ROLE OF MULTIMODAL TREATMENT FOR CHRONIC RECURRENT PAIN IN A PATIENT WITH CHRONIC ANKLE INSTABILITY: A CASE REPORT

¹Ashok & Rita Patel Institute of Physiotherapy, Physiotherapy, Changa, India

Background: Recurrent ankle pain episodes following moderate to vigorous physical activities are common in chronic ankle instability (CAI) patients. As chronic pain is multifactorial, psycho-social factors along with biological factors influence pain. These factors lead to a myriad of activity limitations from difficulty in climbing stairs to inability to participate in leisure activities. The best available evidence suggests that multimodal treatments such as patient-centred functional exercise, pain education (PE) and behavioural intervention lead to reduction of pain and disability.

Purpose: The aim of the case report is to narrate the development of a multimodal treatment encompassing the bio-psycho-social factors and its impact on a patient with CAI.

Methods: A 25 years old engineer woman had a fall in November 2015. Following that, she gradually developed chronic pain in the ankle between 2015 to 2019 and had to discontinue full-time employment twice due to recurrent ankle pain episodes. Her pain and disability did not reduce following ankle surgery and multiple physiotherapy sessions.
She visited our physiotherapy department in January 2019. During her initial interview, she informed that her priority was return to work and pain reduction. Thus, return to work was determined as one of the primary outcomes along with FADI (Foot and Ankle Disability Index) and NPRS (Numerical pain rating scale). In addition, functional measures such as 6-minute walk test (6 MWT), 30 sec sit to stand test (30 sec STS test) and 1 minute stair climbing test (1 MSCT) were evaluated. Secondary outcomes evaluated were catastrophization, kinesiophobia, anxiety, depression, social support and motivation. Primary and secondary outcomes were evaluated at 1st, 3rd, 6th and 12th month.
Exercise program was developed according to her ability, physical activity requirements (prolong walking, stair climbing) and interest (dancing) to improve compliance. To mimic real life context, low intensity aerobics exercise and dance therapy was performed outdoors with her favourite music. Concurrently, the patient was encouraged to learn about pain using a book. She was also encouraged to accept some pain while doing the exercises and learn to implement gradual progression and pacing techniques in her routine.

Results: Patient returned to her job at the end of 3 months and sustained in the same job till 12-month follow-up. FADI and NPRS improved from the baseline score of 31/100 to 76/100 and 9/10 to 3/10 which were more than the minimal clinically important difference (MCID) at one year follow-up. 6 MWT and 30 sec STS test scores exceeded MCID ranges till 3 months and deteriorated afterwards till 12 months. 1 MSCT could not exceed beyond MCID range in any follow up; however, her functional capacity remained higher than the baseline capacity for all functional measures. Sixth month onwards, all secondary outcomes except social support and motivation were below cut off ranges.

Conclusions: Patients with chronic pain can be helped to return to work with a multimodal treatment protocol.

Implications: Multimodal treatment aligned with patient's needs and interest can address bio-psycho-social impairments and facilitate social participation.

Funding acknowledgements: None

Keywords:
Chronic ankle and foot pain
Multimodal treatment
Return to work

Topics:
Pain & pain management
Musculoskeletal: lower limb
Orthopaedics

Did this work require ethics approval? No

Reason:

Ethical approval was not required as it is a case report. Informed consent of the patient was taken.