Interventions for treating persistent pain in survivors of torture
Persistent (chronic) pain is a frequent complaint in survivors of torture, particularly but not exclusively pain in the musculoskeletal system. Torture survivors may have no access to health care; where they do, they may not be recognised when they present, and the care available often falls short of their needs. There is a tendency in state and non‐governmental organisations' services to focus on mental health, with poor understanding of persistent pain, while survivors may have many other legal, welfare, and social problems that take precedence over health care.
To assess the efficacy of interventions for treating persistent pain and associated problems in survivors of torture.
We searched for randomised controlled trials (RCTs) published in any language in CENTRAL, MEDLINE, Embase, Web of Science, CINAHL, LILACS, and PsycINFO, from database inception to 1 February 2017. We also searched trials registers and grey literature databases.
RCTs of interventions of any type (medical, physical, psychological) compared with any alternative intervention or no intervention, and with a pain outcome. Studies needed to have at least 10 participants in each arm for inclusion.
Data collection and analysis
We identified 3578 titles in total after deduplication; we selected 24 full papers to assess for eligibility. We requested data from two completed trials without published results.
We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. We calculated standardised mean difference (SMD) and effect sizes with 95% confidence intervals (CI). We assessed the evidence using GRADE and created a 'Summary of findings' table.
Three small published studies (88 participants) met the inclusion criteria, but one had been retracted from publication because of ethical problems concerned with confidentiality and financial irregularities. Since these did not affect the data, the study was retained in this review. Despite the search including any intervention, only two types were represented in the eligible studies: two trials used cognitive behavioural therapy (CBT) with biofeedback versus waiting list on unspecified persistent pain (58 participants completed treatment), and one examined the effect of complex manual therapy versus self‐treatment on low back pain (30 participants completed treatment). Excluded studies were largely either not RCTs or did not report pain as an outcome.
There was no difference for the outcome of pain relief at the end of treatment between CBT and waiting list (two trials, 58 participants; SMD ‐0.05, 95% CI ‐1.23 to 1.12) (very low quality evidence); one of these reported a three‐month follow‐up with no difference between intervention and comparison (28 participants; SMD ‐0.03, 95% CI ‐0.28 to 0.23) (very low quality evidence). The manual therapy trial also reported no difference between complex manual therapy and self‐treatment (30 participants; SMD ‐0.48, 95% CI ‐9.95 to 0.35) (very low quality evidence). Two studies reported dropouts, one with partial information on reasons; none of the studies reported adverse effects.
There was no information from any study on the outcomes of use of analgesics or quality of life.
Reduction in disability showed no difference at the end of treatment between CBT and waiting list (two trials, 57 participants; SMD ‐0.39, 95% CI ‐1.17 to 0.39) (very low quality evidence); one of these reported a three‐month follow‐up with no difference between intervention and comparison (28 participants; SMD 0, 95% CI ‐0.74 to 0.74) (very low quality evidence). The manual therapy trial reported superiority of complex manual therapy over self‐treatment for reducing disability (30 participants; SMD ‐1.10, 95% CI ‐ 1.88 to ‐0.33) (very low quality evidence).
Reduction in distress showed no difference at the end of treatment between CBT and waiting list (two trials, 58 participants; SMD 0.07, 95% CI ‐0.46 to 0.60) (very low quality evidence); one of these reported a three‐month follow‐up with no difference between intervention and comparison (28 participants; SMD ‐0.24, 95% CI ‐0.50 to 0.99) (very low quality evidence). The manual therapy trial reported superiority of complex manual therapy over self‐treatment for reducing distress (30 participants; SMD ‐1.26, 95% CI ‐ 2.06 to ‐0.47) (very low quality evidence).
The risk of bias was considered high given the small number of trials, small size of trials, and the likelihood that each was underpowered for the comparisons it reported. We primarily downgraded the quality of the evidence due to small numbers in trials, lack of intention‐to‐treat analyses, high unaccounted dropout, lack of detail on study methods, and CIs around effect sizes that included no effect, benefit, and harm.
There is insufficient evidence to support or refute the use of any intervention for persistent pain in survivors of torture.
Emma Baird, Amanda C de C Williams, Leslie Hearn, Kirstine Amris
Plain language summary
Treating persistent pain in torture survivors
There is no good evidence about any method of treating long‐lasting pain following torture.
Psychological problems following torture, such as depression and post‐traumatic stress disorder (PTSD), receive a lot of attention in refugee healthcare. Physical problems after torture tend to be overlooked by staff trained in mental health care. Survivors of torture often suffer long‐lasting pain, usually affecting muscles and joints.
We wanted to know whether any treatments were successful in improving pain, and reducing disability and distress in survivors of torture. We searched the academic literature to February 2017 and found three randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups).
Two studies (58 participants) compared cognitive behavioural therapy (CBT; talking therapy that helps people change the way they think and behave) plus learning to control muscles and breathing with no treatment, and we were able to combine these for analysis. Neither study showed any meaningful improvement in pain, reduction in disability, or reduction in distress, over eight to 13 weeks of treatment. One study (30 participants) compared complex manual therapy with self‐treatment for low back pain but could not be combined with the other two studies; it reported no difference in pain relief, but did report that the physical intervention reduced disability and distress at the end of treatment.
