Candidate. Dr. Gunisha Kaur is an anesthesiologist and medical anthropologist with a background in basic neuroscience research, two decades of fieldwork with torture survivors, and clinical expertise in pain management, an anesthesia sub-specialty. She has spent the past five years conducting research on pain after torture. She has demonstrated that evaluators using only the United Nations Istanbul Protocol (UNIP, global standard for medical assessment of torture survivors) detected and treated pain 16% of the time as compared to a pain specialist (gold standard) who identified pain in 85% of subjects. Her use of a validated pain screen accurately captured all of the pain diagnoses when employed. Dr. Kaur hypothesizes that the novel application in this population of a validated pain screen, similar to those used for posttraumatic stress disorder (PTSD) and major depression (MD), can augment the UNIP and improve its sensitivity for pain from approximately 15% to 90%, as compared to the gold standard. She further proposes an evidence-based somatic pain treatment model, adapted to feedback from torture survivors on acceptability and practicality. Career Development Plan. Dr. Kaur's career goals are to become an independent physician-scientist focused on the diagnosis and treatment of chronic pain in refugee torture survivors. For this training she will: 1. Acquire instruction in quantitative methods of pain research, 2. Gain skills in the conduct of complex, mixed-methods clinical trials, 3. Develop expertise in advanced ethics of clinical research with vulnerable populations. Dr. Kaur will develop these skills through mentorship, coursework, and implementation of her research project. Environment. The proposed research and training will take place at Weill Cornell Medicine through the Weill Cornell Center for Human Rights, one of the most established academic human rights centers in the US. Research. An estimated 87% of torture survivors (27 million people) worldwide suffer chronic somatic pain related to trauma mechanism, such as brachial plexopathy from suspension by upper extremities or lumbosacral plexus injury from leg hyperextension. However, a vast majority of this pain is likely undiagnosed by providers who use only the standard evaluation protocol of torture survivors, the United Nations Istanbul Protocol. Without evidence-based diagnostic tools and treatment guidelines for use by general providers, the complex clinical presentation of torture survivors results in somatic pain being confounded by concurrent psychiatric illness such as PTSD or MD. Rehabilitation from complex trauma is possible, but it requires considering somatic pain a substantial component of pathology.
In Aim 1, a blind comparison to gold standard study with 100 torture survivors will compare the diagnosis of pain using the standard UNIP versus the UNIP with the novel application of a validated pain screen.
Aim 2 will evaluate the acceptability of somatic pain treatment using qualitative interviews with 30 torture survivors.
Aim 3 will assess the feasibility of recruiting and retaining subjects in somatic pain treatment, to inform the design of a subsequent clinical trial.
27 million people worldwide are estimated to suffer chronic somatic pain as a result of systematic torture, which is likely undetected by evaluators due to confounding psychiatric illness and a lack of diagnostic tools. This gap in the detection of pain results in exclusive psychological treatment rather than multimodal therapies, substantially limiting rehabilitation, placing vulnerable individuals at higher risk of drug abuse, and increasing healthcare expenditures. The objectives of this study are to improve the diagnosis of pain in torture survivors (SA 1), to qualitatively characterize acceptability of somatic pain treatment (SA 2), and to assess the feasibility of recruiting and retaining subjects in a subsequent clinical trial (SA 3).