SUMMARY DECISION NO. 1058/98 Fibromyalgia. The worker suffered a wrist injury in 1984. The worker appealed a decision of the Appeals Officer denying entitlement for fibromyalgia. Considering the evidence of the worker's treating doctors and a Tribunal medical assessor, the Panel found that persistent pain from the wrist injury led to the widespread development of fibromyalgia. The appeal was allowed. [5 pages] DECIDED BY: Sajtos; Beattie; Donaldson DATE: 22/10/99 ACT: WCA CROSS-REFERENCE: Decision No. 1058/98I
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 1058/98 [1] This appeal was heard in Toronto on July 20, 1998, by a Tribunal Panel consisting of : E.J. Sajtos : Vice-Chair, J.J. Donaldson : Member representative of employers, D.B. Beattie : Member representative of workers. THE APPEAL PROCEEDINGS [2] The worker appealed a decision of Appeals Officer, S. Marangoni, dated April 7, 1997. That decision concluded that the worker was not entitled to benefits for secondary conditions of bilateral shoulder pain, bilateral carpal tunnel syndrome and abdominal pain arising from a 1984 compensable injury to his right wrist. The worker was also denied entitlement for a fibromyalgia disability. [3] Subsequent to the hearing of July 20, 1998, the Panel, in Decision No. 1058/98I, requested the assistance of a Tribunal Assessor in order to obtain a medical opinion with respect to the worker s appeal. The Panel received a report from Dr. Duncan Gordon, rheumatologist, dated July 5, 1999 and submissions from the worker s representative dated August 4, 1999. EVIDENCE [4] The Panel considered the additional material found in Post-hearing Addendum #1 and correspondence dated August 4, 1999. THE ISSUES [5] The Panel must determine whether the worker has entitlement to: 1. secondary conditions including bilateral shoulder pain, bilateral carpal tunnel syndrome and abdominal pain arising from a 1984 workplace injury to the worker s right wrist; and 2. fibromyalgia/chronic pain disability. THE REASONS (i) Background [6] The Panel, in Decision No. 1058/98I, set out the relevant facts, testimony, and law and policy with respect to this appeal. The following is an abbreviated version of the relevant facts in order to summarise the matter before us. [7] The worker commenced employment with the accident employer as a machinist in 1974. He sustained a twisting injury of his right wrist on February 24, 1984 and was able to return to
Page: 2 Decision No. 1058/98 modified work. Due to persistent right wrist pain and an eventual diagnosis of avascular necrosis of the right carpal lunate bone, the worker stopped working in November 1987. [8] Vocational rehabilitation services for educational upgrading and computer training were provided to the worker and these were completed in 1989. The worker, however, has never returned to employment. During the time that the worker was in school, he began to suffer from widespread musculoskeletal symptoms in his neck, shoulders arms, wrists, fingers, lower back and legs, in addition to the constant pain in his right wrist. [9] Based on the Panel s request, the Tribunal assessor examined the worker and was provided access to the Case Record materials. The worker, during the course of his examination, complained of a non-restorative sleep pattern due to pain in his right upper extremity, chronic fatigue and psychological depression. It was also noted that he described right wrist stiffness and his single main pain problem with stiffness and restricted range of movement, associated with swelling of his right MCP and right lateral region with limitation of his right shoulder, associated with right lower cervical pain. The worker also related a history of pain and stiffness on the right side of his neck, which radiated into the occiput and trapezius. As well, he had shoulder stiffness, right lateral elbow pain, tingling of his fingers, periodic lumbar pain, aching hip and knee discomfort. He also had right ankle aching and right 1 st MTP joint pains. [10] With respect to the worker s current condition, Dr. Gordon, made the following comments: I believe the worker suffers from post-traumatic osteoarthritis of his right wrist related to previous avascular necrosis of his lunate, in keeping with Keinbock s disease. He also exhibits subjective and objective features of a fibromyalgia syndrome. In his case, pain is the most prominent subjective symptom, whereas tender points are the only clinically available objective diagnostic feature of fibromyalgia. In the worker s case, features of fibromyalgia syndrome include widespread pain associate with decreased pain threshold at site-specific soft tissue tender points. He also shows features of sleep disturbance, morning stiffness, fatigue, and psychological distress along with symptoms of headache, irritable bowel and bladder, subjective joint swelling and paresthesiae. As well, he has symptoms in keeping with carpal tunnel and Raynaud s phenomenon, also characteristic of fibromyalgia. All of the foregoing features of his fibromyalgia syndrome have, interfered with his ability to perform a normal range of human activity. In the worker s case, the question of causality of his fibromyalgia syndrome has been raised, and it is noteworthy that many patients with fibromyalgia report their condition started with a physical trauma or surgery. Psychological factors, physical deconditioning and frequently generalised hypermobility are factors that appear to contribute to the pain magnification symptoms of fibromyalgia. A clinical Case Study of 104 randomly selected workers, by my colleagues Dr. Moldofsky and Joan Crook, examining workers who had not returned to work in three months following soft tissue injury, shows that the greatest negative effect for return to work was associated with psychological distress and functional disability. In this study, the presence of fibrositic tender points was one of the valid predictors of delay in return to work. Unfortunately, studies such as these do no meet the gold standard for verifying causation, and unfortunately, no prospective studies have addressed the question. The absence of prospective studies indicating that trauma precipitates or aggravates fibromyalgia, however, does not exclude that possibility. Other factors linked to the cause of fibromyalgia include anxiety, depression, stress, obesity and like the worker, generalised joint hypermobility. Psychological stress also appears to worsen psychological symptoms.
