Evidence-based Management of Pain in Refugees

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Original Editor - Zafer Altunbezel

Top Contributors - Naomi O'Reilly  

Introduction

Prolonged conflicts, forced displacement and mass migration continue to be a major issue in the 21st Century. At least 79.5 million people around the world have been forced to flee their homes. Among them are nearly 26 million refugees, around half of whom are under the age of 18.[1] Whether in a refugee camp next to an active conflict zone or a safe third country, multiple complex health problems of refugees are becoming a bigger problem for healthcare workers. 

Regardless of type and severity, trauma has potential to impact biological, psychological and social well-being of the individuals. Traumatized refugees often report significant levels of chronic pain in addition to Post Traumatic Stress Disorder symptoms.[2] Studies indicate a high prevalence of persistent pain in torture survivors, with overall incidence up to 83%.[3]

Clinical picture may include headache, neck pain, back pain, extremity pain and regional or widespread pain. Psychological disorders and other comorbid conditions may be interacting with persistent pain. Therefore, chronic pain may be very complex for clinicians in some cases due to its multifactorial nature. Proper assessment and treatment of chronic pain in refugees require understanding of traumatic experiences of refugees and its consequences on different determinants of health. 

Traumatic Experiences of Refugees Contributing to Development of Chronic Pain 

Refugees are frequently exposed to different types of traumatic events, which may lead to development of pain and other relevant health problems both in their origin countries and on the migration routes. Usually these experiences have repetitive and continuous character. It is not unusual to see that such traumatic events continue to happen in the second or third countries.   

Refugees often experience multiple traumatic experiences causing complex and interacting biological, psychological and social impacts on their well-being. Due to its complex and multifactorial nature, chronic pain in refugees might be exhausting for clinicians to deal with and always require involvement of different clinical disciplines. Having adequate knowledge about common experiences of refugees is of utmost importance in order to make a through assessment of pain and rule out serious medical conditions that can risk both patient’s and clinician’s safety. Common traumatic experiences of refugees include but not exclusive to:  

War and Conflict

Wars and conflicts are causing displacement of millions of people each year. Civilians are typically targeted by armed assaults, aerial attacks, improvised explosive devices, landmines or chemical weapons. High number of people sustain war injuries such as gunshot wounds, burns, amputations and complex trauma. Various mental health disorders such as PTSD, Depression and sleeping problems may occur after being exposed or witnessed to these traumatic events. Moreover, disruption of health system and other infrastructure may cause deprivation of healthcare and basic needs. All these factors create an environment for development of chronic pain and other health issues. 

Torture and Ill-Treatment

Despite all the international efforts, torture is still being used worldwide, especially in war zones and in the countries where political oppression is present. Individuals can be randomly or deliberately detained or kidnapped and tortured for interrogations, spreading terror or demanding ransom. Refugees can also be exposed to torture and violence on their migration route by smugglers or different armed actors. Physical torture such as blunt violence, suspension, electrocution, forced physical positions etc. and psychological violence as threats, humiliation, mock execution are just some of the common methods of torture seen. Sexual violence is often used against people regardless of age or gender. Torture results in severe physical and psychological consequences but despite its severity, its impact may be invisible due to feelings of shame, insecurity or stigmatisation. 

Imprisonment

Illegal detentions based on ethnic, political or religious orientation and long term prison sentences exceeding decades without fair trial are often seen in countries having conflict and political instability. In addition to risk of torture and ill-treatment, extremely unhealthy conditions may be present in prisons. Extremely crowded cells, lack of hygiene, deprivation of proper and clean food and water-sometimes even sunshine, inaccessibility of healthcare and psychological impact of captivity as well and witnessing ill-treatment in prison are important risk factors both for physical and psychological well-being. These conditions may also lead to spread of communicable diseases, worsening of existing non-communicable chronic diseases, general decrease in biological health, physical condition and development of psychological disorders. 

