Disability and Rehabilitation

ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: https://www.tandfonline.com/loi/idre20

Functioning in schizophrenia: a Delphi study

covering the perspective of physiotherapists

Laura Nuño, Maite Barrios, Davy Vancampfort, Emilio Rojo, Juana Gómez-
Benito & Georgina Guilera

To cite this article: Laura Nuño, Maite Barrios, Davy Vancampfort, Emilio Rojo, Juana
Gómez-Benito & Georgina Guilera (2020): Functioning in schizophrenia: a Delphi
study covering the perspective of physiotherapists, Disability and Rehabilitation, DOI:
10.1080/09638288.2020.1748729

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DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2020.1748729

ORIGINAL ARTICLE

Functioning in schizophrenia: a Delphi study covering the perspective of

physiotherapists
~oa , Maite Barriosb,c
Laura Nun , Davy Vancampfortd , Emilio Rojoe,f mez-Benitob,c
, Juana Go and
Georgina Guilerab,c
a
Clinical Institute of Neurosciences (ICN), Hospital Clinic, Barcelona, Spain; bDepartment of Social Psychology and Quantitative Psychology,
University of Barcelona, Barcelona, Spain; cInstitute of Neurosciences, University of Barcelona, Barcelona, Spain; dDepartment of Rehabilitation
Sciences, KU Leuven, Leuven, Belgium; eHospital Benito Menni CASM, Sisters Hospitallers, Sant Boi de Llobregat, Spain; fDepartment of
Psychiatry, International University of Catalonia, Sant Cugat del Valles, Spain

ABSTRACT ARTICLE HISTORY

Purpose: This qualitative study explores the barriers, personal characteristics/resources, and environmen- Received 15 September 2019
tal factors that experienced physiotherapists identify as relevant in the assessment and treatment of per- Revised 24 March 2020
sons living with schizophrenia, and whether the identified aspects are represented in the International Accepted 25 March 2020
Classification of Functioning, Disability and Health Core Sets for schizophrenia.
KEYWORDS
Methods: A three-round Delphi study with physiotherapists was conducted between April and July 2018. Physiotherapy; schizophre-
In the first round, participants had to list all the aspects they considered to be relevant when assessing nia; International
and/or treating individuals with schizophrenia, and they were asked six open-ended questions. Their Classification of
responses were linked to categories. In the second and third rounds, physiotherapists had to judge Functioning, Disability and
whether each category/personal factor was relevant for describing functioning in schizophrenia. Health; Core Set;
Results: Thirteen of 22 eligible physiotherapists from eight countries responded to the first round, and content validity
10 completed all three rounds. Eighty-two (84.5%) of the 97 categories in the Comprehensive Core Set
for schizophrenia and all 25 categories in the Brief Core Set were considered relevant. A total of five cate-
gories were additionally identified.
Conclusions: The barriers, personal characteristics/resources, and environmental factors from the physio-
therapists’ perspective have been identified. The results largely confirm the content validity of the Core
Sets for schizophrenia.

ä IMPLICATIONS FOR REHABILITATION

This study shows which barriers, personal characteristics/resources, and environmental factors in per-
sons with schizophrenia are relevant from physiotherapists’ perspective and should be integrated in
the rehabilitation process.

The content validity of the Comprehensive and Brief Core Sets for schizophrenia is largely supported
from the physiotherapists’ perspective and therefore could be used in the assessment of functioning
in persons with schizophrenia.

The Comprehensive and Brief ICF Core Sets for schizophrenia could be used to plan and assess multi-
disciplinary rehabilitation interventions.

