Managing Distress Can Enhance Outcomes

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    Anyone walking in on the presentation about midway through would’ve been in for a rather … calming surprise: a silent room, full of physical therapists (PTs) sitting, eyes closed, taking and releasing breaths to the count of a presenter. But make no mistake, this was serious business, because it had to do with getting a handle on a response from a patient or client that can harm outcomes, no matter how evidence-based the intervention—distress.

    In their June 12 presentation "From the Crying Infant to the Anxious Adult: Strategies to Decrease Behavioral Distress During Physical Therapy Interventions," presenters Elizabeth Regan, PT, DPT, OCS, and Mary Swiggum, PT, PhD, PCS, led attendees through an overview of the signs of pediatric and adult distress and possible techniques PTs can use to help their patients and clients keep calm and rehab on.

    And yes, breathing exercises help.

    "We are good at identifying impairment, we're great at activity, and we're even good at participant restrictions," said Regan of PTs' abilities to address the International Classification of Functioning (ICF) model. "But when it comes to environmental and personal factors, I don't think we have a lot of training in how to do that."

    It's the environmental and personal factors that can contribute to distress, Regan said, which can in turn manifest itself not only in clinical outcomes, but patient and caregiver wellbeing, other physical conditions, and general psychosocial functioning. "We are expecting our patients to have a certain amount of stress," she said. "But when does it become a problem?"

    Swiggum took the lead in explaining how distress can manifest itself. She explained that in the pediatric setting, the expression of distress is highly contextual and based in large part on social learning between the child and caregiver. For the infant patient, PTs need to be tuned into nonverbal cues indicating distress: lowering or furrowing brows, "tongue show," and splayed fingers can be fairly reliable signs of a problem. At the same time, she added, some infants react to distress by retreating into sleep. Instead of thinking that a child falling asleep during therapy is a good sign, Swiggum suggested that "it could be, poor thing, that he's overstimulated and highly stressed."

    Among verbal adults and older children, chronic stress can manifest both physiological and psychosocial symptoms. Physiologically, patients experiencing chronic stress may have increased blood pressure, difficulty sleeping, weakened immune systems, muscle tension, and breathing problems. At the psychological level, chronic stress may result in learned helplessness, a loss of hope or purpose, and social isolation. The effect on the patient's or client’s attitude about his or her physical condition can be dramatic and include pain catastrophizing, misdirected problem solving, and feelings of helplessness.

    So what can PTs do? Swiggum and Regan emphasized the importance of attentiveness and careful observation with an eye toward what calms individuals, and an understanding that a calming technique for one person may be the source of even more stress for another. Still, they said, there are some general ideas that may help.

    For children, Swiggum suggested that PTs pay particular attention to the role that sensory input can have in relaxing the child by turning focus away from the intervention. Different children react differently, she said, but PTs should be ready to provide visual or auditory stimulation of some sort. Also worth considering—room lighting, the colors and textures of mats, and the temperature and lighting in rooms, including the waiting room.

    As for positioning, Swiggum suggested that PTs think about the ways in which "containment"—things such as deep hand pressure, swaddling, and facilitated tucking—can give a child a feeling of security that can be calming. PTs may also want to consider avoiding placing a child in the supine position and facilitating greater flexion and access to midline. Ultimately, she said, the PT's strategy must be "cue matched," which makes careful observation critical.

    Swiggum emphasized that caregivers are critical components in stress reduction, and that PTs need to be sure that the people providing day-to-day care are not unconsciously adding to stress. "We really need to work with the moms, don't we?" she said.

    Regan said that many of the same principles of matching strategies to cues can be effective with adults. "A lot of the things we do with children we can apply in an adult context," she said. As with children, an awareness of the surroundings faced by patients, as well as sensitivity to nonverbal indicators, can help guide the PT toward stress reduction that fits the individual.

    The one big advantage of working with verbal adults and older children, Regan said, is that PTs can explain and demonstrate stress reduction techniques, such as the breathing exercises she demonstrated with attendees. "Relaxation, like many skills, needs to be practiced," she said.

    Regan talked about the importance of diaphragmatic breathing and grounding, saying "why wouldn't we want to breathe instead of taking antidepressants if we can?"

    In the end, the presenters said, helping patients and clients effectively manage stress demands that the PT be aware of where the individual is physically, emotionally, and socially. "If you can help them care again and not be afraid of the future, you increase chances of success," said Regan.

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