Rehabilitation for Survivors of Torture: Observations from Humanity and Inclusion

Original Editor - Eric Weerts from Humanity and Inlcusion as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Wanda van Niekerk, Kim Jackson and Kirenga Bamurange Liliane  

Value Added Practice and Considerations for Enhancement in Migrant Care

Physiotherapy services are being used to support the recovery of survivors of torture within an interdisciplinary setting. As the contexts of the victims are changing and new ways are needed to increase access to physiotherapy for the users, it is important to back up these needs with more evidence based practice allowing smooth integration of physiotherapy practice in the mental health driven care models currently. This situation presents a significant challenge to the activity set up and needs attention and consideration from the field actors and stakeholders making the care possible and  involved in it. Evidence based practices available so far suggest that they need to be scaled up and proposed as complete  activities, either as standalone or in a care chain as difficulties in context allow, for patients and the care team monitored by clinical practice scaling, with use of common outcome measures, operational research and capacity building of the workforce involved. Techniques applied and their modalities should pay attention to the specific background and particular ‘ history of the patients' traumatic experiences to withhold trust and therapeutic connexion with the patient. As there is a need to continue developing research and translate this research into practice for the field, it should also be backed up by adapting the methods of delivery of the services to constant changing environments. The ultimate goal for the physiotherapy is to ensure that the patient can integrate the acquired skills from the treatment into their recovery and reconstruction process. This should not be limited to the therapeutic compliance only face to face, but should be put in perspective with minimum conditions of safety, protection and benefit of basic needs. The shift of care as recovery advances and its follow-up and ultimately discharge from treatment should also be taken into account in the care model of physiotherapy, be it to equip the patient with skills that can use to increase their resilience as well as promote elements of an inclusive immediate living environment the recovered person can return too at community level. 

Rational for Enhancing the Role of Physiotherapy Treating Survivors of Torture

Physiotherapy services are considered as a significant  care component for enhancing parts and phases of the recovery of survivors of torture, especially when the first intake of these patients shows lesions and injuries requiring physical rehabilitation in order to recover from injury and regain normal function again. It is known that the effects of Violence and Torture, having a devastating impact on the individual and their environment, are not only physical but of a psychological nature as well. It is crucial therefore to have all necessary services (medical, psychological, legal, social) aligned in the most appropriate and relevant way for the benefit to the patient in order to maximise a  recovery that should make sense to them and their surroundings . 

More recent development in the humanitarian space relating to increased migration of populations that are exposed to a higher risk of contact with violence / injury events and effects, service provision for this population got more attention from a small number of experienced  health providers in physical and psychological rehabilitation attempting to raise more attention to the needs for these victims beyond the classical medical and psychological approach and its  available evidence base. Alongside the pool of health professionals working with this population, physiotherapist staff working in these conditions/environments face important challenges on how to combine functional recovery with the special and unique needs these patients have when it comes to managing the symptoms and complaints the patients present with once the first wave of physical impairments (muscular skeletal, neurological,…) have been addressed and should answer to the widely accepted holistic recovery path when possible.

At this point, physiotherapist and/or rehabilitation workers are confronted with an additional therapeutic questioning that, at times, is addressed by a range of approaches such as  specialised and dedicated treatment techniques combining other care elements beyond the classical body systems and structures ’ observation that physiotherapy uses. They include managing the clinical signs of persistent pain, for example altered body perception by the patient, reactions towards flashbacks relating to traumatic events leading to a  continuing search for solutions and self-care options to help the patient manage the signs, live with them, insert them in the patient's own resilience pattern and daily life struggles that they are trying to overcome . 

Taking this into consideration, it is inconceivable  that physiotherapy is being able to address these issues alone, and there is a need to integrate these issues through the wider circle of health care workers that need to offer and share their specialties (mental health professionals, medical specialties, social workers, legal experts ,… ) in the holistic care program of the patient that was formulated during of the initial intake into the care program .

Barriers and Challenges to Consider for Physiotherapist Treating Survivors of Torture

The practice space and clinical environment of the physiotherapy integration contributing to access to services for Survivors of Torture and more particularly for physiotherapy must face a certain number of barriers. To mention a few, is the access to physiotherapy put in competition with other services (medical, social, legal, psychological ) on the basis of prioritising financial means to these other services be it on the local level but also on the more global level of allocating finances to care for Survivors of Torture.

