Why Physical Therapy in Mental Health?

Dear colleagues, at the beginning were an international network of physical therapists working in the field of psychiatry and mental health with the origin at Leuven University (Belgium) from in 2006. The International Organization of Physical Therapy in Mental Health (I.O.P.T.M.H) was accepted as a W.C.P.T subgroup at the 17th General Meeting, in 2011 and reconfirmed in 2015 and 2019, including 21 member countries, Australia, Austria, Belgium, Colombia, Denmark, Estonia, Finland, Greece, Iceland, Japan, Latvia, Mexico, The Netherlands, Norway, Poland, Spain, South Africa, Sweden, Switzerland, Turkey, UK, but within I.O.P.T.M.H, there is a network of individual physical therapists, representing 59 nations from 6 continents. The I.O.P.T.M.H provides a consensus statement on the role of qualified physical therapists within mental health. This policy statement has been developed by the Executive Committee and physical therapists with expertise in mental health (2019).

It is implemented in different health and mental health settings, psychiatry and psychosomatic medicine. Physical therapy in mental health is person-centered and aimed at children, adolescents, adults and elderly with mild, moderate and severe, acute and chronic mental health problems, in primary and community care, inpatients and outpatients. Physical therapists in mental health provide health promotion, preventive health care, treatment and rehabilitation for individuals and groups. Physical therapists in mental health create a therapeutic relationship to provide assessment and services specifically related to the complexity of mental health within a supportive environment applying a bio-psycho-social model. The core of physical therapy in mental health is to optimize wellbeing and empowering the individual by promoting functional movement, movement awareness and physical activity, exercise, bringing together physical and mental aspects. Physical therapists in mental health play a key part in the integrated multidisciplinary team/interprofessional care. Physical therapy in mental health is based on the available scientific and best clinical evidence.

Observation & Evaluation Tools

It based on:

·      observation of the person's behavior or physical characteristics, in movement or posture (recording information)

·      self-observation and self-esteem of the individual (completion of questionnaires)

It applicable at the beginning, in between & at the end of the physiotherapy session

Design and implementation of individual and group therapeutic exercise programs

Exercise as a means of treatment, either supervised or guided:

·         Protects against the onset of depression

·         Prevents the development of mental illness

·         Patients with depression and schizophrenia are less likely to stop exercising when monitored by a physiotherapist

·         It improves the quality of life and self-esteem of people experiencing mental health issues

·         It has a large and significant antidepressant effect in people with pre-existing depression

·         It helps to better manage anxiety disorders

·         Reduces food symptoms in food intake & improves body image

·         Prevents weight gain & deteriorates mental health in patients of psychiatric prison structures

·         It protects against dementia but also slows the progression of the disease.

Closeness/Touch/Massage

Since ancient times it has been a valuable therapeutic and preventive measure, keeping pace with the mental and psychosomatic evolution of the human species.

By contacting and manipulating, it transmits the feeling of a wave of euphoria, relaxation and calm.

It is not an individual technique but is a functional part of the broader therapeutic intervention

The physiotherapist is responsible for the delicate balance between positive and negative reactions related to contact and immediacy.

Biofeedback

According the international references for biofeedback and the guidelines of the International Society of Applied Psychophysiology and Biofeedback is indicated with a high-level score (4/5) in:

·         Anxiety disorders

·         Headaches and especially tension type

·         Phobias

·         Somatoform disorders

Relaxation and breathing techniques

Prevents the growth of harmful effects on the physical and mental health, reduces the respiratory rate by improving the way of breathing, normalizes the process of ventilation and restores the normal cardio-respiratory parameters.

It is demanding and need:

·         Explaining and understanding how to execute and act.

·         Repetitions and precise guidance from a physiotherapist.

·         Effort, perseverance and patience for the right way of execution

Psychomotor therapy

It is based on the unity of mind and body. Uses physical awareness and various motor activities, to positively affect the motor and emotional development of individuals

A non-invasive, painless technique in which a pulsed magnetic field exerts an effect on electroencephalogram activity with general indications with strong based evidence in chronic neuropathic pain & major depression but possible efficacy in depression & schizophrenia

Virtual reality application techniques

Research findings that it can cause significant behavioral changes in real-life situations and so its application is mainly supported in the treatment of phobias & stressful events.

