Targeted Physical Rehabilitation for Physical Function Decline in Patients with Schizophrenia: A Narrative Review

Abstract

Prolonged hospitalization contributes to a decline in physical function and immobilization. This narrative review aims to explore physical rehabilitation approaches that address the specific characteristics of physical dysfunction in patients with schizophrenia. A literature review was conducted following an electronic search of PubMed for English-language articles published between January 2014 and January 2025. Based on the findings, a framework was constructed to categorize symptoms and physical challenges into three domains: (1) movement disorders and obesity induced by antipsychotic medications, which alter motor performance and lead to compensatory movements; (2) negative symptoms and cognitive impairments, which promote sedentary behavior and result in dysphagia, dynapenia, sarcopenia, and frailty; and (3) accelerated brain aging and disuse syndrome by schizophrenia, which impair neuromotor and cognitive function and increases the risk of physical dependency. These interconnected factors emphasize the need for targeted physical rehabilitation to maintain independence and reduce the risk of hospitalization. This review proposes a multidisciplinary approach involving psychiatrists, physical therapists, and occupational therapists, along with individualized nutritional support, as essential components of comprehensive rehabilitation strategies aimed at improving physical outcomes and reducing early mortality in this population.

1. Introduction

1.1. Background

Schizophrenia affects approximately 24 million people globally. Moreover, individuals with the disorder account for approximately half of all patients in long-term psychiatric hospitals [1]. Patients with schizophrenia have a life expectancy 10–25 years shorter than that of the general adult population [2], largely due to cardiovascular disease, metabolic syndrome, physical inactivity, and sedentary lifestyle [2,3,4]. In addition to psychiatric symptoms, many patients experience physical challenges, such as obesity, emaciation, dynapenia, sarcopenia, and frailty [5,6,7,8]. These issues are associated with negative symptoms that reduce motivation and movement, as well as long-term use of antipsychotic medications, which can cause weight gain and adverse effects on muscle composition [9]. Consequently, many individuals face an increased risk of immobility, physical dependence, and early mortality [10,11].

Psychosocial rehabilitation is a well-established intervention for schizophrenia that focuses on improving skills for daily living and interpersonal functioning [12]. However, physical rehabilitation enhances psychosocial rehabilitation by directly targeting illness-associated motor and functional impairments [13]. These major physical challenges, including motor disorders, obesity, and frailty, underscore the urgent need for structured rehabilitation strategies. Among various physical interventions, aerobic exercise, resistance training, or a combination of both reportedly improves not only psychiatric symptoms but also cardiopulmonary function and muscle strength [14].

These multifaceted factors—including the physical decline severity, extrapyramidal symptoms, compensatory movements, body composition, range of motion, psychiatric symptoms, age, and nutritional status—highlight the complexity of physical decline in schizophrenia. Thus, rehabilitation must be planned with consideration of these interacting factors, which also helps prevent inactivity-related complications, including muscle weakness, metabolic syndrome, and sedentary behavior. Understanding these interactions is crucial for developing targeted interventions, a process facilitated by our study’s structured conceptual framework.

Despite the recognized need for physical rehabilitation in this population, current understanding and programmatic approaches lack a comprehensive, integrated framework that specifically accounts for the multifaceted and often unique factors causing physical function decline in patients with schizophrenia. Existing rehabilitation models are often adapted from other populations or focus narrowly on physical symptoms, without fully considering the complex interplay of antipsychotic medication side effects (such as movement disorders and metabolic changes), the profound impact of negative symptoms on motivation and activity levels, and the contributions of cognitive impairments to sedentary behavior and functional limitations [15,16]. Consequently, current interventions may not adequately capture the specificity of these mechanisms, such as the development of compensatory movements, distinct patterns of muscle loss (such as dynapenia and sarcopenia), or accelerated brain aging that impairs neuromuscular control.

This gap underscores the insufficiency of current rehabilitation methods and highlights the need for a new conceptual framework that explicitly tailors interventions to the characteristic pathologies of physical dysfunction in patients with schizophrenia to achieve more effective and sustainable outcomes.

1.2. Literature Review to Develop a Conceptual Framework for Physical Rehabilitation

1.2.1. Search Strategy

This search was conducted according to Koskela-Huotari’s conceptual study’s storyline [17]. A conceptual review was performed following an electronic search on PubMed databases for English-language articles published between January 2014 and January 2025.

The symptoms and specific physical challenges of patients with schizophrenia were organized into a conceptual framework to guide the development of tailored physical rehabilitation approaches addressing their unique motor and functional impairments.

Figure 1 shows the review process of physical rehabilitation for patients with schizophrenia.

1.2.2. Literature Review to Develop a Conceptual Framework

Figure 2 illustrates the conceptual framework for the physical rehabilitation development process.

This study focused on the six main factors contributing to physical decline in patients with schizophrenia: (1) symptomatic limitations and restrictions in activities of daily living (ADL), (2) antipsychotic-induced movement disorders, (3) dynapenia, sarcopenia, sarcopenic obesity, and frailty, (4) abnormal functional motor performance, (5) cognitive limitations and ADL, and (6) accelerated brain aging and disuse syndrome.

