|Year : 2022 | Volume
| Issue : 3 | Page : 205-208
Physiotherapy and behavioral techniques in management of posttraumatic stress disorder in health-care workers amid COVID pandemic
Srishti Bipul Banerjee
Assistant Professor, LJ Institute of Physiotherapy, LJ University, Ahmedabad, Gujarat, India
|Date of Submission||19-Mar-2022|
|Date of Decision||06-Apr-2022|
|Date of Acceptance||26-Apr-2022|
|Date of Web Publication||01-Aug-2022|
Dr. Srishti Bipul Banerjee
LJ Institute of Physiotherapy, LJ university , LJ Campus, Sarkhej, Off Sarkhej – Gandhinagar Highway Ahmedabad - 382 210, Gujarat
Source of Support: None, Conflict of Interest: None
Since the outbreak of coronavirus in 2019, the health-care workers (HCWs) are tirelessly battling through these unprecedented times. Although the pandemic has shaken the health-care systems globally due to its unpredictable course and spread, HCWs continue to remain on the frontline. the focus is always on patient care and limiting the spread amidst which the mental health and challenges faced by HCWs takes a back seat, the purpose of this opinion is to focus on the mental health issues HCWs are facing globally while fulfilling their duties. The article discusses the clinical features and risk factors and also provides evidence-based management strategies for posttraumatic stress disorder in HCWs.
Keywords: COVID-19, health-care workers, posttraumatic stress disorder
|How to cite this article:|
Banerjee SB. Physiotherapy and behavioral techniques in management of posttraumatic stress disorder in health-care workers amid COVID pandemic. Curr Med Issues 2022;20:205-8
|How to cite this URL:|
Banerjee SB. Physiotherapy and behavioral techniques in management of posttraumatic stress disorder in health-care workers amid COVID pandemic. Curr Med Issues [serial online] 2022 [cited 2023 Mar 22];20:205-8. Available from: https://www.cmijournal.org/text.asp?2022/20/3/205/352975
| Introduction|| |
The outbreak of coronavirus has challenged the health-care system like never before; the preparedness of the health-care system was put to the test. Health-care workers have stepped up beyond all the odds putting their own and family's health at risk. The untiring and extraordinary efforts by the HCWs were well appreciated, and the psychological burden from the “cost of caring” went unrecognized.
A recent systematic review and meta-analysis by Abdulla et al. stated that the prevalence of depression was 41.90%, anxiety was 42.87%, stress was 58.04%, and insomnia was 31.94% in an Indian health-care setting.
A study conducted on 2800 HCWs during the first lockdown in India by Parashar et al. stated that the prevalence of secondary traumatic stress was 88.2% in doctors, 79.2% in nurses, and 58.6% in allied health-care professionals which included physiotherapists, laboratory technicians, phlebotomists, dieticians, administrative staff, and pharmacists.
The factors contributing to development of psychiatric illness such as PTSD during the coronavirus includes long working hours with work overload, ethical and moral conflicts, lack of experience in tackling such situations, the anxiety of getting infected, spreading the infection, and transmitting the infection to their families, difficult living environments where there is a continuous increase in severity infection, death of their patients and lack of medical supplies. All these factors contribute to developing posttraumatic stress disorder (PTSD)., PTSD is defined as a mental illness experienced by traumatized individuals during or after emergencies. The individual affected with PTSD continues to experience trauma even after the traumatic event.
| Antecedents of Mental Health Burden in Health-Care Workers|| |
- Virus contamination risk and stigmatization of HCWs treating infected patients by society
- Adhering to new biosecurity measures
- Periods of social isolation
- Mourning for the death of loved ones
- Obsession to maintain hygiene to avoid infection
- No predictable outcomes in terms of treatment, spread, and variants of the virus
- Disruption in sleep schedules and an excessive amount of stress which leads to a weak immune system
- Feelings of hopelessness, vulnerability, and loss of control over situations
- Feelings of uncertainties about going home and also spreading the infection to family
- Disruption in work schedules
- Misbehavior of isolated patients.
| Risk Factors|| |
Occupation-related stress is the major risk factor for the development of PTSD, HCWs because of the nature of their profession come in direct contact with the patients, fear of transmission of infection, the fact that there exists no effective treatment, continuous mutation, and development of variants of the virus. HCWs experience perceived stress which refers to the feelings or thoughts an individual experiences about how much stress they experience in a particular situation and their ability to cope up.
