The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB")that she had recovered from her right wrist injury sustained in November 2013and that her ongoing condition was not related to her compensable accident.A hearing was held on March 9, 2015to consider the matter.

Issue

Whether or not the worker is entitled to benefits afterApril 14, 2014.

Decision

That the worker is not entitled to benefits after April 14,2014.

Decision: Unanimous

Background

The worker filed a claim with the WCB for injury to her right wrist that occurred on November 3, 2013.

On November 12, 2013, the worker advised the WCB adjudicator that she was leaving a client's apartment when she struck her right wrist on a hand rail on the wall. When her wrist hit the rail she felt immediate pain but she continued to work. On November 4 and 5 she worked her normal duties and her wrist was swollen and sore. On November 5, 2013, she was assisting another client to lift herself up when the client grabbed onto the worker's right hand. The worker said she felt immediate pain that shot through her hand. The pain level before this was 6/10 and after the client grabbed her hand, it was 10/10.

Medical reports on file show that the worker attended a physician for treatment on November 6, 2013 and was diagnosed with a right wrist contusion and a possible fractured radius. X-rays taken the same day of the right wrist were read as follows:

No acute or chronic bone, joint or soft tissue abnormality is visualized. Specifically a radiostyloid fracture is not visualized. If there is ongoing clinical concern regarding a fracture repeat imaging in ten day's time would be recommended.

On December 8, 2013, the worker's treating physiotherapist noted that the worker had very little useful function of her right hand and he was concerned that the worker was developing complex regional pain syndrome ("CRPS"). On December 17, 2013, a sport medicine physician also reported that the worker was starting to develop an early phase of CRPS.

On January 28, 2014, the treating physiotherapist reported that the worker had severely limited range of motion of her wrist, hand and fingers and she was extremely sensitive to light touch to the forearm. There was only moderate swelling and the therapist could not accurately test for strength.

On February 1, 2014, a WCB medical advisor reviewed the file information at the request of initial adjudication and a WCB call-in examination was later held on February 10, 2014.

Following the examination, the WCB medical advisor reported the following findings:

• The November 3, 2013 mechanism of injury and the incident whereby a client grabbed the worker's wrist would not lead to a structural injury to the wrist. The diagnosis of a contusion reported by the treating physician was consistent with the mechanism of injury.
• The natural progression of a contusion would be worsening pain over a day or two with some limited range of motion of the affected body part.
• The worker's caregivers have queried a diagnosis of CRPS. CRPS was a rare condition and the cause was not known. Since the cause was not known, it could not be determined whether the workplace accident caused the condition. The diagnosis of CRPS was based mainly on pain being out of proportion to an inciting event, with no pathophysiological basis for the presentation.
• the worker had some symptoms that meet the criteria for CRPS however she had none of the classic findings to support the diagnosis
• the sports medicine physician provided the diagnosis of CRPS on February 10, 2014 but provided no objective findings to support the diagnosis.
• the worker's current presentation of symptoms could not be medically accounted for in relation to the minor workplace injury.

On February 27, 2014, the worker underwent a bone scan and the radiologist's report stated: The findings of the right hand region may represent complex regional pain syndrome.

On March 7, 2014, the WCB medical advisor commented that the bone scan findings were non-specific and were very mild. The radiologist's finding of "may represent complex regional pain syndrome" was likely due to the history provided.

On March 14, 2014, a second radiologist reviewed the bone scan findings and stated: "These findings are consistent with complex regional pain syndrome. An alternate diagnosis of synovitis would not account for the periarticular activity in the hand."

On March 19, 2014, the WCB medical advisor confirmed that the findings on the bone scan did not change the opinion previously outlined in the call in examination notes. The medical advisor stated:

It remains that the diagnosis of CRPS cannot be confirmed based on the worker's presentation at call-in exam. The Pain Clinic did not provide objective evidence to support the diagnosis. They reported loss of range of motion and strength and that everything was painful. There were none of the classic features of this condition: abnormal skin, temperature, moisture, hair, or nail changes.

