Abstract
Background and Purpose Sexual violence has been identified as one of the most common predictors of posttraumatic stress disorder (PTSD). This case report describes the emergence of delayed PTSD symptoms, disclosure of history of sexual trauma, and the influence of re-experiencing, avoidance, and hyperarousal symptoms on physical therapy treatment.
Case Description A 60-year-old woman was seen for treatment of low back pain. Discussion of a discord between fear of falling and no balance impairments led to disclosure of sexual assault by a physician at 19 years of age. The patient's PTSD symptoms emerged after 10 weeks of physical therapy. The physical therapists monitored somatic responses and body language closely and modified and planned treatment techniques to avoid PTSD triggers and limit hyperarousal. Collaborative communication approaches included reinforcement of cognitive-behavioral strategies introduced by her psychotherapists.
Outcomes Trauma-cognizant approaches supported the patient's efforts to manage PTSD symptoms sufficiently to tolerate physical therapy and participate in a back care class. Nonlinear psychological healing is illustrated.
Discussion Symptoms of PTSD may emerge during physical therapy treatment, and patient-sensitive responses to disclosure are important. The trauma-cognizant approach (2-way communication, patient-centered management, and integration of psychological elements into clinical decision making) helped identify and respond to triggers. The physical therapists reinforced cognitive-behavioral strategies introduced by psychotherapists to manage PTSD symptoms. Patient-centered care with further refinement to a trauma-cognizant approach may play an important role in assisting patients with PTSD or a history of sexual trauma to manage symptoms while addressing rehabilitation needs.
The impact of trauma such as physical violence, childhood sexual abuse, or rape is extensive, and can influence long-term physical and psychological health of survivors. Kessler et al1 reported that 60% of men and 51% of women had been exposed to one or more traumatic events, whereas Laumann et al2 estimated that coercive sexual encounters have been reported by 3% of men and 15% to 22% of women in the United States. Physical therapists in many practice specialties are likely to work with male or female survivors of sexual trauma, whether the history of the sexual incident is disclosed or not. The long-term impact of physical and sexual trauma can result in increased health risk factors,3,4 with manifestations such as chronic pain4 and headaches.5 Survivors of sexual trauma may have psychological diagnoses such as posttraumatic stress disorder (PTSD), anxiety disorders, depression, substance abuse, and suicidal tendencies as primary diagnoses or comorbidities.6–9 Sexual trauma is strongly associated with PTSD.10 Kilpatrick et al11 surveyed 4,000 women who had been sexually assaulted and found that 32% developed PTSD. The psychological sequelae of sexual trauma necessitate adaptation of physical therapy interventions and responsive management strategies.
Typically, acute psychological stress symptoms present immediately after trauma. The term “posttraumatic stress disorder” is used when symptoms present more than 4 weeks after the incident. Delayed-onset and chronic PTSD are defined in the Appendix. Posttraumatic stress disorder presents a complex set of symptoms, including re-experiencing the traumatic event, avoiding stimuli that trigger memories, hyperarousal, and hypervigilance. The diagnosis of PTSD by a mental health professional requires the presence of symptoms from each category shown in the Appendix. The pattern of the profile is perhaps the most important aspect for diagnosis of PTSD, and simultaneous presence of numbing and arousal responses is somewhat unique to PTSD.12 It is important to note that although not all survivors of sexual trauma will develop full-blown PTSD, symptoms may present to a greater or lesser extent and influence physical therapy outcomes or result in attrition. The recurrence of disturbing images, smells, sounds, or pain related to the initial incident (flashbacks) can occur along with dissociation from the present environment. Dissociation is an alteration in consciousness but also can manifest as altered linkages between memories and perceptions of past and present.13
Neuroimaging has helped explain that underlying cortical changes are responsible for PTSD symptoms such as reliving the event, attentional difficulty, and hyperarousal.14 When asked to think about triggers for their symptoms, patients with PTSD show relative deactivation of the cingulate and prefrontal cortex areas in the brain with functional magnetic imaging.14,15 These areas normally inhibit emotions, allow extinction of memories, and enable translation of the experience into communicable language.14,15 Hopper and associates15 explained these neural patterns as resulting in excessive and nonvolitional emotional overactivity in response to trauma-related stimuli, along with transient psychological disengagement (dissociation from the present). The inappropriate responses are triggered by sensory aspects associated with the initial trauma. Avoiding the fearful stimuli results in replacement of active coping strategies with passive, fearful responses and inappropriate cognitive or behavioral responses to perceived threats.14 Individuals with PTSD also have problems with sustained attention and working memory.14
