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Cochrane Database of Systematic Reviews

Joga, w porównaniu z niestandardowymi metodami leczenia u chorych na schizofrenię

Información

DOI:
https://doi.org/10.1002/14651858.CD012052.pub2Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 28 septiembre 2017see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:
  1. Grupo Cochrane de Esquizofrenia

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Autores

  • Julie Broderick

    Correspondencia a: Discipline of Physiotherapy, Trinity Centre for Health Sciences, Dublin, Ireland

    [email protected]

    [email protected]

  • Niall Crumlish

    Department of Psychiatry, St. James Hospital, Dublin, Ireland

  • Alice Waugh

    Department of Physiotherapy, St James Hospital, Dublin, Ireland

  • Davy Vancampfort

    Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium

Contributions of authors

Julie Broderick: writing the protocol and writing the review.
Niall Crumlish: development of the protocol and contributing to writing the review.
Alice Waugh: development of the protocol and contributing to writing the review.
Davy Vancampfort: development of the protocol contributing to writing the review.

Sources of support

Internal sources

  • Trinity Centre for Health Sciences, Dublin, Ireland.

    Employs lead author Julie Broderick.

  • St. James Hospital, Dublin, Ireland.

    Employs review authors Niall Crumlish and Alice Waugh.

  • Katholieke Universiteit Leuven, Leuven, Belgium.

    Employs review author Davy Vancampfort.

External sources

  • Health Research Board, Ireland.

    This review was conducted as part of a series of reviews which were funded by a Cochrane Fellowship Grant (CFT‐2014‐880).

Declarations of interest

Julie Broderick: "This work was supported by a Cochrane Training Fellowship funded by the Health Research Board, Ireland. This consisted of protected time to write this review and support for relevant training".
Niall Crumlish: none known.
Alice Waugh: none known.
Davy Vancampfort: none known.

Acknowledgements

The review authors would like to thank Professor Clive E Adams for the opportunity to perform this series of reviews and for his advice throughout, as well as the staff of the Cochrane Schizophrenia Group Editorial Base, particularly Claire Irving, for their support in the writing of the protocol and review. The Cochrane Schizophrenia Group Editorial Base in Nottingham, UK, produces and maintains standard text for use in the Methods section of their reviews, and the review authors have used this text as the basis for what appears here, adapting it as required. The review authors have also used and adapted their previous description of yoga, first published in 'Yoga versus standard care for schizophrenia' (Broderick 2015). This review is part of a series of reviews (Table 1) to populate an overview. As such, there is some consistency between reviews to streamline content for the forthcoming overview.

The review authors would also like to thank the Information Scientist of the Cochrane Schizophrenia Group, Farhad Shokraneh, who developed the search strategy.

We would also like to thank and acknowledge Genevieve Gariepy for peer reviewing this version of the review.

Parts of this review were drafted using RevMan HAL v 4.2. You can find more information about RevMan HAL here.

Version history

Published

Title

Stage

Authors

Version

2017 Sep 28

Yoga versus non‐standard care for schizophrenia

Review

Julie Broderick, Niall Crumlish, Alice Waugh, Davy Vancampfort

https://doi.org/10.1002/14651858.CD012052.pub2

2016 Jan 21

Yoga versus non‐standard care for schizophrenia

Protocol

Julie Broderick, Niall Crumlish, Alice Waugh, Davy Vancampfort

https://doi.org/10.1002/14651858.CD012052

Differences between protocol and review

Renaming of non‐standard care intervention from Non‐standard care or approaches (in addition to standard care) to Non‐standard care: We have removed the 'in addition to standard care' to clarify that both interventions would be 'in addition to standard care', and to keep the interventions the same as the published title.

Some updating of the text in the methods section to reflect changes in Schizophrenia Group's methods template.

Changing of wording of outcomes from 'clinically significant response' to 'clinically important change' in line with current Schizophrenia Group template. Specified outcomes in the 'Summary of findings' table should be 'clinically important'.

As no relapse data were available, we presented 'relapse' as a blank row in the 'Summary of findings' table but added 'leaving the study early' data. This was not prespecified in our protocol.