In a decision dated April 8, 2014, the worker was advised that no further responsibility would be accepted for her claim beyond April 14, 2014 as it was felt that she had recovered from the right wrist contusion of November 3, 2013 and that any ongoing symptoms could not be related to the initial workplace injury.

In a letter dated April 25, 2014, the treating sports medicine specialist stated:

It is unclear to me as to the reasoning behind WCB not covering this lady for her workplace related injury. The bone scan is often negative in patients with complex regional pain syndrome. This being negative does not exclude the diagnosis of complex regional pain syndrome. Certainly on history and examination of her signs and symptoms are compatible with complex regional pain syndrome.

On May 29, 2014, a worker advisor acting on the worker's behalf, appealed the WCB's decision that the worker had recovered from the November 3, 2013 right wrist injury and was not entitled to benefits beyond April 14, 2014. The worker advisor's opinion was that the worker developed CRPS shortly after the November 2013 injuries and that the weight of evidence from two radiologists, two clinic specialists and a physiotherapist who recognized early symptoms of CRPS, outweighed the WCB medical advisor's opinion which was based on literature. The worker advisor submitted that there was overwhelming medical evidence to support that the worker's current condition was causally related to her compensable injury and that this condition had resulted in a loss of earning capacity.

On July 21, 2014, the employer's representative submitted to Review Office that the worker's ongoing symptoms and disability was no longer explained by the initial workplace accident. The representative relied on the WCB medical advisor's opinion that CRPS was an exceptionally rare condition and that the worker did not meet the clinical diagnostic criteria for this condition.

The medical advisor countered the radiologist's opinion that bone scans are not a useful tool in diagnosing CRPS and that the pain clinic did not provide objective findings to support CRPS.

The employer was of the view that the worker's compensable injury was a muscular sprain/strain of some kind given that the x-ray exam was negative which ruled out the initially suspected wrist fracture. The representative concluded that the worker's ongoing symptoms and disability was no longer explained by the initial workplace accident and injury and there was no basis to accept ongoing responsibility in the matter.

On September 5, 2014, Review Office confirmed that the worker was not entitled to benefits beyond April 14, 2014. Review Office indicated that it preferred the position outlined by the WCB medical advisor on February 10 and March 19, 2014 over the worker's healthcare providers who indicate that the worker has CRPS. Review Office felt that the mechanisms of injury described by the worker on November 3 and 5, 2013 would be consistent with the accepted diagnosis of a contusion type injury. Review Office concluded that the worker's loss of earning capacity beyond April 14, 2014 was not related to the compensable injury. On October 16, 2014, the worker advisor appealed Review Office's decision to the Appeal Commission and an oral hearing was arranged.

Subsequent to the hearing on March 8, 2015, the appeal panel requested that additional medical information be obtained from two of the worker's treating physicians. The information was received and was then shared with the parties to the appeal on June 16, 2015. On July 6, 2015, the panel met to further discuss the appeal and render a decision.

Reasons

Applicable Legislation and Policy:

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

The worker has an accepted claim for injuries arising out of a November 3, 2013 accident. She is seeking benefits beyond April 14, 2014 for treatment of her ongoing symptoms and her loss of earning capacity.

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(1) of the Act provides that wage loss benefits will be paid: "…where an injury to a worker results in a loss of earning capacity…" 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 ends, or the worker attains the age of 65 years. Subsection 27(1) of the Act provides that the WCB

"...may provide a worker with such medical aid as the board considers necessary to cure and provide relief from an injury resulting from an accident."

WCB Policy 44.120.10, Medical Aid, sets out in part that "…medical aid attempts to minimize the impact of the worker's injury and to enhance an injured worker's recovery to the greatest extent possible."

Worker's Position:

The worker was represented by a worker advisor who made a presentation on her behalf. The worker answered questions asked by her representative and the panel. Their position was that the worker's ongoing right hand/wrist symptoms are related to the November 3, 2013 compensable injury and that she is not capable of returning to her pre-accident duties. In support of this position the advocate referred to medical reports and opinions on file before the panel.

