Manalo, Anne Marielle D.

February 22, 2016

3NUR6 RLE 6.1 Ma'am Madrazo

Title of the Article: The effects of aerobic exercise on cognition in schizophrenia: A 3-month follow-up study

Authors: Chwen-Yng Su, Peng-Wei Wang, Yi-Jean Lin, Tze-Chun Tang, Mei-Fang Lui, Ming-De Chen

APA format of Bibliography:

Chen, M., Lin, Y., Lui, M., Su, C., Tang, T., Wang, P. (2016). The effects of aerobic
exercise on cognition in schizophrenia: A 3-month follow-up study. Psychiatry
Research. 244, 394-402.

Source of the Article: Science Direct

Key terms used for the Search: Exercise, Neurocognition, Schizophrenia, Aerobic fitness

Guide Questions

1. What is the significance of the research article you have chosen in your Related Learning Experience?
Cognitive dysfunction is a cardinal feature of schizophrenia that primarily affects verbal learning
and memory, attention, processing speed, and executive function. Patients with schizophrenia have
profound and disabling cognitive deficits that impair daily functioning, independent living, quality of life and
contribute most to chronic disability. A number of studies since the early 1990s have found that cognitive
deficits are the best predictor of functional status across a number of outcome domains and patient
characteristics. Thus, the need to treat these impairments has become a priority for the medical field. As
student nurse, it is our duty to help those mentally ill patients to improve their health. We should identify and
answer their needs and help them cope with the changes in their physical and mental abilities, so they can
be independent and active as soon as possible. I must understand how to handle these kind of patient
carefully and extensively. Through this research article, we would be able to gain knowledge about new
interventions on improving the cognition of schizophrenic patients. Since cognitive dysfunction may affect
the functional status of our patients, knowing a new intervention that may treat it would be very useful to
improve patient outcomes. As said in the results, this study provides initial evidence that aerobic exercise
may contribute to improved performance in certain cognitive domains 3 months after the end of intervention
and appear to be a promising addition to the routine treatment of schizophrenia. As a student nurse,
knowing this would enhance my knowledge and help extend my service to improve the mental health of my
patients.

2. What are the implications of the findings in your to patient care?

Cognitive deficits are now considered a central feature of schizophrenia. Major cognitive deficits
include impaired attention, working memory dysfunction particularly verbal working memory, difficulties
producing speech on demand, poor learning and retention of verbal information and impaired executive
functions. As nurses, we should be able to help treat occurring symptoms and prevent further problems
among our patients. As one of the health care team, we should be able to contribute in finding ways on how
to treat and improve the health outcomes of our patients. We should be able to enhance our knowledge and
be able to participate in research studies and development of health treatments for patients. It is our
responsibility to assess our patients needs and to discover ways on how to treat existing problems or on
how to prevent possible complications. In the study, it was said that Aerobic exercise is effective in improving
cognitive domains in schizophrenic patients. Aerobic fitness was significantly correlated with performance in
several cognitive domains including reasoning and problem solving, processing speed, and working
memory, providing evidence of its benefits. Though further studies on longer intervention and follow up are
still needed, it is a good start and a useful study in developing a new treatment for schizophrenic patients to
improve health outcomes.

. For instance, AE has been shown to promote angiogenesis, neurogenesis and synaptogenesis as well as
increase the levels of brain derived neurotrophic factors (BDNF) and neurotransmitters important for
cognitive enhancement in humans. Also the change in hippocampal volume was strongly correlated with
aerobic fitness and moderately correlated with short-term memory.

