For mental health action week 23-29 March, Louise Hunt highlights the work of physios in the field
With one in four adults experiencing a mental health problem at some point in their lives, every physio should have a good understanding of mental health and its physical impact. Yet mental health physios often feel their roles are not well understood by other healthcare professionals and sometimes by their own profession, and that they are fighting a constant battle for recognition. However, they are determined not to be left out in the cold, and are fighting to make their voices heard. Mental health specialist physios traditionally work in acute inpatient units within mental health trusts with patients who have severe and enduring mental health problems, such as schizophrenia, bipolar and personality disorders. To a lesser extent, they may also work in primary care community services, with people with common mental health problems such as anxiety and depression. Increasingly, they work across both settings (see panel: Building bridges). Because there are so few specialists, (the Chartered Physiotherapists in Mental Health clinical interest group has approximately 150 members) mental health physios have to cover a very wide brief. 'We aren't able to specialise in, say musculoskeletal or neurology, because we are spread so thinly. And we have to be able to work across all settings, including inpatients, outpatients and the community,' says Ann Childs, mental health lecturer at the University of Nottingham and clinician for Nottinghamshire healthcare trust. As well as assessing physical dysfunction, mental health physios liaise with and provide specialist advice to other services, such as medical and community mental health teams. 'It's about how we can build bridges for patients so that they can move forward, for example, being able to go on to mainstream physiotherapy,' Ms Childs comments. Mental health physios also serve an important function in improving the well-being of patients with severe mental illness through specific treatment programmes. The stark health inequalities faced by this group were identified as a priority area in the government's Choosing Health white paper and subsequent 2006 commissioners' framework. Sue Coffee, Birmingham and Solihull mental heath trust physical therapy services manager, is implementing the well-being standards in her trust and says: 'Physios are very well placed to lead on the physical health agenda. We are the link with medicine, orthopaedics and neurology that can advance patients in acute care.' Patients with severe and enduring mental illness often suffer from the negative effects of powerful anti-psychotic drugs. Understanding how to counter this is key for physios. People with schizophrenia or bipolar disorder, for example, are twice as likely to have type 2 diabetes, caused by weight gain affected by medication and lethargy. They are also at greater risk of coronary heart disease, hypertension, epilepsy and stroke, caused by increased anxiety and chronic elevation of blood pressure. High stress levels also make these patients more susceptible to musculoskeletal problems. 'The neurophysiology of mental health means patients are more predisposed to clotting problems and therefore more prone to inflammatory diseases that can cause injury during exercise,' Ms Coffee explains.
Exercise therapyMichael Skelly, superintendent physiotherapist across East Lothian and Mid Lothian mental health services, is a firm believer that exercise therapy influences neural structures impacting on mental health. His patients can choose between several different exercise groups a week, including t'ai chi, ballroom dancing and keep fit classes. He has also used Choosing Health funding to establish a network of volunteers, led by a technical instructor, who support service users in community based exercise therapy, on a self-referral basis. Body awareness and mindfulness techniques help patients understand the effects of posture. 'We get people to think about how they are communicating through body language. We tell them movement quality will affect mental state and that they can control their own neurophysiology.' Touch therapy, including massage, is also used effectively in mental health. Ms Childs uses hands on palpation to increase body awareness and feel what is happening in the tissues in relation to their tone and emotional state. She says: 'The concept of touch is very powerful in the therapeutic relationship as a communication aid... It is not about the diagnostic condition of the patient, but the needs of the person and what they respond to at that moment in time.' She finds it particularly helpful for patients who have dissociation (extreme out of body sensations) that can affect many aspects of life such as spatial awareness and decision-making. 'The touch techniques have been very effective in getting patients to engage cognitively. It can keep them grounded while they are receiving other kinds of therapies.' Nicola Jackson, a junior physiotherapist in psychiatric intensive care at Cheadle Royal Hospital in Stockport, finds massage therapy is particularly helpful in reducing anxiety in patients with schizophrenia. 'Often patients can be quite manic at the start, but massage really helps to develop a rapport. It is time for them to just sit and relax and not have to answer questions. It also helps them to develop a coping strategy for hallucinations.'
Future challengesDespite their proven worth in mental health, physios will continually have to stake their claim on their specialty, as other health professions encroach on their core areas of expertise. This battle is exacerbated by constant funding pressures on mental health services and physios' difficulties in influencing national mental health strategies, most notably the National Institute for Health and Clinical Excellence guidelines for schizophrenia, which did not include physio intervention. 'Not many people really understand the role of physiotherapy in mental health,' says Ms Childs. 'What has been our traditional work - massage and exercise therapy - could be taken over by complementary therapists or fitness instructors. How does a physio justify their role when an occupational therapist or a physical health nurse, which is a new nursing role, could do this too? 'We have to be quite open and humble and say “yes, others can perform these roles, but others don't have the medical understanding of the body and our expertise in fitting this into a psychological setting”.' Michael Skelly agrees and says theory is the way forward: 'Mental health offers fantastic opportunities for physios but we need to refocus the profession on massage, manual therapies and exercise from a theoretical basis, otherwise we are leaving ourselves in a vulnerable position.' He adds: We have to take advantage of being the most holistic profession, but we need to ground ourselves in the science. Knowing the science creates whole new vistas for physios.' FL
Building bridgesSupport for mental health patients in the community varies, with more physio-therapists working in the acute sector rather than in community services. 'A lot of physios are tied to working in inpatient units rather than being able to provide longer term community rehabilitation,' says Rosalind Johnstone, a band 6 physio at the Royal Edinburgh Hospital. One advantage of community rehab is being able to work with patients once they are in a more stable condition. Ms Johnstone says: 'We could help structure their days and set up physical activity groups so that they get peer support.' She is hoping to get funding to set up community based fitness clinics for those patients taking the anti-psychotic drug clozapine, which has considerable physical side-effects. Sharon Greensill, is clinical lead physio at Rotherham, Doncaster and South Humber mental health trust, and is part of a shift into increased integration between acute and community services. Her service covers both acute and community settings, but significantly, most of the physical activity interventions are now provided in the community. 'We offer 19 different exercise groups a week across the whole borough,' says Ms Greensill. 'We try to promote the community groups to the acute inpatients so that there is a more seamless integration,' she adds. Although her service is separate from the community mental health team, it takes instant access referrals from the assertive outreach and crisis intervention teams. The key to successful integration, she says, is ensuring mental health physio services are well promoted within the community teams. Unfortunately, it is still rare for a physio to be working directly in a community mental health team, but this would be ideal, she says. Mid Lothian community health partnership, however, is leading the way. It has taken the progressive step of employing a full-time band 7 physio within its community mental health team. 'The psychiatrists and nurses are saying it's wonderful to have a physio in the team because most patients do need to see a physio,' says Michael Skelly, superintendent physio across East Lothian and Mid Lothian mental health services. He adds that another band 7 physio is earmarked for the East Lothian community health partnership.
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