Pilates-Based Training for Postural Stability in Patients with Schizophrenia

Emin Ulaş Erdem; Eda Akbas; Banu Ünver

doi:10.26644/em.2019.005

Exerc Med > Volume 3; 2019 > Article

Erdem, Akbas, and Ünver: Pilates-Based Training for Postural Stability in Patients with Schizophrenia

Research Article

Exercise Medicine 2019; 3: 5.

Published online: September 10, 2019

DOI: https://doi.org/10.26644/em.2019.005

Pilates-Based Training for Postural Stability in Patients with Schizophrenia

Emin Ulaş Erdem¹

, Eda Akbas¹

, Banu Ünver^1,^*

¹Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Zonguldak Bülent Ecevit University, Zonguldak, Turkey

^*Correspondence: Banu Ünver, Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Zonguldak Bülent Ecevit University, Zonguldak, Turkey E-mail address: banuukarahan@yahoo.com

Received July 12, 2019 Accepted September 9, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

OBJECTIVES

Impairment in postural stability is prevalent in schizophrenia patients and this poses potential hazards. This study was planned to investigate whether the Pilates-based training improve the postural stability of patients with schizophrenia.

METHODS

Outpatients with schizophrenia were allocated to either Pilates exercise group (n=10), or control group (n=10) receiving no exercise. Pilates exercise group participated in supervised Pilates mat exercise program twice per week for six weeks, while the control group participated in no regular physical activity during study. Biodex Balance System was used to assess the participants’ postural stability at the baseline and after six weeks.

RESULTS

Statistical analysis revealed that Pilates exercise group showed significant improvement in terms of overall and medial/lateral postural stability scores in static condition (p<0.05). Also, overall and anterior/posterior index scores on left leg, overall and medial/lateral index scores on right leg decreased after training (p<0.05). Postural stability scores in dynamic condition, medial/lateral index score on left leg and anterior/posterior index score on right leg did not change in the Pilates exercise group (p>0.05).

CONCLUSIONS

Our results showed that Pilates-based training benefit and suggest potential particular benefits in terms of postural stability in patients with schizophrenia. Pilates exercise can be added to the rehabilitation program of schizophrenia patients as a safe and effective method. Future research should include comparative exercise groups in order to determine any particular advantage to Pilates-based training in schizophrenia.

Keywords: Balance; Exercise; Pilates; Postural stability; Schizophrenia

INTRODUCTION

Motor dysfunction, postural control disorders, balance and gait abnormalities are prevalent in schizophrenia due to the nature of the disease, intensive antipsychotic drug and/or alcohol use [1,2]. Dysfunction of motor, cerebellar and sensory integration causes deterioration in postural stability, and postural instability may adversely affect daily living activities, increase the risk of falls, cause serious injuries, aggravate cognitive symptoms, and prolong hospitalization [2-4].

Some previous studies reported that postural sway was related with increased symptom severity while others stated this condition was independent of clinical characteristics in patients with schizophrenia [4-6]. Additionally, since postural instability which is common in patients with schizophrenia is expected to affect their physical function and daily living adversely, it is clinically important to regard and to improve postural control and balance mechanisms in this population [1,2].

Heretofore the knowledge obtained about schizophrenia patients point out holistic approaches such as exercise should be included to the treatment for the management of the symptoms in this complicated disease [7,8]. Researchers showed that mental and functional symptoms can be reduced with exercise and physical activity in patients with schizophrenia [9-11]. However, only one study investigated the effect of an exercise method on postural stability of schizophrenia patients in the literature, despite potential promise of exercise therapy to improve postural stability. That study investigating the effect of yoga therapy on postural stability in schizophrenia patients showed that yoga therapy had positive effects on postural stability, but these effects were transient [12].

