Workplace Safety and Insurance Board
Appeals Resolution Officer Decision
Decision Number: 20150030
Decision Date: May 8, 2015
Objecting Party: Worker
Represented by: Worker Representative
Respondent: Employer
Represented by: Self-Represented
Hearing: Hearing in Writing
Heard by: C. Marr, Appeals Resolution Officer
Issues
The worker is objecting to the following decisions:
- The denial of benefits for a psychotraumatic disability.
- The denial of benefits for Chronic Pain Disability (CPD).
- The quantum of the Non-economic Loss (NEL) benefit for her compensable organic injuries.
- The approved work transition (WT) plan and the approved suitable occupation (SO) of customer service and information clerks.
Background
On May 25, 2011 this CNC operator pulled a heavy bin of parts toward her and strained her left upper extremity. She was 45 years of age at the time. She was subsequently granted entitlement to benefits for a repetitive strain injury to the right shoulder and arm as being the result of her job duties. Ultimately it was determined that she had a permanent impairment due to bilateral shoulder and elbow repetitive strain injuries. She was assessed with a ten percent NEL for this condition as explained in correspondence dated November 19, 2014. The worker is seeking a higher NEL benefit as she feels the current NEL quantum does not fairly represent her level of disability.
The employer was unable to accommodate the worker’s restrictions with suitable, sustainable work. The worker last worked for the employer in May 2013. She was referred for WT services and a plan, to help her obtain the skills to be employable in the SO of customer service and information clerks, was developed and approved on November 21, 2014. The worker representative argues that this plan is not suitable for the worker and that she is not capable of completing the program.
The worker developed psychological issues that she relates to her compensable disability. The worker representative is seeking entitlement to benefits for depression under the psychotraumatic disability policy. In the alternative, she is seeking entitlement to benefits under the CPD policy. The Case Manager (CM) denied entitlement to benefits for a non-organic condition under both policies as outlined in correspondence dated December 22, 2014.
Authority
Adjudicative Advice Document: Permanent Impairment (NEL) Rating Guidelines for Upper and Lower Extremity Repetitive Strain Injuries (RSI)
Guides to the Evaluation of Permanent Impairment, Third Edition (Revised) (AMA Guides)
Operational Policies
15-04-02 Psychotraumatic Disability
15-04-03 Chronic Pain Disability
18-05-03 Determining the Degree of Permanent Impairment
19-02-01 Work Reintegration Principles, Concepts and Definitions
19-03-03 Determining Suitable Occupation
19-03-05 Work Transition Plans
Analysis
1. Psychotraumatic Disability
I am unable to establish that the worker’s depression is the direct result of the extended disablement from her compensable organic injuries and related non-medical, socioeconomic factors. The worker is not entitled to benefits for a psychotraumatic disability under this claim.
WSIB Operational Policy 15-04-02 Psychotraumatic Disability outlines the factors and criterion that are considered in order to grant entitlement to benefits for a psychological condition as being the result of a work-related disability. In this case, the worker did not sustain a head injury and the workplace accident was not objectively traumatic. She did not have an emotional response to the treatment process for her work-related injuries. Her compensable disability would not be considered to be severe. Entitlement to benefits for a psychotraumatic disability is considered on the basis of the condition being related to extended disablement and non-medical socioeconomic factors which are directly related to the compensable injuries.
The worker was assessed by a psychiatrist on March 5, 2013. She reported a decline in her mood since the date of injury. She described being forgetful, having low energy and disturbed sleep. She expressed concern about losing her job as there were some issues with her employer accommodating her injuries at this time. Under Axis IV, “workplace stressors” was noted. The worker did not appear to meet the criteria for an Axis I diagnosis, where the psychiatrist only indicated “consider pain disorder”. The worker was prescribed Cymbalta and was told to follow up in one to two months. It appears as though she had not started this medication by September 2013.