Psychotherapy for PTSD involves individual or group treatment16,17 using psychodynamic17,18 or cognitive-behavioral approaches.19,20 Other treatments include systematic desensitization to stimuli in a controlled manner,21 eye movement desensitization and reprocessing,22 self-analysis (journaling),23 hypnosis,24 and relaxation techniques.25 Psychotherapeutic techniques are often combined with antianxiety or antidepressant medication.19
Physical therapy techniques can “trigger” memories, resulting in overwhelming emotional or visceral responses with the potential for re-traumatization.3,26 The importance of patient-centered and patient-sensitive management by physical therapists is compelling, given the underlying potential for triggering stress reactions in patients with a history of sexual violence. Patient-centered health care practice has been described as taking into account the patients' needs, goals, and preferences, using 2-way open communication and involving the patients in their own care.27 Schachter et al3 recommended practices such as considering the patient's needs, taking time with the patient, and respecting boundaries for patients with a history of sexual trauma. Patient-sensitive practice, including empathetic responsive communication, is important for initial and subsequent interactions with survivors of sexual trauma who may or may not disclose their history.
Schachter and colleagues3,26 have published suggestions for sensitive practice from 2 large multidisciplinary grounded theory and action research studies with survivors of sexual trauma. They propose that positive rapport, good communication skills (including responses to body language), establishing partnerships, and cognitive mechanisms such as sharing information and education will help the patient's sense of control and safety.26 Patients value therapists with a caring attitude and strong communication skills, along with education and explanations of their condition.28 Collaborative clinical reasoning also has been linked to patient satisfaction and positive health outcomes.29,30 However, for patients with a history of sexual violence, patient-centered and sensitive practices transcend being valued to being essential to their support and well-being. In addition, Schachter et al3 suggested that physical therapists appreciate the implications of interpersonal violence and understand that nonlinear healing is common. They concluded that the primary consideration when working with survivors of abuse is to facilitate feelings of safety and control for the patient.3 This consideration also is advocated by trauma experts in psychology and psychiatry.31,32
In the editorial commentaries in the special issue of Physical Therapy focusing on psychologically informed practice, Craik33 emphasized the need to consider the influence of psychological impairments. Main and George34 encouraged physical therapists to develop a broader approach to recovering optimal function, which includes identifying and managing psychological obstacles. An organizational model, trauma-informed care, has been used in settings where there is a likelihood of history of interpersonal trauma such as mental health, substance abuse, and child welfare centers.35–37 Health care providers are trained to recognize the symptoms and manifestations of trauma and to be sensitive to trauma-related issues to avoid inadvertent re-traumatization of the survivor of trauma.38 This case report focuses on the specifics of the emergence of delayed-onset PTSD during physical therapy treatment and the patient's disclosure of sexual trauma 40 years after the incident. As a trauma-informed model was not in place when the patient was seen for treatment of back pain, the term “trauma-cognizant” is used for the purposes of this case report to describe an approach to communication, management, and decision making in the context of the history of sexual trauma and subsequent delayed PTSD symptoms. The trauma-cognizant approach used while addressing the patient's musculoskeletal dysfunction is presented, and the effectiveness of the principles is discussed.
Case Description
This case report follows a patient who was treated for an initial episode and an exacerbation of lumbar pain and an ankle sprain over a period of 4 years. She also attended a group back care class during and after management of the musculoskeletal injuries. Time lines are referenced to the initial physical therapist evaluation (Fig. 1). The patient was seen in an outpatient, open-plan clinic setting by 2 female physical therapists, each with more than 20 years of experience.
Time lines of pain, Posttraumatic Stress Disorder (PTSD) Symptom Scale–Interview (PTSS-I)40 values, and critical incidents. The PTSS-I measures symptoms in 3 of the DSM-IV-TR categories: (B) re-experiencing incident, (C) avoidance, and (D) hyperarousal (see Appendix). Critical incidents: (A) initial physical therapist's evaluation, (B) PTSD emerges, (C) psychotherapy starts, (D) low back pain reinjury, (E) second physical therapist starts treating patient, (F) ankle sprain, and (G) hypnosis starts.
