Jump to content

Trauma-Informed Physiotherapy for Human Rights Defenders and Activists

Original Editor - Farah Al Dweik Top Contributors - Farah Al Dweik, Alexandra Stead and Vidya Acharya


Introduction

Physiotherapists increasingly work with people affected by conflict, detention, and political violence, yet the rehabilitation needs of human rights defenders and activists remain underrepresented in physiotherapy literature and practice.[1] [2] Human rights defenders (HRDs) are individuals or groups who work to protect and advocate for human rights and fundamental freedoms.[3] This includes activists, journalists, lawyers, healthcare workers, humanitarian staff, and community leaders working in challenging or unsafe environments.[4]

Many human rights defenders live and work under continuous stress and insecurity. Some have experienced detention, torture, forced displacement, or threats linked to their advocacy and humanitarian work.[5][6] These experiences often affect both physical and psychological health.[5][6] [1]

[7]

Human Rights, Rehabilitation, and the Istanbul Protocol

The Istanbul Protocol is the international standard for the effective investigation and documentation of torture and other cruel, or inhuman treatment.[5] The second edition of the protocol expanded the role of healthcare professionals involved in rehabilitation and documentation processes, including physiotherapists and other rehabilitation professionals. This reflects growing recognition that torture and trauma can have long-term physical and psychosocial consequences that may not be fully captured through medical examination alone.[5]

The updated protocol highlights the importance of interdisciplinary assessment and rehabilitation approaches involving medical, mental health, and rehabilitation professionals.[5] Physiotherapists may contribute by documenting pain and the impact of trauma on daily activities. This may help provide a more comprehensive understanding of how torture and trauma affect quality of life over time.[6][8]

The inclusion of rehabilitation professionals within the Istanbul Protocol also reflects increased recognition of rehabilitation as part of dignity and reparation after human rights violations.[5][2]

[9]

Trauma Exposure and Common Clinical Presentations

In Syria, torture and arbitrary detention targeting activists, journalists, humanitarian workers, and other civilians have been widely documented throughout the conflict, with the Syrian Network for Human Rights reporting more than 15,000 deaths due to torture since 2011.[10] Similarly, in Sudan, violence against civilians, and mass displacement have further limited access to rehabilitation for many injured and trauma-affected individuals, including human rights defenders and community actors working in highly insecure environments.[11][12]

Survivors of torture and trauma may experience complex and overlapping physical, psychological, and functional difficulties.[13] [14] In physiotherapy settings, trauma is not always disclosed directly, and people presenting with conditions such as persistent pain may also be living with hypervigilance, disrupted sleep, or traumatic memories related to violence, detention, or ongoing stress. Physiotherapy assessment and rehabilitation therefore need to consider the broader biopsychosocial impact of trauma rather than focusing on physical injury alone.[1]

In practice, this broader understanding may influence clinical reasoning and treatment approaches during assessment and rehabilitation. For example, a physiotherapist may adapt pacing when symptoms increase with stress, recognise that pain responses may be linked to previous trauma experiences, or modify positioning during assessment if certain positions feel unsafe.[6][14]

Trauma Exposure Symptoms

Common reported symptoms include:

  • Headaches, dizziness, fatigue, and poor sleep.[6][13]
  • Persistent pain and pain sensitisation.[15]
  • Reduced activity tolerance and physical exhaustion.[13]
  • Difficulty participating in work, caregiving, or community activities.[13]
  • Fear of movement or reduced movement.[6]

Clinical Considerations During Assessment:

Common clinical considerations may include:

  • Difficulty concentrating during rehabilitation sessions.[6]
  • Heightened startle responses or discomfort with physical touch during assessment.[6][1]
  • Increased guarding, tension, or distress during movement assessment.[15]
  • Fluctuating rehabilitation engagement linked to stress, fatigue, or ongoing insecurity.
  • Functional limitations associated with detention, or injury.[13]
  • Symptoms associated with PTSD, and chronic stress influencing responses to pain and movement.[1]

Even among individuals who have not directly experienced torture or detention, the nature of human rights and humanitarian work itself can lead to chronic stress, reduced resilience, secondary trauma, and burnout.[14] In these contexts, physical symptoms are often closely connected to ongoing stress, grief, and fear.[6]

Trauma-focused Physiotherapy for Human Rights Defenders

Trauma-focused physiotherapy recognises that trauma can affect how people experience pain and rehabilitation.[5] Using trauma-informed principles and a person-centred approach can help physiotherapists understand symptoms through a broader biopsychosocial lens rather than focusing only on physical findings.[13]

Trauma-informed physiotherapy is also relevant within rehabilitation and justice frameworks, including the Istanbul Protocol, which recognises the role of rehabilitation professionals in supporting recovery after torture and trauma.[5][14]

