Background: Multidisciplinary rehabilitation has proven effective for treating war-related trauma in Western countries, but it remains unclear whether this approach is applicable to civilians living in resource-poor coun- tries affected by war. The Danish Institute against Torture (DIGNITY) in Copenhagen has been involved since 1999 in a number of research and intervention projects among victims of torture and war in Kosovo, in partner- ship with the Kosova Rehabilitation Centre for Torture Victims (KRCT). In 2012-14, we carried out a randomized controlled trial to examine the effects of multidisciplinary intervention on comorbid chronic pain and affective disorders, physical conditions, emotional well-being and employment.
A single-center, randomized, parallel-arm, single-masked waiting-list controlled trial was implemented in Northern Kosovo. Thirty-four participants meeting the recruiting criteria were randomized to either intervention group which received integrated treatments plus a once-daily multivitamin or to waiting list group which received multivitamin alone. The integrated treatments consisted of 10 weekly individual 60-minute sessions of cognitive behavior therapy (based on an adapted prolonged exposure therapy manual), an individual 20-minute breathing exercise with an emWave biofeedback device, and 90-minutes of group physiotherapy.
The waiting list group also received integrated treatments when the intervention group completed all the sessions. Outcome assessments were conducted at 3, 6 and 9 months after baseline assessment. Additionally, to check treatment integrity and compliance for quality assurance, at least 15% of the individual treatment sessions were randomly selected and recorded using a digital voice recorder. An independent assessor reviewed these recorded sessions with the assistance of translators and provided feedback. Primary outcome measures were changes of PTSD, depression, anxiety, chronic pain and anger expression. The secondary outcome measures included body mass index, handgrip strength, standing balance, income, employment rate and level on the WHO-Disability Assessment Schedule II (WHODAS-II). To estimate intervention effects we used multivariable models.
Over 1/3 of PTSD cases were successfully treated but inconsistent pattern with primary outcomes were observed while there was a definite impact of intervention on secondary outcomes, especially the employment rate, which increased nearly 15%, and the monthly wage, which rose from 45-137%. There was also a noticeable improvement in handgrip strength and disability score, and feelings of anger and hatred diminished. However, most of these changes did not reach statistical significance. The problems resulting from disability must be seen in the context of the post-war economy in Kosovo. The potential of bio-psycho-social approach in intervention for improving the physical health and employment outcome in victims was demonstrated. A larger scale randomized controlled trial in a similar setting is needed, with close monitoring of treatment integrity and data reliability.
Funding & No Conflicts Declaration
The study was funded by the Novo Nordisk Research Foundation and DIGNITY. The authors declare that they have no competing interests.