On “Emergence of delayed posttraumatic stress disorder symptoms…” Dunleavy K, Kubo Slowik A. Phys Ther. 2012;92:339–351.

I thank the authors of this thoughtful case report¹ for helping to inform the physical therapy community about the unique and often poorly understood ways in which patients with a history of abuse or violent trauma may respond in a physical therapy setting. I also thank the authors for their careful discussion of the management strategies they used to effectively treat the patient in this case. I appreciate the authors' work because I am a health care professional and a patient whose psychological issues and experience in physical therapy have many similarities to those of the patient in this case report.

As the authors of the case report note, a substantial number of men and women in the general population have a history of significant trauma due to child abuse or physical or sexual violence; therefore, physical therapists in most specialties are likely to encounter some of them as patients. Yet individuals with a history of this kind of trauma may have avoidant behaviors (which can include not disclosing their trauma histories) and other behaviors that often are exacerbated in stressful environments—which may make them appear to be unstable, uncooperative, unfriendly, distant, controlling, or simply unpredictable, and thus difficult to treat. But when such patients are recognized and effectively managed, as happened in this reported case, not only may health care providers who have significant contact with these individuals (eg, physical therapists) succeed in treating the primary somatic complaints, they also may play a role in promoting psychological healing. I would like to reinforce this particular message of the case report by offering another illustration of how this might work through a brief description of my own experience.

I should first state that, unlike the patient in the case report, I have not been a victim of rape. My trauma history is not related to an individual experience of physical or sexual violence, but rather to a more protracted—over several years of my childhood—exposure to a home environment where the parents were intensely unhappy with each other, interpersonal communication was disrupted, and parental issues often were displaced onto their children in the form of outbursts of anger and both physical and psychological boundary violations. This type of history may be associated with what is referred to as “complex posttraumatic stress disorder.” Apparently, I had sufficient psychological resources so that, as soon as I was able, I moved away from that home environment to attend college. I did not know until years later that what I had experienced could be regarded as “abuse” or “neglect.” And only recently have I come to understand the source and significance of stress symptoms that I've experienced to varying degrees over the years, symptoms that also were exacerbated recently by the diagnosis of a potentially life-threatening medical condition and “triggers” in my physical therapy sessions.

I am a physician-researcher now in my late 50s. I was diagnosed with breast cancer in early 2011, underwent a mastectomy followed by radiation therapy, and subsequently developed a near-frozen shoulder for which I was referred for physical therapy. When I initially came to the physical therapy clinic, I was feeling very vulnerable. Up to that point, I had been being shuttled rather quickly through various hospital departments (diagnostic radiology, surgical oncology, plastic surgery, radiation oncology) for different aspects of my treatment. Although I felt challenged by the process, my contacts with practitioners in each of those departments were limited. During those 3 months, I tried to simply maintain a sense of forward progress, with my sights on getting well again. But, as I began physical therapy, with new onset pain and limited ability to use my dominant arm, I was quite anxious, feeling abruptly disabled and uncertain as to how things were going to proceed.

I was acutely aware of the pain in my shoulder at rest and with any attempt at movement, active or passive. My physical therapist noted my anxiety and was careful to take time to explain to me what she saw and what she was doing with me. She informed me that I exhibited significant muscle guarding. Having my attention brought to this guarding was actually profound feedback for me. I had not been aware that my body was doing this, that it could actually be doing something that impeded treatment efforts. I struggled to think about how to address this guarding and to “cooperate.” My therapist perceived my discomfort and worked to help me manage my body's defensiveness. For example, over several weeks of our twice-weekly sessions, as I lay supine and she sat by my side offering instruction, she would calmly encourage me to “breathe,” to “try to relax and let [my] arm go” and “just let gravity take it” (eg, during shoulder rotation exercises). Perhaps even more important to me, she often would say things such as “don't worry, I'll catch you.”

As I (or, more specifically, my body) slowly came to appreciate that what she said worked and that I could count on her to provide the necessary monitoring and support to minimize my pain, my trust and confidence in the process grew. My fears that my pain might suddenly worsen from some unanticipated movement began to diminish, and I was able to pay more attention to the details of specific movements and the related internal sensations themselves. My guarding lessened. Not only was my physical therapist able to execute more effective stretches of my arm and shoulder, but responsibility for therapeutic progress began to be shared, as I was able to take more initiative for guiding stretching movements on my own.

