Chronic pain in refugees with posttraumatic stress disorder (PTSD): A systematic review on patients' characteristics and specific interventions

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Review article

Chronic pain in refugees with posttraumatic stress disorder (PTSD): A systematic review on patients' characteristics and specific interventions ⁎

Rometsch-Ogioun El Sount C.a, , Windthorst P.a, Denkinger J.a, Ziser K.a, Nikendei C.b, Kindermann D.b, Ringwald J.a, Renner V.a,c, Zipfel S.a, Junne F.a a

Department of Psychosomatic Medicine and Psychotherapy, Medical University Hospital Tuebingen, University of Tuebingen, Osianderstr. 5, 72076 Tuebingen, Germany Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany c Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Tübingen, Tübingen, Germany b

A R T I C LE I N FO

A B S T R A C T

Keywords: Chronic pain Pain Posttraumatic stress disorder PTSD Refugees Trauma

Objective: Chronic pain in patients with posttraumatic stress disorder (PTSD) is a frequent symptom and a complicating factor in the treatment of patients. The study’ purpose is to systematically review the scientific literature on patients' characteristics and the effects of specific interventions implemented for the treatment of chronic pain in traumatized refugees. Method: A systematic search of the current literature was conducted in PubMed and Web of Science, from 1996 to 2017. A structured screening process in accordance with the PRISMA-statement was used with eligibility criteria based on the modified PICOS-criteria including refugees with chronic pain and diagnosed PTSD to investigate sample size, gender, country of origin, residential status, pain locations, predictors and correlations and type and efficacy of specific interventions. Results: The initial search resulted in a total of 2169 references, leading to 15 included studies. Most frequently, patients reported headaches, backaches, and pain in the arms and legs. Pain symptoms were associated with higher age, female gender, general living difficulties and PTSD symptoms. Cognitive behavioral therapy (CBT) and, Narrative Exposure Therapy (NET) with biofeedback, manualized trauma psychotherapy, Traditional Chinese Medicine (TCM) and Emotional Freedom Techniques were evaluated as specific interventions, resulting in positive outcomes for both pain severity and PTSD symptoms. Conclusions: To date, the existing literature shows scarce evidence evaluating specific interventions that address the needs of traumatized refugees with chronic pain. However, the current reported evidence allows for a preliminary evaluation of the characterizations of patient dimensions as well as promising results found in intervention studies.

1. Introduction According to the Office of the United Nations High Commissioner for Refugees (UNHCR), by the middle of August 2017, 65.6 million displaced people were registered worldwide, of which 22.5 million were defined as refugees [1]. Refugees often lack access to regular healthcare and necessary treatment programs [2]. According to current literature, the prevalence of posttraumatic stress disorder (PTSD) in the refugee population shows a wide range from 3% [3] up to 86% [4]. Steel and colleagues (2009) identified a high prevalence of posttraumatic stress disorder (30.6%) after exposure to torture [5]. Overall, refugees are ten times more likely to be diagnosed with PTSD than the general population [6]. To date, summaries of studies investigating

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comorbid chronic pain in refugees with PTSD are scarce. Thus, this review seeks to first summarize existing evidence about patient characteristics and specific interventions targeting pain in traumatized refugees and then aims to give an overview of (chronic) pain symptoms in refugees with PTSD. According to the American Psychiatric Association (APA) and the DSM-5, PTSD is defined as a mental disorder in which patients have experienced or witnessed a significant traumatic event. Examples of such an event include: natural disasters, serious accidents, terrorist acts, war/combat, rape, or other violent personal assaults [7]. When diagnosing PTSD symptoms, the following categories must be present in a patient in the aftermath of a traumatic event: intrusive thoughts, avoidance of reminders of the traumatic event, negative thoughts and

Corresponding author at: University of Tuebingen, Osianderstrasse 5, 72076 Tuebingen, Germany E-mail address: [email protected] (C. Rometsch-Ogioun El Sount).

https://doi.org/10.1016/j.jpsychores.2018.07.014 Received 29 December 2017; Received in revised form 20 July 2018; Accepted 25 July 2018 0022-3999/ © 2018 Elsevier Inc. All rights reserved.

Please cite this article as: Rometsch-Ogioun El Sount, C., Journal of Psychosomatic Research (2018), https://doi.org/10.1016/j.jpsychores.2018.07.014

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PRISMA-Statement [27–28]. Inclusion and exclusion criteria as well as methods of analysis were specified in advance and documented in a protocol.

feelings, and arousal and reactive symptoms such as being irritable, having angry outbursts or having problems in concentration or sleep [7–8]. In the DSM-5 [7], chronic pain is listed among the somatic symptom disorders, which are defined as a hyper-focus on physical symptoms such as pain that disturbs daily functioning and leads to heightened patient distress. Criteria for diagnosis are a disruption in daily life by one or more somatic symptoms, excessive thoughts, feelings or behaviors related to the somatic symptoms and a pain duration of more than six months [7–8]. When the predominant somatic symptom is pain, patients are diagnosed with chronic pain within the somatic symptom disorder framework [7]. The prevalence of persistent pain in refugee populations seems to be as high as 83% [8]. The prevalence for headache ranges from 39% in a study conducted in Uganda [9] to 93% reported in data from Denmark [10]. Furthermore, a past experience of torture, especially psychological torture, is associated with an increased risk for prolonged pain [11]. However, few studies have investigated the comorbidity of pain and PTSD in refugee populations (e.g. [12]). Both Miro and colleagues (2008) and Shaw and colleagues (2010) describe that PTSD possibly leads to an increase in pain perception, and can thus be considered a risk factor in developing chronic pain [14–15]. As reported in a systematic review by Asmundson and colleagues (2002), a co-occurrence of pain in patients with a diagnosed PTSD is reported in 20–80% of PTSD patients complaining of persistent pain symptoms. Furthermore, 10–50% of patients suffering primarily from chronic pain also fulfill the criteria for PTSD [13]. Fishbain and colleagues (2016) confirmed these findings and found an association between chronic pain and PTSD in 16 of their 19 included studies. They show differences in prevalence of PTSD according to the specific type of chronic pain shown by patients [14]. For example, veterans with chronic lower back pain show a PTSD prevalence of 0.69% to 50.1%, whereas sufferers of lower back pain in the general population show a PTSD prevalence of 9.8%. A recent metaanalysis conducted by Siqveland and colleagues (2017) also shows varying PTSD prevalence when pain location is specified. For example, a PTSD prevalence of 20.5% in patients with widespread pain, 11.2% in patients with headache, and 0.3% in patients with back pain [15]. These, moderately high numbers of prevalence rates indicate the importance of special treatment options. Evidence for the effectiveness of PTSD treatment has been shown in a variety of studies including numerous meta-analyses. The guidelines for diagnosis and subsequent treatment of PTSD published by the National Institute for Health and Clinical Excellence (NICE) [16] acknowledge the effectiveness of psychotherapeutic interventions, such as cognitive behavioral therapy (CBT), trauma-focused therapy, Narrative Exposure Therapy (NET) [17], cognitive processing therapy (CPT), exposure therapy, prolonged exposure (EP) [18] or eye movement desensitization and reprocessing (EMDR) [22−23]. When treating both PTSD and chronic pain in general, CBT proves an effective treatment option [19]. For patients suffering from chronic pain and also showing a history of traumatic events, trauma specific treatment should also be considered for both comorbidities [24–25]. Despite having effective treatment options for patients with PTSD as well as chronic pain disorder, there is, to the best of our knowledge, scarce evidence of the specific needs of traumatized refugees with chronic pain. Norbrandt and colleagues (2015) also criticize a lack of research on specific treatments and outcomes in refugee populations [20]. Considering the urgent need to improve the clinical practices and services provided to this very vulnerable group of patients, an overview of the existing evidence is urgently needed. Hence, this review seeks to summarize and analyze patient characteristics (of the refugees) as well as specific interventions found in the existing literature that target traumatized refugees suffering from chronic pain.

