Systematic Review of the Benefits Of

Systematic Review of the Benefits ofPhysical Therapy Within aMultidisciplinary Care Approach forPeople With SchizophreniaDavy 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 disability-adjusted life years worldwide in people aged 15 to 44 years, the clinical evidence ofphysical therapy as a complementary treatment remains largely unknown.

Purpose. The purpose of this study was to systematically review randomizedcontrolled trials (RCTs) evaluating the effectiveness of physical therapy for peoplewith schizophrenia.

Data Sources. EMBASE, PsycINFO, PubMed, ISI Web of Science, CumulativeIndex to Nursing and Allied Health Literature (CINAHL), Physiotherapy EvidenceDatabase (PEDro), and the Cochrane Library were searched from their inception untilJuly 1, 2011, for relevant RCTs. In addition, manual search strategies were used.

Study Selection. Two reviewers independently determined study eligibility onthe basis of inclusion criteria.

Data Extraction. Reviewers rated study quality and extracted information aboutstudy methods, design, intervention, and results.

Data Synthesis. Ten RCTs met all selection criteria; 6 of these studies addressedthe use of aerobic and strength exercises. In 2 of these studies, yoga techniques alsowere investigated. Four studies addressed the use of progressive muscle relaxation.There is evidence that aerobic and strength exercises and yoga reduce psychiatricsymptoms, state anxiety, and psychological distress and improve health-related qual-ity of life, that aerobic exercise improves short-term memory, and that progressivemuscle relaxation reduces state anxiety and psychological distress.

Limitations. The heterogeneity of the interventions and the small sample sizes ofthe included studies limit overall conclusions and highlight the need for furtherresearch.

Conclusions. Physical therapy offers added value in the multidisciplinary care ofpeople with schizophrenia.

D. Vancampfort, PT, MSc, Facultyof Kinesiology and Rehabilita-tion Sciences, Catholic Univer-sity Leuven, Leuven, Belgium,and University Psychiatric Centre,Catholic University Leuven, Cam-pus Kortenberg, Leuvensesteen-weg 517, 3070 Kortenberg, Bel-gium. Address all correspondenceto Mr Vancampfort at: [email protected].

M. Probst, PT, PhD, University Psy-chiatric Centre, Catholic Univer-sity Leuven, Campus Kortenberg,and Faculty of Kinesiology andRehabilitation Sciences, CatholicUniversity Leuven.

L. Helvik Skjaerven, PT, MSc,Department of Physical Therapy,Faculty of Health and Sciences,Bergen University College, Ber-gen, Norway.

D. Catalan-Matamoros, PT, PhD,Faculty of Health Sciences, Univer-sity of Almeria, Almeria, Spain.

A. Lundvik-Gyllensten, PT, PhD,Division of Physical Therapy, Fac-ulty of Health Sciences, Lund Uni-versity, Lund, Sweden.

A. Gomez-Conesa, PT, PhD,Department of Physical Therapy,University of Murcia, Murcia,Spain.

R. Ijntema, PT, MBA, Institute ofHuman Movement Studies, Fac-ulty of Health Care, HU Universityof Applied Sciences Utrecht,Utrecht, the Netherlands.

M. De Hert, MD, PhD, UniversityPsychiatric Centre, Catholic Uni-versity Leuven, Campus Korten-berg, and Faculty of Medicine,Catholic University Leuven.

[Vancampfort D, Probst M, HelvikSkjaerven L, et al. Systematicreview of the benefits of physicaltherapy within a multidisciplinarycare approach for people withschizophrenia. Phys Ther. 2012;92:11–23.]

© 2012 American Physical TherapyAssociation

Published Ahead of Print:November 3, 2011

Accepted: August 30, 2011Submitted: July 8, 2011

Research Report

Post a Rapid Response tothis article at:ptjournal.apta.org

January 2012 Volume 92 Number 1 Physical Therapy f 11

mailto:[email protected]

mailto:[email protected]

Schizophrenia is one of the mostdebilitating psychiatric disor-ders.1 It accounts for 1.1% of

total disability-adjusted life years andfor 2.8% and 2.6% of years lived withdisability for men and women,respectively. In addition, it is thefifth leading cause of disability-adjusted life years worldwide inpeople who are 15 to 44 years old.2

Its lifetime prevalence and inci-dence range from 0.30% to 0.66%and from 10.2 to 22.0 per 100,000person-years, respectively.3 Accord-ing to criteria in the Diagnosticand Statistical Manual of MentalDisorders, Fourth Edition (DSM-IV),schizophrenia comprises both posi-tive and negative symptomatologysevere enough to cause social andoccupational dysfunction.4 Positivesymptoms reflect an excess or dis-tortion of normal functions andinclude delusions, hallucinations, anddisorganized speech and behavior.Negative symptoms reflect a reduc-tion or loss of normal functions andinclude affective flattening, apathy,avolition, and social withdrawal.Mesolimbic dopaminergic hyperac-tivity is believed to be part of theunderlying pathology associated withpositive symptoms,5 but the patho-physiology of negative symptoms ispoorly understood. Negative symp-toms therefore remain a relativelytreatment-refractory and debilitatingcomponent of schizophrenia.6

Once the diagnosis is made, anti-psychotic drugs that block dopa-mine D2 receptors are the maintreatment for people with schizo-phrenia.7 First-generation antipsy-chotics (eg, chlorpromazine, flu-phenazine, and haloperidol) are

effective in the management of psy-chotic symptoms but often lead tomotor side effects. In the past 15years, so-called second-generationagents (eg, amisulpride, aripiprazole,olanzapine, quetiapine, and risperi-done) that less frequently causemotor side effects have been intro-duced for symptom management.Although second-generation anti-psychotics are as effective as first-generation agents in managing posi-tive symptoms, their promise ofgreater efficacy against negativeand cognitive symptoms has notbeen borne out.8 Many people withschizophrenia continue to have per-sistent symptoms and relapses, par-ticularly when they fail to adhereto prescribed medication regimens.This situation underlines the needfor multimodal care, including psy-chosocial therapies, as an adjunctto antipsychotic medications to helpalleviate symptoms and to improveadherence, functional outcomes,and health-related quality of life.9

Research on psychosocial approachesto treatment for people with schizo-phrenia has yielded incremental evi-dence of the efficacy of cognitivebehavioral therapy, social skills train-ing, family psycho-education, asser-tive community treatment, and sup-ported employment.7–9 Additionalresearch is needed to examine theaspects of therapeutic modalitiesthat work and to identify the syner-gistic effects of combinations ofinterventions. Recently, there hasbeen interest in the relative effective-ness of physical therapy interven-tions in multidisciplinary treatmentfor people with schizophrenia.10

The International Organization ofPhysical Therapy in Mental Health(formerly the International Councilof Physiotherapy in Psychiatry andMental Health) stated that in themultidisciplinary care of people withschizophrenia, physical therapy isintended to improve physical andmental health and health-related

quality of life.11 For people withschizophrenia, an enhanced abilityto cope with disease symptomstends to improve health-related qual-ity of life.12 Numerous physical ther-apy interventions are potentiallyeffective in improving physical andmental health and health-relatedquality of life. The techniques mostcommonly used in daily clinical prac-tice are aerobic and strength exer-cises, relaxation training, and basicbody awareness exercises.10,13

