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WCAT Decision Number: WCAT-2008-02320
WCAT Decision Date:
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Introduction

The worker appeals from four decisions of review officers of the Workers’
Compensation Board, operating as WorkSafeBC (Board).
The” A” appeal is from the decision of a review officer dated January 17, 2007 (Review
Decision #R0069683) in which the officer confirmed the May 24, 2006 decision of a
case manager of the Board. The case manager had advised the worker that:
• her wage loss benefits would be terminated effective May 28, 2006 as her condition
• that she would be referred to the Vocational Rehabilitation Department for • that she would be referred to the Disability Awards Department for determination of her permanent partial disability arising from her right foot chronic regional pain syndrome (CRPS). The review officer agreed with the decision of the case manager and explained that the worker’s pain complaints in areas of her body other than her right foot were not related to the compensable injury under this claim and therefore were not considered in the determination of whether her condition had stabilized or plateaued. The review officer concluded that the worker’s right foot condition had plateaued and therefore her wage loss benefits were properly terminated. The worker submits that her CRPS condition has spread to various other parts of her body and therefore her condition had not plateaued but was continuing to worsen. The worker therefore believes she is entitled to ongoing wage loss benefits. The “C” appeal is from an April 10, 2007 decision of a review officer (Review Decision #R0072512). The review officer confirmed two decisions of a case manager contained in a letter of August 10, 2006. The case manager said that the worker’s chest, back, and bilateral arm pain were not due to the injury under this claim. The case manager also said that the cost of the prescription for Citalopram™ would not be reimbursed by the Board. He said that this drug was intended to treat depression which had not been accepted by the Board as a consequence of the compensable injury under this claim. 150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1 Telephone: (604) 664-7800; 1-800-663-2782; Fax (604) 664-7898
The “D” appeal is from the July 5, 2007 decision of a review officer (Review Decision
#R0074376). The review officer confirmed the July 5, 2007 decision of a disability awards
officer of the Board advising the worker that she had been granted a permanent partial
disability pension (PPD) equal to 6.25% of her pre-injury earnings. No potential loss of
earnings award was granted pursuant to section 23(3) of the Workers Compensation Act
(Act).
The “E” appeal is from the October 26, 2007 decision of a review officer (Review Decision
#0080901). The review officer confirmed the decision of a case manager with respect to
which medications would be approved for reimbursement by the Board. Nine separate
medications were dealt with in the decision letter, but only two were contested at the review
division by the worker. Neither Ativan™ nor Citalopram™ was accepted as treatment for
conditions arising from the injury under this claim. Ativan™ was prescribed for anxiety or
depression and Citalopram™ was prescribed for depression. The review officer found that
neither of these conditions had been adjudicated under this claim.
Issue(s)

Under the “A” appeal, the question to be answered is whether the worker’s condition
had plateaued by May 28, 2006. In answering this question, the key element to be
determined is whether the worker’s complaints of pain in her left leg, upper body and
chest are due to her CRPS condition.
The worker makes no complaint about her referral to the Vocational Rehabilitation
Department, or her referral for a permanent functional impairment (PFI) assessment,
although both of these referrals and the action taken by officers of the Board in those
departments may be affected by the decision with respect to the question noted above.
The main issue arising from the “C” appeal is the same as that in the “A” appeal; that is,
whether the worker’s symptoms in her left leg, upper body and chest are due to the
compensable injury under this claim.
The further issue that arises is whether the medication Citalopram™ is required to treat a
condition arising from the injury under this claim.
The issue arising from the “D” appeal is whether the PPD granted to the worker accurately
reflects the disability suffered as a result of the injury under this claim.
The issue arising from the “E” appeal is whether payment for the medication Ativan™
should be accepted as a Board responsibility under this claim.
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1 Telephone: (604) 664-7800; 1-800-663-2782; Fax (604) 664-7898
Jurisdiction

This appeal was filed with the Workers’ Compensation Appeal Tribunal (WCAT) under
section 239(1) under the Act. No oral hearing was requested by the worker and the
respondent is not participating. On review of the issue identified, I conclude that as this
matter is mainly one of medical evidence, no oral hearing is required.
