Decision #20/04 - Type: Workers Compensation

Preamble

A non-oral file review was held on October 10, 2003, at the request of a worker advisor, acting on behalf of the claimant.

Issue

Whether or not the claimant's symptoms commencing in July 2000 are related to her compensable injury of December 22, 1996.

Decision

That the claimant's symptoms commencing in July 2000 are not related to her compensable injury of December 22, 1996.

Decision: Unanimous

Background

In late December 1996, the claimant was assaulted at her place of employment and filed a claim with the Workers Compensation Board (WCB). Initial medical reports diagnosed the claimant with a contusion to her right shoulder, upper arm and left elbow together with a muscle strain to her lower back. The claimant was treated with analgesics and a course of physiotherapy treatments. On February 18, 1997, based on a review of the medical information, a WCB medical advisor determined that the claimant could return to modified duties for a two week period and then back to her full regular duties.

Following a telephone conversation with the attending physician on June 12, 1997, a WCB medical advisor noted that the claimant was complaining about pain after a few hours of working. The claimant had no problems with post-traumatic stress, depression or stress of any other nature. The medical advisor agreed that the claimant could undergo eight to ten chiropractic treatments and if she did not improve, a call-in examination would be beneficial.

On a hand-written certificate dated July 14, 1997, the attending physician noted that the claimant was unable to work night shifts because of the medication she needed to take on a regular basis. In a report dated August 28, 1997, the attending physician outlined his examination findings and noted that the claimant was developing myofascial pain syndrome in the lower back. In a report dated September 18, 1997, the physician reported that the claimant now had features suggestive of a lumbar disc herniation.

On October 7, 1997, a CT scan of the lumbar spine was performed. The results revealed "No central or lateral spinal stenosis or disc herniation demonstrated. Mild central disc bulging at L5,S1 of uncertain clinical significance."

Following a Review Office decision dated January 16, 1998, the claimant was paid time loss benefits for September 19, 20 and 21, 1997. The payment of these benefits related to the injuries sustained on December 22, 1996. Review Office also determined that no responsibility would be accepted for the costs associated with any of her prescribed medications after November 14, 1997 as it felt that no relationship existed between these medications and the compensable accident of December 22, 1996.

On November 23, 2000, the claimant filed a second claim with the WCB in which she stated the following: "Over the past 2 months, while working turning keys, pulling doors, carrying trays, I have experienced increasing pain and loss of strength and ability in hands, arms, wrists, shoulders, including loss of feeling - the use has been deteriorating and the pain increasing - to unbareable (sic)."


The following is a brief summary of medical information received with respect to this claim:
  • November 14, 2000 - x-rays of the cervical spine showed cervical spondylosis with the degenerative changes being most marked at the C5-6 disc.
  • Doctor's First Report regarding an examination on November 15, 2000 - the diagnosis rendered was "bilateral median nerve neuropathy - R - L, R/O carpal tunnel syndrome. Turning keys painful; opening heavy steel doors more so."
  • Initial physiotherapy assessment dated December 12, 2000 - assessment findings revealed "at least myofascial pain and perhaps fibromyalgia."
  • Consultant in Physical Medicine dated February 8, 2001 - assessment was "neck pain that may be ligamentous in origin".
  • Internal medicine consultant's report dated February 26, 2001 - diagnoses were listed as follows: polymyalgias and polyarthralgias NYD, possibly anemia due to a gynecologic pelvic condition associated with left adnexal pain, possible sleep apnea, fibromyalgia syndrome presentation, remote history of skin psoriasis.
  • Physical Medicine & Rehabilitation report dated February 14, 2001 - impression was post-traumatic myofascial pain syndrome arising from work "which appeared to be WCB related."
  • Memo dated March 21, 2001 - a WCB medical advisor was asked to outline the probable diagnosis of the claimant's difficulties. He responded that the diagnoses were pre-existing degenerative spondylosis of the cervical spine (C-spine), rule out fibromyalgia, polymyagia not yet diagnosed (NYD), rule out (R/O) sleep apnea and possible non medical issues. The medical advisor was also asked to comment on whether or not the mechanics of the job performed by the claimant would lead to her present conditions. The medical advisor responded that the only true objective evidence of any problem was multilevel spondylosis of C-spine. If the claimant indicated that the bulk of her physical activity was/is "work" then this would possibly aggravate the pain from pre-existing osteoarthritic (O/A) of spine. He also stated that the diagnosis/diagnoses were vague and elusive and he suspected a strong emotional/social component to the situation.
In a letter dated April 2, 2001, primary adjudication advised the claimant that her claim for compensation was denied because it had been unable to establish that she suffered a personal injury due to an accident arising out of and in the course of her employment.