Precarious Living Conditions

Disruption of infrastructure, forced displacement and inhuman conditions in refugee camps and host countries are the factors leading refugees to live under precarious conditions. Absence of healthcare, psychosocial services and even basic fundamental needs are causing gradual decrease in individual’s health status. In some host countries where resources for social support are insufficient, refugees are often exposed to labour exploitation while struggling to earn a livelihood. Working long hours in heavy labour jobs and frequent job accidents are causing development of secondary injuries in addition to their traumatic experiences. Failure to establish a basic stability in daily life may increase the severity of existing health problems and hinder physical and mental healing. 

Consequences of Trauma on Refugee Health

Traumatic experiences of refugees cause multiple complex and interacting consequences on their health. Physical and psychosocial trauma as well as development of communicable and non-communicable diseases may result in risk of early death, disability, decreased quality of life and chronic pain. Being aware of possible scenarios allows clinicians to detect red flags, make thorough assessment and identify main problems to be addressed. 

Physical Consequences

Various traumatic orthopaedic and neurological injuries may be seen in people with refugee experience. Some type of traumatic injuries such as pelvic trauma, amputations, spinal cord injury and traumatic brain injury may require special training in order to gain adequate clinical skills . 

Figure.2 Physical Consequences of Trauma on Refugee Health
Physical Consequences
Fractures
Soft Tissue Injury
Arthritis and Arthrosis
Deformity
Burns
Gunshot Wounds
Spinal Cord Injury
Peripheral Nerve Injury
Traumatic Brain Injury
Concussion
Pelvic and Genital Trauma

Psychosocial Consequences

Inadequate attitudes or approaches to individuals with traumatic psychological conditions has the potential to cause re-traumatisation. Some mental health disorders such as PTSD and sleep disturbances can easily interact with chronic pain and hinder physiotherapy treatment. Social issues commonly experienced by refugees can negatively impact the participation and commitment of individuals to physiotherapy process.

Figure.3 Psychosocial Consequences of Trauma on Refugee Health
Psychosocial Consequences
PTSD
Depression
Anxiety
Sleeping Disorders
Somatic Disorders
Psychotic Disorders
Livelihood Issues
Nutrition Issues
Access to Health
Stigmatsation
Discrimination

Communicable and Non-Communicable Diseases

Although it seems like it is within focus of physicians, physiotherapists working with refugees must have enough knowledge about common communicable and non-communicable diseases in their patient population. Detecting any clinical red-flag and ensuring proper referral is of importance for both patients’ and clinician’s safety.

Figure.4 Communicable and Non-Communicable Diseases
Communicable and Non-Communicable Diseases
HIV
Tuberculosis
Cardiovascular Disease
Respiratory Diseases
Gastrointestinal Disease
Urinary and Gynaecological Disease
Neurological Disease
Rheumatological Disease
Metabolic Disease
Endocrinological Disease

In summary traumatic experiences of refugees are often resulting in interacting biological, psychological and social consequences. Multiple complex health problems may exist at the same time and these problems are mostly detected in chronic phase. In the treatment, external resources such as involvement of multiple disciplines, imagings and medical interventions as well as internal resources such as trust relationship, resilience and commitment of the individual are often needed.

Integration of Modern Pain Theories into Refugee Health

Physiotherapy profession has witnessed great improvements in pain sciences during recent years and clinicians have started to adopt the biopsychosocial approach and the novel techniques in treatment of chronic pain. Physiotherapy for refugees is often provided within brief and limited time with minimal resources. Integration of some modern pain concepts into clinical reasoning process, such as peripheral sensitization, abnormal impulse generating sites, central sensitization, autonomic and immune system contributions and psychosocial factors, can enhance overall success in rehabilitation.

Peripheral Sensitisation

IASP defines peripheral sensitisation as “Increased responsiveness and reduced thresholds of nociceptors to stimulation of their receptive fields". It is also named as primary hyperalgesia. Peripheral sensitivity occurs following an injury with the aim of protecting the injured site from further damage. Inflammatory chemicals released from injury site as well as nerves themselves and immune system cells play an active role in peripheral sensitivity. As nociception or inflammation persist, up-regulation of existing and new ion channels in the nerve occurs. 