Paediatric Psychiatry Specific Elements

Though physical therapy in mental health for children and adolescents is currently well embedded in different setting (such as child psychiatry, rehabilitations centers, private practices, etc.), it is a relatively young domain. The field of physical therapy in mental health in children and adolescents encompasses different approaches and therapeutic techniques, ranging from assessment and observation to body awareness techniques, relaxation, experienced oriented family therapy, physical activity, etc. (Simons, 2018).

Geriatric Psychiatry Specific Elements

The cornerstones are to improve the quality of life of the elderly with mental health problems (e.g. dementia and functional psychiatric disorders)

The goals are:

·         Slowing down the reduction of daily activities

·         Improving cardiovascular function

·         Strength, coordination and balance improvement

·         Reduction of the risks of falling due to the psycho-pharmaceutical treatment but also the weakening of the possibilities of vision and gait

Adapted therapeutic exercise and body-oriented approaches such as yoga-, tai chi-, mindfulness-derived exercises or massage have a positive influence on cognition, communication, social behavior, sleep, depression and anxiety.

Incorporating physical therapy into mental health will lead to improve both physical and mental health as well as experiencing feelings of well-being from our patients.

Let’s bring the contribution of physical therapists in mental health into the spotlight, starting from completing the application as an interested physiotherapist (http://www.ioptmh.org/Colleagues.html) and participating en masse at the 8^th international conference of physiotherapy in psychiatry and mental health (February 8-10, 2021 due Covid19), Helsinki, Finland and at the 9^th in Athens, Greece, in 2022.

1. Probst M, Skjaerven L. Physiotherapy in mental health and psychiatry. A Scientific and Clinical Based Approach. 1^st edn, Elsevier, 2017; 348.
2. Stubbs B, Rosenbaum S. Exercise-based interventions for mental illness. Physical Activity as Part of Clinical Treatment. 1^st edn, Elsevier, 2018; 374.
3. Chekroud SR, Gueorguieva R, Zheutlin AB, Paulus M, Krumholz HM, Krystal JH, et al. Association between physical exercise and mental health in 1·2 million individuals in the usa between 2011 and 2015: A cross-sectional study. The Lancet Psychiatry. 2018; 5: 739-746.
4. Lefaucheur JP, André-Obadia N, Antal A, Ayache SS, Baeken C, Benninger DH, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clinical Neuro-Physiol. 2014; 125: 2150-2206.
5. Muñoz-Saavedra L, Miró-Amarante L, Domínguez-Morales M. Augmented and virtual reality evolution and fu-ture tendency. Appl Sci. 2020; 10: 322.
6. Stubbs B, Vancampfort D, Hallgren M, Firth J, Veronese N, Solmi M, et al. EPA Guidance on Physical Activity as a Treatment for Severe Mental Illness: A Meta-Review of the Evidence and Position Statement from the European Psychiatric Association (EPA), Supported by the Interna-tional Organization of Physical Therapists in Mental Health (IOPTMH). Eur Psychiatry. 2018; 54: 124-144.
7. https://www.wcpt.org/ioptmh
8. http://www.ioptmh.org/
9. https://www.icppmh2020.com/
10. https://www.aapb.org/i4a/pages/index.cfm?pageid=1
11. https://australian.physio/inmotion/five-facts-about-mental-health-practitioners-and-patients?fbclid=IwAR2qo4ERk7Sll-MSIToJtgo4WlmtCL91ysALOZ25MvBQ_gv9Q1NpH2R3PWQ
12. https://www.fda.gov/medical-devices/guidance-documents-medical-devices-and-radiation-emitting-products/repetitive-transcranial-magnetic-stimulation-rtms-systems-class-ii-special-controls-guidance
13. https://www.smarttms.co.uk/nice-approval-rtms
14. https://www.euro.who.int/en/health-topics/noncommunicable-diseases/mental-health/news/news/2017/05/working-together-towards-an-effective-and-influential-mental-health-workforce-in-europe-consensus-statement
15. Probst M. The role of physical therapists within mental health and psychia-try. General Meeting of IOPTMH, Geneva, 2019.