It is noted that the worker attended the hospital on May 15, 2013 for anxiety. Unfortunately the notes on the report from this visit are illegible. There were some employment and job suitability issues at this time. The worker reported to the CM that she was upset about the way she was being treated by the employer. There is a physician’s chart note from May 30, 2013 that indicates the worker was nervous and had chest pains after being told by her employer to clean out her locker and go home.
WT services were initiated in April 2014. The worker expressed to the Work Transition Specialist (WTS) who was trying to arrange a meeting with the employer that she wanted to work somewhere, but that she would “be in a mental ward” if she went back to her employer. She looked forward to getting out of the house and working toward a new employment goal.
The worker began seeing a different psychiatrist, in April 2014. The worker reported having nightmares and a fear and mistrust of people. She was sad almost every day and described being irritable and forgetful. The worker reported having developed symptoms of anxiety after her employment with the incident employer ended, and she later became depressed. The psychiatrist’s notes from the May 12, 2014 visit indicate that the worker was having some illusions. She was diagnosed with major depressive disorder with psychotic features and chronic pain.
The worker was subsequently assessed by a psychiatrist at the Centre for Addiction and Mental Health (CAMH). Her mood symptoms were said to have developed after she lost her job. The worker’s daughter states that the worker’s personality changed after this. The worker reported being very anxious, having panic attacks up to four times per day, and being forgetful. She avoided answering the phone or door, even if she knew who was knocking, and said that at times she hears voices. The worker said that she had gained weight despite a decreased appetite. This psychiatrist noted that the worker developed diabetes mellitus and hypothyroidism since the workplace accident, the latter reportedly in early 2013. Both of these conditions were being treated with medication. The worker was diagnosed by this psychiatrist with a major depressive disorder with mild psychosis, precipitated by her job loss. The worker’s thyroid condition was suspected as possibly being a contributing factor to her symptoms as well. Due to the worker’s “profound depression”, electroconvulsive therapy and repetitive transcranial magnetic stimulation were recommended as treatment options. This psychiatrist did not seem to relate her depression to her pain symptoms.
Having considered all of the available information, I am unable to determine that this worker’s severe depression is the direct result of her compensable elbow and shoulder injuries. The majority of the worker’s non-medical, socioeconomic issues cannot be directly related to her injuries. The worker appears to have developed anxiety and depressive symptoms in early 2013. She was still working with the employer at that time. Her relationship with her employer was strained and the subsequent loss of her job was upsetting to her. It is noted that she did not appear to have met the criteria for an Axis I diagnosis of depression during this period.
By 2014 her psychological symptoms were rather severe. She was hearing voices and having illusions. Two psychiatrists opined that the worker met the criteria for major depressive disorder with psychotic features by 2014. Somewhat aggressive treatment was recommended. I have difficulty determining that this condition to this degree is directly related to the worker’s pain and disability from her compensable upper extremity repetitive strain injuries. Maximum medical recovery (MMR) for her injuries was achieved by August 2013
The worker’s other medical issues must be considered as well. She was diagnosed with diabetes and hypothyroidism around the time that her psychological symptoms developed. While thought to be unlikely, the doctor from the CAMH suggested that there could be a relationship as some of the worker’s “symptoms [are] highly suggestive of thyroid insufficiency, what used to be called myzedema madness.” Depression is a symptom of hypothyroidism. These two conditions share many symptoms. When her thyroid medication was adjusted in early 2015 the worker seemed to be able to focus better in her retraining program. Although the medical documentation on file does not say for certain that the worker’s non-compensable medical issues are the clear cause of her psychological symptoms and condition, the nature, degree and timing of the symptoms suggest that there could be a relationship.
The evidence does not support that there is a clear relationship between the worker’s psychological condition and her work-related organic disability. Entitlement to benefits for her major depressive disorder is denied under this claim.
2. Chronic Pain Disability
WSIB Operational Policy 15-04-03 Chronic Pain Disability outlines the criterion that is considered in determining entitlement to benefits for CPD. All five of the listed criterion must be met for entitlement to be established. I find that the worker is not entitled to benefits under the CPD policy as I cannot determine that the worker’s pain is caused by the work-related injuries and the degree of pain is consistent with the organic findings.
