SUMMARY DECISION NO. 990/99. White finger disease.

Transcription

1 SUMMARY DECISION NO. 990/99 White finger disease. The worker appealed a decision of the Appeals Officer denying entitlement for hand-arm vibration syndrome. The worker's condition was a disablement from use of vibratory tools in his work as a pipefitter. The worker stopped work in July The first evidence of vasospastic response was noted in the spring of This was within the requirement of Board policy that vasospastic response be identified within two years of exposure. The Vice-Chair also noted more recent Board policy which identifies vascular, neurologic and musculoskeletal components of the disability. It is not necessary that all three of these components exist in symmetry, and the policy does not preclude a finding of hand-arm vibration syndrome even in the absence of a significant vascular component. The appeal was allowed. [8 pages] PANEL: Newman DATE: 29/06/99 WCA BOARD DIRECTIVES AND GUIDELINES: Operational Policy Manual, Document No

2 WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 990/99 [1] This appeal was heard in Timmins on June 1, 1999, by Tribunal Vice-Chair E. Newman. THE APPEAL PROCEEDINGS [2] The worker brings this appeal from the decision of Appeals Officer John Tinto, dated March 26, The worker attended, represented by Ms. Carol E. Lamoureux-Chaylt of the Office of the Worker Adviser. The employer did not attend, but Sandra Haddad, consultant, provided a submission on its behalf. THE EVIDENCE [3] The worker gave evidence under oath. The following documents were marked as Exhibits: Exhibit #1: Case Record (Vols. I & II); Exhibit #2: Addendum #1; Exhibit #3: Addendum #2; Exhibit #4: Exhibit #5: employer s submission; THE NATURE OF THE CASE Worker Information Request Form. [4] The worker claims entitlement to benefits for carpal tunnel syndrome or hand-arm vibration syndrome, or both, resulting from his exposure to vibratory tools in the course of his employment as a pipe-fitter. THE REASONS [5] The worker has been employed as a pipe-fitter, and the evidence reveals that he has been employed in this capacity quite consistently since May of The work history appears at pages of Vol. I of Exhibit #1, and there is no evidence which contradicts this work history. [6] There is no dispute, and no reason to doubt that in the course of this employment, the worker used grinders, kangoo hammers, drills, and impact wrenches. These are high-frequency vibratory tools. [7] In 1985, the worker injured his back in the course of employment. He took one year off work, and returned in or around He only worked until July of 1988, when he stopped work, and

3 Page: 2 Decision No. 990/99 underwent surgery for the removal of a disc as a consequence of the back injury. Since that time, he has not returned to work. [8] In evidence at this hearing, the worker s testimony was that in the late 1980s, he began to notice some loss of strength in his hands and arms. He did not become concerned, and attributed the loss of strength to his age (then 42). However, he continued in testimony to explain that while fishing in 1990, a companion noticed that his fingers were white. Since then, the spring of 1990, the worker s evidence is that he has noticed periods of blanching of his fingers, and numbness and tingling. He has pain in his hands which radiates to the elbows, and testifies that his sleep is disturbed. There are no particular conditions which cause the onset of discomfort, and the worker testifies that he will have episodes of discomfort, depending upon how his hands are positioned, depending upon his sleep position, and depending on his exposure to cold. [9] The worker further testified that since his back injury in 1985, he has been taking Tylenol #3 with some regularity, for pain. Until he recovered from the back surgery in 1989, he asserts that the medication taken for back pain masked the discomfort in his hands and arms. Since noticing the blanching in the spring of 1990, the worker asserts that he has had considerable discomfort and loss of strength in his hands and fingers. [10] When originally determining the worker s entitlement to benefits, the Appeals Officer focussed upon conflicting medical evidence, and concluded that the weight of the evidence did not confirm a diagnosis of hand-arm vibration syndrome, and did not establish a vascular disability. [11] Originally, by a report dated December 10, 1990, Dr. W.M. Mitchell, specialist in physical medicine and rehabilitation, did offer the diagnosis of early mild Renaud s phenomenon and early bilateral carpal tunnel syndrome. [12] Subsequently, the worker underwent testing at the Sudbury Vascular Laboratory, and was evaluated by Dr. Edwin O.W. Knight. By a report dated December 17, 1991, Dr. Knight concluded that there was no objective evidence of a vasospastic disease, and Doppler studies tended to confirm this. Dr. Knight reported that the worker s hands do get cold in exposure to low temperatures, but he concluded that that was a normal physiological response. Dr. Knight found no evidence of carpal tunnel syndrome. [13] The worker was seen by Dr. P. Field, in October of 1992, with vascular studies repeated at the Sudbury Vascular Laboratory. On this occasion, Dr. Field reported: Since he has stopped working, rather than improving, his hands are getting worse. The man has been once again studied in the Vascular Laboratory. His hands were of normal colour at the start of the test, and they were of normal temperature. There was no evidence of any significant arterial occlusive disease. Following cold exposure, there was no significant digital artery pressure changes, and there has been no objective evidence of vasospastic disease demonstrated on either side. Conclusion: this man does complain of cold sensitivity, which came on after he stopped using vibratory tools. He does have E.M.G. evidence of bilateral carpal tunnel syndrome, and he has the clinical picture of bilateral carpal tunnel syndrome.