Patient History and Examination
A 60-year-old woman with lumbar degenerative disk disease was referred for physical therapy after injuring her back while lifting furniture. She had low back pain and referred pain down the left leg (8/10), without numbness, tingling, or weakness. Initial system reviews were negative for “red flag” and “orange flag” responses (see Nicholas et al39). Pain during sitting, standing, and walking was reported as 8/10 on the visual analog scale. The patient did not have any signs of psychological distress, but did show elevated anxiety levels manifesting as nervous body language and tension (“yellow flag”).39 Lumbar spine active range of motion and muscle flexibility tests were limited by pain. Neurological tests were normal. The patient appeared uncomfortable lying prone, and joint play was limited by pain and muscle guarding. During palpation, the physical therapist noticed a generalized increase in muscular tension and anxiety responses (facial expressions, lip twitching, and lack of eye contact), so she tried to put the patient at ease for the remainder of the evaluation and chose spinal stabilization over manual therapy techniques.
Emergence of PTSD and Disclosure of Sexual Trauma
After 10 weeks, the pain was intermittent (5/10), and the patient tolerated work-related activities with some modifications (Fig. 1). At this point, she started experiencing panic attacks (fearful shaking) in physical therapy and reported difficulty descending stairs as well as a fear of falling. One-leg standing balance was unsteady, but she was able to manage more than 30 seconds. More complex balance tasks and functional activities such as negotiating stairs were demonstrated without difficulty. Reach and lunge activities caused some increase in low back pain, but no major balance loss. Myotomal and dermatomal tests were within normal limits, and there were no bowel or bladder complaints. The physical therapist gently initiated a conversation about the discrepancy between the fear of falling and lack of physical balance deficits, with the intent of clarifying and exploring the reported balance difficulties. The patient acknowledged the discord between her perceived symptoms and her physical capabilities. Retrospectively, the patient reported that she experienced her first flashbacks at this point, but did not understand that she had PTSD. Approximately 2 weeks later, she informed the physical therapist that she had been sexually assaulted at age 19 years by a general medical practitioner while seeking treatment for a kidney infection.
Much later, the patient revealed that in the years after the sexual trauma she struggled with alcohol abuse, suicide ideation, and anorexia nervosa. She began psychotherapy at age 23 years, and after 5 years ceased self-destructive behaviors without addressing the sexual assault. The patient avoided medical settings for 40 years, with the exception of obstetrical care for one child. Only decades later did flashbacks of the physician raping her emerge.
PTSD Symptoms and Psychotherapy
Table 1 presents signs and symptoms experienced by the patient for each of the PTSD diagnostic categories. At the time of disclosure, the patient was having difficulty sleeping and experiencing flashbacks of the sexual assault (initially outside of physical therapy and at a later point during treatment).
Physiological Signs Noted by the Physical Therapists and Symptoms Communicated by the Patient Consistent With Diagnostic Criteria for Posttraumatic Stress Disorder (PTSD)a
As the patient shared from her journal notes:
There are some things that cannot live in your head, so they are not there. But I guess your body knows, just the same. The details of what happened stay in your body and explode on you later. There's the overwhelming emotion of terror, along with some detail like what he was wearing or how he smelled or a position that your body was in. That's what a flashback is—that, and the feeling of shame because you didn't stop him.
The physical therapist supported the client's decision to re-enter psychotherapy and encouraged her to inform her internist. The internist prescribed Celebrex (G. D. Searle & Co, Division of Pfizer, New York, New York), then meloxicam, but no mood disorder medications. The patient started once-weekly or twice-weekly psychotherapy, and the psychotherapist administered the PTSD Symptom Scale–Interview (PTSS-I)40 around 8 months after physical therapy started (initial score=33/51) and every 6 months thereafter (see Fig. 1 for time lines, back pain, and PTSS-I scores).40,41 Psychotherapy included psychodynamic and cognitive-behavioral approaches and keeping a journal. Memories of the sexual assault and the subsequent 6 months previously lost to amnesia (dissociation) emerged slowly, typically in the form of flashbacks. The patient worked with 2 psychotherapists to identify the triggers for flashbacks, to develop cognitive strategies for controlling the flashbacks (delay emergence until she was in a safe, private place), and to develop behavioral strategies (such as deep breathing) for managing anxiety. The patient's PTSD symptoms worsened with the impact of memories around 26 months after the back injury, and one of the psychotherapists introduced self-hypnosis techniques, which provided some relief (Fig. 1). Both psychotherapists favored a systematic desensitizing approach, and the patient chose to progressively challenge herself with exposure to triggers in physical therapy and the back care class, as well as in the community.