Introduction specialty within the broader field of physiotherapy, and its poten-
tial contribution has been increasingly recognised in recent deca-
Schizophrenia is a chronic and severe mental disorder involving
des. In addition to general physiotherapy interventions,
positive symptoms (e.g., delusions, hallucinations, racing
physiotherapists who work in mental health require supplemen-
thoughts), negative symptoms (e.g., apathy, lack of emotion, poor
tary knowledge (e.g., of psychopathology and psychology) and
or non-existent social functioning), and neuropsychological specific skills and competences (e.g., communication) in order to
impairments such as disorganized thoughts and difficulty concen- assess, treat, support, and refer people with mental disorders
trating and/or following instructions [1,2]. It is among the most effectively [6]. Individuals with mental disorders may have numer-
disabling disorders [3] and it affects various areas of an individu- ous physical health complaints (cardiovascular diseases, metabolic
al’s daily functioning, including the ability to live independently, syndrome, obesity, osteoporosis, etc.) due to their medication,
productive activities, and social relationships [4]. sedentary behaviour or inactivity, and consequently they fre-
Physiotherapists can play an important role in the care of peo- quently consult primary care services. As part of a multidisciplin-
ple with schizophrenia, helping to improve their mental, physical, ary team, physiotherapists are ideally placed to promote lifestyle
and social quality of life [5]. Physiotherapy in mental health is a choices and to improve the functional outcomes of individuals

CONTACT Georgina Guilera [email protected] Department of Social Psychology and Quantitative Psychology, Faculty of Psychology, University of Barcelona,
Passeig Vall d’Hebron 171, Barcelona 08035, Spain.
Supplemental data for this article can be accessed here.
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 L. NUÑO ET AL.

with schizophrenia by motivating them towards physical activity, worldwide representativeness of experts, participation was pos-
addressing clinical pain, improving body awareness, and promot- sible in any of five languages (i.e., Chinese, English, French,
ing bone health [6,7]. The ultimate goal of physiotherapists work- Russian, or Spanish).
ing in mental health is to change unhealthy habits and promote A total of 22 physiotherapists met the eligibility criterion and
an active positive lifestyle. expressed an interest in participating. These 22 professionals were
A detailed and multidisciplinary understanding of a person’s then sent a personal email that included a detailed description of
functioning and health status is crucial for designing and imple- the project aims and the Delphi process, it being made clear that
menting better interventions [5]. The International Classification of no previous knowledge of the ICF was required to participate.
Functioning, Disability and Health (ICF) [8] is based on a bio-psy- Demographic and professional data were also requested.
cho-social model and offers a list of indicators (ICF categories)
that can be used to comprehensively assess functioning in any
Delphi process
health condition. The ICF considers that problems associated with
a disease can be related to the components Body functions, Body The Delphi process followed in the present study has been used
structures and Activities and participation in community life, which in several other previous studies [12–14]. Data from the physio-
in turn are influenced by the components Environmental factors therapists were collected between April and July 2018 across
and Personal factors. All these components interact in a dynamic three rounds, each separated by a two-week interval. In each
and bidirectional way. The ICF system includes more than 1400 round, and in order to increase the participation and completion
hierarchically organized categories, making its implementation a rate, three reminders were sent by e-mail (one week and two
major challenge for clinical practice. To facilitate its application, days before the response deadline and on the deadline day itself).
the World Health Organization (WHO) suggests developing ICF An online survey system (Qualtrics) was used in all three rounds
Core Sets (ICF-CSs), consisting of a selection of ICF categories that (www.qualtrics.com).
are considered essential for describing the functioning of a person