4 Page: 3 Decision No. 990/99 I think that any vasospastic symptoms that he has must be attributed either to his carpal tunnel syndrome or to cold sensitivity, which has come, and is of the idiopathic type, since it not only developed after he stopped work, but has progressed since that time, even though it is not associated with vibrating tools. I do not think therefore that he has vibration-induced white hand syndrome. [14] In evidence, the worker has complained that the testing processes and investigation processes which led to the reports of Dr. Knight and Dr. Field were, in his view, too brief and insufficiently detailed to provide an accurate response. The worker, however, was seen by Dr. Pelmear, in the St. Michael s Hospital in Toronto, and asks that greater weight be provided to the opinion of Dr. Pelmear, flowing as it did from a lengthy investigatory process of somewhere between three and four hours. Dr. Pelmear s report appears at page 146 of the Case Record, and is here repeated in its entirety: Thank you for referring the above named for an assessment of his hands. I was able to examine him on the 28 th January Work History worked for numerous construction companies as a plumber/steam fitter/ gas fitter and has been exposed to hand-arm vibration (HAV) from 1 ½ impact wrenches, disc grinders, drills, hilte guns, kango rammers, and skill saws for about 2 hours a day; 6 days a week; 40 weeks a year; for 22 years. At work he did not usually wear gloves. Away from work he has not had any significant HAV exposure. There is no restriction of outdoor pursuits. Medical History He has not had any injuries to his upper limbs. No history of Raynaud s phenomenon before starting work and none in the family. Apart from back problems in 1988, with surgery in 1989, he has not had any significant illnesses. He is only taking analgesics and anti-inflammatory drugs at the present time. He has never smoked and his consumption of alcohol is very moderate. From about the mid 80 s he has noticed blanching of the fingers on exposure to cold and it will extend to the MP joints of all fingers. The feet also get cold. The fingers are numb when blanched or cold, and when driving his car. They tingle on recovery and his sleep is disturbed. His grip strength is less then [sic] it used to be, he has difficulty handling small objects, and he drops things at times. He now suffers from aches and pains in the forearms, particularly on the right. Stockholm Grading: Vascular - 3R(4); 3L4. (History) Sensorineural - 3 SN both hands. He was examined in October 1991 by Dr. Field and a diagnosis of VWF could not be confirmed. When re-examined in 1992 a diagnosis of CTS was made and accepted by the WCB. He has not had any specific treatment and has not used splints. Examination His fingers were cool and the skin was moist. An early Dupuytren s contracture was noted in the left palm between digits 4 & 5. (a) Vascular Blood pressure - 140/90 right; 120/80 left. Adson s test - both wrists. Allen s test - just within normal limits in both hands.

5 Page: 4 Decision No. 990/99 Duplex scan of upper and lower extremities - no evidence significant occlusive disease; diameter of radial artery - right 2.1 mms - left 3.2 mms diameter of ulna artery - right 1.8 mms - left 2.6 mms Arterial peripheral study - arms (see attached) - normal. Digital plethysmography - fingers (see attached) - mild contour changes in the right hand. - toes (see attached) - normal. Arterial peripheral study - legs (see attached) - normal. Digit temperature test - prior to immersion in water at 10 C the digit temperatures were as follows: Thumb Index Middle Ring Little Right Left After immersion in water at 10 C for 5 minutes the digit temperatures were as follows: Thumb Index Middle Ring Little Right Left While immersed there was some reactive hyperaemia in both hands, and at 7 minutes the digit temperatures were as follows: Thumb Index Middle Ring Little Right Left Following immersion recovery of skin temperature was within normal limits. Opinion The vascular test results revealed minimal vasospasm on cold stress. The vascular impairment is Stage 0 left hand, and mild Stage 1 right hand. (b) Neurological Arm reflexes - present and equal. Tinel s test - positive with both middle fingers, the left index and the right thumb. Phalen s test - positivie with the left middle, ring and little fingers; right hand. Depth sense appreciation - very impaired with all fingers in both hands Two-point discrimination - normal both hands. Grip strength - right 43.0 Kg; left 42.0 Kg. Manipulative dexterity - normal and Moberg test normal. Vibration perception threshold test (see attached) - decreased sensitivity with the median nerve at 63 Hz and above on the left, and at 125 Hz and above on the right. - decreased sensitivity with the ulnar nerve at 31.5 Hz and above on the left, and at 250 & 500 Hz on the right. Neurometer current perception threshold test (see attached) - normal.

