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traumatic brain injury,TBI, PTSD, car accident, pain in neck, back

EXPERIENCE PROVIDING THERAPY TO PEOPLE with Traumatic Brain Injury (TBI)

July 13, 2012

Rachel Katz is a Physical Therapist with over 30 years of clinical experience.

She has treated many people with Traumatic Brain Injury (TBI) as the main treatment focus. She has also treated  TBI combined with other physical injuries. Rachel works with the psychological and emotional problems that can be present and part of the whole recovery picture. Often Rachel is part of a team of providers.

Rachel is one of a small number, worldwide, of Physical Therapists who have the credential of being a Somatic Experiencing Practitioner. The 3 year training program developed by international pioneer and educator Dr. Peter Levine, instructs predominantly Professionals in the Psychology field in how to resolve many kinds of traumatic stress including Post Traumatic Stress Disorder (PTSD).

This is helpful and relevant for clients whose TBI occurred in traumatizing situations, or for clients who have prior life experiences that were traumatic.

TBI can deregulate and alter many kinds of brain function. Chronic physical pain is also known to alter the brain and how it communicates with the body. Traumatic stress may also have significant influence on many deep brain and body functions.

Therapy with Rachel for TBI may include issues related to balance, movement, pain, and ability to modulate activities to limit brain overload. Work with how the head and neck coordinate with hearing and looking around may be needed. Balance reactions may need to be developed again. Home environments may need to be modified.

PROFESSIONAL CURRICULUM

Physical Therapy studies at the University of Colorado Health Sciences Center involve study of brain anatomy and brain function for many aspects of normal health, illness and injury including many facets of Traumatic Brain Injury. Physical Therapy curriculum includes an in depth understanding of nerve pathways, nerve function and how the brain works as a whole system. PTs are trained in working with family dynamics and psychological aspects of impairments.

HOSPITAL, INTENSIVE CARE SETTINGS, REHABILITATION Units, HOME CARE, ASSISTED LIVING

Approximately 30 years ago, early in my career, I worked with TBI in acute care settings in Saint Anthony’s Central Hospital. I treated patients who were in a coma, patients who were beginning to rouse from coma states, and treated patients who were in their early phases of regaining function in speech, movement, thought, and organization for tasks. I have worked with clients in the hospital to assist with very basic skill recovery such as being able to walk and look around without loss of balance or becoming too overwhelmed. I have experience pacing my communication and tasks for individuals with moderately severe TBI and moderately impaired functional capacity.

I worked in the Boulder Memorial Hospital rehabilitation unit as part of a team who treated TBI patients. In this setting, moderately impaired people were in the first phases of rehabilitation after their acute care treatment phase was past. Therapy was directed at restoring independent ability to walk or transfer into wheelchairs, ability to handle hygiene, treating pain, increasing strength, pacing therapy schedules, increasing ability to become independent and progress towards a return to home and community activity.

In the above settings I worked with TBI from physical forces as well as people with impaired brain function from medical conditions such as strokes, cancer, and mentalfunction issues associated with aging.  I have worked in intensive care units, home health care settings, and nursing homes, transitional care units, and in the psychiatric wings of assisted care settings where people have had altered or impaired brain function, some of which was from a TBI.

OUTPATIENT THERAPY CLINIC

I have worked primarily in private practice, outpatient clinics, my own, for over 20 years. Here I have treated a typically higher functioning level of TBI clients. The therapy goals and issues tend to be different from hospital settings.

I might be the professional who first recognizes that there are overlooked brain function issues for some clients who have had concussions in sports, falls, or from car accidents. I may need to coordinate additional providers and testing. If needed, I communicate with the client’s doctor, neuropsychologists, vision testing and vision therapists. Cognitive testing may be recommended to assist people in achieving clarity about their situation. My therapy goals include helping my clients find the appropriate resources they need to recover.

I understand that clients with TBI may need less noise, less talk, less stimulation visually. They may need slower pace of activity or talk. They may need an individualized combination of visual instruction, kinesthetic (actual physical practice) and spoken instructions. For some people slower pacing may be too slow and out of synch with their need to engage rapidly. With a TBI, sometimes a person will entirely lose a train of thought if interrupted or distracted, so care needs to be taken so communication is the least stressful.

AREAS OF SPECIAL EXPERTISE

I have a number of special areas of expertise that relate to Traumatic Brain Injury recovery.

1.) CRANIAL-SACRAL THERAPY
2.) TRAUMA THERAPY using SOMATIC EXPERIENCING adapted for a PT practice
3.) CHRONIC AND COMPLEX PAIN SPECIALIST
4.) CAR ACCIDENTS
5.) PERSONAL CHALLENGES with TBI, PTSD

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1.)  CRANIAL-SACRAL THERAPY

My training in Cranial-Sacral Therapy began about 30 years ago as a new graduate from PT school. This gentle touch work helps restore fluid flow around the brain, decompress bone junctions in the skull, and may assist in improving eye function as it relates to the large eye muscles that control eyeball movement. Many people find this therapy deeply calming and pain relieving. Sometimes ringing in the ears (tinnitus) is helped. I have used this treatment over the years with head trauma patients. As with any treatment, the response varies from a clear sense of help to none. In my practice, Cranial-Sacral Therapy is typically used as a part of a broader approach versus being  the sole treatment method.

