Abstract
Background and Purpose Adolescents who have chronic pain after common orthopedic injuries such as ankle sprains may present a multidimensional clinical problem stemming from both physical and psychological issues. A traumatic incident such as a motor vehicle accident can produce clinical issues ranging from a specific tissue injury to multisystem complications such as complex regional pain syndrome (CRPS) or posttraumatic stress disorder (PTSD). The purpose of this retrospective case report on an adolescent with chronic ankle pain stemming from a motor vehicle accident is to demonstrate how reflection and the evidence base influenced the modification of the plan of care. Description of the screening methods, clinical findings, interventions, and outcomes of the case may help physical therapists identify and improve the quality of care in cases of suspected CRPS and PTSD.
Case Description The patient was a 12-year-old girl with a medical diagnosis of recurrent right ankle sprain and with signs of potential CRPS and PTSD. Poor initial response to ankle sprain management led to reflective reconsideration of the diagnosis and plan of care. The revised plan of care supported by the evidence base emphasized empathetic consideration of the traumatic motor vehicle accident and focused on CRPS prevention and management of potential non-physical pain via mirror therapy and motor imagery therapy.
Outcomes Pain was relieved, behavior improved, and functional movement began to normalize after 3 sessions of mirror therapy and motor imagery therapy.
Discussion Patient symptoms were inconsistent with the medical diagnosis, and the clinical outcome of the original plan of care was unsuccessful. Reflection inspired a more-detailed history and systems review, which led to greater understanding and more-effective care.
Ankle sprains are considered the most common injury in the United States pediatric population, accounting for 20% of emergency care visits.1 The peak incidence rate of ankle sprains occurs between the ages of 10 and 19 years, with females more likely to be injured within this age group.2 Although incidence of chronic ankle sprains in the non-athlete population is unknown, more than 70% of athletes report recurrent sprains3 marked primarily by ankle pain.4,5 In the adolescent population, if the physical presentation of an ankle sprain is inconsistent with the patient's signs and symptoms, 2 additional possibilities can be added to the differential diagnosis: complex regional pain syndrome (CRPS) and posttraumatic stress disorder (PTSD).
No clear pathophysiologic mechanism exists for CRPS. However, the sympathetic nervous system and the somatomotor system are thought to be involved, leading to autonomic changes and severe impairment.6,7 In pediatrics, CRPS is most commonly seen around puberty, and there is a higher prevalence in females versus males (4:1).7 In adolescents with CRPS, the lower limb is more commonly affected, and psychological factors are thought to play a large role.7 The 2 most common precipitating events of CRPS are reported to be foot trauma (27.2%) and ankle sprains (14.6%).6
Traumatic events may precipitate PTSD in adolescents, which the American Psychiatric Association defines as “experiencing, witnessing or confrontation with an event or events that involve actual or threatened death or serious injury, or a threat to the physical integrity of self or others.”8(p427) Characterized by increased anxiety, the hallmark signs and symptoms of PTSD fall into 3 clusters: re-experiencing the event, avoidance and emotional numbing, and increased arousal.8 A motor vehicle accident is one of the most common traumatic events, and the likelihood of developing PTSD after a motor vehicle accident has been reported to be greatest in females and young people.9 For children under the age of 18 years, 38% were reported to have PTSD 1 month after a motor vehicle accident and 15% were found to have PTSD 6 months postinjury.10 Survivors of a motor vehicle accident with PTSD 1 month postinjury were shown to have poor psychosocial outcomes.11
The purpose of this case report is to demonstrate how reflective practice and review of the literature led to a holistic screening process and alternative modes of treatment in an adolescent girl with chronic ankle pain due to a traumatic motor vehicle accident and with signs of potential CRPS and PTSD.
