Public Decisions | The Appeal Commission

Decision #14/01 - Type: Workers Compensation

Preamble

A non-oral file review was held on May 11, 2000, at the request of a worker advisor, acting on behalf of the claimant. At this time, the Appeal Panel requested that a Medical Review Panel (MRP) be convened in accordance with Section 67(3) of the Workers Compensation Act (the Act). A MRP was later held on October 23, 2000 and the findings and opinion of the MRP were distributed to the interested parties for comment. On December 5, 2000, the Panel met again to render its final decision on the issue under appeal.

Issue

Whether or not the claimant is entitled to compensation benefits after August 12, 1999.

Decision

That the claimant was not entitled to compensation benefits after August 12, 1999.

Background

In October 1997, the claimant submitted a compensation claim stating that she developed pain in both arms during the course of her regular duties as a data entry operator "prior to 1997". A Doctor's First Report dated October 17, 1997 (date of first visit was February 19, 1997) diagnosed the claimant's condition as bilateral epicondylitis and a repetitive strain injury. The attending physician referred the claimant for physiotherapy sessions and to an orthopaedic specialist.

In a report dated April 28, 1997, the orthopaedic specialist noted that the claimant complained of a left anterior arm lump. The claimant also had pain in her forearms, medial wrists, medial elbows, and numbness and tingling in the hands, getting worse over time. The specialist indicated that the claimant likely had medial epicondylitis and likely also bilateral carpal tunnel.

On August 27, 1997, the orthopaedic specialist indicated that the claimant was seen in follow-up concerning her bilateral hand numbness and forearm pain. According to the specialist, nerve conduction studies were negative for any carpal tunnel syndrome. The specialist determined that the claimant "may have possibly something like fibromyalgia", and suggested a referral to a rehabilitation medicine specialist.

The rehabilitation medicine specialist (physiatrist) provided a report to the Workers Compensation Board (WCB) dated April 20, 1998. The physiatrist's assessment indicated that the claimant had a definite history and physical findings of multiple muscle myofascial trigger points with objective signs. Treatment included a cortisone injection of the myofascial trigger points in the left brachioradialis muscle. The specialist also arranged to carry out a series of myofascial trigger point needling and stretch procedures for extensor and flexor muscles of the left forearm.

A follow-up report from the physiatrist dated September 8, 1998, noted that the claimant was last seen on August 31, 1998 and she had a major decrease in her pain symptoms and a major increase in her functional abilities. The physiatrist felt that the claimant had not reached the stage where she could return to her former employment. A functional assessment in occupational therapy was recommended in order to assess the claimant's upper limb function and ability to return to data entry and keyboarding type of work.

The claimant was subsequently referred to Par Health Services for treatment. In a discharge summary report from Par Health Services dated March 24, 1999, it was recommended that the claimant return to an occupation that was at a sedentary or light level of work that did not require repetitive upper extremity movements or excessive or repetitive lifting.

On April 28, 1999, a WCB medical advisor reviewed the file at the request of primary adjudication. The medical advisor was of the opinion that there was no cause and effect relationship between the claimant's ongoing problems and the compensable injury and that no restrictions were required. In addition, the medical advisor commented that the claimant had been off work for a long time and believed she had recovered from the effects of the compensable injury. He indicated that the claimant's current problem was pain with increased activities without any solid objective evidence. The medical advisor stated he could not relate the claimant's subjective symptoms to the compensable injury.

A further report was received from the physiatrist dated April 28, 1999. The physiatrist stated that he agreed with conclusions and recommendations noted in the discharge report from Par Services dated March 24, 1999. He stated that the claimant had a significant benefit from a series of trigger point needling and stretch procedures which eliminated pain at rest and increased her functional abilities. The specialist noted, however, that the degree of muscle overload and the length of time this occurred while the claimant continued at work had led to physical impairment that could not be reversed by further treatment. The physiatrist concluded that the claimant was capable of gainful employment in the future but not the type of work required in the occupation of a data entry operator.

