Chronic Pain

Articles

Acupuncture and Traditional Chinese Medicine for Survivors of Torture and Refugee Trauma: A Descriptive Report

This article, by  Ellen Silver Highfield, Puja Lama, Michael A. Grodin, Ted J. Kaptchuk, and Sondra S. Crosby, was published in the Journal of Immigrant and Minority Health, and is available for a fee through SpringerLink.

Refugees with trauma histories are a difficult medical population to treat. Acupuncture care has gained acceptance in many mainstream hospitals in the United States, but research on acupuncture and refugee populations is limited. Herein, we report our experiences with 50 refugees (total acupuncture treatments = 425) at a major tertiary teaching hospital. Patients often reported extreme trauma including physical torture, rape and witnessing the same in family members. Patients represented 13 different countries, with about half the patients being Somali. The primary complaint of all patients was pain (100%). Using the Wong-Baker Faces Pain scale, 56% patients reported pain decreases. Patient acceptance of acupuncture was high. We provide three case histories as illustrative examples. Further research is warranted.

Link is to abstract; full article is available for purchase.

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Acupuncture for refugees with posttraumatic stress disorder: initial experiences establishing a community clinic

This article, by Pease, M., R. Sollom, and P. Wayne, was published in Explore (NY), 2009. 5(1): p. 51-4 and is available for FREE through Tree of Life TaiChi.

This article describes the establishment of an acupuncture clinic to provide free treatments to Boston-based refugees suffering from PTSD. We provide a brief overview of PTSD as viewed from Traditional Chinese Medicine (TCM) and summarize the literature evaluating the use of acupuncture for PTSD. We discuss the treatment strategies employed in treating refugees and summarize a few case reports from the clinic.

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Chronic pain in multi-traumatized outpatients with a refugee background resettled in Norway: a cross-sectional study

Dinu-Stefan Teodorescu, Trond Heir, Johan Siqveland, Edvard Hauff, Tore Wentzel-Larsen and Lars Lien (2014). BMC Psychology

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Chronic pain in survivors of torture

Kirstine Amris, Amanda C. de C. Williams (2007)IASP.

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Chronic pain in torture survivors

Thomsen AB1, Eriksen J, Smidt-Nielsen K. (2000) Forensic Sci Int. 2000 Feb 28;108(3):155-63.

Link is to abstract; full article available for purchase.

 

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Chronic pain in torture victims

Torture is widely practiced throughout the world. Recent studies indicate that 50% of all countries, including 79% of the G-20 countries, continue to practice systematic torture despite a universal ban. It is well known that torture has numerous physical, psychological, and pain-related sequelae that can inflict a devastating and enduring burden on its victims. Health care professionals, particularly those who specialize in the treatment of chronic pain, have an obligation to better understand the physical and psychological effects of torture. This review highlights the epidemiology, classification, pain sequelae, and clinical treatment guidelines of torture victims. In addition, the role of pharmacologic and psychologic interventions is explored in the context of rehabilitation.

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Education as Treatment for Chronic Pain in Survivors of Torture and Other Violent Events in Cambodia: Experiences with Implementation of a Group-based "Pain School" and Evaluation of its Effect in a Pilot Study

Phaneth, S., Panha, P., Sopheap, T., Harlacher, U., & Polatin, P. (2014). Education as Treatment for Chronic Pain in Survivors of Torture and Other Violent Events in Cambodia: Experiences with Implementation of a Group-based "Pain School" and Evaluation of its Effect in a Pilot Study. Journal of Applied Biobehavioral Research, 19(1), 53-69.

The DIGNITY Institute Against Torture is a Danish nongovernmental organization with a Copenhagen-based rehabilitation program for torture survivors, where the majority of patients suffer from chronic pain and are treated with a group-based, ten-session, psycho-educational “pain school.” This material was presented to therapists at the Transcultural Psychosocial Organization Cambodia, so as to develop a culturally adapted “Khmer Pain School,” which was subsequently tested in a pilot study with 34 completers. The Brief Pain Inventory and the Disability Rating Index, contextualized and translated into Khmer, were the main outcome measures. Results revealed that therapists and clients found the Cambodian pain school to be relevant and helpful. The quantitative outcome indicators demonstrated clinical improvement, with significant effect sizes.

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Managing chronic pain in survivors of torture

Amris K, Williams AC. Pain Manag. 2015;5(1):5-12. 

All generalist and specialist clinicians are likely to encounter torture survivors among refugees and asylum seekers. A minority of people survive torture and a smaller minority reach a developed country; those who do tend to be the more resilient and resourceful. They have many health, social and welfare problems; persistent pain in the musculoskeletal system is one of the most common. There is little specific evidence on pain in survivors of torture; the guidelines on interdisciplinary specialist management are applicable. Most of the literature on refugee survivors of torture has an exclusive focus on psychological disorders, with particularly poor understanding of pain problems. This article summarizes the current status of assessment and treatment of pain problems in the torture survivor.

