Nature and Extent of Injury Caused
60There is a strong degree of consensus between the experts about the symptoms and consequent disabilities complained of by the Plaintiff:
Pain in neck, back, chest and right shoulder.
Occasional other pain and cracking or clicking in back and chest, hip and right knee.
These in turn lead to problems: driving, sleeping for long periods, depression and anxiety, increased tiredness, and pain.
There is consequent inability to work more than about 6 hours per day.
The pain and tiredness restricts her ability to do common household, garden, or work tasks such as lifting overhead, driving, or repetitive tasks for very long.
61By 2009 despite regular assessments and rehabilitation a pattern had been established. Ms Duncan could, as she said in evidence on 13 May 2013, manage the symptoms with painkillers and by avoiding tasks that aggravated her condition. If she "pushed over that level it was too much" and symptoms would be exacerbated, especially "fatigue", "forgetfulness", "stinging in back of neck" and "being rundown".
62There is no consensus however about what is the cause of these symptoms. Ms Duncan is, I find, now convinced the cause is organic. She does not and cannot accept there is a functional, psychological or psychiatric element to her symptoms. If, as I have found, the symptoms are causally related to the accident and the Defendant's breach of duty it matters not whether the case is organic or psychological.
63A court cannot make an award of damages for future economic loss "unless satisfied by the claimant that the assumptions about future earning capacity or other events or which the award is to be based in accord with the Plaintiffs most likely future circumstances but for the injury": s 126. Further, an injured person is under a duty to mitigate their damages: s 136.
64Apart from the Plaintiff's contentious expert support for a continuing organic or physical cause for the injury comes primarily from Dr Patrick, a surgeon. A number of his reports were tendered: 16/05/2008; 31/12/2008; 23/01/2009; 21/12/2012; 18/02/2013 and 19/02/2013 all in exhibit A at pages 43,75,79,157,162 and 164. After examination of the Plaintiff in May 2008 his initial belief was Ms Duncan "sustained significant hyperflexion injury to cervical spine with likely ligamentous and cervical zygapophyseal joint injury with disc injury not excluded" and "also sustained significant upper and mid-thoracic facet injury with continuing symptoms and signs in this spinal region." He also noted "evidence clinically for some degree of likely post traumatic subacromial bursitis/impingement of the right shoulder": exhibit A page 47 (16/05/08). He noted that the accident has resulted in "physical and psychological sequelae." He did not believe the Plaintiff was "embellishing her situation": exhibit A page 47.
65Contrary to other experts, Dr Patrick found the Plaintiff's injuries rateable for assessment at over 10%: exhibit A pages 75, 77. In 2012 he noted her presenting symptoms and her "belief" she would be working to capacity, working six hours per day: exhibit A pages 158,159. He noted "Thoracolumbar spine is stiff ... there is significant muscle guarding now at lumber spine para vertebrally": exhibit A page 160. In his opinion the Plaintiff's condition had "deteriorated with significant ongoing symptoms ... definite signs clinically now at lumber spine" and "signs at all three spinal regions cervical, thoracic and lumbar": exhibit A page 60.
66Dr Todhunter, a pain specialist, saw the Plaintiff in 2007. He "believed" the Plaintiff had "a muscular type of pain in the form of a myofascial syndrome": exhibit A page 29. Dr Todhunter recommended a cognitive behavioural pain management programme as the "best approach" as "no direct treatment would reduce her pain significantly in the long term". He found "no structural problems", "no neurological signs" and "a good degree of flexibility and range of movement".
67Dr Evans, orthopaedic surgeon, 10/07/2009, diagnosed "multiple musculo-ligamentous sprains in the cervical, thoracic and lumber region". He noted "it might seem odd making this diagnosis in the absence of objective findings". He did not think treatment would make any difference: exhibit A pages 94 - 107, 10.07.2009
68I have considerable problems accepting Dr Patrick's opinions. He qualifies his opinion as statements of belief. He says there are clinical signs but does not say what these clinical signs are, other than noting symptoms described by the Plaintiff. His whole body of assessments are out of kilter with all other qualified experts. For example, Dr Pell noted "otherwise normal pathology": exhibit A page 11. Dr Zeman, a consultant in rehabilitation medicine, whose opinions on this issue answers what was said by Dr Patrick, explained why Dr Patrick's reference to "facet joint injury" is surmise: exhibit 1 page 88:
"In essence she has symptoms and the clinical signs are minimal, certainly not enough to warrant assessable impairment. The restrictions that he [Dr Patrick] places on her activity can be self-fulfilling": exhibit 1 page 90 15/4/13.
69On 17 July 2012, Dr Zeman said "the pains at this stage depend predominantly on factors unrelated to the degree of underlying organic pathology". He noted:
"Her investigations have been essentially normal. There is a consensus of medical opinion about this.
Pain is a symptom not a clinical sign. Complaints of pain are readily influenced by non-organic factors such as depression or behavioural reactions. A complaint of pain in itself is not a sign of pathology or the severity of the pathology. She has complaints of pain but no objective clinical signs of significant organic pathology. Her complaints of pain and impaired function are greater than would be expected from the degree of identified organic pathology. This is my opinion.
There has been general agreement by most doctors about this except for Dr Patrick": exhibit 1 p88.
