Systematic Review of the Benefits of Physical

Therapy Within a Multidisciplinary Care Approach for

People With Schizophrenia
Davy Vancampfort, Michel Probst, Liv Helvik Skjaerven,
Daniel Catalán-Matamoros, Amanda Lundvik-Gyllensten,
Antonia Gómez-Conesa, Rutger Ijntema and Marc De
Hert
PHYS THER. 2012; 92:11-23.
Originally published online November 3, 2011
doi: 10.2522/ptj.20110218

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 Research Report
D. Vancampfort, PT, MSc, Faculty
of Kinesiology and Rehabilita-
tion Sciences, Catholic Univer-
Systematic Review of the Benefits of sity Leuven, Leuven, Belgium,
and University Psychiatric Centre,
Physical Therapy Within a Catholic University Leuven, Cam-
pus Kortenberg, Leuvensesteen-

Multidisciplinary Care Approach for weg 517, 3070 Kortenberg, Bel-

gium. Address all correspondence
to Mr Vancampfort at: davy.
People With Schizophrenia vancampfort@uc-kortenberg.be.
M. Probst, PT, PhD, University Psy-
Davy Vancampfort, Michel Probst, Liv Helvik Skjaerven, chiatric Centre, Catholic Univer-
Daniel Catalán-Matamoros, Amanda Lundvik-Gyllensten, Antonia Gómez-Conesa, sity Leuven, Campus Kortenberg,
Rutger Ijntema, Marc De Hert and Faculty of Kinesiology and
Rehabilitation Sciences, Catholic
University Leuven.
Background. Although schizophrenia is the fifth leading cause of disability- L. Helvik Skjaerven, PT, MSc,
adjusted life years worldwide in people aged 15 to 44 years, the clinical evidence of Department of Physical Therapy,
physical therapy as a complementary treatment remains largely unknown. Faculty of Health and Sciences,
Bergen University College, Ber-
gen, Norway.
Purpose. The purpose of this study was to systematically review randomized
controlled trials (RCTs) evaluating the effectiveness of physical therapy for people D. Catalán-Matamoros, PT, PhD,
Faculty of Health Sciences, Univer-
with schizophrenia.
sity of Almeria, Almeria, Spain.

Data Sources. EMBASE, PsycINFO, PubMed, ISI Web of Science, Cumulative A. Lundvik-Gyllensten, PT, PhD,
Division of Physical Therapy, Fac-
Index to Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence ulty of Health Sciences, Lund Uni-
Database (PEDro), and the Cochrane Library were searched from their inception until versity, Lund, Sweden.
July 1, 2011, for relevant RCTs. In addition, manual search strategies were used.
A. Gómez-Conesa, PT, PhD,
Department of Physical Therapy,
Study Selection. Two reviewers independently determined study eligibility on University of Murcia, Murcia,
the basis of inclusion criteria. Spain.
R. Ijntema, PT, MBA, Institute of
Data Extraction. Reviewers rated study quality and extracted information about Human Movement Studies, Fac-
study methods, design, intervention, and results. ulty of Health Care, HU University
of Applied Sciences Utrecht,
Data Synthesis. Ten RCTs met all selection criteria; 6 of these studies addressed Utrecht, the Netherlands.
the use of aerobic and strength exercises. In 2 of these studies, yoga techniques also M. De Hert, MD, PhD, University
were investigated. Four studies addressed the use of progressive muscle relaxation. Psychiatric Centre, Catholic Uni-
versity Leuven, Campus Korten-
There is evidence that aerobic and strength exercises and yoga reduce psychiatric
berg, and Faculty of Medicine,
symptoms, state anxiety, and psychological distress and improve health-related qual- Catholic University Leuven.
ity of life, that aerobic exercise improves short-term memory, and that progressive
[Vancampfort D, Probst M, Helvik
muscle relaxation reduces state anxiety and psychological distress. Skjaerven L, et al. Systematic
review of the benefits of physical
Limitations. The heterogeneity of the interventions and the small sample sizes of therapy within a multidisciplinary
the included studies limit overall conclusions and highlight the need for further care approach for people with
research. schizophrenia. Phys Ther. 2012;
92:11–23.]

Conclusions. Physical therapy offers added value in the multidisciplinary care of © 2012 American Physical Therapy
people with schizophrenia. Association

Published Ahead of Print:

November 3, 2011
Accepted: August 30, 2011
Submitted: July 8, 2011

Post a Rapid Response to

this article at:
ptjournal.apta.org

January 2012 Volume 92 Number 1 Physical Therapy f 11

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Multidisciplinary Care for People With Schizophrenia
S
chizophrenia is one of the most
debilitating psychiatric disor-
ders.1 It accounts for 1.1% of
total disability-adjusted life years and
for 2.8% and 2.6% of years lived with
disability for men and women,
respectively. In addition, it is the
fifth leading cause of disability-
adjusted life years worldwide in
people 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 100,000
person-years, respectively.3 Accord-
ing to criteria in the Diagnostic
and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV),
schizophrenia comprises both posi-
tive and negative symptomatology
severe enough to cause social and
occupational dysfunction.4 Positive
symptoms reflect an excess or dis-
tortion of normal functions and
include delusions, hallucinations, and
disorganized speech and behavior.
Negative symptoms reflect a reduc-
tion or loss of normal functions and
include affective flattening, apathy,
avolition, and social withdrawal.
Mesolimbic dopaminergic hyperac-
tivity is believed to be part of the
underlying pathology associated with
positive symptoms,5 but the patho-
physiology of negative symptoms is
poorly understood. Negative symp-
toms therefore remain a relatively
treatment-refractory and debilitating
component of schizophrenia.6
Once the diagnosis is made, anti-
psychotic drugs that block dopa-
mine D2 receptors are the main
treatment for people with schizo-
phrenia.7 First-generation antipsy-
chotics (eg, chlorpromazine, flu-
phenazine, and haloperidol) are
Available With
This Article at
ptjournal.apta.org
• eTable: Excluded Randomized
Controlled Trials
12 f Physical Therapy Volume 92 Number 1
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effective in the management of psy-
chotic symptoms but often lead to
motor side effects. In the past 15
years, so-called second-generation
agents (eg, amisulpride, aripiprazole,
olanzapine, quetiapine, and risperi-
done) that less frequently cause
motor 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 of
greater efficacy against negative
and cognitive symptoms has not
been borne out.8 Many people with
schizophrenia continue to have per-
sistent symptoms and relapses, par-
ticularly when they fail to adhere
to prescribed medication regimens.
This situation underlines the need
for multimodal care, including psy-
chosocial therapies, as an adjunct
to antipsychotic medications to help
alleviate symptoms and to improve
adherence, functional outcomes,
and health-related quality of life.9
Research on psychosocial approaches
to treatment for people with schizo-
phrenia has yielded incremental evi-
dence of the efficacy of cognitive
behavioral therapy, social skills train-
ing, family psycho-education, asser-
tive community treatment, and sup-
ported employment.7–9 Additional
research is needed to examine the
aspects of therapeutic modalities
that work and to identify the syner-
gistic effects of combinations of
interventions. Recently, there has
been interest in the relative effective-
ness of physical therapy interven-
tions in multidisciplinary treatment
for people with schizophrenia.10
The International Organization of
Physical Therapy in Mental Health
(formerly the International Council
of Physiotherapy in Psychiatry and
Mental Health) stated that in the
multidisciplinary care of people with
schizophrenia, physical therapy is
intended to improve physical and
mental health and health-related
quality of life.11 For people with
schizophrenia, an enhanced ability
to cope with disease symptoms
tends to improve health-related qual-
ity of life.12 Numerous physical ther-
apy interventions are potentially
effective in improving physical and
mental health and health-related
quality of life. The techniques most
commonly used in daily clinical prac-
tice are aerobic and strength exer-
cises, relaxation training, and basic
body awareness exercises.10,13
People with schizophrenia, who are
more likely to be less physically
active than people in the general
population14,15 and are consequently
at high risk for chronic medical con-
ditions associated with physical inac-
tivity,16,17 have the same physical
health needs as other people who
are sedentary. For example, meta-
bolic and cardiovascular diseases
have become a major concern in
people with schizophrenia.18 People
with schizophrenia are 1.5 to 2 times
more likely to be overweight, their
risk for diabetes and hypertension is
2-fold higher, and dyslipidemia is 5
times more prevalent in people with
schizophrenia than in people in the
general population.19 The excess
morbidity from cardiovascular dis-
eases results in increased premature
mortality—2 or 3 times as high as
that in the general population.20,21
The mortality gap translates to a
shortening of life expectancy by 13
to 30 years compared with that in
the general population22,23 and is still
widening.24,25 A previous systematic
review of physical activity with or
without diet counseling concluded
that lifestyle interventions are feasi-
ble and effective in reducing weight
and improving the obesity-related
cardiometabolic risk profile in peo-
ple with schizophrenia.26
Beneficial mental health effects from
physical therapy interventions also
have been reported. For example,
earlier systematic reviews indicated
January 2012

