Rehabilitation need for migrant populations: physiotherapy treatment of the PostTraumatic Stress Disorder and chronic pain from torture results

NUMBERS OF THE MIGRATION PHENOMENON

In the ICD 10 the PTSD is defined as an anxiety disorder accompanied by a triad of symptoms, like intrusions, avoidance, hyperarousal (Frommberger, Angenendt, & Berger, 2014). The attempt to think back again the trauma fails and lead to a dysfunctional avoidance behavior, so symptoms become prolonged and chronic. PTSD also includes dissociative symptoms (e.g. total or partial amnesia) and emotional numbness (Frommberger et al., 2014). Sometimes the affected person seeks “relief” (often worsening the situation) with alcohol abuses and various drugs. The above mentioned disturb also involves the onset of physical symptoms such as muscle tensions, breathing difficulties, changes in psychomotor behavior, cardio-respiratory and gastro-intestinal symptoms (Pacella, Hruska, & Delahanty, 2013), physical disabilities and chronic pain following injuries resulting from torture (Buhmann, 2014).
The evaluation of the organic symptoms from post-traumatic stress disorder is being investigated by a Danish study, in which healthy control are compared with a group of immigrates and one of Danish war veterans. The aim of this study is to evaluate the effectiveness of the Body Awareness Movement Quality and Experience Scale (BAS MQ-E) in assessing stability, balance, flexibility and coordination in movement. The results achieved by the patients of the study group were poorer than the medical supervisions and also showed more muscular tensions, pain, breathing limitations and in the Activity of Daily Living (ADL) (Nyboe, Bentholm, & Gyllensten, 2017).
Mental health and psychosocial tension problems of the refugees in Western countries belong to the traumatic and stressful experiences made during wars and after their arrival, such as waiting moments during asylum procedures, poverty, loss of social support and discriminations (Danon & Miltenburg, 2001). In order to work on this kind of problems, in 2018 was published a Danish study (Beck et al., 2018), in which has been shown that for each participant was made a global rehabilitation proposal: it has a multidisciplinary approach including physiotherapy and psycomotor treatments. Adding musicotherapy (Longacre, Silver-Highfield, Lama, & Grodin, 2012) to all the above mentioned
treatments, came out that it can improve the adherence and reduce the pain which often accompanies pathology with rehabilitation interest (Martin-Saavedra, Vergara-Mendez, & Talero-Gutiérrez, 2018).
Similar results are achieved with treatments based on the narration of tortures of the survivors coming from unsafe region of Middle East and North Africa (Kirstine Viller Hansen, Sloth Hansen-Nord, Smeir, Engelkes-Heby, & Modvig, 2018). Narration is associated to a reduction of PTSD symptoms, anxiety, depression, pain perception, disability level and improvements in self-reported health. Consequently, it seems necessary to reduce linguistic barriers between therapist and patient. In Scandinavian countries physiotherapy is an integral part of the multidisciplinar rehabilitation treatments for the traumatized refugees and its aim is to alleviate and cope with pain, correct dysfunctions and regain body awareness (Madsen, Carlsson, Nordbrandt, & Jensen, 2016).
A review of the Danish Literature on the evidence-based treatments for traumatized refugees concluded that them were limited, but Basic Body Awareness Therapy (BBAT) had shown promising results in other patients with chronic pain and psychiatric disease. BBAT was invented in the early 1970 by Gertrud Roxendal (Roxendal, 1985), a Swedish physiotherapist. This treatment involves an holistic approach and it’s rooted in the Eastern tradition of movement. The exercises make up by the BBAT are based on easy and slow movements aimed at improving the awareness of the biomechanical, physiological, psyco-socio-cultural and existential aspects of the movement, but also on the cognition of the body as the basis of the self-awareness (Blaauwendraat, Levy Berg, & Gyllensten, 2017).
BBAT is the study object in a Danish trial in which 26 patients carefully evaluated were directed to a psychotherapy, pharmacological and physiotherapy treatment, based on BBAT and awareness of the own body to fight against pain and stress. The proposal included 16-18 weeks of treatment in which physiotherapy and psychotherapy aspects took place in different times. Unfortunately, the absence of control groups doesn’t allow to diversify results from all the treatments, even though had produced an improvement in the medical case (Palic & Elklit, 2009).
This kind of approach was very appreciated also by the three patients who underwent in semi structured interviews at the end of the BBAT treatment period. These people have also noticed that the presence of the physiotherapist increases compliance and the therapy quality, compared to the self-guided exercise (Madsen et al., 2016). At the same time also Arabic speaking patients who joined this study in 2015, have shown their improvements regarding psychiatric and somatic symptoms, the quality of life and about the level of functioning and quality of movement during treatment with BBAT (Stade, Skammeritz, Hjortkjær, & Carlsson, 2015).
Similar results are present in a study that include Tai Chi, an ancient Chinese technique which uses slow movements to produce psycho-physical relax and increases body awareness (Grodin, Piwowarczyk, Fulker, Bazazi, & Saper, 2008). Tai Chi is also used in other disease rehabilitation as Parkinson, with good results (Yang, Li, Gong, Zhu, & Hao, 2014).

