The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB")that her bilateral carpal tunnel syndrome was not a result of her workduties.  A hearing was held on June11, 2015 to consider the matter.

Issue

Whether or not the claim is acceptable.

Decision

That the claim is acceptable.

Decision: Unanimous

Background

In March 2014, the worker filed a claim with the WCB for carpal tunnel syndrome ("CTS") which she related to the repetitive nature of her job duties. The worker reported that she first noticed symptoms in June 2013 and was not sure of the exact date that she reported the injury to her employer. The worker noted that she was currently off work for another WCB claim.

On February 5, 2014, a WCB case manager called the worker to discuss her claim for CTS. The case manager obtained information related to the worker's job duties and the onset of symptoms in both hands. The worker indicated that she had recovered from her prior injury until she was placed in her recent job where she experienced symptoms in her fingers.

A doctor progress report dated May 27, 2013, diagnosed the worker with tenosynovitis left hand and possible carpal tunnel syndrome both wrists.

In a report dated July 4, 2013, a physical medicine and rehabilitation specialist noted that the worker was employed as a store keeper which seemed like a very physical job using her hands. The specialist noted that the worker's symptoms were present for over a year and that the left was worst than the right and involved pain and paresthesia. Nerve conduction studies were performed and the results showed moderate to severe right median neuropathy at the wrist (carpal tunnel syndrome) and mild to moderate left median neuropathy. The specialist stated "It is highly unusual that an electrical carpal tunnel syndrome will be discordant from the patient's description of symptoms as in the most clinically severely affected sides tend to be most electrically severe which is opposite for her case. She clearly has pain as her main complaint and the paresthesia are secondary. They are not typical of carpal tunnel syndrome as they do not come on at night or first upon awakening in the morning. I think she should first seek treatment through physiotherapy for the tendonitis and look at possible ergonomic modifications to her workplace."

By letter dated June 9, 2014, the WCB advised the worker that her claim for compensation was not acceptable. The case manager noted that the worker's job duties entailed decanting work which involved pinch gripping and fine motor skills. The worker also had a medical history related to high blood pressure, arthritis and smoking. The case manager found that the file information did not establish a relationship between the worker's job duties, the nature of her symptoms and medical history with the natural history of her bilateral wrist difficulties. On July 4, 2014, the worker appealed the decision to Review Office.

On August 26, 2014, the employer's advocate submitted to Review Office that the worker's claim for bilateral CTS was not acceptable and that the case manager's decision of June 9, 2014 should be upheld.

On September 18, 2014, Review Office confirmed that the worker's claim for compensation was not acceptable. In making its decision, Review Office noted that CTS was a condition that could develop from both work-related and non-work related causes. Following a review of the worker's job duties which included a physical demands analysis, photographs of the worker's work station and the description of job duties provided by the worker and employer, Review Office concluded that the worker's bilateral CTS was not causally related to the physical demands of the storekeeper position.

Review Office noted that on May 27, 2013, a nurse practitioner noted a "possible" diagnosis of CTS based on clinical testing. The worker reported no symptoms suggestive of CTS or wrist difficulties associated with her job duties. This was not in keeping with the worker's account that her bilateral wrist symptoms developed in May 2013 as a result of her job duties. On November 6, 2014, a worker advisor appealed Review Office's decision to the Appeal Commission and an oral hearing was arranged.

Reasons

Applicable Legislation

In considering appeals, the Appeal Commission and its panels are bound by The Workers Compensation Act (the "Act"), regulations and policies of the Board of Directors.

Subsections 1(1) and 4(1) of the Act set out the circumstances under which claims for injuries can be accepted by the WCB, and state that the worker must have suffered an injury by accident that arose out of and in the course of employment. Once such an injury has been established, the worker is entitled to the benefits provided under the Act.

This appeal deals with claim acceptance. The key issue to be determined by the panel deals with causation and whether the worker’s CTS arose out of and in the course of her employment.

Worker's Position

The worker was represented by a worker advisor who provided a written submission on the worker's appeal and provided an oral outline of the worker's position. He advised:

• the worker is a long-term employee with the accident employer initially working in assembly.
• subsequently she worked in stores department for about six years decanting various paints and adhesives for use on the production floor. She reported that this job was getting progressively busier over time.
• this job is highly repetitive, with time-sensitive demands and activities that stress the hands and wrists with awkward and forceful gripping. The worker reported that her hands began to tire while doing this work. She continued, however, addressing the tiredness by either switching hands, shaking them out or doing something else.
• on March 14, 2013, the worker suddenly developed a problem in her left hand. This was accepted by the WCB in relation to the physical demands of her work.
• the worker decants products with the viscosity of hard molasses or that of peanut butter.
• the employer has acknowledged that changes to the process of decanting were needed.
• the worker continued to work her regular duties, self-modifying the tasks that she did in order to reduce her symptoms and accommodate her impaired left hand. The occasional soreness that she had been experiencing in both hands and wrists became worse and worse as she continued to work.
• in May of 2013, her nurse practitioner made a diagnosis of carpal tunnel syndrome based on clinical examinations which included a positive Tinel and Phalen test. A physical medicine specialist later confirmed the diagnosis of the carpal tunnel syndrome with nerve conduction studies.
• the WCB initially accepted carpal tunnel syndrome along with the left hand issue on the same claim and later split the claim and denied the CTS claim.

