Changes to treatment for post traumatic stress disorder and chronic pain following injury

Now, happily, 3 years later she has made a fantastic recovery and has had her first child.

Now there is a considerable increase in the awareness of the psychological effects of suffering injuries, and the approach to treating the same as well as the physical effects.

The devastating accident, which left her requiring serious reconstructive surgery, required months of physiotherapy and support from medical professionals. Psychological treatment was also needed to aid her recovery.

The psychological effects of serious injuries are well known but the development into treatment for a multi-disciplinary approach to treatment for the same as well as the physical injuries is a recent change.
The recovery process for both serious and less serious injuries has changed in recent years and earlier psychological treatment, such as Cognitive Behavioural Therapy and / or Eye Movement Desensitization Reprocessing is known to assist in a much more satisfactory recovery / improvement in symptoms.

Many of the injured clients that we represent in the legal profession, are suffering from Post Traumatic Stress Disorder (PTSD), as the trauma of an accident can cause serious psychological damage.

We see a lot of our clients struggle with Psychological symptoms and in many instances the recovery from PTSD can be more difficult than the rehabilitation from the physical injury.

Our advice to clients that suffer from PTSD is to seek out the best possible psychological treatment which can make a big difference to the rehabilitation process.

We can help organize treatment for clients and ensure that they receive the best care from the early stages of their recovery.

In addition, although the process of rehabilitation has traditionally been viewed as ‘physical’ in nature, it is now considered a multi-disciplinary process involving not only the services of various Consultants/surgeons and physiotherapists but also psychologists.

Particularly over the last decade, we have identified increasing numbers of injured parties suffering from increasing psychological injuries; on some occasions, being far more severe than the physical injuries sustained by the injured person initially. These could be related to the incident itself or the difficulties they have had in dealing with the effects of the physical injuries upon them, and their families.

These can be office workers, members of the rescue services, sportsmen and women, or office workers. There is no particular ‘type’ of injured person that can suffer with psychological injuries following accidents resulting in injuries, no matter what the circumstances of the accident are.
Rehabilitation has increasingly become a multi-disciplinary approach and must be dealt with in this way. The psychological impact can be more devastating than the physical impact, and if not dealt with may leave the injured person with permanent injuries, and, in addition, if untreated can even prolong the physical injuries.

Where an injured person does not make a recovery from the physical injuries, they can develop Complex Regional Pain Syndrome (CRPS) formerly Reflex Sympathetic Dystrophy, this can be a particularly debilitating condition and again requires a multi-disciplinary approach to treatment.
There is much research into this area at the present time and experts are turning away from medication as a form of treatment to physical pain management such as physiotherapy, steroid injections and psychological treatment.

Lady Gaga cancelled her European tour in 2017 due to “severe physical pain that has impacted her ability to perform”. A Neflix Documentary, Gaga: Five Foot Two, was made by her to raise awareness about her long-term condition, Fybromyalgia.

George Clooney turned to a Pain Management Specialist following a Spinal Injury in 2005, which left him with chronic back pain.
Complex Regional Pain Syndrome is a poorly understood condition in which a person experiences persistent severe and debilitating pain, often caused by an injury.

The courts have now recognised a number of pain disorders in their own right and have dedicated a full chapter in the Judicial Studies Guidelines:-

Chapter 8: Chronic Pain (14th Edition)

This chapter deals with a variety of what may loosely be described as ‘pain disorders’. This includes Fibromyalgia, Chronic Pain Syndrome, Chronic Fatigue Syndrome (also known as ME), Conversion Disorders (also known as Dissociative Disorders) and Somatoform Disorders. Many such disorders are characterized by subjective pain without any, or any commensurate, organic basis. The figures given here assume causation of relevant symptoms is established. Cases of short-lived pain disorders, short-term exacerbation of an existing pain disorder, or brief acceleration of the onset of a pain disorder, all fall outside the suggested brackets and will require separate consideration.

With the exception of cases of Complex Regional Pain Syndrome (also known as CRPS), no attempt has been made to sub-divide between different clinical conditions. Guidance is instead provided based in particular on the impact, severity and prognosis of the condition. Where the condition principally affects a single part of the anatomy, cross-reference to the relevant chapter within the Judicial College Guidelines may assist. The presence of an overlapping psychiatric injury is commonplace in such cases.

