Physiotherapy July 2001/vol 87/no 7

IntroductionThe Medical Foundation for the Care of Victims of Torture (‘The MedicalFoundation’):

� Provides survivors of torture in the UKwith medical treatment, socialassistance and therapeutic support.

� Documents evidence of torture.

� Provides training for healthprofessionals, educators and others inthe UK and overseas in working withsurvivors of torture.

Language and CultureFor torture survivors whose first languageis not English, the presence of an inter-preter is recommended and is oftenessential. Even when the client’s under-standing is fairly good, interpreting allowsexpression of subtler experiences andfeelings. A skilled interpreter alsoprovides a cultural and advocacy role,

hearing or understanding words in acultural context that can be shared beforeor after the session. Interpreting meansthe session takes longer and may result in the assessment taking more than one session to complete. The interpreterdoes not have to be of the same sex as the client but it is important to checksensitivities on this, particularly beforeany examination or intervention. Careshould be taken when working withinterpreters to ensure that all presentunderstand and agree that confidentialitywill apply to both physiotherapist andinterpreter.

SettingHospitals as institutions can be reminisc-ent of prison or other torture settings.Being led down corridors by a strangermay provoke intense discomfort, evenflashbacks, and if the patient brings afamily member, trusted friend or advocatehe or she should be able to accompanythe patient (although not be expected to translate). Similarly, white coats,uniforms, and electrical equipment mayrecall torture experiences to patients.Awareness of this and particular careestablishing trust and explaining pro-cedures to the patients can help them tofocus on the session and ensure there is no fear in returning for subsequentsessions.

Privacy and space are crucial in estab-lishing trust and allaying fears of publichumiliation, particularly if clients arerequired to undress. Deprivation ofclothing is a common experience in thetorture environment and being asked toundress can seem threatening. It may behelpful to provide or suggest bringingloose clothing for exercises, stretches, and relaxation sessions. Lying prone, forsomeone who has been tied or even raped in that position, can also feel quitethreatening; again therapists should

Physiotherapy with TortureSurvivors

Summary With rising numbers of asylum seekers, andamong them a significant number of torture survivors,physiotherapists are increasingly likely to receive referrals for patients with torture related problems. While torturesurvivors evoke compassion and the wish to help in healthprofessionals, it is also easy to feel overwhelmed orunderskilled in relation to the complexity of psychologicaland cultural issues, and to assume that they can only betreated in a specialised unit, such as the Medical Foundationfor Victims of Torture. This paper explores the role ofphysiotherapists in the rehabilitation of such clients, throughincorporation of psychological, social and cultural concerns inassessment and treatment procedures, so that their skills andknowledge are as accessible to this patient group as to anyother.

Although the treatment of these clients requires a number of special considerations, the right care generally offers them the chance of remarkable recovery from both physicaland mental traumas.

Key WordsTorture, rehabilitation,ethnic/cultural differences.

by Claude Franklin

Franklin, C (20001).‘Physiotherapy withtorture survivors’,Physiotherapy, 87, 7,374-377.

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Author

Mrs Claude FranklinMCSP DEMK workedas a seniorphysiotherapist andco-ordinator ofphysical therapies at The MedicalFoundation betweenMay 1996 and July2000.

This article wasreceived on May 26,2000, and acceptedon February 16, 2001.

Address forCorrespondence

Mrs Claude Franklin,care of The MedicalFoundation Caringfor Victims of Torture, 96-98 Grafton Road,London NW5 3EJ.

use judgement and check that clients are comfortable. If in doubt, delay thatapproach for one, two or even severalsessions.

Therapists’ Feelings, Clients’ FearsTorture evokes horror, avoidance, and arange of uncomfortable emotions, issuesof asking versus not inquiring, needing toknow a history without wanting to offendor re-traumatise. The clients have feltrepeatedly failed by other people, acutelyso in the horrific context of torture, andnurturing realistic hopes is important, if difficult.

Support for the physiotherapists them-selves is valuable, whether debriefing withpeers, opportunities for case discussionwith colleagues, and/or supervision frompsychologically trained colleagues, orreference to specialist centres like theMedical Foundation. Time to build arelationship, and to learn from theinterpreter, pays off for physiotherapistsand patients.

Common Torture-related Clinical ProblemsIt is well to remember that clients seen in the UK are indeed survivors. The rangeof violent traumas and areas of the bodyaffected by torture are limited only by theextent of the wickedness of the torturers.The traumas are frequently repeated overmonths and years. The illustrations pro-vided below are distressing but unfort-unately common examples that physio-therapists may encounter.

