Decision #15/06 - Type: Workers Compensation

Preamble

An Appeal Panel hearing was held on November 30, 2005, at the employer’s request. The hearing adjourned and reconvened on December 6, 2005. On December 6, 2005, the Panel met to discuss the case.

Issue

Whether or not the claim is acceptable.

Decision

That the claim is acceptable.

Background

On July 28, 2003, the worker filed a claim with the Workers Compensation Board (WCB) for bilateral wrist problems that she attributed to the repetitive nature of her job duties. The worker provided the WCB with the following work history:

  • has been with the employer for 22 years;
  • the first 14 years involved sorting. The next 6 years involved keying information on a keyboard using both hands;
  • the last 2 years involved lifting, pushing or throwing parcels. The parcels varied in weight and height (3 to 80 lbs; over 6” by 4” by 4”). The worker stated she used a one handed keyboard and that she “lifted & keying or pushing and keying at the same time with opposite hands”.

  • in January 2002, was trained on a forklift. The worker first noticed a problem after being trained on this machine. The worker stated “Was on it constantly for the 3 months, January February & March 2002. Was no job rotation for the first 3 months. The machine is used every day. Some of them are harder on your thumbs than others. Some have been refurbished, others need to be. Other employees have trouble with the machines too.”

The worker further advised the WCB that she saw a doctor in February 2002 and was sent for tests. In April 2002, she was referred to a surgeon because of the test result findings. The worker said she told a co-worker about the numbness she experienced and she told her supervisor that she needed surgery.

Initial medical reports showed that the worker was diagnosed with moderate to severe bilateral carpal tunnel syndrome (CTS), worse on the left.

In a letter dated July 22, 2003, the employer’s representative opposed the acceptance of the claim based on the following rationale:

  • there was no specific incident that occurred and therefore a dominant cause of a work relationship could not be established;
  • the worker did not report her carpal tunnel condition when she was diagnosed in March 2002.
  • that non-occupational factors must be considered. If occupational factors were the predominant cause of the worker’s difficulties, she would have sustained problems earlier on in her career.
  • the worker had rotation of duties and had regularly scheduled breaks throughout her shifts.

On August 29, 2003, a WCB adjudicator spoke with the worker regarding her claim. The worker indicated that she had been in her current position since October of 2001. She started to have problems with her hands soon after changing positions in October 2001. At that time, she started to experience pain in her wrist that would come and go. She was trained to operate a forklift in January 2002 and this was when her symptoms increased and continued to get worse ever since. The worker operated the forklift almost all day for a couple of months. She noted that both hands are required to operate the machine. She used her left thumb to operate the forks and horn and her right thumb to steer and control the speed. They started rotating duties between the forklift and parcel sorting in February or March of 2002.

In an e-mail dated March 17, 2004, the employer responded to the WCB’s request for additional information concerning the amount of time the worker spent on the forklift along with other activities such as sorting, racking, loading trucks, etc. The employer provided information concerning the force, pressure, twisting and gripping movements of operating the forklift.

On March 18, 2004, the employer’s representative provided the WCB with further argument to support the position that the claim for compensation was not acceptable.

On May 27, 2004, a WCB medical advisor reviewed the file information and commented that the worker was at high risk of developing CTS based on a combination of her pre-existing condition and work-related duties.

In a decision dated June 2, 2004, the employer was advised that the claim for compensation was acceptable as it was determined that a relationship existed between the development of the worker’s bilateral wrist difficulties and an accident arising out of and in the course of her employment. The employer was also advised of the WCB’s position that the worker’s outside activities did not play a role in the development of her condition.

On September 8, 2004, the employer appealed the acceptance of the claim to Review Office. On December 23, 2004, the worker’s union representative presented rebuttal arguments to the employer’s submission.