People with schizophrenia, who aremore likely to be less physicallyactive than people in the generalpopulation14,15 and are consequentlyat high risk for chronic medical con-ditions associated with physical inac-tivity,16,17 have the same physicalhealth needs as other people whoare sedentary. For example, meta-bolic and cardiovascular diseaseshave become a major concern inpeople with schizophrenia.18 Peoplewith schizophrenia are 1.5 to 2 timesmore likely to be overweight, theirrisk for diabetes and hypertension is2-fold higher, and dyslipidemia is 5times more prevalent in people withschizophrenia than in people in thegeneral population.19 The excessmorbidity from cardiovascular dis-eases results in increased prematuremortality—2 or 3 times as high asthat in the general population.20,21

The mortality gap translates to ashortening of life expectancy by 13to 30 years compared with that inthe general population22,23 and is stillwidening.24,25 A previous systematicreview of physical activity with orwithout diet counseling concludedthat lifestyle interventions are feasi-ble and effective in reducing weightand improving the obesity-relatedcardiometabolic risk profile in peo-ple with schizophrenia.26

Beneficial mental health effects fromphysical therapy interventions alsohave been reported. For example,earlier systematic reviews indicated

Available WithThis Article atptjournal.apta.org

• eTable: Excluded RandomizedControlled Trials

Multidisciplinary Care for People With Schizophrenia

12 f Physical Therapy Volume 92 Number 1 January 2012

http://ptjournal.apta.org/content/92/1/11/suppl/DC1

that aerobic exercise reduces nega-tive and positive symptomatologyand alleviates secondary symptoms,such as depression, low self-esteem,and social withdrawal.27–30

The conclusions of these system-atic reviews, however, were mainlybased on data from uncontrolledtrials, and the findings, therefore,should be interpreted with caution.More recently, a meta-analysis ofaerobic exercise31 indicated that reg-ular physical activity is possible forpeople with schizophrenia. Aerobicexercise can have beneficial effectson both the physical and mentalhealth and the well-being of peoplewith schizophrenia, although thereis currently insufficient evidence tosupport or refute the use of aerobicand strength exercises as a comple-mentary intervention.31 To ourknowledge, no systematic reviews ofrelaxation training and basic bodyawareness exercises are available.The question of whether aerobic andstrength exercises, relaxation train-ing, and basic body awareness exer-cises are effective additions to themultidisciplinary management ofschizophrenia, therefore, remainslargely unanswered. Thus, the pur-pose of this systematic review was toevaluate the methodological qualityof and summarize the evidence fromrandomized controlled trials (RCTs)examining the effectiveness of thesephysical therapy interventions in themultidisciplinary management ofschizophrenia.

MethodData Sources and SearchesA literature search was conductedaccording to the search strategy ofDickersin et al.32 No restrictionswere made regarding the language ofpublication. EMBASE, PsycINFO,PubMed, ISI Web of Science, Cumu-lative Index to Nursing and AlliedHealth Literature (CINAHL), Physio-therapy Evidence Database (PEDro),and the Cochrane Library were

searched from their inception untilJuly 1, 2011, for RCTs. Medical sub-ject headings included “schizophre-nia” AND “physical therapy” OR“exercise” OR “relaxation” in thetitle, abstract, or index term fields.Two investigators independentlyscreened the titles of the publica-tions found in the databases and, ifavailable, the abstracts of the publi-cations as well. If either investigatorbelieved that any published articlepotentially met the inclusion criteriaor if there was inadequate informa-tion to make a decision, a copy of thearticle was obtained or the authorswere contacted to obtain the neces-sary data.

The next phase of the search strat-egy involved searching for unpub-lished RCTs and for RCTs potentiallyoverlooked or absent from the data-bases. This step involved manuallysearching the reference lists in allretrieved articles and the availablesystematic reviews for potential stud-ies to locate unpublished or over-looked research. Furthermore, wesearched Web sites housing detailsof clinical trials, theses, or disserta-tions. Citation indexing was used totrack referencing of key authors inthe field, and local experts were con-tacted for further information.

Study SelectionInclusion in this review wasrestricted to studies of people with adiagnosis of schizophrenia or othertypes of schizophrenia spectrumpsychoses (schizoaffective or schizo-phreniform disorder, excludingbipolar disorder and major depres-sion with psychotic features) on thebasis of any criteria, any length ofillness, and any treatment setting.We did not exclude trials because ofthe age, nationality, or sex of theparticipants.

Types of interventions. Studieswere considered eligible for inclu-sion if they were RCTs compar-

ing physical therapy interventionswith a placebo condition, controlintervention, or standard care. Theexperimental physical therapy inter-ventions could comprise aerobicexercises, strength exercises, relax-ation training, basic body aware-ness exercises, or a combination ofthese in accordance with the WorldConfederation for Physical Therapyposition statement.33 A physicaltherapy intervention could be usedalone or in conjunction with otherinterventions, with physical therapybeing considered the main or activeelement. Interventions that includedphysical therapy in a multiple-component weight managementprogram were excluded becausethe specific effects of the physicaltherapy intervention could not beaddressed. Other interventions couldinclude any of the following: phar-macotherapy, psycho-education, andcognitive-behavioral or motivationaltechniques related to exercisebehavior. Standard care was definedas care that people would normallyreceive had they not been includedin the research trial. Such care wouldinclude medication, hospitalization,community psychiatric nursing sup-port, and outpatient care. For anRCT to be included, the experimen-tal and comparison interventionsmust have had similar durations.

Types of outcomes. Outcomeswere grouped according to assess-ments of mental health, physicalhealth, and health-related quality oflife.

Data Extraction andQuality AssessmentAssessments of quality were com-pleted independently by the 2reviewers. Disagreements wereresolved by discussion. If no consen-sus was achieved, a third reviewermade the final decision. Each studywas evaluated with the previouslyvalidated 5-point Jadad scale34 toassess the completeness and quality



of reporting of RCTs as well as toassess for potential bias in the trials.This widely used scale focuses on3 dimensions of internal validity:quality of randomization, double-blinding, and withdrawals. This scaleis the only published instrumentthat has been created according topsychometric principles.35,36 A scoreof 0 to 5 is assigned, with higherscores indicating higher quality inthe conduct or reporting of a trial. Atrial scoring at least 3 of 5 is consid-ered to be of strong quality. A trialscoring below 3 is considered to bemethodologically weak.

