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Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares, and severe anxiety, as well as uncontrollable thoughts about the event. About 8 million adults have PTSD during a given year. This is only a small portion of those who have gone through trauma. About 10 of every 100 women (or 10%) develop PTSD sometime in their lives compared with about 4 of every 100 men (or 4%). PTSD is also becoming ever more prevalent in VA hospitals across the country. Post-traumatic stress disorder (PTSD) is now affecting more and more people daily with severe consequences, even death. PTSD is responsible for more suicides every year due to a lack of availability in treatment and resources. Some causes of PTSD are pain, trauma experienced, and chronic illness/diagnosis. These are just some of the common areas that are associated with PTSD and there are many other reasons for the severe effect to occur. There are medical implementations such as medications that are often used to help individuals cope with this diagnosis, however, it has been proven that therapeutic exercise and life coaching are some of the greatest tools used to fight this battle.

CASE STUDY:

“Tom” is a 23-year-old, single, white male who presented for treatment approximately 1 year after a traumatic event that occurred during his military service in Iraq. Tom received CPT while on active duty in the Army. Background Tom was born the third of four children to his parents. He described his father as an alcoholic who was frequently absent from the home due to work travel prior to his parents’ divorce. Tom indicated that his father was always emotionally distant from the family, especially after the divorce. Tom had close relationships with his mother and siblings. He denied having any significant mental health or physical health problems in his childhood. However, he described two significant traumatic events in his adolescence. Specifically, he described witnessing his best friend commit suicide by gunshot to the head. Tom indicated that this event severely affected him, as well as his entire community. He went on to report that he still felt responsible for not preventing his friend’s suicide. The second traumatic event was the death of Tom’s brother in an automobile accident when Tom was 17 years old. Tom did not receive any mental health treatment during his childhood or after these events, though he indicated that he began using alcohol and illicit substances after these traumatic events in his youth. He admitted to using cannabis nearly daily during high school, as well as daily use of alcohol, drinking as much as a 24- pack of beer per day until he passed out. Tom reported that he decreased his alcohol consumption and ceased using cannabis after his enlistment. Tom served in the Infantry. He went to Basic Training, then attended an advanced training school prior to being deployed directly to Iraq. While in Iraq, Tom witnessed and experienced a number of traumatic incidents. He spoke about fellow soldiers who were killed and injured in service, as well as convoys that he witnessed being hit by improvised explosive devices (IEDs). However, the traumatic event that he identified as most distressing and anxiety-provoking was shooting a pregnant woman and child. Tom described this event as follows: Suicide bombers had detonated several bombs in the area where Tom served, and a control point had been set up to contain the area. During the last few days of his deployment, Tom was on patrol at this control point. It was dark outside. A car began approaching the checkpoint, and officers on the ground signaled for the car to stop. The car did not stop in spite of these warnings. It continued to approach the control point, entering the area where the next level of Infantrymen were guarding the entrance. Per protocol, Tom fired a warning shot to stop the approaching car, but the car continued toward the control point. About 25 yards from the control point gate, Tom and at least one other soldier fired upon the car several times. After a brief period of disorientation, a crying man with clothes soaked with blood emerged from the car with his hands in the air. The man quickly fell to his knees, with his hands and head resting on the road. Tom could hear the man sobbing. According to Tom, the sobs were guttural and full of despair. Tom looked over to find in the pedestrian seat a dead woman who was apparently pregnant. A small child in the backseat was also dead. Tom never confirmed this, but he and his fellow soldiers believed that the man crying on the road was the husband of the woman and the father of the child and fetus. Tom was immediately distressed by the event, and a Combat Stress Control unit in the field eventually had him sent back to a Forward Operating Base because of his increasing re-experiencing and hypervigilance symptoms. Tom was eventually brought to a major Army hospital and received individual CPT within this setting. Tom was administered the CAPS at pretreating. Tom has also been diagnosed with Parkinson’s disease and feels overwhelmed by the aforementioned and the newly discovered diagnosis.

Tom, took part in a 6-month program that was a 360-degree approach to his overall wellness. The program was meant to follow the cause and effects of his PTSD and implement behavioral change techniques to reinforce positive behaviors. More specifically, Tom also took part in therapeutic and neuro-intensive exercises to help battle the depression and anxiety and bring back a sense of control as well as positivity through achievement reinforcement AND to fight the symptoms of Parkinson’s disease. The program was set-up to deliver a biopsychosocial model approach where we not only provided help for Tom but for his family as well. Life coaching took place within the exercise sessions (3 times per week) and one time per week family members were encouraged to join the sessions to discuss progress and concerns in an open forum. After, 6 months Tom not only had his depression and anxiety associated with PTSD under control, but he also reported 50% fewer episodes associated with PTSD (i.e., flashbacks, etc). Additionally, Tom was also able to stabilize his Parkinson’s symptoms and was able to go back with confidence doing the things he used to enjoy.  

