Summary of Proposed Amendments Amendments to the policy, Repetitive Strain Injuries (POL 91), are proposed to set out the criteria for acceptance of repetitive strain injuries and provide clarification on how the WCB determines if a repetitive strain injury is work related. The amendments expand the application of the policy beyond upper extremities to other parts of body and explain how the WCB considers and weighs risk factors to determine entitlement to compensation. This draft policy has been developed in conjunction with the proposed amendments to the policy, Arising Out of and in the Course of Employment/Conditions for Entitlement (POL 71). The proposed amendments are described in the policy document below. New content is bolded and content to be deleted is shown with a strikethrough. An unmarked version of the proposed policy can be found at the end of the document. Chapter: CLAIMS Subject: REPETITIVE STRAIN INJURIES Effective Date: June 27, 2002 Last Updated On: September 12, 2016Draft October 25, 2018 PURPOSE STATEMENT: The purpose of this policy is to explain how the Workers Compensation Board determines whether an injury or condition is considered to be a compensable repetitive strain injury. REFERENCE: Workers Compensation Act R.S.P.E.I. 1988, Cap. W 7.1, Section 18 Workers Compensation Board Policy, POL 62, Benefit of Doubt Workers Compensation Board Policy, POL 68, Weighing of Evidence Workers Compensation Board Policy, POL 71, Conditions for Entitlement Page1
DEFINITION: In this policy: Bursitis means the inflammation of the bursae, which are fluid lined sacs that separate tendons, muscles and bony prominences such as those found in the shoulder and elbow. Carpal tunnel syndrome means a compression of the median nerve as it passes through an area in the wrist known as the carpal tunnel. Neurovascular disturbances of the extremities means those situations where there is prolonged exposure to excessive vibration or a combination of repetition, force and/or extreme postures. E.g. carpal tunnel syndrome. Repetitive strain injury means a variety of medical conditions affecting muscles, tendons or ligaments caused by repetition, force, or maintenance of sustained or dynamic awkward postures. Tendinitis means the inflammation of a tendon which attaches the muscle to bone, such as those found in the shoulder, elbow, wrist or hand. Upper extremities means the shoulder, arm, forearm, wrist, and hand. POLICY: 1. An activity related soft tissue injury A repetitive strain injury is the result of the cumulative effect of an activity or activities and conditions. Injuries of this type are not attributable to a single incident. 12. A repetitive strain injury is affects muscles, tendons or ligaments and condition that may include, but is not limited to, tendinitis, bursitis, carpal tunnel syndrome, and tennis elbow, and neurovascular disturbances. The Workers Compensation Board will adjudicate repetitive strain injuries of the upper extremities using the principles set out in this policy. Page2
3. For a claim to be accepted as a repetitive strain injury, all of the following criteria must be met: there must be sufficient evidence of significant risk factors for the development of a repetitive strain injury related to work activities; the medical information must support that there is a repetitive strain injury; and the repetitive strain injury must be work related, i.e., the activities that caused the injury must have happened at a time and place that is consistent with work, and while in the course of an activity whose purpose is related to work. 4. The Workers Compensation Board will adjudicate claims for repetitive strain injuries using the principles set out in this policy and Workers Compensation Board policy, POL 71, Conditions for Entitlement. Risk Factors 5. Determining whether a repetitive strain injury is work related requires an analysis of risk factors. There must be sufficient evidence of significant work risk factors related to work activities to be considered a work related repetitive strain injury. All relevant information, including significant risk factors outside of work, will be considered. 6. The major risk factors for repetitive strain injury in the workplace are: Repetition the number of times the specific activity(s) is repeated and the percentage of the workday during which it occurs. Force the weight or impact of the object being handled and/or the force of body action required to carry out the activity. Posture the sustained or dynamic posture or body positioning required to do the activity in the work area. Repetitive strain injuries that are determined to be caused by the performance of specific work tasks are treated primarily through education and the modification of specific workplace risk factors as recommended by an Occupational Therapist. 7. Repetition and force are the primary risk factors involved in repetitive strain injuries, with awkward posture increasing the effect of the two primary factors. If work involves high force and high repetition, this indicates a high probability of a relationship between the repetitive strain injury and work. This probability is Page3
