Strength training integrated in long term collaborative care of patients with schizophrenia.

INTRODUCTION: Skeletal muscle strength is reduced in patients with schizophrenia, contributing to their impaired physical health, functional performance, and potentially mental health challenges. Although short-term training programs have shown promising results, improving muscle strength and functional performance, it is unknown how exercise can be successfully integrated into the long-term clinical care of outpatients with schizophrenia. OBJECTIVE: To investigate effects of strength training with adherence support in a collaborative care model. METHODS: We randomized 28 men and 20 women (mean ± SD, 35 ± 11 years) to leg press maximal strength training (MST) with 4 sets at 90 % of one repetition maximum (1RM) 2 × week, facilitated by municipal service and professional supervision (TG), or a control group (CG). RESULTS: The TG increased scaled leg press 1RM (0-3 months: 19 %; 0-6 months: 31 %, 0-12 months: 40 %, all p < .001, and 3-12 months: 18 %, p < .05) and power (0-3 months, 11 %; 0-6 months: 22 %, 0-12 months: 26 %, all p < .001, and 3-12 months: 13 %, p < .05) throughout the 1-year period compared to the CG. The increased muscle strength was accompanied by improved sit-to-stand performance (20 %) after 12 months (p < .001). Both groups also exhibited within-group improvements in walking work efficiency after 6 months (TG: 13 %; CG: 23 %) and 1 year (TG: 11 %; CG: 21 %, p < .01-0.05), but with no evident differences between the groups. Stair climbing performance remained unchanged. CONCLUSION: Our results reveal that strength training can successfully be integrated as a part of long-term clinical care of outpatients with schizophrenia, contributing to improved functional performance.

Test-Retest Reliability of the Patient Activation Measure-13 in Adults with Substance Use Disorders and Schizophrenia Spectrum Disorders.

Patient Activation Measure-13 (PAM-13) is a valid and widely used questionnaire that assess an individual's knowledge, confidence, and skills for self-management of their chronic illness. Although there is some evidence regarding its reliability, the test-retest reliability has not been investigated among patients with substance use disorders (SUDs) or schizophrenia spectrum disorders. We investigated the internal consistency and test-retest reliability of PAM-13 in these populations. Test-retest reliability was analysed using data from 29 patients with SUDs and 28 with schizophrenia spectrum disorders. Cronbach's α and Intraclass Correlation Coefficient (ICC) scores were used to examine internal consistency and test-retest reliability, respectively. Of the 60 collected test-retest questionnaires, 57 were included in the analyses. No mean differences between time one (T1) and time two (T2) were observed in either patient group, except for item 12 in schizophrenia spectrum disorders patients (p < 0.05). Internal consistency for T1 and T2 was 0.75 and 0.84 in SUDs patients and 0.87 and 0.81 in schizophrenia spectrum disorders patients, respectively. The ICC was r = 0.86 in patients with SUDs and r = 0.93 in patients with schizophrenia spectrum disorders. To conclude, PAM-13 showed good internal consistency and test-retest reliability in SUDs and schizophrenia spectrum disorders patients.

Strength training restores force-generating capacity in patients with schizophrenia.

Patients with schizophrenia spectrum disorders have impaired skeletal muscle force-generating capacity (FGC) of the lower extremities, that is, one repetition maximum (1RM) and rapid force development, and poor functional performance. We therefore investigated whether 12 weeks of maximal strength training (MST) could (a) restore FGC and functional performance to the level of healthy references, (b) increase patient activation and quality of life, and (c) explore associations between symptom severity, defined daily dose of medication, illness duration, level of patient activation, and improvements in FGC and functional performance. Forty-eight outpatients were randomized to a training group (TG) or control group (CG). TG performed leg press MST 2 day/week at ~ 90% 1RM. The CG received two introductory training sessions and encouragement to train independently. Leg press 1RM, rapid force development, a battery of functional performance tests, Patient Activation Measure-13, and 36-Item Short Form Health Survey were tested. Healthy references performed baseline tests of FGC and functional performance. Thirty-six patients completed the study (TG: 17, CG: 19). TG improved 1RM (28%) and rapid force development (20%, both P < .01) to a level similar to healthy references, while no change was apparent in the CG. TG's improvement in rapid force development was negatively associated with defined daily dose of medication (r = -0.5, P = .05). Both TG and CG improved 30-second sit-to-stand test performance (P < .05) which was associated with improved rapid force development (r = 0.6, P < .05). In conclusion, 12 weeks of MST restored patients' lower extremity FGC to a level similar to healthy references and improved 30-second sit-to-stand test performance.