On May 1, 2001, a worker advisor, acting on behalf of the claimant, asked primary adjudication to reconsider its decision based on additional medical information dated March 14, 2001. The worker advisor felt that the medical report supported the claimant's position that her wrist, hand, arm and shoulder conditions were a recurrence of the December 22, 1996 compensable injury. On May 25, 2001, primary adjudication wrote to the worker advisor indicating that the decision to deny responsibility for the claim would not be reversed and that the case would be referred to another adjudicator to consider a possible entitlement under the 1996 claim.

In a further letter to the claimant dated July 24, 2001, a WCB case manager noted that both claims were reviewed in consultation with a WCB healthcare advisor, who had provided the opinion that the claimant's current signs and symptoms were not likely related to her compensable injury of 1996 given the length of time that had passed and the vague nature of the current diagnosis. There was a lack of evidence relating the present suggestion of fibromyalgia to the compensable injury of December 1996. The WCB was therefore unable to accept responsibility for further medical treatment and time loss commencing November 12, 2000.

On August 17, 2001, Review Office determined that the claimant's symptoms commencing in July 2000 were not acceptable as a new claim and that these symptoms were also not acceptable as a recurrence of the December 22, 1996 work injury. Review Office noted that the medical evidence from the 1996 claim did not indicate that the claimant had incurred any condition beyond that of soft tissue bruising and strain. Review Office felt that the claimant's symptoms in the summer of 2000, commencing 3 ½ years post the aforementioned trauma, would not have any relationship to this incident. Review Office pointed out that with no definitive diagnosis involved in this claim, it was clearly difficult to determine the cause of the claimant's conditions. Review Office commented that current medical literature did not link fibromyalgia to trauma and that fibromyalgia seemed to be an entity which medical science knew little about.

On November 16, 2001, the worker advisor asked Review Office to reconsider its August 17, 2001 decision based on new medical information dated September 25, 2001 and November 2, 2001. The worker advisor contended that the claimant's repetitive duties of turning keys, opening doors, closing heavy steel doors and carrying trays caused her injury. The worker advisor believed that the additional medical reports supported a "presumption that the onset of the claimant's symptoms occurred in the course of her employment."

In a decision dated November 30, 2001, Review Office confirmed that the claim for compensation was not acceptable as it had been unable to establish a relationship between the said physical complaints and either a specific incident occurring in the summer of 2000 during the course of her employment or even her employment duties in general. Review Office reiterated that there was no definitive diagnosis involved in this claim. It was also significant that more than one physician had brought up a diagnosis of fibromyalgia and that current medical literature did not link such a diagnosis to trauma.

In a submission dated December 21, 2001, the worker advisor requested a Medical Review Panel (MRP) pursuant to Section 67(4) of The Workers Compensation Act (the Act) as she felt there was a clear difference in medical opinion between the claimant's treating physicians and a WCB medical advisor regarding the diagnosis and relationship of the claimant's symptoms to her work duties. The request for an MRP was granted by primary adjudication and an MRP took place on March 31, 2003.