[16]

Therapeutic Engagement

Therapeutic engagement can strongly influence how human rights defenders and activists experience physiotherapy assessment and rehabilitation.[14] Physiotherapists should pay attention to the nature of the individual’s work and daily environment. A journalist working under ongoing threat, a humanitarian worker exposed to repeated traumatic stories, or a person injured during protests may each experience rehabilitation differently.[3] [1] These experiences may affect how comfortable the person feels during physical assessment, or interaction within the rehabilitation session.[15]

Table 1: Clinical Consideration During Physiotherapy Application
Clinical consideration Physiotherapy application
Therapeutic Engagement and Rehabilitation Adaptation
  • Trust is often built gradually over multiple rehabilitation sessions.[14]
  • Clear communication and respecting boundaries can reduce distress and support rehabilitation engagement.[14]
  • Asking permission before physical contact may help individuals feel safer during assessment and treatment.[14]
  • Sessions may need pacing adjustments, breaks, or modifications depending on stress levels and symptom tolerance.[6]
  • Understanding the individual’s experiences and work context is important during rehabilitation planning.[12]
  • Survivors of detention or assault may feel unsafe in certain assessment positions or during hands-on assessment.[13]
  • Journalists or humanitarian workers exposed to repeated violence may become overwhelmed more quickly during rehabilitation sessions.[1]
Trauma disclosure Trauma-informed physiotherapy does not require individuals to disclose traumatic experiences. Physiotherapists instead recognise how trauma may influence pain responses, movement, and rehabilitation engagement.[8]
Stigma and Help-Seeking Some individuals may minimise symptoms, delay seeking rehabilitation, or prioritise work over their own health needs. Physiotherapists may need to support gradual engagement and realistic rehabilitation planning.[1][17]
Remote and Flexible Rehabilitation
  • Flexible rehabilitation approaches may be needed to support continuity of care for individuals affected by relocation, living in exile, or safety concerns related to attending in-person rehabilitation sessions.[18]
  • Physiotherapists should consider legal, professional, and organisational considerations when delivering remote services, particularly for individuals living in contexts affected by surveillance, or ongoing conflict[19]
  • Language barriers within the hosting country may also affect access to local rehabilitation services and increase the need for remote rehabilitation approaches.[19][12]
  • Additional care may be needed when sharing exercise videos or personal health information, including the use of secure and approved communication platforms.[19]
  • Rehabilitation approaches may need adaptation depending on the individual’s environment and access to technology.[18][19]

Intersectoral Considerations

In some situations, rehabilitation may be closely connected to legal or security related concerns. Physiotherapists may therefore need to understand the wider context affecting the individual and work within an intersectoral approach involving mental health teams, legal representatives, or security focal points already involved in the person’s support network.[14] This may help support safer communication, continuity of care, or during periods of insecurity.[5]

Functional Rehabilitation

In trauma-informed physiotherapy, rehabilitation also supports dignity and community reintegration. Functional recovery can therefore become closely connected to broader recovery and reparation processes after human rights violations.[14] For example, the Coalition for Just Reparations (C4JR), which contributed to the development of the Yazidi Survivors Law in Iraq, identified rehabilitation as an essential component of reparation processes for survivors of grave human rights violations.[20]

In many situations, rehabilitation goals are guided by the HRD's functional priorities. This may include improving tolerance for prolonged sitting while preparing investigation reports or reducing shoulder or neck pain while holding a camera or computer for long periods. Rehabilitation approaches may therefore include targeted strengthening, stretching, and movement-based strategies linked to the specific physical demands of the individual’s daily activities and work roles.[15][20] Tools such as the Patient-Specific Functional Scale (PSFS) may help identify meaningful functional goals from the person’s perspective, while the International Classification of Functioning, Disability and Health (ICF) model may support broader understanding of how trauma, symptoms, participation, environmental factors, and work context interact within rehabilitation planning.[2]

The nature of human rights defenders’ work and lifestyle may also contribute to secondary trauma and burnout, which may further affect pain, fatigue, sleep, and physical exhaustion.[2] [8]Physiotherapy approaches may therefore include psychoeducation about stress and its biopsychosocial impact, supporting self-care, healthy lifestyle routines including sleep hygiene, movement-based practices during work, and posture awareness linked to emotional regulation.[15]

[21]

Conclusion

Working with human rights defenders and activists often means working with people who continue living and functioning under ongoing stress, insecurity, or the physical consequences of detention and violence.[3] In many situations, rehabilitation is not only about symptom reduction, but about helping the person continue daily life and advocacy despite ongoing instability and stress.[14][13]