3. What intervention/ innovation was used or implemented in the study reviewed?

The participants of both groups were scheduled to meet with a trainer at least three times per week
for three months in their respective facilities, with the goal of attending 45 times per week. The aerobic
exercise intervention was individually tailored for each participant as exercise prescriptions are based on
each individual's age-adjusted maximum heart rate (HRmax; 220-age). Each participant received one-to-one
supervision throughout the training sessions to enhance fidelity with target training intensity. Considering the
high prevalence of sedentary lifestyle among these patients, exercise duration and intensity was gradually
increased during the first 46 weeks until participants were exercising at a moderate intensity, equivalent to
5569% of their HRmax, in the 1316 (somewhat hard to hard) RPE zone. This target intensity was then
maintained for the remainder of the 3-month intervention period.
Each Aerobic Exercise session involved a warm-up by walking for 5 min on a treadmill, followed by
30 min of exercise, and finally ended with a 5-minute cool-down, lasting altogether 40 min. Fidelity with the
in-session training intensity was monitored every 5 min using Polar HR monitors and RPE during each
session. Blood pressure (BP) readings were taken before and after exercise. On the occasion where
participant's HR was lower than the individually targeted training zone, the trainer verbally encouraged the
participant to achieve his/her target goal.
The stretching and toning control program consisted of a 30-min videotaped program of 14 exercise
routines, including a 3-min warm-up, 25 min of flexibility, toning and balance exercises designed to use all
major muscle groups of the upper and lower extremities, and 2 min of cool-down exercise done to music.
Each stretch was held for approximately 10 seconds and repeated 10 times. All sessions were conducted
individually, in the presence of the trainer who provided guidance and support. Participants were
encouraged to exercise at their own pace. They received the same social interactions as those in AE group.
The trainer was blinded to the results of all assessments.

4. Does the intervention support/contradict current nursing practice? Support your answer using other
relevant references.

Pertinent to the researches that I have gathered and obtained from respected research journals,
the intervention supports the current nursing practice. According to Firth, Rosenbaum, Stubbs et al., a
number of recent meta-analyses have shown that physical activity, and particularly structured exercise, can
significantly improve positive symptoms, negative symptoms, and social functioning in this schizophrenic
patients. Furthermore, by increasing cardiorespiratory fitness and metabolic health, exercise may also
reduce the physical health problems associated with schizophrenia, such as obesity and diabetes, which
contribute towards reduced life expectancy. Firth also claims in their study that taking part in regular exercise
would help people with psychosis and schizophrenia to concentrate more, hold more information in mind,
and think more clearly about social situations, all of which would improve their ability to function in the real
world and recover from their condition.

According to Kandola, Hendrikse, Lucassen and Yusel, the beneficial impact that Aerobic Exercies
has on the brain may have a useful clinical application in treating disorders in which hippocampal damage is
a significant factor that underlies its symptomatology. There is currently a particular need to develop effective
strategies that alleviate cognitive dysfunction and targeting deficits in the neuroplasticity of crucial areas to
cognition like the hippocampus, is a promising approach to remediating cognitive dysfunction. Aerobic
Exericse interventions represent an effective method of promoting hippocampal neuroplasticity and function
that encompasses few risks and several additional benefits to the patient, such as combating
pharmacologically induced side effects.

In the general population, exercise has been shown to have modest effects on attention,
processing speed, memory, and executive functioning, perhaps through stimulating neuroplasticity. Exercise
has also been found to increase hippocampal volume and white matter integrity in healthy older adults and
those with schizophrenia. Additionally, cross-sectional research in people with schizophrenia has
demonstrated that physical activity and fitness are associated with better cognitive performance, greater
grey and white matter volumes, and higher levels of neurotrophic factors which promote brain plasticity. A
number of narrative reviews have also discussed the potential benefits of exercise on brain health and
cognition.

References:

Firth, J., Rosenbaum, S., Stubbs, B., Vancampfort, D., et al. (2016). Aerobic Exercise
Improves Cognitive Functioning in People With Schizophrenia: A Systematic Review
and Meta-Analysis. Schizophrenia Bulletin.. 1(1), 1-11.

Hendrikse, J., Kandola, A., Lucassen, P., Yucel, M. (2016). Aerobic Exercise as a Tool to
Improve Hippocampal Plasticity and Function in Humans: Practical Implications for
Mental Health Treatment. Frontiers in Human Neuroscience. 10(373), 1-25.

