EXERCISE INTERVENTIONS FOR POSTURAL STABILITY IN PATIENTS WITH SCHIZOPHRENIA: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Ikai-Tani *Saeko , Kamiyma Saki , Tani Hideaki , Uchida Hiroyuki 
Published: February 2025

Abstract

Background
Patients with schizophrenia generally need long-term antipsychotic treatment for relapse prevention. On the other hand, antipsychotic drugs cause postural instability, resulting in an increased risk of falls. Therefore, potential interventions that could enhance postural stability have long been desired for this population. While exercise reportedly improves positive and negative symptoms, cardiopulmonary function, and cognitive functions in patients with schizophrenia, its impact on the postural sway remains unclear in schizophrenia.

Aims & Objectives
This systematic review and meta-analysis aimed to investigate whether exercise improves postural sway in schizophrenia.

Method
We conducted comprehensive literature searches in multiple electronic bibliographic databases using terms related to physical activity interventions, combined with keywords such as "schizophrenia," "exercise," and "postural sway" according to the PRISMA statement (RPOSPERO-ID: CRD42023425865). We included studies investigating the postural stability in patients aged 18 and over with schizophrenia who underwent any exercise intervention in addition to their pharmacotherapy. The primary outcome measure was the postural sway, as indicated by pre- and post-intervention scores. A standardized data collection tool extracted statistical information from the primary studies. For each included trial, treatment effects measured by continuous variables were calculated using standardized mean differences (SMD) along with 95% confidence intervals (CI) using EZR statistical software. We assessed the data for risk of bias, heterogeneity, reporting bias, and quality of evidence.

Results
Out of the 328 articles initially identified, a total of nine studies were selected for inclusion, involving 317 participants with a mean age of 46.3 years (including 151 men). There were five randomized controlled trials (55.6%), following two experimental studies (22.2%), a longitudinal study (11.1%) and one pilot study (11.1%). The duration of the intervention ranged from six weeks to 14 months, with sessions lasting 20 to 90 minutes (mean 56.1 minutes) and occurring 1 to 3 times per week. Most interventions incorporated body-mind interventions (55.6%), such as yoga therapy and Pilates.
Despite the variation in evaluation methods, seven studies (77.8%) demonstrated a significant improvement in postural instability following each intervention.
Meta-analysis of any exercise interventions revealed lack of significant improvement in postural sway (N=7, n=265, SMD=-0.19, 95% CI: -0.81 to 0.43, p=0.54, I2=78%, p&lt;0.01). However, in a subgroup analysis, both yoga therapy (N=4, n=158, SMD=-0.42, 95% CI: -0.74 to -0.11, p=0.009, I2=0%, p=0.48) and Pilates (N=2, n=40, SMD=-0.81, 95% CI: -1.47 to -0.15, p=0.015, I2=1%, p=0.32) significantly improved the postural instability. In addition, each study exhibited ineligible bias in randomization, and the overall study quality was not high.

Discussion & Conclusion
While the meta-analysis of all exercise types combined found no significant improvements in postural sway, subgroup analyses focusing on Pilates and yoga therapy significantly enhanced postural stability. Exercises targeting core muscles and relaxation elements may reduce postural instability in schizophrenia. Since this review is limited by the scarcity of exercise types, further exercise interventions in addition to pharmacotherapy are warranted.