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WHAT’S INSIDE
Chapter 1: An Introduction to Post Traumatic Stress Disorder (PTSD) for Therapy Professionals [ 2CEUs] Gain a comprehensive understanding of post-traumatic stress disorder (PTSD) and its impact on clients in therapy settings. Explore the history, symptoms, and therapeutic approaches associated with PTSD, including dissociation, flashbacks, and various modalities such as somatic therapies and trauma touch therapy. By the end of this course, participants will be equipped to recognize, understand, and effectively support clients affected by PTSD. Chapter 2: Introduction to Pharmacology for Massage Therapists
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12
[4 CEUs] This course is intended for all manual therapists that use massage as part of their practice. It gives a general outline to the contraindications, precautions, and considerations connecting medications and massage therapy. The course informs the therapist with pertinent information about pharmaceuticals that can interact with their treatment in an easy understand layout. Chapter 3: Musculoskeletal Assessment and Treatment for Manual Therapists 32 [2CEUs] The course commences with an exploration of fundamental terminology and prevalent manual therapy techniques. Participants will review comprehensive orthopedic assessments covering the entire body. Course sections are structured to delve into typical tests utilized for differential diagnosis across major joints and their associated musculature. In addition, this course will provide manual therapy or stretching techniques for the positive result of a given dysfunction. Chapter 4: Pathophysiology of Chronic Cardiovascular Conditions for Therapy Professionals: An Overview 46 [2CEUs] This course reviews the general anatomy of the cardiovascular system and the circulatory schemes. Learners will gain foundational knowledge of the most common chronic cardiovascular diseases and associated symptoms. In understanding the cardiovascular system, learners will understand appropriate ways to educate their patients on the implications of diet and other lifestyle factors have on cardiac health. Chapter 5: Understanding Plantar Fasciitis: A Multidisciplinary Approach 58 [2CEUs] The purpose of this course is to identify what plantar fasciitis is and what methods we can use to treat it in our clients. We will examine the anatomy of the plantar fascia, its role in the movement of the foot and ankle, and what happens when it becomes inflamed. We will also examine techniques that can be used to treat it when our clients present with either acute or chronic plantar fasciitis, as well as some self-care tools they can use at home.
Final Examination Answer Sheet
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©2024: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. i MASSAGE THERAPY CONTINUING EDUCATION Book Code: MLA1225
What are the requirements for license renewal? License Expires Frequently Asked Questions
CEU’s Required
Mandatory Subjects
12 (All hours are allowed through home-study)
Renewals are due on March 31st each year
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How much will it cost? If you are only completing individual courses in this book, use the code that corresponds to the course when completing online. COURSE TITLE HOURS PRICE COURSE CODE
An Introduction to Post Traumatic Stress Disorder (PTSD) for Therapy Professionals
2
$33.00 MLA02PT
Chapter 1:
Chapter 2: Introduction to Pharmacology for Massage Therapists
4
$65.00 MLA04PH
Chapter 3: Musculoskeletal Assessment and Treatment for Manual Therapists
2
$33.00 MLA02MA
Pathophysiology of Chronic Cardiovascular Conditions for Therapy Professionals: An Overview
2
$33.00 MLA02PC
Chapter 4:
Chapter 5: Understanding Plantar Fasciitis: A Multidisciplinary Approach
2
$33.00 MLA02PF
Best Value - Save $122 - All 12 Hours
12
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How do I complete this course and receive my certificate of completion? See the following page for step by step instructions to complete and receive your certificate. Are you an Louisiana board-approved provider? Colibri Healthcare, LLC is an approved provider with the Louisiana Board of Massage Therapy (Provider #LAP0291). Are my hours reported to the Louisiana board? Yes, we report your hours electronically to the Louisiana Board of Massage Therapy within two business days. Keep your certificate in a safe place for your records. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Massage-Therapy you will see our robust FAQ section that answers many of your questions, simply click FAQs at the top of the page, email us at office@elitelearning.com, or call us toll free at 1-866-344-0973, Monday - Friday 9:00 am - Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Disclosures Resolution of conflict of interest 6:00 pm and Saturday 10:00 am - 4:00 pm EST. Important information for licensees:
Sponsorship/commercial support and non-endorsement It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.
Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity.
Licensing board contact information:
Louisiana Board of Massage Therapy 9619 Interline Avenue, Suite B | Baton Rouge, LA 70809 Phone: (225) 756-3488 | Fax: (225) 925-7834 https://www.labmt.org/site.php
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Book Code: MLA1225
MASSAGE THERAPY CONTINUING EDUCATION
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ALL HOURS IN THIS CORRESPONDENCE BOOK $75.00 MLA1225 If you are only completing individual courses in this book, enter the code that corresponds to the course below when completing online. An Introduction to Post Traumatic Stress Disorder (PTSD) for Therapy Professionals 2 $33.00 MLA02PT Introduction to Pharmacology for Massage Therapists 4 $65.00 MLA04PH Musculoskeletal Assessment and Treatment for Manual Therapists 2 $33.00 MLA02MA Pathophysiology of Chronic Cardiovascular Conditions for Therapy Professionals: An Overview 2 $33.00 MLA02PC Understanding Plantar Fasciitis: A Multidisciplinary Approach 2 $33.00 MLA02PF 12 Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: Elite Learning, PO Box 997432, Sacramento, CA 95899 BY MAIL Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided. Implicit Bias in Health Care The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals’ attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients’ trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals’ implicit biases can further exacerbate these existing disadvantages. Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual’s behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.
