Decision #61/03 - Type: Workers Compensation

Preamble

A non-oral file review was held on March 6, 2003, at the claimant's request.

Issue

Whether or not the diagnosis of fibromyalgia is related to the 1994 compensable jaw injury.

Decision

The diagnosis of fibromyalgia is not related to the 1994 compensable jaw injury.

Decision: Unanimous

Background

While employed as a registered nurse on September 13, 1994, the claimant approached a resident in the dining room when the resident, without warning, struck the claimant on the side of her face. Initial medical reports from an oral and maxillofacial surgeon revealed that the claimant had a history of temporomandibular (TM) joint difficulties for which she had undergone arthroscopic surgery in 1994 and was doing well. The September 13th incident caused the claimant to experience an immediate return of symptoms in her TM joint.

The oral and maxillofacial surgeon kept the WCB apprised of the treatment that the claimant received with respect to her TM joint difficulties. In July 1997 the claimant underwent a right TM joint arthroplasty but continued to experience pain and limited movements. A Toronto specialist who had examined the claimant reported a working diagnosis of degenerative joint disease of the right TM joint with fibrosis, possible left TM joint synovitis, chronic pain in the right fascial region, headache, rheumatoid arthritis and concomitant psycho-social issues. The specialist thought that the claimant would be an excellent candidate for total joint reconstruction using a Christiansen appliance. The claimant was provided with psychotherapy and pain management techniques and the proposed surgery was carried out on August 17, 1999.

On September 12, 2001, an independent rheumatologist described various pain complaints reported by the claimant since the total replacement of her right TM joint. The rheumatologist could not comment on the status of the right TM joint as this problem was outside his area of expertise. He did feel, however, that the claimant's diffuse symptoms were consistent with fibromyalgia. The specialist stated the following:
"By history, Ms. [the claimant] describes that her diffuse soft tissue pain began in August 1999, after she had her replacement of the right temporomandibular joint. She gives no history of any diffuse pain symptoms prior to this, and therefore I do not think there were any significant rheumatologic conditions pre-existing her current situation. There is a past history of a diagnosis of rheumatoid arthritis. Clearly at this time there is no evidence for a diagnosis of rheumatoid arthritis, and I think in all likelihood that previous diagnosis is suspect given the fact that it is highly unlikely for rheumatoid arthritis to completely enter remission, and furthermore she has no findings on physical examination suggestive of any inflammatory arthritis in the past."
On November 1, 2001, a WCB medical advisor responded to several questions posed by primary adjudication on September 25, 2001. On a balance of probabilities, the medical advisor agreed with the diagnosis of fibromyalgia. However, he stated there was no cause and effect relationship between the diagnosis of fibromyalgia and the 1994 compensable injury or subsequent surgery.

In a decision dated September 4, 2002, the claimant was informed that it was the opinion of Rehabilitation and Compensation Services that the diagnosis of fibromyalgia was unrelated to her September 13, 1994 work injury and subsequent surgery. On September 9, 2002, the claimant appealed this decision to Review Office.

After reviewing the medical evidence and file documentation, Review Office concluded that there was no medical evidence to establish a relationship between the multitude of diffuse symptoms experienced by the claimant and the compensable injury to her right jaw on September 13, 1994. Review Office commented that fibromyalgia was a condition which was well known to cause flare-ups from time to time with unknown causative factors. On January 14, 2003, the claimant appealed Review Office's decision and a non-oral file review was held.

Following the non-oral file review, the Appeal Panel referred the case back to the WCB medical advisor who had reviewed the case on November 1, 2001. The medical advisor was asked to comment on whether or not there was a cause and effect relationship between the diagnosis of fibromyalgia and the 1994 compensable injury or subsequent surgeries. The Appeal Commission received a response from the medical advisor dated April 2nd and 3rd, 2003 which was forwarded to the claimant for comment. On April 23, 2003, the Panel met further to discuss the case and to render a decision with respect to the issue under appeal.

Reasons

On or about November 1st, 2001, a WCB medical advisor commented in a memorandum to file that on balance he agreed with a diagnosis of fibromyalgia being ascribed to the claimant. In the same memorandum he also concluded on balance that there was no cause and effect between this diagnosis and the compensable injury. Prior to arriving at any decision with respect to this case, we sought clarification from this medical advisor as to his rationale in coming to the foregoing conclusions.

The medical advisor responded to our request as follows:

“I called a case conference at that time in order to consider ALL aspects of this claim very carefully. Dr. [name] (our senior surgeon with a wealth of experience) pointed out that EXHAUSTIVE diagnostic + therapeutic intervention had failed to link this clmt’s [claimant’s] TM [temporomandibular joint] problem and subsequent surgery with FIBROMYALGIA. All of us agreed. As the GMA [General medical advisor] randomly reassigned to this claim in recent years, I must reiterate my opinion which was based on appropriate consultation, expert opinion + ultimately my best judgement. Fibromyalgia is a condition which can be multifactorial & to this day evokes much controversy regarding etiology.”

We find based on the weight of evidence that the diagnosis of fibromyalgia is not, on a balance of probabilities, related to the 1994 compensable jaw injury. Accordingly, the claimant’s 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 9th day of June, 2003

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