that aerobic exercise reduces nega-
tive and positive symptomatology
and alleviates secondary symptoms,
such as depression, low self-esteem,
and social withdrawal.27–30
The conclusions of these system-
atic reviews, however, were mainly
based on data from uncontrolled
trials, and the findings, therefore,
should be interpreted with caution.
More recently, a meta-analysis of
aerobic exercise31 indicated that reg-
ular physical activity is possible for
people with schizophrenia. Aerobic
exercise can have beneficial effects
on both the physical and mental
health and the well-being of people
with schizophrenia, although there
is currently insufficient evidence to
support or refute the use of aerobic
and strength exercises as a comple-
mentary intervention.31 To our
knowledge, no systematic reviews of
relaxation training and basic body
awareness exercises are available.
The question of whether aerobic and
strength exercises, relaxation train-
ing, and basic body awareness exer-
cises are effective additions to the
multidisciplinary management of
schizophrenia, therefore, remains
largely unanswered. Thus, the pur-
pose of this systematic review was to
evaluate the methodological quality
of and summarize the evidence from
randomized controlled trials (RCTs)
examining the effectiveness of these
physical therapy interventions in the
multidisciplinary management of
schizophrenia.
Method
Data Sources and Searches
A literature search was conducted
according to the search strategy of
Dickersin et al.32 No restrictions
were made regarding the language of
publication. EMBASE, PsycINFO,
PubMed, ISI Web of Science, Cumu-
lative Index to Nursing and Allied
Health Literature (CINAHL), Physio-
therapy Evidence Database (PEDro),
and the Cochrane Library were
January 2012
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Multidisciplinary Care for People With Schizophrenia
searched from their inception until
July 1, 2011, for RCTs. Medical sub-
ject headings included “schizophre-
nia” AND “physical therapy” OR
“exercise” OR “relaxation” in the
title, abstract, or index term fields.
Two investigators independently
screened the titles of the publica-
tions found in the databases and, if
available, the abstracts of the publi-
cations as well. If either investigator
believed that any published article
potentially met the inclusion criteria
or if there was inadequate informa-
tion to make a decision, a copy of the
article was obtained or the authors
were contacted to obtain the neces-
sary data.
The next phase of the search strat-
egy involved searching for unpub-
lished RCTs and for RCTs potentially
overlooked or absent from the data-
bases. This step involved manually
searching the reference lists in all
retrieved articles and the available
systematic reviews for potential stud-
ies to locate unpublished or over-
looked research. Furthermore, we
searched Web sites housing details
of clinical trials, theses, or disserta-
tions. Citation indexing was used to
track referencing of key authors in
the field, and local experts were con-
tacted for further information.
Study Selection
Inclusion in this review was
restricted to studies of people with a
diagnosis of schizophrenia or other
types of schizophrenia spectrum
psychoses (schizoaffective or schizo-
phreniform disorder, excluding
bipolar disorder and major depres-
sion with psychotic features) on the
basis of any criteria, any length of
illness, and any treatment setting.
We did not exclude trials because of
the age, nationality, or sex of the
participants.
Types of interventions. Studies
were considered eligible for inclu-
sion if they were RCTs compar-
Volume 92 Number 1
ing physical therapy interventions
with a placebo condition, control
intervention, or standard care. The
experimental physical therapy inter-
ventions could comprise aerobic
exercises, strength exercises, relax-
ation training, basic body aware-
ness exercises, or a combination of
these in accordance with the World
Confederation for Physical Therapy
position statement.33 A physical
therapy intervention could be used
alone or in conjunction with other
interventions, with physical therapy
being considered the main or active
element. Interventions that included
physical therapy in a multiple-
component weight management
program were excluded because
the specific effects of the physical
therapy intervention could not be
addressed. Other interventions could
include any of the following: phar-
macotherapy, psycho-education, and
cognitive-behavioral or motivational
techniques related to exercise
behavior. Standard care was defined
as care that people would normally
receive had they not been included
in the research trial. Such care would
include medication, hospitalization,
community psychiatric nursing sup-
port, and outpatient care. For an
RCT to be included, the experimen-
tal and comparison interventions
must have had similar durations.
Types of outcomes. Outcomes
were grouped according to assess-
ments of mental health, physical
health, and health-related quality of
life.
Data Extraction and
Quality Assessment
Assessments of quality were com-
pleted independently by the 2
reviewers. Disagreements were
resolved by discussion. If no consen-
sus was achieved, a third reviewer
made the final decision. Each study
was evaluated with the previously
validated 5-point Jadad scale34 to
assess the completeness and quality
Physical Therapy f 13
Multidisciplinary Care for People With Schizophrenia
Table 1
Data Extraction
Criterion
Design
Participants
Intervention
Outcome measures
of reporting of RCTs as well as to
assess for potential bias in the trials.
This widely used scale focuses on
3 dimensions of internal validity:
quality of randomization, double-
blinding, and withdrawals. This scale
is the only published instrument
that has been created according to
psychometric principles.35,36 A score
of 0 to 5 is assigned, with higher
scores indicating higher quality in
the conduct or reporting of a trial. A
trial scoring at least 3 of 5 is consid-
ered to be of strong quality. A trial
scoring below 3 is considered to be
methodologically weak.
Data Synthesis and Analysis
Each study was assessed with a rat-
ing system originally developed by
de Vet et al.37 This rating system pro-
vides a detailed evaluation of study
methods and was used previously in
systematic reviews for physical ther-
apy.38,39 The rating system of de Vet
et al37 considers criteria relevant to
the practice of physical therapy,
such as participant characteristics,
sample size, description of interven-
tions, and the validity and reliability
of the chosen outcome measures.
The 2 assessors independently
reviewed each study on the basis of
the specific criteria of this rating sys-
tem. For each criterion, 3 ratings
were available: pass (met the crite-
rion), moderate (incompletely or
14 f Physical Therapy Volume 92 Number 1
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Items
First author name
Year published
Number, mean age or age range, sex
Setting (inpatients, outpatients, mixed)
Type of intervention
Duration, frequency, intensity
Cointerventions
Types of outcome measures
Assessment tools
Adverse effects
partially met the criterion), and fail
(did not meet the criterion); the fail
rating also was assigned when no
information about a specific crite-
rion was provided in the publication.
Each quality criterion was evaluated
separately. At present, there are no
clear decision rules for establishing
cutoff 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 included
studies while a second reviewer
(M.P.) cross-checked the extracted
data. The data items extracted are
shown in Table 1.
Results
Study Selection
The initial electronic database search
resulted in a total of 2,162 articles.
Through additional manual searches
of reference lists, searches of Web
sites, and consultation of experts in
the field, 1 other potentially eligible
article was identified. After the
removal of duplicates and screening
of titles, abstracts, or full texts, 10
RCTs were included (Fig.).40 – 49 Rea-
sons for exclusion are shown in the
Figure. A list of excluded screened
RCTs with reasons for exclusion is
provided in the eTable (available at
ptjournal.apta.org). On the basis of
the first full-text screening, we
decided that there was too much
heterogeneity in study designs and
protocols to apply a formal
meta-analysis.
Participants
In total, 322 participants were
included in the analyses. Except for
participants in 2 studies40,41 pub-
lished before the appearance of
DSM-IV (the most recent edition of
the Diagnostic and Statistical Man-
ual of Mental Disorders, published
in 1994), all participants were diag-
nosed with schizophrenia on the
basis of DSM-IV criteria. Two studies
included both inpatients and outpa-
tients,43,45 2 studies concentrated
solely on outpatients,42,47 and the
other studies included only inpa-
tients. The participants ranged in age
from 18 to 63 years. With this strat-
egy, both participants with first epi-
sodes and participants with chronic
conditions were included. In most of
the studies, the participants were
men. Detailed information on the
characteristics of the participants is
provided in Table 2.
Methodological Quality
Two of the included studies40,41
were considered to be of weak meth-
odological quality (Tab. 2). Further
details of the study characteristics
are provided in Table 3. The 2 most
common methodological concerns
were limited sample size and lack of
masking (“blinding”), especially of
participants.
Effectiveness of aerobic exercises,
strength exercises, or both in the
multimodal care of people with
schizophrenia. The investigators
in 6 studies42,43,45– 48 examined the
effectiveness of aerobic exercises,
strength exercises, or both in multi-
disciplinary standard care for people
with schizophrenia. All 6 studies
were considered to be of strong
methodological quality. In 1 study43
of 3 studies42,43,46 examining the
January 2012
 Multidisciplinary Care for People With Schizophrenia

