Catering Industries (NSW) Pty Ltd v Kelley
[2022] NSWPICMP 13
•31 January 2022
| DETERMINATION OF APPEAL PANEL | |
| CITATION: | Catering Industries (NSW) Pty Ltd v Kelley [2022] NSWPICMP 13 |
| APPELLANT: | Catering Industries (NSW) Pty Ltd |
| RESPONDENT: | Milton Kelley |
| APPEAL PANEL: | Member Deborah Moore Dr J Brian Stephenson Dr Drew Dixon |
| DATE OF DECISION: | 31 January 2022 |
| CATCHWORDS: | WORKERS COMPENSATION- Appellant challenged finding by the Medical Assessor (MA) that the worker suffered from Complex Regional Pain Syndrome (CRPS); Panel accepted that on the face of it there appeared to be some errors in the MA’s assessment failing to follow Table 17.1 of the NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed 1 April 2016; re-examination required; Held - Panel found the criteria in each of the Sections 1, 2, 3 and 4 in Table 17.1 are satisfied and the diagnosis CRPS 1 is made; Medical Assessment Certificate confirmed. |
STATEMENT OF REASONS FOR DECISION OF THE APPEAL PANEL IN RELATION TO A MEDICAL DISPUTE
BACKGROUND TO THE APPLICATION TO APPEAL
On 15 December 2020 Catering Industries (NSW) Pty Ltd (the appellant) lodged an Application to Appeal Against the Decision of a Medical Assessor. The medical dispute was assessed by Dr Greggory Burrow, a Medical Assessor (MA) who issued a Medical Assessment Certificate (MAC) on 17 November 2020.
The appellant relies on the following grounds of appeal under s 327(3) of the Workplace Injury Management and Workers Compensation Act 1998 (1998 Act):
· the assessment was made on the basis of incorrect criteria,
· the MAC contains a demonstrable error.
The delegate is satisfied that, on the face of the application, at least one ground of appeal has been made out. The Appeal Panel has conducted a review of the original medical assessment but limited to the ground(s) of appeal on which the appeal is made.
The WorkCover Medical Assessment Guidelines 2006 set out the practice and procedure in relation to the medical appeal process under s 328 of the 1998 Act. An Appeal Panel determines its own procedures in accordance with the WorkCover Medical Assessment Guidelines 2006.
The assessment of permanent impairment is conducted in accordance with the NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment, 4th ed 1 April 2016 (the Guidelines) and the American Medical Association Guides to the Evaluation of Permanent Impairment, 5th ed (AMA 5).
PRELIMINARY REVIEW
The Appeal Panel conducted a preliminary review of the original medical assessment in the absence of the parties and in accordance with the WorkCover Medical Assessment Guidelines 2006.
As a result of that preliminary review, the Appeal Panel determined that the worker should undergo a further medical examination because we were of the view that the MA erred in failing to follow Table 17.1 of the Guidelines as regards complex regional pain syndrome (CRPS).
EVIDENCE
Documentary evidence
The Appeal Panel has before it all the documents that were sent to the MA for the original medical assessment and has taken them into account in making this determination.
Further medical examination
Dr Brian Stephenson of the Appeal Panel conducted an examination of the worker on 8 December 2021 and reported to the Appeal Panel on 29 December 2021.
SUBMISSIONS
Both parties made written submissions. They are not repeated in full, but have been considered by the Appeal Panel.
The appellant submits that the MA erred in two respects, firstly in assessing impairment of the right shoulder, elbow, wrist and hand where a diagnosis of CRPS as required by Table 17.1 of the Guidelines was not found, and secondly that the MA ought to have assessed the underlying diagnosed condition of the right middle finger only in accordance with paragraphs 1.12 and 17.3 of the Guidelines.
In reply, the respondent submits that no errors were made.
FINDINGS AND REASONS
The procedures on appeal are contained in s 328 of the 1998 Act. The appeal is to be by way of review of the original medical assessment but the review is limited to the grounds of appeal on which the appeal is made
In Campbelltown City Council v Vegan [2006] NSWCA 284 the Court of Appeal held that the Appeal Panel is obliged to give reasons. Where there are disputes of fact it may be necessary to refer to evidence or other material on which findings are based, but the extent to which this is necessary will vary from case to case. Where more than one conclusion is open, it will be necessary to explain why one conclusion is preferred. On the other hand, the reasons need not be extensive or provide a detailed explanation of the criteria applied by the medical professionals in reaching a professional judgement.
