Estratégias de gerenciamento de fisioterapia em pessoas com esquizofrenia Ir para: navegação, pesquisa

Type of drug

Mild narcolepsy, bradykinesia, weight gain, loss of libido, diabetes, blood pressure variability and dizziness.

In high doses, some have Parkinsonian side-effects (stiffness of the limbs).

Long-term use can cause tardive dyskinesia (movements of the face and rarely, of the arms or legs) ^[73].

Tranquilsers/ Sleeping Pills

Mood Stabilsers

Polydipsia, dampened creativity and flattened personality.

Change in their self perspective which can be very difficult for patients to deal with. ^[83]

Patients also experience weight gain which can effect their self esteem and body image.^[84]

Unfortunately lithium can be toxic in the long term and cause liver failure from fatty liver disease.^[85]

Beta Blockers

As we have discussed adherence to medication can be a big problem in people with schizophrenia. It is possible that as a physiotherapist or physiotherapy student you may have a role in addressing this issue.

• Pause here and reflect on a previous occasion when you had to encourage a patient to partake in an activity you know they were not keen on.
• How did you get them to change their mind? Would you use the same techniques with patients with schizophrenia? Write down your reflections and review them when you have read the section 6 “communication strategies” and see if your thoughts have changed.

• Pause here and take 20-30 minutes to note down the major side effects and physiological effects that these medications can cause. 
• Take time to create something that you could use as a study aid e.g. a mind map, a table, flashcards.

• The role of the physiotherapist in health promotion (in people with schizophrenia)
• Physical activity – the barriers and benefits in people with schizophrenia
• A range of therapy interventions that physiotherapists may use in the management of people with schizophrenia

The information in this section is designed to allow you to work towards achieving LO3: ‘Critically appraise the evidence underpinning some of the key physiotherapy managment approaches for schizophrenia and reflect on how they could be used in practice.’

• Spend 10-15 minutes reflecting on your previous placement experiences or work experiences.
• Can you recall any situations where you promoted physical activity to your patients?

      – How did you do this?
      – What types of activity did you recommend?

• Keep this patient/patients in mind as you will be asked to think back to them again later in the wiki.

• Think back to the experience you were asked to reflect on above.
• Did you face any challenges/barriers when trying to promote physical activity? Spend 10-15 minutes reflecting and jot these down.
• If you have not had any situations like this, spend 10-15 minutes thinking about any barriers that may influence an individual with schizophrenia’s engagement in physical activity.
• At the end of this section, compare your thoughts to the barriers identified.

• Take 5 minutes to consider the impact that sleep deprivation could have from a physiotherapy point of view when trying to promote physical activity.
• You can compare your answers to the suggestions we have provided at the end of the wiki. These answers may be slightly different to what you have put but remember, they are only suggestions.

Impact on Physiotherapy Management:

This barrier will have an impact on physiotherapy management because if someone cannot appreciate or recognise the benefits of physical activity then they will see no reason to engage. As a result, education will be key to help the individual develop an understanding of the impact physical activity can have on not only their physical health but mental health too. 

• Improved body image
• Enhanced social interaction
• Increased motivation
• Improved physical body perceptions
• Improved physical self-efficacy and independence

• Before moving onto reading about some examples of the interventions physiotherapists can use, please take time to watch Specific Therapy Interventions For People with Schizophrenia

  As mentioned earlier the physiotherapist plays a key role in health promotion and encouraging physical activity in people with schizophrenia. This section of the wiki aims to expand your physiotherapy toolbox by discussing and evaluating common physiotherapy strategies used in mental health including aerobic and strengthening exercise prescription, touch based skills and movement based therapies.

  Other techniques to be aware of which are effective in managing anxiety associated with schizophrenia are relaxation, breathing control and tension awareness which are learnt during cardio-respiratory studies in physiotherapy training [106].

  Aerobic and Strengthening Exercise

  It is recommended in the most recent NICE Guidelines^[110] that people with psychosis or schizophrenia, especially those taking antipsychotics, should be offered a physical activity/exercise programme by a health care professional. A systematic review on the benefits of exercise in people with schizophrenia^[137] found that regular exercise programmes are possible in this population, and that they can have beneficial effects on both physical and mental health. Although, studies included in this review were small and used various measures of physical and mental health it is difficult to establish the true benefits of exercise.