Being a useful and protective physiological response at the beginning, peripheral sensitisation may eventually lead to central sensitisation. Therefore detecting and managing the peripheral sensitisation is of importance to prevent negative outcomes.

Abnormal Impulse Generating Sites

Abnormal Impulse Generating Sites (AIGS) are defined as the damaged sites along the nerve in which the number, kind and excitability of ion channels are altered. When injured, a segment of peripheral nerve may develop the ability to repeatedly generate its own impulses. Spontaneous activity and mechanosensitivity are the main features of an AIGS.[4] An AIGS fires antidromically and orthodromically, resulting in constant noxious stimulus into the Central Nervous System and neurogenic inflammation in the tissues. 

AIGS can develop anywhere along the nerve where nerve tissue is compromised including dorsal root ganglion. Traumatic experiences of refugees such as explosions, gunshot wounds, burns or different methods of torture may cause excessive compression, traction or direct injury of the nerve and surrounding connective tissue and thus leading to development of AIGS.  

Central Sensitisation

Central sensitisation corresponds to an enhancement in the functional status of neurons and circuits in nociceptive pathways throughout the neuraxis caused by increases in membrane excitability, synaptic efficacy, or a reduced inhibition. [5] 

Central sensitisation is characterised by allodynia, hyperalgesia, expansion of the receptive field  and unusually prolonged pain after the stimulus has been removed. A number of explanations have been proposed to explain the development of central sensitisation, including dysregulation in both ascending and descending central nervous system pathways due to physical trauma and sustained pain impulses, and the chronic release of pro-inflammatory cytokines by the immune system, as a result of physical trauma or viral infection.[6] In addition, it is well-recognised that psychiatric disorders, including anxiety, panic and depression, are often associated with central sensitisation.[7][8] Due to the interaction between psychosocial factors and biological mechanisms, it has been recommended that central sensitisation be viewed within a biopsychosocial model. [9] 

Given the chronicity and complexity of the pain experience of refugees, central sensitization is one of the important factors likely to be involved in the clinical picture. Overlooking the presence of central sensitisation may lead to false assumptions about the patient such as psychosomatic pain or secondary benefit as well as failure in treatment.

Autonomic and Immune System Contributions

Stress neurobiology has only recently been associated with the neurobiology of pain.[10] Systems such as the endocrine, immune, motor and autonomic are foremost protective systems, yet while they can protect and heal, something which requires considerable power, they can also damage, especially in states of maintained stress and pain.[11]

Cortisol, one of the critical hormones for homeostasis, is secreted from adrenal cortex by the triggering effect of the Hypotalamus-Pituitary-Adrenal Axis (HPA). In an emergency, cortisol shuts down activities not needed for survival and enhances those that are. Hence the inflammatory and immune systems, digestive and reproductive systems are shut down. A chronic excess of cortisol as in chronic pain or stress poses problems. The features include immunosupression, osteoporosis, cardiovascular disease, depression and insulin resistance.[12] More subtle cases of tissue degeneration, mood swings, slow tissue healing and susceptibility to infection may be noted by cilinicians managing patients with chronic pain.[13]          

Mental and physical effects and psychosocial conditions evoke adrenaline and noradrenaline secretions. They stimulate symphatetic response in order to prepare organism for action. Adrenaline and noradrenaline are useful secretions for emergency situations, but like cortisol, maintained high levels lead to the risk of cardiovascular disease and tissue damage. The sympathetic nervous system can contribute to the sensitivity of inflamed tissues and it can also contribute to the sensitivity of damaged nerves. Noradrenaline pathways in the brain are also closely linked to negative emotional states.[14]

Cytokines secreted by the immune system in response to different physical and emotional stressors can modulate inflammation and pain. While some cytokines such as Interleukin-1, Interleukin-2 and Tumor Necrosis Factor Alfa are pro-inflammatory other cytokines such as Interleukin-4, Interleukin-10 and Interleukin-13 are anti-inflammatory. Immune system is closely linked to peripheral and central nervous system. Thus any stressor having impact on nervous system can also result in immunity. changes. 