1.2.3. Symptomatic Limitations and ADL Restrictions

Psychotic symptoms of schizophrenia are substantial predictors of long-term disability [18]. Positive symptoms impair concentration, making it challenging to perform ADLs. Symptoms, such as delusions, may also trigger avoidance behaviors, restricting social and occupational functioning [19]. Moreover, negative symptoms reduce goal-directed behavior and compromise motor skill application due to decreased motivation, leading to reduced physical activity in patients [20]. In addition, depression in schizophrenia is often underdiagnosed and worsens functional ability. Motor retardation, or psychomotor slowing, occurs in 40–60% of depressive episodes and is associated with impaired posture control and motor planning. Similarly, reduced eye movements are associated with poor interpersonal functioning and overall motor coordination [6,21].

1.2.4. Antipsychotic-Induced Movement Disorders

Antipsychotic medications frequently cause extrapyramidal side effects, such as antipsychotic-induced Parkinsonism and tardive dyskinesia [22]. These effects are often mistaken for negative or cognitive symptoms, contributing to under-recognition and under-treatment [23]. Long-term use may lead to chronic motor function deterioration.

Anticholinergic medications used to manage these side effects may themselves impair cognitive and psychomotor functioning, disrupting adaptive motor learning [24]. Furthermore, disruptions in the dopaminergic and cholinergic pathways impair the temporal coordination of movements, limiting physical function and ADL [25].

Abnormal involuntary movements have been observed even in drug-naïve patients, supporting the role of underlying neurological dysfunction [6,26]. Individuals with mental illness aged <50 years reportedly have a higher risk of developing Parkinson’s disease compared with older individuals with mental illness [27].

1.2.5. Dynapenia, Sarcopenia, Sarcopenic Obesity, and Frailty

Obesity and metabolic syndrome worsen cognitive dysfunction. Increased body mass index (BMI) is associated with impaired cognitive ability, difficulty in decision-making, and brain structural changes [28]. Comorbid conditions, such as chronic hyperlipidemia, hypertension, and diabetes, impair attention, processing speed, memory, and executive function, partly due to reduced blood flow to the prefrontal cortex [12,29,30]. These effects occur not only in the general population but also in patients with schizophrenia and bipolar disorder [31,32].

Sarcopenic obesity is characterized by low muscle mass and excess body fat, which leads to a progressive decline in muscle quality, strength, and physical function [33]. Furthermore, obesity exacerbates cardiovascular and metabolic burdens through mechanisms such as elevated triglycerides, reduced high-density lipoprotein, increased fasting glucose, and elevated blood pressure [34]. These systemic effects accelerate musculoskeletal, respiratory, and cardiovascular decline, leading to impaired ADLs and greater dependence. Dynapenia—described as age-related muscle weakness—further amplifies these effects [35].

Mobility impairments limit social participation and independence. The correlation between sarcopenia, mental health, and quality of life is a significant concern [36,37,38]. Obesity reduces muscle adaptability, leading to muscle fiber atrophy, fat infiltration, reduced contractile strength, and neuromuscular inefficiencies [39]. These physiological changes restrict daily movements, such as walking, standing, and stair climbing.

Reduction in walking speed, a key marker of functional independence, is associated with reduced capability for dynamic tasks, such as fall recovery or transit navigation [40,41,42]. Thus, improving muscular function through targeted rehabilitation is essential for maintaining ADLs and preventing premature decline.

1.2.6. Abnormal Functional Motor Performance

The neurodevelopmental hypothesis of schizophrenia suggests early, pre-symptomatic abnormalities in functional motor performance [43]. Neurological “soft signs”, such as deficits in motor sequencing [44], integration, and stability, are common and can significantly affect motor function and ADL execution [45]. Notably, catatonic symptoms, including postural abnormalities, immobility, rigidity, and stereotyped behaviors, further limit performance of instrumental ADL (IADL) [4]. Further, a study of eye movement behavior reported diminished exploratory motion and fixation among patients, suggesting underlying compensatory mechanisms [46]. These impairments may reflect disrupted inhibitory control and altered use of motor planning networks, particularly among those with a familial predisposition to schizophrenia [47].

1.2.7. Cognitive Limitations and ADL

Cognitive impairment has a profound impact on both ADLs and IADLs. Deficits in processing speed, executive function, and attention contribute to physical function decline, including difficulties in ambulation, fine motor coordination, communication, and facial expressiveness, all of which complicate self-care and social interaction [48,49]. Sedentary behavior is prevalent among individuals with schizophrenia and is associated with worsened cognitive outcomes and reduced independence in daily life [7]. These findings highlight the need to consider the interplay between cognitive and motor functions when evaluating functional limitations.

