Evidence Based Assessment of Pain in Displaced Persons

Original Editor - Zafer Altunbezel

Top Contributors - Ewa Jaraczewska, Naomi O'Reilly, Jess Bell, Kim Jackson, Wanda van Niekerk, Tarina van der Stockt and Nupur Smit Shah  

Introduction

Prolonged conflicts, forced displacement and mass migration are major issues in the 21st century. In 2021, at least 89.3 million people worldwide have been forced to flee their homes due to conflict, violence, fear of persecution and human rights violations. In this group, nearly 27.1 million were refugees - around half of these individuals were aged under 18. Whether in a camp for displaced persons next to an active conflict zone or a safe third country, the multiple and complex health problems of displaced persons are becoming a big challenge for healthcare workers. 

Regardless of type and severity, trauma can potentially impact an individual's biological, psychological and social well-being. Traumatised displaced persons often report significant levels of chronic pain , as well as symptoms of Post Traumatic Stress Disorder (PTSD). Studies indicate a high prevalence of persistent pain in torture survivors, with an overall incidence of up to 83%.

The clinical picture of chronic pain syndrome may include headaches, neck, back and extremity pain, and regional or widespread pain. Psychological disorders and other co-morbidities may interact with persistent pain. Therefore, in some cases, chronic pain may be a very complex condition for clinicians to manage due to its multifactorial nature. To ensure proper assessment and treatment of chronic pain in displaced persons, we need to understand these individuals' traumatic experiences and their consequences on different determinants of health.

Chronic Pain Contributing Factors

Displaced persons are frequently exposed to different types of traumatic events, both in their country of origin and on the migration routes. These experiences are often repetitive and continuous as they occur in second or third countries, and they may lead to the development of pain and other health problems.

Multiple traumatic experiences can have complex and interacting biological, psychological and social impacts on a displaced person's well-being. Due to its complexity and multifactorial nature, it can be difficult for clinicians to help address chronic pain in displaced persons. It always requires the involvement of different clinical disciplines. Adequate knowledge about common experiences of displaced persons is required for a clinician to complete an assessment of pain and rule out serious medical conditions that can risk both the patient’s and clinician’s safety. Common traumatic experiences of displaced persons include but are not exclusive to: war and conflict; torture and ill-treatment; imprisonment; precarious living conditions.

War and Conflict

Wars and conflicts are causing the displacement of millions of people each year. Armed assaults, aerial attacks, improvised explosive devices, landmines or chemical weapons typically target civilians. Many people sustain injuries such as gunshot wounds, burns, amputations and complex trauma. Various mental health disorders such as PTSD, depression and sleeping problems may occur after being exposed to or witnessing these traumatic events. Moreover, disruption of the health system and other infrastructure may cause deprivation of health care and basic needs. All these factors create an environment for developing chronic pain and other health issues. 

Torture and Ill-Treatment

Despite international efforts, torture is still being used worldwide, especially in war zones and countries with political oppression. Individuals can be randomly or deliberately detained, kidnapped and tortured for interrogations to spread terror or demand ransom. Displaced persons can also be exposed to torture and violence on their migration route by smugglers or armed actors. Common methods of torture include physical torture and psychological or sexual violence. Blunt violence, suspension, electrocution, and forced physical positions are examples of torture. Threats, humiliation, and mock execution are common methods of psychological violence. Sexual violence is often used against people regardless of age or gender. Torture has severe physical and psychological consequences, but despite its severity, its impact may be invisible to others due to the individual's feelings of shame, insecurity or stigmatisation.

Imprisonment

Illegal imprisonment and detention based on ethnic, political or religious grounds are often seen in countries experiencing conflict and political instability. Individuals may be given long-term prison sentences, potentially exceeding decades, without a fair trial. In prison, individuals may be exposed to torture, ill-treatment, and unhealthy conditions. Extremely crowded cells, lack of hygiene, deprivation of daylight, clean food and water, inaccessibility of health care, the psychological impact of captivity, and witnessing ill-treatment in prison all affect detainees' physical and psychological well-being. Poor prison conditions may also lead to the spread of communicable diseases, the worsening of existing non-communicable chronic diseases, a general decrease in physical health, and psychological disorders.