Parkinson's Disease

The following case study illustrates a 54-year old man with middle stage Parkinson’s Disease, marked by difficulties with gait, increased stiffness and reduced range of motion (ROM), cogwheel rigidity, resting tremor, and some issues with coordination. Patient-centered goals were developed, surrounding increasing Timed-Up and Go (TUG) score, improving ROM and coordination, being able to continue participating in dancing with his wife, as well as navigating throughout his home with fewer difficulties. A 4-week “LSVT Big”-style training program was proposed, in order to work towards these goals, which included both supervised training, a home exercise program, as well as an educational component. Following this training program, the patient displays improvements in balance, gait, as well as reduced parkinsonism. His confidence has improved, and he is much less worried in general than during his initial assessment.

Introduction

Parkinson's Disease is a neurological progressive disorder associated with the degeneration and eventual loss of dopaminergic cells in the substantia nigra pars compacta. Based on statistics from 2012-2013, approximately 84,000 Canadians 40 years and older were diagnosed with parkinsonism and 10,000 Canadians were newly diagnosed with Parkinson's Disease, with a higher prevalence in males compared to females. Those with this condition typically present with bradykinesia, tremors, and rigidity, and progression of the disease can be associated with loss of independence in basic Activities of Daily Living and Instrumental Activities of Daily Living. Currently, there is no cure for the disease but there are multiple treatments to slow the progression of the disease. Treatment aims to control symptoms, optimize activity and participation, and improve quality of life in all stages of the disease.

Previous studies show that exercise programs targeting gait, balance, transfers or physical capacity can reduce motor symptoms. Movement programs specifically addressing hypokinesia and bradykinesia such as the Lee Silverman Voice Treatment or LSVT-Big, requires the patient to think big when initiating and carrying out movements to increase the speed and amplitude of movement. Studies found that 1-hour sessions, 4x a week for 4 weeks showed promising results when compared to shortened intervention or regular physiotherapy, improving the Unified Parkinson's Disease Rating Scale specifically the motor components. These studies also showed trends towards better outcomes in gait speed and TUG scores.

Client Characteristics

Ted is a 54-year old man with a 2-year diagnosis of middle stage Parkinson’s Disease. He has been experiencing an increase in the severity of symptoms regarding the slowness of movement and tremors. He has been referred to outpatient physiotherapy for management and a home exercise program.

The patient is a retired carpenter who was previously very active with a history of hypertension and high cholesterol. Ted enjoyed keeping himself busy by doing small renovations around the house, going to dance classes with his wife, and visiting their grandchildren. He and his wife live in a two-story home outside of Kingston. They have three children; one daughter who travels frequently, a son who lives in the city with his wife and two young children, and another son who lives with his family in British Columbia. Ted retired early to support his wife who was diagnosed a few years ago with early-onset Alzheimers, which they were managing well prior to Ted’s worsening symptoms.

Examination Findings

History of Present Illness

The onset of his Parkinson’s diagnosis started with Ted experiencing difficulties with regular tasks around the house because he was experiencing ‘shaking’ and noticed a lot of his movements were much slower and difficult to ‘get going’. His son suggested he see his doctor after witnessing him have difficulty entering the front door of his home, ‘he was frozen and needed guidance to step in’. Prior to these symptoms, Ted recalls losing his sense of smell intermittently and noticed his handwriting becoming smaller but dismissed these as part of “getting old”.

Current Status

The patient spoke about how he has become heavily reliant on the medications he was given by his physician of Levodopa and Trihexyphenidyl. He has indicated that they are effective at "taking his shaking and slow movement away" but that the effects tend to wear off quickly. Ted reported having difficulty initiating movements, stiffness, and slowness in general, explaining that he often "freezes" when having to walk through narrow spaces and has hesitation with turning. His shaky movements in his dominant hand (right) prevent him from working on small projects in his shed and completing his regular tasks around the house, stating that sometimes he will "miss" his television remote. Ted raised concerns over having trouble adapting to his condition as he is the primary caregiver for his wife and is worried about losing his independence. He goes on to share that he has always been the provider for the family and fears for what his condition will do for him and his wife moving forward. Recently, Ted had to move his bedroom to the main floor as his children were concerned with him helping their mother up and down the 10 steps of stairs in their home.