2.1. Literature search The databases PubMed and Web of Science were systematically searched for publications from 1996 to October 2017 to provide an overview of the actual literature. We excluded studies before 1996 to sum up the newest research results. The search terms applied included: chronic pain, posttraumatic stress disorder, PTSD, and refugees. The full search term in both databases applied was as follows: ((chronic pain AND (posttraumatic stress disorder OR PTSD)) AND refugees. In PubMed the detailed search pathway using the MESH-terms is: ((“chronic pain”[MeSH Terms] OR (“chronic”[All Fields] AND “pain”[All Fields]) OR “chronic pain”[All Fields]) AND (“stress disorders, post-traumatic”[MeSH Terms] OR (“stress”[All Fields] AND “disorders”[All Fields] AND “post-traumatic”[All Fields]) OR “posttraumatic stress disorders”[All Fields] OR (“posttraumatic”[All Fields] AND “stress”[All Fields] AND “disorder”[All Fields]) OR “posttraumatic stress disorder”[All Fields]) OR (“stress disorders, posttraumatic”[MeSH Terms] OR (“stress”[All Fields] AND “disorders”[All Fields] AND “post-traumatic”[All Fields]) OR “post-traumatic stress disorders”[All Fields] OR “ptsd”[All Fields])) AND (“refugees”[MeSH Terms] OR “refugees”[All Fields]). Additional articles were identified using a hand search through the reference lists of the included studies. 2.2. Eligibility criteria To be eligible for study inclusion, articles had to fulfill the following modified PICOS-criteria [21]: Participants (P): refugees with chronic pain and the diagnosis of PTSD or refugees with chronic pain due to diverse traumatic aetiologies, such as suffering from torture or warexperiences. PTSD had to be diagnosed according to the definition of either the Diagnostics and Statistical Manual of Mental Disorder (DSM) [22] or the International Classification of Diseases and Related Health Problems (ICD) and could also be the sub-syndromal states of both definitions. Sub-syndromal thereby refers to having PTSD symptoms that not fulfill all of the diagnostic criteria. Exclusion criteria encompassed participants consisting of soldiers deployed in a combat area and thus not classifying as refugees (e.g. [23]). There were no restrictions of the patients' gender, religion, country of origin or residential status. Intervention (I): There were no inclusion restrictions regarding the kind of therapeutic intervention implemented. Comparators (C): Control groups were defined as waiting groups, refugees without mental disorders, and refugees without experiences of fleeing or war background. Outcomes (O): The target variables included descriptive sample characteristics, such as sample size, country of origin, gender, or the residential status of affected individuals. Furthermore, main target dimensions included were pain locations, predictors for pain and correlations of chronic pain in traumatized refugees, as well as the tools applied in the measurement of refugees' pain. Additionally, the second main target dimension including the effects of specific interventions in addressing persistent pain shown by traumatized refugees was included. Book chapters, editorials, studies in languages other than German or English, and study protocols (e.g. [20]) were excluded. The protocol of the applied PICOS-criteria is available on request. 2.3. Study selection and data collection procedure After excluding the duplicates, the titles and abstracts were systematically examined by two independent screeners according to the eligibility criteria. The interrater reliability between the two independent screeners was excellent with к = 0.91 indicating sufficient quality of eligibility criteria. A full-text analysis was conducted by the first author in all included studies. Studies with divergent screener

2. Methods This review was conducted in accordance with the guidelines of the 2

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Carlsson et al. (2006), Punamaki et al. (2010) and Persson et al. (2013) included only male refugees in their analyses [37, 39, 43]. Four studies reported no information on gender distributions within the sample [25, 35, 38, 45]. Twelve out of 15 studies recruited participants while they were receiving medical and/or psychological treatment, Church (2014) recruited the sample by public announcements and referrals [28], Punamäki and colleagues (2010) used a human rights organization's archive for recruitment [29], and finally Carlsson and colleagues (2006) did not provide any further information on their recruitment process [30]. Not all studies provided information on the residential status of the participants. Three studies reported an insecure residential status [24, 34, 42] and two studies included only refugees with a secure residential status [36, 44]. Another four studies included refugees seeking asylum [37, 39, 40–41]. Six studies did not offer information about the samples' residential status [25, 35, 38, 43, 45–46].

judgments were verified based on the abstracts as well as the full-text analyses conducted by the senior author, who acted as an independent rater. To assess the risk of bias in the included studies, we conducted a quality rating by two independent raters (C-RO and J-D). For this, the Qualitative Assessment Tool for Quantitative Studies by the Effective Public Health Practice Project was used [31−32]. This is an assessment tool that is recommended by the Cochrane Handbook for Systematic Reviews of Interventions to be used for assessing any quantitative study design [24]. The quality assessment consists of component ratings of the following categories: selection bias, study design, confounders, blinding, data collection methods, and withdrawals and dropouts in “strong” “moderate” or “weak” categories. In the included studies relevant data was extracted according to an a priori developed data extraction form based on the PICOS-criteria [21]. These data contain 1.) Patient characteristics including sample size, gender, country of origin, residential status, pain locations, predictors and correlations for chronic pain in traumatized refugees; and 2.) Type and efficacy of specific interventions targeting pain in traumatized refugees.