IDENTIFICATION OF THE REHABILITATION NEED

The present work arises following the desire to investigate the rehabilitation need of the migrant populations. From the analysis of the literature about the incidence and prevalence of the disease, two conditions of physiotherapy interest come to light: Post traumatic stress disorder (PTSD) and the rehabilitation from torture outcomes. Among them, there’s a focus on the falanga torture, a method in which the soles of the feet (especially the heels) are brutally and repeatedly hit using sticks, iron bars, causing chronic pain and foot sensibility deficit.

POST-TRAUMATIC STRESS DISORDER (PTSD)

Mental healthy and psychosocial tension problems of the refugees in Western countries belong to the traumatic and stressfull expieriences made during wars and after their arrival, such as waiting moments during asylum procedures, poverty, lackness of social support and discriminations (Danon & Miltenburg, 2001). In order to work on this kind of problems, in 2018 was published a Danish study (Beck et al., 2018), in which has been shown that for each participant was made a global rehabilitation proposal: it has a multidisciplinary approach including physiotherapy and psycomotor treatments. Adding musicotherapy (Longacre, Silver-Highfield, Lama, & Grodin, 2012) to all the above mentioned treatments, came out that it can improve the adherence and reduce the pain which often accompain pathology with rehabilitation interest (Martin-Saavedra, Vergara-Mendez, & Talero-Gutiérrez, 2018).

Similar results are achieved with treatments based on the narration of tortures of the survivors coming from unsafe region of Middle East and North Africa (Kirstine Viller Hansen, Sloth Hansen-Nord, Smeir, Engelkes-Heby, & Modvig, 2018). Narration is associated to a reduction of PTSD symptoms, anxiety, depression, pain perception, disability level and improvements in self-reported health. Consequently it seems necessary reduct linguistic barriers between therapist and patient. In Scandinavian countries physiotherapy is an integral part of the multidisciplinar rehabilitation treatments for the traumatized refugees and its aim is to alleviate and cope with pain, correct dysfunctions and regain body awareness (Madsen, Carlsson, Nordbrandt, & Jensen, 2016).

A review of the Danish Literature on the evidence-based treatments for traumatized refugees concluded that them were limited, but Basic Body Awareness Therapy (BBAT) had shown promittent results in other patiens with chronic pain and psychiatric desease. BBAT was invented in the early 1970 by Gertrud Roxendal (Roxendal, 1985). a Swedish physiotherapist. This treatment involves an holistic approach and it’s rooted in the Eastern tradition of movement. The exercises make up by the BBAT are based on easy and slow movements aimed at improving the awareness of the biomechanical, physiological, psyco-socio-cultural and existential aspects of the movement, but also on the cognition of the body as the basis of the self-awareness (Blaauwendraat, Levy Berg, & Gyllensten, 2017).

