WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20090054
OBJECTION BY: The Worker
REPRESENTATIVE: Worker
EMPLOYER: Not participating
ISSUE
The worker objects to the denial of entitlement to a psychotraumatic disability.
HOW THE ISSUE ARISES
The worker, a 40 year old hoist operator at the time of the accident identified as February 26, 2004, developed bilateral carpal tunnel syndrome (CTS) as a result of repetitive pushing, pulling and lifting with both hands. She continued to work until September 20, 2004 and the employer has been unable to accommodate her as she developed a permanent impairment (PI) for the CTS. She received a 9% non-economic loss assessment for the bilateral CTS. In a letter dated June 13, 2007, the worker’s representative requested entitlement to a bilateral elbow and neck condition. The case manager reviewed the evidence and accepted entitlement to the elbow condition but denied entitlement to the neck condition. The worker underwent another NEL assessment as it was determined she had a PI for the bilateral elbow condition. Her NEL award was increased to 14% recognizing the combined PI for the bilateral elbow and wrist conditions.
During the course of the worker’s treatment for her compensable condition, it was identified that she had some psychiatric issues which needed to be addressed in order to help with her recovery. The case manager authorized entitlement to psychotherapy treatment but there was no decision with respect to entitlement to a psychotraumatic disability. In a letter dated April 7 2008, the worker’s representative requested entitlement to the psychotraumatic disability and the case manager reviewed the evidence and after obtaining an opinion from a WSIB consultant psychologist denied entitlement. She advised the worker of this decision in a letter dated May 14, 2008.
The worker is objecting to this decision.
AUTHORITY
11-01-02 – Decision-Making
15-04-02 – Psychotraumatic Disability
RESOLUTION METHOD & PROCESS
I discussed and confirmed the issues on objection with the worker’s representative and agreed an oral hearing would be the most effective resolution method. At the time of our discussion the issues on the agenda were:
Entitlement to a left shoulder condition
Entitlement to the cervical condition
Entitlement to a psychotraumatic disability
The quantum of the NEL award for the bilateral neck and wrist conditions
An oral hearing was scheduled for October 15, 2009 and the worker attended along with her representative. The employer was notified of the objection but did not return the completed employer participant form and was not included in the process.
During preliminary discussions the worker representative withdrew the issues of entitlement to the neck and left shoulder conditions. He agreed to present additional medical evidence to the case manager and request a NEL redetermination so that issue was withdrawn as well. The only issue left was entitlement to psychotraumatic disability and we agreed on a decision without a hearing to address the matter.
ASSESSMENT OF THE EVIDENCE
I have reviewed the record and considered the evidence and submissions.
WSIB Operational Policy Manual Document 15-04-02 – Psychotraumatic Disability provides the criteria for when entitlement for psychotraumatic disability may be established. It states in part:
“Entitlement for psychotraumatic disability may be established when the following circumstances exist or develop
Organic brain syndrome secondary to - traumatic head injury - toxic chemicals including gases - hypoxic conditions, or - conditions related to decompression sickness.
As an indirect result of a physical injury - emotional reaction to the accident or injury - severe physical disability/impairment, or - reaction to the treatment process.
The psychotraumatic disability is shown to be related to extended disablement and to non-medical, socioeconomic factors, the majority of which can be directly and clearly related to the work-related injury.”
The first mention of a psychotraumatic impairment is documented in a Physician’s First Report dated March 18, 2005 which provides a diagnosis of major depression. This report states the family doctor provided the first treatment and her history of injury/disease was work-related injuries to her hands and wrists as well as stress.
The nurse case manager reviewed the worker’s treatment and documented in Memo 14 dated March 23, 2005 that the worker was scheduled to undergo left carpal tunnel release on May 11, 2005 and had developed a secondary condition of major depression. She suggested referral to the WSIB Specialty Hand and Upper Extremity Program to assist with the management of depression and expressed concern about the diagnosis of major depression and possible worsening of the condition if the worker did not receive specific treatment until May 2005.
The worker attended a psychological screening at the WSIB Specialty Hand and Upper Extremity Program on April 21, 2005. During this assessment, the worker reported she began experiencing problems in her workplace in about December 2003 when she felt people were talking about her. She reported a case of harassment at the workplace and acknowledged her union sent co-workers a warning letter but did not feel that much occurred in response to her complaint. She started having difficulty with her hands and wrists in February 2004 and stopped working in September 2004 after taking pain killers and performing modified work which did not help her situation. She has not returned to work with the employer since that time and participated in LMR services in an effort to pursue alternate employment.
The worker reported that since the injury, she had five to six hours of interrupted sleep each night and was easily tired. She described having nightmares and a reduced appetite and interest in sexual activity. She described changes in her social life and home activities and felt she was more easily emotional and often cried. She expressed some suicidal ideation but indicated she would not follow through with such thoughts. She expressed being hopeful that her life would improve and be better in the future. She reported being afraid to return to her workplace because of the treatment she received there. The doctor did not identify any specific psychological precautions or restrictions regarding her future ability to work but felt if she returned to her previous workplace, her symptoms of depression would likely worsen given her workplace atmosphere.
The psychologist, after assessing her, reported, the worker had some stress relating to her upcoming surgery for carpal tunnel syndrome and her continued pain. He also identified prominent depressive symptoms related to the worker’s current situation and regarding her workplace and how she was treated in the past. He reported since her pain difficulties began in 2004, she experienced “an exacerbation of prominent depressive and anxiety symptoms. She is currently being treated effectively by a psychiatrist, however, she would also likely benefit from individual psychotherapy.” The psychologist recommended ten sessions initially of psychotherapy to address her reported difficulties and stated; “It is clear that the worker was experiencing emotional difficulties prior to her pain onset as a result of reported workplace harassment; however, it appears that her emotional state has become worse since the onset of her pain difficulties.”