Precarious Living Conditions

The disruption of infrastructure, forced displacement and inhumane conditions in camps and host countries create precarious living conditions for displaced persons. The absence of health care, psychosocial services and basic fundamental needs can cause a gradual decline in an individual’s health status. In some host countries where resources for social support are insufficient, displaced persons are often exposed to labour exploitation while struggling to earn a livelihood. In addition to their traumatic experiences, secondary injuries can develop while working long hours in heavy labour jobs and being exposed to frequent job accidents. Failure to establish basic stability in daily life may increase the severity of existing health problems and hinder physical and mental healing. 

Figure.1 Traumatic Experience of Displaced Persons

Consequences of Trauma on Health

Traumatic experiences have complex and interacting consequences on the health of displaced persons. Physical and psychosocial trauma and communicable and non-communicable diseases may increase the risk of early death, cause disability, decreased quality of life and chronic pain. Being aware of these scenarios helps clinicians to detect red flags, make a thorough assessment and identify the main problems to be addressed. 

Physical Consequences

Various traumatic orthopaedic and neurological injuries may be seen in people who have experienced displacement. Some traumatic injuries, such as pelvic trauma, amputations, spinal cord injury and traumatic brain injury, require clinicians to have specialist training. 

Table.1 Physical Consequences of Trauma on Displaced Persons Health

Physical Consequences
Fractures
Soft Tissue Injury
Arthritis and Arthrosis
Deformity
Burns
Gunshot Wounds
Spinal Cord Injury
Peripheral Nerve Injury
Traumatic Brain Injury
Concussion
Pelvic and Genital Trauma

Psychosocial Consequences

Inadequate/insensitive attitudes or approaches to individuals with traumatic psychological conditions may cause re-traumatisation. Some mental health disorders, such as PTSD and sleep disturbances, interact with chronic pain and hinder treatment. Social issues commonly experienced by displaced persons can negatively impact their participation and commitment to the rehabilitation process.

Table.2 Psychosocial Consequences of Trauma on Refugee Health.

Psychosocial Consequences
PTSD
Depression
Anxiety
Sleeping Disorders
Somatic Disorders
Psychotic Disorders
Livelihood Issues
Nutrition Issues
Access to Health
Stigmatisation
Discrimination

Communicable and Non-Communicable Diseases

Rehabilitation professionals working with displaced persons must have some knowledge of communicable and non-communicable diseases in their patient population. Detecting any clinical red flags and ensuring proper referral is important for patients and clinicians’ safety.

Table.3 Communicable and Non-Communicable Diseases.

Communicable and Non-Communicable Diseases
HIV
Tuberculosis
Cardiovascular Disease
Respiratory Diseases
Gastrointestinal Disease
Urinary and Gynaecological Disease
Neurological Disease
Rheumatological Disease
Metabolic Disease
Endocrinological Disease

In summary, traumatic experiences of displaced persons often have biological, psychological and social consequences. Multiple, complex health problems may exist simultaneously, and these problems are mostly detected in the chronic phase. External resources such as the involvement of multiple disciplines, imaging and medical interventions, as well as internal resources such as trust relationship, resilience and commitment of the individual, are often needed during the treatment phase.

Modern Pain Theories and Health for Displaced Persons

Rehabilitation professions have witnessed great improvements in pain sciences in recent years. Clinicians have started to adopt the bio-psycho-social approach and novel techniques in treating chronic pain. Rehabilitation for displaced persons is often provided within a brief and limited time with minimal resources. Integrating some modern concepts of the multidimensional nature of pain into the clinical reasoning process can enhance overall success in rehabilitation. It includes:

• Peripheral sensitisation
• Abnormal impulse-generating sites
• Central sensitisation
• Autonomic and immune system contributions
• Psychosocial factors

Peripheral Sensitisation

The International Association for the Study of Pain (IASP) defines peripheral sensitisation as “increased responsiveness and reduced threshold of nociceptors to stimulation of their receptive fields". It is also called primary hyperalgesia. Following an injury, peripheral sensitivity protects the injured site from further damage. Inflammatory chemicals released from the injury sites, the nerves themselves and immune system cells play an active role in peripheral sensitivity. As nociception or inflammation persists, up-regulation of existing and new ion channels in the nerve occurs. 