The worker advisor submitted that the claim for bilateral CTS is acceptable because the evidence supports that this condition was caused by the worker's work. He acknowledged that the worker does have some non-occupational risk factors, but the evidence supports a work-related etiology in her case.

The worker advisor noted that the employer’s own ergonomic assessments suggest that forceful and repetitive gripping is a requirement of the worker's position. He also noted that a WCB medical advisor accepted that CTS in this case was likely related to the work because it involved prolonged firm grasp and repetitive movements of the wrist against force.

The worker answered questions from the worker advisor and the panel. She described her duties and the onset of her symptoms. She said they decanted more than 50 products. Regarding the decanting of some of the substances she described the substance as thicker than molasses and said:

"This stuff is like, oh, frozen, hard frozen ice cream. It’s really, really hard to get. So you’re playing with tongue depressors. So you’re pinch-gripping them out of the cans, and then you wind it up. Now, everything is on a scale to start with."

The worker acknowledged that the substances had different viscosities. She said that the paints were either 2 or 3 part substances. She said they would put the substances into bottles and squeeze the bottles. She demonstrated her technique for squeezing bottles .

She said that pinch gripping tongue depressors was the hardest part of her job. She estimated that 75% of the jobs require the use of these sticks and estimated that she produces 1200 to 1400 items per week. She described the task of fastening lids on the containers. She noted that the majority of containers required pop-lids which require the use of her full hand to tighten.

In answer to a question from the panel about the percentage of time the worker works with her right hand, versus her left-hand, she replied:

"I would say probably 50/50 when I was alone, and if I had a right-handed person work with me, I let them have the right, have them work on whichever side they felt more comfortable."

The worker acknowledged that her right hand is stronger.

In closing the worker advisor stated that:

"In our view, the work that [worker] has demonstrated does have very forceful gripping. She is not in a neutral position. Her wrists are going through awkward and varied ranges of motion. In our view, these are causative for her carpal tunnel."

Employer Position

The employer was represented by an advocate and its Disability Management Specialist.

The employer representative noted that a relationship must exist between the activities and actions performed in the workplace with the establishment of whether the claim is acceptable.

She also noted that CTS is a unique medical condition that can arise from work-related and non-work-related activities for factors. She said that non-work factors can include factors such as age, from age 40 and up, gender, female, body mass index, other disease conditions such as diabetes, hyperthyroidism. She also noted that many CTS cases are idiopathic.

She said that where work duties are suggested to be a source of the problem, medical literature addresses very specific types and frequencies of body mechanics that could lead to the development of CTS. She said that the factors most commonly cited as leading to the development of CTS are high force, high repetition activities involving the hands, or activities involved with awkward bending of the wrist or forceful and gripping, or direct pressure on the carpal tunnel area of the palm or wrist. As well, vibration can be a factor. She noted that when an individual develops bilateral CTS, there is a strong suggestion that the cause is not work related.

The employer representative said that the worker's duties do not meet the requirement for high force and high repetition, noting that many of the activities are done "two hours, two to three times a week, one hour, three times a week, 56 items, two to three times a week." She noted that the worker had "some variation, some ability to rotate the tasks." She said there is no evidence of awkward hand positioning. There is no evidence of working repetitively against resistance. "There may be episodic periods when she meets some resistance, when the viscosity is very thick, as she has described, but that’s not continuous, nor continual. So, it’s sporadic."

The employer representative noted that the worker has many of the non-occupational CTS risk factors, including the use of a scooter to drive to work.

Analysis

The worker has been diagnosed with carpel tunnel syndrome in her right and left wrists. She is appealing the WCB decision that her claim is not acceptable. For the worker's appeal to be approved the panel must find that the worker's duties caused her bilateral carpal tunnel condition.

The panel notes the September 2013 comments of a WCB medical advisor that the development of CTS has been associated with activities which involve prolong firm grasp, repetitive movements of the wrist against force, or prolonged exposure to vibrations. The medical advisor commented that there is a probable relationship between the worker's job duties and her CTS.

The panel questioned the worker extensively on her duties, equipment used, her posture and the use of her hands. Upon considering all the evidence, panel finds, on a balance of probabilities that the worker's duties caused the worker's bilateral CTS.

The panel found that the worker's duties required constant use of her hands often in awkward positions, prolonged and intense. The task of capping (placing and attaching pop lids on containers) involved twisting and squeezing more than 80 lids per day. Her other tasks involving the use of sticks and the mixing of high viscosity substances also required continual use of force.

The employer noted that the worker's condition is bilateral and this suggests that the cause of the condition is not related to the work duties. In this case, the panel finds that the bilateral nature of her diagnosis is due to the worker's use of both hands to perform her job duties. At the hearing, the worker told the panel that she worked in an ambidextrous manner, switching from right to left frequently.

There was discussion at the hearing regarding when the worker became symptomatic for CTS. The panel is satisfied the condition was developing over a period of time during which the worker performed the causative duties.

The worker's claim is acceptable and her appeal is approved.

Panel Members

A. Scramstad, Presiding Officer
A. Finkel, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

A. Scramstad - Presiding Officer

Signed at Winnipeg this 20th day of July, 2015