Physiotherapy for Survivors of Torture

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Original Editor - Ilona Fricker from The Center for Victims of Torture, Claire O'Reilly and Karen Wilson as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Karen Wilson and Kim Jackson  

Contents

Introduction

Source: Pixabay, License: CC0
Individuals who have experienced torture are found throughout the international community. Among the most vulnerable are persons who have been forcibly displaced from their homes. According to the UNHCR[1], this includes 25.4 million refugees, 40 million internally displaced persons, and 3.1 million asylum-seekers. Before and during flight, many forcibly displaced individuals experience torture,[2] which can result in serious physical and psychological harm. As the population of forcibly displaced persons continues to grow,[1] so does the reach of its social, physical, and psychological consequences. As a result, physiotherapists are increasingly likely to work with individuals who have experienced torture. In order to meet the comprehensive rehabilitation needs of this population, it's imperative that physiotherapists be aware of and address special considerations for patient care.

What is Torture

Trauma refers to any event that is experienced as being emotionally harmful and has a lasting negative impact on an individual's well-being.[3] Torture is a specific type of trauma and is clearly defined by the ‘United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment and Punishment’, known at the UNCAT, which came into force in 1987. Article 1 of the UNCAT states: [4]

"Torture means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions." [4]

In simple terms, this definition means that to be classified as torture, an act must inflict severe suffering, be carried out intentionally and for a specific purpose, by a person acting in an official capacity .

Surviving torture can result in long term physical impairments, and may also cause survivors to question their basic trust in the world and other people. Survivors of torture (SoT) are frequently classified as primary or secondary. Primary SoT are people who were directly tortured or forced to witness or participate in the torture of another person. Secondary SoT are close family members or relationships to the primary survivor. Secondary survivors can be vicariously traumatised, meaning they may experience secondary traumatic stress from second-hand exposure to their loved ones trauma, resulting in their own trauma reaction, including physical symptoms.

Epidemiology

According to the United Nations High Commission on Refugees (UNHCR), in 2019 there are 22.5 million refugees worldwide, of whom  up to 35% report being survivors of torture. [5] Despite the UNCAT and the ban on torture, in 2009, the number of countries worldwide who continue to practice systematic torture was estimated as 50% of all countries worldwide [6] or as many as 141 countries. [7] The use of torture remains a global public health problem among refugees and has been shown to have long-standing impact on individuals, their families, and communities. [8]

Physiotherapy Response to Torture

Dignity (Danish Institute Against Torture), founded in 1982, was the first European centre for the rehabilitation of survivors of torture that included physiotherapy, and the evidence base for physiotherapy as part of the rehabilitation of SoT has been growing steadily since then. [9][10][11] Currently, over 200 centers for the medical treatment and rehabilitation of SoT exist worldwide. While advice for physiotherapists working with this patient group for the first time readily acknowledges the apprehension physiotherapists might feel working with such a sensitive patient group, given the increasing focus within the profession on skills such as management of chronic pain, patient education and self-management, the modern physiotherapy ‘tool-box’ is well equipped with knowledge and skills that can be adapted to work with this group.

Types of Torture

The Istanbul Protocol,[12] which is the official UN Guideline for documenting torture and it’s effects, considers torture as a process that can involve both physical and psychological methods, producing both physical and psychological effects.

Methods of Torture

The Istanbul Protocol outlines a number of commonly recognised methods of torture, the list is extensive and includes blunt trauma such as whipping or beating, positional torture, burns, electric shocks, sexual violence, conditions of detention such as solitary confinement, deprivation of sleep, water, food, threats of death or harm to themselves or family members, forcing the victim to witness or cause harm to others, acts of humiliation verbally or physically. [12]

Understanding the method of torture used can aid the physiotherapist in understanding the injuries and managing the assessment and treatment appropriately and sensitively. There may be national and regional patterns in the types of torture that are carried out. Some methods, such as forcing someone to maintain a cramped position in a small cage or box, may be selected because they are less likely to leave incriminating marks or wounds on the body. The lack of physical scars should not be taken as an indication that the person did not experience torture. Understanding the types of torture employed is importanct for health professionals documenting alleged torture and can support the validity of the survivors statement.

Impact of Torture

Pre-, Peri- and Post-Migration Factors and the Social Impact

At its root, torture aims to destroy the integrity of a person and eviscerate their sense of self.  Torture seeks to “break” its victim through the intentional use of intolerable pain to destroy and / or damage the physical and psychological integrity of the individual and, by extension, the integrity of the family and community.

Torture is an intimate, interpersonal trauma that often occurs in secrecy or seclusion and renders its victims silent and ashamed. This is particularly true for sexual torture or torture which breaks cultural taboos. It may instill intense and overwhelming feelings of distrust, betrayal, and isolation. In the patient - therapist relationship, this can impact disclosure and trust.