living with a particular health condition. The ICF-CSs for schizo- First round
phrenia have already been developed [9], and both comprehen- Participants were sent an e-mail with a link to the survey home-
sive (97 categories) and brief versions (25 categories) are page. The latter included instructions on how to complete the
available. However, a prerequisite for the application of these ICF- survey (i.e., list all the aspects they considered to be relevant
CSs in clinical practice is their content validation from the per- when assessing and/or treating individuals with schizophrenia)
spective of different professionals who work with people with and six open-ended questions that covered all components of the
schizophrenia. This includes physiotherapists. Accordingly, the ICF. The Environmental factors component was divided into sup-
present study sought to address the following two questions: portive and hindering factors.
Between the first and second rounds, physiotherapists’
1. What are the barriers, personal characteristics/resources, and responses were independently linked to the corresponding ICF
environmental factors that experienced physiotherapists iden- category by two health professionals, both with experience of
tify as relevant in the assessment and treatment of persons treating persons with schizophrenia and trained in the use of the
living with schizophrenia? ICF system. This was done in accordance with established linking
2. To what extent are the identified aspects represented in the criteria [15,16]. Personal factors were also coded. Disagreements
International Classification of Functioning, Disability and were resolved by consensus involving two other health professio-
Health Core Sets (ICF-CSs) for schizophrenia? nals. All the categories reported by at least 5% of the experts and
any additional categories that form part of the Comprehensive
Methods ICF-CS for schizophrenia were selected for presentation in the
second Delphi round. Details of the linking process are reported
Design
elsewhere [12].
A three-round worldwide electronic-mail survey based on a con-
sensus-building Delphi method was conducted with physiothera- Second round
pists with expertise in the treatment of persons with Participants who responded in the first round were then sent an
schizophrenia. The Delphi technique is a widely used and e-mail with a link to the second-round survey and instructions on
accepted method for gathering data from a panel of individuals how to complete it. This time they were presented with the
with knowledge of the topic being investigated. It involves an selected list of ICF categories and the Personal factors that
iterative multistage process in which a series of rounds is used to resulted from the first round. The task for physiotherapists in this
transform individual opinion into group consensus [10,11]. second round was to judge whether each category/personal fac-
tor was relevant for describing functioning in schizophrenia. There
were two possible response options: yes or no. In order to facili-
Participants
tate their task, each ICF category was accompanied by its corre-
Physiotherapists with at least one year of experience in the field sponding definition. The definition of each ICF category, along
of schizophrenia were eligible to participate in the Delphi study. with inclusion/exclusion examples, can be consulted in the ICF
Potential participants were identified via the following: the web- manual [8], and all this material is also available at the ICF
site of the International Organization of Physical Therapists in browser (http://apps.who.int/classifications/icfbrowser/). Personal
Mental Health, the list of contributors to the International factors are not yet classified in the ICF system. However, as they
Conference of Physical Therapy in Psychiatry and Mental Health, are relevant to assessment and intervention planning, concepts
electronic database searches of authors who have published on related to Personal factors were summarized and considered in
the topic of schizophrenia, universities with health professional rounds two and three of the Delphi study, in each case accompa-
training programs, hospitals, LinkedIn contacts, and personal rec- nied by a definition created by our research group. The proposed
ommendations. In order to maximise the participation rate and categorization of Personal factors and their corresponding
 PHYSIOTHERAPISTS’ PERSPECTIVE IN SCHIZOPHRENIA 3