4.2. Patient characteristics – Type of pain and locations Four out of 15 studies reported that refugees often suffer from headaches [24, 40–41, 44] with a range from 50% [27] up to 99% [31]. Six studies reported symptoms of backaches [24, 35, 40–41, 44, 46] with a range from 50% [27] to 94% [31]. Three studies reported the complaint of pain in arms and legs with a range from 71.9% [19] up to 85.0% [32]. Other reported pain localizations were pelvic pain [33], unspecific pain [29] and stomach pain, joint and chest pain, and pain during urination as well as pain locations not otherwise specified [44, 46]. Teodorescu and colleagues (2015) reported no significant difference in pain location for patients with or without a PTSD diagnosis and no significant difference between patients with or without a PTSD diagnosis in the total number of chronic pain locations reported [32].

3. Results 3.1. Study selection In the two databases, 2167 studies were identified through applying the above given search terms and two articles were identified through a hand search, resulting in a total of 2169 identified records. Subsequently, 426 studies were identified as duplicates, leaving 1741 studies to be screened for titles and abstracts. Another 1686 studies were excluded for not fulfilling eligibility criteria since they did not match the term “refugee” as sample population or the diagnosis PTSD or chronic pain. The remaining 55 studies were included for full-text analysis resulting in 42 studies discarded since they did not match the eligibility criteria (n = 3 sample characteristics do not fulfill inclusion criteria; n = 23 not including chronic pain; n = 10 not including PTSD; n = 4 language; n = 1 wrong year; n = 1 study protocol). Two studies were added by a manual search. Finally, 15 studies were included for data extraction. The results were grouped as follows:

4.3. Predictors and associations of chronic pain in traumatized refugees Several pain predictors shown by traumatized refugees were identified. The number of body parts afflicted with pain predicted the total score of the Hopkins Symptom Checklist-25 (HSCL-25) and the quality of life questionnaire (physical and environmental domain) (WHOQOLBref) [30]. Correlations were identified by Morina et al. (2017) for overall reported pain and all PTSD criteria when viewed along with postmigration living difficulties as assessed by the Postmigration Living Difficulties Checklist (PMLDC) [34]. Similar findings were confirmed by Nyboe and colleagues (2017) who report increased complaints of pain in traumatized refugees when assessed by the Body Awareness Scale Movement Quality and Experience (BAS MQ-E) than compared to the answer tendencies of healthy control groups [35]. Morina et al. (2017) also described in a multiple regression analysis associations between overall pain and age, female gender, living difficulties and the PTSD criteria “cognition and mood” and “arousal and reactivity” [34]. Carlsson et al. (2006) reported other predictors for mental health, which concern the number of torture methods experienced and/or successful escape as a significant predictor for the HSCL-25, anxiety subscale and in the WHOQOL-Bref for the physical and environmental domains [30]. In the included studies, there were also predictors associated with refugees' resources. Time spent with family or friends was determined as a predictor for lower scores on the Harvard Trauma Questionnaire (HTQ), HSCL-25, Hamilton Depression Scale (HDS) and the WHOQOLBref. The level of education was a predictor for the HTQ and HDS and a learned occupation was a predictor for the HTQ-PTSD, WHOQOL-Bref, and HSCL-25 [30]. Ambiguous results were found in studies regarding refugees' ages as a predictor for pain levels. On the one hand, Buhman and colleagues (2014) identified a predictor for health outcome between lower age and higher self-reported pain [31]. In contrast, Carlsson and colleagues (2006) did not find age as a predictor for health outcome [30]. Furthermore, the non-interventional studies show that patients with

(1) Samples consisting of refugees with chronic pain and diagnosed with PTSD; (2) Samples consisting of refugees with chronic pain who were exposed to torture, but only showing sub-syndromal states of PTSD (see Error! Reference source not found.). 3.2. Studies with samples fulfilling criteria for PTSD and chronic pain Overall, 7 out of 15 studies chose PTSD as an inclusion criteria for their investigation using criteria according to DSM-lV or ICD-10 [24–25, 34–38]. In Group 2 the authors investigated refugees who were exposed to torture and who partly fulfilled the criteria for PTSD [39–46] (see Fig. 1). 4. Study and sample characteristics 4.1. Sample size, country of origin, gender, residential status of participants Five out of 15 studies investigated the situation of refugees from the Middle East (Iraq, Syria, Iran, Afghanistan, Turkey and Palestine) [37, 39, 41, 43, 45]. Eight studies included refugees from different countries in Asia, Africa and Europe [25, 34–36, 40, 42, 44, 46]. One study reported results concerning refugees from Bosnia [19]. The size of the study samples ranged from N = 11 refugees [25] up to N = 810 [26]. The age of participants ranged from 30.0 years [27] up to 47.0 years [26]. Most studies included participants of both genders: however, 3

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Identification

C. Rometsch-Ogioun El Sount et al.

Records identified through database searching –Pub Med n =1239

Records identified through database searching - Web of Science n = 928

Additional records identified through other sources n=2

Records after duplicates removed n =1741 Screening

Records excluded, with reasons n = 1686

Included

Eligibility

Records screened n = 1741

- sample not fulfilling diagnosis of PTSD or chronic pain or definition of refugee

Full-text articles assessed for eligibility n = 55

Studies included in qualitative synthesis n = 15 (Plus those added by hand search n = 2) Sample Group 1: full diagnosis of PTSD and chronic pain Group 2: partial/sub-syndromal PTSD and chronic pain

Full-text articles excluded, with reasons n = 42 - wrong sample: n = 3 - somatic complaints not including chronic pain: n = 23 - torture not including PTSD n = 10 - language: n = 4 - wrong year: n = 1 - study protocol: n = 1

n 7 8

Fig. 1. PRISMA flow chart depicting study selection regarding the sample of refugees with chronic pain and posttraumatic stress disorder (PTSD) resulted in two groups. Group 1 contains refugees with pain complaints and a PTSD diagnosis and Group 2 contains refugees with chronic pain and with a partial/sub-syndromal PTSD diagnosis.

disability in terms of personal care, family, household and social activities, and persistent somatoform pain disorder [26]. Carlsson and colleagues (2006) did not find any association between the duration of time since exposure to torture and mental health symptom scores/ health-related quality of life scores [30].

chronic pain had significantly more PTSD symptoms than patients without chronic pain. More specifically, patients with chronic pain showed significantly higher distress levels, more depressive and anxiety symptoms, and more symptoms of the Disorder of Extreme Stress Otherwise Not Specified (DESNOS), than those without chronic pain [32]. There were no significant differences between patients with or without chronic pain regarding demographic variables and trauma exposure, number of types of traumatic exposures, pain location with or without PTSD diagnosis, or between patients with or without PTSD diagnosis and total number of chronic pain locations [32]. Buhman and colleagues (2014) found an association between back pain and untreated somatic symptoms (including leg pain) with more reported depression symptoms on the HSCL-25 [31]. Teodorescu and colleagues (2015) showed that women reported significantly more pain locations than men [32]. In contrast, Bradley and colleagues (2006) found no correlation between gender and chronic pain, between gender and psychological problems, between head trauma and chronic headaches, or between chronic pain and psychological problems [27]. Van Ommeren and colleagues (2003) reported a univariate association between

