RESEARCH ARTICLE

The Assessment, Benefits and Delivery of Physical

Activity in People with Schizophrenia: A Survey of
Members of the International Organization of
Physical Therapists in Mental Health
Brendon Stubbs1*, Andy Soundy2, Michel Probst3,4, Marc De Hert3, Amber De Herdt3,4,
Anne Parker5 & Davy Vancampfort3,4
1
School of Health and Social Care, University of Greenwich, Southwood Site Avery Hill Road Eltham, London SE9 2UG, UK
2
School of Health and Population Sciences, College of Medicine and Dentistry, University of Birmingham, 52 Pritchatts Road, Birmingham
B15 2TT, UK
3
KU Leuven, Department of Neurosciences, University Psychiatric Centre, B-3070 Kortenberg, Belgium
4
Department of Rehabilitation Sciences, KU Leuven, Tervuursevest 101, B-3001 Leuven, Belgium
5
Physiotherapy Department, Royal Edinburgh Hospital, Morningside Terrace, Edinburgh EH10, UK

Abstract
Background. People with schizophrenia typically die over a decade before members of the general population.
Physical activity is a low cost and effective intervention that can have a multitude of beneficial effects on people with
schizophrenia. Physical therapists lead in the delivery of physical activity in many of the commonly observed co-
morbidities in schizophrenia, yet their role in the delivery of physical activity in patients with schizophrenia remains
unclear. Objective. This study aimed to establish an international consensus on physical therapists’ beliefs, potential
benefits and practices in the use of physical activity in schizophrenia. Method. All members of the International
Organization of Physical Therapists in Mental Health were invited to take part in a cross-sectional online survey.
All data were analysed using descriptive statistics and quantitative content and/or thematic analysis. Results. One
hundred and fifty-one physical therapists from 31 countries responded. Almost all respondents (92%) felt that
physical activity benefited patients with schizophrenia, and 75.2% and 22.5%, respectively, felt that it was very
important and important that physical therapists oversee in the delivery of physical activity in psychiatric services.
Resultant themes established that physical activity has a plethora of beneficial effects on people with schizophrenia
including physical health benefits and biopsychosocial effects such as improved mental health, socialization and
quality of life. In addition, participants felt they have the necessary theoretical knowledge and clinical skills required
for leading and overseeing physical activity programmes in this complex patient group. Conclusion. Physical ther-
apists identified that physical activity has a plethora of benefits for patients with schizophrenia and that they have
the necessary knowledge and skills to lead and oversee the successful delivery of physical activity in patients with
schizophrenia in clinical practice. Copyright © 2014 John Wiley & Sons, Ltd.

Received 28 October 2013; Revised 13 February 2014; Accepted 11 March 2014

Keywords
physical activity; physical health; schizophrenia; serious mental illness

*Correspondence
Brendon Stubbs, School of Health and Social Care, University of Greenwich, Southwood Site Avery Hill Road Eltham, London SE9 2UG, UK.
E-mail: b.stubbs@greenwich.ac.uk

Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1592

Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
Physiotherapy in Schizophrenia
Introduction
There is an alarming disparity in the physical health of
people with schizophrenia compared with members of
the general population (Hoang et al., 2013; Nielsen
et al., 2013). People with schizophrenia are at an ele-
vated risk of a range of physical health conditions
including cardiovascular disease (CVD), obesity, cancer,
metabolic syndrome and diabetes (Cimo et al., 2012;
Crump et al., 2013). Despite having twice as much con-
tact with health services than members of the general
population, it has been estimated that individuals with
schizophrenia often die between 11 and 15 years prema-
turely (Crump et al., 2013; Nielsen et al., 2013).
Physical activity is an effective, modifiable and
low risk intervention that can improve the health of
people with schizophrenia (Richardson et al., 2005;
Vancampfort et al., 2010). Physical activity is associated
with improved quality of life (Vancampfort et al.,
2011), psychological well-being (Holley et al., 2011)
and overall mental and physical health (Gorczynski
and Faulkner, 2010) in people with schizophrenia.
Despite this, it is apparent that very few people with
schizophrenia meet the recommended guidelines for
physical activity (Faulkner et al., 2006; Soundy et al.,
2013) and many are sedentary for prolonged periods
(Janney et al., 2013).
Physical therapists are in a unique position to pro-
vide personalized programmes of physical activity,
exercise and therapeutic movement while promoting
self-efficacy and well-being in psychiatric services
(Probst, 2012; Stubbs et al., 2014). Physical therapists
often lead physical activity prescription in clinical
populations (e.g. diabetes, Hansen et al., 2013, and
CVD, Eriksson et al., 2006) and could similarly lead
exercise prescription for individuals with schizophre-
nia. There have been calls to incorporate physical activ-
ity in psychiatric services for some time (Richardson
et al., 2005), yet little research has documented the
practice of physical therapists in physical activity pre-
scription in schizophrenia. Recent work has established
that physical therapists have a central role within
psychiatric services (Stubbs et al., 2014) and are well
placed to help individuals with schizophrenia over-
come central barriers to physical activity (Soundy
et al., 2014). However, the current practices of physical
therapists’ prescription and delivery of physical activity
are not well understood. Given this, the purpose of this
paper was to examine the beliefs and practices of an
B. Stubbs et al.
international group of specialist mental health physical
therapists.
Method
Participants
All members of the International Organization of Phys-
ical Therapists in Mental Health (IOPTMH) (n ≈ 480)
were invited to take part (eligible n ≈ unknown) and
were asked to forward the survey to other physical ther-
apy colleagues working with people with schizophre-
nia. Ethical approval was gained from the University
of Birmingham (Ref: ERN_13-0151). Participants were
informed that taking part in the survey was voluntary
and all responses were anonymous.
The questionnaire
The questions were developed with reference to the
literature (Vancampfort et al., 2010; Vancampfort
et al., 2012a). The questionnaire included both open-
ended and closed-ended questions and a section on
demographic information and physical therapists’
perceived value, assessment and prescription of physi-
cal activity in schizophrenia. A small pilot study was
conducted (n = 4) to assess face validity and ease of
use. A copy of the final questionnaire can be obtained
from the corresponding author. The survey was
conducted via a secure online survey tool (Qualtrics
available at http://www.qualtrics.com/).
Protocol
The survey was emailed to all members of the
IOPTMH in April 2013. A second email reminder
encouraging non-responders to complete the survey
was sent out after 2 weeks.
Data analysis
The quantitative data were analysed utilizing descriptive
statistics with SPSS (version 20) (IBM Corp., Armonk,
NY). The free text qualitative responses to questions were
analysed by two different methods. First, a quantitative
content analysis was undertaken (Pope and Mays, 2006)
for two questions regarding physical therapists’ current
use of outcome measures (question 1) and exercises
(question 2). Second, a thematic analysis was utilized to
analyse the free text responses of two questions (1. physical
Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
B. Stubbs et al. Physiotherapy in Schizophrenia

therapists’ views of the benefits of physical activity and 2. Table 1. Demographic, training, education and clinical
information of respondents
why physical therapists are equipped to lead in the delivery
of physical activity). Within this, the primary author be- Overall survey
came immersed in the data, coding all free text comments, respondents N (%)
and identified a thematic framework that was critiqued by
Number 151
a second author. The second author acted as a critical Age (years) 40 ± 11.2
friend and considered the emergent categories developed. Female 106 (70)
An audit trail is available from the corresponding author Continent
upon request. Indicative verbatim quotations were used Africa 4 (2.6)
Asia and Western Pacific 18 (11.9)
to illustrate the themes and subsequent categories, and
Europe 104 (68.9)
on each occasion, the physical therapists study number North America and Caribbean 24 (15.9)
(P), age, gender and country are also reported. South America 1 (0.7)
What clinical setting do you work in? π
Inpatient 111 (74)
Results Outpatient 69 (45)
Respondents Community 39 (26)
Years of mental health clinical experience 10.17 ± 9.0
One hundred and fifty-one physical therapists from 31 Received educational or clinical training for
different countries completed the survey. Most respon- treating people with mental illness at: π
dents were from Europe (68.9%; 104/151) and female University 75 (49.7)
Mental health placement 52 (34.4)
(70.0%; 106/151). The mean age of respondents was
Another placement 47 (31.1)
40 years (±11.2), and the average number of years of
Received training and/or education in: π
clinical experience in mental health was over 10 years Symptoms of schizophrenia 110 (72.8)
(±9.0). The physical therapists’ experiences of training Physical co-morbidities of schizophrenia 67 (44.4)
in mental health varied. Further details of the demo- Side effects of psychotropic medication 85 (56.2)
graphic, training and education experiences of the Would like further training in schizophrenia 119 (78.8)

