PAGE 107
1 A. No.
2 Q. And the studies that have been done,
3 have they suggested to the contrary, that there
4 is no correlation?
5 A. Yeah, there is no, no statistically
6 significant relationship between psychological
7 factors and who develops CRPS later.
8 Q. Okay. Let me ask you just about one
9 other category, and that is your own clinical
10 experience with patients in response to what I
11 anticipate is going to be Dr. Ochoa's testimony
12 about his own clinical response with these
13 patients.
14 You, you indicated in your CV that you
15 have treated well over 100 CRPS patients.
16 A. Yes.
17 Q. And have you followed those patients
18 over time, or some of them?
19 A. Some of them were followed over a
20 period of at least a year.
21 Q. And when I say you have treated them,
22 you have, you have seen them for the purposes
23 of both psychological diagnosis and to sort of
24 assist them in terms of coping strategies and
25 with reference to other medical providers, and
PAGE 108
1 so on?
2 A. Yes.
3 Q. And coordinated care?
4 A. Yes.
5 Q. Have you had patients who have, who
6 have -- these questions are going to go to the
7 impact of CRPS.
8 If you could -- I assume that this
9 varies widely from patient to patient.
10 A. Correct.
11 Q. In patients that have CRPS that becomes
12 chronic, let's say -- can we define chronic as
13 year or longer, or would you define it by some
14 other --
15 A. I would actually say it's shorter than
16 that. I think that by three to -- if it's
17 going to spontaneously remit, it typically does
18 so in the first three months or so.
19 Q. All right. In patients that have CRPS
20 that's chronic in nature, and say, lasts years,
21 rather than months, and understanding that
22 there is variability from patient to patient,
23 can you generalize the impact of CRPS on
24 people?
25 A. Well, it, it is variable, and it
PAGE 109
1 depends in part upon whether it's upper
2 extremity or lower extremity.
3 What I can say, having worked with a
4 pain program that had a big focus on
5 return-to-work issues, which was the one at the
6 Rehab Institute of Chicago, that a common issue
7 that had to be addressed was work modifications
8 to allow the person to successfully go back to
9 the kind of work they did before.
10 And, you know, for example, in people
11 with lower extremity CRPS, if their previous
12 career had been a construction worker, it's
13 going to be quite difficult to go back to that
14 kind of heavy labor. In patients with upper
15 extremity CRPS, the issues were, functional
16 issues were the ability to use the hand to do
17 things like type and grip and carry and that
18 kind of thing.
19 And while it wasn't impossible to do
20 those tasks, the ability to succeed in some
21 jobs requires modifications to work around any
22 limitations that may be associated with that.
23 Q. Let me follow up briefly, then.
24 Do you have an opinion concerning
25 whether the majority of the patients that you
PAGE 110
1 have followed and treated with CRPS had to make
2 either changes of career or significant job
3 modifications?
4 A. It depends on how you define
5 "significant." I mean it -- we had a few cases
6 of CRPS where it appeared to be total
7 resolution, but it was much more frequent to
8 have better control of the symptoms, but it
9 basically was continuing at a lower level.
10 And in those kinds of individuals, or
11 in the individuals who had severe CRPS that
12 didn't respond at all to treatment, then there
13 were modifications that were pretty routinely
14 made to their work situation as a condition of
15 their release. There was a standard process,
16 was a vocational rehab evaluation and an
17 occupational therapy evaluation at the work
18 site. And then they would meet with the
19 physician to make determinations of what
20 limitations would be put in writing when the
21 person was released to work.
22 Q. And if we talk about it in terms of
23 just generally the impact of this chronic pain
24 condition, CRPS, has it been your experience
25 that patients that have chronic CRPS that
PAGE 111
1 doesn't resolve, that it does have an impact in
2 most cases on people's ability to work or the
3 type of work they do?
4 A. That's very common. I mean, it's --
5 you can look in the literature and see some
6 cases are so severe that they do amputations
7 of the limbs because of the patient's
8 difficulties and the non-responsiveness, which
9 obviously is going to create, require
10 modifications in how you go about life.
11 Q. In your experience, how common is it
12 for chronic CRPS to cause major depression?
13 A. There's one study that has specifically
14 addressed that issue, and it was I think Monti,
15 M-o-n-t-i, is the first author. And they did
16 structured psychiatric diagnostic interviews to
17 look at how -- what percentage of CRPS patients
18 could be diagnosed with an Axis I disorder, and
19 that was generally referring to mood disorders,
20 like major depression and anxiety disorders.