Compassion fatigue is associated with the work-related stress HCWs experience. Compassion fatigue results secondary to the psychological stress HCWs experience due to the suffering of patients. Compassion fatigue is characterized by physical, social, emotional, and mental fatigue HCWs experience during prolonged care of their patients. This results due to fear of infection and being in contact with the infected patients for a prolonged duration of time. As the HCWs are in contact with infected patients for a prolonged duration of time, they experience frustration, the feeling of powerlessness, and negativity leading to a mental distance from the profession as well as the patient. This avoidance behavior is considered a coping mechanism. It was found that females were more susceptible than males. As women tend to assume a caregiver's role at home, it was found that women found it challenging to establish a work–life balance which makes them more susceptible to developing PTSD. Females were found to get affected more during the acute exposure to stressful situations, whereas males were found to be affected in the long run. The hypothesis here is, as women tend to be more aware of their emotions and are better at expressing them than their male counterparts, leading to self-regulation of their emotions, which diffuses the impact of these emotions over the period. PTSD was found to more prevalent in the younger population as compared to the older population as older population holds more clinical as well as emotional experience which makes them less anxious.,, The prevalence of PTSD was higher in untrained HCWs as compared to trained ones. HCWs who lived alone and received lack of social support were at a greater risk of developing PTSD.
Symptoms of posttraumatic stress disorder
The International Classification of Diseases-10 classifies the symptoms of PTSD into three groups
- Intrusion: Here, the individual experiences recurring dreams, images, or memories related to the traumatic incident
- Avoidance: Here, the individual avoids people, places, or topics related to the traumatic incident which is usually accompanied by reduced overall activity
- Arousal: There is a heightened psychophysiological reactivity which manifests as attention-deficit disorders, disorders in circadian rhythm, or an increase in vigilance.
Assessment measures for posttraumatic stress disorder
Posttraumatic Stress Disorder Checklist Civilian Version
PTSD Checklist Civilian Version (PCL-C) is one of the most widely used scales for the evaluation of PTSD following traumatic events and can be used by medical staff. PCL-C consists of 17 items rated on a 5-point Likert scale which asses three parameters, i.e., hyperarousal, re-experiences, and avoidance/numbing. The score ranges from 17 to 85. The interpretation suggests higher the score, the more severe the symptoms. A score of 38 and above confirms PTSD.,
Perceived Stress Scale
The scale consists of 10 items on a 5-point Likert scale which measures the rate of perceived stress over the past month, where 0 = never, 1 = almost never, 2 = sometimes, 3 = fairly often, and 4 = very often. The score ranges from 0 to 40 points where the higher the score, the higher is the rate of perceived stress.,
Insomnia Severity Index
This subjective scale measures the insomnia severity over the past 2 weeks. The scale consists of 7 items on a 5-point Likert scale where 0 = no problem and 4 = very severe problem; the score ranges from 0 to 28 points. The interpretation is categorized as no insomnia (0–7), subthreshold (8–14), moderate (15–21), and severe (22–28).,
Compassion Fatigue-Short Scale
Compassion Fatigue-Short Scale consists of two parts, i.e., (1) a 5-item secondary item scale and (2) an 8-item job burnout scale. Each item is rated on a 10-point Likert scale which ranges from 1 (rarely/never) to 10 (very often).
- The World Health Organization has provided a workbook to take care of the mental health of the HCWs. The workbook provides the following:
- Management strategies for within oneself , deals with taking care of personal well-being by paying attention to mind and body. The strategies include:
- Avoid using your phone as an alarm clock rather opt for an old fashioned clock to avoid checking messages first thing in the morning and avoid information overload
- Try carrying out your activities of daily living without going through a newspaper or television news
- Engage in non-COVID-related conversations
- If you feel too overwhelmed with COVID-related information, pause and ask yourself. Is this information relevant in my practice, such as COVID-related statistics?
- If you feel you are on autopilot mode, pause for about 15 s and breathe in to try to focus on your 5 senses. For example, feel the floor under your feet, feel the chair you are sitting on, try to describe the taste of the food you are eating, look at colors on your screen mindfully, and pay attention to the sounds surrounding you.
Management strategies for between deals with relationships an individual has with others. These strategies encourage individuals to talk about their vulnerabilities in relationships they feel safe. Second, it encourages the individual to ask for help as and when required without a feeling of burden.,,The World Health Organization has provided resources and a framework to address the mental health concerns in HCWs.
This consists of psychological first aid which includes assessment of concerns and needs of HCWs, which functions on the “RAPID” model which stands for reflective listening, assessment, prioritization, intervention, and disposition.
Reflective listening includes empathetic listening of the experiences the individual had through active listening techniques which help in the determination of important aspects of the concern. Assessment techniques consisting of binary answers help in reaching a definite diagnosis. Prioritization arranges the needs of the individual according to the functional requirements which aid in devising treatment protocol. Intervention includes management strategies in addressing the concerns derived from the previous methods in the model. Disposition determines whether the individual has regained necessary functional capabilities. This step involves referral if needed.
