#81: OT and CRPS with Megan Doyle

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Learn more about our guest: Megan Doyle MS, OTR/L, TPS, FPS, CERT-APHPT

In a massive 53 page treatment guideline on Complex Regional Pain Syndrome (CRPS), the authors state:

“Occupational therapists are the ideal therapeutic leaders in the functional restoration process…”

And, go on to devote 2 pages to what this OT care can entail.

In this one hour course, we’ll pull out important implications for OT practice from the entire guideline. As you’ll see, when it comes to treating chronic pain, like CRPS there are a lot of best practices to draw on—but also a lot of unknowns that necessitates close attention to the individual in front of you.

See all Pain Assessments

:white_check_mark: Agenda

Intro (5 minutes)

Breakdown and analysis of journal article (10 minutes)

Discussion on practical implications for OTs (50 minutes)

  • 00:10:45 Intro to Megan Doyle
  • 00:13:57 How Megan became interested in pain
  • 00:19:13 Becoming program manager at an outpatient chronic pain clinic
  • 00:25:31 Understanding the mechanisms of CRPS
  • 00:31:56 Client education on CRPS
  • 00:37:40 Impressions of the treatment guideline
  • 00:41:30 Assessments Megan uses for CRPS
  • 00:46:48 Megan’s go-to treatment approaches
  • 00:58:27 Advice for coordinating with other disciplines
  • 01:01:38 How do we need to change to meet the massive global needs around pain

:white_check_mark: Supplemental Resources

:white_check_mark: Article Review

Read Full Text: Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition
Journal: Pain medicine
Year Published: 2022
Ranked 95th on our 2019-2023 list of the 100 Most Influential OT Journal Articles

In a massive 53-page treatment guideline on Complex Regional Pain Syndrome (CRPS), the authors state:

“Occupational therapists are the ideal therapeutic leaders in the functional restoration process…”

They then devote 2 pages to what this OT care can entail.

In our review, we’ll pull out important implications for OT practice from the entire guideline. As you’ll see, when it comes to treating chronic pain conditions like CRPS, there are plenty of best practices to draw on—but also a lot of unknowns. As such, paying close attention to the individual in front of you is absolutely critical.

To help us flesh out what this means for OT practice, we’ll welcome to the podcast Megan Doyle, MS, OTR/L, TPS, FPS, Cert-APHPT a program manager at an outpatient pain program and a leading voice on OT’s role in pain management.

Let’s dive in.

What is the intent of these guidelines?

There is only modest high-quality research in the area of CRPS treatment. But, even without robust research, there remains a responsibility to treat these patients.

Better evidence is certainly needed, but our patients cannot wait.

These guidelines are an attempt to synthesize the best available evidence to aid in informed practice.

Where do we stand on the diagnosis of CRPS?

The label “CRPS” first appeared in 1994, making it a relatively new diagnosis. Criteria for CRPS have shifted many times since the ’90s, but the “Budapest Criteria” remain a benchmark in defining the syndrome. And, with a few clarifications, the criteria have been adopted by the International Association for the Study of Pain.

Here are the general features of this condition:

CRPS is a syndrome characterized by a continuing (spontaneous or evoked) regional pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or lesion.

The pain is regional and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, or trophic findings.

(See the full criteria here.)

Standardizing Assessment of CRPS

The International Research Consortium for CRPS has recommended a core set of outcome measures for use in all CRPS clinical studies. Here are the ones that seem most helpful to the practicing OT clinician:

Functional Restoration through an Interdisciplinary Approach

Interdisciplinary/multidisciplinary pain management techniques emphasizing functional restoration are thought to be the most effective therapy for chronic pain.

(This approach may work by resetting altered central nervous processing and/or normalizing the distal environment.)

Functional restoration is based on a steady progression from activation of pre-sensorimotor cortices (i.e., visual motor imagery and tactile discrimination) to very gentle active movements to weight bearing.

Shown below, the Malibu protocol is an algorithm of what this can look like.

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Interdisciplinary Considerations for Treatment

The article covers the role of each of the following in CRPS treatment:

  • Occupational therapy
  • Physical therapy
  • Recreational therapy
  • Vocational rehabilitation
  • Pharmacotherapy
  • Psychological interventions

Each section offers a wealth of information, but for the sake of this review, I am going to zoom in on the occupational therapy section. But, there are many gems in the other sections that are relevant to OT, so I encourage anyone treating this condition to read the guideline in full!

Occupational therapy treatment

OT professionals are ideal therapeutic leaders in the functional restoration process, because they are trained in the biopsychosocial approach and are primary practitioners in functional assessment and treatment.

The OT evaluation of CRPS has remained consistent over the past few decades. It includes:

  • Use of the extremity during ADL
  • Coordination/dexterity
  • Skin temperature/vasomotor changes
  • Pain/sensation

However, treatment for CRPS has shifted. I’ve pulled out the main takeaways from this section below. Note that the naming of stages is my own, and is meant to orient you to the Malibu treatment algorithm above. Treatment may not be linear.

Stage 1

The theoretical underpinnings of treatments in this early stage are still under examination, but the use of these treatments is increasing. More definitive trials are needed.

