Evidence-based Management of Pain in Displaced Persons
Original Editor - Zafer Altunbezel
Introduction[edit | edit source]
Chronic pain is one of the most disabling and challenging conditions for rehabilitation professionals working with traumatised individuals.  An effective treatment strategy requires an understanding of different contributing domains due to the multifactorial nature of chronic pain in traumatised displaced persons. The personal and cultural background of individuals which can only be understood through a proper pain assessment should be considered while framing a treatment strategy.
While the overall approach is very similar to routine practice, the selection of tools and techniques while working with displaced persons depends on two factors:
- Duration and frequency that the patient is able to attend treatments. While in some settings it is possible to schedule long-term regular follow-ups, another settings may only allow for a brief intervention.
- Acceptance from the patient. Some treatment options may not be well-received by patients due to their cultural background, personal beliefs or expectations. Available resources such as building, equipment, supplies, transportation, and human resources should be considered.
Whether the intervention is long-term or brief, the planning of the treatment strategy should always include the patients’ perspective. Many patients just want to be “fixed” and set free of pain, but it is always essential to help patients to embody their wishes and expectations. In this way, patients can be empowered to adopt a more active coping style. 
The Pain and Disability Drivers Model (PDDM)  is one clinical framework that helps clinicians to identify and map the contributing factors during pain assessment. Overall treatment strategy and priorities can be defined based on the findings of the pain assessment. While it is possible to have differences between individuals, the following principles can guide the treatment process: 
- Ensuring the psycho-social stability and security of the individual
- Establishing a therapeutic relationship through a trauma-informed approach
- Eliminating serious pathologies and identifying contributing factors through a proper examination
- Addressing unhelpful cognitive and emotional contributors (catastrophisation, fear, avoidance etc.)
- Addressing nervous system dysfunctions (peripheral and central sensitisation)
- Treating conditions causing nociceptive input and improving physical well-being
- Addressing co-morbid conditions through medical and integrative approaches 
Interventions for Nociceptive Pain[edit | edit source]
Given the high frequency of traumatic experiences of displaced persons, there is a high likelihood there will be nociceptive contributors to an individual's pain, either due to direct physical trauma or non-specific de-conditioning. Ensuring nociceptive pain is managed in the early stages of the treatment process is important. Moreover, a patient's relationship with the rehabilitation team depends on the effective management of this pain as most patients frame their relationship based on pain reduction first. Initial pain control is also a good tool for patient engagement, particularly for patients who are not familiar with physiotherapy.
The selection of treatment tools depends on various factors such as the clinical picture, cultural background, beliefs and expectations, tolerance and acceptance.  Also, the estimated length of the treatment period in which the patient can participate should be considered. In any case, the principles below should be followed while making decisions on treatment:
- The selected tools should ensure pain reduction starting from the early stages
- The tissue healing process should be maintained
- Physical dysfunctions should be addressed
- Transition from passive treatments to active treatments should be ensured as early as possible
- Patients should be supported to develop self management skills 
Manual Therapy[edit | edit source]
Manual therapy provides an opportunity for detailed examination and treatment of complex physical dysfunctions. It can be a good option for patients who have nociceptive pain and other physical dysfunctions. Manual mobilisations and manipulations can be utilised for the spine and other joints with the aim of pain reduction and improving movement. Soft tissue interventions can be very effective for patients suffering from excessive muscle tension or scars. However, hands-on techniques may not be accepted by some patients due to their cultural or religious background or their personal traumatic history and fear.
Spinal manipulation/mobilisation is effective in adults for acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness. Manipulation/mobilisation is effective for several joint conditions of the extremities and thoracic manipulation/mobilisation is effective for acute/subacute neck pain.
Modalities[edit | edit source]
Various modalities can be used in the initial phases of treatment for patients who are not yet ready for manual treatments or exercise. Some patients may refuse hands-on treatments in the early stages, due to their cultural background or traumatic memories. They might expect or believe in more medicalised, solid or equipment-based treatments initially:
- Cold packs can be used for inflammation control in acute injuries. 
