Decision #76/10 - Type: Workers Compensation
Preamble
The worker is appealing a decision made by Review Office of the Workers Compensation Board (“WCB”) which denied responsibility for her current neck and left upper extremity symptoms. A hearing was held on June 22, 2010 to consider the matter.Issue
Whether or not further responsibility should be accepted for this claim.Decision
That further responsibility should not be accepted for this claim.Decision: Unanimous
Background
In August 2007, the worker filed a claim with the WCB for right arm, wrist and shoulder pain that commenced at work on or about April 16, 2007. The worker related her difficulties to the repetitive nature of her work duties. These included pulling patient charts, answering phones, putting charts into new file folders, entering data on the computer, checking in patients, re-booking appointments, and attaching hospital charts to specific clinic charts. With regard to the development of her symptoms, the worker noted that she first noticed an ache in her right wrist which progressed to sharp pains in the right forearm. She felt general weakness when trying to pick up things and sharp pains at night in the forearm area which moved to her shoulder. She now had constant pain behind her right shoulder.
A doctor’s first report dated August 10, 2007 reported complaints of pain in the forearm and lateral aspect of the right elbow, tenderness in the lateral epicondyle, and strain to the right arm. The worker’s description of accident reported to the physician was chronic, repetitive strain injury and recent increase in chart volume lifting. The diagnosis was lateral epicondylitis.
On August 22, 2007, the worker spoke with a WCB adjudicator and described in detail the actions involved when handling patient charts (i.e. grabbing, pulling and reaching charts above head level, etc.). The worker noted that her right wrist symptoms began in April then progressed up the arm to the elbow. In July 2007, she noticed pains in her neck and right shoulder. The worker indicated that she was diagnosed with left sided carpal tunnel syndrome (“CTS”) about two years ago. She was not claiming for CTS but was claiming for right sided tendonitis and right shoulder and neck pain. The worker noted that in October 2006, her work load doubled as two clinics combined their charts together. The worker advised that they also converted to a new filing system and that she had to convert 4000 files over the past year.
A physiotherapist reported on August 27, 2007, that the worker’s upper extremity complaints were related to cervical radiculopathy. There was tenderness over the right rotator cuff insertion, myotomal weakness in the right C6 and C7 cervical spine and C3 to C7 levels.
On August 30, 2007, an employer representative indicated that the worker pulls about 60 charts a day and they can weigh 1 to 5 lbs. The employer confirmed that the amalgamation of 4000 charts ran from November 2006 to April 2007. She noted that the worker appeared to be in discomfort about 6 weeks ago and that she related her symptoms to pulling charts. The worker was the only one who pulled that amount of charts on a daily basis.
On August 30, 2007, the worker was advised that her claim for compensation was accepted based on the diagnosis of right arm tendonitis, right shoulder and neck strain.
Subsequent file records showed that the worker’s right upper extremity injury was slowly resolving and that she had decreased neck and shoulder symptoms. Range of motion in the worker’s neck was near normal. On October 15, 2007, the worker reported numbness in both hands.
A CT scan of the cervical spine dated November 30, 2007 showed multilevel degenerative change and no central canal stenosis was identified. At C3-C4, there was a moderate central disc protrusion which displaced the spinal cord posteriorly. Cord compression was not strongly suspected on the CT.
A report received from a neurologist dated December 18, 2007 indicated that the worker described a five month history of pain in the right arm, mostly affecting the elbow and wrist. The worker also had posterior neck pain and restriction of movement. The worker complained of left arm numbness from the elbow down. The neurologist opined that at the present time there was no definite evidence of either an entrapment or neuropathy or cervical radiculopathy.
On January 7, 2008, a WCB medical advisor examined the worker’s upper extremities to confirm a diagnosis. The examination findings demonstrated a reasonable range of motion of the cervical spine with some mild pain, localized pain and tenderness in the low back on palpation and with range of motion testing. Provocative tests for right lateral epicondylopathy were positive. The examination did not demonstrate any convincing evidence of cervical radiculopathy. The medical advisor stated that the worker’s current neck symptoms appeared to be related to pre-existing unrelated degenerative disc disease in the cervical spine and that she had an element of degenerative changes in her right wrist. Her right lateral elbow symptoms were consistent with right lateral epicondylopathy. He noted that physiotherapy treatment to date related to a suspected cervical radiculopathy and that the worker may not have received adequate treatment for the right lateral epicondylopathy. He felt that the worker was ready to return to modified duties with workplace restrictions related to the right hand.