Although being part of a multi-disciplinary approach for Survivors of Torture, physiotherapy may not always be included systematically in the care set up of Survivors of Torture Programs. Competition for financial means between medical and mental health providers, the difficulties in integrating physiotherapy in the care model have also their reasoning in not using the already available evidence-based physiotherapy in existing and functioning care systems to patients that could benefit from it. This has an impact on the interest to pursue more research in this field that would feed into the need for better and consistent indicators used by all care stakeholders around the patient in order to share the same focus and goals on the recovery of the patients and answering to their needs and expectation in one voice shared by the team. When these issues are compounded, this might lead to the actual reality leading to limited tools, approaches, treatment techniques for the physiotherapy stakeholders to handle. Moreover the geographical spread of the physiotherapy workforce in the areas where the Survivors of Torture population meets most of the needs is unevenly distributed and compounded by the lack of skills development either at entry level practice but also at post graduate education level, leaving few offers for specialised physiotherapy training in the field of Survivors of Torture skills management.

A small number of stakeholders have developed specialised models of care in physiotherapy for Survivors of Torture and lead to substantial proof of impact and changes in terms of outcomes for patients as a standalone input or integrated with other services. Their practice record and subsequent publication of their results have lead to results and impact that can be reproduced in a variety of settings.

Environment of Care Accessibility, Modalities and Impact on Care and Caretakers

Next to contend is the position of physiotherapy within models of care. They need to be put in perspective with the environment as to where the care is provided and the living conditions that patients are returning too after their treatment. Examples of these challenges and approaches within a constantly changing environment include the choice of offering the best care possible within an unsecure setting not being conducive to ensuring a holistic approach for survivors of torture care. This seems to reflect the situation of an increasing number of settings where delivery of physiotherapy is being either considered or ongoing. How can physiotherapy find its place in order to ensure its fullest range of known impact and changes in the lives of survivors of torture?

Some answers can be found in the operational capacity of the structures where the care is provided, either under a mandate of government health care provision, private care institutions, charity based providers and so called ‘informal spaces ‘’ where the care is offered in order to ensure protection and confidentiality for users and providers alike. The latter might have seen an evolution more recently in being able to capture an even more ‘’invisible ‘’ cohort of service users that is aspiring to access the care in very unstable conditions be it to access the services, become a user of the service and being a user of services going back to an environment that could expose them to new or additional trauma that they were seeking care for in the first place.

It is clear that organisations, structures and providers of physiotherapy services, either as a relative standalone or integrated in a multidisciplinary service, do not chose the context of the survivors of torture, especially in the humanitarian space made up of a mixture of conflict, migration, violence / torture exposure and sustained insecure environments. The dimensions of protection, basic needs (food, shelter, education) delivered in a safe environment need also to be considered in order to create minimum care conditions for the victims and providers alike.

This leads us to the crucial reflection on how physiotherapy providers and their immediate network can be sufficiently prepared, briefed and trained in additional skills to function in such environments either adapting themselves to a changing context locally and/or fulfilling their roles in technical expertise provision when not familiar with the environment. Self care, psychological resilience, mental health hygiene should also play an important part in the training of physiotherapist when dealing with survivors of torture in these environments supplemented with a constant follow-up and staff care component during the active clinical exposure to the patients and briefing opportunities during breaks or end of assignments.

Core Techniques and Competencies for Physiotherapists Treating Survivors of Torture

Clinical intake information relating to mobility, pain, function and special attention to avoid flashbacks during intake and after (avoiding treatment modalities implying certain positions, use of physical agents, touch on certain body parts, room lighting … )  should be prioritised, and ideally completed and/or informed by other members of the care team focusing especially on gender/age issues Some indications that might be indicative for treatment focus: 

• Acute and Chronic Pain;
• Decreased Posture, Body Awareness, Self-regulation, Proprioception;
• Decreased Strength;
• Decreased Range of Motion (ROM);
• Decreased Mobility;
• Decreased Ability to Perform Desired Activities;
• Specific Types of Torture (Falanga, Suspension) effects on the Neuro-muscular Skeletal System 

During intake, most survivors of torture will have many clinical similarities with mainstream physical trauma patients aimed at enhancing the functional regain of mobility and activities, this stops when the issue of the experienced deep trauma with the patient takes over their clinical picture as the initial signs of visible trauma (MSK, Neurology,…) subside and the role of rehabilitation needs to be sensitive to the specifics of Violence and Torture and its deep impact on the affected person not always visible through the clinical signs. Most practitioners will relate then to the chronic pain remaining, its perception and impact on function and body awareness among others.    

The physiotherapist needs to take extra precautions on how to pinpoint these vulnerabilities and how to build confidence and safety with the patient. Next to recovering and accompanying the functional regain initially started, the recovery of body image with all its limits and possibilities needs to be gradually pursued and spread over the treatment time. Good practices in group for instance focusing on common thematics such as body awareness, pain perception and even relationship between awareness, body and lived trauma should start to be reconnected.  

