The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

This is an appeal by the worker of the Workers Compensation Board (“WCB”) Review Office decision dated October 27, 2006 under Order No. 720/2006 which held that the worker’s claim for bilateral carpal tunnel syndrome (“CTS”) was not acceptable.

On January 12, 2006, the worker filed a claim with the WCB for numbness and tingling in both hands as well as neck pain. Responsibility for the worker’s neck difficulties was accepted, however, her diagnosed condition of bilateral CTS was denied as being related to her work duties by both the WCB’s Rehabilitation and Compensation branch and Review Office. The worker disagreed and appealed to the Appeal Commission.

A hearing was held at the Appeal Commission on March 22, 2007. The worker appeared and provided evidence. She was represented by an advocate. No one appeared on the employer’s behalf. The panel discussed this appeal on the same day.

Issue

Whether or not the claim for CTS is acceptable.

Decision

That the claim for CTS is acceptable.

Decision: Unanimous

Background

Reasons

Introduction

This appeals deals with the causal relationship between the worker’s bilateral CTS and her work duties. Central to this issue are the worker’s duties, the onset of her condition, and the medical reports on her condition.

Background

The work duties

The worker has been employed as a healthcare provider for approximately 10 years. In 2001 she began in her current position. In 2004 she increased her work week from a .8 position to a full-time position.

The worker essentially works in three different capacities – a scrub nurse, a circulating nurse and a holding area/recovery nurse. Generally, these duties require the worker to prepare patients for angiograms and angioplasties and assist in the recovery from these procedures. As such she is required to open packages containing medical equipment, manipulate medical equipment, and perform manual transfer and recovery procedures, all of which require wrist, finger and hand movements. Although she is right-hand dominant, a great deal of her duties requires the use of both hands.

A more complete description of her varied duties is contained in a 10 page submission to Review Office, as well as in an 18 page January 22, 2007 occupational therapy report. At the hearing, the worker described these duties at length and demonstrated the positioning of her fingers and wrists while performing them. What follows is a non-exhaustive list of the duties which require a manual, i.e. finger and wrist, component to them: 

•  As a scrub nurse, the worker:

- puts on disposable gowns and gloves

- obtains sterile skin preparation solution-iodine and prepares the patient’s exposed groin using a sponge in a circular motion;

- pulls paper cover and positions stick-down sterile drape over patient with forceful right hand and finger manipulations;

- assists in placing sheaths with a right wrist rotation;

- assists in the threading and removal of wire through a catheter with forceful circular right wrist and hand movements with the right fingers grasped onto the thin wire and the left fingers grasped around the wire to wipe it with a moistened gauze;

- injects viscous contrast dye with forceful bilateral wrist, hand and finger movements ;

- inflates angioplasty balloons with a right wrist rotation;

- twists and pulls out plungers with her right wrist and hand in a flexed position;

- assists with the transfer of a patient to a stretcher by forcefully grasping the transfer sheet with both hands clenched and lifting and transferring the patient between two surfaces;

- pushes and steers patients on stretchers with both hands clenched;

- pushes and pulls various plungers with both hands in a forceful gripping manner;

- draws up medications using both hands.

· As a circulating nurse:

- opens sterile packaging of various sizes by peeling wrap forcefully with both hands in a twisting motion, fingers gripped;

- assists with transfer of patients as indicated above;

- opens multiple packages, bottles and containers with both hands.

• As a holding area/recovery nurse:

- Performs forceful manual compression with both hands for sheath removal.

The onset of symptoms and medical treatment

The worker first felt CTS symptoms in about December 2005; her fingers started to tingle and go numb and she started dropping things. She also noted difficulty performing certain tasks at work, and in particular, doing manual compressions and injecting contrast dye.

She saw her doctor who sent her for a nerve conduction study on February 23, 2006; the study indicated that she had bilateral CTS, moderate on the left and mild on the right.

Opinions as to the cause of her CTS

The cause of the worker’s CTS was investigated by the WCB case manager and commented on by medical practitioners.

The WCB case manager noted that the worker had very few non-work related risk factors; she was relatively young, was only slightly overweight, did not smoke or have any inflammatory disorders or hormonal changes.