His goals include improving walking through doorways and turning, continue doing projects in his shed, and return to dance classes with his wife. He is independent with his activities of daily living and ambulates using a quad cane. He did not have any problems with transfers. He presented with mild kyphosis and stooped posture and spoke with mild sialorrhea.

Sensation

Superficial sensation intact, he had decreased proprioception and kinesthesia in the upper limbs.

Motor Function

Resting tremor "pill-rolling". Cogwheel rigidity pronounced in the upper extremities and mild-moderate rigidity in the trunk and lower extremities. Bradykinetic movement, dysmetria, and mild-moderate difficulty with rapid alternating movement.

Range of Motion

Decreased range of motion, limited shoulder flexion, and elbow extension. No contractures were noted.

• Thoracic Rotation L/R: 20/18

• Cervical Rotation L/R: 74/72

• Shoulder flexion L/R: 125/120

• Elbow flexion L/R: 130/127

• Hip flexion 100 b/l

• Hip extension 3 b/l

• Knee flexion 130 b/l

• Knee extension 5 b/l

Strength

Decreased strength of the upper limb, specifically at the shoulder, and slight weakness of the elbow, hip, and knee. Fatigue noted with sustained contractions.

• Bilateral shoulder flexion: 3+/5

• Bilateral elbow flexion: 4/5

• Bilateral hip flexion: 4/5

• Bilateral knee flexion: 4/5

Balance/Gait

His sitting balance was good but his standing balance was moderate during Mini-BESTest. He was able to transfer his weight side to side and forwards and backward.

• Mini-BESTest: 22/28

During Timed Up and Go, asymmetrical gait, with poor hip extension, minimal trunk rotation, decreased step length, and diminished arm swing. When turning, slight shuffling of gait and hesitation around the cone.

• Timed Up and Go – 17 seconds

• Timed Up and Go (without a quad cane) – 20 seconds

Standardized Assessments

Towards the end of the physical examination, the patient started to experience an increase in symptoms specifically with tremors. Ted's medication had started to wear off indicating that he was in the "off-time".

Physiotherapy Diagnosis

The patient is a 54-year-old retired carpenter that has recently been diagnosed with Parkinson’s disease and was referred to outpatient physiotherapy for a home exercise program as well as guidance with managing his condition. He displays issues with gait including difficulty initiating movements, navigating narrow spaces and hesitates with turning, has reduced cervical and thoracic rotation, ROM in the; shoulder, elbow, hip, and knee along with mild postural deficits. The patient has expressed his concern about not being able to continue participating in dance classes with his wife. He additionally presents with cogwheel rigidity in both upper extremities, a moderate resting tremor, and some issues with coordination, that are impairing his ability to help his wife, who has Alzheimer’s, around the house, as well as working on small projects.

Problem List

• Some issues with gait including difficulty initiating movements, navigating narrow spaces, and hesitates with turning - the patient is concerned this may limit his ability to participate in dancing with his wife

• Increased stiffness and decreased range of motion (shoulders, hips, and knee ROM)

• Mild thoracic kyphosis and a stooped posture in both sitting and standing

• Cogwheel rigidity in upper extremities

• Bilateral, moderate resting tremor in the upper extremities

• Some issues with coordination and UE goal-directed aiming accuracy

• Jerky movements in his dominant arm and hand are limiting him from working on small carpentry projects, as well as helping his wife around the house

Intervention

Goals were planned in collaboration with the therapy team, patient, and family. Ted was encouraged to keep a diary of his "off times" that would outline[10]:

• times of day when taking his Parkinson’s medication

• times of day when he is able to control his symptoms

• and, which symptoms tend to re-emerge during the day and when

Patient-centered Goals

1. Initiating movement & turning efficiency – Increase the TUG score to < 15 seconds by the end of the training program.

2. Improve stiffness

1. Increase shoulder flexion and abduction by 5º by week 2 of the training program

2. Increase thoracic and cervical spine rotation by 5º by week 2 of the training program.

3. Improve coordination and proprioception in UE

1. Be able to complete 10 consecutive goal-directed aiming movements with little to no error by week 2 of the training program

2. Increase Mini-BESTest score of activity #8, and #9 from moderate (1) to normal (2) by the end of the training program.

