# Exercise as it relates to Disease/The effect of an exercise therapy intervention for individuals with schizophrenia

This page is a factual analysis written by student u3141154 of the article "Exercise therapy improves mental and physical health in schizophrenia: a randomized controlled trial" by Scheewe et al (2012).

## Research Background
##### Schizophrenia Definition, Causes and Symptoms

Schizophrenia is a syndrome which incorporates signs and symptoms from a variety of psychiatric conditions. Products of schizophrenia include delusions, hallucinations, disorganized behaviour and emotional and social dysregulation. Disability can be both minimal and extreme, however most are in the middle and live good lives undergoing treatment. A combination of genetic, environmental and social influences are thought to be causes of schizophrenia.

##### Prevalence: Australia

* Approximately 1 in 100 will be diagnosed
* Top 10 cause of disability in developed countries
* Onset between 15 and 30
* Approximately 50% attempt suicide, 5% complete suicide
* Life expectancy reduced by up to 18 years
* Costs Australia approximately $2.6billion per year in health costs and loss of productivity

##### Antipsychotic Medication as treatment

Side effects such as involuntary movements, dyslipidemia, elevated glucose levels and weight gain as well as deficits in social interaction and memory can occur with use.

## Research Location

The study was conducted at the University of Medical Center Utrecht in the Netherlands where one of the authors; Thomas W. Scheewe works in the psychiatric department. Scheewe has coauthored many papers regarding schizophrenic patients and health interventions. Participants were recruited from the University Medical Center Utrecht and three regional mental healthcare institutes, were stable on antipsychotic medication and had no existing medical issues that prevented safe participation.

## Type of research

The intervention was a randomized controlled trial (RCT). RCT's are quantitative studies and involve random allocation of participants into treatment groups. RCT's are important tools in investigating effects between two or more interventions and are regarded as the gold standard approach within clinical testing.

#### Advantages and Disadvantages of RCTs (table)

| Advantages | Disadvantages |
| Minimizes bias | Artificial conditions |
| Makes groups comparable against unknown factors that might effect outcomes | Expensive and timely |
| Differences can be attributed to treatments | Often difficult to replicate in the 'real world' |
| Good internal validity - control over treatment exposure | Ethical considerations limit treatment options |

## Research Involvement

63 participants were randomly assigned to 2 hours of exercise therapy (ET) or occupational therapy (OT) weekly over 6months. ET focused on cardiovascular exercises however, strength exercise were incorporated into the program 6 times a week with 3 sets of 10-15 repetitions for variation. Intensity was increased gradually from 45-75% of heart rate reserve throughout the program. OT involved creative activities such as painting and reading. Measured outcomes included schizophrenic and depressive symptoms, cardiovascular fitness levels of peak Vo2 and power, need of care, BMI and body fat percentage (BF).

#### Additional comments

Each participant was screened before participation - minimizing result variation, creating good internal validity. Supervision by specialists (psychomotor therapist, occupational therapist) ensured accurate prescription, monitoring and implementation. It would've be interesting to have two different ET's to see whether aerobic or anaerobic exercise had the greatest effect. It would also be beneficial to see if a combination of OT and ET had an impact on results aswell as a control group with no intervention. Also, only immediate follow-up occurred; it would be informative to include further tests after study cessation to observe long term effects.

## Results of the research
#### Basic Results (table)

(% change in mean score from baseline to follow up)
| Test | ET | OT |
| Schizophrenic Symptoms | -20.7 | 3.3 |
| Depressive Symptoms | -36.6 | -4.4 |
| Need of Care | -22 | -4 |
| Peak Power | 9.7 | -3.3 |
| VO2 Max | -0.3 | -9.2 |
| BMI | -1.1 | 4.8 |
| BF | -2.0 | 3.3 |
Interpretation of analyses was quite accurate in that ET significantly increased peak power, reduced schizophrenic and depressive symptoms and need of care compared to OT. Power was improved with ET compared with OT - but this is expected when comparing exercise interventions against an almost sedentary intervention. Neither had much of an effect on BMI or BF; potentially due to the side effects of antipsychotic drugs including weight gain.