The respondent was referred to the MA for assessment of whole person impairment (WPI) in respect of the Right upper extremity (shoulder, elbow, wrist and hand) as a result of CRPS resulting from an injury on 29 June 2015.
The MA obtained the following history:
“At work on 29/06/2015, Mr Kelley was lifting a cast iron stove weighing 20kg with a ‘grill scraper’, holding it with one hand, mostly the right, when he felt first time right long finger pain about the DIP joint. He found he could not move the right long finger after.
He consulted Dr Artinian and was referred to Dr Beard, Orthopaedic and Hand Surgeon. X-rays and scans were taken excluding fracture or dislocation with a presumptive diagnosis of mallet finger made and Dr Beard placed him in an extension splint. He attended hand therapy.
On 17/06/2016, Dr Beard confirmed that Mr Kelley ‘has had dystrophic changes but has not developed a full blown Reflex Sympathetic Dystrophic or Chronic Regional Pain Syndrome’. Certainly, he has pain out of proportion to the injury and function. With persisting pain and complaints of altered sensation in the hand, EMG and nerve conduction studies were performed on 04/07/2016 and reported by Dr Sank, Neurologist, as showing no evidence of median neuropathy. Those tests were repeated on 27/02/2017, Dr Sank finding ‘evidence for mild right median neuropathy at the wrist’. Dr Beard went on to perform carpal tunnel release surgery. There was no improvement in pain or numbness.
During this period, Mr Kelley had increasing severe pain, now complaining of pain into his wrist, elbow, shoulder and then neck and down the left arm, down his back and sometimes into his legs. Cervical spine investigations were performed and reported as showing moderate foraminal narrowing of right C4/5 and right C5/6.
He was referred to Dr Vasili, Orthopaedic and Cervical Spine Surgeon, who found no evidence of radiculopathy and recommended continued non-operative treatment.
Mr Kelley was referred to Pain Specialist, Dr Standen, on 20/02/2018 who confirmed ‘neuropathic pain involving widespread distribution of all of his right upper limb, shoulder, cervical and cranium.’ Dr Standen recommended complex medical treatment, ADAPT program and there have been ongoing, significant, subjective symptoms and disability.
On 28/11/2019, Dr James Yu, Pain Specialist at Sydney Spine and Pain, confirmed ‘persistent right upper limb, right-sided neck pain with associated generalised body pain. He gave the history of workplace injury whilst lifting heavy objects whilst at work in 2015. This injury resulted in chronic right upper limb pain with significant physical deconditioning and psychological issues.”
Present symptoms were noted as follows:
“Mr Kelley has extreme, ongoing, right upper extremity pain ‘all the time’ from his shoulder, to the elbow, to the wrist and to the hand. He tells me it feels like he has ‘bumped (his) funny bone’. Pain goes up into the neck, down his back, he experiences pins and needles and altered sensation on an intermittent but regular basis most days into both legs and feet, and also says there is ‘numbness in the left arm as well, to the fingertips’ most of the time.
He complains that he cannot feel anything in the right arm like it has ‘gone dead’. Movement of the right upper extremity but also the left upper extremity and neck produces pain. He cannot use the right upper extremity really for anything in terms of ADL, self-care, home chores, gardening or sports.”
The MA added:
“At the time of the incident of concern, he had been working for Catering Industries on a full- time basis as a Chef for 15 years. He continued working after the incident of concern for about 2 years on restricted duties until he was dismissed in June 2017 and has not worked since.”
As regards social activities and activities of daily living (ADL’s), the MA said:
“Mr Kelley is married. His wife returned to Thailand in December 2019 for her mother’s funeral and has not been able to come back to Australia since because of the COVID problem.
He is currently living alone in rental accommodation in Artarmon. He has difficulties with home chores particularly vacuuming, sweeping, washing and hanging clothes and is unable to manipulate heavy shopping. He is alone, he receives no assistance, and he tends to do all the shopping left handed.
He has similar difficulties when he works in the garden although he does live in an apartment. He can drive for about 20 minutes. Prior to his work injury, he enjoyed fishing, water skiing, golf, surfing, martial arts, snorkelling and motor cycle riding. He has been unable to participate in any of these activities since the work incident.”