As discussed in detail above, the worker has several non-compensable medical issues that developed subsequent to and were concurrent with her work-related injuries. The symptoms from her hypothyroidism could be contributing to her overall diffuse pain symptoms. I note that the psychiatrist at CAMH did not diagnose a pain disorder or suggest that the worker’s pain was causing her psychological issues. The worker has a major depressive disorder with psychotic features or psychosis. While a non-compensable condition, her severe degree of depression would certainly be expected to be a prominent factor in her pain profile.
There is medical evidence to support that there is an organic explanation for her upper extremity pain. She has a recognized ten percent NEL for these injuries. There is objective evidence to support this degree of disability. There are documented findings of tenderness and swelling of her elbows and shoulders, with the left being worse than the right. Imaging studies from 2012 showed evidence of tendinosis in the left shoulder and lateral epicondyle. The localized upper extremity pain symptoms are consistent with her compensable bilateral epicondylitis and shoulder tendonitis.
The worker made a concerted effort to work with her disability, performing duties at the incident employer that were eventually determined to be unsuitable for her compensable injuries and restrictions. The degree of function that she demonstrated while attempting to perform this work was consistent with the organic impairment. This work was unsuitable for her work-related injuries but by her own words she was able to push through the pain to continue in the job for an extended period. This is consistent with someone with a degree of pain from repetitive strain injuries, not a CPD. Performing repetitive work duties served to increase her symptoms, which is to be expected.
Having regard for the medical and non-medical evidence, I am unable to establish that the worker’s pain symptoms are caused by the compensable injuries. Also, the degree of pain and the worker’s related limitations appears to be consistent with the objective organic injuries. The criterion for entitlement to benefits under the CPD policy has not been met.
3. NEL Quantum
The worker was determined to have achieved MMR for her compensable bilateral epicondylitis and shoulder tendonitis by August 7, 2013. Based on the clinical findings from the medical documentation from the period contemporaneous to the MMR date, the NEL Clinical Specialist found that the worker’s condition would more fairly be rated as a repetitive strain injury rather than based on the clinical findings and the Guides to the Evaluation of Permanent Impairment, Third Edition (Revised) (AMA Guides). I agree with this and will also use the Adjudicative Advice Document: Permanent Impairment (NEL) Rating Guidelines for Upper and Lower Extremity Repetitive Strain Injuries (RSI) in order to determine the worker’s NEL Quantum.
I note that in her submission dated March 9, 2015, the worker representative provided a report from a chiropractor dated October 31, 2014. While it is noted that this report is dated only a few weeks prior to the NEL decision, it is more than a year after MMR was achieved. It would not be a fair assessment of the worker’s condition at that time.
The representative argues in part that the NEL rating did not take into account the worker’s range of motion (ROM) for her elbows and shoulders. The NEL Clinical Specialist did consider this. The documented ROM was normal at the time MMR was achieved. That is why the worker’s condition was not rated with the AMA Guide as these are based largely on ROM measurements.
When the worker was assessed by an orthopaedic specialist on August 7, 2013, she had “full but uncomfortable” ROM of the left shoulder with tenderness over the left trapezius and lateral epicondyle. No clinical findings of the worker’s right upper extremity were provided. Prior to this, a physiatrist noted on May 6, 2013 that the worker had diffuse tenderness and decreased ROM, but of which joint(s) and the ROM measurements was not indicated. The family doctor’s report of May 7, 2013 indicates tenderness over the left elbow but no ROM findings are provided. This is also the case with the physiatrist’s July 22, 2013 report. The worker’s degree of impairment cannot be fairly determined based on elbow and shoulder ROM.