  Further to this, a systematic review and meta-analysis was undertaken by Pearsall et al.^[138] which looked at exercise therapy in adults with serious mental health conditions. There were 8 randomised control trials (RCTs) involved in the review which all explored different exercise programmes including some form of cardiovascular training and resistance training. The effects of these exercise programmes were compared. Exercise programmes in this review were found to have a modest beneficial effect on levels of exercise activity in this population, however no true benefits were found for relief of symptoms.

  There were limitations to this review. Firstly the heterogeneity of programmes affected the impact and generalisability of studies found in the review. Secondly, studies failed to quantify the frequency and intensity of exercise in their programmes. And lastly, interventions tended to use non-standardised exercise programmes and a variety of outcome measures. This makes it challenging to recommend the most suitable and effective programme of exercise to individuals with serious mental illness including schizophrenia.

  Having said this, there seems to be a lack of continuity between literature results as Rosenbaum et al^[139] found through an extensive review of 39 RCTs that physical activity reduced symptoms of schizophrenia and improved aerobic capacity and quality of life among people with mental illness. 

  In light of this, here are examples of exercise prescription that could be advised for people with schizophrenia:

  

  Dodd et al.^[140] found that group exercise classes which incorporated walking and aerobic elements were deemed feasible in the schizophrenic population with no negative effect and participants in this study experienced weight loss as a benefit. Similar results were found by Marzolini et al.^[141] who investigated the feasibility of group exercise in patients with schizophrenia. They found a 12-week community-based programme with aerobic exercise and strength training resulted in significant improvements in overall mental health, muscular strength and a trend for improvement in functional exercise capacity. Exercise in this study took place twice a week for 90 minutes. There was also a low dropout rate- alluding to improved social interaction amongst this group. However this study was potentially limited by its small sample size.

  Group exercises are seen to have their benefits, but we should bear in mind that group situations may not be suitable for everyone and therefore individual tailored treatment plans would be given. Furthermore, Richardson et al.^[142] found that individual supervision is hard to do in group situations and treatment cannot be altered as easily to keep in line with individual patient progress. Fogarty et al.^[143] carried out a study whereby 6 indivdulas with schizophrenia took part in a 3-month physical conditioning programme aimed at improving cardiovascular fitness, endurance and strength; walking and cycling appeared to be of most benefit and low cost. Two qualified exercise specialists were recruited to design and implement individualised exercise programmes based on the participants fitness levels. They found that the majority of participants improved their physical strength and endurance and exhibited enhanced weight control and flexibility. This alludes to the importance of tailored individual exercise plans as all participants in this study had varying degrees of improvement.

  Summary
  
  There is growing evidence in this area but there lacks wealth of evidence with regards to the specific exercises that should be prescribed in this population or what is seen best out of the recommended exercise programmes. Having said this, it is vital as physiotherapists that we prescribe exercise to individuals with schizophrenia as part of their rehabilitation as the benefits of physical exercise are substantial. Therefore, taking into account what the patient may enjoy doing, their needs as well as their social and environmental circumstances may help in divising a suitable exercise programme. This approach will ensure patient-centred care which will be explored at the end of this wiki.

  Touch Based Skills

  We know that skilled touch is a distinctive skill possessed by physiotherapists. This is an essential skill to use when treating patients with mental health conditions such as schizophrenia as their need for physical contact is greatly increased as mental health declines.^[144] Treatment such as therapeutic massage can be used as this is proven to reduce levels of anxiety and depression which can be present in this population.^[145]

  

  Further evidence has shown that touch based therapies can decrease blood pressure, cortisol levels, stress and gives relief from pain.^[146] This is beneficial as people with mental health disorders often feel pain as a result of emotions and therefore physiotherapists can use gentle touch as a way of relieving this pain and increasing patient comfort.^[147]

  Movement Based Therapies

  The importance of physical activity and exercise prescription has been presented to you which are forms of movement based therapies. More specific ones used in the rehabilitation of people with schizophrenia are Basic Body Awareness Therapy, The Alexander Technique, Tai Chi and Yoga.^[106] These therapies are amongst others and it is advised that you have a look at what these therapies involve as you can use elements of them in practice.