physical therapists are summarized in Table 1.
Physical therapists’ views on the
importance of physical activity assessment
in schizophrenia
The overwhelming majority of respondents agreed that
physical activity helped people with schizophrenia
(92.1%; 117/127), and three quarters (75.2%; 97/129)
believed it was very important that physical therapists
lead in prescribing and the delivery of physical activity
for people with schizophrenia. Despite this, under
two-thirds (64.2%; 72/112) currently assessed the levels
of physical activity for people with schizophrenia, and
most were unaware of any guidelines to support the use
of physical activity in schizophrenia (69.7%; 83/119).
See Table 2 for a summary.
Physical therapists’ views on how physical
activity helps individuals with
schizophrenia
One hundred and four physical therapists (68.9%) pro-
vided a range of perceived benefits of physical activity
Key: π = participants were able to answer multiple choices to each
question, and some totals are higher than the total number of
respondents (n = 151).
to benefit patients with schizophrenia. Two themes
emerged from the thematic analysis: 1) the physical
benefits of physical activity and 2) the biopsychosocial
benefits of engaging in physical activity. The thematic
analysis is presented and summarized in Table 3.
Theme 1: the general physical health benefits
of physical activity
A large number of physical therapists (n = 64) pro-
vided details of the perceived physical health benefits
from physical activity. Two emergent categories were
apparent: first, the general physical health benefits of
physical activity and avoiding sedentary behaviour
and, second, the disease-specific benefits associated of
physical activity in schizophrenia.
A range of physical health benefits were reported
by physical therapists, this is highlighted by one who
reported that ‘Exercise not only promotes physical
fitness. but also … improves cardio respiratory

Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
Physiotherapy in Schizophrenia
Table 2. Participants use and value of physical activity for
schizophrenia
Do you think physical activity helps people with
schizophrenia? (n = 127)
Yes
Unsure
No
Do you assess the physical activity levels of individuals with
schizophrenia? (n = 112)
Yes
No
Are there any guidelines that you are aware of that support
the use of physical activity in schizophrenia? (n = 119)
Yes
No
How important is it that physiotherapists prescribe physical
activity for people with schizophrenia? (n = 129)
Very important
Important
Neutral
Not important
Definitely not important
function and mental fitness preventing physical disor-
ders that could develop from a sedentary lifestyle.’
(Participant 74, Female, 29 years old, Malta). Other
physical therapists were able to report how physical
activity was important for maintenance of the physical
health structures and physiology, such as weight
regulation and cardiovascular health, and how this is
inextricably linked to quality of life. In the second
category, a number of physical therapists (n = 33) made
comments about the specific benefits of physical
activity to prevent common adverse conditions in
schizophrenia, namely metabolic syndrome, diabetes
and weight gain.
Theme 2: the biopsychosocial benefits of
engaging in physical activity
Sixty-six physical therapists made comments within
this theme, and four resultant categories emerged
including the benefits of physical activity on mental
health, social integration and engagement, body
awareness and image and, finally, activities of daily
living and quality of life. See Table 3 for further
details.
In summary, a number of physical therapists
(n = 43) made specific comments about the mental
B. Stubbs et al.
health benefits of physical activity, with common ben-
efits including reduction in depression and anxiety
Overall
and improving self-esteem and even a distraction from
N (%) psychosis. For example, one remarked that physical
activity: ‘improves self-esteem, provides natural endor-
phin release so patient benefit from relief of depression,
117 (92.1) provides a distraction from psychosis’ (Participant 52,
10 (7.8) Female, 23 years old, UK). Another reported that
0 (0)
‘Physical activity plays an important role in the regula-
tion of endocrine/hormonal function which directly
72 (64.2)
affects mental health.’ (Participant 48, Female, 29 years
40 (35.7) old, Namibia).
A number of physical therapists stated that im-
proved social interactions and engagement with others
36 (30.3) was a common and welcomed consequence of group
83 (69.7)
physical activity in schizophrenia. For example, one
physical therapist reports that physical activity enables
97 (75.2) the patient to be
29 (22.5)
‘More relaxed, more safe, more real, not so
3 (2.3)
0 (0) hallucinated (hearing voices), they get a break
0 (0) from all their thoughts, their self-efficacy grows,
they get to meet other people in a set up without
a lot of talking.’ (Participant 89, Female, 39 years
old, Denmark).
Another physical therapist stated how the positive
effects of physical activity help achieve increased social-
ization: ‘I have personally seen how physical activity
can increase individuals’ energy level, attention to task,
focus, decrease anxiety, decrease weight, improve self-
esteem, and increase socialization’ (Participant 142,
Female, 29 years old, Antarctica).
A number of physical therapists (n = 13) reported
that physical activity helped with increasing mindful-
ness and being present. For example, one stated physi-
cal activity helps ‘the individual to be here and now’
(Participant 103, Female, 53 years old, Sweden).
Lastly, a number of physical therapists reported that
physical activity helped the patients maintain a good
quality of life and be effective in doing their activities
of daily living. One physical therapist remarked that
physical activity helps ‘improving quality of life,
offering healthy coping strategies’ (Participant 10,
Male, 31 years old, Belgium). Another directly linked
the physical benefits from being active to an individ-
ual’s ability to perform their ADL ‘it helps to maintain
the range of movement, balance by improving the
strength and maintain their daily living’ (Participant 79,
Male, 30 years old, Malaysia).
Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
B. Stubbs et al. Physiotherapy in Schizophrenia

