International Organization of Physical Therapy in Mental Health ...

Disability & Rehabilitation, 2011, 1-12, Early Online Copyright © 2011 Informa UK, Ltd. ISSN 0963-8288 print/ISSN 1464-5165 online DOI: 10.3109/09638288.2011.587090

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International Organization of Physical Therapy in Mental Health consensus on physical activity within multidisciplinary rehabilitation programmes for minimising cardio-metabolic risk in patients with schizophrenia Davy Vancampfort1, Marc De Hert1, Liv Helvik Skjerven2, Amanda Lundvik Gyllensten3, Anne Parker4, Nathalie Mulders5, Lene Nyboe6, Felicity Spencer7 & Michel Probst1 1

University Psychiatric Centre Catholic University Leuven, Kortenberg, Belgium, 2Bergen University College, Faculty of Health and Sciences, Department of Physiotherapy, Bergen, Norway, 3Lund University, Department of Health Sciences, Division of Physiotherapy, Lund, Sweden, 4Royal Edinburgh Hospital, Edinburgh, Scotland, United Kingdom, 5Dutch Society of Psychosomatic Physical Therapy, The Netherlands, 6Aarhus University Hospital, Centre of Psychiatric Research, Risskov, Denmark and 7Sydney Children’s Hospital, Sydney, Australia Implications for Rehabilitation

Purpose: The excess cardiovascular morbidity associated with schizophrenia is attributed to an interplay between behavioural (physical inactivity, unhealthy diet, substance abuse), genetic and illness related factors, as well as the effects of antipsychotic treatment. Patients have limited access to physical healthcare with less opportunity for cardiovascular risk prevention and treatment programmes than the non-psychiatric population. The aim of this paper is to improve physical activity (PA) within rehabilitation programmes for people with schizophrenia. Method: The development process consisted of: a) systematic literature review on PA in schizophrenia in eight databases up to May 2010; b) review on existing national and international guidelines; c) consensus meetings, and d) formulation of the final consensus document. Results: There is insufficient evidence for the relative contribution of PA reducing cardiometabolic risks in people with schizophrenia. Demographical, biological, psychological, cognitive-behavioural, emotional, social and environmental barriers for PA could be identified. Conclusions: Although PA outcomes on cardio-metabolic parameters are still unknown, the benefits of physical activity as part of a larger lifestyle programme are sufficient for the recommendation that persons with schizophrenia follow the 2008 U.S. Department of Health and Human Services PA Guidelines with specific adaptations based on disease and treatment-related adverse effects.

• For substantial health benefits, patients with schizophrenia should do at least 150 min a week of moderateintensity, or 75 min of moderate- to vigorous-intensity aerobic activity. • The promotion of a healthy lifestyle should be the shared responsibility of all health care providers under supervision of general practitioners and psychiatrists. • Each patient with schizophrenia should have access to high quality physical health services with a high quality physical assessment and follow-up. • The choice between the two equally effective training alternatives should be based on the patients’ preference, and availability of equipment and resources. • Health care providers should consider illness symptoms, side-effects of antipsychotic medication, low self-efficacy and the lack of social support when motivating patients to a healthy lifestyle.

Introduction Schizophrenia is one of the most debilitating psychiatric disorders.[1] The Diagnostic Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR) criteria for schizophrenia includes positive and negative symptomatology severe enough to cause social and occupational dysfunction.[2] Positive symp-

Keywords: Physical activity, physiotherapy, schizophrenia, guidelines

Correspondence: Davy Vancampfort, University Psychiatric Centre Catholic University Leuven, Campus Kortenberg, Belgium. E-mail: [email protected]