Keywords

MeSH

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

37Study flow diagram for 2015 searches
Figuras y tablas -
Figure 1

37Study flow diagram for 2015 searches

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 1 Mental state: 1. Clinically important change (PANSS ‐ not improved) short term.
Figuras y tablas -
Analysis 1.1

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 1 Mental state: 1. Clinically important change (PANSS ‐ not improved) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 2 Mental state: 2. Average endpoint score (various scales) short term.
Figuras y tablas -
Analysis 1.2

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 2 Mental state: 2. Average endpoint score (various scales) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 3 Global state: Average endpoint score (CGIS, low score=good) short term.
Figuras y tablas -
Analysis 1.3

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 3 Global state: Average endpoint score (CGIS, low score=good) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 4 Social functioning: 1. Clinically important change (SOFS ‐ not improved) short term.
Figuras y tablas -
Analysis 1.4

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 4 Social functioning: 1. Clinically important change (SOFS ‐ not improved) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 5 Social functioning: 2. Average score at endpoint (two scales).
Figuras y tablas -
Analysis 1.5

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 5 Social functioning: 2. Average score at endpoint (two scales).

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 6 Quality of life: Average endpoint scores (various scales) short term.
Figuras y tablas -
Analysis 1.6

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 6 Quality of life: Average endpoint scores (various scales) short term.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 7 Adverse effects.
Figuras y tablas -
Analysis 1.7

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 7 Adverse effects.

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 8 Leaving the study early ‐ short term.
Figuras y tablas -
Analysis 1.8

Comparison 1 YOGA versus NON‐STANDARD CARE, Outcome 8 Leaving the study early ‐ short term.

Table 2. Comparisons relevant to other reviews suggested by excluded and included studies

Intervention

plus

Control

Participants

Reference tag

Relevant Cochrane review

Yoga

nil

standard care

people with schizophrenia

Behere 2011; Ikai 2013; Ikai 2014; Jayaram 2013; Lin 2006;Lin 2015;Varambally 2012a; Visceglia 2011

Yoga versus standard care for schizophrenia

counselling

standard care

motivational and feedback session

nil

caregivers of people with schizophrenia

Varambally 2013

Yoga

non‐standard care

people with schizophrenia

SLCTR‐2013‐008*; Paikkatt 2012; Xie 2006;

Yoga as part of a package of care versus non‐standard care

Chlorpromazine

nil

placebo

Mahal 1976; Ramu 1999

Chlorpromazine versus placebo for schizophrenia

'Tagara' (local drug with anti‐psychotic properties) and 'Brahmyadiyoga' (a herbal compound)

nil

Chlorpromazine versus herbal compounds for schizophrenia

chlorpromazine

* This particular study used yoga combined with relaxation exercises, breathing exercises, body movement exercises, basic acting exercises, the Alexander technique, theatre games, exercise ''to build self confidence'', creative work using props, use of music to enhance creativity and moods.

Figuras y tablas -
Table 2. Comparisons relevant to other reviews suggested by excluded and included studies
Table 3. Design of a future study

Methods

Allocation: randomised (clearly described).
Blinding: single‐blind (outcomes assessor).
Duration: minimum 1 year.
Design: parallel.
Setting: outpatient and inpatient settings.

Participants

Diagnosis: people with a clinical diagnosis of schizophrenia.
History: from waiting list and referred to research staff.
N=300.
Age: > 18 years.
Sex: males and females.
Inclusion criteria: .age 18 years or greater.
Exclusion criteria: presence of physical disability or illness which precludes participation in yoga intervention.

Interventions

1. Yoga: the yoga intervention should be clearly described and consist of the following components; (i) shithileekarana vyayama (loosening exercises) for approximately 10 minutes (ii) yoga postures (asanas) for approximately 20 minutes (iii) breathing exercises and relaxation techniques for approximately 20 minutes using a manualised protocol, yoga programme for 12 weeks, 3 times weekly, follow‐up at 6 months and 1 year, yoga delivered by a trained yoga instructor, meditation not included.

2. Standard care control*.

All groups stable pharmacotherapy.

Outcomes

Mental state (binary outcomes).

Relapses (binary outcomes).

QOL (binary outcomes).

Disability (binary outcomes).

Activities of daily living (binary outcomes).

Costs: cost of services, cost of care.

Adverse events related to yoga (number and type of injuries).

Service outcomes: days in hospital, time attending outpatient psychiatric clinic.

Notes

Adherence should be logged with patients expected to adhere to 70% to 75% of scheduled sessions.

* Regarding design of a future study, readers are directed to the first yoga review in this series (Broderick 2015) ‐ as a comprehensive yoga versus standard care study has not yet been published, this would be the initial priority. When this is conducted, many legitimate active comparators to yoga could be suggested; such as, but not limited to the following; yoga versus talking therapy, yoga versus expressive therapies, yoga versus other forms of exercise such as Tai'chi.

