The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on January 17, 2002, at the request of a union representative, acting on behalf of the claimant. The Panel discussed this appeal on several occasions, the last one being May 6, 2002.

Issue

Whether or not the worker's current complaints are related to any of her compensable injuries of August 16, 2000, February 3, 2000 or August 25, 1999; and

Whether or not the worker is entitled to compensation benefits and services beyond December 18, 2000.

Decision

That the worker's current complaints are not related to any of her compensable injuries of August 16, 2000, February 3, 2000 or August 25, 1999; and

That the worker is not entitled to compensation benefits and services beyond December 18, 2000.

Decision: Unanimous

Background

In August 1999, the claimant filed a claim for compensation benefits regarding left arm difficulties that she related to her employment activities as a hospital registration clerk. The employer's report of injury provided the following accident description: "Left wrist, elbow, shoulder, neck continues to cause pain, when using pain is increased, shooting pain, worker has been diagnosed with tendonitis."

During a telephone conversation on September 9, 1999, a Workers Compensation Board (WCB) adjudicator documented that the claimant had been working as a registration clerk, in emergency, for about nine months. The claimant used her left hand for the rolodex and telephone (hand set only) and her right hand for the computer and intercom (hand set only). It was not uncommon for the claimant to have the phone jammed under one ear and the intercom under the other. When her wrist started hurting, the claimant did not think it was serious. Her wrist continued to be sore so she had a nurse look at it. The nurse thought it might be tendonitis. The next day, a Wednesday, her elbow began to hurt laterally and she couldn't move her wrist. Thursday and Friday were her days off. On Thursday, her shoulder began to hurt and on Friday her neck was so sore that she couldn't turn to the left.

On October 12, 1999, primary adjudication accepted responsibility for the claimant's left wrist difficulties, but denied responsibility for her shoulder and neck complaints. It determined that the claimant's shoulder and neck difficulties occurred while on her days off. It could not be established that her neck and shoulder difficulties were a progression of her wrist problems. On September 7, 1999, the claimant returned to her regular duties.

In February 2000, the claimant filed a second claim for repetitive strain injury. The employer's report of injury described the accident as follows: "back and neck pain, and arms, repetitive movement, a lot of reaching, due to work environment, constantly with equipment around worker."

On February 28, 2000, the claimant advised a WCB adjudicator that she had been pain free for about one month when her symptoms gradually started to reappear. Her symptoms were very mild in the beginning, but were now more constant. The claimant described her workstation and the changes that were being implemented by her employer to alleviate some of her symptoms. Medical information dated February 12, 2000, diagnosed the claimant with neck/back strain secondary to RSI (repetitive strain injury). On February 17, 2000, the claimant returned to her regular work duties and was paid wage loss benefits up to that date.

On August 16, 2000, the claimant while quickly turning her head to respond to a call she felt an immediate sharp pain in her neck. A compensation claim was filed on August 31, 2000. On August 22, 2000, the attending physician noted that the claimant had subjective complaints of neck pain radiating down both arms with minimal objective findings of tenderness of the cervical spine. The diagnosis rendered was neck sprain. The claim was accepted by the WCB and benefits were paid accordingly.

A WCB medical advisor assessed the claimant on November 29, 2000. Clinical history and examination suggested that the claimant had a muscular strain of the neck and upper extremities. There was no evidence of any anatomical or functional limitations. The medical advisor noted that although the claimant was fit to return to work, a referral to a physiatrist would be beneficial in order to rule out fibromyalgia. Subsequent file records showed that the claimant returned to work on December 18, 2000, but shortly thereafter experienced increasing pain in her neck and shoulders.

On January 9, 2001, a WCB medical advisor commented that there was no ongoing cause and effect between the claimant's current symptoms and the compensable injury. The medical advisor noted that when he examined the claimant on November 29, 2000 she appeared to be quite fine with a full, pain free range of motion in her cervical spine and a normal neurological exam. The differential diagnosis included fibromyalgia which the medical advisor thought may be the cause of the claimant's symptoms.

On January 11, 2001, the claimant was informed by primary adjudication that after a review of the file information and of the opinion expressed by a WCB medical advisor, the WCB was of the opinion that her current complaints were unrelated to her August 16, 2000 work injury. Responsibility for treatment beyond December 18, 2000, would no longer be that of the WCB's.

In early January 2001, the treating physiatrist recorded the following comments regarding the claimant's medical status: "I feel this young woman has a combination of muscle fatigue and overuse in the neck and upper extremities which, if her description of her work environment is correct, have been precipitated by her work in the Emergency Department. She is usually much better if she is not at work than when she is, although now, she has pain all the time."

On February 19, 2001, a union representative requested Review Office to rescind primary adjudication's decision and to accept responsibility for the claimant's ongoing neck and shoulder difficulties. She contended that the claimant's neck and shoulder problems started in 1999 and that the claimant was sent back twice to the same work and to the same workstation, which led to the development of her condition.

In the interim, the claimant was then examined by a WCB physical medicine and rehabilitation consultant on March 1, 2001. The consultant was of the following impression: "On the current clinical examination, there was essentially a normal screening neurologic and musculoskeletal examination. There was only slight tenderness over the lower cervical spinous processes and slight tenderness over the forearm extensor soft tissues and trapezius. There was discrepancy between the amount of pain as reported as present and the lack of findings on examination." In a decision dated April 6, 2001, primary adjudication determined that the claimant's current complaints were not related to her prior WCB injury.

