Disability among tortured refugees
Summary by Karen Prip
At DIGNITY - Danish Institute Against Torture, formerly Rehabilitation and Research Centre for Torture Victims in Copenhagen, tortured refugees are offered clinical assessment and multidisciplinary rehabilitation for long-term sequelae, among them pain and mobility problems. One frequent form of torture is falanga which is the term for systematic repeated application of blunt trauma to the foot soles. The patients’ multiple problems interact profoundly with each other; thus not reducible to a single central diagnosis or domain of suffering.
This thesis includes a summarizing chapter and four published articles, with the overall purpose to analyse the mechanisms of chronic pain and self-reported disability caused by generalized torture and falanga torture.
Paper 1, explores clinical findings in 11 men with chronic pain after falanga torture ascompared with 11 controls.
Paper 2, describes activity limitations in tortured refugees referred for rehabilitation, particularly the impact of neuropathic pain resulting from falanga. Main outcome measure was the Disability Rating Index (DRI; 12 items) to assess self-reported capacity to carry out daily activities.
Paper 3, examines the underlying pain mechanisms by quantifying sensory impairments in the feet of torture victims who had experienced both generalized torture and those who in addition had been exposed to falanga. Data from these two groups was compared with data from a separately recruited group of 14 ethnically matched controls. Quantitative Sensory Testing was used, including thresholds for touch, cold, warmth, cold-pain, heat-pain, deep mechanical pressure pain and wind-up to cutaneous noxious stimuli in the foot soles.
Paper 4, extended the group analysis into individual sensory profiles of victims’ feet and explored relations between external violence (torture), reported pain, sensory symptoms and Quantitative Sensory Testing data to help clarify the underlying mechanisms in the same sample as in paper 3.
(1) Clinical presentation of chronic pain
The torture victims reported high levels of pain intensity and chronic pain in several parts of the body including the foot soles. Almost all the falanga victims had moderate or severe pain in their feet and in twice as large an area of their foot soles as those torture victims not exposed to falanga. One third of the latter did not report pain in their feet at all and many reported only slight pain. Screening for fibromyalgia-like tender points showed no significant differences between victims exposed to and not exposed to falanga, indicating that this, when present, may be a sign of central sensitization after all forms of torture. Chronic pain in the feet after falanga can be divided into stimulus-independent pain (pain appearing spontaneously) and stimulus-evoked pain (pain evoked by activity). The stimulus-evoked pain was predominant.
(2) Possible pain mechanisms as detected by Quantitative Sensory Testing
Compared to the normal data available, all cutaneous sensory fibre groups (Aβ, Aδ and C-fibres) from torture victims’ feet except those transmitting cold pain and heat pain were less sensitive to external stimuli. Since this occurred also in victims not exposed to falanga a central de-sensitisation must be postulated. Most victims displayed deep mechanical hyperalgesia, irrespective of whether having been exposed to falanga or to other forms of torture. This indicates that central sensitization may be a general phenomenon after torture. Peripheral sensitization may also play a role. Taken together, it is likely that the predominating pain type in the victims’ feet is neuropathic and of a post-traumatic nature.
(3) Pain-related disability
The torture victims perceived extensive activity limitations according to the Disability Rating Index over a wide range of daily activities compared to the normal population. Falanga victims with chronic pain in the feet were more disabled than victims with no foot pain after falanga and victims exposed to other forms of torture. The activity limitations were usually more pronounced in the activities that involved foot load. When examined, anxiety and depression were found in all the torture victims, whether exposed to falanga or not.
Paper 1: Karen Prip and Ann L. Persson: Clinical findings in Men With Chronic Pain After Falanga Torture. Clin J Pain, Volume 24, Number 2, February 2008
Paper 2: Karen Prip; Ann L. Persson & Bengt H. Sjölund: Self-reportet activity in tortured refugees with long-term sequelae including pain and the impact of foot pain from falanga – a cross-sectional study. Disability and Rehabilitation, 2011;33(7):569-578
Paper 3: Karen Prip, Ann L Persson and Bengt H. Sjölund: Sensory function in the foot soles in victims of generalized torture, in victims also beaten under the feet (falanga) and in healthy controls – A blinded study using quantitative sensory testing. Prip et al. BCC International Health and Human Rights 2012, 12:39
Paper 4: Karen Prip, Ann L Persson and Bengt H Sjölung: Pain when walking – individual sensory profiles in the foot soles of torture victims – a controlled study using quantitative sensory testing. Prip et al. BMC International Health and Human Rights 2012, 12:40