Case Description
The patient in this case was a 12-year-old girl of Hispanic descent with the medical diagnosis “recurrent right ankle sprain.” The patient was seen in an outpatient hospital 14 days after the most recent aggravation of pain occurred while in gym class after jumping, albeit without her ankle twisting. The patient's primary complaint was unremitting pain of 8/10 intensity upon palpation of the dorsal surface of her right foot and with prolonged ambulation. When asked about management of her pain after the most recent sprain, she stated ice was immediately applied to the ankle. The patient stated her goal was to perform recreational activities in school without pain.
Of note, the patient reported that the initial incidence of ankle pain occurred after a motor vehicle accident 2 years previously and had continued with periods of aggravation ever since. Her parents mentioned the possibility of a lawsuit stemming from the motor vehicle accident, but a greater likelihood of dropping the case. The patient had visited 2 outpatient physical therapy clinics previously but discontinued treatment before achieving pain-free function. Recent radiographs and magnetic resonance imaging (MRI) scans showed no signs of ligament tear or fracture.
Examination
Observation and Palpation
Pain was assessed using a 0 to 10 numeric pain rating scale, with “0” denoting “no pain” and “10” denoting “worst possible pain.” The patient complained of 8/10 intensity pain upon palpation of the anterior talofibular ligament and dorsum of her right foot. The digits of her right foot were mildly cool to touch, and no signs of hematoma, discoloration, or volume difference were present (Appendix). The specificity and sensitivity of delayed physical examination for the presence of an ankle ligament sprain utilizing observation and pain on palpation have been shown to be 84% and 96%, respectively.12
Range of Motion and Manual Muscle Test
A student therapist practicing alongside a clinical instructor with 10 years of experience measured range of motion using a standard goniometer. Range of motion was measured in a sitting position for ankle plantar flexion and dorsiflexion and in a prone position for ankle inversion and eversion. Ankle motion was limited passively and actively in all planes due to pain of 8/10 intensity (Appendix). Intraclass correlation coefficients (ICCs) for intratester reliability range from .74 to .90 for measurements of ankle range of motion.13
Manual muscle tests were performed in a sitting position for ankle dorsiflexion, inversion, and eversion against examiner's resistance. Manual muscle tests for plantar flexion were done in a supine position against examiner's resistance, as standard measurement in a standing position reproduced her pain. Right ankle strength (force-generating capacity) was 4/5 in all planes compared with 5/5 left ankle strength (Appendix).
Special Tests
Following the Ottawa Ankle Rules,14 the patient had no tenderness along the malleolus, navicular bone, or fifth metatarsal and bore weight on either leg to take a step. The Ottawa Ankle Rules have a sensitivity of almost 100%, with modest specificity14; thus, fracture was unlikely. Negative radiographs reinforced this assumption.
The anterior drawer test for the anterior talofibular ligament was performed in both prone and supine positions with feet off the mat and has a sensitivity of 86% and a specificity of 74% if performed 4 to 5 days postinjury.12 The Thompson test for Achilles tendon rupture was performed in a prone position with knee bent and has a sensitivity of 96% and a specificity of 93%.15 The squeeze test for syndesmotic sprain was performed with the patient in a supine position, squeezing the tibia and fibula together around the mid-calf and at more distal locations toward the ankle, and has moderate reliability (κ=.50).16 The anterior drawer, Thompson, and squeeze tests were all negative. Normal MRI findings strengthened the conclusion that the ankle ligaments and Achilles tendons were intact.
Gait and Stairs Assessment
The patient was instructed to walk at a self-selected speed across a level surface area and then to ascend and descend stairs. Asymmetrical weight bearing with decreased right stance time was noted upon clinical observation. In addition, the patient complained of pain of 8/10 intensity upon completion of the gait and stairs assessment (Appendix).