increased with awkward posture. Low force and low repetition indicate a low probability of a relationship to work. Thorough investigation to determine causation and to establish a well defined medical diagnosis is essential as it forms the basis of appropriate treatment. Claims will be considered when there is a probable association between the medical condition and exposure to the task risk factors. Investigations may include the following: a comprehensive medical assessment including: clinical history, physical examination with diagnostic testing (nerve conduction studies/x rays); investigation of non occupational risk factors; assessment of occupational risk factors by an Occupational Therapist including a worksite visit. 4.8. The investigation into a repetitive strain injury will include an Occupational Therapist assessment and, wherever feasible, a worksite visit. The Occupational Therapist will, if possible, assess the worker performing the workplace activities and to evaluate the extent of exposure to repetition, force and awkward posture. The following factors may also be considered: high repetition; high force; extreme postures; vibration; frequency; duration of task or employment; recovery time/ biological resting; length of employment; individual work style; unaccustomed activity; extreme cold temperatures. High repetition = 2 to 4 times per minute or cycles less than 30 seconds. High force = hand weights of > 4 kg. High vibration = >1,000 hours exposure. Duration = minimum 2 4 hours 9. Current medical research is used to evaluate the impact of each risk factor which varies depending on the diagnosis. The extent to which the activity or risk factor is a Page4
significant component of the employment will be considered. Carpal Tunnel Syndrome 710. Where the repetitive strain injury is carpal tunnel syndrome and is bilateral (involving both wrists), the Workers Compensation Board will consider whether both wrists became symptomatic at the same time and the degree to which each hand/wrist is utilized in carrying out the employment activities. Research indicates that since both hands may not perform identical activities and are therefore subject to different risk factors, a work related carpal tunnel syndrome may be more likely to be unilateral. The diagnosis of bilateral carpal tunnel syndrome is more probably due to non occupational risk factors such as a systemic illness. Work Relatedness 11.6. The presence of the following circumstances, although not conclusive, may support a relationship to work: a. precise symptom onset during work activity, b. new to the activities in the job, c. recent increase in activities at work, d. improved symptoms away from work. 127. The presence of the following circumstances, although not conclusive, may support that the diagnosis is not related to work: symptom onset away from employment, activities performed for many years, recent increase in activities outside work, other medical considerations (conditions, medications or therapies), bilateral symptoms without bilateral activity, continued or increasing symptoms away from work. 3. Non occupational or personal risk factors which may contribute to the development of repetitive strain injuries include the following: congenital: anatomical anomalies, genetic predisposition; Page5
auto immune/haematological: inflammatory arthritis, psoriasis, lupus, renal disease, anticoagulant therapy, acromegaly, hypothyroidism, hormone replacement therapy, colitis, gout, diabetes tumours: nerve sheath/bone tumours, cysts, ganglions; vascular: circulatory disturbances, Raynaud s; other: age, hobbies/leisure activities, body mass index (>29), high psychosocial distress, previous trauma, gender, smoking. 13. A claim for repetitive strain injury will be accepted if: Having weighed all of the available evidence, and on the balance of probabilities, the work related risk factors are more likely to have caused the repetitive strain injury than non work related risk factors, as set out in Workers Compensation Board policy, POL 68, Weighing of Evidence; and The claim meets the criteria set out in Workers Compensation Board policy, POL 71, Conditions for Entitlement. Date of Accident 5. Each claim for a repetitive strain injury will be considered on its own merits and within the context of Workers Compensation Board policy, POL 62, Benefit oof Doubt. 614. The date of accident for repetitive strain injuries is outlined in Workers Compensation Board policy, POL 90, Time Frame Limitations for Claims Filing and Invoicing. Carpal Tunnel Syndrome The Workers Compensation Board will also give consideration to whether the symptoms of carpal tunnel syndrome improve with rest (stopping work) or whether they continue to progress or worsen. If the symptoms continue to progress or worsen after rest, this may suggest a non occupational cause. HISTORY: September 12, 2016 Non substantive changes to reference Workers Compensation Board policy, POL 90, Time Frame Limitations for Claims Filing and Invoicing. Page6
March 29, 2012 Amended to include the content of POL 79, Carpal Tunnel Syndrome, which was rescinded. July 31, 2008 Amended to add #6, which clarifies what the WCB considers to be the date of accident for repetitive strain injuries. March 30, 2006 Amended to reflect an updated review of the medical literature on repetitive strain injuries. June 27, 2002 Replaces Policy and Practice Repetitive Motion Injuries dated November 14, 1994. Board of Directors Approval Date: June 27, 2002 Chapter: CLAIMS Subject: REPETITIVE STRAIN INJURIES Effective Date: June 27, 2002 Last Updated On: Draft October 25, 2018 **UNMARKED VERSION of the DRAFT POLICY** PURPOSE STATEMENT: The purpose of this policy is to explain how the Workers Compensation Board determines whether an injury or condition is considered to be a compensable repetitive strain injury. REFERENCE: Page7