On June 12, 2006, an occupational health physician supported the position that there was a link between the worker’s job description and her bilateral CTS condition. He stated:

“…it is obvious that you are using a forceful grip in order to stabilize the 10 cc syringe as well as compress the plunger. The fluid that must be injected is quite viscus [sic] and you have even had to resort to using your right thenar and hypo thenar eminences with the wrist in extension in order to forcefully compress the fluid at the appropriate rate. As well, there are many other repetitive tasks which require flexion and gripping of the hands. You were performing the syringing at least 30 times per day, five days a week and engaged in many other manual tasks. I believe there is a recognized biologically plausible mechanism related forceful grip to the compression of the median nerve.

Essentially when your wrist is flexed and there is increased grip force, this correlates with increased tension in the flexor digitorum tendons which in turn causes increased pressure on the flexor retinaculum which is functioning as a pulley for these tendons. Since median nerve is located between the flexor tendons and the flexor retinaculum the pressure on it also increases. Hence, I believe that a case can be made strongly to correlate your job activities with the development of carpal tunnel syndrome. In addition, the daily requirement for manual compression of the femoral artery after the procedure would result in using extremely forceful pressure with both wrists extended. This would be an activity which would result in maintaining this pressure for a period of 15 to 20 minutes. This would occur on a daily basis and this also would directly contribute toward the development of carpal tunnel syndrome.”

This was the same position taken by a WCB medical advisor who examined the worker on August 4, 2006. After a thorough history of her occupation, he thought that there was “fair evidence” that the worker’s CTS was caused by her work duties.

The worker also hired her own occupational therapist to examine her work duties and determine whether they could be the cause of her CTS. The occupational therapist described her findings in a January 22, 2007 report. She described the causes of CTS:

“…With increases of pressure within the [carpal] tunnel, the median nerve is entrapped, causing the symptoms of [CTS]. The lowest tunnel pressure is produced in the neutral wrist posture. Movements of the wrist outside of the neutral posture cause increases in pressure, with positions of flexion and extension causing the most substantial increases.

Compounding work related risk factors (other work related and non-work related risk factor exist) include repetition (with respect to frequency over course of day and duration over course of weeks/months/years), force (static and dynamic), duration of movement, and coordination required.”

The occupational therapist thought that the worker’s job duties contained risk factors for the development of CTS as they contained multiple movements of the wrist outside of the neutral position, including wrist flexion, wrist extensions and wrist rotation, with each movement completed 3 – 33% of the day. She found her job to be repetitive with respect to her hand movements and well as the number of years that she had been doing her job. She also found extensive coordinated hand manipulations with forceful gripping for many tasks, 3 – 33% of the day and forceful gripping with weight and forceful pushing and pulling movements of the hand, sometimes onto extended wrist positions for lengthy periods of time.

Based on her assessment she thought that the worker’s position “could have significantly contributed to her current [CTS]”.

Analysis

To accept the worker’s appeal, we must find on a balance of probabilities that the worker suffered an accident at work in accordance with subsections 4(1) and 1(1) of The Workers Compensation Act and more particularly, that the worker’s bilateral CTS is related to her job duties. Based on the evidence before us we are able to make that finding.

As stated by the Review Office and the occupational therapist, CTS has many etiologies including non-occupational factors. The panel finds the non-occupational risk factors are not significant. In assessing the acceptability of a claim for bilateral CTS, it is important to assess the worker’s job duties to determine whether they might, on a balance of probabilities, be causative of or contributing to the worker’s syndrome in each wrist.

In the case before us the evidence is that the worker’s job duties comprise bilateral hand and wrist movements that include forceful and repetitive movements in non-neutral positions. These job duties have been examined by several medical practitioners who have all opined that there is a relationship between the worker’s job duties and her CTS. We accept these opinions based on the evidence before us.

Given the foregoing, we find that the worker’s claim for bilateral CTS is acceptable.

Accordingly, the worker’s appeal is accepted.

Panel Members

L. Martin, Presiding Officer
A. Finkel, Commissioner
M. Day, Commissioner

Recording Secretary, B. Kosc

L. Martin - Presiding Officer

Signed at Winnipeg this 15th day of May, 2007