Known approaches and techniques that have proved their impact and report satisfaction with the patients include;

• Sensory awareness recovery through Basic Body Awareness Therapy; 
• Sensory re-education in case of nerve sensation loss;
• Relaxation techniques with a focus on respiratory modalities; 
• Massage for relaxing or tension release; 
• Passive and active mobilisations  of motor system with focus on connective and soft tissue;
• Reconditioning exercise with attention on daily living activities and gait perimeter increase. 

These techniques should always be briefed and introduced to the patient, taking into account their sensitivities and eventual reservations for certain modalities. Trust building and progressive increase and intensity of the activities should be done carefully. 

Additional techniques and modalities such as use of physical agents (hot, cold, vibrations, electrical currents stimulation) can be considered for pain relief and relaxation though applying the highest vigilance in case this could create discomfort in relation with former experiences relating to the patients’ trauma. Use of assistive devices to increase motor stability, pain relief or facilitate impaired motion can also be proposed as long as there is not resistance from the patients’ perception or compliance. Ensuring these are worn to support function and do not compensate for acquired amyotrophy caused by wearing it too long.

Special Attention on Pain management for Survivors of Torture 

Within the realm of intervention of physiotherapy in humanitarian contexts confronted with pain issues, focus will point towards checking if an holistic approach within a multidisciplinary team is possible when offering  a limited range of interventions for the patients’ health seeking behaviour is more the rule then the exception . 

Clinical assessment of pain is essential and its particulars should be shared with all professionals of the care team in the interest of the patient. The different dimensions of this pain should be seen from the level of linking nociceptive pain through physical observation and functional performance, consider neuropathic pain linked with injuries and anamnesis of patient, as well as from altered central pain modulation mechanisms linked with the mental health status of the patient. All dimensions might be present and intertwined in one person. Treatment techniques and modalities when using physiotherapy, preceded by a multidisciplinary assessment mentioned above should be complemented with teaching the patient self-management skills to increase resilience against pain in daily life and development of coping strategies. Continuous observation and monitoring of the pain against all other aspects of the recovery process should be ensured within a team and interdisciplinary consensus. Physiotherapy professionals should be made aware of the mechanisms of pain encountered and cultural background of survivors of torture to ensure maximum precautions in place to avoid flashbacks and fostering a confidence relationship between therapist and victim.   

Outcome Measures, Impact Indicators and How the Patient Makes Sense of Them

As the impact of evidence based physiotherapy in the literature needs to be more looked into, the care providers and stakeholders need to integrate systematically the use of outcome measures and indicators to support for further development of this evidence base. It should also create a means to measure the progress of the patient, share this information within the multidisciplinary team. Adopting common outcome measures between the disciplines is still very difficult and comes into practice only at the end of the timeline of projects and care organization leaving no opportunity and validity to translate the data collected  into research findings. Operational research on the use of provisional choices of outcome measures (reported with pain scales, functional scales, quality of life perception on daily living activities by the patient, clinical changes in behaviour and symptoms during the patient intake period) agreed upon for a testing period should be the means to build this in every care set up and connect it with research questions leading to publications and findings. It allows an increase in evidence based practice of physiotherapy becoming more available within the interdisciplinary setting and can provide a perspective to the patients for feedback on progress during their treatment.

Follow Up and Community Outreach Care for Survivors of Torture

As much as attention is focused on intake and treatment for survivors of torture, it is as crucial to give shape throughout the care process on how and when the care process should end or shift towards a status where intensity, frequency, modality and relevance of treatment should be adapted or end. It is known that combination between individual sessions and group sessions can be an interesting modality for the patient to measure their own progress and be a mirror for personal feedback. Outcome measures that define the improved status are one important component to help decision making in this process. Additionally, the patient needs also to be prepared to join the living environment again and be equipped with new skills and advice to maintain the progress achieved throughout the recovery phases. Skills and attitudes acquired during treatment should enable them to reproduce these skills and translate them in a means for better resilience for future participation. Close relatives in their surroundings should also be part of this process either by being sensitised to the particular background of the patient and be instrumental in providing support. Physiotherapist are able to teach and equip the patients with such skills such as self care, relaxation, breathing exercises, mobility and exercise that is reproducible in their living environment.    

Resources

Humanity and Inclusion

Humanity and Inclusion is an independent and impartial aid organisation working in situations of poverty and exclusion, conflict and disaster since 1982. The organisation works alongside people with disabilities and vulnerable populations, taking action and bearing witness in order to respond to their essential needs, improve their living conditions and promote respect for their dignity and fundamental rights. They work in around sixty countries in emergency, reconstruction, chronic crisis and development contexts.

References