Data Synthesis and AnalysisEach study was assessed with a rat-ing system originally developed byde Vet et al.37 This rating system pro-vides a detailed evaluation of studymethods and was used previously insystematic reviews for physical ther-apy.38,39 The rating system of de Vetet al37 considers criteria relevant tothe practice of physical therapy,such as participant characteristics,sample size, description of interven-tions, and the validity and reliabilityof the chosen outcome measures.The 2 assessors independentlyreviewed each study on the basis ofthe specific criteria of this rating sys-tem. For each criterion, 3 ratingswere available: pass (met the crite-rion), moderate (incompletely or

partially met the criterion), and fail(did not meet the criterion); the failrating also was assigned when noinformation about a specific crite-rion was provided in the publication.Each quality criterion was evaluatedseparately. At present, there are noclear decision rules for establishingcutoff scores for high- and low-quality studies with this tool; there-fore, summary scores were not used.

A data collection form was devel-oped and used by 1 reviewer (D.V.)to extract data from the includedstudies while a second reviewer(M.P.) cross-checked the extracteddata. The data items extracted areshown in Table 1.

ResultsStudy SelectionThe initial electronic database searchresulted in a total of 2,162 articles.Through additional manual searchesof reference lists, searches of Websites, and consultation of experts inthe field, 1 other potentially eligiblearticle was identified. After theremoval of duplicates and screeningof titles, abstracts, or full texts, 10RCTs were included (Fig.).40–49 Rea-sons for exclusion are shown in theFigure. A list of excluded screenedRCTs with reasons for exclusion isprovided in the eTable (available atptjournal.apta.org). On the basis of

the first full-text screening, wedecided that there was too muchheterogeneity in study designs andprotocols to apply a formalmeta-analysis.

ParticipantsIn total, 322 participants wereincluded in the analyses. Except forparticipants in 2 studies40,41 pub-lished before the appearance ofDSM-IV (the most recent edition ofthe Diagnostic and Statistical Man-ual of Mental Disorders, publishedin 1994), all participants were diag-nosed with schizophrenia on thebasis of DSM-IV criteria. Two studiesincluded both inpatients and outpa-tients,43,45 2 studies concentratedsolely on outpatients,42,47 and theother studies included only inpa-tients. The participants ranged in agefrom 18 to 63 years. With this strat-egy, both participants with first epi-sodes and participants with chronicconditions were included. In most ofthe studies, the participants weremen. Detailed information on thecharacteristics of the participants isprovided in Table 2.

Methodological QualityTwo of the included studies40,41

were considered to be of weak meth-odological quality (Tab. 2). Furtherdetails of the study characteristicsare provided in Table 3. The 2 mostcommon methodological concernswere limited sample size and lack ofmasking (“blinding”), especially ofparticipants.

Effectiveness of aerobic exercises,strength exercises, or both in themultimodal care of people withschizophrenia. The investigatorsin 6 studies42,43,45–48 examined theeffectiveness of aerobic exercises,strength exercises, or both in multi-disciplinary standard care for peoplewith schizophrenia. All 6 studieswere considered to be of strongmethodological quality. In 1 study43

of 3 studies42,43,46 examining the

Table 1Data Extraction

Criterion Items

Design First author name

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



???

effectiveness of these exercises forpositive and negative symptoms, thereductions found were significant. Inthe studies of Duraiswamy et al43 andBehere et al,46 aerobic exercises,strength exercises, or both werecompared with yoga as a comple-

mentary intervention. Participantspracticing yoga reported signifi-cantly greater reductions in positiveand negative symptoms. Health-related quality of life improved onlyafter yoga.43 The investigators in 3studies42,45,47 examined changes in

aerobic fitness, muscular fitness, orboth; 2 studies42,45 included the Six-Minute Walk Test; and 1 study47

included incremental cycle ergom-etry. Although both studies includ-ing the Six-Minute Walk Testrevealed increases in the distance

Figure.Flow chart of systematic review inclusion and exclusion. CINAHL�Cumulative Index to Nursing and Allied Health Literature,PEDro�Physiotherapy Evidence Database, RCT�randomized controlled trial.



Tab

le2.

Det

ails

ofIn

clud

edRa

ndom

ized

Con

trol

led

Tria

lsa

Stu

dy

Par

tici

pan

ts

Exp

erim

enta

lvs

Co

ntr

ol

Inte

rven

tio

n(N

o.

of

Par

tici

pan

ts)

Du

rati

on

Freq

uen

cyIn

ten

sity

Rel

evan

tO

utc

om

es(E

xp

erim

enta

lvs

Co

ntr

ol)

Rel

evan

tIn

stru

men

tsC

om

ple

men

tary

Co

inte

rven

tio

nJa

dad

Sco

re

Haw

kins

etal

40

40in

pat

ient

s(1

7m

en)

with

schi

zop

hren

ia(D

SM-I

II);

mea

nag

e�35

y

PMR

(10)

vsm

inim

altr

eatm

ent

(ask

edto

rela

x)(1

0)vs

ther

mal

feed

back

(10)

vsPM

R�

ther

mal

feed

back

(10)

2w

k40

min

5tim

es/w

kRe

duct

ions

acro

ssgr

oup

sfo

rst

ate

anxi

ety

(F�

3.95

;df

�1,

36;

P�.0

5);

nogr

oup

diffe

renc

es(F

�1.

34;

df�

12,8

5;P�

.21)

;re

duct

ions

asso

ciat

edw

ithfe

wer

hosp

itala

dmis

sion

sat

1-y

follo

w-u

p( �

2�

6.6,

P�.0

5)

Ham

ilton

Anx

iety

Stat

e;Br

ief

Psyc

hiat

ricRa

ting

Phar

mac

othe

rap

yin

allc

ondi

tions

2

Phar

ran

dC

ours

ey4

1

30in

pat

ient

sw

ithsc

hizo

phr

enia

(DSM

-III

);m

ean

age�

35y

PMR

(10)

vsEM

Gbi

ofee

dbac

k(1

0)vs

liste

ning

tore

cord

edre

adin

gs(1

0)

20m

in7

indi

vidu

alse

ssio

nsN

osi

gnifi

cant

chan

ges

inte

nsio

n-an

xiet

ysc

ores

Tens

ion-

anxi

ety

dom

ain

ofPO

MS

Phar

mac

othe

rap

yat

mai

nten

ance

-le

veld

osag

esin

allc

ondi

tions

2

Beeb

eet

al4

210

outp

atie

nts

(8m

en)

with

schi

zop

hren

ia(D

SM-I

V);

age�

40–6

3y

Aer

obic

exer

cise

s(t

read

mill

wal

king

)(6

)vs

care

asus

ual(

4)

16w

kFr

om25

min

3tim

es/w

k(w

k1)

to50

min

3tim

es/w

k(w

k3

toen

d)

10m

inof

war

min

gup

,5–

30m

inof

mod

erat

e-in

tens

ityw

alki

ng,

and

10m

inof

cool

ing

dow

n

Low

erbo

dyfa

tp

erce

ntag

e(�

3.7%

vs�

0.02

%,

P�.0

3);

low

erBM

I(�

1.3%

vs�

0.02

%,

P�.0

5);

high

er6M

WT

scor

e(�

10%

vs�

4%,

P�.0

5);

few

erp

ositi

vean

dne

gativ

esy

mp

tom

s(�

13.5

%vs

�5%

,P�

.05)

Skin

fold

mea

sure

men

ts;

6MW

T;PA

NSS

Phar

mac

othe

rap

yin

stan

dard

care

asus

ual

3

Dur

aisw

amy

etal

43

41in

pat

ient

san

dou

tpat

ient

s(2

8m

en)

with

schi

zop

hren

ia(D

SM-I

V);

age�

18–5

5y

Aer

obic

and

stre

ngth

exer

cise

s(2

0)vs

yoga

(21)

16w

k60

min

5tim

es/w

kin

wk

1–3

unde

rsu

per

visi

onan

dth

en3

mo

ofse

lf-p

ract

ice

Not

men

tione

dFe

wer

pos

itive

(�24

%)

and

nega

tive

(�18

%)

sym

pto

ms

afte

rae

robi

can

dst

reng

thex

erci

ses

(vs

�33

%an

d�

35%

)(g

roup

diffe

renc

es:

P�.2

4an

dP�

.01)

;si

gnifi

cant

lyim

pro

ved

phy

sica

l(�

4.6%

)an

dp

sych

olog

ical

(�9.

