Physiotherapy management strategies in people with schizophrenia

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Introduction

Aims and Learning Outcomes

Aims:

1. To provide final year physiotherapy students and newly qualified physiotherapy graduates with an online learning resources which will develop their knowledge and understanding of schizophrenia and its impact on the individual.

2. To enable final year students and newly qualified physiotherapy graduates to develop their knowledge and awareness of physiotherapy management strategies for people/adults with schizophrenia.

Learning outcomes:

By the end of this online learning resource you should be able to:

1. Identify and evaluate the biopsychosocial impact of schizophrenia on the individual.

2. Explain the effects of the common medications used in the management of schizophrenia and how these effects can impact physiotherapy management.

3. Critically appraise the evidence underpinning some of the key physiotherapy management approaches for schizophrenia and reflect on how the could be used in practice.

4. Select evidence informed communication strategies to be able to interact effectively with individuals with schizophrenia.

Medications

Introduction to Schizophrenia medication

Patients with mental health conditions may need medication to help with any symptoms that they are experiencing to live life normally. In the UK 2.75 million people go to the GP for a mental health condition every year which accounts for one in four GP consultations (Lee and Lyon 2009). Common conditions that require medication are depression, anxiety, schizophrenia, and bipolar disorder. There are five main sub branches of psychotropic medications for managing the effects of mental health conditions. They are: antipsychotics, antidepressants, tranquillisers/sleeping pills, mood stabilisers and beta blockers (MIND 2015). Each patient is different and may react differently to different medications. Mind.org.uk has an extensive A-Z on drugs used in mental health. Physiotherapists need to be able to understand the effects these drugs will have on the patients and how it may limit their interaction with physical management. During an assessment or treatment session a Physiotherapist also needs to be aware of how all these medications will affect cognition, proprioception and the patients’ body image.

Types of Medication

Antipsychotics

The basic aims of antipsychotics are to help the patient feel better or happier without feeling drowsy, alleviate hallucinations and delusions, help patients think clearly, help with extreme mood swings (Manic depressive disorder) and help with severe depression. Most antipsychotics affect neurotransmitter levels like dopamine in the brain. Overproduction of dopamine has been linked to hallucinations, delusions and thought disorder. (Royal Collage of Psychiatrist 2015). Patients taking antipsychotics will need extra physical prompting when undertaking exercises. Problems with proprioception will need to be addressed with verbal queues and physical prompts.

Antidepressants

Antidepressents help patients alleviate depression and its symptoms. Even though it is not fully understood It is known that two chemicals involved in depression are Serotonin and Noradrenaline. Anti depressants are used in moderate to severe depression, anxiety and panic attacks, OCD, Chronic pain, eating disorders and PTSD. Common antidepressants are: amitriptyline, clomipramine, citalopram, fluoxetine, phenelzine and venlafaxine. (RCPSYCH 2015).

Tranquilisers/ sleeping pills

Tranquilisers are used for patients to improve sleep patterns and for anxiety disorders (anxiolytics). They have a sedative effect due to an increase in GABA (gamma amino butyric acid) a neurotransmitter. This causes areas of the brain responsible for rational thought, memory, emotions and breathing to slow down. These medications shouldn’t be used long term as patients can become addicted, CBT may be more effective for long term management (MIND 2015). Common tranquilisers are benzodiazepines: nitrazepam, flurazepam, loprazolam, lormetazepam and temazepam. Diazepam is commonly used to treat anxiety and insomnia (BNF 2014). Accommodating for patients who are taking tranquillisers may include clear and concise instructions as concentration levels may be low. Timing treatments around taking medication is always important but finding the right time for a patient is necessary. Finding out patient preferences to time of day for treatment is also important as some may find exercises in the morning more difficult compared to the evening or vice versa.

Mood stabilisers

Mood stabilisers allow patients who experience very high and low moods to experience a more balanced life. They are used for patients as a long term treatment option with conditions such as manic depressive disorder, Drugs like lithium, valproate and carbamazepine are examples of mood stabilisers. The side effects of these drugs can make patients very thirsty. Some patients report that the drugs limit their creativity and flatten their personality. This might combat the mood swings but changes their self perspective and this can be very difficult for patients to deal with (MIND 2015). Lithium is a very effective mood stabiliser and is prescribed as a prophylactic as it has unique anti-suicidal properties. Patients need to have good kidney function as it is an element that cannot be metabolised by the body. Patients also experienced weight gain which will effect their self esteem and body image (Bschor 2014). Unfortunately lithium can be toxic in the long term and cause liver failure from fatty liver disease (LIVESTRONG 2015).