Despite this, physiotherapy still remains underrepresented within many torture rehabilitation and human rights discussions. The inclusion of rehabilitation professionals within the Istanbul Protocol reflects growing recognition that physiotherapists may contribute not only to rehabilitation, but also to documenting the long-term functional impact of torture and trauma.[5]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Edwards AJ. Trade in torture tools threatens detainees and protestors everywhere – it must be banned. Torture. 2024;34:44-47.
  2. ↑ 2.0 2.1 2.2 2.3 International Rehabilitation Council for Torture Victims. United against torture: healing and justice for survivors 2026-2029. Copenhagen: IRCT; 2025.
  3. ↑ 3.0 3.1 3.2 United Nations Office of the High Commissioner for Human Rights. Declaration on Human Rights Defenders. Geneva: OHCHR; 1998.
  4. ↑ Office of the United Nations High Commissioner for Human Rights. The Declaration on Human Rights Defenders. Geneva: OHCHR.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 Office of the United Nations High Commissioner for Human Rights. Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. 2nd ed. Geneva: OHCHR; 2022.
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 Diaz M, Lundell IW. Hidden scars: The impact of torture, traumatic brain injury, and PTSD on executive functions – a narrative review. Torture. 2025;35:38-49.
  7. ↑ UN Human Rights. Protect Human Rights Defenders [YouTube]. Published 30 June 2022. Available from: https://www.youtube.com/watch?v=auQkdTl-U5k [Last accessed 25 June 2026]
  8. ↑ 8.0 8.1 8.2 Amris K, Jones LE, Williams ACC. Pain from torture: assessment and management. Pain Rep. 2019;4:e794.
  9. ↑ IRCT. Istanbul Protocol Update: What Does the Updated Istanbul Protocol Say to Health Professionals? [YouTube]. Published 27 September 2022. Available from: https://www.youtube.com/watch?v=UtJJPPeEMY4 [Last accessed 25 June 2026]
  10. ↑ Syrian Network for Human Rights. On the International Day in Support of Victims of Torture: SNHR Has Documented the Death of 15,383 Syrians Under Torture Since March 2011. 2024.
  11. ↑ World Health Organization. Public health situation analysis: Sudan conflict and complex emergency. Geneva: WHO; 2024.
  12. ↑ 12.0 12.1 12.2 Humanity & Inclusion. Sudan crisis: Rehabilitation services critical for war-wounded and persons with disabilities. London: Humanity & Inclusion; 2024.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 13.7 DIGNITY - Danish Institute Against Torture. Health consequences of torture. Copenhagen: DIGNITY.
  14. ↑ 14.00 14.01 14.02 14.03 14.04 14.05 14.06 14.07 14.08 14.09 14.10 Substance Abuse and Mental Health Services Administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Rockville (MD): SAMHSA; 2014.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 Hasha W, Igland J, Fadnes LT, Kumar B, Haj-Younes J, Strømme EM, et al. The effect of physiotherapy group intervention in reducing pain disorders and mental health symptoms among Syrian refugees: a randomized controlled trial. Int J Environ Res Public Health. 2020;17:9468. doi:10.3390/ijerph17249468.
  16. ↑ UN Human Rights. Finding justice after torture is essential. Published 21 June 2016. Available from: https://www.youtube.com/watch?v=sD8asQZRXaw [Last accessed 25 June 2026]
  17. ↑ Wachter K, Murray SM, Hall BJ, Annan J, Bolton P, Bass J. Stigma modifies the association between social support and mental health among sexual violence survivors in the Democratic Republic of Congo: implications for practice. Anxiety Stress Coping. 2018;31:459-474.
  18. ↑ 18.0 18.1 Humanity & Inclusion. Designing and implementing telerehabilitation: At a glance. Lyon: Humanity & Inclusion.
  19. ↑ 19.0 19.1 19.2 19.3 World Physiotherapy/INPTRA Digital Physical Therapy Practice Task Force. Report of the World Physiotherapy/INPTRA Digital Physical Therapy Practice Task Force. 2019 May.
  20. ↑ 20.0 20.1 Coalition for Just Reparations. Right to rehabilitation as reparation for survivors of grave human rights violations: C4JR launch new monitoring guide for ISIL survivors in Iraq. 2024 Jun 12.
  21. ↑ Coalition for Just Reparations - C4JR. What is rehabilitation as a form of reparation and why is it important? [YouTube]. Published 28 August 2023. Available from: https://www.youtube.com/watch?v=_dcZs0yDJhg [Last accessed 25 June 2026]
Retrieved from "https://www.physio-pedia.com/w/index.php?title=Trauma-Informed_Physiotherapy_for_Human_Rights_Defenders_and_Activists&oldid=380298"