# Exercise as it relates to Disease/The effectiveness of Yoga therapy and aerobic exercise on people with Schizophrenia
## What is the background to this research?

State anxiety, psychological stress, and negative wellbeing are known to be common responses and co-morbidities individuals on the Schizophrenia spectrum. The poor management of these responses work cyclically with the exacerbation of Schizophrenic symptoms. Davy Vancampfort and his accompanying cohort completed a randomized comparative trial to evaluate acute changes in these psychological responses after single sessions of Yoga therapy and aerobic exercise, accompanied with a controlled condition.
There have been copious amounts of studies investigating how particular types of PA, including Yoga and aerobic exercise, impact numerous psychological and physiological health outcomes of Schizophrenia. Exercise has long been known to improve both acute and chronic levels of anxiety and stress in the general population. However, this study is the first to demonstrate large effect sizes in transient reductions in state anxiety, psychological stress, and increases in subjective wellbeing for individuals with Schizophrenia. The research constructs on solid foundations, with some practical implications for add-on physiotherapy treatment. However the topic requires further research investigating other components of underlying physiological, psychological, and behavioural mechanisms and outcomes.

## Where is the research from?

In Kortenberg, Belgium a cohort of patients with Schizophrenia or Schizoaffective disorder of an acute inpatient care unit of the University Psychiatric Centre of Kortenberg were invited to participate in the study. Published fairly recently, in 2010, the study was collectively conducted by eight authors, Davy Vancampfort et al.,. Vancampfort is a reputable Belgium Physiotherapist with vast skills and expertise, and numerous published research, much alike his co-authors. The process of authorization of this paper involved approval through the Ethical Committee of the University of Psychiatric Centre, in accordance with the principles of the declaration of Helsinki. The declaration is a highly regarded statement outlining ethical principles involved in research of human subjects which has long been adopted by the World Medical association. The authors also report no conflicts of interest and were solely responsible for the content and writing of the paper.

## What kind of research was this?

This study construct was a randomized controlled trial conducted over an 8-month period. Patients with Schizophrenia and Schizoaffective disorder participated in three within-subject conditions, Yoga therapy, aerobic exercise, and a control condition used for a comparative purpose of the study. A randomized control trial is a high regarded baseline as it is the only study design that assesses cause-effect relationships between the intervention and outcome. Because it was a with-in subject design there was no effects of individual variation, however, there would have been potential for a carry-over effect without the reduced bias due to the randomisation of the condition order.

## What did the research involve?
### Inclusion and exclusion criteria for participant recruitment

| Inclusion Criteria | Exclusion Criteria | Exclusion Criteria |
| Diagnosed Schizophrenia or Schizoaffective disorder | Psychiatric co-morbidities | Somatic co-morbidities |
| Clinical Global Impression Score (CGIS) ≥ 4 | Anxiety disorders | Cardiovascular disorders |
| Cooperative in Yoga therapy or aerobic exercise conditions | Depressive disorders | Neuromuscular disorders |
| | Substance dependence | Endocrine disorders |

### Sample size

* Participants initially recruited (n=57)
* Excluded/non-compliant participants (n=17)
** Anxiety disorder (n=1)
** Substance dependence (n=5)
** Neuromuscular disorder (n=2)
** Did not agree to participate (n=5)
** Did not complete test conditions (n=2)
* Participants included in final analysis (n=40)
** Males (n=22)
** Females (n=18)

