Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
Prevalence of pain in the head, back and feet in refugees previously exposed to torture: a ten-year follow-up study.
Olsen DR, Montgomery E, Bojholm S, Foldspang A. Disabil Rehabil. 2007 Jan 30;29(2):163-71.
Quote:
AIM: To estimate change over 10 years concerning the prevalence of pain in the head, back and feet, among previously tortured refugees settled in Denmark, and to compare associations between methods of torture and prevalent pain at baseline and at 10-year follow-up. METHODS: 139 refugees previously exposed to torture in their home country were interviewed at a Danish rehabilitation clinic on average 8 years after their final release from confinement and re-interviewed 10 years later. Interviews focused on history of exposure to physical and mental torture and on pain in the head, back and feet prevalent at study.
RESULTS: The mean number of times imprisoned was 2.5 and the mean cumulative duration of imprisonment 19.4 months. The most frequent physical torture method reported was beating (95.0%) and the main mental torture method deprivation (88.5%). Pain reported at follow-up was strongly associated with pain reported at baseline, and the prevalence of pain increased considerably (pain in the head, 47.5% at baseline and 58.3% at follow-up; back, 48.2% and 75.5%; feet, 23.7% and 63.3%). Predictor patterns at baseline and at follow-up had common traits, so that pain in the head and pain in the feet both were associated with the number of torture methods as well as specific methods, both at baseline and at follow-up. Pain in the back at baseline was associated with torture.
CONCLUSION: Two decades after the torture took place, increasing proportions of survivors seem to suffer from pain associated with the type and bodily focus of the torture. This presents a considerable challenge to future evidence-based development of effective treatment programs
I have seen this twice in the Community health service with some of the refugee population. Truly horrific and x-rays shows plantar fat pad ruptures and multiple old fractures. Apart from a load of counseling, podiatry provided some relief in the form of cushioned insoles, supportive insoles and a friendly smile.
OBJECTIVES: To explore clinical findings in men with chronic pain after falanga torture as compared with controls, and to try to understand the nature of the pain mechanisms responsible.
METHODS: Eleven male torture victims from the Middle East with chronic pain after falanga, and 11 age, sex, and ethnically matched controls with no history of torture were recruited. All participants were interviewed regarding pain characteristics in the feet and lower legs at rest and when walking. Structural changes and motor and sensory function were clinically assessed according to a standardized protocol. The walking pattern was observed for compensatory gait patterns.
RESULTS: The torture victims had pain in their feet and lower legs and a compensated gait pattern, usually with severe pain during walking. Reduced light touch and thermal sensation, tactile dysesthesia, allodynia, and tenderness on palpation were common findings. Structural changes in the feet were found in more than half of the victims, but did not correlate with pain reports. These clinical findings were nonexistent or seen only rarely in controls.
DISCUSSION: We found clear clinical signs of nerve injury in the feet. The sensory findings indicated 2 neuropathic pain mechanisms, one dominated by a peripheral pain generator and other by irritative phenomena (dysesthesia, allodynia), indicating central sensitization. It is reasonable to assume that these changes are due to the falanga exposure. A nociceptive contribution cannot be excluded. It is important to perform an individual diagnostic analysis to facilitate adequate treatment.
You promised me you would never tell anyone what I did in my spare time
Paul Tinley has published a case history paper in the Australian Journal and Evelyn Weir and myself wrote a paper on Falanga for the UK podiatry journal. Here in Perth (WA) there is a Torture Victims Service for migrants and I briefly worked with the physiotherapist on some of her cases. I had a chapter on foot torture at the Curtin University ebook on the history of Shoes (now no longer hosted by the Universty), prior to the beginning of the Iraq War the chapter on Foot Torture was one of the highest hit sites out of the 33 chapters posted. Closer inspection of who was visiting revealed one of the biggest users was the Australian Department of Defense. Further enquiry revealed the web site contained an accumulation of detail not seen anywhere else, and as it was feared 'falanga' would be a torture used on captured personnel> The department were collecting as much data as they could prior to the invasion . In some of the press coverage of the war there was reference to flanaga which many of the political prisoners endured. There were even falanga stocks to hold many prisoners feet so multi beatings could be done.
