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Eurofit test battery in patients with schizophrenia or schizoaffective disorder: Reliability and clinical correlates
European Psychiatry 27 (2012) 416–421
Original article
Eurofit test battery in patients with schizophrenia or schizoaffective disorder: Reliability and clinical correlates D. Vancampfort a,*,b, M. Probst a,b, K. Sweers a, K. Maurissen a,b, J. Knapen a,b, J.B. Willems a, T. Heip a, M. De Hert a,c a
University Psychiatric Centre Catholic University Leuven, Campus Kortenberg, Leuvensesteenweg 517, 3070 Kortenberg, Belgium Faculty of Kinesiology and Rehabilitation Sciences, Catholic University Leuven, Leuven, Belgium c Faculty of Medicine, Catholic University Leuven, Leuven, Belgium b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 September 2010 Received in revised form 29 January 2011 Accepted 30 January 2011 Available online 12 March 2011
Objective: To investigate the reproducibility of the Eurofit physical fitness test battery in patients with schizophrenia or schizoaffective disorder. Secondary aims were to assess clinical and demographic characteristics that correlate with the performance on the Eurofit and evaluation of the feasibility of the test. Methods: Fifty patients with schizophrenia or schizoaffective disorder (mean age of 32.9 9.5 years) with a mean body mass index (BMI) of 26.1 6.0 kg/m2 performed two Eurofit tests administered within 3 days. Results: All Eurofit items showed good reproducibility with intraclass correlation coefficients ranging from 0.72 for flamingo balance to 0.98 for standing broad jump test. All participants could perform five of the seven test items without problems. The whole body balance and abdominal muscle endurance test could be executed by 74 and 90%, respectively. Significant correlations were found with age, BMI, waist circumference, dose of antipsychotic medication and extrapyramidal, negative and cognitive symptoms. Conclusions: The Eurofit test showed good reproducibility and can be recommended for evaluating physical fitness parameters in patients with schizophrenia or schizoaffective disorder. Physical fitness measures were related to both physical and mental health parameters. ß 2011 Elsevier Masson SAS. All rights reserved.
Keywords: Physical Fitness Eurofit Schizophrenia Reliability
1. Introduction In recent years, metabolic and cardiovascular diseases (CVD) have become a major concern in the multidisciplinary treatment of people with schizophrenia or schizoaffective disorder [20,25]. People with schizophrenia or schizoaffective disorder are 1.5 to 2 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 [13]. In addition to the effects of antipsychotic treatment [12,29,30], the association of schizophrenia or schizoaffective disorder with increased cardio-metabolic risk factors is a complex interplay between unhealthy lifestyle (physical inactivity, unhealthy diet, smoking and substance use) [5,23,39], genetic risk [28,34] and illness related factors [24]. In adults from the general population, low physical fitness is a strong and independent predictor of CVD and all-cause
* Corresponding author. Tel.: +32 2 758 05 11; fax: +32 2 759 9879. E-mail address: [email protected] (D. Vancampfort). 0924-9338/$ – see front matter ß 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2011.01.009
mortality and of comparable importance as diabetes mellitus and other CVD risk factors [44]. Physical fitness is a multifactorial concept comprising a set of more or less independent attributes which are related to the ability to perform physical activities. Some of these components (including cardio-respiratory fitness, muscular endurance, muscular strength and flexibility) are more closely related to health, while others (such as coordination and whole body balance) are more related to performance [32]. Health-related physical fitness has been defined as the ability to perform daily activities with vigour and to demonstrate capacities that are associated with a lower risk of premature development of hypokinetic diseases (i.e., those associated with physical inactivity). Performance-related physical fitness refers to those components that are necessary for optimal work or sport performance [6]. Associations between high levels of physical fitness and lower rates of overall morbidity and mortality are robust and have been demonstrated to be independent from other major risk factors [2–4,18,19]. Also in persons with schizophrenia or schizoaffective disorder, physical fitness seems to emerge as a major modifiable risk factor for CVD and overall morbidity and mortality [39].
D. Vancampfort et al. / European Psychiatry 27 (2012) 416–421
Low physical fitness and poor physical health are important arguments for the implementation of physical activity into multidisciplinary treatment programmes for patients with schizophrenia or schizoaffective disorder [14,15,39]. Designing wellconsidered physical activity programmes for these patients requires a measurement of their physical fitness [39]. To the best of our knowledge, only one study has systematically assessed the reliability of one aspect of health related physical fitness in persons with schizophrenia or schizoaffective disorder [40]. This study focused on cardio-respiratory fitness and indicated that the six minute walk test is a reliable cardio-respiratory fitness test. No studies explored the reliability of other components of health related physical fitness, such as muscular endurance, muscular strength and flexibility in patients with schizophrenia or schizoaffective disorder. Different field test batteries on physical fitness have been developed which assess different physical fitness parameters [42]. One of these tests is the Eurofit test battery for adults [31]. It has been used previously in non-psychotic adult psychiatric patients [41]. The Eurofit test battery is designed by the Committee for the Development of Sport of the Council of Europe to assess healthrelated fitness of individuals, communities and population samples [31]. Its reproducibility has never been assessed in psychiatric patients. The primary aim of the present study therefore was to investigate the test-retest reliability of the Eurofit test battery in patients with schizophrenia or schizoaffective disorder. Secondary aims were: (a) to assess both physical and mental health parameters that correlate with the performance on the Eurofit test and (b) to evaluate the feasibility of the Eurofit test in these patients. 2. Methods 2.1. Participants and setting Over a 4-month period, all consecutive acute and chronic inpatients with schizophrenia or schizoaffective disorder of the University Psychiatric Centre of Kortenberg (a 400 beds hospital) in Belgium were invited to participate in the study. Patients were excluded if they had co-morbid substance abuse. The somatic exclusion criteria included evidence of significant cardiovascular, neuromuscular and endocrine disorders which according to the American College of Sports Medicine [16] might prevent safe participation in exercise testing. Psychiatric diagnosis based on DSM-IV criteria was established by experienced psychiatrists responsible for the patients’ treatment. No formal semi-structured diagnostic interview was done. 2.2. Sample size analysis The sample size was estimated using the methodology proposed by Walter et al. [17,43] for approximating the number of participants required for test-retest reliability. The required optimal sample size for intraclass correlations (ICC) was based on the desired power level, the magnitude of the predicted ICC, and the lower confidence limit. Assuming an ICC of 0.8 to be a minimal level of reliability but hypothesising an ICC of 0.9 with administration of the Eurofit test on two occasions, a sample size of 46 is considered appropriate (p < 0.05, 80% power). The hypothesis that present findings would be consistent with an ICC of 0.90 was based on a previous reliability study on the 6minute walk test in schizophrenia [40]. It was anticipated that more or less 15% of patients needed to be excluded, 10% would refuse for motivational reasons and 10% would dropout from the testing for both motivational and practical reasons. In this way, a sample size of 70 participants was pre-specified.
