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Medication and physical activity and physical fitness in severe mental illness
Psychiatry Research 267 (2018) 19–24
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Medication and physical activity and physical fitness in severe mental illness a
David Perez-Cruzado , Antonio Cuesta-Vargas a b c
a,b,⁎
a,c
, Elisa Vera-Garcia , Fermín Mayoral-Cleries
T
c
Department of Physiotherapy, University of Malaga, Spain School of Clinical Science, Faculty of Health Science, Queensland University Technology, Australia Hospital Regional de Málaga, Grupo de Investigación de Salud Mental, IBIMA, Spain
A R T I C LE I N FO
A B S T R A C T
Keywords: Medication Physical activity Physical fitness Fitness condition Physical activity psychiatry
Anti-psychotic medication has emerged as the primary medical treatment for people with severe mental illness, despite the great risks involved in the use of this medication. In addition, this population suffers from problems of obesity, sedentary lifestyle and poor physical fitness, which is aggravated by the use of this type of medication. The objective of this study is to explore the influence of the most commonly used antipsychotics in this population (Olanzapine and Risperidone) on physical activity and the physical fitness of people with severe mental illness. Sixty-two people between 26 and 61 years of age with severe mental illness were assessed. All participants were evaluated with a battery of 11 physical tests to assess their physical fitness and with the IPAQ-short version questionnaire to determine their level of physical activity. The doses of Risperidone and Olanzapine were also evaluated in all participants. Significant differences were found for physical activity, with higher levels reported in those patients with severe mental illness who did not take any of these medications. Regarding physical fitness, significant differences were only found for the consumption of Risperidone, with better physical fitness levels seen in patients who did not consume this medication; on the other hand, for the consumption of Olanzapine, differences were found in muscular strength, balance and aerobic condition with better values in non-Olanzapine consumers compared with Olanzapine consumers.
1. Introduction Severe mental illness (SMI) includes functional psychosis, and an ICD-10 diagnosis of a functional affective or non-affective psychotic disorder (codes F10-F22, F24, F25, F28-F31, F32.3 and F33.3) (Ruggeri et al., 2000). In most developed countries, second-generation (atypical) antipsychotics have emerged as the drug of choice for individuals with severe mental disorders (Komossa et al., 2010). These are even used in young patients with other mental health problems, such as non-psychotic disorders like autism or intellectual disability (Park et al., 2016), despite the increased risk of diabetes, dyslipidemia and cardiovascular disease as a side effect of this medication (Mangurian et al., 2016; Nicol et al., 2016). These health problems are aggravated in people with severe mental disorders, in whom are also found high levels of obesity, as well as sedentary lifestyle and poor physical fitness (Vancampfort et al., 2013a,2016b) and may be associated with the use of antipsychotics (Koivukangas et al., 2010; Vancampfort et al., 2016a). Inactive patients with SMI present considerably higher levels of sedentary than to other types of patients with different pathologies, thus presenting a
deterioration of health as well as lower physical fitness compared to a control group of healthy individuals (Vancampfort et al., 2015,2013b,c). In patients with schizophrenia and schizoaffective disorders, physical fitness seems to emerge as an important modifiable risk factor for metabolic and cardiovascular diseases, as well as morbidity and mortality (Vancampfort et al., 2015,2013b,c). In addition to the modifiable lifestyle factors and side effects of psychotropic medications, poor access to medical care as well as low quality of the medical care received are problems that SMI patients face daily (Wang et al., 2016). As a result, this population frequently suffers from associated problems such as greater social exclusion, fewer employment opportunities or a greater dependence on others to accomplish activities of daily living (Vancampfort et al., 2016c). Among the different second-generation antipsychotics, Olanzapine and Risperidone are those which show the greatest improvement in general health; therefore, these are the most frequently used from this group of medications when compared with other second-generation antipsychotics (Komossa et al., 2010). Given the potential for a higher incidence of SMI diseases, and as a result of the introduction of second-
⁎ Corresponding author at: Cátedra de Fisioterapia, Universidad de Malaga, Andalucia Tech, Instituto de Investigacion Biomédica de Malaga (IBIMA) Grupo de Clinimetria (F-14). Av/ Arquitecto Peñalosa, 3 (Teatinos Campus Expansion) 29071 Malaga (Spain). E-mail addresses: [email protected] (D. Perez-Cruzado), [email protected] (A. Cuesta-Vargas), [email protected] (E. Vera-Garcia), [email protected] (F. Mayoral-Cleries).
https://doi.org/10.1016/j.psychres.2018.05.055 Received 29 September 2017; Received in revised form 23 April 2018; Accepted 22 May 2018 Available online 23 May 2018 0165-1781/ © 2018 Elsevier B.V. All rights reserved.
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beyond the fully straight position into hyperextension, the value was recorded as positive (e.g., +5°). The reliability of the PKE test was explored and compared with other clinical tests for assessing hamstring muscle as proposed by Gajdoski et al. (1993). Calf Muscle Flexibility (CMF): The participant was positioned supine on a table, with the hip and knee on the side to be measured in as much extension as possible. The fulcrum of the goniometer was placed over the lateral malleolus, with one of its arms in the direction of the fibular head and the other one in parallel to the lateral midline of the fifth metatarsal. Their ankle was passively dorsiflexed and its angle measured while their knee remained in extension. If the participant could not reach neutral position, the angle was recorded as negative (e.g., −10°). If the participant went beyond neutral, it was recorded as positive (e.g., +10°). If the participant only reached neutral, it was recorded as 0°. The reliability of this test can be found in Ekstrand et al. (1982). Anterior Hip Flexibility (AHF): The participant was positioned supine on a table, both hips flexed to 90°. The hip to be measured was flexed up to 100° with a hand beneath the lower back to ensure that it remained flattened. Opposite hip was kept at 90° and not allowed to move into extension during the test. The fulcrum of the goniometer was placed over the greater trochanter, with its arms aligned with the lateral midline of the pelvis and with the lateral midline of the femur respectively. The degrees of extension between the pelvis and thigh were measured before the pelvis began to move forward. If the thigh lowered to the table surface, the result was recorded as 0°. If the thigh did not reach the table, the angle was recorded as negative (e.g., −25°). The reliability of this test can be found in Ekstrand et al. (1982). Functional shoulder rotation (FSR) (Apley's Scratch Test): The participant stood or was seated facing the back of a chair. The participant was instructed to reach one arm behind the head and down the back, while the other arm reached behind the hip and up the back. The participant was instructed to “try to touch their index fingers together.” A tape measure was used to measure the distance in cm between the index fingers in this position (one arm was in flexion/abduction/lateral rotation; the other was in extension/adduction/ medial rotation). The arm on top defined the recorded side (i.e., left arm on top = left; right arm on top = right). If the fingertips touched, the distance was recorded as 0. If the fingertips could not touch, the separation was recorded as negative (e.g., 15.2 cm). If the fingers overlap, the overlap was recorded as positive (e.g., +2.5 cm). The FSR is a reproducible measure of upper extremity function task that was validated in people with disabilities. The reliability of this test can be found in Edwards et al. (2002). The Timed-Stands Test (TST): The timed-stands test was the method to quantify functional lower extremity muscle strength (hip and knee extension). The test requires the participant to complete 10 full stands from a seated position as quickly as possible without the use of their arms. The participant was seated in a firm straight-backed chair with the elbows flexed to 90° during the test. The participant had to stand 10 times as quickly as possible and the time to perform the task in minutes and seconds was recorded. If the participant could not perform 10 repetitions, the number of repetitions and the time taken was recorded. The TST is a reproducible measure of lower extremity function that was validated in people with disabilities. The reliability of this test can be found in Newcomer et al. (1993). Partial Sit-Up Test (PSUT): The partial sit-up test was the method to quantify abdominal muscle strength/endurance. The test requires the participant to complete as many sit-ups as possible from a supine position in one minute. The participant was positioned supine on a table or mat, with the legs placed on a chair or stool to keep their hips and knees bent at 90°. Their arms were placed straight out in front of the chest with the elbows extended during the entire test. Test-retest reliability and validity was established in a previous study (Faulkner et al., 1989). Seated Push-Up (SPU): The seated push-up test is a method of