1.2.8. Accelerated Brain Aging and Disuse Syndrome

Schizophrenia is recognized as an accelerated aging syndrome. Physiological declines in muscle mass, bone density, endurance, cardiac output, and fat-to-muscle ratio are observed 20–25 years earlier in patients with schizophrenia than in the general population [50]. Disuse syndrome, which stems from chronic sedentary behavior and further accelerates musculoskeletal and cardiovascular deterioration, often aggravates these early-onset declines [12]. These premature changes limit their ability to perform ADL and IADL [51] and increase susceptibility to frailty and physical dependence [52].

1.3. Aim

Based on our literature review, we developed a conceptual framework outlining three key contributors to physical decline in patients with schizophrenia: (1) antipsychotic-related motor dysfunction; (2) dynapenia, sarcopenia, sarcopenic obesity, and frailty; and (3) neuro-motor and cognitive deficits.

This narrative review aims to explore the underlying mechanisms of these contributors and suggests physical rehabilitation strategies for promoting functional recovery and improving long-term outcomes.

2. Physical Rehabilitation for Antipsychotic-Related Motor Dysfunction

Antipsychotic medications—although essential for managing positive symptoms—are associated with a range of adverse effects, including movement disorders, such as drug-induced Parkinsonism and tardive dyskinesia, as well as metabolic side effects like obesity [53,54]. These complications often lead to abnormal motor performance and compensatory movements, compromising a patient’s functional mobility and their ability to perform daily activities [13,55,56,57,58,59]. Therefore, tailored physical rehabilitation strategies are essential to mitigate these risks and prevent early mortality and physical dependency.

2.1. Targeted Interventions and Their Rationale

As outlined in Table 1, rehabilitation programs should be structured around improving strength, flexibility, balance, and gait. A comprehensive program typically includes resistance training to enhance lower-limb and core strength, which directly counteracts the muscle weakness associated with antipsychotic-induced metabolic syndrome and Parkinsonism [14,60,61]. Unlike age-related sarcopenia, the etiology of this muscle weakness is distinct; hence, addressing medication side effects as part of the rehabilitative process is vital.

Flexibility and range of motion are maintained through both dynamic and static stretching routines. This is particularly important for mitigating the muscle rigidity and stiffness that are common in drug-induced Parkinsonism, a factor less prominent in non-medication-related mobility decline [61,62,63,64].

Table 1. Physical rehabilitation for antipsychotic-related motor dysfunction.

Rehabilitation Approach	Rationale & Intervention	Key Characteristics of Schizophrenia	Comparative Insight	Reference Number
Mobility enhancement	Strength training to counteract drug-induced muscle weakness and improve functional mobility.	Antipsychotic-induced Parkinsonism and metabolic syndrome contribute to muscle weakness and altered gait patterns.	Although similar to sarcopenia in older adults, the etiology is distinct, emphasizing the need to address medication side effects.	[14,60,61]
	Balance and postural control exercises to prevent falls.	Extrapyramidal symptoms and cognitive deficits impair balance and increase fall risk.	Unlike typical aging, fall risk is directly associated with medication-induced motor symptoms, requiring a specific focus on these side effects.	[64,65,66]
Flexibility & Range of Motion	Stretching routines to maintain joint mobility and reduce stiffness.	Drug-induced Parkinsonism causes muscle rigidity and stiffness, limiting joint range of motion.	This approach is crucial for mitigating drug side effects, a factor less prominent in non-medication-related mobility decline.	[61,62,63,64]
Balance & Stability Training	Core strengthening and dynamic balance activities.	Impaired proprioception and trunk instability are common due to motor symptoms.	The focus on compensatory movement patterns is a unique aspect not always emphasized in other populations.	[65,66]
	Dual-task and visual–vestibular training to improve adaptability.	Cognitive deficits and attentional impairments are prominent.	This approach integrates cognitive and motor tasks, directly addressing the dual impairment often seen in schizophrenia, which is a key differentiator from other single-domain conditions.	[67,68,69,70]
Individualized Assessment	Using objective tools like Timed Up and Go and the Functional Reach Test.	Objective assessments are vital to measure subtle changes in motor function influenced by medication and symptoms.	The need for ongoing, sensitive monitoring is critical due to fluctuations in medication dose and symptom severity, making it a more dynamic assessment than in stable chronic conditions.	[32,71,72,73,74]

Table 1. Physical rehabilitation for antipsychotic-related motor dysfunction.

