January 2012

searched from their inception until


July 1, 2011, for RCTs. Medical subject headings included schizophrenia AND physical therapy OR
exercise OR relaxation in the
title, abstract, or index term fields.
Two investigators independently
screened the titles of the publications found in the databases and, if
available, the abstracts of the publications as well. If either investigator
believed that any published article
potentially met the inclusion criteria
or if there was inadequate information to make a decision, a copy of the
article was obtained or the authors
were contacted to obtain the necessary data.
The next phase of the search strategy involved searching for unpublished RCTs and for RCTs potentially
overlooked or absent from the databases. This step involved manually
searching the reference lists in all
retrieved articles and the available
systematic reviews for potential studies to locate unpublished or overlooked research. Furthermore, we
searched Web sites housing details
of clinical trials, theses, or dissertations. Citation indexing was used to
track referencing of key authors in
the field, and local experts were contacted for further information.
Study Selection
Inclusion in this review was
restricted to studies of people with a
diagnosis of schizophrenia or other
types of schizophrenia spectrum
psychoses (schizoaffective or schizophreniform disorder, excluding
bipolar disorder and major depression with psychotic features) on the
basis of any criteria, any length of
illness, and any treatment setting.
We did not exclude trials because of
the age, nationality, or sex of the
participants.
Types of interventions. Studies
were considered eligible for inclusion if they were RCTs compar-

ing physical therapy interventions


with a placebo condition, control
intervention, or standard care. The
experimental physical therapy interventions could comprise aerobic
exercises, strength exercises, relaxation training, basic body awareness exercises, or a combination of
these in accordance with the World
Confederation for Physical Therapy
position statement.33 A physical
therapy intervention could be used
alone or in conjunction with other
interventions, with physical therapy
being considered the main or active
element. Interventions that included
physical therapy in a multiplecomponent weight management
program were excluded because
the specific effects of the physical
therapy intervention could not be
addressed. Other interventions could
include any of the following: pharmacotherapy, psycho-education, and
cognitive-behavioral or motivational
techniques related to exercise
behavior. Standard care was defined
as care that people would normally
receive had they not been included
in the research trial. Such care would
include medication, hospitalization,
community psychiatric nursing support, and outpatient care. For an
RCT to be included, the experimental and comparison interventions
must have had similar durations.
Types of outcomes. Outcomes
were grouped according to assessments of mental health, physical
health, and health-related quality of
life.
Data Extraction and
Quality Assessment
Assessments of quality were completed independently by the 2
reviewers. Disagreements were
resolved by discussion. If no consensus was achieved, a third reviewer
made the final decision. Each study
was evaluated with the previously
validated 5-point Jadad scale34 to
assess the completeness and quality

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Table 1
Data Extraction
Criterion

Items

Design

First author name

the first full-text screening, we


decided that there was too much
heterogeneity in study designs and
protocols to apply a formal
meta-analysis.

Year published
Participants

Number, mean age or age range, sex


Setting (inpatients, outpatients, mixed)

Intervention

Type of intervention
Duration, frequency, intensity
Cointerventions

Outcome measures

Types of outcome measures


Assessment tools
Adverse effects

of reporting of RCTs as well as to


assess for potential bias in the trials.
This widely used scale focuses on
3 dimensions of internal validity:
quality of randomization, doubleblinding, and withdrawals. This scale
is the only published instrument
that has been created according to
psychometric principles.35,36 A score
of 0 to 5 is assigned, with higher
scores indicating higher quality in
the conduct or reporting of a trial. A
trial scoring at least 3 of 5 is considered to be of strong quality. A trial
scoring below 3 is considered to be
methodologically weak.
Data Synthesis and Analysis
Each study was assessed with a rating system originally developed by
de Vet et al.37 This rating system provides a detailed evaluation of study
methods and was used previously in
systematic reviews for physical therapy.38,39 The rating system of de Vet
et al37 considers criteria relevant to
the practice of physical therapy,
such as participant characteristics,
sample size, description of interventions, and the validity and reliability
of the chosen outcome measures.
The 2 assessors independently
reviewed each study on the basis of
the specific criteria of this rating system. For each criterion, 3 ratings
were available: pass (met the criterion), moderate (incompletely or
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partially met the criterion), and fail