After several weeks of treatment, I was making clear progress, with my muscle guarding dropping away and the range of motion of my shoulder slowly improving. But then, like the patient in the case report, I started having some new issues whose origin and significance were unclear to me and my physical therapist at the time. I began to have disturbing dreams. I recalled that I had had similar dreams in my late teens when I had moved away from home to go to college. One involved my having a dissociative reaction (intense fear with “spacing out”) in response to an unexpected fit of rage and verbal abuse from my father when I was quite young. The other involved seeing myself encased in a frozen-over river where the ice was audibly and visibly cracking. (I also had had 4 sessions of craniosacral treatment by another female therapist around that time; but the point at which my dreams emerged during treatment was close to that at which nightmares are reported to have been noted by the patient in the case report, who apparently did not undergo any craniosacral treatment.)

I mentioned these dreams to my physical therapist, who expressed concern and encouraged me to consider consulting a counselor or psychotherapist. Probably because of my own intransigence related to deep-seated fears and years of avoiding confronting my trauma issues (which I now understand to be common for patients who have experienced trauma), I verbally deflected her suggestion, indicating that I felt I could manage and would get such help “if things got worse.”

Well, some things did indeed get worse. I began to develop other symptoms and signs consistent with features of posttraumatic stress disorder (ie, hyperarousal, avoidance/numbness, and re-experiencing) that were quite similar in many respects to those of the patient in the case report. For example, I felt that I was getting oddly jumpy and would find myself twitching or having more full-body reactions (strong startle responses) to unexpected sounds and movements of people in my environment. I was irritable at times. I recoiled and became tremulous on a couple of occasions when my therapist stretched my arm over my head. I had a strange sense of her “hovering” over me on some occasions when I was supine or “pinning” me to the wall on one occasion when I was standing. Later, I came to understand that I was apparently responding to “triggers” in my environment that were reminiscent of earlier traumas and that I was “flashing back” to them. These episodes were typically short-lived, lasting seconds, although I did have one that was associated with my nearly fainting, and I often had strong visceral reactions during them, feeling my heart pounding and breathing more rapidly. In a discussion with my physical therapist where I encouraged feedback, she informed me that she had been finding me “hard to read,” that I could be reactive at times, but I appeared unemotional and uncommunicative, with very poor eye contact, at other times.

Such feedback—along with my growing awareness that I was having moments where I was only partially aware of what had just transpired in the preceding seconds and then finding myself in some defensive or other frozen posture—ultimately led to my growing concern that something was going on that was outside of my conscious control and interfering with my usual functioning. Because of my medical background, I began searching the scientific literature for information that might allow me to better understand and control my symptoms. Finally, and as a result of all of this information, I followed up on my physical therapist's advice and sought counseling.

During my physical therapy treatment, my therapist was never aware that I had any history of significant emotional trauma (aside from that possibly associated with being diagnosed with cancer), as I had never discussed details of my early life experience with her. I also was unaware at the time that I had symptoms and signs that pointed to a diagnosis of posttraumatic stress disorder. Fortunately for me, my physical therapist is a sensitive and highly skilled individual who was able to adjust her treatment approach so that I was still able to make significant progress in regaining the full use of my shoulder.

But it wasn't just my body that experienced healing. I believe my psyche benefited as well. I believe it was my physical therapist's real consistency in communicating her concern and respect for my feelings, my autonomy, and my physical and psychological boundaries (despite my being a rather “difficult” patient) that encouraged me to keep returning to the clinic and to feel engaged over the several months it took to complete my treatment. I also believe that having this relatively unique opportunity to repeatedly participate in such “person-centered” forms of interaction (that were in such contrast to my early traumatic experiences) at a time when I was in pain and feeling quite vulnerable (as I had in earlier trauma states) was instrumental in beginning to undermine some of my old defensive patterns of coping and set them in the direction of potential reorganization and healing.

Being encouraged to also consider psychotherapy as I was, or doing coordinated work with psychotherapists and using cognitive-behavioral techniques as the patient and authors of this case report did, is likely to be important for many traumatized patients as well. Higher cognitive functions involving language and conscious awareness are thus able to be engaged and help patients like myself understand and manage symptoms, integrate traumatic experiences, and support the learning of new and better coping strategies.

I regard the sum of my experiences in physical therapy, now complemented by psychotherapy, as potentially life changing. And I would simply like to encourage others to keep a low threshold of suspicion for a history of abuse and psychological trauma in their patients, because it may never be too late for intervention to occur and healing to begin.

• © 2012 American Physical Therapy Association