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2 D. Vancampfort et al. toms reflect an excess or distortion of normal functions and manifests itself in symptoms such as delusions, hallucinations, and disorganised speech and behaviour. Negative symptoms reflect a reduction or loss of normal functions consisting of symptoms such as affective flattening, apathy, avolition, social withdrawal and cognitive impairment. The lifetime prevalence and incidence range from 0.30 to 0.66% and from 10.2 to 22.0 per 100,000 person-years, respectively.[3] According to the Global Burden of Disease Study,[4] schizophrenia accounts for 1.1% of the total disability-adjusted life years (DALYs) and 2.8% for men and 2.6% for women of years lived with disability (YLDs). Schizophrenia is listed as the 5th leading cause of DALYs worldwide in the age group 15–44 years.4 Moreover, people with schizophrenia have a two and a half times greater rate of mortality after excluding deaths from unnatural causes.[5] This has led in recent years to a growing concern about physical illness in schizophrenia, specifically the increased cardiovascular disease (CVD) risk.[6] Patients with schizophrenia are one and a half to two times more likely to be overweight, have a twofold increased risk for diabetes and hypertension and show a five times higher prevalence of dyslipidemia compared with the general population.[7] The association of schizophrenia with cardio-metabolic risk factors is a complex interplay between environmental (physical inactivity, unhealthy diet, substance abuse),[8–10] genetic [11] and illness related factors,[12] as well as effects of antipsychotic treatment.[13,14] Effective treatment of cardiometabolic risk factors therefore includes increasing physical activity (PA) and decreasing sedentary behaviour combined with a low-calorie diet.[15] Increasing PA in the schizophrenia population is of particular importance as physical inactivity is identified as one of the most important modifiable risk factors strongly associated with CVD-related mortality. [16] People with schizophrenia spend less time performing strenuous activities than the general population, while during leisure time a greater proportion are not involved in sport activities.[17] Only about 30% can be classified as being regularly active relative to 62% of a non-psychiatric comparison group.[18] Although within multidisciplinary rehabilitation programmes for people with schizophrenia, the interest in PA and exercise is growing,19 people with schizophrenia have poorer access to quality physical health services with less opportunity for CVD risk screening, prevention and treatment than would be expected in a non-psychiatric population.[20,21] Physical therapists are trained to prescribe safe PA participation. In current practice, they generally provide secondary and tertiary prevention for those who have impaired movement due to a wide variety of causes that may or may not be related to PA.[22] Physical therapists’ clinical decisions should be guided by the best available medical evidence. For translating research into clinical practice, clinical practice guidelines are commonly assumed to be the best option. Clinical practice guidelines are defined as ‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’.[23] Their objective is to provide explicit recommendations for clinical

practice in order to optimize outcomes, minimize risks and promote cost-effectiveness. To gain a better understanding of the relationship between PA and cardio-metabolic risk factors and the best available evidence for PA related interventions in schizophrenia, the International Organization of Physical Therapy in Mental Health (IOPTMH) held a first consensus development meeting at the Third International Conference of Physical therapy in Psychiatry and Mental Health, February 4th 2010 in Lund, Sweden. At this meeting the IOPTMH commissioned a workgroup on schizophrenia to develop a consensus position on the following questions: 1. What is the relative contribution of PA in the prevention and treatment of cardio-metabolic risk factors in schizophrenia? 2. What are the major PA participation barriers in patients with schizophrenia? 3. What are the current PA guidelines on minimising cardio-metabolic risk in schizophrenia? 4. How could PA related interventions best be organised within a multidisciplinary lifestyle programme? 5. What research is needed to better understand the relationship between PA levels and cardio-metabolic risk factors in schizophrenia? 6. What actions need to be taken to implement the PA related guidelines in daily practice? The first aim of this paper is to provide a review of the current evidence for PA within the multidisciplinary management of cardio-metabolic risk factors in schizophrenia. The second aim is to outline the recommendations for PA management of cardiometabolic risk factors in patients with schizophrenia.

Methods Development procedure The following steps were taken to develop the present consensus document. 1. The available literature on the relative contribution of PA interventions within the multidisciplinary treatment of cardio-metabolic risks in schizophrenia was reviewed. 2. The available literature on correlates and barriers of PA in schizophrenia was reviewed. 3. The available literature on national and international clinical practice guidelines and recommendations on PA for schizophrenia was reviewed. 4. A first draft of the IOPTMH consensus document was discussed with six members of the IOPTMH board on June 7th, 2010 in Copenhagen, Denmark. 5. A first version of the consensus document was written and discussed throughout online conferences with 15 international experts in schizophrenia and metabolic syndrome issues (one psychiatrist with international expertise on the metabolic syndrome in schizophrenia and one endocrinologist with international expertise on diabetes were consulted). 6. Writing of the final version of the consensus document. Disability & Rehabilitation