The worker commenced a graduated return to work program on January 15, 2008 and returned to her regular work duties on March 4, 2008.
On November 22, 2008, the worker advised the WCB that she was not 100% recovered from her compensable injuries. She noted that she had been able to compensate to do her job when needed. She had been using her whole body to turn instead of turning her neck. She had difficulties on the left side of her neck. She saw a massage therapist and was told she had problems with her rotator cuff.
On January 30, 2009, the worker reported that she started to see a chiropractor, as she had severe pain in her chest area. The chiropractor indicated that her problems were in her back just below the neck area. She last worked on January 27 and has been off since due to the pain in her left shoulder. She needed to rest her arms while typing and did have a keyboard tray at work. She reported difficulties with holding the phone up, pulling patient charts and lifting.
Primary adjudication asked a WCB medical advisor to review the reports on file and provide the current diagnosis related to the worker’s left shoulder condition and its relationship to the April 2007 compensable injury.
On March 11, 2009, the WCB medical advisor indicated that the findings on the medical reports were consistent with left shoulder rotator cuff pain and neck symptoms. He noted the previous CT scan of the cervical spine had demonstrated degenerative changes and disc herniation in the past. He was unable to relate the worker’s current symptoms to the April 16, 2007 compensable injury.
In a letter dated March 29, 2009, the worker was advised that the WCB was unable to establish a relationship between the workplace injury of April 2007 and her current neck and left shoulder difficulties. On April 21, 2009, the decision was appealed by the worker’s advocate. He submitted that the worker’s neck difficulties were a continuation of her 2007 compensable work related injury. He said the worker had no previous problems with her neck and any pre-existing condition was asymptomatic. Her condition had been aggravated/enhanced by her work related activities and by poor ergonomics in the workplace which had not been totally resolved. He argued that a work related aggravation and/or enhancement of a pre-existing condition was the responsibility of the WCB.
In a submission to Review Office dated June 3, 2009, the employer’s advocate questioned the initial acceptance of the claim. It was felt that the temporary increase in the number of charts handled by the worker from November 2006 to April 2007 did not account for the increase in her reported symptoms. The advocate also agreed with the opinion of the WCB medical advisor that the worker’s current left shoulder symptoms were not related to the compensable injury but rather were solely due to pre-existing cervical disc degeneration.
On June 9, 2009, Review Office received a submission from the worker outlining the events that led to her injury.
On June 9, 2009, a WCB physiatrist responded to questions posed by Review Office in relation to the worker’s job duties and her current difficulties. The physiatrist noted that in late 2006, the worker had an increase in workload related to file handling; however, there was no plausible diagnosis to support a neck injury in regard to the worker’s reported work activities in late 2006 through to the spring/summer of 2007. While the physical demands of her job would not have been expected to produce a right upper extremity injury, it was possible that it aggravated some pre-existing issue in the lateral elbow area. The physiatrist stated that the onset of the worker’s more recent left upper extremity symptoms did not appear to have a plausible physical relationship to her current described work activities. He indicated that the file evidence did not support any strong relationship between the described work duties and the worker’s neck and upper extremity symptoms.
On July 2, 2009, Review Office determined that it was appropriate to accept the claim as an aggravation of a pre-existing condition. It also found that no further responsibility should be accepted for the worker’s claim based on the following evidence:
· the opinion by the WCB physiatry consultant that the physical demands of the worker’s job would not cause her neck and right upper extremity symptoms.
· the worker developed transitory left sided symptoms and numbness in the arm, hand and fingers several weeks after she stopped working in the fall of 2007. There was no evidence to support a relationship between the left upper extremity symptoms and the work activities which could cause an asymptomatic right upper extremity condition to become symptomatic.