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.

effectiveness of these exercises for
positive and negative symptoms, the
reductions found were significant. In
the studies of Duraiswamy et al43 and
Behere et al,46 aerobic exercises,
strength exercises, or both were
compared with yoga as a comple-
mentary intervention. Participants
practicing yoga reported signifi-
cantly greater reductions in positive
and negative symptoms. Health-
related quality of life improved only
after yoga.43 The investigators in 3
studies42,45,47 examined changes in
aerobic fitness, muscular fitness, or
both; 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 Test
revealed increases in the distance

January 2012 Volume 92 Number 1 Physical Therapy f 15

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 16
Table 2.
Details of Included Randomized Controlled Trialsa

f
Experimental vs Relevant Outcomes
Control Intervention (Experimental vs Relevant Complementary Jadad
Study Participants (No. of Participants) Duration Frequency Intensity Control) Instruments Cointervention Score

Hawkins et al40 40 inpatients (17 men) PMR (10) vs minimal 2 wk 40 min 5 times/wk Reductions across Hamilton Anxiety Pharmacotherapy 2
with schizophrenia treatment (asked to groups for state State; Brief in all conditions
(DSM-III); relax) (10) vs thermal anxiety (F⫽3.95; Psychiatric Rating

Physical Therapy
mean age⫽35 y feedback (10) vs PMR df⫽1,36; P⬍.05); no
⫹ thermal feedback group differences
(10) (F⫽1.34; df⫽12,85;
P⫽.21); reductions
associated with fewer
hospital admissions at
1-y follow-up
(␹2⫽6.6, P⬍.05)

Pharr and 30 inpatients with PMR (10) vs EMG 20 min 7 individual No significant changes Tension-anxiety Pharmacotherapy 2
Coursey41 schizophrenia (DSM- biofeedback (10) vs sessions in tension-anxiety domain of POMS at maintenance-

Volume 92 Number 1
III); mean age⫽35 y listening to recorded scores level dosages in
readings (10) all conditions
Beebe et al42 10 outpatients (8 men) Aerobic exercises 16 wk From 25 min 3 10 min of Lower body fat Skinfold Pharmacotherapy 3
with schizophrenia (treadmill walking) (6) times/wk (wk 1) warming up, percentage (⫺3.7% measurements; in standard care
(DSM-IV); vs care as usual (4) to 50 min 3 5–30 min of vs ⫺0.02%, P⫽.03); 6MWT; PANSS as usual
age⫽40–63 y times/wk (wk 3 moderate- lower BMI (⫺1.3% vs
to end) intensity ⫺0.02%, P⬎.05);
Multidisciplinary Care for People With Schizophrenia

walking, and higher 6MWT score

10 min of (⫹10% vs ⫹4%,
cooling down P⬎.05); fewer
positive and negative
symptoms (⫺13.5%
vs ⫹5%, P⬎.05)