Background and Evidence

On May 27, 2005 this then 42-year-old residential and commercial cleaner was exiting a
company vehicle at a job site when the car ran over her right foot. The worker sought
medical attention from a local emergency department where she was diagnosed with a
soft tissue injury and X-rays demonstrated no fracture. The worker saw her family
physician on June 28, 2005 and he confirmed that diagnosis.
On June 30, 2005 a bone scan showed decrease flow in blood pool volume in her right
foot, which the medical imaging physician said was consistent with disuse.
The worker continued to be symptomatic with her right ankle and was referred for
physiotherapy. A physiotherapy report of May 8, 2005 indicates that the worker was
using a cane and was “limping ++.” The physiotherapist thought that the worker’s
progress was slow and that she might need further evaluation.
The worker was referred to Dr. J.J. van Sittert, an orthopaedic surgeon, who saw her on
August 15, 2005. He thought that the worker had sustained a soft tissue
compression-type of injury and, although the bone scan did not report reflex
sympathetic dystrophy (also known as CRPS) Dr. van Sittert did not feel he could rule
that out.
An MRI ordered by Dr. van Sittert was reported on August 24, 2005 to be normal. The
radiologist’s impression was that “the examination does not identify a significant injury
or tendon abnormality.”
In his consultation report of September 9, 2005 Dr. van Sittert said that the appearance
clinically was suspicious of reflex sympathetic dystrophy.
A repeat bone scan of September 20, 2005 again said that the appearance was likely
on the basis of disuse. The radiologist went on to say “chronic reflex sympathetic
dystrophy would also have this appearance in the chronic phase, which is not expected
until after 34 weeks.”
Dr. van Sittert saw the worker again on October 13, 2005. He noted that the worker had
“read up on reflex sympathetic dystrophy” and felt that her symptoms correlated with
this condition. The worker told Dr. van Sittert at this time that she had “diffuse
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1 Telephone: (604) 664-7800; 1-800-663-2782; Fax (604) 664-7898 altered sensation in other areas of her limbs, including the upper limbs with patchy areas of sensory changes.” Dr. van Sittert thought that the worker should be investigated by a neurologist to rule out other possible problems such as multiple sclerosis and if those were ruled out, she should be treated at a pain clinic where nerve blocks might be of some value in diagnosing her condition. Board medical advisor, Dr. J, saw the worker on October 19, 2005. The worker also told Dr. J that she had done some research on the Internet on the issue of reflex sympathetic dystrophy and she was convinced that she had this condition and required nerve blocks as soon as possible. On the basis of his examination, Dr. J concluded that a reasonable working diagnosis was CRPS. The worker was next seen at the Board’s Visiting Specialists Clinic by Dr. Jeff Beckman, a neurologist, on December 6, 2005. He said that the worker’s examination was normal for any neurological issues. The worker was seen by Dr. Baggoo, an orthopaedic surgeon, also at the Board’s Visiting Specialists Clinic, on December 7, 2005. He also said that the worker fulfilled the criteria for CRPS. However, Dr. Baggoo thought that the worker was also likely suffering from lupus or some other early inflammatory arthropathy. He did not think that her CRPS was spreading “more proximally”, but rather thought that her pain in other joints was due to lupus. Dr. Baggoo thought that the worker should be seen by a rheumatologist. The worker was referred to a pain clinic where she was assessed on February 6 and 72006. She received a variety of treatments there, including a series of nerve blocks, some of which were conducted on both the left and right side. Although the worker had temporary relief from these nerve blocks, however, there were no objective improvements in terms of range of motion, strength, or reduced hypersensitivity. The discharge report indicated the worker was not fit to return to her pre-injury employment. In the meantime, the worker had been seen by Dr. R. Shuckett, a rheumatologist. Dr. Shuckett noted that the worker’s left leg was also symptomatic and this had begun about four months after the initial injury. The pain, bilaterally, extended from the ankles all the way to the hips and sacroiliac regions. The worker also complained of pain all over her body and a burning sensation all over her body. The worker said that she experienced cramps in both of her arms and her hands, as well as pain in the upper scapula regions and over the extensor aspect of the forearms. On examination, Dr. Shuckett concluded