APPEALS RESOLUTION OFFICER DECISION
decision number:
20230006
OBJECTING PARTY:
employer
REPRESENTED by:
employer representative
RESPONDENT:
worker
REPRESENTED by:
not participating
HEARING:
HEARING IN WRITING
HEARD by:
Kim Mcdonnell, appeals resolution officer
ISSUE
The employer, through their representative, has objected to the Case Manager’s March 29, 2022 decision. That decision denied the employer Second Injury and Enhancement Fund (SIEF) cost relief.
BACKGROUND
On October 20, 2017, this then 44-year-old worker reported they had felt an electric shock in their right hand and chest when they unplugged their medical cart from the wall. They reacted to the shock and, as they drew their hand back, they hit their hand on either the cart or the wall. They sought medical attention in the emergency room where they were diagnosed with an electrocution type injury. Entitlement was initially allowed for a chest injury. The worker lost time on October 21, and 22, 2017, and then returned to their next scheduled shift on October 25, 2017. At the time of the incident, the worker had been a part-time Registered Nurse on a medically complex floor with the employer since July 1996. Prior to this incident, in July 2017, the worker had sought health care with their family physician for cold fingers and, in September 2017, they had been diagnosed with Raynaud’s disease.
On November 9, 2017, the worker reported the injury was not to their chest, but to their right hand and arm. They required modified work and reduced hours that limited the use of their right hand. On January 15, 2018, entitlement was extended to include electrocution type injuries to the right arm, wrist, hand, and fingers. The worker continued to perform modified duties. The possible diagnosis of complex regional pain syndrome (CRPS) was considered given swelling, colour changes, and hypersensitivity in the right fingers. On March 16, 2018, the worker was assessed by surgeon Dr. Tuli through the Hand and Wrist Specialty Program who confirmed the worker had suffered a traumatic right hand injury that had resulted in CRPS of the right forearm and hand as well as right cubital tunnel syndrome. The operating area extended entitlement to include both new diagnoses.
In June 2018, the worker’s physiotherapist continued to recommend limited use of the right hand and reduced work hours. On June 13, 2018, the worker stopped working due to reported increased pain. They confirmed that there had not been an incident to account for the increased pain. In a June 27, 2018 decision, a Case Manager allowed entitlement to loss of earnings (LOE) benefits for a recurrence.
On July 4, 2018, the worker returned to a new full-time role as a Case Manager on a behaviour unit with the employer. As of September 6, 2018, they were able to perform the essential duties of their new job at full hours. On November 7, 2018, the worker was assessed by neuropsychologist Dr. Nikkhou who diagnosed the worker with a subclinical adjustment disorder and specific phobia, without indication that the problems were of a substantive nature. Community-based psychology sessions were allowed.
On June 5, 2019, the worker was discharged from the Hand and Wrist Specialty Program having reached maximum medical recovery (MMR) with the recommendation to continue physiotherapy to maintain range of motion, dexterity, function, and grip strength along with the permanent restriction of using the right hand as a helper hand only. On April 29, 2020, a Non-economic Loss (NEL) review was completed for CRPS and cubital tunnel syndrome. The worker received a 5% whole person NEL benefit.
In the March 29, 2022 decision now before me, a Case Manager concluded that the claim had been allowed on its own merit. There was no indication that the accident had been caused by a pre-existing condition. The Case Manager stated that the worker had not complained of a right arm or hand issue prior to the accident date and they had been fully functional at work.
AUTHORITY
Operational Policy Manual
Published
14-05-03 Second Injury and Enhancement Fund (SIEF)
February 20, 2006
ANALYSIS
I have carefully considered all of the available information, legislation and relevant operational policies in reaching this decision. I find the employer is not entitled to SIEF cost relief. My rational is set out below. The employer’s objection is denied.
Employer’s Position
On July 25, 2022, the employer’s representative provided an Appeal Readiness Form along with a submission. I found the employer’s position to be the following:
Severity of accident
The Case Manager had concluded that the accident was “moderate” in nature. While the use of the term “electrocution” sounded significant, there were varying degrees of injury associated with shorts and sparks. The specific mechanics of this particular type of accident would not have been expected to cause a disabling injury.