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2.3. Test-retest of the EUROFIT A test-retest design was used to test the reproducibility of several Eurofit test battery items. Supervision and measurement of the Eurofit test battery was performed by one of three trained members (one physical therapist one research nurse and one physiotherapist). The test was repeated within 3 days. Patients performed the re-test at the same hour in standardized conditions. Patients were requested to refrain from eating, drinking coffee or smoking during a two-hour period prior to the tests. At testing days medication was taken at the same hour of the day. The battery of physical fitness tests included the assessment of the following physical fitness measures: whole body balance, speed of limb movement, flexibility, explosive strength, static strength, abdominal muscular endurance and running speed [31]. Whole body balance (Flamingo balance [FBA]) was measured as the number of trials needed by individuals to achieve a total duration of 30 s in balance on their preferred foot on a flat firm surface. While balancing on the preferred foot, the free leg is flexed at the knee and the foot of this leg held close to the buttocks. Lower FBA-scores indicate a better whole body balance. Speed of limb movement (plate tapping [PLT]) was assessed using a PLT table on which two discs at 80 cm distance had to be touched alternately with the preferred hand as fast as possible, completing 25 cycles. The higher the score, the lower the speed of limb movement. Flexibility was measured using the sit-and-reach test (SAR). Participants sat on the floor with straight legs and reached forward as far as possible. The knees were held in extended position by the investigator throughout the test. The feet were placed against a test box with a ruler placed on the top of the box. The ruler had to be pushed with the fingertips and this in a smooth and slow movement. Higher scores indicate better flexibility. Explosive strength was measured by a standing broad jump (SBJ), using a tape measure on a foam mat. Participants were asked to stand behind a line drawn perpendicular to the tape measure and jump forward as far as possible using arm swing and knee bending before jumping. The distance jumped was recorded from the takeoff line to the farthest point backward of the participant. Higher scores indicate a better explosive strength. Handgrip strength (HGR) was assessed using a handgrip dynamometer (Lafayette Instruments Hand Dynamometer) to be squeezed as forcefully as possible with the preferred arm fully extended slightly away slightly away from the body, and palm facing inward. The higher the score the better the handgrip strength. Abdominal muscle endurance was measured as the number of correctly completed sit-ups in 30 s (SUP). Sit-ups were performed with the hands placed at the side of the head, knees bent at 90 degrees, and the feet secured by the investigator. A full sit-up is defined as touching the knees with the elbows and returning the shoulders to the ground. A higher number of SUP indicate a better abdominal muscle endurance. Running speed was assessed using a 10 by 5 m shuttle run (SHR). Each participant was required to sprint 10 times between two lines placed 5 m apart. The track was 1.3 m wide. The sprint was followed by immediately turning and running back. The lower the score the better the running speed. Except for FBA, SUP and SHR each test was done twice and the better score was recorded. Related to the anthropometric measurements, data on body weight, height and waist circumference was collected. Body weight was measured in light clothing to the nearest 0.1 kg using a SECA beam balance scale, and height to the nearest 0.1 cm using a wall-mounted stadiometer. Waist circumference (WC) was measured to nearest 1 cm at the level of the umbilicus and at the end of expiration with the subject upright and his/her hands by the side.
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The study procedure was approved by the Scientific Committee of the University Psychiatric Centre of the Catholic University of Leuven, Belgium in accordance with the principles of the Declaration of Helsinki. All participants gave their informed consent. 2.4. Psychosis evaluation tool for common use by caregivers (PECC) Psychotic symptoms were assessed by an independent and well trained nurse using the PECC [10]. The semi-structured PECCinterview evaluates 20 symptom items on a 7-point scale. Symptoms are grouped in five factors: positive, negative, depressive, cognitive and excitatory symptoms. The scores for each factor range from 4 to 28. Also extrapyramidal symptoms (EPS) were evaluated with the PECC-instrument. Scores range from 4 to 16. Higher scores indicate more severe symptoms. Validation results suggest that the PECC can be successfully used for the evaluation of these symptoms in schizophrenia or schizoaffective disorder [11]. 2.5. Medication use
analysis. No significant differences in demographical and clinical variables were found between participants and dropouts. The sex distribution of the final sample of participants was 30 men (32.3 10.1 years; BMI 25.9 5.7; WC 94.3 5.7 cm) and 20 women (33.5 8.5 years; BMI 25.8 6.6; WC 92.3 17.0 cm). Age and BMI did not differ between men and women. Differences in Eurofit-scores between men and women are given in Table 1. Men scored better on SBJ, HGR, SUP, SHR. Except for one, all individuals were white, Belgian natives. Twenty-nine (58%) patients were smokers. Mean daily cigarettes was 21.5 13.3. An overview of the medication intake is presented in Table 2. Mean daily equivalent dosage of chlorpromazine was 637 434 mg/day. Psychiatric symptoms and EPS of the included sample (n = 50) are presented in Table 3. The highest scores were obtained for negative and depressive symptoms. 3.2. Test-retest reliability of the Eurofit items
Current antipsychotic medication was recorded for each patient and converted into a daily equivalent dosage of chlorpromazine according to Gardner et al. [21].
Means and standard deviations for the performed Eurofit tests on both occasions and the associated ICCs with 95% CIs are presented in Table 4. All Eurofit items demonstrated a ICC above 0.70. The ICCs range from 0.72 for FBA till 0.98 for SBJ.
2.6. Reliability analysis
3.3. Correlates of Eurofit measures with patients’ characteristics
The ICC between the two Eurofit tests using a one-way random single measures intraclass correlation analysis and its associated 95% confidence interval (CI) was calculated to objectively assess reliability between the two tests. An acceptable level of reliability was defined, acknowledging that such limits are essentially arbitrary. ICC values greater than 0.70 indicated sufficient reliability [33] to determine which Eurofit test items might be retained or discarded.
The correlations between Eurofit items and demographical and clinical variables are presented in Table 5.
2.7. Correlation analysis Pearson correlations were used to compute associations between the Eurofit test scores and demographical data and clinical variables. We used the following correlation classification according to Surwillo [37]: 0–39 = low; 40–69 = moderate to substantial; 70–100 = high to very high.