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MASSAGE THERAPY CONTINUING EDUCATION
Book Code: MLA1225
Chapter 1: An Introduction to Post Traumatic Stress Disorder (PTSD) for Therapy Professionals 2 CEUs
By: Claudia Phillips, LMT Learning outcomes
Analyze the phenomena of dissociation and flashbacks in individuals with PTSD, exploring their prevalence, triggers, and implications for therapy professionals. Explore various therapeutic approaches as modalities for addressing PTSD symptoms to improve patients’ functional, emotional and occupational outcomes.
After completing this course, the learner will be able to: Analyze the concept and history of post-traumatic stress disorder (PTSD), including its origins, development as a diagnostic category, and historical contexts. Differentiate the symptoms of PTSD, including emotional, cognitive, behavioral, and physical, to recognize potential signs in clients. Course overview Gain a comprehensive understanding of post-traumatic stress disorder (PTSD) and its impact on clients in therapy settings. Explore the history, symptoms, and therapeutic approaches associated with PTSD, including dissociation,
flashbacks, and various modalities such as somatic therapies and trauma touch therapy. By the end of this course, participants will be equipped to recognize, understand, and effectively support clients affected by PTSD.
INTRODUCTION
trauma, such as sexual assault (U.S. Department of Veterans Affairs, 2023a). Individuals may show many symptoms of PTSD or none at all. Since touch can reactivate trauma, therapists should be aware that the condition exists. There are particular interventions, specifically within manual therapy, that can be effective individuals with PTSD. Working with these patients requires special training and a partnership with a mental health professional who can guide the process. This course provides therapists with valuable insight on how to work with this special population, so that you are more capable of recognizing symptoms and have a better understanding of trauma. It aims to give therapists confidence and compassion when planning an appropriate treatment plan for the client. of the event, and/or feel emotionally cut off from others or without feelings. Some traumatic events causing PTSD include: ● Invasive surgery or medical procedures. ● Giving birth. ● Death of loved ones. ● Experiencing or witnessing an accident, violent or sexual crime, or abuse. ● War/combat. ● Imprisonment or torture. ● Natural disasters, such as earthquakes or floods. PTSD is diagnosed when there has been exposure to extreme stress, resulting in a set of symptoms that persist for more than a month but can continue for much longer periods. In some cases, referred to as “delayed PTSD,” symptoms do not appear until several months, or even years, later. This may be more likely to happen on the anniversary of the traumatic event or if another trauma is experienced, especially if it reminds the person of the original event. Therapists have begun to talk about “complex PTSD,” where the person has been exposed to a series of repeated stressors rather than a single one—for example, previous (childhood) trauma plus being attacked (Bonde et al., 2022).
As a healthcare professional, there is a possibility that you will come across patients who have experienced trauma. Trauma is defined by the Oxford dictionary as a deeply distressing or disturbing experience (Oxford Languages, n.d.). Many think of people who suffer from post-traumatic stress disorder typically as veterans, abuse survivors, and so on. In reality, the number of people who are suffering from post-traumatic stress disorder (PTSD) is far greater and from more varied sources of trauma than the stereotypical causes. This means you are more likely to encounter clients with this condition in your practice. Approximately 6% of the population in the United States will experience PTSD in their lifetime. Women on average will have a higher change of developing PTSD then men (8% of women compared to 4% in men) due to their increased chance of exposure to What is post traumatic stress disorder? Post-traumatic stress disorder is a mental health condition resulting from trauma in one’s life. Today we hear the word trauma used more frequently. Trauma can occur from any physically or emotionally distressing or disturbing experience. Traumatic incidents can also be described as terrorizing, degrading, and visually horrible. People can be traumatized at any age. This disorder can result immediately after a trauma or can develop in a variety of timelines following trauma. Therefore, symptoms may begin immediately after the stressful event, or there may be a delay of months or years before the symptoms begin. In most cases, symptoms occur for about a month after the stressful event and then subside for a period. Conditions or symptoms occurring within one month after the event are referred to as acute stress disorder. After that month, there may be a period or periods of remission, as well as the return of symptoms that can continue for months or years. Most people recover from trauma within a few weeks. However, 20-30% of people exposed to trauma develop the range of symptoms referred to by psychologists as PTSD (Al Jowf et al., 2022). This diagnosis applies when stress symptoms do not disappear after a month or so. Individuals may experience nightmares or difficulty sleeping, feel hyper- alert and unable to relax, find themselves with memories