As torture is, by definition, carried out by persons acting in an official capacity, it may mean that the survivor has to flee their country in search of safety. However, refugees fleeing torture encounter many barriers to resettlement in Europe, or their country of refuge. While physiotherapy may focus on the outcomes of the torture experience itself (e.g. scar tissue, fracture mal-union, chronic pain), SoT have likely experienced many additional stressors that impact their health status and wellbeing. During flight SoT may experience significant physical and psychological hardships, making unsafe journeys or dealing with exploitation from attempted human traffickers or kidnappers. Upon resettlement SoT experience many losses (e.g., status, identity, family, employment, property, etc.), and often to live with uncertainty about their immigration status and their safety in their country of arrival. These experiences interact with and compound their distress related to their torture.

This continuum of potentially traumatising experiences, also knows as the ‘Triple Trauma Paradigm’, occur at the pre-, peri- and post-displacement phase for refugees [15], meaning;

  1. The traumatic experiences that disrupt life and cause the person to flee.
  2. The uncertainties and trauma experienced during the flight to safety.
  3. The adjustment and uncertainties confronted in a new country, often without an understanding of the language or culture, or the ability to work (Center for Victims of Torture 2005)

Physical Assaults

Physical torture is in most cases directed towards the Musuloskeletal system. It is aimed at producing soft tissue lesions and pain and usually leaving no visible evidence after the acute stage. Some studies have shown that pain of the musculoskeletal system (prevalence up to 48%); headache (38 - 50%); pain in the back (up to 43%); pain in the feet (19 - 28%); and joint pain (19 - 43%) are examples of frequently reported somatic symptoms among previously tortured refugees. [16]

The impact of physical assaults on the body varies depending upon which type of torture method(s) have been used. The impact of some methods have been more widely documented than others.

For example; victims of Falanga, which is the repeated application of blunt trauma to the feet, typically present with persistent pain of burning, stinging and/or cramping nature, sensory disturbances, walking difficulties including alterations in gait pattern, reduced stride and walking speed. [17] Clinical findings include reduced elasticity in the footpads, skin changes, damage to the plantarneurosis and myofascial changes in the lower limb including compartment syndrome. Palestinian hanging can cause major damage to the shoulder joint complex and creation of brachial plexus damage. [18]

More broadly, fractures, dislocations, muscular contusions, lacerations, amputation of digits, peripheral nerve lesions, pelvic floor trauma, neurological damage, hearing loss, visual problems, pain, scars and headaches are just a handful of the direct physical effects seen on the body as a result of torture. In addition to these assaults, a number of factors may have affected the healing and chronicity such as lack of access to proper medical treatment or rehabilitation during the time of healing.

Torture as a ‘Traumatic Event’

In order for a method to be classified as torture, it must cause ‘severe pain and suffering’. [12] This can be very difficult to classify as it is a largely subjective measure and can be impacted by factors such as age, gender, health, cultural background or religious conviction of the victim.

Clients who have experienced the same methods of torture can present in very different ways. As a treating physiotherapist, it is important to keep in mind that as with any other experience, the physical and psychological impact of torture is subjective and a person who has an isolated experience of torture may have lesser, equal or greater needs for rehabilitation that a survivor of prolonged or severe torture. When treating a torture survivor, it’s important to not only treat the impact that the physical assaults have had on the body, but also recognize and treat the impact that experiencing a traumatic event has on the body.

Trauma can be defined as ‘A shock to your system’, physically or mentally. Defining characteristics are that it is;

  • Outside the range of normal experience
  • The event threatens the person’s life or physical integrity, or the life or physical integrity of a close other
  • The event makes the person feel helpless and out of control
  • The event exceeds a person’s ability to cope

When you have experienced trauma, you realize it can happen again. As a result of this, your brain and your body can start function in ‘survival mode’. This affects the way the brain and body communicate and affects our normal homeostatic mechanisms.

Essentially, trauma dysregulates the autonomic nervous system. The results of this are that multiple body systems are affected.

Symptoms of Trauma

Psychological Physical Social
  • Intense anxiety/fear
  • Anger or irritability
  • Feeling sad or hopeless
  • Poor memory
  • Confusion/difficulty concentrating
  • Loss of meaning or purpose
  • Feeling of guilt or shame
  • Shock/denial or feeling numb
  • Easily startled
  • Wanting to avoid places/people
  • Insomnia or nightmares
  • Feeling tired
  • Racing heartbeat
  • Sweating
  • Breathing difficulties
  • Muscle tension
  • Chronic pain
  • Coordination/balance problems
  • Nausea/vomiting
  • Dizziness or fainting
  • Weight change
  • Upset stomach, cramps
  • Isolation
  • Not being able to trust others
  • Loss of interest in others
  • Insecurity
  • Avoidance of intimacy
  • Family problems
  • Loss of interest in work/hobbies
  • Overprotective behavior
  • Aggressive behavior towards others
  • Being overly critical of others
Long Term Psychological Effects:

Include difficulty concentrating, nightmares, insomnia, memory loss, fatigue, anxiety, depression and posttraumatic stress disorder

Long Term Physical Effects: 

The effects of these physical symptoms in the body chronically cause a number of conditions and disorders that physiotherapists commonly treat.