Pilates exercises have an increasing popularity among the general population in the last decades [13]. It has also been used by clinicians and researchers to improve the individuals' physical fitness, posture, muscle strength and functional performance. Previous studies have reported that the holistic approach of Pilates-based training can provide positive influence in the management of various diseases [14-16]. In addition, there are studies in the literature showing that Pilates exercises increase balance and postural stability in elderly individuals, dancers and athletes [17-20]. However, there are almost no studies or reports in terms of the effects of Pilates-based training on postural stability in schizophrenia patients.

Literature reported that prospective exercise intervention would be worthy of investigation to enhance postural stability in an effort to prevent falls in patients with schizophrenia-spectrum disorders [2]. The current study aimed to investigate the effects of Pilates-based exercise training on the postural stability of schizophrenia patients. Our hypothesis was that Pilates-based training would improve the postural stability in outpatients with schizophrenia.

METHODS

Experimental approach to the problem

This single-blind, controlled, experimental study was conducted with the patients who were diagnosed with schizophrenia according to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [21]. Inclusion criteria were having symptoms of schizophrenia for at least six months, not to change the type of antipsychotic medication prescribed for at least six weeks prior to study (although dosage may change) and willingness to participate in groups [22]. Exclusion criteria were any additional neurological or medical diseases, or any other condition that impairs postural stability. Patients with a severe physical disability or a physical condition that makes their participation impossible or potentially harmful (such as serious musculoskeletal or neurological disabilities) were also excluded from the study [23, 24]. Twenty-five individuals were assessed for eligibility, 2 were excluded, and 23 were enrolled into the study. On receipt of a completed consent form, individuals were assigned to the Pilates-based exercise group (PEG) or the control group (CG) based on their willingness. The PEG participated in 6-week supervised Pilates-based exercise training twice a week; while the CG participated in a routine non-specific activity program in Community Mental Health Center. Finally, 10 individuals with schizophrenia from each group completed the study (Figure 1).

Ethical approval for this study was obtained from the Clinical Research Ethics Committee of Zonguldak Bülent Ecevit University (Protocol no: 2015-84-21/10). All the individuals volunteered to participate in this research and signed the informed consent form.

Procedure

Both groups received the similar medication (atypical antipsychotic drugs) during the study. Antipsychotics were described in cumulative dosage (clozapine, 40 : 1; olanzapine, 2.5 : 1; risperidone, 1 : 1; aripiprazole, 3.75 : 1). CG had no additional intervention to pharmacological treatment. They maintained their normal sedentary activities for six weeks. PEG participated in a supervised Pilates-based training program twice per week for six weeks (totally 12 sessions). Previous research demonstrated that 6 to 8 weeks of Pilates training improves physical and psychological health [25, 26]. Besides, six-week Pilates exercise protocol, which consists of two sessions per week, was revealed to contribute to physical and psychological well-being in healthy individuals [13]. Based on these results, we established the same protocol (twice per week for six weeks) in the current study. Outcomes of the participants were measured at the baseline and after six weeks.

Exercises were performed as group training and supervised by an experienced physiotherapist. They trained 50 minutes duration via a Pilates-based training protocol including a warm-up period, main exercises period, and a cool-down period. Pilates-based training protocol focused on core stabilization and alignment, included breath control (Appendix). Individual limitations were respected, and exercises were modified according to the subjects’ capability. Therapist demonstrated each activity using verbal and visual instructions. All the exercises were performed coordinated in the group.

Outcome measures

Demographic features including gender, age, weight, and height of the patients were recorded. Postural stability was assessed by Biodex Balance System (Biodex® Medical Systems, Shirley, NY, USA) which was indicated as a reliable balance device [27]. Biodex Balance System has a circular movable platform that allows up to 20° of surface tilt in all directions (Figure 2). Participants were evaluated in static (on stable platform), dynamic (on moving platform) and single leg (on each left and right legs) conditions. Overall (OA), anterior/posterior (AP), and medial/lateral (ML) stability scores were obtained from Biodex software (Version 3.1, Biodex Medical Systems). Higher stability scores indicate poor balance.