· even if the worker’s neck symptoms were provoked by work activities, examinations by a neurologist, WCB medical advisor and treating doctor supported that any neck complaints were at or near resolution.
· most of the worker’s workplace ergonomic concerns had been addressed and the worker no longer was working through breaks and doing extensive overtime.
· while there were some continued reports of right lateral elbow symptoms, the medical report of June 19, 2008 indicated that there was a new diagnosis and that this was not related to the prior injury.
· the January 27, 2009 chiropractic report diagnosed the worker with chronic cervicothoracic intersegmental dysfunction and left pectoralis minor strain. Review Office was unable to find any evidence to support a causal link between these diagnoses and the compensable injury.
On November 16, 2009, the worker’s advocate appealed Review Office’s decision to the Appeal Commission and an oral hearing was arranged.
Reasons
Applicable legislation:
The Appeal Commission and its panels are bound by The Workers Compensation Act (the “Act”), regulations and policies of the Board of Directors.
The issue before the panel is whether or not further responsibility should be accepted for the worker’s claim. Under subsection 4(1) of the Act, where a worker suffers personal injury by accident arising out of and in the course of employment, compensation shall be paid to the worker by the WCB. Subsection 39(2) of the Act provides that the WCB will pay wage loss benefits until such a time as the worker’s loss of earning capacity resulting from the accident ends. Subsection 27(1) provides that medical aid will be paid by the WCB for so long as is necessary to cure and provide relief from the injury.
Worker’s position:
The worker was assisted by an advocate at the hearing. It was submitted that the worker had an accepted claim in 2007 and the diagnosis accepted as compensable was her right arm, right shoulder and neck strain. She stated the cause of her injury was due to the repetitive nature of her work. She took time away from the workplace to recover, then participated in a gradual return to work program from January 14, 2008 to March 4, 2008. When she resumed her regular pre-accident work duties in March, 2008, she returned to the same environment; there were no alterations in her work conditions and no ergonomic improvements had been made. She continued to experience pain with her neck and right shoulder, with pain radiating to her left shoulder. It was suggested that the movement of the pain to her opposite side was partly due to overuse of her left side.
The advocate acknowledged that the worker had a pre-existing condition, but submitted that this pre-existing condition had been asymptomatic. By having her return to work in the same working conditions she has previously been exposed to, her condition was aggravated, and possibly enhanced. She was finally no longer able to continue working, and it was requested that she be compensated for her time loss from January 28, 2009 to March 29, 2010. Since March 29, 2010, the worker had been back to work and was being accommodated by her employer within restrictions recommended by her chiropractor.
Employer’s position:
An advocate appeared on behalf of the employer at the hearing. The employer’s position was that the worker's claim had been accepted for the right arm, right shoulder and upper extremity difficulties and the medical evidence showed that by January 2009, the right sided tendonitis, lateral epicondylitis and right shoulder difficulties had cleared up. The left sided problems only developed months and weeks after the worker stopped working in 2007 and therefore there was no evidence of a relationship between the left upper extremity problems and the work activities. The employer felt that the worker had been adequately compensated for the initial compensable strain-type injury, which had been caused by the increase in duties associated with the amalgamation. Any of the other job duties she has done did not contribute to her diverse left sided complaints and it was submitted that her problems were more consistent with her cervical degenerative disc disease. It was therefore submitted that the worker was not entitled to further benefits.
Analysis:
In order for the worker’s appeal to be successful, the panel must find that the left-sided neck and shoulder difficulties which disabled the worker from January 2009 to March 2010 are related to the compensable injuries she suffered from her workplace duties of April 16, 2007. On a balance of probabilities, we are unable to make that finding.