2.)  TRAUMA THERAPY using SOMATIC EXPERIENCING adapted for a PT practice

I became a Somatic Experiencing Practitioner, SEP, in 2000 after graduating from a 3 year program in healing Traumatic Stress. This training is called Somatic Experiencing(SE). The types of overwhelming traumatic stress a person might face was extensive. We learned to treat particular symptoms from types of threat. Examples of external threats that might result in ongoing disruption in brain function are: assaults, falls, car accidents, being struck with a moving object, natural disasters, medical trauma, unsafe intrafamily dynamics, rape and war. We learned to treat trauma from internal sources such as from illness or poisoning. Sometimes there are layers of trauma in an individual’s life experiences.
Childhood exposure to overloading stress can create extra vulnerability later in life, if new challenges occur.

For example: a child may grow up in a home that feels unsafe because of parental or sibling anger or behaviors or abuse. If later in life this person has a TBI, there may be magnified difficulty understanding and solving problems with the nuances of communication with a family member or coworker. There can be an intensified reaction of anxiety, withdrawal, frustration, or anger. Pain symptoms may be part of these patterns. The ability to be with others in pleasant and productive ways is addressed as part of treatment.

This treatment method is about restoring a normal ability or improved ability to regulate oneself both consciously and unconsciously. After exposure to overwhelming threat plus helplessness, a person’s central nervous system may become super sensitized to particular cues and react as if there is another terrible threat present when there isn’t. Fight, flight, and/or freeze responses to threat are processed in a safe, gradual, and individualized way. Acute sensitivity to cues perceived as threats will escalate emotional reactions, can ramp up muscle activity and pain, and can create difficulty with concentration, work, parenting, schooling, and enjoyment of life.

People are helped to learn to observe and regulate the internal disruptive functioning in their bodies. Therapy is directed at helping a person increase their sense of control and safety in their unique settings and relationships. Calming strategies and self management are taught. Eventually, the elements of traumatic stress responses specific to their situation are diffused, reworked and integrated into a more stable ability to cope and thrive.

Because Post Traumatic Stress Disorder (PTSD) can produce disrupted brain function, it’s important to settle this down. In the presence of PTSD plus TBI it’s especially critical to restore calmer states for the brain so that sleep happens, stress chemicals in the body are minimized, and a better ability to learn is nurtured.

I have adapted my training in Somatic Experiencing to help patients decrease pain, calm themselves despite the presence of triggering cues, and desensitize negative reactions to many types of intrusive cues. Intrusive cues can be from the body itself. Muscle patterns related to defense or protective reactions during car accidents, falls, assaults etc can be shifted from their locked associations with a trauma. The muscles can return to strength and fluid comfort.

Body based trauma cues can come from eye movements, from sounds and particular pitches of noise. Balance reactions may need to be rebuilt back into someone’s skills. Therapy may include practice with eye motions and exploration of muscle tensing patterns elsewhere in the neck or body that may relate to looking in certain directions. I have worked with dizziness and balance problems. I have used SE to help patients restore their protective instincts and regain a sense of safety and decrease the frequency and intensity of feeling anxiety or stress.

Somatic Experiencing methods are especially helpful in restoring a sense of self and safety in the world. TBI is often accompanied by a disrupted and chaotic sense of the space around oneself. Work with boundaries and self protective strategies can be part of this treatment.
Somatic Experiencing is typically done as non touch verbal dialogue explorations of traumatic cues and sensations. The focus is to assist the client in completing and releasing the blocked orienting, protective, and freeze responses that are part of a trauma symptom picture.

Rachel’s professional scope normally includes touch and she has developed unique applications of SE therapy in a PT setting. With TBI, clients often need to regain head, eye and neck orienting and coordination, reduce muscle spasm and pain as part of both trauma and physical injury patterns. Hands on support of movement, and the use of gentle contact into the muscles and joints combined with SE dialogue methods can help resolve trauma and improve function in many situations that dialogue alone doesn’t accomplish.

3.)  CHRONIC AND COMPLEX PAIN SPECIALIST

Traumatic Brain Injury may leave a person with pain issues in the head, neck, back or other body areas. For many years I have focused on solving complex pain issues. Informal data assessment of my clients done in 2007 showed outcome success measured as significant satisfaction and improvement associated with 75% of treatment sessions despite 57% of my clients having had severe physical and/or emotional traumaas a part of their current situation or life history.

I am a specialist in treating chronic pain in the head, neck, and spine or limbs. Many people with TBI continue to also struggle with pain issues. I have a higher than average success rate working with complex and chronic pain issues that have not previously resolved.

I see many clients who have been in car accidents. There can be components of injury that relate to TBI, Post Traumatic Stress Disorder, and physical injuries. All these conditions can overlap contributing to a tangle of altered function and comfort.