Rehabilitation Approach	Rationale & Intervention	Key Characteristics of Schizophrenia	Comparative Insight	Reference Number
Mobility enhancement	Strength training to counteract drug-induced muscle weakness and improve functional mobility.	Antipsychotic-induced Parkinsonism and metabolic syndrome contribute to muscle weakness and altered gait patterns.	Although similar to sarcopenia in older adults, the etiology is distinct, emphasizing the need to address medication side effects.	[14,60,61]
	Balance and postural control exercises to prevent falls.	Extrapyramidal symptoms and cognitive deficits impair balance and increase fall risk.	Unlike typical aging, fall risk is directly associated with medication-induced motor symptoms, requiring a specific focus on these side effects.	[64,65,66]
Flexibility & Range of Motion	Stretching routines to maintain joint mobility and reduce stiffness.	Drug-induced Parkinsonism causes muscle rigidity and stiffness, limiting joint range of motion.	This approach is crucial for mitigating drug side effects, a factor less prominent in non-medication-related mobility decline.	[61,62,63,64]
Balance & Stability Training	Core strengthening and dynamic balance activities.	Impaired proprioception and trunk instability are common due to motor symptoms.	The focus on compensatory movement patterns is a unique aspect not always emphasized in other populations.	[65,66]
	Dual-task and visual–vestibular training to improve adaptability.	Cognitive deficits and attentional impairments are prominent.	This approach integrates cognitive and motor tasks, directly addressing the dual impairment often seen in schizophrenia, which is a key differentiator from other single-domain conditions.	[67,68,69,70]
Individualized Assessment	Using objective tools like Timed Up and Go and the Functional Reach Test.	Objective assessments are vital to measure subtle changes in motor function influenced by medication and symptoms.	The need for ongoing, sensitive monitoring is critical due to fluctuations in medication dose and symptom severity, making it a more dynamic assessment than in stable chronic conditions.	[32,71,72,73,74]

2.2. Addressing Balance and Cognitive–Motor Deficits

Given the high risk of falls associated with extrapyramidal symptoms, balance training is especially critical for this population [64,65]. Postural control exercises and core strengthening are effective methods for improving trunk stability and proprioception [7,56,66]. Moreover, dual-task training, which combines motor and cognitive tasks, is a key differentiator of rehabilitation for schizophrenia. This approach directly addresses the prominent cognitive and attentional impairments that coexist with motor deficits, a “dual impairment” not always seen in other single-domain conditions [67,68]. Visual–vestibular integration exercises further enhance a patient’s adaptability to environmental challenges, a crucial skill for safe community ambulation [69,70].

2.3. Individualized Assessment and Ongoing Monitoring

To ensure interventions are effective, rehabilitation strategies must be personalized based on objective assessments. Quantitative tools, including the “Timed Up and Go” [71], Functional Reach Test [32], and Berg Balance Scale [72], provide objective measurement of balance and functional mobility. These tools are vital for identifying fall risk and functional limitations, allowing clinicians to tailor individualized plans [71]. Continuous and sensitive monitoring is especially important in this population, as changes in medication dosage and symptom severity can make the assessment process more dynamic than in stable chronic conditions. Physical therapists play a critical role not only in delivering these interventions but also in encouraging long-term physical activity habits to manage deconditioning and sustain functional gains over time [73,74].

3. Physical Rehabilitation for Dynapenia, Sarcopenia, Sarcopenic Obesity, and Frailty

Negative symptoms and cognitive deficits in patients with schizophrenia often lead to a sedentary lifestyle, increasing their risk for conditions such as dynapenia, sarcopenia, sarcopenic obesity, and frailty [10,59,60,61]. Evidence shows that targeted exercise interventions can effectively alleviate these conditions by improving aerobic capacity and muscular strength [62,63].

3.1. Comprehensive Rehabilitation Strategies

Preventive rehabilitation is crucial for preserving physical independence as it mitigates the effect of accelerated aging in this population [75]. A core component of this approach involves promoting sustained exercise habits through a combination of aerobic and resistance training. This dual approach helps maintain muscle mass, reduce fat, and improve cardiovascular health [6,14,76,77], which is especially important for pre-frail or physically inactive patients.

Rehabilitation programs should incorporate balance exercises and flexibility-enhancing stretches to further enhance physical function [78]. In addition, when implemented early, multidisciplinary interventions—including occupational therapy and lifestyle modifications—can yield improved cognitive and physical outcomes [78].

3.2. Nutritional and Swallowing Interventions

Given that malnutrition, sarcopenia, and frailty often coexist, a collaborative rehabilitation-nutrition approach is essential [79]. To preserve muscle mass and function, this strategy should include tailored nutritional assessments and aggressive nutrition therapy alongside physical therapy. The correlation between sarcopenia of the swallowing muscles, dysphagia, malnutrition, and frailty is well-documented [80,81]. In these cases, combining exercise and protein supplementation is a valuable strategy for preserving swallowing function and overall ADL performance [81]. Specific macronutrient strategies, such as high-protein and low-carbohydrate diets, may further support metabolic health and muscle maintenance [80,82].

3.3. Cardiovascular and Functional Enhancement

Cardiovascular impairments are highly prevalent in schizophrenia and significantly impact endurance and mobility. Recent findings suggest that even individuals with first-episode schizophrenia exhibit below-average cardiorespiratory endurance and muscular strength [83], underscoring the need for early intervention. Incorporating aerobic and interval training into rehabilitation regimens can enhance aerobic fitness, lower cardiovascular risk, and promote resilience during ADLs [84]. Moreover, strengthening lower limb muscles and implementing respiratory muscle training further reduces cardiovascular strain during daily tasks, supporting sustained functional independence [85,86].

Posture correction and load-reducing movement guidance are essential for patients with obesity-related joint complications (including knee osteoarthritis) [87]. Individualized programs may include the use of orthotic insoles and supportive braces to facilitate pain-free movement, improving adherence and functional recovery [87,88,89].