The worker reported no previous psychiatric history or medical problems and mentioned a prior suicide attempt in her home country when she took pills and was taken to the hospital. The attempt occurred when the worker’s husband left her alone in her country with her children. The psychologist reported,
“At the time of the workplace injury, the worker was working as a hoist operator. In addition to working full time, she kept busy by completing house chores, cooking, cleaning and going to the gym three times per week. She slept well prior to her injury and indicated that life was good because she was social and happy.”
The psychiatrist, in response to a letter from a WSIB nurse case manager, provided a report confirming that he saw the worker initially on November 4, 2004 and had seen her regularly ever since. He reported she indicated she was having some problems in the workplace and since early 2004 she started experiencing pain in her hand and wrist which affected her function. She reported experiencing tension and anxiety as a result of these problems and was feeling worried all the time and not enjoying anything. She was fearful and anxious about her future and worried about failure. The psychiatrist reported whenever the issues of change of status, loss of health, as well as financial losses are raised, the worker becomes emotional. He diagnosed a major depressive disorder, chronic insomnia and identified her physical problem as CTS. She was treated pharmacologically and the psychiatrist reported, “pain and limitations as a result of it has been the triggering factor of depression. She is not able to engage in many activities such as socializing and prefers isolation.” He felt her prognosis was guarded given the nature of her illness and the combination of depression and anxiety as well as pain and limitation of function.
In a report addressed to the worker’s representative dated December 18, 2008, the psychiatrist confirmed he first saw the worker on November 4, 2008 (presumably he meant November 4, 2004 as he previously reported) and indicated he had not seen her before that time and was not aware of any other previous psychiatric consultations. He noted the worker had been able to work regularly and without problems until the work-related incident and in addition to pain, she experienced some emotional problems related to workplace harassment. He offered the opinion that the effect of her family issues in the past may have made her more sensitive to workplace stress; however, the major issue to determine is establishing whether workplace harassment occurred or not. He did not feel her current emotional situation could be attributed to the remote distant conflicts when recent traumatic events such as physical impairment and harassment for the worker immediately preceded the emotional reaction. He offered the opinion that to the best of his knowledge, the worker in spite of distant conflict with her parents and some marital relationship problems, never suffered from any mental problems before her work-related incidents. She has been very depressed after the above mentioned incident and problems and he concluded the work-related issues are most likely the cause of her depression and anxiety.
A WSIB psychology consultant reviewed the evidence in the file and provided a memorandum in the file dated March 29, 2008. He offered the opinion that maximum medical recovery had been reached from a psychological perspective and there appears to be evidence of a permanent impairment (PI) for depression although “It is clear that there are pre-existing and co-existing factors (example: prior emotional problems, personality traits, marital stress, co-worker/employer conflict) that would predispose, contribute to maintain and exacerbate symptoms. There are no psychological restrictions.”
The worker’s treating psychiatrist submitted a report dated September 15, 2009 outlining the nature of the worker’s ongoing condition and her treatment. He reiterated his opinion that the worker’s psychiatric issues are most likely related to the workplace injuries. In this report the psychiatrist identified pain with the cervical and lumbar spine in addition to the compensable elbows and wrists.
I carefully reviewed the evidence presented and concluded the worker has entitlement to a psychotraumatic disability which developed as an indirect result of a physical injury. Although there are other areas identified that contribute to the worker’s ongoing pain, the preponderance of the medical evidence supports that pain from the bilateral elbow and wrist conditions are the significant contributing factors in the worker’s degree of ongoing pain and her emotional reaction to her condition. Her treating psychiatrist and the WSIB psychologist all identified the work related injuries as the precipitating factors in the development of the psychotraumatic condition.
I acknowledge there is evidence of pre-existing and co-existing psychological and emotional issues which would predispose the worker to react the way she did. In spite of these issues which include reports of harassment at the workplace prior to her injury, all the treating psychiatrists report the worker’s difficulty appeared subsequent to the onset of her pain issues in February 2004. Her treating psychiatrist identified she was a fully functioning individual in spite of any psychotraumatic issues in her past and the majority of her problems can be linked to her response to the effects of the work related injury. It is recognized that the worker identified some issues with workplace harassment prior to the onset of her wrist injuries which is not at issue here. However the medical evidence clearly describes the workplace injuries as the catalyst for the deterioration of her condition.
I accept the opinion of the treating psychologist and psychiatrist as well as the WSIB consultant and conclude the worker has entitlement to major depression for which there is a permanent impairment. The date of MMR is November 19, 2007 based on the last report from a psychotherapist to whom the worker was referred by her psychiatrist. According to the record, the worker has undergone several treatments beginning in 2004 and her progress appears to have been quite limited. As a result, I find it is unlikely there will be significant improvement in her condition in spite of ongoing treatment.
CONCLUSION
I conclude the worker developed a psychotraumatic condition in response to the effects of her compensable injuries. The medical records suggest there is a PI with an MMR date of November 19, 2007 and the worker is entitled to a NEL assessment to determine the degree of any residual impairment.
The worker’s objection is granted.
DATED October 15, 2009
D. Hart
Appeals Resolution Officer
Appeals Branch