- Strategies included in psychological first aid: These strategies are a combination of physical activities and behavior modifications.
- Physical activities and physiotherapy management strategies
- Pursed lip breathing: a slow deep inhalation for about 4 s with a hold of 2–3 s, followed by exhalation by pursing lips for about 6 s
- Stretching and yoga can be incorporated into the everyday routine and also between patients
- Progressive muscle relaxation is a two-step process where step 1 includes tensing all your muscles such as tightening your fists and curling your toes. After about 5 s, this is followed by step 2 where you relax the tense muscles with exhalation and feel the tension flowing out of the muscles. This can be audio-assisted
- Strategies for sensory grounding include shifting focus in things around such as taking a note of sounds around, focusing just on the soap and water while washing hands rather than drifting into thoughts, completing feeling the warmth of a cup while sipping a beverage, and focusing on the taste of water while drinking it. Sensory grounding involves “living in the present” rather than being in a continuous loop of disturbing thoughts.
Physiotherapy strategies are proven to be effective in treating physical symptoms associated with PTSD in military personnel. The most commonly occurring physical symptom with PTSD is chronic nonspecific pain which can be addressed by physiotherapy interventions such as mobilization, manipulation, and massage. In addition to this, cardiovascular endurance training and overall physical activity are proven to enhance mental health. Simpler physical activities such as taking the stairs instead of the elevator and also dancing in the living room can help. Moderate aerobic exercises such as stationary cycling or brisk walking are proven to be effective in the management of PTSD symptoms.Mindful eating and appropriate hydration.
Digital platforms, tele support through psychological telephone hotlines was made available in various countries.
In hospitals in China, implementation of scenario-based stimulation showed an increase in the personal strengths of HCWs.
Journaling: answering “how you feel by writing down the feelings in a journal on regular should be encouraged as this helps in getting in touch better touch with the emotional state should be encouraged.
Similarly, in the COVID unit of the University Hospital of Bari, the HCWs were provided with music therapy which included energy, breathing, and serenity playlist has shown to improve the mental health of HCWs.
The spread of COVID-19 pandemic has come up with unpredictable challenges. The mental health of HCWs is a challenge that often goes unnoticed. This article attempts to provide insights that shine a light on subtle clinical signs along with quick and easily applicable management strategies for this overlooked yet extremely sensitive concern.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abdulla EK, Velladath SU, Varghese A, Anju M. Depression and anxiety associated with COVID- 19 pandemic among healthcare professionals in India- A systematic review and meta-analysis. Clin Epidemiol Glob Health 2021;12:100888.
Manohar KN, Parashar N, Kumar CR, Verma V, Rao S,Sekar Y, et al
. Prevalence and severity of secondary traumatic stress and optimism in Indian health care professionals during COVID-19 lockdown. PLoS One 2021;16:e0257429.
Mei S, Liang L, Ren H, Hu Y, Qin Z, Cao R, et al
. Association between perceived stress and post-traumatic stress disorder among medical staff during the COVID-19 epidemic in Wuhan City. Front Public Health 2021;9:666460.
Ghio L, Patti S, Piccinini G, Modafferi C, Lusetti E, Mazzella M, et al
. Anxiety, depression and risk of post-traumatic stress disorder in health workers: The relationship with burnout during COVID-19 pandemic in Italy. Int J Environ Res Public Health 2021;18:9929.
Foa EB, Ehlers A, Clark DM, Tolin DF, Orsillo SM. The posttraumatic cognitions inventory (PTCI): Development and validation. Psychol Assess 1999;11:303-14.
Tomlin J, Dalgleish-Warburton B, Lamph G. Psychosocial support for healthcare workers during the COVID-19 pandemic. Front Psychol 2020;11:1960.
Lecic-Tosevski D, Vukovic O, Stepanovic J. Stress and personality. Psychiatriki 2011;22:290-7.
Liu S, Lithopoulos A, Zhang CQ, Garcia-Barrera MA, Rhodes RE. Personality and perceived stress during COVID-19 pandemic: Testing the mediating role of perceived threat and efficacy. Pers Individ Dif 2021;168:110351.
Song X, Fu W, Liu X, Luo Z, Wang R, Zhou N, et al
. Mental health status of medical staff in emergency departments during the coronavirus disease 2019 epidemic in China. Brain Behav Immun 2020;88:60-5.
Löwe B, Wahl I, Rose M, Spitzer C, Glaesmer H, Wingenfeld K, et al
. A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. J Affect Disord 2010;122:86-95.