As accepted throughout the file, the worker had unplugged their medical cart and as they did so, a loud noise and sparks occurred. The sparks touched their hand and left black soot on their fingertips. There were no significant burns nor did the current did pass through the body as there were no entry and exit wounds. They were not held by a current nor were they thrown away from the wall. What was described was some minor pain associated with the connection to sparks without actual burns.
The worker did strike their hand on the wall or the cart and this had been diagnosed by the family doctor as a simple strain. The emergency report indicated that the minor pain initially experienced was expected to resolve quickly.
Significance of a pre-existing condition
The clinical records confirmed that the worker had previously fractured their right wrist in a fall on January 26, 2015, only two years prior to this incident. By March 26, 2015, an orthopaedic specialist diagnosed the worker’s ongoing pain as tendinosis, which was a degenerative condition that would be expected to deteriorate over time.
The ultrasound taken after the accident also established mild extensor tendinosis. It did not appear that the Hand and Wrist Specialty Program was aware that the tendinosis had been a diagnosed as a symptomatic condition two years prior to this accident.
A June 27, 2017 clinical note indicated that there were concerns about an underlying problem as there was no obvious case for Raynaud’s disease. Four months prior to the accident, the family doctor had documented that on June 27, 2017, the worker had complained of numbness in their fingers along with colour changes in their hand, similar to that experienced with CRPS. The worker had described a frequent symptom and related it to cold exposure. The doctor had questioned whether the worker had suffered from Raynaud’s disease.
On September 19, 2017, just one month prior to the accident, a rheumatologist report offered reassurance that there was no evidence of a connective tissue disease, but the report did not identify the cause nor did the rheumatologist conduct the full range of tests that might have identified underlying issues.
The Specialty Program assessment provided the diagnosis of CRPS “on the background of Raynaud’s”, thus acknowledging the diagnosis. The report did not discuss any connection nor did it acknowledge a non-occupational diagnosis although the report had referenced both tendinosis and Raynaud’s in the body of the report.
CRPS and Raynaud’s are of unknown etiology, but both are considered to arise from an abnormality of the autonomic nervous system. Attached to the submission was an article that suggested that where both conditions presented concurrently, this tended to be an indication that there was a sympathetic dysfunction underlying both disorders, responsible for their co-existence.
The July 13, 2017 bloodwork report suggested that there was an underlying process given the antinuclear antibodies (ANA) interpretation was that of “a speckled pattern is seen in systemic lupus erythematosus (SLE), mixed connective tissue disease (MCTD, Sjogren’s syndrome, and systemic sclerosis…”
The point was that Raynaud’s disease was a “background” condition that did not influence CRPS, but the co-existence of the two conditions was evidence of a third underlying condition of the sympathetic nervous system. That third condition would support SIEF.
The representative included a case report published in April 2013 from the Gazi University Faculty of Medicine in Ankara, Turkey titled, A case of recurrent complex regional pain syndrome accompanying Raynaud’s disease: a prospective coincidence? I reviewed the article and I found the following information:
The patient had been diagnosed with Raynaud’s disease accompanying CRPS without a significant intervening event such as a trauma. The authors had proposed that a sympathetic dysfunction underlying the pathophysiology of both disorders might be responsible for the co-existence of the two distinct entities.
The case involved a 21-year-old male with pain, swelling, and cyanosis of their right hand with no history of trauma that might have triggered the complaints. Based on the clinical and laboratory findings, primary Raynaud’s phenomenon accompanying CRPS type I was diagnosed. The patient responded well to three weeks of physical therapy.
Deteriorated peripheral vasoconstrictor responses after sympathetic stimulation had recently been detected, not only during the acute and early phases, but also before the onset of the disease and even after years in a chronic state. Accordingly, patients who develop CRPS may have an underlying sympathetic nervous system abnormality, which may recover to a certain extent during the course of the disease.
The case of recurrent and idiopathic CRPS accompanying Raynaud’s disease was the first one reported in the literature. Recurrence and unknown etiology may be explained by an underlying sympathetic nervous system abnormality, which exacerbated temporarily.