What follows is a Brief History of Foot Torture (not recommended for the faint hearted).
S&m toeslayer
In earlier times the desire to quell free thought and the need to elicit perceived truth were indistinguishable and achieved, in the main, through the medium of torture. Throughout history the black art of inflicting pain has been ever present but perhaps had its heyday in the middle ages. By the sixteenth century it was plain persuasion by means of pressing which usually ended in death. Whilst this solved one problem by removing the deviant, it was less satisfactory in court cases where confessions and names of accomplices were required. Feet provided a most acceptable alternative. Reasonably easy to inflict excruciating pain with added advantage on not causing death, foot torture became well established in civilised societies and continues to exist to this day. Torture may be described as a form of cruelty or method of tormenting sanction by the State, and executed by duly accredited or appointed officials, through judicial authorities. Torture justifies itself as the most satisfying method of compelling acceptance of dictatorial jurisdiction, by repressing and preventing all attempts to rebel against that authority or the tenets of its creed. In the State, as in the Church, in waging war upon treason on the one hand and heresy on the other torture was admitted to be the most powerful instrument available. Torture and punishment was the primitive law that provided a means for forcing the individual to act contrary to their wishes as well as preventing them from rebelling against the existent rules of the governing body. (Scott, 1995) Whilst torture was never recognised by the common law of England, it was practised with the full authority of the reigning monarchs. Torture was used to extract confession and to obtain evidence but the activities were disguised, euphemised or justified under the name of punishment or as a discipline. The Anglo Saxons were callous and cruel. Judges and executioners of the Middle Ages were compelled to be continually inventing new and more severe forms of torture. The brutal form of punishment practised in one decade became a commonplace method in the next. The principle of public exhibitions involving torture and cruelty may have been an attempt to lessen the incidence of lust, murders and lynching’s. Recorded history indicates witches were persecuted from the time of Noah but it was not until the end of the fifteenth century when Pope Innocent VIII issued a bull which specifically called to exterminate sorcerers and witches as enemies of the Christian religion. Pain was often so extreme the victim was impelled to confess anything which the interrogator might wish. The provisions of the Magna Carta represented torture as abhorrent to the principle of English freedom but for 400 years judicial torture was used and inflicted as a form of punishment. Many brave people tried to put and end to the painful persecution but it took until the nineteenth century to become outlawed. The English renounced judicial torture in 1640 and it was abolished in Scotland in 1708. Frederick the Great abolished torture in Prussia. (1740). The Italians abolished torture in 1786, the French 1789. In Russia it came to an end 1801, in Spain 1812. China acquired a reputation for torture through the ages. Whilst in reality most of this was ill founded and more than likely what ever measures were deployed these were probably learned from so called more civilised countries. In the seventeenth century writers Kia Quen a form of torture which consisted of three pieces of wood connected by rope to the foot and was placed between them, then systematically squeezed until the heel compressed into the foot. Ankle torture was reserved for male culprits and finger torture (Tean Zu) was restricted to females. Bastinado (beating the sole of the foot) was preferred for both sexes and often inflicted with sufficient vigour as to case the victim to die. Falanga (or bastinado) describes a form of foot torture where victims were bound with their feet raised and their soles beaten with sticks (later cables or metal implements). It is thought falanga had its origins in the Turkey. Sometimes blows were direct to bare feet or through shoes. In severe cases, casualties were forced to walk on glass; or jump, on the spot, carrying a heavy weight. The immediate effects are pains, with bleeding and tissue swelling but permanent damaged is dependent on posttraumatic oedema (or swelling). Torturers might limit this, as part of the ordeal, by cooling the feet or forcing the victim to put their shoes on after a beating. Smashing the heel and ball of the foot destroys the natural fatty-fibro padding, which assists shock absorption in normal walking. Depending on the severity of damage this would leave the victim unable to walk without pain. Skin wounds heal by second intention, leaving painful scars. Detachment of the skin at its deeper levels results in damage to proprioception adding considerable to pathological gait. Many victims report aponeuritis where the whole sole of the foot has become painful. Changes in pressure within muscle compartments caused a radical change in walking style. The feet are reported as hot and cold and there is an increase in the rate of perspiration. Stability and balance may also be adversely affected due to falanga. In many regions of the world falanga is still practiced as a form of corporal punishment in bringing up children. In the Middle Ages falanga was a punishment often used on traders who were dishonest. For some reason bakers were particularly singled and this sent shock waves across Europe. In England, bakers attempted to avoid such official scrutiny by making a good will gesture to their customers and supplying a thirteenth role with any dozen purchased. Hence the origins of the bakers dozen. A common misunderstanding was the thirteen, represented the twelve disciples plus Jesus.