Bruine de Bruin W. Age differences in COVID-19 risk perceptions and mental health: Evidence from a National U.S. Survey Conducted in March 2020. J Gerontol B Psychol Sci Soc Sci 2021;76:e24-9.
d'Ettorre G, Ceccarelli G, Santinelli L, Vassalini P, Innocenti GP, Alessandri F, et al
. Post-traumatic stress symptoms in healthcare workers dealing with the COVID-19 pandemic: A systematic review. Int J Environ Res Public Health 2021;18:E601.
Chew NW, Ngiam JN, Tan BY, Tham SM, Tan CY, Jing M, et al
. Asian-Pacific perspective on the psychological well-being of healthcare workers during the evolution of the COVID-19 pandemic. BJPsych Open 2020;6:e116.
Adriaenssens J, de Gucht V, Maes S. The impact of traumatic events on emergency room nurses: Findings from a questionnaire survey. Int J Nurs Stud 2012;49:1411-22.
Peters L, Slade T, Andrews G. A comparison of ICD10 and DSM-IV criteria for posttraumatic stress disorder. J Trauma Stress 1999;12:335-43.
Weathers FW, Litz BT, Herman DS, Husha JA, Keane TM. The PTSD checklist: Reliability, validity, and diagnostic utility. Int Soc Trauma Stress Stud 1993;2:90-2.
Metregiste D, Boucaud-Maitre D, Aubert L, Noubou L, Jehel L. Explanatory factors of post-traumatic distress and burnout among hospital staff 6 months after Hurricane Irma in Saint-Martin and Saint-Barthelemy. PLoS One 2020;15:e0229246.
Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav 1983;24:385-96.
Song Y, Yang F, Sznajder K, Yang X. Sleep quality as a mediator in the relationship between perceived stress and job burnout among Chinese nurses: A structural equation modeling analysis. Front Psychiatry 2020;11:566196.
Morin CM, Belleville G, Bélanger L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 2011;34:601-8.
Sagherian K, Steege LM, Cobb SJ, Cho H. Insomnia, fatigue and psychosocial well-being during COVID-19 pandemic: A cross-sectional survey of hospital nursing staff in the United States. J Clin Nurs 2020;Nov 20:10.1111/jocn.15566. doi: 10.1111/jocn.15566. Epub ahead of print. PMID: 33219569; PMCID: PMC7753687.
Sun B, Hu M, Yu S, Jiang Y, Lou B. Validation of the compassion Fatigue Short Scale among Chinese medical workers and firefighters: A cross-sectional study. BMJ Open 2016;6:e011279.
McCann CM, Beddoe E, McCormick K, Huggard P, Kedge S, Adamson C, et al.
Resilience in the health professions: A review of recent literature. Int J Wellbeing 2013;3:60-81.
Johnson SM. Attachment theory in practice: Emotionally focused therapy (EFT) with individuals, couples, and families. New York: Guildford Press; 2019.
Kisely S, Warren N, McMahon L, Dalais C, Henry I, Siskind D. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. BMJ 2020;369:m1642.
Shah K, Bedi S, Onyeaka H, Singh R, Chaudhari G. The role of psychological first aid to support public mental health in the COVID-19 pandemic. Cureus 2020;12:e8821.
Malik M, Peirce J, Wert MV, Wood C, Burhanullah H, Swartz K. Psychological first aid well-being support rounds for frontline healthcare workers during COVID-19. Front Psychiatry 2021;12:669009.
Gallegos AM, Crean HF, Pigeon WR, Heffner KL. Meditation and yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials. Clin Psychol Rev 2017;58:115-24.
Orr Robin M, Neanne B. Posttraumatic stress disorder management: A role for physiotherapists and physical training instructors. J Mil Veterans' Health 2012;20:37-42.
Hegberg NJ, Hayes JP, Hayes SM. Exercise intervention in PTSD: A narrative review and rationale for implementation. Front Psychiatry 2019;10:133.
Zaçe D, Hoxhaj I, Orfino A, Viteritti AM, Janiri L, Di Pietro ML. Interventions to address mental health issues in healthcare workers during infectious disease outbreaks: A systematic review. J Psychiatr Res 2021;136:319-33.
Cheng W, Zhang F, Liu Z, Zhang H, Lyu Y, Xu H, et al
. A psychological health support scheme for medical teams in COVID-19 outbreak and its effectiveness. Gen Psychiatr 2020;33:e100288.
Giordano F, Scarlata E, Baroni M, Gentile E, Puntillo F, Brienza N, et al
. Receptive music therapy to reduce stress and improve wellbeing in Italian clinical staff involved in COVID-19 pandemic: A preliminary study. Arts Psychother 2020;70:101688.