Being a useful and protective physiological response initially, peripheral sensitisation may eventually lead to central sensitisation. Therefore, detecting and managing peripheral sensitisation is important to prevent negative outcomes.

Abnormal Impulse Generating Sites

Abnormal Impulse Generating Sites (AIGS) are the damaged sites along the nerve in which ion channels' number, kind and excitability are altered. When injured, a segment of a peripheral nerve may develop the ability to generate its own impulses repeatedly. Spontaneous activity and mechano-sensitivity are the main features of an AIGS. An AIGS fires antidromically and orthodromically, resulting in constant noxious stimulus into the central nervous system and neurogenic inflammation in the tissues. 

AIGS can develop anywhere along the nerve where nerve tissue is compromised, including the dorsal root ganglion. Traumatic experiences of displaced persons such as explosions, gunshot wounds, burns or different methods of torture may cause excessive compression, traction or direct injury of the nerve and surrounding connective tissue, thus leading to the development of AIGS.  

Central Sensitisation

Central sensitisation corresponds to an enhancement in the functional status of neurons and circuits in nociceptive pathways throughout the neuraxis. This is caused by increased membrane excitability, synaptic efficacy, or reduced inhibition. 

Central sensitisation is characterised by allodynia, hyperalgesia, expansion of the receptive field and unusually prolonged pain after removing the stimulus. Several explanations have been proposed to explain the development of central sensitisation. They include:

• dysregulation in both ascending and descending central nervous system pathways due to physical trauma and sustained pain impulses
• chronic release of pro-inflammatory cytokines by the immune system due to physical trauma or viral infection 
• psychiatric disorders, including anxiety, panic and depression.

Due to the interaction between psychosocial factors and biological mechanisms, it has been recommended that central sensitisation be viewed within a bio-psycho-social model. 

Given the chronicity and complexity of the pain experience of many displaced persons, central sensitisation is one of the important factors likely to be involved in the clinical picture. Overlooking the presence of central sensitisation may lead to false assumptions about the patient, such as psychosomatic pain or secondary benefit, as well as failure in treatment.

Autonomic and Immune System Contributions

Stress neurobiology has only recently been associated with the neurobiology of pain. The endocrine, immune, motor and autonomic systems are central protective systems. While they can protect and heal, they can also damage, especially in maintained stress and pain states.

Cortisol

Cortisol, one of the critical hormones for homeostasis, is secreted from the adrenal cortex by the triggering effect of the Hypothalamus-Pituitary-Adrenal Axis (HPA). In an emergency, cortisol shuts down activities not needed for survival and enhances those that are. Hence the inflammatory and immune systems, digestive and reproductive systems are shut down. A chronic excess of cortisol, as in chronic pain or stress, poses problems. The features include immuno-suppression, osteoporosis, cardiovascular disease, depression and insulin resistance. Clinicians managing patients with chronic pain may note more subtle cases of tissue degeneration, mood swings, slow tissue healing, and susceptibility to infection.    

Adrenaline and Noradrenaline    

Mental and physical effects and psychosocial conditions evoke adrenaline and noradrenaline secretions. They stimulate a sympathetic response to prepare the organism for action. Adrenaline and noradrenaline are useful secretions for emergency situations, but like cortisol, maintained high levels lead to the risk of cardiovascular disease and tissue damage. The sympathetic nervous system can contribute to the sensitivity of inflamed tissues, and it can also contribute to the sensitivity of damaged nerves. Noradrenaline pathways in the brain are also closely linked to negative emotional states.

Cytokines

Cytokines are proteins secreted by the immune system in response to physical and emotional stressors that can modulate inflammation and pain. Some cytokines, such as Interleukin-1, Interleukin-2 and Tumor Necrosis Factor Alfa, are pro-inflammatory. Other cytokines such as Interleukin-4, Interleukin-10 and Interleukin-13 are anti-inflammatory. The immune system is closely linked to the peripheral and central nervous systems. Thus, any stressor that impacts the nervous system can also change immunity. 