generation antipsychotic drugs, research aimed at optimising the physical health these individuals with schizophrenia should be carried out with a sense of urgency (Vancampfort et al., 2012a,b). The aim of the present study is to explore whether patients with SMI who are being treated with second-generation antipsychotics (Olanzapine and Risperidone) show differences in their activity and physical fitness compared with those with SMI who take other pharmacological treatments in order to define whether this population is at elevated risk of other disorders and if a specific intervention is justifiable. 2. Methods 2.1. Participants The study procedure was approved by the Ethics Committee of Research, Malaga Northeast. The participants were recruited during a 6 month period from the mental health service of the Hospital Regional University of Malaga. The total sample consisted of 62 participants (37 men and 25 women), between 26 and 61 years of age, diagnosed with SMI by a psychiatrist of the Hospital Regional University of Malaga (a set of pathologies with, an ICD-10 diagnosis of an affective or non-affective functional psychotic disorder [codes F20-F22, F24, F25, F28F31, F32.3 and F33.3]). Prior to participation in the study, participants had to sign an informed consent form to participate. The inclusion criteria were: (1) individuals aged between 18 and 65 years, (2) individuals who had not suffered a psychotic crisis in the last 4 weeks (these people were isolated), and (3) individuals who did not have any cardiovascular, neuromuscular or endocrine pathology that prevented them from performing physical exercise or limited their physical fitness. Participants were grouped into Risperidone consumer, Olanzapine consumer, non-Risperidone consumer and non-Olanzapine consumer. Non-Risperidone consumer and non-Olanzapine consumer participants received another kind of antipsychotic medication. 2.2. Study design and procedures A cross-sectional study was performed. Data on sociodemographic variables were collected using a semi-structured interview format when the study was introduced to the participants and the aim of the research was explained. Anthropometric measurements (body weight, height and waist circumference) were collected according to the standards of the International Society for the Advancement of Kinanthropometry (Marfell-Jones et al., 2006). The assessors were one physiotherapist and one occupational therapist who had previously been trained in the proper performance of physical tests and the scoring scale. The scale was explained to the patients and the examiners demonstrated how to perform the tests. 2.3. Outcome measures The following 11 physical tests were used to measure physical fitness: passive knee extension test; calf muscle flexibility test; anterior hip flexibility test; functional shoulder rotation test; timed-stand test; partial sit-up test; seated push-up test; grip test; single leg stance, open and closed eyes; functional reach test; and the two minute step test (Cuesta-Vargas et al., 2011). Those tests include measures of the various categories of physical fitness (flexibility, balance, strength, and endurance). Passive knee extension (PKE): The participant was positioned supine on a treatment table with hip and knee flexed at 90°. The passive knee extension was measured using a goniometer, with the fulcrum placed over the lateral femoral epicondyle and its arms in the direction of the greater trochanter and lateral malleolus respectively. Their ankle remained in a neutral position or in plantar flexion. If the knee went fully extended, the final value was recorded as 0°. If the knee did not extend, the value was recorded as negative (e.g., −40°). If the knee went 20
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assessing the strength of the triceps, shoulder and scapular muscles. The test involves pushing the body up out of a seated position, and slowly lowering it back into the seat. The participant was placed with the knees out straight and the heels resting on the floor or table. The participant had to push their body up from the table or floor until the elbows were straight, held for 20 s and then slowly lowered back into the seat. The reliability of revised push-up test protocol in people without disabilities was 0.80 to 0.96 (Hong et al., 2011). HandGrip Test (HGT): The handgrip test is a standardized method for assessing strength of the hand and forearm muscles, as it has been correlated to upper extremity function. The test involved completing three grips on each side (preferred and non-preferred hand) and recording the better of the three trials using an adjustable handgrip dynamometer. The participant had to keep the arm and hand at the side with the elbow bent at 90° while squeezing as forcefully as possible. The handgrip dynamometer have being found to be highly reliable (ICC = 0.98) and valid (ICC = 0.99) for measuring handgrip strength (Bellace et al., 2000). Single-Leg Stance With Eyes Opened (SLSEO): The single-leg stance test with eyes open is designed to assess balance with the assistance of visual cues. The test required the participant to stand on one leg with the eyes open. Balance must be maintained as long as possible. The arms were placed at the sides with elbows slightly flexed during the test. The test continued until participant lost balance, or put the other foot down (maximum time was 30 s). Interclass correlation coefficients were moderate to excellent (0.41 to 0.91) (Birmingham 2000). Single-Leg Stance With Eyes Closed (SLSEC): The single-leg stance test with eyes closed is similar to the previous one but without the assistance of visual cues, so the participant's eyes are kept closed or covered with a blindfold. Interclass correlation coefficients were moderate to excellent (0.41 to 0.91) suggesting that the standing balance tests are appropriate for distinguishing among group performances (Birmingham 2000). Functional Reach Test (FRT): The test requires the participant to reach forward beyond the length of his/her arm without loss of balance. The participant was on two legs, positioned shoulder width apart (or seated if the participant could not stand). The participant was requested to lift one arm up to 90°, forward flexion and extend fingers. Test-retest reliability and validity was established in a previous study (Duncan et al., 1990). Two-minute step test (2MST): Pre-exercise resting heart rate (RHR) was recorded with the participant seated before the test and again twominute after the test is finished (2MAF). The participant was located next to a wall, and the minimum stepping height for the participant was marked. The test required a running tape measure from the iliac crest to the mid-patella, and to mark the midway point on the tape. This mark was transferred to the wall. The participant was requested to march for a maximum of two minutes, bringing each knee alternatively up to the tape mark in the wall. The number of times that the participant touched the tape with the right knee was recorded. The 2MST showed an acceptable reliability (0.63) (Burnstein et al., 2011) The International Physical Activity Questionnaire (IPAQ)-short version (Craig et al., 2003) was used to measure self-reported physical activity. This questionnaire allows us to ascertain the physical activity undertaken in the last seven days. The IPAQ scale provides us with data about vigorous physical activity, moderate physical activity and light (walking) physical activity. The reliability of the IPAQ was ρ = 0.47 (Duncan et al., 2017).
Table 1 Characteristics of participants.
Age Height (cm) Weight (Kg) Abdominal perimeter (cm) Vigorous PA (min) Moderate PA (min) Light PA (min) Total PA (min) Risperidona dose
Age Height (cm) Weight (Kg) Abdominal perimeter (cm) Vigorous PA (min) Moderate PA (min) Light PA (min) Total PA (min) Olanzapine dose
Non-Risperidona consumer N = 52 Mean ( ± sd)
Risperidona consumer N = 10 Mean ( ± sd)
Difference
46.28 ( ± 8.44) 164.27 ( ± 22.11) 81.78 ( ± 16.66) 103.83 ( ± 13.98)
45.75 ( ± 8.50) 168.19 ( ± 7.89) 77.72 ( ± 8.41) 97.68 ( ± 8.91)
81.51 ( ± 502.423)
0.00 ( ± 0.00)
0.46
426.42 ( ± 813.71)
1110.00 ( ± 2950.39)
−1.42
2062.18 ( ± 1122.61) 2579.11 ( ± 1645.33) 0.00 ( ± 0.00)
1150.28 ( ± 828.38) 1218.86 ( ± 803.72) 5.31 ( ± 2.60)
2.07⁎ 2.14⁎
Non-Olanzapine consumer N = 50 Mean ( ± sd)
Olanzapine consumer N = 12 Mean ( ± sd)
Difference
46.98 ( ± 8.28) 163.14 ( ± 22.58) 79.92 ( ± 15.62) 102.80 ( ± 13.67)
43.00 ( ± 8.35) 171.63 ( ± 8.30) 86.85 ( ± 16.22) 104.04 ( ± 13.49)
360.00 ( ± 1041.12)
0.00 ( ± 0.00)
2.48⁎
395.00 ( ± 681.18)
545.71 ( ± 1394.11)
−0.36
2615.25 ( ± 1114.84) 3370.25 ( ± 2186.70) 0.00 ( ± 0.00)
1785.16 ( ± 1076.04) 2174.52 ( ± 1375.94) 14.17 ( ± 5.47)
2.34⁎ 2.36⁎
(Student-t)
(Student-t)
PA: Physical activity. ⁎ Level of significance 0,05.
statistically significant (Fisher and Yates, 1963). The correlation cut-off was established as r ≤ 0.3, with a mild correlation being denoted by r > 0.3 r ≤ 0.6, and a high correlation as r > 0.6 (Portney and Watkins, 2009).
