The Pain Torturer

[ebusch19]

I have a 58 year old woman that I have been working with since November for chronic right ankle sprain that happened in September last year from a fall. Initially she was very loading intolerant and had a lot of pain with walking, standing longer durations and with going down>going up stairs. She had allodynia in her lateral ankle and hyperalgesia in her lower leg with light pressure, but was able to tolerate Gr I/II ankle mobilizations to her TC and distal TF joints. I started off working a lot on manual with Gr I/II mobilizations then progressing to Gr III/IV to work on DF ROM since that was limited. I worked on gradual loading with her exercises and incorporated ankle mobilization with movement on the stair. We were making good progress, she was reporting that she was able to stand and walk longer with less pain and going up>down stairs was improving. She was able to step up and down an 8 inch step with 1 UE support with mild discomfort. Then the holidays hit and her pain started to get bad again to the point she could not do a step up/down on the 8 inch step due to her pain. I got her in on my schedule with AJ since I felt like we hit a wall and regressed with her progress.

During our sessions together, she would always joke around with me about how I was one of her “pain and torturers” (another PT had treated her previously) and was not a fan of exercise in general. She would also always complain that she is cold and would wear a heated blanket to clinic if she could. She also had a previous fall 5 years ago (which brought her in previously for her knee and shoulder) and would tell me when it was colder out her knee and shoulder would ache more. When she came in for the session with AJ, he had brought up cold sensitivities with central sensitization and how the feel of an air conditioner on the arm can aggravate their pain and immediately she shouted “YES!” and explained how that happens to her. That session we took a step back with her exercises and modified them to meet her where she is at and provided pain science education.

I can’t say whether the colder weather was the exact cause of her increase in pain, but I definitely think it played a role and probably the stress from the holidays as well. Looking back, I feel like I missed the small signs of her cold sensitivity relating to her ankle and only thought of it in regards to her knee and shoulder. I also should have thought more about her comments and how that relates to how she thinks about therapy in general with doing the exercises which is more activity than she likes to do. It’s hard working with patients like that since I knew she was not keeping up with her exercises at home. I think trying to find a happy medium with them is hard, but giving patients more autonomy with their care, providing a lot of education, and making their exercises goal oriented helps with that which is something I am improving on.

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