Findings on physical examination were reported as follows:
“During confirmation of the history, he sat comfortably but when dressing and undressing was very protective of his right upper extremity and quite obviously had pain moving his arm. Observed range of motion, however, while dressing and undressing was greater than that during the examination.
Inspection of the palm of the right upper extremity when he was undressed showed that it was a darker colour to the left and subsequently changed colour during the course of the examination. There was no sweating or temperature asymmetry. There was no oedema. There was no difference in arm circumference, but the right forearm was 2cm greater than the left and there were no trophic changes.
Inspection of the right upper extremity showed no wasting or deformity, but he tended to hold the arm adducted to his side at the shoulder. The elbow was held in a flexed position slightly pronated at about 80° of flexion. The wrist was slightly deviated to the radial side in a pronated position and the hand was held in an open fist.
On exiting the examination room today, I noticed that his elbow extended to 0°.
Examination of the right upper extremity for active range of motion was meaningless as he had an arc of motion of about 10° or 15° of the shoulder and showed signs of extreme pain with marked vocalisation and sighing.
He was able to move the elbow when sitting over an arc of about 15°, about 80° flexed and 20° pronated.
There was a jog of movement in the wrist around neutral flexion/extension and 10° of radial deviation.
He was not able to make a full fist and made minimal movement of the hands with all the digits and the thumb.
In order to assess whether there was true joint stiffness, I gently passively moved some of the joints including the shoulder, elbow, wrist and index MCP joint. It was quite obvious that formal passive range of motion examination could not be performed because of extreme pain.
On exiting the building, I observed Mr Kelley to significantly increase shoulder movements whilst walking to include an arc of about 30° of flexion.
He complained of non-peripheral nerve pattern whole right arm altered sensation. I noted reduced range of motion in the contralateral left shoulder which he says is ‘affected’, much like the right shoulder.”
In summarising the injuries and diagnoses, the MA said:
“Mr Kelley suffered a soft tissue mallet finger injury to the right long finger as a result of the work incident on 29/06/2015.
He has subsequently developed a pain syndrome.
His Treating Surgeon has confirmed a chronic pain syndrome but detailed that Mr Kelley did not have all the features of CRPS (Reflex Sympathetic Dystrophy, the former name).
Dr Standen has commented that Mr Kelley has a pain syndrome but has not formally diagnosed CRPS.
The formal examination was troubling today as Mr Kelley exhibited very little active range of motion from the shoulder to the fingertips, actively resisted passive range examination by me today but was observed to have some movement of the shoulder when dressing and undressing, at odds with the physical examination, and when exiting the examination room was observed to show shoulder forward flexion to at least 30°. He was unable to move the elbow from a position of about 80° of flexion when formally examined, but clearly walked out of the examination room with his elbow extended to 0°.
He did not have all the features to confirm or assess CRPS as per SIRA Table 17.1.
There is an element of inconsistency.
There are significant internal inconsistencies with the physical examination as seen today. I will make comment on these during the assessment of impairments.”
The MA assessed 54% WPI of the right upper extremity.
He explained his calculations as follows:
“Mr Kelley has a Chronic Pain Syndrome. The question is whether he meets the criteria as per Table 17.1 for assessment of CRPS Type 1 or Type 2. Despite him having carpal tunnel release surgery, there is no evidence that CRPS is due to an injury of a specific nerve, as his pain pattern complaints are to the whole right upper extremity. I note that he also complains of similar symptoms in the contralateral left arm, symptoms of numbness in both feet and pain into his neck and back. This is quite atypical, even of CRPS. His diagnosis therefore is not CRPS TYPE 2, the pattern is not of a specific nerve.
He meets the criteria for assessment of Section 2 and reports symptoms of hyperaesthesia, allodynia, temperature asymmetry, colour asymmetry, sweating asymmetry and decreased range of motion as well as trophic changes, however I noted no temperature asymmetry today on exam but there were skin colour changes. There is certainly evidence of hyperalgesia and allodynia.
There was no evidence, however, of oedema or sweating asymmetry but the right forearm had a greater circumference than the left, suggesting it meets the criteria for swelling.
There was evidence of reduced joint range of motion both actively and to some extent passively, but there were some internal inconsistencies, as noted above.