Duraiswamy et al43 41 inpatients and Aerobic and strength 16 wk 60 min 5 times/wk Not mentioned Fewer positive (⫺24%) PANNS; WHOQOL- Pharmacotherapy 3
outpatients (28 men) exercises (20) vs yoga in wk 1–3 under and negative (⫺18%) BREF in standard care
with schizophrenia (21) supervision and symptoms after as usual; no
(DSM-IV); then 3 mo of aerobic and strength change for at
age⫽18–55 y self-practice exercises (vs ⫺33% least 4 wk
and ⫺35%) (group before entry into

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differences: P⫽.24 study
and P⬍.01);
significantly
improved physical
(⫹4.6%) and
psychological
(⫹9.8%) quality of
life only after yoga
(vs ⫹22.9% and
⫹29.1%) (group
differences: P⫽.04
and P⬍.01)

(Continued)

January 2012
 Table 2.
Continued

Experimental vs Relevant Outcomes

Control Intervention (Experimental vs Relevant Complementary Jadad

January 2012
Study Participants (No. of Participants) Duration Frequency Intensity Control) Instruments Cointervention Score

Chen et al44 14 inpatients (4 men) PMR (8) vs care as usual 11 d 40 min/d Less anxiety after 11 d BAI Pharmacotherapy 3
with schizophrenia (6) (P⬍.001) and 1 wk in acute care
(DSM-IV); later (⫺65%) psychiatric ward
mean age⫽40 y (P⬍.0446) (vs ⫺13%
in controls)

Marzolini et al45 13 inpatients and Aerobic and muscle 12 wk 90 min 2 times/wk From 60% HR 6MWT score ⫹5.1% 6MWT; 1 RM; Borg Pharmacotherapy 3
outpatients (8 men) strength exercises (7) to 80% HR, (vs ⫺5.5% in Scale in standard care
with schizophrenia vs care as usual (6) Borg Scale controls) (difference: as usual
or schizoaffective scores of P⫽.1); muscle
disorder (DSM-IV); 11–14, and strength ⫹28.3%
mean age⫽44.6 y 60 RM (P⬍.001) (vs
⫹12.5% in controls)
(P⫽.2) (difference:
P⫽.01); no
significant reductions
in resting blood
pressure or BMI

Behere et al46 66 outpatients Aerobic and muscle 3 mo 60-min sessions in Not mentioned Significantly fewer PANSS Pharmacotherapy 3
(47 men) with strength exercises wk 1–4 under positive (⫺21.2% at stable doses
schizophrenia (17) vs yoga (27) vs supervision and and ⫺19.9%, in standard care
(DSM-IV); waiting list (22) then 3 mo of P⫽.002) and as usual
mean age⫽31.8 y self-practice negative (⫺17.4%
and ⫺17.4%,
P⬍.001) symptom
scores only 2 and 4
mo after yoga,
respectively;
reductions after
aerobic and muscle
strength not
significant

Pajonk et al47 16 male outpatients Aerobic exercises 3 mo 30 min 3 times/wk HR at blood STM improved by 34% RAVLT; CBTT; MRI; Pharmacotherapy 3

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with schizophrenia (cycling) (8) vs table lactate level (vs ⫺17%, P⫽.007); V̇O2max with at stable doses
(DSM-IV); football (8) of 1.5–2 HV and V̇O2max/kg incremental cycle for at least 6 wk
age⫽20–51 y mmol/L increased after ergometry

Volume 92 Number 1
exercise (⫹12% and
⫹5%) (vs ⫺1% and
⫺3%) (group
difference: P⬍.002
and P⫽.35); STM
and V̇O2max
correlated with HV
(r⫽.51 and r⫽.71,
P⬍.05 and P⫽.07)

Physical Therapy f
(Continued)

17
Multidisciplinary Care for People With Schizophrenia
Multidisciplinary Care for People With Schizophrenia

covered by their respective par-

Jadad
Score

Manual of Mental Disorders, Fourth Edition; BMI⫽body mass index; 6MWT⫽Six-Minute Walk Test; PANSS⫽Positive and Negative Syndrome Scale; WHOQOL-BREF⫽World Health Organization Quality of Life
BREF version; BAI⫽Beck Anxiety Inventory; HR⫽heart rate; RM⫽repetition maximum; STM⫽short-term memory; HV⫽hippocampal volume; V̇O2max⫽maximum oxygen consumption; RAVLT⫽Rey Auditory
DSM-III⫽Diagnostic and Statistical Manual of Mental Disorders, Third Edition; PMR⫽progressive muscle relaxation; EMG⫽electromyogram; POMS⫽Profile of Mood States; DSM-IV⫽Diagnostic and Statistical
ticipants, only participants in the
3

3
study of Marzolini et al45 increased
Complementary

in standard care

in standard care
Cointervention
Pharmacotherapy

Pharmacotherapy
their distance walked significantly.