Statistical analysis

Data was evaluated using the Statistical Package for Social Science 18 (SPSS Inc., Chicago, IL, USA) program for Windows. The significance level was set to p<0.05. Normality tests (visual and analytical) were conducted. Mann Whitney U test was used to compare age, height, weight, BMI (Body Mass Index) which were not normally distributed between groups. Chi-square test was used to compare sex ratio between two groups. Initial outcomes were compared between the groups using Mann-Whitney U test. Wilcoxon signedrank test was used comparing intra-group analysis. Posthoc power analysis was performed using G* Power (Version 3.0.10 University of Dusseldorf, Germany).

RESULTS

Twenty-five individuals were assessed for eligibility, two were excluded, and 23 were enrolled into the study and allocated to either the PEG (n=12) or the CG (n=11). Finally, 10 individuals with schizophrenia from each group completed the study.

Demographic features of the participants including age, weight, BMI, and gender were similar in the both of the groups (p>0.05) (Table 1). Baseline assessments including postural stability scores were also similar in the both of the groups (p>0.05) except ML index score on right leg (p<0.05) (Table 2).

Statistical analysis revealed that PEG showed significant improvement in terms of OA and ML postural stability scores in static condition (p<0.05). Also, OA and AP index scores on left leg, OA and ML index scores on right leg decreased after training (p<0.05). Postural stability scores in dynamic condition, ML index score on left leg and AP index score on right leg did not change in the Pilates exercise group (p>0.05). Postural stability outcomes did not change in the CG (p>0.05), except OA index score in static condition and OA index score on left leg (p<0.05) (Table 3).

DISCUSSION

Present study was conducted to determine the influences of a six-week Pilates-based training on postural stability of schizophrenia patients. According to our results, Pilatesbased training improves postural stability in terms of static and single-leg conditions in patients with schizophrenia.

Increased postural sway in schizophrenia patients is thought to be primarily depending on cerebellar abnormalities [4,28,29]. As another possible reason, balance deficiency might arise as a side effect of the atypical antipsychotic drug use [4]. In the literature, the majority of the exercise interventions in schizophrenia are standard steady-state aerobic exercises; coupled with progressive resistance and body relaxation and only one of these studies investigated the effectiveness of exercise therapy on postural stability [10,11,30-32]. Our results are consistent with the previous study investigating the effects of yoga therapy on postural stability in patients with schizophrenia-spectrum disorders in terms of providing positive influences on postural stability. According to the results of the study, a total length of trunk motion, the Romberg ratio, and anteflexion in standing of the participants were significantly improved in the yoga group at week eight [10]. In our study postural stability analysis indicated that OA and ML index scores in static condition and on right leg. Also, OA and AP index scores on left leg decreased while none of dynamic postural stability scores change after training. However, since the evaluation tool used in the previous study (Clinical Stabilometric Platform) was different from that in our study and the assessments of different parameters of postural stability, it is difficult to clearly demonstrate the consistency of the results.

The effectiveness of Pilates exercises was investigated in the elderly population in which balance and postural stability problems are common. Although balance and postural stability problems in elderly individuals are not exactly same to those of schizophrenic individuals, previous studies showed that Pilates based exercise program may be effective in improving balance, mobility and postural stability to decrease fall risk in older adults [17,18].

Pilates as a mind-body integrity exercise method focuses on strength, core stability, flexibility, muscle control, posture and breathing [33]. In our study, the mechanisms explaining the improvement in postural stability were not investigated. However according to the results of a previous study, Pilates core stability training enhances motor performance skills by increasing lower extremity muscle strength and improving postural stability and can prevent musculoskeletal disorders and improve quality of life [34].

This study is unique in terms of investigating the effects of Pilates-based training on postural stability in patients with schizophrenia. But the small amount of sample size limits the exact outcomes indeed. Yet considering the characteristics of this disease such as problems in social interaction, concentration, and motivation, it is admissible even this study performed with a small number of participants and groups is valuable as an evidence-based trial.