Flagellation is the oldest form of punishment. Although this is not always the same as torture, private individuals may use to it to this effect. At one time or another many types of whips rods and cudgels have been employed. Bastinado of the Eastern nations. Historically the Irish were not a nation known to use torture however a preferred punishment mooted out by many Irish terrorists was knee capping, i.e. shooting the victim through the knee. Because this was so commonplace, Belfast orthopaedic surgeons perfected new reconstructive techniques and combined with rehabilitation improved the victim’s chances of walking without a limp. Agents of terror soon changed their modus operandi and shot their victims through the foot instead. The term toe cutter is Australian slang for a person who lives by torturing other criminals, then robbing them. As the name implies the torture usually involves painful removal of the digits or in some cases the complete foot. Few victims ever inform since their loss has been acquired illegally. The first toe cutter was "Jimmie the Pom" and his gang operated in the Sydney area during the seventies. Fellow criminals were threatening bodily harm, until they disclosed the whereabouts of their ill begotten gains. Their modus operandi was to cut people's toes off, with bolt cutters. By day the leader of the extortionists ran a dress shop. He immigrated to Australia in 1967 and claimed to be a member of the notorious Kray Brothers Gang from East London where he picked up the idea. His technique seemed to work because over the years it is reputed the Toe Cutter Gang was able to amass considerable loot from their fiendish toe fetish. Less adept copycats used blowtorches applied to the soles of the feet to achieve the same end.
Torture of the boot was considered by contemporary observers to be most severe and cruel. The alarm caused by the idea of the torture was enough to upset those who witnessed and oversaw the persecution. Orders compelling the number of people required to stay were necessary. Used frequently from sixteenth century well documented. Women were not immune to the torture of the boot The Scots have never been backward when it comes to ingenuity and invention and were at the forefront of niche torture, inventing the boot (bootkins). The cunning device ensured maximum agony but without endangering life in anyway. There were several versions of the boot and all caused excruciating agony. The earlier boot consisted of a frame around the lower leg and foot, similar to those that support young saplings. In a systematic way increasing the tension to the tissues by driving wooden wedges into the framework caused compression of soft tissue and crushing to the legs and feet. Later the wooden frame was replaced with an iron boot. Wedges were driven downward between the boot and flesh causing pure agony. The Royals would frequently visit the torture sessions and considered them as entertainment. The boot was often reserved for suspected practitioners of the occult with many accused witches and warlocks forced to endure foot torture. Sometimes the boot was heated until red hot during interrogation a reference to this practice is found in Grimm's fairytales. The victims were often kept trussed up for weeks, usually naked and in extreme cold and damp conditions before confessions were secured. The caspicaws (or cashielawis meaning warm hose) was notorious as the Spanish Boot. The Spanish Boot was an iron casing for the leg and foot which had a screw attachment for compressing the calf of the leg. Sometimes the leggings were applied to the leg then heated or pre heated before application. The advantage of the former method was questions could be asked before applying heat, otherwise damages was so immediate by the latter , there was little advantage to the interrogator and the threat of application was the greatest and often the treat of last resort. High boots made of spongy leather were placed on the legs of the victim and then placed in front of a burning fire. Boiling water was poured into the boots penetrating the leather, subsequent shrinkage tore at the flesh. Brodequins described another type of torture where the victim was seated on a strong bench, and boards of suitable width and length were placed on the inside and outside of each leg, and tightly bound in position with strong rope, the two legs in their casing being fixed together. Wedges of wood or metal