Beta blockers

Beta Blockers are beta-adrenoreceptor blocking agents used for decreasing heart rate by blocking adrenaline receptors (NHS 2015). In mental health they are used for patients with anxiety. They can control rapid heartbeat, shaking, trembling, blushing and sweating. Propranalol is an example of a beta blocker commonly used for anxiety (anxieties.com 2015). Some users may feel light headed so therapies that involve moving from lying to sitting/standing will need to be carefully administered for patients using beta blockers.

The Role of the Physiotherapist in Health Promotion

The Problem of Poor Health in Schizophrenia

It is well documented in the literature that people with schizophrenia have much poorer physical health than the general population and despite having more contact with health services they have a much poorer life expectancy, dying on average 15-20 years earlier. One of the key factors that contributes to the poor physical health in this population is very high rate of physical inactivity and the tendency to adopt a far more sedentary lifestyle than the general population (Lindamer et al. 2008, Janney et al. 2013, Stubbs et al. 2014).

In general, physical inactivity is associated with an array of health risks and is said to be one of the leading causes of long term and secondary conditions such as coronary heart disease, diabetes, obesity and different types of cancers (Booth et al.2012 and Lee et al. 2012). It is important to remember that the same health risks apply to people with schizophrenia but due to the nature of their condition and other influencing factors the risk is much greater (Gorczynski and Faulkner 2010). Along with physical inactivity and sedentary behaviour there are a whole range of other factors that could influence the physical health of people with schizophrenia. These include; antipsychotic medications (as discussed earlier), poor diet, high alcohol intake, high rates of smoking and high rates of substance misuse (Phelan et al. 2001, McCreadie 2003 and Vancampfort et al. 2012). ).Together these factors put people with schizophrenia at much higher risk of developing long term conditions and as such they are 1.5-2 times more likely to be overweight, have a two-fold increased risk of developing diabetes and hypertension and an increased risk of cancer of which they are 50% less likely to survive than the general population (NICE 2014, Vancampfort et al.2012).

The evidence shows that there is great disparity between the physical health of those with schizophrenia and the general population and this ‘problem’ is now becoming widely recognised. We feel it is important to explore the role of the physiotherapist in terms of addressing these modifiable factors that are contributing to poor health whilst also paying special attention to the fact that these people have a mental health condition and recognising that it could be influencing their ability to engage in a healthy lifestyle.

Physiotherapists Perspectives of thier Role

The role of the physiotherapist and even physiotherapy is often misunderstood within the general population with many people assuming that massages are the only thing we are good for. Just think how many times a family member or friend has said ‘oh I’m a bit sore, do you think you could give me a massage?’ In reality the role of the physiotherapist is much more significant, particularly in relation to mental health.

In general, the key role of physiotherapists and principle of physiotherapy is to ‘help restore movement and function when someone is affected by injury, illness or disability’ (NHS 2014). Physiotherapy is based on science and it requires physiotherapists to take a holistic approach to health and wellbeing – including the patients’ general way of life and it looks to involve the individual as much as possible (CSP 2013).

Looking at the Role in Mental Health
Physiotherapists’ are involved in a variety of different health care specialities but it is only within the last 10-15 years that their role within mental health has become increasingly recognised, not only by the health care system in general, but by the physiotherapists themselves.

Until recently physical care and mental care have been regarded as two separate entities (MHF 2015). However, it is now being acknowledged and accepted that there are links between the two and this is resulting in changes to the way that health care is being delivered. According to the Royal college of Psychiatrists (2013, p.9) “poor mental health is associated with a greater risk of physical health problems and poor physical health is associated with a greater risk of mental health problems.” By acknowledging the connection between physical care and mental care the focus within the NHS is now on how the gaps that currently exist between physical care, social care and mental care can be closed. The Chartered Society of Physiotherapy (CSP) has recognised that physiotherapist’s are perfectly positioned and have the necessary skills to bridge the gap between physical and mental health. ‘Commissioning Mental Health Services’ (2008) is a document that was published by the CSP that looked to provide an overview of the contribution of physiotherapy in the delivery of high quality evidence based mental health and well-being services. This document states that “the physiotherapist as a member of the multidisciplinary team can demonstrate the advantages of harnessing the links between mind and body” (CSP 2008, p.5).

There is a growing body of literature looking at the role of the physiotherapist in mental health however it is limited in regards to looking specifically at schizophrenia. A recent article by Stubbs et al. 2014 is the first to get an international understanding of the role of mental health physiotherapists, from their point of view, with regards to the treatment of people with schizophrenia. This qualitative study involved a secure online survey (which contained open and closed questions) and included 3 sections: demographic information, training and education and the role of the physiotherapist in schizophrenia. 151 physiotherapists from 31 countries, who had on average 10 years of experience in mental health, completed the study but only 115 (76.1%) provided a valid response. From the study emerged two main themes: Physiotherapists felt their role was to be the physical health expert within the MDT and physiotherapists felt they played a crucial role in health promotion for patients with schizophrenia (Stubbs et al. 2014).