Worker’s Position
The worker is not participating in this appeal.
Evidence
Prior to this injury, on March 5, 2015, the worker was assessed by family physician Dr. Blake for ongoing pain following a fractured right scaphoid resulting from a fall on January 29, 2015. Dr. Blake wrote, “Query faint line seen on x-ray.”
Prior to this injury, on March 26, 2015, the worker was assessed by Dr. Blake for ongoing pain to the right wrist. Dr. Blake noted that the orthopaedic surgeon opined the pain was mostly tendinitis and pain limited range of motion. The worker had been provided with physiotherapy exercises, but they were not actively involved in physiotherapy due to a lack of coverage. They were using a splint for repetitive activity.
Prior to this injury, on April 23, 2015, the worker was assessed by Dr. Blake who noted the worker’s right wrist was feeling better and they were doing more at work, but their wrist continued to be painful with any weight over two pounds. This was the last note from Dr. Blake prior to the worker being assessed on June 27, 2017.
Prior to this injury, on June 27, 2017, the worker sought medical attention with their family physician Dr. Blake for numbness and colour changes to their fingers. Dr. Blake’s note stated that the worker frequently experience numbness when their fingers were cold. On examination, Dr. Blake found full range of motion, normal power, colour, and sensation along with good warmth. Dr. Blake queried the diagnosis of Raynaud’s disease. The worker refused medication and stated they were concerned that there might be an underlying problem. Dr. Blake recommended bloodwork to rule out other causes and stated, “Otherwise, likely idiopathic Raynaud’s.”
On July 13, 2017, the worker underwent bloodwork. The ANA test was positive and the pattern was speckled and homogeneous. In the section ANA interpretation, the following was noted
A speckled pattern is seen in SLE, MCTD, Sjogren’s syndrome and systemic sclerosis. Clinical correlation as required for interpretation. Note: a positive result may also be seen in about 10% of a normal healthy population.
A positive homogeneous pattern is consistent with SLE. It may also be seen in other systemic autoimmune rheumatic diseases. Clinical correlation as required for interpretation. Note: a positive result may also be seen in about 10% of a normal healthy population.
Prior to this injury, on September 19, 2017, the worker was assessed by rheumatologist Dr. Rai who diagnosed the worker with primary Raynaud’s phenomenon. Dr. Rai noted the history as follows:
The worker was there for fingers changing colour in the cold.
The symptom had started one year ago when the worker had begun to notice their fingers were changing colour in the cold.
They had been swimming in a lake and notice that their left finger turned white in the cold, then red, and then maybe blue.
They had noticed it in another finger since then, often when they were cold, such as in a grocery store in the winter.
They did not have a history of inflammatory arthritis or connective tissue disease.
In reviewing the bloodwork, Dr. Rai noted the ANA 1:80 speckled ratio and negative extractable nuclear antigen antibodies (ENA).
Dr. Rai summarized
The worker has a one-year history of fingers turning white, red, and sometimes blue and exposed to cold. No evidence on history, exam, or investigations of underlying connective tissue disease. There ANA level is very low and likely of no clinical significance. They likely have primary Raynaud’s phenomenon and they been counselled on trigger avoidance and management of this. They do not require ongoing follow-up.
Dr. Rai reported they had counselled the worker on primary Raynaud’s phenomenon including trigger avoidance, keeping their core warm and pharmacological therapy, which they did not require at the time. Dr. Rai counselled the worker on the features of secondary conditions associated with Raynaud’s disease and advised the worker to contact the office if they had any concerns. Dr. Rai recommended the worker follow-up as needed and assured the worker that primary Raynaud’s disease had a benign course.
On October 20, 2017, the worker was assessed in the emergency room
On October 25, 2017, the employer provided in Employer’s Report of Injury (Form 7) that stated the prongs from the electrical plug had touched a loose metal switch plate as the worker unplugged the cart.
