# Exercise as it relates to Disease/Can exercise training improve the quality of life for individuals living with schizophrenia?

The research study 'The Health Benefits and Challenges of Exercise Training in Persons Living with Schizophrenia: A Pilot Study' by Shannon S. D. Bredin, Darren E. R. Warburton, and Donna J. Lang (2013), is a randomised control trial that will be further critiqued in this wiki.

## What is the background to this research?

* Schizophrenia is an illness that impacts the functioning of the brain. The condition causes intense psychosis that involve delusions, hallucinations, long periods of reduced expression, motivation and functioning.
* Evidence suggests that schizophrenia is also associated with an increased risk for the development of multiple cardio-metabolic diseases. The increased risk is thought to be contributed towards by physical inactivity and metabolic side effects psychotropic medication.
* Recently, more holistic approaches have gained traction, for improving brain health, physical health and well-being, removing the need for pharmaceutical drugs that may contribute to secondary complications.
* Current antipsychotic medication reduces the symptoms of psychosis, however, have various side effects that place individuals at an increased risk of developing chronic medical conditions such as type 2 diabetes, cardiovascular disease and metabolic syndrome.
* There is a higher prevalence of being overweight/obese and hyperglycaemia in individuals living with a mental illness creating the potential for many health implications.
* Numerous health benefits of exercise has contributed to the growing interest in the potential to aid individuals living with schizophrenia. Routine exercise has shown to decrease the risk of developing secondary complications and premature mortality as well as reduce the severity negative symptoms, stress, anxiety and depression in individuals with schizophrenia.
* Examining the most effective means to evaluate and prescribe exercise to individuals living with schizophrenia may aid combatting the secondary complications and risk of cardiovascular disease associated with pharmaceutical treatments

## Where is the research from?

* Research was conducted by multiple units of the University of British Columbia in Vancouver, Canada. The following units were involved: Cognitive and Functional Learning Laboratory; Physical Activity Promotion and Chronic Disease Prevention; Cardiovascular Physiology and Rehabilitation Laboratory; International Collaboration on Repair Discoveries; and the Department of Radiology.
* The research was supported by the Canadian Institutes of Health Research.
* Both the University of British Columbia and the Canadian Institutes of Health Research have excellent reputations for academics and research. Therefore, the credibility and validity of the study is accurate.

## What kind of research was this?

* The research conducted was a randomised clinically controlled trial.
* Patients were randomly assigned to one or more controlled trials where the intervention of either a resistance or aerobic training program was monitored and evaluated throughout.
* Randomised controlled trials are considered the gold standard for evaluating psychotropic medications and psychological interventions.

## What did the research involve?

* Thirteen patients (7 males: 6 females) living with schizophrenia enrolled in exercise trials in the Centre of Excellence in Brain Health and Wellness at the University of British Columbia.
* Patients participated in a series of tests pre and post intervention, including several assessments of health-related physical fitness (body mass, composition, aerobic fitness, blood pressure, heart rate and lipid profiles. The demographic and physical activity behaviours of the clients were also assessed, and adherence to the program was monitored objectively throughout the program via recording of attendance
* Patients were assigned randomly to a 12-week, supervised, aerobic or resistance training program (7 in aerobic and 6 in resistance).
* Exercise prescriptions were created by qualified exercise professionals, with all sessions containing a standard warm up, cool down and stretching. Program was reviewed weekly by an exercise professional.
| Aerobic Intervention | Resistance Intervention |
| 30 mins of moderate-to-vigorous intensity exercise Three times a week on varying exercise forms Progression was based on changes in individual heart rate (approx. 5% per week) | 30 minutes of moderate intensity resistance exercises at 50-70% of one-repetition maximum Three times a week, targeting major muscle groups. |
Limitations to methodology
* No cross over between groups, meaning the types of exercise cannot be evaluated in terms of effectiveness of reducing secondary complications.
* Groups were randomised, and did not account for the varying different medications the participants may be prescribed and side affects associated.
* Biases in design, recruitment, sample populations and data analysis are inevitable in real-world studies, therefore the results are only relevant in the setting that the study establishes.
* As this is a pilot study, there is no existing research to draw upon and guide the study to produce the most accurate results.

