WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
decision number: 20180035
OBJECTING PARTY: Worker
REPRESENTED by: Self
RESPONDENT: Employer
REPRESENTED by: Representative
HEARING METHOD: Hearing in Writing
HEARD by: H. Mohamed, Appeals Resolution Officer
DATED: May 7, 2018
ISSUES
The worker objects to the Eligibility Adjudicator’s (EA) decision dated October 3, 2017, which concluded:
The worker did not have entitlement to left-sided weakness following his workplace accident on December 2, 2015.
The worker was not entitled to loss of earnings (LOE) benefits from December 3, 2015, to March 3, 2017.
BACKGROUND
On December 2, 2015, this now 61-year-old truck driver was found lying on the ground in front of his tractor at a loading yard. The worker claimed that he was unhooking a trailer from his truck when he lost his balance and fell off, landing on his left side. The worker was taken to the hospital by ambulance where his primary complaint was left-sided upper and lower extremity pain. Doctors at the hospital initially suspected the worker had suffered a stroke or seizure causing him to fall.
In a decision dated January 22, 2016, the EA denied the worker’s claim on the basis that his fall was caused by a non-work related stroke. The worker objected to this decision.
Upon receipt of further medical information, the EA referred the claim for a medical opinion. The file was reviewed by Dr. DeRocher, medical consultant (MC), who confirmed that it was unlikely that the worker had suffered a stroke. However, the MC noted that there was no definite diagnosis to explain the worker’s persistent symptoms of left-sided weakness, and therefore she could not relate these symptoms to the workplace accident.
Based on this opinion, the EA reconsidered the previous decision and granted initial entitlement to a laceration of the left upper arm and forehead. The EA, however, denied entitlement to the undiagnosed left-sided weakness. Since the worker’s lost time beyond December 3, 2015, was due to his left-sided symptoms, entitlement to LOE benefits was not accepted in this claim. This was communicated in a decision dated October 3, 2017.
The worker’s objection to this decision forms the basis for this appeal.
AUTHORITY
11-01-01 – Adjudicative Process
18-03-02 – Payment and Reviewing LOE Benefits
11-02-02 – Lost time Claims
ANALYSIS
For the reasons that follow, I find the worker’s left-sided weakness was not caused by the workplace accident of December 2, 2015. As such, the worker is not entitled to LOE benefits for the period in question. In arriving at this decision, I have considered the submissions from the workplace parties, the file record, as well as the relevant sections of the Workplace Safety and Insurance Act (WSIA) and the appropriate Operational Policies.
The worker’s position is outlined in his submission dated June 14, 2017. The worker argues that he sustained a chance event type accident on December 2, 2015, resulting in his inability to work. The worker notes that due to the injuries he sustained, the Ministry of Transportation (MOT) placed his professional driving license on hold. He was unable to return to his truck driving duties until his license was reinstated in March 2017. The worker submits that he sustained a loss of earnings due to his injuries and therefore should be entitled to LOE benefits.
The employer representative (ER) submits that there is no objective medical evidence to support the payment of LOE benefits following the workplace accident of December 2, 2015. The ER argues that the worker’s inability to work beyond December 3, 2015, was due to an undiagnosed left-sided weakness that had nothing to do with the workplace injury. The ER requests that significant weight to be placed on the MC opinion on file which concluded that the worker’s left-sided symptoms were not related to the workplace accident. Accordingly, the ER requests that the EA’s decision to deny LOE benefits be upheld.
Policy 11-01-01 titled “Adjudicative Process” states that a five-point check system is used to adjudicate initial entitlement claims. Each point must be satisfied for initial entitlement to be allowed. There must be an employer, a worker, a personal work-related injury, proof of accident and compatibility of the diagnosis to the accident or disablement history.
Entitlement in this case has already been accepted for lacerations to the left arm and forehead as a result of the accident on December 2, 2015. As such, the appeal turns on whether the worker’s left-sided weakness is compatible with the accident mechanism. With respect to compatibility, policy 11-01-01 states that if it is not clear that the (injury or disablement) diagnosis provided is the result of the accident or disablement history described, a decision-maker may consult with the WSIB's clinical staff to assist in making this determination.
In reviewing the facts of this case, I note the worker was found lying on the ground beside his truck on December 2, 2015. A number of witness statements were attached to the Employer’s Report of Injury (Form 7) confirming this; however, no one witnessed the fall. In fact, the worker last spoke to someone 20 minutes before his fall, and therefore it appears the worker was all alone in the moments before his accident.
One of the witnesses notes the worker was found lying on his back and appeared unresponsive until he touched his left side, at which point the worker started to groan. This witness noted the worker had a laceration on the right side of his forehead and his left arm. Another witness noted the worker reported he had fallen from the catwalk; however the worker was unable to remember anything else. According to this witness, the worker could not even recall arriving into the yard.