On February 4, 2005, Review Office confirmed that the claim for compensation was acceptable. Review Office accepted that the worker’s job duties were repetitive. It noted that although there was a rotation of job duties, the hand/wrist mechanics in all the job duties were similar in that they required repetitive motion, gripping, extension, flexion and movements of the wrists and hands. It also placed weight on the opinion expressed by the WCB medical advisor on May 27, 2004. Review Office indicated there was sufficient evidence to establish that an accident, as defined under The Government Employees Compensation Act (GECA), the Government Employees Compensation Regulations (GECR) and WCB policy 44.05.10, did occur.

On March 17, 2005, the employer appealed Review Office’s decision and an oral hearing was requested.

On November 30, 2005, an oral hearing took place but was adjourned. The hearing was subsequently reconvened on December 6, 2005.

Reasons

Chairperson Scramstad and Commissioner Day:

This is an employer appeal of a WCB decision to accept the worker’s claim for bilateral CTS. The stated issue is whether or not the claim is acceptable. For the appeal to be successful, the Panel must find there is not a causal relationship between the worker’s condition and her employment duties. The majority did find, on a balance of probabilities, that a relationship exists. Specifically the majority finds that the duties commencing in October 2001 in the parcel area aggravated the worker’s pre-existing bilateral CTS and as such is acceptable under the GECA and applicable WCB policies.

Evidence and Argument at Hearing

The employer was represented by its WCB specialist. The employer representative made a submission on behalf of the employer and called a witness to provide evidence in support of its submission.

The worker attended the hearing and made a presentation on her behalf. The worker was assisted by a union representative. The worker answered questions posed by the parties and the Panel. The worker called three witnesses to provide evidence.

The employer representative submitted that the worker’s condition was not caused by her work in the parcel area. The employer representative also submitted that the WCB had misapplied WCB Policy 44.05.10. The employer representative reviewed the evidence on the claim file and referred to literature which supported the employer’s position.

The employer called as a witness, a physiotherapist with training in the areas of ergonomics, anatomical biomechanics and biostatistics. The witness was called to support the employer’s position that the equipment used at the workplace and, specifically in the parcel area requires minor forces to operate. The employer’s witness described her methodology, using standardized objective measurements to measure the forces required to perform the tasks. The witness answered questions posed by the parties and the Panel.

While the worker noted that she commenced employment with the employer in 1981, she attributed her CTS to duties which began in October 2001 in the parcel area. With regard to the physiotherapist’s evidence, the worker noted that the job set-up in the parcel area has changed from when the worker started in the area in 2001. She noted that the physiotherapist did not assess the job tasks as they were initially performed.

The worker provided information regarding her job duties in various positions with the employer. She indicated that tingling in her wrists began within a month of commencing work in the parcel area in late 2001. She acknowledged that she has been diagnosed with hypothyroidism and is being treated for this condition. She was not diagnosed with this condition until 2003, after her CTS symptoms were in play.

The worker called a co-worker to give evidence regarding working conditions and duties in the parcel area. The co-worker described the various duties and noted that since the inception of the parcel area in 2001, many changes have been made.

The worker called an ergonomist and occupational health nurse who conducted an assessment of three specific tasks in the parcel area. They explained the assessment which included the use of a discomfort survey. The ergonomist noted that their “…purpose was to review the system, process as it is that day and make recommendations.” He noted that the assessment was agreed to by union and management. Worksite visits were conducted in late 2003. The witnesses answered questions posed by the parties and Panel.

The employer representative noted that the ergonomist’s focus was on ergonomics and not on risk factors associated with CTS.

Analysis

This case involves a worker who was diagnosed with bilateral CTS. The majority is aware that this condition may be caused by work related factors and non-work related factors. The condition can also be idiopathic, of unknown origin. As well, CTS which is not initially work related can be aggravated by work factors.