## What were the basic results?

* Results indicated relevant changes in many of the pre exercise assessments (anthropometry & body composition, resting lipid profile, resting blood pressure and heart rate, aerobic fitness, and physical activity).
* Results were interpreted by comparisons between post and pre exercise assessments, this showed clear changes in capacity of exercise as well as in body composition
Significant Results include:
* A clear improvement to the exercise tolerance post training intervention, reflected in the individuals VO2 peal power output and time until exhaustion.
* Significant increase in the physical activity of the patients.
* Training interventions resulted in a reduction in body mass of approximately 3 kg by the end of the study in participants that completed the exercise intervention.
* Clinically relevant reduction in waist circumference throughout the study.
* Clinically relevant reduction in resting systolic blood pressure.
* Referring psychiatrists reported the symptom severity of the patients in the program was improved over the duration, 15.8% reduction in symptom severity assessed by the Positive and Negative Syndrome Scale.

## What conclusions can we take from this research?

* An individualised program addresses the low adherence rate to exercise found in people living with schizophrenia, in turn getting the population more actively participating in physical activity.
* Research has investigated the most successful methods to engage individuals, aiding improvements in their cognitive and physiological function, status and overall well-being.
* The study looked at a population with schizophrenia, however the majority of results (body composition changes, cardiovascular health improvements and exercise capacity) of the exercise training is to be expected for any population that engages with, and increases, physical activity.
* The program demonstrated a reduction in negative symptoms relating with schizophrenia (assessed by the Positive and Negative Syndrome Scale) which is a positive outcome for those living with schizophrenia, as well as general society as it reduces the burden associated with the condition.
* Other, more recent studies have concluding similar results that negative symptoms associated with schizophrenia could be improved through exercise interventions. Exercise programs reduce cardio-metabolic risk, negative symptoms, cognitive deficits as well as aspects of the illness that may go untreated
* In turn, improving the quality of life by promoting a healthier, fitter lifestyle.

## Practical advice

* Engaging in routine exercise programs, functional activities, and individualised prescription tailored to the interests of the individual will aid in adherence rates and optimise the health benefits.
* In terms of helping people living with schizophrenia to engage, one on one instruction with appropriate medical/safety supervisions is required.
* Individuals prefer to exercise in a small group setting with others living with schizophrenia.
* In terms of exercise prescription, warming up as well as cooling down appropriately is an important component of an effective intervention.
* When engaging, specifically with resistance training, a lower resistance and relative intensity are required for each exercise.

## Further information/resources

* Further research into a program of a longer duration, and it’s impacts upon the negative symptoms of schizophrenia may provide more insight into how different variations of exercise can aid individuals living with the condition.
Support for individuals living with Schizophrenia can be found from the following resources:
* Mable
* SANE

## References

* ↑ (Unknown) SAA. Schizophrenia SANE.org: SANE Australia; 2017 [Available from: https://www.sane.org/information-stories/facts-and-guides/schizophrenia.
* ↑ Bredin S, Warburton D, Lang D. The health benefits and challenges of exercise training in persons living with schizophrenia: a pilot study. Brain sciences. 2013;3(2):821-48.
* ↑ Vancampfort D, Probst M, Helvik Skjaerven L, Catalán-Matamoros D, Lundvik-Gyllensten A, Gómez-Conesa A, et al. Systematic review of the benefits of physical therapy within a multidisciplinary care approach for people with schizophrenia. Physical therapy. 2012;92(1):11-23.
* ↑ Mulder R, Singh AB, Hamilton A, Das P, Outhred T, Morris G, et al. The limitations of using randomised controlled trials as a basis for developing treatment guidelines. Evidence-based mental health. 2018;21(1):4-6.
* ↑ Firth J, Cotter J, Elliott R, French P, Yung AR. A systematic review and meta-analysis of exercise interventions in schizophrenia patients. Psychological medicine. 2015;45(7):1343-61..
* ↑ Andrade e Silva B, Cassilhas RC, Attux C, Cordeiro Q, Gadelha AL, Telles BA, et al. A 20-week program of resistance or concurrent exercise improves symptoms of schizophrenia: results of a blind, randomized controlled trial. Brazilian Journal of Psychiatry. 2015;37(4):271-9.