WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20090025
OBJECTION BY: Worker
EMPLOYER: Participating
REPRESENTATIVES: Employer Representative
HEARING DATE: N/A
ISSUE
The worker is objecting to the Adjudicator’s letter dated January 10, 2008 and letter dated May 27, 2009 from the Case Manager which denied secondary entitlement for a left hand condition which the worker related to the effects from his original injury of September 25, 2003.
HOW THE ISSUE ARISES
On September 25, 2003, the worker reported an onset of right shoulder and right wrist pain which he related to the repetitive duties involved in his job. In September 2004, the worker was granted a 7% Non-Economic Loss (NEL) award for the right shoulder/arm. In April 2005, he underwent an arthroscopic decompression surgical procedure on his right shoulder. Although the employer was originally able to provide the worker with suitable modified duties, in January 2006 the worker was provided with Labour Market Re-entry (LMR) services in order to obtain suitable employment in another field.
In a previously released Appeals Resolution Officer’s (ARO) decision dated July 18, 2008, it was determined the worker’s LMR services were appropriately closed in November 2007 for non-co-operation in the program. His loss of earnings (LOE) benefit rate was adjusted to the expected earnings from the suitable employment or business (SEB) of security guard. This calculation was based on earnings of $9.00 per hour.
However, during the completion of the portion of the LMR plan which involved typing, the worker related an onset of left arm problems to this activity. Subsequently, it was determined by the operating area that a causal relationship was not evident and entitlement for this secondary impairment was denied.
The worker has appealed this determination.
AUTHORITY
As per the Workplace Safety and Insurance Board (WSIB) Operational Policy Manual (OPM)
11-01-01 Adjudicative Process
15-05-01 Resulting from Work-Related Disability
11-01-15 Aggravation Basis
14-05-03 Second Injury and Enhancement Fund (SIEF)
11-01-02 Decision-Making
11-01-03 Merits and Justice
11-01-13 Benefit of Doubt
RESOLUTION METHOD & PROCESS
The worker submitted a request that a decision be rendered within sixty days without the need for a formal hearing regarding this issue in dispute.
After reviewing the entire claim record file, I am prepared to render my decision.
ASSESSMENT OF THE EVIDENCE
The sole issue before me pertains to the worker’s request to have his left arm impairment be considered as being causally related to the activities he was performing while in the LMR program.
With regards to the physical restrictions which resulted from the September 2003 onset, the worker was told to avoid grasping, gripping and overhead activities which involved the right arm. At the commencement of the LMR program, the worker stated he experienced difficulties using his right arm for writing; thus, he started using a keyboard/computer, using his left hand, to take notes.
In a report by his physiotherapist dated March 23, 2009, the worker advised his physiotherapist that he was typing for three hours while in class and three hours in the evening. This lasted approximately one year in duration. The physiotherapist’s report continues to state,
“During this time he was expected to use only his left hand. The worker reported having rested his arm/elbow on the desk and used to slide this back and forth to use the mouse and type. In June 2007, he noted numbness in the 3rd, 4th and 5th digits of his left hand. Eventually, the 1st and 2nd digits of the left (hand) also went numb.”
The EMG tests demonstrated left carpal tunnel syndrome (CTS) was present. Based on the worker’s description of his LMR activities, the opinion of the physiotherapist, provided at the end of the report, concluded:
“It is in this assessor’s professional opinion that the worker has developed carpal tunnel from using his left hand repetitively for his activities of daily living, which include typing. The worker was forced into typing with only his left hand because of a work-related injury to his right upper extremity. As a result, his left carpal tunnel syndrome is a secondary injury form the right-sided work-related injury.”
However, the WSIB Medical Consultant did not agree with this conclusion. In memo 197A of the claim record file, the WSIB Medical Consultant noted the worker had carpal bossing of the right wrist. Carpal bossing is an abnormal bone growth that forms before birth, or develops as a result of degenerative arthritis on the back of the CMC joint of the index or middle fingers. Often, this condition can be mistaken for a ganglion. Noting the worker had a history of ganglion prior to the September 2003 work-related problem to the right upper extremity, which the WSIB Medical Consultant thought was probably carpal bossing, the WSIB Medical Consultant concluded that if the worker was overcompensating for his right wrist by using the left wrist more, than the overcompensation was due to a pre-existing condition and not as a result of the effects of the right shoulder impairment from the September 2003 injury.
Thus, entitlement for the left carpal tunnel syndrome was denied by the operating area because the worker’s over-compensation was due to a pre-existing right wrist condition and was not as a result of the work-related impairment.
In his submission dated June 30, 2009, the worker provided the following arguments why entitlement should be granted:
Since he was right hand dominant, after the injury of September 2003 he became more dependent of his left arm for everyday activities.
While on modified duties with the employer prior to 2006, he was required to use pneumatic sanders, buffers and spray guns.
