APPENDIX F INTERJURISDICTIONAL RESEARCH

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1 Ontario Scheduled Presumption: Bursitis, listed in Schedule 3, of the Ontario Workers Compensation Act, entry number 18 Description of Disease Bursitis Process Any process involving constant or prolonged friction to or pressure on the bursae. Scheduled Presumption: Tenosynovitis, listed in Schedule 3, of the Ontario Workers Compensation Act, entry number 20 Description of Disease Tenosynovitis Process Any process involving continual or repetitive injury to tendons of the limbs. Quebec Scheduled Presumption: Bursitis, tendinitis or tenosynovitis, Presomption de maladie professionnelle s applique of An Act Respecting Industrial Accidents and Occupational Disease, R.S.Q. Chapter A-3.001, Quebec In the case of bursitis, tendinitis, or tenosynovitis, the presumption of a workplace injury applies where the work involves repetitive movements or pressure for a prolonged period of time. 1 1 The policy contains additional guidance in French on the circumstances in which the presumption applies. Nerve Entrapments and Tendinopathies of the Arm, Neck and Shoulder Page 1

2 Nova Scotia Scheduled Presumption: Tenosynovitis, listed in Appendix B, Workers Compensation General Regulations, Schedule 3 of the Ontario Workers Compensation Act, Description of diseases tenosynovitis Description of process any process involving constantly repeated vibration or excessive use of muscles of arm, forearm, hand, leg, ankle or foot Specific : 1.2.4R Carpal Tunnel Syndrome, of the WCB of Nova Scotia Manual Definitions Carpal Tunnel Syndrome is a compression of the median nerve as it passes through an area in the wrist known as the Carpal Tunnel. 1. Claims for traumatic Carpal Tunnel Syndrome will be considered for acceptance if the condition arises out of and in the course of employment. For example: 1.1 the client's work involves repetitive flexion and extension of the wrist on a fairly full time basis; or 1.2 the client's work involves the use of vibratory tools; or 1.3 the client s work involves the use of tools which place the wrist/hand in an awkward position; or 1.4 the client s work involves sustained or repeated stress over the base of the palm; or 1.5 there is direct, blunt trauma to the integrity of the carpal tunnel structures (ie. crush injury, wrist fracture, etc.). Frequency, intensity and duration of force on the median nerve should all be considered in each claim. Nerve Entrapments and Tendinopathies of the Arm, Neck and Shoulder Page 2

3 2. The length of time doing a particular occupation should be considered. Short term work with appropriate factors present (as listed above) would favour a traumatic etiology. Long term work with a recent change, ie. overtime, would also favour a traumatic etiology. 3. Physical signs of trauma are often absent, but with appropriate history claims can still be considered for acceptance. 4. Where there is evidence that non-occupational factors have contributed to development of the condition, section 10(5) of the Act will apply. 5. There should be objective evidence of median nerve conduction delay at the wrist as compared to the ipsilateral ulnar nerve for carpal tunnel surgery. In cases when the electrodiagnostic studies are normal, and the diagnosis of carpal tunnel is being made and surgery contemplated, the Board requires a second opinion from a physician of its choice. If the first and second opinion are not in agreement, a third opinion by a physician mutually acceptable to the worker s physician and the Board will be sought. Regardless of the number of opinions received, all medical evidence must be weighed before a final decision on the surgery is made. 6. Before bilateral carpal tunnel is accepted, the criteria listed above must be met for each wrist independently. Prince Edward Island General ASTD policy POL-91, Repetitive Strain Injuries. DEFINITION: In this policy: 1. 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. 2. Carpal tunnel syndrome means a compression of the median nerve as it passes through an area in the wrist known as the carpal tunnel. Nerve Entrapments and Tendinopathies of the Arm, Neck and Shoulder Page 3

4 3. 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. 4. Tendinitis means the inflammation of a tendon which attaches the muscle to bone, such as those found in the shoulder, elbow, wrist or hand. 5. Upper extremities means the shoulder, arm, forearm, wrist, and hand. POLICY: 1. A repetitive strain injury is a condition that may include, but is not limited to, tendinitis, bursitis, and neurovascular disturbances. The Workers Compensation Board will adjudicate repetitive strain injuries of the upper extremities using the principles set out in this policy. 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. 2. 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. 3. Non-occupational or personal risk factors which may contribute to the development of repetitive strain injuries include the following: Nerve Entrapments and Tendinopathies of the Arm, Neck and Shoulder Page 4