were driven with a mallet between the centre boards. Four wedges were used for ordinary torture and eight wedges in what was termed extraordinary torture. As the chords bit through the flesh it caused excruciating pain. In many case the bones were fractured. This type of boot was used exclusively in Scotland in the seventeenth century An other modification on the boot was to encase the victim's legs in crude stockings, made from parchment. Applied wet, the victims were placed next to a fire with and when the fabrics shrunk the ensuing pain was agonising. The French version of the boot required victims to be forced into high boots made of thick spongy leather. Quantities of scalding hot water were poured into the watertight boots causing the flesh to cook. The Irish customised the boot and modified the French practice by pouring melted resin into the boots. Confessions were swift. The Spanish and Austria Hungarian Empire used both crusher boots with wedges as well as the iron boot. Later variations on the basic boot theme included shin crushers from Germany and bone crushing tongs from Spain and the iron slipper was used by the Lisbon Inquisition (1704). Often the implement of torture was applied red hot and placed on the naked foot. (Scott G R 1995) Boots and other instruments of torture were in constant use (seventeenth century) the boots were used in the persecution of witches. It was rare for anyone to survive the ordeal without permanent disfigurement.
The Indians used an implement called the Kittee. It was made of wood and resembled a domestic lemon squeezer. Sensitive parts pf the body including the feet were squeezed between two plates until the victim could bare it no more. When applied to the foot, the executioner would stand on the upper board or heap heavy stones leaving the victim for hours at a stretch. Torture by the kittee usually left the victim crippled. A bizarre torture practiced in Medieval France called for the victim to tied to a bench and their feet bathed in salt water. A goat was brought to the poor unfortunate prisoner and allowed to lick their feet. The rough tongue to the sensitive soles of the feet, plus the fear of being bitten by the goat soon brought a confession. In the days of the British Empire when the armies were stationed in the outposts living in tented camps, spiked tent pegs provided an elementary but effective form of punishment. The technique was called the Piquet or Picket. A long post was driven into the ground and the soldier left to stand on a stool beside it. His right hand was attached to a hook at the top of the post. A short length of timber was driven into the ground near the stool, its upper end rounded to a blunt point. The soldier had to rest one heel on the stake when the stool was removed. Suspended from one wrist with his weight pressing on the spike into his bare heel, the most unruly private learnt the error of his ways especially when, after fifteen minutes, the position would be reversed. This torture was almost exclusive to the military but there was one case reported in Trinidad (1801) where young women had to undergo a modified form of picket where her big toe was balanced on a sharp spike in the ground as she was suspended from the wrists.
Bibliography
Abbott G 1997 Rack, rope and hot pincer: a history of tortuture and its instruments London: Brockhampton Press
Read MB 1991 Chopper: from the inside NSW: Sly Ink
Scott GR 1995 A history of torture London: Senate
Diagnostic accuracy of heel pad palpation - A phantom study.
Torp-Pedersen ST, Matteoli S, Wilhjelm JE, Amris K, Bech JI, Christensen R, Danneskiold-Samsøe B. J Forensic Leg Med. 2008 Oct;15(7):437-442
Quote:
Falanga torture involves repetitive blunt trauma to the soles of the feet and typically leaves few detectable changes. Reduced elasticity in the heel pads has been reported as characteristic sequelae and palpatory testing of heel pad elasticity is therefore part of medicolegal assessment of alleged torture victims. The goal was to test the accuracy of two experienced investigators in determining whether a heel pad model was soft, medium or hard. The skin-to-bone distance in the models varied within the human range.
METHOD: Two blinded investigators independently palpated nine different heel pad models with three different elasticities combined with three different skin-to-bone distances in five consecutive trials and categorized the models as soft, medium or hard.
