Rehabilitating Torture Survivors - Dignity - Danish Institute Against ...

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PLENARY LECTURES: Rehabilitation of <strong>Torture</strong> <strong>Survivors</strong>(Thursday Dec 4 morning)Evidence for Pain RehabilitationInvited lecturerAmanda C de C Williams, PhD, CPsycholUniversity College,London, UKPersistent (noncancer) pain is commonly treated using psychologically-basedrehabilitation to improve quality of life. By definition, persistent pain has notresolved with physical and pharmacological treatments; or if partially improvedhas not led to the individual returning to his or her valued activities and roles inlife, or becoming self-managing. This is largely because the problems of persistentpain – loss of social and vocational activity, and pervasive distress, isolationand frustration – result not only from pain but from the fears and confusionsabout it, and from dealing with it in ways appropriate only to acute painproblems. These cognitive, emotional, and behavioural contributions to the persistentpain problem need to be addressed directly in treatment.Treatment using psychologically-based methods usually takes the form of apain management programme, with psychologists and physiotherapists in activetreatment roles, and doctors and others in important educational roles. 40years of such programmes has resulted in diverse methods and outcomes, onlypartly reflected in the randomised controlled trials incorporated in systematicreviews and meta-analyses 1-5 . These show consistently good outcomes: reduceddisability, reduced distress, and even reduced pain although this is not aprimary aim.None of the treatment elements alone is outstandingly effective, although allcontribute to better outcome. Treatment which uses predominantly physicalexercise and retraining has somewhat disappointing results 6 , and the model ofdeconditioning as a consequence of persistent pain is undergoing reevaluation 7 .Education is a weak way to change behaviour 3 ; cognitive therapy has evolvedfrom relaxation/stress management through changing catastrophic beliefs andthinking to problem solving and acceptance, and each shows benefits. The mosteffective alone is behavioural exposure 8 , but it can be hard to engage patientsor to apply across activities and social roles.Overall, the field needs a reassessment of implicit and explicit models, of outcomes(which may overlap little between patients and health care providers),and of process variables such as social context and group factors which maycontribute substantially to outcome. All of these issues will be considered in thelight of provision for torture survivors, amongst whom persistent pain is commonand disabling.28
ReferencesHoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychologicalinterventions for chronic low back pain. Health Psychol 2007;26:1-9.Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercisetherapy for nonspecific low back pain. Ann Intern Med 2005;142:765-775.Ostelo RWJG, van Tulder MW, Vlaeyen JWS, et al. Behavioural treatment forchronic low-back pain. Cochrane Database Systematic Reviews 2005:1-25.Verbunt JA, Sieben JM, Seelen HAM, et al. Decline in physical activity, disabilityand pain-related fear in sub-acute low back pain. Eur J Pain 2005;9:417-425.European Guidelines (2004) European Guidelines for the management of nonspecificlow back pain, www.backpaineurope.org/web/files/WC2_Guidelines.pdfVlaeyen JW, de Jong J, Geilen M, et al. Treatment of fear of movement/(re)injury in chronic low back pain: Further evidence on the effectiveness of exposurein vivo. Clin J Pain 2002;18:251-61.Guzmán J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation forchronic low back pain:systematic review. Brit Med J 2001;322:1511-6.Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomizedcontrolled trials of cognitive behaviour therapy and behaviour therapyfor chronic pain in adults, excluding headache. Pain 1999;80:1-13.29
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