Workers Compensation Act R.S.P.E.I. 1988, Cap. W 7.1, Section 18 Workers Compensation Board Policy, POL 68, Weighing of Evidence Workers Compensation Board Policy, POL 71, Conditions for Entitlement DEFINITION: In this policy: Repetitive strain injury means a variety of medical conditions affecting muscles, tendons or ligaments caused by repetition, force, or maintenance of sustained or dynamic awkward postures. POLICY: 1. A repetitive strain injury is the result of the cumulative effect of activities and conditions. Injuries of this type are not attributable to a single incident. 2. A repetitive strain injury affects muscles, tendons or ligaments and may include, but is not limited to, tendonitis, bursitis, carpal tunnel syndrome, and tennis elbow. 3. For a claim to be accepted as a repetitive strain injury, all of the following criteria must be met: there must be sufficient evidence of significant risk factors for the development of a repetitive strain injury related to work activities; the medical information must support that there is a repetitive strain injury; and the repetitive strain injury must be work related, i.e., the activities that caused the injury must have happened at a time and place that is consistent with work, and while in the course of an activity whose purpose is related to work. 4. The Workers Compensation Board will adjudicate claims for repetitive strain injuries using the principles set out in this policy and Workers Compensation Board policy, POL 71, Conditions for Entitlement. Risk Factors 5. Determining whether a repetitive strain injury is work related requires an analysis of risk Page8
factors. There must be sufficient evidence of significant work risk factors related to work activities to be considered a work related repetitive strain injury. All relevant information, including significant risk factors outside of work, will be considered. 6. The major risk factors for repetitive strain injury in the workplace are: Repetition the number of times the specific activity(s) is repeated and the percentage of the workday during which it occurs. Force the weight or impact of the object being handled and/or the force of body action required to carry out the activity. Posture the sustained or dynamic posture or body positioning required to do the activity in the work area. 7. Repetition and force are the primary risk factors involved in repetitive strain injuries, with awkward posture increasing the effect of the two primary factors. If work involves high force and high repetition, this indicates a high probability of a relationship between the repetitive strain injury and work. This probability is increased with awkward posture. Low force and low repetition indicate a low probability of a relationship to work. 8. The investigation into a repetitive strain injury will include an Occupational Therapist assessment and, wherever feasible, a worksite visit. The Occupational Therapist will, if possible, assess the worker performing the workplace activities to evaluate the extent of exposure to repetition, force and awkward posture. The following factors may also be considered: vibration frequency duration of task or employment recovery time/ biological resting individual work style unaccustomed activity extreme cold temperatures 9. Current medical research is used to evaluate the impact of each risk factor which varies depending on the diagnosis. The extent to which the activity or risk factor is a significant component of the employment will be considered. Page9
Carpal Tunnel Syndrome 10. Where the repetitive strain injury is carpal tunnel syndrome and is bilateral (involving both wrists), the Workers Compensation Board will consider whether both wrists became symptomatic at the same time and the degree to which each hand/wrist is utilized in carrying out the employment activities. Research indicates that since both hands may not perform identical activities and are therefore subject to different risk factors, a work related carpal tunnel syndrome may be more likely to be unilateral. The diagnosis of bilateral carpal tunnel syndrome is more probably due to non occupational risk factors such as a systemic illness. Work Relatedness 11. The presence of the following circumstances, although not conclusive, may support a relationship to work: precise symptom onset during work activity new to the activities in the job recent increase in activities at work improved symptoms away from work. 12. The presence of the following circumstances, although not conclusive, may support that the diagnosis is not related to work: symptom onset away from employment activities performed for many years recent increase in activities outside work other medical considerations (conditions, medications or therapies) bilateral symptoms without bilateral activity continued or increasing symptoms away from work. 13. A claim for repetitive strain injury will be accepted if: Having weighed all of the available evidence, and on the balance of probabilities, the work related risk factors are more likely to have caused the repetitive strain injury than non work related risk factors, as set out in Workers Compensation Board policy, POL 68, Weighing of Evidence; and The claim meets the criteria set out in Workers Compensation Board policy, POL Page10
Date of Accident 71, Conditions for Entitlement. 14. The date of accident for repetitive strain injuries is outlined in Workers Compensation Board policy, POL 90, Time Frame Limitations for Claims Filing and Invoicing. Page11