BBAT is the study object in a Danish trial in which 26 patients carefully evaluated were directed to a psychotherapic, pharmacological and physiotherapic treatment, based on BBAT and awareness of the own body to fight against pain and stress. The proposal included 16-18 weeks of treatment in which physiotherapic and psycotherapic aspects took place in different times. Unfortunately, the absence of control groups doesn’t allow to diversify risults from all the treatments, even though had produced an improvement in the medical case (Palic & Elklit, 2009).

This kind of approach was very appreciated also by the three patients who underwent in semi structured interviews at the end of the BBAT treatment period. These people have also noticed that the presence of the physiotherapist increases compliance and the therapy quality, compared to the self-guided exercise (Madsen et al., 2016). At the same time also Arabic speaking patients who joined this study in 2015, have shown their improvements regarding psychiatric and somatic symptoms, the quality of life and about the level of functioning and quality of movement during treatment with BBAT (Stade, Skammeritz, Hjortkjær, & Carlsson, 2015).

Similar results are present in a study that include Tai Chi, an ancient Chinese technique which uses slow movements to produce psycho-physical relax and increases body awareness (Grodin, Piwowarczyk, Fulker, Bazazi, & Saper, 2008). Tai Chi is also used in other desease rehabilitation as Parkinson, with good results (Yang, Li, Gong, Zhu, & Hao, 2014).

TORTURES AND VIOLENCES

In the International Legal System the word “torture” means a voluntary infliction of physical or psychological pain, sometimes exerted by state authorities themselves for many reasons (Rica, 2016).
The “Convention against tortures and other cruelties, treatments or degrading, inhuman punishments” was ratified by 174 states of the 192 members of United Nations (Rights & Cruel, 2012). However, don’t exist global estimates and several studies which report the prevalence of the torture in specific countries or territories that are or have been in war, where it’s known that torture is a widely used tool of coercion.
As regard the prevalence of torture among asylum-seeking refugees, above is reported the situation in some European countries.

• England: about half of asylum-seeking refugees who go to health facilities for chronic pain was a torture victim (A. C. D. C. Williams, Peña, & Rice, 2010).
• Denmark: about half of the first generation of asylum-seeking refugees was tortured (Masmas et al.2008).
• Italy: according to the data collected by the Medical Volunteers Against Torture Association, about the 80% of the asylum-seeking refugees who have passed through Libia have been tortured (Camilli, 20017).

Torture methods can be both psychological and physical, although there isn’t a clear distinction because all hit body and soul, as Basoglu et al demonstrated (Başoǧlu, Livanou, & Crnobarić, 2007).
Some psychological torture methods are false executions, like to be forced to see tortured family and friends, sexual abuses, sleep deprivation and isolation (Olsen, Montgomery, Carlsson, & Foldspang, 2006). The most often reported physical methods are: unsystematic beatings, violence carried out on the whole body (often described as generalized tortures) with various tools, being tied for long periods in painful positions, stress and coercion techniques (Olsen, Montgomery, Bøjholm, & Foldspang, 2006).
Because of the significant rehabilitative consequences, now let’s focus the attention on the falanga torture. This definition is used to describe systematic and repeated beatings that causes traumas to the
sole of the feet and widely practiced expecially in Middle East countries. Linked torture victim it’s violently struck with wooden or iron bars (Rejali, 2009). After that, some victim put their feet in cold water, others are forced to walk during or after they were beated to increase the amount of damage (Rasmussen, Amris, & Blaauw, 2002).
The entity of the damage depends on various elements such as the chosen tools, the force applied (eg. whipping or hitting) and its duration (Byard & Singh, 2012). The consequent effects are very difficult to detect clinically, although the permanent damage inflicted on soft tissue of the heels leads to a chronic pain and a difficulty in walking (Savnik et al., 2000) (Byard & Singh, 2012)
Because of the pain, generally the tortured person will be able to walk only for a while (Danneskiold-Samsøe, S., Amris, S., & Torp-Pedersen, 2007). Among the acute consequences we find internal blooding and swelling of tissues, which disappear spontaneously in 1-2 weeks.
The most serious complication of the torture is that the cushioning effect of the heel is lost forever. Clinical examinations based on the palpation (Prip & Persson, 2008) have reported a reduced elasticity of the heel tissue, thinning of the skin, thickened and irregular plantar aponeurosis.
Chronical pain’s etiology, pathogenesis and disability found after the falanga torture aren’t clear yet (Amris, Rasmussen, & Baykal, 2009). Also, the torture confirmation is difficult, especially in cases evaluated after several months after the trauma.
From an epidemiological point of view, in a study conducted at the Kris and Trauma Centrum (KTC) in Stockholm has been examined 131 torture victims and falanga was reported in 45% of the cases. It is most commonly found among Bangladeshi, Syrian, Middle East and North Africa patients. 82% of falanga torture’s victims show scars, foot and legs pigmentations, palpable irregularities of the soften tissues, while persistent pain was reported by 48% of the patients. Signs and symptoms are highly significative when compared with a control group which hadn’t suffered from falanga torture (p <0,0001) (Edston, 2009).
Almost all the victims suffer of chronic, widespread and high intensity pain (Kaur, 2017). However, regional painful conditions such as headache, backpain, lower limbs, shoulders and upper limbs have recently been reported.
Thomsen et al. (Thomsen, Eriksen, & Smidt-Nielsen, 2000) have found a high prevalence of neuropatic pain in falanga torture patiens (81%) and partial brachial plexus lesions in 64% of patients who underwent torture by suspension.