Clinical Impression
Various aspects of the patient's history appeared to be atypical for an ankle sprain. For instance, most ankle sprains occur when the lower limb lands in an overly inverted and plantar-flexed position.3 The patient, however, reported not rolling over on her ankle. Furthermore, functional recovery for ankle sprains has been reported to take 6 days following early cryotherapy.17 The therapist evaluated the patient 14 days after the most recent ankle injury, yet the patient still had difficulty with weight bearing. In addition, recent MRI scans showed no signs of ligament tear. Atypical mechanism of injury, exaggerated recovery time, and negative images all warranted suspicion of the ankle sprain diagnosis. One finding that was typical for an ankle sprain was pain on anterior talofibular ligament palpation; however, palpation pain has been reported to be only 48% specific for an ankle sprain.12
Although the patient history and quantitative assessment did not fully match typical findings of an ankle sprain, due to the physician's prescription and given the high incidence of ankle sprains in female adolescents, it was possible that the patient had a chronic ankle sprain dating back to her initial ankle injury from the motor vehicle accident 2 years previously. A systematic review evaluating conventionally treated ankle sprains showed that at 1-year follow-up, 5% to 33% of patients still experienced pain and 15% to 64% reported lack of full recovery.5 Thus, the presumed ankle sprain diagnosis was not unjustified, and the plan of care to address the ankle sprain was initiated. Due to parental time and transportation constraints, the patient was scheduled for one 30-minute session per week. In general, ankle sprain management programs include strengthening, sensorimotor control training, and proper footwear, all considered essential for recovery and injury prevention4,18 (Tab. 1).
Treatment Plan of Carea
Intervention and Outcome
The first 2 sessions of the ankle sprain management program had poor outcomes. Reassessment of pain before and after treatment revealed an increase in pain and lack of adherence to her home exercise program (Tab. 2). Throughout treatment session 2, the patient complained of pain of less than 8/10 intensity. After the end of the session when sitting with her foot not moving and resting off the ground, she reported increased pain. Upon palpation, the digits of her right foot were moderately cool, and pain was reported along the dorsal surface. An expanded systems review including Veldman's criteria for diagnosing CRPS and a search of the literature pertaining to CRPS and non-physical pain complaints typical in PTSD was performed19 (Tab. 3).
Clinical Outcome Measuresa
Clinical Criteria for Diagnosing Complex Regional Pain Syndrome (CRPS) Type 1 Based on Veldman's Clinical Observation and Palpation Criteria of the 3 W's of Diagnosing CRPS: What, When, and Where19
Clinical Impression
For the majority of ankle sprain injuries, pain is commonly reproduced during weight-bearing positions and is relieved by rest.4,5 At the end of treatment session 2, it became evident that the patient complained of pain regardless of weight bearing and that her pain was not relieved by rest. Her presentation suggested an alternate source of pain such as CRPS and PTSD.
The patient would have been classified as having CRPS had she presented one more symptom, according to Veldman's criteria. Thus, in development of a new treatment plan, the prevention of CRPS was integral.
Asked about the motor vehicle accident, the parent replied that the accident was “very traumatic” to the patient. In regard to “re-experiencing” the first cluster of symptoms of PTSD, the parent stated that the patient needed constant emotional support whenever images of the accident were recalled. Effortful avoidance and emotional numbing may have presented through her newly introverted behavior and, as per the parent, her fear of commuting by car. The last cluster, increased arousal, may have manifested through pain and irritability in her right ankle, the side where the motor vehicle accident collision took place. When asked about patient behavior before and after the motor vehicle accident, the parent replied that the patient was extremely lively prior to the accident and became “anxious” after the accident.
