Top Contributors - Naomi O'Reilly
- 1 Introduction
- 2 Impact of Migration on Health
- 3 Major Health Concerns
- 4 Role of Physiotherapy Services
- 5 References
The physical, psychological and social experiences of a refugee as one flees conflict and persecution and seeks safety are referred to as refugee experiences.  According to 1951 Refugee Convention, a refugee is one who is unable or unwilling to return to ones country of origin owing to a well-founded fear of being persecuted for reasons of race, religion, nationality and membership of a particular social group or political opinion. There is an increased risk of health problems among individuals with refugee experience as they are faced with both mental and physical stress in their home countries and also during the migration process. 
Immigrant populations are large and heterogeneous which results in a wide variety of different health situations. Migration itself is not considered a risk factor for health, and migrants have in general less health problems than the population both in their home country and in their new country. However, forced migration is a completely different situation, and it is very important to acknowledge this difference. People with refugee experience are at risk of complex physical, mental and social problems, which can contribute to poor health outcomes and impede successful social integration. Forced migration has a massive impact on the lives of refugees and asylum seekers including depression, anxiety, post-traumatic stress disorder, sleeping problems, respiratory and digestive infections, among others. Furthermore, individuals have struggled with finding a sense of belonging or social recognition, with developing trust and confidence, with maintaining motivation to try to adapt to their new circumstances, with financial and social disadvantages, communication difficulties due to cultural and language differences, instability and a constant fear of being deported, all of which can have an impact on health. The literature also indicates that a significant proportion of refugees will have been subject to severe physical and/or psychological torture and that this exposure may have long-term physical and psychological consequences.
Impact of Migration on Health
In order to recognise the need for the inclusiveness of this topic and to incorporate whole societies (that includes that of refugees and migrants), it is necessary to vocalise the importance of how migration can and has been affecting the refugee population. Addressing communicable disease control and immunisation programs holds importance on its own and needs to have increased awareness amongst this population. Research highlights that the number of communicable diseases such as Tuberculosis (TB), and Hepatitis (B & C) are recorded to be on the higher end in migrant populations. These vaccine-preventable diseases have vaccines that lie in abundance, however, are not widely known and sought for in the migrant population, particular in those seeking asylum.  We seek to understand this proposition to fully maximise including the migrant population within the health sector i.e. health services and health whereabouts before their health becomes an unsolvable factor for the country. 
Another aspect that comes into role play is what is termed as Health Vulnerability, defined this as the extent to which the individual (in this case, a migrant) can live with anticipation, to cope with, resist and even recover from the impact of post disease/pandemics. One of the factors that lead to health vulnerability is socioeconomic status. When it comes to migrants, there lies the fear/occurrence of isolation, insecurity, Post-traumatic Stress Disorder (PTSD) and even the journey of travelling so far per se. 
Refugee and Migrant Expectations toward Health Services
A term contrary to health vulnerability is Health resilience, which accounts for all the access to resources and services that are available to the migrants; whether this is material or intangible.  Research suggest that from a migrant’s point of view this would be their general expectation, to have access to necessary commodities and not be vulnerable to diseases that hold vaccines and can be easily preventable.  However, some migrants are in better health conditions from their previous country as opposed to their new country of migration.
Major Health Concerns
Each country has its management of communicable diseases, health structure and programs that support the non-communicable diseases, mental health, and women health. In addition to the health policies that cover the occupational accident, when it comes to refugees or displaced people there is no track of health support for these communicable diseases and thereby elevated conflicts in the home country. 
Example of health conditions that affect majority of the refugee populations:
- Communicable Diseases (Tuberculosis, Hepatitis, HIV/AIDS and other Sexually Transmitted Infections)
- Parasitic Infections (Malaria, Giardiasis, Leishmaniasis)
- Mental Health
- Women Health
- Occupational Health, Job Status or Unemployment.
Moreover, cultural issues might lead to developing health conditions, thereby investing more time in understanding the cultural diversity of the refugees would help understand their health condition and the origin of symptoms such as pain.
According to World Health Organization, a burn is an injury to the skin or other organic tissue primarily caused by heat (hot liquids, hot solids and flames) or due to radiation, radioactivity,electricity, friction or contact with chemicals. This is one of the most common health condition seen in refugees 4 . It becomes life threatening especially in the very young and very old individuals. Due to pain and discomfort, the individuals tend to keep their body in the position of comfort, thus encouraging joint contractures and pressure sore formation. Hence, the physiotherapist plays a role of joint mobilization and turning the individual every 2 hourly during the first few days after a burn injury. 