8%)

qua

lity

oflif

eon

lyaf

ter

yoga

(vs

�22

.9%

and

�29

.1%

)(g

roup

diffe

renc

es:

P�.0

4an

dP�

.01)

PAN

NS;

WH

OQ

OL-

BREF

Phar

mac

othe

rap

yin

stan

dard

care

asus

ual;

noch

ange

for

atle

ast

4w

kbe

fore

entr

yin

tost

udy

3

(Con

tinue

d)



Tab

le2.

Con

tinue

d

Stu

dy

Par

tici

pan

ts

Exp

erim

enta

lvs

Co

ntr

ol

Inte

rven

tio

n(N

o.

of

Par

tici

pan

ts)

Du

rati

on

Freq

uen

cyIn

ten

sity

Rel

evan

tO

utc

om

es(E

xp

erim

enta

lvs

Co

ntr

ol)

Rel

evan

tIn

stru

men

tsC

om

ple

men

tary

Co

inte

rven

tio

nJa

dad

Sco

re

Che

net

al4

414

inp

atie

nts

(4m

en)

with

schi

zop

hren

ia(D

SM-I

V);

mea

nag

e�40

y

PMR

(8)

vsca

reas

usua

l(6

)11

d40

min

/dLe

ssan

xiet

yaf

ter

11d

(P�

.001

)an

d1

wk

late

r(�

65%

)(P

�.0

446)

(vs

�13

%in

cont

rols

)

BAI

Phar

mac

othe

rap

yin

acut

eca

rep

sych

iatr

icw

ard

3

Mar

zolin

iet

al4

513

inp

atie

nts

and

outp

atie

nts

(8m

en)

with

schi

zop

hren

iaor

schi

zoaf

fect

ive

diso

rder

(DSM

-IV)

;m

ean

age�

44.6

y

Aer

obic

and

mus

cle

stre

ngth

exer

cise

s(7

)vs

care

asus

ual(

6)

12w

k90

min

2tim

es/w

kFr

om60

%H

Rto

80%

HR,

Borg

Scal

esc

ores

of11

–14,

and

60RM

6MW

Tsc

ore

�5.

1%(v

s�

5.5%

inco

ntro

ls)

(diff

eren

ce:

P�.1

);m

uscl

est

reng

th�

28.3

%(P

�.0

01)

(vs

�12

.5%

inco

ntro

ls)

(P�

.2)

(diff

eren

ce:

P�.0

1);

nosi

gnifi

cant

redu

ctio

nsin

rest

ing

bloo

dp

ress

ure

orBM

I

6MW

T;1

RM;

Borg

Scal

ePh

arm

acot

hera

py

inst

anda

rdca

reas

usua

l

3

Behe

reet

al4

666

outp

atie

nts

(47

men

)w

ithsc

hizo

phr

enia

(DSM

-IV)

;m

ean

age�

31.8

y

Aer

obic

and

mus

cle

stre

ngth

exer

cise

s(1

7)vs

yoga

(27)

vsw

aitin

glis

t(2

2)

3m

o60

-min

sess

ions

inw

k1–

4un

der

sup

ervi

sion

and

then

3m

oof

self-

pra

ctic

e

Not

men

tione

dSi

gnifi

cant

lyfe

wer

pos

itive

(�21

.2%

and

�19

.9%

,P�

.002

)an

dne

gativ

e(�

17.4

%an

d�

17.4

%,

P�.0

01)

sym

pto

msc

ores

only

2an

d4

mo

afte

ryo

ga,

resp

ectiv

ely;

redu

ctio

nsaf

ter

aero

bic

and

mus

cle

stre

ngth

not

sign

ifica

nt

PAN

SSPh

arm

acot

hera

py

atst

able

dose

sin

stan

dard

care

asus

ual

3

Pajo

nket

al4

716

mal

eou

tpat

ient

sw

ithsc

hizo

phr

enia

(DSM

-IV)

;ag

e�20

–51

y

Aer

obic

exer

cise

s(c

yclin

g)(8

)vs

tabl

efo

otba

ll(8

)

3m

o30

min

3tim

es/w

kH

Rat

bloo

dla

ctat

ele

vel

of1.

5–2

mm

ol/L

STM

imp

rove

dby

34%

(vs

�17

%,

P�.0

07);

HV

and

V O2m

ax/k

gin

crea

sed

afte

rex

erci

se(�

12%

and

�5%

)(v

s�

1%an

d�

3%)

(gro

updi

ffere

nce:

P�.0

02an

dP�

.35)

;ST

Man

dV O

2m

axco

rrel

ated

with

HV

(r�

.51

and

r�.7

1,P�

.05

and

P�.0

7)

RAVL

T;C

BTT;

MRI

;V O

2m

axw

ithin

crem

enta

lcyc

leer

gom

etry

Phar

mac

othe

rap

yat

stab

ledo

ses

for

atle

ast

6w

k

3

(Con

tinue

d)



covered by their respective par-ticipants, only participants in thestudy of Marzolini et al45 increasedtheir distance walked significantly.Although participants performing 30minutes of aerobic training, strengthtraining, or both 3 times per weekfor 3 months improved their maxi-mal oxygen uptake, as measuredwith incremental cycle ergometry,this improvement was not signifi-cant compared with that in a con-trol condition.47 In contrast, partici-pants performing aerobic training,strength training, or both improvedtheir short-term memory, a resultthat was related to an increase inhippocampal volume. Marzolini etal45 reported a significant increasein strength but no improvement inblood pressure. Changes in bodymass index were examined in 2 stud-ies42,45; no effect was found. Van-campfort et al48 reported significantreductions in state anxiety and psy-chological distress and improve-ments in subjective well-being aftersingle sessions of aerobic exerciseand yoga.