5. Specific interventions Six out of 15 studies reported interventions specifically targeting pain in traumatized refugees, 3 studies by Muller and colleagues (2009), Morina and colleagues (2012) and Liedl and colleagues (2011) used treatments including biofeedback interventions [34, 36, 42]; Kruse and colleagues (2009) used manualized trauma psychotherapy [19] and Pease and colleagues (2009) used Traditional Chinese Medicine (TCM) [33] (see Appendix A for further information). To evaluate the quality of the intervention studies in a systematic way, the above mentioned assessment of risk of bias in individual studies (quality rating) was used. The global rating of the included studies shows results ranging from strong to moderate; only the study of Pease et al. (2009) resulted in a 4

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Table 1 Interventions addressing pain in traumatized refugees in included studies. Intervention

Primary target in therapy

Format of Interventions

Study

Quality global rating [24]

Manualized trauma psychotherapy

Trauma Trauma and Chronic Pain Trauma and Chronic Pain Trauma and Chronic Pain Mental health disorders

Kruse et al. (2009) [19] Muller et al. (2009) [25] Morina et al. (2012) [36] Liedl et a. (2011) [37] Pease et al. (2009) [33]

strong

Short term cognitive behavioral biofeedback

25 h of manualized psychotherapy in Bosnian language according to consensus model of trauma therapy Short-term cognitive behavioral biofeedback (BF) for 10 sessions á 90 min 10 sessions pain-focused treatment with biofeedback (BF) + 10 sessions of Narrative Exposure Therapy (NET) Biofeedback-based (BF) cognitive behavioral therapy (CBT) for 10 sessions for 90 min TCM (Traditional Chinese Medicine) 111 treatments with acupuncture for chronic pelvic pain, nightmares, anxiety, back pain 6 sessions of emotional Freedom Techniques (EFT)

Pain-focused therapy with biofeedback (BF) and Narrative Exposure Therapy (NET) Biofeedback-based cognitive behavioral therapy (CBT-BF) Traditional Chinese Medicine (TCM)

Emotional Freedom Techniques

Trauma

Church (2014) [28]

strong strong strong weak

strong

Notes. Pease et al. (2009) received a weak global rating due to being rated weak on at least 2 out of 6 components (specifically on selection bias, confounders and withdrawals and dropouts).

lower than after the third treatment. Pease and colleagues (2009) used 111 acupuncture treatments for chronic pelvic pain and back pain within the context of Traditional Chinese Medicine (TCM) [33]. The treatment framework showed a reduction of PTSD symptoms, but no effect was reported regarding individual pain complaints. Kruse and colleagues (2009) implemented an intervention with 25 h of manualized trauma psychotherapy with refugees suffering from PTSD and partly suffering from chronic pain. They found a statistically significant “time by group interaction for PTSD” and a decrease of the mean value of the PTSD scale as measured in the HTQ in the intervention group. In contrast they measured an increase in the PTSD scale in the comparison group. They also reported a reduction in the SCL-90-R assessed symptoms in the intervention group; whereas, they found an increase in SCL90-R assessed symptoms in the comparison group. Overall in their intervention they achieved an improvement of the health status for refugees in the intervention group, while the health status in the comparison group remained stable [19]. In the SF-36 Kruse et al. (2009) determined a physical and mental health improvement for the intervention group, and no change was shown in the comparison group. The authors provided no explicit information on the results for the development of specific pain markers in general [19].

weak quality rating [33] (see Table 1).

5.1. Reported outcomes All included studies that investigated one of the above mentioned interventions reported a positive outcome on chronic pain and on trauma severity, which will be reported below. Three studies implemented biofeedback therapy as part of the applied intervention [34, 36, 42]. In addition to biofeedback, Morina and colleagues (2012) used Narrative Exposure Therapy (NET) [19, 36]. Their protocol consisted of ten sessions of manualized pain-focused treatment with biofeedback followed by ten sessions of Narrative Exposure Therapy. The authors found moderate effects on pain intensity after conducting biofeedback therapy combined with Narrative Exposure Therapy, which was not reached by conducting biofeedback therapy only. Liedl and colleagues (2011) used biofeedback therapy combined with cognitive behavioral therapy (CBT) [37]. The therapy lasted for 10 weeks with sessions of 90 min that included psychoeducation explaining the relationship between stress and pain followed by relaxation strategies and the identification of dysfunctional cognitions and behavior. The intervention group showed significant improvement in pain, anxiety and behavioral coping when compared to the control group [37]. The intervention group that received more activity treatments, such as daily physical exercises including stretching, endurance training, and muscle strength developed by a physical therapist, showed larger effect sizes pertaining to the reduction of pain intensity, cognitive, and behavioral coping for pain and PTSD symptoms than the intervention group without activation [37]. Muller and colleagues (2009) used a manualized standard biofeedback procedure [25] in accordance with Arena et al. (1996) and Flor et al. (1992) [47–48]. However, they added a therapy component including a psychoeducation for trauma-related chronic pain, while conducting 10 weekly sessions that lasted 90 min. In this constellation they reported significant effects on the cognitive and behavioral ability to cope with pain [25]. When merely viewing the biofeedback intervention, they found only medium effects on pain intensity and small effects on pain disability [25]. In a three-month follow-up measurement they determined medium effects for reductions in pain intensity in cognitive and behavioral coping and medium to large effects for the PTSD symptoms. Emotional Freedom Techniques (EFT) is a technique that stimulates acupressure points by pressuring, tapping, or rubbing these points while focusing on situations that represent personal fear or traumata. This technique implemented by Church (2014) uses a series of six sessions [28]. The reported pain ratings decreased after the third and the sixth treatment, and after the sixth treatment, the rating was significantly

6. Discussion This review depicts an overview of the existing scientific literature concerning chronic pain in traumatized refugees. Overall the included studies and results are very heterogeneous. In regard to patients' characteristics, refugees were mainly from the Middle East, Asia, Africa and Europe with an age range of 30 to 47. The included studies did investigate neither the cultural backgrounds nor the religion of the refugees. On the one hand, religious beliefs could function as a resource for coping with trauma [49–51], while other studies show opposite effects [38]. No evidence was found for possible influences concerning the country of origin and reported chronic pain in refugees with PTSD. In the included studies, the variable of cultural background might account for the inconsistent results between age and/or gender and reports of chronic pain by refugees with PTSD [41, 44]. Furthermore, specific cultural backgrounds and, in particular, cultural group differences between these samples may influence the level of chronic pain symptoms and PTSD reported overall [39]. Another important influencing factor may arise out of the refugee's residential status. Residential status has the potential to influence the occurrence of chronic pain in refugees suffering from PTSD in the sense that an insecure residential status causes a higher overall stress rate, which may also lead to more painful somatic locations for pain experiences. In comparison, refugees with a secure residential status 5

