Physiotherapy and Patients with Post-Traumatic Stress Disorder

Why physiotherapists should learn about PTSD

Introduction

Physiotherapists are bound by codes of conduct to provide person centred care (Physiotherapy Board of Australia, 2014), which involves considering the patient as a whole person and considering how comorbidities and contextual factors may impact in their presentation and their management.

PTSD is associated with a range of comorbid psychological conditions, poorer physical health, increased treatment utilization, impaired functioning, and reduced quality of life (The Management of Posttraumatic Stress Disorder Work Group, 2017), and is highly likely to affect patient presentations in a physiotherapy context, as will be discussed later in the module.

The dissatisfaction of PTSD sufferers with their treatment in health care is well documented, with patients frequently complaining of healthcare professionals having low levels of awareness of PTSD and its relevance to their complaint (National Collaborating Centre for Mental Health, 2005).

Understanding how PTSD is relevant to physiotherapy practice will assist physios in improve the quality of care for patients with PTSD and trauma related injuries. 

This video provides a brief overview of PTSD and how it may impact on a  person holistically


(Veterans Health Administration, 2014)

Patients with PTSD are likely to present to physiotherapists

A large scale study found that 50-65% of the Australian community will experience a traumatic event in their lifetime, and 5-10% will develop PTSD as a result. 1.3% of the population have had a PTSD diagnosis in the last year (Creamer, Burgess & Mcfarlane, 2001), which is already a large proportion. 

The likelihood of encountering a patient with PTSD is even higher in a physiotherapy setting. Refer to the figure below for examples:

Implications of PTSD

PTSD is a disorder that has profound and widespread implications. Below is the WHO-ICF framework physiotherapists are familiar with, outlining the breadth of potential affects PTSD can have on a sufferer in a biophychosocial context.

References: (Spoont et al., 2015) (Nielsen, 2014) (Forbes et al., 2007)

Image: (World Health Organization, 2008)

Activity: the PTSD experience

Activity:

Watch this video of a soldier speaking about his experience with PTSD, and reflect on the widespread and significant impact PTSD can have on a person. Consider how each of these impacts would fit into the WHO-ICF framework.

Content warning: graphic discussion of self harm, suicide and violence 

(MiliSource, 2013)

Have you completed the activity for this section?

  • Yes
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Screening for PTSD

Why should we screen for PTSD?

“Effective treatment of PTSD can only take place if the disorder is recognized” (NICE, 2005)


Though PTSD is a common condition, it is frequently undiagnosed in primary health care settings (Spoont et al., 2015).

Identification and diagnosis of PTSD means physiotherapists can provide targeted care, as well as referring patients so they can receive critical mental health care, which will in turn have a positive effect on physiotherapy outcomes.

Why is it underdiagnosed by physiotherapists?

A key feature of PTSD is avoidance of traumatic stimuli, including thinking and talking about it, so the patient is less likely to report.

Patients and physiotherapists have been shown to have a poor understanding of the relevance of mental health conditions to physiotherapy (Lee, Waters, Briffa & Fary, 2017), thus reducing the likelihood of reporting and identification.

Who should we screen?

It isn’t realistic or good practice to screen every patient for every condition, this takes up valuable time and resources and is not individualistic care.

Indications for screening (The Management of Posttraumatic Stress Disorder Work Group, 2017)

  • Known exposure to trauma
  • Patient’s presentation is suggestive of PTSD 
  • At-risk groups 

Known exposure to trauma

A patient may disclose that they have been exposed to a potentially traumatic event, which is any event that causes a real or perceived threat to the persons wellbeing (Forbes et al., 2007).

Patient’s presentation is suggestive of PTSD 

 The patient may display or disclose symptoms of PTSD without understanding what they are

  • Re-experiencing the traumatic event
  • Avoidance of trauma-related stimuli
  • Negative thoughts or feelings
  • Hyperarousal symptoms 

Later in the module you will learn about how these symptoms may present in physiotherapy practice.