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History of post-traumatic stress disorder While combat-related trauma had been documented for centuries, PTSD was first formally identified in Vietnam veterans and was added to the American Psychiatric Association’s list of mental afflictions (in the Diagnostic and Statistical Manual of Mental Disorders [DSM]) in 1980. Before PTSD was officially recognized as its own condition, it was most often recognized in soldiers. Even as far back as the U.S. civil war, there are many documented cases of soldiers coming back with “melancholia” or “nostalgia,” as it was being diagnosed at the time. Symptoms had been reported as having “over emotionality” or being withdrawn, and even with recognition of physical cardiac symptoms as well. These symptoms were called “soldier’s heart” or “irritable heart.” It was believed at the time that these conditions were a result of the physical exhaustion that was demanded of the men coming back from war (U.S. Department of Veteran Affairs, 2023b) When PTSD became officially recognized as a psychological disorder, it was limited to clinical documentation of Vietnam Symptoms and signs Many times, the patient who walks into your office who has suffered from trauma and is experiencing PTSD will not feel comfortable enough to share that they are experiencing this condition. Often, they may not even be aware of the benefit therapy, specifically manual therapy, can have on their condition or the effects that physical touch can awaken in a session. Therapists should consider including post-traumatic stress disorder as an option to check under the medical conditions listed on your physical intake form. This allows the patient a certain amount of privacy and sense of security when informing their therapist about their condition. However, it is also important to educate yourself around the other surrounding physical and emotional signs of PTSD that may present with your clients. Having a better understanding of the symptoms of this disorder can help you be more mindful of your treatment plan with the client. Possible symptoms can include (NIMH, 2023): ● Emotional signs : Sadness, helplessness, feeling numb, anxiety, fear, apprehension, uncertainty, grief, denial, guilt, depression, feeling overwhelmed, loss of emotional control, irritability, agitation, intense anger with self or others, shame. ● Cognitive (thinking) effects : Confusion or mental fuzziness; poor attention and concentration; poor problem-solving; poor decision-making; memory problems; loss of orientation; disturbing thoughts; flashbacks and intrusive images; avoidance of thinking; nightmares, panic attacks, hyper-vigilance, guilt, and blaming others or yourself. ● Behavioral signs : Withdrawal; tearfulness and emotional outbursts; an inability to feel settled; suspiciousness; consumption; increased use of medication; change in sexual functioning; altered sleep patterns; strained relationships; increased accidents; avoidance of places, people, or situations; loss of interest in life; reluctance to discuss the event or wanting to talk about it all the time; apparent personality change or antisocial behavior. ● Physical effects : Fatigue, weakness, nausea, dizziness, chest pain, elevated blood pressure, difficulty breathing, hyper-alertness/intensified startle-response; a loss or increase in appetite; increased alcohol sweating, teeth-grinding, rapid heart rate, muscle tremors, visual difficulties, menstrual changes, feeling faint, stomach upsets, muscular tension leading to head, neck, or backache.
vets, combining symptoms described before as “shell shock,” “battle fatigue,” “dissociative amnesia,” and “physio neurosis.” Once the diagnosis was developed, it became clear that other types of traumas produced the same types of symptoms. With this new name and growing awareness of the condition, the amount of research addressing post-traumatic care and treatment increased sharply. Dr. Bessel van der Kolk (2000), one of the first researchers to describe the psychobiology of PTSD, noted: In a well-functioning organism, stress produces rapid and pronounced hormonal responses. However, chronic and persistent stress inhibits the effectiveness of the stress response and induces desensitization. PTSD develops following exposure to events that overwhelm the individual's capacity to reestablish homeostasis. Instead of returning to baseline, there is a progressive kindling of the individual’s stress response. As mentioned, if symptoms last more than a month, the condition is called post-traumatic stress disorder (PTSD). Before that symptoms after a traumatic event can be called acute stress disorder (NIMH, 2023). Symptoms can present in various ways, including (NIMH, 2023): ● Reexperiencing the trauma : Through troublesome or obsessive thoughts or dreams; flashbacks and/or panic attacks or feeling like the experience is happening again ● Avoidance or numbing : Avoiding topics, places, people, etc., who remind you of the trauma, mentally blocking out significant portions of memory of the event, feeling numb or emotionally distant from relatives and friends; lack of feelings, or feelings of hopelessness. ● Hyper-alertness : Difficulty sleeping or resting, frequent anger, irritability, or suspicion, poor concentration or ability to focus, and/or easily startled or scared, constant readiness or feeling “on guard” Other specific problems associated with PTSD include (NIMH, 2023): ● Panic attacks : Individuals who have experienced a trauma may have panic attacks when exposed to something that reminds them of the trauma. Physical symptoms include pounding or racing heart, sweating, trembling or shaking, a feeling of shortness of breath or choking, chest pain, nausea, dizziness, chills, hot flushes, numbness, or tingling. The person may also experience psychological symptoms such as feeling unreal or detached or fearing that they are going crazy, dying, or having a heart attack. ● Severe avoidance behavior : Sometimes avoidance begins to extend far beyond reminders of the original trauma to all sorts of situations in everyday life. This can become so severe that the person becomes virtually housebound. ● Depression : Many people become depressed and no longer take interest or pleasure in things they used to enjoy before. They may also develop unjustified feelings of guilt and self-blame and feel that the experience was their fault, even when this is clearly not true. For example, an activist may blame themselves for being attacked by the police or not being able to prevent someone else being beaten.
