**7. The content of physiotherapy in mental health**

Physiotherapy is a specialized field in health care and is recognized as a conventional therapy. Physiotherapists who work in mental health are physiotherapists first and use interventions within the scope of general physiotherapy. In addition, due to the complex situation, physio‐ therapists who work in mental health require supplementary knowledge (e.g. psychopathol‐ ogy and psychological frames) and specific skills and competences (e.g. communication) to assess, treat, support and refer people with mental disorders effectively (see **Figure 3**).

#### **7.1. Psychomotor therapy with children and adolescents**

Psychomotor therapy is a type of body‐oriented therapy. The cornerstones of this approach are body awareness, movement and physical activities. However, psychomotor therapy encompasses 'movement' or 'physical activity' in a strict sense. It is based on the holistic view and, therefore,

**Figure 3.** Overview of physiotherapy interventions in mental health.

integrates cognitive, emotional, social and motor aspects into an individual's development. The starting point is a strong acknowledgement of the continuous and complex interactions between the different developmental domains. Moreover, the functioning of a child is not only always integrated into but also dependent upon a certain context [35]. Psychomotor therapy is offered in different disciplines, including mental health care, child psychiatry, youth care, special education and rehabilitation, as well as private practice. The wide variety of psychomotor therapy interven‐ tions can be categorized into two main areas: psychomotor functional training and psychothera‐ peutic‐oriented psychomotor therapy [35]. Although both approaches are aimed at supporting and aiding a child's personal development, the methods can be distinguished based upon the pri‐ mary focus of the intervention. Psychomotor functional training is primarily aimed at improving the motor domain and includes activities that are aimed at learning, developing, practicing and training (psycho) motor, sensorimotor and perceptual abilities. In psychotherapeutic‐oriented psychomotor therapy, the motor domain is employed as a gateway to ameliorate the social and affective development of individual functioning. More concretely, specific goals are formulated such as learning to recognize bodily signals, regulate aggression, play cooperatively, enhance self‐confidence, reduce social anxiety, etc. The techniques that are employed include relaxation techniques [36], Sherborne Developmental Movement [37], movement and play situations, psy‐ chomotor family therapy [38, 39], physical activity, etc.

#### **7.2. Norwegian psychomotor physiotherapy**

**Physiotherapy in Mental Health**

Exercise and Physcial Acvity in Mental Health

Relaxaon, Tai Chi, Yoga & related approaches

Psychomotor therapy is a type of body‐oriented therapy. The cornerstones of this approach are body awareness, movement and physical activities. However, psychomotor therapy encompasses 'movement' or 'physical activity' in a strict sense. It is based on the holistic view and, therefore,

to note that it is not the physical activity itself but the patient's experiences and inner percep‐ tion that play the central role. The careful guidance and encouragement of the physiotherapist and the opportunity to experience feelings in a safe environment allow the patient to develop behaviour, which would not have developed otherwise. Although the underlying problems are not necessarily resolved, the therapist tries to improve problem management of the patient. The patient shares his behaviour, feelings, and thoughts with the therapist initially and, eventually, with his peers. More emphasis is placed on experiences and how reactions to these experiences

Physiotherapy is a specialized field in health care and is recognized as a conventional therapy. Physiotherapists who work in mental health are physiotherapists first and use interventions within the scope of general physiotherapy. In addition, due to the complex situation, physio‐ therapists who work in mental health require supplementary knowledge (e.g. psychopathol‐ ogy and psychological frames) and specific skills and competences (e.g. communication) to assess, treat, support and refer people with mental disorders effectively (see **Figure 3**).

> Psychosomac Physiotherapy approach

**Figure 3.** Overview of physiotherapy interventions in mental health.

Psychomotor Physiotherapy for children

function as a dynamic source of power [23].

