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Physiotherapy Assessment of Pain within a Trauma-Informed Care Model

Original Editor - Redisha Jakibanjar


Top Contributors - Farah Al Dweik, Redisha Jakibanjar, Naomi O'Reilly, Kim Jackson, Alexandra Stead, Amal Abbasi, Admin, Vidya Acharya and Anna Fuhrmann  


Introduction

Trauma-Informed Care (TIC) in physiotherapy for refugees extends beyond applying specific treatment techniques to prioritise the therapeutic relationship, emotional safety, and the patient's capacity for affect regulation.[1] This approach requires cultural openness and flexibility on the part of the clinician.[2][3]

Pain is a common and often central presenting concern in this population. Understanding it requires a biopsychosocial lens: pain in displaced people is shaped not only by physical injury or illness, but by the neurobiological effects of chronic stress, psychological distress, social isolation, and cultural context.[4] This page applies the principles of the Trauma-Informed Care model to the specific task of physiotherapy pain assessment and provides a practical clinical framework to guide that process.[1][5]

Refugee Experiences

The following experiences from refugees highlight how fear, uncertainty, and ongoing stress can continue even after physical displacement. These experiences help illustrate the importance of trauma-informed approaches when assessing pain in displaced populations.[6]

"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

Understanding Pain in a Trauma Context

Definition of Pain

According to the International Association for the Study of Pain (IASP) (Revised 2020) "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." [7]

Several key notes within the IASP definition are particularly relevant to trauma-informed practice. Pain is influenced by biological, psychological, and social factors, and pain should not be viewed only as a physical symptom. The notes also highlight that pain and nociception are not the same, that a person's report of pain should be respected, and that pain may be expressed in different verbal and non-verbal ways. This reinforces a need for patient-centred and biopsychosocial approaches used in trauma-informed physiotherapy.[3]

How Trauma Affects Pain

Trauma can affect the way pain is perceived and processed. Chronic traumatic stress may alter the limbic system, autonomic nervous system, and hypothalamic-pituitary-adrenal (HPA) axis, which can contribute to persistent pain and changes in central pain processing.[8]

Pain responses in people with trauma histories are not always the same. Some people may experience increased pain sensitivity (hyperalgesia), while others may show reduced sensitivity (hypoalgesia) or mixed responses depending on the body region, type of stimulus, and chronicity of trauma.[9] Physiotherapists should avoid making assumptions about pain presentation and instead use careful, individualised assessment.

Central Sensitisation may be present when pain is widespread, disproportionate to tissue findings, or associated with features such as allodynia, hyperalgesia, fatigue, or sleep disturbance. It refers to increased responsiveness of nociceptive neurons within the central nervous system.

Trauma-Informed Care Model

The trauma-informed care model is a framework that acknowledges the impact of trauma and provides a structured approach to responding to it. Its purpose is to enhance the physical, psychological, and emotional safety of both service providers and patients, while offering patients opportunities to rebuild a sense of control and empowerment.[1][10]

Table 1. Application of the Six Trauma-Informed Care Principles to Physiotherapy Pain Assessment
Principle Application to Pain Assessment
1.Safety[1] Create a physically and psychologically safe environment. Ensure the patient can discontinue the assessment at any point.
2. Trustworthiness & Transparency[1] Make clinical reasoning transparent. Record findings consistently; use validated outcome measures; respect autonomy.
3. Peer Support[1] Where appropriate, offer peer support. Normalise pain experiences linked to emotional suffering or central sensitisation.
4.Collaboration & Mutuality[1] Discuss findings with the multidisciplinary team. Involve the patient in interpretation and planning. All team members have a role.
5. Empowerment, Voice & Choice[1] Support patients to describe pain in their own words. Involve them in goal-setting and shared decision-making.
6. Cultural, Historical & Gender Issues[1] Respect cultural and gender preferences. Adapt examination approach accordingly. Address implicit bias.