COVID-19 is an infectious disease caused by the SARS-CoV-2 virus. In addition to the physical medical effects through contracting the disease, the psychological or mental impact of the pandemic could be significant, even in people who have not got the disease. Factors such as loss of job / income, separation from family, isolation, fear of the disease etc. can lead to negative psychological conditions. It was in this background that the study reported in this paper was carried out to analyse the psychological state of people during the pandemic period.

The COVID-19 pandemic will contribute to a negative mental state for majority of people, which will also be influenced by some of their characteristics.

Kontoangelos K, et al. opined that extensive stressors will emerge or become worsened due to the COVID-19 pandemic [1]. AL-Omiri MK, et al. reported that COVID-19 was associated with feelings of stress, depression, sadness, and loneliness [2]. Elements such as separation from loved ones, loss of freedom, uncertainty about the advancement of the disease, and the feeling of helplessness due to the pandemic affect people more [3,4].

The study was undertaken by WEDO (NGO), Kozhikode, Kerala, India using an on-line questionnaire among a sample of 300 respondents from various parts of India using the snow ball sampling technique. 15 psychological traits were considered to analyse the psychological state of the respondents during the COVID-19 pandemic period (Table 1). The responses to the level of experience of the traits (on an average during the pandemic period) were: Felt very strongly, felt strongly, felt moderately, felt slightly, did not feel with scores of 1, 2, 3, 4 and 5 respectively. The sum of scores of the traits was considered as the psychological state score of the respondents during the pandemic period. A higher score indicates a more positive psychological state and vice versa. The data was analysed as proportion / score and through statistical techniques such as Random Forest technique, Chi-square test and Odds Ratio.

Table 1 shows the proportion of respondents reporting the experience of various psychological traits during the COVID-19 pandemic period.

Table 2 gives details of respondents attributing the experience of psychological traits to the pandemic.

Table 3 shows the responses reading the effect of pre-COVID tension on post COVID tension.

In order to identify the psychological traits, which influence the psychological state score, the Random Forest technique based on Inc Node purity values was attempted. The results are presented in Table 4.

Table 5 shows the distribution of psychological state score into low, medium and high groups based on quartile method.

Table 6 shows the results of the Chi square test of psychological state score with respect to the score of various characteristics of the respondents such as age, gender, qualification etc.

Table 7 shows the psychological state score under various categories of the characteristics of respondents, which was worked out based on the quartile method.

Odds ratio comparing high and low categories of the psychological state score was attempted. The ratios shown in Table 8 indicate the chance of exposure of an individual to a high score, implying a better psychological state of the respondents during the pandemic period.

It can be made out from Table 1 that 50 % and more of the respondents have not at all experienced and experienced only slightly the positive traits such as happiness, feeling lively, satisfied, energetic, enthusiastic and peaceful during the COVID-19 pandemic period. Similarly, more than 50 % and more of the respondents have experienced the negative personality traits, namely, sadness, tiredness, anger and uneasiness moderately during the pandemic period (Table 1). These results indicate that the pandemic has influenced the psychology of the respondents in a negative manner. It can be observed from Table 2 that respondents in the range of 60 to 80 % attribute less experience (indicating the responses, namely, did not feel at all, and felt slightly only) of six out of the seven positive psychological traits to the COVID-19 pandemic. Similarly, 66.7 to 100 % respondents have attributed more experience (indicating the responses, namely, felt strongly, and felt very strongly) of five out of six negative psychological traits to the occurrence of the pandemic (Table 2). 

These results also indicate the negative influence of the pandemic on the psychology of the respondents. 60 % of the respondents reported that pre-COVID tension has affected the tension experienced by them after the pandemic (Table 3). It can also be made out from Table 3 that a comparatively higher proportion of people having moderate and high pre-COVID tension mention that it has affected their post COVID tension, when compared to those who reported less and very less pre-COVID tension. These results indicate the influence of existing tension of people in creating more tension during the pandemic period. The pandemic induced uncertainty, individual health threat and quarantine measures may exacerbate pre-existing conditions such as depression, anxiety etc. Inc Node purity values above 300 obtained through random Forest technique only were considered for analysis. Accordingly, as per Table 4, the traits, namely, Enthusiasm, Satisfaction, Loving nature and Peacefulness are the main ones, which influence the personality state score. These traits can be considered to contribute to a positive mental state for people under the conditions such as fear of contracting the disease, isolation, loss of job/income etc. existing during the COVID-19 pandemic. All the other traits showed Inc Node purity values in the range of 12.6 to 271.8 only. 

