Group physiotherapy with survivors of torture in urban and camp settings in Jordan and Kenya
Keywords:group physiotherapy, interdisciplinary, refugee, pain, pelvic floor
Introduction: In this paper we report provisional field results on the impact of CVT’s (the Center for Victims of Torture) interdisciplinary group treatment on physiotherapy indicators in refugees living in urban and camp settings in Kenya and Jordan. The physiotherapy component of this model includes pain neuroscience education, sleep hygiene, posture and body mechanics instruction and healing of pain and trauma from a biopsychosocial perspective, in a program of ten weekly sessions. This program is supported by a clinical assessment that records a broad set of indicators of participant experience and functioning. In addition, some survivors report having pelvic floor dysfunction and data will be offered about a subset of survivors looking at prevalence of these issues.
Methods: Survivors are identified through referral systems, community education and sensitization campaigns, contacts and trainings with other NGOs and health care providers. Prospective survivors are screened into CVT services or referred to other agencies that can better meet their needs. CVT focuses its services on refugees with physical and emotional difficulties that may be effectively treated through its interdisciplinary treatment model and who have survived torture or related human rights violations. Following an informed consent process, survivors participate in a comprehensive individual assessment and then progress to the 10-week program. Wherever possible, follow-up assessments are conducted 2 weeks after the sessions end, and at 3, and 9 months following completion of the 10-week long intervention.
Results: On average, participants who completed 3-month follow-up assessments showed statistically and clinically significant improvements on physiotherapy indicators.
Discussion: Provisional results are encouraging and suggest that the model is adaptable to the needs of different populations and settings. As nearly all participants receive both counseling and physiotherapy, it is difficult to know which benefits can be attributed to physiotherapy alone.
Amris, K., Jones, L. E., & Williams, A. C. (2019). Pain from torture: Assessment and management. Pain Reports, 4(6), e794. https://doi.org/10.1097/PR9.0000000000000794
Andrews, N. E., Strong, J., Meredith, P. J., & D’Arrigo, R. G. (2014). Association between physical activity and sleep in adults with chronic pain: A momentary within person perspective. Physical Therapy, 94(4), 499-510.
Andersen, T. E., Ellegaard, H., Schiottz-Christensen, B., Mejldal, A., & Manniche, C. (2020). Somatic Experiencing ® for patients with low back pain and comorbid posttraumatic stress symptoms—a randomised controlled trial. European Journal of Traumatology, 11(1), https://doi.org/10.1080/20008198.2020.1797306
Baird, E., Williams, A. C., Hearn, L., & Amris, K. (2017) Interventions for treating persistent pain in survivors of torture. Cochrane Database Systems Review, 8(8), https://doi.org/10.1002/14651858.CD012051.pub2
Buczynski, R., van der Kolk, B., Ogden, P., Levine, P., & Lanius, R. (2018). Treating trauma master series: How to work with the limbic system to reverse the physiological imprint of trauma. NICABM, 5, 1-29.
Bunn, M., Goesel, C., Kinet, M., & Ray, F. (2015). Group treatment for survivors of torture and severe violence: A literature review. Torture 26(1), 45-67. https://doi.org/10.7146/torture.v27i1.108062
Crosby, S. S. (2013). Primary care management of non-English speaking refugees who have experienced trauma: A clinical review. Journal of the American Medical Association, 310(5), 519-528.
de Ruiter, M., Gamble, A., Gueron, L. P., Kibet, J. J., & O’Reilly, C. (2018). Physiotherapy with survivors of torture and trauma. In M. Probst & L.H. Skjaerven (Eds.) Physiotherapy in mental health and psychiatry: A scientific and clinical based approach (pp. 206-225). Edinburgh: Elsevier.
Dibaj, I., Halvorsen, J. O., Kennair, L. E.O., & Stenmark, H. I. (2017). An evaluation of combined narrative exposure therapy and physiotherapy for comorbid PTSD and chronic pain in torture survivors. Torture, 27(1), 13-27. https://doi.org/10.7146/torture.v27i1.26534
Gard, G., & Gyllensten, A. L. (2018). Musculoskeletal pain: Evidence and critical factors in rehabilitation relevant for physiotherapy in mental health. In M. Probst & L.H. Skjaerven (Eds.) Physiotherapy in mental health and psychiatry: A scientific and clinical based approach (pp. 134-140). Edinburgh: Elsevier
Harlacher, U., Nordin, L., & Polatin, P. (2016). Torture survivors’ symptom load compared to chronic pain and psychiatric in-patients. Torture, 26(2), 74-84.
Harlacher, U., Polatin, P., Taing, S., Phana, P., Sok., P., & Sothera, C. (2019). Education as a treatment for chronic pain in survivors of trauma in Cambodia: Results of a randomized controlled outcome trial. International Journal of Conflict and Violence, 13, 1-26. doi: 10.4119/ijcv-3124
Herman, Judith. (1992). Trauma and Recovery: The Aftermath of Violence-From Domestic Abuse to Political Terror. New York, NY: Basic Books.