Effectiveness of progressive mus-cle relaxation in the multimodalcare of people with schizophre-nia. Three of the 4 studies examin-ing the effectiveness of progressivemuscle relaxation40,41,44,49 revealedsignificant reductions in anxiety. Inthe methodologically weak study ofPharr and Coursey,41 no significantdifferences were found for 7 pro-gressive muscle relaxation sessions(20 minutes each) compared witheither 7 electromyographic feedbacksessions or 7 sessions of readingexercises. The RCTs of Hawkins etal40 (methodologically weak) andVancampfort et al49 (methodologi-cally strong) revealed significantreductions in state anxiety. In thestudy of Hawkins et al,40 state anxi-ety reductions were associated withfewer hospital admissions in the yearafter the intervention; in the study ofVancampfort et al,49 state anxietyTa

ble

2.C

ontin

ued

Stu

dy

Par

tici

pan

ts

Exp

erim

enta

lvs

Co

ntr

ol

Inte

rven

tio

n(N

o.

of

Par

tici

pan

ts)

Du

rati

on

Freq

uen

cyIn

ten

sity

Rel

evan

tO

utc

om

es(E

xp

erim

enta

lvs

Co

ntr

ol)

Rel

evan

tIn

stru

men

tsC

om

ple

men

tary

Co

inte

rven

tio

nJa

dad

Sco

re

Vanc

amp

fort

etal

48

40in

pat

ient

s(2

2m

en)

with

schi

zop

hren

iaor

schi

zoaf

fect

ive

diso

rder

(DSM

-IV)

;m

ean

age�

32.7

7y

Aer

obic

exer

cise

vsyo

gavs

rest

ing

cont

rol

cond

ition

30m

inof

yoga

and

20m

inof

cycl

ing

Sing

lese

ssio

nSe

lf-se

lect

edae

robi

cex

erci

se

Redu

ced

stat

ean

xiet

y(�

24.6

%an

d�

21.5

%,

both

P�.0

01)

and

psy

chol

ogic

aldi

stre

ss(�

32.2

%an

d�

29.5

%,

both

P�.0

01)

afte

ryo

gaan

dae

robi

cex

erci

sebu

tno

taf

ter

cont

rol

cond

ition

SAI;

SEES

Phar

mac

othe

rap

yin

stan

dard

care

asus

ual;

med

icat

ion

unch

ange

ddu

ring

test

ing

per

iod

3

Vanc

amp

fort

etal

49

52in

pat

ient

s(3

1m

en)

with

schi

zop

hren

ia(D

SM-I

V);

mea

nag

e�35

.6y

PMR

(27)

vsre

adin

gco

ntro

lcon

ditio

n(2

5)25

min

Sing

lese

ssio

nRe

duce

dst

ate

anxi

ety

(�26

.1%

,P�

.001

)an

dp

sych

olog

ical

dist

ress

(�35

.5%

,P�

.001

)af

ter

mus

cle

rela

xatio

nbu

tno

taf

ter

cont

rol

cond

ition

(�1%

and

�0%

,re

spec

tivel

y)(d

iffer

ence

:P�

.001

)

SAI;

SEES

Phar

mac

othe

rap

yin

stan

dard

care

asus

ual;

med

icat

ion

unch

ange

ddu

ring

test

ing

per

iod

3

aD

SM-I

II�D

iagn

ostic

and

Stat

istic

alM

anua

lof

Men

talD

isor

ders

,Th

irdEd

ition

;PM

R�p

rogr

essi

vem

uscl

ere

laxa

tion;

EMG

�el

ectr

omyo

gram

;PO

MS�

Profi

leof

Moo

dSt

ates

;D

SM-I

V�D

iagn

ostic

and

Stat

istic

alM

anua

lof

Men

talD

isor

ders

,Fo

urth

Editi

on;

BMI�

body

mas

sin

dex;

6MW

T�Si

x-M

inut

eW

alk

Test

;PA

NSS

�Po

sitiv

ean

dN

egat

ive

Synd

rom

eSc

ale;

WH

OQ

OL-

BREF

�W

orld

Hea

lthO

rgan

izat

ion

Qua

lity

ofLi

feBR

EFve

rsio

n;BA

I�Be

ckA

nxie

tyIn

vent

ory;

HR�

hear

tra

te;

RM�

rep

etiti

onm

axim

um;

STM

�sh

ort-

term

mem

ory;

HV�

hip

poc

amp

alvo

lum

e;VO

2m

ax�

max

imum

oxyg

enco

nsum

ptio

n;RA

VLT�

Rey

Aud

itory

Verb

alLe

arni

ngTe

st;

CBT

T�C

orsi

Bloc

kTa

pp

ing

Test

;M

RI�

mag

netic

reso

nanc

eim

agin

g;SA

I�St

ate

Anx

iety

Inve

ntor

y;SE

ES�

Subj

ectiv

eEx

erci

seEx

per

ienc

esSc

ale.



reductions were associated withreduced psychological distress andimproved perceived well-being.

Effectiveness of basic bodyawareness exercises in the multi-modal care of people with schizo-phrenia. The effectiveness ofbasic body awareness exercises forpeople with schizophrenia was notinvestigated in any of the includedRCTs.

Adverse EffectsDuraiswamy et al43 indicated that forboth aerobic and strength exercisesand yoga, no significant differencesin extrapyramidal symptoms andabnormal involuntary movements aspotential adverse effects were found.Pajonk et al47 also reported findingno adverse events during the testingperiod.

DiscussionGeneral FindingsThis systematic review explored theefficacy of aerobic and strength exer-

cises, relaxation training, basic bodyawareness exercises, or a combina-tion of these as an adjunct treatmentfor people with schizophrenia. Ingeneral, the included RCTs showedthat, in particular, aerobic andstrength exercises and progressivemuscle relaxation can have animpact on mental health outcomes,such as mental state, state anxiety,and psychological distress. Aerobicand strength exercises also have alimited effect on physical health out-comes, such as aerobic and muscularfitness, with no adverse effects. NoRCTs demonstrating the added valueof basic body awareness exerciseswere available. An interesting find-ing was that when aerobic andstrength exercises were comparedwith other types of exercises, suchas yoga (combining breathing exer-cises, relaxation techniques, andbody postures), the benefits of aero-bic and strength exercises were notas profound. Overall, the presentreview indicated that physical ther-apy as an adjunct treatment might

improve a person’s mental and phys-ical health and health-related qualityof life.