Graded Motor Imagery/Visual Motor Feedback

The author specifically points to the protocol outlined by McCabe for Mirror Visual feedback (MVF) and the protocol developed by Moseley for Graded Motor Imagery (GMI).

Mobile apps like the Recognise App are often utilized as part of a GMI program.

Stage 2

Following the implementation of MVF or GMI, the following objectives can be addressed.

Initiation of Gentle Active Movements

Minimize Edema
This is often done using specialized garments and manual edema mobilization.

Normalize Sensation
This can be done through superficial or surface desensitization techniques.

Stage 3

From here, the OT can introduce a stress loading program to initiate active movement and compression of the affected joints.

Stress Loading
Stress loading incorporates two approaches: scrubbing and carrying. Scrubbing involves moving the affected joint back and forth while weight bearing through the extremity. Devices like the Dystrophile can assist with maintaining consistent weight bearing.

With carrying, progressively heavier loads are carried throughout the day whenever the client is standing or walking.

Stage 4

While general use of the affected extremity as tolerated is encouraged throughout the rehab process, the next stage really focuses on increasing functional use of the extremity.

Movement Therapies
At this stage, the patient should be better able to tolerate active range of motion as well as coordination/dexterity tasks. Proprioceptive Neuromuscular Facilitation patterns are also often well tolerated.

Collaboration with a Vocational Counselor for Return to Work
Services like job site analysis, job-specific reconditioning or work hardening, work capacity evaluation, transferable skills analysis, and a formal functional capacities evaluation should be considered.

As a final note, in the OT section, the authors emphasize that it is very important for the therapist to upgrade/downgrade programs according to therapeutic response.

Conclusion

As this 5th-edition guideline demonstrates, there has been progress in managing CRPS. But, more high-quality research is still needed. In each clinical situation, the specific risk, benefit, and expense of any intervention must be weighed carefully and continuously.

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Please share any other feedback below! Including, ideas for future programming, and most importantly, how you feel this podcast will impact your practice!

3

Thank you for covering CRPS! I can only imagine how challenging/life altering it can be for the person diagnosed but it’s great to see OT acknowledged in the article along with ways that we can address it. I actually haven’t seen a patient with CRPS in acute care or inpatient rehab (yet) so I look forward to hearing what Megan’s perspective is working with these patients in an outpatient setting. I’m also curious if outpatient OTs are commonly referred to CRPS patients by general practitioners and pain management MDs or if we aren’t always a first thought yet?

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4

I think that in most hospital systems there is still a lot of education needed to get these patients on our caseload. But, @megan75 is really trailblazing a new reality for us, where OTs serve as the go-to pain specialists in their hospital system! @sarah112, you’ll love the episode! (And, I hope to have Megan back on in the next year to talk explicitly about acute pain- which will be super relevant for acute care therapists!)

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5

Loved this talk! Working in the largest health care system in my state, I am the first and only pediatric OT to be a part of our pain team. So much more research is needed to further validate the great work we do and quality we bring to this population. Thanks you @megan75 for your work and advocacy

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6

Thank you so much for that Jason, I am grateful you enjoyed the interview and also you should be proud of the advocacy and amazing work you are doing. Ensuring there is an OT presence especially in the realm of pediatrics and pain is everything, keep up the hard work and know you are changing lives.

7

@JasonKreuzman When I saw that you listened to the FND podcast, I was definitely thinking you needed to listen to this one next, AND here you are!!

@JasonKreuzman and @megan75, when I recorded my podcast on interoception this summer, I was definitely thinking about our pain OTs! I feel like I only have half-formulated thoughts on the intersection of interoception interventions and pain management, so I would be super curious to hear what you both think!

8

The FND and Pain talk go so well together as their presentations and symptoms can have crossover. The BioPsychoSocial approaches to care and self management skills are very similar. The talk on interception was very interesting and caused me to go down a rabbit hole of research! Interoception training as a part of pain management education adds to the holistic care and awareness we act OTP can provide. Without awareness of interoceptive changes in our body, it can be difficult to know when to proactively utilize self regulation, neuro calming or non-pharmacological pain management strategies. I feel most of us do interoception training without truly labeling it as such.

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9

I can only speak to my hospital setting, but most of our pain clinic referrals are to Physical Therapy. But I feel once we highlight the benefit for not just treating to biomechanics components of chronic pain, OT have so much to offer

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10

This is exactly how I felt listening to @kelly46! @kelly46 do you feel like you have connections in the OT pain management world who are really leveraging interoception concepts and research?

11

Thank you both Sarah and Jason, and for looping in Kelly regarding OT, pain management and interoception. I am so in love with interoception and assessing and addressing this with my adult clients with persistent pain, those who are neurodivergent and those who are neurotypical. There is so much crossover between operating from a trauma-informed lens, Polyvagal Theory, and providing validation to my clients as to why not feeling safe in and aware of their internal bodies is a component of pain neurophysiology. I wanted to share one of the assessments I will use with my clients, The Multidimensional Assessment of Interoceptive Awareness, Version 2 (MAIA-2) - PMC (nih.gov), which includes pain related question items and has led towards us addressing this together. Sensory related strategies, somatic techniques/exercises, mindfulness and self-regulation is all integrated into an occupation based practice.

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12

Wow… that assessment looks awesome! I’m going to add it to our assessment search!