The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An appeal panel hearing was held on June 28, 2007, at the worker’s request. The panel discussed this appeal on June 28, 2007 and again on August 13, 2007.

Issue

Whether or not the worker’s mental health problems are related to the compensable injury; and

Whether or not the worker is entitled to wage loss and/or medical aid benefits after April 21, 2001.

Decision

That the worker’s mental health problems are not related to the compensable injury; and

That the worker is entitled to wage loss benefits after April 21, 2001 in respect of his chest injury and any associated medical aid benefits if applicable.

Decision: Unanimous

Background

The worker filed a claim with the Workers Compensation Board (WCB) for chest, back and right leg pain which he attributed to an injury in December 2000 following a change in his job duties. He continued working until February 12, 2001 when he stopped due to the pain that he was experiencing.

Prior to August 2000 the worker’s normal duties required him to work at a machine that trims the edges from boots. As he was usually able to complete the required production quota prior to the end of his shift, he was asked by his employer to spend the remainder of his shift at a fine scouring machine. This required him to hold a boot in both hands and rotate it around a high speed sander. For a period of eight months the worker performed both the trimming and the scouring, but he began to experience pain and discomfort in his chest, right rib cage, lower back and right hip. He says that he advised his foreman on a daily basis that the pain was too much and that he could not work both machines. The foreman acknowledged in March 2001 that in fact the worker had complained about “an achy body and pain for the last eight months”.

In January and February 2001 the worker was treated at the hospital for chest pains. Chest x-rays showed no acute abnormality and in a February 28, 2001 report a cardiologist noted that the worker complained of feeling very weak, with pain and discomfort radiating into the low abdomen, low back and legs over the previous 2-3 weeks, and an irregular heart beat. He concluded the worker’s symptoms were non-cardiac in nature, and suggested the possibility of neurological or neuromuscular abnormality.

On January 30, 2001 the worker presented to his treating physician with a history of progressive and recurrent chest pain, and chest tightness only at work while “cutting soles on heavy work boots . . . which requires strong pushing.” On February 19, 2001 he diagnosed the worker with chest wall pain, costochondritis of the lower chest wall, musculoskeletal strain of the right flank and right buttock strain and said he was unable to return to work for six to eight weeks. In a March 21, 2001 report the treating physician concluded that the worker had sustained a right lower chest wall strain extending into the right flank and right buttock “from his over-use activity at work”. He noted that commencing March 9, 2001, the worker was experiencing major depressive symptoms related to concern over his health, his ability to return to work, and resulting financial problems.

On March 29, 2001, the treating physiotherapist advised the WCB that the worker had multiple pain complaints involving his whole body and demonstrated signs of a possible neurological condition. Consequently she was unable to do a proper examination and discontinued treatment. On April 2, 2001 a WCB medical advisor commented that it was possible to develop a muscular strain of the chest wall and right flank, however, noted that not all of the worker’s complaints related to his work activity. He concurred with the cardiologist that further investigations would be important to rule out metabolic and/or neuromuscular problems.

In a progress report dated April 6, 2001, the treating physician noted that the worker’s recovery was not satisfactory as the worker had unnecessary stressors and was physically and psychologically disabled. An x-ray of the lumbar spine and both sacroiliac (SI) joints was performed on April 2, 2001, which showed slight reactive degenerative changes present in the lumbar spine. The SI joints were unremarkable.

In a decision dated April 9, 2001, the worker was advised that his claim for chest, back and right leg difficulties was accepted by the WCB as work related and that benefits would be paid for 8 weeks. Any further time loss beyond April 9, 2001 was considered to be related to his other non-work related health issues and would not be the responsibility of WCB.

A WCB medical advisor saw the worker for an assessment on April 20, 2001 after his treating physician expressed concerns regarding the suggestion that the worker was suffering from a neurological or neuromuscular condition. While the medical advisor acknowledged that changing a 20 year habit of work activity could be expected to cause problems of a musculoskeletal nature, he thought the worker ought to have recovered from the sprain/strain type of injury. He could not relate the constellation of the worker’s symptomatology, including the appearance of tremors and psychomotor retardation, to the injury. He noted that “the blunt facies and emotional lability may be as a result of a depression,” and that there was “clear evidence of concern about the workplace and his changed job duties.”