I think the most important comment is that no other diagnosis adequately or better explains the signs and symptoms, and I note the history that multiple Surgeons and Pain Specialists have diagnosed a pain syndrome, but just have not used the diagnosis of CRPS. Given these difficulties, I think the only way that Mr Kelley can be adequately assessed for impairment is to use the criteria for CRPS Type 1, assess range of motion impairment and rate the extremity impairment resulting from sensory deficit or pain then making a deduction to reflect the level of inconsistency. Active range of motion examination today was significantly inconsistent.
However if we just look at the sensory deficit I believe this provides adequate assessment of his particular impairment.
AMA-5, Table 16-10: Sensory deficit or pain grade 1, as there is deep cutaneous sensibility present, absent superficial pain and tactile sensibility with abnormal sensations or severe pain that prevents most activities: 90%.
Table 17.1: 90% upper extremity impairment = 54% WPI.
There is a significant degree of inconsistency present today as per SIRA paragraph 1.36. SIRA instructs that the Assessor must use their entire range of
clinical skill and judgment when assessing whether or not the measurements or test results are plausible and consistent with the impairment being evaluated. If in spite of observational test results the medical evidence appears insufficient to verify that the impairment of a certain magnitude exists, the Assessor may modify the impairment rating accordingly and then describe and explain the reason for the modification in writing. It is my opinion that in this particular case assessment for the sensory part of the impairment, as opposed to the inconsistent motion exam adequately assesses impairment of the whole atypical presentation.I completely acknowledge how this approach differs from the normal assessment tools recommended by SIRA, but do not believe any other methods would be better or more accurate in this very atypical case.”
The MA then turned to consider the other medical opinions, stating:
“08/05/2020: Dr Machart, Orthopaedic Surgeon, noted the complex history, the ongoing significant pain and disability, the failure of the carpal tunnel release surgery to achieve significant improvement but noted no trophic or colour changes, no sweating or nail changes and therefore found the criteria to assess under CRPS was not met. He showed bilateral reduction of shoulder movement and gross loss of right elbow range of motion within an arc of about 40°-90° but found pronation and supination full after some encouragement. I found absolutely no pronation or supination despite repeated attempts at both active and passive ranges of motion and encouragement. Dr Machart recorded absolutely no radial or ulnar deviation but generous wrist flexion and extension of 50°.
Similar comments were made in relation to the digits of the hand, noting all digits flexed to about 30° with ‘reported pain’.
Whilst Dr Machart found ‘no evidence of CRPS’, he found evidence of unexplained chronic pain which appeared to be as a result of psychological rather than physical conditions. ‘I have not identified specific pathology relating to the incident of 29/06/2015 is responsible for the plethora of symptoms and diminished function not supported by objective clinical signs.’
Accordingly, Dr Machart found no evidence of impairments.
I would disagree, Mr Kelley developed a chronic Pain syndrome after the relatively benign finger injury, any ongoing impairment stems from that condition.
In contrast, Dr Kwong, Rheumatoid Consultant, on 11/11/2019 recorded that in relation to a diagnosis of CRPS, Dr Beard had confirmed that diagnosis: I found no evidence of this in the documentation made available to me. Specifically, Dr Beard said that Mr Kelley did not have all the features of Reflex Sympathetic Dystrophy (CRPS). Nonetheless, there was chronic pain. Dr Kwong then suggested that the North Shore Pain Clinic had confirmed a diagnosis of CRPS in that he attended a 4 week intensive pain management program. This is correct, but a formal diagnosis of CRPS was not provided.
Doctor then found extensive range of motion of the shoulder including flexion to 100° and abduction to 90°. This is completely inconsistent with the examination I found today. Generous range of motion was also found at the elbow from 10°-120° and the right wrist with flexion to 40° and extension to 40°.
These figures were in complete contrast to the almost ankylosed joints that were presented to me today for examination.
Dr Kwong then found loss of active range of motion of the thumb and digits including thumb apposition of 5cm and adduction of 5cm. Mr Kelley barely moved his thumb for me.
I cannot explain the differences in our physical examinations. I believe these differences reflect the underlying inconsistency of the physical examination that I experienced today.
Nevertheless, Dr Kwong found 53% whole person impairment, a figure similar to that I came to but did not comment upon any inconsistency and therefore I come to a different conclusion regarding impairment to Dr Kwong accordingly.