Applying TIC Principles to Pain Assessment: A SOAP Framework

The following section organises clinical guidance for trauma-informed pain assessment using the SOAP format (Subjective, Objective, Assessment, Plan). This structure helps translate trauma-informed care principles into practical physiotherapy assessment, and clinical reasoning.[11][5]

Subjective Assessment

Relevant trauma-informed principles in this stage include safety, empowerment, voice and choice, and cultural considerations.[1] The subjective assessment is where the patient has the opportunity to tell their story, describe their pain experience, and establish a therapeutic relationship. In a trauma-informed context, this stage requires particular attention to the environment, the phrasing of questions, and the pace of the interaction.[2][3][11]

Environment and Safety

  • Before beginning the assessment, introduce yourself, explain your role, and describe what the assessment will involve. Ask the patient if they have any questions or concerns before proceeding.[1]
  • The assessment space should be private, quiet, and free from objects or environmental triggers that may cause distress. Check the patient’s comfort throughout the session.[1][5]
  • Inform the patient that they may pause or stop the assessment at any time, either verbally or non-verbally.[1]
  • Explain confidentiality, including what information may be shared and with whom, and obtain consent for this. [1] Allow enough time for the subjective assessment and follow the patient’s pace, especially in early sessions.[5]

Subjective Pain History

  • Ask about pain location, onset, quality, duration, and behaviour (aggravating and easing factors) using open questions rather than leading ones.[11]
  • Use inclusive language and avoid assumptions about family structure, occupation, religion, culture, or gender.[1]
  • Ask about the person’s understanding of their pain to better understand their experience, beliefs, and explanatory model, and to identify areas where education may be helpful.[11]
  • Document pain using the patient’s own words where possible, rather than paraphrasing or interpreting their experience.[1][11]

Trauma-Associated Conditions

Be alert to features in the pain history that may indicate trauma-related conditions:[9]

Table 2. Trauma-Associated Conditions and Subjective Clinical Indicators in Pain Assessment
Condition What to listen For
Post-Traumatic Stress Disorder (PTSD)[9] Hypervigilance, avoidance of body regions or movements, flashback-triggered pain, difficulty describing symptoms, dissociation during history-taking
Anxiety[9] Pain catastrophising, fear-avoidance beliefs, widespread body tension, somatic complaints without clear physical cause, difficulty relaxing during assessment
Chronic Pain[9] Pain >3 months, multiple pain sites, significant functional limitation, prior unsuccessful treatments
Sleep Disturbance Pain worse in the morning or after rest, fatigue-driven pain amplification, nightmares or insomnia alongside pain, difficulty recovering between sessions

Language and Interpreter Considerations

Many displaced persons will require an interpreter. This has significant implications for the subjective assessment:[12]

  • Use trained medical interpreters where possible. Avoid using family members, especially children, as interpreters for pain and trauma history.[12]
  • Allow additional time when working with interpreters to support accurate translation and allow space for patient reflection.[12]
  • Be aware that pain, emotional distress, and bodily experiences may be described differently across languages and cultures.
  • Meanings may not always translate directly.[12][13]
  • Questions and communication should be directed to the patient rather than the interpreter.[12]

Objective Assessment

Relevant trauma-informed principles in this stage include safety, trustworthiness and transparency, and cultural and gender considerations.[1] The objective assessment involves physical examination and use of validated outcome measures. In a trauma-informed context, this requires explicit attention to consent, body positioning, and the patient's right to modify or stop the examination at any point.[1][5]

Consent and Preparation

  • Explain each part of the physical examination before starting, including what will be done, why it is being performed, and what the patient may experience during the assessment.[1][5]
  • Obtain verbal consent before physical contact and again before moving to a different body region.[1]
  • Be aware of cultural and gender preferences during the examination. Requests for a physiotherapist of a specific gender should be accommodated where possible.[1]
  • Allow the patient to choose their position and level of undressing within clinical necessity, and maintain privacy throughout the assessment.[1]

Physical Examination

  • Begin the physical examination with body regions that are less sensitive or less likely to cause distress, and progress gradually as tolerated. [5]
  • Pay attention to both verbal and non-verbal responses during the examination. Pause if the patient shows signs of distress, discomfort, or dissociation.[1][5]
  • Be aware of your positioning during the examination and avoid positions that may feel threatening or restrict the patient’s ability to move freely.[5]
  • Avoid sudden movements, unexpected touch, or loud noises during examination.[5]

Clinical Features During Physical Examination

During physical examination, look for signs that may indicate central sensitisation or trauma-related pain responses.[9] These may include:

  • Allodynia (pain from light touch or non-painful stimuli)[9]
  • Widespread tenderness that appears disproportionate to the reported mechanism of injury
  • Differences between reported pain severity and objective findings[9]
  • Autonomic responses during examination, such as sweating, flushing, or tachycardia
  • Guarding, bracing, or avoidance patterns that are not fully explained by structural pathology[9]

Assessment - Clinical Reasoning

Relevant trauma-informed principles in this stage include trustworthiness and transparency, and collaboration and mutuality.[1] The assessment stage involves integrating subjective and objective findings into a clinical formulation. In a trauma-informed model, this formulation is shared transparently with the patient and with the wider multidisciplinary team.[1][5]