3.4. Addressing Sedentary Behavior

Patients with schizophrenia often remain sedentary for > 12 h per day [65], which significantly increases their risk of metabolic disorders, poor functional endurance, and premature aging [90]. Low cardiorespiratory fitness has been identified as an independent predictor of mortality in adults, and higher fitness levels are associated with a reduction in both overall mortality and cardiovascular disease incidence [91]. Therefore, cardiopulmonary enhancement through regular aerobic exercise and interval training must be prioritized in a targeted rehabilitation strategy [31,39]. By combining these interventions, patients can improve their endurance, ADL capacity, and overall mental well-being, while mitigating functional decline associated with a sedentary lifestyle [34,37].

Table 2. Physical rehabilitation for dynapenia, sarcopenia, sarcopenic obesity, and frailty.

Rehabilitation Focus	Rationale & Key Interventions	Characteristics of Schizophrenia	Comparative Insight	Reference Number
Muscle and motor function	Strength and resistance training to enhance muscle mass and adaptability.	Sarcopenia and dynapenia are accelerated by sedentary behavior caused by negative symptoms and cognitive deficits.	Unlike age-related sarcopenia, the driving factors are behavioral (sedentary lifestyle) and symptom-related, requiring a focus on motivational strategies.	[62,63]
Cardiovascular & metabolic health	Aerobic and interval training to improve cardiorespiratory fitness and reduce metabolic risk.	High prevalence of metabolic dysfunction and cardiovascular disease due to sedentary behavior and antipsychotic medication.	Although relevant to many chronic conditions, the rate of decline is significantly accelerated in this population, necessitating early, aggressive intervention.	[31,39,83,84,90,91]
Nutrition & metabolic Balance	Collaborative rehabilitation-nutrition approach to ensure adequate protein intake and metabolic health.	Malnutrition and poor dietary habits exacerbate muscle wasting and frailty, often coexisting with symptoms.	This is a crucial element that links physical therapy with nutritional care, which is often overlooked in general rehabilitation models.	[79,80,82]
Swallowing function	Exercise and protein supplementation to strengthen swallowing muscles.	Dysphagia and aspiration risk are associated with sarcopenia of the swallowing muscles, a complication of severe frailty.	This is a specialized need that is directly connected to overall physical decline, highlighting the importance of a comprehensive approach to frailty management.	[81,82]
ADL	Task-oriented training to improve walking speed, movement efficiency, and social participation.	Reduced ADL independence due to both physical and behavioral factors (such as lack of motivation from negative symptoms).	The focus is not just on physical capacity but also on re-engaging patients in purposeful activities, which addresses the behavioral aspects unique to schizophrenia.	[34,37,78]

Abbreviation: ADL, activities of daily living.

outlines the rehabilitation strategies for managing dynapenia, sarcopenia, sarcopenic obesity, and frailty in schizophrenia.

4. Physical Rehabilitation for Neuro-Motor and Cognitive Deficits

Accelerated brain aging and disuse syndrome contribute to neurobiological impairments that further degrade motor performance [60,92]. These changes often manifest early in the disease course and are not solely medication-induced, suggesting a fundamental central nervous system vulnerability [6,7]. These factors can lead to a significant loss of physical independence and increase the risk of hospitalization, making comprehensive physical rehabilitation strategies essential.

4.1. Targeted Neuromotor and Gait Training

Targeted rehabilitation is crucial for managing extrapyramidal symptoms and other neuromotor and cognitive deficits. Exercise therapy that incorporates rhythmic, coordinated, and postural control movements [93,94] can help restore voluntary motor function and reduce fall risk. Core training is crucial in supporting motor recovery; strengthening the deep abdominal muscles, spinal stabilizers, and pelvic floor improves postural alignment, gait efficiency, and dynamic balance [95,96,97].

Gait dysfunction in this population is often characterized by bradykinesia, reduced stride length, and lower ankle plantar flexion strength [12]. Therefore, to optimize walking ability and minimize fall risk, physical rehabilitation should integrate core training, stride enhancement, and plantar flexion exercises with balance-focused interventions [53,95,98].

4.2. The Role of Occupational Therapy

Occupational therapy is a crucial component of functional rehabilitation. Interventions can include fine motor training to enhance finger dexterity [99], sensory integration therapy to coordinate tactile, visual, and proprioceptive inputs [100], and environmental modifications to support the execution of ADLs and IADLs [101]. Applied movement training, such as performing eating or writing tasks, further reinforces skills essential for daily living [55].

4.2.1. Beyond Motor Skills: Impact on Mental and Cognitive Symptoms

Although antipsychotic medication remains the primary treatment for schizophrenia, recent evidence highlights the substantial added value of physical rehabilitation in improving both positive and negative symptoms, as well as cognitive function [65,102]. Moderate-intensity physical activity can reduce distractibility and improve concentration while promoting motivation, social interaction, and goal-directed behavior. Regular exercise has also been consistently associated with cognitive maintenance and enhancement.