Because the patient's presentation met 2 of 3 criteria for CRPS with signs and symptoms in all 3 PTSD clusters, the original plan of care was modified to focus on alternative pain management and CRPS prevention, with empathetic consideration of the traumatic event. Although physical therapy does not include psychological treatment of anxiety associated with PTSD, a plan of care rooted in empathy was developed, as clinicians who exemplify compassion were more successful in decreasing anxiety in patients.20 The patient and her parents were educated about the benefits of cognitive-behavioral therapy and were referred for psychological counseling. Evidence in the literature supports physical therapy for CRPS, with success reported with massage,21 relaxation techniques,22 and more recently mirror therapy23 and motor imagery programs.24 Because the patient exhibited fear and avoidance of simple non–weight-bearing movements, mirror therapy and motor imagery therapy were considered as interventions to address the patient's fear of moving her right ankle, potentially relieving pain without involving the ankle directly and build up to introduce active motion. Over the previous 10 years, several studies have supported the use of mirror therapy and motor imagery therapy for patients with CRPS. A high-quality clinical trial in patients with CRPS showed a good analgesic effect in people with acute symptoms.23 A motor imagery study showed that 50% of patients no longer fulfilled the diagnostic criteria for type 1 CRPS after 6 weeks of treatment.24 Additionally, mirror therapy and motor imagery therapy are simple and inexpensive treatment techniques that the patient could perform at home with assistance from her parents, facilitating both family interaction and self-management of pain.
Mirror therapy was incorporated by first draping the right lower limb and performing specific exercises with the left lower limb. The patient was told to observe the reflection of her left lower limb in the mirror and consciously believe that it was her affected right lower limb performing the activity. As she complained of less pain, the mirror exercises were progressed to functional closed-chain exercises, including step-ups and sit-to-stand maneuver. Motor imagery with relaxation was utilized by having the patient imagine performing simple open-chain exercises, progress to imagining more-complex activities such as running, and later imagine participating in those movements in a social environment. For the patient's home exercise program, mirror therapy and motor imagery with relaxation techniques were drawn on a sheet of paper, with directions for patient and parents to perform them twice a day (Tab. 1).
At the end of sessions 4 and 5, the patient had very good outcomes with no complaints of pain upon palpation or during ambulation and adherence to her home exercise program (Tab. 2). The patient no longer met any of the CRPS criteria (Tab. 3), and all signs and symptoms of PTSD began to subside. Her parents mentioned that social participation with her family and friends began to normalize and that her anxiety gradually diminished with successive sessions.
Discussion
The case presented is that of a 12-year-old female patient diagnosed with chronic ankle sprains with a history of a motor vehicle accident. After 2 sessions of an ankle sprain management program, the patient complained of worsening pain regardless of weight bearing. Upon her third treatment session, an alternative pain management program was developed focusing on CRPS prevention via mirror therapy and motor imagery therapy while empathetically addressing her feelings about the past trauma. After 3 sessions, the patient's complaints of pain dramatically decreased to a grade of 0 on the numeric pain rating scale and no longer met any criteria for CRPS.
Although the mechanism of mirror therapy for reducing pain is still not well understood, some theories include the mismatch of motor and sensory components and the reduction of kinesophobia. The first theory hypothesizes that the mismatch between the movement of the unaffected limb and the movement observed in the reflection increases alertness and spatial attention to the painful limb.25 The second theory suggests that perception of the normal moving limb breaks the cognitive association of movement with pain to reduce kinesophobia. Thus, the patient becomes less anxious about moving the affected limb, improves in behavior, and increases movement.26
Aside from being a relatively new diagnostic entity in medicine, pediatric CRPS differs from that in adults primarily in having a high correlation to psychological factors.7 Had therapy continued, a multidisciplinary approach involving physical therapy and cognitive-behavioral therapy has been reported to be effective for CRPS7 and PTSD27 and may have been warranted. Cognitive-behavioral therapy through exposure to traumatic memories would have allowed the patient and the clinician to address and process traumatic triggers until they were no longer distressing, rather than avoid them. Cognitive restructuring, a type of cognitive-behavioral intervention, teaches patients to spot dysfunctional thoughts of the trauma and elicit rational alternative thoughts, re-evaluating distorted beliefs about themselves and the trauma. Exposure and cognitive restructuring, singly or combined, have been shown to improve symptoms of PTSD, with gains lasting up to 6 months.27
Allowing the patient to recognize behavioral change before and after the motor vehicle accident while addressing her fear of commuting by car and negative recollection of the accident may have helped her overcome the first 2 clusters of PTSD: re-experiencing the event and avoidance and emotional numbing. Mirror therapy and motor imagery therapy may have been integral in preventing CRPS and remedying the last cluster of PTSD, “increased arousal,” which may have manifested as pain and irritability in the right ankle. Accordingly, when addressing non-physical pain due to trauma, cognitive-behavioral therapy can be an effective psychotherapeutic approach complementing mirror therapy and motor imagery therapy. Although psychological testing is beyond the scope of physical therapist practice, physical therapists indirectly use behavioral approaches to coax participation in physical therapy. In the current case, the patient was gently reminded that the trauma was not equivalent to experiencing the trauma, and general movement of her leg was encouraged. It is possible that allowing the patient to realize that fearful ideas were contrary to her current situation helped her pain and anxiety to subside.