As noted previously, the issue in this case is whether there is a relationship between the worker’s CTS and her employment. If there is a relationship, the claim is acceptable and the worker is entitled to receive benefits from the WCB. The WCB, at both the primary level and the reconsideration level (Review Office) found a relationship between the worker’s CTS and her work duties. In reviewing this case, the majority has also found a relationship between the worker’s CTS and her employment duties, however the majority did not find that the employment duties caused her CTS. Rather, it finds it most probable that the worker had a pre-existing CTS which was aggravated by her employment duties, to the point where surgery was required.

The majority notes that the worker’s CTS is bilateral which is frequently an indication of a non-work related condition. The majority also notes that the worker has a number of non-work related risk factors, specifically, age, gender and hypothyroidism. While there is no evidence that the worker had CTS symptoms prior to commencing work in the parcel area in October 2001, the majority notes that the symptoms developed very quickly after she commenced working in this area. The worker indicated at the hearing that the intermittent tingling started within a month of commencing work in the parcel area. The majority considers that the rapid development of symptoms after commencing this employment suggests that the CTS was already present although not symptomatic. The majority considered the duties which were being performed by the worker in the parcel area and concluded that they aggravated the worker’s pre-existing condition. The worker’s evidence was that the symptoms worsened as she worked in the parcel area to the point where surgery was required.

The majority notes that the claim file was reviewed by a WCB medical advisor who comments in a memo dated May 27, 2004 that: “Based on pre X and work related duties, [C] is at high risk of developing CTS. Therefore the current complaints (CTS) are work related.” The majority notes this opinion is consistent with its findings.

There is significant evidence regarding the worker’s duties in the parcel area. The evidence comes from many sources including the worker, a co-worker who appeared as a witness, WCB staff memos, an ergonomist and occupational health nurse who conducted an ergonomic assessment of certain tasks performed in the worksite, employer representatives, and a physiotherapist contracted by the employer. The Panel also acquired knowledge of the employment duties through a worksite visit conducted in respect of a different claim.

Much of the evidence deals with the current employment duties and worksite yet the worker’s symptoms were first noticed in late 2001. In arriving at its decision, the majority has found the evidence of the conditions at that time to be most relevant. This evidence is provided largely by the worker and co-worker, but the majority notes that the employer has confirmed much of this evidence. The evidence of current operations is of less relevance and is given less weight by the majority in reaching its decision.

The majority notes that the parcel area commenced operation in October 2001 as a pilot project. At that time there were no formal job descriptions and no formal rotation from position to position. During the first months of operation the emphasis was on loading trucks. The evidence at the hearing is that workers could spend a significant portion of the work day loading trucks, as much as 30 to 32 hours in a work week. When busy, scheduled breaks were not taken. After loading was completed, other tasks were performed. The workforce at this time was nine workers, later expanded to 14.

With respect to loading trucks the co-worker testified that she did not move parcels one at a time but rather would grab as many as she could and compress them between the hands. She stated that “quite a bit of force was required to squeeze the parcels together so that the middle ones did not slide out.”

Scanning parcels was an important part of the process of loading trucks. The worker described the task of scanning parcels in these words:

“So when we started down there, everything was a little more condensed, so you had parcels that were stacked two, three, four, five high on that and you actually had to dig through each and every row of those in order to scan the labels. So you would be holding parcels up with your left hand while scanning with your right on those shelves. And that wasn’t in a neutral position.”

The majority also notes these duties have changed since 2001-2002 with more racks for the parcels and better labeling, and handles for the scanners.

After loading trucks, staff performed other duties which included removing parcels from containers, pushing parcels along and across roller belts and coding. In these areas the tasks have also been modified and ergonomic changes have been made.

The Panel viewed the various tasks performed in the parcel area in November 2005. The majority accepts the evidence that the tasks have changed significantly but notes that during its visit it observed the handling of parcels with wrists in non-neutral positions involving awkward postures, forceful gripping and repetition. The majority considers that the occurrences of such non-neutral postures were likely greater in 2001-2002 than observed in 2005, given there were fewer staff working in the parcel area and the evidence regarding the busy nature of the operation, missing breaks and no formal rotation of duties.

