Simpson v Bunnings Group Limited
[2024] NSWPICMP 94
•22 February 2024
| DETERMINATION OF APPEAL PANEL | |
| CITATION: | Simpson v Bunnings Group Limited [2024] NSWPICMP 94 |
| APPELLANT: | Katrina Joy Simpson |
| RESPONDENT: | Bunnings Group Limited |
| APPEAL PANEL | |
| MEMBER: | Richard Perrignon |
| MEDICAL ASSESSOR: | David Crocker |
| MEDICAL ASSESSOR: | James Bodel |
| DATE OF DECISION: | 22 February 2024 |
| CATCHWORDS: | WORKERS COMPENSATION - Appeal from assessment of complex regional pain syndrome (CRPS); whether criteria for CRPS were satisfied; worker referred for examination by medical member of the Appeal Panel; Held – Medical Assessment Certificate confirmed. |
BACKGROUND TO THE APPLICATION TO APPEAL
The appellant worker, Ms Simpson, appeals from the Medical Assessment Certificate of Medical Assessor Ho dated 20 October 2022.
While working for Bunnings (the respondent) on 11 June 2019, Ms Simpson picked up a box containing a kitchen cabinet door, two feet in length and width, and experienced a ‘pop’ and pain in the right ring finger. The pain spread to her arm and neck. She claimed compensation for impairment of the whole person, and commenced these proceedings.
By agreement of the parties, the President referred her to Medical Assessor Ho for assessment of chronic regional pain syndrome type 1 (CRPS1) only, in respect of the right upper extremity. Dr Ho examined her on 13 October 2022. He was not satisfied that CRPS1 was present, and accordingly assessed 0% whole person impairment (right upper extremity) as result of injury on 11 June 2019.
Ms Simpson says that, having regard to her presentation and other evidence before the Medical Assessor, his failure to diagnose CRPS1 demonstrates error and the application of incorrect criteria.
The Appeal Panel conducted a preliminary review of the Medical Assessment Certificate in the absence of the parties and in accordance with the NSW Workers Compensation Guidelines for the Evaluation of Permanent Impairment (4th edition) (the Guidelines).
Submissions
The appellant submits in summary as follows.
(a) The Guidelines at [17.5] require that, in order for whole person impairment to be assessed as a result of CRPS1:
(i)the diagnosis is to be made in accordance with the criteria in Table 17.1;
(ii)the diagnosis must have been present for at least one year;
(iii)it must have been verified by more than one examining physician, and
(iv)other possible diagnoses have been excluded.
(b) Table 17.1 of the Guidelines prescribes four diagnostic criteria for assessing whether CRPS1 is present.
(c) The appellant satisfied each of the diagnostic criteria as follows:
Criterion 1: there was continuing pain disproportionate to the causal event, as found by the Medical Assessor.
Criterion 2: the appellant complained of numbness and pain (sensory); she complained that her right hand was “cold, darker in colour” (vasomotor); the Medical Assessor noted oedema, and she had complained of it to other clinicians (sudomotor/oedema), and the appellant complained that all the joints were stiff (motor/trophic).
Criterion 3: on examination, the appellant displayed pain and numbness (sensory); some change in colour of at least part of the right hand (vasomotor); right hand swelling (sudomotor/oedema); and reductions in active range of motion, referred to by the Medical Assessor as a refusal “to move every joint … actively” (motor/trophic).
Criterion 4: the Medical Assessor offered a diagnosis of minor flexor tenosynovitis (trigger finger), but this did not explain the other signs and symptoms in the right upper extremity. He referred to “psychosomatic overlay”, but made no formal diagnosis of psychosomatic disorder.
(d) With respect to the remaining three requirements of [17.5]:
(i)by the time of assessment, the diagnosis had been present for at least one year, because it had been diagnosed by physiotherapist Mr Kearton in July 2021, by treating general practitioner Dr Spadini dos Santos in August 2021, by orthopaedic surgeon Dr Tawfik in February 2022, and by occupational physician Dr Dias in February 2022;
(ii)the diagnosis has been verified by more than one examining physician, including the physicians in the preceding paragraph, and occupational therapist Mr Nohra, and
(iii)other possible diagnoses had been excluded by other investigations and specialists, and there is no diagnosis which better explains the signs and symptoms.
(e) As the diagnostic criteria in Table 17.1 and the remaining requirements of [17.5] were satisfied, CRPS1 should have been diagnosed. The failure to do so demonstrates error.