## Conclusion of results

The study highlighted important conclusions for readers. It was shown that ET when compared to OT undertaken 1-2 times a week over a 6 month period significantly improves both mental and cardiovascular health for individuals with schizophrenia. Results indicating a decrease in BMI and BF would've been desirable considering that weight gain is a harmful side effect of antipsychotic medication. Such results might have occurred if the researchers incorporated different methodology as mentioned in "additional comments". Experimental changes could've created more useful statistics ie type, duration, occurrence and intensity of physical activity which improves symptoms the greatest. Older studies highlight how aerobic exercise improves schizophrenic symptoms and either discount the effect of anaerobic exercise or do not include it in their study - and so limited research exists. It is only up until recently that focus on both aerobic and anaerobic exercise has been explored; whereby results have shown they are equally effective in reducing schizophrenic symptoms such as depression.

## Practical advice

For those interested in alleviating symptoms of schizophrenia, participating in an exercise intervention is an ideal way to achieve relief and improve quality of life. Before participating few considerations must be addressed.
For safe participation you MUST be
* stable on medication
* free of underling medical condition that may impair ability to exercise
* supervised by a professional to avoid injury and inappropriate prescription
For improved results you should
* adhere to the program
* undergo continual testing for program development
* incorporate both aerobic and anaerobic activities and fat burning exercises to reduce body fat
* incorporate other healthy lifestyle habits ie good nutrition, regular sleeping patterns and OT (creative activities)
Exercise interventions are a relatively cheap and versatile treatment option for schizophrenia. They can be catered to individuals for location, cost, equipment, health status and time allocation preferences. Social interaction and behaviour can also be improved by training in groups.

## Further information/resources

Follow the below links for further information regarding schizophrenia, support and its treatment options or consult a GP, psychiatrist or exercise physiologist.
* Support: http://www.sfnsw.org.au/Support-Groups#.V-d0DfVOJdg
* About Schizophrenia: http://www.schizophreniaresearch.org.au/schizophrenia/about-schizophrenia/
* Schizophrenia - treatments and drugs: http://www.mayoclinic.org/diseases-conditions/schizophrenia/basics/treatment/con-20021077
* Exercise and Schizophrenia: https://www.livingwithschizophreniauk.org/advice-sheets/exercise-schizophrenia/

## References

* 1 2 3 4 5 6 7 About schizophrenia. (2013, June 26). Retrieved from The Schizophrenia Research Institute of Australia web site: httpreniar://www.schizophesearch.org.au/schizophrenia/about-schizophrenia/
* ↑ Adkins, D. E., Åberg, K., McClay, J. L., Bukszár, J., Zhao, Z., Jia, P., . . . Van Den Oord, E. J. C. G. (2011). Genomewide pharmacogenomic study of metabolic side effects to antipsychotic drugs. Molecular Psychiatry, 16(3), 321-332. doi:10.1038/mp.2010.14
* ↑ Gobira, P. H., Ropke, J., Aguiar, D. C., Crippa, J. A. S., & Moreira, F. A. (2013). Animal models for predicting the efficacy and side effects of antipsychotic drugs. Revista Brasileira De Psiquiatria, 35(2), S132-S139.
* ↑ Definition of randomized controlled trial (2016, May 13). Retrieved from the Medicine Net website: http://www.medicinenet.com/script/main/art.asp?articlekey=39532
* ↑ Sullivan, G. M., (2011). Getting off the “gold standard”: randomized controlled trials and education research, (3): 285–289.
* ↑ Antipsychotic-induced weight gain in first-episode psychosis patients: A meta-analysis of differential effects of antipsychotic medications: Weight gain in FEP patients. Early Intervention in Psychiatry, 10(3), 193-202.
* ↑ Motta, R. W., & Stein, P. N., (1992). Effects of aerobic and nonaerobic exercise on depression and self-concept, 74(1):79-89.