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Persistent Pain in Survivors of Torture: A Cohort Study

Context: Refugee survivors of torture in the United Kingdom have multiple problems, of which pain may be underrecognized, given the high prevalence recorded in similar populations in Denmark.

Objectives: To establish in a UK sample the prevalence of persistent pain and to investigate associations between specific pains and torture methods.

Methods:A cohort of a random 20% sample attending a specialist UK center for survivors of torture in 2005 was taken. All complaints of pain recorded at initial interview were categorized for body site and putative pain mechanism. These were compared with the database of personal variables and data on torture using odds ratios (ORs) and exact probability.

Results: Of 115 men and 63 women, with mean age of 30 years, 78% reported persistent multiple pains, mainly in the head and low back. They had experienced a median of six torture methods. There was a clear association between female abdominal/pelvic/genital pain and rape/sexual assault (17 of 34 vs. zero of 17: exact P<0.001) and between male anal pain and rape (two of nine vs. two of 77: OR=6.00; 95% confidence interval=1.79–20). Tests of foot/leg pain with falaka and shoulder pain with suspension did not show expected associations.

Conclusion: A significant relationship emerged between torture and report of persistent pain at a high prevalence. Findings do not support the widespread clinical assumption that complaint of persistent pain after torture is predominantly a manifestation of psychological distress. Rather, complaints of pain in torture survivors should be assessed and treated in relation to physical trauma.

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Perspectives on Yoga Inputs in the Management of Chronic Pain

This article, by Nandini Vallath, was published in the Indian Journal of Palliative Care, and is available for free through PubMed.

Chronic pain is multi-dimensional. At the physical level itself, beyond the nociceptive pathway, there is hyper arousal state of the components of the nervous system, which negatively influences tension component of the muscles, patterns of breathing, energy levels and mindset, all of which exacerbate the distress and affect the quality of life of the individual and family. Beginning with the physical body, Yoga eventually influences all aspects of the person: vital, mental, emotional, intellectual and spiritual. It offers various levels and approaches to relax, energize, remodel and strengthen body and psyche. The asanas and pranayama harmonize the physiological system and initiate a “relaxation response” in the neuro endocrinal system. This consists of decreased metabolism, quieter breathing, stable blood pressure, reduced muscle tension, lower heart rate and slow brain wave pattern. As the neural discharge pattern gets modulated, hyper arousal of the nervous system and the static load on postural muscle come down. The function of viscera improves with the sense of relaxation and sleep gets deeper and sustained; fatigue diminishes. Several subtle level notional corrections can happen in case the subject meditates and that changes the context of the disease, pain and the meaning of life. Meditation and pranayama, along with relaxing asanas, can help individuals deal with the emotional aspects of chronic pain, reduce anxiety and depression effectively and improve the quality of life perceived.

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Psychological, social and welfare interventions for psychological health and well-being of torture survivors

Patel N, Kellezi B, Williams ACDC. Cochrane Database of Systematic Reviews 2014, Issue 11. 

This article is a systematic literature review, assessing the beneficial and adverse effects of psychological, social and welfare interventions for torture survivors, and comparing these effects with those reported by active and inactive controls.

Nine RCTs were included in this review. All were of psychological interventions; none provided social or welfare interventions. The nine trials provided data for 507 adults; none involved children or adolescents. Eight of the nine studies described individual treatment, and one discussed group treatment. Six trials were conducted in Europe, and three in different African countries. Most people were refugees in their thirties and forties; most met the criteria for post-traumatic stress disorder (PTSD) at the outset. Four trials used narrative exposure therapy (NET), one cognitive-behavioural therapy (CBT) and the other four used mixed methods for trauma symptoms, one of which included reconciliation methods. Five interventions were compared with active controls, such as psychoeducation; four used treatment as usual or waiting list/no treatment; we analysed all control conditions together. Duration of therapy varied from one hour to longer than 20 hours with a median of around 12 to 15 hours. All trials reported effects on distress and on PTSD, and two reported on quality of life. Five studies followed up participants for at least six months.