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6.1. Limitations

report less pain experience. Data from Gerritsen and colleagues (2006) indicates that asylum seekers with an insecure status show a higher number of PTSD symptoms, higher levels of depression and anxiety, and consider their overall health poorer than refugees with secure residential status [40]. The specific kind of traumatization and refugee's personal trauma experiences are insufficient in the current research. Overall there are wide gaps in the evidence concerning patients' characteristics. In reference to the pain locations, the most common locations (e.g. headaches, backaches, pain in arms and legs) were described without having a closer look at the preceding trauma. Inconsistent results were found regarding age as a potential predictor of chronic pain. On the one hand, lower age is found to be associated with higher pain ratings [31]. There is a clear association between pain and age shown with the multiple regression analysis by Morina and colleagues (2017) [34]. On the other hand the age was not confirmed as a predictor by the results of Buhmann and colleagues (2014) or in the work of Carlsson and colleagues (2006) [37, 40]. Anderson and colleagues (1993) found an increased prevalence for chronic pain in the age group of 50–59 years for both genders. In regard to even older cohorts, they reported a decreased prevalence of reported pain [41]. It is not an unreasonable assumption that there is a relationship between age and pain or trauma symptoms in refugees suffering from chronic pain and PTSD; however, in order to understand this relationship, further research has to more precisely consider the age at which the patient was traumatized and the age at which both the symptoms of chronic pain and PTSD occurred. Specific interventions were conducted in the various treatment procedures. Given that the studies used very different treatment procedures, a comparison of the studies is not possible. However, most studies show a strong or moderate global quality rating. There is evidence that a significant reduction in pain symptoms can be achieved after conducting Emotional Freedom Techniques (EFT) [28]. However, the danger of pain exacerbations during treatment was also found by Bosco and colleagues (2013) using EFT [42]. A significant improvement of PTSD symptoms was achieved with CBT and NET [3, 42]. Not only was this an effective treatment for PTSD, but it was also highly effective for the sample of refugees with combined chronic pain and PTSD (see summary table for effect sizes and further information). Further effective strategies in the treatment of comorbid chronic pain and PTSD in refugees were interventions using manualized trauma therapy and/or EFT, with the addition of biofeedback or TCM. As mentioned earlier, due to the lack of comparability of these studies future research is needed to analyze the treatment of comorbid chronic pain and PTSD in patients with a refugee background. When viewing the near future, continuing military disagreements and the unstable political landscape will cause the number of refugees to increase [43]. These global developments place a focus on developing treatments that will help this vulnerable population psychosomatically. The need for treating refugees with chronic pain and PTSD will continue to prove necessary; thus further specialized treatment options must be developed and evaluated. Also of interest, next to psychosocial care and psychotherapeutic support, is the use of pharmaco-therapy. Schwarzt and colleagues (2006) have shown that patients with PTSD use analgesic medication (opiate and non-opiate) significantly more often than patients with other mental disorders [44]. The results of Brune and colleagues (2003) that report the use of opioids as self-medication in the attempt to avoid and reduce intrusive symptoms of PTSD (i.e. flashbacks), especially in the population of refugees, further supports the need for data collection [45]. Furthermore, Brune and colleagues (2003) appeal to the importance of simultaneous treatment for both disorders [45]. To date, there have been no studies investigating the use of medications in the population of traumatized refugees with chronic pain.

A methodological limitation of this review might exist due to the search process; only studies published in the English or German language were included (e.g. [60–61]). There is a risk of publication bias, since currently there is a sizable interest in researching refugees. While we found studies that described reliable data concerning disorder definitions, there is sizable literature investigating the relationship between somatization and PTSD in the refugee population. These papers were at first included in the full-text articles screening; however, there was no detailed information about the specific somatoform disorder investigated. Pain disorders were not reported in detail or clearly distinguished from somatization in general, thus these papers could not fulfill our inclusion criteria. For example, Spiller and colleagues (2013) implemented a psychotherapy intervention with 134 patients in Switzerland and found predictors (age, somatisation, anger, postmigration living difficulties for PTSD as well as a correlation of 0.69 between PTSD symptoms and somatic symptoms), but they do not differentiate their results in regard to pain complaints and other somatic complaints [46]. Another example of research that did not fulfill our inclusion criteria is the intensive research done on torture victims with chronic pain; however, the participants of these studies did not fulfill the criteria of PTSD (e.g. [63–64]). Furthermore, Jamil and colleagues (2006) found significant differences between specific pain distress in a nonPTSD group when compared to a PTSD group. They also found that the PTSD group took more pain medication than the non-PTSD group; however, these results were not statistically significant [23]. Due to the heterogeneity of our data there is a large variety of methods, procedures and interventions used, which renders it impossible to compare results on a meta-analytical basis. Even though the performed assessment of risk of bias in individual studies (quality rating) of the included intervention analyses indicated mostly strong results, they are low in number and no randomized controlled trials could be identified. The experimental protocols of the included studies are very detailed. An overview and summary of the technical issues can be found in the summary table (see Appendix A for further information).

7. Conclusion For refugees with chronic pain and PTSD, the existing literature is scarce and very heterogeneous. The results of this review delineate further research is needed in the following areas: 1.) Patients' characteristics: Accurate information regarding cultural background, religion, country of origin, age, gender, and residential status. Additionally, investigations of the association between pain location and original trauma experience are needed, which could be gathered through the specific inquiry of the overall reported pain locations. Further studies are necessary and comorbidities and drug use have to be included 2.) Specific interventions: Cognitive behavioral therapy with biofeedback, Narrative Exposure Therapy, manualized trauma psychotherapy, Traditional Chinese Medicine and Emotional Freedom Techniques were evaluated interventions with positive outcomes on both pain severity and PTSD symptoms. Further specialized treatment options should be developed and evaluated for the growing need of treatment within this patient population. This review demonstrates that further studies are urgently required regarding the psychosocial care of traumatized refugees with chronic pain in order to expediently offer adequate psychotherapeutic support when indicated.

Conflict of interests The authors assure no conflicts of interests.

6

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Funding The authors declare that there was no funding for this manuscript.

Appendix A. Summary table of the included studies.