On July 6, 2001, Review Office ruled that the claimant's physical problems after December 17, 2000 were not related to the August 16, 2000 compensable injury and that there was no direct causal relationship to the worker's two prior claims of February 3, 2000 and August 25, 1999. Review Office placed weight on the following evidence when making its decision:

• the August 1999 claim was accepted for a left wrist tendonitis only. Any problems arising from the claimant's neck and shoulder became symptomatic while off on compensation benefits.
  
  
• the February 2000 claim was accepted for a neck and back strain. There was no evidence that these injuries had not healed by the time the claimant returned to work on February 17, 2000. Review Office referred to a medical report in which the physician noted that the worker's complaints now included other anatomical areas such as her knees and arms.
  
  
• the August 2000 claim was accepted for "a sharp pain in her neck and shoulders". Review Office noted that the initial diagnosis was a neck strain. In its view, there was essentially a normal examination when examined by both a physical medicine and rehabilitation consultant and a medical advisor. There was no contraindications of returning to full regular duties.

Review Office concluded that the claimant had sufficiently recovered from the effects of her compensable injury of August 16, 2000 and was not entitled to benefits after December 17, 2000. On September 11, 2001, the union representative appealed Review Office's decision and an oral hearing was held on January 17, 2002.

Following the hearing and discussion of the case, the Appeal Panel requested that additional information be obtained prior to discussing the case further. On April 12, 2002, all parties were provided with reports received from the claimant's attending physicians and from an insurance carrier and were asked to provide comment. On May 6, 2002, the Panel met to discuss the case which included submissions from the union representative dated April 15, 2002 and from the employer's advocate dated April 26, 2002.

Reasons

As the background notes indicate, the claimant sustained a compensable injury on August 25th, 1999, which was diagnosed as tendonitis of the left wrist together with muscular difficulties of the neck and shoulder. Several months later in February 2000, the claimant incurred a second compensable injury, which was diagnosed as a neck and back strain. We find based on a preponderance of evidence, that the claimant fully recovered from both of these compensable incidents and was able to return to her regular employment duties.

On August 16th, 2000, the claimant reported to the WCB that she had been experiencing on a daily basis a sharp pain in her neck and shoulders, which radiated down to both hands. This condition was initially diagnosed as a neck sprain. As the claimant's difficulties continued she was eventually called in for an examination by the WCB. An exam by a physical medicine and rehabilitation consultant took place on March 1st, 2001. The following comments recorded in his examination notes are significant:

"There was some tenderness but minor over the extensor forearm and some tenderness of the right trapezius, but minor. There were no other areas of tenderness identified. There was no tenderness reported in the lower body. None of the tender points described for fibromyalgia syndrome were present. There was no referral of pain induced on palpating over any areas of tenderness.

On the current clinical examination, there was essentially a normal screening neurologic and musculoskeletal examination. There was only slight tenderness over the lower cervical spinous processes and slight tenderness over the forearm extensor soft tissues and trapezius. There was discrepancy between the amount of pain reported as present and the lack of findings on examination.

She apparently has a trial of needling treatment planned. Based on the current examination, I would not see the indication for proceeding to the needling treatment. However, if needling treatment is proceeded to, it would potentially help diagnostically as well. If there were significant improvement in the pain symptomatology, this would support a muscle-basis such as myofascial pain.

There did not appear to be any contraindication for progressing her in general fitness activities on a graduated basis. I see no contraindication either to progressing to a return to her full regular work duties." (Emphasis ours)

Subsequent evidence revealed that the needling treatment was ineffective and therefore ruling out the potential compensable diagnosis of myofascial pain syndrome.

Notwithstanding the foregoing, the claimant's treating physician provided a medical report to a long-term disability insurer that the claimant's primary diagnosis was "myofascial pain syndrome upper torso/neck" and her secondary diagnosis was "fibromyalgia". In addition, this same treating physician in a referral letter dated November 13th, 2001 to a consulting neurologist stated the following:

"She has been given a diagnosis of fibromyalgia in the past and she also has some evidence of tender taut bands in the muscles around the shoulder girdles and hips. She has 16/18 tender points corresponding with the usual points seen with fibromyalgia." (Emphasis ours)

On January 29th, 2002, the treating neurologist noted these findings in his report to the attending physician. "Neck and back move reasonably well. There are tender spots in the trapezii and cervical paraspinal muscles. In conclusion, I don't find any evidence of neurological dysfunction on today's examination." We conclude this report does not support any of the claimant's ongoing difficulties as being related to the original compensable injury.

We note that the claimant's current complaints are related to fibromyalgia, which condition was tested for and found not to be present at the time she was examined by the WCB's medical advisor in March 2001. Accordingly, we find that the claimant's current complaints are not causally related to the compensable injury of August 16th, 2000. Therefore the claimant is not entitled to compensation benefits and services beyond December 18, 2000 and her appeal is hereby dismissed.

Panel Members

R. W. MacNeil, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Miller

R. W. MacNeil - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 14th day of May, 2002