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Individuals who have experienced torture are found throughout the international community. The most vulnerable include people who have been forcibly displaced from their homes. According to the UNHCR, this includes 27.1 million refugees with 53.2 million internally displaced persons and 4.6 million respectively asylum seekers. Before and during evacuation, many IDPs face abuse that can lead to severe physical and psychological harm. As the number of displaced people continues to increase, so does the reach of the physical and psychological consequences of life. Thus rehabilitation professionals are increasingly working with individuals who have experienced abuse. In order to meet the full rehabilitation needs of this population it is important for rehabilitation professionals to recognize and address special considerations for the patient consider.
What is Torture?
Trauma refers to any event that is seen as emotionally harmful and has lasting negative effects on an individual’s well-being. Torture is a specific form of mental disorder and is clearly defined by the ‘United Nations Convention against Torture and Other Inhuman or Degrading Cruelty’ Treatment and Punishment’ known as UNCAT which it implemented in 1987. Article 1 of UNCAT states:
Torture refers to any act of intentionally causing severe pain or suffering whether physical or mental for purposes such as obtaining information from him or another person or confession to punish him in action copy of which he or a third party has made or suspects that you have caused or intimidated or coerced or by a third person or for any discriminatory reason when such pain or suffering is caused by a public official or another person employed by an official or consents or consents what force may. It’s not like that it includes only pain or suffering caused by natural or incidental legal punishment.
Simply put, this definition means that for an act to be classified as torture, it must cause severe suffering and be committed by an official agent and intentionally for a specific purpose.
Surviving abuse can lead to long-term physical disabilities and can also cause survivors to question their basic trust in the world and other people.   Survivors of torture (SoT) are often classified as either primary or secondary. SoT in particular are people who were directly or coerced victims of abuse to witness or participate in the torture of another person. A secondary SoT consists of immediate family members or relationships with the primary survivor. Secondary survivors may be vicariously traumatized which means they can develop secondary traumatic stress from their loved ones involved’. depression causing their own depression including physical symptoms.  .
According to the United Nations High Commissioner for Refugees (UNHCR) in 2019, there were 22.5 million refugees worldwide, of whom approximately 35% report surviving torture. Despite UNCAT and the ban on torture in 2009, the number of countries around the world that still make policy torture was estimated to occur in 50% of all countries or more than 141 countries. The use of torture remains a global public health concern in displaced populations and has been shown to have long-term effects on individuals their families and communities.
Rehabilitation Response to Torture
Founded in 1982, Dignity (Danish Institute Against Torture) was the first European center for torture survivors with multidisciplinary care including physiotherapy ; the evidence base for physical therapy as part of SoT rehabilitation is steadily increasing since then. There are now more than 200 SoT treatment and rehabilitation centers worldwide. Counseling for professionals working with this group of patients for the first time readily acknowledges that rehabilitation professionals may feel at work and group of patients who feel this way. But given the increasing attention within the profession to skills such as chronic pain patient education and self-management, today’s rehabilitation ‘tool-box’ has knowledge and skills that can be adapted for effectiveness and this group.
Types of Torture
The Istanbul Protocol  revised in 2022 on the basis of the previous 2004 edition is an official United Nations Guideline on torture and its output considers torture as a phenomenon that can take both physical and psychological forms in methods of physical and psychological effects.
Methods of Torture
The Istanbul Convention outlines some commonly accepted methods of torture. The list is extensive and includes pseudo trauma such as whipping or beating in the stands torture burns electrocution sexual violence situations of incarceration such as solitary confinement without semen feeding threats of death or harm to self or family members forcing the victim to witness humiliating acts or verbally or physically harming others.
Understanding the mechanism of abuse can help the physical therapist understand the injuries and manage the assessment and treatment objectively and sensitively. There may be national and regional policies in the forms of abuse. Some methods are like coercion maintaining a cramped position in a small cage or box may be selective as they are less likely to leave marks or scars indicating a charge on the body. The absence of physical wounds should not be taken as an indication that the person did not experience abuse. Understanding abuses occupation is important for rehabilitation workers documenting allegations of abuse and can support the veracity of the survivor’s story.  .
Impact of Torture
Pre- Peri- and Post-Migration Factors and Social Impact
At its root, abuse aims to destroy a person’s integrity and remove their sense of self from the body. Abuse seeks to “break” the victim by deliberately using unbearable pain to destroy and/or destroy the person’s physical and psychological integrity and by extension family and community integrity.  .
Abuse is an intimate interpersonal trauma that often occurs in private or in isolation and leaves victims silenced and ashamed. This is especially true for sexual abuse or abuse that violates cultural taboos. It can instill a strong and overwhelming sense of distrust that leads to betrayal and isolation. In the patient-therapist relationship this can impact disclosure and trust.