In a letter dated May 30, 2001, a worker advisor requested the worker’s benefits be reinstated. He relied upon the treating physician’s opinion that the worker had not recovered from his workplace injury, that he had myofascial pain syndrome and that he had developed a major depression that prevented him from returning to work and was predominantly attributable to the compensable injury.

The worker was assessed in July 2001 by the WCB’s psychiatric consultant about his motor difficulties and the possibility of a depressive illness. He noted that the worker was “very afraid of doing both jobs alternatively because scouring is a very difficult, physical job, that would require using his hands and arms in a strenuous fashion over a period of time”. The worker reported that he told his supervisor he could not perform both jobs, but the foreman had “forced him to do it anyway”. The consultant found the worker to likely have “biological and temperamental predispositions to the development of psychiatric disorders, such as anxiety and depressive disorder…He responded to pressure in the workplace by experiencing extreme stress and by the rapid onset of physical symptoms when doing a new job of which he was afraid and in which he was not wanting to participate. As such there appears to be significant psychological factors that are contributing to his physical symptoms... These psychiatric diagnoses of panic disorder and somatoform disorder have developed since the onset of his workplace conflict. If the principal diagnosis is generalized anxiety, his symptoms have deteriorated since the onset of the workplace conflict...his psychiatric symptoms are such that he would not be able to return to work at this time.”

In a decision dated August 7, 2001, the case manager determined that the stress and associated psychological problems experienced by the worker resulted not from the compensable injury, but from the workplace environment, and there was therefore no “accident” under subsection 1(1) of The Workers Compensation Act (the Act). He noted that the worked had reported a depressive episode 18 years previously for which he continued to receive treatment. Further, the case manager confirmed that responsibility for wage loss or medical treatment would not be accepted beyond April 9, 2001, as there was no medical evidence that the worker had myofascial pain syndrome, and he had recovered from the effects of his sprain/strain injury.

On September 2, 2005, a worker advisor requested reconsideration of the August 7, 2001 decision on the basis that the worker had not yet recovered from his February 2001 injury, and that the injury had enhanced his pre-existing anxiety and depressive disorder. He relied upon a report dated January 30, 2002 from the worker’s treating physician in which he expressed the opinion that the worker had not recovered from a previous injury sustained in 1994. He diagnosed the 1994 and the 2000 injuries as myofascial pain syndrome, chronic pain syndrome, chronic recurrent musculo-skeletal abuse and over-use and secondary major depression and anxiety attacks. The February 1994 injury had been accepted by the WCB as a strain/sprain injury to the worker’s chest, right side and low back. A WCB medical advisor diagnosed the worker in May 1994 as having possible myofascial pain due to overuse at work. In June 1994 a WCB medical consultant examined the worker and concluded that the worker may have incurred an injury to the chest wall muscles involving the serratus anterior and intercostal muscles. He found there to be no major objective findings and concluded that the worker had returned to his pre-accident physical status. The worker returned to his full time duties in September 1994.

The treating physician confirmed in a report dated November 28, 2005 that the worker’s first visit had been in October 1987 and that early visits were related to psychological problems that were chronic in nature. He was prescribed medication in April 1988 and felt well until February 2001. He concluded that the worker continued to suffer from his compensable injuries and a secondary psychological disorder. In a report to the treating physician dated July 21, 2003, a psychiatrist states that he diagnosed the worker in 2001 with major depression in partial remission with the primary stressor involving “disputes at work with the foreman”. When seen on July 17, 2003, the worker had significant psychomotor retardation and appeared to be very distressed. The worker attributed his depression to stresses at his previous employment. The psychiatrist did not feel the worker’s symptoms were severe enough to force treatment.