3. Results A total of 62 adults with SMI participated in the study. No patients were excluded due to cardiovascular or neuromuscular problems. None of the 62 study participants refused to participate in the study or abandoned the study during the data collection period. The dose of Risperidone taken by the patients was 5.31 ( ± 2.60) mg/day, whereas the consumption of Olanzapine was 14.17 ( ± 5.47) mg/day.
3.1. Differences in physical activity between adults with SMI who did or did not receive antipsychotic medication Differences were found between individuals with SMI who took antipsychotic medication and those who did not (Table 1). There were significant differences both in patients who consumed Risperidone (light physical activity and total physical activity) and in those who consumed Olanzapine (vigorous physical activity, light physical activity and total physical activity), with higher levels of physical activity reported in the group of individuals with SMI who did not take these medications.
2.4. Data analysis Descriptive data for all variables were presented as mean and standard deviation. To assess the homogeneity of the sample (Risperidone and Olanzapine takers and non medication takers), the Kolmogorov–Smirnov test was used to divide parametric and nonparametric measures. A P-value < 0.05 was considered to be 21
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Table 2 T-Student differences of the physical fitness test between both groups.
Flexibility
Strength
Balance
Cardiovascular endurance
PKE_right (°) PKE_left (°) CMF_right (°) CMF_left (°) AHF_right (°) AHF_left (°) FSR_right (°) FSR_left (°) TST (s) PSUT(Repetition/1 m) SPU (s) HGT_right (kg) HGT_left (kg) SLS_OE_right (s) SLS_OE_left (s) SLS_CE_right (s) SLS_CE_left (s) FRT_right (cm) FRT_left (cm) 2MST_before (bpm) 2MST_after (bpm) 2MST_2 min after (bpm)
Risperidona Non-consumer (mean ± sd)
Risperidona consumer (mean ± sd)
Difference (Student-t)
−26.12 ( ± 15.76) −23.58 ( ± 17.52) −0.61 ( ± 2.63) −1.63 ( ± 5.09) −0.18( ± 1.36) −0.19 ( ± 1.29) −13.12 ( ± 18.99) −16.50 ( ± 16.56) 33.38 ( ± 31.12) 26.84 ( ± 13.69) 15.26 ( ± 9.62) 25.02 ( ± 11.25) 28.08 ( ± 12.68) 17.50 ( ± 12.55) 12.13 ( ± 12.34) 6.68 ( ± 5.68) 11.55 ( ± 12.42) 35.31 ( ± 11.53) 33.74 ( ± 10.90) 75.75 ( ± 15.85) 108.38 ( ± 32.63) 81.50 ( ± 71.92)
−29.12 ( ± 17.82) −28.75 ( ± 19.59) −1.25 ( ± 3.53) −1.25 ( ± 3.53) −1.25 ( ± 3.53) −1.25 ( ± 3.53) −14.07 ( ± 14.36) −19.33 ( ± 14.29) 26.06 ( ± 10.54) 20.00 ( ± 8.17) 15.14 ( ± 8.45) 21.87 ( ± 11.14) 26.71 ( ± 7.62) 14.22 ( ± 11.69) 12.05 ( ± 10.02) 6.54 ( ± 7.79) 4.72 ( ± 6.11) 34.03 ( ± 10.396) 30.75 ( ± 10.69) 90.78 ( ± 14.91) 111.03 ( ± 16.94) 94.60 ( ± 14.47)
0.49 0.76 0.61 0.20 1.59 1.57 0.16 0.51 1.33 1.19 0.34 0.74 0.29 0.69 0.26 0.05 2.42 0.32 0.72 −2.64a −0.36 −2.31a
PKE: Passive knee extension; CMF: Calf muscle flexibility; AHF: Anterior hip flexibility; FSR: Functional shoulder rotation; TST: Time-stands test; PSUT: Partial sit-up test; SPU: Seated push-up; HGT: Handgrip test; SLS_OE: Single-leg stance with opened eyes; SLS_CE: Single-leg stance with closed eyes; FRT: Functional reach test; 2MST: Two-minute step test a p < 0.05.
3.2. Differences in physical fitness between adults with SMI who received antipsychotic medication or not
between people who consumed Risperidone and those who did not. On the other hand, regarding the consumption of Olanzapine (Table 3), significant differences were found in the physical fitness of the people who took this medication, with higher physical fitness values reported for muscle strength (Partial sit-up test, Seated push-up and Handgrip test), balance (Single-leg stance with opened eyes and closed eyes) and aerobic condition (Two-minute step test) in the group of individuals who did not take this medication. It is important to note that no significant differences were found in flexibility among people with SMI who took Risperidone or Olanzapine and those who did not.
There were also significant differences in physical fitness between patients with SMI who took antipsychotic medication and those who did not. On the one hand, regarding Risperidone (Table 2), significant differences were found only in aerobic condition (Two-minute step test), with better values of aerobic condition reported in the group of patients who did not take this medication. Despite this, no significant differences were found in flexibility, muscle strength or balance
Table 3 T-student differences of the physical fitness test between both groups.
Flexibility
Strength
Balance
Cardiovascular Endurance
PKE_right (°) PKE_left (°) CMF_right (°) CMF_left (°) AHF_right (°) AHF_left (°) FSR_right (°) FSR_left (°) TST (s) PSUT(Repetition/1 m) SPU (s) HGT_right (kg) HGT_left (kg) SLS_OE_right (s) SLS_OE_left (s) SLS_CE_right (s) SLS_CE_left (s) FRT_right (cm) FRT_left (cm) 2MST_before (bpm) 2MST_after (bpm) 2MST_2 min after (bpm)
Olanzapine non-consumer (mean ± sd)
Olanzapine consumer (mean ± sd)
Difference (Student-t)
−24.58 ( ± 14.68) −24.61 ( ± 15.58) −0.83 ( ± 2.88) −1.66 ( ± 5.77) 0.00 ( ± 0.00) 0.00 ( ± 0.00) −7.25 ( ± 7.66) −12.83 ( ± 6.67) 28.43 ( ± 15.88) 36.67 ( ± 17.05) 19.22 ( ± 12.13) 33.09 ( ± 9.90) 37.44 ( ± 11.26) 19.21 ( ± 12.13) 17.42 ( ± 9.73) 11.11 ( ± 10.00) 6.66 ( ± 8.56) 37.33 ( ± 8.60) 38.58 ( ± 11.07) 88.44 ( ± 14.86) 108.10 ( ± 19.18) 91.39 ( ± 14.68)
−26.98 ( ± 16.31) −24.18 ( ± 18.35) −0.66 ( ± 2.73 −1.56 ( ± 4.72) −0.40 ( ± 1.97) −0.33 ( ± 1.85) −15.59 ( ± 15.77) −20.46 ( ± 15.50) 21.08 ( ± 3.79) 22.66 ( ± 9.94) 13.47 ( ± 11.48) 22.70 ( ± 10.65) 25.57 ( ± 11.21) 13.47 ( ± 11.48) 10.89 ( ± 9.98) 5.44 ( ± 6.46) 5.22 ( ± 7.03) 33.43 ( ± 10.76) 32.10 ( ± 10.50) 90.50 ( ± 19.65) 122.27 ( ± 16.37) 99.36 ( ± 17.87)
0.46 −0.07 −0.19 −0.07 −0.69 −0.67 1.77 1.65 1.58 3.54a 2.19a 2.95a 3.28a 1.53 2.04a 2.42a 0.61 1.16 1.90 −0.41 −2.26a −1.56
PKE: Passive knee extension; CMF: Calf muscle flexibility; AHF: Anterior hip flexibility; FSR: Functional shoulder rotation; TST: Time-stands test; PSUT: Partial sit-up test; SPU: Seated push-up; HGT: Handgrip test; SLS_OE: Single-leg stance with opened eyes; SLS_CE: Single-leg stance with closed eyes; FRT: Functional reach test; 2MST: Two-minute step test a p < 0.05 22
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4. Discussion
and Risperidone with patients categorised according to type of medication (first generation antipsychotics, second generation antipsychotics or both). Finally, another point to consider is the fact that sedentay behaviour is a strong contributor to lower levels of physical fitness, which exacerbate of psychiatric symptoms in this population and increases the consumption of antipsychotic medication (Catalan-Matamoros et al., 2016). Therefore, specific physical activity programmes should be developed for this patient population (Vera-Garcia et al., 2015), not only focused on aerobic activity, but also on improvements in muscular strength and corporal balance. Also, participation in these programmes should be promoted due to the harmful impact caused by physical inactivity and poor physical fitness on the mental and physical health of individuals with SMI, as this population is quite vulnerable to suffering other types of pathologies.
