Physiotherapy Assessment of Pain within a Trauma-Informed Care Model

Original Editor - Redisha Jakibanjar

Top Contributors - Redisha Jakibanjar, Naomi O'Reilly, Kim Jackson, Admin and Anna Fuhrmann  

Introduction[edit | edit source]

Trauma-Informed Care in  physiotherapy for refugees can involve seeing beyond specific treatment methods, and rather striving to develop a safe relation, including a focus on affect regulation. This also seems to be dependent on an openness and flexibility in the encounter between different cultures. The trauma-informed care model is the framework that involves the understanding of the impact of trauma, ways to respond to the trauma and it also enhances the physical, psychological and emotional safety for both service providers and patients. It also provides opportunities for the patients to rebuild the self-control and empowerment.

"It took a long time before we knew what would happen to us. It was still a possibility that we might be returned to a place where we would definitely be imprisoned and harmed in any other way. It was like a nightmare"

"By moving from one country to another, the change in environment, another type of weather and climate will cause a change and impact your health. Change requires time, some learn fast, some learn slow, changing is not for all".

"Stress continues even when you are in a safe place. It might be a different type of stress associated with daily chores, such as language difficulties, work barriers, and not understanding the culture".

"Even if we are in a safe environment a lot of refugees will tell you they are not safe. The many changes in the regulations leaves everyone feeling unsafe and if you are not included - you are vulnerable and fear might still prevail".

Anonymous Refugees

Pain[edit | edit source]

According to the International Association For Study of Pain (IASP), pain is defined as" An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage". [1]

Trauma-informed Care Model[edit | edit source]

The trauma-informed care model is the framework that involves the understanding of the impact of trauma, ways to respond to the trauma and it also enhances the physical, psychological and emotional safety for both service providers and patients. It also provides opportunities for the patients to rebuild the self-control and empowerment.[2]

There are six key elements of a trauma-informed approach[3] and they are:

  • Safety
  • Trustworthiness and Transparency
  • Peer support
  • Collaboration and Mutuality
  • Empowerment, Voice, and Choice
  • Cultural-historical and Gender Issues

Pain Assessment within Key Elements[edit | edit source]

Safety[edit | edit source]

While doing pain assessment, the physiotherapist should create an environment. where patients can feel safe physically and psychologically.[3] A physiotherapist should interact and ask questions in such a way that patient feels comfortable to tell his/her story, describe his/her subjective feeling, emotion and during the assessment process, a physiotherapist should ensure patient that if he/she feels uncomfortable at any point of time he/she can disclose the assessment process at any time.[4]He/she should be assured that confidentiality will be maintained between the physiotherapist and the patient.[5]

Trustworthiness and Transparency[edit | edit source]

The decision which is taken and the goal prepared should be transparent so that patient can have trust towards the physiotherapist. The assessment should be client-oriented and the findings should be recorded so that there is consistency between the therapy sessions.[4]The type and behavior of pain described should be recorded exactly as described by the patient. The patient's autonomy should be respected. While measuring pain, validated outcome measures should be used. [6]

Peer Support[edit | edit source]

Peer means the group of people who have faced the same kind of trauma. During the assessment, if the patient feels comfortable being with the peer group, the therapist can offer the option to the patient.[3] Many patients may have little knowledge regarding their pain experience as some pain might be due to emotional suffering and central sensitization.[4]Peer support might provide emotional support and it can be provided face to face, in a group, or via the internet as per the patient's choice.[5]

Collaboration and Mutuality[edit | edit source]

The assessment findings should be discussed with the other health professionals for the betterment of the client. Mutual collaboration between the health professionals and the caregiver gives a positive outcome. The patient may perceive pain differently at different points of time with different people. So, discussing the patient's pain assessment findings among the caregivers and other members of the team will give us accurate assessment findings. Physiotherapists should know that everyone has a role in trauma-informed care and everyone should not be an expert to help the client feel better. [3][4][5]

Empowerment, Voice, and Choice[edit | edit source]

The physiotherapist can provide emotional and psychological support to the patient so that he/she can describe the pain in a comfortable manner. The patient should be involved in the shared decision-making process, goal setting, and strategies to cope with the pain. The physiotherapist should help the patient in developing self-advocacy skills.[3][4]

Cultural, Historical and Gender Issues[edit | edit source]

All the patients should be equally treated with respecting the cultural and historical background of the patient. While doing the examination, the patient's privacy and cultural aspects should be considered for example: taking proper consent and explaining the procedure before undressing the female patient for the examination if needed. If some patients feel comfortable with the physiotherapist of the same gender, the organization should consider the patient's decision.[3][4][5]

Considerations[edit | edit source]

  • The assessment shouldn't be done in a rush. The patient should be given adequate time to express himself. The physiotherapist should follow the pace of the patient allowing the patient to cope with the situation.[4]
  • Physiotherapists should be aware of the objects and environment that can retraumatize the patient and continuously ask the patient and remove those things if possible.[4]
  • While palpating or doing any examination, the physiotherapists should highly respect the patient's boundaries. Body positioning of the patient and physiotherapist also affect the assessment session.[4]
  • Usually the traumatized patients have a low pain threshold. so, the physiotherapist should perform the special tests and examination from parts that are less painful and give proper information to the patient about the procedure you are going to perform. [4]
  • Physiotherapists should be able to differentiate either the pain is due to central sensitization or not.[4]

Outcome Measures[edit | edit source]

The pain of the patient should be recorded while assessing. Physiotherapists can choose whether to use the self-report measure, functional measure, or physiological response measures. Routine reassessment should be performed as per the assessment findings.

References[edit | edit source]

  1. International Association for the Study of Pain.IASP terminology.Available from: [Accessed:19 July 2020]
  2. Hopper EK, Bassuk EL, Olivet J. Shelter from the storm: Trauma-informed care in homelessness services settings. The open health services and policy journal. 2010;3(2):80-100.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration,2014.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 HF N. Intervention for physiotherapists working with torture survivors with special focus on chronic pain, PTSD, and sleep disturbances. Denmark: dignity; 2014
  5. 5.0 5.1 5.2 5.3 Sanders MR, Hall SL. Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness. Journal of Perinatology. 2018 Jan;38(1):3-10.
  6. Wideman TH, Edwards RR, Walton DM, Martel MO, Hudon A, Seminowicz DA. The multimodal assessment model of pain: a novel framework for further integrating the subjective pain experience within research and practice. The Clinical journal of pain. 2019 Mar;35(3):212.