Quality of the evidence
We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low quality evidence means that we are very uncertain about the results. High quality evidence means that we are very confident in the results. The quality of the evidence was very low for pain relief, reduction in distress, and reduction in disability. This was due to the small size of the studies, poor study design, and substantial dropout of participants from studies.
Emma Baird, Amanda C de C Williams, Leslie Hearn, Kirstine Amris
Implications for practice
For torture survivors with chronic pain
We found no direct evidence for or against either cognitive behavioural therapy (CBT) with biofeedback or manual therapy, for achieving pain relief, reduced disability, or reduced distress. However, there are very few studies, and the quality of evidence they provide is very low.
We found no direct evidence for or against CBT with biofeedback or manual therapy, for achieving pain relief, reduced disability, or reduced distress in survivors of torture, as the interventions were delivered in the three included trials. As in other chronic pain conditions, any pain treatment should be based on thorough assessment and identification of pain mechanisms involved, including of neuropathic pain and sensitisation phenomena, and should aim not only to reduce pain but to improve function and quality of life. Assessment and treatment should, as is recognised best practice, involve a multidisciplinary team. The patient should be asked about possible countertherapeutic associations of particular treatments with torture methods, such as forcible medication or electrical interventions.
A human rights context, with reference to cultural difference in expressing pain and distress and seeking help, and with reference to the personal meaning of torture, is highly desirable as a basis for treatment initiatives.-
For policy makers
The small number of randomised controlled trials and the resulting paucity of information means that no conclusions concerning the management of post‐torture pain can be drawn. As recommended for chronic pain in general, an interdisciplinary, multimodal approach to pain management in survivors of torture is probably optimal, with a focus on agreed goals of improved understanding, functioning, and social participation. This should be applied sensitively to patients who may be seriously traumatised.
For funders of the intervention
Rehabilitation after torture is a human right, yet provision is scant even in well‐resourced countries where refugees settle. It is important that best practice from pain treatment in general is extended to torture survivors, and that pain is not mistakenly assumed to be a symptom of post‐traumatic stress and pain treatment neglected in favour of intervention for post‐traumatic stress disorder. Funders can take a role in requiring robust assessment of the outcomes of interventions, and partnerships with academic teams where intervention teams do not have the necessary expertise.
Implications for research
The search yielded only three studies, and one more ongoing. All four used psychological and physical therapy methods: none used pharmacotherapy or other medical interventions for pain. This means that we know almost nothing about whether treatments for pain that are otherwise of known effectiveness can also reduce pain and pain‐associated problems in survivors of torture. The impact of torture, flight, and exile are factors that may complicate behavioural and cognitive aspects of pain and disability, and undermine treatment feasibility, adherence, and outcome. Given the large number of refugees in high‐income countries, healthcare services will be treating pain in survivors of torture, although not necessarily identified as such, but without any research literature to guide clinical decisions.
Our understanding of persistent pain from torture is seriously lacking, so we have little to inform development of research questions or interpretation of outcome study data. Despite contributions from forensic and accident medicine, little is known about the long‐term effects of many forms of torture.
Careful studies of torture survivors are beginning to establish connections between some forms of torture and persistent pain, better described by mechanism than by site (Amris 2015), and this could be used to advance theory development and guide future studies addressing outcome of pain rehabilitation.
Most studies of torture survivors are set in specialised non‐governmental treatment centres in high‐income countries, or in less well‐resourced countries, and academic expertise may be lacking when it is needed to design worthwhile studies. Despite the difficulties of recruitment from what is often an unstable population (in terms of civil status, income, and accommodation), studies must be adequately powered. Ideally, treatment methods are drawn from those showing best outcomes in the general chronic pain population, and delivered by therapists qualified in those methods. The studies included in this review appeared weak in their understanding of pain and of its effective treatment, so interventions fell short of what could be provided and tested.
In the short‐term, careful observational studies of torture survivors in treatment for pain would help to formulate research hypotheses and questions to be addressed by controlled studies.
Outcomes in the studies in this review were very narrow and did not consider harm, a significant risk in this population, particularly in participants with moderate to severe post‐traumatic stress symptoms. However, conceptualising psychological distress, whether at baseline or after treatment, only in terms of PTSD diagnosis or caseness is inadequate for the range and extent of psychological problems in this population (Patel 2014; Quiroga 2005). Similarly, many torture survivors' lives are very constrained by lack of resources (money, language, social networks, and others) that both disability and quality of life scales may be difficult to answer in terms only of pain, and care should be taken to select those (perhaps from international bodies such as the WHO) with most appropriate content.
Interview assessment is inevitably unstandardised, and conducting it via an interpreter adds further unreliability. While questionnaires can be translated and checked by back‐translation, this falls short of adequate development of a questionnaire incorporating cultural as well as linguistic equivalence: these methods are well described in Sousa 2011.
Given the impossibility of blinding participants or therapists to most psychologically based treatments, collecting ratings from participants of their expectation of benefit from their assigned treatment (or comparison condition) before it starts, and satisfaction when it ends, is a helpful substitute, particularly when the treatments may be drawn from psychological models and methods that are culturally unfamiliar to participants.
The right to rehabilitation after torture is enshrined in international law, as is the right to asylum, but is not yet realised in any country. Apart from the human rights grounds, there are obvious humanitarian grounds for trying to provide best health care to torture survivors with the aim of restoring as far as possible their capacity to participate in their host country and chosen communities. There is no substitute for good quality treatment studies, using best clinical and scientific practice.