PLENARY LECTURES: Assessment of <strong>Torture</strong> <strong>Survivors</strong>(Wednesday Dec 3 Morning)Chronic PainRefugees Presenting to a Rheumatological Servicewith Spinal Pain: Medical and Psychosocial ImplicationsInvited lecturerAndrew Frank, MBBS, FRCP, DSc (Hon); Arthritis Centre, Northwick ParkHospital and <strong>Institute</strong> of Medical Research, Harrow, UKAmanda C de C Williams, PhD, CPsychol, University College, London, UKAim of Investigation: To document the medical, physical and psychosocialproblems faced by refugees presenting to Northwick Park Hospital rheumatologicalneck and back pain clinics.Introduction: Audits from the rheumatology back and neck pain clinics fromNorthwick Park Hospital in the 1990s did not describe a single patient who hadbeen tortured 1;2 . We first reported patients who had been systematically torturedin 2002 3 , and since then increasing numbers have been seen in the spinalpain clinics.Many health care professionals still feel uncertain as to how to assess and treatrefugees who may have been tortured. Furthermore their rapid movement intoareas not previously exposed to their problems emphasises these difficulties.Methods: Patients likely to be recent refugees seen in the rheumatological lowback or neck pain clinics are normally asked their country of birth, duration ofstay in the UK and reasons for coming to the UK. A history of trauma or physicalabuse, where present, is documented during their NHS clinical consultation,sufficient to facilitate their medical management. A sleep history is taken. Patientsknown to the author will have their records reviewed retrospectively.Unique identification numbers were assigned and records entered (into an Exceldatabase) against them in accordance with the Data Protection Act. Descriptivestatistics were performed and data stored in password-protected hospital computers.Results: Sixty three refugees were seen in the rheumatology service with spinalpain between October 1993 and September 2006. Their country of birth wasIraq 24 (all Muslim apart from one Christian), Somalia 16, Afghanistan 8, Iran4, Lebanon 2 and one each from Libya, Sri Lanka, Algeria and Syria. Duration inthe UK had been a mean of 65 (range 5-228, SD 77) months.Discharge diagnoses: - mechanical low back pain 55 (87%), mechanical neckpain 28 (40%), anxiety/depression 48 (75%), post-traumatic stress symptoms41 (65%), torture/beating 30 (48%), knee pains 11 (17%), hiatushernia/reflux 11 (17%), abdominal pains ? cause 7 (11%) and metabolic bonedisease 7 (11%). Twenty six (41%) complained of some kind of gastrointestinaldisorder.8
Even when torture/abuse was denied, patients often admitted to repetitive horrificdreams consistent with post-traumatic psychological distress.Therapies tried included standard analgesia (using the analgesic ladder), tricyclicantidepressants and amelioration of social problems when possible. Standardphysiotherapy (aiming to improve self-management) usually appearedunhelpful whilst passive measures e.g. corsets seemed acceptable. Psychologicaltherapies were not usually available.CommentThe presentation will open up the hypotheses that, for many individuals, socialissues dominate psychological issues which dominate physical issues.ReferencesFrank AO, De Souza LH, Frank CA. Neck pain and disability: a cross-sectionalsurvey of the demographic and clinical characteristics of neck pain seen in arheumatology clinic. Int J Clin Pract 2005; 59: 173-182McCarthy J, Frank AO. Post-traumatic psychological distress may present inrheumatology clinics. BMJ 2002; 325: 221.Frank AO, De Souza LH, McAuley JH, Sharma V, Main CJ. A cross-sectional surveyof the clinical and psychological features of low back pain and consequentwork handicap: use of the Quebec Task Force Classification. Int J Clin Pract2000; 54: 639-44.9
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