- Hot packs and other heating agents can be used in joint hypo-mobility and increased muscle tone.
- Hot and cold gel packs are low-cost tools that can be distributed to the patients if any benefit is reported.
- Systematic reviews suggest that TENS, when applied at adequate intensities, is effective for post-operative pain, osteoarthritis, painful diabetic neuropathy and some acute pain conditions. TENS may be effective in the restoration of central pain modulation, a measure of central inhibition.
While modalities can be useful tools in the initial phases, clinicians should keep in mind that they can’t substitute active approaches in the long term. Another important point is that psychological factors should be considered and the patient’s consent must be obtained before using any modalities. Some patients may have had traumatic exposure to cold, hot or electricity in the past and modalities can trigger unwanted psychological effects.
Therapeutic Exercise and Physical Activity[edit | edit source]
Pain and other physical impairments may result in a circle of pain and immobility in the absence of proper treatment in the long term. This situation causes fear-avoidance and withdrawal from physical activity, thus decreasing physical and psychosocial well-being. Once the initial physical symptoms of the patients are stabilised, the following therapeutic exercises and graded physical activity should be introduced:
- Range of motion exercises
- Stretching exercises
- Strengthening and stabilisation exercises
- Self-mobilisations for joints and soft tissues
- Neural mobilisations
- Balance and coordination exercises
- Aerobic exercises
An exercise programme should be easy to understand and implement for the patients. The number of exercises, as well as their difficulty, should be adjusted based on the patient’s physical capacity, available time and acceptance. Preferably exercises requiring minimum equipment should be selected and if needed, basic materials (e.g. resistance bands) should be provided to the patients. Patients should receive a list and instructions for prescribed exercises in their language in order to remember and keep logs.
Assistive and Adaptive Support[edit | edit source]
Some patients may not be physically or mentally ready for independent movement due to severe physical injuries or fear of pain and movement. Others may undergo surgical interventions and come to the clinic in the post-operative phase when complete loading is not yet safe. For protection or promotion purposes in the early phases, some assistive supports can be used.
- Walking aids such as walkers, crutches, walking sticks etc.
- Slings, braces, splints
- Taping, bandaging
- Adaptive tools for daily activities
Clinicians should make decisions carefully regarding the usage of assistive and adaptive support since it can increase patients’ dependency. External supports should only serve to ensure safety and encourage patients to be physically active for a predetermined period.
Interventions for Nervous System Dysfunctions[edit | edit source]
Direct trauma to the nervous system (explosions, gunshot wounds, torture etc.) and secondary injuries during daily life (e.g. work-related injuries) may lead to situations such as neuropathic pain, peripheral sensitivity, radiculopathy or myelopathy. Central sensitisation may also develop due to lack of access to proper treatment, mental health disorders and social and emotional factors.
Since pain is an output of the nervous system, it is essential to address nervous system dysfunctions in chronic painful conditions. Injured or compromised neural tissues as well as dysfunctional central pain modulation can cause extreme suffering and, thus, deteriorate an individual's overall well-being.
Manual Therapy[edit | edit source]
Manual therapy can be utilised for both the assessment and treatment of musculoskeletal conditions leading to compromised neural tissue. These conditions may include trauma-related injuries (e.g. scars causing pressure on nerves) or secondary conditions (e.g. degenerative spinal disorders). Hands-on techniques directed at soft tissues as well as joints can provide pain relief.
Neural Mobilisation[edit | edit source]
Neurodynamics refers to the communication between different parts of the nervous system and to the nervous system's relationship to the musculoskeletal system. It has been shown that the nerves move independently from other tissues.
Various injuries may impact neurodynamics negatively and thus result in nervous system dysfunctions. A penetrating injury can leave excessive scarring and hinder the movement of nerves passing through the area. Suspension torture may cause injuries in the connective tissue of the nerves while not causing a significant impact on nerve conduction. Degenerative conditions of the spine may cause radicular symptoms.