The outcome measures were all clinically realistic, as many physical therapists utilize the numeric pain rating scale to assess pain, along with manual muscle tests, range of motion, and gait observation to assess impairment and function. Although diagnosing CRPS should be left to medical specialists, special diagnostic interventions such nerve blocks and radiographs have been shown to be unhelpful in diagnosing CRPS.28,29 Alternately, Veldman's clinical observation and palpation criteria have been shown to be cost-effective, noninvasive, and simple in diagnosing CRPS, with good interrater reliability (Tab. 3).19 As for psychological screening, a thorough history with attention to the patient's feelings should identify hallmark signs and symptoms linked to trauma such as re-experiencing the event, effortful avoidance and emotional numbing, and increased arousal.
This case report has limitations beyond the use of only one patient. Although the patient experienced pain relief after only a few sessions, no long-term pain or functional outcomes were obtained. Although the outcome measures were standard to physical therapy, no reliability or validity testing was done using the individual taking the measures. Furthermore, mirror therapy and motor imagery therapy were customized to the individual and not taken from established protocols. Although the parents and the patient were referred for psychological evaluation, they did not follow up. Larger studies involving multiple groups and long-term follow-up would be warranted to investigate whether mirror therapy or motor imagery therapy can relieve chronic pain in adolescents with some of the criteria of CRPS and PTSD.
This case report has demonstrated how reflective practice can lead to improved clinical care through the development of a deeper understanding of complex situations when an unexpected problem arises. In this case, the poor initial response to treatment led to reconsideration of the diagnosis and plan of care. The subsequent expanded systems review and literature search led to a deeper understanding of the case and served as an error-checking process, merging both intuitive and deductive reasoning in a process guided by experience and shaped by science.30 For instance, upon reflection, a clearer picture emerged of the patient's change in demeanor from lively to anxious, affecting her social participation. In addition, through a search of the evidence, the incidences of ankle sprains, pediatric CRPS, and PTSD post–motor vehicle accident were all found to be highest among adolescent females. The revised plan of care focused on the management of potential non-physical pain. Mirror therapy and motor imagery were a logical adaptation, given that the patient's physical presentation did not match the evidence or clinical experience of an ankle sprain diagnosis.
This case report of an adolescent case of chronic ankle pain due to a motor vehicle accident has demonstrated how reflecting on the case and considering the unexpected outcomes led to a broader systems review, screening for CRPS and PTSD, and alternate modes of treatment to address non-physical components of the case. The successful outcome in this single case highlights the value of a careful screening for potential cases of CRPS or PTSD.
Appendix.
Systems Review and Evaluationa
a AROM=active range of motion, ATFL=anterior talofibular ligament, B=bilateral, DF=dorsiflexion, Ev=eversion, IE=initial evaluation, In=inversion, MMT=manual muscle test, Neg=negative, Nl=normal, NT=not tested, PF=plantar flexion, Pos=positive, PROM=passive range of motion, PT=physical therapist, WB=weight bearing, WNL=within normal limits.
Footnotes
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Both authors provided concept/idea/project design and writing.
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This work was completed while Dr Mohamed was a Doctor of Physical Therapy student in training.
- Received February 2, 2011.
- Accepted May 7, 2011.
- © 2011 American Physical Therapy Association
References
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