4. Be able to participate in an hour of dancing once a week with his wife.

5. Be able to better navigate through challenging spots in his house without freezing in order to best care for his wife.

The 4-week Training program, supervised by a certified LSVT BIG physical therapist

1. 16 1-hour sessions of supervised training (4x/week)

2. Home Training program throughout

1-hour sessions that are one-to-one with the therapist and the emphasis is to encourage Ted to focus on making his movements feel and look big. The tasks are also encouraged to be performed at an 80% max effort (this will be defined on a 10-point VAS scale, 8/10 will depict the 80% required) in order to meet the high-intensity demands of the program.

Program Outcomes

After 9 months of progressive therapeutic neuro-intensive exercise, Ted was able to increase the quality of life and reduce symptoms through AV360’s Neuro-Rebound and behavioral movement techniques. In addition to the exercise modalities, Ted has also exposed to life coaching and during fine motor movement therapy as well as the LSVT (Big and Loud program) to ensure a well-rounded approach to his wellness. Coming 4 days per week even 5 some weeks proved to be the turning point both physically and mentally for Ted. The ongoing investigations of his conditions and life experiences (at home etc) become part of his overall narrative which leads to better medical management of his conditions by his neurologists and movement disorder specialist. The approach has the medical team the ability to go beyond the “self-report” from Ted and enter into his world through the AV360 platform which leads to many progressive and customized approaches the doctors were able to take with a very particular data set. 

Self-Esteem

Kate is 21 years of age and has a very poor self-image; in fact, she hates the way she looks. As a result, Kate has such low self-esteem that it prevents her from looking for work. Kate’s mother is concerned about her daughter’s feelings and subsequent unemployment and therefore has encouraged her to attend counseling.

A summary of the sessions is as follows. For ease of writing the Life Coach is abbreviated to “C”. In the first session C focused on building rapport with Kate and encouraged her to talk about her feelings. As Kate is an extremely shy and softly spoken person, C asked open questions and then validated her as she responded. From this session, C was able to elicit useful background information and begin to build some rapport with Kate.

Essential Case Information

Kate is 21 years of age and has struggled with her weight all her life. She remembers back in primary school how the kids used to call her “fatty” and would not want to play with her. The taunting continued throughout high school however it was more subtle. Kate found it difficult to make friends and often found herself excluded from social events.

Although Kate’s mother is very supportive, the put-downs continued at home. Kate’s father would say things like “why don’t you go on a diet” or “what are you eating that for it’s only going to make you fatter”. Her elder brother was embarrassed to be seen with her and to make things worse, he was quite athletic.

A few months back, things were starting to turn around for Kate. She began a relationship with a man (Mark), started exercising, and lost about 10 kilograms. Slowly she started feeling better about herself, however, the relationship didn’t last and consequently, Kate’s self-esteem is now at its lowest. She blames herself for the break-up and believes that her boyfriend ended the relationship because she’s fat. However, when questioned further about this Kate could not recall a time when Mark had ever criticized her appearance, in fact, he seemed to be very supportive.

At the moment Kate has such low self-esteem that she doesn’t even want to try to find a job, she thinks “who is ever going to hire me”. Kate also described how her friends have stopped calling her because they say she is constantly criticizing them. Kate stays at home all day and every time she looks in the mirror she thinks how ugly she is. It is important to note that Kate is currently within the healthy weight range for her age and height.

It is obvious that the foundations for Kate’s low self-esteem were laid down early in life, however, as an adult, it is important for Kate to now recognize that she is in control of her self-image and hence has the power to change it. Therefore at the beginning of the second session C discussed the issues of personal control and how it would benefit Kate if she took responsibility for her self-esteem regardless of the influence that others may have had. C established Kate’s commitment to improving her self image and stressed that it was not constructive to “blame” others.

C then discussed with Kate the importance of setting her own standards and not listening to those people who tell her what she “ought” to do or look like. Kate’s father was the most obvious culprit, however, C stressed that social standards also have a big influence on young people, especially women today.

The ideal woman is portrayed in magazines and on television to be extremely thin and therefore the average person who compares themselves to these models is going to feel overweight. Kate revealed that she does read a lot of popular magazines in her spare time and often feels saddened afterward, she agreed to stop this for a while.

Finally, C asked Kate exactly what aspects of herself she would like to change in order to enhance her self esteem. Kate’s response was to lose weight, get more confidence so she could find a job, and hang out with her friends more.