Refugees are often exposed to repetitive physical and mental stressors. Given the long term exposure to stress and pain, dysfunctional physiological changes in stress response systems are likely to present and it can be the main driving mechanism behind the multiple physical problems and chronic pain. Therefore physiological effects of stress should be evaluated. 

Psychosocial Factors 

Within a biopsychosocial approach, the effect of mental health and social domains that are frequently impaired by trauma can not be overlooked. Variables such as attitudes, beliefs, mood state, social factors and work appear to interact with pain behaviour, and are cumulatively referred to as psychosocial factors.[15]

Comprehensive assessment of pain in trauma survivors should always include the evaluation of psychosocial factors, which can be a main driving factor behind the persistence of pain. Studies found that increased PTSD symptoms are related to increased pain levels, pain disability and widespread pain.[16] 40-50% of chronic pain patients experience depression and pain[17], which may lead to decreased physical activity and insufficient participation in treatment. Chronic pain can interfere with sleep and sleep disturbance may impair pain-inhibitor function[18] as well as tissue healing. Unhelpful cognitive processes and behaviours about pain such as catastrophizing, fear of pain or movement, filtering, polarized thinking, passive coping may frequently contributing to the pain experience. Finally, social factors such as access to the fundamental needs, stigmatization, lack of social support, legal status, financial concerns and work issues may have reflections on pain experience. 

Assessment Using the Pain and Disability Drivers Model

Given the long term and repetitive traumatic experiences as well as multifactorial nature of pain in traumatized refugees, the Pain and Disability Drivers Model (PDDM) may provide an effective framework to the clinicians assessing pain. PDDM is originally developed for management of low back pain [19] but it can be applied to other forms of chronic pain. 

***Figure-4: PDDM

PDDM describes five main domains that may be contributing to pain and disability. There are also key assessment elements and findings under each domain. Different domains interact with each other in a bi-directional concept, meaning that a change in one of the domains can have positive or negative effects on other domains. 

To understand the whole picture of pain and disability, the key elements and finding should be identified and a mapping of all the elements should be made. Understanding the weight of each contributing domain will help clinicians to direct their interventions to the most needed factors.   

Nociceptive Pain Drivers 

Nociceptive pain is “pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors”. [20] Nociceptive input, as the most frequent initiating factor of many chronic painful condition, should be targeted initially if any presence is detected. 

Explosions, blunt trauma, torture and other forms of traumatic experiences as well as domestic events may result in different orthopedic injuries creating severe nociceptive input. Despite the chronicity of pain in most traumatized refugees, nociceptive input may be still ongoing due to re-traumatization, absence of treatment, improper healing, general immobility or unhelpful behaviours. 

Key Assessment Elements and Findings:

  • Symptom Modulation (Pain triggered by a specific movement pattern)
  • Movement Control (Pain triggered by functional stability deficits)
  • Mobility and Pain (Pain caused by increased or decreased mobility)
  • Nonspecific De-conditioning (Pain caused by general deconditioning)
  • Structural Stability Deficits  (Pain caused by actual structure damage e.g. joint dislocations, ligament ruptures) [19]

Careful physical examination based on anamnesis; including inspection, palpation and functional tests can reveal the key findings above and shift the focus of treatment towards local tissue based treatments. 

Nervous System Dysfunctions Drivers

Given the fact that multiple physical trauma and long term neglect of its consequences are the common characteristics of refugee trauma, examining the presence of any nervous system dysfunction is essential in the assessment. Pain from nociceptive origin and nervous system dysfunction have important differences in their underlying mechanisms as well as treatment options. 