When combined with cognitive behavioral therapy (CBT), physical rehabilitation can further strengthen adherence, address motivational deficits, and improve functional outcomes in ADLs and IADLs [103].

4.2.2. The Role of CBT

CBT is defined as “a structured therapy that focuses on an individual’s behaviors and cognitions (automatic thoughts) that aims to rationally address behavioral challenges, cognition, emotions, beliefs, and motivation, providing a process of learning directed toward problem-solving and self-control based on self-understanding” [104].

In individuals with schizophrenia, CBT can help improve positive symptoms (including delusions and hallucinations), negative symptoms (including avolition and social withdrawal), and cognitive functions (such as attention, memory, and executive function) [105,106]. One of the core techniques of CBT, cognitive restructuring, focuses on automatic thoughts that arise in stressful situations and helps identify distorted cognitions, thereby facilitating a shift toward more adaptive thinking; this technique reduces depression and anxiety [107].

Moreover, combining physical rehabilitation with CBT may enhance motivation, promote sustained participation in rehabilitation programs, and improve performance in ADLs and IADLs. Specifically, goal-setting and self-monitoring strategies derived from CBT are useful in exercise therapy, as they are expected to enhance patients’ self-efficacy [104,107]. Therefore, CBT should be regarded as an important psychosocial adjunct to physical rehabilitation in schizophrenia, positioned as part of an integrated approach that contributes to quality of life improvement and relapse prevention [105,106,108].

Table 3. Physical rehabilitation for neuro-motor and cognitive deficits.

Rehabilitation Focus	Rationale & Key Interventions	Characteristics of Schizophrenia	Comparative Insight	Reference Number
Neuromotor function	Rhythmic exercises and core training to improve motor coordination and postural control.	Motor and gait dysfunctions are not solely medication-induced but also associated with central nervous system vulnerabilities and disuse syndrome.	This approach differs from typical Parkinson’s disease rehabilitation, as the underlying cause is more complex and not strictly dopaminergic, requiring a broader focus on neuroplasticity and motor control.	[93,94,95,96,97,98]
Cognitive–motor integration	Dual-task and visual–vestibular training to enhance attention and executive function.	Cognitive deficits (including attention and working memory) directly impair a patient’s ability to perform complex motor tasks and navigate their environment safely.	This is a unique dual-benefit approach that directly addresses the simultaneous impairment of both cognitive and motor domains, which is a major challenge in schizophrenia.	[67,68,69,70]
Functional Motor Skills	Fine motor training and sensory integration therapy to improve the execution of ADLs and IADLs.	Fine motor deficits and sensory-motor impairments contribute to a loss of independence and social withdrawal.	This emphasizes a holistic approach that bridges physical limitations with real-life functional tasks, which is essential for improving social participation and quality of life, a key goal in schizophrenia rehabilitation.	[55,99,100,101]
Psychiatric symptom improvement	Moderate physical activity and regular exercise to improve motivation and cognitive function.	Physical activity not only improves motor function but also directly alleviates positive/negative symptoms, enhances motivation, and promotes goal-directed behavior.	This is a unique dual-benefit aspect of physical rehabilitation in schizophrenia that is less pronounced in purely physical conditions, making it a powerful adjunctive treatment.	[65,102,103]
CBT	Cognitive restructuring, goal-setting, and self-monitoring to address distorted cognitions and enhance self-efficacy.	CBT improves positive/negative symptoms and cognitive functions. When combined with physical rehab, it enhances motivation and adherence.	CBT is an important psychosocial adjunct to physical rehabilitation, offering an integrated approach to improve quality of life and prevent relapse.	[103,104,105,106,107,108]

Abbreviations: CBT, cognitive behavioral therapy; ADL, activities of daily living; IADL, instrumental activities of daily living.

summarizes the physical rehabilitation modalities tailored to neuromotor and cognitive deficits in this population.

5. Discussion

This conceptual framework delineates three distinct yet interconnected domains of physical decline in patients with schizophrenia (antipsychotic-related motor dysfunction, dynapenia/sarcopenia/frailty, and neuro-motor and cognitive deficits) and proposes tailored rehabilitation strategies for each, with significant implications for both clinical practice and future research.

5.1. Physical Rehabilitation for Antipsychotic-Related Motor Dysfunction

The contents summarized in Table 1 suggest that physical rehabilitation for patients with schizophrenia requires an individualized approach that extends beyond general physical therapy principles. Although many interventions, such as strength and balance training, are common in geriatric and neurological rehabilitation, their application in this population is uniquely influenced by the specific pathophysiology of schizophrenia and its treatment.

The etiology of motor dysfunction is a key distinction. In geriatric populations, physical decline is primarily caused by age-related processes, including sarcopenia and frailty [109]. However, in schizophrenia, a considerable portion of motor dysfunction—including muscle weakness, rigidity, and gait abnormalities—is directly attributable to antipsychotic-induced side effects, such as extrapyramidal symptoms [110,111,112]. Our proposed framework, therefore, uniquely emphasizes the need to address these medication-related factors.