More or less equal proportion of respondents are there under the high, medium and low personality state groups, implying that the more respondents were not able to maintain a better level of psychological status due to the pandemic (Table 5). Except sex, the other characteristics of the respondents, namely, age, qualifications, level of pre COVID tension and pre COVID tension affecting post COVID tension are influencing the psychological state score significantly through Chi square test (Table 6). As per data shown in Table 7, 52 % of the middle-aged respondents and 14 % in the young age group fall in the high and medium psychological state categories together, while nobody in the old age group falls under these two categories. While 46 % of males fall in the high plus medium psychological state groups, the figure is only 20 % for females, implying that males were able to maintain a better psychological state than females during the pandemic period. None of the respondents with Degree and PG qualifications have low psychological state score, when compared to 22 % and 12 % respectively under the up to 10th and plus two educational categories (Table 7). This indicates that people with higher education were able to maintain a comparatively better psychological state during the pandemic period. While 20 % and 18 % respondents having high and very high pre COVID tension respectively fall in the low psychological state category, none of the respondents reporting low and middle levels of pre COVID tension are there in the low category, indicating the influence of higher tension before the COVID pandemic period in reducing the psychological state of the respondents during the pandemic period. This trend is again confirmed from the fact that, while only 8 % of the respondents who mention that pre COVID tension has not affected their post COVID tension get a low post COVID psychological state score, 26 % respondents who report that pre COVID tension has affected their post COVID tension get a low psychological state score after the pandemic started (Table 7). From the odds ratio data presented in Table 8, it can be inferred that respondents with PG qualification have 4.62 times more chance of getting a higher psychological state score than those with lesser qualification, indicating a better psychological condition for more educated respondents during the pandemic period.  Similarly, males have 1.16 times more chance of maintaining a better psychological state than females during the pandemic period (Table 8). This confirms the already observed result shown in Table 7 that male respondents maintain a better psychological state than females during the pandemic period.

The results of the study prove the hypothesis that the pandemic has influenced the psychology of the respondents in a negative manner, and that the characteristics of people will influence their psychological state during the COVID-19 pandemic period. Less experience of positive psychological traits and more experience of negative traits have been attributed to the COVID-19 pandemic by 60 % and more of the respondents. The influence of existing tension of people in creating more tension during the pandemic period is evident from the study. Random Forest technique results show that Enthusiasm, Satisfaction, Loving nature and Peacefulness are the main psychological traits, which influence the personality state score. These traits could contribute to a positive mental state for people under the conditions such as fear of contracting the disease, isolation, loss of job/income etc. existing during the COVID-19 pandemic. The characteristics of the respondents such as age, education, pre COVID tension and pre COVID tension affecting the tension during the pandemic period are found to influence the personality score statistically through Chi-square test. Odds ratio test shows that respondents with PG qualification have about 4.62 times more chance of getting a higher psychological state score than those with lesser qualification, indicating a better psychological condition for more educated respondents during the pandemic period.  Similarly, males are found to have 1.16 times more chance of maintaining a better psychological state than females during the pandemic period.

1. Kontoangelos K, Economou M, Papageorgiou C. Mental Health Effects of COVID-19 Pandemia: A Review of Clinical and Psychological Traits. Psychiatry Investig. 2020; 17: 491-505.
2. AL-Omiri MK, Alzoubi IA, Al Nazeh AA, Abdallah K. COVID-19 and Personality: A Cross-Sectional Multicenter Study of the Relationship between Personality Factors and COVID-19-Related Impacts, Concerns, and Behaviors. Front. Psychiatry. 2021.
3. Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The psychological impact of the COVID-19 epidemic on college students in China. Psych. 2020; 287: 112934.
4. Li LZ, Wang S. Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom. 2020; 291: 0165-1781.