The factors to be taken into account in valuing claims for pain disorders (including CRPS) include the following:

i. the degree of pain experienced;
ii. the overall impact of the symptoms (which may include fatigue, associated impairments of cognitive function, muscle weakness, headaches etc. and taking account of any fluctuation in symptoms) on mobility, ability to function in daily life and the need for care/assistance;
iii. the effect of the condition on the injured person’s ability to work;
iv. the need to take medication to control symptoms of pain and the effect of such medication on the person’s ability to function in normal daily life;
v. the extent to which treatment has been undertaken and its effect (or its predicted effect in respect of future treatment);
vi. whether the condition is limited to one anatomical site or is widespread;
vii. the presence of any separately identifiable psychiatric disorder and its impact on the perception of pain;
viii. the age of the claimant;
ix. prognosis.
with 10% uplift

(a) Complex Regional Pain Syndrome (CRPS)—also known as Reflex Sympathetic Dystrophy
The condition is characterized by intense, burning pain which can make moving or even touching the affected limb intolerable.

(i) Severe: in such cases the prognosis will be poor; ability to work will be greatly reduced if not completely eliminated; significant care/domestic assistance needs; co-existing psychological problems may be present. At the top end of the scale, symptoms may have spread to other limbs. £41,860 to £66,970 £46,040 to £73,670

(ii) Moderate: the top end of this bracket will include cases where significant effects have been experienced for a prolonged period but prognosis assumes some future improvement enabling a return to work in a significant (not necessarily full-time) capacity and with only modest future care requirements. At the lower end will be cases where symptoms have persisted for some years but are more variable in intensity, where medication is effective in limiting symptoms and/or where the prognosis is markedly better, though not necessarily for complete resolution. May already have resumed employment. Minimal, if any, future care requirements.
£22,340 to £41,860 £24,580 to £46,040

(b) Other Pain Disorders

(i) Severe: In these cases significant symptoms will be on-going despite treatment and will be expected to persist, resulting in adverse impact on ability to work and the need for some care/assistance. Most cases of Fibromyalgia with serious persisting symptoms will fall within this range. £33,590 to £50,210 £36,950 to £55,240
(ii) Moderate: At the top end of this bracket are cases where symptoms are on-going, albeit of lesser degree than in (i) above and the impact on ability to work/function in daily life is less marked. At the bottom end are cases where full, or near complete recovery has been made (or is anticipated) after symptoms have persisted for a number of years. Cases involving significant symptoms but where the claimant was vulnerable to the development of a pain disorder within a few years (or ‘acceleration’ cases) will also fall within this bracket. £16,800 to £30,690 £18,480 to £33,750

Guidelines for the Assessment of General Damages in Personal Injury Cases, Fourteenth Edition (2017) by Judicial College. By permission of Oxford University Press
[JC Guidelines Index] [PI Quantum Reports] [PI Index]

Document No. BL0000161

As identified in the Judicial Studies Guidelines the brackets for pain disorders can be significantly higher than an Orthopaedic injury.
In the following case the total damages awarded were substantial:
BARNETT v LEONARD CHESHIRE DISABILITY (2017) Lawtel
Total Damages: £375,000 (£393,338.73 RPI)
Trial/settlement date: 21/12/2017
Age at trial: 44 PSLA: £42,000 (£44,053.94 RPI)
Type of Award: Out of Court Settlement
Court: Out of Court Settlement
Age at injury: 39
Sex: Female

The claimant, a 44-year-old woman, received £375,000 for the knee injury she sustained in October 2012 and the chronic regional pain syndrome she subsequently developed. She suffered pain in different areas of the body, nightmares, flashbacks, panic attacks and limited mobility and she was unable to work and required ongoing care and assistance.

Employers’ Liability: On 25 October 2012 the claimant employee (C), whilst working for the defendant employer (D) as a support worker at a care home for the elderly, slipped on some water which had been spilt.

C sustained injury and brought an action against D alleging that it was negligent in allowing for an unsafe work environment to develop.

Liability admitted, but causation was disputed. C set out her claim as noted below. D, however, alleged that C’s current condition was not as a result of the accident, but would have occurred in any event due to pre-existing knee pain that would have resulted in the same circumstances that led to C’s current condition.

Injuries: C jarred and twisted the left knee.

Total injury duration: permanent

Effects: C developed pain and swelling which became progressively worse. On 10 April 2013 she underwent an arthroscopy on the knee. She subsequently developed a burning neuropathic pain at the site of the arthroscopy which then developed into chronic regional pain syndrome (CRPS). She also suffered depression, nightmares, flashbacks and panic attacks.

By November 2013 C’s CRPS had spread to the upper right limb. She suffered continuous and unrelenting pain in the left knee, left hip, right shoulder, the arm and fingers and the lower back, which radiated to the right side of the body. The symptoms of CRPS she suffered in the left knee included allodynia, temperature asymmetry, sweating, oedema, a reduction in the range of movement and mild skin discolouration. She also experienced weakness in the foot, tremors and atrophic changes in the nails and skin. The right hand and arm also showed an alteration in colour and temperature and were swollen.