No immediate benefits of psychological therapy were noted in comparison with controls in terms of our primary outcome of distress (usually depression), nor for PTSD symptoms, PTSD caseness, or quality of life. At six-month follow-up, three NET and one CBT study (86 participants) showed moderate effect sizes for intervention over control in reduction of distress (standardised mean difference (SMD) -0.63, 95% confidence interval (CI) -1.07 to -0.19) and of PTSD symptoms (SMD -0.52, 95% CI -0.97 to -0.07). However, the quality of evidence was very low, and risk of bias resulted from researcher/therapist allegiance to treatment methods, effects of uncertain asylum status of some people and real-time non-standardised translation of assessment measures. No measures of adverse events were described, nor of participation, social functioning, quantity of social or family relationships, proxy measures by third parties or satisfaction with treatment. Too few studies were identified for review authors to attempt sensitivity analyses.

Very low-quality evidence suggests no differences between psychological therapies and controls in terms of immediate effects on post-traumatic symptoms, distress or quality of life; however, NET and CBT were found to confer moderate benefits in reducing distress and PTSD symptoms over the medium term (six months after treatment). Evidence was of very low quality, mainly because non-standardised assessment methods using interpreters were applied, and sample sizes were very small. Most eligible trials also revealed medium to high risk of bias. Further, attention to the cultural appropriateness of interventions or to their psychometric qualities was inadequate, and assessment measures used were unsuitable. As such, these findings should be interpreted with caution.

No data were available on whether symptom reduction enabled improvements in quality of life, participation in community life, or in social and family relationships in the medium term. Details of adverse events and treatment satisfaction were not available immediately after treatment nor in the medium term. Future research should aim to address these gaps in the evidence and should include larger sample sizes when possible. Problems of torture survivors need to be defined far more broadly than by PTSD symptoms, and recognition given to the contextual influences of being a torture survivor, including as an asylum seeker or refugee, on psychological and social health.

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Treating Survivors of Torture and Refugee Trauma: A Preliminary Case Series Using Qigong and T'ai Chi

This article, by Michael A. Grodin, Linda Piwowarczyk, and Robert B. Saper, published in the Journal of Alternative and Complementary Medicine, is available for free through PubMed.

This paper seeks to explore the potential value of qigong and t'ai chi practice as a therapeutic intervention to aid in the treatment of survivors of torture and refugee trauma.

The common effects of torture and refugee trauma are surveyed with a focus on post-traumatic stress disorder. An alternative theoretical framework for conceptualizing and healing trauma is presented. Evidence is reviewed from the scientific literature that describes how qigong and t'ai chi have been used in studies of the general population to alleviate symptoms that are also expressed in torture survivors. Observations are presented from a combined, simplified qigong and t'ai chi intervention with a convenience sample of four refugee survivors of torture.

Preliminary observations from four cases and a review of the literature support the potential efficacy of incorporating qigong and t'ai chi into the treatment of survivors of torture and refugee trauma.

The incorporation of qigong and t'ai chi into the treatment of torture survivors, within a new framework for healing trauma, merits further investigation.

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Webinars

The Treatment of Chronic Pain in Survivors of Torture and Refugee Trauma: an Integrative Approach

This webinar, presented on 2/22/2012, features Dr. Michael Grodin, Ellen Silver Highfield, and McKenna Mary Longacre, of the Boston Medical Center.

This webinar is part of the National Capacity Building (NCB) webinar series. NCB is a project of the Center for Victims of Torture.

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Wednesday, 22 February 2012

Webinar Summary and Resources

This webinar focuses on the potential alleviation of torture-induced chronic pain through alternative medicine and techniques. While the webinar is intended for medical professionals, it is accessible to a wider audience as well. After establishing that western conceptions both of pain and the necessity of pharmaceutical or surgical treatment are not universal, the webinar elaborates on a series of alternative medicines that have clinically and anecdotally been shown to be helpful. These include: the use of herbs, traditional Chinese medicine, cupping, yoga, acupuncture, and more. Ultimately, the webinar promotes “integrative medicine,” or a style of medicine in which western medicine and alternative medicine are complementarily combined in order to best serve the patient.  

We recommend that before watching the webinar, you watch this short (three and a half minute) video of the Complementary and Alternative Medicine Refugee Health Clinic at Boston Medical Center: http://www.bu.edu/bostonia/web/grodin/

Wong-Baker FACES pain scale

Additional Resources on Complementary and Alternative Medicine (CAM) and Refugees

http://nccam.nih.gov/

Highfield, E.S., et al., Acupuncture and Traditional Chinese Medicine for Survivors of Torture and Refugee Trauma: A Descriptive Report. J Immigrant Minor Health, 2011. Available for purchase, through SpringerLink.  

