post traumatic stress disorder paper public
TRANSCRIPT
ABSTRACT
An ever growing number of people world-wide are being diagnosed with Post-
Traumatic Stress Disorder, or PTSD. PTSD is an anxiety disorder that is brought on by a
traumatic event. It presents as a combination of several psychological disorders combined
into one. The psychological distress that one who suffers from PTSD feels could easily
interfere with their day to day quality of life and reported feelings of more severe physical
pain. Treatments for this condition are medication and group therapy sessions.
Alternative treatments include touch therapy with guided imagery and yoga.
The client participating in this case study is a single mother with three children.
The client reported suffering with PTSD since 2010 and was diagnosed with it in 2011. The
client reported that the symptoms were felt on a daily basis and interfered tremendously
with her sleep as well as her day to day quality of life. The objective for this case study
was to see if massage therapy could be useful to someone suffering from PTSD.
Client received two sessions of focused massage therapy targeting specific muscle
tension and pain and three sessions of Craniosacral therapy. While the muscle focused
massage therapy did help, the client experienced more pain when muscles began to tense
back up. The client was able to report and exhibit more positive outcomes after each of the
Craniosacral therapy sessions. The client was also able to report and marked increase in
the quality of sleep obtained between each session as well as a decrease in PTSD symptoms
and pain experienced.
The outcomes of this case study lead this student massage therapist to believe that
more positive results could be found in future studies involving those who suffer from
PTSD, massage therapy, and Craniosacral therapy. Due to the possibility the client may
experience an increase in uncontrollable emotions, it is advised by this student massage
therapist, that the client be under the care of a mental health provider during their
treatments.
Keywords: Massage Therapy, Alternative Medicine, Chronic Pain, , Post-Traumatic Stress
Disorder.
INTRODUCTION
Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that is resulting from direct
or indirect exposure to actual or threatened death, serious injury, or sexual violence. PTSD is
characterized by persistent difficulties that negatively affect an individual’s social interactions,
capacity to work, or other areas of functioning. [1] PTSD may also develop as a result of natural
disasters, war, domestic violence, rape, violent crime, accidents, and medical procedures. Since
it first started being recognized in the medical community in 1980, PTSD is recognized as having
four core distinguishing features. Those features are: “experiencing or witnessing a stressful
event; re-experiencing symptoms of the event that include nightmares and (or) flashbacks;
efforts to avoid situations, places, and people that are reminders of the traumatic event; and
hyperarousal symptoms, such as irritability, concentration problem, and sleep disturbances.” [2]
Symptoms of PTSD
The list of possible symptoms “may include recurrent, involuntary, and intrusive thoughts
and memories of the traumatic event, flashbacks that can result in loss of consciousness; intense
psychological distress following exposure to reminders of the event; recurrent and disturbing
dreams or nightmares; difficulty sleeping; irritability or outbursts of anger; aggression; self-
destructive behavior; distorted sense of blame of self or others; detachment from others or
diminished interest in activities; difficulty concentrating, hypervigilance; exaggerated startle
response.”[1] There have been multiple studies done linking chronic pain with PTSD. In a study
done by Rebecca Mayer, and Doctors Katherine E. Porter, E. Brooke Pope, and Sheila A. M.
Rauch, their findings show that “the majority of patients (86.8%) reported some problem with
pain. Further, the findings indicate that there is a significant relations between PTSD severity
and pain severity.” [3] Another study done by Allison T. Robbins, and Doctors Jennifer Jane
Runnals, Elizabeth Van Voorhees, Mira Brancu, Kristy Straits-Troster, Jean C. Beckham, and
Patrick S. Calhoun shows that “Women are more likely to endorse back pain and headaches
[specifically] but no gender by diagnosis interactions were significant.” [4]
Treatments for PTSD
Treatment methods for PTSD include individual and (or) group therapy, medications for
anxiety and depression, and eye movement desensitization are reprocessing. Studies on
alternative treatment methods include healing touch with guided imagery [5] and the use of yoga
in specialized treatment programs. [6] Though there are few studies that have been done on the
treatment of PTSD specifically with massage therapy, there have several studies conducted on
the use of massage therapy for chronic pain. Studies have been done on chronic neck pain [7],
chronic shoulder pain [8], and chronic low back pain [9] just to name a few, in which
participants reported a decrease in their pain after receiving massage therapy treatments. The
purpose of this case study is to explore the value of massage therapy in a client with PTSD who
suffers with possibly related chronic pain and also explore the emotional effects massage therapy
could have in said client.