Author

Patients` characteristics

Instruments for diagnosis

Prevalence Comorbidity Pain locations

Group 1: Sample including participants with PTSD as diagnosis for including criteria N/A N/A Headache - Refugees from 1.) DSM-lV Kruse, J. (81,3%) 2.) The Harvard Bosnia et al. Backaches Questionnaire - 64 refugees (2009) (79.7%) (Mollica et al., - 34 in [19] Pain in the 2001) intervention legs group, mean age 3.) Symptom Checklist (71.9%) (SCL-90-R, 44.7 (SD = 9.0), Fatigue Derogatis & Cleary, 67.2% women (74.6%) 1977) - 30 in control group, mean age 4.) Health Survey Questionnaire (SF44.3 36, Ware et al., (SD = 12.2) 1992 and SF-36, - Insecure Creed et al., 2005) residence status - Psychosomatic 5.) Structured Clinical Interview for DSM department Disorders (SCID, First t al., 1996)

Church, D. (2014) [28] added

- 49 veterans - RCT: controlled group vs. waiting list - N/A: age, sex, residential status Announcement, referrals

1.) PTSD ChecklistMilitary (PCL-M) 2.) Symptom Assessment-45 3.) Pain: 11-point Likert scale

N/A

Depression Anxiety

7

N/A

Predictors/ Interventions

Outcome

-Analyses of covariance (ANCOVAs) -Statistical significant time by group interaction for PTSD F (1,60) = 114.73, p < .001, η2 = 0.657 - Decrease of the mean value of the PTSD scale in the HTQ in the intervention group ES = 2.73, t(33) = 10.52, p < .001 - Increase in the comparison group ES = −0.25, t(29) = −2.36, p < .05 - Reduction in the result of the SCL-90-R in intervention group, increase in the comparison group - Improvement of the health status in the intervention group, stable in the comparison group - SF-36 shows physical and mental health improvement, no change in comparison group - Assessments 4 times: 6 sessions of after third/sixth session emotional and follow-up after Freedom Techniques (EFT) three and six months -After 6 treatment/ 3 month follow up: anxiety and depression and PCL-M was significant -After 6 months: significant relationship between anxiety and depression - Mixed-effect models for pain ratings: significant main effect for time (p < .0005) - Significant main effect for group, F(1, 169) = 7.72, P = .0061 - Pain ratings decreased 25 h of manualized psychotherapy in Bosnian language according to consensus model of trauma therapy (Courtois, 2004; Reddemann, 2004)

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1.) Mini International N/A - 11 refugees Neuropsychiatric - Kurdish n = 8 Interview (M.I.N·I, - Bosnian n = 3 Sheehan et al., - mean age 1998) Plus version 36 ± 6 years (Ackenheil, Stotz- 73% female Ingenlath & Dietz- Partly insecure Bauer, 1998) - Residence 2.) Posttraumatic status n = 8 Diagnostic Scale -Treatment (PDS, Foa, 1995) center 3.) Pain Disability Index (PDI, Tait et al., 1990) 4.) Hopkins Symptom Checklist-25 (HSCL-25, Mollica et al., 1987) 5.) Self-reported Verbal Rating Scale (SF-36, Ware & Sherbource, 1992) 6.) Visual Rating Scale 7.) Recording EMG activity at pain site and heart rate 8.) German Pain Coping Questionnaire (FESV, Geissner, 2001) 9.) Distress/ Endorsement Validation Scale (DEVS, Devilly, 2004) N/A 1.) Psychiatrists Pease, M., R. - 16 refugees diagnosed PTSD - From 13 et al. following the DSM different (2009) IV TR countries [33] - N/A sex, age, 2.) Wong-Baker Faces Pain Scale residence status -Refugee organization Muller, J., A. et al. (2009) [25]

Morina, N., T. et al. (2012) [36]

1.) DSM-IV criteria for N/A - 15 refugees diagnoses of PTSD - Turkey (n = 8) and persistent pain - Bosnia (n = 3) (Excluding - Sri Lanka neuropathic pain) (n = 1) 2.) Mini International - Iraq (n = 1) Neuropsychiatric - Syria (n = 1) Interview Plus - Vietnam version (Ackenheil, (n = 1) Stotz-Ingenlath & - 9 male Dietz-Bauer, 1998) - Mean age 43.1 3.) Self-reported (SD = 6.9) Verbal Rating Scale - Time in

N/A

N/A

Most common complaint: Pain Secondary complaint: mentalemotional symptoms N/A

Chronic pelvic pain Back pain

8

N/A

after 3/6 treatment, treatment 6: rating was significantly lower than treatment 3 -Pain rating decreased significantly at sixmonth follow-up from the pretest ratings - High acceptance of BF Short-term - Significant effects on cognitive the coping with pain, behavioral biofeedback (BF) both cognitive and for 10 sessions at behavioral - Medium effects on 90 min each pain intensity - Small effects on pain disability −60% reported clinical change in pain disability at the post-treatment using reliable change index Follow up: - Medium effects for pain intensity and cognitive and behavioral coping - Medium/large effects for PTSD

TCM (Traditional Chinese Medicine) 111 treatments with acupuncture for chronic pelvic pain, nightmares, anxiety, back pain Ten sessions painfocused treatment with biofeedback (BF) plus ten sessions of Narrative Exposure Therapy (NET)

- Reduction of symptoms of PTSD 14 in 16 of 19 refugees

- No significant reductions in pain intensity at T1/2 (d = 0.45, t(14) = 1.47, p = .164) - Strong effect on posttraumatic stress symptoms at T3 (PTSD Severity), T1/2: d = 0.1, T2/3: d = 1.43, T3/4: d = −0.01 - Moderate effects on

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Switzerland x = 11.0 years (SD = 5.8) - No insecure residence status - University hospital

4.)

5.)

6.)

7.) Carlsson, JM et al. (2009) [30]

- 63 refugees - Iraq (n = 37) - Afghan (n = 7) - Iran (n = 5) - Other (n = 14) - Mean age 37.8 (SD = 8.11) - 63 men - 21 women for pretreatment assessment - Asylum in Denmark - Recruitment unclear

1.)

2.)

3.)

4.)

5.)

Nybo, L. et al. (2016) [35]

(SF-36, Ware & Sherbource, 1992) Pain Disability Index (PDI, Tait et al., 1990 ClinicianAdministered PTSD Scale (CAPS, Clake et al., 1990) Self-reported EUROHIS-QOL (Nossikov & Gudex, 2003) Motivation: Visual Analogue Scale N/A Demographic background: Selfadministered questionnaires and semi-structured and structured interviews Hopkins Symptoms Checklist- 25 (HSCL-25) Hamilton Depression Scale (HDS) The Harvard Questionnaire (HTQ) WHO Quality of Life-Bref (WHOQOL-BREF)

1.) BAS MQ-E - 14 refugees (Gyllensten and - Mean age Mattsson, 2011) 31.3 years - N/A country of origin, sex, age, residence status - Patients from psychiatry

N/A

pain intensity at T3 (pain intensity, pain disability) (T2/3: d = 0.61, T3/4: d = 0.44) - Increase of Quality of Live (QoL) Follow up: -Medium effects for pain intensity, pain disability and quality of life, not for PTSD