At the hearing the worker provided considerable detail regarding her pre-accident duties with the accident employer. She explained that there were three secretarial positions in her department. Two of the positions were mainly receptionist jobs and the position description provided to the WCB by the employer related more to these jobs. The worker described her duties as being primarily related to the collection of charts. Prior to an amalgamation with another office, she was responsible for organizing 30 charts per day. After the amalgamation (which started in October 2006), she had to collect approximately 60 charts per day. This involved retrieving shadow files from their internal office filing system. The charts could be anywhere from the size of a magazine to a telephone book, but they did try to keep these charts as thin as possible. The maximum weight of a shadow chart would be 5 lbs. The files would be very tightly packed, so it took some effort to pull them off the shelf. There were several levels of shelves on each unit and some of the charts had to be pulled from overhead; others were at chest height or lower. The worker would stand on a stool to reach the higher shelves. The office filing system itself consisted of 3 or 4 shelving units which were on a track which could be moved by turning a circular crank. The crank was at approximately stomach height and required some force to turn. A regular adult could turn it but a child would have difficulty.
After the worker collected all the shadow files, she would place them in a crate by her desk. She would then retrieve the hospital files which would be delivered to her office in a large rolling cart. The hospital files would be significantly larger and she would lift them from the large cart, place them in a smaller rolling cart, and roll them to her desk. The worker would then place the shadow file in the hospital file, and then put the combined files in a cabinet until they were needed.
When asked to identify the tasks which were most troublesome for her neck, the worker identified the pulling of shadow files off the shelves and the cranking of the shelving units. She estimated that of her workday, she spent at least 3 hours collecting charts.
After considering the evidence on the WCB file and the evidence given by the worker at the hearing, the panel is not satisfied on a balance of probabilities that the worker’s job duties, as described, would be causative of the left sided neck and left upper extremity difficulties which caused the worker to start missing time from work in January 2009. In that regard, we note the following:
- While the connection between the right wrist/forearm/elbow/shoulder and the filing duties is understandable, it is difficult to see the relationship between the left side of the neck and the pulling of files;
- Although the worker’s recollection at the time of the hearing was that the pain in the left side of her neck was present from the outset, the medical reports would suggest otherwise. Complaints of neck pain are recorded, but do not specify a specific side of the neck. The best evidence would be the pain diagram which the worker drew at the time of the call-in examination by a WCB medical advisor in January 2008. At that time, the worker illustrated a right sided aching pain in her neck. There is no indication of any left sided pain in her neck, shoulder or arm;
- The first record of left sided neck and upper extremity pain was in November, 2008. At that point in time, the right sided epicondylitis had completely resolved and the worker had been back at full regular duties since March, 2008;
- The panel did not view the worker’s job duties as being highly repetitive or involving significant loads. It was a self-paced job which involved a variety of tasks. The maximum load of 5 pounds for shadow files was not particularly heavy and would tend to be the exception rather than the rule. As the worker noted, the office tried to keep the shadow files thin and many were only as thick as a magazine. The volume of files had increased from 30 per day to 60, and while comparatively this was a significant increase, overall the panel does not consider this to be an overwhelming volume of work such that it would cause a strain injury to the neck;
- There would be some overhead reaching involved, but not all of the charts would be on the higher shelving.
Overall, the panel finds that the worker’s job duties were not causative of her left sided neck and left upper extremity difficulties. Rather, the panel is of the opinion that there were two parallel medical conditions present. We accept that the extra work and overtime required to amalgamate the charts during the period October 2006 to April 2007 aggravated a pre-existing asymptomatic condition in the worker’s right wrist/arm/forearm/shoulder and caused it to become problematic. We do not, however, accept that her neck pain was caused by work. The worker acknowledged that her neck difficulties felt like they arose from a separate condition than the one affecting the right arm. The panel views the worker’s neck pain, whether left sided or right, as being related to a pre-existing degenerative condition which was steadily progressing regardless of the job duties being performed by the worker. The CT Scan of November 2007 confirmed multilevel degenerative changes. On a balance of probabilities, the panel finds that these degenerative changes are the cause of the worker’s difficulties after her return to regular work on March 4, 2008, and therefore no further responsibility should be accepted by the WCB for this claim.
The worker’s appeal is dismissed.
Panel Members
L. Choy, Presiding OfficerA. Finkel, Commissioner
P. Walker, Commissioner
Recording Secretary, B. Kosc
L. Choy - Presiding Officer
Signed at Winnipeg this 30th day of July, 2010