As torture is by definition, carried out by official actors it can mean that the survivor has to flee their country for safety. But IDPs fleeing persecution face many barriers to settling in Europe or in their country of asylum. During preparation employees can focus on the consequences of the abuse experience itself (e.g. scar tissue fracture malunion chronic pain) SoT are likely to have experienced many additional stressors that affect their health status and well-being.   In flight SoT can have physical and. psychological challenges associated with unsafe travel or dealing with the exploitation of attempted human trafficking or kidnapping. When they go back on SoT, they lose a lot of things (e.g. status identity family employment property etc.) and often live without uncertainty about their immigration status with them safety in the country of their arrival.  These experiences interact with and exacerbate their distress about their victimization.
This continuum of potentially traumatic experiences, also known as the “triple trauma paradigm” , occurs in displaced persons during the pre- and post-displacement phases , meaning;
- A traumatic experience that disrupts life and causes a person to flee.
- The uncertainty and trauma experienced while flying to safety.
- Adjustment and uncertainty in a new country without understanding the language or culture or ability to work 
In most cases, physical torture is directed at the musculoskeletal system. It is designed to produce soft tissue injury and pain, and usually leaves no obvious evidence beyond the acute phase. Some studies have shown that pain in the musculoskeletal system (prevalence up to 48%); headache (38 – 50%); back pain (up to 43%); foot pain (19 – 28%); and joint pain (19 – 43%) are examples of somatic symptoms frequently reported in displaced persons who were previously tortured. 
The physical impact of physical assault depends on the type of torture method used. The effects of some methods are more widely documented than others.
For example; Falanga suffers from repeated blunt trauma to the foot, usually presenting with persistent burning, stabbing and/or cramping pain, disturbance of natural sensation, difficulty walking including altered gait, decreased stride length and walking speed .  Clinical findings include decreased footpad elasticity, skin changes, plantar aponeurotic injury, and lower extremity myofascial changes, including compartment syndrome. Palestine suspension can cause significant damage to the shoulder complex and cause damage to the brachial plexus. 
More broadly, fractures, dislocations, muscle contusions, lacerations, finger amputations, peripheral nerve injuries, pelvic floor trauma, nerve damage, hearing loss, vision problems, pain, scarring, and headaches are just some of the direct physical effects of torture on the body a small part of it. In addition to these attacks, there are many factors that can affect healing and chronicity, such as lack of access to proper medical care or rehabilitation during the healing period.
Torture as a “traumatic event”
In order for a method to be classified as torture, it must cause “severe pain and suffering.”  This can be difficult to classify as it is a largely subjective measure and can be influenced by factors such as age, gender, health, cultural background, or the victim’s religious beliefs.
Clients who have experienced the same method of torture may present themselves in very different ways. As therapeutic rehabilitation professionals, it is important to remember that, like any other experience, the physical and psychological effects of torture are subjective, and a person has an isolated People who have been tortured may have less or greater needs for rehabilitation than survivors of prolonged or severe torture. When treating torture survivors, it is important to not only treat the effects of physical assault on the body, but also to recognize and treat The physical effects of experiencing a traumatic event.
Trauma can be defined as a physical or mental “shock to the system”. The defining characteristics are:
- Outside the range of normal experience
- The event threatened the life or bodily integrity of the person or the life or bodily integrity of an intimate person
- Events that leave people feeling helpless and out of control
- Events beyond a person’s ability to cope
When you experience trauma, you realize that it could happen again. So your brain and body can start operating in “survival mode.” This affects how the brain and body communicate and affects our normal homeostatic mechanisms.
Trauma, in essence, dysregulates the autonomic nervous system. As a result, multiple body systems are affected.
Symptoms of Trauma
Table 1 Symptoms of Trauma Psychophysiological Social Intense Anxiety/Fear Anger or Irritability Feeling Sad or Hopeless Poor Memory Confusion/Lack of Concentration Loss of Meaning or Purpose Feelings of Guilt or Shame / person insomnia or Nightmares Feeling Tired Heartbeat Rapid Sweating Difficulty Breathing Muscle Tension Chronic Pain Coordination/Balance Problems Nausea/vomiting Dizziness or Fainting Weight Changes Upset Stomach Cramps Problems Loss of interest in work/hobbies Overprotective behavior Aggressive behavior towards others Overly critical of others
Long Term Psychological Effects:
These include difficulty concentrating, nightmares, insomnia, memory loss, fatigue, anxiety, depression, and post-traumatic stress disorder.
Long Term Physical Effects:
The effects of these physical symptoms on the body can lead long-term to many conditions and disorders that rehabilitation professionals typically treat.
Common “trauma” situations treated by rehabilitation professionals:
- Anxiety – decreased balance, dizziness, headaches, muscle tension, panic attacks
- Depression – Low energy, fatigue
- Post-traumatic stress disorder – avoiding certain exercises associated with torture experiences Cardiorespiratory symptoms such as racing heart Shortness of breath Chest tightness Difficulty breathing
- Chronic stress – musculoskeletal changes due to painful tension and decreased core stability
- Pelvic Dysfunction – Pelvic Floor Weakness Painful Sex Avoid Intimacy Incontinence
- Difficulty sleeping – falling asleep and waking up frequently
- persistent pain – widespread and pervasive pain
- Decreased body awareness – feeling numb Difficulty recognizing sensations of postural changes Reduced flow and energy of movement
- Self-regulation problems – an escalation of disturbing feelings such as an inability to control a racing heart, dizzy breathing, etc.