In the next session, C began to introduce the principles of Cognitive Behavioral Therapy in order to modify Kate’s negative thinking. C explained how constantly telling herself that she was ugly and overweight was only reinforcing her negative body image and low self-esteem. Therefore, Kate needed to recognize and combat inappropriate negative thinking in order to enhance her self image.

C, therefore, suggested Kate use a strategy called Thought Stopping and explained to her how it works. C explained that, as an example, when Kate looks in the mirror and thinks how ugly and overweight she is she needs to identify this as a negative thought and get herself to stop. C described how even saying STOP out loud will help her become more aware of negative thinking.

C then explained to Kate how the use of positive affirmations would help her replace negative thoughts. For example, whenever a negative thought about her appearance did pop into her mind, Kate needed to replace it with affirmations such as “I’m a fit and healthy person” and/or ” I’m honest and friendly”. C explained further that it would help to get the focus off her physical appearance and affirm her personal qualities. Kate agreed with C that she would try and implement these techniques.

At the beginning of the next session, Kate told C how she had tried to stop her negative thoughts but was concerned about how frequent and automatic they were. C assured Kate that it is normal for someone beginning to use Thought Stopping to be amazed by the extent of their negative thoughts. C also assured Kate that recognizing the extent of her negative thinking may help her realize the importance of the thought-stopping exercise. C assured Kate that she had made some progress, however, she should keep persevering as it will take some time.

As Kate had a lot of time on her hands to think, C thought it appropriate to recommend some sort of activity to keep her busy and her mind more occupied. Until now C hadn’t administered the PNTP as she felt that while Kate’s self-esteem was so low that she may perceive the profile as a test and therefore something to “fail at”. C now felt that Kate had already begun to improve her self-esteem and the profile would be of use to help with activity choice. C, therefore, administered the Personality Need Type Profile and the results indicated that Kate was a Personality Type B with a score of 2,10.

Kate was not surprised at the results as she longed for greater social involvement, however as she was hardly ever invited out she had not had the opportunity to develop appropriate social skills. This lead to a discussion about the effects of not meeting needs and how it might contribute to her lack of confidence and low self-esteem. C discussed with Kate a range of issues including how having a boyfriend provided greater opportunity for socializing, and that since the break up she has also had little interaction with her friends

The discussion then moved to how Kate could actually gain more need gratification. C suggested to Kate that finding employment and going to work would meet a lot of her social needs, however, in the meantime she could get involved in some type of team sport. Kate stated that she wouldn’t mind playing netball again and agreed that this would provide an opportunity to socialize, meet new people, and also increase her fitness. Kate was excited about the idea and was going to ask her mum to help her find a netball club.

Next, C talked to Kate about her estranged friends and asked if there was truth to their claims that she was critical of them. Kate admitted that she had been negative towards them and after a big argument they told her that they didn’t want anything to do with her until she stops being so critical. C explained how it’s common for people with low self-esteem to cut others down through constant fault-finding and criticism, however, the rejection Kate experienced, as a result, has only served to lower her self esteem even further. C explored the possibility of Kate talking with her friends and explaining how important their friendship is to her and that she is trying to be more positive.

In the following sessions, Kate gradually became more confident as she continued to use positive self-talk, as a result, her attitude also became more positive. Kate also gained the acceptance of her friends again as they noticed this change. Kate started to go out more frequently and there was a noticeable change in her level of self-esteem. Consequently, it was time to address the issue of her unemployment.

Cause and effect relationships are difficult to establish with cases of poor self-esteem as it is such a vicious cycle. Nevertheless, it will be easier for Kate to eliminate negative thoughts such as “Who is ever going to hire me” if she begins to focus on developing some new skills. In time she will begin to believe that she does have something to offer an employer.

C approached this issue by explaining to Kate that everyone has their own personal shortcomings and some we are powerless to change, like our body type and physical features. However, working on those things which are changeable, like skills and abilities are extremely rewarding and may give a huge boost to one’s self-esteem. Kate explained how she has always wanted to be a legal secretary and would love to do a secretarial course. It was decided that Kate would research the availability of courses and immediately begin teaching herself to type.

By the next session, Kate was really excited as she had enrolled in a course and was due to start the following term. She explained to C how she has been quite busy and was starting to feel a lot better about herself again. When C was truly confident that Kate had accepted herself for who she was and was no longer dwelling on those things she could not change but channeling her energy it into proactive thoughts and behaviors, there was no further need for counseling. Kate may still have a long road to travel in continuing to enhance her self-esteem however now she has more skills to help her on her way.