Key Assessment Elements and Findings:

If the presence of neuropathic pain is suspected through the patient’s history or clinical signs (for example; paresthesia, dysesthesia, hyperalgesia), the following measurement tools can be used to either rule in or out:

  • Douleur Neuropathique en 4 Questions (DN4) 
  • Leeds Assessment of Neuropathic Symptoms and Signs (LANNS)
  • Neuropathic Pain Questionnaire
  • painDETECT

Aside from neuropathic pain, central sensitisation might be an important factor in persistence of pain. Clinical signs such as general fatigue, mechano-sensitivity, allodynia, widespread pain or incompatible presentation with actual physical status should raise doubts for central sensitisation. The following tool can be used for assessment of central sensitivity. 

Comorbidity Pain and Disability Drivers

Comorbidity refers to presence of one or more additional conditions often co-occuring with a primary condition. Traumatic experiences and precarious life conditions in war zones, prisons and refugee settlements may often lead to communicable and non-communicable diseases as well as mental health disorders. 

Figure: Common CDs/NCDs in refugees.

Since long term inaccess to healthcare is a common experience in refugees, assessment of the comorbidities are essential in pain assessment. A thorough medical examination may not have happened prior to physiotherapy assessment and any kind of life-threatening condition, red flags and hidden factors contributing to persistence of pain may be present. That’s why a detailed medical examination and screening of comorbidities should be ensured. 

Key Assessment Elements and Findings 

The Charlson Comorbidity Index (CCI) and the Elixhauser Comorbidity Index (ECI) are the two best-known indices in the field of patient risk adjustment and outcome prediction [21][22] 

  • Charlson Comorbidity Index (CCI)
  • Elixhauser Comorbidity Index (ECI)

Persistent pain has a well proven impact on sleep but the relationship between both phenomena is bidirectional since disturbed sleep affects pain perception by lowering the pain threshold.[23] Lack of sleep hygiene also has negative effects on tissues healing and mental health. Therefore quality of sleep should be questioned in patients with chronic pain. 

  • Pittsburgh Sleep Quality Index (PSQI)

Cognitive and Emotional Pain and Disability Drivers

Through scientific research, we are now aware of the thought processes which are powerful enough to maintain a pain state.[24] Unhelpful cognitions about pain not only contribute to persistence of pain, they also increase the level of pain related disability. 

Refugee experience in which populations are deliberately traumatized and left helpless for long time provides a suitable environment for development of negative cognitions and emotions about pain. Lack of health literacy, harmful cultural beliefs and thoughts about pain may direct people to negative coping strategies.

Key Assessment Elements and Findings 

  • Catastrophization, filtering or polarized thinking [25]
  • Fear of Pain and Movement
  • Low Self-efficacy
  • Low expectations towards treatment and healing
  • Pain related behaviours (facial or verbal expressions, guarding, changes in daily activities)

Negative cognitions and emotions may be an important barrier for establishing a cooperative relationship with the patients and lead to non-compliance and poor outcomes. The following tools can be used in assessing cognitive factors:

Social and Environmental Disability Drivers

Refugees are often dealing with precarious living conditions and socioeconomic constraints in their daily lives. While focusing too much on physical and psychological elements, social determinants of health can be overlooked by clinicians. For a successful assessment of pain, the clinician should have the general overview of social and economical situation of the individual.

Key Assessment Elements and Findings

  • Legal Status
  • Access to Basic Needs 
  • Access to Healthcare
  • Economic Stability
  • Security in the living space and community

Gaps in the key factors above may be the hidden factor behind the poor outcomes or non-compliance to treatment. Therefore, proper referrals to the social support resources should be ensured. 

Assessment in Practice

Once the clinician develops a good understanding of traumatic experiences of refugees and their reflections on different determinants of health, a good practice in assessment of pain can be guaranteed.

The first and most important aim of an assessment session is building a trust relationship with the patient. Without building trust and cooperation, no benefit can be expected from the physiotherapy process. In every step of assessment and treatment, the general principles of trauma-informed care model must be implemented to prevent re-traumatization.