Table 1 Gender differences in Eurofit-scores. Subtest
Men (n = 30)
Women (n = 20)
p
FBA (number/30 s) PLT (s) SAR (cm) SBJ (cm) HGR (kg) SUP (number/30 s) SHR (s)
14.1 10.0 14.2 3.8 19.6 11.7 169.0 40.0 48.7 12.6 15.2 6.4 24.4 4.1
16.0 10.5 16.1 3.5 20.3 9.3 118.3 35.1 30.2 4.7 9.4 6.7 29.6 8.0
0.55 0.10 0.81 < 0.001* < 0.001* 0.004* 0.018*
Data are expressed as mean SD; FBA: flamingo balance; PLT: plate tapping; SAR: sitand-reach; SBJ: standing broad jump; HGR: handgrip strength; SUP: sit-ups; SHR: shuttle run. * Significant.
2.8. Statistical analysis Descriptive statistics are presented as mean standard deviation (SD). To assess the sex differences in Eurofit scores an unpaired student t test was used. A priori, a two-sided level of significance was set at p < 0.05. Statistical analysis was performed using the statistical package SPSS version 16.0 (SPSS Inc., Chicago, IL). 3. Results 3.1. Subjects A total of 70 patients with schizophrenia or schizoaffective disorder were initially recruited. Four persons with co-morbid substance abuse were excluded. Three patients were excluded as a consequence of a cardiovascular or neuromuscular disorder that could prevent safe participation. Nine patients declined to participate (six were not interested and three could not be motivated for the retest). Reasons for additional drop-out were incomplete data (one), transfer to another hospital (n = 1), clinical deterioration between both test occasions (n = 1) and being anxious to become aggressive when performing physical strength exercises (n = 1). Fifty participants were included in the final
Table 2 Medication use in assessed patients with schizophrenia (n = 50). No antipsychotic
1 (2%)
Monotherapy antipsychotic Aripiprazole Clozapine Quetiapine Risperidone Olanzapine Paliperidon Flupentixol
5 1 5 10 4 1 1
Combination of antipsychotics Second-generation First- and second generation
10 (20%) 12 (24%)
Other medication Anticholinergic Antidepressant Benzodiazepine Betablocking agent Mood stabiliser Somatic medication
11 19 12 2 5 11
(10%) (2%) (10%) (20%) (8%) (2%) (2%)
(22%) (38%) (24%) (4%) (10%) (22%)
D. Vancampfort et al. / European Psychiatry 27 (2012) 416–421 Table 3 PECC characteristics of the experimental group (n = 50).
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The number of cigarettes smoked per day was significantly related to SBJ and SUP. Mean SD
PECC total score Positive symptoms Negative symptoms Depressive symptoms Exitement Cognitive symptoms EPS
42.0 14.1 8.2 3.7 9.7 4.4 10.0 4.9 7.2 3.0 6.9 3.6 5.2 1.8
PECC: psychosis evaluation tool for common use by caregivers; EPS: extrapyramidal symptoms.
Except for SAR and HGR all Eurofit items were significantly associated with age. Younger patients performed better than older patients. In the same way, except for PLT and HGR, significant low to moderate correlations were found between the Eurofit test and BMI. Patients with a higher BMI performed worse than those with a lower BMI. With the exception of HGR, WC was in general moderately associated with all physical fitness parameters. The total PECC score was related to worse performances on the FBA and PLT. Worse scores on negative and cognitive symptoms were both respectively low to moderate correlated with worse FBA- and PLT-scores while more excitatory symptoms were only lowly associated with worse FBA. A higher dose of antipsychotic medication was moderately related to a lower FBA. Higher chlorpromazine equivalents were also significantly associated with worse performances on PLT and SAR. More severe EPS ratings were associated with FBA and slower speed of limb movement on the PLT.
3.4. Feasibility of the Eurofit test Except for FBA and the SUP, all Eurofit test items could be executed without problems. Thirteen participants (26%) were not able to perform the FBA (Table 4). Compared to completers, noncompleters were significantly older (p = 0.008), and had a higher BMI (p = 0.002), and WC (p < 0.001) and more excitatory symptoms (p = 0.018). Five participants (10%) could not perform the SUP test (Table 3). Four were obese (BMI > 30) and one was with 58 years the oldest participant). 4. Discussion 4.1. Reliability This is the first study investigating the reliability of the Eurofit test in patients with schizophrenia or schizoaffective disorder. Our findings demonstrate that all the investigated Eurofit items are good to highly reproducible and reliable in these patients. This suggests that the Eurofit test can be used to quantify physical fitness in patients with schizophrenia or schizoaffective disorder. 4.2. Factors interfering with the Eurofit test The observation that male patients with schizophrenia or schizoaffective disorder perform better than women on most physical fitness tests has been reported recently by our group [40]. Also in accordance with previous research [9] is the association
Table 4 Descriptive statistics and intraclass correlation coefficients (ICC) and 95% confidence intervals (CI) for the Eurofit test. Subtest
Number of completers
First test
Retest
ICC
95%CI
FBA (number/30sec) PLT (s) SAR (cm) SBJ (cm) HGR (kg) SUP (number/30 s) SHR (s)
37 50 50 50 50 45 50
9.6 5.0 14.9 3.8 19.8 10.8 149.1 46.3 41.9 13.7 13.0 7.0 26.3 6.0
10.1 6.6 13.8 3.6 20.5 11.0 152.5 44.8 42.5 13.2 13.3 7.2 25.9 5.7
0.72 0.84 0.96 0.98 0.91 0.91 0.93
0.52–0.85 0.74–0.91 0.94–0.98 0.96–0.99 0.84–0.95 0.83–0.95 0.88–0.96
Test-retest data are expressed as mean SD; FBA: flamingo balance; PLT: plate tapping; SAR: sit-and-reach; SBJ: standing broad jump; HGR: handgrip strength; SUP: sit-ups; SHR: shuttle run.
Table 5 Correlations between Eurofit test items (mean of the two trials) and patients’ characteristics.