Figure 1. The Delphi process.

definitions were developed by consensus among three psycholo- also given feedback regarding their previous responses for each
gists (L.N., M.B., G.G.) based on previously proposed categoriza- category and were told the percentage of experts who had con-
tions of Personal factors [12–14] and on the experts’ responses to sidered each category/personal factor as relevant. A flow chart of
the question about personal factors. the process, including examples of the survey questions used and
the feedback given in round three, is shown in Figure 1.
Third round
Physiotherapists who responded in the second round were then
Data analysis
sent an e-mail with a link to the third-round survey and instruc-
tions on how to complete it. The survey showed the same list of Kappa coefficients and 95% bootstrapped confidence intervals
categories and Personal factors as was used in the previous round (95% CI) were calculated in order to assess inter-coder reliability
and once again they were asked to judge the relevance of each in the linking process of experts’ responses to the first Delphi
(yes/no). However, in contrast to the second round, they were round. In addition, we computed frequencies of ICF categories
4 L. NUÑO ET AL.

Table 1. Demographic and professional characteristics of participants in the first physiotherapists (a further 67 categories) comprised the second-
round and participation rate across the three Delphi rounds. round list. In addition, a total of 14 concepts were classified as
Variable Description Personal factors and were also presented in the second round, in
Participation rate n (%) a list that also included nine sociodemographic variables that
Round 1 13 (59.1) were considered essential. Consequently, 110 ICF categories and
Round 2 10 (76.9)
Round 3 10 (100) 23 personal factors were presented to physiotherapists in the
WHO region n (%) second round.
Americasa 2 (15.4)
Europeb 7 (53.8)
South-East Asiac 1 (7.7) What are the problems, personal characteristics/resources and
Western Pacificd 3 (23.1) environmental factors that physiotherapists identify as relevant
Gender n (%) in persons living with schizophrenia?
Male 6 (46.2)
Female 7 (53.8) Of the 110 categories and 23 personal factors presented in the
Age mean (SD) 43.23 (10.63) second round, 87 (79.1%) and 21 (91.3%) respectively reached
Years of experience in schizophrenia mean (range) 10.46 (1-30)
Expertise mean (range)e 3.31 (1-5) consensus in the third round (i.e., agreement of at least 70%), and
Type of population treatedf 23 categories (20.9%) and 2 personal factors (8.7%) did not reach
Acute 7 (53.8) consensus. Table 2 provides a summary of categories for which
Chronic 12 (92.3) consensus was reached, as well as a comparison with the catego-
Place of residence of population treatedf,g
Rural 3 (37.5) ries included in the Comprehensive ICF-CS for schizophrenia.
Urban 7 (87.5) Regarding the Body functions component, physiotherapists
a
Brazil and Canada. listed 22 ICF categories. Consensus was reached for 20 of these,
b
Belgium, Spain and Ukraine. with agreement of 100% for seven categories, all pertaining to
c
Thailand. chapter b1 Mental functions (see Supplemental material S1 for
d
Australia and China. more details). In relation to Body structures, consensus was
e
Self-rating of schizophrenia expertise: 1 ¼ limited expertise to
5 ¼ extensive expertise. reached for two of the six ICF categories identified (i.e., “s110
f
It was possible to select more than one option. Structure of brain” and “s770 Additional musculoskeletal structures
g
Percentages are based on eight experts. related to movement”) (see Supplemental material S2). Regarding
the Activities and participation component, physiotherapists identi-
and personal factors in the first round. If several responses from fied 49 ICF categories and reached consensus over 42 (see
the same participant were assigned to the same ICF category or Supplemental material S3 for more details). Finally, 33 categories
personal factor, they were counted only once to avoid from the Environmental factors component were identified, 23 of
overestimation. which yielded consensus in terms of their relevance to function-
The percentage of third-round participants who agreed with ing in schizophrenia (see Supplemental material S4 for more
respect to each category considered in the second and third details). In summary, of the 110 ICF categories presented, 87
Delphi rounds was then calculated. Since there is no universally (79.1%) yielded agreement of at least 70%.
accepted definition of consensus [17], and based on previous Regarding Personal factors, a component that has yet to be
studies [18], agreement among at least 75% of participants was classified in the ICF system, consensus was reached for 21 of the
initially considered. However, as only 10 participants in the pre- 23 concepts (91.3%) that were presented to the physiotherapists.
sent study completed all three rounds, the consensus level was Supplemental material S5 shows the personal factors listed and
set at 70%. their corresponding percentages of agreement in round 3.
Finally, the categories for which there was agreement in the Finally, Supplemental material S6 shows the explanations given
third round were compared with the categories included in both by the experts in the first round for those categories and personal
the Comprehensive and Brief ICF-CSs, paying special attention to factors where consensus was not reached in the third round.
those categories that did not match in the two sets of data.
To what extent are the aspects identified by physiotherapists
Results represented in the ICF-CSs for schizophrenia?