Common ‘Trauma conditions treated by a physiotherapist;

  • Anxiety - Decreased balance, faintness, dizziness, headaches, muscle tension panic attacks
  • Depression - Low energy, fatigue
  • Post Traumatic Stress Disorder - Avoidance of certain movements related to torture experience, cardiorespiratory symptoms such as heart racing, shortness of breath, chest heaviness, difficulty breathing
  • Chronic Stress - Musculoskeletal changes as a result of pain, tension and decreased core stability
  • Pelvic Dysfunction - Pelvic floor weakness, dyspareunia, avoidance of intimacy, incontinence
  • Sleep Difficulties - Falling asleep, frequent night waking
  • Persistent Pain - Widespread and generalized pain
  • Decreased Body Awareness - Numbing of sensations, and difficulty identifying sensations, changes in posture, decreased flow and vitality to movement
  • Self-regulation Problems - Unable to control escalation of disturbing sensations such as heart racing, breathing, dizziness
  • Gastrointestinal Problems - IBS symptoms including nausea, pain and constipation

These conditions may be worsened by prison or refugee camp conditions where there may have been a lack of access to water, food, medicine and general sanitary conditions. Infections and poor health amplify these existing conditions.

Role of Physiotherapy with Torture Survivors

In light of the physical consequences of trauma and torture, physiotherapy is an important part of recovery for survivors. As a result of the complex interplay between psychological, physical and social factors, physiotherapists should use a biopsychosocial approach with survivors of torture. Torture survivors struggle to manage both the injuries sustained as a result of the physical assaults and the disturbing physical symptoms of trauma and subsequently cope with activities of daily living. The overall goal of physiotherapy is therefore to enable them to manage these symptoms in order to improve their functional ability. The key goals of rehabilitation can be summarised as follows;

  • Treat the direct effects of physical assaults of torture
  • Treat the physical effects of trauma on the body

In doing so, the primary impacts on their health can be summarized as;

  • Improved Functional Ability
  • Decreased Pain Levels
  • Improved Management of Specific Conditions e.g. incontinence, stress and sleep
  • Improved Social Participation and Functioning
  • Improved Coping and Outlook
  • Improved Body Awareness and Self-Regulation

Due to the complex needs of torture survivors, an interdisciplinary approach to rehabilitation ensures that an individual can be treated holistically. Interventions are effective if delivered through individual or group settings alongside other disciplines, especially counselling. Where appropriate, combined interdisciplinary sessions can be delivered to facilitate shared goals and enhance the biopsychosocial response to the conditions being treated.

The Interdisciplinary Team

When working as an IDT, a deep understanding of each other’s goals and treatment approaches enables the team to work together on shared and realistic goals and recognize those areas of overlap between the disciplines and maximize them. Examples of this overlap includes consistency with delivering pain neuroscience education, reinforcement and practice of the same mind-body approaches such as breathing and relaxation, providing psychoeducation on trauma and its symptoms.

Interdisciplinary Team members typically include;

  • Physiotherapists
  • Psychosocial counselors
  • Social Workers
  • Medical Doctors
  • Nurses
  • Interpreters or Cultural Mediators
  • Specialist referral to psychiatrists and surgeons may be necessary.

Providing Physiotherapy to Survivors of Torture

In this section we will discuss i) the Principles of Trauma Informed Care (TIC), ii) Recommendations for a successful assessment which helps to build a relationship of trust with your patient/client, and iii) the Judith Herman’s mental health model of trauma recovery and how it can be adapted to physiotherapy, including treatment approaches to different symptom presentations that are common among SoT

Trauma Informed Care

Sometimes your patient will come to you with a known background of torture, but given the high prevalence of torture among refugees, and the multiple reasons why they may be reluctant to disclose (e.g. fear, shame, lack of trust) you may or may not be aware of your patients torture history. Therefore, we advocate using a trauma-informed approach with all patients/clients, irrespective of known torture status. Of course, TIC is also helpful for persons with a non-torture background of trauma, such as sexual assault, domestic violence etc. TIC is relevant across all physiotherapy practice, not only with refugees or SoT.

Applying the principles of trauma-informed care (TIC) to your treatment approach is about recognizing the many ways in which a traumatic experience can impact all aspects of care, from communication to clinical reasoning. The basic principles of TIC and be summarised as follows:

  • Establish an environment where the client feels safe, connected, valued, informed, empowered and hopeful of recovery.
  • Apply the knowledge of trauma and paths to recovery to practices, policies and procedures.
  • Recognize the signs and symptoms of trauma in clients, families, staff and others involved in the system.
  • Work purposefully with individuals, family, friends and other social service agencies to promote and protect the autonomy of the client
  • Understand the concept of re-traumatisation and apply that knowledge to your services at the level of practices, policies and procedures.
  • Practice culturally competent and non-discriminatory policies, procedures and practices .