The points will be described below can be used as a practical framework while planning and conducting an assessment. The order of these points may change based on the needs and information provided by other professionals.

Preparation

  • Setting of the room should be arranged prior to the session. This can include seating plan, treatment table, curtains, forms, assessment equipment, hygiene materials etc.
  • Related background information should be obtained from referring professional with the consent of the patient.
  • If a translator or cultural mediator is involving to the session, he or she should be briefed before the session.

Starting the Session

  • The patient should be welcomed with respect and kindness by showing importance to cultural sensitivities. (e.g. shaking hands, direct eye contact etc.)
  • A general introduction including reason and aim of that session, scope of physiothereapy, role of the physiotherapist, details of the interview and examination should be made to the patient.
  • It must be clearly explained that the patient will have control over the session and may pause or stop it whenever he or she needs.
  • After the introduction, feedback regarding patient’s expectations and cautions (if any) should be obtained.

Medical History

Following details should be collected by continuously observing the patient’s reactions and amount of the questions should be decreased if there is any negative reaction observed from the patient. This part should happen in a atmosphere of friendly conversation rather than a detailed interrogation.

  • Main complaints which motivated the patient to seek help
  • Location and the distribution of pain as well as the type of pain for each location
  • Chronological details of the onset and progress of the pain
  • Mechanism of the injury and pain, be cautious about potential sensitivities
  • Pain Intensity, preferably both subjective and on a numeric or visual scale
  • Daily course of the pain
  • Aggravating and relieving factors of pain
  • Sleep Disturbance
  • Previous medical interventions

Ideally the patient should undergo an initial medical and mental health assessment prior to the physiotherapy assessment. Following information regarding comorbidities should be asked either from referring professional or the patient.

  • Presence or suspicion of any current or previous communicable disease (tuberculosis, hepatitis etc. )
  • Presence or suspicion of any current or previous non-communicable disease (heart disease, hypertension, diabetes, kidney disease etc.
  • Presence of any mental health disorder (PTSD, Depression, Anxiety etc.) or any psychological symptom causing distress

In addition to the routinely collected information, the clinician should try to understand the patient’s subjective pain experience through following points.

  • The meaning of pain for themselves and their lives. While some patients see the pain as a temporary, treatable condition; other patients may see it a permanent sequel of traumatic experiences due to personal or cultural factors.
  • Patient's beliefs about the cause of his or her pain. The reason thought by the patient can be a particular event (e.g. torture) or a structural explanation (e.g. disc herniation).
  • Patient’s beliefs, expectations and plans about treatment of pain. While some patients have positive motivation towards physiotherapy and exercise, others may see medical or surgical interventions as the only solutions.
  • Presence of fear of pain and movement and linked withdrawal from physical activity.
  • Presence of hopelessness or catastrophisation.
  • Patient’s perception of self-efficacy as well as physical incapacitation.
  • Socioeconomic details which may be related with pain (e.g. unemployment or long working hours, house without proper heating, nutrition, absence of private space or secure neighborhood for physical activity, family support, stigmatization)

To supplement the qualitative information collected during the interview, related outcome measures explained in PDDM sub-domains can be used.

Physical Evaluation

In every step of the physical evaluation, general principles of trauma-informed care model should be implemented. Breaching the patient’s boundaries may result in re-traumatization and loss of trust.

  • Inspection including posture, deformities, gait, transfers and guarding movements
  • Localization of pain through patient’s guidance and palpation
  • Movement testing including active, passive and accessory movements
  • Functional and specific physical tests
  • Muscle Strength and endurance assessment
  • Neurological Assessment including sensation, reflex and neural tension tests
  • Balance Assessment

Analyzing Findings and Delivering Results

It’s important to keep in mind that individuals suffering from pain expect a conceivable explanation about the reason of their pain and meeting this expectation is one of the essential steps in building therapeutic relationship.