- Gastrointestinal issues – symptoms of irritable bowel syndrome (IBS), including nausea, pain and constipation
These conditions may be exacerbated by prison or camp conditions, where access to water, food, medicines and general sanitation may not be available. Infections and poor health exacerbate these existing conditions.
The role of physical therapy for torture survivors
Given the physical consequences of trauma and torture, physical therapy is an important part of a survivor’s recovery. Because of the complex interplay between psychophysiological and social factors, physical therapists should use a biopsychosocial approach to torture survivors. torture Survivors struggle to cope with the injuries and disturbing physical symptoms of trauma from the physical assault and subsequently cope with activities of daily living. Therefore, the overall goal of physical therapy is to enable them to manage these symptoms so that Improve their functional capabilities. The main goals of rehabilitation can be summarized as follows:
- Direct effects of physical assault on treatment of torture
- Healing the Physical Effects of Trauma on the Body
The main effects of doing so on their health can be summarized as:
- Improved functional ability
- Decreased pain levels
- Improve the management of specific conditions, such as incontinence, stress and sleep
- Improve social engagement and function
- Improved coping and outlook
- Improve body awareness and self-regulation
Due to the complex needs of torture survivors, an interdisciplinary approach to rehabilitation ensures holistic treatment of the individual. Interventions are effective if delivered in an individual or group setting together with other disciplines, especially counseling. where appropriate Joint interdisciplinary sessions may be offered to promote common goals and enhance biopsychosocial responses to the conditions being treated.
The Interdisciplinary Team
When working as an interdisciplinary team, a deep understanding of each other’s goals and therapeutic approaches allows the team to work together towards common and realistic goals, recognizing and maximizing areas of overlap between disciplines. Examples of such overlap include Consistently providing pain neuroscience education reinforces and practices the same mind-body methods, such as breathing and relaxation, and provides psychoeducation about trauma and its symptoms.
Interdisciplinary team members typically include:
- Psychosocial Counsellors
- Social Workers
- Medical Doctors
- Interpreters or Cultural Mediators
- Specialist referrals to psychiatrists and surgeons may be required.
Rehabilitation services for torture survivors
In this section, we discuss the recommendations of the principles of trauma-informed care for successful assessments that help build a relationship of trust with your patient/client. We also explore Judith Herman’s mental health model of trauma recovery and how to adapt Physiotherapy includes treatments for the different manifestations common to torture survivors.
Sometimes your patients will come to you with a known background of torture, but given the high rate of torture among displaced people and the number of reasons they may be reluctant to disclose (eg fear of shame lack of trust) you may or may not know your patient’s torment history. Therefore, we advocate the use of a trauma-informed approach to all patients/clients regardless of known torture status. Of course, trauma-informed care is also helpful for people with non-torture trauma backgrounds, such as sexual assault, domestic violence, etc. Trauma-informed care is Relevant to all rehabilitation practices, not just displaced persons or SoTs.
Applying the principles of trauma-informed care to your approach to treatment is recognizing the myriad ways in which traumatic experiences can affect every aspect of care, from communication to clinical reasoning. The basic principles of trauma-informed care can be summarized as follows:
- Create an environment where clients feel securely connected, valued, informed empowerment, and restored hope.
- Apply trauma knowledge and recovery pathways to practice policies and procedures.
- Recognize signs and symptoms of trauma among client family staff and others involved in the system.
- Purposefully partner with individuals, family, friends, and other social service agencies to promote and protect client autonomy
- Understand the concept of retrauma and apply this knowledge to your services at the policy and procedural level of practice.
- Practice culturally competent and non-discriminatory policy procedures and practices.
Here are some guiding tips for your first assessment with a patient. Remember that most of your “normal” treatment tips (such as taking a thorough medical history, observing range of motion, etc.) will still apply. You just need to pay extra attention to how you interact with your patients/clients. Due to the complex history and need to build trust, multiple assessments with the SoT may be required. If you feel the patient is uncomfortable, give them the opportunity to ask questions or provide feedback and move on. A good doctor-patient relationship is the most important!
Simple Tips for a Successful Assessment
Interpreter / Translator
Keep in mind that if you will be working through translation, you should be familiar with some of the dos and don’ts of doing a good job here. Reassure your patients/clients that translators are also bound by strict confidentiality. Try to use the same translator in each session and apply the Potential issues with translators and patients/clients who speak the same language but are from different races or tribes (for example, if their home country has a background of civil unrest).
Taking a moment to familiarize yourself with some basic social customs in the patient’s country or learning how to say hello in their language can help put the patient at ease and break the ice.
