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Dr. D. Love
Dr. D. Love, Doctor
Category: Medical
Satisfied Customers: 17986
Experience:  Family Physician for 10 years; Hospital Medical Director for 10 years.
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My 15 yr old daughter has been experiencing so called, physical

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My 15 yr old daughter has been experiencing 'so called', physical symptoms without any obvious physical cause. This has been over the last 14 months and includes horrendous pain in the base of her left rib initially, that now radiates across the abdomen and her back. It had been disabling enough for the first 11 months, in that she had days when, together with the pain she was unable to walk. At this stage she was always able to move her legs to a greater or lesser degree. However since march 11th 2014 she has been unable to move her legs at all. An MRI of her brain and spine and nerve conductivity tests to her legs were normal. She is currently under a local pain team for 14 months,but there has been no improvement (in fact she has deteriorated). She is a normally a lively highly intelligent teenager who was (before this happened - orthopaedic surgeon diagnosed a healing stress fracture}a National swimmer. Unfortunatately even on good days she is in a wheelchair, and experiences pain. On her bad days she is pretty much confined to a bed as even small movements such as turning over are extremely painful. We (her family and friends) are desperate to help, but feel we have come to a dead end. Her current Paediatric Consultant does not think referral to a Neurologist would create any more answers. Could you please advise?
Submitted: 2 years ago.
Category: Medical
Expert:  Shantal-Mod replied 2 years ago.
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Expert:  Dr. D. Love replied 2 years ago.
Has there been any mental health assessment?

Customer: replied 2 years ago.


Hi,


Yes there has by the clinical psychologists who see and work with her approximately fortnightly, and a CAHMS at the latter end of 2013. The psychologists have not identified any concerns; and are well aware of the potential for serious reactive depression with this unexplained illness. CAHMS also concluded that Kay's mood at times was totally understandable in the circumstances, Most of the time she is incredibly brave and remains reasonably up beat. Obviously there are times when she is very low and cannot see herself coping any longer with the pain. No psychiatric referral has been deemed necessary by the psychologists or CAHMS. I hope this is helpful. Please feel free to ask any other queries you may have.


Thanks,


 

Expert:  Dr. D. Love replied 2 years ago.
Thank you for the additional information.

First, let me provide some background information. Most people understand someone that is paralysed because of an anatomic problem, such as a spinal cord injury. However, there is another possible cause of paralysis that is partly a mental health issue, which can go by various names, but commonly a conversion disorder. A conversion disorder can cause a variety of neurologic symptoms beyond paralysis, such as numbness, blindness, etc. Essentially, any neurologic symptom can occur during a conversion disorder. It is thought to be a manifestation of an anxiety disorder, but it is not completely understood.

So, when faced with a person with paralysis, there are certain medical problems that can cause paralysis, either of the nervous system or the muscles or a systemic illness that affects the nervous system or muscles, but if no medical cause can be identified, then it is appropriate to consider whether there is a conversion disorder causing the symptoms.

Differentiating between a true medical neurologic symptom and a conversion disorder associated symptom can sometime be done by the pattern of symptoms. In a conversion disorder, certain patterns of symptoms will follow the anatomy of a lay person's understanding of anatomy, rather than the true anatomy. For example numbness on one side does not stop directly in the middle of the body, because the nerves from each side overlap in the middle. We also can sometime detect conversion disorder because of certain reflexes that the person does not know to control. For example, I had a patient with blindness, and the Ophthalmologist used rapidly moving items of a certain size to show that the eye was following the items, so could see the items.

This leads to the dilemma in this situation. If it is thought that this is a medical condition that is not yet explained, then it would typically result in consultation with a Neurologist (or another appropriate specialist for the specific symptom). If it is thought that this is not a medical condition, then it would be appropriate to seek further mental health assessment, and a Psychiatrist would be more familiar with a conversion disorder than would be a Psychologist. There also may need to be appropriate communication between the various specialists.

So, at this point, it is appropriate to first pursue an appropriate evaluation for medical causes for the symptoms, and that would mean a consultation with a Neurologist, but if no medical cause can be identified, it would be appropriate to see a Psychiatrist.

If I can provide any further information, please let me know.

Customer: replied 2 years ago.


Hi,


Thank you very much for your reply.


I will endeavour to further explain Kay's symptoms. Kay has no movement in her legs when awake, but occasionally when she is asleep I have witnessed obvious and large movements from her legs. The other night she turned over and placed her right leg over both of mine. her arms were alongside her head. She normally uses her hands to move her legs. She describes periodic numbness to both of her legs, and this is very intermittent and can vary greatly.


She also has hyper sensitivity; for example about a week ago I used some foot cream I had used several times before, however on this particular occasion she couldn't bear the sensation. I quickly removed the cream with cold water.


The pain originally started in her left lower rib area and gradually spread across her abdomen and across her back. This pain can be very debilitating and often leads to several days spent in bed. She has also recently experienced pain down the length of her spine. During these occasions, her spine is so sensitive that even light finger touches are intolerable.


A neuro physiotherapist Kay is now seeing, has identified contraction and relaxation of her quads. She assesses this by placing a hand lightly on the muscle. Therefore any movement accomplished is very subtle.


I have asked Kay's paediatric consultant on several occasions about the idea of her seeing a neurologist. He consistently replies that this was not necessary as her MRI to brain and spine were normal, together with the nerve conductivity tests,


Kays medication currently comprises gabapentim 300 mg three times a day, paracetamol 1 G 4 times aday, naproxen 250 mg 3 times a day and tramadol and oromorph as required.


Although I suggest the neurologist, the consultant disagrees. He has never offered an alternative suggestion. This attitude has been both unhelpful and anxiety provoking. From the information I have provided do you have any further understanding of the cause of this illness?

Expert:  Dr. D. Love replied 2 years ago.
Without being able to examine her, it is difficult to make a better assessment, but if you are saying that the therapist evaluation was that there is more strength in the leg muscles than would be indicated by her use of the muscles, then that would be more suggestive that there is a mental health issue underlying the symptoms.

However, as I noted above, the issue remains that it is either a medical issue, and should be seen by a Neurologist, or a mental health issue, and should be seen by a Psychiatrist. If this therapist evaluation is suggesting that the symptoms are out of proportion to the objective findings, then it would be appropriate to pursue a Psychiatrist evaluation, but I would usually prefer a Neurologist assessment rather than relying solely on a therapist evaluation.

Dr. D. Love, Doctor
Category: Medical
Satisfied Customers: 17986
Experience: Family Physician for 10 years; Hospital Medical Director for 10 years.
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