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● Suicidal thoughts and feelings : Sometimes depression can lead to thoughts of suicide. If you or someone you know is having suicidal thoughts following a traumatic event, it is very important to consult a professional immediately and get help. ● Substance abuse : People with PTSD may, understandably, turn to alcohol or drugs—legal or illegal—to try to deaden their pain. However, inappropriate substance use greatly aggravates the symptoms and makes successful treatment difficult. Alcohol and drugs will make a bad situation much worse. ● Feelings of alienation and isolation : People with PTSD need support, but they often feel very alone and isolated by their experience and find it very difficult to reach out to others for help. They find it hard to believe that other people will be able to understand what they have gone through. They may also find it difficult to function socially. Relationships with partners, friends and family are difficult after a severe trauma. ● Anger and irritability : Anger and irritability are common reactions among trauma survivors. If you have been assaulted, anger is a natural and justified reaction. However, extreme anger can interfere with recovery and make it hard for a person to get along with others at home, at work, and in treatment. A survivor may express disproportionate anger about a minor issue—this can turn out to be displaced anger about the trauma. ● Severe impairment in daily functioning : Some people with PTSD have very severe problems functioning in simple day-to-day life. A person may lose their ability to do ordinary tasks that were formerly easy and may be unable to fulfill their previous obligations. ● Uncontrolled crying : Sometimes people cry a lot for a long period of time. The pure thought of the event, or any “triggers,” produces a deep grief that expresses itself through intense crying and even screaming. If your patient experiences any of the symptoms mentioned, they should be encouraged to consult a mental health professional or healthcare provider who is licensed and trained to diagnose PTSD. He or she can also inform you about strategies to address your symptoms. Having knowledge of these signs and symptoms can help you address anything that may arise during a treatment session, while then being able to take the proper course of action to best meet the client’s needs. If a patient begins to cry and becomes emotional during a treatment, you can stop whatever interventions you are performing but maintain a physical connection with the client. A hand of their back or maintaining pressure can assure the client that you are there, and they are safe to feel their emotions. You can verbally ask if they would like to continue the session or offer them a tissue. Sometimes, patients can benefit from a few minutes alone in the room if they would like. Verbally assure them that they are in a safe space to cry, and that it is perfectly normal for emotions to come out in a treatment. If someone begins to have disassociation or a flash back, it is important that you stop physical touch and any interventions immediately. Give the person space and try Flashbacks and dissociation While more uncommon, flashbacks and dissociation are one of the more severe symptoms that can occur during a treatment, and therapists should be prepared to handle these situations appropriately. Given the sometimes violent history of their trauma, it is understandable that even subtle things—an odor, a photo, or a touch—can trigger explosive emotional releases in individuals (e.g., combat veterans), leading to possible rage or violence toward an inappropriate
to connect with them verbally. Ask the client what they are seeing and reassure them of where they are and that they are safe. Dealing with someone who is having a flashback and bringing them out of it requires extensive psychotherapy training and is generally outside our scope of practice for rehabilitation professionals. However, if this occurs during a therapy session, make sure to give the patient space and assure them they are safe. Ensure you can alert a coworker or trusted person in case of a violent outburst, which is a possibility if the patient is not present or aware of their surroundings. During the flashback you may also: ● Remind the client who he or she is and where both of you are at the moment. ● Have the client open his or her eyes and describe what he or she sees. ● Have the client shift to a different position (sitting instead of lying down). ● Remind him or her that this is a memory, but is not actually occurring, and that it will pass momentarily. After the flashback, offer water, sit, and give the client time to talk about what happened if they need to. Refer them to a psychotherapist if they are not already seeing them and ask permission to make future treatment plans in accordance with their recommendations. You can help a patient avoid a flashback or disassociation by: ● Using the client’s name. ● Helping them to stay connected by asking, for example, “Are you able to hear me? Is this okay?” ● Engaging the client in what is being done in each part of the process (e.g., what you are doing and why), rather than in talk that distracts from what you are doing. Other considerations you can take with intake or treatment of a client with PTSD can include: ● Involve the survivor in the plan of care and review treatment approaches before initiating. This will help open a line of communication with the client and provide the therapist with an understanding of any possible triggers. ● Provide a checklist that helps patients identify which concerns they have about the encounter (e.g., discomfort with certain procedures, boundary issues and others). ● Ask patients for ideas to make the procedure more comfortable (e.g., specific signals to stop or have a time out). ● Start with a straightforward procedure with patients, especially those who are hesitant to participate in therapies due to their diagnosis. ● Let the patient know that they can stop the procedure or exam at any time if they find it too uncomfortable, which shows that you will respect the client’s wishes and limitations. ● Adjust the set-up of treatment to enable the patient to be in a favorable position (i.e., sitting vs. laying). This may help them feel more empowered and enables visual contact to be maintained. target. Powerful outbursts during a session can be very uncomfortable, distressing, and even dangerous for the client and the practitioner. Flashbacks can cause patients to feel flooded by horrifying images or terrifying feelings. They may dissociate, removing them mentally from the current time and place. They may curl up in a ball, scream, tremble, or become violent.