On August 25, 1999, the claimant was informed that in the opinion of Rehabilitation and Compensation Services, the weight of evidence did not support a cause and effect relationship between her ongoing difficulties and the compensable injury of March 1, 1997. As of August 12, 1999, no further wage loss benefits were payable.

On September 9, 1999, the claimant appealed the above decision to Review Office. In a decision dated December 17, 1999, Review Office requested that the claimant be examined by a WCB medical advisor prior to rendering a final decision. The claimant was later examined by a WCB physical medicine and rehabilitation consultant on January 6, 2000.

In a decision dated February 4, 2000, Review Office determined that the weight of evidence did not support the contention that the claimant continued to remain disabled as a result of the workplace injury of March 1997. "The Physical and Rehabilitation Specialist was unable to find any evidence of an active myofascial pain syndrome related to the worker's activities as a Data Entry Operator. He reported the findings were more suggestive of a fibromyalgia condition, which in our view is unrelated to this claim or the worker's employment." Review Office concluded that the claimant was not entitled to compensation benefits after August 12, 1999.

On March 3, 2000, a worker advisor appealed Review Office's decision to the Appeal Commission. Additional medical information was also submitted from the treating physiatrist dated April 27, 2000.

On May 11, 2000, a non-oral file review was held at the Appeal Commission. Following discussion of the case and the issue under appeal, the Panel requested that a Medical Review Panel (MRP) be convened in accordance with Section 67(3) of the Workers Compensation Act (the Act). A MRP was then held on October 23, 2000 and the MRP's report/findings were distributed to the parties with a direct interest for comment. On December 5, 2000, the Panel met to decide on the issue under appeal and took into consideration a submission from the worker advisor dated November 28, 2000.

Reasons

The issue in this appeal is whether or not the claimant is entitled to compensation benefits after August 12, 1999. The relevant subsection of The Workers Compensation Act (the Act) in this appeal is subsection 39(2) which provides for the duration of wage loss benefits.

Subsection 39(2) states:

Duration of wage loss benefits

39(2) Subject to subsection (3), wage loss benefits are payable until

the loss of earning capacity ends, as determined by the board; or
the worker attains the age of 65 years.

Relevant WCB Policy in this appeal is Section 44.10.20.10, Pre-Existing Conditions.

In this appeal we reviewed all the evidence on file and submitted during the review process. We find that the weight of the evidence, on a balance of probabilities, supports a finding that the claimant is not entitled to further compensation benefits beyond April 12, 1999.

In reaching this decision we note that the Employers Report of Injury dated October 16, 1997 indicated that " Employee states: That during the course of her regular duties as a data entry operator, pain developed to both arms." Similarly in the Workers Report of Injury dated October 6, 1997 the employee indicated; " That during the course of my regular duties as a data entry operator, pain developed in both arms." We note that the initial diagnosis based on an examination on February 19, 1997 by an attending physician was bilateral epicondylitis and repetitive strain injury. Bilateral carpal tunnel syndrome was suggested but was not confirmed by nerve conduction studies. Further a tentative diagnosis of "something like fibromyalgia" was made by a consulting orthopaedic surgeon, as recorded in a report dated August 27, 1997.

We note in a report dated January 30, 1998 that the claimant's attending physician indicated that the claimant had been attending his clinic for pain in her arms since 1992. During that time the claimant had been referred to several specialist practitioners and investigated for various diagnoses. The attending physician further indicates that, " at present the diagnosis is fibromyalgia." The attending physician also noted in the same report that, "as far as I have been able to see no injury has been reported in the past ten years."

During that time the claimant had also been referred to a consulting orthopaedic surgeon who indicated in a report dated December 9, 1992:

. The patient states she was involved in a motor vehicle accident in April 9/88, she was apparently in her truck and ran into the back of another vehicle, she thought there was about three thousand dollars damage to her truck. The patient states that having her seat belt on knocked the wind out of her initially, but later that evening she had a lot of pain in her neck and had to go to the hospital.

