Event 3: Followup

Patient returns to multidisciplinary clinic, two weeks post discharge, with complaint of increasing left knee and lower leg pain. Entire leg is now sensitive to light touch and cold. Does not tolerate a sheet /  blanket at the left knee and left  lower leg. Patient is wearing shorts.

Pain at discharge: 2/10 at rest.

This visit: pain:

  • c/o 8/10 burning pain at rest
  • Leg pain pain worse with touch , cold , weight bearing
  • no relief with current medications

Additional Features to be Incorporated in a Pain Assessment

Provide additional pain assessment to distinguish acute post-surgical pain from persistent neuropathic pain.

  • Full reassessment of pain:  location, quality, duration, what makes it better or worse, tactile allodynia (pain with light touch).
  • Range of motion: Full AROM
  • Temperature of extremity: Left leg is cooler on palpation
  • Weight bearing and gait: Avoids weight bearing on the left and walks with a limp and shortened stance time on the left
  • Functional scale: On the Patient Specific Functional Scale, she reports she is unable to walk 1mile, ride a stationary bike for 15min, climb 1 flight of stairs, participate in gardening for 4 hours, or go out to dinner with her husband
  • Pain with quad contraction

Neuropathic Pain

Neuropathic pain often goes unrecognized and therefore is under-reported being unsuccessfully treated with agents such as non-steroidal anti-inflammatory drugs (NSAIDS) and / or acetaminophen.

Although there is no  “gold standard” or pathognomonic sign or symptom for the diagnosis of neuropathic pain, a focused history and sensory exam can often provide clinicians the critical insight for early recognition and subsequent treatment.

A combination of signs (hypoesthesia, hyper/hypo-algesia, heat / cold hyperalgesia, allodynia) and symptoms (paraesthesias, sensation of burning and/or shooting pain) together with the appropriate clinical context increases the likelihood of a reliable diagnosis of neuropathic pain

“First Line” Pharmacologic therapies for Neuropathic Pain

An evolving list of “first-line” medications have been recommended that include: antidepressants with both norepinephrine and serotonin reuptake inhibition, calcium channel alpha 2 delta ligands (gabapentin and pregabalin) and topical lidocaine.

Given the often difficult job  in effectively managing pain with neuropathic features, a multi-modal / interdisciplinary  approach should be applied to ensure early recognition and  broad treatment including  psychosocial maladies that are critical for long-term success in any treatment plan and goal to improve functional status and overall quality of life.

First-Line Treatments for the Management of Non-Cancer Neuropathic Pain

  • Gabapentinoids (gabapentin / pregabalin)
  • Lidocaine
  • Antidepressants (Includes SRIs, SNRIs, TCAs-amitriptyline)

Post-Surgical Persistent Pain without evidence of nerve injury

Probable Diagnosis

Complex Regional Pain Syndrome (CRPS- type 1)

Formally know as (RSD) Reflex Sympathetic Dystrophy. Sympathetic mediated pain is a clinical impression more than a definitive diagnosis (like headache or backache)

Criteria: pain and autonomic changes usually in absence of demonstrable nerve damage with pain usually in extremity (hand and foot are common) in trans-dermatome distribution; pain is usually burning in quality, often accompanied by diffuse tenderness and pain on light touch

May benefit from early sympathetic blockade plus antineuropathic pain medications but they are not helpful in this case.

Clinic Progress Updates

Patient returns to the multidisciplinary clinic two weeks later, with only mild improvement.

Plan: Patient to continue with current medications and physical therapy plan and Physical Therapy Plan is reinforced.

Reinforce Physical Therapy Plan with Patient

  • Education on Complex Regional Pain Syndromes and physiology of pain
  • Instruction on cardiovascular and conditioning exercises that do not exacerbate the pain
  • Use of mirror feedback for pain free recognition of the affected side
  • Movement with visualization training
  • Pacing of exercise and functional activities to avoid pain and improve function
  • Desensitization to improve touch tolerance  
University of California, San Francisco
University of California, San Francisco