Six articles26–31 identified andreviewed existing research studiesin which physical activity was usedas a form of adjunct treatment forpeople with schizophrenia. Four ofthese reviews27–30 included variousresearch designs, such as qualitative,quantitative, and mixed methods.The previously reported results arein line with those of the presentreview. Faulkner and Biddle,27

Faulkner,28 Ellis et al,29 and Holley etal30 indicated that physical activitycan improve psychological healthand psychological well-being in peo-ple with schizophrenia, and Van-campfort et al26 indicated that phys-ical activity with or without dietcounseling is feasible in reducingweight and improving the obesity-related cardiometabolic risk profile.Additionally, all of these reviewsstressed the need for more method-ologically rigorous research, given

Table 3.Critical Appraisal of Included Studiesa

Study

Rating for Criterion:

Main Concerns1 2 3 4 5 6 7 8 9 10

Hawkins et al40 P M M M F F F M M P Sample size; reliability andvalidity of outcomemeasures; no masking(“blinding”)

Pharr and Coursey41 P P M M F P F P M M Sample size; no masking

Beebe et al42 P P F M F M M P M M �60% agreed to participate;sample size

Duraiswamy et al43 P P F M F M M M M M No decline data; sample size

Chen et al44 P P F M F M F M M P No decline data; samplesize; no masking

Marzolini et al45 P P F M M M F P M M �60% agreed to participate;no masking

Behere et al46 P P F M F M M M M P No decline data; sample size

Pajonk et al47 P P M M F P M M M M Sample size

Vancampfort et al48 P P P M M M F P M P No masking

Vancampfort et al49 P P P M F M F P M P No masking

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



that nonrandomized designs wereused in most of the studies. Our dataconfirm the findings of Gorczynskiand Faulkner31 in a recent review of3 randomized controlled studiesinvestigating physical activity in peo-ple with schizophrenia; the findingssuggested that calls for more meth-odologically rigorous research arestarting to be addressed.

To our knowledge, the presentreview is the first to offer evidencefor the effectiveness of aerobic andstrength exercises in reducing stateanxiety and psychological distress;for the effectiveness of aerobic andstrength exercises in improvingshort-term memory; for the effective-ness of progressive muscle relax-ation as an adjunct intervention toreduce state anxiety and psycholog-ical distress; and for the effectivenessof yoga in reducing positive and neg-ative symptoms, state anxiety, andpsychological distress. The cognitiveimprovements observed after aero-bic exercise seemed to be related toexercise-induced neurogenesis inthe hippocampus.

The ability to deal with state anxietyand psychological stress during aer-obic exercise, progressive musclerelaxation, and yoga might be of par-ticular relevance for people withschizophrenia. First, there is a gen-eral consensus that worsening ofschizophrenia symptoms is relatedto stress and anxiety.50 Second, peo-ple with schizophrenia experiencedifficulties in coping with stress andanxiety and possess a relatively lim-ited repertoire of coping strategies.51

The use of alcohol, nicotine, or ille-gal drugs, which is common in peo-ple with schizophrenia,18 has beensuggested to be an attempt to allevi-ate or to cope with psychiatric symp-toms, unpleasant affective states, andfeelings of state anxiety and psycho-logical distress.52 The limited benefitof such behaviors supports the needto provide other, more healthful

methods to regulate the variability ofsubjective well-being. The presentreview showed that aerobic exer-cise, progressive muscle relaxation,and yoga might be easily learned,healthful alternatives for symptom,stress, and anxiety regulation.

LimitationsAlthough we believe that this sys-tematic review is the first to investi-gate the effectiveness of severalphysical therapy interventions inpeople with schizophrenia, thereview does have some limitationsthat need to be acknowledged. First,as with any systematic review, thereis a potential for selection bias; how-ever, we used a comprehensivesearch strategy. In addition, 2 inde-pendent reviewers analyzed theresearch data, and reasons for studyexclusions were clearly docu-mented. Second, performance biasmay limit our findings. None of theincluded studies were double-blindstudies. The reported results there-fore may exaggerate estimates oftreatment effects.53 Althoughresearchers may not always be ableto mask participants to physical ther-apy interventions to remove thechance of performance bias, everyattempt should be made to collectresearch data in a masked manner. Inthe present review, only 4 of theincluded studies were single-blindstudies.42,43,46,47 Third, the heteroge-neity among the RCTs, particularlywith regard to the frequency andduration of the experimental inter-vention and the chosen control orcomparison intervention, was a chal-lenge in the present review. Thisdiversity, as well as the small samplesizes and other methodological gapsin many of the included studies, lim-ited overall conclusions and high-lighted the need for further research.

Implications for PracticeThe results of this systematic reviewsupport the use of physical therapyin the multidisciplinary care of peo-

ple with schizophrenia. However,clear guidance regarding the typeof intervention and optimal dose islimited by the small number of avail-able RCTs and the variability of theinterventions themselves in terms offrequency, intensity, and duration.Physical therapists, therefore, shouldassess the types of exercises or tech-niques that would best fit a person’spreferences. Along with emphasison the benefits of physical therapy,careful attention to several barriersthat prevent people from participa-tion in physical therapy is needed.Before offering any kind of pro-gram, physical therapists should con-sider and address psychiatric symp-toms, antipsychotic medication sideeffects, and structural barriers. Inaddition to addressing barriers, phys-ical therapists should structure pro-grams to be informative, continu-ously motivate people to participate,and allow them to progress at theirown pace. To achieve these goals,the Organization of Physical Ther-apy in Mental Health54 recommendsthat physical therapists be trained inrecognizing and adequately address-ing symptoms of severe mental ill-ness, physical comorbidities, andside effects of medications. Physicaltherapists would benefit from acquir-ing various cognitive-behavioral andmotivational skills to help theirpatients participate in physical ther-apy programs.

Implications for Future ResearchThere is a clear need for well-designed RCTs examining physicaltherapy interventions as adjuncttreatment for people with schizo-phrenia. Trials should be largeenough to be clinically meaningful,should be adequately powered, andshould include valid and reliableoutcome measures. Furthermore,attempts should be made to maskraters to a person’s clinical status,group allocation, and treatmentcondition; to mask therapists to out-come measures; and, when pos-



sible, to mask participants as well.Researchers should consider thefindings of this systematic reviewwhen designing trials and shouldattempt to overcome the limitationsof the RCTs presented. Because mostof the RCTs retrieved in this reviewdid not have longitudinal follow-upto determine whether the improve-ments observed after physical ther-apy were maintained over time, thequestion of whether short-term ben-efits result in long-term changesremains largely unanswered. There-fore, long-term trials are needed tofurther enhance knowledge aboutphysical therapy prescription forpeople with schizophrenia.

Future research should clearlydefine the exact nature of a physi-cal therapy program, with specialattention to the duration, frequency,and intensity of any interventionreported. Adherence, participants’characteristics (age, sex, illnessduration, and medication proto-col), and adverse events should beclearly described. Outcome mea-sures should include measures rele-vant to schizophrenia-related symp-toms and broader clinical outcomes,such as health-related quality of life,hospital admissions, and behavioraloutcomes (eg, through increasingrates of abstinence from alcohol,nicotine, or illegal drugs). For exam-ple, future studies could examinewhether implementing self-managedaerobic exercise and relaxation tech-niques increases rates of abstinencefrom substance abuse and whetherany effects of these interventions aremediated by decreases in psycholog-ical distress and state anxiety andincreases in perceived well-beingduring or after these activities.

Future research also needs to exam-ine potential physiological mecha-nisms (eg, increased norepineph-rine, serotonin, and beta-endorphinlevels and increased parasympa-thetic activity) or psychological

mechanisms (eg, increased self-efficacy and distraction) that couldbe responsible for an improved men-tal health state and reduced stateanxiety and psychological stress.55

Future studies on aerobic exercisein people with schizophrenia alsoshould confirm whether their brainsretain a degree of plasticity inresponse to exercise.