It was the worker's evidence that she hit her wrist on a solid wooden handrail when she was walking to the next client and swinging her arm upward. The contact was in the center of the wrist bone right under her thumb. The worker testified:

Like when you stub your toe or something you feel the initial pain…I tried hard not to use my hand the rest of the day…When I got home I went and sat in a bath, and it seemed like it was okay. Like, it seemed like it was fine, so I didn’t think anything of it, I just figured, well you know, whatever it's just, I banged my hand. It's like stubbing your toe at home. So you don't think anything.

When asked by the worker advisor to describe the incident on November 5, 2013 the worker stated:

…then I was trying to help her to stand up, you know like when you’re arm-wrestling somebody…you're holding the person, and the person is holding around your hand, so they've got around your thumb and they've got around your wrist. So, she's grabbing, you know around. And as I went to go and help her up she wasn't even a few inches off [seat] when I felt this huge shock, everything went numb, and it kind of just shot up my arm.

It was submitted that the worker attended 21 physiotherapy visits with no relief and was referred to a sports medicine clinic. At the clinic she was examined and prescribed medication to get the pain under control.

The worker advisor noted a bone scan showed there were right hand region findings "that may represent complex regional pain syndrome." Following a review by the WCB a second opinion was sought that noted "These findings are consistent with complex regional pain syndrome." Since those opinions were rejected by the WCB, the worker attended for treatment at a pain clinic and underwent brachial plexus blocks. The worker stated:

So the first couple of blocks worked, and my hand froze, and at around the third, fourth block my hand wasn't freezing anymore…on the sixth block they did two different areas…on the seventh and eighth one they did under my armpit and they actually had to wait for my partial arm to freeze and then they did another needle in my forearm to freeze my hand, my wrist and my fingertips…and it seemed to work. I was getting pain relief at least for a few hours, where I wasn't sitting with my hand being sore and it constantly kind of, a low dull throb, as long as you're not excessively using it.

It was the worker's evidence that currently "My symptoms haven't gotten better. If anything, they've gotten worse."

The worker advisor noted the reports of several specialists provide clinical findings of right hand/wrist symptoms. The February 2, 2014 bone scan identified findings which may represent complex regional pain syndrome. This medical information supports that the worker continues to experience right hand/wrist symptoms associated to the November 3, 2013 compensable injury and affects her ability to return to the workforce.

Employer's Position

The employer was represented by an advocate at the hearing. The employer agreed with the decisions made by the WCB to end responsibility effective April 14, 2014. It was submitted that while the worker is apparently still exhibiting some symptoms, there appears to be no viable medical diagnosis for her ongoing condition. It was the employer's position that there no longer appears to be a direct causal link between her symptoms and the original workplace accident and injury.

It was further submitted that the first x-ray exam was negative, which ruled out the initially suspected wrist fracture. In the absence of a confirmed diagnosis of either a fracture or CRPS, one must conclude that her compensable workplace injury was either a contusion or a muscular sprain/strain of some kind.

Overall, the employer's advocate noted those types of injuries generally fully resolve within a few months post-injury, certainly they would not be an issue almost a year and a half post-accident. He concluded by noting the employer doesn't see where there's any findings to support the degree of disability and lack of function being presented.

Analysis

The issue before the panel is whether the worker is entitled to benefits beyond April 14, 2014. In order for the worker's appeal to be successful, the panel must find that the worker continues to suffer from and requires treatment for, her compensable injury. The panel is unable to make that finding.

The panel reviewed the file's contemporaneous medical documentation regarding first reported symptoms, diagnoses and findings. The treating physician noted on November 6, 2013 that the worker complained of pain to her right wrist with clinical exam findings of normal range of motion and intact neurovascular. The physician's diagnosis was right wrist contusion with a possible fractured radius which was ruled out on the same day. At a return visit the next day the worker reported her splint was loose and uncomfortable. Exam findings were normal range of motion and the physician rewrapped the splint on her right wrist. In a follow-up visit on November 13, 2013 the worker complained of pain with movement after removing the splint. Exam findings were a normal range of motion but painful over the radius bone. The diagnosis at that time was a wrist contusion/sprain.