  Basic Body Awareness Therapy

  One of the therapies that is provided by physiotherapists in mental health for people with physical and psychological problems, evident in people with schizophrenia, is basic body awareness therapy (BBAT) which is seen to be growing in popularity.^[148] This technique was firstly developed in Scandinavian countries around 40 years ago.^[149] In order to practice this technique, physiotherapists must undergo specific training yet basic principles can be used in everyday practice. We have chosen to provide a brief overview of BBAT in order to let you know what treatment methods are currently in place in the mental health setting.

  Roxendal^[149] suggest that BBAT should be used where disturbances in body awareness are an important part of the pathological picture and hence can be a useful treatment in helping patients with schizophrenia.

  

  According to Hedlund and Gyllensten^[150], basic body awareness therapy encompasses a range of different elements including slow movement, breathing, massage/hands on and awareness in the hope to restore balance, freedom and harmony between body and mind. It is often carried out in lying, sitting, standing, walking and running with the physiotherapists encouraging the patient to move in ways that promote postural control, balance, coordination and free breathing.

  The number of therapy sessions needed depends upon the diagnosis and abilities of the patient. One study by Gyllensten et al.^[151] found that improvements were seen in people with moderate depression or anxiety in 12 sessions, however, Roxendal^[149] found that people with schizophrenia needed approximately 9 months or longer, so therapy can be a lengthy process.

  The Impact of BBAT on Patients:

  Gyllensten et al.^[151] looked at the outcomes of BBAT in patients in psychiatric outpatient care. The treatment group received BBAT along with treatment as usual compared to the control who just received treatment a usual. It was concluded that those who received BBAT had a reduction in their psychiatric symptoms and developed a far more positive attitude towards their body. On top of this, patients appeared more motivated and showed improvements in their physical capacity as well as a more open outlook towards their exercise habits. Follow up/longer term results however were not established in this research study which is a limitation to the results.

  The results of the above study were very similar to a qualitative study by Hedlund and Gyllensten^[150] which focused on experiences of BBAT in people with schizophrenia. 7 out of the 8 patients reported that they felt they had better contact with their bodies and had become more aware of their movement behaviour, postures and balance. They also reported becoming more physically active and felt they had increased self-esteem and were able to cope more effectively in social situations. A later study by Hedlund and Gyllensten^[152] explored physiotherapists views on their experiences of using BBAT. They similarly reported that they notice a positive change in their patients’ self esteem after treatment sessions. The physiotherapists in this study also shared experiences of patients reporting that their positive symptoms related to their condition such as hallucinations and hearing voices being were dampened when a state of postural balance was achieved.

  Summary

  These studies imply that BBAT has positive outcomes. Having said this, the literature on BBAT covers a range of conditions so the evidence regarding the benefits of using this therapy for people with schizophrenia is not strongly documented. This evidence base is growing and it is therefore your clinical decision making which would inform whether you use elements of BBAT as part of your treatment plan or not.

  The strength of how effective BBAT is also dependendant on how well the patient interacts with the treatment session – so keeping focus and engagement is paramount to patient progress.^[153]

  Now that you have read the literature surrounding the various physiotherapy management strategies for schizophrenia hopefully you will have a better understanding of how these interventions could improve the physical and mental state of individuals. Taking into consideration knowledge gained and existing skills, please take some time to reflect on how you may use elements of these in practice. If you feel it is appropriate for your setting, create an action plan of how you would implement this.

  Communication Strategies

  Most physiotherapists will, at some point in their career encounter individuals who suffer from a mental health condition^[3]. It may be that the physiotherapist will be treating another condition, but in order to treat the individual holistically, it is important to understand how this condition may impact the delivery of treatment and require a modified approach.

  The previously mentioned survey by Dandridge et al.^[4] on the views of physiotherapy students towards treating individuals with mental illness, found that one of the key issues was regarding communication. Students raised concerns about how to approach someone with mental illness, discussing a lack of knowledge of how to communicate effectively or adjust their approach to individual needs. As such there is a need to explore communication in relation to people with schizophrenia within this physio-pedia page.

  Discussing communication in the context of schizophrenia How schizophrenia may impact effective communication Communication strategies that can help to overcome the barriers to effective communication The information in this wiki is designed to allow you to work towards achieving LO4: ‘Select evidence informed communication strategies to be able to interact effectively with individuals with schizophrenia.’