Refugees encounter frequent falls during migration process, there by exposing them to ankle sprain. Thus, Ankle sprain is an injury to the lateral ligament complex of the ankle joint and graded on the basis of severity.  It is associated with significant socioeconomic cost as well as pain, swelling and impaired function.  The long term prognosis of acute ankle sprain is low and usually results in persistent residual symptoms and injury recurrence as reported by high proportion of individuals.  The physiotherapist aims at reducing swelling and pain, restoring the stability of the ankle joint and regaining full functional status.  Strong evidence supports the use of exercise therapy and bracing in prevention of Ankle Sprain recurrence while early mobilization is best used for the treatment of acute ankle sprain. 
Fracture is one of the most prevalent injuries caused by trauma in refugees. The Physiotherapist handles fracture at various stages / phases;
- Active Phase: This phase is characterized with pain and edema. Hence, the physiotherapist employs the use of cold packs and splinting. While the former controls pain and edema, the later prevents movement at the fracture site. After bone reduction and the healing process sets in: The affected limb is engaged in partial weight bearing, Grade 1 and 2 mobilisation of joints, active and active assisted exercises. The aim is to prevent muscle wasting.
- After Fracture Healing: The aim is to build up muscle strength by involving the affected limb in resistive exercises, grade 3 and 4 joint mobilisation. 
Spinal Cord Injury
Spinal cord injury is one of the major types of war injuries experienced by refugees. In many cases the spinal cord injury is not completely severed,  with injuries classified as either complete or incomplete based on the American Spinal Injury Association (ASIA) Classification System. There is low probability of neurological recovery in individuals with complete lesion while motor recovery following incomplete lesion is highly common  Spinal cord injuries are usually accompanied with associated impairments such as vertebral damage and instability, deep venous thrombosis, spasticity, postural hypotension, osteoporosis and pressure ulcers. The role of the physiotherapist is to conservatively manage these complications. Vertebral damage and instability result from a structural damage and instability of the vertebral column. This is managed conservatively by immobilising the spine for 6-12 weeks either with an extensive bracing or skeletal traction/pillow wedge.  This prolonged bed rest can cause respiratory complications, disuse weakness and contractures.
Venous blood stasis results from lack of movement and paralysis and is aggravated by bed rest. The role of the physiotherapist is to prevent deep vein thrombosis from setting in by the use of electrical stimulation  and external pneumatic compression device after the individual has been routinely placed on anticoagulant.  The use of passive movement is now disputed.
Spasticity is only seen in individuals with intact lower motor neurons and is usually troublesome with incomplete lesions 34 . Due to neural sprouting or changes in the sensitivity of neural receptors, spasticity tends to increase over the first year of injury 35 . Spasticity predisposes individuals to pain, contractures and pressure ulcers as movement is restricted 35-37 . The physiotherapist provides a transients relief not a long lasting reductions in spasticity with the use of passive movements, hydrotherapy, stretch, heat, TENS, cold, electrical stimulation, therapeutic exercises and vibration. 38, 39
Postural hypotension is the loss of supraspinal control of the sympathetic nervous system, resulting to the inability to regulate blood pressure. This is typically seen in individuals with lesions above T6 and is exacerbated by poor venous return secondary to lower limb paralysis and loss of lower limb muscle pump 40-43 . The physiotherapist employs the use of slowly implemented mobilization by sitting out in bed with the legs elevated at different angles. This aims at increasing the individual’s tolerance of lightheadedness with lower blood pressure 44-47 .A common long term complication of spinal cord injuries is Osteoporosis, which predispose individuals to fractures 48-50 . Individuals experience 25-50% reduction in bone mineral contents of the lower limb over a lifetime, although most of the mineral contents are lost in the first year following spinal cord injury 48-57 . Assumptions have been made that the loss of the bone mineral content is due to lack of weight bearing and axial loading 58, 59 . The use of early standing and electrical stimulation therapy has been advocated for Physiotherapy treatment 60-64 .