Age BMI WC PECC total score Positive symptoms Negative symptoms Cognitive symptoms Depressive symptoms Excitatory symptoms Daily AP dose EPS Smoking (cig/day)
FBA
PLT
0.41** 0.47** 0.57*** 0.39** 0.01 0.34* 0.50** 0.25 0.38** 0.47** 0.44** 0.28
0.45* 0.18 0.31* 0.36* 0.04 0.30* 0.44* 0.26 0.25 0.33* 0.29* 0.28
SAR 0.12 0.30* 0.39** 0.12 0.03 0.16 0.21 0.022 0.14 0.38** 0.20 0.14
SBJ 0.55*** 0.41** 0.47** 0.17 0.20 0.16 0.27 0.24 0.09 0.30* 0.19 0.37*
HGR 0.002 0.17 0.25 0.003 0.24 0.08 0.01 0.17 0.017 0.08 0.10 0.12
SUP 0.58*** 0.52*** 0.59*** 0.15 0.20 0.19 0.25 0.23 0.002 0.27 0.18 0.32*
SHR 0.58*** 0.54*** 0.59*** 0.13 0.19 0.18 0.20 0.23 0.006 0.19 0.13 0.20
BMI: body mass index; WC: waist circumference; PECC: psychosis evaluation tool for common use by caregivers; EPS: extrapyramidal symptoms; AP: antipsychotic medication, expressed in chlorpromazine equivalents; FBA: flamingo balance; PLT: plate tapping; SAR: sit-and-reach; SBJ: standing broad jump; HGR: handgrip strength; SUP: sit-ups; SHR: shuttle run. * p < 0.05. ** p < 0.01. *** p < 0.001.
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between a higher BMI and a poorer performance on physical tests requiring propulsion or lifting of the body mass (SBJ, SUP, SHR, FBA). These poorer performances are likely due to the fact that the excess body weight is an extra load to be moved during weightbearing tasks [1]. A second reason for the poorer performance can be the higher prevalence of physical complaints during physical activities in patients with a high BMI [39]. Also in tests requiring flexibility (SAR), a higher BMI was related to a worse performance, in speed of limb movement exercises (PLT). Except for HGR all Eurofit items correlated with WC. WC is in schizophrenia one of the most important predictors of the metabolic syndrome [35]. The present findings offer preliminary evidence for the hypothesis that also in patients with schizophrenia or schizoaffective disorder a decreased physical fitness status is related to an increased risk for developing cardio-metabolic diseases. Not only WC and a high BMI but also antipsychotic dose was associated with poorer performances on body balance (FBA), speed of limb movement (PLT), flexibility (SAR) and muscle strength (SBJ) exercises. Previous research on performance on line- and figurecopying tasks demonstrated that both atypical and conventional antipsychotics appear to have differential effects on psychomotor speed in schizophrenic in-patients [27]. Our findings offer the first evidence for the association between antipsychotic dose and physical fitness parameters including body balance, flexibility and muscle strength [39]. The relatively high average dose in the patients studied can be explained by the fact that the majority of patients were admitted to an acute in-patient care ward. EPS might be one of the underlying mediators for the association between high dosages of antipsychotics and poor Eurofit performance. In our study, EPS was associated with FBA and PLT scores. A recent study [7] on movement kinematics for quantifying EPS in patients treated with atypical antipsychotics showed that psychomotor slowing was correlated with daily antipsychotic medication dose. Given the present findings clinicians prescribing antipsychotic medications should not only be aware of metabolic and motor side-effects of antipsychotics, but they should also take into account the potential influence of medication on physical fitness parameters. Physical fitness on its turn directly influences the ability to perform health related physical activities [6]. In accordance with previous research in the general population [8], smoking was related to a reduced muscle strength and endurance. As in the general population [8], patients with schizophrenia who smoke exercise less than non-smokers [5]. Less physical activity stimuli result in impaired muscle strength and endurance [8]. Lastly, our study confirms the hypothesis that psychiatric symptoms are related to physical fitness parameters [39]. Handeye coordination and arm speed as measured with the PLT test and whole body balance are associated with both worse negative and cognitive symptoms scores. Our data confirm the observation that performance on the psychomotor tasks assessing processing speed are related to negative symptoms [26]. More research is needed to elucidate the underlying mechanisms. Several imaging studies showed a slowed psychomotor performance to coincide with dopaminergic striatal activity [26]. The observed associations between FBA and cognitive and negative symptoms warrants further investigation. The association between FBA and excitatory symptoms might be due to marked hyperactivity and agitation, which seriously influences behaviour and impairs functional capacity. 4.3. Feasibility of the Eurofit test Except for FBA and the SUP, no Eurofit item had to be terminated prematurely and none of the patients required a rest
stop. Given present observations and its safety profile based on previous studies [36,41] physician attendance is not required. However, it is important that the Eurofit test is supervised by an experienced clinician (e.g., physical therapist or physiotherapist) who has had training in cardiopulmonary resuscitation. The Eurofit test should be conducted in a setting where a rapid response to an emergency is possible. For patients with a high BMI the FBA and SUP tests seem less feasible. Twenty-six percent of the patients were not able to perform the FBA. A factor that influenced the results might have been the fast contractibility of the quadriceps. To our knowledge, no study investigated quadriceps flexibility in patients with schizophrenia or schizoaffective disorder nor the influence of quadriceps flexibility on FBA performance. 4.4. Study limitations and future research The first limitation of our study is that structured interviews were not used to diagnose schizophrenia or schizoaffective disorder. The present study also only included a sample of inpatients from one centre. This may affect the ability to generalise the results. However, the sample size was pre-specified and included participants with a wide age range. Future studies should determine whether present results are also applicable to outpatients. Thirdly, EPS was only rated using the PECC-instrument. It is known that these observer-based EPS severity ratings can be unreliable and are subject to examiner bias. In contrast, quantitative instrumental methods should have been less subject to bias [7]. The present study did not evaluate the potential influence of previously observed psychomotor planning deficits [22] on Eurofit test performances. Future research should explore the influence of these psychomotor planning deficits. In the same way, future research should investigate if the observed diminished activation in the extrastriatal area in the posterior temporaloccipital cortex during observation of sports-related actions [38] may lead to impairments on Eurofit test performances in psychotic patients. Lastly, future research should investigate if first and second generation antipsychotics differentially affect health and performance related physical fitness in these patients. In conclusion, although with limitations, the present study demonstrates that the Eurofit test is a reliable and feasible test battery to assess the physical fitness in patients with schizophrenia or schizoaffective disorder. Because it is easy to perform and safe, the Eurofit test could be used in daily psychiatric care.
Conflict of interest statement M. De Hert has been a consultant for, received grant/research support and honoraria from, and has been on the Astra Zeneca, Bristol-Myers Squibb, Eli Lilly, Janssen-Cilag, Lundbeck, Pfizer and Sanofi-Aventis. He did not receive a financial compensation for writing the article. The other authors declare that they have no conflicts of interest to disclose relative to the article and did not receive a financial compensation for writing the article.