Patient-Centered Multidisciplinary Communication
The patient granted the physical therapists and psychotherapists permission to discuss her management; however, the physical therapists chose to communicate through the patient. The client is very intelligent, and they believed that she was able (and willing) to be the center of the communication and that she would benefit from relaying the multidisciplinary communication. The patient was able to control the pace at which she met the challenges of the trauma-related symptoms. The physical therapists encouraged the patient to document her responses, to offer feedback (via e-mail or in person), and to communicate with the psychotherapists about her experiences in the physical therapy environment.
Influence of PTSD Symptoms on Physical Therapy Treatment
Identifying stress responses.
The patient was monitored closely by the physical therapists during both individual and group exercise for signs of physiological reactivity (Tab. 1). This monitoring required attentive listening and watching for signs of stress, rigorous attention to the physical therapist's own body and verbal language, and scrutinizing the environment for potential stressors. The patient sometimes left the room without explanation, which was an obvious indicator of stress; however, she also showed other signs of discomfort such as eye darting, lip twitching, muscle tension, distraction, and slumped posture. If the physical therapists observed any of these indicators, they modified the treatment immediately and later assessed the activity for its relationship to the patient's known triggers. The physical therapists would attempt to redirect the patient's focus to the task at hand or provide the option of relocating to a private room. Specific triggers are described in Figure 2.
Triggers of psychological stress for the patient described in this case report (sometimes causing full-blown flashbacks).
As the patient identified additional triggers, she discussed the emerging memories with the psychotherapist, and she informed the physical therapists of issues that were identified as problematic. The patient shared her journal notes related to these episodes:
Maybe it isn't falling that I fear. I am slowly getting a memory of having been on the floor in this doctor's office. I'm on my back. It may be that the panic attack was because my pelvis was elevated, my legs were apart, and my legs were in the air. The position may have been a trigger for memory. If so, it's not falling I'm afraid of. I'm afraid of remembering.
Working with the patient to avoid and manage triggers and hyperarousal.
Specific techniques to manage anxiety, hyperarousal, or impending flashbacks were used in physical therapy (Tab. 2). The physical therapist's role was to limit the exposure to multiple stressful stimuli and choose treatment or environmental options to avoid increasing the patient's stress reactions. Strategies such as selecting the most private area in the open-plan exercise space, moving to different locations when stressors were noted, and using mirrors so the patient could discreetly monitor others were helpful. Because of a lack of privacy in the open-plan exercise space, the physical therapist was sometimes unable to respond immediately to the patient's needs. In these instances, the patient initiated e-mail communication with the physical therapists. E-mail communication became a valuable tool for addressing concerns in a private, yet timely, manner.
Immediate Physical Therapist Management, Communication, Prevention Choices, and Psychological Intervention Support Used to Minimize the Influence of Posttraumatic Stress Disorder Symptoms for This Patient
If the physical therapist noticed symptoms of distress (Tab. 1), asking a direct cognitive question or redirecting the patient's attention often diffused stress responses. The patient communicated what did and did not work well for her (Tab. 2). On one occasion, a flashback occurred during the back care class. The physical therapist noticed that the patient had curled up in a fetal position and was not interacting with anyone around her. Later, the physical therapist initiated a discussion with the patient about the event. As a result, the physical therapist used direct questioning in the group class setting if she noticed signs of physiological stress. The patient reflected on the events in her journal:
I realized that the PT [physical therapist] was talking to me, and that's what brought me out of the flashbacks…(she) was saying: “Are you using the edge of the mat to line up your body?” It made me look at the mat, realign my body, and answer her—all of which made me come back into the present moment. I realize now that…forcing me to interact with her in the present moment (crouching down next to me, looking into my eyes, but not touching me), is what made the flashbacks dissolve. She did 2 things that were helpful: calling me by name and asking me a question about my body at that moment. This is actually much better than asking something like “Are you all right?”, which can be embarrassing in front of other people.
