Treating the Whole Person: Trauma-Informed Care Part 2

By Jillian Giannini, DPT, PHRC Westlake Village

Just like it was discussed in our previous post it is not within the scope of practice for a physical therapist to treat trauma; however, educating yourself on ways to implement trauma-informed care can help you to provide a safe and conducive environment for a patient’s path to healing.

In a 2018 cross-sectional study by M. Bruce et. al, they looked at the “attitudes, knowledge, perceived competence, and practice of trauma-informed care (TIC) among providers” through an anonymous web-based survey. The providers consisted of nurses, physicians, therapists (occupational, physical, and respiratory) that worked at a “trauma resuscitation, trauma critical care and trauma care unit.” Here are a few things they found:

Majority of the participants saw themselves as “somewhat” or “very competent” in their skills for providing TIC. They felt they had the ability to respond with a calm and unbiased demeanor with a patient in emotional distress and engage with them so they felt comforted.
Half of physicians and therapists did not feel competent in educating patients on stress reactions and symptoms or “understanding the empirical evidence behind assessment and interventions for traumatic stress.”
Almost one in two physicians did not feel competent in “avoiding or altering a situation within the hospital that a patient might experience as traumatic and in understanding how traumatic stress may present differently in different ages, genders, or cultures.”¹

This study has limitations to only surveying a select group and more studies should be done to other settings or regions. However, this gives you some insight on the necessity of training for healthcare providers to help better support patients and prevent re-traumatization.

So where to begin? TIC is a process and can be implemented from all areas of the organization from the person who first greets the patient to the physical therapist. This not only benefits patients or clients, but everyone working within the organization. The Substance Abuse and Mental Health Services Administration (SAMHSA) based their trauma-informed approach on four assumptions and six key principles. The four assumptions are called the four R’s:

Having a basic realization about trauma and how it can affect not only individuals but also families, communities, groups and organizations.
Recognizing signs and symptoms of trauma.
Responding by incorporating trauma-informed principles.
To resist re-traumatization of clients and staff.²

The Key Principles include:

Safety: All that are involved in the organization including the clients or patients feeling physiologically and psychologically safe (e.g. Allowing employees the ability to provide feedback on how safe they feel in their work environment). Some other examples provided by the Center for Health Care Strategies (CHCS) include:
1. Keeping common areas well lit like bathrooms, entrances, and exits.
2. Easy accessibility to doors to easily exit whether in a treatment room or in the facility.
3. Welcoming patients with respect and support.
4. Having staff that understands maintaining healthy boundaries and that can manage conflict.³

Trustworthiness and Transparency: The company or organization is transparent with employees and clients with decisions and operations (e.g. Being transparent with your patient about objective findings and decisions on the treatment plan).

Peer Support: Supporting those who are trauma survivors with “establishing safety and hope, building trust, enhancing collaboration, and utilizing their stories and lived experience to promote recovery and healing.” This can help with burn-out that is common in health care settings, as well as, prevent secondary trauma. The CHCS provides some examples on ways to help prevent secondary trauma:
1. Allowing “mental health days.”
2. Recommend your staff to engage in various types of self-care like physical activity, yoga or meditation (Check out Tips for Managing the Stress of COVID-19 and Your Pelvic Floor that shares some great examples).
3. Supporting regular meetings with clinicians and supervisors to discuss and address feelings about patient interactions.
4. Trainings on awareness about secondary trauma.³

Collaboration and Mutuality: Showing the importance of partnering and assessing the power dynamic between all the levels of staff and between staff and clients, so that healing can be promoted when power and decision-making is shared. (e.g. Having your patient play an active role in their treatment plan. Asking for the patient’s input and allowing space for more dialogue versus the practitioner dictating the set plan).