Finally, no RCTs investigated the roleof basic body awareness exercises.The use of basic body awarenessexercises as an adjunct treatmentmay be highly relevant for peoplewith schizophrenia. Various bodyexperience distortions have beenobserved in schizophrenia; theseinclude symptoms of disembodi-ment, such as not feeling comfort-able in one’s body, or disintegration,as if one’s body were being tornapart.56,57 Previous qualitativeresearch58,59 in people with schizo-phrenia reported improvements inbody balance and postural control,increased self-esteem, and animproved ability to think after aphysical therapy program based onbasic body awareness exercises.However, rigorous research isneeded before basic body awarenesstherapy can be considered effectivein multidisciplinary treatment forpeople with schizophrenia.

ConclusionThis systematic review demon-strated that specific physical therapyinterventions, including aerobic andmuscle strength exercises, progres-sive muscle relaxation, and yoga,resulted in beneficial outcomes forpsychiatric symptoms, psychologicaldistress, state anxiety, health-relatedquality of life, and aerobic and mus-cular fitness. Future research intospecific features of physical ther-apy interventions, such as tailoringinterventions to the needs of peoplewith schizophrenia, may contributeto evidence for the efficacy of

physical therapy for people withschizophrenia.

Mr Vancampfort, Ms Skjaerven, Dr Catalan-Matamoros, Dr Lundvik-Gyllensten, andDr Hert provided concept/idea/researchdesign. Mr Vancampfort, Dr Probst, MsSkjaerven, Dr Catalan-Matamoros, DrGomez-Conesa, and Dr Hert provided writ-ing. Mr Vancampfort, Ms Skjaerven, DrCatalan-Matamoros, and Dr Gomez-Conesaprovided data collection. Mr Vancampfort,Ms Skjaerven, and Dr Catalan-Matamorosprovided data analysis. Mr Vancampfort pro-vided project management. Dr Probst pro-vided participants. Dr Probst and Dr Gomez-Conesa provided facilities/equipment. DrProbst, Dr Lundvik-Gyllensten, Dr Gomez-Conesa, and Mr Ijntema provided institu-tional liaisons. Dr Probst, Ms Skjaerven, DrLundvik-Gyllensten, and Dr Gomez-Conesaprovided consultation (including review ofmanuscript before submission).

Mr Vancampfort was the first author of 2of the assessed studies. Dr De Hert andDr Probst were coauthors of 2 of theincluded studies. The other authors declarethat they have no conflict of interest relatedto the present review.

DOI: 10.2522/ptj.20110218

References1 Rossler W, Salize H, van Os J, Riecher-

Rossler A. Size of burden of schizophreniaand psychotic disorders. Eur Neuropsy-chopharmacol. 2005;15:399–409.

2 The Global Burden of Disease: 2004Update. Geneva, Switzerland: WorldHealth Organization; 2008.

3 McGrath J, Saha S, Chant D, Welham J.Schizophrenia: a concise overview of inci-dence, prevalence, and mortality. Epide-miol Rev. 2008;30:67–76.

4 Diagnostic and Statistical Manual ofMental Disorders, Fourth Edition. Arling-ton, VA: American Psychiatric Association;1994.

5 Keshavan MS, Tandon R, Boutros NN, Nas-rallah HA. Schizophrenia, “just the facts”:what we know in 2008; part 3: neurobiol-ogy. Schizophr Res. 2008;106:89–107.

6 Stahl SM, Buckley PF. Negative symptomsof schizophrenia: a problem that will notgo away. Acta Psychiatr Scand. 2007;115:4–11.

7 Tandon R, Nasrallah HA, Keshavan MS.Schizophrenia, “just the facts”: part 5:treatment and prevention: past, present,and future. Schizophr Res. 2010;122:1–23.

8 van Os J, Kapur S. Schizophrenia. Lancet.2009;374:635–645.



9 Kern RS, Glynn SM, Horan WP, Marder SR.Psychosocial treatments to promote func-tional recovery in schizophrenia. Schizo-phr Bull. 2009;35:347–361.

10 Probst M, Knapen J, Poot G, VancampfortD. Psychomotor therapy and psychiatry:what is in a name? Open Compl Med J.2000;2:105–113.

11 Physiotherapy in Psychiatry and MentalHealth Special Interest Group for Schizo-phrenia. Patients with schizophrenia andphysiotherapy in psychiatry and mentalhealth: what are our experiences? Roundtable discussion held at: Third Interna-tional Conference for Physiotherapy inPsychiatry and Mental Health; February 4,2010; Lund, Sweden.

12 Faulkner G, Carless D. Physical activityand the process of psychiatric rehabilita-tion: theoretical and methodologicalissues. Psychiatr Rehabil J. 2006;29:258–266.

13 Skjaerven LV, Kristoffersen K, Gard G.How can movement quality be promotedin clinical practice? A phenomenologicalstudy of physical therapist experts. PhysTher. 2010;90:1479–1492.

14 Faulkner G, Cohn T, Remington G. Valida-tion of a physical activity assessment toolfor individuals with schizophrenia. Schizo-phr Res. 2006;82:225–231.

15 Lindamer LA, McKibbin C, Norman GJ,et al. Assessment of physical activity inmiddle-aged and older adults with schizo-phrenia. Schizophr Res. 2008;104:294–301.

16 Vancampfort D, Knapen J, Probst M, et al.Considering a frame of reference for phys-ical activity research related to the cardio-metabolic risk profile in schizophrenia.Psychiatry Res. 2010;177:271–279.

17 Vancampfort D, Probst M, Sweers K, et al.Relationship between obesity, functionalexercise capacity, physical activity partic-ipation and physical self-perception inpeople with schizophrenia. Acta Psychi-atr Scand. 2001;123:423–430.

18 De Hert M, Correll CU, Bobes J, et al. Phys-ical illness in patients with severe mentaldisorders, I: prevalence, impact of medi-cations and disparities in health care.World Psychiatry. 2011;10:52–77.

19 De Hert M, Schreurs V, Vancampfort D,van Winkel R. Metabolic syndrome inpatients with schizophrenia: a review.World Psychiatry. 2009;8:15–22.

20 Brown S, Inskip H, Barraclough B. Causesof the excess mortality of schizophrenia.Br J Psychiatry. 2000;177:212–217.

21 Osby U, Correia N, Brandt L, et al. Mortal-ity and causes of death in schizophrenia inStockholm county, Sweden. SchizophrRes. 2000;45:21–28.

22 Colton CW, Manderscheid RW. Congru-encies in increased mortality rates, yearsof potential life lost, and causes of deathamong public mental health clients ineight states. Prev Chron Dis. 2006;3:A42.

23 Tiihonen J, Lonnqvist J, Wahlbeck K, et al.11-year follow-up of mortality in patientswith schizophrenia: a population-basedcohort study (FIN11 study). Lancet. 2009;374:620–627.

24 Saha S, Chant D, McGrath J. A systematicreview of mortality in schizophrenia. ArchGen Psychiatry. 2007;64:1123–1131.

25 Capasso RM, Lineberry TW, Bostwick JM,et al. Mortality in schizophrenia andschizoaffective disorder: an OlmstedCounty, Minnesota, cohort—1950–2005.Schizophr Res. 2008;98:287–294.