Participants All 25 categories included in the Brief ICF-CS for schizophrenia

were confirmed as relevant by the physiotherapists, with an
A total of 13 physiotherapists from eight countries completed the agreement of at least 70%. Therefore, the following comparative
first round, representing 59.1% of those who were sent the survey analyses are limited to the Comprehensive ICF-CS for
material. The main demographic and professional characteristics schizophrenia.
of the participants from the first round are shown in Table 1. Ten Eighty-two of the 97 categories in the Comprehensive ICF-CS
of the 13 physiotherapists responded to the second round of the for schizophrenia (84.5%) were confirmed by the physiotherapists:
survey and also completed the third. The completion rate across all 17 (100%) from the Body functions component, 42 out of 48
rounds one to three was 76.9%. (87.5%) from the Activities and participation component, and 23
out of 32 (71.9%) from the Environmental factors component.
Results for the comparison between physiotherapists’ responses
Linking process
and the content of the Comprehensive ICF-CS for schizophrenia
The Kappa coefficient for the linking process was .72 [95% CI: are shown in Table 3. Five categories not included in the
.64–.79]. In the first round, physiotherapists’ responses yielded 97 Comprehensive ICF-CS for schizophrenia were regarded as rele-
concepts that were linked to 43 ICF categories. These categories vant by at least 70% of the physiotherapists. Three of these cate-
and those from the ICF-CSs that had not been referred to by the gories referred to Body functions (i.e., “b126 Temperament and
 PHYSIOTHERAPISTS’ PERSPECTIVE IN SCHIZOPHRENIA 5

Table 2. Summary of categories for which consensus was reached and comparison with the categories included in the Comprehensive ICF-CS for schizophrenia.
ICF component
Number of categories … Body functions Body structures Activities and participation Environmental factors Total
… presented to experts in the second and third rounds 22 6 49 33 110
… for which consensus was reached 20 2 42 23 87
… from the ICF-CS for which consensus was reached / 17 / 17 0/0 42 / 48 23 / 32 82 / 97
… in the ICF-CS for schizophrenia

Table 3. Summary of ICF categories for which consensus among physiotherapists was reached and comparison with the categories included in the Comprehensive
ICF-CS for schizophrenia.
Percentage of
ICF component ICF category agreement (%)a
Categories for which consensus was Body functions b126 Temperament and personality functions 90
reached but which do not feature b735 Muscle tone functions 80
in the Comprehensive ICF-CS b770 Gait pattern functions 70
Body structures s110 Structure of brain 100
s770 Additional musculoskeletal structures related to movement 70
Categories from the Comprehensive Activities and d210 Undertaking a single task 60
ICF-CS for which consensus was participation d470 Using transportation 40
not reached d510 Washing oneself 50
d540 Dressing 50
d860 Basic economic transactions 40
d930 Religion and spirituality 60
Environmental factors e125 Products and technology for communication 60
e130 Products and technology for education 60
e165 Assets 60
e330 People in positions of authority 60
e415 Individual attitudes of extended family members 60
e425 Individual attitudes of acquaintances, peers, colleagues, neighbours 60
and community members
e430 Individual attitudes of people in positions of authority 50
e525 Housing services, systems and policies 60
e560 Media services, systems and policies 50
a
Percentage of participants who considered the respective ICF category as relevant in the third round.