Empowerment, Voice, and Choice: The organization develops and services to “foster empowerment for staff and clients alike. Organizations understand the importance of power differentials and ways in which clients, historically, have been diminished in voice and choice and are often recipients of coercive treatment.” Some examples include:
1. Allowing patients or employees to have a voice and choice.
2. Prior to a specific treatment explaining what you will be doing and asking the patient or client if you can precede can be a way of allowing them to have a voice and choice.
3. Employees having the ability to share their voice while still feeling safe to do so.
4. Not pushing a survivor to disclose their trauma history and allowing it to be their choice.

Cultural, Historical, and Gender Issues: Also adopted as humility and responsiveness by the CHCS. Active movement “past cultural stereotypes and biases (e.g. based on race, ethnicity, sexual orientation, age, religion, gender identity, etc.)…and recognizes and addresses historical trauma.” Implementing policies that would respond to any racial, ethnic, and cultural needs of staff and clients. (e.g. Asking an individual what their pronouns are and calling the individual by the selected pronouns without judgement or biases).²

This is just a brief explanation of SAMHSA’s trauma-informed approach with some adaptations and examples from the CHCS to help bring more awareness and to hopefully start the conversation around this topic. If you would like to dive further into their concepts and educational materials check out SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach and Video: What is Trauma-Informed Care?.³

This may have been a lot of information to digest, but just remember that we are constantly learning more and more about the effects of trauma and how to help. There is no perfect formula and be kind to yourself throughout the process. As someone who is still learning, remind yourself of what is within your scope of practice and assist with referrals (e.g. hotlines, psychologists, trauma experts, etc.). This is mainly more insight to better understand ourselves and others we may encounter.

Here are a few resources, but if you would like to share more, feel free to contribute in the comments below! The more the merrier, to remind us that we are not alone.

Resources:

RAINN (National Sexual Assault Hotline): 800-656-HOPE (4673)
National Suicide Prevention Lifeline: 800-273-8255
National Domestic Violence Hotline: 800-799-7233 or https://www.thehotline.org
National Human Trafficking Hotline: 888-373-7888
Strength United Support and Referral Lines: 818-886-0453; 661-253-0258 / https://www.csun.edu/eisner-education/strength-united/services
- “Strength United is honored to be an important part of making the world a safer place for all. Our work supports families, prevents sexual and domestic violence, and provides healing and support for those who have survived abuse. We aim to take a traumatic event in an individual or family’s life and turn it into a point of strength.”
211: vital service that connects people with help. https://www.211.org
Department of Mental Health (https://dmh.lacounty.gov/get-help-now/) : Help Line 800-854-7771
Lumos Transforms
- “Lumos Transforms is a social enterprise founded in 2015 to shepherd individuals, communities, and organizations through positive change. Whether people are dealing with unpleasant symptoms, overwhelming stress, difficult past experiences, or unjust circumstances, we meet clients exactly where they are– providing responsive solutions that help people feel better, prepare for change, and unlock their inner potential. By empowering individuals to access wellness, grow resilience, and cultivate beneficial behaviors, we initiate a transformation process that ripples outward. The ultimate goal? Creating socio-cultural systems that are healthy, balanced, interdependent, sustainable, and equitable.”(https://lumostransforms.com/about/)
Trauma-Informed Care Champions: From Treaters to Healers : Informative videos on TIC

References:

Bruce, M. M., Kassam-Adams, N., Rogers, M., Anderson, K. M., Sluys, K. P., & Richmond, T. S. (2018). Trauma Providers’ Knowledge, Views, and Practice of Trauma-Informed Care. Journal of trauma nursing : the official journal of the Society of Trauma Nurses, 25(2), 131–138. https://doi.org/10.1097/JTN.0000000000000356
SAMHSA’s Concept of Trauma and Guidance for a Trauma … (2014). Retrieved August 26, 2020, from https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf
Menschner, Christopher, and Alexandra Maul. “Key Ingredients for Trauma-Informed Care Implementation.” Center for Health Care Strategies, 20 Apr. 2020, www.chcs.org/resource/key-ingredients-for-successful-trauma-informed-care-implementation/.

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Are you unable to come see us in person? We offer virtual physical therapy appointments too!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.

Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $85.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.

PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.