26 Vancampfort D, Knapen J, De Hert M,et al. Cardiometabolic effects of physicalactivity interventions for people withschizophrenia. Phys Ther Rev. 2009;14:388–398.

27 Faulkner G, Biddle S. Exercise as anadjunct treatment for schizophrenia: areview of the literature. J Ment Health.1999;8:441–457.

28 Faulkner G. Exercise as an adjunct treat-ment for schizophrenia. In: Faulkner G,Taylor A, eds. Exercise, Health and Men-tal Health: Emerging Relationships. Lon-don, United Kingdom: Routledge; 2005:27–45.

29 Ellis N, Crone D, Davey R, Grogan S. Exer-cise interventions as an adjunct therapyfor psychosis: a critical review. Br J ClinPsychol. 2007;46:95–111.

30 Holley J, Crone D, Tyson P, Lovell G. Theeffects of physical activity on psychologi-cal well-being for those with schizophre-nia: a systematic review. Br J Clin Psychol.2011;50:84–105.

31 Gorczynski P, Faulkner G. Exercise ther-apy for schizophrenia. Schizophr Bull.2010;36:665–666.

32 Dickersin K, Scherer R, Lefebvre C. Iden-tifying relevant studies for systematicreviews. BMJ. 1994;309:1286–1291.

33 WCPT Description of Physical Therapy.London, United Kingdom: World Confed-eration for Physical Therapy; 2007.

34 Jadad AR, Moore RA, Carroll D, et al.Assessing the quality of reports of random-ized clinical trials: is blinding necessary?Control Clin Trials. 1996;17:1–12.

35 Juni P, Altam D, Egger M. Assessing thequality of randomized controlled trials. In:Egger M, Smith G, Altman D, eds. System-atic Reviews in Health Care. 3rd ed. Lon-don, United Kingdom: BMJ Books; 2003:87–108.

36 Moher D, Jadad AR, Nichol G, et al. Assess-ing the quality of randomized controlledtrials: an annotated bibliography of scalesand checklists. Control Clin Trials. 1995;16:62–73.

37 de Vet HC, de Bie RA, van der Heijden G,et al. Systematic reviews on the basis ofmethodological criteria. Physiotherapy.1997;83:284–289.

38 McNeely ML, Torrance G, Magee DJ. Asystematic review of physiotherapy forspondylolysis and spondylolisthesis. ManTher. 2003;8:80–91.

39 McNeely ML, Armijo Olivo S, Magee DJ. Asystematic review of the effectiveness ofphysical therapy interventions for tem-poromandibular disorders. Phys Ther.2006;86:710–725.

40 Hawkins RC Jr, Doell SR, Lindseth P, et al.Anxiety reduction in hospitalized schizo-phrenics through thermal biofeedbackand relaxation training. Percept Mot Skills.1980;51:475–482.

41 Pharr OM, Coursey RD. The use of EMGbiofeedback with chronic schizophrenicpatients. Biofeedback Self Regul. 1989;14:229–245.

42 Beebe LH, Tian L, Morris N, et al. Effects ofexercise on mental and physical healthparameters of persons with schizophre-nia. Issues Ment Health Nurs. 2005;26:661–676.

43 Duraiswamy G, Thirthalli J, Nagendra HR,Gangadhar BN. Yoga therapy as an add-ontreatment in the management of patientswith schizophrenia: a randomized con-trolled trial. Acta Psychiatr Scand. 2007;116:226–232.

44 Chen WC, Chu H, Lu RB, et al. Efficacy ofprogressive muscle relaxation training inreducing anxiety in patients with acuteschizophrenia. J Clin Nurs. 2009;18:2187–2196.

45 Marzolini S, Jensen B, Melville P. Feasi-bility and effects of a group-based resis-tance and aerobic exercise program forindividuals with severe schizophrenia: amultidisciplinary approach. Ment HealthPhys Act. 2009;2:29 –36.

46 Behere RV, Arasappa R, Jagannathan A,et al. Effect of yoga therapy on facial emo-tion recognition deficits, symptoms andfunctioning in patients with schizophre-nia. Acta Psychiatr Scand. 2011;123:147–153.

47 Pajonk FG, Wobrock T, Gruber O, et al.Hippocampal plasticity in response toexercise in schizophrenia. Arch Gen Psy-chiatry. 2010;67:133–143.

48 Vancampfort D, De Hert M, Knapen J,et al. State anxiety, psychological stressand positive well-being responses to yogaand aerobic exercise in people withschizophrenia: a pilot study. Disabil Reha-bil. 2011;33:584–689.

49 Vancampfort D, De Hert M, Knapen J,et al. Effects of progressive muscle relax-ation on state anxiety and subjective well-being in people with schizophrenia: a ran-domised controlled trial. Clin Rehabil.2011;25:567–575.

50 van Winkel R, Stefanis NC, Myin-Germeys I. Psychosocial stress and psy-chosis: a review of the neurobiologicalmechanisms and the evidence for gene-stress interaction. Schizophr Bull. 2008;34:1095–1105.

51 Phillips LJ, Francey SM, Edwards J,McMurray N. Strategies used by psy-chotic individuals to cope with life stressand symptoms of illness: a systematicreview. Anxiety Stress Coping. 2009;22:371– 410.

52 Winterer G. Why do patients with schizo-phrenia smoke? Curr Opin Psychiatry.2010;23:112–119.



53 Boutron I, Tubach F, Giraudeau B, RavaudP. Blinding was judged more difficult toachieve and maintain in non-pharmacologic than pharmacologic trials.J Clin Epidemiol. 2004;57:543–550.

54 Vancampfort D, De Hert M, SkjaervenLH, et al. Organization of Physical Ther-apy in Mental Health consensus on phys-ical activity for minimizing cardiometa-bolic risk in patients with schizophrenia.Disabil Rehabil. In press.

55 Mutrie N, Faulkner G. Physical activity andmental health. In: Everett T, Donaghy M,Fever S, eds. Physiotherapy and Occupa-tional Therapy in Mental Health: An Evi-dence Based Approach. London, UnitedKingdom: Routledge; 2003:82–97.

56 Koide R, Tamaoka A. Body image devia-tion in chronic schizophrenia: newresearch. In: Kindes M, ed. Body Image:New Research. New York, NY: Nova Sci-ence Publishers; 2006:145–197.

57 de Haan S, Fuchs T. The ghost in themachine: disembodiment in schizophre-nia—two case studies. Psychopathology.2010;43:327–333.

58 Gyllensten A, Hansson L, Ekdahl C. Patientexperiences of basic body awareness ther-apy and the relationship with the physio-therapist. J Bodyw Mov Ther. 2003;7:173–183.

59 Hedlund L, Gyllensten AL. The experi-ences of basic body awareness therapy inpatients with schizophrenia. J Bodyw MovTher. 2010;14:245–254.



Documents

Systematic Review of the Benefits Of