While in the LMR program, he was provided with a computer program entitled “Five-Fingered Typist” which would allow him to develop his left hand typing skills.
In June 2007, he reported the numbness in his left hand to the school and LMR service provider.
He questioned the WSIB Medical Consultant’s comments regarding carpal bossing, especially noting the opinions of medical studies which indicate a relation between repetitive duties and carpal tunnel syndrome exists.
The first recorded evidence of a right hand problem is in his employer’s original report of accident and there is no mention of it on his pre-employment medical history.
ANALYSIS:
There is always difficulty in determining whether an impairment is causally related to overcompensating because of a work-related condition on the other side of the body. Additional concerns arise when the medical literature on the new impairment is inconclusive with regards for a cause of the impairment. This is especially the case for carpal tunnel syndrome.
As indicated in the medical documentation available on the subject of carpal tunnel syndrome, what causes carpal tunnel syndrome is debatable. As stated in a document on the internet site “WebMD”, regarding the subject, “While there are many possible causes of carpal tunnel syndrome, the vast majority of people with the condition have no known cause.” The document continues to state that it is known that excessive repetitive movements of the arms, wrists or hands can aggravate the carpal tunnel bringing out the symptoms of carpal tunnel syndrome.
The Workplace Safety and Insurance Appeals Tribunal (WSIAT) Medical Discussion Paper on the subject of carpal tunnel syndrome provided the following comments:
“There is so much variation in the manner in which carpal tunnel syndrome is diagnosed, that comparison between studies of the workers of different industries is difficult and sometimes impossible.”
“The role of vibratory exposure in the etiology of carpal tunnel syndrome is unclear… The establishment of causality requires that there be demonstration of temporal and dose-response relationships as well as a biologically plausible explanation. The available literature does not satisfy these criteria, and so a definitive relationship between exposure to vibration and the development of carpal tunnel syndrome has not been proven. However, there is evidence to suggest that a plausible biologic link between exposure to vibration and carpal tunnel syndrome does exist and therefore, given a reasonable duration and extent of exposure, there is reason to consider this possible etiologic connection in certain cases. What remains unknown is how much exposure constitutes a threshold beyond which this relationship should be held to exist.”
“The role of repetitive movements has been alluded to above. The data available on this subject suggests little if any relationship between this type of exposure and carpal tunnel syndrome. The exception would be in instances where the repetitive activity requires both frequent and forceful movements.”
The National Institute of Neurological Disorders and Stroke developed its own fact sheet. Under the category “What Are the Causes of Carpal Tunnel Syndrome” it states,
“Carpal tunnel syndrome is often the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel, rather than a problem with the nerve itself. Most likely the disorder is due to a congenital predisposition – the carpal tunnel is simply smaller in some people than in others. Other contributing factors include trauma or injury to the wrist that cause swelling, such as sprain or fracture; overactivity of the pituitary gland; hypothyroidism; rheumatoid arthritis; mechanical problems in the wrist joint; work stress; repeated use of vibrating tools; fluid retention during pregnancy or menopause; or the development of a cyst or tumour in the canal. In some cases no cause can be identified.
There is little clinical data to prove whether repetitive and forceful movements of the hand and wrist during work or leisure activities can cause carpal tunnel syndrome. Repeated motions performed in the course of normal work or other daily activities can result in repetitive motion disorders such as bursitis and tendonitis.”
Therefore as demonstrated by the above, there is debate, or uncertainty, within the medical community as to the specific cause(s) of carpal tunnel syndrome.
WSIB decision-makers, noting this conflict, have usually accepted the premise continuous repetitive activities can cause carpal tunnel syndrome and there must be evidence that the work duties being performed can reasonably be presumed to have contributed to the impairment, i.e. were the activities sufficient enough to cause CTS on their own, or is an alternative explanation more likely? In addition, with regards to the present appeal, not only is it necessary to determine if the duties the worker was performing using his left hand because of the limitations to his right hand were sufficient to cause the development of CTS in the left wrist, but was the reason for using the left wrist a result of the shoulder impairment, or as mentioned by the WSIB Medical Consultant, related to an underlying or pre-existing right wrist condition?
To assist me in my determination, I have considered the following:
The worker’s NEL award was comprised of a 6% right shoulder impairment, combined with a 6% aggravation to the pre-existing carpal boss condition. This resulted in a 12% impairment of the right upper extremity, which was then adjusted to a 7% whole person award.
Although the worker mentioned using vibrating tools while still in the employ of the employer, noting the delay in onset of a diagnosis of CTS in the left wrist, I do not consider this employment activity to be the cause of the CTS.
With regards to the activities while in the LMR program, the LMR reports indicate the worker commenced his program on September 11, 2006 with academic upgrading for a year. In August 2007, he was to learn computer fundamentals for two months and a training program for an additional two months, followed with a work placement. Mention was made on the very first progress report for the need of non-dominant hand training as the worker was experiencing pain on his right side.