REHABILITATIVE TREATMENT OF CHRONIC PAIN

Regarding the rehabilitative treatment of chronic pain in migrant populations there are few evidences in literature.
In a 2009 review (Amris & Rasmussen, 2009) and in a 2015 report (Amris & Williams, 2015), a quick reference is made to the physiotherapy intervention related to falanga torture, recommending an intervention aimed at limiting overloading damages caused by an altered gait pattern and then the use of suitable footwear. Various physiotherapy treatments have been recommended, including manual and progressive exercises, balance training based on an individual and systematic assessment aimed at reducing pain, improving function and developing skills of active imitations (Amris & Williams, 2015).
Taping, stabilizing bandage, shoe modifications and orthoses are recommended for improving gait and walking tolerance. No recommendations on pharmacological treatment of the pain have emerged, but Transcutaneus Electrical Nervous Stimulation (TENS) and education on pain self-management based on a cognitive behavioral approach have been suggested as an integral part of the pain management (Amris & Williams, 2015).
However in the report is underlined the lack of data regarding chronic pain management in the tortured refugees. According to the authors, this lack is linked to the fact that post torture rehabilitation interventions are largely carried out by health professionals who work in human right organizations, and today these services remain far from traditional health institution and focuses the attention on psychological problems, rather than the clinical ones (Amris & Williams, 2015). From 2008 until 2012 Prip et al. have conducted four studies in Denmark (Prip & Persson, 2008) (Prip, Persson, & Sjölund, 2011) (Prip, Persson, & Sjölund, 2012a) (Prip, Persson, & Sjölund, 2012b).
All the included patients suffered from long-term outcomes related to the various kind of torture they had underwent in the previous years (from 5 to 30 years before) in their homelands. In order to eliminate communication difficulties, interpreters have been used for the 171 patients recruited for the 4 studies. Before starting, all of the patients were evaluated by a multidisciplinar team made up by doctor, psychologist, physiotherapist and social assistant. The inclusion criteria were: 1) a torture victim with asylum in Denmark; 2) physical, psychological and social needs; 3) no obvious psychosis; 4) no abuse of drugs and alcohol; 5) willingness to undertake the treatment.
From these studies emerged that torture victims suffer from foot and lower legs pain, showing various compensations and pains during their walk. Strong pain is often combined with a reduced tactile and
thermal sensitivity. Tactile dysesthesia, allodynia and hypersensitivity to palpation of the plantar fascia or under the heel were found extensively. These clinical results were non-existent or only rarely found in healthy controls. The presence of sensibility alterations has been attributed by the authors to changes that occur at central level, in response to the structure of the chronic pain.
As reported in a 2009 review concerning pain symptoms, the sites where patients most frequently report pain are low back, neck and a widespread pain, so physiotherapy goals are to increase the awareness of their body in order to augment physical activity levels and the functional ability in everyday activities, to promote pain management, increasing self-efficacy level (Sjölund, Kastrup, Montgomery, & Persson, 2009).
In a 2007 study, asylum seekers were studied for 10 years in order to evaluate the association between pain location and type of torture suffered. At baseline, low back pain was associated to a psychologic torture and to a sensory deprivation, while at follow-up there was no significant association between psychological status and physical torture. Foot pain, instead, at baseline was associated to generalized tortures and electric shock, while at the follow-up there was a significant association with specific torture locus, age of the first incarceration, duration of imprisonment, but not to psychological violence (Olsen, Montgomery, Bøjholm, & Foldspang, 2007). Regarding chronic pain treatment due to torture, from a review published in 2016 emerge the following conclusion: treatment indications are only relative to three type of treatments, two of them consist in a cognitive-behavioral therapy with biofeedback, but without any relevant benefits for pain and disability after the treatment and very weak effects on pain at follow-up. Third study focused on physiotherapy but despite the improvements in terms of disability, didn’t seem to have efficacy in the pain treatment (maybe the study was small and understaffed) (de C Williams & Baird, 2016). Non-randomized studies included various methods for the treatment of the pain (its management education with or without any physical exercise instructions), that lead to modest or none at all improvements. However, in general, physiotherapy seems to be more accepted and tolerated than psychologic interventions. In a second revision published in 2017 by Williams et al. emerge the following evidences: pain management starts from providing informations on chronic pain to the patients and must include a therapeutic exercise and a gradual recover of the ADL; very important is a cognitive approach at the treatment of the pain which encourage changes in the behavior of the people with pain as for maximize autonomy and confidence in pain management (A. C. d. C. Williams & Amris, 2017). An interesting explorative study was driven by the Copenhagen Rehabilitation and Research Centre for Torture Victims. In that, 15 Arabian speaking refugees who have chronic pain were asked about
what they expect from a rehabilitation program. Patients show their interest toward the physiotherapy intervention and express the need for active and passive treatments, which must be combined to educational/preventive joint hygiene interventions, moreover refer the need to fine compensation strategies that are best suited to tackle chronic pain (Persson & Gard, 2013).