The present study found differences in physical activity and fitness (muscle strength, flexibility, balance and aerobic condition) between people with SMI who consume Risperidone and Olanzapine or those who received other pharmacological treatments. The data of the present study show lower levels of physical activity as well as physical fitness in patients with SMI who were taking antipsychotic medication compared with those who were not, but these differences were not found for moderate physical activity or flexibility. The present data confirm previous findings that adults with SMI taking antipsychotic medication are less physically active, and have altered body balance, and lower muscular strength. This suggests that the use of antipsychotic medication is associated with lower physical activity and poorer physical fitness (Vancampfort et al., 2016a). A point to emphasise in the present study is that physical fitness was evaluated with a greater range of physical tests (that cover muscular strength, flexibility, balance and aerobic condition) and in a larger sample than in the study by Vancampfort et al. (2016b), which gives us more information about the use of antipsychotics in this population. In addition, in the present study, it was found that aerobic condition is also altered by the use of antipsychotic medication, with worse levels of aerobic condition in the group taking this type of medication. The results of the present study, confirmed that a higher dose of antipsychotic medication is associated with lower levels of physical activity and physical fitness; this association can be explained by several hypotheses. On the one hand, the consumption of antipsychotic medication may be associated with the severity of the pathology, which means that these patients will have more severe psychiatric symptoms which will decrease their activity levels and physical fitness in general. On the other hand, differences in physical fitness between the two groups could also be explained by adverse effects of antipsychotics such as increased fatigue, which is one of the symptoms reported to cause patients to be physically less active. It is important to highlight the kind of antipsychotic medication that people with SMI consume, because in the present study differences in aerobic condition have been reported between Risperidone and Olanzapine consumers and consumers of another kind of medication, but these differences in aerobic condition are not produced by all kinds of antipsychotic medication. (Vancampfort et al., 2017). The present findings should be interpreted with caution due to some methodological limitations. On the one hand, since this is a cross-sectional study, it is not possible to establish a cause-effect correlation between medication consumption of medication and levels of activity and physical fitness. On the other hand, it is also important to note that physical activity was evaluated by a subjective questionnaire (IPAQ-S) which, despite its reliability levels (Duncan et al., 2017), must be interpreted with caution since the ideal would be to evaluate physical activity with an objective instrument (accelerometer or similar instrument). The present study did not evaluate variables such as psychiatric symptoms, alcohol and tobacco consumption, social support for physical activity or consumption of other kind of psychotropic medication which would be important to evaluate in future studies to determine whether they also influence levels of activity and physical fitness. These variables have not been addressed in the present study, so it should be considered that the physical fitness, as well as the physical activity, of the population in the present study have been influenced by a series of these factors. Finally, the unequal number of participants in each group (52 vs 10, and 50 vs 10) might have affect the results of the study. Despite these limitations, the data presented in the present study have important practical implications. On the one hand, these results are clinically relevant and add more information about health and active lifestyles for people with SMI following the guidelines of Healthy Active Lives (HeAL), the objectives of which is to decrease the risk factors for possible future problems such as obesity, diabetes or cardiovascular disease. A future objective may be to compare Olanzapine
Ethics approval and consent to participate The institutional review committee at the University of Malaga approved the procedures used in this study and ethical recommendations were taken into consideration at all stages during the research. The study complied with the principles laid out in the Declaration of Helsinki. Competing interest The authors state that no conflicts of interest have been reported by the authors or by any individual in control of the content of the present study. This information has not been presented previously. Funding This research was partially funded by grants from OTRI-UMA (ref 806/423505-1) with a part-time assistant research grant to David Perez-Cruzado. Authors contributions Antonio I. Cuesta-Vargas made contributions to the conception of this study. Elisa Vera-Garcia and Fermin Mayoral-Cleries participated in data collection. Antonio I. Cuesta-Vargas and David Perez-Cruzado participated in the analysis and interpretation of data and were involved in drafting the manuscript or revising it critically for important intellectual content. All the authors have given final approval of the version to be published. Acknowledgment The authors would like to thank all participants and collaborating staff who took part in the research. Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.psychres.2018.05.055. References Bellace, J.V., Healy, D., Besser, M.P., Byron, T., Hohman, L., 2000. Validity of the Dexter evaluation system's Jamar dynamometer attachment for assessment of hand grip strength in a normal population. J. Hand Ther. Off. J. Am. Soc. Hand Ther. 13, 46–51. http://dx.doi.org/10.1016/S0894-1130(00)80052-6. Birmingham, T.B., 2000. Test-retest reliability of lower extremity functional instability measures. Clin. J. Sport Med. Off. J. Can. Acad. Sport Med. 10, 264–268. http://dx. doi.org/10.1097/00042752-200010000-00007. Burnstein, B.D., Steele, R.J., Shrier, I., 2011. Reliability of fitness tests using methods and time periods common in sport and occupational management. J. Athl. Train. 46, 505–513.
