Therapeutic scarification, shadow pain, and integrative geriatric rehabilitation for chronic musculoskeletal pain in older adults in Cameroon: a prospective mixed-methods observational study.

BACKGROUND: In sub-Saharan Africa, the coexistence of conventional medicine and traditional healing practices creates a complex therapeutic landscape that disproportionately affects older adults. Therapeutic scarification-cutaneous incisions performed on painful body areas-remains one of the most widespread traditional approaches to chronic pain management. Its geriatric-specific complications and functional consequences remain poorly documented. With a projected 67% increase in the population aged over 60 in Cameroon by 2030 and fewer than 15% of older adults benefiting from effective social coverage, this represents a major public health priority.

OBJECTIVE: To analyze the prevalence, typology, and geriatric-specific complications of therapeutic scarification among older adults with chronic musculoskeletal pain in Cameroon, and to evaluate the preliminary effectiveness of a culturally integrative physiotherapy approach bridging traditional and conventional medicine.

METHODS: A prospective single-center mixed-methods observational study was conducted from February 2023 to May 2025 at Bafoussam Regional Hospital. Patients aged ≥65 years with chronic articular pain (≥6 months) and documented history of therapeutic scarification were included. The quantitative component involved standardized clinical assessment and statistical analysis; the qualitative component comprised semi-structured interviews (n = 92, 30-45 min) analyzed thematically following Braun and Clarke's framework (kappa = 0.78). A culturally adapted integrative physiotherapy protocol over 16 sessions was implemented, with follow-up of 6-18 months.

RESULTS: Ninety-two patients were enrolled (mean age 73.1 ± 8.4 years; 60 women, 65.2%). Four scarification modalities were identified: parallel linear (63.0%), punctiform (20.7%), deep cruciform (12.0%), micro-scarification with cupping (4.3%). Knee osteoarthritis predominated (44.6%). Complications included infections (15.2%), keloids (34.8%), and proprioceptive impairment (35.9%) associated with a 29% increase in relative fall risk (p < 0.01). A significant age-complication gradient was observed (OR = 4.9 for >75 vs. 65-70 years; p = 0.032). Education level was inversely correlated with scarification frequency (r = -0.67; p < 0.001). Among 68 patients receiving the integrative approach, 73.5% reduced scarification use (p < 0.001), with significant functional improvements and 89.7% patient satisfaction. Five qualitative themes of adherence drivers were identified.

CONCLUSION: Therapeutic scarification exposes older adults to preventable geriatric complications, including a previously unrecognized fall risk from proprioceptive disruption. The "shadow pain" mechanism-transient nociceptive inhibition by iatrogenic pain-offers a novel neurophysiological explanation for treatment adherence. The culturally integrative rehabilitation model achieved preliminary effectiveness supporting development of context-sensitive geriatric care strategies in low-resource settings. Randomized controlled trials are needed to confirm these findings.