C walked using two elbow crutches. Her hand movement was poor with a weak grip. She was unable to kneel or to stand for long periods. She experienced difficulty cooking, shopping and carrying out housework and was unable to cope with her personal care. As a result she required care and assistance.

Due to her condition, C was unable to work.

Prognosis: C’s CRPS and depression were not expected to improve and she would require ongoing care and assistance.

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Out of Court Settlement: £375,000 total damages

Background to damages:

The total damages figure included CRU and interim payments. It also reflected a number of issues: C had a history of knee problems and a prior vulnerability to musco-skeletal pain, migraines and episodic depression; she had very little or no residual earning capacity and required ongoing care and assistance; there was a very substantial litigation risk. C also provided for a Malvicini discount on account of her vulnerability in developing such a condition in any event.

PSLA was pleaded at £42,0000 before litigation risk. Therefore, £35,000 would be a reasonable estimate in relation to the settlement.

The case was settled on a global basis with no particular breakdown of damages. However, the following breakdown was estimated by the claimant’s solicitors:

Breakdown of General Damages: Pain, suffering and loss of amenity: £35,000.

Simmons v Castle [2012] EWCA Civ 1288 10 per cent uplift: not applied.

Marcus Grant instructed by Brian Barr Ltd for the claimant. Pankaj Madan instructed by Keoghs LLP for the defendant.

This Quantum Report was provided courtesy of Steven Akerman of Brian Barr Ltd, solicitors for the claimant.

The NHS website records the symptoms for CRPS as follows:-

“Symptoms – Complex regional pain syndrome

The main symptom of complex regional pain syndrome (CRPS) is pain, which can sometimes be severe, continuous and debilitating. It’s usually confined to one limb, but can spread to other parts of the body in some cases.
Chronic pain
The pain associated with CRPS is usually triggered by an injury, but is a lot more severe and long-lasting than would normally be expected.
The pain may be a mix of burning, stabbing or stinging sensations, but there may also be a tingling sensation and numbness.
You may have periods of pain lasting a few days or weeks, called flare-ups, where the pain gets worse. Stress in particular can lead to flare-ups, which is why relaxation techniques and mindfulness training can be an important part of treating CRPS.
If you have CRPS, your skin in the affected area can become very sensitive. Even the slightest touch, bump or change in temperature can provoke intense pain.

You may hear this described in the following medical terms:

• hyperalgesia – feeling pain from pressure or temperature that wouldn’t normally be painful
• allodynia – experiencing pain from a very light stroke of the affected skin

Other symptoms

In addition to chronic pain, CRPS can also cause a range of other symptoms, including:

• strange sensations in the affected limb – it may feel as if the affected limb doesn’t belong to the rest of your body, or it may feel bigger or smaller than the opposite, unaffected limb
• alternating changes to your skin – sometimes your skin in the affected limb may be hot, red and dry, whereas other times it may be cold, blue and sweaty
• hair and nail changes – your hair and nails in the affected limb may grow unusually slowly or quickly and your nails may become brittle or grooved
• joint stiffness and swelling in the affected limb (oedema)
• tremors and muscle spasms (dystonia)
• difficulty moving the affected body part
• difficulty sleeping (insomnia)
• small patches of fragile bones (osteoporosis) in the affected limb – although there’s no evidence this could lead to fractures

In very rare cases, CRPS can also lead to further physical complications, such as skin infections and ulcers (open sores), muscle atrophy (where the muscles begin to waste away) and muscle contractures (where the muscles shorten and lose their normal range of movement).

Some of these problems can make it very difficult for people with CRPS to move around.

Psychology in CRPS

The emotional strain of living with chronic pain can sometimes lead to psychological problems, such as depression and anxiety. During periods of extreme pain, some people may even consider suicide.”
The NHS website advice also states the following multi-disciplinary approach is needed:-

Treating CRPS

Treatment for CRPS involves four main aspects:

• education and self-management – being given clear information about your condition and advice on any steps you can take to help manage your condition yourself
• physical rehabilitation – treatment to help manage your symptoms and reduce the risk of long-term physical problems, such as physiotherapy exercises
• pain relief – treatments to help reduce your pain, such as anticonvulsants or antidepressants
• psychological support – interventions to help you cope with the emotional impact of living with CRPS, such as cognitive behavioural therapy (CBT)

Due to the complex nature of CRPS, a number of different professionals will usually be involved in your care.”

The research into treatment for CRPS is developing into a multi-disciplinary approach thankfully rather than simply being treated by medication, which can be extremely addictive.

The cost of the treatment however, is expensive and needs to be available as soon as possible to victims of personal injures to ensure a speedy and good recovery. Whilst they may not be put back in the position they were in prior to injury, treatment as well as compensation will ensure they make the best recovery possible.

Away With The Pain and the British Pain Society are two charities offering support to those suffering from this debilitating condition.