With regards to the academic upgrading portion, the worker advised the LMR Service Provider that he did not wish to use voice-activated software, but discussion did occur with regards to a Five-Finger Typist program and training to switch hand dominance. The mouse on the computer was then switched to the left side; however, there are subsequent indications this was changed back to the right side.
The LMR progress reports indicate the worker’s main barrier in succeeding with the academic upgrading was progressing challenges experienced by the worker between verbal and written communication and spelling. There is no mention of excessive hours on the computer, whether in the classroom or in doing homework in the academic upgrading program. Most of the concentration was in regards to the worker’s concerns on his ability to perform the work for which he was being trained, as opposed to physical barriers in performing the academic portion of his LMR program.
The LMR progress report, dated July 16, 2007, noted the worker was not using computer voice-activated programming and the worker was not able to work in the classroom for more than three to three and a half hours per day. Prior to this date, there is no confirmation in the LMR service provider reports that the worker was continuously on a computer for three hours a day while in the classroom or that he was performing three hours of homework per night.
The first medical treatment for the CTS in the left hand occurred in September 2007 and EMG studies were ordered.
The EMG report dated October 10, 2007 indicated the worker underwent a carpal tunnel release on the right wrist ten years previously. Based on the current findings in the right wrist, it was not possible to distinguish between ongoing compression of the median nerve at the right wrist, or residual effects from the prior compression and surgery from ten years ago. However, if there was an ongoing compression, it seemed to be asymptomatic.
There was evidence of a left ulnar neuropathy at the elbow and a carpal tunnel syndrome condition was also noted. However, as the symptoms were intermittent and only moderately abnormal, a conservative approach was considered to be in order.
The first mention of the left hand problem to the WSIB was in memo 140 of the claim record file (dated October 2007) when the worker attributed his problem to the LMR program.
The LMR progress report dated October 17, 2007 indicated the instructor indicated the use of the keyboard was about an hour and a half per day and the worker was provided with frequent breaks. It was confirmed the worker completed one finger typing with the left hand, and then clicks the mouse with the right.
Although the worker’s present psychological reports indicated the worker claims he had a learning disability at a younger age and the worker considered himself to have a cognitive impairment which prevented him for participating in a vocational rehabilitation program to the fullest extent, I found his submission to have been professionally presented in a reasonable fashion. However, after reviewing the entire claim record file, I concur with the operating area that entitlement for the CTS in the left wrist is not in order. I base this conclusion on the following:
Although the WSIB Medical Consultant related the need for using the left hand was based on a pre-existing carpal boss condition in the right wrist, I note the NEL award was partially calculated based on an aggravation to the right carpal boss. Therefore, the WSIB has accepted a permanent aggravation occurred to the right wrist; thus, it is considered part of the entitlement under this claim and cannot be used as a reason for denying consideration of the left wrist CTS as being a secondary condition. Entitlement for the CTS condition must be based on whether the activities performed were sufficiently repetitive to provide a causal relationship between the activities and the diagnosis.
There is little in the way of supportive documentation that the worker worked to the extent he claims on a continuous basis on a computer using only his left hand. The worker did have concerns at the beginning of the program of his ability to use his right extremity and requested assistance in alternative methods of performing his tasks; however, it is not evident that this activity was sufficiently repetitive to cause a CTS condition.
I note the worker had previous right CTS surgery for a condition which was not work-related. This would indicate the worker was pre-disposed to developing CTS without the need for an external force to be present as the cause.
The medical literature already quoted in this decision, indicates that a direct causal relationship between repetitive motion and the development of CTS has not been established; however, when excessive motion is evident there is a tendency by the WSIB to grant entitlement based on the balance of probability. In the worker’s specific case before me, I do not see evidence of excessive left wrist activity. The worker may have been one-finger typing, or using other fingers as well on the left hand; however, I do not see a medical relationship between this activity and the development of CTS. There is no evidence to support the worker was performing continuous typing which is similar in nature to that performed by a professional secretary in for a full day. The only observations at the school recorded in the LMR service provider reports were half of what the worker claimed he was performing and the worker was seen taking frequent breaks.
In summary, it is understandable the worker would attempt to relate an activity which he was performing to a diagnosis of CTS; however, the evidence would suggest that noting a prior history of developing CTS in the right wrist without repetitive duties being involved and an activity which I do not consider to be excessively repetitive involving the left wrist, the left wrist CTS developed without a causal relationship existing between the activity of typing using the left hand and the diagnosis.
Thus, the denial to entitlement for a left wrist CTS impairment is upheld.
CONCLUSION
I conclude the development of left wrist CTS is not related to the worker overcompensating for this right upper extremity impairment.
The worker’s objection is denied.
DATED August 6, 2009
N. Norvack
Appeals Resolution Officer
Appeals Branch