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Original article
Eurofit test battery in patients with schizophrenia or schizoaffective disorder: Reliability and clinical correlates D. Vancampfort a,*,b, M. Probst a,b, K. Sweers a, K. Maurissen a,b, J. Knapen a,b, J.B. Willems a, T. Heip a, M. De Hert a,c a
University Psychiatric Centre Catholic University Leuven, Campus Kortenberg, Leuvensesteenweg 517, 3070 Kortenberg, Belgium Faculty of Kinesiology and Rehabilitation Sciences, Catholic University Leuven, Leuven, Belgium c Faculty of Medicine, Catholic University Leuven, Leuven, Belgium b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 17 September 2010 Received in revised form 29 January 2011 Accepted 30 January 2011 Available online 12 March 2011
Objective: To investigate the reproducibility of the Eurofit physical fitness test battery in patients with schizophrenia or schizoaffective disorder. Secondary aims were to assess clinical and demographic characteristics that correlate with the performance on the Eurofit and evaluation of the feasibility of the test. Methods: Fifty patients with schizophrenia or schizoaffective disorder (mean age of 32.9 9.5 years) with a mean body mass index (BMI) of 26.1 6.0 kg/m2 performed two Eurofit tests administered within 3 days. Results: All Eurofit items showed good reproducibility with intraclass correlation coefficients ranging from 0.72 for flamingo balance to 0.98 for standing broad jump test. All participants could perform five of the seven test items without problems. The whole body balance and abdominal muscle endurance test could be executed by 74 and 90%, respectively. Significant correlations were found with age, BMI, waist circumference, dose of antipsychotic medication and extrapyramidal, negative and cognitive symptoms. Conclusions: The Eurofit test showed good reproducibility and can be recommended for evaluating physical fitness parameters in patients with schizophrenia or schizoaffective disorder. Physical fitness measures were related to both physical and mental health parameters. ß 2011 Elsevier Masson SAS. All rights reserved.
Keywords: Physical Fitness Eurofit Schizophrenia Reliability
1. Introduction In recent years, metabolic and cardiovascular diseases (CVD) have become a major concern in the multidisciplinary treatment of people with schizophrenia or schizoaffective disorder [20,25]. People with schizophrenia or schizoaffective disorder are 1.5 to 2 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 [13]. In addition to the effects of antipsychotic treatment [12,29,30], the association of schizophrenia or schizoaffective disorder with increased cardio-metabolic risk factors is a complex interplay between unhealthy lifestyle (physical inactivity, unhealthy diet, smoking and substance use) [5,23,39], genetic risk [28,34] and illness related factors [24]. In adults from the general population, low physical fitness is a strong and independent predictor of CVD and all-cause
* Corresponding author. Tel.: +32 2 758 05 11; fax: +32 2 759 9879. E-mail address: [email protected] (D. Vancampfort). 0924-9338/$ – see front matter ß 2011 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.eurpsy.2011.01.009
mortality and of comparable importance as diabetes mellitus and other CVD risk factors [44]. Physical fitness is a multifactorial concept comprising a set of more or less independent attributes which are related to the ability to perform physical activities. Some of these components (including cardio-respiratory fitness, muscular endurance, muscular strength and flexibility) are more closely related to health, while others (such as coordination and whole body balance) are more related to performance [32]. Health-related physical fitness has been defined as the ability to perform daily activities with vigour and to demonstrate capacities that are associated with a lower risk of premature development of hypokinetic diseases (i.e., those associated with physical inactivity). Performance-related physical fitness refers to those components that are necessary for optimal work or sport performance [6]. Associations between high levels of physical fitness and lower rates of overall morbidity and mortality are robust and have been demonstrated to be independent from other major risk factors [2–4,18,19]. Also in persons with schizophrenia or schizoaffective disorder, physical fitness seems to emerge as a major modifiable risk factor for CVD and overall morbidity and mortality [39].
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Low physical fitness and poor physical health are important arguments for the implementation of physical activity into multidisciplinary treatment programmes for patients with schizophrenia or schizoaffective disorder [14,15,39]. Designing wellconsidered physical activity programmes for these patients requires a measurement of their physical fitness [39]. To the best of our knowledge, only one study has systematically assessed the reliability of one aspect of health related physical fitness in persons with schizophrenia or schizoaffective disorder [40]. This study focused on cardio-respiratory fitness and indicated that the six minute walk test is a reliable cardio-respiratory fitness test. No studies explored the reliability of other components of health related physical fitness, such as muscular endurance, muscular strength and flexibility in patients with schizophrenia or schizoaffective disorder. Different field test batteries on physical fitness have been developed which assess different physical fitness parameters [42]. One of these tests is the Eurofit test battery for adults [31]. It has been used previously in non-psychotic adult psychiatric patients [41]. The Eurofit test battery is designed by the Committee for the Development of Sport of the Council of Europe to assess healthrelated fitness of individuals, communities and population samples [31]. Its reproducibility has never been assessed in psychiatric patients. The primary aim of the present study therefore was to investigate the test-retest reliability of the Eurofit test battery in patients with schizophrenia or schizoaffective disorder. Secondary aims were: (a) to assess both physical and mental health parameters that correlate with the performance on the Eurofit test and (b) to evaluate the feasibility of the Eurofit test in these patients. 2. Methods 2.1. Participants and setting Over a 4-month period, all consecutive acute and chronic inpatients with schizophrenia or schizoaffective disorder of the University Psychiatric Centre of Kortenberg (a 400 beds hospital) in Belgium were invited to participate in the study. Patients were excluded if they had co-morbid substance abuse. The somatic exclusion criteria included evidence of significant cardiovascular, neuromuscular and endocrine disorders which according to the American College of Sports Medicine [16] might prevent safe participation in exercise testing. Psychiatric diagnosis based on DSM-IV criteria was established by experienced psychiatrists responsible for the patients’ treatment. No formal semi-structured diagnostic interview was done. 2.2. Sample size analysis The sample size was estimated using the methodology proposed by Walter et al. [17,43] for approximating the number of participants required for test-retest reliability. The required optimal sample size for intraclass correlations (ICC) was based on the desired power level, the magnitude of the predicted ICC, and the lower confidence limit. Assuming an ICC of 0.8 to be a minimal level of reliability but hypothesising an ICC of 0.9 with administration of the Eurofit test on two occasions, a sample size of 46 is considered appropriate (p < 0.05, 80% power). The hypothesis that present findings would be consistent with an ICC of 0.90 was based on a previous reliability study on the 6minute walk test in schizophrenia [40]. It was anticipated that more or less 15% of patients needed to be excluded, 10% would refuse for motivational reasons and 10% would dropout from the testing for both motivational and practical reasons. In this way, a sample size of 70 participants was pre-specified.