Displaced persons are often exposed to repetitive physical and mental stressors. Given their long-term exposure to stress and pain, dysfunctional physiological changes in stress response systems will likely be present. This can be the main driving mechanism behind multiple physical problems and chronic pain. Therefore, the physiological effects of stress should be evaluated. 

Psychosocial Factors 

When using the bio-psycho-social approach, the impact of trauma on mental health and social domains cannot be overlooked. Variables such as attitudes, beliefs, mood state, social factors and work appear to interact with pain behaviour and are cumulatively referred to as psychosocial factors.

A comprehensive assessment of pain in trauma survivors should always include evaluating psychosocial factors. It can be the main driving factor behind the persistence of pain. Studies have found that increased PTSD symptoms are related to increased pain levels, pain disability and widespread pain. 40-50% of chronic pain patients experience depression and pain, may lead to decreased physical activity and insufficient participation in treatment. Chronic pain can interfere with sleep. Sleep disturbance may impair pain-inhibitor function, as well as tissue healing. Unhelpful cognitive processes and behaviours about the pain, such as catastrophising, fear of pain or movement, filtering, polarised thinking, and passive coping strategies, may frequently contribute to the pain experience. Finally, social factors such as access to fundamental needs, stigmatisation, lack of social support, legal status, financial concerns and work issues may impact the pain experience. 

Assessment Using the Pain and Disability Drivers Model

Given the long-term and repetitive traumatic experiences and the multifactorial nature of pain in traumatised displaced persons, the Pain and Disability Drivers Model (PDDM) may provide an effective framework for clinicians assessing pain. The PDDM was originally developed to manage low back pain, but it can be applied to other forms of chronic pain. 

Fig.2 Pain and Disability Driver Model

The PDDM describes five main domains contributing to pain and disability. There are also key assessment elements and findings under each domain. Different domains interact with each other in a bi-directional concept, meaning that a change in one of the domains can have positive or negative effects on other domains. To understand the whole picture of pain and disability, the key elements and findings should be identified and mapping of all the elements should be completed. Understanding each contributing domain's weight will help clinicians direct their interventions to the most needed factors.   

Nociceptive Pain Drivers 

Nociceptive pain is “pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors”. Nociceptive input is the most frequent initiating factor of many chronic pain conditions. Thus, it should be targeted initially if its presence is detected. 

Domestic events, explosions, blunt trauma, torture and other traumatic experiences may result in different orthopaedic injuries and are associated with significant nociceptive input. While chronic pain is common in traumatised displaced persons, it is important to remember that nociceptive input may be ongoing due to re-traumatisation, absence of treatment, improper healing, general immobility or unhelpful behaviours. 

Key Assessment Elements and Findings

• Symptom modulation (pain triggered by a specific movement pattern)
• Movement control (pain triggered by functional stability deficits)
• Mobility and pain (pain caused by increased or decreased mobility)
• Nonspecific de-conditioning (pain caused by general deconditioning)
• Structural stability deficits (pain caused by actual structure damage, e.g. joint dislocations, ligament ruptures)

A thorough physical examination should include the following:

• inspection
• palpation
• functional tests.

A thorough assessment reveals the key findings and shifts the focus of treatment towards local tissue-based treatments. 

Nervous System Dysfunctions Drivers

Displaced persons frequently experience multiple physical traumas, and their consequences are often neglected in the long term. Thus, examining for the presence of any nervous system dysfunction is essential. Pain of a nociceptive origin and nervous system dysfunction have important differences in their underlying mechanisms and treatment options. 

Key Assessment Elements and Findings

• Radicular pain pattern
• Signs of radiculopathy
• Signs of myelopathy
• Hyperalgesia
• Allodynia
• Central sensitisation 

Suppose the patient's history of clinical signs (paresthesia, dysesthesia, hyperalgesia) suggests the presence of neuropathic pain. In that case, the following measurement tools can be used to either rule it in or out:

• Douleur Neuropathique 4 Questions (DN4)
• Leeds Assessment of Neuropathic Symptoms and Signs (LANNS)
• Neuropathic Pain Questionnaire
• painDETECT

Aside from neuropathic pain, central sensitisation might be an important factor in the persistence of pain. Clinical signs such as general fatigue, mechano-sensitivity, allodynia, widespread pain or incompatible presentation with actual physical status should raise concerns about central sensitisation. The following tools can be used for the assessment of central sensitivity. 