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Initially this numbing out or repressing memories is an adaptive response that helps the individual cope. Unfortunately, humans appear unable to numb out selectively, so in numbing or stopping the pain of trauma, other feelings or emotions, like the capacity to feel joy or peace, may also be numbed or stopped. Although dissociation or repressing memories helps the brain and body store the memory of the event in the body in a compartmentalized way, these experiences may never be integrated into the individual’s consciousness. To complicate the situation, traumatized individuals learn dissociative survival skills or strategies like drug and alcohol abuse to numb themselves further (SAMHSA, 2017). Approximately 84% of those suffering from PTSD may be diagnosed with comorbid conditions including drug and alcohol abuse. Armed forces members are the more likely population with PTSD to additionally develop drug and alcohol abuse tendencies. A work-related PTSD diagnosis is common among health and social service workers, deployers in combat specific occupations, emergency service workers (such as emergency medical, police, and fire), and journalists (Javidi & Yadollahie, 2012). The following factors are also correlated with a greater likelihood that a person will develop PTSD (Javidi & Yadollahie, 2012): ● Increased severity of the trauma. ● Increased length of trauma. ● Increased proximity to the trauma. ● Increased danger. ● Increased incidence exposure to trauma. ● If the trauma was inflicted deliberately by other people. ● If the person gets negative reactions from friends and relatives (this is why support for victims is so important). ● The longer it took to get into safe and supported circumstances afterward. It is evident that certain occupations and types of traumas experienced directly affect the probability of someone developing PTSD. We will now look a little further into specific populations that have a greater likelihood of developing this disorder and how therapy can be impactful for these patients. Although PTSD was first recognized officially as a psychological disorder in Vietnam war veterans, you are now far more likely to see trauma from the Iraq and Afghanistan wars these days in your practice. A 2021 case study discussed mental health and other conditions that can present in veterans with reference to how manual therapies, massage, exercise, and wellness routines helped the overall health of the veteran, specifically post-traumatic stress disorder in accompaniment to combat injury. Veterans who were present with combat injury were at significantly greater risk to present with PTSD, depression, pain, and disassociation than other veterans. Some may also be surprised to know that many of these veterans sought out alternative and complementary medicine to treat these disorders (Rosenow & Munk, 2021). The case study showed that therapeutic manual therapy techniques have meaningful benefits, such as improved range of motion and decreased environmental comfort behaviors, in a veteran with PTSD who experienced a combat shoulder injury. Techniques used on this patient were trigger point therapy, myofascial release, and proprioceptive neuromuscular facilitation (Rosenow & Munk, 2021).
Someone suffering from PTSD is more likely to experience dissociation than a flashback during a therapy session as this is a much more common manifestation of PTSD. According to the DSM-V, “dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior” (APA, 2022, p. 291). While minor dissociation is a common coping mechanism (we all tune out certain experiences by daydreaming, for example), severe dissociation may manifest itself in the inability of the individuals to feel; he or she may be unaware of physical sensation or may mentally “check out” from his or her body during the period of dissociation. Probability of PTSD Not all people who experience trauma end up having PTSD. Why it appears in one person over another involved in similar traumatic experiences such as rape, war, or an accident is not clear. Some factors that may make one more prone to PTSD include: ● A personal or family history of mental illness. ● Severity of the traumatic event. ● Lack of proper treatment. ● Lack of support structures in place for the individual following the event. A 2012 study looked closely into occupations and correlations between types of traumas that have persisted and resulted in PTSD. The study also observed the correlation between substance abuse and development of other anxiety conditions as a result of misdiagnosis or nondiagnosis of PTSD in the individual. Research showed first responders (police and firefighters) make up 21% of the population of rescue workers that report PTSD symptoms. Victims of disasters made up 30-40% of the population will be diagnosed with PTSD. Beyond the differences in occupations and how the trauma was experienced, this study also showed us information about age, gender, and accompanying mental health conditions that may affect the likelihood of one being diagnosed with PTSD. Children experiencing trauma are more likely than adults to develop symptoms. As we already noted, women also are more likely than men to do so. Populations Veterans For many veterans, forms of manual therapy, such as massage, physical or occupational therapy, and chiropractic adjustments have proven a useful and effective treatment option for addressing some of their symptoms. In the great majority of cases, combat veterans can peacefully receive therapeutic touch bodywork, which can play a useful role in treatment of PTSD. In some cases, however, veterans have experienced powerful reactions such as crying, sweating, shaking, or even, in rare cases, flashbacks during a session. Flashbacks, defined as the mental re-experiencing of a traumatic event, are as terrifying each time they occur as the original time. Unlike other memories, they do not fade with age. Veterans may be surprised at the intensity of their own responses to massage—that memories of traumatic events that had happened so long ago were brought back so vividly in the massage session. Indeed, touch has a powerful ability to trigger vivid memories.