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2.3. Test-retest of the EUROFIT A test-retest design was used to test the reproducibility of several Eurofit test battery items. Supervision and measurement of the Eurofit test battery was performed by one of three trained members (one physical therapist one research nurse and one physiotherapist). The test was repeated within 3 days. Patients performed the re-test at the same hour in standardized conditions. Patients were requested to refrain from eating, drinking coffee or smoking during a two-hour period prior to the tests. At testing days medication was taken at the same hour of the day. The battery of physical fitness tests included the assessment of the following physical fitness measures: whole body balance, speed of limb movement, flexibility, explosive strength, static strength, abdominal muscular endurance and running speed [31]. Whole body balance (Flamingo balance [FBA]) was measured as the number of trials needed by individuals to achieve a total duration of 30 s in balance on their preferred foot on a flat firm surface. While balancing on the preferred foot, the free leg is flexed at the knee and the foot of this leg held close to the buttocks. Lower FBA-scores indicate a better whole body balance. Speed of limb movement (plate tapping [PLT]) was assessed using a PLT table on which two discs at 80 cm distance had to be touched alternately with the preferred hand as fast as possible, completing 25 cycles. The higher the score, the lower the speed of limb movement. Flexibility was measured using the sit-and-reach test (SAR). Participants sat on the floor with straight legs and reached forward as far as possible. The knees were held in extended position by the investigator throughout the test. The feet were placed against a test box with a ruler placed on the top of the box. The ruler had to be pushed with the fingertips and this in a smooth and slow movement. Higher scores indicate better flexibility. Explosive strength was measured by a standing broad jump (SBJ), using a tape measure on a foam mat. Participants were asked to stand behind a line drawn perpendicular to the tape measure and jump forward as far as possible using arm swing and knee bending before jumping. The distance jumped was recorded from the takeoff line to the farthest point backward of the participant. Higher scores indicate a better explosive strength. Handgrip strength (HGR) was assessed using a handgrip dynamometer (Lafayette Instruments Hand Dynamometer) to be squeezed as forcefully as possible with the preferred arm fully extended slightly away slightly away from the body, and palm facing inward. The higher the score the better the handgrip strength. Abdominal muscle endurance was measured as the number of correctly completed sit-ups in 30 s (SUP). Sit-ups were performed with the hands placed at the side of the head, knees bent at 90 degrees, and the feet secured by the investigator. A full sit-up is defined as touching the knees with the elbows and returning the shoulders to the ground. A higher number of SUP indicate a better abdominal muscle endurance. Running speed was assessed using a 10 by 5 m shuttle run (SHR). Each participant was required to sprint 10 times between two lines placed 5 m apart. The track was 1.3 m wide. The sprint was followed by immediately turning and running back. The lower the score the better the running speed. Except for FBA, SUP and SHR each test was done twice and the better score was recorded. Related to the anthropometric measurements, data on body weight, height and waist circumference was collected. Body weight was measured in light clothing to the nearest 0.1 kg using a SECA beam balance scale, and height to the nearest 0.1 cm using a wall-mounted stadiometer. Waist circumference (WC) was measured to nearest 1 cm at the level of the umbilicus and at the end of expiration with the subject upright and his/her hands by the side.
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The study procedure was approved by the Scientific Committee of the University Psychiatric Centre of the Catholic University of Leuven, Belgium in accordance with the principles of the Declaration of Helsinki. All participants gave their informed consent. 2.4. Psychosis evaluation tool for common use by caregivers (PECC) Psychotic symptoms were assessed by an independent and well trained nurse using the PECC [10]. The semi-structured PECCinterview evaluates 20 symptom items on a 7-point scale. Symptoms are grouped in five factors: positive, negative, depressive, cognitive and excitatory symptoms. The scores for each factor range from 4 to 28. Also extrapyramidal symptoms (EPS) were evaluated with the PECC-instrument. Scores range from 4 to 16. Higher scores indicate more severe symptoms. Validation results suggest that the PECC can be successfully used for the evaluation of these symptoms in schizophrenia or schizoaffective disorder [11]. 2.5. Medication use
analysis. No significant differences in demographical and clinical variables were found between participants and dropouts. The sex distribution of the final sample of participants was 30 men (32.3 10.1 years; BMI 25.9 5.7; WC 94.3 5.7 cm) and 20 women (33.5 8.5 years; BMI 25.8 6.6; WC 92.3 17.0 cm). Age and BMI did not differ between men and women. Differences in Eurofit-scores between men and women are given in Table 1. Men scored better on SBJ, HGR, SUP, SHR. Except for one, all individuals were white, Belgian natives. Twenty-nine (58%) patients were smokers. Mean daily cigarettes was 21.5 13.3. An overview of the medication intake is presented in Table 2. Mean daily equivalent dosage of chlorpromazine was 637 434 mg/day. Psychiatric symptoms and EPS of the included sample (n = 50) are presented in Table 3. The highest scores were obtained for negative and depressive symptoms. 3.2. Test-retest reliability of the Eurofit items
Current antipsychotic medication was recorded for each patient and converted into a daily equivalent dosage of chlorpromazine according to Gardner et al. [21].
Means and standard deviations for the performed Eurofit tests on both occasions and the associated ICCs with 95% CIs are presented in Table 4. All Eurofit items demonstrated a ICC above 0.70. The ICCs range from 0.72 for FBA till 0.98 for SBJ.
2.6. Reliability analysis
3.3. Correlates of Eurofit measures with patients’ characteristics
The ICC between the two Eurofit tests using a one-way random single measures intraclass correlation analysis and its associated 95% confidence interval (CI) was calculated to objectively assess reliability between the two tests. An acceptable level of reliability was defined, acknowledging that such limits are essentially arbitrary. ICC values greater than 0.70 indicated sufficient reliability [33] to determine which Eurofit test items might be retained or discarded.
The correlations between Eurofit items and demographical and clinical variables are presented in Table 5.
2.7. Correlation analysis Pearson correlations were used to compute associations between the Eurofit test scores and demographical data and clinical variables. We used the following correlation classification according to Surwillo [37]: 0–39 = low; 40–69 = moderate to substantial; 70–100 = high to very high.