CONCLUSIONS

Postural instability is a common problem in schizophrenia and it is important to improve postural stability to protect patients from potential injuries. According to the results of the present study, a six-week Pilates-based training improves postural stability of patients with schizophrenia in terms of static and single leg conditions. Pilates exercise method can be added to the rehabilitation program of schizophrenia patients as a safe and effective method to improve postural stability.

ACKNOWLEDGEMENTS

Authors thank Elif GÜNEŞ YALÇIN for referring schizophrenia patients to this study, Tuğçe DUMAN ÖZKAN for her supervision to the training sessions and Cansu GEVREK for her contributions to the statistical analyses.

Notes

Conflict of Interest

The authors declare no conflict of interest.

Supplementary materials

Supplementary materials related to this article can be found at https://doi.org/10.26644/em.2019.005

em-2019-005-suppl.pdf

Figure 1.

Flow diagram

Figure 2.

Postural stability assessment with Biodex Balance System

Table 1.

Demographic features of the participants

	CG (n=10)	PEG (n=10)	p
	Mean±SD	Mean±SD	p
Age (year)	39.13±6.69	40.40±8.40	0.573
Weight (kg)	86.00±19.46	73.44±8.69	0.190
Height (cm)	168.38±7.96	163.40±8.73	0.203
BMI (kg/m²)	29.79±5.61	27.42±3.28	0.364
Gender (f/m)^a	3/5	5/5	0.596

Mann Whitney U test, ^aChi-square test

CG: Control group, PEG: Pilates-based exercise group, SD: Standard deviation, BMI: Body mass index

Table 2.

Intra-group comparison of initial postural stability scores of the participants

	CG (n=10)	PEG (n=10)	p
	Mean±SD	Mean±SD	p
PSS-Static OA	1.79±1.82	1.85±1.42	0.762
PSS -Static AP Index	1.30±1.84	1.05±0.85	0.897
PSS-Static ML Index	0.81±0.79	1.23±1.38	0.762
PSS-Dynamic OA	2.61±1.38	2.27±1.04	0.887
PSS-Dynamic AP Index	1.74±1.05	1.43±0.58	0.813
PSS-Dynamic ML Index	1.56±0.87	1.39±0.99	0.740
PSS-Single Leg OA (L)	3.05±2.00	3.63±2.56	0.829
PSS-Single Leg AP Index (L)	2.20±1.88	2.63±2.27	0.829
PSS-Single Leg ML Index (L)	1.56±0.90	2.03±1.65	0.696
PSS-Single Leg OA (R)	2.21±1.55	3.05±1.09	0.109
PSS-Single Leg AP Index (R)	1.70±1.62	1.66±1.23	0.740
PSS-Single Leg ML Index (R)	1.03±0.40	2.04±1.10	0.043*

Mann Whitney U test, ^*p<0.05

CG: Control group, PEG: Pilates-based exercise group, SD: Standard deviation, PSS: Postural stability score, OP: Overall, AP: Anterior/posterior, ML: Medial/lateral, L: Left, R: Right

Table 3.

