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The Benefits of an Exercise Program for People With Schizophrenia: a Pilot Study

Posted on: Thursday, 16 December 2004, 03:00 CST

White the benefits of physical fitness have been extensively documented, there is a paucity of literature examining the impact of an exercise program on people experiencing a mental illness. An exploratory study was conducted with six patients diagnosed with schizophrenia who participated in a 3-month physical conditioning program. The findings suggest that most participants increased their physical strength and endurance and exhibited improvements in weight control and flexibility. The majority of patients reported increased fitness levels, exercise tolerance, reduced blood pressure levels, perceived energy levels and upper body and hand grip strength levels.

Introduction

The positive effects of exercise on human health and well-being have been widely researched (Arkin, 1999; Goldman & Cook, 1984). Exercise may be of particular relevance to people diagnosed with a mental illness (Conley & Kelly, 2001; Hellewell, 1999). Furthermore, medication may also induce unwanted side effects that can impair quality of life and lead to reduced compliance with medication regimes (Green, Patel, Goisman, Allison & Blackburn, 2000).

Research studies examining the effects of physical exercise on fitness or quality of life are sparse in patients with psychiatric morbidity. The available research evidence suggests that physical exercise enhances both physical and mental health (Sexton, Maere & Dahl, 1989; Blumenthal et al., 1991; McNeil, Leblanc & Joyner, 1991). Unger, Skrinar, Hutchinson, and Yetmokas, (1992) reported positive attitude changes in patients with psychiatric disabilities after a carefully planned aerobic and weight training program. Some researchers believe that exercise can improve moods but the underlying mechanisms often remain unknown (Morrissey, 1997). Green et al. (2000) suggest that a moderate level of exercise should be included in any weight control initiatives for people with schizophrenia.

People diagnosed with schizophrenia appear to be at increased risk for certain obesity-related conditions. Studies suggest that 40% to 80% of people taking antipsychotic medications experience weight gain that exceeds ideal body weight by 20% or greater (Umbricht, Pollacks Kane, 1994; Masand, Blackburn, Ganguli, Goldman & Gorman, 1999). Exercise may play an important role in alleviating symptoms of mental illnesses and some argue that it can be promoted as an adjunct treatment for schizophrenia (Faulkner & Biddle, 1999). Research evidence shows that regular exercise can make some improvement in psychometric outcome variables in people diagnosed with schizophrenia (Adams, 1995; Pelham, Campagna, Ritvo & Birnie, 1993).

The potential benefit of exercise training as an alternative or complementary treatment for schizophrenia has, however, received very little attention. Most of the literature refers to using exercise in depression, anxiety, anorexia nervosa, and phobias and there is little discussion regarding its use in schizophrenia and other psychoses.

Purpose

The purpose of this pilot study was to document the effectiveness of regular exercise training on people with schizophrenia, and to determine if they would benefit from an exercise program in relation to physical fitness.

Method

Six (6) psychiatric in-patients of the Community Care Unit in Victoria volunteered to participate in this study. All six patients aged between 20 and 42 were males diagnosed with schizophrenia. The diagnosis of schizophrenia was confirmed by a consultant psychiatrist. A medical clearance form was completed by each patient's treating doctor to ensure their level of fitness was sufficient to enable participation. After giving written, informed consent, they were invited to participate in individually designed exercise programs. Two qualified exercise physiologists were recruited to conduct the exercise training program. The exercise physiologists designed and implemented an individualized exercise program for 3 months. Individual physical fitness assessments were conducted for each of the participants prior to and following their involvement in the program.

Participants were given a demonstration of any exercise activity by an exercise physiologist and they were given specific instructions about the nature and duration of any exercise activity. Cardiovascular fitness was measured by a standard exercise test administered by an exercise physiologist. The fitness test consists of measuring weight, blood pressure and pulse before and after exercise. Endurance and muscle strength were measured by determining the number of sit-ups that could be performed initially in one minute. Upper limb strength was measured using dynamometers. The norm for left and right hand grip is 45-54 kg. The lung function was measured using a peak flow meter. A 6-minute walking test on the treadmill was used to ascertain the base level of aerobic capacity. Weight and height were measured using standard equipment. The Body Mass Index (BMI) was calculated to determine whether the participants are overweight or underweight.