Assessment

Below are some guiding tips for your first assessment with your patient. Remember, that most of your ‘usual’ physiotherapy skills such as taking a thorough history, observing range of movement etc. are still relevant, you just need extra care in how you interact with your patient/client. Assessment may take multiple sessions with SoT due to a complicated history and the need to build trust. If you feel that the patient is uncomfortable, give them an opportunity to ask a question or offer feedback, and then move on. A good physio to patient relationship is most important!

Simple Tips for a Successful Assessment

Interpreter / Translator

Remember that if you will be working through a translator, you should familiarise yourself with some considerations for doing that well here (hyperlink to that page). Reassure your patient/client that the translator is also bound by strict confidentiality, try to use the same translator for every session and be sensitive to potential issues of the translator and patient/client speaking the same language but being from different ethnic groups or tribes (e.g. if there is a background of civil unrest in their home country).

Greetings

Spending a little time familiarising yourself with some basic social customs from your patients home country or learning how to say hello in their language can help to set the patient at ease and break the ice.

Trust

Experiencing torture fundamentally affects a persons ability to trust others. Unfortunately, health professionals have also historically been involved in administering torture - if your patient has experienced this, they may naturally be fearful of your role. Know that building a therapeutic relationship may take longer than usual, and remain patient.

Environment

SoT will likely feel more comfortable in a quiet, private space. If there is a door, do not lock or fully close it without their permission. Offer some time for the patient to explore the space and ask any questions about the room. Be aware that some equipment, such as pulleys or electrotherapy machines may trigger unpleasant memories for the patient (being bound or gagged, electrical torture). A ‘Do no disturb’ sign outside the treatment space can help your patient/client to relax.

Body Language

Non-threatening body language such as smiling, resting with your palms face up, sitting or standing at the same level or lower than the patient, and not ‘squaring’ your shoulders or torso toward the patient can help to set them at ease.

Explanations

Offer your patient an explanation of what will happen before it does, and check in frequently to ensure you have their consent to continue, or to address any new fears or concerns that may arise as the session proceeds. Never touch a patient unexpectedly or without their explicit consent, e.g. I’d like to take a look at your shoulder now, and to do that I will stand beside you and put one hand on your shoulder and one on your ribcage. Is that ok for you?

Social

Understanding the social environment of the patient forms part of any biopsychosocial physiotherapy assessment but is particularly key with this patient group. Some considerations to keep in mind involve both the impact of displacement and your patient/client’s altered identity as a ‘refugee’ and the impact of torture itself. While these impacts are diverse and wide ranging, and part of the reason why SoT are best treated using an interdisciplinary approach. This section is limited to practical examples of the implications for your approach and treatment.

Family and Interpersonal Dynamics

Torture is a form of interpersonal trauma that is purposefully used to create shame and destroy social bonds. Family members and close friends may or may not be aware that the person has experienced torture, or it’s extent. This isolation may have practical implications for your treatment such as your patient/client trying to keep appointments (or their purpose) secret, or not feeling comfortable carrying out home exercise programmes in a shared space.

Community Standing

People may have been targeted for torture because of their prominent position in the community, for example as a public intellectual, political opponent or community organiser. Their new refugee status leaves them open to anti-immigrant sentiment, and refugees often struggle to (re)attain stable socio-economic standing in a new country. Being aware of different power dynamics across your cultures, e.g. with regard to gender or age, and ways to demonstrate respect e.g. using more formal address such as Dr. or Mrs., ensuring punctuality, can be a way to treat your patient/client in a way that respects their inherent dignity.

Livelihoods

Be aware that many refugees live in precarious financial situations. If they rely on public transportation to reach your appointments try to allow some flexibility on the appointment time, know that securing childcare may affect their ability to attend sessions and if you need to contact them about an appointment etc., make sure to call them directly and not leave a message that necessitates them having to initiate a new call.

Religious and Cultural Practices

This might impact whether your patient/client feels comfortable alone in the treatment room/cubicle with a physiotherapist, working with a physio of the opposite gender, or the level of undress or movement they feel comfortable with. Culturally specific holidays may affect their ability to attend sessions. An advance phone call before your first session where you give the client/patient time to express their preferences and anything that might help them to comfortably engage in their session, can help.

Vulnerability

Refugee SoT may be in a vulnerable position - removed from their usual home, culture, language, social support network and dealing with the physical and psychological impact of their experience. If you have concerns about the wellbeing of the patient (e.g. domestic violence, food insecurity) working with other members of the interdisciplinary team, such as the social worker, is helpful.