Table 3. Themes of the perceived benefits of physical activity for patients with schizophrenia

Theme of benefits Category (n = number of

of physical activity participants commenting) Indicative quotation

1. Physical health benefits
of physical activity
2. Biopsychosocial benefits
of engaging in physical
activity
General lifestyle benefits of being
active (n = 47)
Disease-specific physical health benefits
(e.g. metabolic syndrome, cardiovascular
disease, diabetes and neurotransmitter
effects; n = 33)
Mental health benefits (n = 43)
Social/interaction and engagement
benefits (n = 29)
Body awareness/body image benefits
(n = 13)
Quality of life and activity of daily living
benefits (n = 13)
‘If physical activity is not undertaken by individuals with schizophrenia,
deconditioning in addition to side effects from psychotropic medication
can lead to significantly reduced physical health and ability. Increased
serotonin levels can improve sleep, diet, affect and also have a positive
effect on memory and learning. individuals with schizophrenia often have
poor hygiene, reduced diet and reduced levels of cognition. affect is also
dictated by disease progression and severity. Regular exercise can in turn
benefit these areas and maintain good physical health’ (Participant 4,
Female, UK)
‘Being physically active provides great health benefits for all people, also
for patients with Schizophrenia since it reduces inactivity, obesity, and
other factors that many patients striving. It can also give good mastery
experiences, participation in social relations, etc.’ (Participant 101,
Female, Norway)
‘Helps with physical health. Reducing weight gain, risk of
cardiometabolic problems, diabetes, also it is important for reducing the
risk of osteoporosis (increased risk due to antipsychotic medication) by
increased weight bearing and access to sunlight (vitamin D reducing
fracture risk)’ (Participant 151, Female, UK)
‘Many inpatients with schizophrenia put on masses of weight due to
psychotropic medication and excess eating. Physical activity is essential
to combat this and prevent cardiovascular disease and neuromuscular
deconditioning’ (Participant 35, Female, 39, USA)
‘Stabilization of chemical neurotransmitters that influence mood and
stress. Learn how to act with incentives like social pressure, connectivity’
(Participant 64, Male, Belgium)
‘Physical activity plays an important role in the regulation of endocrine/
hormonal function which directly affects mental health.’ (Participant 48,
Female, Namibia)
‘Anxiety management, above and beyond the usual benefits of exercise’
(Participant 139, Female, 57, USA)
‘(Physical activity) builds confidence/self esteem, can give meaningful
structure to their day and increases social opportunities. If they go on to join
a group, it can giver partner/ carer a break’ (Participant 68, Female, UK)
‘I have personally seen how physical activity can increase individuals’
energy level, attention to task, focus, decrease anxiety, decrease weight,
improve self-esteem, and increase socialization’ (Participant 142,
Female, 29, Antarctica)
‘(physical activity helps) The body helps the individual to be here and
now (if not doing mechanical disembodied movements, of course). It is
a good way to start experiencing the self as a context and not the content
(ones thoughts, emotions, sensations).’ (Participant 103,
physiotherapist, Sweden)
‘Improving quality of life, offering healthy coping strategies’ (Participant
10, Male, Belgium)
‘It helps to maintain the range of movement, balance by improving the
strength and maintain their daily living’ (Participant 79, Male, Malaysia)