(did not meet the criterion); the fail
rating also was assigned when no
information about a specific criterion was provided in the publication.
Each quality criterion was evaluated
separately. At present, there are no
clear decision rules for establishing
cutoff scores for high- and lowquality studies with this tool; therefore, summary scores were not used.
A data collection form was developed and used by 1 reviewer (D.V.)
to extract data from the included
studies while a second reviewer
(M.P.) cross-checked the extracted
data. The data items extracted are
shown in Table 1.

Results
Study Selection
The initial electronic database search
resulted in a total of 2,162 articles.
Through additional manual searches
of reference lists, searches of Web
sites, and consultation of experts in
the field, 1 other potentially eligible
article was identified. After the
removal of duplicates and screening
of titles, abstracts, or full texts, 10
RCTs were included (Fig.).40 49 Reasons for exclusion are shown in the
Figure. A list of excluded screened
RCTs with reasons for exclusion is
provided in the eTable (available at
ptjournal.apta.org). On the basis of

Number 1

Participants
In total, 322 participants were
included in the analyses. Except for
participants in 2 studies40,41 published before the appearance of
DSM-IV (the most recent edition of
the Diagnostic and Statistical Manual of Mental Disorders, published
in 1994), all participants were diagnosed with schizophrenia on the
basis of DSM-IV criteria. Two studies
included both inpatients and outpatients,43,45 2 studies concentrated
solely on outpatients,42,47 and the
other studies included only inpatients. The participants ranged in age
from 18 to 63 years. With this strategy, both participants with first episodes and participants with chronic
conditions were included. In most of
the studies, the participants were
men. Detailed information on the
characteristics of the participants is
provided in Table 2.
Methodological Quality
Two of the included studies40,41
were considered to be of weak methodological quality (Tab. 2). Further
details of the study characteristics
are provided in Table 3. The 2 most
common methodological concerns
were limited sample size and lack of
masking (blinding), especially of
participants.
Effectiveness of aerobic exercises,
strength exercises, or both in the
multimodal care of people with
schizophrenia. The investigators
in 6 studies42,43,45 48 examined the
effectiveness of aerobic exercises,
strength exercises, or both in multidisciplinary standard care for people
with schizophrenia. All 6 studies
were considered to be of strong
methodological quality. In 1 study43
of 3 studies42,43,46 examining the
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Figure.
Flow chart of systematic review inclusion and exclusion. CINAHLCumulative Index to Nursing and Allied Health Literature,
PEDroPhysiotherapy Evidence Database, RCTrandomized controlled trial.

effectiveness of these exercises for


positive and negative symptoms, the
reductions found were significant. In
the studies of Duraiswamy et al43 and
Behere et al,46 aerobic exercises,
strength exercises, or both were
compared with yoga as a compleJanuary 2012

mentary intervention. Participants


practicing yoga reported significantly greater reductions in positive
and negative symptoms. Healthrelated quality of life improved only
after yoga.43 The investigators in 3
studies42,45,47 examined changes in

aerobic fitness, muscular fitness, or


both; 2 studies42,45 included the SixMinute Walk Test; and 1 study47
included incremental cycle ergometry. Although both studies including the Six-Minute Walk Test
revealed increases in the distance

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30 inpatients with
schizophrenia (DSMIII); mean age35 y

10 outpatients (8 men)
with schizophrenia
(DSM-IV);
age4063 y

41 inpatients and
outpatients (28 men)
with schizophrenia
(DSM-IV);
age1855 y

Beebe et al42

Duraiswamy et al43

40 inpatients (17 men)


with schizophrenia
(DSM-III);
mean age35 y

Participants

Pharr and
Coursey41

Hawkins et al40

Study

Number 1
Aerobic and strength
exercises (20) vs yoga
(21)

Aerobic exercises
(treadmill walking) (6)
vs care as usual (4)

PMR (10) vs EMG


biofeedback (10) vs
listening to recorded
readings (10)

PMR (10) vs minimal


treatment (asked to
relax) (10) vs thermal
feedback (10) vs PMR
thermal feedback
(10)

Experimental vs
Control Intervention
(No. of Participants)

Details of Included Randomized Controlled Trialsa

Table 2.