On June 6, 2003, following review of the MRP's findings, Review Office determined that the claimant's symptoms occurring in July 2000 were not related to her injury of December 22, 1996. Review Office was still unable to conclude that the symptoms occurring in the summer and fall of 2000 and more recently at the MRP of March 31, 2003, had any relationship to the claimant's claim regarding her injuries of December 22, 1996. There were psychosocial issues involved as well as numerous non-compensable physical traumas that the claimant's upper body had incurred since December 22, 1996, all of which may be playing a role in the perpetuation of subjective complaints of pain leading to a chronic condition with depression and fibromyalgia. In July 2003, the worker advisor disagreed with Review Office's decision and a non-oral file review was held on October 10, 2003.

Following discussion of the case, the Appeal Panel requested clarification from the MRP with respect to its report to the WCB dated May 14, 2003. Clarification from the MRP dated December 18, 2003 was later received and forwarded to the interested parties for comment. On January 7, 2004, the Panel met to render its final decision with respect to the issue under appeal.

Reasons

The claimant currently presents with several abnormalities that are not necessarily causally related to her compensable injury of December 22nd, 1996. It should be remembered that the claimant was initially diagnosed with an injury to her right shoulder, right arm, left elbow and lower back. With respect to these anatomical sites the claimant was provided with appropriate treatment by her treating physician, who prescribed analgesics and recommended that the claimant enter a course of physiotherapy. Eventually, the claimant was able to return to work firstly performing modified duties and then finally full-time pre-accident duties commencing on August 28th, 1997.
    We note that on July 11th, 1997 the attending physician reported in conversation with a WCB medical advisor that the claimant was experiencing "no problems with post traumatic stress, no depression and no problems with stress." There is no further medical information on file dealing with depression, stress and/or other mental health issues until at least two years following this particular conversation.

    As to the current diagnosis of reactive depression, we find that this is, on a balance of probabilities, related to the numerous factors outlined in the succeeding discussion dealing with the condition of fibromyalgia and not as a consequence of the compensable injury of December 22nd, 1996.

    In September 1997, the claimant began to experience non-compensable lower back problems for which she undertook a course of physiotherapy. The physiotherapist requested on November 6th, 1997 permission from the WCB to administer additional treatments to the claimant. However, we note that the proposed treatments were to involve the claimant's low back. This request was ultimately denied and in fact the physiotherapist advised, "R shoulder has recovered fully. Low back continues to give [the claimant] trouble at work…".

    The claimant continued to perform her regular pre-accident duties without the necessity of regular medical intervention up until the fall of 2000 when she reported a significant increase in physical difficulties over a two month period. These problems were eventually diagnosed in October of 2000 as amounting to fibromyalgia with 18 out of 18 tender points being positively identified. This condition was also later confirmed by the Medical Review Panel (MRP) on March 31st, 2003. The attending physician recorded the following comments in a 2001 medical report: "Since October 2000, she started getting increasing widespread pain and weakness in arms, hands, shoulders, back and legs. She has been off work since 12 Nov 2000 for this disability, which now is DXed (diagnosed) as Fibromyalgia."

    After carefully reviewing and considering all of the evidence, we find that the claimant's condition identified as fibromyalgia is not in any way causally related to the compensable injury of December 22nd, 1996. In coming to this conclusion, we attached considerable weight to the following established facts:
    • Continuous work with minimal medical intervention;
    • The rapid onset of fibromyalgia symptoms beginning in October of 2000;
    • A myriad of non-compensable physical problems including lower back difficulties eventually leading to surgery, Type II diabetes, sleep apnea; low iron and B12 levels;
    • Significant non-compensable personal problems including, anxiety depression, poor coping skills, probable bipolar depression, anemia, family issues+ +, labour issues related to her return to work.
    Based on the preponderance of evidence, we find that the claimant's symptoms commencing in July 2000 are not, on a balance of probabilities, related to her compensable injury of December 22, 1996. 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 19th day of January, 2004

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