that the worker did not meet the criteria for fibromyalgia. She said that the worker’s presentation was in keeping with CRPS in both the right and left legs. 150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1 Telephone: (604) 664-7800; 1-800-663-2782; Fax (604) 664-7898 The worker went on to experience severe chest pains and was seen by Dr. J.J. Simice, a cardiologist. In his consultation report of August 31, 2006, Dr. Simice said that the worker suffered from atypical chest pain and thought it might be gastroesophageal reflux. Further testing eventually ruled out reflux. The worker’s family physician requested consultation from the pain program at St. Paul’s Hospital. However, in a letter of October 21, 2006 Dr. McDonald, a pain program physician at St. Paul’s Hospital said that, as the hospital was not an approved pain program provider by the Board, it would not be useful to provide an examination and opinion with respect to this worker. Dr. McDonald said that one of the greatest detriments to improvement in CRPS cases, as well as other pain cases, was “ongoing disputes with the WCB.” He also went on to say that CRPS spreading to other limbs had been reported in the literature, as had CRPS affecting bladder function. Dr. McDonald said he was not aware of CRPS affecting any other internal organs, although there was speculation that such a spread might account for some of the “bizarre symptoms that CRPS patients report.” Dr. Shuckett wrote to a Board officer on January 30, 2007 in support of the worker’s claim. She confirmed her view that the worker’s left foot symptoms were also due to CRPS. Dr. Shuckett commented on the worker’s diffuse pain and chest pain which she said were now part of a confirmed fibromyalgia diagnosis. The worker was seen by Dr. B. Fehlau, a pain specialist, on February 20, 2007. She confirmed that the worker’s diagnosis was CRPS with diffuse fibromyalgia pain. In a letter of May 4, 2007 addressed to the Board, Dr. Fehlau now said that the worker’s CRPS had “generalized.” She said there was literature confirming that CRPS could be a generalizing condition. Dr. Shuckett continued to treat the worker. In a May 28, 2007 letter of support she made the following comments: At issue is whether or not CRPS can become bilateral. There are some articles in the medical literature which support the spread of chronic regional pain syndrome, particularly to the contra-lateral limb.… Some of the theories about CRPS include a central brain etiology to the pain. The question is whether there is some central problem in the neurological system which makes the patient at risk for other areas of symptoms once they have had one area involved. I believe that, in particular, her mirror imaged symptoms in the left leg are part of the complication of her right CRPS and reflect the mirror like or symmetric spread that can occur. 150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1 Telephone: (604) 664-7800; 1-800-663-2782; Fax (604) 664-7898 Dr. Shuckett went on to discuss the possibility of CRPS spreading to the chest and trunk. She said that there was some support for this in the literature but she had had no personal experience with trunk or chest area CRPS. Dr. Shuckett said that she felt much more comfortable implicating the left leg symptoms as a complication of the right CRPS. The worker submitted a short consultation letter dated May 23, 2007 from Dr. Trace Thomas, an internal medicine specialist. He said that the worker had chronic reflex sympathetic dystrophy and chronic non-cardiac chest pain as well as right wrist pain and swelling as a complication of coronary angiography as of December 27, 2006. The worker submitted a 24-page form completed for the British Columbia Ministry of Employment and Income Assistance by both the worker’s family physician, Dr. Howard, and a nurse assessor. Dr. Howard’s portion of the report was completed on June 5, 2007. He said that the worker suffered from CRPS in her right leg with mirror-like symptoms in her left with a date of onset of September 2005. Dr. Howard said there was a suspected internalized spread of the CRPS. Dr. Howard went on to say the worker suffered from fibromyalgia with a date of onset of January 2007. In a letter dated June 28, 2007 submitted as part of the worker’s 66-page submission to this appeal, Dr. Howard said he had done further reading and research and discussed the worker’s condition with Dr. Fehlau, the chronic pain specialist, and had concluded that all the worker’s upper body symptoms were the effect of the spread of the worker’s CRPS originating in her right leg. The worker submitted copies of a number of articles from scientific journals on the subject of CRPS. The worker also submitted a January 19, 2006 memorandum setting out the Board’s “diagnostic criteria for CRPS.” Among other factors, this memorandum says, under the heading “Definition of CRPS”: … • is a functional disorder of the spinal cord that involves to varying degree the dorsal and ventral horns, as well as the intermediolateral columns, so as to produce sensory, motor, and autonomic abnormalities. The original dysfunction may spread to the adjacent spinal cord level and can cross the midline and travel from cord segments serving lower to upper limbs and vice versa.