The group environment also made it difficult for open communication and to manage outside variables, such as new male class participants. If the physical therapist anticipated male participants joining the class, she alerted the patient in advance to offer her the choice of canceling the session. Other strategies included encouraging the patient to focus on specific kinesthetic tasks (cognitive control), patient education (alternate cognitive attention focus), or breathing techniques (see Tab. 2 for other examples).
Initially, any identified triggers were avoided as much as possible (Tab. 2, Fig. 2). At a later stage, the patient was able to slowly re-introduce these stimuli at her own pace. To facilitate patient trust and control, the patient was offered a variety of options, including different exercise positions, equipment, and intensity that would still address the same goal. If the physical therapist noted any signs of anxiety, she explained the goals of the activity and sometimes used humor to redirect the patient's attention. Initially, manual treatment and other forms of touch were avoided; however, the patient later requested that the physical therapists use touch to prepare her for the challenge of manual search during airline travel. The patient was taught to palpate her own body first, and therapeutic touch was introduced slowly in a sequence similar to approaches used for patients with hyperesthesia. The patient was asked for consent to touch each time and encouraged to say “No” if she was not comfortable.
Outcomes
Back Pain
After 3 months of biweekly treatment, the patient reported a decrease in intensity and frequency of low back pain, as well as functional improvements (Fig. 1). She joined a group back care class, and pain gradually decreased to 3/10. Her back pain flared up (3–5/10) after walking on uneven ground 13 months after the initial visit, and she received an additional 12 physical therapy sessions. The back pain levels stabilized 2 years after the initial visit (Fig. 1). After the musculoskeletal injuries were addressed, the patient was able to tolerate all work, social, and recreational activities, including softball.
PTSD Symptoms
Despite improvements in the musculoskeletal complaints, the patient's PTSS-I scores remained at 33 to 35/51 for 2 years after the initial evaluation. Approximately 12 months after the initial low back pain, the patient became increasingly hypervigilant. She was unable to tolerate anyone positioned behind her, even at a distance. Anxiety responses also increased when noise levels increased or when unfamiliar individuals (particularly males) were present. At around 26 months, the PTSD symptoms increased, along with anger and frustration responses. Once she began self-hypnosis, her PTSS-I score gradually decreased to 25/51 (Fig. 1). At around 4 years after the symptoms emerged, the patient was able to control the flashbacks approximately 97% of the time in the exercise and work environments, but nightmare frequency had increased. Other symptoms such as numbing and anger subsided, resulting in lower overall PTSS-I scores. Despite the ongoing PTSD symptoms, the patient was able to address her back pain, participate in a group back care class, and return for further treatment of musculoskeletal complaints. The overall health benefits of continued care included increased confidence when needing medical treatment and participating in regular exercise and community activity.
Discussion
Emergence of PTSD Symptoms
The first signs of PTSD emerged during back pain treatment, and the patient first disclosed her history of assault to the physical therapist 40 years after the incident. Physical injury42 or pain14 can be a catalyst for reawakening stored emotional memories associated with sexual trauma. Retrospectively, the patient linked the emergence of memories of the rape to memories of back pain from the kidney infection that prompted the physician visit. The role as a patient also may have contributed to the emergence of PTSD symptoms, particularly because the sexual trauma occurred in a medical setting. The physical therapist's role as an authority figure, use of touch, or other reminders of the trauma could potentially evoke memories of past abuse.3,43 Even if patients do not have full-blown PTSD, some of the lessons learned—such as the need to explore options for nonstressful treatment methods and the importance of patient-centered management—are relevant for patients who have a history of sexual or physical trauma.
Disclosure
The physical therapist's response to disclosure is extremely important, and a positive experience may be the catalyst for those patients with a history of sexual trauma or PTSD symptoms to seek support.3,26,44 Schachter and colleagues3,26 offered suggestions for appropriate reactions to disclosure, such as not questioning the accuracy of memories, showing empathy, acknowledging the prevalence of abuse, validating the disclosure, and asking about support mechanisms. In this case, the physical therapist's response was, “I am so sorry that this has happened to you,” which the patient reports allowed her to feel enough acceptance to be able to continue to work with her. Disclosure can be deterred by time constraints or environments that limit confidentiality.3 In this particular situation, conversations could easily be overheard, and options for a more secure location had to be identified for future patients.