6 Page: 5 Decision No. 990/99 Nerve conduction test (see attached) - the latencies of the sensory components of both median nerves are mildly prolonged. Opinion The sensory test results indicated that there is a neuropathy of the median and ulnar nerves, and the grip strength is below the normal for his age. The sensorineural impairment is moderate/severe Stage 3 in both hands. Laboratory Tests Anti-nuclear factor (s 1:10) - 1:100* Cryoglobulins - Serum immuno-electrophoresis - no significant abnormality. Serum Chemistry Sodium ( ) mmol/l 143 Potassium ( ) mmol/l 4.7 Chloride (96-106) mmol/l 98 Total CO 2 (22-30) mmol/l 28 Creatinine (<120) umol/l 96 Uric acid (<450) umol/l 375 Urine analysis Routine dipstick: Specific gravity ph Protein Nitrites Glucose Ketones Urobilinogen normal <17 umol/l Bilirubin Haemoglobin Leukocytes Others Urine chemistry free of abnormalities No Microscopy done. Automated CBC WBC (4-11) 8.5 RBC ( ) 5.55 HGB ( ) 174 PCV ( ) MCV (76-100) 86.5 MCH (27-32) 31.4 MCHC ( ) 363* RDW (11-15) 12.9 PLT ( ) 238 %Gran ( ) 0.821* %Lymphs ( ) 0.142* %Mono ( ) %Eo ( ) 0.008* %Baso ( ) Retic (1-20) 23* ESR-Sed Rate (0-9) 7

7 Page: 6 Decision No. 990/99 Film coment [illegible] normal. Conclusion This patient had significant HAV exposure and suffered from the hand-arm vibration syndrome with repetitive strain. There has been no HAV exposure since 1988, so there has probably been some recovery. The vascular impairment is now Stage 0 left hand, and mild Stage 1 right hand. The sensorineural impairment is now moderate/severe Stage 3 SN both hands. I advised him to use wrist splints at night. No further treatment is required at present. His ANF is significantly increased, so the test should be repeated to verify. [15] Dr. Pelmear confirms a diagnosis of hand-arm vibration syndrome with only minimal vascular impairment in the right hand, and none in the left. He does, however, identify sensorineural impairment at a moderate or severe stage III of both hands. This is consistent with the worker s evidence that he has little feeling in his fingers, and tends to drop small objects. [16] The Workplace Safety and Insurance Act took effect on January 1, It requires, as a consequence of section 126 and 112, that applicable policies of the Board be applied to appeals. Among the policies identified as relevant by the Board in this case, are operational policy Document # , pertaining to the determination of a permanent impairment due to hand-arm vibration syndrome. Also identified as relevant is the pre-existing policy, which continues to apply, and which continues to assert entitlement criteria. This is policy Document # , pertaining to vibrationinduced white finger disease. This policy requires: There is a clear and adequate history of two or more years continuous employment on high-frequency rapid acceleration vibratory tools immediately preceding the onset of vasospastic response. [17] Considerable discussion was had in the course of hearing regarding the concern that the symptoms appeared in this worker after he ceased exposure to vibratory tools. According to the Board policy, in order for entitlement to be considered, Vasospastic responses must be identified within two years of the exposure. [18] The worker stopped work in July of The first evidence of vasospastic response was in the spring of This, in my view, is within the guideline established by Board policy, and satisfies the entitlement criteria. [19] The more recent Board policy pertains to the determination of permanent impairment due to hand-arm vibration syndrome, and identifies the fact, now well-recognized, that workers with hand-arm vibration syndrome may have three different components to their disability: the vascular, the neurologic and the musculoskeletal. It is not necessary for a diagnosis of hand-arm vibration syndrome that all three exist in symmetry. The policy intends, however, to insure that each aspect of the disability in a particular case is recognized when permanent impairment is assessed. [20] It is true in the instant case that Dr. Pelmear has confirmed a diagnosis of HAVS, with very little vascular impact. Contrary to the conclusion achieved by the Appeals Officer, however, I am satisfied that Board policy does not preclude a finding that there is hand-arm vibration syndrome, even in the

8 Page: 7 Decision No. 990/99 absence of a significant vascular component. Dr. Palmear has identified the sensorineural impairment as moderate to severe at stage III, and in my view, has persuasively established the diagnosis. [21] So it is that I am satisfied that the worker does suffer from hand-arm vibration, and that the Board s entitlement criteria has been established. THE DECISION [22] The worker s appeal is allowed. The Board is instructed to assess the worker s entitlement to benefits for hand-arm vibration syndrome, as a consequence of his employment as a pipe-fitter. DATED: June 29, 1999 SIGNED: E. Newman