  Barriers to Communication

  Impact of Negative Symptoms

  In schizophrenia, while the positive symptoms (hallucinations and delusions) are widely recognised as the hallmarks of the condition, it is the negative symptoms which are harder to treat and are more indicative of the long-term ability of the individual to function in society ^[154]. These negative symptoms include poverty of thought and speech, apathy, anhedonia (inability to experience pleasure), lack of motivation and decreased engagement in social interactions ^[155]. These symptoms have a significant impact on how an individual experiences life. They usually exist prior to the emergence of positive symptoms and will often endure long after the psychotic symptoms have disappeared ^[156]. Negative symptoms also have implications for physiotherapy treatment as they will affect the client-physiotherapist interactions as well as the ability of the individual to participate actively with their treatment plan.

  Deficits in Social Cognition

  It has also been identified that individuals may experience deficits in social cognition which can impact their ability to interact socially with others. This can include difficulties with; interpreting facial expressions or tone of voice, recognising the emotions or intentions of others and understanding their own feelings and emotions^[157]. Furthermore, a study by Lavelle et al. ^[158] on non-verbal communication found that poor social cognition and increased negative symptoms had an adverse impact on social interactions leading participants to perceive poorer rapport when having conversations with individuals suffering from schizophrenia. Interestingly, a higher level of rapport was reported with individuals exhibiting mild positive symptoms, possibly due to these symptoms manifesting as more engagement with the social interaction. As establishing a therapeutic relationship is essential in patient-therapist interactions ^[159], it is important that these deficits in social cognition are understood and that clinicians engage in strategies to help establish rapport and ensure effective communication is achieved.

  Communication Skills

  Approaches to Enhance Communication: from Pounds 2010^[160]

  A qualitative and descriptive pilot study was carried out to investigate the interaction of an experienced mental health nurse specialist with 3 of her schizophrenic clients. The aim was to describe how she altered her verbal and non-verbal communication in order to enhance effective communication and develop a therapeutic relationship.

  Some key approaches that emerged included:

  Exaggeration of facial and vocal cues	As mentioned above, individuals may experience deficits in social cognition, including difficulty reading facial expressions or tone of voice. In this study, the nurse exaggerated her facial expressions (for example, showing concern) or her verbal language (for example, greater inflection in her tone of voice, reflecting a clients’ statement back to them). When applied, these subtle changes in behaviour elicited responses from her clients (such as increased eye contact) and improved their engagement with the interaction.
  Open body language	Displaying open body language, such as leaning forward, smiling and nodding can demonstrate to the client that the clinician is willing to engage with them and can encourage an individual to be involved in the interaction.
  Accepting silence/giving time to answer	Some of the negative symptoms (as mentioned above) that an individual with schizophrenia may face are poverty of thought and speech. This means that when asked a question, a person may require longer to gather their thoughts and give an answer. In her interactions with her clients, there were often periods of silence whilst they were considering a question (lasting between 5-15 seconds).

  What can we take from this study?:

  The main limitation of this pilot study is that it had an extremely small sample size of three participants and only monitored the behaviour of one clinician, and therefore the results may not be representative of this patient population. However, it does begin to describe what may be some useful but subtle changes to the interactional behaviours of the clinician that could encourage communication and help them connect with their clients ^[160]. These strategies, in combination with adequate time to get to know the individual will facilitate the building of trust and help establish a positive therapeutic relationship ^[161].

  Next time you engage in conversation with someone, be aware of your non-verbal communication. Do you naturally do any of the above behaviours? Think about the subtle changes in behaviour described and see if you can implement them. If you ask a question and there is a pause, are you comfortable with short periods of silence or do you feel the need to fill it?

  Promoting Engagement with Treatment

  Amotivation as a Key Problem

  Lack of motivation (amotivation) is one of the main negative symptoms experienced by those with schizophrenia ^[155] and has been identified as having a significant impact on all aspects of behaviour ^[162]. Motivation is essential for engagement in self-care actions and has an important role in the process of change ^[163]. A qualitative study by Abed ^[164] identified lack of motivation to be a major factor that influenced health-related decisions and behaviour. Foussias et al. ^[165] conducted a longitudinal study and found that amotivation was responsible for 74% of variance in functional outcomes at baseline and 72% of variance at 6-month follow-up, therefore indicating that motivation has a crucial role in predicting the functional outcomes for individuals with schizophrenia. Addressing motivation is of great importance to promote engagement with change and healthy lifestyle choices within this population ^[163].