Results

Participant A

Participant A was a 33-year-old man diagnosed with schizophrenia. He had first contact with psychiatric services at the age of 19. At 105 kg weight and 165 cm height, he is well above recommended weight for height norms. His resting blood pressure was at 157/99 mmHg. Resting heart rate was at 106 b.p.m. Left hand grip was 41 kg (Norm: 45-54 kg) and the right hand grip was 42 kg (Norm: 45-54 kg).

Participant A's training program included physical training activities in a gym and at a local community fitness centre. His involvement during the 3-month physical conditioning program resulted in a gradual improvement in his willingness to participate and be involved with physical activity. During this period he completed up to 20 minutes of walking or cycling combined. Weeks 5- 8, he was completing up to 50 minutes of aerobic exercise and completed some strength training with hand weights. During weeks 9- 12, he demonstrated an improved self-confidence and willingness to try new activities. He actively participated in different activities including walking, swimming, cycling, rowing, boxing, weight training, skipping and stretching.

His resting heart rate also decreased from 106 beats/min to 68 beats/min. He was able to lose 3.9 kg in body weight. His lower back and hamstring flexibility improved by 7 cm. His grip strength improved from 42 to 45 for his right hand and from 41 to 44 for his left hand.

Participant B

Participant B is a 20-year-old man formally diagnosed with schizophrenia. At 65.6 kilograms weight and 165 cm height, he is within recommended weight for height norms (BMI=24.1). Blood pressure was normal at 121/82 mmHg.

He completed the physical conditioning program which included initial physical fitness assessment, and an individualized exercise program. During the 3 months of exercise training program, he was able to improve his upper body and hand grip strength levels. His upper body push strength increased from 32 to 47 units, his upper body pull strength increased from 31 to 36 units whilst his right hand grip improved from 32 to 37 units and his left hand increased from 31 to 34 units. He maintained his body weight during this period whilst his girth measurements for his waist and hips have both decreased indicating the likelihood of loss of fat mass and an increase of muscle mass. This gain in muscle mass can be attributed to the strength training he completed.

Participant C

Participant C is a 20-year-old man, who was diagnosed with schizophrenia in 1997. At 108 kilograms weight and 178 cm height, he is well above recommended weight for height norms (BMI=34.1). His blood pressure was at 131/90 mmHg. His resting heart rate was at 86 bpm.

His involvement during the 3-month physical conditioning program has primarily involved walking and cycling. The initial 4-week period of the conditioning program was his most consistent where he was exercising up to 5 days per week and walking up to 30 minutes at a time. During weeks 5-8, he continued his walking and cycling routines. His assessment results showed that he was able to increase his upper body strength levels from 30 to 69 units. This increase in strength can be attributed to his ability to exert himself better during exercise. During the conditioning program, he gained a nominal 1 kg of body weight. His blood pressure has also moderated to a level of 124/86 down from 131/90. The treadmill test showed that his aerobic capacity and exercise tolerance has improved slightly and he is walking at the same speed of 6.0 km/hr with decreased heart rate levels, thus showing an improvement in fitness.

Participant D

Participant D is 29 years of age and has a 10-year history of schizophrenia. He has a body mass of 105 kg and a height of 166 cm (BMI=38.1). He has well below average grip strength. Left hand grip was 28 kg (norm: 45-54 kg) and the right hand grip 33.5 kg (norm: 45- 54 kg).

During the 3-month physical conditioning program he has been able to display a continuous commitment to exercise once per week with increased intensity levels. During the period of the program, his body weight increased by 8.5 kg while his waist and hip girth measurements increased \by 1.5 cm and 1 cm respectively. His lower back and hamstring flexibility showed a small improvement of 2 cm. He was able to improve his walking speed from 4.0 km/hr to 5.5 km/ hr. His resting heart rate also improved from 103 beats/min to 60 beats/min.