Being tortured fundamentally affects a person’s ability to trust others. Unfortunately, health professionals have also historically been involved in torture – if your patients have experienced this, they will naturally be afraid of your role. know to build a treatment Relationships may take longer than usual so be patient.
SoT may feel more comfortable in a quiet private space. If there is a door, do not lock it or close it completely without their permission. Give the patient some time to explore the space and ask any questions about the room. Be aware of certain equipment, such as pulleys or electrotherapy Machines may trigger unpleasant memories in patients (bound or gagged electrocution). A “Do Not Disturb” sign outside the treatment area can help your patients/clients relax.
Non-threatening body language such as smiling, palms facing up, sitting or standing at or below the patient’s level, and not turning your shoulders or torso toward the patient can help put them at ease.
Explain to your patient what to expect before you start, and check back often to make sure you agree with them to continue or address any new fears or concerns that may arise as the session progresses. Never touch a patient accidentally or without the patient’s express consent, such as I want to look over your shoulder right now, and for that I will stand beside you with one hand on your shoulder and one on your ribcage. Is this ok?
Understanding the patient’s social environment forms part of any biopsychosocial assessment, but is especially critical for this patient population. Some considerations to keep in mind relate to the impact of displacement and your patient/client’s changed status as a “displaced person” people” as well as torture itself. These effects are diverse and wide-ranging, and are part of the reason SoT is best treated using an interdisciplinary approach. This section is limited to practical examples of effects on your approach and treatment.
Family and Interpersonal Dynamics
Torture is a form of interpersonal trauma that is purposefully used to create shame and break social bonds. Family members and close friends may or may not know that the person has been tortured or to what extent. This isolation can have real effects on your treatment, such as your Patient/client trying to keep appointment (or their purpose) private, or uncomfortable with a home exercise program in a shared space.
People may be targeted for torture because of their prominence in the community, for example as public intellectuals, political opponents or community organizers. Their new displaced status leaves them open to anti-immigrant sentiment, and they often struggle to (re)get a stable life Socioeconomic status of the new country. Know the different power dynamics in your culture e.g. regarding gender or age and ways to show respect e.g. using a more formal title like doctor or madam making sure you are on time can be a way of treating patients/clients Respect their inherent dignity.
Be aware that the financial situation of many displaced people is precarious. If they rely on public transportation to get to your appointment, try to allow some flexibility in the timing of the appointment. Know that securing child care may affect their ability to attend the meeting if you need to be contacted. They are about dating etc. Make sure to call them directly instead of leaving a message that has to force them to initiate a new call.
Religious and Cultural Practices
This can affect whether your patients/clients are comfortable working alone in a treatment room/cubicle with a therapist and a therapist of the opposite sex, or how comfortable they are to undress or move. Culturally specific holidays may affect their ability to attend Meeting. By calling ahead of your first session, you give the client/patient time to express their preferences, and anything that might help them comfortably participate in their session will help.
Displaced people SoT may be in a vulnerable position – away from their usual home cultural language and social support network, and dealing with the physical and psychological impact they experience. If you are concerned about your patient’s health (e.g. domestic violence food insecurities) working with other members of the interdisciplinary team, such as social workers, can be helpful.
Strategies for Avoiding Retraumatization of Clients
Table 2 Considerations for Strategies to Avoid Retraumatization Strategies Language and Culture English may not be the client’s first language. Use an interpreter to facilitate clear communication and the expression of subtle experiences and feelings.  Sensitivity to working with locals opposite sex. Assess client comfort and sensitivity. Arrange for treatment with a same-sex therapist if necessary. Trust is afraid of being disappointed. Be consistent and attend therapy on time.  Encourage realistic customer expectations.  Fear of losing privacy. Respect client confidentiality. make sure Interpreters know that the rules about respecting client confidentiality apply to them as well.  Safety Some position setting devices or therapeutic interventions may induce discomfort and flashbacks. All procedures are explained to the client in advance.  Ask permission before touching client. Check for continued tolerance to physical contact.  Provide clients with treatment-related choices (eg, location of treatment, pace of progression, focus of intervention, choice of modality)  Be careful with mirrors, bright lights, and uniforms.  Questions about long-term sensitivity and trial. Gather history using an open listening/discussion approach.  Avoid excessive questioning.  break down the initial evaluation into several sessions. 
Judith Herman is an American psychiatrist whose mental health-based trauma recovery model is used by many torture treatment centers around the world and can be used by rehabilitation professionals for SoT treatment. Hermann’s approach emphasizes survivor empowerment and rebuild their relationships.  Therefore, therapy in a group setting can support recovery if appropriate for your patient/client. The model is divided into three phases;
i) establishing safety
ii) reconstruction and
As mentioned earlier, it is critical to comprehensively address the needs of SoT through an interdisciplinary or multidisciplinary approach. Close collaboration with a psychologist or other mental health care colleague is strongly recommended when applying the Herman model to rehabilitation.