As per the Adjudicative Advise Document referenced above, I have rated the worker’s degree of permanent impairment as follows:
Physical Findings:
Left Shoulder – 2 percent for documented tenderness with some swelling
Right Shoulder – 1 percent due to minimal documented findings
Left elbow – 2 percent for tenderness, inflammation, pain with flexion
Right elbow - 1 percent due to minimal documented findings
Left Upper Extremity – 1 percent
Right Upper Extremity – 1 percent
Left Upper Extremity – 2 percent for physiotherapy, injections, medications
Right Upper Extremity – 1 percent for medications
Activities of Daily Living:
Left Upper Extremity – 3 percent for impact of basic function and interactive activities. Left-sided symptoms are greater than right.
Right Upper Extremity – 2 percent as this is her dominant arm.
The total impairment for the left upper extremity repetitive strain injury is ten percent which reduces to a whole person impairment of six percent as per Table 3 of the AMA Guide.
The total impairment for the right upper extremity repetitive strain injury is six percent which reduces to a whole person impairment of four percent as per Table 3 of the AMA Guide.
As per the Combined Values Chart of the AMA Guide, a six percent impairment combines with a four percent impairment for a total whole person impairment of ten percent. The worker’s compensable organic conditions result in a ten percent NEL.
4. WT Plan and SO
In her submission dated March 9, 2015 the worker representative argues in part that worker’s psychological and physical issues make her incapable of completing the approved WT program. She submitted a report from a chiropractor in which he opines that the worker is disabled from performing any work duties. Specific concerns about the SO or the components of the WT program were not raised in this submission.
From a physical perspective, the worker is partially disabled and fit to perform suitable work duties within the restrictions for her compensable upper extremity injuries. I have confirmed her NEL rating at ten percent.
I note that when the worker underwent a psycho-vocational assessment prior to her WT program, the evaluating psychologist expressed that psychological barriers were present and that without proper treatment, “they may impact her ability to progress with re-training.” The worker has been under the care of a psychiatrist since this assessment was completed on April 29, 2014. The evaluating psychologist also noted that the worker did not complain about the number, length of difficulty of the tests that were administered to her. While she was in noticeable pain, the worker was not “pain focused”. The worker expressed to the psychologist a willingness to return to school for re-training.
The worker had also informed the WTS that she wanted to return to work in a suitable capacity and was positive about the idea of getting out of the house and into a routine. The worker’s daughter expressed the same sentiment to the WTS, indicating that the WT program would likely have a positive effect on her mother. Noting that the worker was reportedly upset when she lost her job and the identity that went with this it is likely that being in a routine with educational and employment goals would be positive experience for the worker.
The claim file documentation supports that the worker is progressing well in the English as a second language (ESL) component of her WT program. This does not mean that the worker’s compensable and non-compensable health issues are not making the program challenging for her, but she appears to be working through these. Fatigue seems to be a prominent issue as her thyroid condition continues to be treated and the medications for this adjusted. Despite the health barriers, the instructor frequently reports that the worker is a pleasant addition to the classroom and is putting forth a good effort.
The SO of customer service and information clerks is reasonable and suitable for the worker’s physical disability. The training program which consists of ESL training, computer training, job search training and employment placement services, is appropriate for this SO. The duration and pace of the program also appears to be reasonable given that the worker has to improve her ESL skills.
Therefore, I am confirming the approved WT program and SO as being reasonable and suitable for this worker and her compensable injuries. However, her non-compensable conditions must be monitored and her ability to participate in the program may change. If necessary, consideration to alternative or additional WT services can be given to help the worker be successful in her program and the employment goal, or under WSIB Operational Policy 15-06-08 Adjusting Benefits Due to Post-accident, Non-work-related Changes in Circumstances.
Conclusion
The worker is not entitled to benefits for a psychotraumatic disability.
The worker is not entitled to benefits for Chronic Pain Disability.
The worker’s ten percent Non-economic Loss for her organic bilateral shoulder and elbow injuries is confirmed.
The work transition plan with a suitable occupation goal of customer service and information clerks is confirmed.
The objection is denied.
DATED May 8, 2015
C. Marr
Appeals Resolution Officer
Appeals Services Division