Interpreting Findings

  • Consider whether pain features are consistent with nociceptive, neuropathic, or nociplastic pain mechanisms. Nociplastic pain is linked to altered nociception without clear evidence of tissue damage or nerve injury and is commonly associated with central sensitisation.[9][14]
  • Contextualise findings within the patient's biopsychosocial history: social isolation, ongoing threat to safety, stress, and previous experiences of healthcare can all influence pain presentation.[11]
  • Avoid explaining complex presentations through a single biomedical diagnosis alone. Pain experiences should be documented in a way that reflects their physical, psychological, and social dimensions.[11]

Multidisciplinary Communication

  • Share relevant assessment findings with other members of the healthcare team, including mental health practitioners, social workers, and medical staff, where appropriate and with the patient's consent.[1]
  • Recognise that patients may present differently across settings and with different practitioners. A patient's pain experience may vary depending on their felt sense of safety with a given provider.[5]
  • Use consistent, patient-centred language in written and verbal communication.. Document pain descriptors in the patient's own words.[1][11]

Plan

Relevant trauma-informed principles in this stage include empowerment, voice and choice, and collaboration and mutuality.[1] The planning stage includes selecting appropriate outcome measures, setting goals together with the patient, and planning follow-up where needed. Decisions should be discussed openly with the patient and guided by their priorities and preferences.[15]

Recommended Outcome Measures

Outcome measures should be selected based on the patient’s presentation, preferences, and the available evidence for the population being assessed. Commonly used measures can be grouped into three main categories:[11][15]

Table 3. Recommended Outcome Measure Categories for Trauma-Informed Physiotherapy Pain Assessment
Category Example Note
Self-report[11][15] Numeric Pain Rating Scale (NPRS); Brief Pain Inventory (BPI); Central Sensitisation Inventory (CSI) NPRS and BPI validated in multiple languages. CSI useful when central sensitisation suspected.
Functional[15] Patient-Specific Functional Scale (PSFS); Pain Disability Index (PDI) Select goals collaboratively. Use activities meaningful in patient's daily context.
Physiological[11] Pressure pain threshold (algometry); Heart rate variability; Observable pain behaviours Use with caution, as anxiety or dissociation may influence the results.

Collaborative Goal-Setting

  • Goals should be identified together with the patient and should reflect what is meaningful and realistic within their daily life and current situation.[15]
  • Where appropriate, goals can also be discussed with other members of the care team, including mental health practitioners, to support a more coordinated approach across services.[1]
  • Patients should be supported to express their needs and concerns throughout the rehabilitation process, both within physiotherapy and when accessing other services.[15]

Clinician Self-Reflection Checklist

The following checklist can be used before, during, or after a trauma-informed pain assessment to support clinical reflection and guide trauma-informed physiotherapy practice.[5]

Table 4. Clinician Self-Reflection Checklist for Trauma-Informed Pain Assessment
Before the Assessment During the Assessment After the Assessment
The environment should be private, safe, and comfortable, with as few potential triggers as possible.[1] Explain the clinician’s role, the purpose of the assessment, and what the assessment will involve before starting.[1] Share assessment findings with the patient using clear and accessible language.[5]
Review any available background information that may require additional sensitivity (e.g., trauma history, cultural, or gender considerations).  Inform the patient that they may pause or stop the assessment at any stage.[1] Involve the patient in goal-setting and treatment planning decisions.[15]
Arrange for an interpreter when required and ensure they understand the assessment process.[12] Obtain explicit consent before each component of the physical examination.  Communicate relevant findings to the multidisciplinary team, with the patient’s consent.[1]
Allow enough time for the assessment and avoid rushing the session. Use inclusive and non-gendered language throughout the session. Select outcome measures that are appropriate to the patient’s context and language.[11][15]
Be aware of personal assumptions or biases that may influence the assessment.[13] Document pain using the patient’s own words where possible.[11] Consider the emotional impact of the session and seek supervision or peer support if needed.[16][17]
Monitor for signs of distress, dissociation, or re-traumatisation, and pause the assessment where appropriate.[1][5]
Respect cultural and gender preferences related to examination and privacy.[11]
Be aware of possible features of central sensitisation, anxiety, PTSD, or sleep-related pain.[9]