5. Would this practice change/improve process of patient care? Patient outcomes?

This practice would improve process of patient care in sense that it would help the medical team in
improving the cognitive function of schizophrenic patients. Since, taking care of schizophrenic patients
involves more extensive care, being able to know a new intervention that would treat symptoms of these
patients would improve health care. AE has been shown to stimulate hippocampal neuroplasticity and
successfully counteract deteriorating hippocampal function. It is plausible that AE interventions could be
used to counteract hippocampal harm caused by disorders that profoundly impact upon hippocampal
functioning, and through this approach, aid in the alleviation of certain aspects of cognitive dysfunction. n
recent years, AE has started to attract attention as a therapeutic target for schizophrenia treatment, but only
a handful of studies have systematically investigated the capacity for an AE intervention to remediate
cognitive deficits associated with the disorder. Cross-sectional (Kimhy et al., 2014) and interventional studies
(Pajonk et al., 2010; Oertel-Knchel et al., 2014;Kimhy et al., 2015; McEwen et al., 2015) have
demonstrated that AE can promote cognitive functioning in patients with schizophrenia across a range of
cognitive domains including speed of processing, short-term and working memory and visual learning.
Although one review was unable to find an association between AE and a reduction of cognitive symptoms
in patients with schizophrenia (Dauwan et al., 2016) these early results are largely promising.
The capacity for Aerobic exercises to induce neuroplastic changes that improve both hippocampal
integrity and promote hippocampus dependent cognition may be of particularly clinical importance for two
reasons. Firstly, a number of psychiatric and neurological disorders seem to have a particularly potent
influence on hippocampal structure and its deterioration may underlie certain aspects of their
symptomatology. Secondly, psychiatric symptoms can be dichotomously described as being either affective
or cognitive in nature, yet a disproportionate amount of the current literature has exclusively focussed on
ameliorating affective symptoms (Millan et al., 2012). Comparatively little attention has been afforded to the
potential application of AE in treating psychiatric disorders that have a similarly deleterious impact on the
hippocampus and are associated with severe cognitive deficits. For these reasons, it is really good to be
able to have this kind of study. By having this research study, us in the medical field will gain more
knowledge and we will be able to apply it to our patients so that they could produce better outcomes and we
could improve the quality of their lives. It increases the possibility for schizophrenic patients to return to their
functional cognitive abilities and be able to perform activities well.
6. Based on your knowledge and background of statistics:
a. What is level of measurement of the outcome variable?
Interval/ratio

b. What is the aim of the study?

The aims of this study were to evaluate change in cognitive performance associated with exercise
immediately after the intervention and 3 months later in schizophrenia patients and examine the relationship
between aerobic fitness and cognitive performance.

c. What are the variables of the study?

Independent variable: Aerobic Excercise
Dependent variable: Effects on the cognition of schizophrenic patients

d. What statistical treatment was used?

Independent Sample T-test
X2 Test
ANCOVA
ANOVA
Bonferroni-corrected pairwise comparisons
Cohen's D
Pearson's correlations
e. What are the assumptions before using the identified statistical test?

