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Chronic Pain as a Consequence of Torture: Management

When treating torture survivors, pain and its consequences need to be addressed.

Torture is associated with a wide range of health-related consequences, among which persistent pain and pain-related disability are defining features [4,8,11]. When treating torture survivors, pain and its consequences need to be addressed.

Therefore, it is essential that health professionals engaged in the care of torture survivors are familiar with the physiology of pain mechanisms, with biopsychosocial models of pain, and with best evidence-based practice in managing pain, acute as well as persistent.

Persistent pain not only causes disability and restricted functioning, but also produces psychological impairments, compounding the impact on overall personal and social functioning. Yet the research literature on the rehabilitation of torture survivors predominantly targets mental health problems without reference to pain in its own right or as a significant cause of distress and disability [9,15]. 

Treating torture survivors requires the same intervention methods as for other pain states. It is very important that health professionals educate themselves on different torture methods and their physical consequences. Reviews of rehabilitation literature note a lack of scientifically rigorous studies of multicomponent interventions for torture survivors [6,10]. Few studies evaluate outcomes of pain management, and the quality of evidence is low [2,5], so these provide little guidance. Treatment recommendations are that good clinical practice is applied sensitively to patients who may be seriously traumatized [1,2]. 

A broader concern is that pain is not recognized, assessed, and managed as a problem in its own right. Left unaddressed, persistent pain may undermine attempts to treat other common problems, such as distress and sleep disturbance, and hinder acquisition of essential self-management skills. It is important that best practice from pain management in general is extended to torture survivors, and that pain is not mistakenly assumed to be a symptom of post-traumatic stress, neglecting pain treatment [1]. For instance, it is of uttermost importance that neuropathic pain that can occur after suspension by the arms or after falaka is properly assessed and medically treated.

Pain rehabilitation in a biopsychosocial model is concerned with limited functioning and disability associated with pain, and the complex interaction with personal and environmental factors – factors that may influence the experience of and response to pain [14]. 

It should be recognized that torture survivors may have considerable psychological and social problems in addition to pain and other health concerns, complicating presentation, assessment, and treatment: uncertainty about civil status; unstable accommodation; isolation from family, friends, culture; and usual means of support and access to work [3,13]. 

As is recommended for chronic pain in general, an interdisciplinary, multimodal approach to pain management in survivors of torture is optimal, with a focus on agreed goals of improved understanding, function, and participation. Rehabilitation can be a mixture of individual sessions in combination with psychoeducation in-group, with or without an interpreter.

To promote self-management and a return to desired activities and lifestyle, pain management for survivors of torture should integrate education about the nature of persistent pain, psychological interventions targeting cognitive and behavioral aspects of adaptation to pain, physical therapy to enhance overall physical functioning, reduction of musculoskeletal impairment caused by the torture, and pharmacological pain treatment.

It can be difficult for torture survivors to accept the permanence of pain from their torture, to abandon hopes of complete relief, and to accept that pain reduction and improvement in activity and societal level functioning are more realistic goals, implying consideration of physical, practical and psychological skills development. Survivors’ expectations must therefore be addressed at the outset of rehabilitation. Explanation of mechanisms of persistent pain without damage is important and enables reframing of pessimistic beliefs about the possibility of improved function, and discussion of changes in behavior to promote rehabilitation. It is very important for all survivors of torture to understand the interaction of pain and psychological problems [7].

There are no systematic studies of pharmacological treatment for chronic post-torture pain to suggest variation from best practice. As in other chronic pain conditions, pharmacological pain treatment should be based on thorough pain assessment and identification of underlying pain mechanisms. Adherence to medical treatment is often low and accurate information, especially about side effects, is therefore essential. Neuropathic pain should be treated, as mentioned earlier.

The benefit of interdisciplinary pain management should be evaluated, not just by pain relief, but should aim to improve health-related quality of life, including activity and societal level functioning [12]. These should be in addition to, not instead of, outcomes identified by torture survivors themselves.

REFERENCES 

[1] Amris K, Williams A. Pain Clinical Update: Chronic pain in survivors of torture. IASP Press, 2007.

[2] Baird E, Williams ACC, Hearn L, Amris K. Interventions for treating persistent pain in survivors of torture. Cochrane Database Syst Rev 2017;8:CD012051.

[3] Berliner P, Mikkelsen E, Bovbjerg A, Wiking M. Psychotherapy treatment of torture survivors. Journal of Psychosocial Rehabilitation 2004;8:85-96.

[4] Burnett A, Peel M. Asylum seekers and refugees in Britain. The health of survivors of torture and organised violence. BMJ 2001;322:606-609.

[5] Jansen G, Nordemar R, Larsson L, Blyhammar C. Pain rehabilitation for torture survivors. European Journal of Pain Supplements 2011;5:284.

[6] Jaranson J, Quiroga J. Evaluating the series of torture rehabilitation programmes: history and recommendations. Torture 2011;21:98-140.

[7] Morasco BJ, Lovejoy TI, Lu M, Turk DC, Lewis L, Dobscha SK. The relationship between PTSD and chronic pain: mediating role of coping strategies and depression. Pain 2013;154:609-616.

[8] Olsen D, Montgomery E, Carlsson J, Foldspang S. Prevalent pain and pain level among torture survivors. Dan Med Bull 2006;53:210-214.

[9] Patel N, Kellezi B, Williams AC. Psychological, social and welfare interventions for psychological health and well-being of torture survivors. Cochrane Database Syst Rev 2014;CD009317.

[10] Quiroga J, Jarason J. Politically-motivated torture and its survivors: a desk study of the literature. Torture 2005;16.

[11] Rasmussen O. Medical aspects of torture. Dan Med Bull 1990;37:1-88.

[12] Taylor AM, Phillips K, Patel KV, Turk DC, Dworkin RH, Beaton D, Clauw DJ, Gignac MA, Markman JD, Williams DA, Bujanover S, Burke LB, Carr DB, Choy EH, Conaghan PG, Cowan P, Farrar JT, Freeman R, Gewandter J, Gilron I, Goli V, Gover TD, Haddox JD, Kerns RD, Kopecky EA, Lee DA, Malamut R, Mease P, Rappaport BA, Simon LS, Singh JA, Smith SM, Strand V, Tugwell P, Vanhove GF, Veasley C, Walco GA, Wasan AD, Witter J. Assessment of physical function and participation in chronic pain clinical trials: IMMPACT/OMERACT recommendations. Pain 2016;157:1836-1850.

[13] Teodorescu DS, Heir T, Siqveland J, Hauff E, Wentzel-Larsen T, Lien L. Chronic pain in multi-traumatized outpatients with a refugee background resettled in Norway: a cross-sectional study. BMC Psychol 2015;3:7.

[14] Turk DC, Okifuji A. Psychological factors in chronic pain: evolution and revolution. J Consult Clin Psychol 2002;70:678-690.

[15] Williams ACC, Amris K. Treatment of persistent pain from torture: review and commentary. Med Confl Surviv 2017;33:60-81.

AUTHORS

Kirstine Amris, MD
The Parker Institute
Frederiksberg Hospita
Copenhagen, Denmark

Gunilla Brodda Jansen, MD
Department of Clinical Sciences
Karolinska Instituet
Stockholm, Sweden

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