Decision #94/07 - Type: Workers Compensation

Preamble

This case deals with whether the worker’s Carpal Tunnel Syndrome (CTS) is related to her work activities as a registered nurse. Both primary adjudication and Review Office concluded that the worker’s work activities did not place her at risk for developing her CTS condition. The worker disagreed and appealed to the Appeal Commission.

A hearing was held at the Appeal Commission on May 31, 2007. The worker appeared and provided evidence. The worker was represented by a worker advisor who made a submission on her behalf. The employer did not attend or participate in the hearing. The panel discussed this appeal on the same day.

Issue

Whether or not the claim is acceptable.

Decision

That the claim is acceptable as an aggravation of an underlying right carpal tunnel condition.

Decision: Unanimous

Background

In February 2006, the worker filed a claim with the WCB for CTS in her right arm that she felt was related to the repetitive nature of her employment activities as a registered nurse. These duties included heavy lifting, turning and repositioning patients. She also advised that when she works as a scrub nurse in the operating room, she is gloved and gowned for about four to six hours at a time and the gloves apply pressure to her wrists.

The employer’s accident report noted that the worker had continuous numbness and pain in her wrists and hands, mainly on the right side.

On April 10, 2006, a plastic surgeon reported that the worker was first seen on January 24, 2003 and that nerve conduction studies taken in January 2003 revealed moderate right and left CTS.

On April 11, 2006, the worker provided additional details regarding her main duties and responsibilities in the operating room. She stated that she worked part time 7.75 hours a day at three days a week with one hour lunch and one 15 minute break. She also is on call and comes to work sometimes once or twice a week. She is right hand dominant. The worker said she felt numbness and tingling in both hands while in the operating room for a couple of years prior to 2001 and that she started to have pain in her right elbow around 2001.

On May 2, 2006, the case manager spoke with an employer representative who confirmed that the worker has had wrist difficulties for a couple of years. It was confirmed the worker’s job entailed lifting of heavy trays and moving patients. The maximum weight of an instrument tray was about 40 lbs. and most trays weighed 15 to 20 lbs. The worker may lift 3 or 4 trays during an operation.

In a decision dated June 15, 2006, a WCB case manager denied responsibility for time loss and medical treatment related to the worker’s bilateral CTS. It was the case manager’s opinion that the worker’s work activities did not place her at risk for developing bilateral CTS. The worker disagreed and appealed to Review Office on August 22, 2006. She stated in part that she strongly believed that her CTS was directly related to the pressure of her rubber surgical gloves over a creased gown to her wrist areas along with the repetitive lifting and positioning of anesthetized patients for surgery preparation.

Review Office also considered a submission from the employer’s representative dated September 22, 2006. He submitted that the evidence did not support a causal connection between the worker’s CTS condition and her work activities.

On September 29, 2006, Review Office confirmed that the worker’s bilateral CTS was not work related as it did not meet the requirements of subsection 4(1) of The Workers Compensation Act (the Act) based on the following factors:

  • although the worker’s job required involvement of her wrists, it did not involve a significant amount of sustained mechanical stress and force or high repetition;
  • the worker performed a variety of duties and high constant repetition was not evident;
  • it was not aware of scientific literature to support the worker’s contention that ill-fitting gloves caused her condition to develop;
  • the onset of the worker’s bilateral symptoms occurred simultaneously which went against the worker’s assertion that her duties were causal in the development of her CTS;
  • the nerve conduction studies of June 2005 showed an improvement in the worker’s left sided CTS. This left sided improvement together with the fact that the worker continued to work without change to her duties since 2001, suggested that other factors unrelated to work were at play.

Reasons

Applicable Legislation and Policy

The Appeal Commission and its panels are bound by the Act, regulations and policies of the Board of Directors.

For the worker's claim to be accepted the worker must have had an accident as provided in subsection 1(1) of the Act and the accident must have arisen out of and in the course of employment as provided in subsection 4(1) of the Act.

Accident is defined in subsection 1(1) of the Act as;

"accident" means a chance event occasioned by a physical or natural cause; and includes

(a) a wilful and intentional act that is not the act of the worker,

(b) any

(i) event arising out of, and in the course of, employment, or

(ii) thing that is done and the doing of which arises out of, and in the course of, employment, and

(c) an occupational disease,

and as a result of which a worker is injured;

The Board of Directors has not made any policies dealing with the acceptance of CTS cases. However, if the worker’s condition is considered a pre-existing condition, Board Policy No.44.10.20.10, Pre-existing Conditions, may be applicable. This policy provides when the WCB will accept responsibility for pre-existing conditions.

Worker’s Position and Evidence at Hearing

In answer to questions from her representative and the panel, the worker provided details of her employment and duties. She advised that she has been employed as a nurse with the employer since 1975. She has worked in the operating room since that date. She is scheduled for three shifts per week but usually picks up other shifts and serves on call, which can result in shifts of 16 hours duration.

The worker advised that there are three different nurse positions in the operating room. There are two circulating nurses and one scrub nurse. She advised that she found the scrub nurse position placed the most pressure on her wrists.