Figuras y tablas -
Table 3. Design of a future study
Table 4. Possible active comparators to yoga for the design of future trials

Intervention

plus

Active Comparator Broad Group

Specific interventions*

Yoga

nil

expressive therapy

art therapy

drama therapy

music therapy

dance therapy

writing therapy

talking therapies

cognitive behavioural therapy

dialectic behaviour therapy

humanistic therapies

exercise

aerobic‐based interventions

combined aerobic and resistance programme

resistance‐based interventions

Tai'chi

qi'gong

*This list of specific interventions is not exhaustive and merely provides some examples of legitimate active comparators to yoga which are not currently available. These interventions could also be considered alternatively. For instance, exercise consists of heterogeneous interventions, it is accepted there could be other equally justifiable intervention titles such as 'supervised' exercise, 'non‐supervised exercise', or 'group‐based exercise', 'individual exercise', or exercise could be considered in terms of intensity such as 'high intensity', 'moderate intensity' and 'low intensity'. Note the specific intervention should be delivered by suitably qualified personnel.

Figuras y tablas -
Table 4. Possible active comparators to yoga for the design of future trials
Summary of findings for the main comparison. YOGA versus NON‐STANDARD CARE for schizophrenia

YOGA versus NON‐STANDARD CARE for schizophrenia

Patient or population: people with schizophrenia
Settings: hospitals, in India and China
Intervention: YOGA versus NON‐STANDARD CARE

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

YOGA versus NON‐STANDARD CARE

Mental state: clinically important change
PANSS ‐ not improved

Follow‐up: 4 months

Low1

RR 0.81
(0.62 to 1.07)

84
(1 study)

⊕⊕⊝⊝
low2

800 per 1000

648 per 1000
(496 to 856)

Moderate1

900 per 1000

729 per 1000
(558 to 963)

High1

1000 per 1000

810 per 1000
(620 to 1000)

Global state: relapse

No trial reported this outcome.

Social functioning: clinically important change
SOFS ‐ overall, not improved
Follow‐up: 4 months

Low1

RR 0.90
(0.78 to 1.04)

84
(1 study)

⊕⊕⊝⊝
low2

700 per 1000

630 per 1000
(546 to 728)

Moderate1

900 per 1000

810 per 1000
(702 to 936)

Adverse effects ‐ any

See comment

See comment

Not estimable

85
(1 study)

⊕⊕⊕⊝
medium7

Risks were calculated from pooled risk differences. The study reported no adverse effects.

Quality of life: clinically important change

SF‐36 average change score mental health *
Follow‐up: 12 weeks

The mean quality of life: average change ‐ mental health in the intervention (yoga) groups was
‐5.30 lower
(17.78 lower to 7.18 higher)

69
(1 study)

⊕⊕⊝⊝
low3,4,5

* no trial reported binary data; we chose 1 of 2 QOL measures as proxy measure

Physical health: clinically important change

WHQOL‐BREF ‐ average change score *
Follow‐up: 12 weeks

The mean physical health: average change in the intervention (yoga) groups was
9.22 higher
(0.42 lower to 18.86 higher)

41
(1 study)

⊕⊕⊝⊝
low3,4,6

* no trial reported binary data; we chose physical health dimension of QOL measure as proxy measure.

Costs: direct and indirect costs of care

No trial reported this outcome.

Leaving the study early: short term

Low1

RR 0.64
(0.49 to 0.83)

586
(6 studies)

⊕⊕⊕⊝
medium8

200 per 1000

120 per 1000
(88 to 166)

Moderate1

400 per 1000

240 per 1000
(176 to 332)

High1

600 per 1000

360 per 1000
(264 to 498)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

CI: confidence interval; RR: risk ratio

1 Moderate risk approximates to that of non‐standard care in trial(s).
2 Imprecision: Downgraded two levels due to small sample size and substantial loss to follow‐up which was uneven between groups (40.5% non‐standard care, 17% yoga)

3 Imprecision: Downgraded one level due to small sample size
4 Indirect: Downgraded one level as no trial reported binary data and review authors had to use one of 2 sub‐measures.
5 Indirect:Downgraded one level as unclear of clinical meaning of scores from 4 to 26.
6 Indirect:Downgraded two levels as no trial reported binary data and reviewers had to use one of 2 sub‐sets.