• Central Sensitisation Inventory (CSI) 
• Fatigue Severity Scale

Comorbidity Drivers

Co-morbidity is the presence of one or more additional conditions often co-occurring with a primary condition. Traumatic experiences and precarious living conditions in war zones, prisons, and displaced persons settlements can lead to increases in communicable and non-communicable diseases, as well as mental health disorders. 

Since long-term lack of access to healthcare is a common experience for displaced persons, the pain assessment should include screening for co-morbidities. A thorough medical examination may not have happened before a displaced person accessed rehabilitation services, so it is important to remember that life-threatening conditions, red flags and hidden factors contributing to the persistent pain may be present.

Key Assessment Elements and Findings 

• Presence of communicable and non-communicable diseases.
• Visceral damage due to physical trauma and suspicion of referred visceral pain
• Any medical condition compromising tissue healing (for example Diabetes)
• Sleep disorders 
• Mental health conditions (for example PTSD, depression)

The Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI) are the two best-known indices for patient risk adjustment and outcome prediction.

Persistent pain has a well-proven impact on sleep. The relationship between pain and sleep disturbance is bidirectional; disturbed sleep affects pain perception by lowering the pain threshold. Lack of sleep hygiene also negatively affects tissue healing and mental health. The following outcome measure can be used to assess the quality of sleep in patients with chronic pain:

• Pittsburgh Sleep Quality Index (PSQI)

Cognitive-Emotional Drivers

It has been shown that thought processes are powerful enough to maintain a pain state. Unhelpful cognitions about pain contribute to the persistence of pain and increase the level of pain-related disability. 

Displaced person populations who are deliberately traumatised and left helpless for a long time are at risk of developing negative cognitions and emotions about pain. Lack of health literacy, harmful cultural beliefs and thoughts about pain may encourage negative coping strategies.

Key Assessment Elements and Findings 

• Pain avoidance behaviours
• Catastrophisation, filtering or polarised thinking
• Fear of pain and movement
• Low self-efficacy
• Low expectations toward treatment and healing
• Pain-related behaviours (facial or verbal expressions, guarding, changes in daily activities)

Negative cognitions and emotions may be an important barrier to establishing a cooperative relationship with patients, leading to non-compliance and poor outcomes. The following tools can be used to assess cognitive factors:

• Pain Catastrophizing Scale (PCS)
• Tampa Scale for Kinesiophobia (TSK)
• Pain Self-Efficacy Questionnaire (PSEQ)
• Pain Disability Index (PDI)

Contextual Drivers

Displaced persons often deal with precarious living conditions and socioeconomic constraints daily. Thus, it is important always to consider social determinants of health and physical and psychological elements. For a successful pain assessment, the clinician should obtain a general overview of the social and economic situation of the individual.

Key Assessment Elements and Findings

• Legal status
• Access to basic needs 
• Access to healthcare
• Economic stability
• Degree of security in living spaces and the community

Gaps in the key factors above may be the hidden factor behind poor outcomes or non-compliance to treatment. Therefore, referrals to social support services should be ensured where necessary. 

Assessment in Practice

Once the clinician develops a good understanding of the traumatic experiences of the displaced person and considers their impact on different determinants of health, they will be better able to conduct a successful pain assessment.

The assessment session's first and most important aim is to build a trusting relationship with the patient. Without building trust and cooperation, no benefit can be expected from the physiotherapy process. The general principles of the trauma-informed care model must be implemented in every step of assessment and treatment to prevent re-traumatisation.

The points described below can be used as a practical framework while planning and conducting an assessment. The order of these points may change based on the needs and information provided by other professionals.

Preparation

• The setting of the room should be arranged before the session. This can include a seating plan, treatment table, curtains, forms, assessment equipment, hygiene materials etc.
• The referring professional should obtain related background information with the patient's consent.
• If a translator or cultural mediator is involved in the session, they should be briefed before the session.

Starting the Session

• The patient should be welcomed with respect and kindness - consider what is culturally appropriate for each patient (e.g., shaking hands, direct eye contact etc. culturally sensitive?).
• The patient should be given a general introduction, including the reason and aim of the session, the scope of the therapist, the role of the therapist, and details of the interview and examination.
• It must be clearly explained that the patient controls the session and may pause or stop it whenever needed.
• After the introduction, feedback should be obtained regarding the patient’s expectations and cautions (if any).