Neural mobilisation (NM) is effective in the management of nerve-related low back pain, nerve-related neck and arm pain, plantar heel pain and tarsal tunnel syndrome. Neural mobilisations (gliders and tensioners) can improve the movement and adaptability of neural tissues and can be used in peripheral nervous dysfunctions.
Graded Motor Imagery[edit | edit source]
Graded Motor Imagery (GMI) is a novel treatment method used in the treatment of chronic painful conditions. Graded motor imagery is one treatment technique from the "top-down" paradigm designed to treat chronic pain. This technique attempts to sequentially normalise central processing to remediate chronic pain.
Graded Motor Imagery consists of three sequential stages. In the first stage, patients try to identify left or right images of their painful body parts. In the second stage, patients imagine movements which are painful for them. In the last stage, patients perform exercises with their pain-free extremities in front of the mirror and thus send visual input to the brain as if they are exercising the painful limb. 
Although the history of Graded Motor Imagery is relatively short and studies around GMI are ongoing, it can be an added component of treatment programmes in the case of central sensitisation. 
Basic Body Awareness Therapy[edit | edit source]
Basic Body Awareness Therapy (BBAT) is a mental health physiotherapy intervention developed in Scandinavia in the 1970s. BBAT is based on the hypothesis of a person’s lack of contact with and awareness of the body concerning physical, mental, and relational factors. The contact deficiency may lead to dysfunctional movement quality, pain, and reduced function. BBAT focuses on movement quality and how movements are performed and experienced in relation to space, time, and energy.
The aim of BBAT is to establish increased awareness of the body and consciousness in movements, progressing towards less effort and a better function in being, doing and relating. The therapy programme includes movements from everyday life: lying, sitting, standing and walking. The use of voice, relational exercises and massage are also incorporated into the programme. Free breathing, balance and awareness in all exercises are central.
Interventions for Co-morbid Conditions[edit | edit source]
Traumatic experiences, as well as long-term precarious living conditions of displaced persons, often result in multiple co-morbid conditions. Some of these conditions may contribute to the persistence of pain and impair overall wellbeing.
Referral to Needed Services[edit | edit source]
Traumatic experiences and precarious living conditions in war zones, prisons and displaced person settlements may often lead to communicable and non-communicable diseases as well as mental health disorders. Co-morbidities may act as a strong contributor to chronic pain and hinder recovery.
In some settings, the biological and mental health disorders may not have been addressed properly before the physiotherapy intervention. Some patients may be lacking social stability for regularly attending physiotherapy or showing compliance. In the presence of indicators for the involvement of other disciplines, proper referral and follow-up should be provided.
Physical Activity[edit | edit source]
Regular physical activity can improve different domains of health simultaneously and should be included in the treatment programs while working with displaced persons.  Possible benefits of physical activity include:
- Weight control
- Reduced risk of Cardiovascular Diseases, Type-2 Diabetes and Metabolic Syndrome 
- Improved musculoskeletal health
- Improved mental and social well-being
- Improved sleep
Displaced persons with chronic pain often tend to have a sedentary lifestyle due to pain avoidance and other psychosocial and environmental factors. This tendency may impact their compliance with the physiotherapy process and should be discouraged.
For health and wellbeing, the World Health Organisation recommends at least 150 to 300 minutes of moderate aerobic activity per week (or the equivalent vigorous activity) for all adults, and an average of 60 minutes of moderate aerobic physical activity per day for children and adolescents.  All physical activity counts and can be done as part of work, sport and leisure or transport (walking, wheeling and cycling), as well as every day and household tasks. Selected physical activity and dosage must be adjusted according to a person's physical performance as well as social and environmental factors (e.g. working hours, conditions in the living space, factors related to community etc.).
Lifestyle Modifications[edit | edit source]
Simple lifestyle modifications may have a significant effect on overall well-being in the short and long term. Chronic health issues, mental health disorders and social instability create an environment which can lead to the development of negative lifestyle habits, which can exacerbate the impact of co-morbidities. When detected, the following lifestyle habits should be reversed with proper behavioural approaches:
- Physical immobility in daily life
- Adverse dietary habits (saturated foods, low-quality carbs, excessive salt usage etc.)