I acknowledge that my treatment of assessment of impairment in this particular case is quite radical, but given the physical examination today, I see no other way to reasonably assess impairment related to the work condition.”
The appellant’s submissions
The appellant submits as follows:
(a) The MA has erroneously assessed impairment for chronic pain as analogous to CRPS.
(b) The MA appropriately concluded that the respondent did not have all of the features to confirm or assess CRPS, pursuant to Table 17.1 of the Guidelines. However, the MA recorded “he has subsequently developed a pain syndrome.”
(c) The MA then said:
“I think the most important comment is that no other diagnosis adequately or better explains the signs and symptoms, and I note the history that multiple Surgeons and Pain Specialists have diagnosed a pain syndrome, but just have not used the diagnosis of CRPS. Given these difficulties, I think the only way that Mr Kelley can be adequately assessed for impairment is to use the criteria for CRPS Type 1, assess range of motion impairment and rate the extremity impairment resulting from sensory deficit or pain then making a deduction to reflect the level of inconsistency.”
(d) The MA then proceeded to assess a 90% upper extremity impairment for sensory deficit pursuant to Table 16-10 of the AMA 5th Edition Guides (or 54% WPI).
(e) In utilising Table 16-10 of the Guides, the MA has erroneously applied paragraph 1.23 of the Guidelines to assess the chronic pain syndrome as analogous to CRPS.
(f) Paragraph 1.23 of the Guidelines provides that:
“AMA5 (p 11) states: ‘Given the range, evolution and discovery of new medical conditions, these Guidelines cannot provide an impairment rating for all impairments… In situations where impairment ratings are not provided, these Guidelines suggest that medical practitioners use clinical judgment, comparing measurable impairment resulting from the unlisted condition to measurable impairment resulting from similar conditions with similar impairment of function in performing activities of daily living. The assessor must stay within the body part/region when using analogy.
The assessor’s judgment, based upon experience, training, skill, thoroughness in clinical evaluation, and ability to apply the Guidelines criteria as intended, will enable an appropriate and reproducible assessment to be made of clinical impairment.”(g) His methodology in this regard is inconsistent with paragraph 17.3 of the Guidelines which specifically excludes chronic pain as a separate condition from the Guidelines and states as follows:
“The reasons for excluding chronic pain, as a separate condition from the Guidelines are:
• It is a subjective experience and is, therefore, open to exaggeration or fabrication in the compensation setting. Assessment depends on the credibility of the subject being assessed. In order to provide reliability, applicants undergoing pain assessments require more than one examiner at different times, concordance with the established conditions, consistency over time, anatomical and physiological consistency, agreement between the examiners and exclusion of inappropriate illness behaviour.
• Pain cannot be measured and no objective assessment can be made.
• Tools to measure pain are based on self-reports and may be inherently unreliable.
• Some impairment ratings take symptoms into account and some of the ranges of impairment – eg whole person impairment (WPI) of the spine, may reflect the effect of the injury and pain on activities of daily living (ADL). This is not so for impairment assessment of the upper and lower limb, which is based on range of movement and diagnosis-based estimates, other than for peripheral nerve injury.”(h) The MA erred in invoking paragraph 1.23 of the Guidelines noting that chronic pain is expressly covered in the Guidelines at paragraph 17.3 and clearly excluded as a separate condition. The presence of chronic pain in the absence of the Table 17.1 criteria for CRPS, as diagnosed by the MA would therefore result in an assessment of 0% WPI.
(i) Furthermore, paragraph 17.4 of the Guidelines provides that where there is a peripheral nerve injury and there is sensory loss, some of the sensory nerve impairment categories permit pain to be included under Table 16-10 of the Guides.
(j) At page 5 of the MAC, however, the MA records:
“…there is no evidence that CRPS is due to an injury of a specific nerve, as his pain pattern complaints are to the whole right upper extremity. I note that he also complains of similar symptoms in the contralateral left arm, symptoms of numbness in both feet and pain into his neck and back. This is quite atypical, even of CRPS. His diagnosis therefore is not CRPS TYPE 2, the pattern is not of a specific nerve.”