One-year aerobic interval training in outpatients with schizophrenia: A randomized controlled trial.

Although aerobic interval training (AIT) is recognized to attenuate the risk of cardiovascular disease (CVD) and premature mortality, it appears that it rarely arrives at patients' doorsteps. Thus, this study investigated 1-year effects and feasibility of AIT delivered with adherence support in collaborative care of outpatients with schizophrenia. Forty-eight outpatients (28 men, 35 [31-38] (mean [95% confidence intervals]) years; 20 women, 36 [30-41] years) with schizophrenia spectrum disorders (ICD-10) were randomized to either a collaborative care group provided with municipal transportation service and training supervision (walking/running 4 × 4 minutes at ~90% of peak heart rate; HRpeak ) 2 d wk-1 at the clinic (TG) or a control group (CG) given 2 introductory AIT sessions and advised to continue training. Directly assessed peak oxygen uptake ( V ˙ O 2 peak ) increased in the TG after 3 months (2.3 [0.6-4.4] mL kg-1  min-1 , Cohen's d = 0.33[-4.63 to 4.30], P = 0.04), 6 months (2.7 [0.5-4.8] mL kg-1  min-1 , Cohen's d = 0.42[-4.73 to 4.11], P = 0.02) and 1 year (4.6 [2.3-6.8] mL kg-1  min-1 , Cohen's d = 0.70[-4.31 to 4.10], P < 0.001) compared to the CG. One-year cardiac effects revealed higher HRpeak (7 [2-11] b min-1 , Cohen's d = 0.34[-8.48 to 8.65], P = 0.01), while peak stroke volume tended to be higher (0.9 [-0.2 to 2.0] mL b-1 , Cohen's d = 0.35[-1.62 to 2.01], P = 0.11) in the TG compared to the CG. Conventional risk factors (body weight, waist circumference, blood pressure, and lipids/glucose) remained unaltered in both groups. One-year AIT adherence rates were 15/25 (TG; different from CG: P < 0.001) and 0/23 (CG). AIT was successfully included in long-term collaborative care of outpatients with schizophrenia and yielded improved V ˙ O 2 peak , advocating this model for aerobic capacity improvement and CVD risk reduction in future treatment.

Patients with schizophrenia have impaired muscle force-generating capacity and functional performance.

Patients with schizophrenia have impaired physical health. However, evidence of how skeletal muscle force-generating capacity (FGC), a key component of functional performance, may contribute to the impairment is scarce. Thus, the aim of this study was to investigate the patient groups' skeletal muscle FGC and its association with functional performance. Leg-press FGC was assessed along with a battery of functional performance tests in 48 outpatients (28 men, 34 ± 10 years; 20 women, 36 ± 12 years) with schizophrenia spectrum disorder (ICD-10, F20-29), and compared with 48 healthy age- and gender-matched references. Results revealed reduced one-repetition maximum (1RM) in men (-19%, P < .01) and a trend toward reduction in women (-13%, P = .067). The ability to develop force rapidly was also impaired (men: -30%; women: -25%, both P < .01). Patients scored worse than healthy references on all physical performance tests (stair climbing: -63%; 30-second sit-to-stand (30sSTS): -48%; six-minute walk test (6MWT): -22%; walking efficiency: -14%; and unipedal stance eyes open: -20% and closed: -73%, all P < .01). 1RM correlated with 6MWT (r = .45), stair climbing (r = -.44), 30sSTS (r = .43), walking efficiency (r = .26), and stance eyes open (r = .33) and closed (r = .45), all P < .01. Rapid force development correlated with 6MWT (r = .54), stair climbing (r = -.49), 30sSTS (r = .45), walking efficiency (r = .26), and stance eyes open (r = .44) and closed (r = .51), all P < .01. In conclusion, skeletal muscle FGC and functional performance are reduced in patients with schizophrenia and should be recognized as important aspects of the patient groups' impaired health. Resistance training aiming to improve these components should be considered an important part of clinical treatment.

A comprehensive cardiovascular disease risk profile in patients with schizophrenia.