When blood supply is compromised by the compression of small arteries and capillaries between internal bony prominences and external hard surface, soft tissue necrosis occurs. Hence, Pressure ulcers result from the necrosis of soft tissues 65 . The most vulnerable tissues are those underlying the heel, head of fibular, greater trochanter of femur, ischial tuberosity, sacrum, inferior tip of scapular, olecranon and back of the head 66 . The first sign of excessive pressure is redness that does not blanch with localized pressure 67 . This indicates the damage of the underlying tissue as it is the first to be damaged and the last to repair. Skin breakdown is a later stage of pressure ulcer and indicates more destruction to the underlying tissue 68 . The key to pressure ulcer management is prevention. This involves the prescription of pressure relieving equipments such as bed mattresses (either air or water based), wheelchair cushions and wheelchair 68
Role of Physiotherapy Services
Refugee populations are likely to present with a series of complex and complicated health and wellness, including impairments, activity limitations, and participation restrictions. Landry et al  describe the following:
Pre-existing Disability and Physical Limitation
Due to the onset of migration/ displacement, they were either receiving the required careful attention or did not have access to them yet because there was a lack of those services in their system.
Underlying Health Conditions and the Older Adult
The developed chronic disease and disorder accompanied with the activities limitation is more likely to result with a series of short- and long-term disabilities.
Post-migration and Displacement Health Condition
This arises due to the migrant’s journey itself or change of occupation. Majority of the refugees will opt to find jobs in sectors such as construction, seasonal jobs, service industries and domestic industries as a reason for not having to provide health insurance.
The physiotherapist plays its role when these health problems causes pain, limits function and restrict movement of refugees either at ones country or during the migration process. Hence, the Canadian Physiotherapy Association describes physiotherapy as a primary care, autonomous, client-focused health profession dedicated to improving quality of life by:
- Promoting optimal mobility, physical activity and overall health and wellness;
- Preventing disease, injury, and disability;
- Managing acute and chronic conditions, activity limitations, and participation restrictions;
- Improving and maintaining optimal functional independence and physical performance;
- Rehabilitating injury and the effects of disease or disability with therapeutic exercise programs and other interventions; and
- Educating and planning maintenance and support programs to prevent re-occurrence, re-injury or functional decline.
- Ministry of Health. Refugee Health Care: A handbook for health professionals. Wellington: Ministry of Health. 2012
- Palic S, Elklit A. An explorative outcome study of CBT-based multidisciplinary treatment in a diverse group of refugees from a Danish treatment centre for rehabilitation of traumatized refugees. Torture.2009. 19; 3:248-270.
- Razavi MF, Falk L, Björn Å, Wilhelmsson S. Experiences of the Swedish healthcare system: an interview study with refugees in need of long-term health care. Scandinavian Journal of Public Health. 2011. 39; 3:319-325.
- Steel Z, Silove D, Brooks R, Momartin S, Alzuhairi B, Susljik IN. Impact of immigration detention and temporary protection on the mental health of refugees. The British journal of psychiatry. 2006 Jan;188(1):58-64.
- Stewart M, Makwarimba E, Beiser M, Neufeld A, Simich L, Spitzer D. Social support and health: immigrants’ and refugees’ perspectives. Diversity in Health and Care. 2010;7(2):91-103.
- Bhugra D. Migration and mental health. Acta Psychiatrica Scandinavica. 2004 Apr;109(4):243-58.
- Van Hasselt, EJ. BURNS MANUAL.A manual for health workers.2018 2nd edition. pg 51.
- Bernett,P, Schir mann A. Acute sporting injuries of the ankle joint.Unfallheilkunde1979;82:155–160.
- Lassiter TE, Malone TR, Garret WE. Injuries to the lateral ligaments of the ankle.Orthop Clin North Am 1989; 20:629–640.
- Marti RK. Bagatelletsels van de voet. 1982. 56–61. Capita selecta, Reuma Wereldwijd
- Van Dijk CN, Bossuyt PM, Marti RK. Medial ankle pain after lateral ligamentrupture.J Bone Joint Surg Br 1996;78:562–567.[PubMed]
- Watson-Jones R. Fractures and joint injuries. London: Churchill Livingstone,1976.6
- Bridgman SA, Clement D, Downing A, et al. Population based epidemiology of ankle sprains attending accident and emergency units in the West Midlands ofEngland, and a survey of UK practice for severe ankle sprains. Emerg Med J2003; 20:508–10.