16 wk

16 wk

20 min

2 wk

Duration

60 min 5 times/wk
in wk 13 under
supervision and
then 3 mo of
self-practice

From 25 min 3
times/wk (wk 1)
to 50 min 3
times/wk (wk 3
to end)

7 individual
sessions

40 min 5 times/wk

Frequency

Not mentioned

10 min of
warming up,
530 min of
moderateintensity
walking, and
10 min of
cooling down

Intensity

Fewer positive (24%)


and negative (18%)
symptoms after
aerobic and strength
exercises (vs 33%
and 35%) (group
differences: P.24
and P.01);
significantly
improved physical
(4.6%) and
psychological
(9.8%) quality of
life only after yoga
(vs 22.9% and
29.1%) (group
differences: P.04
and P.01)

Lower body fat


percentage (3.7%
vs 0.02%, P.03);
lower BMI (1.3% vs
0.02%, P.05);
higher 6MWT score
(10% vs 4%,
P.05); fewer
positive and negative
symptoms (13.5%
vs 5%, P.05)

No significant changes
in tension-anxiety
scores

Reductions across
groups for state
anxiety (F3.95;
df1,36; P.05); no
group differences
(F1.34; df12,85;
P.21); reductions
associated with fewer
hospital admissions at
1-y follow-up
(26.6, P.05)

Relevant Outcomes
(Experimental vs
Control)

PANNS; WHOQOLBREF

Skinfold
measurements;
6MWT; PANSS

Tension-anxiety
domain of POMS

Hamilton Anxiety
State; Brief
Psychiatric Rating

Relevant
Instruments

Jadad
Score

(Continued)

Pharmacotherapy
in standard care
as usual; no
change for at
least 4 wk
before entry into
study

Pharmacotherapy
in standard care
as usual

Pharmacotherapy
at maintenancelevel dosages in
all conditions

Pharmacotherapy
in all conditions

Complementary
Cointervention

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66 outpatients
(47 men) with
schizophrenia
(DSM-IV);
mean age31.8 y

Behere et al46

16 male outpatients
with schizophrenia
(DSM-IV);
age2051 y

13 inpatients and
outpatients (8 men)
with schizophrenia
or schizoaffective
disorder (DSM-IV);
mean age44.6 y

Marzolini et al45

Pajonk et al47

14 inpatients (4 men)
with schizophrenia
(DSM-IV);
mean age40 y

Participants

Chen et al44

Study

Continued

Table 2.

Aerobic exercises
(cycling) (8) vs table
football (8)

Aerobic and muscle


strength exercises
(17) vs yoga (27) vs
waiting list (22)

Aerobic and muscle


strength exercises (7)
vs care as usual (6)

PMR (8) vs care as usual


(6)

Experimental vs
Control Intervention
(No. of Participants)

3 mo

3 mo

12 wk

11 d

Duration

30 min 3 times/wk

60-min sessions in
wk 14 under
supervision and
then 3 mo of
self-practice

90 min 2 times/wk

40 min/d

Frequency

HR at blood
lactate level
of 1.52
mmol/L

Not mentioned

From 60% HR
to 80% HR,
Borg Scale
scores of
1114, and
60 RM

Intensity

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STM improved by 34%


(vs 17%, P.007);
HV and VO2max/kg
increased after
exercise (12% and
5%) (vs 1% and
3%) (group
difference: P.002
and P.35); STM
and VO2max
correlated with HV
(r.51 and r.71,
P.05 and P.07)

RAVLT; CBTT; MRI;


VO2max with
incremental cycle
ergometry

PANSS

6MWT; 1 RM; Borg


Scale

6MWT score 5.1%


(vs 5.5% in
controls) (difference:
P.1); muscle
strength 28.3%
(P.001) (vs
12.5% in controls)
(P.2) (difference:
P.01); no
significant reductions
in resting blood
pressure or BMI
Significantly fewer
positive (21.2%
and 19.9%,
P.002) and
negative (17.4%
and 17.4%,
P.001) symptom
scores only 2 and 4
mo after yoga,
respectively;
reductions after
aerobic and muscle
strength not
significant