during testing

during testing
unchanged

unchanged
medication

medication
as usual; Although participants performing 30

as usual;
minutes of aerobic training, strength

period

period
training, or both 3 times per week
for 3 months improved their maxi-
mal oxygen uptake, as measured
Instruments

with incremental cycle ergometry,

Relevant

this improvement was not signifi-

Verbal Learning Test; CBTT⫽Corsi Block Tapping Test; MRI⫽magnetic resonance imaging; SAI⫽State Anxiety Inventory; SEES⫽Subjective Exercise Experiences Scale.
SAI; SEES

SAI; SEES cant compared with that in a con-

trol condition.47 In contrast, partici-
pants performing aerobic training,
psychological distress

P⬍.001) after muscle

condition (⫹1% and

Relevant Outcomes

but not after control

strength training, or both improved

and aerobic exercise

(difference: P⬍.001)
Reduced state anxiety

Reduced state anxiety

(Experimental vs

P⬍.001) after yoga

(⫺26.1%, P⬍.001)

⫹0%, respectively)
relaxation but not
and psychological
distress (⫺35.5%,

their short-term memory, a result

⫺21.5%, both

⫺29.5%, both
Control)

(⫺24.6% and

(⫺32.2% and
P⬍.001) and

after control
that was related to an increase in
condition

hippocampal volume. Marzolini et

al45 reported a significant increase
in strength but no improvement in
blood pressure. Changes in body
mass index were examined in 2 stud-
Intensity
Self-selected

ies42,45; no effect was found. Van-

exercise
aerobic

campfort et al48 reported significant

reductions in state anxiety and psy-
chological distress and improve-
ments in subjective well-being after
Frequency
Single session

Single session

single sessions of aerobic exercise

and yoga.

Effectiveness of progressive mus-

Duration

cle relaxation in the multimodal

30 min of

and 20

cycling
min of

25 min
yoga

care of people with schizophre-

nia. Three of the 4 studies examin-
ing the effectiveness of progressive
Aerobic exercise vs yoga

control condition (25)

Control Intervention
(No. of Participants)

muscle relaxation40,41,44,49 revealed

Experimental vs

PMR (27) vs reading

vs resting control

significant reductions in anxiety. In

the methodologically weak study of
condition

Pharr and Coursey,41 no significant

differences were found for 7 pro-
gressive muscle relaxation sessions
(20 minutes each) compared with
40 inpatients (22 men)

52 inpatients (31 men)

mean age⫽32.77 y
with schizophrenia

with schizophrenia
disorder (DSM-IV);

either 7 electromyographic feedback

or schizoaffective
Participants

(DSM-IV); mean

sessions or 7 sessions of reading

age⫽35.6 y

exercises. The RCTs of Hawkins et

al40 (methodologically weak) and
Vancampfort et al49 (methodologi-
cally strong) revealed significant
reductions in state anxiety. In the
study of Hawkins et al,40 state anxi-
Study

Vancampfort

Vancampfort

ety reductions were associated with

Continued
Table 2.

et al48

et al49

fewer hospital admissions in the year

after the intervention; in the study of
Vancampfort et al,49 state anxiety
a

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 Multidisciplinary Care for People With Schizophrenia

Table 3.
Critical Appraisal of Included Studiesa

Rating for Criterion:

Study 1 2 3 4 5 6 7 8 9 10 Main Concerns

Hawkins et al40 P M M M F F F M M P Sample size; reliability and

validity of outcome
measures; 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; sample

size; 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 the
criterion), F⫽fail (did not meet the criterion); the fail rating also was assigned when no information about a specific criterion was provided in the
publication.

reductions were associated with
reduced psychological distress and
improved perceived well-being.
Effectiveness of basic body
awareness exercises in the multi-
modal care of people with schizo-
phrenia. The effectiveness of
basic body awareness exercises for
people with schizophrenia was not
investigated in any of the included
RCTs.
Adverse Effects
Duraiswamy et al43 indicated that for
both aerobic and strength exercises
and yoga, no significant differences
in extrapyramidal symptoms and
abnormal involuntary movements as
potential adverse effects were found.
Pajonk et al47 also reported finding
no adverse events during the testing
period.
Discussion
General Findings
This systematic review explored the
efficacy of aerobic and strength exer-
cises, relaxation training, basic body
awareness exercises, or a combina-
tion of these as an adjunct treatment
for people with schizophrenia. In
general, the included RCTs showed
that, in particular, aerobic and
strength exercises and progressive
muscle relaxation can have an
impact on mental health outcomes,
such as mental state, state anxiety,
and psychological distress. Aerobic
and strength exercises also have a
limited effect on physical health out-
comes, such as aerobic and muscular
fitness, with no adverse effects. No
RCTs demonstrating the added value
of basic body awareness exercises
were available. An interesting find-
ing was that when aerobic and
strength exercises were compared
with other types of exercises, such
as yoga (combining breathing exer-
cises, relaxation techniques, and
body postures), the benefits of aero-
bic and strength exercises were not
as profound. Overall, the present
review indicated that physical ther-
apy as an adjunct treatment might
improve a person’s mental and phys-
ical health and health-related quality
of life.
Six articles26 –31 identified and
reviewed existing research studies
in which physical activity was used
as a form of adjunct treatment for
people with schizophrenia. Four of
these reviews27–30 included various
research designs, such as qualitative,
quantitative, and mixed methods.
The previously reported results are
in line with those of the present
review. Faulkner and Biddle,27
Faulkner,28 Ellis et al,29 and Holley et
al30 indicated that physical activity
can improve psychological health
and psychological well-being in peo-
ple with schizophrenia, and Van-
campfort et al26 indicated that phys-
ical activity with or without diet
counseling is feasible in reducing
weight and improving the obesity-
related cardiometabolic risk profile.
Additionally, all of these reviews
stressed the need for more method-
ologically rigorous research, given