1. Safety and Stabilisation
People affected by trauma often feel insecure about their bodies and relationships with others. This stage is the starting point and is necessary for all subsequent treatments and engagements. This happens in many domains (Psychological Behavioral Physiological Legal Environment Social) And involves creating a safe space and stabilizing the individual’s responses to prior trauma.
In establishing safety and stability rehabilitation professionals should aim to:
- Empower clients as much as possible in all aspects of decision-making and help them adapt to a pace they can tolerate.
- Provides interventions that help manage symptoms of physical emotional distress.
- Consider how the treatment environment can feel safe and non-retraumatizing.
Specific tips for this phase include:
- Allow clients to decide the gender of their therapist, as this will vary based on cultural norms and trauma history.
- Strengthen confidentiality issues and maximize informed consent.
- Considering the use of a translator or cultural mediator will help to understand cultural norms and help build trust.
Treatments commonly used at this stage include:
Pain Education and Trauma Symptom Education
Cognitive restructuring that allows for irrational thoughts reduces fear and reduces catastrophizing.
This teaches the client to stimulate the vagus nerve to generate the body’s parasympathetic response, which helps to downregulate symptoms of hyperarousal (rapid heartbeat, shallow breathing, rapid sweating, nervous feeling).
Physical relaxation techniques work on the principle that progressive muscle relaxation remains relaxed or mutually inhibited to help create a state of physical and mental calm.
Sleep Hygiene Advice and Education
Advice and education around factors that encourage and prevent sleep are important in enabling individuals to modify their behavior during the day and create a “bedtime” to optimize the potential for better sleep.
Helps you to focus on what’s going on in your body or your surroundings instead of being trapped by thoughts in your head that cause you to feel anxious. Have the client focus on an object or feel the sensation of the foot touching the object Ground is an example of grounding that can help if the client is separating.
Mindfulness of breathing and movement, including yoga-based practices
These practices provide opportunities for “interoceptive contact.” Gradually, the client learns to pay attention to the bodily sensations associated with different emotions and different actions. Teach them about their uncomfortable feelings and Those that don’t help them gradually recognize and normalize symptoms and learn how to manage them. 
Posture and emotion (“Body Narrative”)
Posture is related to emotions. Helps clients recognize changes in posture as their emotions change, such as a collapsed circular posture when sad and an open, expanded posture when happy or confident, enabling them to recognize patterns of movement and posture and use them positively as Strategies to support positive emotions throughout the day. 
Using the props they have available at home and teaching self-massage is a way to relieve pain, especially if the client isn’t ready for the therapist’s touch.
2. Process of Reconstruction
Once a basic sense of safety is restored and the survivor stabilizes to the point where the effects of the trauma no longer overwhelm his/her ability to function, the focus is now on accepting the trauma and its impact on one’s life. 
During this phase, rehabilitation professionals should aim to:
- Methods of enhancing stability continue as the search for more challenging sports continues.
- Enables individuals to work towards goals with an emphasis on pacing
- Acknowledge the loss of prior physical ability and work together to restore or compensate for the damage.
Treatments commonly used at this stage include:
Continuation of Mindfulness Activities
Enables individuals to increase awareness of bodily sensations during previously avoided movements that may “trigger” traumatic memories and subsequent bodily responses. Dealing with these feelings as before to achieve self-regulation is critical to being able to recover Normal movement. For example, rape survivors often avoid hip abduction when lying on their backs.
In an educational context, individuals will learn about the benefits to their overall health and reduced symptoms of depression. Engaging in different forms of aerobic exercise during therapy can give individuals an immediate sense of well-being and consideration of which types Possibly work for them in their home environment. A sustained aerobic exercise program can also help alter arousal levels and energy levels to combat fatigue and lethargy, and better enable an individual to participate in other activities of daily life. Consideration should be given to accessing resources and A home environment where spatial security and privacy may be limited.
Often both focus on general body conditioning and more specifically on specific areas of weakness. Attention should be paid to core stability to lessen the effects of the body’s long-term fight-or-flight response following a traumatic experience, where energy is more devoted to global muscle. Strengthening the pelvic floor and lumbosacral muscles is often incorporated into the program. Teaching “protective” movements with a counselor to enable individuals to move away from traumatic memories can be a very effective trauma strategy recover.
Stretching helps to recover from movement and also has the dual effect of relaxing the body. Trauma can dysregulate the autonomic nervous system, and one of its effects is fascial contraction. Targeted myofascial stretches are a key part of the program. 
Decreased balance may manifest as a comorbidity of anxiety , thus improving balance improves anxiety, and decreased anxiety may be accompanied by improved balance. Challenging yoga-based practices have the added benefit of restoring strength and body awareness in addition to balance.
