The Appeal CommissionThe Workers Compensation Act of Manitoba

Introduction

As stated in the preamble, the worker’s PPD award has been considered on two previous occasions. Those decisions provide a thorough background on the worker’s claim and therefore will not be reiterated here. This decision will therefore focus on the new evidence that the worker submitted in support of his request for reconsideration that was granted on October 30, 2006.

Background

As noted earlier, the worker contracted a work-related condition known as vibration-induced white hands syndrome.

He was awarded a 1% PPD in accordance with WCB Policy 44.90.10.02, which establishes a PPD of 1% for a confirmed diagnosis of vibration-induced white hands syndrome where there is no clinical or investigative objective evidence of arterial occlusion as tested by either Allen’s test, digital pressure, or angiography.

On November 3, 2005, the worker underwent an MRI that revealed findings consistent with diffuse small vessel disease. The worker’s treating vascular specialist advised the appeal panel on January 12, 2007 of his opinion that this condition was caused by his vibration-induced white hands syndrome as all other potential causes of the condition were ruled out.

The worker also alleged that in addition to these changes in his condition, he had begun to suffer from ulcerations, peeling and cracking of his hands which he related to his compensable condition. He had sought treatment for it and was prescribed medicated creams by his family physician. A June 11, 2007 report from his family physician noted that he had seen 3 small lesions on the back of the worker’s hand which come and go. He thought they might be seborrheic keratosis but was doubtful given their transient nature. A May 29, 2007 report from the vascular specialist noted that the worker had ischemic symptoms in his hand that were controlled by medication. He added “without the medication he is particularly bothered in the cold and his fingers become very difficult to move and it is nearly incapacitating for him”.

The appeal panel provided this information (in various stages) to the WCB healthcare branch for an assessment of the worker’s PPD award. It is important to note the following opinions:

• A February 13, 2007 report from a WCB internal medicine consultant noted that the “presence of vascular damage in [workers] with vibration induced white finger disease increases the [PPD] impairment rating to 5%. Rating is further increased if a [worker] develops ischemic lesions on fingers such as ulcers or gangrene. Actual number will depend on the severity of the [lesions].”

• A PPD examination was done by a permanent impairment awards medical advisor on May 30, 2007. In his opinion, there was no evidence of any ulcers, ischemic lesions or gangrenous changes that would change the 5% rating recommended by the WCB internal medicine consultant.

• On June 13, 2007, the appeal panel requested clarification and additional information from the permanent impairment awards medical advisor in particular with respect to the presence of ulcers or lesions on the worker’s hand. The panel specifically requested the medical advisor contact both the worker’s treating physician and vascular specialist. On June 29, 2007 he responded stating that he had reviewed the medical reports from both treating doctors with respect to the physical aspect of the worker’s hands and had spoken to them as requested. He noted that the worker’s treating physician had not noted any visible signs of ulceration, gangrene, impending gangrene or other ischemic lesions. While he had treated him for non-specific dermatitis, he did not think that this was related to the worker’s vibration-induced white hands syndrome. The treating vascular specialist concurred in his assessment of the worker’s hands. He noted however that the worker was being treated with topical creams for pain in his hands related to the vibration-induced white hands syndrome. The medical advisor confirmed this information in writing with the treating doctors. There is no reply from either doctor disputing the accuracy of his understanding of their oral comments. Based on this information, the medical advisor maintained his opinion that the worker’s PPD rating should be increased to 5%.

Analysis

To accept the worker’s appeal we must find on a balance of probabilities that his PPD award should be increased above 1%. Based on the evidence before us we are able to make that finding.

WCB Policy 44.90.10.02 provides the parameters for a permanent impairment rating of vibration-induced white hands syndrome:

“1. Confirmed diagnosis of Vibration Induced White Finger Disease. No clinical or investigative objective evidence of arterial occlusion as tested by either Allen's test, digital pressures, or angiography……………………………………1%

2. Confirmed diagnosis of Vibration Induced White Finger Disease with clinical or investigative objective evidence of arterial occlusion as tested by either Allen's test, abnormal digital pressures, or angiography………………………….5%

3. Confirmed diagnosis of Vibration induced White Finger Disease of a severe nature with digital atrophic changes or gangrene. The rating will be judged in accordance with the Medical Officer's assessment based on a percentage of impairment of the whole hand………………………………………………………… up to 50%”

In the case before us, the evidence is that an MRI performed on November 3, 2005 confirmed the presence of arterial occlusion. Though an MRI is not one of the tests indicated by WCB Policy 44.90.10.02, the permanent impairment awards medical advisor advised the Appeal Commission in his June 29, 2007 report that the MRI is a recognized investigative tool for demonstrating small vessel changes. Based on this advice, the panel accepts the findings of the MRI, namely clinical evidence of arterial occlusion.

With respect to the presence of digital atrophic changes or gangrene, the panel does not find sufficient evidence, on a balance of probabilities, that the worker is currently suffering from any such changes. While the worker’s treating physician has treated him for a dermatitis-like condition, there is no evidence that this condition is digital atrophic changes or gangrene or that it is related to the vibration-induced white hands syndrome. This was confirmed in both an oral conversation with the treating physician as well as in a follow-up letter. Further the vascular specialist and the permanent impairment awards medical advisor also did not note any such condition.

The worker disputes the permanent impairment awards medical advisor’s veracity in reporting the condition of his hands. He also says that his treating physician is not a specialist and may not be able to speak to this condition and that his vascular specialist rarely sees him and did not see him on occasions where the changes were present. He further says that his condition is kept at bay by the topical treatment he is prescribed for his hands.

The panel has considered these arguments but is unable to place much weight on them. The medical evidence at this time is that the worker suffers from dermatitis. He also suffers from pain in his hands as a result of his compensable condition. The topical cream prescribed to him is for this pain and not for any lesions that would be related to his compensable condition. We also note that all three doctors, including the permanent impairment awards medical advisor concur in their assessment of the worker’s hand condition. The panel therefore finds on a balance of probabilities that there is insufficient evidence to find that the worker currently suffers from digital atrophic changes or gangrene.

Given the foregoing, the panel finds on a balance of probabilities that the worker does suffer from vibration-induced white finger syndrome with clinical or investigative objective evidence of arterial occlusion and that on the basis of WCB Policy 44.90.10.02, the worker’s 1% PPD is no longer accurate and should be increased to 5%.