By Stephanie Molloy, Canadian Physiotherapist
This piece was written in reflection of personal experiences of Mental Health PT (or rather, the lack thereof) in the Quebec healthcare system.
Physiotherapists (PT) have many diverse roles and ways of treating patients in mental health settings - from preventing to treating various conditions. It is incredibly important to involve physiotherapists in the multidisciplinary team at mental health institutions to ensure that patients are getting the highest quality of care possible, and also to reduce the work of other team members! Let’s explore some ways that physiotherapists are beneficial within mental health care, and are important team members for providing holistic care.
Prevention of Physical Conditions
Hospital-associated deconditioning (HAD) is sadly a common phenomenon, especially in elderly clients. One study found that in previously home-living elderly patients, two-thirds deteriorated in functional levels between admission and discharge (1). Additionally, HAD has been linked to increased stress, length of stay in hospital, and readmission rates (2). Although there is limited data on mental health institutes specifically, for the majority of patients the setting is incredibly similar, and the risks are the same. Deconditioning can lead to various problems such as muscle weakness (which leads to falls), incontinence, increased confusion, issues with appetite/digestion/swallowing, and increasing overall immobility (3). All of this leads to a decrease in autonomy and an increase in required services and levels of care for the patient - within and without of the hospital.
Luckily, HAD is easily preventable and physiotherapists (PTs) can help! Regular physical exercise is known to reduce prevalence of deconditioning, and reduce the risk of numerous other physical affiliations (3). PTs can help to prevent and treat deconditioning by keeping patients physically active and maintaining their current level of function. Physiotherapy interventions for this can include one-on-one sessions to work on gait quality, balance, and transfers among other things. PTs can also introduce the patient to gait aids to ensure they remain autonomous, for example if a patient is unsafe to walk unsupported, they may still be able to safely walk with a cane or walker. Interventions can also include group exercises classes. These are beneficial for a number of reasons - they create socialization for the patients, multiple patients are able to be seen at one time, and the same physical benefits occur. Studies have shown that physical rehabilitation programs improve patients' results on physical function tests (such as TUG and BERG), are less likely to be discharged to a nursing home, and have reduced stays in the hospital (4, 5).
Therefore it is easy to see that every patient can benefit from physical therapy, whether or not it may seem like a patient needs it. It is much easier to prevent physical decline than to try to improve after it has occurred. This also highlights the importance of multidisciplinary team communication. It is important for the PT to know what level of physical function every patient is in when entering the institution. If the patient has a history of falls or starting falling once in hospital, PT’s are able to help intervene. Team members should also communicate about the patient’s well-being, for example if any team member has noticed a change in the patient’s regular daily activities, the PT can intervene. The PT also has to communicate with the team what they have been doing with the patient, what they have observed, and recommendations they may have. Consistent communication between team members is the best way to ensure that everyone is on the same page about a patient’s care, treatment, and discharge plan - so that everyone is working toward the same goal with the patient.
Treating Physical Conditions
Even in mental health settings patients can develop physical conditions that need to be treated. This includes any issue that affects the general population that physiotherapists can treat - joint pain, arthritis, synovitis, tendonitis, sprains and strains, fracture recovery, back pain, balance issues, and decreased function to name a few.
This is the most common use of PTs in mental health institutions, and it is a very important role that they can play to get patients back to their normal physical function and level of autonomy. PTs see these patients through referrals, which highlight what the concern or problem of the patient may be. Again, it is important to continue multidisciplinary team communication to ensure all team members are on the same page in regards to treatment goals and outcomes.
Treating and Managing Mental Conditions
PTs are frequently underused in mental health settings. Did you know that PTs can actually help with the treatment and management of various mental health conditions? Let’s look at a few examples:
Dementia
Physical activity has been shown to have significant benefits to people with dementias. Not only can it help to treat physical function and autonomy, but it can also improve cognitive function, and reduce or delay the onset of neuropsychiatric symptoms such as confusion, depression, apathy, etc (6). Physical activity can also improve patients’ executive functioning, increase their autonomy, and reduce their overall risk of falls. This is an incredible non-pharmacological treatment to this disease, which is frequently overlooked and unused.
Schizophrenia
The International Organisation of Physical Therapists in Mental Health found that PTs have a very important role in the multidisciplinary team in the treatment of individuals with schizophrenia (7). This is especially true when one considers that individuals with schizophrenia are at higher risk of developing preventable physical conditions such as respiratory disease, diabetes, and heart disease (8).
PT treatment has actually been found to help improve the psychiatric, physical and quality of life of individuals with schizophrenia (9). Various exercise techniques and treatments are able to reduce psychiatric symptoms, reduce anxiety and psychological distress, and improve overall health-related quality of life.