The worker advised that her symptoms became more severe after she was trained to operate a form of mechanized forklift in mid January 2002. The majority notes that force measurements were taken on the toggle switch and the handle of a forklift in 2005 and that the tests results do not indicate the need for significant force to operate these controls. However, the majority also notes that the test results do not address the cumulative forces involved in driving the machine (pressure on switch and need to hold handle down) or the impact of rough surfaces and inclined surfaces. The majority considers that the task of operating the forklift, combined with the other tasks, contributed to the aggravation of the worker’s CTS.

Conclusion

The majority notes that the worker’s CTS was asymptomatic until the fall of 2001. In the fall of 2001, the worker began to notice symptoms of CTS. The majority finds, on a balance of probabilities, that from that point in time, the worker’s change in work duties in combination with forceful gripping, pinching and working with awkward wrist postures caused her pre-existing condition to progress and worsen to the point where surgery was required. Accordingly the majority finds that the claim is acceptable and the employer’s appeal is declined.

Panel Members

A. Scramstad, Presiding Officer
M. Day, Commissioner

Recording Secretary, B. Miller

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

Signed at Winnipeg this 26th day of January, 2006

Commissioner's Dissent

Commissioner Finkel’s dissent:

The worker in this case applied to the WCB for benefits, relating to the onset of her bilateral carpal tunnel syndrome (CTS) condition to her transfer to more strenuous job duties in a newly established parcel area in October 2001. Her claim was accepted, and the employer has appealed this claim acceptance to this Panel.

The hearing of this case occurred over two days. The Panel was also familiar with the worker’s job site and job duties, having visited the same workplace a month earlier, in respect of another worker’s claim. After consideration of all the evidence, I find that the worker’s bilateral carpal tunnel syndrome is not causally related to her job duties, and accordingly, I would accept the employer’s appeal. My reasons follow.

Evidence and Arguments:

The Panel heard considerable evidence on a new parcel area that had been launched in mid-October 2001. This evidence was provided by both parties. The Panel also heard evidence from a physiotherapist consultant hired by the employer to assess the worker’s job duties and from the co-authors of an ergonomic study called by the worker, who had assessed certain portions of the workplace.

The worker’s evidence, supported by file evidence, is that she was a long term employee and had moved to a new position in the parcels area in mid-October 2001. Almost immediately thereafter, she noted bilateral and intermittent shooting pains in both hands/fingers, consistent with her later diagnosis of CTS. The job was very busy at the outset, with nine people doing a job that by March 1, 2002 would be expanded to 14 people.

The worker’s evidence was that their primary responsibility each day was to load trucks so that they could make their deliveries, and that this job would consume 30-32 hours of her 40 hour week. The remainder of her job would rotate among a series of jobs including keying codes at a keypad station to place on parcels, feeding a conveyor belt from parcel bins or a chute, and sorting parcels into bins or racks. The worker’s evidence was that the production supervisor did a good job of rotating the workers among the remaining jobs in Phase 1, until a more normalized work schedule, with additional staff, was introduced in Phase II starting March 1, 2002. The employer’s evidence generally concurred with the worker’s evidence on these points.

The worker performed these duties, as described above, until January 2002, when she started training for another component of her job – driving a mechanized forklift. Her evidence was that she trained on this machine, and then operated it for three hours a day for the next month or so. During this time, as described in her Report of Injury, she noted significant flare-ups of CTS symptoms in both hands/wrists, which she attributed to the forklift. This led her to seek medical attention and ultimately surgeries on both wrists. In later documentation on the file, the worker provides information that she had first noticed her symptoms, bilaterally and onset at the same time, three months earlier, in October 2001.

Analysis:

This case focuses on the worker’s job duties during a very limited period of time, specifically the time of the onset of her bilateral CTS symptoms in October 2001, up to and through the increase of her symptoms in January 2002. The worker had no symptoms or complaints prior to her move to the parcel area, and thus her previous job duties were not the focus of this particular case.