RESULTS: Two experienced investigators were able to identify three known elasticities correctly in approximately two thirds of the cases. The skin-to-bone distance affected the accuracy.
CONCLUSION: The use of clinical examination in documenting alleged exposure to torture warrants a high diagnostic accuracy of the applied tests. The study implies that palpatory testing of the human heel pad may not meet this demand. It is therefore recommended that a device able to perform an accurate measurement of the viscous-elastic properties of the heel pad be developed.
Thanks for the posting Newsbot. One of the many surprising things I discovered when I was researching the topic was that GPs were (then) generally unaware of falanga and failed to diagnosis the aftermath of foot torture. Falanga and bastinado (which is more associated with S&M) are still frequently used as corporal punishment or pleasure respectively. The practice is based in Middle Eastern culture and not considered cruel or demeaning purse. Foot beating is also a pernicious torture which continues to be prevalent.
Clinical performance diagnosing alleged exposure to falanga--a phantom study.
Top-Pedersen ST, Matteoli S, Wilhjelm JE, Amris K, Bech JI, Christensen R, Danneskiold-Samsøe B. Torture. 2009;19(1):19-26.
Quote:
BACKGROUND: Falanga torture involves repetitive blunt trauma to the soles of the feet and typically leaves few detectable changes. Reduced elasticity in the heel pads has been reported as characteristic sequelae and palpatory testing of heel pad elasticity is therefore part of medicolegal assessment of alleged torture victims.
OBJECTIVE: The goal was to test the accuracy of two experienced investigators in determining whether a heel pad model was soft, medium or hard. The skin-to-bone distance in the models varied within the human range.
METHOD: Two blinded investigators independently palpated nine different heel pad models with three different elasticities combined with three different skin-to-bone distances in five consecutive trials and categorized the models as soft, medium or hard.
RESULTS: Two experienced investigators were able to identify three known elasticities correctly in approximately two thirds of the cases. The skin-to-bone distance affected the accuracy.
CONCLUSION: The use of clinical examination in documenting alleged exposure to torture warrants a high diagnostic accuracy of the applied tests. The study implies that palpatory testing of the human heel pad may not meet this demand. It is therefore recommended that a device able to perform an accurate measurement of the viscous-elastic properties of the heel pad be developed.
The latest issue of Torture has the full text as pdf's of these papers:
Vascular response to ischemia in the feet of falanga torture victims and normal controls--color and spectral Doppler findings.
Torp-Pedersen S, Amris K, Holm CC, Kønig M, Prip K, Danneskiold-Samsøe B. Torture. 2009;19(1):12-8.
Quote:
OBJECTIVE: To investigate whether signs of chronic compartment syndrome could be found in plantar muscles of falanga torture victims with painful feet and impaired gait. The hypothesis was that the muscular vascular response to two minutes ischemia would be decreased in torture victims compared to controls. On color Doppler this would be seen as less color after ischemia and on spectral Doppler as elevated resistive index (RI).
METHODS: Ten male torture victims from the Middle East and nine age, sex and ethnically matched controls underwent Doppler examination of the abductor hallucis and flexor digitorum brevis muscles before and after two minutes ischemia induced with a pressure cuff over the malleoli. The color Doppler findings were quantified with the color fraction (CF) before and after ischemia. On spectral Doppler the resistive index was measured once before and three consecutive times after ischemia.
RESULTS: Both torture victims and controls responded to ischemia with an increased CF. There was no difference between torture victims and controls. With spectral Doppler all subjects had an RI of 1.0 before ischemia. After ischemia, in nearly all subjects and all muscles the first RI was lowest, the second was higher and the third was highest indicating that the response to ischemia was disappearing as measurements were made. There was a trend that the first RI was higher in torture victims than in controls.