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Prenatal and postnatal patients When we think about post-traumatic stress disorder, it is easy to understand how populations such as veterans or abuse survivors can experience symptoms, but what about less acknowledged traumas? A 2024 study showed that 20% of postpartum patients experience PTSD at 6 weeks (Du et al., 2024). The United States leads the developed world when it comes to negative outcomes for infant and maternal health in correlation to childbirth. Black women share a majority of these negative outcomes. Statistics show that Black women are three to four times more likely to experience complications during pregnancy and childbirth. They are more likely to be overlooked with post-natal mental health conditions and, due to systemic social disparity, have a harder time accessing resources for prenatal and post-natal care (Chambers et al., 2022). Birth trauma is defined as “an event occurring during the labor and birth process that involves actual or threatened serious injury or death to the mother or her infant. The birthing woman experiences intense fear, helplessness, loss or control and horror” (Beck, 2004, p. 28). This definition provides a spectrum of things that could and can go wrong, or perceived danger for mother and baby during childbirth that can result in PTSD. Previous research has demonstrated that approximately 34% of women report a traumatic birth. The emergence of birth trauma seldom stems from a solitary event. Rather, it typically arises from a series of triggering incidents or from experiences that stir up past trauma. While physical events can be the catalyst for birth trauma, the subjective or psychological elements of the trauma often hold greater significance. For instance, two individuals undergoing emergency cesarean (C-section) births may interpret the experience differently due to various factors. As a result, while one may perceive the birth as traumatic, the other may not (Diamond & Colaianni, 2022). Some specific symptoms that accompany birth trauma are: ● Avoidance of reminders of the birth experience. ● Difficulty sleeping. ● Changes in arousal and activity. ● Intrusive thoughts and negative memories. Unfortunately, for new mothers it is incredibly easy for these symptoms to go undiagnosed as PTSD. A new mother is generally too busy and experiencing dramatic hormonal shifts to have normal arousal or activity levels. Most newborn parents experience difficulty sleeping, which could also be due to waking up every two hours with the new infant. Avoidance reminders of the birth experience may be due to PTSD or may be due to the fact that childbirth, even without fear or complications, is a painful and incredibly difficult experience. Intrusive thoughts and negative memories are a clearer sign that the mother may be experiencing PTSD but can also be diagnosed as postpartum depression, and depression as we know is also an accompanying symptom of PTSD. When a postpartum patient comes for a treatment, be sure to offer them the same considerations as you would for instance, a veteran. Clinicians should be providing PTSD and/or postpartum depression as an option on their intake form, providing a safe and comfortable space for them to receive manual therapy, and offer continuous and comforting communication throughout the treatment as you perform manual therapy work. If you notice any concerning symptoms throughout the session, you can talk to the client about reaching out to their primary healthcare provider or psychologist.
A 2019 survey of veterans’ interest in utilizing complementary and integrative health (CIH) interventions, 44% reported using therapeutic massage, 37% use chiropractic care, and 34% engaged in mindfulness. The reasons veterans report using CIH interventions were for pain relief and stress reduction/relaxation (Taylor et al., 2019). Manual therapies can play a useful role in releasing the memory of the trauma from the tissues. Children In 1996, a study examining the use of therapeutic touch to alleviate post-traumatic stress in children worked with sixth grade school students (chosen based on behavioral issues in class and elevated scores on the PTSD Reaction Index). The children who received manual therapy and therapeutic touch reported being happier and less anxious than the control group, and also had lower cortisol levels after the therapy (cortisol is associated with elevated stress levels). Additionally, children showed fewer symptoms of anxiety, and depression, and appeared more relaxed (Field et al., 1996). Child abuse victims In a 2013 study, it was shown that in the U.S. childhood sexual abuse has happened to 16% of men and between 25-27% of women. Of these individuals, 47% will develop childhood physiological disorders, and 26-32% will have adult-onset physiological disorders. The prevalence of childhood sexual abuse (CSA) was found to be the most prevalent in cases where the mother was widowed, single, or divorced. Many CSA survivors will develop physiological disorders, depression, substance abuse, or PTSD due to this unfathomable trauma (Pérez-Fuentes et al., 2013). Because the percentage of the general population that has suffered from CSA is so high, the chances of treating a CSA survivor in your practice also increases. Of course, history of sexual abuse is not something that we ask on a normal intake form as a manual or rehabilitative therapist. Thus, it is critical for therapists to be able to read physical and emotional signs that could indicate a patient may not be comfortable with therapeutic touch or manual therapy. Therapists must be able to adjust the treatment plan and create a safe space for the client to receive therapeutic touch. In essence, when treating someone who may exhibit symptoms of PTSD or even signs of abuse, therapists need to be mindful of their communication and professionalism. Giving this person the safe space to adjust and adapt to manual therapy and therapeutic massage is vital to creating an appropriate therapist-patient relationship. This can include securing privacy, communicating verbally exactly where you are going to have physical touch on the body, working over clothes, and asking permission to perform each technique as you move throughout the session. Every patient is different, and their trauma is unique to them. Therapists should make sure they are informed and prepared to alter the treatment plan if necessary throughout the session.
Self-Assessment Quiz Question #1 Many CSA survivors will develop: a. Anxiety. b. Obsessive compulsive disorder. c. Substance abuse disorders. d. All of the above.