  Strategies to Enhance Motivation

  Goal Setting:

  The importance of setting patient centered goals within this population will be discussed later on this physiopedia page in more detail. However, it is important to note that working with the individual to set personal meaningful goals can help combat amotivation and influence their willingness to be actively involved in their treatment ^[166]. Adams and Drake ^[167] discuss how individuals with serious mental illnesses are capable of meaningfully participating in decisions about their healthcare and it is therefore important to involve them in the planning of treatment. The setting of patient centered goals is one way in which a sense of control can be returned to the patient and can increase their self-determination ^[166]. Progression towards personal goals is also considered to be a powerful influencing factor in promoting psychological recovery ^[168].

  Social Support:

  It has been documented that social interactions can have a positive impact on adherence, enjoyment and motivation to change ^[169], however, individuals with schizophrenia often feel isolated by their condition and have a lack of social support ^[117]. This is due to a number of factors including paranoia, social skill deficits, social and emotional processing problems, negative symptoms and stigma ^[166]. A survey of mental health physiotherapists conducted by Soundy et al. ^[117] investigated the common forms of support they utilised to engage people with schizophrenia in physical activity. Forty physiotherapists provided in depth responses and from this, four dimensions of social support were identified: Informational, tangible, esteem and emotional support. Examples of each dimension are as follows:

  

  While the results from this survey may not be representative or generalisable, a number of key themes were seen to emerge. Many of these suggestions may be useful for physiotherapists to consider in order to better support their clients in their recovery ^[117].

  Cognitive Behavioural Therapy

  Cognitive behavioural therapy (CBT) is a therapeutic technique commonly used in the treatment of mental health conditions and in the UK the National Institute for Health and Care Excellence ^[110] recommends this as a standard treatment to be offered to all individuals with a diagnosis of schizophrenia. The aim of CBT is to change how individuals manage and view themselves, particularly in relation to how they experience their condition, and involves metacognition; the ability to think about one’s own thinking ^[166]. CBT as a specific treatment approach is usually carried out by psychologists or by staff who have undergone specialist training ^[170], but many of the principles of CBT may be useful within everyday physiotherapy practice.

  CBT can be helpful in schizophrenia by challenging beliefs and reasoning in relation to their condition, and through enabling people to establish connections between their thoughts, actions, feelings and symptoms^[110]. One example of this is in addressing compliance behavior in those who hear voices (responding to or acting on the commands of the voice). Trower et al.^[171] used CBT to challenge beliefs about these hallucinations in a randomized control trial. They reported a decrease in compliance behaviour in addition to reductions in depression and distress scores. Whilst no change was observed in the nature or frequency of the hallucinations, the individuals perceived the voices to have less power over them. CBT used in this way for psychosis has shown strong effect sizes in comparison to no treatment ^[170], however the evidence shows little benefit when compared to other available therapies ^[172]. It has been reported in a number of studies that when positive symptoms have been targeted there has also been some improvement in negative symptoms and this has led to recent research into CBT to specifically target negative symptoms ^[173][156].

  Principles of CBT that may be useful in practice

  Initially, a trustworthy therapeutic relationship must be built between the client and the therapist and there must be no attempt to label the persons beliefs as irrational ^[170]. The aim is to help the individual recognise and process maladaptive behaviours and distorted thinking but this should be done collaboratively ^[174]. It may be helpful for some individuals to adapt a third-person perspective as though discussing someone else’s beliefs, and the therapist can pose questions to facilitate their evaluation of those beliefs ^[170]. Working with the therapist, behavioural goals are set and a plan is then developed in order to attain them, considering how personal barriers, dysfunctional thoughts and behaviours may be overcome. Systematic discussions are used to help individuals identify and modify their thoughts and behaviours and the use of carefully structured behaviour assignments can assist the person in bringing about these changes in their life^[174]. CBT may be more useful to physiotherapists where an individual already has the desire to or is already trying to change ^[174].

  The charity organisation MIND have produced Motivational Interviewing

  Motivational interviewing is another technique that may be of use to help combat lack of motivation in individuals with schizophrenia. It can be described as a way of being with people and helping them to navigate change and must take place in the context of a supportive therapeutic relationship [163]. Motivational interviewing takes the form of a collaborative conversation that is goal-orientated and focused on change, with the purpose of strengthening personal motivation by eliciting and exploring the persons own reasons for change in a supportive environment ^[174]. It does not externally impose change, but supports change based on their own goals, desires and values ^[163].