Pacing and Goal Setting Education
The reduced ability to self-regulate physical symptoms after trauma means that individuals often need support to measure the actual amount of activity required to achieve their stated goals. Starting slowly and setting modest steps toward their goals can help clients feel successful. progress Even small changes should be highlighted. To acknowledge the cognitive changes that affect memory and concentration after trauma, keep the message short and not overloaded with detail. Limit the number of prescribed exercises to 4 or 5. Provide written and illustrated instructions. Consider additional support for appointment reminders: written calls, etc. Helping individuals avoid “boom and bust” activity cycles or addressing fear and avoidance at the opposite end is key to helping them self-regulate and restore functional activity levels.
Manual or “hands-on” approach
Manual therapy, such as massage or joint mobilization or “hands on” referring to assisted movements or physical cues, is important to restore a sense of safety in “touching” something that may have been violated during their torture experience. These methods should be Applied with caution to avoid re-injury to the client, acknowledging that there is usually a greater sensitivity to pain. The therapist should provide a full explanation of the intervention as well as what to expect so that the individual can provide full consent. during these periods Intervention therapists should observe physical responses, such as facial expressions or withdrawal, physiological responses, such as sweating, rapid shallow breathing, or psychological responses, such as emotional outbursts to therapy. provide gradual exposure to these interventions and Pausing to help individuals ground themselves will better facilitate the success of such interventions.
At this stage, helping survivors rebuild and restart their current lives becomes the main focus of recovery. The focus should be on fostering empowerment and reconnection. Herman suggests that the essence of this stage can be expressed in terms of “I know I have I. It is at this stage that torture survivors no longer feel trapped by the past and often gain insight into the positive aspects of themselves.
During this phase, rehabilitation professionals should aim to:
- Promote continuous reconnection of the body through graded exercises of body awareness and self-regulation exercises.
- Promote safe physical interaction with others.
- Promote activities that promote the pleasure of movement.
- Achieve functional goals by continuing to facilitate goal-setting cadences and customizing home exercise programs.
- Promote independent management of symptoms, including management of exacerbations.
- Support survivors in seeking out external resources that facilitate reintegration into the community and social support networks.
Treatments commonly used at this stage include:
Pacing and Goal Setting
Continue to help survivors identify coping strategies and interventions that they will continue to use after discharge to continue efforts to achieve continued progress on unmet goals and manage any future exacerbations.
If working in a group setting or with a therapist. Facilitating physical interaction such as stretching or balancing positions can be used as a way to encourage a safe physical connection with others.
Dancing and Games
Depending on culturally appropriate content and delivery, specific cultural dances can be effective in strengthening social bonds and reconnecting through physical contact. Competitive games or exercise loops promote team fun and achievement in challenging activities Regain confidence in your body.
Ergonomics and Preventative Advice
General education on ergonomic principles and related activity or postural practices ensures healthy habits move forward, but also acknowledges that SoTs often have hypersensitive nervous systems with higher comorbidities or conditions such as chronic pain. prevention advice and Education in ergonomics and understanding how to manage acute injury when it occurs can help ease falling into a chronic pain state.
Multiple measures for management of functional pain levels for specific situations (such as incontinence stress and sleep) should be considered Improve social engagement and function Improve coping and outlook and improve body awareness and self-regulation.
Outcome measurements need not specifically address torture as a mechanism of harm. Using a trauma-informed approach, the most appropriate outcome measure can be applied as in most other patient populations to assess progress towards agreed goals or outcomes, such as visual analogue scales Patient-specific functional scales, etc.
- World Physiotherapy Policy Statement: Torture
- WCPT supports the United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment and encourages its member organizations to call on their governments to sign and abide by the Convention. WCPT will support and encourage the international community Its member organizations and physiotherapists support other physiotherapists and physiotherapists’ families facing threats or reprisals for refusing to condone the use of torture or other forms of cruel, inhuman or degrading treatment.
- UNCAT Implementation Tool 5/2018 Rehabilitation for victims of torture and other ill-treatment
- The tool outlines how states implement the right to rehabilitation through a range of practices complemented by the experiences of non-state rehabilitation providers. The practices contained in this tool are designed to inspire countries to learn from each other so that Improve implementation at the national level within and outside the OSCE region. Promising examples of practice from the OSCE area and other parts of the world have been collected to illustrate possible approaches and steps that can be taken on the road to ensuring the fullest rights of victims of torture possible level of recovery.
- Istanbul Protocol; Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment
- The Istanbul Protocol: Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment is intended as an international guideline for assessing investigations by persons alleging torture and ill-treatment Alleging torture and reporting the findings to the judiciary or any other investigative body. This handbook includes principles for the effective investigation and documentation of torture and other cruel, inhuman or degrading treatment or punishment. These principles outline minimum standards States to ensure effective documentation of torture.
- DIGNITY facts about the health consequences of torture and other ill-treatment methods
- This is a series of one-page fact sheets, each defining a method of torture or ill-treatment, restating relevant international standards and outlining health consequences. They use the United Nations prohibition against torture and other cruel, inhuman or degrading treatment or Penalty (UNCAT). The purpose of the fact sheet series is to inform partners; to raise awareness among professionals who encounter survivors, and to initiate dialogue about the use of these methods.