At-risk groups: populations that have a higher than average risk of exposure to trauma

  • Military personnel/veterans
  • Emergency service first responders
  • Refugees
  • Those currently/previously incarcerated
  • Aboriginal and TSI people
  • Gender/sexually diverse people
  • Those reporting specific trauma (eg. car accident, workplace accident, natural disaster, sexual/physical assault)
  • Common comorbid conditions
    • Chronic pain resulting from injury, other mental health issues, substance use disorders

Having a good understanding of at-risk groups allows us to guide our subjective assessments to get the information we need, even if the patient isn’t aware of the relevance.


Many of these are factors you can start thinking about before you even see the patient. For example, you may note that their appointment is being funded by the TAC, DVA or work cover, all of which could be indicators of an at-risk group or exposure to trauma.

Remember, trauma may not lead to PTSD. These are indications for further assessment, not diagnostic tools.

How should we screen?

When a patient has been identified as at risk or you suspect PTSD, it is time to use a screening tool.

As physiotherapists, it is not in our scope of practice to diagnose mental health conditions (Australian Physiotherapy Association, 2011) so the screening process does not need to be strongly diagnostically accurate. However, screening tools can be used to identify the need for further assessment.

The two screening tools below have been extensively tested and have been shown to be reliable and valid in primary care settings for civilian populations (Spoont et al., 2015). They are both brief and easy to access and administer.

In primary care settings in civilian populations it is recommended to use the PC-PTSD-5 as an initial brief screen, and if positive, the PCL-C to further inform care (Sonis, J., 2013).


Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)

For more information and to download the screening tool click HERE

  • 5-item screen 
  • Positive predictive value 54% 
  • Considered positive if patient answers 'yes' to 3 or more items


(Spoont et al., 2015)

Picture: (The Management of Posttraumatic Stress Disorder Work Group, 2017)

PTSD Checklist - Civilian (PCL-C)

For more information and to download the screening tool click HERE

  • 17 item screen
  • Positive predictive value 58%
  • Responses are classed as 'symptomatic' (3-5) or 'non-symptomatic' (1-2) , then questions are weighed against the DSM criteria for diagnosis

(Spoont et al., 2015)

Picture: (The Management of Posttraumatic Stress Disorder Work Group, 2017)

What if the screen is positive?

  • If the PC-PTSD-5 is positive it is recommended the patient have a full structured diagnostic interview, which can be triggering for the patient and requires further training. Thus, this is the time to refer to a mental health professional (The Management of Posttraumatic Stress Disorder Work Group, 2017)
  • The PCL-C is more specific regarding symptoms, and may be used after PC-PTSD-5 to guide further assessment and management and monitor symptom change

Activity: Planning Subjective

Activity

For each of the 17 items in the PCL-C questionnaire (found HERE), reflect on at least one follow up question you would ask the patient to gain information relevant to your practice

Have you completed the activity for this section?

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How PTSD may alter patient presentation

Introduction

PTSD can manifest in many ways, and is very different for each sufferer. The next module outlines each of the 4 symptom groups in detail, and gives examples of how each of these may present in a physiotherapy setting. 

The symptom groups are based on the DSM-5 criteria for PTSD, which can be found HERE



Re-experiencing the Traumatic Event

Activity:

Review Case 1 and reflect on how the PTSD symptoms above impacted the patients presentation 

Note: if link to case is unavailable, manually access in 'Case Studies' section

Avoidance of Trauma-Related Stimuli

Activity:

Review Case 2 and reflect on how the PTSD symptoms above impacted the patients presentation 

Note: if link to case is unavailable, manually access in 'Case Studies' section

Negative Thoughts or Feelings

Activity:

Review Case 3 and reflect on how the PTSD symptoms above impacted the patients presentation 

Note: if link to case is unavailable, manually access in 'Case Studies' section

Hyperarousal symptoms

Activity:

Review Case 4 and reflect on how the PTSD symptoms above impacted the patients presentation 

Note: if link to case is unavailable, manually access in 'Case Studies' section

Have you completed the 4 activities for this section?