  Jackman ^[175] states that there are five principles:

  1. Expressing empathy
  2. Developing discrepancy
  3. Avoiding conflict and arguments
  4. Working with rather than fighting resistance 
  5. Supporting self-efficacy.

  Five key communication skills are used in motivational interviewing:

  1. Open-ended questions
  2. Affirming
  3. Reflecting
  4. Summarizing
  5. Providing information^[174].

  In this way, the therapist can guide the thoughts of the client by understanding their position and by asking questions to enable them to reach a point where they are intrinsically motivated to change and feel empowered to do so.

  There are courses available that teach motivational interviewing and if you think this may benefit your practice you could consider attending one. However, even without formal training the principles of motivational interviewing may be useful to integrate into your everyday client interactions.

  Please take some time to watch the following video to understand how motivational interviewing can be applied in practice.

  Literature on motivational interviewing:

  Most of the evidence to support the efficacy of motivational interviewing has been in the areas of reducing unwanted behaviours such as alcohol, drug and smoking addictions ^[174]. With regards to the schizophrenic population, Pickens^[163] states that there is moderate evidence to support the use of motivational interviewing for a variety of health-related issues. On reviewing the evidence, most of the literature for this population focuses on medication adherence or co-occurring substance abuse.^[176][177]
  A Cochrane review^[177] on psychosocial interventions for people with severe mental illness (including schizophrenia) to combat substance abuse concluded that the quality of the evidence was low and there was no difference between motivational interviewing and usual care. However, it was stated that motivational interviewing may lead to short-term reductions in substance abuse with multiple sessions.
  Vanderwaal^[176] conducted a recent review of the literature on the impact of motivational interviewing for medication adherence in those with schizophrenia. This review was able to identify and include just six studies, and of these only one demonstrated a direct relationship between motivational interviewing and improved medication adherence. This article concluded that motivational interviewing may be beneficial for some patients but should not be used as a first line on treatment. The quality of the six studies included was also questionable as there were methodological limitations within each one. Furthermore, five out of the six studies did not look at motivational interviewing as the primary intervention but rather as combined with CBT.
  In the promotion of physical activity, there is a lack of evidence on motivational interviewing within the schizophrenic population. However, a systematic review and meta-analysis^[178] on those with chronic health conditions included severe mental ill health within their criteria. The results indicated that there was moderate evidence to support a small effect on increasing physical activity. Therefore the use of motivational interviewing within the care plan of an individual with schizophrenia may facilitate physical activity engagement.
  In conclusion, there is currently little evidence to support the use of motivational interviewing for those with schizophrenia. It could be argued that there is a need for more research within areas other than substance abuse and medication adherence, such as the encouragement of physical activity.

  A Patient Centred Approach: Goal Setting

  The need for goal setting when treating people with schizophrenia Setting appropriate goals for the individual throughout their recovery

  A patient centred approach is vital in the management of people with schizophrenia, particularly with regards to treatment planning and goal setting. The practice of setting goals is common in mental health rehabilitation and in general case-management^[168]. The process of goal setting is key to establishing a positive therapeutic relationship and plan^[166]. In relation to schizophrenia, the physiotherapist and individual should work 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^[179]. 

  

  Working towards achievable and meaningful goals that have been determined collaboratively 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^[168].

  Clarke et al.^[168] 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 (e.g. via appropriate medications) whilst also encouraging the attainment of therapeutic goals in order to promote recovery.

  Another article by Clarke et al.^[180] 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 goals 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.^[180]

  In Summary
  A patient centred and collaborative approach to goal setting can provide a sense of autonomy and control to individuals with schizophrenia. Working towards personal goals can help individuals find meaning within their treatment plan and is key in promoting recovery. As discussed by Clarke et al.^[180] the type of goals set are related to the stage of recovery and it is important that we understand where the client is at and help them to form goals that are appropriate to what they feel they can manage at that time.

  Conclusion

  After completing this wiki, hopefully you will have achieved the following learning outcomes:

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

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

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

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

  It is hoped that this learning resource has given you the confidence to approach people with mental health conditions positively and be able to use the knowledge gained to inform your clinical decision making in relation to creating evidence based treatment plans for people with schizophrenia.