personality functions”, “b735 Muscle tone functions”, and “b770 Gait Delphi studies that have explored the perspective of psychiatrists,
pattern functions”) and two to Body structures (i.e., “s110 Structure nurses and psychologists [12–14]. These categories refer to typical
of brain” and “s770 Additional musculoskeletal structures related to and well-described symptoms in schizophrenia, including positive
movement”). It is important to highlight that the Comprehensive symptoms such as hallucinations and delusions (“b156 Perceptual
ICF-CS does not currently contain any category from the Body functions” and “b160 Thought functions”, respectively), negative
structures component. Six of the 48 categories from the Activities symptoms such as flattening of affect (“b152 Emotional functions”),
and participation component and nine of the 32 categories that and specific cognitive functions (e.g., “b140 Attention functions”)
comprise the Environmental factors component in the ICF-CS for and other mental functions (e.g., “b134 Sleep functions”). There is
schizophrenia did not yield consensus in the present strong evidence in the literature that physiotherapists have an
Delphi study. important role to play in the multidisciplinary treatment of all
In summary, five of the 87 ICF categories for which consensus these functions. For example, it is known that exercise reduces
was achieved do not feature in the Comprehensive ICF-CS for both negative symptoms [19–22] and positive symptoms [20–22]
schizophrenia. In addition, 15 categories that are represented in and it can also improve cognitive functioning [23]. Moreover, the
the ICF-CS did not yield 70% agreement among physiotherapists. dropout rate from physical activity interventions decreases signifi-
Finally, consensus was reached for 29 of the 31 Personal factors cantly when exercise is prescribed by physiotherapists [24].
(93.5%) that were presented to the expert panel (see In addition to these mental functions, consensus was reached
Supplemental material S5). on several physical health functions, including “b530 Weight main-
tenance functions”, “b735 Muscle tone functions”, and “b770 Gait
pattern functions.” Most of the physical health issues observed in
Discussion
people with schizophrenia are associated with a sedentary life-
This study has identified the main functioning-related issues that style and physical inactivity [25–27], and there is strong evidence
physiotherapists encounter when treating individuals with schizo- for the role of physiotherapy in addressing this physical comor-
phrenia. Consensus was reached regarding 84.5% of the catego- bidity [5,28–30]. It should be noted, however, that although cate-
ries included in the Comprehensive ICF-CS for schizophrenia and gories “b735 Muscle tone functions” and “b770 Gait pattern
100% of those in the brief version, thus supporting their content functions” yielded consensus in the present study, they do not
validity from the perspective of physiotherapists. currently feature in the ICF-CS for schizophrenia.
Most of the categories from the Body functions component of Regarding the Body structures component, 100% of physio-
the Comprehensive ICF-CS that yielded consensus corresponded therapists considered the structure of brain as important, which is
to “b1 Mental functions.” The average agreement among physio- consistent with the fact that exercise has important neurobio-
therapists of 92.9% is similar to the figure reported in other logical effects [31]. The category “s110 Structure of brain” was also
6 L. NUÑO ET AL.

