A 38-year-old female was referred to the outpatient pain service with persistent spinal and widespread pain, along with intermittent episodes of involuntary, thrashing movements of her left arm, and left leg weakness.
The patient completed a pre-appointment pain service questionnaire, which included a range of psychometric scores. She was assessed at her initial appointment by a multidisciplinary team, comprising a pain consultant, a specialist physiotherapist, and a clinical psychologist.
She first experienced low back pain 15+ years ago; it began gradually with an intermittent ache. Her pain had increased in both severity and extent over the past 8 years. Her back pain was now constant and felt in the centre of her back, spreading to both sides and extending up her spine. She also struggled with neck, shoulder and chest wall pain and tenderness, which was constant but worse with movement. Her pain frequently extended up to give her headaches. She described a ‘heaviness’ down her left side, which affected both her arm and leg. She often dropped things so relied on using her right hand for tasks. Her left arm and left leg felt as if it didn’t belong to her. She found her left leg often dragged behind her as she walked. She also described episodes when her left arm would sometimes shake uncontrollably, these would come out of the blue without warning and would last a variable amount of time, sometimes several minutes, often much longer. She had also fallen to the ground during some of these episodes. In recent months, she had to rely on a wheelchair when outside of her home.
Questions:
- Is there any other information you would like to know?
- What is your differential diagnosis?
- What investigations or specialist opinions would you consider?
- How might you explain her symptoms?
- What management options might be useful?