Abtract: Refugees with trauma histories are a difficult medical population to treat. Acupuncture care has gained acceptance in many mainstream hospitals in the United States, but research on acupuncture and refugee populations is limited. Herein, we report our experiences with 50 refugees (total acupuncture treatments = 425) at a major tertiary teaching hospital. Patients often reported extreme trauma including physical torture, rape and witnessing the same in family members. Patients represented 13 different countries, with about half the patients being Somali. The primary complaint of all patients was pain (100%). Using the Wong-Baker Faces Pain scale, 56% patients reported pain decreases. Patient acceptance of acupuncture was high. We provide three case histories as illustrative examples. Further research is warranted.


Grodin, M.A., et al., Treating survivors of torture and refugee trauma: a preliminary case series using qigong and t'ai chi. J Alternative Complement Med, 2008. 14(7): p. 801-6. Available for FREE on PubMed.

This paper seeks to explore the potential value of qigong and t'ai chi practice as a therapeutic intervention to aid in the treatment of survivors of torture and refugee trauma.Preliminary observations from four cases and a review of the literature support the potential efficacy of incorporating qigong and t'ai chi into the treatment of survivors of torture and refugee trauma.The incorporation of qigong and t'ai chi into the treatment of torture survivors, within a new framework for healing trauma, merits further investigation.

Benedict, A.L., L. Mancini, and M.A. Grodin, Struggling to meditate: Contextualizing integrated treatment of traumatized Tibetan refugee monks. Mental Health, Religion & Culture, 2009. 12(5): p. 485-499. Available for free through Harvard.

As a result of the recent resurgence of violence in the Tibetan Autonomous Region, the Boston Center for Refugee Health and Human Rights has an increased patient demographic: Tibetan refugee monks. Diagnosed by their amchis (traditional healers) as having a srog-rLung (life-wind) imbalance and presenting with posttraumatic stress disorder (PTSD), they struggle with their contemplative meditation, which—as a central focus of their daily lives—normally comes with ease. In this article, we consider the treatment implications of the highly relevant Buddhist context for this dual diagnosis. Specifically, we contextualise the classification of “religious impairment” as well as the significance of ongoing persecution of the devoutly religious for trauma therapy. We then draw upon spiritually oriented Eastern therapies as well as the confluence of specific paradigmatic practices to properly address these pathological intricacies in devising an effective holistic healing approach to the dual PTSD/srog-rLung diagnosis.

Pease, M., R. Sollom, and P. Wayne, Acupuncture for refugees with posttraumatic stress disorder: initial experiences establishing a community clinic. Explore (NY), 2009. 5(1): p. 51-4. Available for FREE through Tree of Life TaiChi.

This article describes the establishment of an acupuncture clinic to provide free treatments to Boston-based refugees suffering from PTSD. We provide a brief overview of PTSD as viewed from Traditional Chinese Medicine (TCM) and summarize the literature evaluating the use of acupuncture for PTSD. We discuss the treatment strategies employed in treating refugees and summarize a few case reports from the clinic.

Vallath, N., Perspectives on yoga inputs in the management of chronic pain. Indian J Palliative Care. 16(1): p. 1-7. Available for FREE on PubMed.

Chronic pain is multi-dimensional. At the physical level itself, beyond the nociceptive pathway, there is hyper arousal state of the components of the nervous system, which negatively influences tension component of the muscles, patterns of breathing, energy levels and mindset, all of which exacerbate the distress and affect the quality of life of the individual and family. Beginning with the physical body, Yoga eventually influences all aspects of the person: vital, mental, emotional, intellectual and spiritual. It offers various levels and approaches to relax, energize, remodel and strengthen body and psyche. The asanas and pranayama harmonize the physiological system and initiate a “relaxation response” in the neuro endocrinal system. This consists of decreased metabolism, quieter breathing, stable blood pressure, reduced muscle tension, lower heart rate and slow brain wave pattern. As the neural discharge pattern gets modulated, hyper arousal of the nervous system and the static load on postural muscle come down. The function of viscera improves with the sense of relaxation and sleep gets deeper and sustained; fatigue diminishes. Several subtle level notional corrections can happen in case the subject meditates and that changes the context of the disease, pain and the meaning of life. Meditation and pranayama, along with relaxing asanas, can help individuals deal with the emotional aspects of chronic pain, reduce anxiety and depression effectively and improve the quality of life perceived.

Kaptchuk, Ted. The web that has no weaver : understanding Chinese medicine. New York : Congdon & Weed : distributed by St. Martin's Press, 1983. Available for purchase through Amazon.com or other booksellers.

Moreno, A., L. Piwowarczyk, and M.A. Grodin. Human rights violations and refugee health. JAMA, 2001. 285(9): p. 1215. Available for FREE through JAMA.

Basoglu, M., Torture and its consequences : current treatment approaches. 1992, Cambridge; New York, NY, USA: Cambridge University Press. Available for purchase through Amazon.com or other booksellers.

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