186 Clinical Physical Therapy

**7. The content of physiotherapy in mental health**

**7.1. Psychomotor therapy with children and adolescents**

Norwegian Psychomotor Physiotherapy

> Psychomotor Physiotherapy for Severe Mental Health Disorders

Basic Body Awareness Methodology

Physiotherapy in Old Age Psychiatry

The roots of Norwegian psychomotor physiotherapy began in the early 1950s and were the result of a collaboration between Trygve Braatøy, a psychoanalytically trained psychiatrist, and Aadel Bülow‐Hansen, an orthopaedic physiotherapist [40–42]. In addition to its focus on how the past continues to influence the present, the psychoanalytic approach develops the cli‐ ent's awareness of what can be done to correct the harmful effects of the past [43]. Indications for this physiotherapy approach are conditions associated with strain and functional dis‐ turbances in the musculoskeletal system as well as psychosomatic disorders. Symptoms are viewed as an expression of a disturbance in posture, respiration, muscle tension or auto‐ nomic functions, which are often related to emotional conflicts or mental problems [44]. In Norwegian psychomotor physiotherapy, the case report and the examination are central to documenting and evaluating respiration, posture, function, muscles and other soft tissues as well as automatic functions and reactions. The patient's body and self‐awareness are taken into consideration. These awareness concepts are based on the philosophy of phenomenol‐ ogy. The major finding of Braatøy and Bülow‐Hansen was that the entire body needs to be examined and treated instead of using a local approach. The basis of the examination is the whole person, and the key is the body [44]. Relaxation treatment has yielded limited results, unless breathing is taken into consideration. Although breathing is an important cornerstone of the approach, breathing exercises are seldom used. The observation of how the patient breathes during massage and exercise is a guideline for the level of intensity of the therapy [45], allowing the therapist to adjust continually to the patient's reactions [44, 46]. Breathing and feelings are considered to be interdependent factors. The body is approached as an inte‐ grated physical‐psychological phenomenon [44]. Changes in breathing could be a signal that the patient is reacting emotionally [44]. The patient's reaction to the examination also provides important information. In Norwegian psychomotor physiotherapy, the emphasis is on res‐ piration because breathing can be viewed in relation to emotion and cognition. At the same time, breathing can contribute to the reduction of somatic disorders in stress‐related and/or psychosomatic disorders [47]. In summary, Norwegian psychomotor physiotherapy aims to release respiration through an interaction among breathing, the musculoskeletal system and emotions [44] and to develop flexibility, versatility and the stability of the person [48]. The treatment is successful when a process of bodily changes is not separated from emotional changes [48–50]. A treatment session is mostly individual in nature and may be short, being composed of active exercises in standing, sitting or lying positions only, or it may be long, consisting of massage of the recumbent body only [49, 50].

#### **7.3. Relaxation therapy and mind‐body‐related approaches**

Relaxation as a therapeutic intervention is recommended in the treatment of stress and stress‐ related problems. The term relaxation therapy is used to describe a number of techniques that promote stress and anxiety reduction by decreasing tension throughout the body and creating a peaceful state of mind [51]. This valued therapeutic approach is frequently used in mental health care, and physiotherapists in mental health care apply relaxation training as one of their interventions. Relaxation is used as prevention (to protect the body), as a treatment (for instance, to relieve stress in individuals with hypertension, tension headache, insomnia and panic) or as a coping skill (to relax the mind and to promote clear and effective thinking). Relaxation therapy consists of three phases: (1) to learn the relaxation technique, (2) to evaluate if there is a relaxation response (physiological and psychological) after some training session, and (3) in the third phase and when the technique becomes automatic, to use relaxation in situations that induce stress. Although there are different techniques [52, 53], physiotherapists have primar‐ ily used the modified Jacobson's progressive relaxation method by Bernstein and Borkovec [54–56], applied relaxation of Öst [57], Mitchell method [58] and autogenic training [59].

Yoga, Tai Chi, mindfulness‐related exercises and Pilates are also used to cope with stressful situations.

The **mindfulness‐based stress reduction (MBSR) program**, which is centred on the principles and practice of mindfulness meditation and the use of stress‐reduction skills, including sit‐ ting meditation, hatha yoga and a somatically focused technique called a 'body scan', which was developed to relieve suffering in patients with chronic pain [60, 61]. MBSR encourages the non‐judgemental awareness of one's cognitive and somatic experiences on a moment‐by‐ moment basis. This decentred stance is thought to disconnect cognitive and affective mental events in an adaptive manner and might reduce the negative impact of thoughts and sensa‐ tions that are associated with chronic pain [60, 61].

**Tai Chi** has been practiced for centuries as a Chinese martial art that combines meditation, postures, slow and graceful movements, diaphragmatic breathing and relaxation. It can be regarded as an intervention that integrates physical, psychosocial, emotional, spiritual and behavioural elements and promotes mind‐body interaction [62, 63].