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Book Code: MLA1225
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TREATMENT APPROACHES
Manual therapy approaches Why does rehabilitation, specifically manual therapy, help people experiencing PTSD? Massage and physical therapeutic touch appear able to address long-term side effects of the sympathetic nervous system response, with patients showing decreased levels of stress hormones such as cortisol or norepinephrine. These therapies can also increase the parasympathetic response by increasing levels of relaxation hormones such as oxytocin. Therapeutic massage and exercise help release endorphins and boost serotonin that can help depression (Gasibat & Suwehli, 2017). In some cases, clients with PTSD cannot initially say whether touch, stretching, adjustments, or massage pressures feel good, bad, or painful. Gradually, over several treatments, clients learn to feel touch again and are able to interpret it as positive or painful. As therapists, it’s important to be understanding and patient with this population. Be aware of any suicidal thoughts the client may share with you, and be sure to help them refer to a psychotherapist and assure them they are in a safe space in your treatment room. Understand that sounds, smells, and touch can trigger PTSD symptoms, so it is important that you always give your client the option to disrobe to their level of comfortability, and only use aromatherapy and essential oils or scented lotions with explicit consent from the client. Keeping music neutral and without lyrics can also be a good way to create a safe and calm for your client (McCafferty, 2016). A recent meta-analysis showed that engaging in exercise led to decreased severity of PTSD symptoms. This effect was particularly pronounced when participants engaged in a higher volume of exercise, exceeding 20 hours, suggesting that there may be increasing benefits with greater exercise involvement, up to a certain threshold. Additionally, exercise demonstrated significant positive effects on depressive symptoms, sleep quality, decreased substance abuse, and enhanced overall quality of life (Björkman & Ekblom, 2022). A comprehensive review done by McGreevy and Boland (2022) explored touch-based interventions implemented in the treatment of adults experiencing PTSD symptoms. Evidence suggests that such interventions can significantly contribute to emotional regulation and symptom reduction in PTSD. The results of this review showed promise for use of therapeutic touch to treat patients with PTSD. If we apply Somatic therapies and PTSD Trauma has been shown to register in bodies on a cellular level. Elevated levels of cortisol are constant triggers to the amygdala in the brain to keep the body in constant “fight or flight” mode. These prolonged elevated levels and chemical imbalances result in physical symptoms in the body. Headaches, neck, jaw, back pain, dizziness, heart palpitations, sweaty hands, and panic attacks all manifest from stress-induced anxiety. Somatic therapy is a developing practice that works with the physical responses of the body to stress by “releasing” stored trauma in our cells. Fascial tissue has been shown to be the primary tissue where these triggers are stored. A somatic therapist may use interventions such as acupressure, dance, tapping, myofascial release, hypnosis, and verbal guided meditations to help the client develop awareness of where in the body particular traumas are being stored and release them. Somatic therapy can work on both psychological and physiological levels, combining both to be able to treat the trauma of the client (Salamon, 2023).
this study to our work as therapists, we can derive that our help with integrating physical touch, exercises, stretches, and being part of an overall wellness plan for the patient is incredibly beneficial to those suffering from PTSD. Cynthia Price, Ph.D., a massage therapist and psychotherapist who specializes in women’s healthcare and counseling, developed a bodywork protocol for adult survivors of sexual abuse to implement in her efficacy study: Body-Oriented Therapy in Recovery from Child Sexual Abuse . Published in 2005, the study showed dissociation and lack of bodily self-awareness are common among women who are survivors of childhood sexual abuse, and that “body connection” was an important motivating reason for women with a history of abuse to seek bodywork. The manual therapist and psychotherapist devote themselves to helping the client experience touch without dissociation, remaining “connected” with their body through the experience. Findings suggest that body-oriented therapy and massage have positive effects on physical and psychological well-being for these clients. Another study published by Collinge and colleagues (2005) reported results for 25 participants (20 male and 5 female) with histories that included trauma. The subjects participated in a brief program of complementary therapy activity accompanying ongoing psychotherapy. Clients receiving psychotherapy participated in a series of sessions of one modality of complementary therapy, including therapeutic massage, acupuncture, Reiki, and therapeutic touch. At its completion, participants were asked to answer questions regarding their satisfaction and perceived changes in four dimensions of trauma recovery: perceived interpersonal safety, interpersonal boundary setting, bodily sensation, and bodily shame. Clients reported high levels of satisfaction with the service and significant levels of perceived (self-rated) change on each outcome measure, as well as enhanced psychotherapeutic outcomes reported by mental health clinicians. The study concluded that the integration of complementary therapies into mental health practice has the potential to enhance mental health outcomes and improve quality of life for long-term users of mental health services. During the 1990s, a number of new modalities related to bodywork for the treatment of PTSD emerged. Three of these methods are Pat Ogden’s Hakomi integrative somatics, Peter Levine’s somatic experiencing, and Chris Smith’s trauma touch therapy. These modalities share the goal of integrated body awareness through a collaboration of manual therapist and psychotherapists. Four main types of psychotherapy have proven especially effective in treating PTSD: ● Anxiety management : Involving relaxation training, breathing retraining, positive thinking and self-talk, and assertiveness training. ● Cognitive therapy : Helping to change irrational or unrealistic beliefs associated with trauma. ● Exposure therapy : Helping you confront situations, people, or emotions which evoke trauma, for instance, asking a police officer for directions. Your fear will gradually begin to dissipate if you force yourself to remain in the situation rather than trying to escape it. ● Group therapy : Self-help groups can be very useful, especially if people who have been through similar traumatic experiences.