The worker also provided a signed statement to the employer a few weeks after the accident. The worker advised that he had driven into the yard carrying a load from the previous day. He was informed by the dispatcher to drop the old load off at the yard and switch the chassis to a different one which would be used for the new load. The worker notes that he exited the truck and climbed to the back of the truck where the air hose and wiring to the chassis were located. While uncoupling the connections, he noticed they were stuck so he pulled the cables and in the process lost his balance and fell to the ground. The worker said he had no recollection of what happened after the fall and was taken to the hospital by ambulance. On the Worker’s Report of Injury (Form 6), the worker indicated that he fell on the left side of his body and became “unconscious.”
The Ambulance Call Report notes the worker was found supine on the ground and appeared confused. The worker thought he might have fallen from the catwalk; however, the paramedic observed there was no mud on it. The report notes the worker possibly fell from a catwalk which was 3-4 feet high. On examination, the worker complained of pain in his left ribs, left hip, left upper leg, back and neck which increased with palpation. There was, however, no swelling or bruising noted. The worker also complained of pain in the back of his head on palpation and blood was seen on his forehead. A few lacerations were noted, and the worker had been incontinent with urine.
The worker was taken by ambulance to Halton Healthcare Services where he underwent a number of investigations. A CT scan of his thoracolumbar and cervical spine showed evidence of degenerative pathology facet disease; however, no fracture or dislocation was seen. A CT scan of the brain was normal with no evidence of any intracranial injury. An MRI of the brain was also normal. A CT angiography revealed a 15 mm long moderate stenosis of the right internal carotid artery caused by not calcified plaque.
Dr. Khera, emergency physician, notes in his consultation report dated December 3, 2015, that the worker presented with objective left-sided weakness during the physical examination but did not appear in any acute distress. Noting that there was evidence of urinary incontinence following the accident, it was his opinion that the worker’s fall was likely precipitated by an acute stroke and possibly a seizure. The worker subsequently underwent an EEG examination which was normal.
In his consultation report dated December 16, 2015, Dr. Gazala, neurologist, notes the worker presented with an unwitnessed fall following which he was noted to have a left-sided weakness. The working diagnosis on admission was possibly stroke versus a seizure versus possible sequela of accidental head injury. Dr. Gazala notes that over the course of the worker’s admission he had multiple investigations which had yielded no particular abnormalities to explain his symptomology. An MRI scan of the brain and a carotid ultrasound were both normal. A CT scan of the lumbar spine showed evidence of a moderate degree of spinal stenosis, worse on the right, but this would not explain his left leg weakness. An MRI of the cervical spine showed no compressive lesion on the spinal cord. Dr. Gazala notes that based on his examination, the worker was presenting with nondescript left hemibody weakness. He went on to conclude:
I cannot explain this patient’s symptoms and presentation. I cannot find any abnormality on the investigations to explain his presentation. I also do not have any further recommendations for any investigations and I hope that rehabilitation will result in some improvement over time.
The hospital discharge report dated December 23, 2015, notes that despite seeing a neurologist and undergoing multiple investigations, the exact origin of the worker’s symptoms and presentation could not be determined. It was recommended that he continue with rehabilitation to help improve his strength on the left side. The discharge diagnosis was listed as left-sided weakness post-fall.
Following his discharge, the worker was referred to Hotel Dieu Shaver in-patient therapy program and was placed under the care of Dr. Luce. In his report dated December 23, 2015, Dr. Luce notes the most responsible diagnosis is left-sided weakness due to suspected ischemic stroke. On examination, he noted the worker was in no acute distress and all extremities were within normal limits except the worker had some weakness and easy fatigability in the left upper extremity and of the left lower extremity.
Physiatrist Dr. Khan assessed the worker on January 6, 2016. He notes that cranial nerve examination showed mild loss of peripheral vision in the left visual field involving the outer aspects of the quadrants. Shoulder shrug was reduced on the left side and sensation was reduced to light touch and pinprick over the left upper and lower extremities. There was a loss of tactile sensation of the left lower leg and the foot. There was also a mild sensory extinction to bilateral stimuli present in the left thigh and left upper extremity. Motor examination confirmed left hemiparesis with loss of strength in the upper and lower limbs. There was also a component of apraxia with difficulty in initiating movements on command: however, spontaneously, the worker showed a more fluid motor control. Dr. Khan concluded the worker presented with moderate left hemiparesis plus/minus apraxia and that his presentation was consistent with a cryptic ischemic stroke. Dr. Khan confirmed the worker was an appropriate candidate for inpatient rehabilitation with continuation through outpatient therapy after discharge.
Dr. Klimek, neurologist, notes in his report dated January 27, 2016, that the worker presented with a walker and stated that his left side “was not working” since the accident. Dr. Klimek notes the worker had no difficulties with word finding and was fully able to understand and follow the conversation. There was no facial droop or nystagmus. The worker had symmetric reflexes and down going planters despite reporting waxing and waning weakness. He also notes that upon distraction the worker was able to move his left arm normally and he was able to stand and walk with a walker. Once the walker was removed, the worker developed a non-rhythmic tremor of the right side that he was unable to explain. Dr. Klimek concluded:
(The worker) has no pathologic findings on neurologic examination and the mysterious diagnosis may well be attributed to volition. There are no features here that cannot be adequately explained by volition.