  • Yes
  • No

Treatment Approaches

Introduction

“Good practice is centred on patients or clients. It involves practitioners understanding that each patient or client is unique and working in partnership with patients or clients, adapting what they do to address the needs and reasonable expectations of each person.” – (Physiotherapy Board of Australia, 2014)

As a new graduate physiotherapist, you have training and experience in delivering holistic, person-centred care. It can be assumed that you are competent in researching and implementing evidence-based management plans. Providing good care for patients with PTSD does not require a different approach to what you know, but it requires the ability to recognise how the condition may be playing an active or contextual role in your patient’s presentation, and tailoring your management plan accordingly. Thus, this module is not an exhaustive list of treatment options, but a general guide based on the ways PTSD is likely to present in physiotherapy practice.

Comprehensive guidelines for various health-care workers based on systematic reviews are available and will be useful to review as a more specific basis for your management. Some relevant guidelines include:

Trauma-Informed Service

Core Values of Trauma-informed service:

Understand trauma and its impact on individuals, families and communal groups

  • Avoids misunderstandings, thus promotes adherence
  • Requires education and training for practitioners
  • May need to seek out/advocate for this within your workplace

Promote safety

  • Collaborate with patient to create safe environment - avoiding triggers, facilitating stress reduction

Ensure cultural competence

  • Culture plays an important role in experience of trauma, processing of trauma and what supports and interventions are most effective

Support patient's control

  • Build competencies that will strengthen their sense of autonomy
  • Keep patients well informed about all aspects of their treatment and give opportunity for them to make decisions about their care
  • Focus on giving information, explaining choices and education more than usual to promote self-efficacy and sense of control
  • Focus on boundaries: touch, positioning, terminology, state of undress etc. should be discussed first with enough notice, and reactions continuously observed. Check in re touch etc. frequently

Integrate multidisciplinary care

  • Good referral practices

Support relationship building

  • Encourage social interaction
  • Facilitate peer support

Enable recovery

  • Empower individuals
  • Build capabilities 


Adapted from Guarino et al. (2009)


Problem Solving: Triggers

Patients with PTSD are likely to have 'triggers' - stimuli that cause a worsening of PTSD symptoms.

These may impede physiotherapy practice, as the patient may need to engage with one or more triggers in order to exercise or manage their pain.

Problem solving these triggers collaboratively with your patient aims to overcome these barriers so the physiotherapist can continue with their management plan.

Problem solving triggers that impede physiotherapy treatment

Identify triggers

  • Ask patient, but be wary. Monitor comfort/arousal levels. Check in regularly. Preface conversation with reassurance that can stop/take breaks. Give reaffirmations and praise.
  • Ask them to think about it in their own time and write them down
  • If they have trouble recalling them, prompt them to ask friends/family/health professionals
  • Make a ‘trigger table
    • Helps identify and contextualize triggers
  • Contact/collaborate with their mental health workers for specifics on triggers and how to avoid them, with patients consent

Get specific

  • Is it everything about the topic that is triggering or something specific? Can part of it be avoided while still engaging with it?
  • Can you do a little bit, in a safe environment, with lots of warning?
  • What is the response? Is it something that can be tolerated in the right circumstances?
  • Remember the patient may not be able to engage with it straight away, be patient and tolerant

Example: 

  • Patient finds pain triggering, but needs to exercise painful area in order to recover
    • Create a relationship/build trust
    • Explain/educate about pain mechanism
    • Collaborate to create a safe, controlled, empowering environment
    • Do relaxation exercises to reduce stress before and during activity
    • Agree on an acceptable level of pain - eg. patient will exercise until the pain is 3/10, and then stop and do relaxation exercises
    • Progress this tolerance with time and patient comfort 

Activity: Problem List

Select one of the case studies provided in the 'Case Studies' section and draw up a problem list from the information provided with the headings

  • Problem
  • Contributing Factors (PTSD related)
  • Assessment/screening
  • Management Plan

Use the trauma-informed care framework and the guidelines provided in this module to guide your management plan 

Have you completed the activity for this section?

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  • No

Feedback

Feedback Survey

Your feedback on this module is appreciated. Feedback will be used to guide further development of the module. Please fill out this short survey available HERE

Case Studies

Case 1 - Re-experiencing

33yo female presents to you in a private practice setting with CLBP. You have seen her once before for a quick assessment, and had prescribed core stability exercises. The patient discloses that she has not been performing the exercises because she is too tired as she hasn’t been sleeping well. You ask if this is because of the pain, and she says the pain isn’t bad overnight, it’s because she often has nightmares.