The Independent Samples t Test compares the means of two independent groups in order to
determine whether there is statistical evidence that the associated population means are significantly
different. It was used to compare baseline demographic, clinical, neurocognitive, and physical variables.
Repeated measure ANOVA is used in studies that investigate either (1) changes in mean scores over three
or more time points, or (2) differences in mean scores under three or more different conditions. A repeated
measures analysis of variance (ANOVA) was carried out for each group to assess differences in cognition
and aerobic fitness over time. Analysis of covariance (ANCOVA) is used to test the main and interaction
effects of categorical variables on a continuous dependent variable, controlling for the effects of selected
other continuous variables, which co-vary with the dependent. To examine the immediate and maintenance
effects of AE, analysis of covariance (ANCOVA) regression (Vickers and Altman, 2001) using the outcome
measure as a dependent variable was conducted separately for posttest and follow-up. Relevant covariates
included baseline scores, a variable for intervention group, and between-group differences on demographic
or clinical variables. The Bonferrini test allows many comparison statements to be made (or confidence
intervals to be constructed) while still assuring an overall confidence coefficient is maintained. There is an
adjustment made to P values when several dependent or independent statistical tests are being performed
simultaneously on a single data set. In the study it was used for post-hoc analyses of the main effect of time.
Cohen's D is an effect size used to indicate the standardised difference between two means. It can be used
to accompany reporting of t-test and ANOVA results. It is also widely used in meta-analysis. It was used to
calculate within-group effect sizes on outcome measures comparing baseline scores to those at posttest and
follow-up. Pearson's correlations is used as a measure of the strength of the linear relationship between two
variables. In the study it wa used to analyze the relationship between VO2max and changes in cognitive
performance for each group.
f. Is it appropriate? Justify your answer. (Support justification using statistical references or use the following
table)
The statistical treatments that were used and analyzed justified the results by means of test for
comparison. The groups were similar at baseline in all studied variables except working memory (Table 1
and Table 2). On this measure, the AE group scored significantly higher than the control group. At follow-up,
the controls reported more severe scores on the PANSS negative syndrome scale than the AE group. This
score was included as one of the covariates in the ANCOVA analysis in which the follow-up measurement
was the outcome variable. Relevant covariates included baseline scores, a variable for intervention group,
and between-group differences on demographic or clinical variables. An advantage of including the pretest
measure as a covariate in the model is to control for the baseline imbalance because of regression to the
mean. The estimated coefficient for group, which corrects for baseline variation, represents the
intervention effects over two time periods. Continuous variables were analyzed using independent samples
t-test, while 2 test was used for categorical variables. Analysis of covariance regression with coefficient
for the group variable and p values was also presented. Significant difference between the AE and control
groups at baseline (p<0.05). Between-group results for all study outcomes from baseline to 6 months are
summarized in Table 2. The pre- to post-test improvements in processing speed and attention were
significantly greater for the AE group than for controls, with no significant difference between groups on
other cognitive domains. Comparison of changes in cognitive performance from baseline to follow-up also
showed no significant differences between the groups. Likewise, no between-group differences were
detected in terms of the observed changes in VO2max as measured at either posttest or follow-up.

Through repeated measures analysis of variance (ANOVA) it was reveealed that visual inspection
of performance data for the AE group showed a slight upward trend at the end of the active phase in all
neuropsychological domain scores; for some variables, the gains made during the active phase were further
enhanced during the follow-up period. Specifically, significant differences in means over time were noted
with respect to processing speed (F2,42=7.02, p=0.002), attention (F2,42=6.40, p=0.004), and verbal
learning (F2,42=10.85, p<0.0001). The pair-wise comparison revealed that processing speed scores at
posttest and follow-up were greater than those at pretest (p=0.005, 95% CI=3.73 to 0.60; p=0.009, 95%
CI=5.39 to 0.68, respectively). For attention domain, scores at follow-up were higher than at pretest
(p=0.006, 95% CI=8.90 to 1.37). There was a significant linear increase in verbal learning from posttest
to follow-up (p=0.009, 95% CI=9.40 to 1.20) after treatment ended, and that scores at follow-up were
also greater than at pretest (p=0.001, 95% CI=14.83 to 3.65). It was the only outcome measure in the
AE group that had an average increase of more than 20% (25.6%) in scores from pretest to follow-up.

7. Identify a nursing theory related to the article findings and discuss/describe how the findings
support/contradicts your identified nursing theory.
The nursing theory which I believe supports the findings of the research article is Betty Neumans
Health Systems Model. Since, it states that nursing is concerned with all the variables affecting an
individuals response to stressors. It aims to provide optimal state of wellness at a given time or stable lines
of defense. Health and wellness exist if all parts and subparts are in harmony with the whole person. In
order to achieve this, the theory presented the levels of prevention: primary, secondary, and tertiary. In the
study, cognitive dysfunction is said to be a cardinal feature in schizophrenic patients. In order to find
treatment to this, the use of aerobic excercise was developed by health professionals. It may be considered
as secondary level of prevention which occurs after the system reacts to a stressor or existing symptoms
and involves early case-finding and treatment of symptoms, strengthening internal lines of defense. Aerobic
excercises was effective in improving the cognitive functions of schizophrenic patients. It can significantly
improve positive symptoms, negative symptoms, and social functioning in this schizophrenic patients.
Furthermore, by increasing cardiorespiratory fitness and metabolic health, exercise may also reduce the
physical health problems associated with schizophrenia, such as obesity and diabetes, which contribute
towards reduced life expectancy. Thus, it helps improve the condition of the patient which if implemented
further may lead to optimal state of wellness.