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Catalan-Matamoros, D., Gomez-Conesa, A., Stubbs, B., Vancampfort, D., 2016. Exercise improves depressive symptoms in older adults: an umbrella review of systematic reviews and meta-analyses. Psychiatry Res. 244, 202–209. http://dx.doi.org/10. 1016/j.psychres.2016.07.028. Craig, C.L., Marshall, A.L., Sjöström, M., Bauman, A.E., Booth, M.L., Ainsworth, B.E., et al., 2003. International physical activity questionnaire: 12-country reliability and validity. Med. Sci. Sports Exerc. 35, 1381–1395. http://dx.doi.org/10.1249/01.MSS. 0000078924.61453.FB. Duncan, M.J., Arbour-Nicitopoulos, K., Subramaniepillai, M., Remington, G., Faulkner, K., 2017. Revisiting the international physical activity questionnaire (IPAQ): assessing physical activity among individuals with schizophrenia. Schizopgr. Res. 179, 2–7. http://dx.doi.org/10.1016/j.schres.2016.09.010. Duncan, P.W., Weiner, D.K., Chandler, J., Studenski, K., 1990. Functional reach: a new clinical measure of balance. J. Gerontol. 45, M192–M197. http://dx.doi.org/10. 1093/geronj/45.6.M192. Cuesta-Vargas, A.I., Paz-Lourido, B., Rodriguez, A., 2011. Physical fitness profile in adults with intellectual disabilities: differences between levels of sport practice. Res. Dev. Disabil. 32, 788–794. http://dx.doi.org/10.1016/j.ridd.2010.10.023. Edwards, T.B., Bostick, R.D., Greene, C.C., Baratta, R.V., Drez, D., 2002. Interobserver and intraobserver reliability of the measurement of shoulder internal rotation by vertebral level. J. Shoulder Elbow Surg. Am. Shoulder Elbow Surg. Al. 11, 40–42. http:// dx.doi.org/10.1067/mse.2002.119853. Ekstrand, J., Wiktorsson, M., Oberg, B., Gillquist, J., 1982. Lower extremity goniometric measurements: a study to determine their reliability. Arch. Phys. Med. Rehabil. 63, 171–175. Faulkner, R.A., Sprigins, E.J., McQuarrie, A., Bell, R.D., 1989. A partial curl-up protocol for adults based on an analysis of two procedures. Can. J. Sport Sci. J. Can. Sci. Sport 14, 135–141. Fisher, R.A., Yates, F., (Eds.) 1963. Statistical Tables for Biological, Agricultural and Medical Research, edited by R.A. Fisher and F. Yates. 6th ed. Oliver and Boyd, Edinburgh. Gajdosik, R.L., Rieck, M.A., Sullivan, D.K., Wightman, S.E., 1993. Comparison of four clinical tests for assessing hamstring muscle length. J. Orthop. Sports Phys. Ther. 18, 614–618. http://dx.doi.org/10.2519/jospt.1993.18.5.614. 1993. Hong, J., Barnes, M.J., Leddon, C.E., Van Ryssegem, G., Alamar, B., 2011. Reliability of the sitting hand press-up test for identifying and quantifying the level of scapular medial border posterior displacement in overhead athletes. Int. J. Sports Phys. Ther. 6, 306–311. Koivukangas, J., Tammelin, T., Kaakinen, M., Mäki, P., Moilanen, I., Taanila, A., et al., 2010. Physical activity and fitness in adolescents at risk for psychosis within the Northern Finland 1986 Birth Cohort. Schizophr. Res. 116, 152–158. http://dx.doi. org/10.1016/j.schres.2009.10.022. Komossa, K., Rummel-Kluge, C., Hunger, H., Schmid, F., Schwarz, S., Duggan, L., et al., 2010. Olanzapine versus other atypical antipsychotics for schizophrenia. Cochrane Database Syst. Rev., CD006654. http://dx.doi.org/10.1002/14651858.CD006654. pub2. Mangurian, C., Newcomer, J.W., Modlin, C., Schillinger, D., 2016. Diabetes and cardiovascular care among people with severe mental illness: a literature review. J. Gen. Intern. Med. http://dx.doi.org/10.1007/s11606-016-3712-4. Marfell-Jones, M., Olds, T., Stewart, A., Carter, J., 2006. International Standards for Anthropometric Assessment. International Society for the Advanced of Kinanthropometry. Underdale, SA. Newcomer, K.L., Krug, H.E., Mahowald, M.L., 1993. Validity and reliability of the timedstands test for patients with rheumatoid arthritis and other chronic diseases. J. Rheumatol. 20, 21–27. Nicol, G.E., Kolko, R.P., Mills, M., Gunnarsdottir, T., Yingling, M.D., Schweiger, J.A., et al., 2016. Behavioral weight loss treatment in antipsychotic treated youth. Scand. J. Child Adolesc. Psychiatry Psychol. 4, 96–104.
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Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Medication and physical activity and physical fitness in severe mental illness a
David Perez-Cruzado , Antonio Cuesta-Vargas a b c
a,b,⁎
a,c
, Elisa Vera-Garcia , Fermín Mayoral-Cleries
T
c
Department of Physiotherapy, University of Malaga, Spain School of Clinical Science, Faculty of Health Science, Queensland University Technology, Australia Hospital Regional de Málaga, Grupo de Investigación de Salud Mental, IBIMA, Spain
A R T I C LE I N FO
A B S T R A C T
Keywords: Medication Physical activity Physical fitness Fitness condition Physical activity psychiatry
Anti-psychotic medication has emerged as the primary medical treatment for people with severe mental illness, despite the great risks involved in the use of this medication. In addition, this population suffers from problems of obesity, sedentary lifestyle and poor physical fitness, which is aggravated by the use of this type of medication. The objective of this study is to explore the influence of the most commonly used antipsychotics in this population (Olanzapine and Risperidone) on physical activity and the physical fitness of people with severe mental illness. Sixty-two people between 26 and 61 years of age with severe mental illness were assessed. All participants were evaluated with a battery of 11 physical tests to assess their physical fitness and with the IPAQ-short version questionnaire to determine their level of physical activity. The doses of Risperidone and Olanzapine were also evaluated in all participants. Significant differences were found for physical activity, with higher levels reported in those patients with severe mental illness who did not take any of these medications. Regarding physical fitness, significant differences were only found for the consumption of Risperidone, with better physical fitness levels seen in patients who did not consume this medication; on the other hand, for the consumption of Olanzapine, differences were found in muscular strength, balance and aerobic condition with better values in non-Olanzapine consumers compared with Olanzapine consumers.
1. Introduction Severe mental illness (SMI) includes functional psychosis, and an ICD-10 diagnosis of a functional affective or non-affective psychotic disorder (codes F10-F22, F24, F25, F28-F31, F32.3 and F33.3) (Ruggeri et al., 2000). In most developed countries, second-generation (atypical) antipsychotics have emerged as the drug of choice for individuals with severe mental disorders (Komossa et al., 2010). These are even used in young patients with other mental health problems, such as non-psychotic disorders like autism or intellectual disability (Park et al., 2016), despite the increased risk of diabetes, dyslipidemia and cardiovascular disease as a side effect of this medication (Mangurian et al., 2016; Nicol et al., 2016). These health problems are aggravated in people with severe mental disorders, in whom are also found high levels of obesity, as well as sedentary lifestyle and poor physical fitness (Vancampfort et al., 2013a,2016b) and may be associated with the use of antipsychotics (Koivukangas et al., 2010; Vancampfort et al., 2016a). Inactive patients with SMI present considerably higher levels of sedentary than to other types of patients with different pathologies, thus presenting a
deterioration of health as well as lower physical fitness compared to a control group of healthy individuals (Vancampfort et al., 2015,2013b,c). In patients with schizophrenia and schizoaffective disorders, physical fitness seems to emerge as an important modifiable risk factor for metabolic and cardiovascular diseases, as well as morbidity and mortality (Vancampfort et al., 2015,2013b,c). In addition to the modifiable lifestyle factors and side effects of psychotropic medications, poor access to medical care as well as low quality of the medical care received are problems that SMI patients face daily (Wang et al., 2016). As a result, this population frequently suffers from associated problems such as greater social exclusion, fewer employment opportunities or a greater dependence on others to accomplish activities of daily living (Vancampfort et al., 2016c). Among the different second-generation antipsychotics, Olanzapine and Risperidone are those which show the greatest improvement in general health; therefore, these are the most frequently used from this group of medications when compared with other second-generation antipsychotics (Komossa et al., 2010). Given the potential for a higher incidence of SMI diseases, and as a result of the introduction of second-
⁎ Corresponding author at: Cátedra de Fisioterapia, Universidad de Malaga, Andalucia Tech, Instituto de Investigacion Biomédica de Malaga (IBIMA) Grupo de Clinimetria (F-14). Av/ Arquitecto Peñalosa, 3 (Teatinos Campus Expansion) 29071 Malaga (Spain). E-mail addresses: [email protected] (D. Perez-Cruzado), [email protected] (A. Cuesta-Vargas), [email protected] (E. Vera-Garcia), [email protected] (F. Mayoral-Cleries).
https://doi.org/10.1016/j.psychres.2018.05.055 Received 29 September 2017; Received in revised form 23 April 2018; Accepted 22 May 2018 Available online 23 May 2018 0165-1781/ © 2018 Elsevier B.V. All rights reserved.
