Participants
Admitted to the Department of Psychiatry of The Meram Medical Faculty Hospital at Necmettin Erbakan University between February and May 2022, the volunteer patients to participate in regular group exercise programs were determined as participants in the study. Informed consent was obtained from the patients and their relatives. Patients with acute suicide and orthopedic problems preventing exercise and those with challenges posing a threat during the use of exercise materials were not included in the study. Forty-six patients (24 females and 22 males) were included in the study. The patients were divided into two groups: the exercise and control groups by simple randomization method using a computer program. The patients participating in the study but not continuing the treatment process or not taking part in the final evaluation were excluded from the study, and so the study was completed with 30 patients (exercise group, n=15 and control group, n=15).
Ethical Approval
The present study was approved by the Ethics Committee of Necmettin Erbakan University for Scientific Researches of Health Sciences with the decision date and number of 02.02.2022 and 2022/19-135.
Assessment Tools
Height, weight, age, marital status, educational level, smoking and/or alcohol use, psychiatric diagnosis, year of psychiatric diagnosis, and family history of psychiatric disorders were recorded.
The Symptom Check List-90-Revised (SCL-90-R), whose validity and reliability of the Turkish version was also performed, was used to scan the psychological symptoms and psychopathological features of the patients10. SCL-90-R is a multidimensional scale with a total of 90 questions and 10 subscales. The subscales consist of somatization (12 items), obsessive-compulsive symptoms (10 items), interpersonal sensitivity (nine items), depression (13 items), anxiety (10 items), anger-hostility (six items), phobic anxiety (seven items), paranoid thought (six items), psychoticism (10 items), and additional scale mostly questioning sleep and eating disorders10. The items are scored from 0 to 4, and the scores demonstrate: 0, none; 1, mild; 2, moderate, 3 above average; 4, severe. In our study, the distribution of symptoms was evaluated by subscale scores11.
The strength measurements of the quadriceps femoris and the anterior part of the deltoid muscles were measured as right and left sides using a hand-held dynamometer. Three measurements were performed in the strength evaluation of each muscle, 60-second intervals were left between each measurement, and the average value of the measurements was recorded. The strength measurements of the same muscles were conducted by the same physiotherapist.
For the strength measurement of the quadriceps, the test was commenced while the participants were in a sitting position on a flat surface with their hips and knees flexed at 90º, and the feet free without support. Before commencing the test, the participants were orally informed about the administration technique of the test, and the dynamometer was placed perpendicular to the leg so that it was 1-2 cm above the level of the malleolus. During the test, the physiotherapist performing the measurements kept the dynamometer steady, and the respondent being tested applied maximum force against the device; therefore, the respondent was also asked to keep the position for five seconds.
The strength measurements of the deltoid muscles were measured with a muscle dynamometer while the anterior part of the deltoideus of the participants was in the sitting position with the arm flexed to 90º. During the measurements, the participant was asked to keep the position for five seconds.
The measurements of chest circumference were carried out with a tape measure at maximum inspiration and maximum expiration from axillary (at the level of the 4th rib), epigastric (at the level of the xiphoid process), and subcostal (at the level of the 11th and 12th ribs) to evaluate the chest mobility and respiratory type by making the patient stand up.
To measure the dynamic balance of the patients, the Functional Reach Test was used, and the Romberg Test was used to evaluate the static balance. The 30-sec Sitting and Standing Test was used to measure lower extremity endurance. In all patients included in the study, the final evaluations were performed 14 days after the initial evaluation
Treatment Methods
While the exercise protocol was performed along with the medical treatment for the psychiatric patients in the exercise group, only the medical treatment was administered to the control group. Divided into three stages, the exercise treatment was performed seven days a week for two weeks, a total of 14 sessions, as group exercises. While the first stage consisted of warm-up, stretching, and respiratory exercises, the second stage included strengthening, balance, and stretching exercises; even so, the exercise program was completed with cool-down exercises in the third stage (Table 1).
The group exercises were performed under the management of a physiotherapist in a quiet and bright exercise room in the psychiatry department so that each patient could be followed up properly. Each patient performed the exercises for an average of 25 minutes, following the instructions on the mat and chair12. For strengthening exercises, the mild- or moderate-resistance band exercises were used according to the patient's muscle strength.
Warm-up/Cool-down Exercises
The warm-up/cool-down exercises are completed with respiratory exercises after the stretching exercises maintained for 30 seconds in each position covering the neck, shoulders, and upper thoracic region. Respiratory exercises were performed while the patient was standing, with one hand on the chest and the other on the abdomen by performing the diaphragm and chest breathing; this procedure lasted an average of five minutes.
Strengthening, Balance, and Stretching Exercises
During the strengthening, balance, and stretching exercises, the patient performed 10 repetitions of resistant shoulder flexion with the elastic band fixed by pressing on the mat with the foot. The patient also performed 10 repetitions of resistance knee extension in the sitting position with the band fixed to the chair leg. Bringing the scapulae closer together at 90° flexion of the shoulders, stepping in situ with posterior pelvic tilt exercise, bilateral trunk lateral flexion, and rotation were performed 10 times while standing. Stretching exercises were carried out by the patient by holding the endpoint for 30 seconds once on the mat, and this phase lasted an average of 15 minutes.
Statistical Analysis
Data recording and all statistical analyses were performed with the Statistical Package for the Social Sciences for Windows, version 20.0 software (SPSS, IBM Corp., Armonk, NY, USA). The Kolmogorov-Smirnov test was used to determine whether the data were appropriate for normal distribution. Descriptive data were expressed as mean, standard deviation (SD), frequency, and minimum and maximum values. Between the groups, discontinuous data, such as age, gender, psychiatric diagnosis, and year of diagnosis were evaluated with a cross table (the chi-square). Since the data were normally distributed, while inter-group analyses were performed with the independent t-test, intra-group analyses were conducted through the paired t-test. The mixed ANOVA analysis was used to examine the effects of exercises on the changes the patients indicated in physical and psychometric data over time. A p-value of <0.05 was accepted as statistically significant.