N/A

Number of body parts with pain past 24 h mean = 4.6 (SD = 2.10)

N/A

N/A

9

Correlation of questionnaire and symptoms (predictors for mental health) - Significant predictors for mental symptom scores: number of torture methods and escape -Predictor of mental scores except HSCL-25 depression subscale: Number of torture methods - Predictor for all: spending time with family or friends - Predictor of HTQ and HDS: education - Predictor for the HTQ PTSD, WQHOQOL-Bref and HSCL-25: occupation -Predictor of the HSCL-25 (total and anxiety) and WHOQOL-Bref (physical/ environmental): number of body parts with pain N/A

- Correlations among mental symptom scales were higher than between symptom scales and healthrelated quality of life items - No association between years since exposure to torture and mental symptom scores/health-related quality of life - No predictors was age and proficiency - Explaining variance for HTQ PTSD by number of torture methods more than for other symptom scores - Linear coefficients for number of torture methods - Quadratic significant result for association between number of torture methods and HSCL-25 and HTQ

- Next to traumatized refugees were a group of 10 Danish war veterans with PTSD and a control group of 20 healthy Danish students - Traumatized refugees had significantly higher scores on the questionnaire BAS MQ, in particular on the subscale “stability in function” and

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“coordination and breathing” compared with the war veterans -Traumatized refugees had significantly more impairment in motor function in the PTSD groups - No differences in subjective experiences and bodily complaints between traumatized refugees and Danish war veterans - Traumatized refugees and Danish war veterans suffered from musculoskeletal pain and muscle tension Group 2: Sample including participants with torture 1.) Diagnosis Buhman, C., - 127 refugees according to ICD- Iraq 41% E. et al. 10 - Iran 9% (2014) 2.) Self-rating scale - Afghanistan [31] 3.) Semi-structured 9% interview - PalestiN/A 4.) Harvard Trauma 13% Questionnaire - Others (Bosnia, (HTQ) Croatia, Serbia) - Mean age 42.5 5.) Hopkins Symptom Checklist-25 - 46% men (HSCL-25) - Mean time in 6.) Quality of life Denmark (WHO—5) 14 years 7.) Level of - Insecure functioning: residence status Sheehand (asylum or Disability Scale family reunification) - Psychiatric Trauma Clinic for Refugees

and partly fulfilling criteria for PTSD Headache PTSD PTSD and (n = 117, (n = 109, Pain 86% 86%) 99%) Depression Pain and Back pain PTSD 96% (n = 120, (n = 111, 86%) 94%) Somatic Pain in syndromes arms pain (n = 96, 78%) Pain in legs pain (n = 100, 81%)

Bradley L. & Tawfiq, N. (2006) [27]

N/A

1.) Unstructured - 97 refugees interviews for - PTSD 14% of PTSD and the patients depression fulfilled DSM-4 according to DSMcriteria, and IV 22% for chronic

Depression 7% Anxiety disorder 7%

10

Back pain 50% Headache 50%

Predictors of health outcome: - Association between lower age with higher self-reported pain - Pre-migratory predictors: Significant association between persecution and higher score in HTQ (PTSD symptoms) and HSCL-25 (depression symptoms) and Imprisonment and HSCLdepression - Significant association between being an ex-combatant and reporting pain - Post-migratory predictors: - Significant association between PTSD symptoms on the HTQ as well as pain and social isolation - No work associated with more HTQ, lower WHO-5 and SDS

- Low score for level of functioning (SDS = 24.3) - Significant correlation between diagnosis of PTSD or depression and corresponding selfrating (HTQ and HSCL25) - More parts with body pain, the higher HSCL25, lower WHO-5 and level of functioning and higher prevalence of untreated somatic complaints - WHO-5 better results in men than women Psychopharmacological drug taking leads to lower WHO-5, more depression symptoms on the HSCL-25 and psychotic symptoms - Association between back pain and untreated somatic symptoms and pain in the legs with more depression symptoms on the HSCL25 - Higher scores in PTSD on the HTQ when existing headache, backache, pain in arms and body pain

- No correlation between head trauma and chronic headache χ2 = 0.687 - No correlation between sex and chronic

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pain - Turkey (East) - Kurdish - Mean age 30 (range 16–64) - 14 women - Medical evaluation 1.) Mini International N/A Neuropsychiatric Interview (MINI) 2.) Clinical Global Impression Scale 3.) Global Assessment of Functioning according to DSMlV 4.) Posttraumatic diagnostic scale (PDS) 5.) Harvard Trauma Questionnaire (HTQ) 6.) Hopkins Symptom Checklist (HSCL25) 7.) Verbal Rating Scale (VRS) 8.) German Pain Coping Questionnaire (FESV) 9.) Electromygraphic activity (EMG) 10.) Heart rate (HR)

Liedl, A., J. et al. (2011) [37]

- 30 refugees - All refugees met criteria for pain disorder, only 87% for PTSD - Turkey (n = 8) - Balkans (n = 10) - Others (n = 12) - Mean age 41.67 - 17 male - 37% with insecure residence status - Outpatient clinic

Punamäki, R. et al. (2010) [29]

1.) The Harvard - 275 refugees Questionnaire - Palestine (Mollica & Caspi- Mean age 30,1 Yavin, 1991) - Men only - N/A residence 2.) Torture and Illtreatment status - Human rights Questionnaire

N/A

Major N/A depression disorder 87%

N/A

11

Dislocated pain

pain χ2 = 0.167 - No correlation between chronic pain and psychological problems χ2 = 0.653 - No correlation between sex and psychological problems χ2 = 0.167 - Moderate symptoms - Biofeedbackand medium levels of based (BF) social, occupational and cognitive psychological behavioral therapy (CBT) for functioning 10 sessions á -Mean pain intensity 90 min 84.4 (SD = 14) - 3 conditions: - Significant outcome CBT-BF, for coping strategies in CBT-BF + active general in and waiting list CBT-BF + acitve (WL) - Significant improvement in anxiety and behavioral coping in CBT-BF and CBT-BF + active group - CBT-BF + active larger effect sizes for PTSD (d = 0.48 vs d = 0.19), pain intensity (d = 0.95 vs d = 0.60), cognitive coping (d = 0.72 vs d = 0.08), behavioral coping with pain (d = 0.83 vs d = 0.56) than CBT-BF treatment - Medium betweengroup effect sizes for CBT-BF + active (d = 0.55 vs d = 0.30) and behavioral (d = 0.04 vs d = 0.66)than to CBTBF at post-treatment and 3-month follow-up - Significant pain group effect for cognitive coping (subscale cognitive restructuring and perceived selfcompetence) and behavioral coping (subscale counter activities) - No significant reduction in EMG or HR in any condition - No significant reduction of pain intensity N/A - Using a regression model that explains 25% of variation of PTSD F (14,254) = 5,89, p < .001, and 12% F (14,255) = 2,56,