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beyond the fully straight position into hyperextension, the value was recorded as positive (e.g., +5°). The reliability of the PKE test was explored and compared with other clinical tests for assessing hamstring muscle as proposed by Gajdoski et al. (1993). Calf Muscle Flexibility (CMF): The participant was positioned supine on a table, with the hip and knee on the side to be measured in as much extension as possible. The fulcrum of the goniometer was placed over the lateral malleolus, with one of its arms in the direction of the fibular head and the other one in parallel to the lateral midline of the fifth metatarsal. Their ankle was passively dorsiflexed and its angle measured while their knee remained in extension. If the participant could not reach neutral position, the angle was recorded as negative (e.g., −10°). If the participant went beyond neutral, it was recorded as positive (e.g., +10°). If the participant only reached neutral, it was recorded as 0°. The reliability of this test can be found in Ekstrand et al. (1982). Anterior Hip Flexibility (AHF): The participant was positioned supine on a table, both hips flexed to 90°. The hip to be measured was flexed up to 100° with a hand beneath the lower back to ensure that it remained flattened. Opposite hip was kept at 90° and not allowed to move into extension during the test. The fulcrum of the goniometer was placed over the greater trochanter, with its arms aligned with the lateral midline of the pelvis and with the lateral midline of the femur respectively. The degrees of extension between the pelvis and thigh were measured before the pelvis began to move forward. If the thigh lowered to the table surface, the result was recorded as 0°. If the thigh did not reach the table, the angle was recorded as negative (e.g., −25°). The reliability of this test can be found in Ekstrand et al. (1982). Functional shoulder rotation (FSR) (Apley's Scratch Test): The participant stood or was seated facing the back of a chair. The participant was instructed to reach one arm behind the head and down the back, while the other arm reached behind the hip and up the back. The participant was instructed to “try to touch their index fingers together.” A tape measure was used to measure the distance in cm between the index fingers in this position (one arm was in flexion/abduction/lateral rotation; the other was in extension/adduction/ medial rotation). The arm on top defined the recorded side (i.e., left arm on top = left; right arm on top = right). If the fingertips touched, the distance was recorded as 0. If the fingertips could not touch, the separation was recorded as negative (e.g., 15.2 cm). If the fingers overlap, the overlap was recorded as positive (e.g., +2.5 cm). The FSR is a reproducible measure of upper extremity function task that was validated in people with disabilities. The reliability of this test can be found in Edwards et al. (2002). The Timed-Stands Test (TST): The timed-stands test was the method to quantify functional lower extremity muscle strength (hip and knee extension). The test requires the participant to complete 10 full stands from a seated position as quickly as possible without the use of their arms. The participant was seated in a firm straight-backed chair with the elbows flexed to 90° during the test. The participant had to stand 10 times as quickly as possible and the time to perform the task in minutes and seconds was recorded. If the participant could not perform 10 repetitions, the number of repetitions and the time taken was recorded. The TST is a reproducible measure of lower extremity function that was validated in people with disabilities. The reliability of this test can be found in Newcomer et al. (1993). Partial Sit-Up Test (PSUT): The partial sit-up test was the method to quantify abdominal muscle strength/endurance. The test requires the participant to complete as many sit-ups as possible from a supine position in one minute. The participant was positioned supine on a table or mat, with the legs placed on a chair or stool to keep their hips and knees bent at 90°. Their arms were placed straight out in front of the chest with the elbows extended during the entire test. Test-retest reliability and validity was established in a previous study (Faulkner et al., 1989). Seated Push-Up (SPU): The seated push-up test is a method of
generation antipsychotic drugs, research aimed at optimising the physical health these individuals with schizophrenia should be carried out with a sense of urgency (Vancampfort et al., 2012a,b). The aim of the present study is to explore whether patients with SMI who are being treated with second-generation antipsychotics (Olanzapine and Risperidone) show differences in their activity and physical fitness compared with those with SMI who take other pharmacological treatments in order to define whether this population is at elevated risk of other disorders and if a specific intervention is justifiable. 2. Methods 2.1. Participants The study procedure was approved by the Ethics Committee of Research, Malaga Northeast. The participants were recruited during a 6 month period from the mental health service of the Hospital Regional University of Malaga. The total sample consisted of 62 participants (37 men and 25 women), between 26 and 61 years of age, diagnosed with SMI by a psychiatrist of the Hospital Regional University of Malaga (a set of pathologies with, an ICD-10 diagnosis of an affective or non-affective functional psychotic disorder [codes F20-F22, F24, F25, F28F31, F32.3 and F33.3]). Prior to participation in the study, participants had to sign an informed consent form to participate. The inclusion criteria were: (1) individuals aged between 18 and 65 years, (2) individuals who had not suffered a psychotic crisis in the last 4 weeks (these people were isolated), and (3) individuals who did not have any cardiovascular, neuromuscular or endocrine pathology that prevented them from performing physical exercise or limited their physical fitness. Participants were grouped into Risperidone consumer, Olanzapine consumer, non-Risperidone consumer and non-Olanzapine consumer. Non-Risperidone consumer and non-Olanzapine consumer participants received another kind of antipsychotic medication. 2.2. Study design and procedures A cross-sectional study was performed. Data on sociodemographic variables were collected using a semi-structured interview format when the study was introduced to the participants and the aim of the research was explained. Anthropometric measurements (body weight, height and waist circumference) were collected according to the standards of the International Society for the Advancement of Kinanthropometry (Marfell-Jones et al., 2006). The assessors were one physiotherapist and one occupational therapist who had previously been trained in the proper performance of physical tests and the scoring scale. The scale was explained to the patients and the examiners demonstrated how to perform the tests. 2.3. Outcome measures The following 11 physical tests were used to measure physical fitness: passive knee extension test; calf muscle flexibility test; anterior hip flexibility test; functional shoulder rotation test; timed-stand test; partial sit-up test; seated push-up test; grip test; single leg stance, open and closed eyes; functional reach test; and the two minute step test (Cuesta-Vargas et al., 2011). Those tests include measures of the various categories of physical fitness (flexibility, balance, strength, and endurance). Passive knee extension (PKE): The participant was positioned supine on a treatment table with hip and knee flexed at 90°. The passive knee extension was measured using a goniometer, with the fulcrum placed over the lateral femoral epicondyle and its arms in the direction of the greater trochanter and lateral malleolus respectively. Their ankle remained in a neutral position or in plantar flexion. If the knee went fully extended, the final value was recorded as 0°. If the knee did not extend, the value was recorded as negative (e.g., −40°). If the knee went 20
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assessing the strength of the triceps, shoulder and scapular muscles. The test involves pushing the body up out of a seated position, and slowly lowering it back into the seat. The participant was placed with the knees out straight and the heels resting on the floor or table. The participant had to push their body up from the table or floor until the elbows were straight, held for 20 s and then slowly lowered back into the seat. The reliability of revised push-up test protocol in people without disabilities was 0.80 to 0.96 (Hong et al., 2011). HandGrip Test (HGT): The handgrip test is a standardized method for assessing strength of the hand and forearm muscles, as it has been correlated to upper extremity function. The test involved completing three grips on each side (preferred and non-preferred hand) and recording the better of the three trials using an adjustable handgrip dynamometer. The participant had to keep the arm and hand at the side with the elbow bent at 90° while squeezing as forcefully as possible. The handgrip dynamometer have being found to be highly reliable (ICC = 0.98) and valid (ICC = 0.99) for measuring handgrip strength (Bellace et al., 2000). Single-Leg Stance With Eyes Opened (SLSEO): The single-leg stance test with eyes open is designed to assess balance with the assistance of visual cues. The test required the participant to stand on one leg with the eyes open. Balance must be maintained as long as possible. The arms were placed at the sides with elbows slightly flexed during the test. The test continued until participant lost balance, or put the other foot down (maximum time was 30 s). Interclass correlation coefficients were moderate to excellent (0.41 to 0.91) (Birmingham 2000). Single-Leg Stance With Eyes Closed (SLSEC): The single-leg stance test with eyes closed is similar to the previous one but without the assistance of visual cues, so the participant's eyes are kept closed or covered with a blindfold. Interclass correlation coefficients were moderate to excellent (0.41 to 0.91) suggesting that the standing balance tests are appropriate for distinguishing among group performances (Birmingham 2000). Functional Reach Test (FRT): The test requires the participant to reach forward beyond the length of his/her arm without loss of balance. The participant was on two legs, positioned shoulder width apart (or seated if the participant could not stand). The participant was requested to lift one arm up to 90°, forward flexion and extend fingers. Test-retest reliability and validity was established in a previous study (Duncan et al., 1990). Two-minute step test (2MST): Pre-exercise resting heart rate (RHR) was recorded with the participant seated before the test and again twominute after the test is finished (2MAF). The participant was located next to a wall, and the minimum stepping height for the participant was marked. The test required a running tape measure from the iliac crest to the mid-patella, and to mark the midway point on the tape. This mark was transferred to the wall. The participant was requested to march for a maximum of two minutes, bringing each knee alternatively up to the tape mark in the wall. The number of times that the participant touched the tape with the right knee was recorded. The 2MST showed an acceptable reliability (0.63) (Burnstein et al., 2011) The International Physical Activity Questionnaire (IPAQ)-short version (Craig et al., 2003) was used to measure self-reported physical activity. This questionnaire allows us to ascertain the physical activity undertaken in the last seven days. The IPAQ scale provides us with data about vigorous physical activity, moderate physical activity and light (walking) physical activity. The reliability of the IPAQ was ρ = 0.47 (Duncan et al., 2017).