- Cooke MW, Lamb SE, Marsh J, et al. A survey of current consultant practice of treatment of severe ankle sprains in emergency departments in the United Kingdom. Emerg Med J 2003; 20:505–7.
- Knowles SB, Marshall SW, Bowling JM, et al. A prospective study of injury incidence among North Carolina high school athletes. Am J Epidemiol 2006; 164: 1209–21.
- Waterman BR, Belmont PJJr, Cameron KL, et al. Epidemiology of ankle sprain at the United States Military Academy. Am J Sports Med 2010; 38:797–803.
- Anandacoomarasamy A, Barnsley L. Long term outcomes of inversion ankle injuries. Br J Sports Med 2005; 39:e14; discussion e14.
- Konradsen L, Bech L, Ehrenbjerg M, et al. Seven years follow-up after ankle inversion trauma. Scand J Med Sci Sports 2002; 12:129–35.
- Struijs, P and ;Kerkhoffs, G.2010.Ankle Sprain.BMJ Clinical Evidence.
- Doherty C,Bleakley C, Delahunt E,et al. Br J Sports Med 2017;51:113–125
- Yigit Duzkoylu, Salim Ilksen Basceken and Emrullah Cem Kesilmez. Physical Trauma among Refugees: Comparison between Refugees and Local Population Who Were Admitted to Emergency Department—Experience of a State Hospital in Syrian Border District. Journal of environmental and Public Health. 2017. https://doi.org/10.1155/2017/8626275
- Johnson, PH. Physical Therapists clinical companion. 2000. 237-238
- Hermansson AC, Thyberg M, Timpka T. War-wounded refugees: the types of injury and influence of disability on well-being and social integration. Med Confl Surviv. 1996; 12(4):284-302. doi:10.1080/13623699608409299
- Hansebout RR: The neurosurgical management of cord injuries. In Bloch RF, Basbaum M (eds): Management of Spinal Cord Injuries. Baltimore, Williams & Wilkins, 1986:1–27.
- Kakulas BA: A review of the neuropathology of human spinal cord injury with emphasis on special features. J Spinal Cord Med 1999; 22:119–124.
- American Spinal Injury Association: Reference Manual for the International Standards for Neurological Classification of Spinal Cord Injury. Chicago, ASIA, 2003.
- 25. Wolfe DL, Hsieh JTC: Rehabilitation practice and associated outcomes following spinal cord injuries. In Eng JJ, Teasell RW, Miller WC et al (eds): Spinal Cord Injury Rehabilitation Evidence.Vancouver, 2006:3.1–3.44.
- Consortium for Spinal Cord Medicine: Outcomes Following Traumatic Spinal Cord Injury:Clinical Practice Guidelines for Health Care Professionals. Washington, DC, Paralyzed Veterans of America, 1999.
- Schmitz TJ: Traumatic spinal cord injury. In O’Sullivan SB, Schmitz TJ (eds): Physical Rehabilitation: Assessment and Treatment. Philadelphia, FA Davis Company, 2000.
- Merli GJ, Herbison GJ, Ditunno JF et al: Deep vein thrombosis: prophylaxis in acute spinal cord injured patients. Arch Phys Med Rehabil 1988; 69:661–664.
- Myllynen P, Kammonen M, Rokkanen P et al: Deep venous thrombosis and pulmonary embolism in patients with acute spinal cord injury: a comparison with nonparalyzed patients immobilized due to spinal fractures. J Trauma 1985; 25:541–543
- Chen D: Treatment and prevention of thromboembolism after spinal cord injury. Top Spinal Cord Inj Rehabil 2003; 9:14–25.
- Anonymous: Prevention of venous thrombosis and pulmonary embolism. NIH Consensus Development. JAMA 1986; 256:744–749.
- Green D, Rossi EC, Yao JST et al: Deep vein thrombosis in spinal cord injury: effect of prophylaxis with calf compression, aspirin, and dipyridamole. Paraplegia 1982; 20:227–234.
- Merli GJ, Crabbe S, Doyle L et al: Mechanical plus pharmacological prophylaxis
- Landry MD, van Wijchen J, Jalovcic D, Boström C, Pettersson A, Alme MN. Refugees and Rehabilitation: Our Fight Against the “Globalization of Indifference”. Archives of physical medicine and rehabilitation. 2020 Jan 1;101(1):168-70.