On examination of this lady, I note she is a little overweight. On examining range of motion of her neck, she has good flexion and extension, good rotation left and right, lateral bending to left is fine, but lateral bending to her right of her cervical spine does show some decrease with her then having pain all across the upper part of her chest just below the clavicular region, this however is both right and left. The patient does have numb reflexes, biceps, triceps, brachioradialis. The patient has normal range of motion of her shoulders, elbows, wrists and hands. The patient has no motor deficit, good radial pulse bilaterally. I note that the patient does have some decreased sensation to light touch of the index finger, but also a bit of the mid finger, but no abnormal touch sensation to the small finger.

. It is my impression clinically that the patient does not have a significant carpal tunnel syndrome, the patient has pain in most of her upper extremity and it is not necessarily in the carpal tunnel or the median nerve distribution, although the numbness the patient usually describes is not in the median nerve distribution, it appears to be more on the dorsum of her wrist, than she does anywhere else."

In a report dated June 9, 1994 a consultant internal medicine specialist also indicated:

"(Dr's name).. asked me to see this patient regarding her paraesthesiae and numbness in the arms. She attributes this to starting after delivery of her child when she was straining during labour."

Following reporting her claim to WCB in October 1997 the claimant returned to light duties until December 1997 when she ceased worked and has not worked since that time.

The claimant was referred to a consulting rehabilitation and physical medicine specialist who noted in a report dated April 20, 1998 that the claimant reported an increase in symptoms related to a decrease in staff and an increase in her workload in data entry over the prior eighteen months.

He found a definite history and physical findings of multiple muscle myofascial trigger points for which he recommended treatment over the next three to six months. The WCB accepted the diagnosis of a regional myofascial pain syndrome as being work-related and accepted responsibility for the claimant's benefits and treatment.

In a further report, dated September 8, 1998 the consulting rehabilitation and physical medicine specialist reported that the claimant was responding well to treatment. He reported a "major decrease in pain symptoms" and a "major increase in her functional abilities in regards to active use of both upper limbs". He suggested functional assessment prior to a return to data entry work.

"Now that I have eliminated the major trigger points responsible for her diffuse pain, muscle shortening and dysfunction she will benefit from a period of muscle strengthening and endurance exercises and subsequent occupational therapy assessment of upper limb functioning in relationship to job demands."

In a further report dated November 9, 1998 to the claimant's disability insurance company, the rehabilitation and physical medicine specialist indicated:

"I saw her last on November 6, 1998 at which time there was further decrease in pain symptoms. Pain was now localized to the medial aspects of the right and left elbows and across the cubital fossa on the left. She was completely asymptomatic in relationship to both hands."

The claimant attended an Occupational Therapy and Physiotherapy treatment program from February 17 to March 16, 1999. In the discharge summary we note that the claimant reported that most household activities increased her bilateral arm symptoms. We note that in the self-report testing part of the assessment the claimant often reported an inability to perform beyond a certain level as the pain in her arms was reported as increased, however we note that during those assessments the claimant "did not reach her maximum heart rate during the testing."

Following the claimant's discharge from her treatment program a WCB medical advisor reviewed the file and indicated on April 28, 1999.

" the claimant has been off work for a long time and I believe the claimant should recover from the effects of C.I. [compensable incident]. Current problem is pain associated with increased activities without any solid objective evidence. I cannot relate the claimant's subjective symptoms to the initial problem related [to] C.I." (emphasis added)

In a report dated April 28, 1999 the consulting rehabilitation and physical medicine specialist indicated:

At this time I have not made any arrangements to see her in follow-up and she has returned to the care of her family physician ."

