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Case Study: Establishing Causation of Complex Regional Pain Syndrome


Newton's Cradle game

Unlike some chronic pain conditions, CRPS does have objective signs which are required to be seen over time in order to meet the diagnosis. The signs of CRPS can include discolouration of skin, adverse hair and nail growth, swelling and sweating to name just a few. This is helpful to establishing causation, but by no means do objective signs alone prove causation, i.e., that the accident or work processes were the cause of the condition or that the signs and symptoms are that of CRPS and not some other unrelated condition or faked for financial gain.


These cases can be very high value, both in terms of compensation/damages and legal costs. Due to the perceived permanency of the condition and the fact that people with CRPS in most cases struggle to work and require care and assistance, means damages can be very high. In turn legal costs can be eye watering because the investigations to prove or disprove high value damages requiring a great deal of work from specialist lawyers.


The future loss element of these claims can run into millions of pounds and so defendant insurers invest heavily in disproving medical causation, i.e, to say that the accident did not cause the condition and almost always will argue that CRPS is the incorrect diagnosis.



Case study


We recently settled a case for a young man who developed bi-lateral upper limb CRPS (both hands) which naturally meant he was extremely disabled. He worked in the motor industry in manufacturing and due to a lack of job rotation, excessive forces, using his hand as a hammer, constantly having wet and cold hands, having to fit defective parts and poor health supervision by his employers, he developed carpal tunnel syndrome and torn TFCC joints in both hands, he was only in his mid-20s when he was injured. Following decompression surgery and TFCC repair surgery and then revision surgery, he developed CRPS in both hands.


At first glance, given the early admission of negligence, which admitted that the workplace processes had caused some injury, we felt confident that we would succeed in pursuing a high value claim.



Dissection of the Claimant’s medical records


In this particular case, the claimant’s medical history was called in to question. It was argued that he had attended his GP and hospital appointments on numerous occasions for health issues over the course of his life, which had no organic basis, i.e., no physical evidence of a condition.


This was important because this supported the defendant’s case that the Claimant was pre-disposed to experience a heightened perception of pain and they produced psychological evidence that he had developed Somatoform Symptom Disorder (SSD). This is a real condition of a psychological origin which in simple terms can cause someone to experience pain, which is genuine, but which is psychological rather than physiological. SSD can be successfully treated with psychotherapy and therefore is thought not to be permanent, unlike CRPS which can be.



Other causes of carpal tunnel syndrome


The Defendants argued that, due to his raised BMI and because he had done weight training in the past, the Claimant was predisposed to develop carpal tunnel syndrome. A proportion of the population, some 10% or more, will develop carpal tunnel syndrome naturally and the defendant’s case was that this Claimant would have developed carpal tunnel syndrome in any event, even if he had not worked for the defendant. They therefore argued that he would have required surgery in any event and so would also have developed CRPS in the absence of carrying out work for the defendants, which they alleged was just incidental.


The Defendant's case was supported by medical experts who disputed the diagnosis of CRPS, accepted he had carpal tunnel syndrome but in terms of ongoing symptoms, stated the Claimant was at best suffering from a psychological disorder (SSD) or else was exaggerating his claim for purposes of financial gain.



Withdrawal of the admission


Some three years after their liability admission, once the true value of the claim became clear, the defendants obtained a report from ergonomist (an expert in forces and workplace systems and their impact on the human body) to disprove that each of the work processes undertaken in the workplace were of sufficient force or repetition to cause carpal tunnel syndrome and TFCC tears.



Surveillance


In addition, the Defendant obtained over 30 hours of surveillance footage on the Claimant over a number of weeks and months throughout the life of the claim.



Medical evidence


The Defendants obtained medical expert reports which were used to interpret the surveillance footage, the medical notes and the ergonomics evidence. The medical experts gave opinions on causation and prognosis. The evidence of those experts was detailed and voluminous and sought to discredit the Claimant at every turn alleging pre-existing vulnerability, psychological illness and even opened the suggestion of conscious exaggeration.


Interestingly, the solicitors were not so convinced as to allege fraud or fundamental dishonesty, leaving the possibility of this a matter for the courts to determine.



Claimant’s response


The defendants were in a difficult position despite mounting what superficially looked to be a strong defence, because they did not have any strong surveillance footage to discredit the Claimant. Much of the footage was in fact very useful to the Claimant in proving specific disadvantages he faced due to what were obviously genuine symptoms of disability.


We were able to look closely through the lifetime of records to show that the defendants medical experts omitted references to numerous entries where there was a physical cause of complaint and that following treatment the complaints stopped, countering to some extent the suggesting of SSD. However, there was no doubt from the records that the Claimant was anxious about his health in general.


Much work was conducted involving a further ergonomist and by preparing highly detailed witness statements and video exhibits to prove that the workplace processes were repetitive, and that great force was required to complete works and that would have exposed the claimant to a risk of injury. We were able to obtain statements from five former colleagues of the claimant, all of whom supported the poor work processes were a significant factor in the onset of the Claimant’s symptoms. These statements discredited the employers attempts to demonstrate a perfect workplace and health surveillance system, which was clearly not present.


We obtained very detailed statements from the Claimant and family members all supporting the onset of pain and the impacts of the injuries on the Claimant and his family over time. Some nice family members were all interviewed, and statements prepared. It had to be said that this approach added a great deal of weight to the Claimant’s case about the variability and severity of his symptoms.


With expert evidence of our own we were able to argue that whilst a proportion of the population are at risk of developing carpal tunnel syndrome, the vast majority are successfully treated with non-invasive techniques, such as physiotherapy and anti-inflammatory medication. Only a very small proportion would go on and require surgery and a smaller proportion still would develop CRPS as a result.


There was very little evidence to show that the Claimant would have been one of the few to have surgical intervention as a result of naturally developing carpal tunnel syndrome. The balance of probability test assisted us in the face of overwhelming evidence about poor work systems and processes.


It helped that the Claimant had never worked in a manual role before working for the defendant and despite numerous other health complaints pre-dating the accident, he had never injured his wrists before or had and signs or symptoms of carpal tunnel syndrome before working for the defendants. He had gone from no symptoms to first surgery within 18 months of commencing his role with the defendants. Onset of discomfort and objective signs and symptoms recorded post injury proved pivotal in linking the workplace processes to the onset of his condition.


It helped in this case that the Defendants also sent the Claimant back onto the production line against doctors’ orders whilst he was on light duties. Subsequent to that he required revision surgery which it was agreed by treating and medico-legal experts had exacerbated his condition.


Eventually we were able to settle the Claimant’s case at a joint settlement meeting for a seven-figure sum.


From the Claimant’s perspective it is very important that a range of experienced and suitably qualified medical experts assess you over time in order to demonstrate the timescale for onset of symptoms of CRPS.



Contact FT Chronic Pain Solicitors today


At FT Chronic Pain Solicitors, we are tried and tested at successfully pursuing CRPS claims. We have a panel of experts that we know give sensible and balanced opinions. The case above was complex and hard fought and we are delighted to learn this client has just purchased himself a house outright with his compensation.


Contact us today and see how FT Chronic Pain Solicitors may be able to change your life.


Call us: 0800 999 1078



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