Date of Award


Document Type


Degree Name

Doctor of Philosophy (PhD)


Clinical and Translational Science

First Advisor

Benjamin Littenberg

Second Advisor

Pablo Bose


Physical and emotional trauma are risk factors for the development of chronic pain. The number of traumatic events experienced increases the likelihood of chronic pain. In the US, exposure to violence impacts 50-70% of the population. Globally, trauma from war, civil unrest, and human rights violations has led to record levels of migration. Adding to the trauma of forced migration are reports of mental and physical abuse. Abuse inflicted under the guise of the government or law is considered torture. Many refugees and displaced persons are thought to have suffered from the act of torture, and chronic pain from torture can continue long after the inciting event. We conducted a scoping review to investigate evidence for the physical therapy (PT) management of chronic pain in survivors of torture. Our search yielded 13 sources of evidence. We used competencies outlined by the Physiotherapy Refugees Education Project to categorize the source described PT interventions into themes. Themes included a trauma-informed model of care, pain management, and body-awareness & empowerment. Sources had varying inclusion of these themes. Studies using only one theme resulted in no between group differences. Two trials included all three themes. Outcomes were positive; however, both studies had methodological flaws. We conducted a controlled trial to compare a global, trauma-informed PT approach to a regional, biomedical approach for survivors of trauma who have chronic pain. The trial included 98 participants who were randomized into one of two groups and received the allocated intervention once a week for six weeks. Treatment effects were assessed using linear mixed models. On average, all participants improved regardless of group allocation, and there were no significant between group differences in any of the outcome measures. There were significant interactions between race and intervention. Both interventions were associated with improvements in pain interference for white participants, but non-white participants experienced improvement only with the global, trauma-informed approach. Lastly, we sought to assess the difference in health care costs for those receiving PT for chronic low back pain compared to those who did not receive PT. Using the Vermont Health Care Uniform Reporting Evaluation System, we identified 34,265 beneficiaries with chronic low back pain who received care between 2014 and 2020; 13% received PT. Robust regression models were used to compare 2-year total insurance and beneficiary paid costs by receipt of PT. Adjusted robust regression estimated greater 2-year total costs for individuals who received PT compared to those who did not ($1,931; 95% CI $1584, $2,278; P<0.001). Sub-group analysis examined the effect of age, comorbidity, and insurance type on costs. Those who received PT and used commercial insurance and Medicaid had significantly higher total costs; costs were not different across groups for Medicare recipients. Among older adults, less PT was utilized. Value-based measures are needed to understand the impact of PT care.



Number of Pages

121 p.

Available for download on Friday, July 11, 2025