METHODS
Profile of Client
A 32 year old single mother of three children, has been diagnosed with Post Traumatic Stress
Disorder (PTSD) by her Primary Care Physician in 2011. Client reports depression, feelings of
re-experiencing the trauma at least once a week, feelings of avoidance in once enjoyed hobbies
and feelings of detachment five or more times a week, and increased arousal which is most
noticed in difficulty sleeping, anger management, difficulty concentrating, and increased
awareness of everyone around her at least five times a week since 2010. Client reports that,
since 2010, she has also suffered from daily headaches and significant sleep loss due to chronic
pain, anxiety, and nightmares. Client reports that the loss of sleep leads to continual physical
exhaustion. Client reports that all of the above listed symptoms interfere with her activities of
daily living.
Client describes pain in her neck, back, shoulders, and knees as aching, gnawing,
exhausting, tiring, nagging, and miserable. The pain felt in client’s hands is more prevalent on
her right side and presents as a numb pain affecting the whole hand. The pain, client states, is
continuous and is worse in the morning. On a subjective pain scale where 0 is not pain at all and
10 is the worse pain imaginable, the client rated her pain at its best 3/10 and at its worse 7/10.
She reports that weather changes, high activity, and high impact activity make her pain worse.
Client did not see any correlation between pain felt and PTSD symptoms experienced. The
client’s goals were to be able to sleep better.
Client has used over the counter pain medications and heating packs for her chronic pain,
prescribed sleep aids to help her sleep, and herbal remedies to aid in anxiety. Client has agreed
to participate in this case study with full knowledge of its possible publication.
Gait assessment results showed both shoulders are rotated forward, head forward posture,
decreased range of motion in side to side neck motion, and walked with both arms moderately in
lateral abduction. Initial palpation assessment revealed hypertonicity in bilateral rhomboid major
and minor, bilaterally throughout trapezius, bilateral erector spinea, bilateral splenius capitus,
and bilateral latissimus dorsi.
Treatment Plan
Five ninety minute treatments for this client occurring weekly. Sessions are divided into
15 minutes of discussion and pretreatment paperwork, 60 minutes of massage therapy, and 15
minutes of post-treatment discussion and paperwork. Pretreatment paperwork consists of: a
PTSD Symptom Scale, a Sleep Assessment Scale, and a Patient Comfort Assessment Guide.
This was done to measure the client’s attitude and pain before treatment began and if there were
any improvements in either between treatments. The PTSD Symptom Scale was done because
client had stated fluctuating moods do interfere with sleep. The Sleep Assessment Scale was
done to measure changes in her sleep patterns, if any. The Patient Comfort Assessment Guide
was done due to the fact that there has been links between PTSD and the severity of pain felt. [3]
The Patient Comfort Assessment Guide has the client list where their pain is located along with
having them describe what the pain feels like. It also has the client rate their pain at its worst,
best, average, and current. It has the client describe any side effects or symptoms along with
how the pain has interfered with different aspects of their every-day life.
Post-treatment paperwork consisted of a Patient Comfort Assessment Guide Post-
Massage. This was done to measure how the client felt during the massage and to compare how
the client felt just before the massage. Client was instructed to keep a sleep journal to measure
the precise amount of sleep achieved each night between treatments since getting more sleep was
client’s main goal. Client was also instructed to keep regular appointments with a counselor in
the event that client may have difficult emotions resurface due to nightmares or circumstances.
Massage therapy sessions were held in a college massage clinic with only student
massage therapist, the client, and a supervising massage instructor. Lighting was low and
relaxing music was played to encourage the client’s relaxation. The room was free of any
aromas in the event that a specific scent may trigger undesired memories or emotions.
Due to the fact that Craniosacral Therapy is said to be useful in many treatments
including (but not limited to) chronic complaints, relaxation, states of exhaustion, concentrations
difficulties, headaches, back problems, sleep disturbances, and stress, Craniosacral Therapy was
the first treatment student massage therapist thought of. [10] However, client did report of having
a cerebral spinal fluid leak in 1997 which the client believed she still suffered issues with. This
would be a contraindication of such treatment. Until client could obtain clearance from Primary
Care Physician, massage directed towards relief of client’s specific pain was performed.
Since the client’s main concern is chronic back, neck and shoulder pain, the first two
treatment sessions consisted of massage targeting those areas. Modality used was deep Swedish,
deep, rhythmic, sweeping strokes. The rhythmic, sweeping strokes were done help to encourage
relaxation while the deeper pressure was used to aid in the release of muscle tension. Where
needed deeper, stationed pressure was held to encourage trigger point releases.
Client was able to obtain clearance for Craniosacral Therapy by the third session and was
reporting an increase in pain during the night when the muscles would start to tense back up so
Craniosacral work took the place of specific muscle tension release. Each following session
commenced with Craniosacral therapy.