What outcome measures do physical
therapists use to assess physical activity?
Sixty-one (40.3%) physical therapists provided infor-
mation about the current types of outcome measures
they use to determine physical activity levels. A wide
range of outcome measures were used, but the most
common consisted of subjective assessment/questions
of a patient’s current level of physical activity (but not
a validated outcome measure; n = 19, 31.4%), 6-minute

Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
Physiotherapy in Schizophrenia
walk test (6MWT, 26.2%; n = 19), mobility or balance
assessments such as the Berg balance scale or the
Barthel Index (18.0%, n = 11), physiological measures
such as heart rate or VO2 max (9.8%, n = 6), body
awareness scales (4.9%, n = 3) or a range of other mea-
sures (e.g. shuttle walk and bicycle tests, 21.3%,
n = 13). Only six physical therapists (9.8%) utilized a
valid instrument to measure physical activity including
the International Physical Activity Questionnaire.
What types of physical activity do you
prescribe?
One hundred and six physical therapists (70.2%) pro-
vided details of the types and/or frequency and inten-
sity of exercise that they prescribed. The most
common activity recommended was walking (34%,
n = 36), and many advocated that this should be en-
couraged in all patients with schizophrenia stipulating
that a 30-minute walk five times a week is beneficial.
A number of other aerobic exercises were also advo-
cated including general cardiovascular exercises (31%,
n = 33) with circuit training, running, cycling and aero-
bics commonly being reported. Twenty-two physical
therapists (20.7%) recommended team sports such as
soccer, basketball and racket sports, whereas 20
(18.8%) also developed specific exercises for patients
to complete using weights in a gymnasium. In addition,
31 (29.2%) physical therapists encouraged mind–body
interventions such as body awareness therapy, relaxa-
tion classes, tai chi and yoga.
Why is it important that physical
therapists prescribe exercise to people
with schizophrenia?
Thirty-four physical therapists provided a range of rea-
sons why physical therapists should lead and oversee
the delivery of physical activity in people with schizo-
phrenia, and two themes emerged from the data. These
are summarized in Table 4 and will briefly be explored.
Theme 1: physical therapists have specialist
knowledge and training
Participants commonly reported that physical thera-
pists had a diverse range of specialist knowledge re-
quired to be optimally placed to develop and deliver
physical activity programs in patients with schizophre-
nia. This is summed up well by one participant:
B. Stubbs et al.
‘Physio’s are physical health specialists, whilst most
others are mental health specialists and do not un-
derstand the physical nature of schizophrenia.
Therefore, we have to take a lead as it is not safe
for all patients to jump in at the deep end, often
we have to develop graded exercise programmes.’
(Participant 1, Male, 32 years old, UK).
Others stated that it is important to utilize their special-
ist knowledge to adapt the physical activities to the
individual ‘Physiotherapists are the experts in move-
ment and are medically based, so they are familiar with
any co-morbidities with the schizophrenic patient and
how to modify activities.’ (Participant 135, Female,
50 years old, USA).
Theme 2: patients with schizophrenia are a
complex group
A number of participants (n = 22) stated that
physical therapists should lead on the prescription of
physical activity in patients with schizophrenia because
they represent a complex group at risk of a range of
multi-morbidities. This is exemplified by one partici-
pant who remarked
‘This is a complex group, you wouldn’t go and take
a non-mental health patient group that were
overweight, diabetics, at risk of a heart attack and
let them start exercising without an assessment.’
(Participant 111, Female, 38 years old, Republic
of Ireland).
Discussion
Our findings demonstrate that physical therapists
recognize that physical activity can have a range of
beneficial effects on the physical and mental health
of people with schizophrenia in addition to improve-
ments in quality of life. Physical therapists also
identified that a ‘one size fits all’ approach to prescrib-
ing physical activity in this patient group is not
recommended because of the complex interactions
between intrapersonal, interpersonal and environ-
mental and policy-related barriers. Three quarters of
the respondents felt that it was very important that
physical therapists oversee the prescription of physical
activity in psychiatric services. Reasons for this
included the fact that physical therapists have the
specialist training and knowledge and have a great
Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
B. Stubbs et al. Physiotherapy in Schizophrenia