We note in this regard that the specialist indicated he would treat only for acute flare-ups caused by activities which would, in our view, be unrelated to the claimant's workplace as the claimant had not worked for some time. We find this consistent with the later expressed view of the WCB rehabilitation consultant that many non-work related activities increased the claimant's symptomatology.

The claimant was referred to a WCB rehabilitation and physical medicine specialist who examined the claimant on January 6, 2000. As part of this examination, the claimant completed a patient's history form dated January 6, 2000. In the section of the form, entitled NDI Questionnaire, designed to indicate to the physician how the claimant's ability to manage her everyday life is affected, we note the claimant indicated that she could drive her car without any neck pain. We note she later stated to the medical review panel that she is unable to drive for more than one hour, or "I cry for two hours."

We note that in the same report the WCB rehabilitation and physical medicine specialist indicated on examination:

"The current clinical examination, had findings restricted to subjective reports of sensitivity to pressure in the soft tissues of the forearm and arms-as well, upper chest and scapular girdles bilaterally, interscapular area, lateral and posterior neck, left buttock and lateral hip. The greatest sensitivity to pressure appeared to be pressure over the forearms and arms. Also some sensitivity to pressure over the medial epicondyles bilaterally but with no evidence of any active medial epicondylitis with stress testing-this being of uncertain significance. There were no areas of active myofascial pain syndrome activity identified on the current examination. The soft tissue examination was suggestive of a fibromyalgia syndrome." (emphasis added)

We further note from the report that the claimant indicated to the specialist:

"She recalled that, with being off work, initially there was improvement in symptomatology. She did note recurrence symptomatology with any activity. (emphasis added).

The report further stated:

"There is no evidence currently of active myofascial pain syndrome related to work activities as a data entry operator.
I am not certain why the claimant has not fully recovered, as she has received an extensive appropriate treatment course. There are, however, more diffuse findings of sensitivity to pressure having features suggesting fibromyalgia; however, these were not exactly typical. The presence of a diffuse state like fibromyalgia could explain the persistence of symptomatology with activity. A portion of her symptomatology related to activity may be related to musculoskeletal deconditioning present.
In my medical opinion, on a balance of probabilities, I would not feel that the continuous signs, symptoms and findings are occupationally related. As above, there may be some contribution to the more diffuse possible fibromyalgia state, and likely contributing to the symptomatology is the apparent musculoskeletal deconditioning present.
I would agree that the claimant has received the necessary and appropriate treatment for the apparent myofascial pain involvement. With respect to her current more diffuse symptomatology, there are suggestions for further investigation and management as per the most recent interview and examination notes.
It would be my opinion, on a balance of medical probabilities, the claimant has essentially recovered from the effects of her prior injury.
I feel the claimant's work capabilities are sedentary to light level. As per my examination notes, she would appear to require preventative restrictions avoiding repetitive work in the upper extremities."

We note that the WCB medical advisor indicates that the claimant should undergo screening serology to rule out metabolic conditions that may be producing pain enhancement. The specialist went on to suggest appropriate fitness, treatment, reconditioning as well as appropriate treatments and indicated that the claimant might require preventative restrictions.

The consulting rehabilitation and physical medicine specialist submitted a further report dated April 27, 2000 based on a reassessment of the claimant on April 4, 2000 in which he stated that:

On April 4, 2000 I examined [the claimant] for spinal segmental sensitization for the first time .I could demonstrate spinal segmental sensitization at the level of C5, C6, and C7 dermatomes in the posterior neck region as well as C5, C6 and C7 dermatomes in the upper limbs. The scratch test revealed hyperalgesia within each of the above named dermatomes ,

Finally her myofascial trigger points were also present in the mytome fashion within muscles innervated by C5, C6, and C7 in the upper limbs. In conjunction with the spinal segmental sensitization the C5-6 and C6-7 supraspinatus/interspinatous ligaments were also very tender."