Major Depression
A 2020 study on individuals with major depression found that when compared with the standard treatment method alone, the addition of physiotherapy methods are more effective as treatment. After the physiotherapy intervention, the experimental group had statistically significant improvements on both anxiety and depression scales when compared to the control group (10).
Eating Disorders
Once again PT is able to help with both the physical and psychiatric aspects of this disorder. A systematic review found that exercise interventions resulted in significantly increased body mass index, muscle strength, and body fat percentage in anorexia patients (11). Additionally, other techniques such as aerobic exercise and basic body awareness therapy (a PT technique), significantly lowered scores of eating pathology and depressive symptoms in both anorexia and bulimia nervosa patients (11). From only four examples of conditions, it is clear to see that PTs are able to help with the actual treatment of many mental disorders and aren’t only there for referrals when a patient experiences physical conditions or issues.
Conclusion
In mental health settings and institutions PTs have an important role to play in the prevention and treatment of both physical and mental conditions. Their role is diverse, they employ a wide variety of techniques, and their impact is tremendous. Therefore, PTs should be included in every aspect of patient care, and are very valuable members of the medical multidisciplinary team. Rather than being left out, forgotten, and ignored by mental health institutions and care settings, PTs should be viewed as respected professionals and an incredible resource who can help improve patients' quality of life - from physical to mental, and everything in between.
Sources
Hospital-Associated Deconditioning and Dysfunction (1991) https://www.researchgate.net/profile/Laurence-Rubenstein/publication/21163966_Hospital-Associated_Deconditioning_and_Dysfunction/links/5a7b0738aca2722e4df6fd13/Hospital-Associated-Deconditioning-and-Dysfunction.pdf
A qualitative study exploring the lived experiences of deconditioning in hospital in Ontario, Canada (2021) https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-021-02111-2
A Comprehensive Guide to Rehabilitation of the Older Patient (2021) https://books.google.ca/books?hl=en&lr=&id=lnEJEAAAQBAJ&oi=fnd&pg=PA105&dq=physiotherapy,+prevention,+deconditioning&ots=NTTRqgU1TR&sig=BXkkZp6FTLHtObCQ--9DaytjpQE&redir_esc=y#v=onepage&q=physiotherapy%2C%20prevention%2C%20deconditioning&f=false
Effectiveness of a Group Exercise Program in a Long-Term Care Facility: A Randomized Pilot Trial (2003) https://www.sciencedirect.com/science/article/pii/S1525861004702790?casa_token=zwAaIHi9HW0AAAAA:aa4aR6uGsO0Jk6i6XDYIXSrwQmMfNGGz1heGLE3raZCqyZINHhHgNzjmWKxtdn4W4PXSyaLm
Effectiveness and feasibility of early physical rehabilitation programs for geriatric hospitalized patients: a systematic review (2013) https://bmcgeriatr.biomedcentral.com/articles/10.1186/1471-2318-13-107
The effect of physical activity on dementia (2019) https://europepmc.org/article/med/31425142
Understanding the role of physiotherapists in schizophrenia: an international perspective from members of the International Organisation of Physical Therapists in Mental Health (IOPTMH) (2013) https://www.tandfonline.com/doi/full/10.3109/09638237.2013.869574?casa_token=1rml0o2mpm4AAAAA%3AZPjJOmsQ4k73WZRKIh0J78JJhFBKANZe-jYRy7UDBvo7516NI-gsL6gSdOaIck8iGm641cXqWtM
Addressing the disparity in physical health provision for people with schizophrenia: an important role for physiotherapists (2014) https://www.physiotherapyjournal.com/article/S0031-9406(13)00120-X/fulltext
A systematic review of the benefits of physical therapy within a multidisciplinary care approach for people with schizophrenia: An update (2015) https://www.sciencedirect.com/science/article/pii/S0165178115005430?casa_token=9ZneQ6nmZaIAAAAA:nUMqmfqC9OPFHpwYHLkOs3aSvu8GmYuswtxPgPaHpJDnTpIhQrQ4yzAjvEpsB7lh6Vlu5lmj
The effects of physiotherapy methods combined with respiratory and relaxation exercises on patients with major depression (2020) https://www.researchgate.net/profile/Elisa-Calisgan/publication/344493187_The_effects_of_physiotherapy_methods_combined_with_respiratory_and_relaxation_exercises_on_patients_with_major_depression/links/5f7c5f9b458515b7cf6a3b7b/The-effects-of-physiotherapy-methods-combined-with-respiratory-and-relaxation-exercises-on-patients-with-major-depression.pdf
A systematic review of physical therapy interventions for patients with anorexia and bulimia nervosa https://pubmed.ncbi.nlm.nih.gov/23826882/
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