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Summary:

Introduction : Sequelae of violence are often difficult to detect behind simple somatic complaints. Physiotherapy may play a major role in the management of victims of violence, enabling the caregiver to get round the patient's reluctance to recall a traumatic event. Material and method : A systematic violence screening was conducted on a number of asylum seekers attributed to the canton of Geneva between May 1993 and February 1994. Within the framework of a new global program of rehabilitation, adapted physiotherapy was proposed to a portion of patients who had experienced a traumatic event linked to violence. Results : Out of 572 asylum seekers, two thirds presented an history of exposure to violence, 37 % expressed somatic complaints and 27 % psychological complaints. These complaints were linked to allegations of violence for 35 % of the asylum seekers vs 17 % with no history of violence. Out of another group of 76 refugees evaluated by a psychologist, and who had all been exposed to violence, 56 suffered from psychological disorders, of which 41 required therapy. In a third group of 82 victims of violence, it was the locomotor system that was most often affected and had justified the first consultation. With regard to the physiotherapeutic management of victims, a systematic assessment of this approach is presently being conducted. In this article, only preliminary results, as well as the arguments that may justify such an approach, are presented.

Discussion : The diagnosis being frequently delayed by a communication barrier, the physiotherapist, in initiating the treatment, should consider the sequelae of violence simultaneously from a biomechanical and a psychological standpoint. The link between psychological and somatic complaints is the most specific aspect of a physiotherapy that is adapted to victims of violence. First developed for victims of torture, this type of physiotherapy could be extended to all forms of violence. By treating the "body memory", it facilitates the psychological approach, may reduce the somatic stress reactions and helps restore the necessary trust through the benefic contact of the other's hand.

Introduction
Sequels of violence are often difficult to detect behind simple somatic complaints. Patients, afraid to stir painful memories or blocked by feelings of shame and guilt, may feel reluctant to recall traumatic events. On the other hand, the caregiver's unawareness of the problem, a lack of specific knowledge on the medical aspects of violence and his/her own reluctance to tackle such painful questions, may delay the diagnosis. Finally, in the context of migration, language and cultural barriers, social and legal difficulties, hinder communication, delaying the establishment of an appropriate treatment. Physiotherapy may play a major role in the management of victims of violence, enabling the caregiver to get around these barriers, providing a soft and indirect approach to the patient's traumatic experience.

Material and method
A systematic screening for violence sequels is conducted on all asylum seekers attributed to the canton of Geneva. The answers to the screening questionnaire presented between May 1993 and February 1994, have been analysed. For validation of this questionnaire, 76 patients underwent a psychological evaluation. In addition, 82 forensic reports documenting torture victims were analysed. Within the framework of a new global program of rehabilitation, adapted physiotherapy, was proposed to patients who had experienced a violent traumatic event.

Results
Out of 572 asylum seekers, 61 % presented a history of exposure to violence and 18 % allegations of torture ; 37 % expressed somatic complaints and 27 % psychological complaints. These complaints were linked to allegations of violence for 35 % of the asylum seekers versus 17 % with no history of violence. Out of another group of 76 refugees evaluated by a psychologist, and who had all been exposed to violence, 56 suffered from psychological disorders, of which 41 required therapy. In the group of 82 victims of torture, the locomotor system was most often affected ; complaints and injuries concerning this system justified the first consultation in most of these cases. More than 80 patients were referred for physiotherapy in 1997. A systematic assessment of the physiotherapeutic management of these victims is presently being conducted. In this article, only the preliminary results as well as the arguments that may justify such an approach are presented.

Discussion
The direct causal links between the type of violence and the somatic sequels are often unknown. The origin of the complaints and the cause of the clinical signs remain therefore unsuspected if the patient remains silent. In front of unclear clinical presentations, the practitioner should bare in mind the possibility of past or present violence and ask about mistreatment. Chronic headache, temporo-mandibular dysfunction, whiplash syndrome, may be caused by blows to the head. Lesions of the scapular belt may follow long period of suspension by the arms or wrists. Lumbar or pelvic injuries may be the result of blows to the back, long term confinement in small cells, coercion to maintain painful positions or sexual abuse. The patients complaints and symptoms form a body language that should be deciphered. Understanding this indirect mean of expression may strengthen the confidence in the practitioners skills and capacity to cope with the situation, and spare the patient a painful recollection of traumatic events, lowering the risk of secondary traumatization. The tight link between psychological and somatic complaints is the most specific aspect of physiotherapy adapted to victims of violence. The physiotherapist, in initiating the treatment, should therefore consider the sequels of violence simultaneously from a bio-mechanical and a psychological standpoint. Particular attention should be given to a full therapeutic alliance based on empathy, on comprehension of the patient's fears and anxiety, on prevention of PTSD symptoms'revival (flash-back, reminiscences), on respect of the patients rights to decide for himself (explanation and discussion of treatment, and freedom in the choice of method). Above all, the physiotherapist should avoid techniques that may be painful or may recall torture methods. In the short range physiotherapy may provide quick pain relief, in the long range the treatment may restore physical functions and autonomy.

Conclusion
By treating the "body memory", physiotherapy facilitates the psychological approach, may reduce the somatic stress reactions and help restore the necessary "basic trust" through the beneficial contact of the other's hand used to provide relief and not to inflict pain. First developed for victims of torture, this type of physiotherapy could be extended to the treatment of all forms of violence.