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

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.