On October 31, 2017, the worker was assessed by Dr. Blake for a right arm injury with improving edema and pain. On examination, Dr. Blake did not find evidence of skin changes, erythema, edema, tenderness, abnormal motion, or reduced strength. Dr. Blake found the neurovascular system to be intact. The doctor noted the worker experienced pain radiating up the wrist with movement. Dr. Blake also examined the worker’s right elbow but did not find signs of obvious erythema, edema, tenderness, or abnormal motion. Dr. Blake diagnosed the worker with a right wrist ligament/tendon strain and recommended the worker returned to modified duties that avoided heavy lifting, pushing, pulling, and vibration.
On December 6, 2017, the worker underwent an ultrasound of the right arm and wrist that showed an unremarkable ulnar nerve and incidental mild common extensor tendinosis.
On January 8, 2018, the worker underwent nerve conduction studies that were essentially normal.
On January 25, 2018, the worker provided a Worker’s Report of Injury (Form 6) that documented the mechanism of injury as follows:
The worker had reached down with their right hand and grabbed the plug to unplug the medical cart.
There was a loud noise and sparks, like fireworks, shot out from the past the cart to the medication room door, about three to four feet.
They might have banged their hand on the wall or on the cart.
They had black marks on the inside of their right hand and a few pinpoint marks on their fingers/palm.
They felt pain in their chest and right arm.
Firefighters responded after 911 had been called and indicated that the metal switch plate was loose. It had touched the metal prongs on the plug. The firefighters told the worker that the black marks on the wall near the outlet and on their hand were the same.
The pain in their chest had subsided by the time emergency medical services arrived.
The pain in their neck and shoulder subsided within a week
The pain and difficulties with their right arm, elbow, forearm, wrist, hand, and fingers persisted.
On February 2, 2018, the worker was assessed in the emergency room for ongoing right hand paraesthesia, radiculopathy, and pain. At the time, the worker reported increased swelling and decreased range of motion of the right middle proximal interphalangeal (PIP) joint. On examination, the emergency room physician noted mild edema and restricted motion to the right middle PIP and distal interphalangeal (DIP) joints. The doctor queried complex regional pain syndrome and referred the worker to a plastic surgeon.
On March 5, 2018, the worker spoke with the Case Manager. I found the following information from their conversation:
The worker had injured their right shoulder about 10 years ago in a workplace accident and they had injured their right thumb and a non-work-related accident about 2 or 3 years ago they had made a full recovery from both injuries and they were not in treatment prior to the workplace accident of October 20, 2017.
The Case Manager discussed Dr. Blake’s June 27, 2017 note and the worker reported that they had been sent for further testing, but they had not been diagnosed with Raynaud’s disease. The worker stated that blood test did not confirm any pre-existing conditions, and autoimmune deficiency, or osteoarthritis.
On March 20, 2018, the worker was assessed at the Hand and Wrist Specialty Program. The report noted a past medical history including Raynaud’s disease and a resolved right shoulder injury.
On September 10, 2018, the worker was assessed by Dr. Blake. On examination, Dr. Blake found the worker’s fingertips were cold again, their grip was minimal, and they were unable to move their shoulder above the horizontal. Dr. Blake wrote, “Query frozen shoulder as well.”
Policy
Policy 14-05-03 (Second Injury and Enhancement Fund) states, in part
If a prior disability caused or contributed to the compensable accident, or if the period resulting from an accident becomes prolonged or enhanced due to a pre-existing condition, all or part of the compensation and health care costs may be transferred from the accident employer in Schedule 1 to the SIEF.
Both physical and psychological disabilities are included.
Definitions
Pre-accident disability is defined as a condition, which has produced periods of disability in the past requiring treatment and disrupting employment.
Pre-existing condition is defined as an underlying or asymptomatic condition, which only becomes manifest post-accident.
Entitlement adjudication
In no lost time, lost time, permanent impairment and fatal claims, the decision to extend relief from the SIEF is usually made at the time of entitlement adjudication, or as soon as it is recognized that aggravation of a pre-existing condition is contributing to the cost of the claim.
When reviewing medical and other information present in the claim file, the decision-maker considers whether the information suggests that a pre-existing condition is present and whether it
contributed to the work-related accident, or
prolonged or enhanced the work-related disability.
