Author Response

We thank the writer of the letter¹ responding to our case report.² We found her description of her experiences extremely powerful and the similarities between her responses and the responses of our patient during physical therapy to be remarkable. The dialogue also highlights the importance of case reports in presenting issues related to clinical practice, along with how patient responses might reveal patterns that are not immediately obvious. Among the notable similarities were: (1) the significant delay in the onset of the posttraumatic stress disorder (PTSD) symptoms after the trauma, (2) the emergence of symptoms while receiving physical therapy after some improvements in physical function, (3) the psychological and somatic symptoms experienced during physical therapy treatment, (4) the disclosure of symptoms to the physical therapist, and (5) suggestions to seek psychotherapy.

As the letter writer notes, the amount of time that physical therapists spend with patients, as well as the amount of physical contact, may set the stage for emergence of the psychological symptoms. Physical therapists, therefore, should be conscious of the possibility of stirring up buried psychological trauma that might or might not be related to the presenting diagnosis. There is a need to consider the potential of confounding psychological comorbidities from past psychological trauma in patients with any type of diagnosis as well as in those who have a more recent history of physical trauma.

Studies of musculoskeletal trauma have found that higher levels of acute posttraumatic stress was one of the predictors of higher levels of pain and disability in patients with whiplash³ and, conversely, that individuals with higher levels of pain continued to be psychologically distressed 6 months later with moderate posttraumatic reactions.⁴ Veterans returning from Iraq who have PTSD have a higher incidence of musculoskeletal disorders—such as low back pain, headaches, and lower-extremity diagnoses—than those without PTSD.⁵ The linkage between pain, physical trauma, and psychological stress is well established, but the exact mechanisms and triggers for delayed onset PTSD may be less clear. Reactions to the physical dysfunction—such as lack of personal control and feelings of vulnerability, as described so eloquently by the letter writer—might be the unpredictable trigger for delayed onset PTSD.⁶ Physical therapists, therefore, should pay attention to signs of somatic stress in all patients regardless of the extent of physical trauma or history of the presenting diagnosis.

The similarities in the time frames and responses between the letter writer and our patient pose the question of whether the emergence of delayed onset PTSD while receiving physical therapy treatment is more common than we realize. Also noteworthy is that, in addition to the delayed onset, the PTSD symptoms appeared when the patients' physical impairments were improving. Although most physical therapists are able to recall patients with acknowledged PTSD diagnoses, or patients who have exhibited unexplained somatic responses during manual therapy or other treatments, we could have easily missed the symptoms and responses of patients who avoided or discontinued physical therapy. As the letter writer clearly articulates, there may be occasions when physical therapists are not sensitive to a patient's complex, frightening, and unexpected needs related to psychological or physical trauma; instead, they may attribute the patient's affective responses to the patient's “difficult” personality. Major time restrictions in the present health care environment may result in missed opportunities to respond appropriately or may limit the amount of time needed to develop a trusting relationship. From the opposite perspective, the amount of time that we spend with our patients compared with the amount of time that other health care professionals spend suggests that we have the responsibility to be able to identify and respond appropriately to psychological reactions.

The patient-centered model relies on 2-way communication and is crucial (and difficult) to use when the topic is so personal. The comments received have provided extremely valuable information for improving our interactions with patients. As physical therapists, we can perform physical examination tests, ask for patient history and other information, and make clinical choices based on evaluation of what we observe or hear. However, sharing the psychological information and reactions of both individuals depended on the patients being honest and brave enough to disclose what was happening to them. The importance of trust has been emphasized by other authors who have interviewed survivors of sexual abuse.^7,8 The trust that has been placed in our hands is a gift, not to be taken lightly.

As the letter writer pointed out, the fear of being perceived as “critical” or “difficult” and the anxiety related to discussing problems of this nature may limit how much is shared. Journaling is advocated by psychologists,^9–11 and both we and our patient's psychotherapist encouraged our patient to keep a journal. This suggestion on our part was partly to provide an outlet for the patient to express herself honestly without feeling that she was being judged, and partly to track the triggers of the emotions. The patient also believes that the journaling allowed her to integrate and reflect on her emotional reactions and organize her thoughts. The “Emergence of PTSD…” article was in part a result of this documentation and retrospective analysis and has extended beyond a personal diary, to reach out to others.

As the letter writer highlights, the involvement of higher cognitive function and conscious awareness contributed to management of the symptoms. The paper and dialogue have provided an outlet for both patients to voice their stories, promote patient-professional communication, increase awareness, and influence clinical practice, as they work toward their psychological healing.

Both the letter writer and the patient discussed in our case report are highly intelligent and successful individuals with academic and clinical backgrounds. The ability to recognize and address the psychological symptoms not only requires financial resources, but also the time, emotional fortitude, and pure courage to work toward managing the alarming condition. It often is easy to assume that patients with this type of background are likely to independently seek assistance for psychological problems, but the physical therapist's suggestion to seek assistance was identified as an important step in both scenarios. As health care providers, seeking options for psychological care for those individuals who are less likely to seek assistance or are unable to afford care is more challenging. We hope that the profound messages that these 2 individuals have been able to articulate will provide hope for others with PTSD and guidance for physical therapists working with patients affected by PTSD or other anxiety disorders. We sincerely thank both the letter writer and our patient for sharing their stories, feelings, and suggestions.

• © 2012 American Physical Therapy Association