considered important in our previous Delphi studies [12–14] that Our data need to be considered in light of an important limita-
explored the perspective of other health professionals, and this tion. Despite our efforts to recruit a large and representative
suggests that it should be considered for inclusion in the panel of experienced physiotherapists (i.e., searching for potential
Comprehensive ICF-CS for schizophrenia. Physiotherapists also participants through several and varied resources and providing
agreed that the category “s770 Additional musculoskeletal struc- survey materials in five different languages), the number who
tures related to movement” was relevant when treating persons were willing to participate in the Delphi study was small in com-
with schizophrenia. This category includes musculoskeletal struc- parison with the relatively large number of physiotherapists who
tures such as bones, joints, and muscles, all of which can be work in mental health settings. A possible explanation for the low
affected by a sedentary lifestyle or by the person being over- participation rate is that although physiotherapists may com-
weight or obese, a highly prevalent problem among people with monly treat persons with a mental disorder, among other types of
schizophrenia [6,32]. Importantly, people with schizophrenia are patients, they might not consider themselves to be experts in
known to have a significantly increased risk of fractures [33], and relation to schizophrenia. A compounding factor here is the diver-
hence there is a need to develop preventive strategies to improve sity of curricula among physiotherapy training programmes, many
their bone health and reduce fracture risk. In this respect, physio- of which do not include a focus on mental health [5,6,42].
therapists can play an important role within the multidisciplinary Moreover, potential participants were informed at the outset of
team by, for example, implementing fall prevention pro- the commitment involved (completing three rounds, etc.), and
grammes [33]. some may have considered this to be too time consuming. On
Regarding the Activities and participation component, consen- the plus side, the sample obtained did have a heterogeneous pro-
sus was reached for categories from all of the chapters featured file, representing four out of the six WHO regions and covering a
in the ICF, which shows that physiotherapists acknowledge that wide range of professional characteristics. Thus, while acknowl-
edging this limitation, we believe that the present study makes a
schizophrenia has major implications for a broad spectrum of
useful contribution in two respects. On the one hand, it identifies
everyday activities. It also demonstrates that physiotherapists are
the most relevant problems and personal and environmental fac-
aware of the scientific evidence supporting the important phys-
tors that physiotherapists encounter when treating individuals
ical, mental, and social benefits which their interventions can
with schizophrenia. In addition, it incorporates the perspective of
have [34]. All categories from this component over which agree-
experienced physiotherapists from different regions of the world
ment was reached are listed in the ICF-CS for schizophrenia.
into the validation process of the ICF-CSs for schizophrenia, thus
However, consensus was lacking for a further six categories that
reinforcing the role that this profession plays in the field of men-
also feature in the ICF-CS (e.g., “d470 Using transportation” or
tal health. The fact that the physiotherapists we surveyed agreed
“d510 Washing oneself”), suggesting that a significant proportion
on the importance of certain categories that do not currently
of the physiotherapists surveyed do not consider them to be form part of the Comprehensive ICF-CS for schizophrenia high-
highly relevant to the treatment of people with schizophrenia. lights the need for the international workgroup on the ICF-CS for
All categories of the Environmental factors component for schizophrenia to consider whether these categories should be
which consensus was reached are listed in the ICF-CS for schizo- included in subsequent revisions of this core set.
phrenia. They cover four of the five chapters included in the ICF In conclusion, our study identifies the mental, physical, and
and concern factors related to the support provided by others, social aspects of functioning that physiotherapists consider to be
the accessibility of services and the provision of products in daily most relevant to their practice when assessing and treating indi-
living. These results indicate that physiotherapists ascribe consid- viduals with schizophrenia. This information will be useful to
erable importance to the impact of environmental factors on the physiotherapists working in the rehabilitation field. The results
functioning of a person with schizophrenia [35–37]. Six categories also largely confirm the validity of the ICF-CS for schizophrenia,
included in the Environmental factors component of the ICF-CS for suggesting that it could be a useful tool in the context of mental
schizophrenia did not achieve consensus in the present study health physiotherapy, not least by facilitating communication and
(e.g., “e525 Housing services, systems and policies”), suggesting that coordination of care within multidisciplinary teams that include
many of the physiotherapists surveyed do not regard them as pri- physiotherapists.
mary targets of a physiotherapy intervention. Overall, the findings
demonstrate that experienced physiotherapists consider the
socio-environmental context as important within their clinical Acknowledgements
practice. This is consistent with the fact that social support is The authors would like to thank all the participating experts for
known to play a pivotal role not only in helping people with their commitment and the time spent, without which the study
schizophrenia to start exercising, but also in ensuring their adher- would not have been possible. Participants who agreed to be
ence to physical activity programmes [38]. acknowledged in the publication are listed in surname alphabet-
A large number of physiotherapists’ responses were coded as ical order: P. Ann, J. Betore Muro, V. Jimenez, L.W.L. Lim, M.
Personal factors in the first Delphi round, with consensus being Probst, R. Sander, V. Schweitzer, P. Serranos, F. Wendelstein Cano
reached for 21 of these. This highlights the relevance of consider- and K. Yuenyongchaiwat.
ing personal characteristics in the treatment of schizophrenia, as
well as the importance ascribed to them by the physiotherapists.
A number of recent studies have shown that personal factors, Disclosure statement
such as premorbid drug use and lifestyle [39], premorbid person- No potential conflict of interest was reported by the author(s).
ality [40], and genetic factors [41] influence how people with
schizophrenia cope with their illness. It would therefore be useful
for these personal factors to be included within the ICF-CS for
Funding
schizophrenia so as to enable a more comprehensive assessment This work was supported by Spain’s Ministry of Economy and
of functioning in this mental disorder. Competitiveness [grant PSI2015-67984-R], and by the Agency for
 PHYSIOTHERAPISTS’ PERSPECTIVE IN SCHIZOPHRENIA 7

the Management of University and Research Grants of the and Health Core Sets for schizophrenia. Int J Mental Health
Government of Catalonia [grant 2017SGR1681]. Nurs. 2019;28(4):867–878.
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