Our conceptual framework highlights the importance of integrating cognitive and motor training. This approach, as observed with dual tasks and visual–vestibular exercises, is particularly critical for patients with schizophrenia who often present with simultaneous cognitive impairments and attention deficits [113,114], which is a crucial difference from many other neurological conditions where either the motor or cognitive domain is the primary focus. Although similar dual-task training is used in stroke rehabilitation [115,116,117], our framework specifically targets the interplay between medication side effects and pre-existing cognitive symptoms that contribute to functional decline.

By systematically comparing the challenges faced by patients with schizophrenia to those in other populations, our findings revealed that a generic rehabilitation strategy is insufficient. Thus, a targeted, multidisciplinary approach is essential. This framework directly addresses the unique factors of drug-induced motor dysfunction and cognitive–motor integration, thereby providing a valuable roadmap for clinicians aiming to improve functional independence and long-term outcomes in this population.

5.2. Physical Rehabilitation for Dynapenia, Sarcopenia, Sarcopenic Obesity, and Frailty

The findings summarized in Table 2 indicate that the physical rehabilitation of patients with schizophrenia must be approached with a clear understanding of the unique factors that contribute to accelerated physical decline. Although conditions like sarcopenia and frailty are prevalent in geriatric populations [118], our proposed framework highlights that their etiology and progression in schizophrenia are distinct, primarily driven by symptom-related and behavioral factors.

Unlike age-related frailty, the sedentary lifestyle often observed in patients with schizophrenia, stemming from negative symptoms and cognitive deficits, is a major accelerator of muscle wasting and metabolic dysfunction [119,120]. This behavioral component necessitates a different rehabilitation strategy that goes beyond simple exercise prescriptions. Our model emphasizes the importance of motivational and psycho-educational interventions to address the apathy and lack of drive that impede physical activity, a key element often less critical in other populations.

Our framework uniquely integrates nutritional and cardiovascular health as central components of rehabilitation. The high prevalence of metabolic syndrome and cardiovascular disease in this population [121] makes cardiopulmonary enhancement not just a goal for general well-being but a critical component for mortality reduction [122]. This comprehensive approach, which links physical therapy with nutritional counseling and cardiorespiratory training, stands apart from traditional models that may focus on a single domain.

A generic “one-size-fits-all” approach to frailty and sarcopenia is insufficient for patients with schizophrenia. Overall, our conceptual framework provides a holistic and targeted strategy for rehabilitation by systematically addressing the unique behavioral, metabolic, and symptomatic drivers of physical decline. This model not only aims to restore physical function but also to combat premature mortality and enhance long-term quality of life by tackling the root causes of their physical deterioration.

5.3. Physical Rehabilitation for Neuro-Motor and Cognitive Deficits

The insights presented in Table 3 indicate that physical rehabilitation for patients with schizophrenia must extend beyond conventional motor recovery to address unique neuro-motor and cognitive deficits and their profound impact on cognition and behavior. Unlike rehabilitation for stroke or spinal cord injury, which primarily targets motor function restoration [123], our framework emphasizes the intrinsic link between physical activity and psychiatric symptom management [124]. This dual-benefit approach is a cornerstone of effective rehabilitation for this population.

The complex etiology of motor deficits in schizophrenia is a critical distinction. Although medication-induced motor side effects are substantial, many deficits are rooted in central nervous system vulnerability and disuse syndrome from an early stage of the illness [125,126], suggesting that rehabilitation must aim for neuroplasticity to a greater extent than in conditions where deficits are more localized. Our proposed strategies, which incorporate rhythmic and core training, are designed to stimulate this neuroplastic change, a focus that is uniquely relevant to the neurobiological underpinnings of schizophrenia.

The integration of occupational therapy is not restricted to restoring ADLs but also involves re-engaging patients in purposeful, daily life activities. Table 3 highlights how training in fine motor skills and sensory integration directly counters the social withdrawal and lack of motivation often driven by negative symptoms [65,102,103]. This approach—which links physical recovery with behavioral activation—is what distinguishes this model from those focused solely on physical outcomes.

Our conceptual framework highlights that physical rehabilitation in schizophrenia is not simply an adjunctive treatment but a multifaceted intervention that targets the core neurobiological, motor, and behavioral deficits of the illness. By addressing the unique neuro-motor and psychiatric challenges of this population, this model offers a comprehensive strategy to not only improve physical function but also to enhance overall quality of life, cognitive function, and social participation.

5.4. Practical Applications and Clinical Workflow

This framework directly addresses critical practical gaps in the current care of patients with schizophrenia, emphasizing a more precise and effective approach to physical rehabilitation. It transforms our conceptual framework into a tangible clinical workflow.

5.4.1. Holistic and Granular Assessment

This framework suggests a transition from generalized physical assessments to a more specific evaluation that identifies the unique contributors to physical decline within each domain. Clinicians, including physical and occupational therapists, will be guided to assess not only overall functional status but also specific antipsychotic-induced movement patterns, precise measures of muscle mass and strength in the context of negative symptoms and nutritional status, and subtle neuro-motor deficits, such as impaired postural control or gait abnormalities. This detailed understanding will enable more accurate diagnosis and personalized treatment planning.