The patient's initial anxiety levels might have warranted some open discussion of discomfort to touch with sensitive inquiry. The survivors of sexual trauma in Schachter and colleagues' study who reported disclosing their abuse did so in the hope that the information would help practitioners understand them better and emphasized that inquiry is appreciated.3 Schachter et al3 provided guidelines for identifying behaviors associated with previous abuse and suggested using task-specific inquiry with clarification of the patient's preferences for each examination or treatment procedure.
Physical therapists practicing in settings where a large number of patients are likely to have a history of physical or psychological trauma may need to consider regular screening. The Veterans Administration health care systems have adopted a universal screen for a history of sexual trauma.45 When the possibility of past history of trauma is not obvious, patient-centered management can assist with identification of PTSD symptoms and may facilitate the development of sufficient trust and a sense of safety to allow disclosure and continuation of care. In settings that require fast-paced treatment and short lengths of stay, the interaction between the physical therapist and the patient during the first visit becomes that much more important. The possibility that each action or conversation may influence whether a patient with a history of trauma is able to develop the courage to seek assistance is a sobering thought for reflection. All health care professionals would benefit by referring to Schachter and colleagues'3 resource for recommendations of sensitive communication and practice and options for how to respond to disclosure.
Trauma-Cognizant Management by Physical Therapists
The need for patient-centered care is evident for all patients; however, the trauma-cognizant approach used for this patient required further refinement and sensitivity based on awareness of the manifestations of the psychological impact of the interpersonal trauma. After the disclosure, trauma-cognizant management for this patient required additional attention to somatic responses and body language, 2-way communication, adaptability, and thoughtful treatment planning to enable a sense of safety for the patient.
One challenge was the patient's reliance on a single physical therapist. The patient's back pain recurred while the first physical therapist was on leave, and the patient became anxious when the therapist to whom she had entrusted her information was not available. The patient suggested another physical therapist with whom she felt comfortable, which increased her sense of control. The patient knew that her PTSD symptoms were not documented in her chart, and she took responsibility for disclosing her history to the second physical therapist. Because the patient's anger responses increased during the same period, the 2 physical therapists were able to support each other and the patient without overreacting on a personal level. In many physical therapy settings, coverage is assigned rather than at the patient's discretion. In these environments, the physical therapist may need to discuss options for coverage with the patient, along with possible mechanisms for sharing the relevant information.
Avoidance of PTSD Triggers
Identifying triggers is difficult, as patients may not know what will induce flashbacks or hyperarousal, and triggers vary, not only from person to person, but with re-emergence of memories.12 In this case, triggers were identified through constant monitoring, patient reflection (journaling and with her psychotherapist), and communication both during and after treatment. A written journal is a practical option when time or privacy is limited for individual communication about the triggers during physical therapy treatment.23 Initially, completely avoiding triggers was necessary, but once the patient was ready, stressors were reintroduced (desensitization) gradually.
Exercise
For this patient, Pilates exercises were used during both the individual treatment and in the back care class to improve her core stability and alignment. The patient reported that there were additional benefits to this approach, including improving her body awareness and “connection” to her body and, in turn, helping to control her PTSD symptoms. Exercise programs involving a body-mind connection, such as yoga,14,43 tai chi,14 and relaxation techniques, including breathing and imagery, have been advocated to manage PTSD.25,32,46 Aerobic exercise also has been used to support reduction of symptoms in children with PTSD.47,48 Rothschild43 suggested that approaches emphasizing body awareness such as Pilates, Feldenkrais, and Alexander techniques are valuable adjuncts for trauma management and advised caution with approaches involving extensive hands-on contact such as craniosacral, Rolfing, or manual physical therapy techniques. Although a case report provides insufficient evidence to advocate any particular intervention, exercise with a mind-body connection may render psychological benefits and is particularly useful when manual techniques are not suitable.