… The document goes on to set out three criteria, presumably for diagnostic purposes: 1. The patient must have continuing pain that is disproportionate to any 150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1 Telephone: (604) 664-7800; 1-800-663-2782; Fax (604) 664-7898 2. The patient must report at least one symptom in at least three out of the following four categories in the affected extremity: • Sensory: reports of hyperesthesia • Vasomotor: reports of temperature asymmetry and/or skin colour changes and/or skin colour asymmetry • Sudomotor/edema: reports of edema (with or without joint stiffness) and/or sweating changes and/or sweating asymmetry • Motor/trophic: reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (nails, hair, skin) 3. The patient must display at least one sign in two or more of the following categories in the affected extremity: • Sensory: evidence of hyperalgesia (to pinprick) or allodynia (to • Vasomotor: evidence of temperature asymmetry and/or skin • Sudomotor/edema: objective evidence of edema (with or without joint stiffness) and/or sweating changes and/or sweating asymmetry • Motor/trophic: evidence of decreased range of motion (including joint stiffness) and/or motor dysfunction and/or trophic changes [Reproduced as written, underlining in the original] The worker was examined for PFI purposes on July 26, 2006. The Board disability awards medical advisor who examined the worker said in a “POSTIMPAIRMENT EXAMINATION MEMO”: The pain as reported is in keeping with the complex regional pain syndrome, but symptoms reported beyond the sight [sic] of injury do not fit the description. Her sensory changes on the right are in keeping with the complex regional pain syndrome, but sensory changes noted on the left are inexplicable. The range of measurements revealed in the PFI examination include reduced dorsiflexon of the ankle on the right to 15 degrees while it was 40 degrees on the left and reduced plantar flexion on the right to 15 degrees while it was 40 degrees on the left. The worker provided a submission on a compact disc, containing not only her written submissions, but also copies of WCAT decisions on the issue of CRPS. There were also several journal articles on CRPS and a copy of a Supreme Court of Canada decision in the case of Nova Scotia v. Martin. 150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1 Telephone: (604) 664-7800; 1-800-663-2782; Fax (604) 664-7898 In her submission dated June 3, 2008 the worker included a pain clinic report dated May 7, 2008 and signed by Dr. J Capstick in which he summarized his findings in the following paragraph: This lady certainly has typical findings suggestive of complex regional pain syndrome in all four extremities. I am not familiar with complex regional pain syndrome affecting the trunk and would like to review the findings of her cardiac workup.
Also included was the referral letter from Dr. Fehlau and a Chronic Pain Assessment
providing a complete history of the worker’s problems.
Decision and Reasons

On the “A” appeal, I allow the worker’s appeal. I find that the worker’s condition had not
plateaued or stabilized by May 28, 2006.
I make the above finding on the basis that I conclude that the worker’s pain complaints
in her left lower extremity and her bilateral upper extremity complaints are a direct result
of the compensable injury under this claim as they represent a spread of her CRPS
condition. I find that the weight of medical evidence supports such a decision.
On the other hand, I cannot conclude that the worker’s upper body and chest pain and
headache complaints are a result of her compensable injury under this claim. There is
simply insufficient direct medical support for such a conclusion.
I rely primarily on Dr. Shuckett’s opinion to reach my conclusion. Dr. Shuckett said in
her first opinion of May 2, 2006 that the left leg complaint was due to CRPS. She
continued to support this conclusion in her January 30, 2007 and May 28, 2007
consultation reports. Dr. Shuckett’s opinion is well reasoned and is supported by the
literature submitted by the worker. A mirror image spread of CRPS is not an unusual
finding.
There is also support for Dr. Shuckett’s opinion from Dr. Fehlau, who acknowledges that
the worker has bilateral lower limb problems attributable to CRPS.