5.4.2. Precision Rehabilitation and Individualized Treatment Plans

This framework facilitates the development of highly individualized rehabilitation programs by clarifying the underlying mechanisms of physical dysfunction. The process is operationalized as a clinical workflow to guide practitioners in delivering targeted physical rehabilitation. The following four steps outline a structured process for assessing, categorizing, and designing individualized rehabilitation plans for patients with schizophrenia.

Step 1: Initial assessment and screening

The process begins with a comprehensive physical assessment to identify the patient’s primary functional limitations, which includes using quantitative, objective tools, such as the Timed Up and Go Test for gait and balance, the Berg Balance Scale for static and dynamic balance, and a handheld dynamometer to measure muscle strength. A thorough review of the patient’s medication history and psychiatric symptoms is also crucial to provide context for the physical findings.

Step 2: Categorization into a primary domain

Based on the initial assessment, the clinician categorizes the patient’s primary dysfunction into one of the three domains of our framework:

• Domain 1 (Antipsychotic-related): Patients with pronounced extrapyramidal symptoms (including rigidity and tremor) or significant metabolic side effects (such as obesity) and impaired gait likely fall into this category.
• Domain 2 (Negative symptom-related): Patients with a history of sedentary behavior, significant apathy, or signs of dynapenia/sarcopenia are primarily guided by this domain. These issues are often associated with long-standing behavioral patterns rather than acute medication effects.
• Domain 3 (Neuro-motor and cognitive deficits): If the patient exhibits subtle neuromotor impairments (including gait abnormalities and poor coordination) that predate medication use or persist despite symptom stability, the rehabilitation focus shifts here, addressing central nervous system vulnerabilities.

Step 3: Tailored rehabilitation plan

Once categorized, a targeted, multidisciplinary rehabilitation plan is developed. Interventions can be meticulously tailored; for example, addressing compensatory movements for drug-induced Parkinsonism (Domain 1), integrating motivational strategies to overcome apathy associated with sarcopenia (Domain 2), or implementing specific neurorehabilitation techniques for gait and balance deficits stemming from accelerated brain aging (Domain 3). This specificity moves beyond generic exercise prescriptions towards interventions designed to counteract characteristic pathologies.

Step 4: Continuous reassessment and adaptation

Physical rehabilitation for patients with schizophrenia is a dynamic process. Clinicians should continuously reassess the patient’s progress using the same objective tools from Step 1. The rehabilitation plan must be adapted as the patient’s symptoms or medication regimen changes, ensuring the intervention remains effective and personalized.

5.4.3. Enhanced Multidisciplinary Collaboration

The interconnected nature of these physical challenges, intertwined with psychiatric symptoms and medication effects, underscores the indispensable need for robust multidisciplinary collaboration. This framework emphasizes that optimal outcomes require seamless integration among psychiatrists, physical therapists, occupational therapists, dietitians, and other healthcare professionals, ensuring that physical rehabilitation is consistently aligned with medication management, mental health support, and nutritional interventions, creating a comprehensive and synergistic care pathway.

5.4.4. Focus on Early and Preventive Intervention

By identifying factors, such as early neuro-motor and cognitive deficits and the accelerated aging process, this framework highlights the importance of proactive and preventive physical rehabilitation, underscoring the need to initiate interventions earlier in the disease course, particularly during prolonged hospitalization, to mitigate the progression of physical decline, reduce hospitalization risk, and ultimately improve long-term independence and quality of life.

6. Limitations and Recommendations

First, this review was based on an analysis of existing literature retrieved from the PubMed database, limited to English-language publications only. Our goal is to assist researchers in getting a comprehensive understanding of the literature. However, this language restriction may have limited the scope of available knowledge on the topic. Future studies should incorporate sources from various languages and regions to achieve a more global perspective.

Second, this review did not cover psychosocial rehabilitation, which involves methods to increase patient interest and motivation. Future studies should also examine the synergistic effects of combining psychosocial and physical rehabilitation.

7. Conclusion and Future Directions

The cascade of a patient’s physical decline occurs in three interconnected domains:

(1) Antipsychotic-related motor complications;

(2) Sedentary behavior associated with negative symptoms;

(3) Neuro-motor impairments resulting from accelerated brain aging.

This model enables clinicians to do more than just manage symptoms; it allows them to actively improve physical function and foster long-term independence.

Ultimately, achieving optimal outcomes requires a multidisciplinary approach with seamless collaboration among psychiatrists, physical therapists, occupational therapists, and dietitians. Individualized nutritional support is also imperative to address the complex sequelae of these health risks.

This conceptual framework opens several critical avenues for future research, including (1) empirical validation of the three-domain framework in diverse populations; (2) rigorous efficacy testing of highly tailored interventions targeting specific domains; (3) investigation of inter-domain synergies to understand how interventions in one area impact others; (4) optimization of integrated care models and collaborative pathways; and (5) identification of biomarkers for early and targeted preventive interventions.