Prevalence of pain in the head, back and feet in refugees previously exposed to torture: A ten-year follow-up study

Summarized by Anne Storey.

Objective: To look at the change over 10 years concerning pain in the head, back, and feet among previously tortured refugees now residing in Denmark, and to compare associations between methods of torture and pain at baseline and after 10 years. Pain in the head, back, and feet were chosen because they are frequently reported symptoms.

Methods: 

• 139 refugees previously exposed to torture in their home country, interviewed at a Danish rehab clinic avg. ~8 years (range 0-32 yrs) after final release from confinement by a psychiatrist who had extensive experience working with torture survivor
• Re-interviewed 10 years later by a research assistant, asked about presence of pain in the head, back, and feet during the last 24 hours, and if they had pain, they were asked about their pain level by use of VAS.
• Interviews focused on history of exposure of physical or mental torture, and pain in the head, back, and feet. Also included background, history of imprisonment, and current physical health.
• 107 refugees were treated at a control clinic in Copenhagen, the rest were referred to other Danish clinics.

Results: 

• Three different relationships were analyzed:
  • 1. Association between pain at baseline and follow-up
  • 2. Association of torture with pain at baseline
  • 3. Association of torture with pain at follow-up
• Average number of times imprisoned was 2.5 (range 0-20 times)
• Mean duration of total imprisonment was 19.4 months, a little over a year and a half (range 0-188 months)
• Most common countries: 1/3 of refugees were imprisoned in Iran, 1/4 in Iraq, and 1/6 in Lebanon
• Most common physical torture reported was beating/shoving (95%), followed by overtaxing of the body, electrical torture, exposure of extreme heat or cold, and suffocation. Most had general abuse of the entire body, but some torture of more specific regions were reported as well.
• Most common mental torture method was deprivation (88.5%), followed by threatening
• Patients being treated at the RCT had an average of 25 psychotherapeutic sessions and26 physiotherapeutic sessions (like physical therapy). Treatment profile at other clinics is not known.
• Pain after 10 year follow up was strongly associated with pain reported at baseline, prevalence of pain increased considerably in all areas, and was usually a daily symptom
  • Pain in head: 47.5%—>58.3%
  • Pain in back: 48.2%—>75.5%
  • Pain in feet: 23.7%—>63.3%
• Pain in the head at baseline and follow-up were more common with greater number of physical torture sessions, greater number of torture methods, and with the head being the target
• Pain in the back associated with mental torture methods of coercion and deprivation, at follow-up there was no association with any torture techniques
• Pain in the feet associated with general abuse of the whole body at baseline, and with the number of torture sessions at follow up as well as with locus-specific torture and electrical torture.

Discussion: 

• Aging could be a possibility for increase in pain (head and back), but there is no solid evidence that makes this the only reason
• May have not been ready to share details about imprisonment and pain at baseline, but had built up trust overtime
• Permanent changes in pain-generating structures can be the result of beating a certain area of the body, leading to a neuropathic pain condition

Conclusion:

• Pain increased, despite treatment at RCT
• Treatment does not decrease risk of continuing or increasing symptoms of pain
• 20 years after torture took place, increasing proportions of survivors seems to suffer from pain associated with the type and bodily focus of the torture. This presents a considerable challenge to future evidence based development of effective treatment programs.