I also note that although the worker was not examined at the St. Paul’s Pain Clinic,
Dr. McDonald did confirm that the literature evidence was that the CRPS condition
could spread to other limbs.
The most recent medical evidence from Dr. Capstick adds further support and
elaboration to the notion of a spread of the workers CRPS symptoms to her upper
extremities. However, Dr Capstick also is unable to confirm the likelihood of her chest
complaints being related to her CRPS condition.
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1 Telephone: (604) 664-7800; 1-800-663-2782; Fax (604) 664-7898 The contrary opinion comes primarily from Dr. Baggoo who posited a diagnosis of lupus which has never been demonstrated and indeed has been ruled out. The disability awards medical advisor found the left lower limb problems to be inexplicable, but I prefer the opinion of the specialists. I am mindful that the Board does have diagnostic criteria for CRPS. I have noted that above. Although such diagnostic criteria is not Board policy and therefore is not binding on Board officers or this panel, one would expect that a Board medical advisor, before providing an opinion on the issue of CRPS would assess the worker against those diagnostic criteria. I see no evidence that this has taken place and therefore I am loath to place any particular weight on the Board medical advisor’s opinion. The diagnostic criteria are not published Board policy and are not, to the best of my knowledge, generally available to the medical community. For that reason, I can have no expectation that any of the independent physicians who have examined this worker would have knowledge of it, nor would I expect that those physicians would have assessed the worker on the basis of those criteria. On the other hand, Dr. Shuckett indicated that she was not comfortable implicating CRPS in the trunk and chest symptoms experienced by the worker. Although Dr. Fehlau does say that generalized CRPS can occur, he provides no specific support for a conclusion that this worker’s CRPS has generalized. There are two policies contained in the Rehabilitation Services and Claims Manual, Volume II (RSCM II) that are relevant to this portion of the decision. Item #97.00 of the RSCM II says that where there is “a preponderance in favour of one view over the other, that is the conclusion that must be reached.” I find that the preponderance of evidence here leads to the conclusion that I have outlined above. The second policy of relevance is contained at item #22.00 of the RSCM II. That says that in order to determine the compensability of subsequent conditions or injuries following a compensable injury that the matter should be looked at “broadly and from a ‘common sense’ point of view, [and that] it should be considered whether the work injury was a significant cause of the later injury.” In this worker’s case, looking at the matter from a common sense point of view, it seems that there is ample evidence that the worker’s left lower extremity symptoms and bilateral upper extremities are causally related to her right foot compensable injury. I am satisfied that the worker’s compensable injury was a significant cause of the later symptoms developing in the worker’s left lower extremity. The left lower extremity and bilateral upper extremity symptoms are therefore compensable. 150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1 Telephone: (604) 664-7800; 1-800-663-2782; Fax (604) 664-7898
All of this begs the question of when the worker’s condition plateaued. I make no
specific finding on that matter, but rather, I simply conclude that the worker’s condition
did not plateau on May 28, 2006. I return the file to the Board to make a new
determination on this matter.
On the issue arising from the “C” and “E” appeals, I deny the worker’s appeals. There
has been no adjudication on the compensability of the worker’s depression and anxiety
and therefore the medications prescribed for these conditions can not be seen as a
Board responsibility.
On the issue arising from the “D” appeal, I make no finding. The issue of the workers
PPD is moot as I have found that her condition had not plateaued by May 28, 2008 as
her CRPS has spread to other areas of her body than the right lower extremity.
Conclusion

I allow the workers appeals, in part and vary the decision of the review officers
accordingly. The worker’s condition had not plateaued by May 28, 2008, but rather
continued to develop and eventually spread to her left lower extremity and bilaterally to
her upper extremities.
No expenses of the appeals were requested and none are apparent on the face of the
file.
P. Michael O’Brien
Vice Chair
PMO/jd/pme
150, 4600 Jacombs Road, Richmond, B.C. V6V 3B1 Telephone: (604) 664-7800; 1-800-663-2782; Fax (604) 664-7898

Source: http://www.wcat.bc.ca/research/decisions/pdf/2008/08/2008-02320.pdf