Table 1 Gender differences in Eurofit-scores. Subtest
Men (n = 30)
Women (n = 20)
p
FBA (number/30 s) PLT (s) SAR (cm) SBJ (cm) HGR (kg) SUP (number/30 s) SHR (s)
14.1 10.0 14.2 3.8 19.6 11.7 169.0 40.0 48.7 12.6 15.2 6.4 24.4 4.1
16.0 10.5 16.1 3.5 20.3 9.3 118.3 35.1 30.2 4.7 9.4 6.7 29.6 8.0
0.55 0.10 0.81 < 0.001* < 0.001* 0.004* 0.018*
Data are expressed as mean SD; FBA: flamingo balance; PLT: plate tapping; SAR: sitand-reach; SBJ: standing broad jump; HGR: handgrip strength; SUP: sit-ups; SHR: shuttle run. * Significant.
2.8. Statistical analysis Descriptive statistics are presented as mean standard deviation (SD). To assess the sex differences in Eurofit scores an unpaired student t test was used. A priori, a two-sided level of significance was set at p < 0.05. Statistical analysis was performed using the statistical package SPSS version 16.0 (SPSS Inc., Chicago, IL). 3. Results 3.1. Subjects A total of 70 patients with schizophrenia or schizoaffective disorder were initially recruited. Four persons with co-morbid substance abuse were excluded. Three patients were excluded as a consequence of a cardiovascular or neuromuscular disorder that could prevent safe participation. Nine patients declined to participate (six were not interested and three could not be motivated for the retest). Reasons for additional drop-out were incomplete data (one), transfer to another hospital (n = 1), clinical deterioration between both test occasions (n = 1) and being anxious to become aggressive when performing physical strength exercises (n = 1). Fifty participants were included in the final
Table 2 Medication use in assessed patients with schizophrenia (n = 50). No antipsychotic
1 (2%)
Monotherapy antipsychotic Aripiprazole Clozapine Quetiapine Risperidone Olanzapine Paliperidon Flupentixol
5 1 5 10 4 1 1
Combination of antipsychotics Second-generation First- and second generation
10 (20%) 12 (24%)
Other medication Anticholinergic Antidepressant Benzodiazepine Betablocking agent Mood stabiliser Somatic medication
11 19 12 2 5 11
(10%) (2%) (10%) (20%) (8%) (2%) (2%)
(22%) (38%) (24%) (4%) (10%) (22%)
D. Vancampfort et al. / European Psychiatry 27 (2012) 416–421 Table 3 PECC characteristics of the experimental group (n = 50).
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The number of cigarettes smoked per day was significantly related to SBJ and SUP. Mean SD
PECC total score Positive symptoms Negative symptoms Depressive symptoms Exitement Cognitive symptoms EPS
42.0 14.1 8.2 3.7 9.7 4.4 10.0 4.9 7.2 3.0 6.9 3.6 5.2 1.8
PECC: psychosis evaluation tool for common use by caregivers; EPS: extrapyramidal symptoms.
Except for SAR and HGR all Eurofit items were significantly associated with age. Younger patients performed better than older patients. In the same way, except for PLT and HGR, significant low to moderate correlations were found between the Eurofit test and BMI. Patients with a higher BMI performed worse than those with a lower BMI. With the exception of HGR, WC was in general moderately associated with all physical fitness parameters. The total PECC score was related to worse performances on the FBA and PLT. Worse scores on negative and cognitive symptoms were both respectively low to moderate correlated with worse FBA- and PLT-scores while more excitatory symptoms were only lowly associated with worse FBA. A higher dose of antipsychotic medication was moderately related to a lower FBA. Higher chlorpromazine equivalents were also significantly associated with worse performances on PLT and SAR. More severe EPS ratings were associated with FBA and slower speed of limb movement on the PLT.
3.4. Feasibility of the Eurofit test Except for FBA and the SUP, all Eurofit test items could be executed without problems. Thirteen participants (26%) were not able to perform the FBA (Table 4). Compared to completers, noncompleters were significantly older (p = 0.008), and had a higher BMI (p = 0.002), and WC (p < 0.001) and more excitatory symptoms (p = 0.018). Five participants (10%) could not perform the SUP test (Table 3). Four were obese (BMI > 30) and one was with 58 years the oldest participant). 4. Discussion 4.1. Reliability This is the first study investigating the reliability of the Eurofit test in patients with schizophrenia or schizoaffective disorder. Our findings demonstrate that all the investigated Eurofit items are good to highly reproducible and reliable in these patients. This suggests that the Eurofit test can be used to quantify physical fitness in patients with schizophrenia or schizoaffective disorder. 4.2. Factors interfering with the Eurofit test The observation that male patients with schizophrenia or schizoaffective disorder perform better than women on most physical fitness tests has been reported recently by our group [40]. Also in accordance with previous research [9] is the association
Table 4 Descriptive statistics and intraclass correlation coefficients (ICC) and 95% confidence intervals (CI) for the Eurofit test. Subtest
Number of completers
First test
Retest
ICC
95%CI
FBA (number/30sec) PLT (s) SAR (cm) SBJ (cm) HGR (kg) SUP (number/30 s) SHR (s)
37 50 50 50 50 45 50
9.6 5.0 14.9 3.8 19.8 10.8 149.1 46.3 41.9 13.7 13.0 7.0 26.3 6.0
10.1 6.6 13.8 3.6 20.5 11.0 152.5 44.8 42.5 13.2 13.3 7.2 25.9 5.7
0.72 0.84 0.96 0.98 0.91 0.91 0.93
0.52–0.85 0.74–0.91 0.94–0.98 0.96–0.99 0.84–0.95 0.83–0.95 0.88–0.96
Test-retest data are expressed as mean SD; FBA: flamingo balance; PLT: plate tapping; SAR: sit-and-reach; SBJ: standing broad jump; HGR: handgrip strength; SUP: sit-ups; SHR: shuttle run.
Table 5 Correlations between Eurofit test items (mean of the two trials) and patients’ characteristics.