The spine is frequently affected bybeatings, often with early increased de-generative changes and severe posturalproblems among others. The neck suffersparticularly if the victim has been tied to achair and then beaten, which producessymptoms resembling those of whiplash.

Prison conditions (being kept squattingin a room with lowered ceiling or beingrolled up inside a truck tyre are exampleswhich have been encountered) may bythemselves leave their legacy of dys-functions which a physiotherapist may notnormally encounter.

Hyperlaxity of the thoracic spine andsymptoms in the shoulder girdles foll-owing hangings is a finding that maysignify plexus brachial injuries of variousdegrees.

Feet beating can leave a high level ofdysfunction, both with severe loss of

mobility in the tarsal bones affectingarches and loss of elasticity of soft tissues.

Hyperventilation is a common disorderfollowing either direct restriction onbreathing (such as by a cloth pushed intothe mouth) or as a pattern acquiredunder severe pain as an initial normalresponse to pain and intense stress and away to dissociate from it (fainting, losingconsciousness).

Headaches and sleep disturbances arealso very commonly reported troubles.

Few of these horrific mistreatmentsnecessarily leave a ‘trade mark’ but beingaware of the circumstances of injurieshelps physiotherapists to understandbetter the complexity of the findings.

Talking to clients in terms of dysfunction(inflammation, over-stretching, muscleweakness, loss of feeling, instability) willbe more helpful than labelling diagnos-es, and will also relate much better to the therapeutic intervention.

Social and Psychological BackgroundMany clients are in a precarious socialsituation and face urgent practical,financial or legal problems, or at worst a deportation order. The process ofapplication for asylum due to persecutionand torture is lengthy; people face manyhurdles often over a period of yearsbefore their case is heard and their legal situation settled. Even without such problems, torture survivors are often in temporary and unsatisfactoryaccommodation, in casual work if workingat all, cut off from family and others ofthe same culture, religion or politicalpersuasion, and sometimes subject toracist abuse or hostility.

All these factors contribute tomaintenance and exacerbation of post-traumatic stress problems and attendantproblems in psychological and physicalhealth. Items such as the length ofimprisonment, the intensity of the abuse, solitary confinement, whether itwas at an early age and so forth are allindications for the depth of the client’strouble and vulnerability and need forextra support.

If clients use sessions mostly to go oververbal material relating to their tortureexperiences, this can be an opportunity to explore with them the possibility ofspecialist psychological support or ‘talking help’ (counselling, psychotherapy,groupwork).

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Without underestimating what simplelistening may achieve, referral on toappropriate agencies to help is animportant consideration. Support fromgroups from the same country of origin,whether social, political or religious, canalso make an essential difference.

There can be a risk that psychologicaland social problems eclipse the physio-therapists’ agenda, in which case the aimof the sessions and the skills of thephysiotherapists need clarification, so thatclients use them as effectively as possiblefor their overall benefit.

Assessment Establishing trust is very important, inaddition to the usual goals and tasks ofassessment. Information may or may notbe available through referral and/ormedical report. Letting clients know whatinformation is known and clarifying earlythe purpose of assessment is essential.The purpose of an NHS referral shouldnot normally be medico-legal authent-ication of the report of torture; it takestime and expertise to make sense of thewhole history, including knowledge of the country, background and historicalevents, as well as documenting symptomsand injuries.

A normal direct questioning style canrecall interrogation. Instead, therapistscan adopt an open listening and dis-cussing style, picking up cues as they goalong. Acknowledging experience, whichmay have been doubted or denied byothers, can be done without insisting on afull account, but still leaving a door openfor disclosure – eg ‘I have read yourreferral by Dr X. I am aware of what youhave been through and it makes verydifficult reading. We do not need to gothrough a fully detailed history today, but do feel free to tell me anything youmay feel would be useful at any time.’

It is important to assess pain in its ownright, as it can be quite widespreadand/or unfamiliar (unsurprisingly, asclients have often undergone multipleand severe maltreatment with whichtextbooks and therapists may beunfamiliar). Pain assessment shouldinclude degree of inter ference with daily life and goals. It is important to demonstrate belief in patients’ reportsof pain and dysfunction, however little they may accord with investigationresults.

It can help clients if they understandthat diagnosis does not necessarily lead to effective treatment, nor does lack ofdiagnosis imply untreatability. Sharingunderstanding of pain syndromes andpossibilities of treatment enables pro-visional prognoses to be accepted.

Treatment DecisionsIf clients are not at ease with a particularapproach (too overwhelmed psycho-logically, unable to apply a technique dueto a poor environment, etc), they may beable to use it later on; it is necessary toallow time for this (session time, numberof sessions).