If it is likely that such circumstances exist, a recommendation to apply the SIEF is made, as well as the rate at which to do so.
Findings
For SIEF cost relief to be granted, two factual elements must be determined according to policy 14-05-03 (SIEF):
the severity of the accident
the medical significance of a pre-existing condition and whether it contributed to the work-related accident, or prolonged or enhanced the worker’s disability
Severity of Accident
When looking at accident severity, the actual injuries are not considered but rather the extent of the disability the accident would reasonably be expected to cause. I find the accident to be of moderate severity. An electrocution type injury would reasonably be expected to cause a number of disabling injuries, including injuries that result in central nervous system injuries and/or organ damage.
The diagnosis in this case was that of electrocution. Rather than diagnose the worker with a less severe electric shock type injury, the treating health care professionals collectively provided the diagnosis of electrocution, indicating the severity of the accident. The diagnosis was first made in the emergency room and confirmed by Dr. Blake and Dr. Tuli throughout the record.
The employer’s representative has argued that there was no evidence that a current passed through the worker’s body. I respectfully disagree with the employer’s representative. In an electrocution injury, an electric current passes through the body or a portion of the body. This is the mechanism of injury leading to the diagnosis of an electrocution. The worker was diagnosed with an electrocution type injury and I accept that when they touched the plug, the electric current passed through their body.
The employer’s representative has also argued that this was a minor injury since there was no evidence of burns on their skin and the strain resulting from the hand trauma had been expected to resolve quickly. In regards to the hand trauma, I agree with the representative. The worker felt an electric shock and instinctively drew their hand away. In doing so, they most likely hit either the wall or the cart. There is no evidence of significant trauma to the worker’s hand contained in the record. The hand strain would have been expected to resolve within a matter of days in a normal person. In this case, the hand trauma, regardless of the severity, most likely contributed to the development of CRPS.
There does not need to be evidence of burns on the skin for a person to have suffered a serious electrocution type injury. The damage may be internal, without any visible external signs. In this case, the worker had reported black marks on their fingertips as well as pinpoint marks on their palm indicating that the current had travelled or touched these areas. I do not accept that since the visible injuries appeared minor in nature, the electrocution type injury was also minor. Rather, internal damage to tissue, muscles, and/or organs remained a possibility. On the balance of probabilities, there was internal damage in this case, causing significant long-term sequelae in the worker.
In summary, an electrocution type injury is one of moderate severity. When an electric current passes through a body, a number of serious consequences are possible. In a normal person, an electrocution type injury might result in a number of disabling conditions.
Significance of Pre-existing Condition
Policy 14-05-03 (SIEF) provides that an employer may be entitled to SIEF cost relief if it can be established that a prior disability caused or contributed to the compensable accident, or if the period resulting from an accident becomes prolonged or enhanced due to a pre-existing condition.
I find that the policy definition of a prior disability is not met.
Policy 14-05-03 (SIEF) defines the term “pre-accident disability” as a condition, which disrupted employment and required treatment prior to the accident.
There is insufficient evidence in the file of a pre-existing disability that caused or contributed to the work-related accident in this case. There is no evidence in the record that the worker lost time from work or had a disabling condition prior to October 20, 2017.
I did not find the right wrist fracture to be significant. From the record, the worker had fractured their right wrist in January 2015, almost three years prior to this event. They had been at work fulfilling their pre-injury duties as a Registered Nurse on a medically complex unit without incident since returning to work sometime in mid-2015. In April 2015, the worker reported to Dr. Blake that they were improving in regards to both pain and function. Following that assessment, the worker did not seek health care with Dr. Blake until June 2017. There is no evidence that they sought medical attention for their right wrist with any other health care professional from 2015 to 2017. The record does not contain evidence that the worker required modified work or lost time from work due to the wrist fracture. Given their ability to perform physical nursing duties on a medially complex floor for this period, I accept that the worker’s right wrist fracture had fully recovered over two years prior to this injury.
Policy 14-05-03 (SIEF) defines the term “pre-existing condition” as an underlying or asymptomatic condition, which only becomes manifest after the accident.