BAI

Relevant
Instruments

Less anxiety after 11 d


(P.001) and 1 wk
later (65%)
(P.0446) (vs 13%
in controls)

Relevant Outcomes
(Experimental vs
Control)

Number 1

Jadad
Score

(Continued)

Pharmacotherapy
at stable doses
for at least 6 wk

Pharmacotherapy
at stable doses
in standard care
as usual

Pharmacotherapy
in standard care
as usual

Pharmacotherapy
in acute care
psychiatric ward

Complementary
Cointervention

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18

Single session
25 min
PMR (27) vs reading
control condition (25)
52 inpatients (31 men)
with schizophrenia
(DSM-IV); mean
age35.6 y
Vancampfort
et al49

DSM-IIIDiagnostic and Statistical Manual of Mental Disorders, Third Edition; PMRprogressive muscle relaxation; EMGelectromyogram; POMSProfile of Mood States; DSM-IVDiagnostic and Statistical
Manual of Mental Disorders, Fourth Edition; BMIbody mass index; 6MWTSix-Minute Walk Test; PANSSPositive and Negative Syndrome Scale; WHOQOL-BREFWorld Health Organization Quality of Life
BREF version; BAIBeck Anxiety Inventory; HRheart rate; RMrepetition maximum; STMshort-term memory; HVhippocampal volume; VO2maxmaximum oxygen consumption; RAVLTRey Auditory
Verbal Learning Test; CBTTCorsi Block Tapping Test; MRImagnetic resonance imaging; SAIState Anxiety Inventory; SEESSubjective Exercise Experiences Scale.

Pharmacotherapy
in standard care
as usual;
medication
unchanged
during testing
period
Reduced state anxiety
(26.1%, P.001)
and psychological
distress (35.5%,
P.001) after muscle
relaxation but not
after control
condition (1% and
0%, respectively)
(difference: P.001)

SAI; SEES

3
Pharmacotherapy
in standard care
as usual;
medication
unchanged
during testing
period
SAI; SEES
Reduced state anxiety
(24.6% and
21.5%, both
P.001) and
psychological distress
(32.2% and
29.5%, both
P.001) after yoga
and aerobic exercise
but not after control
condition
Self-selected
aerobic
exercise
Single session
30 min of
yoga
and 20
min of
cycling
Aerobic exercise vs yoga
vs resting control
condition
40 inpatients (22 men)
with schizophrenia
or schizoaffective
disorder (DSM-IV);
mean age32.77 y
Vancampfort
et al48

Study

Continued

Table 2.

Participants

Experimental vs
Control Intervention
(No. of Participants)

Duration

Frequency

Intensity

Relevant Outcomes
(Experimental vs
Control)

Relevant
Instruments

Complementary
Cointervention

Jadad
Score

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covered by their respective participants, only participants in the


study of Marzolini et al45 increased
their distance walked significantly.
Although participants performing 30
minutes of aerobic training, strength
training, or both 3 times per week
for 3 months improved their maximal oxygen uptake, as measured
with incremental cycle ergometry,
this improvement was not significant compared with that in a control condition.47 In contrast, participants performing aerobic training,
strength training, or both improved
their short-term memory, a result
that was related to an increase in
hippocampal volume. Marzolini et
al45 reported a significant increase
in strength but no improvement in
blood pressure. Changes in body
mass index were examined in 2 studies42,45; no effect was found. Vancampfort et al48 reported significant
reductions in state anxiety and psychological distress and improvements in subjective well-being after
single sessions of aerobic exercise
and yoga.
Effectiveness of progressive muscle relaxation in the multimodal
care of people with schizophrenia. Three of the 4 studies examining the effectiveness of progressive
muscle relaxation40,41,44,49 revealed
significant reductions in anxiety. In
the methodologically weak study of
Pharr and Coursey,41 no significant
differences were found for 7 progressive muscle relaxation sessions
(20 minutes each) compared with
either 7 electromyographic feedback
sessions or 7 sessions of reading
exercises. The RCTs of Hawkins et
al40 (methodologically weak) and
Vancampfort et al49 (methodologically strong) revealed significant
reductions in state anxiety. In the
study of Hawkins et al,40 state anxiety reductions were associated with
fewer hospital admissions in the year
after the intervention; in the study of
Vancampfort et al,49 state anxiety
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Table 3.
Critical Appraisal of Included Studiesa
Rating for Criterion:
1

