Treating persistent pain in torture survivors

Bottom line

There is no good evidence about any method of treating long-lasting pain following torture.

Background

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.

Study characteristics

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).

Key results

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.

Authors' conclusions: 

There is insufficient evidence to support or refute the use of any intervention for persistent pain in survivors of torture.

Read the full abstract...
Background: 

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.

Objectives: 

To assess the efficacy of interventions for treating persistent pain and associated problems in survivors of torture.

Search strategy: 

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.

Selection criteria: 

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.

Main results: 

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.

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