Strategies to Avoid Client Re-traumatisation

Considerations Strategies
Language and Culture English may not be the client's first language.
  • Use of an interpreter to facilitate clear communication and the expression of subtle experiences and feelings.[19]
Sensitivity to working with individuals of the opposite sex.
  • Assess client comfort and sensitivity.
  • Arrange for treatment with a same sex therapist, if necessary.
Trust Fear of being let down.
  • Be consistent and on time to therapy sessions.[20]
  • Encourage realistic client expectations.[19]
Fear of loss of privacy.
  • Respect client confidentiality.
  • Make sure interpreters know that rules regarding respect for client confidentiality extend to them as well.[19]
Safety Certain positions, settings, equipment, or treatment interventions can provoke discomfort and flashbacks.
  • Explain all procedures to clients beforehand.[19][20]
  • Ask for permission before touching a client. Check ongoing tolerance to physical touch.[20]
  • Give clients choices related to treatment (ex. treatment positions, speed of progression, intervention focus, choice of modalities) [19][20]
  • Caution with mirrors, bright lights, and uniforms.[19]
Sensitivity to prolonged questioning and interrogation.
  • Gather history using an open listening/discussion approach.[19]
  • Avoid excessive questioning.[19][20]
  • Break up initial evaluations over several sessions.[19][20]

Treatment Model

Judith Herman is an American psychiatrist whose mental health based model of trauma recovery is employed in many torture treatment centres globally, and can be adapted by physiotherapists for treatment with SoT. Herman’s approach emphasises empowerment of the survivor, and rebuilding their interpersonal relationships. For this reason, if appropriate for your patient/client, treatment in a group setting can support rehabilitation. The model has three stages; i) establishing safety ii) reconstruction and iii) reconnection

As already outlined, it is vital to holistically address the needs of the SoT through an inter or multi disciplinary approach. When adapting the Herman model to physiotherapy treatment, it is highly recommended to work closely with the psychologist or other mental health care colleague.

1. Safety and Stabilization

People affected by trauma tend to feel unsafe in their bodies and in their relationships with others. This stage is the starting point, and is necessary for all healing and engagement that follows. This occurs across many domains (psychological, behavioral, physiological, legal, environmental, social) and involves creating a safe space and stabilizing the individual’s reaction to the preceding trauma.

In establishing Safety and Stabilization, physiotherapists should work towards;

  1. Empower the client as much as possible in all aspects of the decision making and help them adapt to a pace that is tolerable for them.
  2. Provide interventions that help control the body’s symptoms of emotional distress.
  3. Consider how the treatment environment feels safe and not re-traumatizing.

Specifically tips for this stage include;

  • Allow the client to decide on the gender of their therapist as this will vary with cultural norms and trauma history.
  • Reinforce issues of confidentiality and maximize informed consent
  • Consider using a translator or cultural mediator will help understanding of cultural norms and assist in building trust.

Treatment modalities typically used in this phase include;

Pain Education and Education about Trauma Symptoms

Allows cognitive restructuring of irrational thoughts, reduces fear, reduces catastrophisation. (Link to pain education parts)

Diaphragmatic Breathing

This teaches clients to stimulate the vagal nerve to generate a parasympathetic response of the body which helps down-regulate symptoms of hyperarousal (heart racing, shallow fast breathing, sweating, feelings of nervousness).

Relaxation Techniques

Physical relaxation techniques work on principles of progressive muscular relaxation, hold relax or reciprocal inhibition to help create a state of physical and in turn mental calm.

Sleep Hygiene Advice and Education

Advice and education around factors that encourage and prevent sleep are important in enabling an individual to modify their behaviors during the day and create a ‘bedtime routine’ which optimizes the potential for better sleep.

Grounding Techniques

Help bring your focus to what is happening to you physically, either in your body or in your surroundings, instead of being trapped by the thoughts in your mind that are causing you to feel anxious. Having the client bring their focus to an object or feel the sensation in their feet in contact with the ground are examples of grounding and can help if the client is dissociating.

Mindfulness of Breath and Movement including Yoga Based Practices

These practices provide opportunity for ‘interoceptive exposure’. Gradually the client learns to notice the sensations in their body associated with different emotions and different movements. Teaching them to pendulate back and forth between sensations that are disturbing to them and those that are not helps them gradually recognize and normalize symptoms and learn how they can control them.

Posture and Emotion (The ‘Somatic Narrative’)

Posture is linked to emotion. Helping a client identify the changes in their posture when their emotions change such as a slumped, rounded posture when sad and an open expansive posture when happy or confident enables them to recognize patterns of movement and posture and actively use this as a strategy to support positive emotions during their day.

Self-Massage

Using available props they have at home and teaching self-massage is a way to bring pain relief especially if the client is not yet ready to be touched by the therapist.

2. Process of Reconstruction

Once a basic sense of safety is restored and the survivor is stabilized to the extent that the effects of the trauma no longer overwhelm his/her capacity to function, the focus is now on coming to terms with the trauma and its effect on one’s life. In this phase, physiotherapists should work towards;

  • Reinforcing methods of stabilization as exploration into more challenging movements continue.
  • Empower individuals to work towards goals with a focus on pacing
  • Acknowledge the loss of prior physical abilities and working together to regain or compensate for the impairments.

Treatment modalities typically used in this phase include;

Continuation of Mindfulness Activities

Enables individuals to increase awareness of their body’s sensations during previously avoided movements which may ‘trigger’ traumatic memories and subsequent body reactions. Working through these sensations as before to enable self-regulation is crucial in being able to restore normal movement. For example; Hip abduction in supine is often avoided in survivors of rape.