Table 4. Themes why physiotherapists should prescribe physical activity in schizophrenia

Theme (n = number of physiotherapists

commenting on the theme) Indicative quotation

1. Physiotherapists have specialist
knowledge and training (n = 26)
2. Patients with schizophrenia
are a complex group (n = 22)
‘PTs are most likely to have a clinical understanding of all the person’s diagnoses as they relate to exercise.’
(Participant 139, Female, 57, USA)
‘Physiotherapists are the experts in movement and are medically based, so they are familiar with any
co-morbidities the schizophrenic patient may have and how to modify activities.’ (Participant 135,
Female, 50, USA)
‘Physio’s are physical health specialists working in mental health teams, whilst most other members are
mental health specialists through training and do not understand the physical nature of schizophrenia.
Therefore, we have to take a lead as it is not safe for all patients to jump in at the deep end, often we have
to develop graded exercise programmes the same way you would within a cardiac rehabilitation
programme for instance.’ (Participant 1, Male 32, UK)
‘Physiotherapists are in the best position to prescribe physical activity. It is important the they have a full
understanding of the condition and the physical and mental connections. Also to be in a position to
understand resistance, non compliance and he presenting features demonstrated by the patient. It is very
important for physical activity to be prescribed so that quality of life can be improved. patients
demonstrate poor self care and knowledge of physical and mental health benefits of activity. The
physiotherapist can develop a positive therapeutic relationship with the patient and encourage
motivation.’ (Participant 129, Female, 49, UK)
‘As we are trained to look and understand all areas of the body and use this knowledge to treat the whole
person’ (Participant 149, Female, UK)
‘physiotherapists are physical health experts in the clinical team, we have an awareness of the physical
needs of the population.’ (Participant 91, Male, 37, UK)
‘Physio should lead with developing exercise as most other professionals in Mdt (multidisciplinary team)
are mental health specialists not well versed in physical health’ (Participant 46, Female, 48, UK)
‘The prescription of exercise is much more complex than in the general population due to the high
comorbidity and risk of mortality e.g. cardiometabolic manifestations of the illness including obesity.
Physio’s lead in exercise prescription in CVD, diabetes, arthritis etc so we should also lead in this condition
where the typical physical presentation is very complex. Physio’s are experts in physical health and ideally
placed to lead in safe prescription of exercise in this group therefore.’ (Participant 151, Female, 39, UK)
‘This is a complex group, you wouldn’t go and take a non mental health patient group that were
overweight, diabetics, at risk of diabetes and let them start exercising without an assessment. Due to
complex presentation, we should lead’ (Participant 111, Female, 38, Republic of Ireland)
‘People with schizophrenia have suboptimal physical health, more likely to have CVD, diabetes mellitus,
metabolic syndrome. The prescription of exercise is not straight forward and physios should lead with this’
(Participant 109, Female, 39, UK)
‘With an increased risk of metabolic syndrome, CHD, diabetes, osteoporosis,, respiratory conditions,
deconditioning - we can lead on the assessment and intervention. Exercise prescription is not straight
forward in this population to develop a blanket rule’ (Participant 91, Male, 37, UK)
‘Many patients are grossly overweight, reduced respiratory and cardiovascular health ….With our
expansive knowledge we have to take the lead in particular when patients are very overweight.’ (Participant 1,
Male, 32, UK)

