Decision #11/02 - Type: Workers Compensation
Preamble
An Appeal Panel hearing was held on December 17, 2001 at the request of the employer's advocate, on behalf of the claimant. The Panel discussed this appeal on December 17, 2001.Issue
Whether or not the worker is entitled to benefits and services beyond June 24, 1999.Decision
That the worker is entitled to benefits and services beyond June 24, 1999.Decision: Unanimous
Background
The claimant was employed for 17 years as a production worker. Her job involved repetitive taping and wrapping of large bundles of wires using hand and power tools with frequent lifting of heavy objects. In April 1996, the claimant completed a Worker's Report of Injury form for soreness, numbness, tingling and weakness in both hands. In the Doctor's First Report dated May 14, 1996, the claimant was diagnosed as suffering from bilateral carpal tunnel syndrome (CTS). Nerve conduction (EMG) studies completed in June 1996 showed evidence of impaired median nerve conduction across both wrists consistent with a clinical diagnosis of bilateral carpal tunnel syndrome to a moderately severe degree.On October 2, 1996, the Workers Compensation Board (WCB) accepted responsibility for the claimant's bilateral CTS condition based on the medical documentation and the physical requirements of her job duties. On December 30, 1996, the claimant commenced receiving wage loss benefits.
A surgical hand specialist examined the claimant and in a report dated February 27, 1997 indicated findings of positive Tinel's and Phalen's tests bilaterally, positive cubital tunnel Tinel's bilaterally and evidence of right Dupuytren's nodules in the right palm. In view of these findings authorization was requested from the WCB to proceed with surgical decompression. On March 5, 1997, the WCB authorized financial responsibility for all costs associated with surgery. On March 13, 1997 and August 21, 1997, the claimant underwent left and right carpal tunnel releases, respectively.
In a September 19, 1997 progress report, the surgical hand specialist noted that the claimant still had tenderness at the base of her left hand and thumb. The right hand was improving but was tender over the vicinity of the carpal ligament. There was pain noted near the base of the thumb and the claimant complained of decreased grip strength. X-rays of both hands and wrists did not identify significant degenerative changes and no other abnormality was seen.
On November 19, 1997, a WCB neurology consultant assessed the claimant's progress. Although the claimant no longer suffered from nighttime tingling in her hands since the surgery, she complained of pain and loss of power in both hands and an inability to close her fingers in either hand. The consultant was of the view that the claimant needed to improve the mobility of her fingers and that her problems were currently related to physiotherapy and post surgery. The consultant further stated that there was no obvious reason why the claimant should not be able to return to her pre-surgical status in terms of being able to go back to work and that there were no restrictions from a neurological perspective.
The claimant continued to complain of debilitating pain, lack of strength and inability to make a fist in both hands. Her condition was further assessed by the surgical hand specialist and in reports dated December 8, 1997 and March 11, 1998, the specialist noted that repeat EMG studies conducted on December 2, 1998 showed clinical evidence of residual CTS in both hands. On March 24, 1998, the WCB's neurologist reviewed the additional medical reports and the EMG studies. The WCB neurologist recognized that there was some delay in the carpal tunnel; however, he was of the view that the claimant's current symptoms were not consistent with CTS.
On May 7, 1998, a functional capacity evaluation (FCE) was attempted by a WCB therapist, however, due to constant pain indicated by the claimant, the tests could not be completed and the therapist was not able to interpret the results. On July 22, 1998, a WCB medical advisor determined that the claimant should return to work on a graduated basis with restrictions to limit repetitive gripping, heavy lifting and wrist movements for 4 weeks. On August 26, 1998, the claimant returned to work but did not attempt the job as both she and her employer felt she could not do the work because of her hands, which were noted at the time to be swollen. A workplace assessment was conducted by a WCB occupational therapist, who determined that the job involved constant gripping and lifting up to 30 pounds and that the lightest jobs available fell outside of the claimant's restrictions.
On October 27, 1998, a WCB physical medicine and rehabilitation consultant examined the claimant and reviewed the medical information on file. He noted that the claimant had fractured her left wrist 16 or 17 years ago. With respect to her symptomology he noted recurrence of tingling in the hands and numbness at night, discomfort, weakness and inability to close both hands. The most recent electrophysiological studies suggested persisting impairment of median conduction bilaterally, an increase in numbness occurring with Phalen's testing and positive Tinel's testing over the carpal tunnel ligaments bilaterally. It was noted that the claimant appears to have contractures in both hands and inability to close the hands or to fully extend the fingers. The consultant was uncertain as to the cause of the contractures, and noted that the literature describes a higher incident of palmar fibrosis and Dupuytren's contractures following wrist fracture. The consultant recommended a rheumatologic opinion to determine if the contractures are related to an underlying inherited condition or if there is an inflammatory component. Repeat electrophysiological studies were recommended to determine if there is any change in neurological symptoms. The consultant concluded that the claimant appears unable to do her prior work duties as a result of her difficulty with hand closure and grip.
On March 22, 1999, the claimant underwent electrodiagnostic examination. In his report the examining neurologist noted carpal tunnel syndrome of a moderate degree in terms of both sensory and motor criteria and that in terms of motor criteria, there was a mild deterioration in the right hand and mild improvement in the left in comparison to 1997 data.
On April 13, 1999, a WCB physician reviewing the case noted that a rheumatologic assessment should be arranged due to the predisposition to fibrosis that is likely unrelated to her employment.
