Evidence-based Management of Pain in Displaced Persons

Original Editor - Zafer Altunbezel

Top Contributors - Naomi O'Reilly, Ewa Jaraczewska, Jess Bell, Wanda van Niekerk and Kim Jackson  

Introduction[edit | edit source]

Chronic pain is a common and potentially disabling condition for displaced persons, and it can be difficult to manage[1] [2] due to its multifactorial nature. Clinicians must understand the different contributing domains if they are to develop an effective treatment strategy. 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.[1]

While the overall management of pain in displaced persons is very similar to other populations, the selection of tools and techniques while working with displaced persons depends on two factors:

  • available resources, including;
    • time
      • the duration and frequency that the patient can attend treatments
      • while it is possible to schedule long-term regular follow-ups in some settings, other settings may only allow for a brief intervention
    • equipment
    • imaging
    • access to specialists/surgery
  • acceptance from the patient
    • some treatment options may not be well-received by patients due to their cultural background, personal beliefs or expectations
    • resources such as buildings, equipment, supplies, transportation, and human resources should be considered

Whether the intervention is long-term or brief, the patient's perspective must always be considered when planning a treatment strategy. Many patients want to be “fixed” and free of pain, but it is always essential to help patients identify their wishes and expectations. In this way, patients can be empowered to adopt a more active coping style.[3][4]

The Pain and Disability Drivers Model (PDDM)[5] is one clinical framework that helps clinicians identify and map factors contributing to pain during an assessment. The overall treatment strategy and priorities can be defined based on the findings of the pain assessment. While there may be differences between individuals, the following principles can guide the treatment process:[6]

  • ensuring the psychosocial 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[5][6]

Interventions for Nociceptive Pain in Displaced Persons[edit | edit source]

Given the high frequency of traumatic events experienced by displaced persons, there is a high likelihood there will be nociceptive contributors to an individual's pain,[7] either due to direct physical trauma or non-specific deconditioning. Ensuring nociceptive pain is managed early in the treatment process is important. Moreover, a patient's relationship with the rehabilitation team depends on effectively managing 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 unfamiliar with physiotherapy.

The selection of treatment tools depends on various factors such as the clinical picture, cultural background, beliefs and expectations, tolerance and acceptance.[8][9] The estimated length of the treatment period in which the patient can participate should also 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
  • the transition from passive treatments to active treatments should be ensured as early as possible
  • patients should be supported to develop self-management skills[10][11]

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 with nociceptive pain and other physical dysfunctions. Manual mobilisations and manipulations can be utilised for the spine and other joints to reduce pain and improve movement. Soft tissue interventions can be very effective for patients with excessive muscle tension or scars. However, some patients may not accept hands-on techniques due to their cultural or religious background or personal traumatic history and fear.[12]

Spinal manipulation and mobilisation are effective in adults for acute, subacute, and chronic low back pain, migraine and cervicogenic headache, and cervicogenic dizziness. Manipulation and mobilisation are effective for several joint conditions of the extremities, and thoracic manipulation and mobilisation are effective for acute/subacute neck pain.[13][14]

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[15]
  • hot packs and other heating agents can be used in joint hypomobility 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
  • when applied at adequate intensities, systematic reviews suggest that TENS is effective for postoperative pain, osteoarthritis, painful diabetic neuropathy and some acute pain conditions. TENS may effectively restore central pain modulation, a measure of central inhibition.[16]

While modalities can be useful tools in the initial phases, clinicians should remember 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.[17]

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.[18][19][20] Once the initial physical symptoms of the patients are stabilised, the following therapeutic exercises and graded physical activity should be introduced:[21][22]

  • 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 patients. The number of exercises and 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 patients. Patients should receive a list and instructions for prescribed exercises in their language 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 unsafe. Some assistive supports can be used for protection or promotion purposes in the early phases, including:

Clinicians should make decisions carefully regarding assistive and adaptive support usage since it can increase patients’ dependency. External support should only 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 neuropathic pain, peripheral sensitivity, radiculopathy or myelopathy. Central sensitisation may also develop due to a lack of access to proper treatment, mental health disorders and social and emotional factors.

Since pain is an output of the nervous system, addressing nervous system dysfunctions in chronic painful conditions is essential. Injured or compromised neural tissues and dysfunctional central pain modulation can cause extreme suffering and, thus, lead to a deterioration in an individual's overall well-being.