### Conditions

The study was investigating comparative effects of a single bouts of two different types of exercise, with one control condition. In one week, the participants undertook the Yoga and aerobic exercise sessions to get used to the environment and protocol. The week after the exercise conditions were performed in a randomly assigned order, with a physiotherapist present, on a one-one basis on consecutive days, at the same hour. Questionnaires were completed after the sessions without the Physiotherapist present.
30 minute Hatha Yoga therapy session (n=40)
* Cardiovascular warming up- 5 min
* Abdominal breathing exercises - 5 min
* Asanas
** Tadasana (mountain posture) - 3 min
** Vrikshasana (tree posture) - 3 min
** Bidalasana (cat posture) - 3 min
** Bhujangasana (cobra posture) - 3 min
** Apanasana (knees to chest posture) - 3 min
* Relaxation technique (Shavasana) - 5 min
20 minute Aerobic exercise (n=40)
* Electronically braked bicycle ergometer
* Self selected intensity with heartrate feedback
20 minute control condition (n=40)
* Sat quietly in a room with personal and/or supplied reading material
* Physiotherapist present

### Assessment of methodology

Methodological limitations developed from the amount of individuals who were excluded or voluntarily didn't participate. These high drop out rates and small sample size increased the risk of selection bias as the individuals who chose to participate likely already had interest and knowledge of the benefits of PA. However, the excluded criteria was necessary to prevent outlying data and a with-in subject design doesn't always require large sample size. There was no investigation of the physiological or psychological mechanisms potentially responsible for improved responses, limiting a more evidence based outcome and introducing the potential for other determinants of the result.

## What were the basic results?

The analysis of State anxiety, psychological stress, and positive wellbeing all identified significant effect sizes from both the Yoga therapy and aerobic exercise conditions, compared with the no-exercise control conditions. There were no significant differences between the exercise conditions for each psychological response however. These findings support the claim that single bouts of exercise can have a positive transient effect on State anxiety, Psychological stress, and subjective wellbeing for the participants.

## What conclusions can we take from this research?

The research did conclude with significant effect sizes that single bouts of exercise such as Yoga therapy and aerobic exercise have transient effects on several psychological responses in the participants. The study design is highly regarded to prevent bias and assessment of a cause-effect relationship. This has some practical implications for physiotherapy as a form of treatment for this population, however, as there is limited research (when published), which requires more investigation into the underlying mechanisms that improve these responses and the limitations of generalisability.

## Practical advice

This research poses exercise adherence as a generalisability limitation, a result of the clinical population's characteristics. Anxiety, wellbeing and stress are common co-morbidities in individuals with Schizophrenia. Because mental illness, and Schizophrenia in particular, is often so debilitating, there is often a lack of adherence to PA, notable in the large drop out rate, leading to the cyclic deterioration of psychological and physiological health and diagnosed co-morbidities. A result of numerous economic, social, behavioural, and environmental determinants. Providing interesting choice of type and content of PA, monitoring intently, while ensuring specialisation to each individual can improve these limitations. For individuals not in direct care of psychiatric institutions, it can pose even more difficult for the prescription of exercise. Coordinating the advertisement of PA programs through individual's GPs, psychiatrists, and other forms of individual healthcare is a consideration to encourage PA for these external settings.

## Further information/resources

* A brief intervention to improve exercising in patients with schizophrenia: a controlled pilot study with mental contrasting and implementation intentions (MCII)
* Yoga therapy for Schizophrenia
* Aerobic exercise and yoga improve neurocognitive function in women with early psychosis
* Co-morbidities of mental disorders and chronic physical diseases in developing and emerging countries: a meta-analysis