January 2012 Volume 92 Number 1 Physical Therapy f 19

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Multidisciplinary Care for People With Schizophrenia
that nonrandomized designs were
used in most of the studies. Our data
confirm the findings of Gorczynski
and Faulkner31 in a recent review of
3 randomized controlled studies
investigating physical activity in peo-
ple with schizophrenia; the findings
suggested that calls for more meth-
odologically rigorous research are
starting to be addressed.
To our knowledge, the present
review is the first to offer evidence
for the effectiveness of aerobic and
strength exercises in reducing state
anxiety and psychological distress;
for the effectiveness of aerobic and
strength exercises in improving
short-term memory; for the effective-
ness of progressive muscle relax-
ation as an adjunct intervention to
reduce state anxiety and psycholog-
ical distress; and for the effectiveness
of yoga in reducing positive and neg-
ative symptoms, state anxiety, and
psychological distress. The cognitive
improvements observed after aero-
bic exercise seemed to be related to
exercise-induced neurogenesis in
the hippocampus.
The ability to deal with state anxiety
and psychological stress during aer-
obic exercise, progressive muscle
relaxation, and yoga might be of par-
ticular relevance for people with
schizophrenia. First, there is a gen-
eral consensus that worsening of
schizophrenia symptoms is related
to stress and anxiety.50 Second, peo-
ple with schizophrenia experience
difficulties in coping with stress and
anxiety 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 been
suggested to be an attempt to allevi-
ate or to cope with psychiatric symp-
toms, unpleasant affective states, and
feelings of state anxiety and psycho-
logical distress.52 The limited benefit
of such behaviors supports the need
to provide other, more healthful
20 f Physical Therapy Volume 92 Number 1
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methods to regulate the variability of
subjective well-being. The present
review showed that aerobic exer-
cise, progressive muscle relaxation,
and yoga might be easily learned,
healthful alternatives for symptom,
stress, and anxiety regulation.
Limitations
Although we believe that this sys-
tematic review is the first to investi-
gate the effectiveness of several
physical therapy interventions in
people with schizophrenia, the
review does have some limitations
that need to be acknowledged. First,
as with any systematic review, there
is a potential for selection bias; how-
ever, we used a comprehensive
search strategy. In addition, 2 inde-
pendent reviewers analyzed the
research data, and reasons for study
exclusions were clearly docu-
mented. Second, performance bias
may limit our findings. None of the
included studies were double-blind
studies. The reported results there-
fore may exaggerate estimates of
treatment effects.53 Although
researchers may not always be able
to mask participants to physical ther-
apy interventions to remove the
chance of performance bias, every
attempt should be made to collect
research data in a masked manner. In
the present review, only 4 of the
included studies were single-blind
studies.42,43,46,47 Third, the heteroge-
neity among the RCTs, particularly
with regard to the frequency and
duration of the experimental inter-
vention and the chosen control or
comparison intervention, was a chal-
lenge in the present review. This
diversity, as well as the small sample
sizes and other methodological gaps
in many of the included studies, lim-
ited overall conclusions and high-
lighted the need for further research.
Implications for Practice
The results of this systematic review
support the use of physical therapy
in the multidisciplinary care of peo-
ple with schizophrenia. However,
clear guidance regarding the type
of intervention and optimal dose is
limited by the small number of avail-
able RCTs and the variability of the
interventions themselves in terms of
frequency, intensity, and duration.
Physical therapists, therefore, should
assess the types of exercises or tech-
niques that would best fit a person’s
preferences. Along with emphasis
on the benefits of physical therapy,
careful attention to several barriers
that 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 side
effects, and structural barriers. In
addition 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 their
own pace. To achieve these goals,
the Organization of Physical Ther-
apy in Mental Health54 recommends
that physical therapists be trained in
recognizing and adequately address-
ing symptoms of severe mental ill-
ness, physical comorbidities, and
side effects of medications. Physical
therapists would benefit from acquir-
ing various cognitive-behavioral and
motivational skills to help their
patients participate in physical ther-
apy programs.
Implications for Future Research
There is a clear need for well-
designed RCTs examining physical
therapy interventions as adjunct
treatment for people with schizo-
phrenia. Trials should be large
enough to be clinically meaningful,
should be adequately powered, and
should include valid and reliable
outcome measures. Furthermore,
attempts should be made to mask
raters to a person’s clinical status,
group allocation, and treatment
condition; to mask therapists to out-
come measures; and, when pos-
January 2012