Patients with schizophrenia are physically inactive and have high prevalence of cardiovascular disease (CVD). Peak oxygen uptake (V̇O2peak ) is one of the strongest predictors for CVD, yet is rarely investigated in this patient population, and how V̇O2peak relates to other conventional CVD risk measures in this population is unclear. We measured treadmill V̇O2peak along with daily physical activity assessed by triaxial accelerometry, body mass index (BMI), waist circumference, blood pressure, lipid profiles, and glucose in 48 outpatients (28 men, 35 ± 10 (SD) years; 20 women, 35 ± 12 years), diagnosed with schizophrenia, schizotypal, or delusional disorders (ICD-10; F20-29). The patients were compared with 48 age- and sex-matched healthy references (±2 years) and normative data from the population. V̇O2peak was 34.5 ± 8.7 mL/kg/min (men) and 26.4 ± 7.0 mL/kg/min (women), which was 27% and 30% lower than healthy references, respectively (both P < 0.01). V̇O2peak was not associated with daily physical activity in men while a weak association was seen in women (steps per day: r2  = 0.26; counts per minute: r2  = 0.25; P < 0.05). BMI (26.0 ± 6.1 kg/m2 ) revealed that patients were moderately overweight with a waist circumference of 103 ± 17 cm. Lipid- and glucose levels, and blood pressure were all within normative range. Our data advocate the utilization of V̇O2peak assessment for CVD risk profile determination in patients with schizophrenia. Daily physical activity was poorly and inconsistently related to V̇O2peak, suggesting increased daily physical activity might not translate into improved V̇O2peak and CVD risk reduction.

Predictive validity of objective measures of physical fitness for the new onset of mental disorders in adolescents and young adults.

AIM: To systematically review evidence that objectively assessed level of physical fitness is associated with future risk of adverse mental health outcomes during the peak age range for onset of adult mental disorders. METHODS: Searches of Electronic databases (EBSCOhost, SPORTDISCUS, EMBASE, MedLINE, Cochrane database, CINAHL, PsychInfo, and Dissertation Abstracts), supplemented by hand searches of journals, conference proceedings and citations. Random-effects meta-analysis models were used to pool the intervention effects. RESULTS: Eight studies of adolescents and young adults were included in the qualitative review and six studies derived from four independent cohorts were included in the statistical analyses. Most publications reported on large samples (including >1 million), but male conscripts were over-represented in the study cohorts; quality of included studies was modest, and heterogeneity was significant. Meta-analytic estimates were conducted for different adverse mental health outcomes, but all showed an inverse association between fitness and incidence of mental disorders or suicidality. Overall, higher level of physical fitness was associated with lower rates of onset of mental health problems (odds ratio: 0.59; 95% confidence intervals: 0.54, 0.65). CONCLUSIONS: All eligible studies were undertaken since 2010, suggesting this is an emerging but unfinished field of research. The study design and methodological limitations indicate that the reported results should be treated with caution. However, if the meta-analytic findings are reliably replicated for new cohorts of males and females, they have implications for research into the prevention of non-communicable diseases, as our review suggests that interventions should target physical and mental health in equal measure.

High aerobic intensity training and psychological States in patients with depression or schizophrenia.

AIM: To explore changes in psychological states in response to a bout of high aerobic intensity training (HIT) in patients with depression or schizophrenia compared to healthy individuals. METHODS: After familiarization training of HIT, 20 patients with schizophrenia, 13 patients with depression, and 20 healthy individuals performed a no-training day followed by a training day. HIT was 4 × 4 min intervals at 85-95% of peak heart rate, intermitted by 3 min active rest periods at 70% of peak heart rate. Self-evaluation questionnaires of positive affect, negative affect, state anxiety, well-being, distress, and fatigue were completed before training, 15 min after, and 3 h after training. The two latter measures were also completed the no-training day. RESULTS: All three groups improved in positive affect and well-being 15 min after HIT (p < 0.01), but only patients with depression had maintained the effect after 3 h (p = 0.007, p = 0.012). The duration of the improved positive affect was longer in depression (p = 0.002) and schizophrenia (p = 0.025) than in healthy individuals (F 2.50 = 5.83, p < 0.01). Patients with depression or schizophrenia had reduced distress and state anxiety 15 min after HIT and 3 h after HIT (p < 0.05). The improvement in distress 15 min after HIT was larger in patients with depression (p = 0.028) compared to healthy individuals (F 2.50 = 5.05, p < 0.01). No changes were found during the no-training day (p > 0.05). CONCLUSION: High aerobic intensity training used as an acute intervention improved positive affect and well-being and reduced distress and state anxiety in patients with depression and schizophrenia. ClinicalTrials.gov identifier: NCT01310998.

