Evidence Based Assessment of Pain in Displaced Persons - Case Study 2

Original Editor - Zafer Altunbazel

Top Contributors - Naomi O'Reilly, Jess Bell and Vidya Acharya  

Title[edit | edit source]

Mr A Case Study following a history of displacement and torture

Abstract[edit | edit source]

Mr A has a history of persistent and debilitating pain in his shoulder with significant sleep disturbance following time in detention in his home country, where he experienced torture including being beaten and pushed down stairs.

Key Words[edit | edit source]

Displaced Person, Detention, Torture, Persistent Pain, Sleep Disturbance, Diabetes, Hypertension

Patient Characteristics[edit | edit source]

Mr. A. was referred for rehabilitation for pain and severe limitation at his right shoulder. He was detained in his origin country 5 years ago and subjected to ill-treatment during that period. He was beaten and pushed down from the stairs, fell on his shoulders several times. During the following months after detention he couldn’t receive any treatment for his shoulder and the physical complaints have became worse from day to day. He has became more and more disabled because of his shoulder pain.

He stated that he was diagnosed with gastritis, hypertension and diabetes and he is slightly overweight. He also stated that he is suffering from sleep disturbance since he feels too much pain when he lies on his shoulder.

Examination Findings[edit | edit source]

Physical examination revealed significant loss of active and passive range of motion and weakness at the right shoulder. He was constantly keeping his arm and shoulder in a protective posture and there was sensitivity to palpation all over the shoulder joint. Due to over reaction to palpation and manual testing, proper evaluation couldn’t be done. Active flexion at shoulder was only 40 degrees and there was severe crepitation during the movement.  

He generally had positive expectations from the physiotherapy process. But he was extremely concerned about moving his arm due to fear of pain. His CSI score was below the clinical threshold but he showed high scores in PSQI and TSK. MRI screening was conducted in order to understand the clinical situation better and it showed muscle-tendon tears at supraspinatus and biceps long head as well as Hill-Sachs lesion.

Clinical Hypothesis[edit | edit source]

In the light of the information collected from the evaluation it can be said that while he had significant structural damage and related nociceptive input, his exaggerated reaction to palpation and movement was not compatible with his injuries. Seemingly the main reason behind his disability was fear of pain and movement. So it was essential to address cognitive and behavioural contributors before expecting any improvement in nociceptive contributors. In addition to that he had important co-morbidities such as sleep disturbance, diabetes and hypertension which easily hinder tissue healing and decrease pain threshold. That’s why these problems were also needed to be targeted.