Support of Psychological Goals and Patient-Therapist Partnerships
Cognitive-behavioral approaches have been advocated for both psychological and physical problems associated with pain.49 The patient developed coping strategies with her psychotherapist to control her psychosomatic responses, including cognitive reframing, conscious attention to the present moment, and self-hypnosis. The physical therapists were able to support these strategies with reminders to pay attention to alternate thoughts or to the exercise goal, along with utilization of breathing techniques. Physical therapy treatment also used cognitive approaches (goal setting and education), which offered the patient further personal control. As the processor and messenger, the patient applied suggestions, communicated responses, and provided feedback to the physical therapists and the psychotherapists. The patient's role in the communication gave her control of the flow of information and allowed her to feel that her needs were being heard and respected. In other circumstances, particularly in short-term treatment, different communication strategies or referral systems may be necessary. In Schachter and colleagues' research,3 survivors of abuse noted that a collaborative model of health care, particularly between mental health and physical health professionals, was an asset to their healing. The physical therapist's role could include referral to psychotherapy and community resources, encouragement of physical activity, or providing professional reflective support without attempting to serve as a counselor or psychotherapist.
Physical and Psychological Recovery Patterns
It was important for the physical therapists and the patient to understand that patterns of physical and psychological recovery in the same person may not be parallel, which has been reported by other survivors of sexual abuse.3 On many occasions, the patient was in severe psychological distress, and she could very easily have discontinued treatment. Once the memories of trauma are being addressed in psychotherapy, PTSD symptoms may increase,31,50 as in this case. Voluntary attrition probably occurs more often than realized. However, it also was important to understand that the psychotherapists were assisting the patient to develop coping strategies with a desensitization philosophy rather than avoiding stressors. As the authors of another case study explain, this does not mean that that psychotherapy is doing more harm than good.51
The patient tolerated and sought treatment over an extended period despite the stressors in the environment, but the duration of care illustrated in this case report may not be possible in insurance-driven environments. Multiple treatment interactions allowed adequate time and opportunity to develop trust and identify strategies that worked, a luxury that is not always available in busy health care environments. The patient, who was highly motivated and well informed, returned for unreimbursed treatment and back care classes, demonstrating the benefit of taking time to meet her needs. It is more likely that patients will return for care if initial disclosure is managed properly and a collaborative, patient-centered approach is implemented.
Conclusion
This case report presents the emergence of delayed PTSD symptoms during physical therapy 40 years after the incident. Patient-centered practices enabled the patient to feel safe enough to disclose the history of sexual trauma and return for additional physical therapy treatment, despite significant chronic PTSD symptoms. The physical therapists used a trauma-cognizant approach, which included patient-sensitive communication, placement of the patient at the center of the interdisciplinary team, fostering a sense of safety, and integrating psychological elements into clinical decision making. A heightened awareness of nonverbal stress responses and the ability to anticipate triggers for flashbacks played an integral role in selecting appropriate treatment modifications. Two-way communication, collaborative reasoning, and facilitation of patient control further supported the patient's sense of safety in physical therapy treatment and back care classes. The physical therapists reinforced cognitive behavioral strategies introduced by her psychotherapists in attempt to control the PTSD symptoms while nonlinear psychological healing occurred. The patient reported that the physical and psychological aspects of control enabled her to continue full time in her profession and rehabilitate her musculoskeletal injuries while living a productive life.
As the editors of this journal have pointed out,33,34 physical therapists will be more effective if they are informed about psychological issues that influence their patient interactions and treatment. Although PTSD symptoms can present unexpectedly and pose challenges for the patient and physical therapist to manage, patient-centered management may assist with developing sufficient trust for disclosure. Further refinement of interactions and choices to provide trauma-cognizant care may assist patients with PTSD or a history of sexual trauma in controlling symptoms while addressing rehabilitation needs.
Appendix.
Diagnostic Criteria for DSM-IV-TR Code 309.81 Posttraumatic Stress Disordera
aAppendix reprinted with permission from: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Text revision, 4th ed. Arlington, VA: American Psychiatric Association; 2000.
Footnotes
-
Both authors provided concept/idea/project design and writing. Dr Dunleavy provided data collection and analysis.
-
The patient presented in this case report signed an informed consent statement, shared selected journal notes, and contributed to the case report, but is not identified to protect her confidentiality. The authors gratefully acknowledge the psychotherapist's contributions.
- Received October 19, 2010.
- Accepted August 15, 2011.
- © 2012 American Physical Therapy Association
References
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