10

Hawkins et al40

Study

Sample size; reliability and


validity of outcome
measures; no masking
(blinding)

Pharr and Coursey41

Sample size; no masking

Beebe et al42

60% agreed to participate;


sample size

Duraiswamy et al43

No decline data; sample size

Chen et al44

No decline data; sample


size; no masking

Marzolini et al45

60% agreed to participate;


no masking

Behere et al46

No decline data; sample size

Pajonk et al47

Sample size

al48

No masking

Vancampfort et al49

No masking

Vancampfort et

Main Concerns

1study design, 2baseline characteristics, 3agreement to participate, 4intervention, 5sample size, 6data collection methods, 7masking,
8participants starting/finishing, 9external validity, 10statistical tests. Ppass (met the criterion), Mmoderate (incompletely or partially met the
criterion), Ffail (did not meet the criterion); the fail rating also was assigned when no information about a specific criterion was provided in the
publication.

reductions were associated with


reduced psychological distress and
improved perceived well-being.
Effectiveness of basic body
awareness exercises in the multimodal care of people with schizophrenia. The effectiveness of
basic body awareness exercises for
people with schizophrenia was not
investigated in any of the included
RCTs.
Adverse Effects
Duraiswamy et al43 indicated that for
both aerobic and strength exercises
and yoga, no significant differences
in extrapyramidal symptoms and
abnormal involuntary movements as
potential adverse effects were found.
Pajonk et al47 also reported finding
no adverse events during the testing
period.

Discussion
General Findings
This systematic review explored the
efficacy of aerobic and strength exerJanuary 2012

cises, relaxation training, basic body


awareness exercises, or a combination of these as an adjunct treatment
for people with schizophrenia. In
general, the included RCTs showed
that, in particular, aerobic and
strength exercises and progressive
muscle relaxation can have an
impact on mental health outcomes,
such as mental state, state anxiety,
and psychological distress. Aerobic
and strength exercises also have a
limited effect on physical health outcomes, such as aerobic and muscular
fitness, with no adverse effects. No
RCTs demonstrating the added value
of basic body awareness exercises
were available. An interesting finding was that when aerobic and
strength exercises were compared
with other types of exercises, such
as yoga (combining breathing exercises, relaxation techniques, and
body postures), the benefits of aerobic and strength exercises were not
as profound. Overall, the present
review indicated that physical therapy as an adjunct treatment might

improve a persons mental and physical health and health-related quality


of life.
Six articles26 31 identified and
reviewed existing research studies
in which physical activity was used
as a form of adjunct treatment for
people with schizophrenia. Four of
these reviews2730 included various
research designs, such as qualitative,
quantitative, and mixed methods.
The previously reported results are
in line with those of the present
review. Faulkner and Biddle,27
Faulkner,28 Ellis et al,29 and Holley et
al30 indicated that physical activity
can improve psychological health
and psychological well-being in people with schizophrenia, and Vancampfort et al26 indicated that physical activity with or without diet
counseling is feasible in reducing
weight and improving the obesityrelated cardiometabolic risk profile.
Additionally, all of these reviews
stressed the need for more methodologically rigorous research, given