7 Imprecision: Downgraded one level as based on one study with no reported adverse events.

8 Risk of bias: Downgraded one level as a number of participants withdrew from one trial and it was not clear to which group they were randomised.

Figuras y tablas -
Summary of findings for the main comparison. YOGA versus NON‐STANDARD CARE for schizophrenia
Table 1. Yoga titles ‐ relevant to people with schizophrenia

Review title

Status

Yoga versus standard care for schizophrenia

Full review: Broderick 2015

Yoga versus non‐standard care for schizophrenia

This review.

Yoga as part of a package of care versus standard care

Protocol: Broderick 2016b

Yoga as part of a package of care versus non‐standard care

Broderick 2017

Figuras y tablas -
Table 1. Yoga titles ‐ relevant to people with schizophrenia
Comparison 1. YOGA versus NON‐STANDARD CARE

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mental state: 1. Clinically important change (PANSS ‐ not improved) short term Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

1.1 overall

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

0.81 [0.62, 1.07]

1.2 specific ‐ negative symptoms

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

0.72 [0.57, 0.90]

1.3 specific ‐ positive symptoms

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

1.08 [0.84, 1.38]

2 Mental state: 2. Average endpoint score (various scales) short term Show forest plot

4

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

2.1 overall (PANSS)

3

170

Mean Difference (IV, Fixed, 95% CI)

‐4.69 [‐8.35, ‐1.03]

2.2 specific ‐ depressive symptoms (CDS)

1

69

Mean Difference (IV, Fixed, 95% CI)

0.10 [‐1.01, 1.21]

2.3 specific ‐ depressive symptoms (HDRS)

1

60

Mean Difference (IV, Fixed, 95% CI)

‐1.41 [‐2.40, ‐0.42]

2.4 specific ‐ negative symptoms (PANSS)

4

214

Mean Difference (IV, Fixed, 95% CI)

‐1.15 [‐2.30, 0.01]

2.5 specific ‐ positive symptoms (PANSS)

4

214

Mean Difference (IV, Fixed, 95% CI)

‐0.36 [‐1.35, 0.63]

3 Global state: Average endpoint score (CGIS, low score=good) short term Show forest plot

1

60

Mean Difference (IV, Fixed, 95% CI)

‐0.85 [‐1.21, ‐0.49]

4 Social functioning: 1. Clinically important change (SOFS ‐ not improved) short term Show forest plot

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.78, 1.04]

5 Social functioning: 2. Average score at endpoint (two scales) Show forest plot

1

88

Mean Difference (IV, Fixed, 95% CI)

3.20 [‐0.57, 6.97]

5.1 SOFS, high score=good

1

44

Mean Difference (IV, Fixed, 95% CI)

3.70 [‐0.70, 8.10]

5.2 Emotional recognition, TRACS, high score=good

1

44

Mean Difference (IV, Fixed, 95% CI)

1.80 [‐5.54, 9.14]

6 Quality of life: Average endpoint scores (various scales) short term Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

6.1 mental health (SF‐36, average summary score, high score=good))

1

69

Mean Difference (IV, Fixed, 95% CI)

‐5.30 [‐17.78, 7.18]

6.2 physical health (WHOQOL‐BREF, high score=good)

1

41

Mean Difference (IV, Fixed, 95% CI)

9.22 [‐0.42, 18.86]

6.3 physical health (SF‐36, average summary score, high score=good) )

1

69

Mean Difference (IV, Fixed, 95% CI)

‐3.60 [‐11.98, 4.78]

6.4 psychological health (WHOQOL‐BREF, high score=good)

1

41

Mean Difference (IV, Fixed, 95% CI)

17.70 [6.50, 28.90]

6.5 social well being (WHOQOL‐BREF, high score=good)

1

41

Mean Difference (IV, Fixed, 95% CI)

20.75 [7.42, 34.08]

7 Adverse effects Show forest plot

1

Risk Difference (M‐H, Fixed, 95% CI)

Subtotals only

7.1 any serious

1

85

Risk Difference (M‐H, Fixed, 95% CI)

0.0 [‐0.05, 0.05]

7.2 others

1

85

Risk Difference (M‐H, Fixed, 95% CI)

0.0 [‐0.05, 0.05]

8 Leaving the study early ‐ short term Show forest plot

6

586

Risk Ratio (M‐H, Fixed, 95% CI)

0.66 [0.51, 0.86]

Figuras y tablas -
Comparison 1. YOGA versus NON‐STANDARD CARE