Manual Therapy[edit | edit source]

Manual therapy can be utilised to assess and treat 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 and joints can relieve pain.

Neural Mobilisation[edit | edit source]

Neurodynamics refers to the communication between different parts of the nervous system and the nervous system's relationship to the musculoskeletal system. It has been shown that nerves move independently from other tissues.[23]

Various injuries may negatively impact neurodynamics 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 having a significant impact on nerve conduction. Degenerative conditions of the spine may cause radicular symptoms.

Neural mobilisation (NM) effectively manages nerve-related low back pain, nerve-related neck and arm pain, plantar heel pain and tarsal tunnel syndrome.[24] 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 for chronic pain conditions. Graded motor imagery is one treatment technique from the "top-down" paradigm designed to treat chronic pain. This technique attempts to normalise central processing to remediate chronic pain sequentially.[26]

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 exercising the painful limb.[27] [28]

Although the history of Graded Motor Imagery is relatively short and studies around GMI are ongoing, it can be included as a component of a treatment programme for central sensitisation.[29]

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 the person’s lack of contact with and awareness of the body concerning physical, mental, and relational factors".[32][33] This contact deficiency might result in dysfunctional movement quality, pain, and reduced function.[32] BBAT emphasises movement quality and "how movements are performed and experienced in relation to space, time, and energy".[32][34][35]

BBAT aims 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.[36][35][37]

Interventions for Co-morbid Conditions[edit | edit source]

Traumatic experiences and the long-term precarious living conditions of displaced persons often cause multiple co-morbid conditions. Some of these conditions may contribute to persistent pain and impair overall well-being.

Referral to Needed Services[edit | edit source]

Traumatic experiences and precarious living conditions in war zones, prisons and displaced person settlements can increase the spread of communicable diseases, increase/worsen non-communicable diseases and result in mental health disorders. Co-morbidities can be strong contributors to chronic pain and hinder recovery. 

In some settings, biological and mental health disorders may not have been properly addressed before a physiotherapy intervention. Some patients may lack social stability for regularly attending physiotherapy or showing compliance. If there are indications that an individual would benefit from the input of other disciplines, proper referral and follow-up should be provided.

Physical Activity[edit | edit source]

Regular physical activity can simultaneously improve different domains of health and should be included in the treatment programmes of displaced persons.[38] Possible benefits of physical activity include:

Displaced persons with chronic pain often tend to be sedentary 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 well-being, the World Health Organization 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.[38] All physical activity counts and can be done as part of work, sport and leisure or transport (walking, wheeling and cycling), as well as everyday 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 living spaces, factors related to community etc.).[38]

Lifestyle Modifications[edit | edit source]

Simple lifestyle modifications may significantly affect overall well-being in the short and long term. Chronic health issues, mental health disorders and social instability create an environment that can lead to negative lifestyle habits, exacerbating the impact of co-morbidities.[40] 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.[41] [42] Sleep disorders should be addressed with a multidisciplinary approach, including psychiatric treatment, psychotherapy and physiotherapy.[43] [44] The following strategies and advice can be used within a physiotherapy intervention:[45][46]

  • 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 developing negative cognitions and emotions about pain. Lack of health literacy, harmful cultural beliefs and thoughts about pain may direct people to negative coping strategies.[47]

Unhelpful coping styles and negative cognitions towards pain may increase the severity of pain and pain-related disability. These factors also have a negative impact on compliance with treatment.

Patient Education[edit | edit source]

Patient education can be the first therapeutic intervention in the therapy process. It is based on the concept that new perceptions and habits are often built on previous perceptions and beliefs. In this way, negative cognitions and emotions which may interfere with the therapy process in the future can be modified. A patient education session may include [48]

  • 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 their feeling of control.

Breathing Exercises[edit | edit source]

Awareness about breathing patterns and the 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 a relaxed feeling.

Cognitive and Behavioural Approaches[edit | edit source]

Chronic pain can result in fear avoidance and decreased self-efficacy without 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 to treat chronic pain, including grounding exercises, mindfulness 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 living spaces and the community when needed. In case of any accessibility issues, required resources can be mobilised. Family and community education can also prevent stigmatisation and promote a supportive community.

References[edit | edit source]

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