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CRPS as a Women's Health Concern

Needs Assessment

Complex Regional Pain Syndrome (CRPS) Types I and II remain poorly understood, underdiagnosed, and undertreated. Although CRPS is officially classified as a rare disorder (prevalence of less than 200,000)¹, recent epidemiological studies report that more than 50,000 new CRPS-I cases occur annually². Of these over 50,000 new cases, recent studies show that 2.3 to 4.5 times more women are affected than men^3,4.

In large-scale population-based surveys involving non-patient populations, women were found to report more severe pain, more frequent pain, pain in more sites, and pain of longer duration than men⁵. Ten of 13 non-gynecologic symptoms presented in these populations were 1.5 to 2 times more common in women, and when medically unexplained complaints were studied, the sex differences continue to unfold⁵.

Considering that women are more expressive of emotional and psychosocial difficulties upon reporting symptoms, clinicians might be more likely to dismiss nonspecific symptoms with no immediate medical explanation as a somatoform disorder⁵. In the case of CRPS, where early diagnosis and interventions can change the course of the syndrome, more education is needed to prevent underdiagnosis, misdiagnosis, and undertreatment in this population. All people involved with the patient need to understand that the pain is in her head, but organically.

A recent British study noted that there is a relationship between the amount of pain experienced in a CRPS-affected limb and the degree of cortical disorganization for that area⁶. The existence of these cortical disorganizations can created a body perception disturbance, with regard to the affected limb, that physiologically contributes to pain response⁶.

Women appear to experience more numerous, more frequent, and more intense physiological symptoms than men⁴, as well as higher levels of comorbidity⁷. Common comorbidities that present with CRPS include depression, anxiety⁸, and fibromyalgia⁹.

CRPS pain, once developed, may be more sensitive to psychological factors than non-CRPS pain, especially due to the more frequent recollection of major CRPS-related life stressors and the greater emotional stress present⁸. Patient feelings about a CRPS-affected limb can range from mild frustration to hate, disgust, and repulsion, especially because the pain and syndrome can limit the patient from doing activities that he or she was once able to do, to the point of disability⁶.

One recent chronic pain patient study found a stronger relationship between depression and pain-related disability in women compared to men¹⁰. Women overall also have a higher prevalence of several common psychiatric disorders, and current and past traumas, as well as a differentiation in judgment pertaining to symptom-reporting5. Depressive and anxiety disorders are 2 to 3 times more prevalent in women⁵.

The Pediatric Factor

Studies of pain sensitivity in 3- to 12-year-old children show girls to be more sensitive to pain⁵. Although the incidence of pediatric CRPS has not been determined, physicians report an increase in diagnoses in this population¹¹. Compared to the adult female prevalence of CRPS, female children and adolescents are 7 times more likely to develop CRPS than males¹¹, with the average age of incidence at 12.5 years¹².

With a different syndrome presentation than adult CRPS, one study stated one year as an average time between the initial injury and diagnosis in pediatric patients, indicating this population as an under-recognized treatment group¹². In the same study, 60 of the 70 patients were in organized sports, with a high percentage practicing ballet, gymnastics, and competitive sports¹².

Considering the prevalence of CRPS among girls, the role of female endocrine development in CRPS is still unknown¹¹. Many cases of female pediatric CRPS have gone into remission when the patients went through puberty. Other studies in rats and humans denoted that sex difference in CRPS pain response is estrogen dependent¹¹.

While adult CRPS prognosis is variable and commonly leads to long-term disability, in the pediatric population there is an excellent recovery rate in most cases, concurrent with early diagnosis and treatment¹¹. In early pediatric case studies, limb function was nearly completely regained, with a reduction in pain scores, through the use of intensive physical therapy programs and multidisciplinary treatment plans¹¹. Without proper and prompt treatment, symptoms can spread and become chronic, resulting in pain for years to come¹¹.

References

1. Sandroni P, Benrud-Larson LM, McClelland RL, Low PA. Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Pain. 2003;103:199-207.

2. de Mos M, de Bruijn AGJ, Huygen FJPM, Dieleman JP, Stricker BHCh, Sturkenboom MCJM. The incidence of complex regional pain syndrome: A population-based study. Pain. 2007;129:12-20.

3. Allen G, Galer BS, Schwartz L. Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain. 1999;80:539-544.

4. Agarwal S, Broatch J, Raja SJ. Web-based epidemiological survey of complex regional pain syndrome. Presented at the Annual Meeting of the American Society of Anesthesiology. Atlanta, Georgia; October 24, 2005.

5. Barsky AJ, Peekna HM, Borus JF. Somatic Symptom Reporting in Women and Men. Review. J Gen Intern Med. 2001;16(4):266-275.

6. Lewis JS, Kersten P, McCabe CS, McPherson KM, Blake DR. Body perception disturbance: A contribution to pain in complex regional pain syndrome (CRPS). Pain. 2007;133:111-119.

7. Giamberardino MA. Pain in Women: The Dimension of the Problem. Editorial. European Federation of IASP Chapters Newsletter. October 22, 2007. Available at: http://www.efic.org/paininwomeneficnewsletter22oct.pdf. Accessed January 18, 2008.

8. Bruehl S. Do psychological factors play a role in the onset and maintenance of CRPS? In: Harden RN, Baron R, Janig W (Eds). Complex Regional Pain Syndrome. Seattle, Washington: IASP Press; 2001.

9. Wallace DJ, Clauw DJ. Fibromyalgia and Other Central Pain Syndromes. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2005.

10. Keogh E, McCracken LM, Eccleston C. Gender moderates the association between depression and disability in chronic pain patients. Eur J Pain. 2006;10:413-422.

11. Berde CB, Lebel A. Complex regional pain syndrome in Children and Adolescents. Editorial views. Anesthesiology. 2005;102(2):252-255.

12. Wilder RT, Berde CB, Wolohan M, Vieyra MA, Masek BJ, Micheli LJ. Reflex Sympathetic Dystrophy in Children: Clinical Characteristics and Follow-up of Seventy Patients. J Bone Joint Surg. 1992;74(6):910-919.

Added April 30, 2008