You can watch the following video series produced by the Bellevue Torture Survivors Project. Their mission is to help individuals and families who have suffered torture and other human rights violations rebuild healthy, self-sufficient lives and contribute to global efforts to end torture.
You can also check out the survivors’ stories through their “Seeking Asylum” documentary, which recounts the harrowing circumstances of four survivors who were forced to flee their homes as they struggled to regain their lives in America.
- Interventions for Physiotherapists Working with Torture Survivors: Special Focus on Chronic Pain PTSD and Sleep Disorders
- This publication provides practical guidance to help rehabilitation professionals working with torture survivors identify the most pressing issues and which physical therapy tools will be most useful for each client.
- Rehabilitation of Torture Survivors Resource Kit for Service Providers
- This resource kit produced by IRCT explores provider options across a range of services they may choose to offer, from implementing a survivor services component within their ongoing practice to developing a full-service torture rehabilitation program.
- Heal Torture
- The HealTorture webpage provides support for rehabilitation professionals treating torture survivors.
- The Sleep Charity Sleep Advice
- June 18, 2020 Jordanian CVT physiotherapist Ansam Abusabha is making a difference.
- March 12, 2020 At CVT Jordan Physiotherapist Mohammad Atie who helps transform families and society.
- Normalization of breathing and healing by Physiotherapy Physiotherapist Ahmad Al-Taj on February 3, 2020 in CVT, Jordan.
- UNHCR. Global Trends. Available from: https://www.unhcr.org/en-ie/globaltrends.html (accessed 24 June 2022).
- Refugee Health Technical Assistance Center. Traumatic Experiences of Refugees [Internet]. [Cited September 29, 2018]. Available from: https://refugeehealthta.org/physical-mental-health/mental-health/adult-mental-health/traumatic-experiences-of-refugees/
- SAMHSA’s Trauma and Justice Strategic Initiative. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. Rockville, MD: Office of Policy, Planning and Innovation, Substance Abuse and Mental Health Services Administration; July 2014
- United National Human Rights Office of the High Commission. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. 1984. Available from:https://www.ohchr.org/EN/ProfessionalInterest/Pages/CAT.aspx [Accessed 26 September 2020]
- de C Williams AC, Van der Merwe J. The psychological impact of torture. British Journal of Pain. 2013 May;7(2):101-6.
- Ojha P. Survivors of Torture. InDiversity in Action 2022 (pp. 15-31). Springer, Cham.
- Whitton M. Vicarious traumatization in the workplace: a meta-analysis on the impact of social support (Doctoral dissertation, The University of Waikato).
- Fox M, Hopkins D, Graves J, Crehan S, Cull P, Birrell B, Dunn P, Murphy M, Harrison A, Hayes M, Yeomans P. Hospital social workers and their understanding of compassion fatigue and vicarious trauma. Asian Journal of Interdisciplinary Research. 2021;4(1):22-34.
- Campbell TA. Psychological assessment, diagnosis, and treatment of torture survivors: a review. Clinical psychology review. 2007 Jun 1;27(5):628-41.
- Amnesty International. Torture. Available from:https://www.amnesty.org/en/what-we-do/torture/ [Accessed 26 September 2020]
- Dignity Danish Institute Against Torture. Facts about Torture. Available from: https://www.dignity.dk/en/dignitys-work/facts-about-torture/ [Accessed 26 September 2020]
- Grodin MA, Piwowarczyk L, Fulker D, Bazazi AR, Saper RB. Treating survivors of torture and refugee trauma: a preliminary case series using qigong and t’ai chi. The Journal of Alternative and Complementary Medicine. 2008 Sep 1;14(7):801-6.
- Dignity Danish Institute Against Torture. Who We Are. Available from: https://www.dignity.dk/en/about-dignity/ [Accessed 26 September 2020]
- Bloch I, Moller G. Rehabilitation of torture victims: Physiotherapy as part of the treatment. International Perspectives in Physical Therapy. 1990;5:121-44.
- Physiotherapy for survivors of torture. Physiotherapy, 78(5), pp.323-328
- Office of the United Nations High Commissioner for Human Rights Geneva. Professional Training Series No. 8/Rev.2 Istanbul Protocol; Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. 2022. Available from: https://www.ohchr.org/sites/default/files/documents/publications/2022-06-29/Istanbul-Protocol_Rev2_EN.pdf [Accessed 19 July 2022]
- Office of the United Nations High Commissioner for Human Rights Geneva. Professional Training Series No. 8/Rev.1 Istanbul Protocol; Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.2004. Available from: https://www.ohchr.org/documents/publications/training8rev1en.pdf [Accessed 20 September 2020]
- Amnesty International. Torture Animation. Available from: http://www.youtube.com/watch?v=acd7FZgX7_Q[last accessed 25/09/20]
- Terveyden ja Hyvinvoinnin Laitos. Part 8: Victims of Torture, Human Trafficking and Violence. Available from: http://www.youtube.com/watch?v=tCKeVR0Has0[last accessed 25/09/25]
- Sengoelge M, Nissen A, Solberg Ø. Post-Migration Stressors and Health-Related Quality of Life in Refugees from Syria Resettled in Sweden. International journal of environmental research and public health. 2022 Feb 22;19(5):2509.