Table 1 Characteristics of participants.
Age Height (cm) Weight (Kg) Abdominal perimeter (cm) Vigorous PA (min) Moderate PA (min) Light PA (min) Total PA (min) Risperidona dose
Age Height (cm) Weight (Kg) Abdominal perimeter (cm) Vigorous PA (min) Moderate PA (min) Light PA (min) Total PA (min) Olanzapine dose
Non-Risperidona consumer N = 52 Mean ( ± sd)
Risperidona consumer N = 10 Mean ( ± sd)
Difference
46.28 ( ± 8.44) 164.27 ( ± 22.11) 81.78 ( ± 16.66) 103.83 ( ± 13.98)
45.75 ( ± 8.50) 168.19 ( ± 7.89) 77.72 ( ± 8.41) 97.68 ( ± 8.91)
81.51 ( ± 502.423)
0.00 ( ± 0.00)
0.46
426.42 ( ± 813.71)
1110.00 ( ± 2950.39)
−1.42
2062.18 ( ± 1122.61) 2579.11 ( ± 1645.33) 0.00 ( ± 0.00)
1150.28 ( ± 828.38) 1218.86 ( ± 803.72) 5.31 ( ± 2.60)
2.07⁎ 2.14⁎
Non-Olanzapine consumer N = 50 Mean ( ± sd)
Olanzapine consumer N = 12 Mean ( ± sd)
Difference
46.98 ( ± 8.28) 163.14 ( ± 22.58) 79.92 ( ± 15.62) 102.80 ( ± 13.67)
43.00 ( ± 8.35) 171.63 ( ± 8.30) 86.85 ( ± 16.22) 104.04 ( ± 13.49)
360.00 ( ± 1041.12)
0.00 ( ± 0.00)
2.48⁎
395.00 ( ± 681.18)
545.71 ( ± 1394.11)
−0.36
2615.25 ( ± 1114.84) 3370.25 ( ± 2186.70) 0.00 ( ± 0.00)
1785.16 ( ± 1076.04) 2174.52 ( ± 1375.94) 14.17 ( ± 5.47)
2.34⁎ 2.36⁎
(Student-t)
(Student-t)
PA: Physical activity. ⁎ Level of significance 0,05.
statistically significant (Fisher and Yates, 1963). The correlation cut-off was established as r ≤ 0.3, with a mild correlation being denoted by r > 0.3 r ≤ 0.6, and a high correlation as r > 0.6 (Portney and Watkins, 2009).
3. Results A total of 62 adults with SMI participated in the study. No patients were excluded due to cardiovascular or neuromuscular problems. None of the 62 study participants refused to participate in the study or abandoned the study during the data collection period. The dose of Risperidone taken by the patients was 5.31 ( ± 2.60) mg/day, whereas the consumption of Olanzapine was 14.17 ( ± 5.47) mg/day.
3.1. Differences in physical activity between adults with SMI who did or did not receive antipsychotic medication Differences were found between individuals with SMI who took antipsychotic medication and those who did not (Table 1). There were significant differences both in patients who consumed Risperidone (light physical activity and total physical activity) and in those who consumed Olanzapine (vigorous physical activity, light physical activity and total physical activity), with higher levels of physical activity reported in the group of individuals with SMI who did not take these medications.
2.4. Data analysis Descriptive data for all variables were presented as mean and standard deviation. To assess the homogeneity of the sample (Risperidone and Olanzapine takers and non medication takers), the Kolmogorov–Smirnov test was used to divide parametric and nonparametric measures. A P-value < 0.05 was considered to be 21
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Table 2 T-Student differences of the physical fitness test between both groups.
Flexibility
Strength
Balance
Cardiovascular endurance
PKE_right (°) PKE_left (°) CMF_right (°) CMF_left (°) AHF_right (°) AHF_left (°) FSR_right (°) FSR_left (°) TST (s) PSUT(Repetition/1 m) SPU (s) HGT_right (kg) HGT_left (kg) SLS_OE_right (s) SLS_OE_left (s) SLS_CE_right (s) SLS_CE_left (s) FRT_right (cm) FRT_left (cm) 2MST_before (bpm) 2MST_after (bpm) 2MST_2 min after (bpm)
Risperidona Non-consumer (mean ± sd)
Risperidona consumer (mean ± sd)
Difference (Student-t)
−26.12 ( ± 15.76) −23.58 ( ± 17.52) −0.61 ( ± 2.63) −1.63 ( ± 5.09) −0.18( ± 1.36) −0.19 ( ± 1.29) −13.12 ( ± 18.99) −16.50 ( ± 16.56) 33.38 ( ± 31.12) 26.84 ( ± 13.69) 15.26 ( ± 9.62) 25.02 ( ± 11.25) 28.08 ( ± 12.68) 17.50 ( ± 12.55) 12.13 ( ± 12.34) 6.68 ( ± 5.68) 11.55 ( ± 12.42) 35.31 ( ± 11.53) 33.74 ( ± 10.90) 75.75 ( ± 15.85) 108.38 ( ± 32.63) 81.50 ( ± 71.92)
−29.12 ( ± 17.82) −28.75 ( ± 19.59) −1.25 ( ± 3.53) −1.25 ( ± 3.53) −1.25 ( ± 3.53) −1.25 ( ± 3.53) −14.07 ( ± 14.36) −19.33 ( ± 14.29) 26.06 ( ± 10.54) 20.00 ( ± 8.17) 15.14 ( ± 8.45) 21.87 ( ± 11.14) 26.71 ( ± 7.62) 14.22 ( ± 11.69) 12.05 ( ± 10.02) 6.54 ( ± 7.79) 4.72 ( ± 6.11) 34.03 ( ± 10.396) 30.75 ( ± 10.69) 90.78 ( ± 14.91) 111.03 ( ± 16.94) 94.60 ( ± 14.47)
0.49 0.76 0.61 0.20 1.59 1.57 0.16 0.51 1.33 1.19 0.34 0.74 0.29 0.69 0.26 0.05 2.42 0.32 0.72 −2.64a −0.36 −2.31a
PKE: Passive knee extension; CMF: Calf muscle flexibility; AHF: Anterior hip flexibility; FSR: Functional shoulder rotation; TST: Time-stands test; PSUT: Partial sit-up test; SPU: Seated push-up; HGT: Handgrip test; SLS_OE: Single-leg stance with opened eyes; SLS_CE: Single-leg stance with closed eyes; FRT: Functional reach test; 2MST: Two-minute step test a p < 0.05.
3.2. Differences in physical fitness between adults with SMI who received antipsychotic medication or not
between people who consumed Risperidone and those who did not. On the other hand, regarding the consumption of Olanzapine (Table 3), significant differences were found in the physical fitness of the people who took this medication, with higher physical fitness values reported for muscle strength (Partial sit-up test, Seated push-up and Handgrip test), balance (Single-leg stance with opened eyes and closed eyes) and aerobic condition (Two-minute step test) in the group of individuals who did not take this medication. It is important to note that no significant differences were found in flexibility among people with SMI who took Risperidone or Olanzapine and those who did not.
There were also significant differences in physical fitness between patients with SMI who took antipsychotic medication and those who did not. On the one hand, regarding Risperidone (Table 2), significant differences were found only in aerobic condition (Two-minute step test), with better values of aerobic condition reported in the group of patients who did not take this medication. Despite this, no significant differences were found in flexibility, muscle strength or balance
Table 3 T-student differences of the physical fitness test between both groups.