(k) In the absence of evidence of a peripheral nerve injury or of a diagnosis of
CRPS using the Table 17.1 criteria, the assessment of 54% WPI pursuant to
Table 16-10 of the Guides is inconsistent with paragraphs 17.3 and 17.4 of the Guidelines.(l) Paragraph 1.12 of the Guidelines expressly provides that:
“AMA5 Chapter 18, on pain, is excluded entirely at the present time. Conditions associated with chronic pain should be assessed on the basis of the underlying diagnosed condition, and not on the basis of the chronic pain. Where pain is commonly associated with a condition, an allowance is made in the degree of impairment assigned in the Guidelines. Complex regional pain syndrome should be assessed in accordance with Chapter 17 of the Guidelines.”
(m) The underlying diagnosed condition resulting from the injury on 29 June 2015 concerns the injury to the right middle finger…the referral to the MA specifically directed an assessment of the “right upper extremity (shoulder, elbow, wrist and hand – as a result of CRPS)”.
(n) The MA ought to have only assessed impairment of the underlying diagnosed condition of the right middle finger and not in accordance with Table 16-10 by applying Table 17.1 of the Guidelines, noting that the diagnosis of CRPS could not be confirmed on examination.
(o) The MA erred in assessing impairment due to the presence of chronic pain which is specifically excluded from the Guidelines in accordance with paragraphs 1.12 and 17.3.
(p) In accordance with paragraph 1.12 of the Guidelines, conditions associated with chronic pain are to be assessed on the basis of the underlying diagnosed condition… the injury to the right middle finger.
The respondent’s submissions
The respondent submits as follows:
(a) the appellant agreed to the referral to the MA based on a diagnosis of CRPS, consistent with the report of Dr Kwong;
(b) the MA did not appreciate the fact that diagnosis was not in issue, hence his reasons included an unnecessary consideration of whether or not the diagnosis met the Guideline definitions of CRPS;
(c) the body system referred for assessment was the “right upper extremity”. The MA undertook the assessment using AMA Table 16.10, invoking Guideline 1.36 to take account of the respondent’s inconsistency in presentation;
(d) he sought an analogous means of assessment for a condition not covered in the Guidelines. While he does not refer to Guideline 1.23, it is clear that he has applied it in referring to both Table 17.1 of the Guidelines and Table 16-10 of AMA 5.
The respondent’s submission as regards the agreement as to the terms of the referral are correct.
Equally, the Panel had some concerns in our preliminary assessment that the MA may have failed to follow Table 17.1 of the Guidelines as regards CRPS particularly in light of his comments that “He did not have all the features to confirm or assess CRPS as per Table 17.1” and that “I completely acknowledge how this approach differs from the normal assessment tools recommended by SIRA, but do not believe any other methods would be better or more accurate in this very atypical case.”
For these reasons, the Panel considered that a re-examination was appropriate.
Dr J Brian Stephenson of the Panel carried out that re-examination. He confirmed the history obtained by the MA and noted that “The body parts referred to the original assessor, Dr Greggory Burrow, date of injury 29 June 2015, right upper extremity (shoulder, elbow, wrist, and hand as a result of CRPS).”
He continued and as follows:
“Findings on clinical examination.
There was measurable restriction of range of motion of the three large joints of the right upper extremity.
Right Shoulder
Reference AMA5, shoulder page 476-479, Figure 16-40 to 16-46.
Range of Motion Right Shoulder Upper Extremity%
Abduction 30° 7%
Adduction 10° 1%
Flexion 30° 10%
Extension 20° 2%
External rotation 30° 1%
Internal rotation 30° 4%
This is 25% upper extremity impairment for right shoulder.Right Elbow
Reference AMA5, page 472 to 474, Figure 16-34 to Figure 16-36.
Range of Motion Right Elbow Upper Extremity%
Extension 30° 3%
Flexion 70° 15%
Pronation 60° 1%
Supination 60° 1%There was a 20% upper extremity impairment right elbow.
Right Wrist
Reference, AMA5 page 467 to 469, Figure 16-28 to Figure 16-31.
Range of Motion Right Wrist Upper Extremity%
Palmar flexion 20° 7%
Dorsiflexion 10° 13%
Radial deviation 10° 2%
Ulnar deviation 0° 5%There is a 27% upper extremity impairment right wrist.
Right Hand
The range of motion values of right hand of the thumb and the four fingers is entered on the Figure 16-1a Upper Extremity Impairment Evaluation Record, Part 1 Hand at page 436, AMA5.