sible, to mask participants as well.
Researchers should consider the
findings of this systematic review
when designing trials and should
attempt to overcome the limitations
of the RCTs presented. Because most
of the RCTs retrieved in this review
did not have longitudinal follow-up
to determine whether the improve-
ments observed after physical ther-
apy were maintained over time, the
question of whether short-term ben-
efits result in long-term changes
remains largely unanswered. There-
fore, long-term trials are needed to
further enhance knowledge about
physical therapy prescription for
people with schizophrenia.
Future research should clearly
define the exact nature of a physi-
cal therapy program, with special
attention to the duration, frequency,
and intensity of any intervention
reported. Adherence, participants’
characteristics (age, sex, illness
duration, and medication proto-
col), and adverse events should be
clearly 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 behavioral
outcomes (eg, through increasing
rates of abstinence from alcohol,
nicotine, or illegal drugs). For exam-
ple, future studies could examine
whether implementing self-managed
aerobic exercise and relaxation tech-
niques increases rates of abstinence
from substance abuse and whether
any effects of these interventions are
mediated by decreases in psycholog-
ical distress and state anxiety and
increases in perceived well-being
during or after these activities.
Future research also needs to exam-
ine potential physiological mecha-
nisms (eg, increased norepineph-
rine, serotonin, and beta-endorphin
levels and increased parasympa-
thetic activity) or psychological
January 2012
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Multidisciplinary Care for People With Schizophrenia
mechanisms (eg, increased self-
efficacy and distraction) that could
be responsible for an improved men-
tal health state and reduced state
anxiety and psychological stress.55
Future studies on aerobic exercise
in people with schizophrenia also
should confirm whether their brains
retain a degree of plasticity in
response to exercise.
Finally, no RCTs investigated the role
of basic body awareness exercises.
The use of basic body awareness
exercises as an adjunct treatment
may be highly relevant for people
with schizophrenia. Various body
experience distortions have been
observed in schizophrenia; these
include symptoms of disembodi-
ment, such as not feeling comfort-
able in one’s body, or disintegration,
as if one’s body were being torn
apart.56,57 Previous qualitative
research58,59 in people with schizo-
phrenia reported improvements in
body balance and postural control,
increased self-esteem, and an
improved ability to think after a
physical therapy program based on
basic body awareness exercises.
However, rigorous research is
needed before basic body awareness
therapy can be considered effective
in multidisciplinary treatment for
people with schizophrenia.
Conclusion
This systematic review demon-
strated that specific physical therapy
interventions, including aerobic and
muscle strength exercises, progres-
sive muscle relaxation, and yoga,
resulted in beneficial outcomes for
psychiatric symptoms, psychological
distress, state anxiety, health-related
quality of life, and aerobic and mus-
cular fitness. Future research into
specific features of physical ther-
apy interventions, such as tailoring
interventions to the needs of people
with schizophrenia, may contribute
to evidence for the efficacy of
Volume 92 Number 1
physical therapy for people with
schizophrenia.
Mr Vancampfort, Ms Skjaerven, Dr Catalán-
Matamoros, Dr Lundvik-Gyllensten, and
Dr Hert provided concept/idea/research
design. Mr Vancampfort, Dr Probst, Ms
Skjaerven, Dr Catalán-Matamoros, Dr
Gómez-Conesa, and Dr Hert provided writ-
ing. Mr Vancampfort, Ms Skjaerven, Dr
Catalán-Matamoros, and Dr Gómez-Conesa
provided data collection. Mr Vancampfort,
Ms Skjaerven, and Dr Catalán-Matamoros
provided data analysis. Mr Vancampfort pro-
vided project management. Dr Probst pro-
vided participants. Dr Probst and Dr Gómez-
Conesa provided facilities/equipment. Dr
Probst, Dr Lundvik-Gyllensten, Dr Gómez-
Conesa, and Mr Ijntema provided institu-
tional liaisons. Dr Probst, Ms Skjaerven, Dr
Lundvik-Gyllensten, and Dr Gómez-Conesa
provided consultation (including review of
manuscript before submission).
Mr Vancampfort was the first author of 2
of the assessed studies. Dr De Hert and
Dr Probst were coauthors of 2 of the
included studies. The other authors declare
that they have no conflict of interest related
to the present review.
DOI: 10.2522/ptj.20110218
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Volume 92 Number 1 Physical Therapy f 23
 Systematic Review of the Benefits of Physical
Therapy Within a Multidisciplinary Care Approach for
People With Schizophrenia
Davy Vancampfort, Michel Probst, Liv Helvik Skjaerven,
Daniel Catalán-Matamoros, Amanda Lundvik-Gyllensten,
Antonia Gómez-Conesa, Rutger Ijntema and Marc De
Hert
PHYS THER. 2012; 92:11-23.
Originally published online November 3, 2011
doi: 10.2522/ptj.20110218

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