The worker saw a physiotherapist on November 27, 2013 who noted clinical findings of decreased range of motion in right wrist and thumb with tenderness noting questionable pain tolerance. His diagnosis was a wrist contusion with deQuervain's type pain. The panel notes their understanding is that deQuervain's pain is related to a thumb injury. A home exercise program of simple exercises for the wrist and thumb was provided.

On December 17, 2013 six weeks after the compensable injury, the worker was seen by a sports medicine physician who did a full examination of her right upper extremity. He reported edema about her hand and distal arm; no specific coolness or mottling of skin; hypersensitivity to light touch with no numbness; a globally decreased range of motion of all movement in her thumb based on pain. The physician was able to passively move her wrist and fingers in all directions and noted structural findings of ligaments and carpal joints were normal but some clinical tests were unable to be performed due to pain. The worker had no crepitus of her extensor pollicus longus, her snuff box at the base of the thumb was non-tender, x-rays done that day showed no specific abnormality or disuse osteoporosis. The sports medicine physician's diagnosis was a possible early phase of complex regional pain syndrome.

The panel also carefully reviewed the February 10, 2014 clinical examination notes of the WCB medical consultant. The worker reported she had shooting pain from the wrist to her hand and up to her elbow that gets worse with movement. The worker noted that she is unable to put a glove on the hand or allow anything to touch the hand, she further noted that she does not use her right hand for anything. During the exam the worker displayed facial grimaces of pain and became tearful when her sweater was sliding down her arm. When asked to demonstrate range

of motion of the right wrist and hand, she did not move it at all. She repeatedly withdrew her hand from the examiner's touch when attempting testing and palpation. The WCB medical consultant did a CRPS assessment using the American Medical Association criteria and noted:

• The worker has continuing pain, evidence of hyperesthesia, hyperalgesia and allodynia.
• Light palpation to hand caused pain, she withdrew from the touch of a cotton swab.
• Temperature and skin colour were normal, no tremor or dystonia.
• Some generalized puffiness but no difference in moisture between the two hands.
• She had no hair, nail or skin changes.

Following the exam, the WCB consultant concluded that the mechanism of injury and initial presentation was consistent with a contusion. In regard to the diagnosis of CRPS, the consulted opined that the worker has some symptoms that meet the criteria for CRPS but she had none of the classic exam findings to support this diagnosis: no temperature changes, no skin colour differences, no edema, no sweating, skin, nail or hair changes. She further noted the pain clinic treating physician had made the CRPS diagnosis without any clinical findings to support this diagnosis, he only noted non-specific findings of decreased range of movement and strength. These findings do not confirm the diagnosis of CRPS.

The panel found the WCB medical consultant's analysis to be thoughtful and thorough and a persuasive argument. We therefore accept her opinion.

Given the information in the early reports from the treating physician the panel finds, on a balance of probabilities, that the worker suffered a contusion as a result of the incident on November 3, 2013 and mild sprain from a second incident on November 5, 2013.

The panel notes that many of the medical reports from various examining physicians report pain without clinical findings. The worker has undergone many and extensive treatments including physiotherapy, nerve block injections and various medication trials. These treatments provided no lasting benefit or improvement. There are also many opinions on file that suggest the worker might have a chronic regional pain syndrome but there is not a great amount of supporting evidence beyond what the worker verbally reported to the clinicians.

After complete review of the medical evidence on file, including the accepted opinion of the examining WCB medical consultant, the panel finds on a balance of probabilities that the diagnosis of CRPS is not related to either work related incident in November 2013.

The panel finds that the worker had recovered from the accepted diagnoses of a wrist contusion and mild sprain by April 14, 2014. The worker's appeal is dismissed.

Panel Members

M. Bencharski, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

P. Walker - Presiding Officer

Signed at Winnipeg this 6th day of August, 2015