Relaxation should not be overlooked asa technique. The wide range of relaxationapproaches available to physiotherapistscan be explored: counting, hold/relax,feeling for support from the floor,visualising.

Combining gentle ‘holds’ with verbaltechniques can help clients to let gobetter as well as provide them with usefulproprioception, and at the same time givefeedback to the therapists on how clientsare progressing. Simple advice onsleeping positions, posture, footwear, etcall add up to substantial help.

Home exercising may be difficult inpoor housing (cold, cramped, crowded,non-carpeted) but can still be aimed atand can be adapted. For example rollinga ball up and down a foot is simple andcan help regain proprioception andmobility while being easy to carry out.

Mobilisations or electrotherapy are oflimited value and sometimes unwise ifused alone, but can be introduced totorture survivors if care is taken to leavespace for proper understanding andagreement between physiotherapist and client. However, someone who hassuffered electric shocks may obviously bevery wary of an electrical machine and itcertainly would not be a wise first choice.Techniques that involve physical touchcan trigger flashbacks and panic attacks in early sessions, but can be introducedwith care later on. Massage later on isequally useful alongside the relaxationprocess.

Classes (back pain management, hydro-therapy, Pilates, yoga, relaxation, etc) ifavailable can often provide a larger lessoppressive space than a small cubicle,although this has to be assessedindividually.

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ConclusionThis assessment/treatment/education/self management continuum is lengthyand spread over time, making the averageintervention with torture survivors muchlonger than normal. Each session may belonger, and will ideally include somebriefing and de-briefing with theinterpreter at the beginning and the end.Allowance should be made for this, tomaximise the chance of success of theintervention. The special needs of torturesurvivors need to be acknowledged by thephysiotherapy department, so thatinterpreting services, time and flexibilitycan be provided.

Clients may have been denied anyfreedom during imprisonment andtorture, and need extra leeway in

expressing preferences and taking anactive part in decisions to do with theirhealth. In addition, it is rare for torturesurvivors not to face problems related to family and close friends, finances,housing, legal status, and psychologicalhealth, as well as physical difficulties. Theaccumulation of these factors increasesvulnerability to further problems, andmeans facing existing difficulties withdepleted resources. Goals may need to be modest, and progress recognised ineven small changes.

Sessions can be positive experiences,which help clients to feel cared for, and tofacilitate their care for themselves. This isa powerful part of healing and recoveryoverall for torture survivors.

Further Reading

Forrest, D (1995). Guidelines for the Examinationof Survivors of Torture, Medical Foundation forthe Care of Victims of Torture, London.

Harding, V and Williams, A (1995). ‘Applyingpsychology to enhance physiotherapyoutcome’, Physiotherapy Theory and Practice, 11,129-132.

Hough, A (1992). ‘Physiotherapy for survivorsof torture’, Physiotherapy, 78, 5, 323-328.

Skylv, G (1992). ‘The physical sequelae oftorture’, in: Basoglu, M (ed) Torture and itsConsequences, Cambridge University Press,pages 39-53.

Thomsen, A, Madsen, J B, Smidt-Nielsen, Kand Eriksen, J (1997). ‘Chronic pain in torturesurvivors’, Torture, 7, 4.

Ellison, A (1997). Community Outreach Study,Medical Foundation Library, London.

Payne, R (1995). Relaxation Techniques,Churchill Livingstone, Edinburgh.

Other Sources of Information

Medical Foundation for the Care of Victims of Torture96-98 Grafton Road, London NW5 3EJ. Tel 020 7813 7777, fax 020 7813 0011

Amnesty International1 Eastern Street, London WC1 X0DW.Tel 020 7413 5500

Refugee Action3rd Floor, The Old Fire Station, 150 Waterloo Road, London SE1 8SB.Tel 020 7654 7700

Refugee Council3 Bondway, London SW8.Tel 020 7820 3085

Refugee Legal CentreSussex House, Bermondsey Street, London SE1 3XF.Tel 020 7827 9090

Key Messages

� It is essential to have access toprofessional interpreters whenworking with torture survivors whosenative language is not English.

� Experiences of torture survivors areunusual and horrific but symptomscan be addressed so as to make asignificant impact on the clients’quality of life.

� Physiotherapists need to allow for thefact that treatment often takes muchlonger with torture survivors than withmost other client groups even whenpresenting with similar symptoms.

� Physiotherapists need to be sensitiveto clients’ histories and to try to selecttechniques that are unlikely to triggerflashbacks.