• Patients may be in hospital voluntarily or they may be detained under a section of the Mental Health Act for their own or other people’s safety. Detention is often referred to as ‘Sectioning’ which refers to a particular section of the Mental Health Act (HM Government 2007). A very specific process must be adhered to in sectioning someone and there are reviews and processes which must be followed including the right of appeal for the person.

• Whilst in hospital a patient may be cared for at a specific level of observation related to the assessed risk. Risks may be of absconding, self-harm, harm to others, lack of self care. The level of observation 1–3 refers to the frequency of observation and also the proximity of the observer, for instance level 3, 15-minute observations mean that a member of staff would know where a patient was and what they were doing every 15 minutes but they could view this from a distance, ‘level 1 observation constant observations’ would mean a member of staff would be within arm’s length constantly.

• Consider what this might feel like, especially if one already feels paranoid. The status of the patient will affect the treatment options you have. For instance if a walk is part of your treatment plan then a sectioned patient will have to have ground leave agreed by the responsible medical officer. In forensic settings it is likely that the majority of patients will be on section and will need ground leave which may have to be very specific, e.g. 30 minutes, within the grounds with two escorts between the hours of 10.00 and 12.00; or one hour to walk to and from shops with one escort. For some patients who are under a forensic section of the Mental Health Act permission has to be agreed by the Home Office.

• For patients with long-term and enduring mental disorder lack of motivation will be, and will have been, a major barrier to fitness. If the service user has been on psychotropic medication for many years then weight gain will have occurred but the lack of activity and diet are likely to be key factors in lack of well-being.

• Patients with long-term and enduring mental disorder are four times more likely to die of cardiorespiratory diseases than are the general population (Phelan et al 2001).

• The body of evidence linking diet with mental health is growing at a rapid pace. As well as its impact on feelings of mood and general well-being, the evidence demonstrates diet contributes to the development, prevention and management of specific mental health problems (Mental Health Foundation 2007).

• Musculoskeletal assessment should have included checking joint range, muscle power, reported pain but should focus on function.

• Questions about what the service user can and can’t do physically and what if anything he wants to do about it should be the basis for intervention.

• Specific measurement of body mass index (BMI) and waist circumference may be appropriate on initial assessment or may cause distress and need to be addressed at subsequent appointments.

• The expertise of the physiotherapist should be initially employed to assess and treat any musculoskeletal disorders such as painful joints or injured muscles in preparation for a physical activity programme.

• In many mental health settings technical instructors (TIs), with a background in sport and physical fitness, work with the physiotherapists and can be very effective in delivering the activity plan when it has been devised.

• In some mental health gyms the TIs have a lead role and physiotherapists are involved only if there is a specific need due to injury or physical disorder.

• For patients with low motivation self-reporting questionnaires do not always provide full histories or clear progression lines. An interview screening tool with review will be more useful and can be administered by either the physiotherapist or the technical instructor.

• In this case the physiotherapy student or novice physiotherapist may learn from the experienced non qualified staff member the best way to approach a service user.

• Reviews rating to the baseline screening should take place at regular intervals being sure to involve the service user in a way which is meaningful to them.

• Long-term goals

• Short-term goals

• The short-term goals for a person with low motivation and possible fatigue due to lack of activity must initially be about identifying need and encouraging regular attendance.

• This can be facilitated by the use of treatment contracts where the service user agrees both goals and ways of achieving the goals. Contracts provide a structure to describe the methods to be used and this can help the physiotherapist devise relevant and interesting programmes for the service user.

• Motivational interviewing (MI) skills are a useful technique in these circumstances as they encourage the service user to direct the change. Originally used for counselling ‘problem drinkers’ the interviewing technique produces a relationship which reflects partnership rather than following an expert–recipient model (Rollnick and Miller, 1995).

• A service user may be morbidly obese to the point where even the effort of rising to standing is exhausting.

• Alternatively the service user may have been neglecting to eat regularly and have a low BMI which may cause concern in terms of sufficient calorific intake to support exercise.

• If the decision is to provide a physical activity programme then weight must be considered. Each person’s needs should be considered individually but a BMI below about 18.5 would militate against anything other than very gentle exercise and stretching.

• All multigym machines will have a specific weight limit and the service user’s weight may exceed this. Always check before suggesting use of exercise machines.

• For extremes of weight levels some useful forms of exercise are:

• A slow start, mild to moderate level exercise should be planned first and explained carefully to the service user as part of their treatment plan and goals.

• Progression from individual forms of exercise should happen at a pace which encourages the service user to continue with activity and /or exercise, until it becomes part of that person’s habit.

• Examples of progression:

• At this point in the treatment new musculoskeletal disorders may become apparent and they should be assessed and treated as part of the total treatment pathway.

• However the physiotherapist should be ready for intermittent attendance, relapse in illness or poor concordance with diet regimens all of which will interfere with goal time lines.

• Patience and innovation in treatment intervention can make a long process more successful.

• Following assessment the treatment plan will always include achieving safe movement in functional situations, thus, moving in bed, getting in and out of bed, sitting to standing and reverse, stabilising base to allow reaching.

• The other essential is to provide advice to the team and relatives or carers regarding safe management of mobility for the patient.

• Specific goals may be to:

• All the impairments which may accompany dementia will not necessarily be seen in one person, but there are a number of symptoms which will affect both the approach to and the success of treatment.

• The approach is derived first from the attitude of the student or novice physiotherapist who should have a positive attitude and be well motivated; be sympathetic to the individual’s difficulties recognising that dementia will affect different people in different ways and ensure that the patient is treated with dignity and respect.

• The key is to plan for success whilst using your skills to make movement enjoyable and including the team, carer and relatives in the plan.