**Qi Gong** (QG) is an ancient Chinese method that integrates body, energetic, respiratory and mental training with the aim of achieving optimal status of both the mind and the body. QG enhances physical, psychic and emotional rebalancing, thereby improving posture, respira‐ tion and concentration by low‐impact movements [64].

important information. In Norwegian psychomotor physiotherapy, the emphasis is on res‐ piration because breathing can be viewed in relation to emotion and cognition. At the same time, breathing can contribute to the reduction of somatic disorders in stress‐related and/or psychosomatic disorders [47]. In summary, Norwegian psychomotor physiotherapy aims to release respiration through an interaction among breathing, the musculoskeletal system and emotions [44] and to develop flexibility, versatility and the stability of the person [48]. The treatment is successful when a process of bodily changes is not separated from emotional changes [48–50]. A treatment session is mostly individual in nature and may be short, being composed of active exercises in standing, sitting or lying positions only, or it may be long,

Relaxation as a therapeutic intervention is recommended in the treatment of stress and stress‐ related problems. The term relaxation therapy is used to describe a number of techniques that promote stress and anxiety reduction by decreasing tension throughout the body and creating a peaceful state of mind [51]. This valued therapeutic approach is frequently used in mental health care, and physiotherapists in mental health care apply relaxation training as one of their interventions. Relaxation is used as prevention (to protect the body), as a treatment (for instance, to relieve stress in individuals with hypertension, tension headache, insomnia and panic) or as a coping skill (to relax the mind and to promote clear and effective thinking). Relaxation therapy consists of three phases: (1) to learn the relaxation technique, (2) to evaluate if there is a relaxation response (physiological and psychological) after some training session, and (3) in the third phase and when the technique becomes automatic, to use relaxation in situations that induce stress. Although there are different techniques [52, 53], physiotherapists have primar‐ ily used the modified Jacobson's progressive relaxation method by Bernstein and Borkovec [54–56], applied relaxation of Öst [57], Mitchell method [58] and autogenic training [59].

Yoga, Tai Chi, mindfulness‐related exercises and Pilates are also used to cope with stressful

The **mindfulness‐based stress reduction (MBSR) program**, which is centred on the principles and practice of mindfulness meditation and the use of stress‐reduction skills, including sit‐ ting meditation, hatha yoga and a somatically focused technique called a 'body scan', which was developed to relieve suffering in patients with chronic pain [60, 61]. MBSR encourages the non‐judgemental awareness of one's cognitive and somatic experiences on a moment‐by‐ moment basis. This decentred stance is thought to disconnect cognitive and affective mental events in an adaptive manner and might reduce the negative impact of thoughts and sensa‐

**Tai Chi** has been practiced for centuries as a Chinese martial art that combines meditation, postures, slow and graceful movements, diaphragmatic breathing and relaxation. It can be regarded as an intervention that integrates physical, psychosocial, emotional, spiritual and

**Qi Gong** (QG) is an ancient Chinese method that integrates body, energetic, respiratory and mental training with the aim of achieving optimal status of both the mind and the body. QG

consisting of massage of the recumbent body only [49, 50].

**7.3. Relaxation therapy and mind‐body‐related approaches**

tions that are associated with chronic pain [60, 61].

behavioural elements and promotes mind‐body interaction [62, 63].

situations.

188 Clinical Physical Therapy

**Yoga** is an mind‐body therapy (MBT) that potentially fulfils the need for both exercise and coping skills in fibromyalgia syndrome (FMS) patients. Yoga varies greatly in terms of style and, beyond the physical poses that are identified with it, comprises meditation and breath‐ ing exercises [65–71].

**The Pilates method**, which was developed in the 1920s by J. H. Pilates (Germany, 1880–1967), is a low‐impact, non‐aerobic fitness programme (stretching and strengthening exercises) that also integrates physiotherapy [72]. The original exercises were influenced by the two gymnastic systems that dominated rehabilitation at that moment, namely the German (Friedrich Jahn) and the Swedish (Per Hendrik Ling) systems. Pilates became a form of movement that combines characteristics of Eastern (mind control during exercises, relaxation, increasing of elasticity, movement starting from body centre and balance) and Western (forming strength, endurance and exercises with both global and local effects) systems. Today, the applied form of Pilates has been influenced by other mind‐body methods. Additionally, it involves not only the recovery of muscle strength and flexibility but also the correction of muscle imbalance and attention to body awareness, economical breathing, and neuromuscular coordination by executing fluent and precise movement. Pilates can lead to balancing of the body and the mind [72–75].

In some countries, the Mensendieck system [76] and the Feldenkrais method [77, 78] are inte‐ grated into the physiotherapy in mental health. They are seen as educational approaches, rather than interventions. The *Mensendieck system* focuses on teaching patients to understand the concepts of bodily functioning using pedagogically designed exercises and aims to enable them to change suboptimal patterns of movement. The *Feldenkrais method* is a somatic educa‐ tional system that was designed to improve the movement repertoire, aiming to expand and refine the use of the self through awareness to reduce pain or limitations in movement and promote general well‐being [77, 78].