We have some concern with the probability of the above assessment as the claimant had not worked for almost two and a half years, there are inconsistencies noted between this and prior reports as to the status of the claimant's condition and her prognosis as well as evidence on file as to a worsening of the claimant's symptoms with any activity at all. In our view this evidence suggests that the claimant's symptoms appear to be increasing with no causal connection to the workplace for a prolonged period of time. We also have some concern that this report appears to suggest a recurrence of the claimant's condition with no relationship to the workplace.

In the same report the specialist indicated that there is nothing to support a new diagnosis of fibromyalgia. He also supported this by indicating that the claimant did not have a chronic sleep disorder. We would point out that a tentative diagnosis of fibromyalgia had been made by other physicians earlier in this claim. We would also point out with respect to the claimant's sleeping patterns that she later reported to the medical review panel that; "she has great difficulty going to sleep and requires a sleeping pill at night. Sometimes when she goes to bed, she lies awake and only falls asleep late in the night." We would also point out that the WCB rehabilitation specialist found the fibromyalgia presentation to be "not exactly typical," but noted complaints of left buttocks and lateral hip problems during his examination of the claimant.

Following a review of the evidence before us, we asked that a Medical Review Panel (MRP) be convened under subsection 67(3) of the Act. This took place on October 23, 2000.

We have reviewed the MRP report and note the similarities between the physical examination as reported by the MRP panelists and that reported in the examination by the WCB rehabilitation and physical medicine specialist on January 6, 2000.

We note the panelists conclude that the claimant's diagnosis in December 1997 was repetitive stress injury (cumulative trauma) of both forearms and hands. In considering the current diagnosis we note that the panelists do not refer to myofascial pain syndrome or the presence of any trigger points found on examination. Nor did they note any of the new findings reported by the attending rehabilitation specialist in his last report of April 27, 2000. They note only points of tenderness yet speculate a diagnosis of regional soft tissue pain syndrome.

They concur with the WCB rehabilitation and physical medicine specialist that the claimant has musculoskeletal and cardiovascular deconditioning and also concur that the claimant should be further investigated for a metabolic or medical disorder. They further note inappropriate use of medication as also noted by the WCB physical medicine and rehabilitation in his examination of January 6, 2000. When asked if the claimant's condition is causally related to the claimant's 1997 condition, the panelists merely state that the same condition is present. In looking at treatment options the MRP panelists indicated:

In addition to the repetitive nature of her work, other stressors appear in the recorded history and the history given by [the claimant]."

In summary, having reviewed all the evidence we note the following; as of March 28, 1998 no definitive diagnosis had been established; around May 15, 1998 WCB accepted a diagnosis of regional myofascial pain related to the compensable event; and the subsequent evidence suggests a good response to treatment for the extent of its duration.

We place the greatest weight on the evidence of the WCB medical advisors, both the advisor who reviewed the file on April 28, 1999 and the WCB rehabilitation and physical medicine specialist following his examination of the claimant on January 6, 2000. We find this to be the most proximate and consistent evidence in light of all the evidence on file that; the current problem was pain with increased activities; that there was no evidence of active myofascial pain syndrome at that time; that the claimant had essentially recovered from the effects of the compensable event and that any restrictions would be preventative and not related to the compensable event.

As outlined, by inference we find that the MRP evidence essentially supports the position taken by the WCB rehabilitation and physical medicine specialist. We also note the evidence on file which suggests that there may be other non-compensable pre-existing or concurrent conditions which have impacted this claim as suggested by early evidence on file and by both the WCB rehabilitation and physical medicine specialist and the MRP panelists. We find that the weight of the evidence, on a balance of probabilities supports a finding that the claimant is not entitled to further compensation benefits beyond August 12, 1999. Therefore the claimant's appeal is denied.

Panel Members

D.A. Vivian, Presiding Officer
A. Finkel, Commissioner

Recording Secretary, B. Miller

D.A. Vivian - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 24th day of January, 2001

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