A.-M. Karrer1, E. Arida2, A. Gamble3
1DIGNITY - Danish Institute against Torture, International Programmes/International Rehabilitation, Copenhagen, Denmark, 2Restart- Center for Rehabilitation of Victims of Torture and Violence, Rehabilitation/Physiotherapy, Beirut, Lebanon, 3Wchan Organization for Victims of Human Rights Violations and ACR – The American Center for Rehabilitation, Rehabilitation, Sulaimani, Iraq

Background: Persistent pain is highly prevalent among populations affected by psychological trauma(trauma). Persistent pain and trauma-related distress contribute to poor general health and problems with functioning. Research has shown that integrating a biopsychosocial understanding of the complexity of pain and stress is needed for therapy resulting in functional improvements.  In the Middle East and Northern African (MENA) region, there is a lack of biopsychosocial-focused physiotherapy treatment approaches. Even though in MENA region there is high prevalence of populations affected by trauma, physiotherapists are traditionally taught a biomechanical understanding of health and functioning. Through discussions with four local organizations, a need was identified for evidence-based and contextualized treatment programs to supplement the existing rehabilitation services offered to refugees and other populations affected by trauma. An additional need for future trainings in Arabic including “Training of Trainers” was identified.

Purpose: The purpose of this mixed method feasibility study is to explore the acceptability and feasibility of the Pain School treatment manual and training program with 11 physiotherapists throughout six communities in MENA. Pain School is a manualized 10-session treatment addressing Persistent pain, Distress, Sleep and Daily activities. It integrates therapeutic patient education, body-awareness exercises, and active planning for behavioral changes. The study aims to
(1) Evaluate the collaborative development of Pain School during a 1-year capacity building program;
(2) Qualitatively examine the acceptability and feasibility of the Pain School manual by the physiotherapists delivering the treatment;
(3) Explore the preliminary therapeutic quantitative pilot results.

Methods: The Pain School treatment was tested with a mixed-method analysis using qualitative interviews with physiotherapists in MENA who participate in trainings, contributed to development of treatment manual and monitoring and evaluation tool, and also delivered the Pain School treatment. Quantitative analysis of preliminary effects of this 10-session treatment was carried out on 38 patients suffering from persistent pain and trauma-related stress.

Results: The pilot study demonstrated feasibility, high acceptance and preliminary benefits of the delivery of the Pain School treatment with 7 physiotherapists in Jordan, Tunis, Morocco and Lebanon and 38 patients in Jordan and Morocco. Monitoring and evaluation of treatment was useful, but mental health status assessments were missing.

Conclusion(s): This study reveals that it is feasible and acceptable to co-develop, train, and deliver an evidence based standardized physiotherapy program for populations affected by pain and trauma in MENA. Based on the positive results of this pilot study, next  steps will include
1) Baseline study assessing the prevalence of co-existing persistent pain and trauma- related distress among refugees in MENA
2) Larger patient sample sizes
3) Control groups
4) Evaluation of possible mental health benefits and
5) Final editing of the treatment manual Arabic, Kurdish Sorani and French.

Implications: This study aims to translate results into practice by:
1) discussing practical strategies and common pitfalls encountered during the multi-cultural co-development, training, and delivery of Pain School in MENA and
2) sharing the results of phases III and IV where 19 physiotherapists from Kurdistan Iraq, Iraq, Jordan and Tunis  participate with four physiotherapists from the initial Pain School program serving as co-trainers.

Funding, acknowledgements: The study was funded by Danish Ministry of Foreign Affairs: Danish Arab Partnership (DAPP) Program (2017 – 2021).

Keywords: Persistent pain, Psychological trauma, Self-reliance

Topic: Mental health

Did this work require ethics approval? No
Institution: DIGNITY - Danish Institute against Torture. Copenhagen Denmark
Committee: Internal Non-Official Committee. See the below text
Reason: Early stage of development of manualized treatment

All authors, affiliations and abstracts have been published as submitted.

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