Case of the Month #13: Persistent pain following total knee replacement

What would be your management plan?
A holistic biopsychosocial approach was adopted to help Mrs B.  This included:

1.    An explanation to Mrs B regarding persistent pain following total knee replacement surgery.  In particular, how pain can persist even when the prosthesis has been placed appropriately and there is no underlying infection process.  Moreover, an explanation of how mechanically, walking with a painful knee leads to an increased risk o mechanical back pain and how this in turn can then contribute to further pain down the leg into the knee. 
2.    Engaging with a specialist pain physiotherapist, using a combination of education, in particular on the concepts of pain science, pacing, goal setting, core strengthening exercises. Also considered use of TENS and acupuncture treatment and learning to walk with two sticks which helped to improve posture and reduce referred and radicular pain from the back  this had a considerable impact on her level of function and pain. 
3.    Assessment with an occupational therapist who arranged for a social services assessment to improve facilities at home to allow Mrs B and her husband to remain as independent as possible. She also put Mrs B in touch with Age Concern who in turn helped with a befriending service to help reduce their social isolation and reliance on neighbours.
4.    Assessment by a clinical psychologist, who using an acceptance and commitment therapy approach, helped Mrs B come to terms with the failed expectations of a painless surgical fix following the knee replacement.  She helped to address the rumination and sense of helplessness that Mrs B had developed over the years and the pain catastrophisation score reduced significantly.
5.    Review of medication.  Mrs B was discouraged from using Ibuprofen after an explanation that in her age group risks of precipitating renal impairment and a gastric bleed were not insignificant.  With physiotherapy and finding TENS and application of heat also useful, Mrs B became less reliant on Co-Codamol.
6.    A genicular nerve block was discussed during her initial consultation, but her level of improvement was such that it was mutually agreed to leave this in reserve should her pain levels became unmanageable once again.
7.    Mrs B was discharged from the pain service approximately a year following her first attendance, with an improvement in both her physical and mental well being and coping skills.