Participant E

Participant E is a 41-year-old man with a 20-year history of schizophrenia. At 105 kg and 163 cm, he is well above recommended weight for height norms (BMI=39.5). His upper limb strength demonstrates well below average grip strength. Left hand grip was 39 kg (norm: 45-54 kg) and the right hand grip was 37 kg (norm: 45-54 kg).

Throughout the physical conditioning program, he continued to walk daily to the shops for a total of 20 minutes. He also started to go swimming and was enjoying the variety of exercise in the water. He was unable to show any significant change in body weight (lost .5 kg), grip strength or his upper body push test. He was, however, able to show significant improvements in his lower back and hamstring flexibility (+4 cm) and his upper body pull strength. He was able to show excellent improvement in the treadmill tolerance test. He was successful in doubling his walking speed from 2.7 km/ hr to 5.5 km/hr for a slight decrease in heart rate. This indicates a marked improvement in his aerobic capacity and willingness to exercise and exert himself.

Participant F

Participant F is a 42-year-old man with a 15-year history of schizophrenia. At 125 kilograms and 181.5 cm, he is well above recommended weight for height norms. His blood pressure was borderline at 140/80 mmHg but his resting heart rate was at 106 bpm. His upper limb strength was below average. Left hand grip was 40 kg (norm: 45-54 kg) and the right hand grip was 43 kg (norm: 45-54 kg).

During the 3-month program he was able to build up his walking capacity to over 60 minutes. He showed no significant change in his upper body and handgrip strength levels. However, his lower back and hamstring flexibility has improved slightly by 3 cm. He increased his exercise tolerance from 4.5 km/hr to 5.5 km/hr.

Discussion

Results from this pilot study suggest that persons with schizophrenia can participate in and benefit from a physical exercise program. The participation in the physical conditioning program assisted participants to set and work towards achieving their goals and to maintain a certain degree of fitness. It was found that individuals could increase their physical strength and endurance and exhibit improvements in weight control and flexibility. Participation in a graded exercise program would facilitate a positive move towards a more proactive approach to managing weight and back pain in some cases. In this study, patients' abilities and strengths were focused upon, rather than their disabilities and weaknesses. Furthermore, the physical conditioning program gave patients with schizophrenia an opportunity to experience normality in their lives.

Motivation is often the primary factor in completing a successful exercise program. The high attendance rate indicates not only the motivation and dedication of participants but also the benefits they perceived during the 3-month period. The majority of participants reported increased fitness levels, exercise tolerance, reduced blood pressure levels, perceived energy levels and upper body and hand grip strength levels.

It is, however, premature to suggest that the physical conditioning program is a useful adjuvant in the treatment of patients with schizophrenia. These findings suggest that considering exercise as a therapeutical component of any psychosocial rehabilitation program for patients experiencing a long-term mental illness has merit. Walking and cycling were the most useful exercise modality for the majority of patients, which do not require any expensive equipment or specialized training. Psychosocial rehabilitation programs can include walking and cycling as a therapeutic coping tool, which can be incorporated into treatment programs. The findings are potentially significant in facilitating innovative thought and hypotheses generation for future research in this area. Future research should address the issues related to exercise dosage, intensity, mode of exercise, frequency and duration.

Limitations

The limitations of this study relate to the small sample size (n=6). For this reason, it was not the intention of this study to establish a statistical correlation between exercise training and well-being of psychiatric patients. The effects of the physical conditioning program were likely to be a very individual experience with each patient relying on an individualized exercise program. As this study was conducted with six patients, it is also difficult to ascertain the generalizability of research findings.

References

Adams, L. (1995). How exercise can help people with mental health problems. Nursing Times, 91, 37-39.

Arkin, S. M. (1999). Elder rehab: A student supervised exercise program for Alzheimer's patients. The Gemntologist, 39, 729-735.

Blumenthal, J. A., Emery, C. F., Madden, D. J., et al. (1991). Long-term effects of exercise on older men and women. Journal of Gerontology, 46, 352-361.

Conley, R. R. & Kelly, D. L. (2001). Management of treatment resistance in schizophrenia. Biological Psychiatry, 50, 898-911.

