Evidence-based Management of Pain in Refugees
Original Editor - Zafer Altunbezel
Top Contributors - Naomi O'Reilly
- 1 Introduction
- 2 Interventions for Nociceptive Pain
- 3 Interventions for Nervous System Dysfunctions
- 4 Interventions for Comorbid Conditions
- 5 Interventions for Cognitive and Emotional Contributors
- 6 Interventions for Social and Environmental Factors
- 7 Resources
- 8 References
Chronic pain is one of the most disabling and challenging conditions for physiotherapists working with traumatized individuals. Multifactorial nature of chronic pain in traumatized refugees requires understanding of different contributing domains for framing an effective treatment strategy. Also 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 physiotherapy practice, selection of tools and techniques while working with refugees depends on several factors. The first important factor is the duration and frequency that the patient is able to attend the treatment with compliance. While in some settings it is possible to do long term regular follow-up, another scenario may only allow a brief intervention. Another factor is acceptance from the patient. Some treatment options may not be well-received by the patients due to cultural background, personal beliefs or expectations. Available resources such as building, equipment, supplies, transportation, human resource etc. should also be considered.
Whether long term or brief intervention, planning of 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 the patients can be empowered to adopt a more active coping style.
Pain and Disability Drivers Model one of the clinical frames helping clinicians to identify and map the contributing factors during pain assessment. Overall treatment strategy and priorities can be defined based on the findings of 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 (catastrophization, fear, avoidance etc.)
- Addressing nervous system dysfunctions (peripheral & central sensitization)
- Treating conditions causing nociceptive input and improving physical well-being.
- Addressing comorbid conditions through medical and integrative approaches.
Interventions for Nociceptive Pain
Given the high frequency of traumatic experiences of refugees, it is very likely to detect nociceptive contributors in individuals either due to direct physical trauma or non-specific deconditioning. Ensuring the management of nociceptive pain in early stages of the treatment process is of importance since most patients frame their relationship with physiotherapy based on pain reduction first. Initial pain control is also a good tool for patient engagement particularly for the ones who are not familiar with physiotherapy.
Selection of treatment tools depends on various factors such as clinical picture, cultural background, beliefs and expectations, tolerance and acceptance. Also estimated length of treatment period in which the patient can participate should be considered. In any case, the principles below should be followed while decision-making:
- The selected tools should ensure pain reduction starting from early stages.
- Tissue healing process should be maintained.
- Physical dysfunctions should be addressed.
- Transition from passive treatments to active exercise and physical activity should be ensured as early as possible.
- Patients must learn how to manage their condition by themselves and should be provided with basic tools and supplies.
Manual therapy offers wide abilities to clinicians for detailed examination and treatment of complex physical dysfunctions. Manual therapy can be a good option for the patients who have nociceptive pain and other physical dysfunctions. Manual mobilizations and manipulations can be utilized for 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 either due to cultural or religious background or personal traumatic history and fear.
Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. 
Various modalities can be used in initial phases of treatment for the patients who are not yet ready for manual treatments or exercise. In early stages of the treatment, some patients may refuse hands-on treatments due to cultural background or traumatic memories. Some patients might be expecting or believing in more medicalized, solid or equipment-based treatments initially.
Cold packs can be used for inflammation control in the acute injuries. Hot packs and other heating agents can be used in joint hypomobility and increased muscle tone. Hot & 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 postoperative pain, osteoarthritis, painful diabetic neuropathy and some acute pain conditions. TENS may be effective in restoration of central pain modulation, a measure of central inhibition. 
While modalities can be proper tools for initial phases, clinicians should keep in mind that they can’t substitute active approaches in long term. Another important point is that the psychological factors should be considered and patient’s consent should be obtained before using any modalities. Some patients may have traumatic exposure to cold, hot or electricity in the pass and modalities can trigger unwanted psychological effects.
Therapeutic Exercise & Physical Activity
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 decreased physical and psychosocial well-being. That’s why, following the initial stabilization of physical symptoms of the patients, therapeutic exercises and graded physical activity should be introduced.
- Range of motion exercises
- Stretching exercises
- Strengthening & stabilization exercises
- Self-mobilizations for joints and soft tissues
- Neural mobilizations
- Balance and Coordination exercises
- Aerobic exercises
Exercise program should be easy to understand and implement for the patients. Amount of exercises as well as difficulty should be adjusted based on the patient’s physical capacity, available time and acceptance. Preferably the exercises requiring minimum equipment should be selected and if needed, basic materials (e.g. resistance bands) should be provided to the patients. Patients should be provided with a list and instructions of prescribed exercises in their language in order to remember and keep logs.
Assistive & Adaptive Support
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 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 stick etc.
- Slings, braces, splints
- Taping, bandaging
- Adaptive tools for daily activities
Clinicians should carefully make decisions regarding usage of assistive and adaptive support since it can increase patients’ dependency. An external support should only serve for ensuring safety and encouraging patients for being physically active for a predetermined period.
Interventions for Nervous System Dysfunctions
Direct trauma to 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 sensitization 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 the overall well-being.
Manual therapy can be utilized as a good option for both assessment and treatment of the musculoskeletal conditions leading 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.
Neurodynamics refers to the communication between different parts of the nervous system and to the nervous systems 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 the nerves passing through the area. Suspension torture may cause injuries in the connective tissue of the nerves while not causing significant impact on nerve conduction. Degenerative conditions of the spine may cause radicular symptoms.