RESULTS
Client came into first session reporting frequent levels of PTSD symptoms along with
extreme severity levels. Pain levels reported at that time were also reported to be on the higher
level of the pain scale. Sleep scale reported a fair amount of sleep but with a more extreme level
of feeling less rested during that time period leading to interference in activities of daily life
(ADL).
At the final session client reported a marked decrease in the frequency as well as a
decrease in severity in PTSD symptoms experienced. Pain was reported as being on the lower
end of the pain scale and more tolerable. Though less average sleep was reported by client, a
better quality of sleep was also reported. Final gait assessment shows the client walking with
shoulder back with better range of motion in head rotation.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
5
10
15
20
25
30
At First Session
At Second Session
At Third Session
At Forth Session
At Fifth Session
Graph 1: PTSD Symptom Scale
FREQUENCY CUMULATIVE MODERATE + SEVERITY
DISCUSSION
PTSD is becoming an increasing problem for many people that not only affects their
mental well-being but also affects the quality of their daily life. The most common treatment for
this condition is medication.
0
1
2
3
4
5
6
7
8
Before first
session
After first
session
Before second session
After second session
Before third
session
After third
session
Before forth
session
After forth
session
Before fifth
session
After fifth
session
GRAPH 2: PAIN ASSESSMENT
SEVERITY ON 1-10 SCALE
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
5
5.05
5.1
5.15
5.2
5.25
5.3
5.35
5.4
Between Session 1 & 2
Between Session 2 & 3
Between Session 3 &4
Between Session 4 & 5
Graph 3: Sleep Assessment Scale
AVERAGE HOURS SLEPT
MODERATE TO EXTREME SEVERITY OF INTERFERENCE IN ADL
Graph 1 shows the frequency the client reported feeling the PTSD symptoms decreased
significantly, as did the level of severity. Client did report an increase of in-home stress in the
third and fifth session however the client felt better able to handle the stress emotionally. Client
did seem more emotionally able to express herself, and client stated that she was able to tell a
significant difference between how she felt prior to the first session and after the final session.
The client’s body language at the end of the fifth session displayed more confidence as she was
standing taller with her shoulders back. The client stated that she felt better able to tackle
problems in home life and she reported being able to have a “relaxing” week. The client also
reported an increased ability to stand up to those she felt were a threat to her or her children.
Graph 2 shows the pain the client reported both before and after each session. When the
sessions first began the client reported that her pain was nearly unbearable. There was a
significant decrease in the clients reported pain level even after the first session. The third
session was the first in which Craniosacral therapy was used instead of targeted muscle release.
The client reported feeling the least amount of pain after this session. However, after each of the
five sessions, the client reported that pain felt had decreased and was more tolerable.
Graph 3 shows the average hours the client reported getting sleep in a journal between
each session. Also shown in the graph by the red line is the percentage of interruptions such as
nightmares, anxiety, and inability to sleep interfered in the client’s activities of daily living.
While the client’s average hours slept did not increase, the client did report the ability to sleep
for seven hours up to two nights each week. The client also reported feeling better rested which
can be seen by the decrease in interruption that interfered with the client’s sleep.
The client’s goal through participation in this case study was to be able to sleep better.
Though there were several different measurements done to aid in the case study, this student
massage therapist believes that they are all interconnected. Just as the client reported decreased
symptoms of PTSD, a decrease in the client’s pain was also reported. As both of these decreases
were being reported, an increase in the client’s quality of sleep was being reported as well. The
client also reported that the sessions “increased the quality of life I was looking for, and I
absolutely believe that this helped me to regain focus on various parts of my life and work
through some very difficult times.” The client also reported that she was in a lot less pain. The
client stated about the pain she does experience “It is not as intense and I can do more activities
than I was able to do while I was in so much pain.”
When this student massage therapist asked if the client would recommend this treatment
to others who suffer with PTSD the client stated, “I believe that this could be very beneficial to
other people diagnosed with PTSD. The effects that PTSD has on the body is not fully
understood, but some are very evident. The physical stress that is held within the body is
immense, and this [participating in the case study] allowed my body to release a lot of the
tension and become more relaxed.”
This student massage therapists believes there should be more studies done on massage
therapy as a treatment for PTSD as, stated earlier, there have been few. There have been
numerous studies on massage therapy as a treatment for the different symptoms that go along
with PTSD. This massage therapist believes that, from the findings of this study, massage
therapy has the possibility to make monumental changes in many people who suffer with PTSD.
Of course, the massage therapists involved would have to be well skilled in the art of
Craniosacral Therapy along with knowledge of contraindications and side effects. Due to the
increase in probability of uncontrollable emotional releases felt by the client though out the
sessions, it would be recommended by this student massage therapist that the client also maintain
regular contact and appointments with a counselor.