Aerobic Exercise

In an educational context, individuals will understand the benefits both for their general health and in alleviating symptoms of depression. Practicing different forms of aerobic exercise during treatment sessions enables individuals to feel the immediate sense of wellbeing and consider which types may work for them in their home context. A consistent program of aerobic activity also helps alter levels of arousal and energy combating fatigue, lethargy and better enabling individuals to engage in other activities of daily life. Consideration should be given to access resources and the home setting where there may be limitations of space, safety and confidentiality. (Link to interventions in urban and camp settings)

Strength Work

Is typically both on general body conditioning and more specifically on a particular area of weakness. There should be a focus on core stability to mitigate the effects of the body’s chronic fight or flight response following a traumatic experience where energy is directed more to the global muscles. Strengthening of pelvic floor and lumbosacral muscles are often incorporated into programs. Working alongside a counsellor to teach ‘protective’ movements that empower an individual to move through their trauma memories can be a very powerful strategy in trauma recovery.

Flexibility

Stretching helps recover movement and also have a dual effect of relaxing the body. Trauma dysregulates the autonomic nervous system and one impact of this is on constriction of fascia. Targeted myofascial stretches are a key part of the program. [21][22]

Balance

Decreased balance may present as a co-morbidity of anxiety [23] and so improving balance can improve anxiety, while decreased anxiety may be accompanied by improved balance. Challenging yoga based practices have the added benefit of recovering strength, and body awareness in addition to balance.

Pacing and Goal Setting Education

A decreased ability to self-regulate symptoms in the body following trauma means that individuals often need support around gauging realistic amounts of activity towards their determined  goals. Starting slowly and setting modest steps towards their goals helps clients feel successful. Progress should be highlighted for even small changes. To acknowledge the cognitive changes that impact memory and concentration following trauma, keep information short and simple without too much detail. Limit the number of prescribed exercises to 4 or 5. Provide written and illustrated instructions. Consider additional support for appointment reminders: written, phone calls, etc. Helping individuals avoid ‘boom and bust’ cycles of activity or addressing issues of fear and avoidance on the opposite end are key in helping them self-regulate and return to functional levels of activity.

Manual or ‘Hands On’  Approaches

Manual treatments such as massage or joint mobilizations or ‘hands on’ referring to assisted movement or physical prompts can be important to restore safety in ‘touch’, something that may have been violated as part of their torture experience. These approaches should be applied cautiously to avoid re-traumatizing the client and acknowledging usually heightened levels of sensitivity to pain. The therapist should provide full explanation to the intervention along with the expected sensations in order to empower the individual to provide full consent. During these interventions, the therapist should observe for physical reactions such as facial expressions or withdrawing, physiological reactions such as sweating, fast shallow breathing, or psychological reactions such as emotional outbursts to the treatment. Providing gradual exposure to these interventions and stopping to help the individual ground themselves will better enable success in progressing such interventions.

3. Reconnection

In this stage, assisting the survivor in rebuilding and re-engaging in his/her current life becomes a primary focus of rehabilitation. The focus should be on cultivating empowerment and reconnection. Herman suggests that the essence of this stage can be captured by the phrase, “I know I have myself.”  It is during this stage that torture survivors no longer feel held captive by their past and are often filled with insight into the positive aspects of themselves.

In this phase, physiotherapists should work towards;

  • Facilitating a continued reconnection of the body through graded exercise, body awareness and self-regulation exercises.
  • Facilitate safe physical interactions with others.
  • Facilitate activities which promote a sense of joy to movement.
  • Achieving functional goals by continuing to facilitate goal setting, pacing and tailoring of home exercise programs.
  • Facilitate independent management of symptoms including management of exacerbations
  • Supporting the survivor to seek external resources that promote reintegration into the community and social support networks.

Treatment modalities typically used in this phase include;

Pacing and Goal Setting

Continuing helping survivors identify the coping strategies and interventions that they will continue to use after discharge to continue working towards to sustain progress, meet unmet goals and manage any future exacerbations.

Partner Activities

If working in a group setting of partnering with the therapist. Physical interaction to facilitate for example, stretches or balance positions can be utilised as a way to encourage safe physical connection with others.

Dancing and Games

Depending upon what is culturally appropriate and the mode of delivery, specific cultural dances are effective in enhancing social bonding and reconnection through physical touch. Competitive games or exercise circuits promote a sense of joy in teams and the achievement of challenging activities renews a sense of confidence in their bodies.

Ergonomics and Preventative Advice

General education about ergonomic principles and practice of relevant activities or postures ensures healthy habits moving forward, but also acknowledges that SoT often have an overly sensitized nervous system with higher co-morbidities or conditions such as chronic pain. Preventative advice and education ergonomically and in understanding how to manage acute injuries as they arise can help mitigate the descent into chronic pain states.

Outcome Measures

A variety of measures for functional ability,  pain levels, management of specific conditions such as incontinence, stress and sleep, improved social participation and functioning, improved coping and outlook and improved body awareness and self-regulation should be considered.