21 And they compared that to a group of, I think
22 it was, low back pain patients, so non-CRPS
23 chronic pain.
24 And what they found was both groups had
25 a rate of about 24 percent being diagnosed with
PAGE 112
1 Axis I disorders of some of kind, and major
2 depression was the most common.
3 Q. I guess what I want to get a sense of
4 is, in your own clinical experience, working
5 with these patients, how much do they struggle
6 with CRPS? How severe of a pain disorder is
7 this?
8 A. It is a, it's a serious pain disorder,
9 because it not only has kind of the persistent
10 underlying pain that tends to be there, which
11 can vary intensity depending upon activity, but
12 it's also got frequently allodynia associated
13 with it, which is where even things like
14 clothing touching the area feels painful.
15 Um, and I had a patient in Chicago who
16 went around in short pants during the winter in
17 the snow because he could not stand the feeling
18 of his pants touching his leg.
19 Q. In your clinical experience working
20 with patients with CRPS diagnoses that you were
21 working with, how common were complaints of
22 problems with cognitive efficiency, either
23 because of the medications they were taking or
24 because of either sleep disturbance or the pain
25 itself?
PAGE 113
1 A. Every medication that is used for
2 treatment of chronic pain, which could include
3 narcotic medications, the neuroleptics, like
4 Gabapentin, that kind of thing, that are
5 antiseizure medications, and antidepressants,
6 which are the three big categories of drugs
7 that might be used in CRPS, those all are
8 associated with some type of cognitive side
9 effects, which people often report as, you
10 know, decreased concentration.
11 But, I mean, the truth is, even if
12 you're taking no medications at all but you
13 have chronic pain, we do know that that's
14 associated with sleep disruption; it's often
15 awakening during the night with pain;
16 difficulty falling asleep.
17 And the combination of poor sleep and
18 this constant distraction of having, you know,
19 pain being input into your nervous system, does
20 affect your concentration and does make it more
21 difficult to do things that require very high
22 levels of concentration. That is a common
23 report of patients that I have seen.
24 MR. EISENBERG: Okay. Thank you.
25 REDIRECT EXAMINATION
PAGE 114
1 BY MR. TANNER:
2 Q. I just have one or two real quick.
3 A. Sure.
4 Q. And Doctor, I appreciate your
5 experience on the last couple of topics that
6 Mr. Eisenberg has covered.
7 Your report that you provided in this
8 matter did not discuss things like this
9 chronic -- I'm sorry, I mumbled through that.
10 Let me start over.
11 You discussed with Mr. Eisenberg some
12 of the ongoing, for example, vocational
13 problems --
14 A. Um-hum.
15 Q. -- that these kind of people may
16 experience. Were you asked to do any of that
17 in the report provided to us on 12/15/05?
18 A. Those were not included in the report.
19 Q. Were any of your responses to
20 Mr. Eisenberg regarding Axis I disorders that
21 may result from a chronic pain, such as CRPS,
22 covered anywhere in your report?
23 A. Yes, in some way, because we did make
24 reference in there, I believe, to the -- I'm
25 trying to remember which version of this we're
PAGE 115
1 looking at here.
2 This may be in Exhibit -- what was it?
3 Exhibit 4? The raw notes? Maybe that was
4 mentioned in there.
5 In looking here now, I'm trying to see
6 if that was specifically mentioned in here.
7 Now, we -- what we did say was we would
8 address the question of whether preexisting
9 psychological factors exert a strong impact,
10 and one of those factors would be Axis I
11 disorders, mood disorders, such as depression
12 and anxiety.
13 Q. And I'm talking in the context of
14 developing the disorder as a result of --
15 A. Post?
16 Q. Post. Which I believe is what you were
17 discussing with Mr. Eisenberg.
18 A. Yes. I don't know if that is listed in
19 here as such.
20 Q. All right. Were you ever asked in
21 preparation for your report to discuss
22 specifically as to Ms. Nave any potential
23 concerns she might have regarding, let's start
24 with, vocational limitations in her life?
25 A. No.
PAGE 116
1 Q. As to potential developments of
2 depression or anxiety disorders?
3 A. Repeat the wording of that, please.
4 Q. The same question. Were you asked to
5 prepare any, in any way, any report or any
6 testimony regarding the development of the
7 potentiality or the actuality of any anxiety or
8 stress disorders developed by Ms. Nave, as a
9 result of her CRPS?
10 MR. EISENBERG: I'm not going to ask
11 Dr. Bruehl to -- well, I guess I have to
12 withdraw the partial comment made.