Differences in Aerobic Fitness between Inpatients and Outpatients with Severe Mental Disorders.

BACKGROUND: Patients with severe mental disorders have increased mortality, and cardiovascular disease (CVD) accounts for a large part. Physical inactivity and low aerobic fitness have been recognized as significant risk factors for CVD. In this study, we investigated the differences in aerobic fitness and physical activity between in- and outpatients with severe mental disorders. METHOD AND SUBJECTS: Fifty in- and outpatients from a regional psychiatric department were included. The patients filled in a questionnaire on physical activity and completed a clinical examination. An estimation of aerobic fitness was calculated for each patient, using gender, age, waist circumference, resting heart rate, and physical activity level as variables. RESULTS: Inpatients had lower estimated aerobic fitness than outpatients (VO2peak 42 vs. 50 mL kg(-1) min(-1), p < 0.001). Compared to population data matched for age and gender, inpatients had lower aerobic fitness, while outpatients were not different from the population average. CONCLUSION: Inpatients at a psychiatric department had lower estimated aerobic fitness than outpatients, and a lower aerobic fitness compared to the general population. Our findings suggest that inpatients with severe mental disorders should be considered a high risk group for CVD.

Maximal strength training improves work economy, rate of force development and maximal strength more than conventional strength training.

This study compared maximal strength training (MST) with equal training volume (kg × sets × repetitions) of conventional strength training (CON) primarily with regard to work economy, and second one repetition maximum (1RM) and rate of force development (RFD) of single leg knee extension. In an intra-individual design, one leg was randomized to knee-extension MST (4 or 5RM) and the other leg to CON (3 × 10RM) three times per week for 8 weeks. MST was performed with maximal concentric mobilization of force while CON was performed with moderate velocity. Eight untrained or moderately trained men (26 ± 1 years) completed the study. The improvement in gross work economy was -0.10 ± 0.08 L min(-1) larger after MST (P = 0.011, between groups). From pre- to post-test the MST and CON improved net work economy with 31 % (P < 0.001) and 18 % (P = 0.01), respectively. Compared with CON, the improvement in 1RM and dynamic RFD was 13.7 ± 8.4 kg (P = 0.002) and 587 ± 679 N s(-1) (P = 0.044) larger after MST, whereas isometric RFD was of borderline significance 3,028 ± 3,674 N s(-1) (P = 0.053). From pre- to post-test, MST improved 1RM and isometric RFD with 50 % (P < 0.001) and 155 % (P < 0.001), respectively whereas CON improved 1RM and isometric RFD with 35 % (P < 0.001) and 83 % (P = 0.028), respectively. Anthropometric measures of quadriceps femoris muscle mass and peak oxygen uptake did not change. In conclusion, 8 weeks of MST was more effective than CON for improving work economy, 1RM and RFD in untrained and moderately trained men. The advantageous effect of MST to improve work economy could be due to larger improvements in 1RM and RFD.

Therapeutic effects of maximal strength training on walking efficiency in patients with schizophrenia - a pilot study.

BACKGROUND: Patients with schizophrenia frequently have disabling gait deficits. The net mechanical efficiency of walking (ϵnet) is an accurate measure often used to evaluate walking performance. Patients with gait deficits have a reduced ϵnet with excessive energy expenditure during sub-maximal walking. Maximal strength training (MST) improves ϵnet in healthy individuals and is associated with reduced risk of mortality. The aim of this study was to investigate whether MST improves ϵnet in patients with schizophrenia. METHODS: Patients (ICD-10 schizophrenia, schizotypal or delusional disorders (F20-F29)) were included in a non-randomized trial. Patients were assigned to one of two groups: 1) MST consisting of 4x4 repetitions at 85-90% one repetition maximum (1RM) performed in a leg press apparatus or 2) playing computer games (CG). Both groups carried out their activity three days per week for eight weeks. 1RM, ϵnet at 60 watt walking, peak oxygen uptake (VO2peak), the Positive and Negative Syndrome Scale (PANSS) and the 36-items short form (SF-36) were measured pre and post intervention. RESULTS: The baseline ϵnet was 17.3 ± 1.2% and 19.4 ± 3.0% in the MST (n = 6) and CG groups (n = 7), respectively, which is categorized as mechanical inefficiency. The MST group improved 1RM by 79 kg (p = 0.006) and ϵnet by 3.4% (p = 0.046) more than the CG group. The MST group improved 1RM and ϵnet, by a mean of 83 kg (p = 0.028) and 3.4% (p = 0.028), respectively. VO2peak at baseline was 34.2 ± 10.2 and 38.3 ± 9.8 ml·kg-1·min-1 in the MST and CG groups, respectively, and did not change (p > 0.05). No change was observed in PANSS or SF-36 (p > 0.05). CONCLUSIONS: MST improves 1RM and ϵnet in patients with schizophrenia. MST could be used as a therapeutic intervention for patients with schizophrenia to normalize their reduced ϵnet.