Inter-group comparison of postural stability outcomes of the participants

	CG (n=10)			PEG (n=10)
	Baseline Mean±SD	Final Mean±SD	p	Baseline Mean±SD	Final Mean±SD	p
PSS-Static OA	1.79±1.82	0.98±0.71	0.034	1.85±1.42	0.68±0.39	0.037
PSS -Static AP Index	1.30±1.84	0.59±0.33	0.236	1.05±0.85	0.48±0.34	0.109
PSS-Static ML Index	0.81±0.79	0.61±0.59	0.058	1.23±1.38	0.36±0.22	0.041
PSS-Dynamic OA	2.61±1.38	2.28±0.88	0.279	2.27±1.04	1.65±0.60	0.066
PSS-Dynamic AP Index	1.74±1.05	1.40±0.72	0.138	1.43±0.58	1.06±0.47	0.155
PSS-Dynamic ML Index	1.56±0.87	1.50±0.65	1.00	1.39±0.99	1.05±0.51	0.674
PSS-Single Leg OA (L)	3.05±2.00	2.49±2.22	0.046	3.63±2.56	1.62±0.70	0.019
PSS-Single Leg AP Index (L)	2.20±1.88	1.85±1.99	0.092	2.63±2.27	1.02±0.60	0.005
PSS-Single Leg ML Index (L)	1.56±0.90	1.21±0.90	0.138	2.03±1.65	1.04±0.52	0.110
PSS-Single Leg OA (R)	2.21±1.55	2.71±2.22	0.752	3.05±1.09	1.62±1.11	0.028
PSS-Single Leg AP Index (R)	1.70±1.62	1.64±1.34	0.292	1.66±1.23	1.24±1.12	0.313
PSS-Single Leg ML Index (R)	1.03±0.40	1.89±1.67	0.249	2.04±1.10	0.76±0.49	0.007

Wilcoxon Signed Ranks Test

CG: Control group, PEG: Pilates-based exercise group, SD: Standard deviation, PSS: Postural stability score, OP: Overall, AP: Anterior/posterior, ML: Medial/lateral, L: Left, R: Right

REFERENCES

1. Sanders RD, Gillig PM. Gait and its assessment in psychiatry. Psychiatry (Edgmont) 2010; 7:38–43.

2. Ikai S, Uchida H, Suzuki T, et al. Postural sway and flexibility in patients with schizophrenia-spectrum disorders: A cross-sectional study. Asian J Psychiatr 2016; 19:14–18.

3. Tsuji Y, Akezaki Y, Mori K, et al. Factors inducing falling in schizophrenia patients. J Phys Ther Sci 2017; 29:448–451.

4. Kent JS, Hong SL, Bolbecker AR, et al. Motor deficits in schizophrenia quantified by nonlinear analysis of postural sway. PLoS One 2012; 7:1–10.

5. Dean DJ, Kent JS, Bernard JA, et al. Increased postural sway predicts negative symptom progression in youth at ultrahigh risk for psychosis. Schizophr Res 2015; 162:86–89.

6. Teng YL, Chen CL, Lou SZ, et al. Postural stability of patients with schizophrenia during challenging sensory conditions: Implication of sensory integration for postural control. PloS One 2016; 11:1–16.

7. Pearsall R, Smith DJ, Pelosi A, Geddeset J. Exercise therapy in adults with serious mental illness: a systematic review and meta-analysis. BMC Psychiatry 2014; 14(1):117

8. Scheewe TW, Takken T, et al. Exercise therapy improves mental and physical health in schizophrenia: a randomised controlled trial. Acta Psychiatr Scand 2013; 127(6):464–473.

9. Dauwan M, Begemann MJ, Heringa SM, et al. Exercise improves clinical symptoms, quality of life, global functioning, and depression in schizophrenia: a systematic review and meta-analysis. Schizophr Bull 2015; 42(3):588–599.

10. Behere RV, Arasappa R, Jagannathan A, et al. Effect of yoga therapy on facial emotion recognition deficits, symptoms and functioning in patients with schizophrenia. Acta Psychiatr Scand 2011; 123(2):147–153.

11. Vancampfort D, Probst M, De Hert M, et al. Neurobiological effects of physical exercise in schizophrenia: a systematic review. Disabil Rehabil 2014; 36(21):1749–1754.

12. Ikai S, Uchida H, Suzuki T, et al. Effects of yoga therapy on postural stability in patients with schizophrenia-spectrum disorders: a single-blind randomized controlled trial. J Psychiatr Res 2013; 47(11):1744–1750.

13. Akbaş E, Ünver B. A six-week pilates exercise protocol for improving physical and mental health-related parameters. MoHE 2018; 7(2):65–79.

14. Roh S, Gil HJ, Yoon S. Effects of 8 weeks of mat-based Pilates exercise on gait in chronic stroke patients. J Phys Ther Sci 2016; 28(9):2615–2619.