You ask the patient to lie down on her front so you can palpate her back. When she does, you notice her muscle tension increases and her skin goes clammy. After a short time she begins shaking and crying, gets up and excuses herself to the bathroom.

You are very confused as she seemed fine before lying down, and wonder if the position was causing her pain. When she returns, you ask if lying on her front was painful and she says no, but confides that ever since she was sexually assaulted that happens whenever she is in that position, as it feels like she is ‘back there’ and can’t stop the memories.

Case 2 - Avoidance

37yo male presents to you in a community health setting with significant lower limb deconditioning. You notice that he was referred by the refugee health nurse.

You are surprised at the amount of deconditioning the patient shows, considering his relatively young age and absence of disability. When asked about his exercise habits he discloses that he doesn’t do any exercise, as when his body feels tired it makes him ‘panic’. As a result, he avoids even short walks and does not go out of the house often and has very few social interactions.

You feel hydrotherapy would be very beneficial to this patient, but the patient declines as he doesn’t want to go in the pool. When you ask why, he repeatedly responds with “I don’t know”, no matter how you phrase the question.

Case 3 - Negative affect

45yo female presents to you in community health after being attacked on the street while on holiday 3 months ago.

They report their shoulder has been getting worse since the attack, but can’t remember what happened during the attack or what the symptom trajectory was. You would like to know the mechanism of injury, but the patient can’t remember and can only tell you that it started hurting after the attack.

On assessment, you conclude that there are high degrees on pain sensitisation and protective postures, but that there don’t seem to be any tears or obvious pathologies. You suggest a local hydrotherapy group for gentle exercise, to which the patient responds: “I can’t just go roaming around my neighbourhood, what if I’m attacked again? I can’t defend myself and I don’t have anybody to go with me because I’m too much to deal with. All I can do is sit in my house by myself. I’m never going to get better anyway, if I can’t even go out I’ll never be able to fix myself. There’s no point.” You reassure the patient as best you can, and prescribe them some exercises to do at home instead.

A week later, the patient fails to attend their appointment. You call them to reschedule and they tell you they don’t want to come back as when they did the exercises you prescribed they felt pain, and they believe you are trying to hurt them.

Case 4 - Hyperarousal

27yo male presenting in a musculoskeletal outpatient clinic of a hospital with chronic right knee pain on background of an injury sustained from military combat 2 years ago.

You decide to start slow with exercises and perform knee extensions and squats in the consultation room, which the patients completes with ease and minimal pain. You decide to progress the exercise and suggest moving to the gym to practice on the equipment, as this might be a better suited level for the patient. When in the gym you notice the patient becomes easily distracted, keeps looking around the room and jumps whenever one of the machines another patient is using makes a sudden noise. You start with low resistance on the leg press machine, but the patient is visibly struggling more than they were performing squats in the consultation room. After only a few reps, he becomes frustrated and angrily states ‘this is pointless, it’s making my knee hurt, I’m not doing it anymore’.

You’re confused as to why he got so frustrated so quickly, but agree to move back to the consultation room in hopes to calm him down. When back in the room, his breathing gradually slows and dis demeanor returns to normal. He explains that being in the gym made him feel very ‘on-edge’ and paranoid, because of the sudden noises, other people and bright lighting.

Reference List

Reference List

Australian Physiotherapy Association (2011). Mental Health and Physiotherapy. Retrieved from https://www.physiotherapy.asn.au/documentsfolder/advocacy_position_mental_health_2011.pdf

Bosco, M., Gallinati, J., & Clark, M. (2013). Conceptualizing and Treating Comorbid Chronic Pain and PTSD. Pain Research And Treatment, 2013, 1-10. http://dx.doi.org/10.1155/2013/174728

Creamer, M., Burgess, P., & Mcfarlane, A. (2001). Post-traumatic stress disorder: findings from the Australian National Survey of Mental Health and Well-being. Psychological Medicine, 31(07). http://dx.doi.org/10.1017/s0033291701004287

Dedert, E., Calhoun, P., Watkins, L., Sherwood, A., & Beckham, J. (2010). Posttraumatic Stress Disorder, Cardiovascular, and Metabolic Disease: A Review of the Evidence. Annals Of Behavioral Medicine, 39(1), 61-78. http://dx.doi.org/10.1007/s12160-010-9165-9