Conclusion

In conclusion, from what has been found in literature, it’s clear that falanga tortured patients show chronic pain and foot sensibility alterations more than the others. The treatment of these kind of disorders includes a well-structured rehabilitation proposal with a neurocognitive approach (eg. Cognitive therapeutical exercise, Mirror Therapy, Motor Imagery, Action Observation Therapy) (Ciriello & Calabrese, 2019) that is certainly useful in overcoming the deficiencies of the Functional System of walking (in which the foot performs the function of double eye). These deficits are related to structural foot alterations due to falanga torture, but also generated from a bad information collection from the periphery (Mulder, 2007) (Bowering et al., 2013). Recent studies, in fact, show how the pain etiology can be associated with an altered coherence between informations coming from periphery, that should be subsequently processed and modulated by the SNC in order to create a center-periphery unit useful to the organization (Perfetti, Pante’, Rizzello, & AAVV, 2015). The alteration of information is related to the impairment of the body’s ability to fragment and therefore to change itself following the interaction with the external environment, imposing on them to establish correct useful relations to the knowledge. As for chronic pain caused by generalized tortures, physiotherapy treatment recommended by literature studies, also aim to intervene on the central sensitization mechanisms, through interventions that lead to reappropriation of a coherent body image. In essence, the physiotherapy intervention suggested by some studies is aimed to teach patients strategies of articular hygiene that avoid overloadings (eg. in the low back pain) (Olsen et al., 2007). Unfortunately, the rehabilitative intervention in no study is well clarified in terms of duration, frequency and type of exercise, so repeatability is definitely invalidated, and the effectiveness of it continues to be uncertain.

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