The Truth Behind No Pain No Gain

[iwhitney]

For this patient encounter reflection, I am looking back on the many treatment sessions that I’ve had with a patient who is 7 months post-op ankle reconstruction using a Brostrom-Gould procedure. I actually evaluated this patient back when I was a student at UVA, so I’ve seen his journey through PT from the beginning until now. Initially when I began treating him again this September, he was doing great and had progressed to tolerating most weightbearing exercises, had improved his ankle ROM, improved his peroneal strength, and was ready in my mind to progress towards plyometrics. The patient is 41 y.o. and a father of two (8 & 9 years old) and one of his main goals is to be able to play basketball with his kids. The patient had a long history of chronic ankle instability which ultimately led to the surgery, but he previously had no other serious injuries or surgeries to his ankles. As I began to implement plyometrics, I started light with step downs onto a half bosu and total gym hopping unweighted, but this ended up increasing the patient’s pain significantly over the span of a week. Due to this response, I regressed all the way back to ankle isometrics as this was the only exercise he could tolerate. Over the last couple weeks, it has been much of the same where we’ve started to progress slightly but ultimately had to regress again due to his pain.

I’ve had many conversations with the patient about expectations following a surgery like this including the expectation of some pain and discomfort with the interventions we perform as he progresses. Where I feel caught up some with this patient is that whenever we progress just slightly, his response is more than I would expect, with his pain sitting around a 6-7/10. Reflecting back on the interventions I provided, I feel that perhaps I progressed too quickly towards plyometrics and I should’ve increased the intensity of his isotonic ankle strengthening prior to implementing any plyometric based exercise, even if it is primarily unweighted. I feel that given his surgical timeline, plyometrics should begin to be incorporated around that 6 month timeframe, but he simply wasn’t ready for it and needs more strength and stability at the ankle before we can progress to dynamic loading.

I also feel that I should’ve set better expectations for the level of pain he can expect with therapy as we progress the intensity of his exercises. Something I often hear said to patients by clinicians is that the exercise shouldn’t increase their pain past a 5 or 6/10. I agree this is a good number because it ensures the patient understands some discomfort is expected with the interventions provided, but it shouldn’t be excessive. However, I feel I could do a better job at explaining this to the patient early on so that it isn’t a surprise or hindrance to progress later on in rehab. I’d be curious to hear from anyone else what kind of explanations they use when educating patients on how much pain is expected.

I’m also curious about experiences with post-op ankle surgeries and when/how plyometrics were implemented into the plan of care. Where do you start? How do you ensure the patient is ready to accept that load through their ankle without flaring them up?

[AJ Lievre]

Ian
I enjoyed reading this. What do you think he is thinking when his pain is increasing and having set-backs? Have you asked?
The 5-6/10 pain may be a nice starting point to consider, however, some patients do not tolerate that intensity. I think you need to find out what intensity they are comfortable with and work in that range.
For me, if I have come to the conclusion that increased pain is not damaging tissue, I’m OK with the patient working into a tolerable amount (their tolerable) of pain. Then what I want to know is if the pain is increasing with the activity or staying the same or possibly decreasing with the activity. That may hep guide me on whether this is too much load or just right for the person. The other thing I want to know is what the response is after the activity. Sometimes this is trial and error, but it should be an informed decision to get started.

On a side note, could setting a range for a patient become problematic if the are hypervigilant? What would be an alternative? Thoughts?

[iwhitney]

Hey AJ,

Thanks for the reply, those are great questions. I have not specifically asked this patient what he’s thinking when he experiences an increase in pain. I think that brings up a great point as to the individual influences, environmental, and personal factors that can impact a person’s pain experience. Perhaps he fears that experiencing pain is impeding his progress with rehab or maybe he feels that pain is interfering with the integrity of the ankle reconstruction. Or maybe in his cultural experience, having any pain at all is a bad thing and not acceptable. We have certainly had multiple conversations on the expectation for some pain with the rehabilitation process, especially considering the type of procedure he had performed and where it is located.
On one occasion with this patient, we were performing SL balance ball toss and he mentioned he began to experience some pain. I automatically noted that as an expected amount and stated “ok, some soreness in the ankle, that’s ok.” He then replied “just to be clear, this is not soreness I am experiencing, it’s pain.” Reflecting back on this encounter, I could’ve used this as an opportunity to dive deeper into what intensity of pain he is comfortable with while exercising.
On the instances where I have had to regress with this patient, it is due to him stating an increase in pain in between our sessions. Often, he is explaining this increase in pain is limiting his ability to perform ADLs, which keys me in to regressing our intensity of exercise. I also think you bring up a great point on hypervigilance, as I think this is something that this patient is struggling with as it relates to his ankle. Rather than using a set range such as 4-6/10 for an acceptable amount of pain with exercise, I could use another subjective form of pain rating, such as low, moderate, and high. Perhaps, using something such as low and moderate as an acceptable amount of pain could help prevent this patient from being so hypervigilant towards the amount of pain he is experiencing. Low and moderate are much more vague and therefore, I feel it could open the door to him becoming more accepting of the fact that some pain is expected with therapy and not feel the need to be so specific when questioning what his level of pain is and what’s okay vs what’s not.

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