IOPTMH physical activity guidelines 3

Review of literature on the relative contribution of PA interventions within the multidisciplinary treatment of cardio-metabolic risks in schizophrenia Search strategy The aim of the review was to identify all studies from the first paper on the metabolic syndrome in schizophrenia24 until May 2010 investigating PA interventions for cardiometabolic risk factors in people with schizophrenia. Recently, a review was published on PA as part of multidisciplinary treatment programme for minimising cardio-metabolic risks.[25] In order to investigate the relative contribution of PA, papers including PA as a sole intervention were selected from this review.[25] Also a number of search methods were applied26 to find more recent papers. The 8 databases searched included PubMed, SPORTDiscus, Cochrane Central Register of Controlled Trials, EMBASE, PEDro, DARE, ProQuest Dissertations and Theses and PsycINFO. Medical Subject Headings (MeSH) terms “schizophrenia” (OR “psychotic disorders”) AND “physical activity” (OR “exercise”) AND “cardiometabolic” (OR “metabolic” OR cardiovascular) were used. Second, literature was also identified by citation tracking using reference lists from selected papers. There were no limitations in terms of study design. Inclusion criteria were: 1) published in an English language, peer-reviewed journal; 2) participants had to be individuals with schizophrenia or schizophrenia-spectrum psychoses (schizoaffective or schizophreniform disorder excluding bipolar disorder and major depression with psychotic features) meeting DSM-IV criteria; 3) except for antipsychotic medication no other interventions were allowed. If any of the three inclusion criteria were not fulfilled, then the study was excluded from the literature review. criteria [27] was used for randomised controlled trials (RCTs) and clinical controlled trials (CCTs) (see Table I). Review of the available literature on correlates and barriers of PA in schizophrenia For reviewing the correlates and associations the same databases were screened for the same period as in the review

on the current evidence for PA. The search terms included “schizophrenia” (OR “psychosis”) AND “physical activity” (OR “exercise”). The inclusion criteria extended to Englishlanguage studies of persons with schizophrenia, which included either an objective (i.e. PA attendance/completion) or a subjective (i.e. self-report, activity check-list) measure of PA, and at least one documented correlate or barrier.

Review of the available literature on national and international clinical practice guidelines and recommendations on PA for schizophrenia In a third review, previous databases were searched to summarise the currently available clinical practice guidelines and recommendations on PA for schizophrenia. The search strategy consisted of the following three parts intersected by “AND”: (a) MeSH terms regarding the diagnosis (i.e. schizophrenia, psychotic disorders), (b) MeSH terms related to cardio-metabolic risk (i.e. metabolic syndrome, metabolic disease, cardiovascular disease) and (c) terms that cover clinical practice guidelines (i.e. prevention and control, consensus, guideline, practice guideline, management). Lastly, literature was also identified by citation tracking using reference lists from selected papers. Evaluation was based on full English language guidelines, but summary versions, where available, were also included in the review process. Systematic reviews were excluded because these publications are one of the sources for developing guidelines. Also RCTs were excluded since the results of internally valid RCTs may not be applicable to other populations or outcomes and therefore should not always be assumed to provide high-quality evidence for therapy recommendations. For an article to be excluded, two reviewers (MP and DV) had to agree that the article was ineligible. Discrepancies between the reviewers were discussed and resolved by consensus. The final selection for full data extraction was made by the second author (MDH) because of the broad array of potentially eligible guidelines.

Table I. Best-evidence synthesis Strong evidence Provided by consistent, statistically significant findings in outcome measures in at least two high quality RCTs* Provided by consistent, statistically significant findings in outcome measures in at least one high quality RCT and at least Moderate evidence one low quality RCT or high quality CCT* Limited evidence Provided by statistically significant findings in outcome measures in at least one high quality RCT* or Provided by consistent, statistically significant findings in outcome measures in at least two high quality CCTs* (in the absence of high quality RCTs) Provided by statistically significant findings in outcome and/or process measures in at least one high quality CCT or low Indicative findings quality RCT* (in the absence of high quality RCTs) or Provided by consistent, statistically significant findings in outcome and/or process measures in at least two ODs with sufficient quality (in absence of RCTs and CCTs)* No or insufficient evidence In the case that results of eligible studies do not meet the criteria for one of the above stated levels of evidence or In the case of conflicting (statistically significant positive and statistically significant negative) results among RCTs and CCTs or In the case of no eligible studies RCT = randomised controlled trial, CCT = clinical controlled trial, OD = other design. *If the amount of studies that show evidence is less than 50% of the total number of studies found within the same category of methodological quality and study design (RCTs, CCTs or ODs), we will state no evidence.