Jones, F., & Kulnik, S. T. (2018). Self-management. In S. Lennon, G. Ramdharry, & G. Verheyden (Eds.), Physical management for neurological conditions, 3rd ed., (pp. 379–396). Edinburgh: Elsevier Churchill Livingstone
Kaur, G., Weinberg, R., Milewski, A. R., Huynh, S., Mauer, E., Hemmings Jr., H. C., & Pryor, K. O. (2020). Chronic pain diagnosis in refugee torture survivors: A prospective, blinded diagnostic accuracy study. Journal of Physical Medicine and Rehabilitation. 17(6), e1003108. https://doi.org/10.1371/journal.pmed.1003108
Knapen, J., Morien, Y., & Marchal, Y. (2018). Physiotherapy for patients with depression. In M. Probst & L.H. Skjaerven (Eds.) Physiotherapy in mental health and psychiatry: A scientific and clinical based approach (pp. 253-257). Edinburgh: Elsevier
Louw, A., Puentedura, E.L., Diener, I., Zimney, K., & Cox, T. (2019). Pain neuroscience education: Which pain neuroscience education metaphor worked best? South African Journal of Physiotherapy, 75(1). https://doi.org/10.4102/sajp.v75i1.1329,
Louw, A., Zimney, K., Puentedura, E. J., & Diener, I. (2016). The efficacy of therapeutic neuroscience education on musculoskeletal pain: A systemic review of the literature. Physiotherapy Theory and Practice, 32(5), 332-355. https://doi.org/10.1080/09593985.2016.1194646
Nielsen, H. F. (2014). Interventions for physiotherapists working with torture survivors, with special focus on traumatic pain, PTSD, sleep issues. Dignity Publication Series on Torture and Organized Violence—Praxis Paper, No. 6, 1-82. Copenhagen, Denmark.
Nordbrandt, M. S., Sonne, C., Mortensen, E. L., & Carlsson, J. (2020). Trauma-affected refugees treated with basic body awareness therapy or mixed physical activity as augmentation to treatment as usual—A pragmatic randomised controlled trial. PLos One, 15(3), e0230300. https://doi.org/10.1371/journal.pone.0230300
Nordin, l., & Perrin, S. (2019). Pain and posttraumatic stress disorder in refugees who survived torture: The role of pain catastrophizing and trauma-related beliefs. European Journal of Pain, 23, 1497-1506. https://doi.org/10.1002/ejp.1415
O’Keeffe, M., Hayes, A., McCreesh, K., Purtill, H., & O’Sullivan, K. (2017). Are group-based and individual physiotherapy exercise programmes equally effective for musculoskeletal conditions? A systematic review and meta-analaysis. British Journal of Sports Medicine, 51(2), 126-132. https://doi.org/10.1136/bjsports-2015-095410
Olsen, D., Montgomery, E., Carlsson, J., & Foldspang, S. (2007). Prevalence of pain in the head, back and feet in refugees previously exposed to torture: A ten year follow up study. Disability and Rehabilitation, 29(2), 163-171. https://doi.org/10.1080/09638280600747645
O’Sullivan, V. (2015). Releasing the pain: Physiotherapy with victims of torture and trauma. Refugee Transitions, Publications of STARTTS (NSW Service for the treatment and rehabilitation of torture and trauma survivors), 30, 31-37.
Persson, A. L., Veenhuizen, H., Zachrison, L., & Gard, G. (2008). Relaxation as treatment for chronic musculoskeletal pain: A systematic review of randomised controlled studies. Physical Therapy Reviews, 13(5), 355-365. https://doi.org/10.1179/174348808X356366
Price, C. J., & Hooven, C. (2018). Interoceptive awareness skills for emotional regulation: Theory and approach of mindful awareness in Body-Oriented Therapy (MABT). Frontiers in Psychology, 9(798), published online 2018 May 28. https://doi.org/10.3389/fpsyg.2018.00798
Prip, K., Persson, A. L., & Sjolund, B. H. (2011). Self-reported activity in tortured refugees with long-term sequelae including pain and the impact of foot pain from falanga: A cross-sectional study. Disability and Rehabilitation, 33(7), 569-578. https://doi.org/10.3109/09638288.2010.493597
Probst, M., Van Damme, T., & Vancampfort, D. (2018). Psychomotor therapy or physiotherapy in mental health for patients with psychiatric problems. In M. Probst & L.H. Skjaerven (Eds.) Physiotherapy in mental health and psychiatry: A scientific and clinical based approach (pp. 69-73). Edinburgh: Elsevier
Rosenberg, T. Y. (2007). Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: A literature review. The Journal of Sexual Medicine, 41(1),3-13. https://doi.org/10.1111/j.1743-6109.2006.00393.x
Rossettini, G., Camerone, E. M., Carlino, E., Benedetti, F., & Testa, M. (2020). Context matters: The psychoneurobiological determinants of placebo, nocebo and context-related effects in physiotherapy. Archives of Physiotherapy, 10(11). https://doi.org/10.1186/s40945-020-0082-y