13 Dr. Bruehl is a rebuttal witness and is
14 dealing with an ever-evolving landscape, by
15 definition.
16 And since, you know, since I initially
17 contacted Dr. Bruehl and asked him to formulate
18 a report, there has been a redeposition of, of
19 Dr. Ochoa. There has been only a matter of
20 days ago a redesignation and amplification of
21 the areas of his testimony.
22 So I guess he will respond to questions
23 as -- based upon what evidence is in the record
24 at trial and based upon what reports have been
25 provided by trial and based upon what Dr. Ochoa
PAGE 117
1 says at trial. But -- therefore, you can
2 cross-examine him on any of these subjects.
3 MR. TANNER: All right. Let me --
4 probably lost the question in all of that, so
5 let me, let me try it again.
6 Q. (By Mr. Tanner) It's my understanding
7 that you have been called as a rebuttal witness
8 specifically with regards to Dr. Ochoa's
9 testimony. Is that your understanding?
10 A. That is my understanding.
11 Q. Okay.
12 MR. EISENBERG: I may be able to
13 shortcut some of this. Let me see if this
14 works.
15 MR. TANNER: I've only got two more
16 questions and then we'll just be done.
17 MR. EISENBERG: Okay. Go ahead.
18 Q. (By Mr. Tanner) Have you prepared,
19 other than the response as to Mr. Eisenberg's
20 questions regarding common cognitive
21 deficiencies that patients with CRPS have
22 developed, have you prepared any materials
23 addressing those same concerns as to Ms. Nave?
24 A. Have I -- are you asking have I
25 evaluated her with regards to those specific
PAGE 118
1 issues?
2 Q. Yes. And that was a much better way of
3 asking the question.
4 A. No, I have not.
5 Q. Okay. And the same question as to have
6 you performed any diagnosis or examination to
7 determine if she's developed stress or anxiety
8 as a result of the CRPS that she's currently
9 suffering?
10 A. I have performed no formal evaluation
11 of her.
12 MR. TANNER: Okay. That's all I have.
13 That's what I should have asked the
14 first time.
15 MR. EISENBERG: I just want to make a
16 record, I guess, that we received Dr. Ochoa's
17 supplemental disclosures and anticipated trial
18 opinions on February 14th, and that was briefly
19 discussed with, with Dr. Bruehl this morning.
20 He hadn't seen that till this morning.
21 I think we have covered the substance
22 of, of his rebuttal testimony today, but of
23 course because he's a rebuttal witness, I'm
24 going to reserve the right to have him respond
25 to whatever Dr. Ochoa discusses in his case in
PAGE 119
1 chief testimony.
2 MR. TANNER: That's fine.
3 MR. EISENBERG: Thanks.
4 MR. TANNER: Do you want to have him
5 read and sign?
6 MR. EISENBERG: Yeah. Could you send
7 this to Dr. Bruehl, and read this. We can
8 waive signature for the purposes of introducing
9 the deposition for impeachment purposes, but
10 please send it to Dr. Bruehl. If you do see
11 anything that's a transcription error, --
12 THE WITNESS: Yes.
13 MR. EISENBERG: -- would you bring to
14 it my attention?
15 THE WITNESS: Yes. I can do that.
16 (Deposition concluded at 1:07 p.m.)
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PAGE 120
1 REPORTER'S CERTIFICATE
2 I, Fred W. Jeske, Court Reporter and
3 Notary Public, do hereby certify that I
4 recorded to the best of my skill and ability by
5 machine shorthand all the proceedings in the
6 foregoing transcript, and that said transcript
7 is a true, accurate, and complete transcript to
8 the best of my ability.
9 I further certify that I am not an
10 attorney or counsel of any of the parties, nor
11 a relative or employee of any attorney or
12 counsel connected with the action, nor
13 financially interested in the action.
14 SIGNED this 20th day of February, 2006.
15
16
17
18 Fred W. Jeske, Court Reporter
Tennessee at-large notary public
19
20 My commission expires:
November 14, 2009
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1 AMENDMENTSHEET
2
I, the undersigned, STEPHEN P. BRUEL,
3 Ph.D., do hereby certify that I have read the
foregoing deposition and that, to the best of
4 my knowledge, said deposition is true and
accurate with the exception of the following
5 corrections listed below:
6 PAGE / LINE
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8
9
10
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12
13
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20 Date Signature of Witness
21 Sworn to and subscribed before me,
this day of , 2005.
22
23
Notary Public My commission expires
24
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