For example, the neck joints may be sprained and muscles may remain in spasm well beyond what is accepted as a typical healing period. There may be eye function disruption associated with head injury, and there may be hyper-reactivity to cues. So, someone may have trouble feeling safe as a driver again because they can’t move their neck, focus their eyes, and remain internally capable of calm states while anxious and flooding with adrenaline in a vehicle in some driving settings. Treatment is also directed at restoring better ability to react to visual, auditory and movement sensations throughthe eyes, ears, and body.

Additionally, I may need to help a person manage their emotions of frustration and confusion as they learn to manage themselves within their new limitations.

The deep muscles of the spine are not easily controlled voluntarily for many people, even atheletes. These muscles are often an overlooked and persistent source of pain. Exercise programs may not stimulate the return of normal muscle action/relaxation patterns needed for comfort in the back for sustained positions like sitting, standing, or sleeping. The loss of fine, subtle shifts in posture causes people to repeatedly stretch and move as a means to allieviate building tension and pain in their bodies. The abnormally entrenched tension is usually felt as pain. This pain responds well to Rachel’s unique approach of addressing movement patterns and the deep brain influences occurring from TBI, Trauma, preexisting habit and posture, and injury.

4.)  CAR ACCIDENTS

Driving involves high level functioning and coordination of eyes, ears, balance, acceleration deceleration, body position and judgements related to speed, spacing, trajectories, and movements of oneself and those around you. TBI from car accidents can leave a person with many functional and physical challenges plus pain.

Rachel works with restoring the ability to drive safely. She helps rebuild needed components in the body and uses many strategies to assist with TBI issues. Confidence, anxiety and hyper-vigilance may be addressed. Avoidance of orientation to boundary space may need to be addressed to enable a client to safely use mirrors. Muscle, joint and nerve issues may need to be addressed to enable a person to sit to drive in a functional level of comfort, and to provide enough movement to see around the sides and behind for safe driving. The sway and bounce of being in a car triggers a barrage of small equilibrium stimulus that may not process at pre-injury levels. This is often addressed with specific vestibular processing challenges done in a progressive and comfortable way.

I wrote The Consumer Guide for Recovery from Car Accidents in 2006. This guide discusses many physical injuries, TBI, PTSD, protective involuntary muscle spasm, and other information. Robert Scaer, MD and internationally recognized author on trauma wrote “Rachel Katz has developed an accurate and informative guide for the auto accident victim, addressing the way the brain works in trauma in an easily understoodformat. In her Consumer Guide for Recovery from Car Accidents she presents an effective model for treatment and healing that encompasses many new and exciting modalities. I wholeheartedly endorse this booklet for any patient facing recovery from and auto accident.” This 30 page guide is on my website.

5.)  PERSONAL CHALLENGES with TBI, PTSD

In 1994 I got PTSD from a car accident. At that time, I thought PTSD was a “mind” issue not a body issue. I thought that PTSD treatment was for the psychology professionals and that my realm was the “physical”. I thought that trauma was about physical forces, not the enduring brain-body effect of overwhelming fear combined with helplessness which is the root cause of becoming traumatized. My knowledge was not enough for me to see that I was having mind and body problems linked to PTSD changes in brain function.

In 1996, while still seeking solutions for my physical injuries, and not realizing I needed help for PTSD, I experienced severe shock, horror and devastating loss over the death of my 10 year old nephew in a horseback riding accident. My car related PTSD became severe and global and I still didn’t see what was happening as PTSD.

Fortunately for me, my dear friend and colleague, Dr. Robert Scaer helped me understand that I had PTSD, and there was an incredibly sensible approach to recovery through Somatic Experiencing. I had the amazing opportunity to both study and undertake treatment by Dr. Levine, who developed this method. I saw Somatic Experiencing Practitioners (SEPs) who used bodywork in my SE sessions.I immersed myself in learning during the 3 year sequence of SE courses. Of course my motivation was personal and professional. I needed to save myself and saw that this was a relevant and previously missing piece of therapy for many of my clients.

My recovery from PTSD and physical issues took a number of years. Along the way I came to understand many aspects of the challenges people face with altered brain function from PTSD and the havoc magnified stress reactions can have in relationships, raising children, recreation, thinking, and enjoyment of life.

In 2008 another car accident occurred and I faced a new round of PTSD related to cars, TBI affecting many of my higher cognitive functions, vision problems, hyper sensitivity to sound, and injury to my arm, neck and head. I have personally directed much of my rehabilitation, have experienced the challenges of coordinating care, frustrations with legal and insurance systems, while needing to run my business and remain an engaged and loving spouse and parent. This time the PTSD was easier to handle having tools and familiarity with the  recovery process.

Undergoing treatment for and adapting to TBI was new. Learning how to advance my own recovery has given me an insider’s sensitivity to some of the challenges my TBI patients face.

Now, I would like to stop being a canary in a coal mine, and focus instead on helping other people out.

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