In a February 16, 2006 decision, the case manager determined that there was no basis to change or alter the August 7, 2001 decision. It remained the position of the WCB that the worker had recovered from the injury suffered at work in December 2000 and that the claim for stress and associated psychologic problems was not directly related to the compensable injury.

In February 2007 the worker submitted a report from an occupational health physician dated January 25, 2007. He found that the worker had extensive findings of muscle shortening, myofascial dysfunction and pain restrictions in the functional use of his right upper extremity and upper body and right abdominal wall, hip and low back. He noted that the most affected muscle groups were consistent with a six year history of repetitive, forceful trimming, scouring shoes and pulling lasts. He concluded that the findings in the right shoulder girdle and chest wall were quite likely lonstanding given the consistency of his pain impairments over years, and stated that “in particular reference to right pectoralis major muscle involvement, active myofascial trigger point activity in the costal division has been associated with cardiac arrhythmias such as he experienced while working and was sent to emergency for cardiologic assessment (which was negative).” He concluded that the worker’s depression was strongly linked to his injury leading to his psychiatric diagnosis of depression, related pain condition and the stressful circumstances of harassment, poor symptom control and eventual unemployment.

On March 6, 2007, the case manager informed the worker that after reviewing both the 1994 and the 2000 compensation claims and the report from the occupational health physician there was no new evidence to warrant a change in the initial decision. On March 19, 2007 the worker appealed the decision to Review Office.

In its decision of April 12, 2007, Review Office confirmed that the worker was not entitled to wage loss or medical aid benefits after April 21, 2001 and that his mental health problems were not related to his compensable injury. Review Office found the worker suffered a gradual onset of muscular strain-type injuries to his chest wall, back and right leg from the performance of his duties in December 2000 that progressed until he went off work in February 2001. There was no clinical or diagnostic evidence to suggest a more significant injury to account for the worker’s ongoing physical problems. Review Office said there was overwhelming evidence to show that the worker’s mental health problems were a reaction to workplace stressors and not as a direct result of his strain injuries of 2000. It was therefore not compensable. In May 2007, the worker appealed Review Office’s decision and a hearing was arranged for June 28, 2007.

Following the hearing, the appeal panel requested additional information prior to discussing the case further. On July 31, 2007, the worker was provided with the information that the panel received and was asked to provide comment. On August 13, 2007, the panel met and rendered its final decision.

Reasons

His conclusions are consistent with the 1994 findings by a WCB medical consultant that the worker may have incurred an injury to the chest wall muscles involving the serratus anterior and intercostal muscles, the 2001 diagnosis by his treating physician of “right lower anterior/laseral (sic) chest wall strain,” the findings by a physical medicine specialist in 2001 that the worker had “some myofascial pain of the chest muscles with decreased mobility of the shoulder,” and the acknowledgment by a WCB medical consultant in 2001 that changing a 20 year habit of work activity as had occurred in this case could be expected to cause problems of a musculoskeletal nature. The concurrent reporting by the worker of cardiac arrhythmia in January and February 2001 is further supportive of an injury to the right pectoralis major muscle in the costal division, most likely generating referred chest pain and presenting as possible cardiac arrhythmia.

While the severity of the pain has decreased over time, that is no doubt a result of the worker not having returned to work after April 2001. As noted by the occupational health physician, “the severity and reactivity in 2007 is likely considerably less than would have been present in his years working with pain”. We are satisfied that the worker’s chest injury resulted from the repetitive nature of his duties, and that he was unable to return to work after April 21, 2001.

The panel has also assessed the worker’s other physical complaints, in particular regarding the lumbar spine, SI joints, right flank, right buttock pain, tremors, and psychomotor retardation, against the worker’s job duties. The panel finds that these conditions are not causally related to the workplace accident.

The worker’s appeal on this issue is therefore allowed.

Panel Members

K. Dangerfield, Presiding Officer
A. Finkel, Commissioner
B. Malazdrewich, Commissioner

Recording Secretary, B. Kosc

K. Dangerfield - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 9th day of October, 2007