CTS is a unique medical condition that can arise from work-related activities, and also from non-work related factors. Medical literature points to such factors as age (40s and up), gender (female), body mass index, diabetes, and hypothyroidism amongst others, as factors leading to the development of CTS in the general population. Many CTS cases simply arise idiopathically (that is, they have no known cause).

Where work duties are suggested to be the source of the problem, there is considerable medical literature focusing on the specific types and frequencies of body mechanics that could lead to the development of CTS. It does not simply arise out of general physical work. The factors most commonly cited as leading to the development of CTS are high force/high repetition activities involving the hands or activities involved with awkward bending of the wrist or forceful pinching and gripping, or direct pressure on the carpal tunnel area of the palm or wrist. Of decreasing causal significance are high force/low repetition activities of the hands, followed by low force/high repetition activities.

In assessing the worker’s job duties and the work site in general, I have concluded that the worker’s job in Phase 1 was certainly a busy one, with a lot of physical work that could in general lead to the development of a variety of musculo-skeletal problems. The question, though, is whether the unique CTS factors were present within her job in sufficient quantity to lead to the development of the worker’s bilateral CTS condition. After careful assessment of all the evidence and having observed the work duties at the job site, I have concluded that the job duties that the worker performed in the parcel area do not provide or present the risk factors that would be causative of CTS.

At the outset, I would note that the primary focus of my analysis is on two major job areas: the parcel scanning/loading of the trucks which the worker performed for 30-32 hours per week, and the forklift job. While considerable evidence was provided on the other jobs performed by the worker in Phase 1, I note that there was considerable rotation among those other jobs by the 9 person crew. Given that the worker first noticed bilateral wrist problems shortly after starting Phase 1, I find it unlikely that the short exposures to those other positions and the low accumulation of time in those positions would have led to the onset of CTS from those other positions.

The worker arranged to have two co-authors of a recent joint union-management ergonomic study present evidence at the hearing, to support her contention that her CTS arose out of her job duties. I found that the study and their evidence had limited value in this case. The authors did not assess the vehicle loading job which was the worker’s primary job in Phase 1, nor the forklift job which was the basis for the worker’s original complaints. Rather, their study focused on the conveyor area job, which dealt with only a small part of the worker’s duties, and into which she rotated in and out, with eight co-workers. As well, the co-authors acknowledged that their study and proposed ergonomic solutions were not driven by an assessment of a history or pattern of workplace injuries or worker compensation claims. Rather, the source data used by the authors was derived solely from workers’ self-reports of discomfort to various areas of their bodies. The authors did not seek information on whether workers had been diagnosed with any specific medical conditions or findings of work-relatedness, in their goal of developing general ergonomic solutions for the workplace. As such, their report and evidence does not provide any meaningful information on whether a worker’s bilateral CTS condition could have been caused by any of the job duties at the workplace.

Dealing with the loading of the trucks, this task required one or two person teams to scan parcels on a rack, then take the parcels from a rack, carry them along a short horizontal ramp into a truck, place them on a shelf inside, then walk back out, and repeat until the truck was loaded. As noted earlier, the Panel has had the opportunity to view this particular job duty at a busy time, and it was acknowledged at the hearing and site visit that the volume and pacing of the job per hour at the time of the site visit was similar to that experienced by the worker in Phase 1 (although more hours would have been devoted to the task in Phase 1).

In my observations, this is a very steady and very busy job, but not the type of job that would lead to the development of bilateral CTS. In this regard, I note that there are very short periods of time (perhaps a second or two) when the wrists might be in non-neutral positions, specifically when parcels are pulled off the cart or placed on the truck shelves. For the remainder of the time, the workers carry the parcels at stomach to chest height in front of them in a neutral wrist/hand position while walking into the truck, and the worker returns to the rack empty-handed, and on occasion may scan parcels prior to next loading. There is a considerable variety in the tasks performed, with significant “rest breaks” in which the wrist structures have the opportunity to recover from any untoward stresses to which they may be subjected. The worker also can self-pace, and can carry as few or as many parcels or large envelops as they wish, on each trip.

