Case Report: Critique of Neurological Examination Report (23.10.2020)

By SWA

A diagnosis of myalgia was confirmed by UNMH (USA/NM) on 25 May 2016. A preliminary suspicion of Post-Polio Syndrome—later confirmed in the UK on 15 July 2022—had also been overlooked. However, a subsequent neurological evaluation in Germany (September 2020) failed to identify definitive signs of muscle weakness.

The German report, detailing a neurophysiological assessment of a 71-year-old female patient, is methodologically robust. The use of repetitive nerve stimulation, nerve conduction studies, and EMG appears technically competent. However, the interpretative aspects are limited.

The report notes:

“The patient is extremely sensitive to pain, screams loudly with almost every needle movement, but does not abort the examination despite repeated reminders that she can stop the procedure at any time.”

Despite this clear indication of marked pain and cold sensitivity, the report does not explore or contextualize this symptom within the clinical assessment. This is a significant omission, especially in light of emerging research that links post-polio syndrome with sensory processing abnormalities.

See:
Post-Polio Syndrome – Somatosensory Dysfunction and Its Relation to Pain: A Pilot Study with Quantitative Sensory Testing
https://medicaljournalssweden.se/jrm/article/view/26192/46674

1. Methodological Rigor vs. Interpretative Narrowness

While the neurophysiological testing effectively rules out neuromuscular transmission disorders, polyneuropathy, or overt myopathic/neurogenic pathology, the interpretation remains narrowly focused on structural findings. The patient’s pronounced pain response during EMG—arguably the most clinically relevant observation—is dismissed without further analysis.

2. Clinical Oversight

The report mentions the patient’s repeated expressions of pain but treats them as incidental, offering no discussion of possible differential diagnoses. This is not a trivial oversight. Hyperalgesia—whether of central or peripheral origin—is recognized in chronic pain conditions, post-surgical states, and disorders involving central nervous system dysregulation. Given the patient’s history of Chiari malformation with decompression and a prior spinal infection, such a response should have prompted a broader diagnostic consideration.

3. Missed Opportunity for Biopsychosocial Integration

The absence of structural nerve or muscle abnormalities should serve as a springboard for further investigation, not as diagnostic closure. The patient’s response warrants exploration of mechanisms like central sensitization, small fiber neuropathy, or non-structural pain amplification—all of which fall outside standard neurophysiological testing. Even in the absence of psychiatric comorbidities or procedural anxiety (both denied by the patient), other contributors—such as prior medical trauma, psychosocial stressors, or low pain-threshold phenotypes—remain clinically relevant but unaddressed.

4. Implications for Clinical Practice

By not contextualizing the heightened pain response, the report risks reinforcing an outdated binary model of nerve function—i.e., that normal test results equate to absence of pathology. Pain science has long moved beyond this model. The failure to acknowledge functional and centrally mediated pain syndromes may delay diagnosis, impair treatment planning, and erode patient trust in neurological evaluation.

5. Overall Assessment

This case highlights a persistent limitation in clinical neurophysiology: equating normal test outcomes with normal system function. While the technical execution is sound, the failure to incorporate or even hypothesize around the conspicuous pain sensitivity renders the evaluation diagnostically incomplete. A more patient-centered interpretation would consider both structural and functional dynamics—and propose at least a working explanation for the observed hyperalgesia.

Recommendation

Future reports should broaden their clinical scope to include contemporary pain neuroscience and patient-reported symptoms. This means moving beyond narrow electrophysiological parameters and embracing a more integrated, biopsychosocial model—ensuring that significant findings such as hyperalgesia are neither dismissed nor ignored.

Addition: 

Polio and Post-Polio Syndrome (PPS): Summary and Key Insights
https://swaresearch.blogspot.com/2024/12/post-polio-syndrome-pps-summary-and-key.html

Case Report: High Nerve Sensitivity Resulting in Burning Pain During PICC Line Insertion and Electromyography
https://swaresearch.blogspot.com/2025/06/case-report-high-nerve-sensitivity.html

Understanding Cold Hyperalgesia and Cold Allodynia incl. Post-polio syndrome (PPS): Mechanisms, Triggers, and Clinical Relevance
https://swaresearch.blogspot.com/2024/11/understanding-cold-hyperalgesia-and_16.html

© 2000-2025 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right. Library of Congress Card Number: LCN 00-192742

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