Outcome measures do not need to be specific to torture as a mechanism of injury. Using a Trauma Informed Approach, the most appropriate outcome measure for assessing the progress of an agreed goal or outcome can be applied, as with most other patient groups, for example, a Visual Analogue Scale, the Patient Specific Functional Scale, etc.

Clinical Guidelines

World Physiotherapy Policy Statement: Torture

    1. WCPT supports the United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment and encourages its member organisations to call on their national governments to sign and comply with the convention. WCPT will support and encourage the international community, its member organisations and physical therapists to support fellow physical therapists and physical therapists’ families in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment.

UNCAT Implementation Tool 5/2018 Providing Rehabilitation to Victims of Torture and other Ill Treatment

  • This tool provides an overview of how states have implemented the right to rehabilitation through a collection of practices, supplemented with experiences from non-state rehabilitation providers. The practices included in this tool are intended to inspire states to learn from each other and thereby improve implementation at the national level, within the OSCE region and beyond. Promising practice examples from the OSCE region and from other parts of the world have been collected to illustrate possible approaches and steps on the way to ensuring torture victims’ right to the fullest possible level of rehabilitation.

Istanbul Protocol; Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment

  • The Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment is intended to serve as international guidelines for the assessment of persons who allege torture and ill-treatment, for investigating cases of alleged torture and for reporting findings to the judiciary or any other investigative body. This manual includes principles for the effective investigation and documentation of torture,and other cruel, inhuman or degrading treatment or punishment. These principles outline minimum standards for States in order to ensure the effective documentation of torture

DIGNITY Facts about the Health Consequences of Torture and Other Il- Treatment Methods

  • This is a series of one-page fact sheets each defining a method of torture or ill-treatment, recapping related international standards and outlining the health consequences. They use the torture definition of the UN Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (UNCAT). The purpose of the fact sheet series is to empower partners with information; to raise awareness of professional staff who encounter survivors, and to initiate dialogue on the use of these methods.

Resources

Video Series

You can watch the following video series developed by The Bellevue Program for Survivors of Torture’s. Their mission is to assist individuals and families subjected to torture and other human rights abuses to rebuild healthy, self-sufficient lives, and to contribute to global efforts to end torture.

You can also view survivors stories through their Seeking Refuge Documentary, which follows four survivors who were forced to flee dire circumstances in their homes, as they work to reclaim their lives in the United States.

Physiotherapy

Interventions for Physiotherapists working with Torture Survivors: With Special Focus on Chronic Pain, PTSD, and Sleep Disturbances

  • Originally, this publication was intended to provide a short description of physiotherapeutic tools that could be applied in those settings where, for some reason, clients are only able to attend therapy a handful of times. However, while developing these tools, the clinical team realised that the same theoretical background knowledge was required for designing shorter interventions as for longer interventions. this publication will provide practical guidelines to assist the clinician in identifying which issues are most pressing, and which physiotherapeutic tools are most useful for each individual client.

Rehabilitation of Torture Survivors Resource Kit for Service Providers

  • The resource kit is produced by the IRCT, the umbrella organisation for more than 140 independent international torture rehabilitation centres promoting and supporting torture rehabilitation and working for the prevention of torture worldwide. This resource kit is produced as part of a three year project entitled “Developing the Capacity of IRCT Member Centres to Deliver Holistic Torture Rehabilitation Services through South-South and South-North Peer Supervision and Support”, funded by the European Commission from 2010-2012. The information included represents a “getting started” and “where to go for more information” guide. We present options for providers along a continuum of services they might choose to provide, from implementing a survivor service component in their ongoing practice to developing a full-service torture rehabilitation program. Some of the main elements to consider when thinking about rehabilitation and related support services to survivors of torture include the need for specialized assessment and care, with a focus on programs that will help survivors to heal, and rebuild lives of self-reliance and hope for themselves and their families. 

Heal Torture

  • The physiotherapy area of the HealTorture webpage has been created in order to help physiotherapists and other members of the team treating torture survivors to have a site where they can go to learn more about physiotherapies’ role in helping survivors to heal.