Flexibility
Strength
Balance
Cardiovascular Endurance
PKE_right (°) PKE_left (°) CMF_right (°) CMF_left (°) AHF_right (°) AHF_left (°) FSR_right (°) FSR_left (°) TST (s) PSUT(Repetition/1 m) SPU (s) HGT_right (kg) HGT_left (kg) SLS_OE_right (s) SLS_OE_left (s) SLS_CE_right (s) SLS_CE_left (s) FRT_right (cm) FRT_left (cm) 2MST_before (bpm) 2MST_after (bpm) 2MST_2 min after (bpm)
Olanzapine non-consumer (mean ± sd)
Olanzapine consumer (mean ± sd)
Difference (Student-t)
−24.58 ( ± 14.68) −24.61 ( ± 15.58) −0.83 ( ± 2.88) −1.66 ( ± 5.77) 0.00 ( ± 0.00) 0.00 ( ± 0.00) −7.25 ( ± 7.66) −12.83 ( ± 6.67) 28.43 ( ± 15.88) 36.67 ( ± 17.05) 19.22 ( ± 12.13) 33.09 ( ± 9.90) 37.44 ( ± 11.26) 19.21 ( ± 12.13) 17.42 ( ± 9.73) 11.11 ( ± 10.00) 6.66 ( ± 8.56) 37.33 ( ± 8.60) 38.58 ( ± 11.07) 88.44 ( ± 14.86) 108.10 ( ± 19.18) 91.39 ( ± 14.68)
−26.98 ( ± 16.31) −24.18 ( ± 18.35) −0.66 ( ± 2.73 −1.56 ( ± 4.72) −0.40 ( ± 1.97) −0.33 ( ± 1.85) −15.59 ( ± 15.77) −20.46 ( ± 15.50) 21.08 ( ± 3.79) 22.66 ( ± 9.94) 13.47 ( ± 11.48) 22.70 ( ± 10.65) 25.57 ( ± 11.21) 13.47 ( ± 11.48) 10.89 ( ± 9.98) 5.44 ( ± 6.46) 5.22 ( ± 7.03) 33.43 ( ± 10.76) 32.10 ( ± 10.50) 90.50 ( ± 19.65) 122.27 ( ± 16.37) 99.36 ( ± 17.87)
0.46 −0.07 −0.19 −0.07 −0.69 −0.67 1.77 1.65 1.58 3.54a 2.19a 2.95a 3.28a 1.53 2.04a 2.42a 0.61 1.16 1.90 −0.41 −2.26a −1.56
PKE: Passive knee extension; CMF: Calf muscle flexibility; AHF: Anterior hip flexibility; FSR: Functional shoulder rotation; TST: Time-stands test; PSUT: Partial sit-up test; SPU: Seated push-up; HGT: Handgrip test; SLS_OE: Single-leg stance with opened eyes; SLS_CE: Single-leg stance with closed eyes; FRT: Functional reach test; 2MST: Two-minute step test a p < 0.05 22
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4. Discussion
and Risperidone with patients categorised according to type of medication (first generation antipsychotics, second generation antipsychotics or both). Finally, another point to consider is the fact that sedentay behaviour is a strong contributor to lower levels of physical fitness, which exacerbate of psychiatric symptoms in this population and increases the consumption of antipsychotic medication (Catalan-Matamoros et al., 2016). Therefore, specific physical activity programmes should be developed for this patient population (Vera-Garcia et al., 2015), not only focused on aerobic activity, but also on improvements in muscular strength and corporal balance. Also, participation in these programmes should be promoted due to the harmful impact caused by physical inactivity and poor physical fitness on the mental and physical health of individuals with SMI, as this population is quite vulnerable to suffering other types of pathologies.
The present study found differences in physical activity and fitness (muscle strength, flexibility, balance and aerobic condition) between people with SMI who consume Risperidone and Olanzapine or those who received other pharmacological treatments. The data of the present study show lower levels of physical activity as well as physical fitness in patients with SMI who were taking antipsychotic medication compared with those who were not, but these differences were not found for moderate physical activity or flexibility. The present data confirm previous findings that adults with SMI taking antipsychotic medication are less physically active, and have altered body balance, and lower muscular strength. This suggests that the use of antipsychotic medication is associated with lower physical activity and poorer physical fitness (Vancampfort et al., 2016a). A point to emphasise in the present study is that physical fitness was evaluated with a greater range of physical tests (that cover muscular strength, flexibility, balance and aerobic condition) and in a larger sample than in the study by Vancampfort et al. (2016b), which gives us more information about the use of antipsychotics in this population. In addition, in the present study, it was found that aerobic condition is also altered by the use of antipsychotic medication, with worse levels of aerobic condition in the group taking this type of medication. The results of the present study, confirmed that a higher dose of antipsychotic medication is associated with lower levels of physical activity and physical fitness; this association can be explained by several hypotheses. On the one hand, the consumption of antipsychotic medication may be associated with the severity of the pathology, which means that these patients will have more severe psychiatric symptoms which will decrease their activity levels and physical fitness in general. On the other hand, differences in physical fitness between the two groups could also be explained by adverse effects of antipsychotics such as increased fatigue, which is one of the symptoms reported to cause patients to be physically less active. It is important to highlight the kind of antipsychotic medication that people with SMI consume, because in the present study differences in aerobic condition have been reported between Risperidone and Olanzapine consumers and consumers of another kind of medication, but these differences in aerobic condition are not produced by all kinds of antipsychotic medication. (Vancampfort et al., 2017). The present findings should be interpreted with caution due to some methodological limitations. On the one hand, since this is a cross-sectional study, it is not possible to establish a cause-effect correlation between medication consumption of medication and levels of activity and physical fitness. On the other hand, it is also important to note that physical activity was evaluated by a subjective questionnaire (IPAQ-S) which, despite its reliability levels (Duncan et al., 2017), must be interpreted with caution since the ideal would be to evaluate physical activity with an objective instrument (accelerometer or similar instrument). The present study did not evaluate variables such as psychiatric symptoms, alcohol and tobacco consumption, social support for physical activity or consumption of other kind of psychotropic medication which would be important to evaluate in future studies to determine whether they also influence levels of activity and physical fitness. These variables have not been addressed in the present study, so it should be considered that the physical fitness, as well as the physical activity, of the population in the present study have been influenced by a series of these factors. Finally, the unequal number of participants in each group (52 vs 10, and 50 vs 10) might have affect the results of the study. Despite these limitations, the data presented in the present study have important practical implications. On the one hand, these results are clinically relevant and add more information about health and active lifestyles for people with SMI following the guidelines of Healthy Active Lives (HeAL), the objectives of which is to decrease the risk factors for possible future problems such as obesity, diabetes or cardiovascular disease. A future objective may be to compare Olanzapine
Ethics approval and consent to participate The institutional review committee at the University of Malaga approved the procedures used in this study and ethical recommendations were taken into consideration at all stages during the research. The study complied with the principles laid out in the Declaration of Helsinki. Competing interest The authors state that no conflicts of interest have been reported by the authors or by any individual in control of the content of the present study. This information has not been presented previously. Funding This research was partially funded by grants from OTRI-UMA (ref 806/423505-1) with a part-time assistant research grant to David Perez-Cruzado. Authors contributions Antonio I. Cuesta-Vargas made contributions to the conception of this study. Elisa Vera-Garcia and Fermin Mayoral-Cleries participated in data collection. Antonio I. Cuesta-Vargas and David Perez-Cruzado participated in the analysis and interpretation of data and were involved in drafting the manuscript or revising it critically for important intellectual content. All the authors have given final approval of the version to be published. Acknowledgment The authors would like to thank all participants and collaborating staff who took part in the research. Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.psychres.2018.05.055. References Bellace, J.V., Healy, D., Besser, M.P., Byron, T., Hohman, L., 2000. Validity of the Dexter evaluation system's Jamar dynamometer attachment for assessment of hand grip strength in a normal population. J. Hand Ther. Off. J. Am. Soc. Hand Ther. 13, 46–51. http://dx.doi.org/10.1016/S0894-1130(00)80052-6. Birmingham, T.B., 2000. Test-retest reliability of lower extremity functional instability measures. Clin. J. Sport Med. Off. J. Can. Acad. Sport Med. 10, 264–268. http://dx. doi.org/10.1097/00042752-200010000-00007. Burnstein, B.D., Steele, R.J., Shrier, I., 2011. Reliability of fitness tests using methods and time periods common in sport and occupational management. J. Athl. Train. 46, 505–513.
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