Faulkner, G. & Biddle, S. (1999). Exercise as an adjunct treatment for schizophrenia: A review of literature. Journal of Mental Health, 85, 441-457.

Goldman, L. & Cook, E. F. (1984). The decline in ischemic heart disease mortality rates. Annals of Internal Medicine, 101, 825-836.

Green, A. I., Patel, J. K., Goisman, R. M., Allison, D. B. & Blackburn, G. (2000). Weight gain from novel antipsychotic drugs: Need for action. General Hospital Psychiatry, 22, 224-235.

Hellewell, J. S. (1999). Treatment resistance schizophrenia: Reviewing the options and identifying the way forward. Journal of Clinical Psychiatry, 60, 14-19.

Masand, P. S., Blackburn, G. L., Ganguli, R., Goldman, L. S. & Gorman, J. (1999). Weight gain associated with the use of anti- psychotic medication. Journal of Clinical Psychiatry Audio-Graphs Series, 2.

McNeil, J. K., Leblanc, A. M. & Joyner, M. (1991). The effects of exercise on depressive symptoms in the moderately depressed elderly. Psychology of Aging, 6, 487-488.

Morrissey, M. (1997). Exercise and mental health: A qualitative study. Mental Health Nursing, 17, 141-142.

Pelham, T. W., Campagna, P. D., Ritvo, P. G. & Birnie, W. A. (1993). The effects of exercise therapy on clients in a psychiatric rehabilitation program. Psychosocial Rehabilitation Journal, 16, 75- 84.

Sexton, H., Maere, A. & Dahl, N. H. (1989). Exercise intensity and reduction in neurotic symptoms-a controlled follow up study. Acta Psychi Scand, 80, 231-235.

Umbricht, D. S., Pollack, S. & Kane, J. M. (1994). Clozapine and weight gain. Journal of Clinical Psychiatry, 55, 157-160.

Unger, K. V., Skrinar, G. S., Hutchinson, D. S. & Yelmokas, A. M. (1992). Fitness: A viable adjunct to treatment for young adults with psychiatric disabilities. Psychosocial Rehabilitation Journal, 25 (3), 21-28.

MARGARET FOGARTY, RPN, IS THE SENIOR PSYCHIATRIC NURSE AT "NORFOLK TERRACE" A COMMUNITY RESIDENTIAL FACILITY IN FLEMINGTON, VICTORIA 3031, AUSTRALIA

PHONE: 8371 7500

Margaret.Fogarty@mh.org.au

BRENDA HAPPELL, RN, PHD, IS ASSOCIATE PROFESSOR/DIRECTOR AT THE CENTRE FOR PSYCHIATRIC NURSING RESEARCH AND PRACTICE, SCHOOLOF POSTGRADUATE NURSING, THE UNIVERSITY OF MELBOURNE, 1/723 SWANSTON ST, CARLTON, VICTORIA 3053, AUSTRALIA

PHONE: 8344 0769

FAX: 9347 4172

b.Happeli@nursing.unimelb.edu.au

DR. JAYA PINIKAHANA, AT THE TIME OF THIS RESEARCH, WAS SENIOR RESEARCH FELLOW, CENTRE FOR PSYCHIATRIC NURSING RESEARCH AND PRACTICE, SCHOOL OF POSTGRADUATE NURSING, THE UNIVERSITY OF MELBOURNE, 1/723 SWANSTON ST, CARLTON, VICTORIA 3053, AUSTRALIA

ADDRESS CORRESPONDENCE TO:

DR. BRENDA HAPPELL

ASSOCIATE PROFESSOR/DIRECTOR

CENTRE FOR PSYCHIATRIC NURSING RESEARCH AND PRACTICE

SCHOOL OF NURSING

THE UNIVERSITY OF MELBOURNE

LEVEL 1, 723 SWANSTON ST.

CARLTON, VICTORIA 3053

AUSTRALIA

Copyright Psychosocial Rehabilitation Journal Fall 2004

Source: Psychiatric Rehabilitation Journal

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