Salen, B.A., Spangfort, E.V., Nygren, A.L., & Nordemer, R. (1984). The Disability Rating Index: An instrument for the assessment of disability in clinical settings. Journal of Clinical Epidemiology, 47(12), 1423-1435. https://doi.org/10.1016/0895-4356(94)90086-8
Sallinen, M. (2018). Physiotherapy interventions in individuals with chronic widespread pain or chronic fatigue syndrome. In M. Probst & L.H. Skjaerven (Eds.) Physiotherapy in mental health and psychiatry: A scientific and clinical based approach (pp. 167-173). Edinburgh: Elsevier
Sandahl, H., Jennum, P., Baandrup., L., Poschmann, I.S., & Carlsson, J. (2017). Treatment of sleep disturbances in trauma-affected refugees: Study protocol for a randomised controlled trial. Trials, 18(1):520. https://doi.org/10.1186/s13063-017-2260-5
Saragiotto, B. T., de Almeida, M. O., Yahato, T. P., & Maher, C. G. (2016). Multidisciplinary biopsychosocial rehabilitation for nonspecific chronic low back pain. Physical Therapy, 96(6), 759-763. https://doi.org/10.2522/ptj.20150359
Siengsukon, C. F., Al-dughmi, M., & Stevens, S. (2017). Sleep health promotion: Practical information for physical therapists. Physical Therapy, 97(8), 826-836. https://doi.org/10.1093/ptj/pzx057
Skjaerven, L.H., Parker, A.R., & Mattsson, M. (2018). Group therapeutic factors for use in physiotherapy in mental health: A core in group physiotherapy. In M. Probst & L.H. Skjaerven (Eds): Physiotherapy in mental health and psychiatry: A scientific and clinical based approach, [pp. 92-96). Edinburgh: Elsevier.
Stammel, N., Knaevelsrud, C., Schock, K., Walther, L.C. S., Wenk-Ansohm, M. P., & Bottche, M. (2017). Multidisciplinary treatment for traumatized refugees in a naturalistic setting: Symptom courses and predictors. European Journal of Psychotraumatology. 8(2), 1-13. https://doi.org/10.1080/20008198.2017.1377552
Tsur, N., Defrin, R., Shahar, G., & Solomon, Z. (2020). Dysfunctional pain perception and modulation among torture survivors: The role of pain personification. Journal of Affective Disorders, 15(265). 10-17. https://doi.org/10.1016/j.jad.2020.01.031
United Nations Convention Against Torture, article 27(1), 1984, New York, NY.
UN General Assembly, Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 10 December 1984, United Nations, Treaty Series, vol. 1465, p. 85
UNICEF, Statistics and Monitoring Section (2013). Female genital mutilation/Cutting: A statistical overview and exploration of the dynamics of changes. New York, New York.
Van Damme, T. (2018). Relaxation therapy. In M. Probst & L.H. Skjaerven (Eds.) Physiotherapy in mental health and psychiatry: A scientific and clinical based approach (pp. 80-85): Edinburgh: Elsevier
Vancampfort, D., & Stubbs, B. (2018). Improving adherence to physiotherapy in mental health settings: The need for autonomy, competence and social relatedness. In M. Probst & L.H. Skjaerven (Eds.) Physiotherapy in mental health and psychiatry: A scientific and clinical based approach (pp. 32-35). Edinburgh: Elsevier
Walker, J., & Shepherd, W. (2001). Anxiety disorders: A nation-wide survey of treatment approaches used by physiotherapists. Physiotherapy, 87(10), 536-548. https://doi.org/10.1016/S0031-9406(05)65452-1
Wang, S., Bytyci, A., Izeti, S., Kallaba, M., Rushiti, R., Montgomery, E., & Modvig, J. (2016). A novel bio-psycho-social approach for rehabilitation of traumatized victims of torture and war in the post-conflict context: A pilot randomized controlled trial in Kosovo. Conflict and Health, 10(34). https://doi.org/10.1186/s13031-016-0100-y
Williams, A. C., & Baird, E. (2016). Special considerations for the treatment of pain from torture and war. Current Anesthesiology Reports, 6(4). 319-326. https://doi.org/10.1007/s40140-016-0187-0
Wood, L., & Hendrick, P. A. (2019). A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: Short- and long-term outcomes of pain and disability. European Journal of Pain, 23(2), 234-249. https://doi.org/10.1002/ejp.1314
How to Cite
We accept that some authors (e.g. government employees in some countries) are unable to transfer copyright. The Creative Commons Licence Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) covers both the Torture Journal and the IRCT web site. The publisher will not put any limitation on the personal freedom of the author to use material contained in the paper in other works which may be published, provided that acknowledgement is made to the original place of publication.