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Teodorescu, D. et al. (2015) [32]

organization archive

30 methods of interrogation and abuse in captivity 3.) Somatic Symptoms Questionnaire by Allodi (1985) examine e.g. - Hearing problems - Dislocated pains - Lack of appetite - Loss of weight - Trembling

−61 refugees - PTSD diagnosis: 50(82%) - Chronic Pain 60 (98%) at one localization, 4 (7%) at 8 localizations - Eastern Europe (22) - Africa + Middle East (26) - Other (13) - Mean age 41,7 - 25 women, 36 men - Permanent residence in Norway - Outpatient psychiatric clinic

1.) Self-report Questionnaire: - National origin - Employment - Having friends - Social integration in Norway - Social integration in the ethnic community 2.) Life Events Checklist (LEC) 3.) Structured Clinical Interview for DSMIV PTSD Module (SCID-PTSD) 4.) Structured Interview for Disorders of Extreme Stress (SIDES) 5.) Chronic Pain: SIDES Subscale VI b 6.) M.I.N·I international Neuropsychiatric Interview 5.0.0 7.) Impact of Event Scale-Revised (IESR) 8.) Hopkins Symptom Checklist (HSCL-25

57% between PTSD and chronic pain

N/A

12

Mean pain location 4.6 (SD = 2.1) All: Head 80% chest74% arms/legs 66% back 62% stomach 57% Chronic pain locations in patients with PTSD diagnosis: Stomach pain 87.7% Chest pain 84.4% Arms/legs pain 85,0% Back pain 82.2% Joint Pain 81.8% Head Pain 85.7% Pain during urination 90% Other pain locations 84.2%

p < .01, of somatic symptoms - Significant association between physical and psychological torture and PTSD - Significant association between psychological torture and somatic symptoms - Significant interaction effect between physical and psychological torture exposure on PTSD - Pearson Correlation between PTSD symptoms and somatic symptoms r = 0.40, p < .001 - Patients with chronic pain had significantly more symptoms of PTSD (M = 55.0; SD = 15.,5) than patients without chronic pain (M = 42.8; SD = 19.1) - No significant differences between men and women regarding prevalence of chronic pain - 70% outpatients with chronic pain had PTSD diagnosis - No significant difference between outpatients with or without chronic pain in having a PTSD diagnosis - 88% outpatients with PTSD had chronic pain - No significant difference between outpatients with or without PTSD in having a chronic pain - No significant differences between patients with or without chronic pain regarding demographic, social variables, and trauma exposure, specific or total number of types of traumatic exposures, total number of chronic pain locations - Patients with chronic pain had significantly more symptoms of PTSD (M = 55.0; SD = 15.5) than patients without chronic pain (M = 42.8; SD = 19.1) - Patients with chronic

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Van Ommeren, M., J et al. (2001) [26]

Morina, N. et al. (2017) [34]

- 418 tortured and 392 nontortured refugees - Bhutanese - Mean age 44.3 (SD = 12.5) - Male 324 - N/A residence status - Center for Victims of Torture Nepal −134 refugees and asylum seekers - Turkey, Iran, Sri Lanka, Bosnia, Iraq, Afghanistan, others - 105 male refugees (78.4% male) - mean age 42.2 years - N = 66 (49.3%) fulfilling PTSD diagnosis - N/A residential status of refugees - outpatient unit for victims of torture and war Zurich

N/A

N/A

N/A

N/A 1.) Harvard Trauma Questionnaire 2.) Post-traumatic Diagnostic Scale (PDS) 3.) Symptom Checklist (SCL) 4.) Single item on fivepoint scale for assessing overall pain 5.) Postmigration Living Difficulties Checklist (PMLDC)

N/A

Pains in lower back; Pains in heart and chest

1.) Modules of the Composite International Diagnostic Interview, version 2.1 2.) Disability: World Health Organization Short Disability Assessment Schedule

13

pain had significantly higher distress level than those without chronic pain, more depressive and anxiety symptoms, and more DESNOS symptoms - Women had significantly more pain locations than men - No significant difference in pain location with or without PTSD diagnosis Multiple Logistic - Univariate associations between disability and Regression Analyses showing 12-month ICD-10 disorder for persistent significant somatoform pain predictors of disorder disability - Physical disease n = 213, disability n = 58, Odds (p < .007) - PTSD (p < .02) Ratio = 2.1 - Specific phobia CI = [1.3–3.4], p < .003 (p < .006)

- Mean of 13.11 (SD = 4.80) types of traumatic events, over 90% torture (N = 114, 92.7%) - Factor loadings for the somatization items of the SCL shows pains in lower back with 0.726 for Factor 1 “weakness” and pains in heart or chest with 0.747 for Factor 2 “arousal” - Significant Pearsons's correlation of overall pain with all PTSD clusters and PMLD - Multiple regression analyses of somatization factors and overall pain: overall pain is associated with age B = 0.023, SE B = 0.009, β = 0.206, T = 2.771, p = .008, female gender B = 0.553, SE B = 0.204, β = 0.206, T = 2.708, p = .008, living difficulties B = 0.043, SE B = 0.021, β = 0.159, T = 2.010, p = .047, PTSD Criterion D (“alterations in cognitions and mood) B = 0.512, SE B = 0.230, β = 0.217, T = 2.231, p = .028 and

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Persson, AL, Gard, G (2013) [47]

Added

- 15 refugees - 13 refugees had PTSD - 14 refugees had chronic pain - Iraq (n = 13) - Lebanon (n = 2) - Mean age 47.0 - Men only - Asylum - Rehabilitation and research center

1.) Pain intensity: Visual Analogue Scale (0–100 mm) 2.) Disability Rating Index (DRI) 3.) Hospital Anxiety and Depression Scale (HADS) 4.) General SelfEfficacy Scale

N/A

Anxiety Depression

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[15]

[16] [17] [18]

[19] [20]

[21]

[22] [23]

[24]

14

Mean pain duration 21 years

PTSD Criterion E (“alterations in arousal and reactivity”) B = 0.646, SE B = 0.226, β = 0.277, T = 2.857, p = .005 - General expectations Explorative of rehabilitation qualitative interview for the program: mostly expectations on a positive, used terms multidisciplinary trust and/or hope, learning, advice, pain solutions for problems, rehabilitation coping strategies, program personal characteristics and acceptance, improvement of health conditions - Specific expectations of professional treatment: physiotherapeutic, medical, psychological and social support - Expectations of mutual participation and communication: active participation in program -Expected rehabilitation outcomes: improvement on physical and psychological health, as well as coping abilities - Expectations positive for improved health, improved coping ability and decreased pain

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