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Book Code: MLA1225
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awareness or physical “literacy.” It may or may not include traditional massage, exercise, or adjustment methods. It is recommended that before integrating somatic therapy in your practice that you complete a training course that will allow you to effectively apply these mind-body combination techniques in your practice. a tense area of the body, for example, without movement. Sometimes the client provides the touch involved by placing his or her hand on a chosen part of the body. An important part of the process is that the work is steered by the client, who is asked to engage in somatic analysis regarding the location and feelings of tension, pain, numbness, etc., held in his or her body. The therapist asks the client where he or she would like to begin, letting the client direct the therapy, and always asking permission to take any action with the client or move from one area to another. The client is continuously checking in with the client, asking about any feelings and encouraging a numbed client to feel present in his or her body. Trauma touch therapy’s objective is an integration of the self, in which the client is able to experience all the sensations related to touch without feeling overwhelmed. He or she learns to: ● Stay present without reliving the experience. ● Maintain communication throughout the session. ● Stay in control by directing the experience and its pace. According to proponents of TTT, individuals learn to experience the joy of their bodies again, feeling more empowered and better able to take care of them. They show increased autonomy and self-sufficiency and know they can feel emotions and not be overwhelmed or diminished by them. Practitioners emphasize that bodywork can play an important role in the PTSD healing process, but the therapist must have not only an intellectual understanding of the physiological mechanisms of trauma (such as dissociation) but must maintain clear boundaries and provide a safe, nonjudgmental space for the client. The work itself can be very draining, and appropriate boundary setting for caregivers is critical (Osborn, 2019). that occurs. When the child feels stuck or unable to escape, he or she learns to repress, deny, or dissociate. These coping mechanisms work in one sense but often become maladaptive over time, causing symptoms of PTSD. Some victims of sexual abuse have an aversion to touch, avoiding it to such an extent that they become touch deprived. Through therapeutic massage, they can begin to experience touch as safe. In the model discussed by Timms and Connors, touch bypasses the cognitive system, facilitating emotional release of muscle memory, which can also assist in remembering repressed memories (Timms & Connors, 1999). Patients may be very fearful and are encouraged to set boundaries with which they are comfortable. In some cases, therapy is limited and may not progress much further for some time. The interdisciplinary team can work to provide a safe space for the clients so that abuse survivors who have learned to shut down their bodies may begin to feel again. As in TTT, it is empowering for the client to know he or she is in control of the amount and type of touch that will occur, and that there is constant feedback.
Disciplines that combine talk therapy with body-oriented protocol typically differ from standard treatment plans in that there is an added focus on sensory awareness and integration of the mind and body, including, for example, steps where the client describes his or her sensory experience or performs an exercise to increase body Trauma touch therapy Trauma touch therapy (TTT), developed in 1993 by Chris Smith, herself a survivor of childhood sexual abuse, has been used extensively with victims of trauma. While there is no set protocol (each series of sessions is uniquely based on the needs of the client), TTT is typically provided in ten fully clothed sessions and requires an extensive physical and emotional health assessment, including a discussion of the work in which the client feels ready to engage. Chris Smith began to consider the possibility of using therapeutic touch to address symptoms of PTSD early in her career. She found practicing therapeutic soft tissue work was healing to her own history of trauma; that healthy touch (both giving and receiving) enhanced her sense of self, acting as a powerful counterpoint to the history of sexual abuse. She also found that her experience with trauma was not uncommon among her fellow practitioners. Increasingly, students shared their own stories of violence and abuse, along with a desire to consciously address the issue. Too often, she heard from manual therapists who felt they were unequipped to handle the powerful emotional releases experienced by their clients (abuse survivors) in sessions. Trauma touch therapy stresses a self-referential process, in which the patient or client is continually monitored for what is going on in his or her body. Before any bodywork begins, however, the client is are asked about his or her history—for example, whether he or she has ever witnessed or experienced a violent crime, has a history of suicide attempts, knows of any triggers to which he or she might react, or any other relevant concerns the client would like to share. The session typically begins with an awareness exercise that may not include touch at all—feeling the sensation of material against one’s wrist or arm, for example. Therapists working with veterans have also tried a range of types of treatments that use only minimal touch, resting the hand on Timms and Connors Two other researchers in this interdisciplinary field are a psychologist named Robert Timms, PhD, and a bodyworker named Patrick Connors, CMT, who developed a different model for integrating therapeutic massage for these patients. Their work began when Timms realized during a bodywork session that he had a history of childhood sexual abuse, an experience of which he had been unaware for the previous 40 years (Timms & Connors, 1999). Timms and Connors caution that some survivors of child sexual abuse are not good candidates for therapeutic touch or manual therapy. It may be inappropriate for those who dissociate, for example, or are hostile and angry. In those cases, therapeutic massage may even be emotionally damaging to the patient and detrimental for the therapist. They remind practitioners that treatment of survivors of childhood sexual abuse is a highly specialized field that requires special training and must be accompanied by verbal therapy with a trained professional (Timms & Connors, 1999). Sexual abuse trauma is unique, say the authors, in its betrayal of trust. Timms and Connor correlate the degree of betrayal of trust with the level of psychological damage
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Book Code: MLA1225
EliteLearning.com/Massage-Therapists
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