Antonia presented with knee pain for 35 years, nasty light touch allodynia and a love of Facebook games and when she got stuck into Recognise Online it resulted in a very gratifying and challenging clinical experience. Antonia’s knee pain and activity tolerance is now the best it has been since she underwent an open menisectomy and follow-up MUA all those years ago. And she no longer has the light touch allodynia.
Antonia (68yrs) did not have CRPS but she did describe intermittent formication, occasional spontaneous pains, constant aching and pain with all active and passive movement. She also described what sounded like mechanical locking of the knee. The weight-bearing x-ray made enough mention of OA for her to be triaged to my OA assessment clinic. The weight bearing x-ray OA changes were perhaps Kellgren-Lawrence Grade 2, mild.
When I initially assessed her she rated her worst pain 72/100mm on a VAS; and at the time of the assessment (10am) she rated it at 49/100; she said the knee was always stiff. The pain was a bit better in the morning and was worst in the evening. Any movement of her knee was painful and she described severe light touch allodynia; even the lightest of touches was painful. Stroking a facial tissue across the skin over the medial and lateral knee produced a grimace and withdrawal reaction; over the scar it was worse. She rated the punctate touch of a No 4.46 Semmes-Weinstein Monofilament over the lateral and medial skin as 5/10 on a 0-10 Borg rating scale (on the left knee she rated it as 0.5). Interestingly punctate touch over the scare was numb but dynamic touch was severely painful. A straight leg raise did not provoke her pain and there was no lumbar or hip pain referral. There were no temperature changes, nor abnormal skin quality. The knee looked ‘normal’, apart from the scar. She did not satisfy the criteria for CRPS. I was not able to assess TPD as the skin was too allodynic to the light touch required.
Left right discrimination scores on Recognise
Antonia had far from fluent spoken English but her comprehension was quite good; she loved playing games on Facebook and so I thought she may be able to use Recognise Online so I assessed her left/right judgement accuracy and speed. She was able to correctly identify the image of a left foot 40% of the time, in 2.8 seconds and correctly identify a right foot image 53% of the time, in 1.9 seconds. I explained the rationale for using Recognise and gave her the log in codes; I was not all that hopeful about how she would go.
The top image is the L (orange) and R (green) accuracy. The bottom image is the speed responses with a trend line showing an increase in speed over time from 2 seconds to 1.4 seconds.Signs of improvement after much hard work
When I reviewed her a month later she said her pain was much the same; but using stairs was easier. She struggled for three weeks with identifying the contralateral foot; consistently ranging in the 40-60% correct; decision speed reduced to the 1.4-1.6 second range. The online display of the months accuracy results was impressive; she had done lots of sessions; see the attached graph; a clear difference between the sides. Her evening pain was unchanged but at 10am she rated it at 0/100mm and the light touch allodynia had also improved; rating at 3 compared to 5/10 a month previously.
After a further two weeks she rated her worst pain at 17/100mm and the pain at the time of the assessment at 4/100mm. Light touch stimulation was normal; the same on both knees (except for the scar which remained quite sensitive). The knee was no longer stiff; active, passive and imagined movement was pain free. No locking, formication or spontaneous pains. The knee pain no longer limited her walking tolerance. The knee was the best it had been since the arthrotomy 35 years before. L/R% and speeds had improved to normal values.
I suggested that she continue with the Recognise online; and perhaps also do the more difficult ‘Context’ and ‘Abstract’ images. I also toyed with the idea of adding in some touch discrimination training but decided not to. The daughter said she had spent 35 years telling her husband not to touch her knee; so now to ask him to touch it might be a bit too much.
I reviewed her again after a further three weeks; 5 days after her Recognise account expired; and the gains had been maintained; the maximum VAS rating during the previous week was 4/100mm. Including the very first appointment, she had had five sessions in 11 weeks.
Is this a clear example of the protective power of pain? Compared to all people I have assessed who had an open arthrotomy/menisectomy 20-30 years ago Antonia’s knee was very well preserved; all the others have been candidates for an arthroplasty. The pain had limited her to light house work; she had done no heavy lifting; squatting or excessive loading of the knee in all that time.
When I looked at the Recognise online results in detail I counted up her sessions in the first five days and she had made over 8,700 laterality decisions!!!! She kept up that intensity for the next four weeks; and it was only after three to four weeks that she began to notice a change in symptoms.