understanding in the barriers encountered by this Clinical implications

population (Soundy et al., 2014). Our findings
suggest that physical therapists have the theoretical
knowledge and clinical experience to oversee and lead
in the delivery of physical activity programmes in
psychiatric services. However, it is surprising that
most (64.2%) physical therapists do not currently
assess the levels of physical activity in patients they
work with and that over two-thirds (69.7%) are
unaware of any guidelines that support the use of
physical activity in schizophrenia.
Physical therapists have an important role in the
multidisciplinary treatment of patients with schizo-
phrenia (Vancampfort et al., 2012a, 2012b). Physical
therapists in the present study reported that physical
activity represents a valuable intervention that has a
range of benefits for people with schizophrenia.
Although it is the task of all members of the
multidisciplinary team (MDT) to promote healthier
lifestyle choices, including the promotion of physical

Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
Physiotherapy in Schizophrenia
activity, physical therapists are ideally placed to oversee
the successful implementation of this in clinical prac-
tice (Stubbs et al., 2014). Physical therapists should ad-
vise other members of the MDT on the frequency,
types and intensity of physical activity that is suitable
for people with schizophrenia on an individual level.
The commencement and continuation of a physically
active lifestyle is complex in people with schizophrenia,
and careful support for an individual’s motivation and
self-efficacy is known to be important (Vancampfort et
al 2013, Soundy et al., 2014). The IOPTMH recently
published physical activity guidelines for patients with
schizophrenia (Vancampfort et al., 2012a). However,
more than two-thirds of the physical therapists in the
current study were not aware of these guidelines. Dis-
semination of the current physical activity guidelines
for patients with schizophrenia therefore is needed,
and IOPTMH is committed to working with the na-
tional organizations to help ensure this happens.
Strengths of this study include the large number of
countries represented (31 in total), the plethora of clin-
ical experience by respondents (mean 10 years) and the
fact that all respondents were specialists in mental
health. There are however a number of limitations to
our study. First, it is not possible to establish an exact
response rate because the survey was sent to a large
number of IOPTMH members (≈480), and the exact
number of those who are working with people with
schizophrenia and were eligible to take part is not
known. In addition, IOPTMH members were encour-
aged to pass the survey on to colleagues working with
people with schizophrenia, yet we have no way to es-
tablish if any did so or if any of the respondents were
recruited this way. This means that there is likely to
be a high social desirability bias in the respondents to
our survey, with members who were not working with
patient with schizophrenia much less likely to respond
to our survey. In addition, the survey was only sent out
in English, and it is possible that a number of non-
English-speaking members of the IOPTMH may not
have been able to respond to our survey. However, in
an attempt to negate this, we offered help with
translation in other languages known to the research
team (Dutch, French, German and Spanish).
Future research
Future research is urgently required to establish the
value and efficacy of physical therapy delivered
B. Stubbs et al.
interventions on the health and well-being of people
with schizophrenia, and this should be delivered
through randomised controlled trials. This would help
consolidate the evidence base and necessity of physical
therapy in psychiatric services. Particular physical ther-
apy interventions may choose to focus on the use of
cognitive–behavioural and motivational interviewing
techniques, which have been demonstrated to be effec-
tive in individuals with high risk of CVD (Hardcastle
et al., 2013). Further research should also explore the
effects of physical activity on mental health, physical
health and quality of life when the current evidence-
based physical activity guidelines (Vancampfort et al.,
2012a) are adopted in state and local government
departments. This work should consider the benefits
of such interventions on weight reduction and the risk
of cardiometabolic risk factors and also on quality of
life and mental health measures.
Conclusion
This international survey of specialist mental health
physical therapists established that physical therapists
are ideally placed to lead and oversee in the delivery
of physical activity for people with schizophrenia.
Respondents stated that physical activity can have a
range of benefits for people with schizophrenia and
physical therapists have the necessary skills to ensure
the successful implementation of physical activity in
people with schizophrenia.
Conflict of interest
One of the authors is the president of the IOPTMH.
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