Conclusion

Trauma-informed pain assessment is not a separate part of physiotherapy practice. It is an approach that considers how trauma may influence the patient’s pain experience, communication, sense of safety, and engagement during assessment and rehabilitation. When working with displaced persons and refugees, creating a safe and collaborative assessment process is often an important part of understanding the patient’s presentation and supporting meaningful rehabilitation outcomes.[1][5][11]

The SOAP framework in this page aims to provide a practical way to apply trauma-informed care principles within physiotherapy assessment and clinical reasoning. The suggested clinical prompts, outcome measures, and reflection points may help physiotherapists adapt their assessment approach to better support people affected by trauma and displacement.[11][15]

Trauma-informed practice continues to develop through clinical experience, supervision, reflection, and shared learning. Physiotherapists should also recognise the importance of their own wellbeing and seek support when needed while working with trauma-exposed populations.[16][17]

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 Substance Abuse and Mental Health Services Administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. Rockville (MD): SAMHSA; 2014.
  2. ↑ 2.0 2.1 Khalil H, Fricker I, Nazzal MS, Al-Qudah A, Lababneh T, Yousef H, et al. Delivering trauma-focused physiotherapy interventions for trauma-exposed refugees: a qualitative study exploring perspectives and experiences from Jordan and Kenya. Physiother Theory Pract. 2025;41:1886-1900.
  3. ↑ 3.0 3.1 3.2 Nazzal MS, Al-Qudah A, Lababneh T, Yousef H, Golden S, Busse M, et al. Refugees' experiences of a trauma-focused physiotherapy program. Physiother Res Int. 2026.
  4. ↑ Anisman H, Doubad D, Asokumar A, Matheson K. Psychosocial and neurobiological aspects of the worldwide refugee crisis: from vulnerability to resilience. Neurosci Biobehav Rev. 2024;169:105736.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 5.15 Berring LL, Holm T, Hansen JP, Delcomyn CL, Søndergaard R, Hvidhjelm J. Implementing trauma-informed care—settings, definitions, interventions, measures, and implementation across settings: a scoping review. Healthcare (Basel). 2024;12:908.
  6. ↑ Nissen A, Hynek Grøholt K, Scales D, Hilden P, Straiton M. Chronic pain, mental health and functional impairment in adult refugees from Syria resettled in Norway: a cross-sectional study. BMC Psychiatry. 2022;22:533.
  7. ↑ Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, et al. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020;161(9):1976-82.
  8. ↑ Young G, Thielen H, Samuelson K, Jin J. Neurobiology of chronic pain, posttraumatic stress disorder, and mild traumatic brain injury. Biology (Basel). 2025;14(6):662.
  9. ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 Tesarz J, Baumeister D, Andersen TE, Vaegter HB. Pain perception and processing in individuals with posttraumatic stress disorder: a systematic review with meta-analysis. Pain Rep. 2020;5(5):e849.
  10. ↑ Substance Abuse and Mental Health Services Administration. Practical guide for implementing a trauma-informed approach. Rockville (MD): SAMHSA; 2023.
  11. ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 11.12 11.13 11.14 11.15 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. Clin J Pain. 2019;35(3):212-21.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 MacFarlane A, Huschke S, Pottie K, Hauck FR, Griswold K, Harris MF. Barriers to the use of trained interpreters in consultations with refugees in four resettlement countries: a qualitative analysis using normalisation process theory. BMC Fam Pract. 2020;21(1):246.
  13. ↑ 13.0 13.1 Brodda Jansen G, Henriksson E, Hasselstrom J. Two patient cases illustrating the importance of addressing physical and mental trauma as a cause of pain in refugee women. Front Psychiatry. 2021;12:628750.
  14. ↑ Karimov-Zwienenberg M, Symphor W, Peraud W, Decamps G, Schalinski I. Childhood trauma, PTSD/CPTSD and chronic pain: a systematic review. PLoS One. 2024;19(8):e0309332.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 15.6 15.7 15.8 Hutting N, Caneiro JP, Ong'wen OM, Miciak M, Roberts L. Person-centred care for musculoskeletal pain: putting principles into practice. Musculoskelet Sci Pract. 2022;62:102663.
  16. ↑ 16.0 16.1 Lim K, Thng S, Yeo AY, Seow G, Goh WC, Ho CS. Secondary traumatic stress disorder among physiotherapists working in high morbidity departments: a cross-sectional study. Front Psychol. 2023;14:1266929.
  17. ↑ 17.0 17.1 Farooq A, Uwagwu J, Keane C, Brosnan M. Healing the healers: a systematic review on the burden of secondary traumatic stress among healthcare providers. BJPsych Open. 2025;11(1):e12.
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