In a progress report of June 14, 1999, the surgical hand specialist noted that the claimant continues to suffer from the same symptoms and that repeat EMG nerve conduction studies showed a slight increase in CTS symptoms on the right and a decrease on the left. On examination there was evidence of decreased sensation, median nerve and motor weakness in both hands and positive Tinel's and Phalen's testing bilaterally. The specialist suggested that the claimant might benefit from open neurolysis of her right median nerve as this was the more symptomatic hand, but this would likely only help relieve symptoms of numbness.
On June 17, 1999 primary adjudication determined that the claimant's current difficulties were not related to her previous compensable condition of CTS and those benefits would end on June 24, 1999. On August 23, 1999 the claimant appealed this decision to Review Office.
Prior to considering the claimant's appeal, Review Office obtained a further opinion from the WCB physical medicine and rehabilitation consultant. The WCB consultant was of the opinion that the claimant's contractures were likely related to fibrosis, an inherited tendency, unrelated to her carpal tunnel syndrome. The consultant did not feel that the claimant's residual CTS was disabling. In a decision dated September 24, 1999, Review Office confirmed that the claimant was not entitled to benefits and services beyond June 24, 1999 based on the following reasons:
- The claimant's primary symptoms were more likely due to palmar fibrosis which is an inherited tendency to which the worker was predisposed and which had been diagnosed bilaterally;
- The claimant's symptoms were supported medically and continued to deteriorate despite being away from her work duties. Her CTS should have resolved following surgery.
- The claimant's symptoms do not indicate a relationship to her left wrist fracture since her symptoms progressed on the right and improved on the left.
- There was no medical evidence to support a relationship between the claimant's palmar fibrosis and the CTS claim and the median nerve symptoms, which if related, were not felt to be disabling.
On June 13, 2001, Review Office referred the case back to WCB's consulting physician to review the new medical information. The WCB physician indicated that his opinion had not changed, that the claimant's hand problems appear unrelated to CTS and that he would not expect any significant impairment related to the residual CTS.
In a further decision dated August 3, 2001, Review Office determined that no change would be made to its earlier decision stating as follows:
- "The issue is a medical one and current medical information does not establish a relationship between the worker's ongoing complaints and her compensable injuries. The external specialist has indicated a diagnosis of flexor tenosynovitis, the cause of which was unclear, but could be related to overuse. The worker hasn't worked at her pre-accident occupation in over four years. The WCB Physical Medicine & Rehabilitation Consultant noted flexor tenosynovitis was a new diagnosis, not previously identified, and would not be related to the prior work injuries."
Reasons
Section 39 of the Workers Compensation Act provides that where an injury to a worker results in a loss of earning capacity, wage loss benefits are payable until the loss of earning capacity ends.The claimant in this case developed bilateral carpal tunnel syndrome that was accepted by the WCB as a compensable work related injury. The issue for this panel to determine is whether, on a balance of probabilities, the compensable injury is continuing to cause a loss of earning capacity. The panel has unanimously determined that it is.
In reaching this decision, the panel considered that the claimant was originally diagnosed as suffering from carpal tunnel syndrome of a moderately severe degree in both hands. Her symptoms at the time were severe pain, numbness, tingling and loss of power in both hands that prevented her from doing her job, which involved repetitive pulling, crimping and wrapping of heavy wiring. The surgery performed in 1997 was not successful in relieving her symptoms other than the numbness she had experienced at night. Since that time to the present, the claimant's symptoms have persisted with continued pain, weakness in both hands and recurrence of numbness. Both the claimant's employer and the WCB occupational therapist that conducted a worksite visit were of the opinion that the claimant was unable to perform her previous job because of her hands.
With respect to the medical information, although the WCB neurologist had indicated in November 1997 that there did not appear to be any clinical evidence of CTS, subsequent nerve conduction studies conducted in December 1997 showed evidence of residual CTS as noted in the March 11, 1998 report of the surgical hand specialist. The report of the examining physician who conducted the December 1997 studies indicated that both median nerves showed 1st and 4th digit sensory latencies to be prolonged and concluded the "nerve conductions in both median nerves show evidence for entrapment at the wrists consistent with bilateral residual carpal tunnel syndrome".
Further nerve conduction studies performed in March 1999 also showed evidence of residual carpal tunnel syndrome. In the report dated March 22, 1999, the examining neurologist described the extent of the CTS, in terms of both sensory and motor criteria, to be of a moderate degree. The surgical hand specialist also indicated in his report of June 14, 1999 that the nerve conduction studies provided clinical evidence of residual CTS, with an increase in symptoms on the right and a decrease on the left. The panel further notes that the WCB physical medicine and rehabilitation consultant confirmed in his examination notes of October 27, 1998 that the claimant's symptoms of numbness and pain as well as the nerve conduction studies were suggestive of progression in the median nerve impairment subsequent to surgery. It was with respect to the claimant's additional symptoms of contractures in both hands that the WCB consultant expressed the opinion that they may be related to an inherited tendency for fibrosis. However, he indicated that he was uncertain as to the cause. The opinion of the rheumatologist indicated that the claimant's discomfort and loss of muscle power in her hands was not related to rheumatoid disease.
After taking into consideration all of the evidence, and in particular the reports of the examining neurologist in March, 1999 and the surgical hand specialist in June, 1999, which confirm that the claimant continues to suffer from bilateral CTS of a moderate degree, the panel is satisfied, on a balance of probabilities, that the claimant's loss of earning capacity is continuing and is caused to a material degree by the effects of residual carpal tunnel syndrome that was not corrected by surgery. The claimant is therefore unable to return to her job duties and is entitled to benefits beyond June 24, 1999.
Panel Members
M. Thow, Presiding OfficerA. Finkel, Commissioner
M. Day, Commissioner
Recording Secretary, B. Miller
M. Thow - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 23rd day of January, 2002