70Dr Zeman is not alone in his opinion and I prefer it, as it is more likely to be correct than Dr Patrick's. While both Dr Evans and Dr Todhunter were prepared to accept or believe the Plaintiff's symptoms had an organic basis, there was no objective evidence to support those conclusions. Having reviewed the opinions in both exhibit A and exhibit 1, I am compelled by the overwhelming weight of expert opinions to agree with Dr Lim: "I believe Dr Patrick was over interpreting subjective response of the claimant and his examination": exhibit 1 page 30.
71Dr Lim also disputes Dr Todhunter's initial diagnosis of myofascial pain syndrome, as, he says, one of its characteristics are not present: exhibit 1 page 22. As an occupational physician, his opinion was the Plaintiff's "ongoing symptoms and disabilities ... could not be supported by objective clinical problems": exhibit 1 page 22.
72Drs Pell, Zeman and Lim have considerable expertise but they are not psychiatrists or psychologists. Each however surmises there is a psychiatric or functional explanation for the Plaintiff's complaints and symptoms. That surmise seems based on three solid premises:
(1)Ms Duncan's symptoms are constant and genuine.
(2)There is no alternative organic cause.
(3)It accords with the concerted view of those who do have the expertise for diagnosing a psychiatric psychological basis for injury.
73The reports in exhibits A and 1 show a consistency in complaint, including over the period 2004-2007. Also consistent was the Plaintiff's reporting that pain symptoms increased when her workload was heavier. Dr Todhunter's recommended the "best approach" was a cognitive behavioural pain management programme: exhibit A page 29. Dr Kafataris however did not support pain clinics as he finds them ineffective: exhibit 1 page 5.
74In 2008, Dr Kenny, a consultant psychiatrist, thought the Plaintiff had a mild adjustment disorder and Post Traumatic Stress Disorder: exhibit 1 page 11. Ms Matsuka, a psychologist, noted a reactive depression and emotional over-reaction: exhibit A page 33. She recommended counselling focussed on pain management and cognitive behaviour therapy to deal with the Plaintiff's "cognitive distortion" that the pain will never end.
75In 2008, Dr Patrick reported "chronic pain syndrome" and he too, strongly recommended psychiatric treatment: exhibit A pages 43 - 48. Dr Parker, a rehabilitation physician, noted chronic pain that in 2009 was still "very problematic. He firmly believed the Plaintiff needed to take part in a residential pain management program: exhibit A pages 89 - 90.
76Dr Robertson, a consultant psychiatrist, preferred diagnosis was Post Traumatic Stress Disorder and Major Depression: exhibit A page 152, 7/10/2012. Given the eight years that had then elapsed since the accident he said her prognosis for recovery was "extremely poor" and that "it was reasonable that she is unable to work for more than six hours per day". He recommended drug treatment and psychological treatment encouraging 12 to 24 sessions but was guarded as to the likelihood of success given the "chronicity of her depression is a poor prognostic factor": exhibit A page 155.
77Dr Moore, psychiatrist, also gave a guarded prognosis given the Plaintiff "did not recognise or acknowledge psychological factors": exhibit 1 page 38. She found the Plaintiff was "suffering" from one of the somatoform disorders "chronic pain without an organic component and a strong psychological component": exhibit 1 page 37. She was not clear what the origin was. Although the only evidence available to her was the accident.
78She too repeated what is clear from most reports, the regular reviews by the Commonwealth Rehabilitation Service (CRS) and from the Plaintiff's evidence, in chief and during cross-examination: "she is not psychologically minded and has specifically rejected psychological forms of treatment": exhibit 1 page 39. Further examples can be found in both parties' exhibits: for example, Professor Pryor 4/12/2009 exhibit 1, pages 52, 53 and 56; CRS Report 3/11/2008 exhibit A page 68.
79In summary, the overwhelming weight of medical opinion is that following the accident the Plaintiff suffered soft tissue and muscular ligamentous injury, and I so find. There are no continuous organic symptoms or objective sources for it but she still, now nine years after the accident, suffers pain. Work stress, increased exercise, and certain movements exacerbate that pain. Ms Duncan has been told that despite the absence of objective findings her complaints have an organic basis. She believes this. She is not psychologically minded - she cannot accept that the problem is psychological or 'in her head'. She has had only moderate success with drug treatment, exercise, massage, and physiotherapy. She has rejected pain management and psychological therapy. She believes she will never improve. If she does not her working capacity will be reduced, as it has been to date. So too will her capacity to lead the life she led but for this injury. The most likely diagnosis for her current symptoms is Reactive Depression, Post Traumatic Stress Disorder, and Chronic Pain Syndrome resulting from the accident and I so find. There is no need to distinguish one from the other. Although exacerbated by work stresses there is no evidence of any other cause for her present position other than the motor vehicle accident, the subject of these proceedings.
80The Plaintiff could have moderated the symptoms to date had she successfully completed recommended psychological pain management therapies, even though those qualified by her Workers Compensation insurer took the view remedies such as pain clinics were ineffective: Dr Kafataris exhibit 1 pages 5 and 6. However, it is most likely her failure to do so arose from matters related to the accident itself and the subsequent advice and treatment she has received. Accordingly I do not find that there has been any failure on the Plaintiff's part to mitigate her loss to date.