Age BMI WC PECC total score Positive symptoms Negative symptoms Cognitive symptoms Depressive symptoms Excitatory symptoms Daily AP dose EPS Smoking (cig/day)
FBA
PLT
0.41** 0.47** 0.57*** 0.39** 0.01 0.34* 0.50** 0.25 0.38** 0.47** 0.44** 0.28
0.45* 0.18 0.31* 0.36* 0.04 0.30* 0.44* 0.26 0.25 0.33* 0.29* 0.28
SAR 0.12 0.30* 0.39** 0.12 0.03 0.16 0.21 0.022 0.14 0.38** 0.20 0.14
SBJ 0.55*** 0.41** 0.47** 0.17 0.20 0.16 0.27 0.24 0.09 0.30* 0.19 0.37*
HGR 0.002 0.17 0.25 0.003 0.24 0.08 0.01 0.17 0.017 0.08 0.10 0.12
SUP 0.58*** 0.52*** 0.59*** 0.15 0.20 0.19 0.25 0.23 0.002 0.27 0.18 0.32*
SHR 0.58*** 0.54*** 0.59*** 0.13 0.19 0.18 0.20 0.23 0.006 0.19 0.13 0.20
BMI: body mass index; WC: waist circumference; PECC: psychosis evaluation tool for common use by caregivers; EPS: extrapyramidal symptoms; AP: antipsychotic medication, expressed in chlorpromazine equivalents; FBA: flamingo balance; PLT: plate tapping; SAR: sit-and-reach; SBJ: standing broad jump; HGR: handgrip strength; SUP: sit-ups; SHR: shuttle run. * p < 0.05. ** p < 0.01. *** p < 0.001.
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between a higher BMI and a poorer performance on physical tests requiring propulsion or lifting of the body mass (SBJ, SUP, SHR, FBA). These poorer performances are likely due to the fact that the excess body weight is an extra load to be moved during weightbearing tasks [1]. A second reason for the poorer performance can be the higher prevalence of physical complaints during physical activities in patients with a high BMI [39]. Also in tests requiring flexibility (SAR), a higher BMI was related to a worse performance, in speed of limb movement exercises (PLT). Except for HGR all Eurofit items correlated with WC. WC is in schizophrenia one of the most important predictors of the metabolic syndrome [35]. The present findings offer preliminary evidence for the hypothesis that also in patients with schizophrenia or schizoaffective disorder a decreased physical fitness status is related to an increased risk for developing cardio-metabolic diseases. Not only WC and a high BMI but also antipsychotic dose was associated with poorer performances on body balance (FBA), speed of limb movement (PLT), flexibility (SAR) and muscle strength (SBJ) exercises. Previous research on performance on line- and figurecopying tasks demonstrated that both atypical and conventional antipsychotics appear to have differential effects on psychomotor speed in schizophrenic in-patients [27]. Our findings offer the first evidence for the association between antipsychotic dose and physical fitness parameters including body balance, flexibility and muscle strength [39]. The relatively high average dose in the patients studied can be explained by the fact that the majority of patients were admitted to an acute in-patient care ward. EPS might be one of the underlying mediators for the association between high dosages of antipsychotics and poor Eurofit performance. In our study, EPS was associated with FBA and PLT scores. A recent study [7] on movement kinematics for quantifying EPS in patients treated with atypical antipsychotics showed that psychomotor slowing was correlated with daily antipsychotic medication dose. Given the present findings clinicians prescribing antipsychotic medications should not only be aware of metabolic and motor side-effects of antipsychotics, but they should also take into account the potential influence of medication on physical fitness parameters. Physical fitness on its turn directly influences the ability to perform health related physical activities [6]. In accordance with previous research in the general population [8], smoking was related to a reduced muscle strength and endurance. As in the general population [8], patients with schizophrenia who smoke exercise less than non-smokers [5]. Less physical activity stimuli result in impaired muscle strength and endurance [8]. Lastly, our study confirms the hypothesis that psychiatric symptoms are related to physical fitness parameters [39]. Handeye coordination and arm speed as measured with the PLT test and whole body balance are associated with both worse negative and cognitive symptoms scores. Our data confirm the observation that performance on the psychomotor tasks assessing processing speed are related to negative symptoms [26]. More research is needed to elucidate the underlying mechanisms. Several imaging studies showed a slowed psychomotor performance to coincide with dopaminergic striatal activity [26]. The observed associations between FBA and cognitive and negative symptoms warrants further investigation. The association between FBA and excitatory symptoms might be due to marked hyperactivity and agitation, which seriously influences behaviour and impairs functional capacity. 4.3. Feasibility of the Eurofit test Except for FBA and the SUP, no Eurofit item had to be terminated prematurely and none of the patients required a rest
stop. Given present observations and its safety profile based on previous studies [36,41] physician attendance is not required. However, it is important that the Eurofit test is supervised by an experienced clinician (e.g., physical therapist or physiotherapist) who has had training in cardiopulmonary resuscitation. The Eurofit test should be conducted in a setting where a rapid response to an emergency is possible. For patients with a high BMI the FBA and SUP tests seem less feasible. Twenty-six percent of the patients were not able to perform the FBA. A factor that influenced the results might have been the fast contractibility of the quadriceps. To our knowledge, no study investigated quadriceps flexibility in patients with schizophrenia or schizoaffective disorder nor the influence of quadriceps flexibility on FBA performance. 4.4. Study limitations and future research The first limitation of our study is that structured interviews were not used to diagnose schizophrenia or schizoaffective disorder. The present study also only included a sample of inpatients from one centre. This may affect the ability to generalise the results. However, the sample size was pre-specified and included participants with a wide age range. Future studies should determine whether present results are also applicable to outpatients. Thirdly, EPS was only rated using the PECC-instrument. It is known that these observer-based EPS severity ratings can be unreliable and are subject to examiner bias. In contrast, quantitative instrumental methods should have been less subject to bias [7]. The present study did not evaluate the potential influence of previously observed psychomotor planning deficits [22] on Eurofit test performances. Future research should explore the influence of these psychomotor planning deficits. In the same way, future research should investigate if the observed diminished activation in the extrastriatal area in the posterior temporaloccipital cortex during observation of sports-related actions [38] may lead to impairments on Eurofit test performances in psychotic patients. Lastly, future research should investigate if first and second generation antipsychotics differentially affect health and performance related physical fitness in these patients. In conclusion, although with limitations, the present study demonstrates that the Eurofit test is a reliable and feasible test battery to assess the physical fitness in patients with schizophrenia or schizoaffective disorder. Because it is easy to perform and safe, the Eurofit test could be used in daily psychiatric care.
Conflict of interest statement M. De Hert has been a consultant for, received grant/research support and honoraria from, and has been on the Astra Zeneca, Bristol-Myers Squibb, Eli Lilly, Janssen-Cilag, Lundbeck, Pfizer and Sanofi-Aventis. He did not receive a financial compensation for writing the article. The other authors declare that they have no conflicts of interest to disclose relative to the article and did not receive a financial compensation for writing the article.
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