Range of motion thumb, reference AMA5, IP Joint, Figure 16-12, page 456.
MP Joint, Figure 16-15, page 457. Thumb carpometacarpal joint, page 459-460, Table 16- 8a, Table 16-8b and Table 16-9. Reference, Finger Joint Impairments, DIP, Figure 16-21, page 461.
Finger Distal interphalangeal joint (DIP Figure 16-21, page 461).
Finger Proximal interphalangeal joint (PIP), Figure 16-23, page 463.
Finger Metacarpophalangeal Joint, Figure 16-25, page 464.
Index finger.
Further to the impairment rating from range of motion loss right upper extremity, there are clear symptoms and signs of CRPS 1, in keeping with the strict requirements of Table 17.1, page 81, WorkCover Guidelines. That is, the diagnostic criteria for a complex regional pain syndrome Type 1:1. There is continuing pain which is disproportionate to any causal events. In that regard I had noted the history of injury. Stronger analgesics such as Palexia have caused sufficient gastric disturbance that he simply puts up with the symptoms, he said.
2. Reference to Table 17.1, Number 2. Must report at least one symptom in each of the following categories:
• He reports sensory disturbance with hypersensitive hyperaesthesia which is caused by even the lightest of touch from the examiner. In addition, there is allodynia with light touch causing pain, reported.
• Vasomotor. He reports temperature asymmetry; the right hand is warm together with the right upper extremity, whereas the left hand is normal, cool in contrast. He reports colour changes with the right hand becoming purple with dependency. He reports the skin colour going purple, the skin colour asymmetry.
• Pseudomotor oedema. He reports oedema right hand.
• Motor/trophic. He reports decreased range of joint motion.3. Must display at least one sign at the time of evaluation in all of the following four categories:
• Sensory. There is evidence of hyperalgesia to pin prick and/or allodynia to light touch. Also, there is sensitivity to deep somatic pressure as one firmly squeezed the right upper extremity above elbow. There is hypersensitivity to pin prick, using the Neurotips pin prick device.
• The vasomotor, there is evidence of temperature asymmetry and also asymmetric skin colour changes. The skin goes purple as the right hand is held in a dependent or hanging arm position. The right hand becomes warm in contrast to the normal temperature of the opposite left hand.
• Pseudomotor/oedema. There is evidence for oedema and there is also evidence of sweating of the right hand as it was found to be warm on examination.4. There is no other diagnosis that better explains the signs or symptoms. The signs were observed at the time of the impairment evaluation. The instructions on Table 17.1 continue.
• The criteria in each of the Sections 1, 2, 3 and 4 in Table 17.1 above are satisfied and the diagnosis CRPS 1 is made.
• I have rated the extremity impairment resulting from loss of range of motion each individual joint involved and that is the rating that I have undertaken, recorded on Figure 16-1a the chart AMA5, page 436. The reference is to AMA5 Table 16-10a, page 482. With reference to Table 16-10a, I found the grade classification that best fits the clinical picture here is Grade 3, namely his distorted superficial tactile sensibility (to any slight touch and two-point discrimination) with some abnormal sensations or slight pain that interferes with some activities.
The sensory deficit to be combined with the range of motion loss is 60%. The combination of the upper extremity impairments for hand 43% WPI with wrist 27%, shoulder 25% and elbow 20%. That combination gains 74% upper extremity.
With reference to Table 16-10a with CRPS 1 a nerve multiplier is not used. I have chosen grade 3 which in the range 26% to 60%. Here the 60% must be chosen. Reference: Figure 16-1b, page 437, for the combined upper extremity value of 74%.
Conclusion: The range of motion loss of 74% upper extremity combines with the peripheral nerve system impairment of 60%. Then the total right upper extremity value is 90%. Finally, 90% upper extremity impairment converts to 54% WPI.”
The Panel accepts the findings and assessment of Dr Stephenson.
As we said earlier, the respondent is correct as regards the agreement between the parties as to the terms of the referral.
The findings of Dr Stephenson are broadly consistent with those of Dr Kwong and the MA.
Complex Regional Pain Syndrome is a difficult condition to assess. Concerns over inconsistencies in presentation have been allayed in our view by the comprehensive and detailed examination carried out by Dr Stephenson.
For these reasons, the Appeal Panel has determined that the MAC issued on 17 November 2020 should be confirmed.
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