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4 D. Vancampfort et al.

Results


What is the relative contribution of PA interventions within the multidisciplinary treatment of cardiometabolic risks in schizophrenia? Search results Thirty-six relevant abstracts were retrieved. A further 32 studies were excluded for the following reasons: not published in English (n = 2), no peer-review (n = 1), no full-text available (n = 1), overlap in data (n = 1), co-interventions used (n = 17), included participants not limited to only patients with schizophrenia (n = 4), no cardio-metabolic parameter included (n = 7). Only four studies [28–31] including two RCTs [30,31] met all inclusion criteria (see Table II). Main findings One RCT30 observed a significant reduction in body fat after a walking programme compared with care as usual while two RCTs [30,31] found non-significant improvements in aerobic fitness as measured with the six-minute walk test. According to the best-evidence synthesis,[27] it might be concluded that there is at the moment insufficient evidence for the relative contribution of PA in reducing cardio-metabolic risks in people with schizophrenia. No data on the effectiveness of PA as a sole intervention for managing other cardiometabolic risk factors (fasting blood glucose, fasting blood lipids and/or blood pressure) was available.

What are correlates and barriers of PA participation in patients with schizophrenia? Search results Twenty-three relevant abstracts were retrieved. A further 10 studies were excluded. Reasons are: diagnoses not mentioned (n = 1), no correlates (n = 6), overlap with other study data (n = 1), only data on physical functioning and not on PA (n = 2). Thirteen studies [18,28–39] met all inclusion criteria (see Table III). Main findings An overview of the different correlates, associations and barriers is given in Table III. In parallel with the general population40 correlates can be mainly categorised in four groups of factors: 1. demographical and biological factors including lack of finances, overweight and obesity, physical complaints, low physical fitness, side-effects of medication and illness symptoms. 2. psychological, cognitive-behavioural and emotional factors including low physical self-perception and low selfefficacy, feelings of sadness, anxiety and stress, disinterest, lack of motivation (stages of change, self-determination). 3. social factors: lack of social support and stigma, tendency to avoid social situations. 4. physical environment: lack of adequate services and facilities, distances to be travelled to access services. 5. Additionally, the attitude of the therapist is often mentioned as one of the most important factors associated with patients’ PA participation.

Table II. Evidence on cardio-metabolic parameters for physical activity in patients with schizophrenia (adapted from Vancampfort et al., 2009) First author Design Participants Physical activity intervention Main cardiometabolic Drop-out and attendance outcomes [vs. controls] 10 stable outpatients with Only regular physical schizophrenia or Drop-out was 40% at 4, 70% at 5 Free 6-month access to fitness facilities. activity is related to Archie [28] OD schizoaffective and 90% at 6 months. decrease in weight. disorder (male = 8); 16–55 yrs. Increased endurance, 6 male in-patients A 3-month individualized physical increased fitness, Fogarty [29] OD with schizophrenia; conditioning programme with emphasis on / improved weight control, 20–42 yrs. group dynamics. reduced blood pressure. Decrease in body fat A 16-week structured treadmill walking 33% of the exercise group (3.69%, p = 0.03) and 10 out-patients programme 3 times/week: 10 min of warm-up dropped out leaving 4 in the BMI (4%, p > 0.05) (n = 4) diagnosed with stretches followed by walking at target heart exercise cohort for final analysis. [vs-.0.02 in body fat and Beebe [30] RCT schizophrenia rate and 10 min of cool-down. From walking Attendance ranged from 43% -0.02 in BMI]; increase (male = 8); 40–63 for 5 min on the first day to 30 min over the to 91% of the sessions, 75% in aerobic fitness (10%, yrs. first 3 weeks; the next 13 weeks 30 min, 3 attended more than half of the p > 0.05) on 6 MWT times/week. sessions and 50% over 2/3. [vs.+4%] Marzolini RCT 13 out-patients 12 weeks; twice/week 90 min (10 min warm- Increase (p = 0.1) of 5.2% Attendance averaged 72% [31] (male = 8); 45 ± 3 up, 20 min weight resistance, 60%1RM or