DISCUSSION: The study was not able to confirm the presence of chronic compartment syndrome. However, the trend in RI still supports the hypothesis. The negative findings may be due to inadequate design where the CF and RI were measured in one setting, perhaps resulting in both methods being applied imperfectly. The response to ischemia seems short-lived and we suggest that the Doppler methods may be re-evaluated with separate ischemic phases for CF and RI.
Clinical performance diagnosing alleged exposure to falanga--a phantom study.
Top-Pedersen ST, Matteoli S, Wilhjelm JE, Amris K, Bech JI, Christensen R, Danneskiold-Samsøe B. Torture. 2009;19(1):19-26.
Quote:
BACKGROUND: Falanga torture involves repetitive blunt trauma to the soles of the feet and typically leaves few detectable changes. Reduced elasticity in the heel pads has been reported as characteristic sequelae and palpatory testing of heel pad elasticity is therefore part of medicolegal assessment of alleged torture victims. OBJECTIVE: The goal was to test the accuracy of two experienced investigators in determining whether a heel pad model was soft, medium or hard. The skin-to-bone distance in the models varied within the human range.
METHOD: Two blinded investigators independently palpated nine different heel pad models with three different elasticities combined with three different skin-to-bone distances in five consecutive trials and categorized the models as soft, medium or hard.
RESULTS: Two experienced investigators were able to identify three known elasticities correctly in approximately two thirds of the cases. The skin-to-bone distance affected the accuracy.
CONCLUSION: The use of clinical examination in documenting alleged exposure to torture warrants a high diagnostic accuracy of the applied tests. The study implies that palpatory testing of the human heel pad may not meet this demand. It is therefore recommended that a device able to perform an accurate measurement of the viscous-elastic properties of the heel pad be developed.
The epidemiology of falanga--incidence among Swedish asylum seekers.
Edston E. Torture. 2009;19(1):27-32.
Quote:
Falanga (falaka), beating of the soles, is commonly reported by torture survivors. It is known to be used in many countries and regions where torture practice is endemic. In this study 131 torture victims were examined at the Kris and Trauma Centrum [KTC]of Stockholm. Falanga was reported in 45 % of the cases. It was most commonly found among Bangladeshian and Syrian patients but was also reported from all Middle Eastern countries and Northern Africa. Scars and/or pigmentations on the feet and/or lower legs as well as palpable soft tissue irregularities were seen in 82% of the patients reporting falanga, of which 36% had scars or pigmentations in the soles. Persistent pain and tenderness of feet and lower legs were reported in 48%. The signs and symptoms were highly significant when compared with a control group who had not received falanga [p<0.0001].
Long-term consequences of falanga torture--what do we know and what do we need to know?
Amris K, Top-Pedersen ST, Rasmussen OV. Torture. 2009;19(1):33-40.
Quote:
The long-term consequences of falanga are probably the best described consequences of exposure to specific forms of physical torture. Theories about casual lesions in the peripheral tissues of the feet have been put forward based on clinical observations along with international guidelines for the clinical assessment, but still knowledge is needed in several areas. A review of the literature on falanga is presented, mainly focusing on the clinical aspects and possible lesions caused by this specific form of torture that may influence the overall management of the condition. Finally, the article closes with a call for future research, which is needed in order to advance a knowledge-based development of the applied clinical practice.
The diagnostic value of clinical examination after falanga--a pilot validation study.
Amris K, Rasmussen OV, Baykal T, Lök V. Torture. 2009;19(1):5-11.
Quote:
Medico-legal documentation of alleged exposure to falanga torture warrants a high diagnostic accuracy of the applied clinical tests. The objective of this study was to establish data on the validity of palpatory examination of the footpads and the plantar fascia and to assess the distribution of observations among selected cases and non-cases in a small study sample. Calculated estimates of sensitivity and specificity of the individual diagnostic tests are reported and, in general, did not meet the authority-based criteria of an 80% cut-off point. The observed total number of true tests in this study was 65 %. It is concluded that future studies of the reliability of clinical examination and assessment of the variability of observations among unselected cases and non-cases should be conducted in a larger cross-sectional study population.
Falanga - foot pain following torture
Linear Mode