## References

* 1 2 Temmingh, H., & Stein, D. J. (2015). Anxiety in Patients with Schizophrenia: Epidemiology and Management. CNS drugs, 29(10), 819–832. https://doi.org/10.1007/s40263-015-0282-7
* 1 2 3 4 5 6 7 Vancampfort, D., De Hert, M., Knapen, J., Wampers, M., Demunter, H., Deckx, S., Maurissen, K., & Probst, M. (2011). State anxiety, psychological stress and positive well-being responses to yoga and aerobic exercise in people with schizophrenia: a pilot study. Disability and rehabilitation, 33(8), 684–689. https://doi.org/10.3109/09638288.2010.509458
* ↑ Richardson, C. R., Faulkner, G., McDevitt, J., Skrinar, G. S., Hutchinson, D. S., & Piette, J. D. (2005). Integrating physical activity into mental health services for persons with serious mental illness. Psychiatric services (Washington, D.C.), 56(3), 324–331. https://doi.org/10.1176/appi.ps.56.3.324
* ↑ Vancampfort, D., Knapen, J., Probst, M., Van Winkel, R., Peuskens, J., Maurissen, K., Demunter, H., & De Hert, M. (2010). [The therapeutic value of physical exercise for people with schizophrenia]. Tijdschrift voor psychiatrie, 52(8), 565-574. http://europepmc.org/abstract/MED/20697996
* ↑ Rosa Rimes, R., Marcos de Souza Moura, A., Khede Lamego, M., Souza de Sa Filho, A., Manochio, J., Paes, F., Giovanni Carta, M., Mura, G., Wegner, M., Budde, H., Barbosa Ferreira Rocha, N., Rocha, J., Manuel R.S. Tavares, J., Arias-Carrion, O., Egidio Nardi, A., Yuan, T.-F., & Machado, S. (2015). Effects of Exercise on Physical and Mental Health, and Cognitive and Brain Functions in Schizophrenia: Clinical and Experimental Evidence. CNS & Neurological Disorders - Drug Targets- CNS & Neurological Disorders), 14(10), 1244-1254. https://www.ingentaconnect.com/content/ben/cnsnddt/2015/00000014/00000010/art00002
* ↑ Carek, P. J., Laibstain, S. E., & Carek, S. M. (2011). Exercise for the Treatment of Depression and Anxiety. The International Journal of Psychiatry in Medicine, 41(1), 15-28. https://doi.org/10.2190/PM.41.1.c
* ↑ Davy Vancampfort (researchgate.net) Michel Probst (researchgate.net) Marc De Hert (researchgate.net) Jan Knapen (researchgate.net) Martine Jaspers (researchgate.net) Hella Demunter (researchgate.net) Seppe Deckx (researchgate.net) Katrien Meuwissen (researchgate.net)
* ↑ Declaration of Helsinki – WMA – The World Medical Association
* 1 2 3 Kapoor, M. (2016). Types of studies and research design. Indian Journal of Anaesthesia, 60, 626. https://doi.org/10.4103/0019-5049.190616
* ↑ Laursen T. M. (2011). Life expectancy among persons with schizophrenia or bipolar affective disorder. Schizophrenia research, 131(1-3), 101–104. https://doi.org/10.1016/j.schres.2011.06.008
* ↑ Sailer, P., Wieber, F., Pröpster, K., Stoewer, S., Nischk, D., Volk, F., & Odenwald, M. (2015). A brief intervention to improve exercising in patients with schizophrenia: a controlled pilot study with mental contrasting and implementation intentions (MCII). BMC psychiatry, 15, 211. https://doi.org/10.1186/s12888-015-0513-y
* ↑ Bangalore, N. G., & Varambally, S. (2012). Yoga therapy for Schizophrenia. International journal of yoga, 5(2), 85–91. https://doi.org/10.4103/0973-6131.98212
* ↑ Lin, J., Chan, S. K. W., Lee, E. H. M., Chang, W. C., Tse, M., Su, W. W., Sham, P., Hui, C. L. M., Joe, G., Chan, C. L. W., Khong, P. L., So, K. F., Honer, W. G., & Chen, E. Y. H. (2015). Aerobic exercise and yoga improve neurocognitive function in women with early psychosis. npj Schizophrenia, 1(1), 15047. https://doi.org/10.1038/npjschz.2015.47
* ↑ Daré, L. O., Bruand, P. E., Gérard, D., Marin, B., Lameyre, V., Boumédiène, F., & Preux, P. M. (2019). Co-morbidities of mental disorders and chronic physical diseases in developing and emerging countries: a meta-analysis. BMC public health, 19(1), 304. https://doi.org/10.1186/s12889-019-6623-6