  Thinking back to the activity you completed at the start of the wiki, have you achieved what you had hoped for by completing this online learning resource. Reflect on what you have learnt throughout this wiki. Below are some points you may wish to consider: How your clinical practice may be influenced by the knowledge you have gained Any areas you feel you lack confidence in and consider how you could address these learning needs Whether there are any areas covered in this wiki that you would like to further your learning on. Are there courses you might consider going on?

  Activity Answers

  These are the answers to the quiz in the ‘Poor physical health in people with schizophrenia’ section:

  Q1) 15-20 years

  Q2) Long term and secondary conditions e.g. coronary heart disease, diabetes, obesity, cancers

  Q3) Anti-psychotic medication, poor diet, high rates of smoking, high alcohol intake, high rates of substance misuse

  These are some suggestions for the impact sleep deprivation could have on physiotherapy management in the ‘barriers to physical activity section’:

  Feeling tired and having no energy can often lead to a lack of desire to do anything^[181]. This can have an impact on physiotherapy management as it will likely lead to increased lack of motivation to engage in physical activity.
  Where individuals have low energy and are sleep deprived they may have reduced concentration and find it difficult to follow and even adhere to a physical activity programme.

  References 

  1. ↑ Chartered Society of Physiotherapy. Keeping a CPD Portfolio. www.csp.org.uk/professional-union/careers-development/cpd/keeping-portfolio (accessed 20 December 2015).
  2. ↑ ^2.02.1 Faber K. Supporting pupils with different learning styles. British journal of school of nursing 2012;8:102-104.
  3. ↑ ^3.03.1 Priestley S. Helping when a mind hurts. Frontline 2011;17. www.csp.org.uk/frontline/article/helping-when-mind-hurts (accessed 6 January 2016).
  4. ↑ ^4.04.14.2 Dandridge T, Stubbs B, Carolyn R, Soundy A. A survey of physiotherapy students’ experiences and attitudes towards treating individuals with mental illness. International Journal or Therapy and Rehabilitation 2014;27:324-330. ↑ 5.0^5.1 The Scottish Government. Mental Health Strategy for Scotland: 2012-2015. Edinburgh: The Scottish Government, 2012.
  5. ↑ Pope C. Recovering mind and body: a framework for the role of physiotherapy in mental health and well-being. Journal of Public Mental Health 2009;8:36-39.
  6. ↑ Kenryck LJ. Mental Health Services Inquiry: The Chartered Society of Physiotherapy. ↑ 8.0^8.18.2 Mental Health Foundation. What is mental health. ↑ World Health Organisation. Definition of health. ↑ NHS Inform. Mental health and wellbeing. ↑ NHS. Mental health. ↑ Government of Western Australia mental health commission. Mental illness and health, what is stigma. ↑ MIND. Information and support. ↑ 14.0^14.1 Bahm A, Forchuk C. Interlocking oppressions: the effect of a comorbid physical disability on perceived stigma and discrimination among mental health consumers in Canada. Health and Social Care in the Community 2009;17:63-70.
  7. ↑ Gearing R, Mackenzie M, Ibrahim R, Brewer K, Batayneh J, Schwalbe C. Stigma and mental health treatment of adolescents with depression in Jordan. Community Mental Health Journal 2014;51:111-117.
  8. ↑ Keene D, Cowan S, Baker A. “When your in a crisis like that, you don’t want people to know”: Mortgage strain, stigma and mental health. American Journal of Public Health 2015;105:1008-1012.
  9. ↑ Idemudia E, Matamela N. The role of stigmas in mental health: a comparative study. Curationis 2012;35:1-8.
  10. ↑ ^18.018.118.2 Mestdagh A, Hansen B. Stigma in patients with schizophrenia receiving community mental health care: a review of qualitative studies. Social Psychiatry and Psychiatric Epidemiology 2014;49:79-87.
  11. ↑ Thornicroft G. Physical health disparities and mental illness: the scandal of premature mortality. The British journal of Psychiatry 2011;199:441-442. ↑ Noblett J, Henderson C. Attitudes and stigma held by healthcare and mental health care professionals towards people with mental illness. Mental Health Today 2015: 79-87.
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