I am not persuaded that the worker had a pre-existing condition that prolonged or enhanced their recovery. The worker returned to work within days. Initially, they experienced pain and swelling that they attributed to the electrocution type injury. As the weeks passed, it became clear to the worker’s health care professionals that the hand trauma and electrocution had led to the development of CRPS.
In general, CRPS describes excessive pain, swelling, and sensitivity along with other changes in skin, nails, colour, and temperature. In this case, the worker required modified work and reduced hours due to their symptoms. Their modified duties and hours were specified solely due to their CRPS symptoms.
I did not find the worker’s recovery to be prolonged. The worker experienced a significant disability due to CRPS. They required light work that limited the use of their hand and reduced hours from November 2017 to September 2018 while attending treatment. I find the 10-month period after their injury and prior to resuming full-time work in an alternate role to be in keeping with the significance of their condition, their pre-injury duties, and their need for therapy.
I did not find that Raynaud’s disease, an undiagnosed connective tissue disorder, or tendinosis contributed to the severity of their injury or prolonged their recovery. My rationale is as follows:
The worker did not have other underlying connective tissue or rheumatic conditions as evidence by Dr. Rai’s September 2017 report. The worker had been diagnosed with primary Raynaud’s phenomenon meaning the condition occurred by itself in the absence of other issues. There was no other health condition associated with primary Raynaud’s disease in the worker. Given the lack of clinical findings of an underlying connective tissue disease, Dr. Rai diagnosed the worker with primary Raynaud’s disease. The report went on to describe the benign course of primary Raynaud’s disease in the worker, including the fact that they did not require medication or follow-up visits with the rheumatologist.
The worker had described a one-year history of two cold fingers to Dr. Rai. There is no evidence that their hand condition prevented them from working during that year.
As evidenced by the March 2018 Hand and Wrist Specialty Program report, Dr. Tuli was aware that the worker suffered from Raynaud’s disease, but did not causally link the pre-existing condition to the worker’s current condition. The employer’s representative has argued that the report did not discuss a connection between Raynaud’s disease and CRPS in the worker nor did the report acknowledge Raynaud’s disease as a non-occupational diagnosis. Dr. Tuli did not find there was a connection between Raynaud’s disease and CRPS in the worker and therefore they did not discuss a connection. In my view, Dr. Tuli had found Raynaud’s disease and CRPS as two distinct entities.
The reduced hours and modified duties were in line with the worker’s condition. CRPS may cause debilitating pain, swelling, and hypersensitivity. The worker experienced significant symptoms best managed with limited use of the affected area and therapy.
The worker was motivated to accept and learn a new role that better suited their reduced right hand abilities. Prior to the injury, they worked part-time. As of September 2018, they were able to work in a new role on a full-time basis.
The worker had pre-existing tendinosis of the common extensor tendon. The evidence does not causally link the tendinosis with the development of CRPS. I understand that the diagnosis of tendinosis indicates a type of degenerative condition that is usually chronic, deteriorating over time. In this case, there is no evidence of a worsening in the condition over the period in question.
I did not place weight on the case report provided by the employer’s representative for the following reasons:
The report anecdotally documented one case. The authors noted that the case of recurrent and idiopathic CRPS accompanying Raynaud’s disease was the first one reported in literature.
In that case, the patient had developed CRPS without evidence of an initiating event such as a trauma. The cause was unknown.
The authors had proposed that there was an underlying dysfunction in both CRPS and Raynaud’s disease that might be responsible for the co-existence of the two separate conditions. The employer’s representative has not provided further research confirming an underlying dysfunction. While the case report proposed a theory, a causal link has not been established.
In summary, the worker developed CRPS following hand trauma and electrocution. Their recovery was not prolonged. They experienced a 10-month period of reduced hours and modified duties before learning a new role within their pre-injury position. They were able to increase their hours from part-time to full-time in their new role despite a right hand permanent impairment.
CONCLUSION
The employer’s objection is denied.
DATED November 17, 2022
Kim McDonnell
Appeals Resolution Officer
Appeals Services Division