Complex Regional Pain Syndrome (CRPS) often rears its ugly head in personal injury cases and can cause issues for lawyers acting on such cases due to the fact that is an injury frequently misunderstood and can be difficult to quantify.
What is CRPS?
CRPS is a condition which is not easily identified and is also not very well publicised. It is, however, an extremely painful condition where sufferers experience persistent, severe debilitating pain which can have an enormous impact on their lives and those around them. It is claimed that doctors are not sure what actually causes some individuals to develop CRPS while others with similar trauma do not. In more than 90 percent of cases, the condition is triggered by a clear history of trauma or injury. The most common triggers are fractures, sprains/strains, soft tissue injury (such as burns, cuts, or bruises), limb immobilisation (such as being in a cast), or surgical or medical procedures (such as needlestick).
The most common symptoms of CRPS to be vigilant for include:-
- A burning intense stabbing pain / it can also be described as a cold pain
- Experiencing pain from the lightest of touches – the medical term for this is allodynia ( an example is experiencing a painful reaction from something that you would not normally expect to cause pain, such as stroking the skin with a feather )
- An extreme pain reaction to painful stimulation – the medical term for this is
- Continued intense pain after injury where you normally would have expected to make a full recovery
- Abnormal swelling in the area affected ( the medical term is oedema )
- Skin Colour Changes / a mottling appearance to the skin
- Excessive sweating in the affected area
- Abnormal nail and / or abnormal hair growth
- Abnormal skin temperature in the affected area ( where one side of the body differs by more than 1% to the other )
- Joint tenderness / stiffness
- Restricted or painful movement
- Cracked / grooved / brittle nails
- Tremors and muscle spasms ( the medical term is dystonia )
It is recognised that there are 2 types of CRPS:-
Type 1 (RSD)
Where the symptoms come on after a trauma / injury to the affected area but where there is no actual damage to the nerves. This is the most common form of CRPS and accounts for the majority of diagnosed CRPS cases.
Type 2 (Causalgia)
This comes on after a distinct injury to the nerve. This is a rarer form of CRPS. Type 2 symptoms tend to be more painful and difficult to control.
What types of injuries are most likely to cause CRPS?
- Cuts from knives / lacerations in the catering industry / meat production / abetoirs
- Injuries where hands or feet become crushed or trapped on machinery /equipment
- Injuries where hands / fingers are crushed by closing doors / doors being obstructed
- Injuries where fingers become trapped in machinery / equipment resulting in finger amputation
- Injuries involving power tool either, causing electrocution or lacerations to fingers / the hand which sever tendons / cause nerve damage
- Any other type of laceration injury caused by handling objects with sharp / rough edges / glass
- Any injuries resulting in fractures to the fingers / hands / wrist / feet which require surgery to repair ( where nerves may be affected ) or a long period of immobilisation in a cast
How are injuries which result in CRPS valued?
Contrary to some old fashioned theories, which have attributed CRPS as a psychological disorder, research has demonstrated that CRPS is a physical disorder. History shows that tactics employed by Defendants to discredit Claimants include accusing them of malingering, in other words exaggerating their claim for financial gain or that they are suffering from a form of a psychological disorder such as a somatoform disorder or hysteria.
In the past, matters were not helped by the fact that Chronic pain conditions, including CRPS were included in the Chapter on Psychiatric and Psychological Damage in the Judicial College (formerly the JSB) Guidelines. The assignment of Chronic Pain as a Chapter in its own right for valuation of damages in the JC Guidelines 11th Edition 2012 reflected a sea change in the classification of Chronic Pain conditions including CRPS which are now recognised as serious injuries in their own right in the publication by the Judicial College. CRPS has thankfully also been afforded its own subcategory within the chapter on Chronic pain, which helpfully gives guidance to the judiciary, Claimant and Defendant Solicitors alike.
The Chronic Pain Chapter in the latest 13th edition of the JC Guidelines provides the following helpful factors to take into account when considering the value for an award of damages for a Chronic Pain Condition including:
- the degree of pain experienced;
- 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;
- the effect of the condition on the injured person’s ability to work;
- 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;
- the extent to which treatment has been undertaken and its effect (or its predicted effect in respect of future treatment);
- whether the condition is limited to one anatomical site or is widespread;
- the presence of any separately identifiable psychiatric disorder and its impact on the perception of pain;
- the age of the claimant;
The guidance does identify the potential link with an identifiable psychiatric disorder and its impact on the perception of pain as a factor to be taken into account, but it is very clear that this is just one of the multiple factors to consider and take into account when dealing with a claim for Chronic pain. This is a welcome step for many injured people who struggle to come to terms with some of the defences raised by some Defendants that there pain is purely a psychological condition.
It is well recognised, however, that many people suffering from Chronic Pain conditions, particularly CRPS can experience psychological symptoms and recognised psychiatric disorders. This can be because living with a long term pain condition can be very distressing and can cause depression and anxiety. Accessing psychological treatment and support can be extremely beneficial to people caught in a cycle of chronic pain. Individuals have described the real benefits of cognitive behavioural therapy treatment to help them come to terms with their injury, their pain and to teach them coping strategies to help manage the pain.
In order to be able to fully assess the likely value of a Claimant’s general damages award for CRPS, given the multiple symptoms and overlap between different specialist areas of medical expertise, it is good practise to instruct a multi-disciplinary team of experts to examine a Claimant to arrive at an accurate diagnosis / prognosis of the injuries and recommended package of treatment which might (depending on the nature of the symptoms) require opinions from the following:-
- Consultant in Pain Medicine
- Orthopaedic Consultant
- Occupational Therapist
Depending on the range of symptoms, reference should then be made to the orthopaedic injuries sustained, psychological injuries and the CRPS pain symptoms for each relevant chapter of JC Guidelines with some discount applied for overlap of symptoms.
What can lawyers do to assist with accessing treatment for a Claimant with CRPS?
Experts recognise that a dedicated multi-disciplinary pain management programme can have enormous benefits in rehabilitating a client with a chronic pain condition.
A collaborative approach, working together with Defendants to access clients a combined package of quality multi-disciplinary treatment is the preferred approach as it is proven that the earlier a sufferer of chronic pain can access a pain management programme, the better the outcome is likely to be.
The package of treatment might include:-
- prescribed pain relief medication
- physical rehabilitation – including input from occupational therapist and physiotherapists with
- psychological support
- the fitting of a spinal chord stimulator( in some severe cases where other methods of pain control do not work ) – this is where a device is surgically implanted which uses electric currents to control and manage the pain
Some people are fortunate to be able to access this treatment on the NHS. However not all recommended pain treatments are widely available on the NHS and in some instances there may be lengthy waiting lists. In these circumstances, funding from Defendants to assist a Claimant to access the treatment they need at an earlier stage can be of real benefit.
Also many professionals, who are injured and do want to continue working find that it is easier to access the treatment privately so this can be arranged at a convenient time for them which will not impact on any time off work.