The idea of bringing physical and mental health together was recognised highly amongst physiotherapists. This study found that 41.7% of respondents felt they had a key role in bridging the gap between mental and physical health in this patient population. Due to the qualitative nature of this study it allowed for physiotherapists to give their own view. One respondent said:

This fits in very well with the patient-centred, holistic approach that physiotherapists are required to take when providing any form of care. Holistic care involves viewing the patient as a whole and considering not only their physical needs but their mental, emotional, social and economic needs (REF). This was another important role established by the physiotherapists in this study – 33.9% felt physiotherapists utilised a “holistic, mind-body approach” when treating patients with schizophrenia. Another participant said:

Looking now at the second theme (a vital role in health promotion), 43.5% of participants felt that promoting physical activity and devising individually tailored programmes was a major role. By encouraging more active lifestyles, the physiotherapists recognised that it would help in the management of some of the secondary conditions associated with schizophrenia whilst also having a positive influence on the patient’s mental health and social functioning (Stubbs et al. 2014).

The ‘Commissioning Mental Health Services’ document referred to earlier believes that physiotherapist’s have a key role in “enabling physical activity for health promotion, disease prevention and relapse” and has a major role in providing lifestyle, weight management and well-being programmes (CSP 2008, p.5). It is clear to see that the study conducted by Stubbs et al. (2014) yielded very similar results. This was the first study looking at the international perspectives of the role of physiotherapists in schizophrenia and it concluded that promoting healthy lifestyles and encouraging physical activity as well as bridging the mind-body gap are the key.

A patient centred approach - treatment planning/goal setting

A patient centred approach is vital in the management of people with schizophrenia, particularly with regards to treatment planning and goal setting. Autonomy is something that many of us take for granted. In schizophrenia, the combination of positive and negative symptoms as well as side-effects from the medication can result in major changes in a person’s personality and the way they live their life that this independence can often be lost.

The Royal college of Nurses (2015) describes person centred care as care which allows the person to become an equal partner in their care. It encompasses shared decision making and in direct relation to schizophrenia it is about working together to develop treatments and set goals that are meaningful and at a level the person is ready for, willing to and able to achieve (Fogarty and Happell 2005). An article by Stubbs et al. (2014) found that physiotherapists had a role in promoting active lifestyles and designing individually tailored interventions which would enable the patient to stay active in their own environment.

The practice of setting goals is common in mental health rehabilitation and in general case-management (Clarke et al. 2009). The process of goal setting is key to establishing a positive therapeutic relationship and plan (Dopke and Batscha 2014). Working towards achievable and meaningful goals that have been determined collaboratively by both therapist and client can contribute to greater life satisfaction, promote self-management and reduce psychological symptoms. Moreover, attainment of goals improves the emotional and psychological wellbeing of an individual (Clarke et al. 2009).

Clarke et al. (2009) states that the levels of distress due to psychotic symptoms are related to goal progress, with greater symptom distress having a negative impact on the progression of goals. It is likely that this is because whilst symptoms are severe the individuals focus will be on alleviating those distressing symptoms rather than looking towards future goals. This issue highlights the importance of a patient-centered holistic approach where the alleviation of symptoms is targeted whilst also encouraging the attainment of therapeutic goals in order to promote recovery.

Another article by Clarke et al. (2012) discusses the types of goals set by individuals with psychiatric disorders (majority of participants suffered from schizophrenia) depending on the stage of recovery that they were in. This study found that those within early stages of recovery focused more on “avoidance” goals (reducing an undesirable outcome such as hearing voices) whilst those is later stages of recovery showed an increase in setting “approach” goals (moving towards a positive outcome).

Also notable, was that physical health goals were overall reported most frequently. These included adhering to mental health medications, weight loss, increased exercise, improved nutrition and physical fitness. This may be due to these types of goal being practical and clearly defined. It is suggested that when life goals become unachievable, simple daily goals may help keep depression at bay and provide a sense of purpose. There is therefore a higher prevalence of health goals at the early stage of recovery and it is likely that these more concrete initial goals must be at least partially met before the individual feels able to progress to goals associated with relationships, employment and personal development.

Barriers to Physical Activity

As mentioned earlier, people with schizophrenia spend large periods of their time being sedentary, with the majority failing to meet the physical activity recommendations of 30 minutes per day (REF). As final year physiotherapy students or newly qualified physiotherapists it is important to be aware of any barriers that you may face when trying to promote healthy lifestyles and physical activity in people with schizophrenia.

Before moving onto the next section, take 10-15 minutes and jot down any potential barriers that you can think of. Hint: Consider some of the information that you have already read and think about all of the different factors that could be influencing the patient.

References

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