- Insufficient water intake
- Excessive consumption of coffee or tea
- Smoking and alcohol consumption
- Substance abuse
- Excessive use of medications (e.g. painkillers)
Sleep Hygiene[edit | edit source]
Sleep quality has a direct relationship with pain intensity. Decreased sleep quality increases pain intensity, decreases pain threshold and hinders tissue healing.  Sleep disorders should be addressed with a multidisciplinary approach including psychiatric treatment, psychotherapy and physiotherapy.  The following strategies and advice can be used within physiotherapy intervention: 
- Regular physical activity and exercise
- Relaxation exercises
- Learning resting positions
- Having a bedtime routine
- Having a quality sleeping space
- Avoiding exposure to social media or disturbing news in the evening
- Decreasing consumption of caffeine and alcohol
- Avoiding daytime naps
Interventions for Cognitive and Emotional Contributors[edit | edit source]
Experiences where displaced persons are deliberately traumatised and left helpless for a long time, provide a suitable environment for the development of negative cognitions and emotions about pain. Lack of health literacy, harmful cultural beliefs and thoughts about pain may direct people to negative coping strategies.
Unhelpful coping styles and negative cognitions towards pain may increase the severity of pain as well as pain-related disability. These factors also have a negative impact on compliance with the treatment.
Patient Education[edit | edit source]
Patient education can be used as the first therapeutic intervention in the overall therapy process. It is based on the concept that new perceptions and habits are often built on previous perceptions and beliefs. In this way, the negative cognitions and emotions which may interfere with the therapy process in the future can be modified. A patient education session may include: 
- Information about the overall therapy process
- Pain and chronic pain neurophysiology
- Post-traumatic stress symptoms
- Negative cognitions and emotions towards pain
- Pain catastrophisation and fear-avoidance
- Coping strategies
Education sessions must happen in an interactive environment. The amount of information and complexity of the used language should be adjusted carefully according to the individual’s education level, cognitive stability level and motivation to change.
Relaxation Exercises[edit | edit source]
Mental and emotional distress can cause increased muscle tension and it can increase the perceived pain intensity. Relaxation exercises can be used in the form of progressive muscle relaxation, hold-relax or reciprocal inhibition. When implemented properly, relaxation techniques are great tools for patients to regulate their symptoms and strengthen the feeling of control.
Breathing Exercises[edit | edit source]
Awareness about breathing patterns and use of diaphragmatic breathing are great tools that can be used by patients for self-regulation of emotional distress. Steady and controlled diaphragmatic breathing decreases the activity of the sympathetic nervous system and creates an overall relaxation feeling.
Cognitive and Behavioural Approaches[edit | edit source]
Chronic pain can result in fear-avoidance and decreased self-efficacy in the absence of proper interventions. Some strategies within Cognitive-Behavioral Therapy can be adapted to therapy interventions. These can include open communication, goal setting, activity pacing and homework.
Other Approaches[edit | edit source]
Some other traditional and complementary approaches can be utilised in the treatment of chronic pain including grounding exercises, mindfulness, pleasant imagination and religious-spiritual practices.
Interventions for Social and Environmental Factors[edit | edit source]
Displaced persons often have to deal with social and environmental challenges including livelihood issues, access to rights and services, legal issues, security problems, discrimination and stigmatisation. These factors can result in a significant decrease in overall well-being when not addressed through social services.
Professionals working with displaced persons must always be aware of social factors that have the potential to interfere with the therapy process and take required measures. While working with interdisciplinary teams, social factors can be addressed through social workers. In other settings, mapping the available social resources and making referrals can be a good strategy.
Aside from social work referrals, physiotherapists can conduct assessments in the living space and community when needed. In case of any accessibility problem, required resources can be mobilised. Family and community education can also be used to prevent stigmatisation and promote a supportive community.
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