  • Based on the information collected during the interview, the clinician should analyse the weight of each main domains of PDDM and make a mapping of the contributors.
  • Identified contributing factors should be explained to the patient by taking his or her current beliefs and capacity to understand into account.
  • While explaining the findings, use of terms and concepts which can cause catastrophization should be minimised (for example; wear and tear, rupture, herniation).
  • Communication should be bi-directional,  feedback regarding provided explanation and whether it is received should be asked from the patient.
  • In addition to explanation of causes of pain, important points such as how physiotherapy can help, estimated treatment duration, expected outcomes, rules and bilateral responsibilities should be discussed with patients in order to set the frame of the treatment process.

Case Examples

Case 1

Mr. A. was referred to physiotherapy for pain and severe limitation at his right shoulder. He was detained in his origin country 5 years ago and subjected to ill-treatment during that period. He was beaten and pushed down from the stairs, fell on his shoulders several times. During the following months after detention he couldn’t receive any treatment for his shoulder and the physical complaints have became worse from day to day. He has became more and more disabled because of his shoulder pain.

He stated that he was diagnosed with gastritis, hypertension and diabetes and he is slightly overweight. He also stated that he is suffering from sleep disturbance since he feels too much pain when he lies on his shoulder.

Physical examination revealed significant loss of active and passive range of motion and weakness at the right shoulder. He was constantly keeping his arm and shoulder in a protective posture and there was sensitivity to palpation all over the shoulder joint. Due to over reaction to palpation and manual testing, proper evaluation couldn’t be done. Active flexion at shoulder was only 40 degrees and there was severe crepitation during the movement.   

He generally had positive expectations from the physiotherapy process. But he was extremely concerned about moving his arm due to fear of pain. His CSI score was below the clinical threshold but he showed high scores in PSQI and TSK. MRI screening was conducted in order to understand the clinical situation better and it showed muscle-tendon tears at supraspinatus and biceps long head as well as Hill-Sachs lesion.

In the light of the information collected from the evaluation it can be said that while he had significant structural damage and related nociceptive input, his exaggerated reaction to palpation and movement was not compatible with his injuries. Seemingly the main reason behind his disability was fear of pain and movement. So it was essential to address cognitive and behavioral contributors before expecting any improvement in nociceptive contributors. In addition to that he had important comorbidities such as sleep disturbance, diabetes and hypertension which easily hinder tissue healing and decrease pain threshold. That’s why these problems were also needed to be targeted.

Case 2

Mr. S. was referred to physiotherapy for debilitating pain at his left calf, ankle and foot. His complaints started 4 years ago after he was shot from his hip. The bullet followed a diagonal track and fragmentized in his lower abdomen. He was operated in a military hospital and put into prison where he was subjected to torture after his medical treatment. The pain below his knee started those days and worsened gradually until today. The pain had constant sharp, burning character and increased with movement and standing. He was also suffering from regular face pain and headaches.

He didn’t have any communicable or non-communicable disease but was suffering from insomnia and PTSD symptoms as well as anxiety. He had positive expectations about physiotherapy but stated that he was extremely concerned and tired because of his pain. His CSI score was above the clinical threshold. 

Physical examination revealed sensitivity to palpation at lower abdominal area and below the knee. Hyperalgesia and allodynia were present below the knee. He didn’t have any loss of ROM or muscle strength in both extremities but he had pale skin and hair loss at left foot and ankle. Interestingly, neural tension tests didn’t provoke his pain. Physical evaluation for tension type headache and cervicogenic headache was negative.

He was referred for advanced screening but EMG and doppler-ultrasound didn’t show any abnormality in nerve conduction or circulation. MRI screening didn’t show any neurological finding can be related with headache. But a second referral to orthopaedist revealed a fracture in his nose remained from prison days and it was the probable cause of head and face pain.

Based on the collected information and findings, it was difficult to establish a clear hypothesis but nervous system dysfunction appeared to be main driver of the pain. A neurovascular compromise due to gunshot wound might have caused neuropathic pain and through the time it might have triggered central sensitization with the contribution of PTSD symptoms and constant headaches.

Resources

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