Page: 3 Decision No. 1058/98 Finally, the role of trauma in the development of fibromyalgia is complex because the relationship between the extent of trauma is difficult to evaluate. Even though trauma often precedes fibromyalgia, it is often the case that trauma is only one component in the development of fibromyalgia, but not the cause. Nevertheless, this does not suggest that trauma might not cause fibromyalgia or that other factors do cause it, since causes might differ from person to person, or could be multiple. Thus, current uncertainties reflect the fact that appropriate studies to settle the question have not yet been done. [11] The Assessor than commented on the specific facts relevant to this worker. It was noted that there was no evidence of pre-existing fibromyalgia prior to the workplace wrist injury. In the physician s opinion, the persistent right wrist pain was the initial focus from which more widespread pain of fibromyalgia developed. The prior diagnosis of bilateral subacromial bursitis with which the worker had been diagnosed was suspect, according to the assessor. In his view, the shoulder symptoms and other musculosketal symptoms were consistent with the development of fibromyalgia; this included the bilateral shoulder pain and bilateral carpal tunnel syndrome. The fact that the worker did not have many of the symptoms for several years postaccident did not affect the physician s opinion because the worker had right wrist symptomatology persistent from the time of the injury. [12] The Assessor was asked if there were any non-compensable contributing factors which might have caused the worker s carpal tunnel syndrome. In response, he acknowledged that the generalised joint hypermobility might be a contributing factor, however, in his experience this was not an accepted cause. [13] Dr. Gordon was also of the view that the worker s stomach pain was related to the nonsteroidal anti-inflammatory medication he ingested in an attempt to control pain. Alternatively, the doctor stated that irritable bowel is a characteristic cause of abdominal pain and this was also a potential cause of the worker s discomfort. [14] At the conclusion of his report, the Assessor provided the following opinion with respect to the medical feasibility that the type of injury sustained by the worker would lead to fibromyalgia: I believe it is quite feasible that this man s wrist injury and persistent chronic pain set the stage for the more widespread characteristic pain of fibromyalgia. It is this persistent pain, associated with a non-restorative sleep pattern and fatigue that also tended to accelerate and advance his fibromyalgia. The delay between the injury and onset of more widespread symptoms is in keeping with this idea. As noted above, however, there are a number of other factors that have been incriminated as associations with fibromyalgia, and these include either auto-immune diseases, profound emotional distress, previous infections, poor body mechanics, which in the worker s case might include his joint hypermobility, although it is not severe, and finally, a single episode of trauma. In the worker s case, however, it seems apparent that the psychological stress and depression that has been associated with his fibromyalgia is likely secondary to his chronic pain disorder related to the severe post-traumatic osteoarthritis of his right wrist. No matter what, however, I regard this man s right wrist trauma and subsequent post-traumatic osteoarthritis as the most important component for the development of his fibromyalgia. [15] The worker s representative provided brief submissions, which concurred with the opinion of the Tribunal assessor.
Page: 4 Decision No. 1058/98 (ii) The Panel s reasons [16] Dr. Silverberg, a rheumatologist, in his report of December 10, 1991, was the first physician to suspect a diagnosis of fibromyalgia based on the worker s diffuse musculosketal pain. He later changed this opinion and indicated that the worker had bilateral subacromial bursitis. The Board Unit Medical Adviser then queried whether the worker s bilateral tennis elbow and rotator cuff disease were compensable given the occupation of machinist. However, the Appeals Officer found that these conditions were not work-related. [17] In a subsequent report of January 1992, Dr. Silverberg noted that the worker s fibromyalgia points were tender. However, when the next Board physician reviewed the file, he returned to the prior bursitis diagnosis and determined that this was not related to the compensable wrist injury. Dr. Reynolds and Dr. Whitton in subsequent reports both confirmed the fibromyalgia diagnosis, which was finally recognised by a Unit Medical Adviser in May 1995. However, the Board physician stated that the fibromyalgia was unrelated to the workplace injury. [18] The worker s family physician, in a report of October 25, 1994, provided information to the Board which supported the worker s contention that his abdomen pain was caused by his medication for his compensable injury. [19] Based on the evidence of the worker s treating physicians and the Tribunal s Assessor, the Panel finds that the worker s fibromyalgia condition, which includes the bilateral shoulder pain and bilateral carpal tunnel syndrome, is as a result of his workplace accident. Our finding is supported by the fact that two rheumatologists have diagnosed fibromyalgia and the symptoms arose following his work related injury and the surgery performed on his right wrist. It is not clear whether the abdominal pain is as a result of the worker s medication, or is due to irritable bowel arising from the fibromyalgia. However, as both of the potential causes arise from the compensable injury, the worker is also entitled to benefits for this condition. THE DECISION [20] The appeal is allowed. DATED: October 22, 1999 SIGNED: E.J. Sajtos, J.J. Donaldson, D.B. Beattie