#### **7.4. Psychomotor physiotherapy for severe mental health problems**

Psychomotor physiotherapy for severe mental health problems is a method of treatment that uses systematically a wide variety of (adapted) physical activities as well as movement, body and sensory awareness to stimulate and to integrate motor, cognitive and affective competences within the psychosocial context. This approach aims to realize clearly formu‐ lated consent goals, which are relevant to the patient's mental health problems (depression, anxiety, schizophrenia, autism, eating disorder, etc.). This approach is based on evidence‐ based research and 50 years of clinical practice. Today, it is an important standard adjunc‐ tive treatment for patients in residential treatment to optimize movement as well as the cognitive, affective and relational aspects of mind‐body functioning (i.e. the relationships between physical movements and cognitive and social‐affective aspects). The approach focuses on the somatic effects of physical activity and the physio‐psychological effects as the core of the treatment. The goal is to stimulate a positive self‐image and personal well‐being in a balanced social relationship using movement activities. This approach is well described in inpatient settings as a different group approach and can be imbedded within diverse psychotherapy settings. On the one hand, the focus is on discovering the present healthy capabilities of the subject ('care') using the moving body as the core to influence psycho‐ logical, social and somatic functioning. On the other hand, the physiotherapy addresses the dysfunctional part of the subject. Depending upon the goals and the competence level of the patient, the therapist can choose among a more health‐related approach (to improve physical activity and to limit sedentary behaviour), a more psychosocial‐related approach (to learn skills that are not only physical but also cognitive and communicative) or a more psychotherapeutic‐related approach (to stimulate the patient to get in touch with his or her inner world). When persons with mental health problems are invited to (group) physical activities, they come out from their comfort zone and experience how they function. The combination of experience and insight drives changes and leads to new experiences. Specific approaches for eating disorders [78–83], schizophrenia [84–91], mood disorders [92–97] and depression and anxiety [23, 32–34] are developed.

#### **7.5. Basic body awareness methodology**

Body awareness is a term that is frequently used in mental health and psychiatry. It refers to the ability to pay attention to ourselves and feel our sensations and movements online, along with the motivational and emotional feelings that accompany them in the present moment, without the mediating influence of judgemental thoughts [98].

Body awareness is the subjective, phenomenological aspect of proprioception and intero‐ ception that enters conscious awareness and is modifiable by mental processes, including attention, interpretation appraisal, beliefs, memories, as well as conditioned attitudes and effect [99]. Different approaches, including those within physiotherapy and beyond, report‐ edly enhance body awareness (yoga, Tai Chi, mindfulness‐based therapies, the Feldenkrais method, the Alexander method, different breathing therapies, etc.). Body awareness has become an umbrella term for different approaches. One such approach in physiotherapy is basic body awareness therapy [100].

Basic body awareness therapy was inspired by the French movement educator and psycho‐ therapist J. Dropsy and further elaborated by Roxendal. The basic body awareness meth‐ odology (BBAM) is a Person‐centered physiotherapeutic movement awareness training programme that is directed towards daily life movement [100–111]. It is used in multiple clinical settings, including primary health care, pain rehabilitation and psychiatric physical therapy, as well as in health promotion.

It is founded upon a three‐dimensional approach to human movement: learning about and through movement and learning while being in movement [107]. Movement awareness in this methodology is defined as the sensitivity to movement nuances, awareness of one's own movements in relation to space, time and energy and identification of subtle movement reac‐ tions to internal and environmental conditions [100, 107]. Persons who are not aware or who have a lack of contact with the physical body and the emotional body (internal life) and who are not aware of the physical environment and their relationship to other people and persons who are cut off from reality, express this lack of awareness throughout their body. This can be observed as dysfunctional movements, for instance, movements that lack vitality, flow, rhythm and unity [100–102, 104–105]. From a broader perspective, the lack of awareness has negative consequences on movement quality, daily function, habits and health [100]. The phenomenological concepts of the body awareness methodology are relaxation, tension regulation, body contact, body consciousness, body image, body experience, body boundar‐ ies, body control, muscle consciousness, muscle control, body awareness and postural attun‐ ement [100, 111]. In general, body awareness combines a series of exercises that are related to posture, coordination, free breathing and awareness. Attending to both the patient's own performance and to the patient's experience during the exercises is a central element of body awareness that stimulates mental presence and awareness that aims to provide increased body consciousness. BBAT offers training situations that focus on healthy movement aspects, lying, sitting, walking, running, using the voice, relational movements and massage [105]. Embodied and mindful presence, awareness and movement quality represent keys to the therapeutic approach. Therapeutically, being in movement, exploring, experiencing, inte‐ grating, mastering and reflecting upon one's own movement coordination are critical to gain‐ ing more functional movement, strengthening the self and preparing for daily life [108]. It offers a strategy to equip the person to handle life more effectively. It is used in individual therapy but is foremost a group treatment. [100, 111]. Body awareness therapy refers to a group of movement awareness interventions that share a common perspective that focuses on the internal subjective experience of the body to promote physical, mental and emotional well‐being [110, 111].