Medical History

This part should happen in a friendly conversation rather than a detailed interrogation. The number of questions should be decreased if any negative reaction is observed from the patient. The following information should be obtained while also continuously observing the patient’s reactions:

• Main complaints which motivated the patient to seek help
• Location and the distribution of pain as well as the type of pain for each location
• Chronological details of the onset and progress of the pain
• Mechanism of the injury and pain, be cautious about potential sensitivities
• Pain intensity, preferably both subjective and on a numeric or visual scale
• Daily course of the pain
• Aggravating and relieving factors of pain
• Sleep disturbance
• Previous medical interventions

Ideally, the patient should undergo an initial medical and mental health assessment before the assessment by the rehabilitation professional. The following information regarding co-morbidities should be obtained from the referring professional or the patient.

• Presence or suspicion of any current or previous communicable disease (tuberculosis, hepatitis etc.)
• Presence or suspicion of any current or previous non-communicable disease (heart disease, hypertension, diabetes etc.)
• Presence of any mental health disorder (PTSD, depression, anxiety etc.) or any psychological symptom causing distress

In addition to the routinely collected information, the clinician should learn about the patient’s subjective pain experience. The following are important points to consider.

• The meaning of pain for themselves and their lives. While some patients see the pain as a temporary, treatable condition, others may see it as a permanent sequela of traumatic experiences due to personal or cultural factors.
• Patient's beliefs about the cause of their pain. The patient might associate this with a particular event (e.g. torture) or provide a structural explanation (e.g. disc herniation).
• Patient’s beliefs, expectations and plans for the treatment of pain. While some patients have positive motivation for physiotherapy and exercise, others may see medical or surgical interventions as the only solutions.
• Presence of fear of pain and movement and linked withdrawal from physical activity.
• Presence of hopelessness or catastrophisation.
• Patient’s perception of self-efficacy as well as physical incapacitation.
• Socioeconomic details which may be related to pain (e.g. unemployment or long working hours, a house without proper heating, nutrition, absence of private space or secure neighbourhood for physical activity, family support, stigmatisation)

To supplement the qualitative information collected during the interview, related outcome measures explained in PDDM sub-domains can be used.

Physical Evaluation

In every step of the physical evaluation, general principles of the trauma-informed care model should be implemented. Breaching the patient’s boundaries may result in re-traumatisation and loss of trust.

• Inspection, including posture, deformities, gait, transfers and guarding movements
• Localisation of pain through patient’s guidance and palpation
• Movement testing, including active, passive and accessory movements
• Functional and specific physical tests
• Muscle strength and endurance assessment
• Neurological assessment, including sensation, reflexes and neural tension tests
• Balance assessment

Analysing Findings and Delivering Results

Individuals must experience pain and receive a comprehensive explanation about the reason for their pain. Meeting this expectation is one of the basic steps in building a therapeutic relationship.

• Based on the information collected during the interview, the clinician should analyse the weight of each of the main domains of PDDM and map the various contributors.
• Identified contributing factors should be explained to the patient - it is essential to consider the patient's current beliefs and capacity to understand the information.
• While explaining the findings, the use of terms and concepts which can cause catastrophisation should be minimised (for example, wear and tear, rupture, and herniation).
• Communication should be bi-directional - seek feedback about your explanation from the patient and check for understanding.
• In addition to an explanation of the causes of pain, it is beneficial to discuss points such as: how rehabilitation can help, estimated treatment duration, and expected outcomes. Rules and responsibilities should also be discussed with patients to create an overall framework for the treatment process.

Case Examples

Evidence Based Assessment of Pain in Displaced Persons - Case Study 1

Evidence Based Assessment of Pain in Displaced Persons - Case Study 2

Resources

• Amris K, Jones LE, Williams AC. Pain from torture: assessment and management. Pain reports. 2019 Nov;4(6).
• Williams AD, Hughes J. Improving the assessment and treatment of pain in torture survivors. BJA education. 2020 Apr;20(4):133.