Reduced peak oxygen uptake and implications for cardiovascular health and quality of life in patients with schizophrenia.

BACKGROUND: Peak oxygen uptake (VO(2peak)) is a strong predictor of cardiovascular disease (CVD) and all-cause mortality, but is inadequately described in patients with schizophrenia. The aim of this study was to evaluate treadmill VO(2peak), CVD risk factors and quality of life (QOL) in patients with schizophrenia (ICD-10, F20-29). METHODS: 33 patients, 22 men (33.7 ± 10.4 years) and 11 women (35.9 ± 11.5 years), were included. Patients VO(2peak) were compared with normative VO(2peak) in healthy individuals from the Nord-Trøndelag Health Study (HUNT). Risk factors were compared above and below the VO(2peak) thresholds; 44.2 and 35.1 ml·kg⁻¹·min⁻¹ in men and women, respectively. RESULTS: VO(2peak) was 37.1 ± 9.2 ml·kg⁻¹·min⁻¹ in men with schizophrenia; 74 ± 19% of normative healthy men (p < 0.001). VO(2peak) was 35.6 ± 10.7 ml·kg⁻¹·min⁻¹ in women with schizophrenia; 89 ± 25% of normative healthy women (n.s.). Based on odds ratio patients were 28.3 (95% CI = 1.6-505.6) times more likely to have one or more CVD risk factors if they were below the VO(2peak) thresholds. VO(2peak) correlated with the SF-36 physical functioning (r = 0.58), general health (r = 0.53), vitality (r = 0.47), social function (r = 0.41) and physical component score (r = 0.51). CONCLUSION: Men with schizophrenia have lower VO(2peak) than the general population. Patients with the lowest VO(2peak) have higher odds of having one or more risk factors for cardiovascular disease. VO(2peak) should be regarded as least as important as the conventional risk factors for CVD and evaluation of VO(2peak) should be incorporated in clinical practice.

Effects of high aerobic intensity training in patients with schizophrenia: a controlled trial.

BACKGROUND: Patients with schizophrenia have a high risk of cardiovascular disease (CVD). High aerobic intensity training (HIT) improve peak oxygen uptake (VO(2peak)), net mechanical efficiency of walking and risk factors for CVD but has not been investigated in patients with schizophrenia. AIMS: To investigate effects from HIT on VO(2peak), net mechanical efficiency of walking and risk factors for CVD in patients with schizophrenia. METHODS: 25 inpatients (F20-29, ICD-10) were allocated to either HIT or playing computer games (CG), 3 days per week for 8 weeks. HIT consisted of 4 × 4-min intervals with 3-min break periods, at 85-95% and 70% of peak heart rate, respectively. RESULTS: 12 and seven patients completed HIT and CG, respectively. The baseline VO(2peak) in both groups combined (n = 19) was 36.8 ± 8.2 ml/kg/min and 3.12 ± 0.55 l/min. The HIT group improved VO(2peak) by 12% from 3.17 ± 0.59 to 3.56 ± 0.68 l/min (P < 0.001), more than the CG group (P = 0.014). Net mechanical efficiency of walking improved by 12% in the HIT group from 19.8 ± 3.0% to 22.2 ± 4.5% (P = 0.005), more than the CG group (P = 0.031). The psychiatric symptoms, expressed as the Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS), did not improve in either group. CONCLUSIONS: VO(2peak) and net mechanical efficiency of walking improved significantly by 8 weeks of HIT. HIT should be included in rehabilitation in order to improve physical capacity and contribute risk reduction of CVD.