#### **7.6. Psychosomatic physiotherapy approach**

psychotherapy settings. On the one hand, the focus is on discovering the present healthy capabilities of the subject ('care') using the moving body as the core to influence psycho‐ logical, social and somatic functioning. On the other hand, the physiotherapy addresses the dysfunctional part of the subject. Depending upon the goals and the competence level of the patient, the therapist can choose among a more health‐related approach (to improve physical activity and to limit sedentary behaviour), a more psychosocial‐related approach (to learn skills that are not only physical but also cognitive and communicative) or a more psychotherapeutic‐related approach (to stimulate the patient to get in touch with his or her inner world). When persons with mental health problems are invited to (group) physical activities, they come out from their comfort zone and experience how they function. The combination of experience and insight drives changes and leads to new experiences. Specific approaches for eating disorders [78–83], schizophrenia [84–91], mood disorders [92–97] and

Body awareness is a term that is frequently used in mental health and psychiatry. It refers to the ability to pay attention to ourselves and feel our sensations and movements online, along with the motivational and emotional feelings that accompany them in the present moment,

Body awareness is the subjective, phenomenological aspect of proprioception and intero‐ ception that enters conscious awareness and is modifiable by mental processes, including attention, interpretation appraisal, beliefs, memories, as well as conditioned attitudes and effect [99]. Different approaches, including those within physiotherapy and beyond, report‐ edly enhance body awareness (yoga, Tai Chi, mindfulness‐based therapies, the Feldenkrais method, the Alexander method, different breathing therapies, etc.). Body awareness has become an umbrella term for different approaches. One such approach in physiotherapy is

Basic body awareness therapy was inspired by the French movement educator and psycho‐ therapist J. Dropsy and further elaborated by Roxendal. The basic body awareness meth‐ odology (BBAM) is a Person‐centered physiotherapeutic movement awareness training programme that is directed towards daily life movement [100–111]. It is used in multiple clinical settings, including primary health care, pain rehabilitation and psychiatric physical

It is founded upon a three‐dimensional approach to human movement: learning about and through movement and learning while being in movement [107]. Movement awareness in this methodology is defined as the sensitivity to movement nuances, awareness of one's own movements in relation to space, time and energy and identification of subtle movement reac‐ tions to internal and environmental conditions [100, 107]. Persons who are not aware or who have a lack of contact with the physical body and the emotional body (internal life) and who are not aware of the physical environment and their relationship to other people and persons who are cut off from reality, express this lack of awareness throughout their body. This can be observed as dysfunctional movements, for instance, movements that lack vitality, flow, rhythm and unity [100–102, 104–105]. From a broader perspective, the lack of awareness

depression and anxiety [23, 32–34] are developed.

without the mediating influence of judgemental thoughts [98].

**7.5. Basic body awareness methodology**

190 Clinical Physical Therapy

basic body awareness therapy [100].

therapy, as well as in health promotion.