- Shi M, Stey A, Tatebe LC. Recognizing and breaking the cycle of trauma and violence among resettled refugees. Current trauma reports. 2021 Dec;7(4):83-91.
- Gleeson C, Frost R, Sherwood L, Shevlin M, Hyland P, Halpin R, Murphy J, Silove D. Post-migration factors and mental health outcomes in asylum-seeking and refugee populations: a systematic review. European Journal of Psychotraumatology. 2020 Dec 31;11(1):1793567.
- Flanagan, N., Travers, A., Vallières, F., Hansen, M., Halpin, R., Sheaf, G., Rottmann, N. and Johnsen, A.T., 2020. Crossing borders: A systematic review identifying potential mechanisms of intergenerational trauma transmission in asylum-seeking and refugee families. European Journal of Psychotraumatology, 11(1), p.1790283.
- Henry B, Ringler-Jayanthan E, Darling I, Wilson M. Challenges in Refugee Resettlement: Policy and Psychosocial Factors. 2019
- Center for Victims of Torture. Helping Refugee Trauma Survivors in the Primary Care Setting. 2005. Available from: https://www.mhinnovation.net/sites/default/files/downloads/resource/%28CVT%2C%202005%29.%20CVT%20Helping%20Refugee%20Trauma%20Survivors%20in%20the%20Primary%20Care%20Setting.pdf [Accessed 26 September 2020]
- Olsen DR, Montgomery E, Bøjholm S, Foldspang A. Prevalence of pain in the head, back and feet in refugees previously exposed to torture: a ten-year follow-up study. Disability and Rehabilitation. 2007 Jan 1;29(2):163-71.
- Amris K, Torp-Pedersen S, Rasmussen OV. Long-term consequences of falanga torture. Torture. 2009;19(1):33-40.
- Peel M, Iacopino V. The Medical documentation of torture. Cambridge; New York: Cambridge University Press; 2008.
- Franklin C. Physiotherapy with torture survivors. Physiotherapy. 2001 Jul 1;87(7):374-7.
- Gueron, LP. Physical Therapy for Survivors of Torture. Center for Victims of Torture. April 17, 2013.
- Herman JL, Kallivayalil D. Group Trauma Treatment in Early Recovery. Guilford Publications; 2018 Nov 19.
- Taylor J, McLean L, Korner A, Stratton E, Glozier N. Mindfulness and yoga for psychological trauma: systematic review and meta-analysis. Journal of Trauma & Dissociation. 2020 Oct 19;21(5):536-73.
- Fisher J. Sensorimotor psychotherapy in the treatment of trauma. Practice Innovations. 2019 Sep;4(3):156.
- Ballard-Kang JL, Sar BK. Reconstructing a Sense of Safety among Resettled Refugee Survivors of Torture: A Constructivist Grounded Theory Study. Journal of Immigrant & Refugee Studies. 2021 Sep 24:1-4.
- Schleip R, Gabbiani G, Wilke J, Naylor I, Hinz B, Zorn A, Jäger H, Breul R, Schreiner S, Klingler W. Fascia is able to actively contract and may thereby influence musculoskeletal dynamics: a histochemical and mechanographic investigation. Frontiers in physiology. 2019:336.
- Schleip R, Zorn A, Klingler W. Biomechanical properties of fascial tissues and their role as pain generators. Journal of musculoskeletal pain. 2010 Oct 1;18(4):393-5.
- Balaban CD, Jacob RG, Furman JM. Neurologic bases for comorbidity of balance disorders, anxiety disorders and migraine: neurotherapeutic implications. Expert review of neurotherapeutics. 2011 Mar 1;11(3):379-94.
- FC ST. Part 1: Torture Survivors: Who are torture survivors?. Available from: https://youtu.be/78hW3-bmGJY[last accessed 01/10/2020]
- FC ST. Part 2: Torture Survivors: What challenges do torture survivors face?. Available from: https://youtu.be/iAhQ1_ON-Y0[last accessed 01/10/2020]
- FC ST. Part 3: Torture Survivors: Advice from practitioners?. Available from: https://youtu.be/pTkaFDH79Co[last accessed 01/10/2020]
- FC ST. Part 4: Torture Survivors: What is the trauma story?. Available from: https://youtu.be/dKlRmlewUBU[last accessed 01/10/2020]
- FC ST. Part 5: Torture Survivors: What can you do. Available from: https://youtu.be/ux9x5GyNq3M[last accessed 01/10/2020]