15. Akbas E, Erdem EU. Does Pilates-Based Approach Provide Additional Benefit over Traditional Physiotherapy in the Management of Rotator Cuff Tendinopathy? A Randomised Controlled Trial. Ann Sports Med Res 2016; 3(6):1083–1088.

16. Karaman A, Yuksel I, Kinikli GI, et al. Do Pilates-based exercises following total knee arthroplasty improve postural control and quality of life? Physiother Theory Pract 2017; 33(4):289–295.

17. Pata RW, Lord K, Lamb J. The effect of Pilates based exercise on mobility, postural stability, and balance in order to decrease fall risk in older adults. J Bodyw Mov Ther 2014; 18(3):361–367.

18. de Siqueira Rodrigues BG, Cader SA, Torres NVOB, et al. Pilates method in personal autonomy, static balance and quality of life of elderly females. J Bodyw Mov Ther 2010; 14(2):195–202.

19. McMillan A, Proteau L, Lèbe RM. The effect of Pilates-based training on dancers' dynamic posture. J Dance Med Sci 1998; 2(3):101–107.

20. English T, Howe K. The effect of pilates exercise on trunk and postural stability and throwing velocity in college baseball pitchers: single subject design. N Am J Sports Phys Ther 2007; 2(1):8

21. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition. Arlington, VA American Psychiatric Association: 2013.

22. Beebe LH, Smith K, Burk R, et al. Effect of a motivational intervention on exercise behavior in persons with schizophrenia spectrum disorders. Community Ment Health J 2011; 47(6):628–636.

23. Beebe LH, Tian L, Morris N, Goodwin A, Allen SS, Kuldau J. Effects of exercise on mental and physical health parameters of persons with schizophrenia. Issues Ment Health Nurs 2005; 26(6):661–676.

24. Bille K, Figueiras D, Schamasch P, et al. Sudden cardiac death in athletes: the Lausanne Recommendations. Eur J Cardiovasc Prev Rehabil 2006; 13(6):859–875.

25. Bavli O, Koybasi O. Investigation the effects of 6 weeks pilates exercises on biomotorical variables and self-esteem scores of young women. Turkish Journal of Sport and Exercise 2016; 18(1):127–131.

26. Pourvaghar MJ, Bahram ME, Sharif MR, Sayyah M. Effects of eight weeks of pilates exercise on general health condition of aged male adults. Int J Sport Stud 2014; 4(8):895–900.

27. Schmitz R, Arnold B. Intertester and intratester reliability of a dynamic balance protocol using the Biodex Stability System. J Sport Rehabil 1998; 7:95–101.

28. Bernard JA, Mittal VA. Cerebellar-motor dysfunction in schizophrenia and psychosis-risk: the importance of regional cerebellar analysis approaches. Front Psychiatry 2014; 5:1–14.

29. Marvel CL, Schwartz BL, Rosse RB. A quantitative measure of postural sway deficits in schizophrenia. Schizophr Res 2004; 68:363–372.

30. Cramer H, Lauche R, Klose P, et al. Yoga for schizophrenia: a systematic review and meta-analysis. BMC Psychiatry 2013; 13:32

31. Hjorth P, Davidsen AS, Kilian R, et al. A systematic review of controlled interventions to reduce overweight and obesity in people with schizophrenia. Acta Psychiatr Scand 2014; 130(4):279–289.

32. Papanastasiou E. Interventions for the metabolic syndrome in schizophrenia: a review. Ther Adv Endocrinol Metab 2012; 3(5):141–162.

33. Wells C, Kolt GS, Bialocerkowski A. Defining Pilates exercise: a systematic review. Complement Ther Med 2012; 20(4):253–262.

34. Yu JH, Lee GC. Effect of core stability training using pilates on lower extremity muscle strength and postural stability in healthy subjects. Isokinet Exerc Sci 2012; 20(2):141–146.