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that nonrandomized designs were
used in most of the studies. Our data
confirm the findings of Gorczynski
and Faulkner31 in a recent review of
3 randomized controlled studies
investigating physical activity in people with schizophrenia; the findings
suggested that calls for more methodologically rigorous research are
starting to be addressed.
To our knowledge, the present
review is the first to offer evidence
for the effectiveness of aerobic and
strength exercises in reducing state
anxiety and psychological distress;
for the effectiveness of aerobic and
strength exercises in improving
short-term memory; for the effectiveness of progressive muscle relaxation as an adjunct intervention to
reduce state anxiety and psychological distress; and for the effectiveness
of yoga in reducing positive and negative symptoms, state anxiety, and
psychological distress. The cognitive
improvements observed after aerobic exercise seemed to be related to
exercise-induced neurogenesis in
the hippocampus.
The ability to deal with state anxiety
and psychological stress during aerobic exercise, progressive muscle
relaxation, and yoga might be of particular relevance for people with
schizophrenia. First, there is a general consensus that worsening of
schizophrenia symptoms is related
to stress and anxiety.50 Second, people with schizophrenia experience
difficulties in coping with stress and
anxiety and possess a relatively limited repertoire of coping strategies.51
The use of alcohol, nicotine, or illegal drugs, which is common in people with schizophrenia,18 has been
suggested to be an attempt to alleviate or to cope with psychiatric symptoms, unpleasant affective states, and
feelings of state anxiety and psychological distress.52 The limited benefit
of such behaviors supports the need
to provide other, more healthful
20

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methods to regulate the variability of


subjective well-being. The present
review showed that aerobic exercise, progressive muscle relaxation,
and yoga might be easily learned,
healthful alternatives for symptom,
stress, and anxiety regulation.
Limitations
Although we believe that this systematic review is the first to investigate the effectiveness of several
physical therapy interventions in
people with schizophrenia, the
review does have some limitations
that need to be acknowledged. First,
as with any systematic review, there
is a potential for selection bias; however, we used a comprehensive
search strategy. In addition, 2 independent reviewers analyzed the
research data, and reasons for study
exclusions were clearly documented. Second, performance bias
may limit our findings. None of the
included studies were double-blind
studies. The reported results therefore may exaggerate estimates of
Although
treatment
effects.53
researchers may not always be able
to mask participants to physical therapy interventions to remove the
chance of performance bias, every
attempt should be made to collect
research data in a masked manner. In
the present review, only 4 of the
included studies were single-blind
studies.42,43,46,47 Third, the heterogeneity among the RCTs, particularly
with regard to the frequency and
duration of the experimental intervention and the chosen control or
comparison intervention, was a challenge in the present review. This
diversity, as well as the small sample
sizes and other methodological gaps
in many of the included studies, limited overall conclusions and highlighted the need for further research.
Implications for Practice
The results of this systematic review
support the use of physical therapy
in the multidisciplinary care of peo-

Number 1

ple with schizophrenia. However,


clear guidance regarding the type
of intervention and optimal dose is
limited by the small number of available RCTs and the variability of the
interventions themselves in terms of
frequency, intensity, and duration.
Physical therapists, therefore, should
assess the types of exercises or techniques that would best fit a persons
preferences. Along with emphasis
on the benefits of physical therapy,
careful attention to several barriers
that prevent people from participation in physical therapy is needed.
Before offering any kind of program, physical therapists should consider and address psychiatric symptoms, antipsychotic medication side
effects, and structural barriers. In
addition to addressing barriers, physical therapists should structure programs to be informative, continuously motivate people to participate,
and allow them to progress at their
own pace. To achieve these goals,
the Organization of Physical Therapy in Mental Health54 recommends
that physical therapists be trained in
recognizing and adequately addressing symptoms of severe mental illness, physical comorbidities, and
side effects of medications. Physical
therapists would benefit from acquiring various cognitive-behavioral and
motivational skills to help their
patients participate in physical therapy programs.
Implications for Future Research
There is a clear need for welldesigned RCTs examining physical
therapy interventions as adjunct
treatment for people with schizophrenia. Trials should be large
enough to be clinically meaningful,
should be adequately powered, and
should include valid and reliable
outcome measures. Furthermore,
attempts should be made to mask
raters to a persons clinical status,
group allocation, and treatment
condition; to mask therapists to outcome measures; and, when posJanuary 2012