The psychosomatic approach differs from the somatic approach. The somatic approach involves the cells of the body and is based on the physical and biological aspects of the problem. The somatic approach is the traditional approach and usually addresses the symptoms of the prob‐ lem. Psychosomatic means that a physical condition is caused or greatly influenced by psycho‐ logical factors. The psychosomatic approach views illness as a form of communication between the conscious and the unconscious mind through the body. Illness is a person's way of adapting to the environment. It is a message that communicates a need for change. Based on the patient's perception, illness is consciously or unconsciously a legitimate way to avoid something unpleas‐ ant. Illness can be a subconscious defence mechanism. There are numerous situations that people would rather avoid than confront. The benefits of the illness are that they receive more attention, love and warmth from family members or friends when they are sick. Some patients are confronted with existential questions, including those relating to the purpose of life. Unable to answer these questions, some people turn their illness into their purpose in life. Everything begins to revolve around it. The scope of psychosomatic physiotherapy is broad, including the treatment of physical symptoms such as pain, fatigue, hyperventilation and distress in relation to psychosocial problems. Somatic symptoms and related disorders [4] are another category of illnesses that primarily are treated within psychosomatic physiotherapy. Medically unexplained symptoms are also categorized under this umbrella term. In all these cases, the therapist explores the relationships among social, psychological and behavioural factors with bodily processes and quality of life. It is obvious that the therapeutic relationship has an important role [112]. During this exploration, the patient is given the space to reflect on behavioural experiences and per‐ ceptions in a developmental process that focuses on the integration of thoughts, emotions and actions in relation to motor performance. With an awareness of the importance of addressing the physical complaint, the psychosomatic physiotherapist focuses specifically on the psychophysi‐ ological and behavioural characteristics of the client's motor performance‐related problem. The aim is to recognize and gain insight into the complex relationship between motor and psycho‐ logical performance within a psychosocial context and positively influence disrupted internal and external regulation mechanisms. The psychosomatic‐oriented physiotherapist is inspired by cognitive behavioural interventions (see **Figure 2**) [113, 114], including graded activity and active pacing therapy. The therapist uses a number of specific awareness‐raising methods such as relaxation techniques, breathing and communication methods, (bio‐) feedback, problem solv‐ ing strategies and stress management. The status of the patient is observed using the 'SCEGS model' (soma, cognitions, emotions, behaviour and social environment). Treatment objectives are formulated in terms of the SMART criteria. The relationships among the need for help as expressed by the patient, body language, body posture, movement and gestures are explored. In addition, verbal language is analysed. The balance between supporting load and supporting strength, tension and relaxation, and body and illness perception and reality is explored during the sessions.

#### **7.7. Exercise and physical activity in mental health**

Mental health problems are the leading predictor of years lived with disability worldwide. Furthermore, without more intensified prevention and management, the burden is estimated to increase to a greater extent [115]. The consequences of mental health problems are devastating for the person and society as a whole and are compounded by physical health comorbidities with which most people with mental health problems are confronted [115, 116]. Physical health comorbidities are a major cause of the reduced life expectancy of 15–20 years in this popula‐ tion [118–120]. The relationship between mental health and physical activity is supported by a growing number of articles [92]. There is rigorous evidence now that physiotherapy improves mental and physical health in this vulnerable population [121]. Unfortunately, these efforts are becoming integrated into clinical practice at a slow pace. Physical activity is not always consid‐ ered to be a worthwhile strategy. The benefits of physical activity are twofold, as people with mental health problems are also at an increased risk of a range of physical health problems, including cardiovascular diseases, endocrine disorders and obesity [115–124]. Physical activity influences cognition [122] and cardiorespiratory fitness [123] and reduces dropout [121] due to a wide range of mental health problems. The relationship between physical activity and men‐ tal health has been widely investigated. The health benefits of regular exercise are improved cardiovascular fitness, improved sleep, better endurance, a positive influence on metabolic syndrome and diabetes, stress relief, improved mood, increased energy and reduced tired‐ ness. Exercise reduces anxiety, depression, negative mood and social isolation and improves self‐esteem, cognitive functions and quality of life [115–124].

#### **7.8. Physiotherapy with the elderly in old age psychiatry**

Old age psychiatry consists of two groups: dementia syndrome ( Alzheimer, frontotemporal degeneration, vascular dementia) and functional psychiatric disorders (depression, addiction, mood disorders, personality disorders and schizophrenia). Elderly people experience declin‐ ing physical activity levels and functional capabilities, loss of dependence, decreasing social contacts, increasing problems with mental health, loss of adaptive capabilities and quality of life. The most frequently observed characteristics in old age psychiatry are apathy ( lack of motivation and interest), depression (fear, hopelessness, sad, low self‐esteem, guilty,etc.), aggression (aggressive resistance, verbal and physical aggression), psychomotor agitation (aimless walking, pacing up and down, restlessness, repetitive actions and sleep disorders) and psychotic features (illusions, false identifications and hallucinations) [4].

Exercise helps to improve general daily activity, cognition and independency; increase car‐ diorespiratory fitness, strength and balance; reduce osteoporosis, sarcopenia, falls and risk factors for falls; increase quality of life and social activities; and reduce social isolation, loneli‐ ness, fear and institutionalization [125–127].