Neural mobilization (NM) is effective in the management of nerve-related low back pain, nerve-related neck and arm pain, and plantar heel pain and tarsal tunnel syndrome. Neural mobilizations (gliders and tensioners) can improve the movement and adaptability of neural tissues and can be used in peripheral nervous dysfunctions.
Graded Motor Imagery
Graded Motor Imagery (GMI) is a novel treatment method used in 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 normalize central processing to remediate chronic pain. 
Graded Motor Imagery consists of three sequential stages. In the first stage the patients try to identify left or right images of their painful body parts. In the second stage the patients use imagination of movements which are painful for them. In the last stage the patients perform exercises with their pain-free extremity 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 still ongoing, it can be an added component of treatment programs in the case of central sensitization.
Basic Body Awareness Therapy
Basic Body Awareness Therapy (BBAT) is a mental health physiotherapy intervention developed in Scandinavia in the 1970’s. 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. The contact deficiency may lead to dysfunctional movement quality, pain, and reduced function. BBAT focuses on movement quality and how the 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 program includes movements from everyday life, lying, sitting, standing and walking. It also includes the use of voice, relational exercises and massage. Free breathing, balance and awareness in all exercises are central.
Interventions for Comorbid Conditions
Traumatic experiences as well as long term precarious living conditions of refugees often result in multiple comorbid conditions. Link: Understanding Refugee Experience. Some of these conditions may contribute to persistence of pain and impair overall wellbeing.
Referral to Needed Services
Traumatic experiences and precarious life conditions in war zones, prisons and refugee settlements may often lead to communicable and non-communicable diseases as well as mental health disorders. Comorbidities may act as a strong contributor of chronic pain and hinder the recovery.
In some settings the biological and mental health disorders may not have been addressed properly before the physiotherapy intervention. Some patients may not have social stability for regularly attending to physiotherapy or showing compliance. In the presence of indicators for involvement of other disciplines, proper referral and follow-up should be provided.
Regular physical activity can improve different domains of health simultaneously and that’s why it should be included in the treatment programs while working with refugees. 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
Refugees with chronic pain often tend to have a sedentary lifestyle due to pain-avoidance and other psychosocial and environmental factors. This tendency may have reflections on their compliance to the physiotherapy process and therefore should be prevented.
Doing at least 30 minutes of at least moderate intensity physical activity on five or more days of the week has been a common recommendation. Some forms of physical activity can be prescribed include walking, cycling or swimming. 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 with community etc.).
Simple lifestyle modifications may have a significant effect on overall well-being in short and long term. Chronic health issues, mental health disorders and social instability create a good environment for developing bad lifestyle habits and that can exacerbate the impact of comorbidities. When detected, the following lifestyle habits should be reversed with proper behavioral 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 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. Following strategies and advices 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 day-time naps
Interventions for Cognitive and Emotional Contributors
Refugee experience in which populations are deliberately traumatized and left helpless for a long time provides a suitable environment for 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.9
Unhelpful coping styles and negative cognitions towards pain may increase the severity of pain as well as pain related disability. These factors also have negative impact on compliance to the treatment
Since new perceptions and habits are often built on previous perceptions and beliefs, patient education can be used as the first therapeutic intervention in the overall physiotherapy process. In this way the negative cognitions and emotions which may interfere with the physiotherapy process in the future can be modified. A patient education session may include:
- Information about overall physiotherapy process
- Pain and chronic pain neurophysiology
- Post-traumatic stress symptoms
- Negative cognitions and emotions towards pain
- Pain catastrophization and fear-avoidance
- Coping strategies
Education sessions must happen in an interactive environment. 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.
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.
Awareness about breathing patterns and use of diaphragmatic breathing are great tools can be used by patients for self-regulation of emotional distress. A steady and controlled diaphragmatic breathing decreases the activity of the sympathetic nervous system and creates an overall relaxation feeling.
Cognitive and Behavioral Approaches
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 physiotherapy interventions. These can include open communication, goal setting, activity pacing and homeworks.
Some other traditional and complementary approaches can be utilized in the treatment of chronic pain including grounding exercises, mindfulness, pleasant imagination and religious-spiritual practices.
Interventions for Social and Environmental Factors
Refugee experience often includes dealing with social and environmental challenges including livelihood issues, access to the rights and services, legal issues, security problems, discrimination and stigmatization. These factors can result in significant decrease in overall well-being when not addressed through social services.
Physiotherapists working with refugees must always be aware of social factors that have the potential to interfere with the physiotherapy 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 assessment in the living space and community when needed. In case of any accessibility problem, required resources can be mobilized. Family and community education can also be used to prevent stigmatization and promote a supporting community.
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- Basson A, Olivier B, Ellis R, Coppieters M, Stewart A, Mudzi W. The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2017 Sep;47(9):593-615. doi: 10.2519/jospt.2017.7117. Epub 2017 Jul 13. PMID: 28704626.
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- Dropsy, J. (1975). Leva i sin kropp.[Living in Your Body.]. Aldus, Lund.
- Skjaerven, L. H., Kristoffersen, K., & Gard, G. (2008). An eye for movement quality: a phenomenological study of movement quality reflecting a group of physiotherapists' understanding of the phenomenon. Physiotherapy theory and practice, 24(1), 13-27.
- World Health Organization. Global recommendations on physical activity for health. World Health Organization; 2010.