Multidisciplinary Care for People With Schizophrenia


sible, to mask participants as well.
Researchers should consider the
findings of this systematic review
when designing trials and should
attempt to overcome the limitations
of the RCTs presented. Because most
of the RCTs retrieved in this review
did not have longitudinal follow-up
to determine whether the improvements observed after physical therapy were maintained over time, the
question of whether short-term benefits result in long-term changes
remains largely unanswered. Therefore, long-term trials are needed to
further enhance knowledge about
physical therapy prescription for
people with schizophrenia.
Future research should clearly
define the exact nature of a physical therapy program, with special
attention to the duration, frequency,
and intensity of any intervention
reported. Adherence, participants
characteristics (age, sex, illness
duration, and medication protocol), and adverse events should be
clearly described. Outcome measures should include measures relevant to schizophrenia-related symptoms and broader clinical outcomes,
such as health-related quality of life,
hospital admissions, and behavioral
outcomes (eg, through increasing
rates of abstinence from alcohol,
nicotine, or illegal drugs). For example, future studies could examine
whether implementing self-managed
aerobic exercise and relaxation techniques increases rates of abstinence
from substance abuse and whether
any effects of these interventions are
mediated by decreases in psychological distress and state anxiety and
increases in perceived well-being
during or after these activities.
Future research also needs to examine potential physiological mechanisms (eg, increased norepinephrine, serotonin, and beta-endorphin
levels and increased parasympathetic activity) or psychological
January 2012

mechanisms (eg, increased selfefficacy and distraction) that could


be responsible for an improved mental health state and reduced state
anxiety and psychological stress.55
Future studies on aerobic exercise
in people with schizophrenia also
should confirm whether their brains
retain a degree of plasticity in
response to exercise.
Finally, no RCTs investigated the role
of basic body awareness exercises.
The use of basic body awareness
exercises as an adjunct treatment
may be highly relevant for people
with schizophrenia. Various body
experience distortions have been
observed in schizophrenia; these
include symptoms of disembodiment, such as not feeling comfortable in ones body, or disintegration,
as if ones body were being torn
apart.56,57
Previous
qualitative
research58,59 in people with schizophrenia reported improvements in
body balance and postural control,
increased self-esteem, and an
improved ability to think after a
physical therapy program based on
basic body awareness exercises.
However, rigorous research is
needed before basic body awareness
therapy can be considered effective
in multidisciplinary treatment for
people with schizophrenia.

Conclusion
This systematic review demonstrated that specific physical therapy
interventions, including aerobic and
muscle strength exercises, progressive muscle relaxation, and yoga,
resulted in beneficial outcomes for
psychiatric symptoms, psychological
distress, state anxiety, health-related
quality of life, and aerobic and muscular fitness. Future research into
specific features of physical therapy interventions, such as tailoring
interventions to the needs of people
with schizophrenia, may contribute
to evidence for the efficacy of

physical therapy for people with


schizophrenia.
Mr Vancampfort, Ms Skjaerven, Dr CatalanMatamoros, Dr Lundvik-Gyllensten, and
Dr Hert provided concept/idea/research
design. Mr Vancampfort, Dr Probst, Ms
Skjaerven, Dr Catalan-Matamoros, Dr
Gomez-Conesa, and Dr Hert provided writing. Mr Vancampfort, Ms Skjaerven, Dr
Catalan-Matamoros, and Dr Gomez-Conesa
provided data collection. Mr Vancampfort,
Ms Skjaerven, and Dr Catalan-Matamoros
provided data analysis. Mr Vancampfort provided project management. Dr Probst provided participants. Dr Probst and Dr GomezConesa provided facilities/equipment. Dr
Probst, Dr Lundvik-Gyllensten, Dr GomezConesa, and Mr Ijntema provided institutional liaisons. Dr Probst, Ms Skjaerven, Dr
Lundvik-Gyllensten, and Dr Gomez-Conesa
provided consultation (including review of
manuscript before submission).
Mr Vancampfort was the first author of 2
of the assessed studies. Dr De Hert and
Dr Probst were coauthors of 2 of the
included studies. The other authors declare
that they have no conflict of interest related
to the present review.
DOI: 10.2522/ptj.20110218

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