Duties of the scrub nurse which the worker thought contributed to her CTS included:

  • wearing tight gloves which placed pressure on the wrist. At the time that her symptoms were emerging, the worker used latex gloves and had to tuck her non-disposable gown sleeves into the wrist of latex gloves. She advised that the gloves were very tight around her wrists and that the day following the use of gloves she would have marks on her wrist where the gown was tucked in. She found that the constant pressure on her wrist joints would make her hands go numb.
  • retracting a patient’s heart during cardiac surgery. The scrub nurse would hold the heart in an awkward position to assist the surgeon who may position the nurse’s hands. In such a procedure there is no where for the nurse to rest her wrist. The worker explained that this may happen several times in one operation and the scrub nurse may have no breaks or be involved in more than one operation each day.
  • using a retractor during surgeries. She advised that the retractor may be held in an awkward position with hands flexed for up to 20 minutes at a time.
  • handling and unloading instrument pans and instruments. She advised there can be more than 100 instruments that must be opened and closed during some procedures. This could require a twisting pushing motion of the wrists.
  • opening suture and other packages. The worker indicated that this can require constant supronating of the wrist.
  • assisting with the transfer of and positioning of patients. This can include lifting a mattress to tuck protectors under the mattress. She noted that patients are asleep so they cannot assist.
  • setting up and adjusting IV’s.
  • the use of syringes including filling the syringes with solutions. The worker said that for some syringes she used her right hand to squeeze a bulb which was like squeezing an exercise ball.

Duties of the circulating nurse which the worker thought contributed to her CTS included:

  • opening and handling instrument pans of various sizes and weights which required moderate force with hands in a twisting motion and fingers gripped.
  • opening other containers and packages.
  • the use of squirt bottles with a trigger to spray decontaminants on the floor. The worker advised that she used her right hand for this function.
  • opening suture packages. Some surgeries require up to 200 sutures.
  • assisting anaesthetist by applying pressure to a patient with fingers or palm of the hand.

Regarding the onset of her symptoms the worker indicated that she began having tingling or numbness in both hands. The symptoms were worse at night. She was diagnosed with CTS in 2001 and obtained night splints in 2001. The splints helped at first but her symptoms worsened.

The worker advised that she had CTS surgery on her right hand in 2006 and that it was successful, although she developed a trigger finger injury. She advised that she does not intend to have the surgery to her left hand unless it worsens.

The worker answered questions regarding risk factors. She advised that she does not smoke, does not have hypertension, is not diabetic, has no thyroid problems and has no hobbies that involve her wrists.

The worker advised that she did not review her job duties with the treating surgeon but noted that he works in an operating room so is familiar with nurses’ job duties. She advised that she did not have a change in job duties between the nerve conduction studies.

The worker’s representative submitted that the worker’s duties are far more likely to have been causative for the worker’s bi-lateral CTS than the non-occupational factors identified by the Review Office. The representative noted that the worker’s job duties demonstrate significant risk factors associated with CTS. She referred to the opinion of the treating plastic surgeon in support of this position.

The representative provided the panel with an article from an occupational health journal which she said supported the worker’s assertion that her tight fitting gloves contributed to the development of her 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 Act and more particularly, that the worker’s CTS is related to her job duties. Based on the evidence before us we are able to find that the worker’s right CTS was aggravated by her workplace duties and in accordance with WCB Policy 44.10.20.10 her claim is acceptable.

This case involves a worker who was diagnosed with bilateral CTS. We are 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 or enhanced by work factors.

As noted previously, this case is concerned with 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) did not find a relationship between the worker’s CTS and her work duties. In reviewing this case, we did find a relationship between the worker’s CTS and her employment duties, however we did not find that the employment duties caused the worker’s bilateral CTS, rather we find it most probable that the worker had pre-existing bilateral CTS and that the CTS in the worker’s right hand was aggravated by her employment duties.

We note that the worker’s CTS is bilateral which is frequently an indication of a non-work related condition. We also note that the worker has some non-work related risk factors, specifically, age and gender. The worker indicated at the hearing that the tingling and numbness started in both hands at the same time. There was no evidence that the worker’s duties changed at that time to cause the development of bilateral CTS. We also note that nerve conduction tests suggest an improvement in the worker’s left hand CTS despite her continuing to work. We find that the worker’s bilateral CTS was not caused by her employment. However, we considered the duties which were being performed by the worker in the operating room and concluded that the duties aggravated the worker’s pre-existing condition in her right hand. The worker’s evidence was that the symptoms in her right hand worsened as she worked in the operating room to the point that surgery was required.

In finding, on a balance of probabilities, that the underlying right hand CTS was aggravated as a result of her workplace duties, we rely on the worker's description of her duties as a nurse in the operating room and particularly her duties as a scrub nurse.

We note that she participated in procedures which involved extension of the hand in awkward, unsupported positions for significant periods of time. This would be repeated several times during a shift in the operating room. The duties also involved the movement and positioning of patients, the drawing of solutions and use of syringes, and the opening and handling of a variety of packages and containers all of which involved forceful gripping.

We find that the tasks involved repetitiveness, awkward postures of the hand including extension and flexion, and forceful pinching and gripping which aggravated the worker’s CTS condition. We note that the treating plastic surgeon opined in a report dated September 28, 2006 that “As a nurse and scrub nurse in the Operating Room, this patient is required to perform repetitive lifting and positioning of patients and I would think her carpal tunnel would be compatible with a work-related illness as much as any other carpal tunnel syndrome could be.”

At the hearing the worker’s advocate introduced as evidence a copy of an article which listed job tasks and occupations associated with CTS. The article refers to the “wearing poorly fitting gloves which apply external pressure” as a task associated with CTS for agricultural workers, mechanics and factory workers. Given that healthcare workers and specifically nurses are not referenced and that no data or studies supporting this finding are included in the article, we did not attach any weight to the article.

The worker’s claim for right handed CTS is acceptable as an aggravation of an underlying right carpal tunnel condition and her appeal is allowed.

Panel Members

A. Scramstad, Presiding Officer
M. Bencharski, Commissioner
M. Day, Commissioner

Recording Secretary, B. Kosc

A. Scramstad - Presiding Officer

Signed at Winnipeg this 13th day of July, 2007

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