Sleep

Blog Posts

References

  1. 1.0 1.1 UNHCR. Refugee Statistics [Internet] Washington, D.C.: UNHCR [Cited September 29, 2018]. Available from: https://www.unrefugees.org/refugee-facts/statistics/
  2. Refugee Health Technical Assistance Center. Traumatic Experiences of Refugees [Internet]. [Cited September 29, 2018]. Available from: https://refugeehealthta.org/physical-mental-health/mental-health/adult-mental-health/traumatic-experiences-of-refugees/
  3. SAMHSA's Trauma and Justice Strategic Initiative. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: Office of Policy, Planning and Innovation, Substance Abuse and Mental Health Services Administration; July 2014
  4. 4.0 4.1 United National Human Rights Office of the High Commission. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. 1984. Available from:https://www.ohchr.org/EN/ProfessionalInterest/Pages/CAT.aspx [Accessed 26 September 2020]
  5. Campbell T.A. Psychological assessment, diagnosis, and treatment of torture survivors: A review. Clin. Psychol. Rev. 2007;27:628–641. doi: 10.1016/j.cpr.2007.02.003. [PubMed] [CrossRef] [Google Scholar]
  6. Amnesty International. Torture. Available from:https://www.amnesty.org/en/what-we-do/torture/ [Accessed 26 September 2020]
  7. Dignity Danish Institute Against Torture. Facts about Torture. Available from: https://www.dignity.dk/en/dignitys-work/facts-about-torture/ [Accessed 26 September 2020]
  8. Grodin MA, Piwowarczyk L, Fulker D, Bazazi AR, Saper RB. Treating survivors of torture and refugee trauma: a preliminary case series using qigong and t'ai chi. The journal of alternative and complementary medicine. 2008 Sep 1;14(7):801-6.
  9. Dignity Danish Institute Against Torture. Who We Are. Available from: https://www.dignity.dk/en/about-dignity/ [Accessed 26 September 2020]
  10. Bloch, I. and Moller, G., 1990. Rehabilitation of torture victims: Physiotherapy as part of the treatment. International Perspectives in Physical Therapy, 5, pp.121-144., Hough, A., 1992.
  11. Physiotherapy for survivors of torture. Physiotherapy, 78(5), pp.323-328
  12. 12.0 12.1 12.2 Office of the United Nations High Commissioner for Human Rights Geneva. Professional Training Series No. 8/Rev.1 Istanbul Protocol; Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.2004. Available from: https://www.ohchr.org/documents/publications/training8rev1en.pdf [Accessed 20 September 2020]
  13. Amnesty International. Torture Animation. Available from: http://www.youtube.com/watch?v=acd7FZgX7_Q[last accessed 25/09/20]
  14. Terveyden ja Hyvinvoinnin Laitos. Part 8: Victims of Torture, Human Trafficking and Violence. Available from: http://www.youtube.com/watch?v=tCKeVR0Has0[last accessed 25/09/25]
  15. Center for Victims of Torture. Helping Refugee Trauma Survivors in the Primary Care Setting. 2005. Available from: https://www.mhinnovation.net/sites/default/files/downloads/resource/%28CVT%2C%202005%29.%20CVT%20Helping%20Refugee%20Trauma%20Survivors%20in%20the%20Primary%20Care%20Setting.pdf [Accessed 26 September 2020]
  16. Olsen DR, Montgomery E, Bøjholm S, Foldspang A. Prevalence of pain in the head, back and feet in refugees previously exposed to torture: a ten-year follow-up study. Disability and Rehabilitation. 2007 Jan 1;29(2):163-71.
  17. Amris K, Torp-Pedersen S, Rasmussen OV. Long-term consequences of falanga torture. Torture. 2009;19(1):33-40.
  18. Peel M, Iacopino V. The Medical documentation of torture. Cambridge; New York: Cambridge University Press; 2008.
  19. 19.0 19.1 19.2 19.3 19.4 19.5 19.6 19.7 19.8 Franklin C. Physiotherapy with Torture Survivors. Physiotherapy Journal, 87 (7): 374-377, July 2001
  20. 20.0 20.1 20.2 20.3 20.4 20.5 Gueron, LP. Physical Therapy for Survivors of Torture. Center for Victims of Torture. April 17, 2013.
  21. Schleip R, Gabbiani G, Wilke J, Naylor I, Hinz B, Zorn A, Jäger H, Breul R, Schreiner S, Klingler W (2019) Fascia Is Able to Actively Contract and May Thereby Influence Musculoskeletal Dynamics: A Histochemical and Mechanographic Investigation. Frontiers in Physiology. 10:336. DOI=10.3389/fphys.2019.00336.
  22. Schleip R, Zorn A, Klingler W (2010) Biomechanical Properties of Fascial Tissues and Their Role as Pain Generators. Journal of Musculoskeletal Pain. 18:4. 393-395. DOI: 10.3109/10582452.2010.502628.
  23. Carey D Balaban, Rolf G Jacob & Joseph M Furman (2011) Neurologic bases for comorbidity of balance disorders, anxiety disorders and migraine: neurotherapeutic implications, Expert Review of Neurotherapeutics, 11:3, 379-394, DOI: 10.1586/ern.11.19
  24. FC ST. Part 1: Torture Survivors: Who are torture survivors?. Available from: https://youtu.be/78hW3-bmGJY[last accessed 01/10/2020]
  25. FC ST. Part 2: Torture Survivors: What challenges do torture survivors face?. Available from: https://youtu.be/iAhQ1_ON-Y0[last accessed 01/10/2020]
  26. FC ST. Part 3: Torture Survivors: Advice from practitioners?. Available from: https://youtu.be/pTkaFDH79Co[last accessed 01/10/2020]
  27. FC ST. Part 4: Torture Survivors: What is the trauma story?. Available from: https://youtu.be/dKlRmlewUBU[last accessed 01/10/2020]
  28. FC ST. Part 5: Torture Survivors: What can you do. Available from: https://youtu.be/ux9x5GyNq3M[last accessed 01/10/2020]