Forbes, D., Creamer, M., Phelps, A., Bryant, R., McFarlane, A., & Devilly, G. et al. (2007). Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Post-Traumatic Stress Disorder. Australian & New Zealand Journal Of Psychiatry, 41(8), 637-648. http://dx.doi.org/10.1080/00048670701449161

Guarino, K., Soares, P., Konnath, K., Clervil, R. & Bassuk, E. (2009). Trauma-Informed Organizational Toolkit for homeless services. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.air.org/sites/default/files/downloads/report/Trauma-Informed_Organizational_Toolkit_0.pdf

Lee, S., Waters, F., Briffa, K., & Fary, R. (2017). Limited interface between physiotherapy primary care and people with severe mental illness: a qualitative study. Journal Of Physiotherapy, 63(3), 168-174. http://dx.doi.org/10.1016/j.jphys.2017.05.014

MiliSource. (2013, August 25). Soldier talks about his struggle with depression and PTSD [Video file]. Retrieved from https://www.youtube.com/watch?v=4DF5caucKjI&feature=youtu.be

National Collaborating Centre for Mental Health. (2005). Post-traumatic stress disorder: the management of PTSD in adults and children in primary and secondary care. Leicester (UK): Gaskell. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21834189

NICE. (2005). Post-Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care: National Collaborating Centre for Mental Health. Psychiatric Bulletin, 30(9). http://dx.doi.org/10.1192/pb.30.9.357-a

Nielsen, H. F. (2014). Interventions for physiotherapists working with torture survivors. Copenhagen. Retrieved from https://dignityinstitute.org/media/2065758/pubseriesno6_web.pdf

Physiotherapy Board of Australia (2014). Code of conduct for registered health practitioners. Retrieved from http://www.physiotherapyboard.gov.au/Codes-Guidelines.aspx

Slepian, P., Bernier, E., Scott, W., Niederstrasser, N., Wideman, T., & Sullivan, M. (2014). Changes in Pain Catastrophizing Following Physical Therapy for Musculoskeletal Injury: The Influence of Depressive and Post-traumatic Stress Symptoms. Journal Of Occupational Rehabilitation, 24(1), 22-31. http://dx.doi.org/10.1007/s10926-013-9432-2

Sonis, J. (2013). PTSD in Primary Care—An Update on Evidence-based Management. Current Psychiatry Reports, 15(7). http://dx.doi.org/10.1007/s11920-013-0373-4

Spoont, M., Williams, J., Kehle-Forbes, S., Nieuwsma, J., Mann-Wrobel, M., & Gross, R. (2015). Does This Patient Have Posttraumatic Stress Disorder?. JAMA, 314(5), 501. http://dx.doi.org/10.1001/jama.2015.7877

Sullivan, M., Thibault, P., Simmonds, M., Milioto, M., Cantin, A., & Velly, A. (2009). Pain, perceived injustice and the persistence of post-traumatic stress symptoms during the course of rehabilitation for whiplash injuries. Pain, 145(3), 325-331. http://dx.doi.org/10.1016/j.pain.2009.06.031

The Management of Posttraumatic Stress Disorder Work Group. (2017). VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress Disorder and Acute Stress Disorder. Department of Veterans Affairs. Retrieved from https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal082917.pdf

Veterans Health Administration. (2014, June 5). What is PTSD? (Whiteboard Video) [Video file]. Retrieved from https://www.youtube.com/watch?v=YMC2jt_QVEE&feature=youtu.be


Image references:

30 Interesting Facts About PTSD. (2017). KickassFacts.com. Retrieved 29 November 2017, from http://www.kickassfacts.com/30-interesting-ptsd-facts/

Physiotherapy. (2017). Physiofitleeds.co.uk. Retrieved 29 November 2017, from http://www.physiofitleeds.co.uk/physio_facilities.php

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Moyle, S. (2017). Giving Feedback - 3 Models for Giving Effective Feedback | Ausmed. Ausmed. Retrieved 29 November 2017, from https://www.ausmed.com/articles/giving-feedback/