My findings in this regard are consistent with those reported by the physiotherapist who attended the hearing on behalf of the employer. She had the opportunity to observe a limited demonstration of this job by a production supervisor. I found that there were some constraints as to the weight to place on the ergonomist’s findings and evidence. In particular, her assessment took place during current operations, and did not reflect the unique work pattern and the high-paced work demands of Phase 1.

Nonetheless, I find the physiotherapist’s evidence regarding the truck loading operation to be of some assistance. Although she did not observe this operation at a high volume period, the physiotherapist did assess the scanners, the scanning tasks, and the gripping and carrying of parcels that comprised the primary tasks of this particular job.

The physiotherapist notes that the scanners were very lightweight, had ergonomic grips, and that the force required to press the scanner trigger to be minimal while scanning parcels on the racks. While the worker asserts that the parcels often needed to be turned with the other hand in order to scan, and that the scanner would often be twisted to read a number of labels, I note that only a small portion of the parcels were large or cumbersome. Scanning was also done in small batches (estimated as lasting perhaps a minute or two), with the worker having the option of doing a row at a time, or the whole cart, while loading the truck. I also note that the worker’s condition was noted to be bilateral, yet the scanning job was one-handed. In light of this evidence, I find that the scanning job was not causative of the worker’s bilateral CTS condition.

Based on these findings, I find that the truck loading job (the primary activity that the worker was doing in Phase 1) was not causative of her bilateral CTS condition.

Dealing with the mechanized fork lift used by the worker in January 2002, the worker presented evidence of recent tests of the force required to move the forklift handle. The tester noted that the forklift was turned while at a standstill, and required “medium” intensity force to initiate a turn. This turn was initiated by pushing or pulling the forklift handle to the right or left, with one hand on the grip at the end of the handle. The employer countered with evidence that the forklift was usually in motion when turned and that it would be far easier to turn when moving than at a standstill. The worker acknowledged that the forklift would rarely be turned while at a standstill. The ergonomist also presented evidence on this point. Her evidence regarding button pressure was that the force required was minimal. She also noted that the forklift could not be safely tested while in motion, but that less force would be required turn a forklift in motion, as compared to a forklift turned at a standstill.

After a review of the forklift job duties and my observations of this job duty at the worksite, I prefer to place greater weight on the physiotherapist’s findings. The forklift operates on a smooth cement floor with a couple inclines where there would be momentary vibration as the machine adjusts to the slopes. The worker has considerable flexibility in selecting their standing position and arm position on the machine, and while the whole arm is used to turn and drive the machine, there are no extreme wrist motions or forceful or repetitive gripping activities involved in the use of the machines. And most importantly, this is a “one-handed” task, and there is no medical explanation for how the worker could attribute her bilateral symptoms in January 2002 to this particular job duty, as she did in her original Report of Injury. Accordingly, I find that the forklift job duties would not have caused the worker’s bilateral CTS condition.

Conclusion:

Based on this analysis, I find, on a balance of probabilities, that the worker’s job duties were not causative of her development of bilateral carpal tunnel syndrome in late 2001. I would accept the employer’s appeal and find the worker’s claim to be not acceptable. Although it is not necessary to establish an alternative source for the worker’s problem, I would note that the simultaneous development of a bilateral CTS condition strongly suggests a non-compensable, non-work-related source. As well as the general factors leading to CTS as noted above, such as age and gender, which are present in this case, there is medical evidence that the worker had an untreated hypothyroidism condition during this period, which is specifically identified as a known systemic cause of CTS.

A. Finkel
Appeal Commissioner

Signed at Winnipeg, this 26th day of January, 2006.

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