Evidence-informed clinical decision-making for lower extremity hyperalgesia and allodynia in a 42 year-old woman presenting with low back pain-a case report

M. Nagarajan, P. Vijayakumar

    Research output: Contribution to journalArticle

    2 Citations (Scopus)

    Abstract

    Pain with spinal cord injured patient remains difficult to understand, diagnose and treat. The presence of peripheral disorders and other (supraspinal) central nervous system pathologies always increases the complexity of clinical manifestations related to pain in patients with persistent spinal cord pathology. It is a clinician's most important responsibility to determine the underlying causes of the patient's symptoms with differential assessment based on sound multidimensional clinical reasoning that is informed by appropriate evidence. The aim of this case report is to describe the importance of implicating available evidence in clinical decision making in a patient, referred for physiotherapy, with left lower quarter hyperalgesia and allodynia and multiple central nervous system disorders associated with spinal, peripheral musculoskeletal disorders and maladaptive psychosocial behaviour. This patient had a past medical history of cervical spine myelomalacia and right parietal lobe epilepsy. During routine musculoskeletal evaluation, we found Grade I spondylolisthesis (L5-S1 level) and a symptom (skin warming) suggestive of mild type-I complex regional pain syndrome (CRPS 1). She also presented with significant positive psychosocial illness. To confirm the predominant causative mechanisms of on-going pain, an evidence search was carried out and correlated with 'diagnostic' clinical reasoning. The evidence search provided accurate validation of all clinical and evaluation findings. In this way clinical decision making regarding the predominant underlying cause for her pain and disability was facilitated. This then helped propose a realistic prognosis as well as a plan for specific physiotherapy intervention and on-going medical management. This case is an example of the vital role and importance of utilising valid evidence for mechanism-based pain diagnosis and treatment in physiotherapy practice.

    Original languageEnglish
    Pages (from-to)64-76
    Number of pages13
    JournalJournal of Physical Therapy
    Volume2
    Issue number2
    Publication statusPublished - 2010

    Fingerprint

    Hyperalgesia
    Low Back Pain
    Lower Extremity
    Pain
    Spinal Cord
    Pathology
    Reflex Sympathetic Dystrophy
    Spondylolisthesis
    Parietal Lobe
    Central Nervous System Diseases
    Epilepsy
    Spine
    Central Nervous System
    Clinical Decision-Making
    Skin

    Keywords

    • Allodynia
    • Clinical decision making
    • Evidence-based pain diagnosis
    • Hyperalgesia
    • Neuropathic pain

    ASJC Scopus subject areas

    • Rehabilitation
    • Physical Therapy, Sports Therapy and Rehabilitation

    Cite this

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    abstract = "Pain with spinal cord injured patient remains difficult to understand, diagnose and treat. The presence of peripheral disorders and other (supraspinal) central nervous system pathologies always increases the complexity of clinical manifestations related to pain in patients with persistent spinal cord pathology. It is a clinician's most important responsibility to determine the underlying causes of the patient's symptoms with differential assessment based on sound multidimensional clinical reasoning that is informed by appropriate evidence. The aim of this case report is to describe the importance of implicating available evidence in clinical decision making in a patient, referred for physiotherapy, with left lower quarter hyperalgesia and allodynia and multiple central nervous system disorders associated with spinal, peripheral musculoskeletal disorders and maladaptive psychosocial behaviour. This patient had a past medical history of cervical spine myelomalacia and right parietal lobe epilepsy. During routine musculoskeletal evaluation, we found Grade I spondylolisthesis (L5-S1 level) and a symptom (skin warming) suggestive of mild type-I complex regional pain syndrome (CRPS 1). She also presented with significant positive psychosocial illness. To confirm the predominant causative mechanisms of on-going pain, an evidence search was carried out and correlated with 'diagnostic' clinical reasoning. The evidence search provided accurate validation of all clinical and evaluation findings. In this way clinical decision making regarding the predominant underlying cause for her pain and disability was facilitated. This then helped propose a realistic prognosis as well as a plan for specific physiotherapy intervention and on-going medical management. This case is an example of the vital role and importance of utilising valid evidence for mechanism-based pain diagnosis and treatment in physiotherapy practice.",
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