5 - congenital: anatomical anomalies, genetic predisposition; - 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. 4. The Workers Compensation Board Occupational Therapist will assess workplace activities and evaluate the extent of exposure of the following potential risk factors: - high repetition; - high force; - extreme postures; - vibration; - frequency; - duration; - recovery time; - 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. Nerve Entrapments and Tendinopathies of the Arm, Neck and Shoulder Page 5

6 Duration = minimum 2-4 hours Current research is used to evaluate the impact of each risk factor which varies depending upon the diagnosis. Carpal Tunnel Syndrome 7. 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 workrelated carpal tunnel syndrome may be more likely to be unilateral. The diagnosis of bilateral carpal tunnel syndrome is more probably due to a systemic illness. 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. Yukon General ASTD EN- 08, Gradual Onset Musculoskeletal Disorders DEFINITIONS For the purposes of this policy, the following definitions shall apply: 1. Gradual onset musculoskeletal disorders: conditions in which symptoms develop in a part of the musculoskeletal system over time due to: a) non-work-related factors including, but not limited to, age, genetics, previous trauma, inflammatory disorders, diabetes mellitus or non-work activities; b) occupational activities involving situations with high force, high repetition, high vibration, extreme temperatures and/or awkward postures. Some examples of gradual onset musculoskeletal disorders include, but are not limited to, prepatellar bursitis from Nerve Entrapments and Tendinopathies of the Arm, Neck and Shoulder Page 6

7 prolonged kneeling without adequate protection, epicondylitis from excessive use of forearm muscles or shoulder tendonitis from prolonged overhead work; or c) a combination of (a) and (b). Gradual onset musculoskeletal disorders are often referred to as multifactorial, arising as a result of a combination of environmental and/or genetic risk factors. 2. Multifactorial: involving more than one risk-factor. 3. Risk-factor: something that may increase the chance of developing a disorder, or change the rate at which the disorder develops. Some risk factors may be work-related (e.g. prolonged overhead work) and some may be non-work-related (e.g. diabetes mellitus). POLICY STATEMENT Gradual onset musculoskeletal disorders are work-related when they are determined by the YWCHSB to have arisen out of and in the course of employment. Unlike sudden onset, where a single incident causing injury can be identified and considered by the decision-maker, gradual onset conditions require more investigation and information to make the determination of arising out of and in the course of employment. Some gradual onset musculoskeletal disorders may be non-work-related pre-existing conditions; that is, they were caused by risk factors having nothing to do with the employment. However, these disorders may still be work-related to the extent they have been aggravated or accelerated by a work-related incident. See YWCHSB policy, Pre-Existing Conditions. 1. Claim Adjudication a) Date of Injury When adjudicating gradual onset musculoskeletal disorders, the date of injury will be deemed to be Nerve Entrapments and Tendinopathies of the Arm, Neck and Shoulder Page 7

8 the earlier of: i) the date the claim was filed with the YWCHSB; ii) the date of the worker s most recent lost time from work as a result of the disorder; or iii) the date the worker first sought medical attention from a physician (or health care provider acceptable to the YWCHSB) as a result of the disorder. b) Three Point Inquiry Gradual onset musculoskeletal disorders can be extremely difficult to adjudicate due to their multifactorial nature and the lack of a straightforward mechanism of injury. The following questions must be considered in cases of gradual onset musculoskeletal disorders: i) Could the work-related risk factors alone have been sufficient to have caused the disorder? If yes, the claim is accepted; If no, ii) Then, Is the condition being claimed the primary disorder, or is it secondary to some other underlying cause (e.g. carpal tunnel syndrome resulting from non-work-related diabetes mellitus)?* iii) Having weighed all of the available evidence, and on the balance of probabilities, were the work-related risk factors more likely to have caused the disorder than the non-workrelated risk factors? If yes, the claim is accepted. If no, the claim is denied. * Whenever a claim is made for a gradual onset musculoskeletal disorder, the decision-maker should make inquiries as to whether the injury being claimed is the primary injury, or whether it is Nerve Entrapments and Tendinopathies of the Arm, Neck and Shoulder Page 8

9 secondary to some other underlying cause. This information will assist in the adjudication of the claim, as well as the claim s management if accepted. In all cases, this information will assist the worker and his/her health care providers to appropriately treat the underlying cause of the worker s medical problem(s) and facilitate recovery. Nerve Entrapments and Tendinopathies of the Arm, Neck and Shoulder Page 9

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