Evidence Based Assessment of Pain in Displaced Persons - Case Study 1

Original Editor - Zafer Altunbazel

Top Contributors - Naomi O'Reilly, Jess Bell and Kirenga Bamurange Liliane  

Title[edit | edit source]

Mr. S Case Study following a history of displacement and torture

Abstract[edit | edit source]

Mr S has a history of persistent and debilitating pain and PTSD following a gun shot wound to the hip 4 years ago that was treated in a military field based hospital and was followed by a period of time in prison where he was subjected to torture.

Keywords[edit | edit source]

Displaced Person,, Conflict, Bullet wound, Complex Injury, Prison, Torture, PTSD, Persistent Pain

Patient History and Characteristics[edit | edit source]

Mr. S. was referred to physiotherapy for debilitating pain at his left calf, ankle and foot. His complaints started 4 years ago after he was shot from his hip. The bullet followed a diagonal track and fragmentised in his lower abdomen. He was operated in a military hospital and put into prison where he was subjected to torture after his medical treatment. The pain below his knee started those days and worsened gradually until today. The pain had constant sharp, burning character and increased with movement and standing. He was also suffering from regular face pain and headaches.

He didn’t have any communicable or non-communicable disease but was suffering from insomnia and PTSD symptoms as well as anxiety. He had positive expectations about physiotherapy but stated that he was extremely concerned and tired because of his pain. His CSI score was above the clinical threshold.

Examination Findings[edit | edit source]

Physical examination revealed sensitivity to palpation at lower abdominal area and below the knee. Hyperalgesia and allodynia were present below the knee. He didn’t have any loss of ROM or muscle strength in both extremities but he had pale skin and hair loss at left foot and ankle. Interestingly, neural tension tests didn’t provoke his pain. Physical evaluation for tension type headache and cervicogenic headache was negative.

He was referred for advanced screening but EMG and doppler-ultrasound didn’t show any abnormality in nerve conduction or circulation. MRI did not show any neurological finding can be related with headache. But a second referral to orthopaedist revealed a fracture in his nose remained from prison days and it was the probable cause of head and face pain.

Clinical Hypothesis[edit | edit source]

Based on the collected information and findings, it was difficult to establish a clear hypothesis but nervous system dysfunction appeared to be main driver of the pain. A neurovascular compromise due to gunshot wound might have caused neuropathic pain and through the time it might have triggered central sensitization with the contribution of PTSD symptoms and constant headaches.