The Hotel Dieu Shaver Discharge Summary report notes that they have been unable to determine whether the worker had a fall and sustained injuries resulting in weakness of his left side or whether he had a stroke which has not been confirmed by any diagnostic intervention to date. The report notes the worker has an upcoming MRI which will hopefully determine whether he had any cord contusion due to his fall or whether he had an ischemic lesion which would correspond to his left-sided weakness. The worker was encouraged to continue with outpatient physiotherapy treatment and was advised not to drive.
The worker had another MRI of the cervical and thoracic spine on April 30, 2016. The MRI revealed the presence of mild multilevel disc bulging and degenerative changes at the facet joints throughout the thoracic spine. There was no evidence of any nerve root or spinal cord compression. The worker also had another MRI of the head which was also normal.
The final consultation report on file is from physiatrist, Dr. McMillan dated November 4, 2016. Dr. McMillan notes the worker was not reporting any stroke-like symptoms. There was no change in his hearing or speech, no difficulties with swallowing, and no reports of any cognitive difficulties. The worker was able to move all his limbs and did not report any pain, weakness or sensory symptoms in his arms or legs. Dr. McMillan concluded the worker had previous weakness of the left arm and leg due to an unknown cause. Dr. McMillan notes the worker has made excellent gains and was not presenting with any abnormalities. Dr. McMillan indicates that he will be forwarding his report to the MOT so the worker’s driver’s license can be reinstated. He would also be sending the report to the WSIB in order to confirm that there was no evidence the worker had suffered a stroke.
The worker’s driver’s license was reinstated after this assessment, and the worker went back to work as a truck driver affective March 3, 2017.
The EA referred the claim file to Dr. DeRocher, MC. In her memorandum dated September 8, 2017, Dr. DeRocher notes that the circumstances surrounding the fall are not entirely clear. She indicates that doctors initially suspected a cryptic ischemic stroke given the worker’s symptoms of diffuse pain, confusion and left-sided weakness; however, multiple investigations ruled out this possibility. Dr. DeRocher observes that none of the medical documentation on file provides a clear diagnosis explaining the worker’s persistent symptoms of left-sided weakness. Imaging studies did not show any evidence of a head injury, and advanced imaging of the cervical and lumbar spine has not provided any further answers. Dr. DeRocher opines that based on the available information, the worker’s persistent left-sided symptoms are not related to a stroke or acute trauma.
As I have indicated above, for entitlement to be accepted there must be compatibility between the diagnosis provided and the accident history accepted under the claim. The primary challenge, in this case, is that there is no diagnosis provided to explain the worker’s left-sided weakness. It is important to keep in mind that weakness is a symptom, not a diagnosis. Since the fall was unwitnessed, a diagnosis is crucial in determining whether the fall caused these symptoms or whether these symptoms caused the worker to fall. So while the worker has presented with significant weakness and fatigability in his left upper and lower extremities to various health professionals, no physician has been able to provide a diagnosis to account for this symptom.
None of the health care practitioners who have examined the worker have clearly related his symptoms to any musculoskeletal trauma as a result of the fall and nor are his symptoms consistent with a head injury. The only credible theory that has been forwarded is that the worker suffered either a stroke or seizure. While numerous tests did not confirm a stroke or seizure, the possibly cannot be excluded entirely. There is also the question of whether these symptoms have a non-organic cause. Dr. Klimek noted that upon distraction the worker’s symptoms disappeared, leading him to conclude that the worker’s symptoms could be explained by “volition.” Regardless, in the absence of an alternative medical opinion relating the worker’s left-sided symptoms to the workplace accident, I place significant weight on the medical opinion offered by Dr. DeRocher.
Policy 11-01-01 makes it very clear that there must be compatibility of the diagnosis with the accident or disablement history. Since there is no diagnosis to explain the worker’s symptoms, I find the worker’s left-sided body weakness is not work-related.
Turning to the issue of LOE benefits, policy 18-03-02 states that a worker who has a loss of earnings as a result of a work-related injury is entitled to payment of loss of earnings (LOE) benefits beginning when the loss of earnings begins. Policy 11-02-02 requires that the clinical evidence on file show that the inability to work is due to the work-related injury.
All the medical reports on file confirm the worker’s primary complaint post-accident has been his left-sided body weakness. I note the worker’s driver’s licence was also revoked due to these symptoms, and this prevented him from going back to work as a truck driver. Since I have not accepted entitlement to the left-sided body weakness in this claim, I find that the worker’s inability to work after December 3, 2015, is not related to his work injury and therefore I cannot approve LOE benefits.
CONCLUSION
Based on the foregoing reasons, I conclude:
The worker’s left-sided upper and lower extremity symptoms are not related to his accident of December 2, 2015.
The worker is not entitled to LOE benefits from December 3, 2015, to March 3, 2017.
The worker’s appeal is denied.
DATED: May 7, 2018
Mr. H. Mohamed
Appeals Resolution Officer
Appeals Services Division