(f) The Medical Assessor should then have proceeded to assess whole person impairment by reference to loss of joint motion and pain or sensory deficits, in accordance with the procedure in [17.5]. His failure to do so demonstrates error.
(g) The Medical Assessor applied incorrect criteria by basing his assessment on findings:
(i)that passive range of motion was good – in circumstances where Table 17.1 refers only to active range of motion;
(ii)that muscle wasting was absent – in circumstances where Table 17.1 does not require that there be evidence of muscle wasting, and
(iii)that the pain or numbness was neither in a “glove and stocking” distribution nor in a dermatomal distribution associated with a nerve root – in circumstances where CRPS1 (unlike CRPS2) does not require proof of neural causation.
In summary, the respondent submits that the Medical Assessment Certificate should be confirmed for the following reasons.
(a) The appellant did not satisfy criterion (2) of Table 17.1, because, though she reported at least one symptom in three of the four categories, she did not report symptoms under the category, “Sudomotor/oedema”, reporting no difference in sweating or swelling.
(b) The Medical Assessor referred to the lack of wasting in the left upper limb only to support the view that the lack of joint movement in the right upper extremity was wilful, and not caused by any physical pathology. His doing so does not amount to the application of incorrect criteria in assessing whether CRPS1 was present.
Reasoning of the Medical Assessor
Medical Assessor Ho took a history of injury consistent with the above summary, and its treatment and other sequelae. Under the heading, “Present symptoms”, he noted the worker complained of numbness of the whole right upper limb except on the lateral side, and pain in the same distribution. He recorded that the worker also complained:
“… the right hand is cold, darker in colour but she did not notice any difference in sweating or hair and nail changes because she has fake nails”.
Under the heading, “Findings on examination”, he recorded – emphasis added:
“The patient during the whole consultation tried to keep the right upper limb straight with the hand hanging down and refused to move all the joints in the right upper limb. …. When I asked her to move the fingers, she says it is too painful and there is no obvious movement in all the digits, however, I cannot find any difference in temperature, or skin texture and sweating pattern. The right hand may be a bit swollen and looks a little bit darker in colour on the dorsum but not on the ventral side. I cannot see any atrophic changes of the soft tissue despite the fake nails, the hair looks the same and I certainly cannot comment on the nails. Most importantly, on tape measurement, she told me she is right handed, both the right arm and right forearm are still bigger than the left and cannot be consistent with a right upper limb that has so much dysfunction as she tried to describe for the past 3 years and certainly on passive movement, I can elicit full external rotation of the shoulder in neutral, I can elicit full flexion of the elbow and full flexion and extension of the wrist and much better movement in all the fingers, not consistent with what she tried to present to me actively.”
At [7], he said – emphasis added:
“She may have tenosynovitis of the flexor tendon of the ring finger but then now tried to present as chronic pain of the right upper limb.
… I believe the history and mechanism of injury but don’t think what she tried to present to me is consistent with the mechanism of injury and all the radiological investigations.”
At [10], he gave the following reasons for assessment – emphasis added.
“She started to have some finger injury which looks like a case of minor flexor tenosynovitis, or what we call trigger finger, which happened 3 years ago, with poor progress and now presents as chronic pain of the right upper limb.
…
I don’t think she has any problems with the upper limb, even though she tried to present as a lot of pain and refused to move every joint in the right upper limb actively with such a poor movement that all the joints hardly have a quarter of the normal function but based on the mechanism of the injury and all the negative radiological investigations, there is no reason to support the poor presentations. Psychosomatic overlay is my opinion. Passive range of movement was good when I examined her and no muscle wasting despite she claims to be in so much pain with lack of use of the right upper limb, all these are not consistent. I don’t think she has any problem and we certainly cannot label her as having chronic regional pain because she doesn’t have enough features to satisfy the diagnosis, besides some soft tissue swelling in the right hand and subjective pain. The ways she describes the pain or the numbness is not associated with chronic pain either because usually it will be either glove and stocking distribution or following particular nerve root or peripheral nerve and with her describing it as ¾ of the circumference of the arm, and the forearm, sparing the lateral side, that is not a case of chronic pain related to any neural reason.”
He continued at [10c] – emphasis added:
“If I believe all the physical examination of her right upper limb, she probably would have a lot of permanent impairment but I don’t think she is genuine and as mentioned above, there is a lot of psychosomatic overlay.”
Requirements of [17.5] generally
As the respondent submits, the Guidelines at [17.5] require that, in order to assess CRPS1:
(a) the four criteria in Table 17.1 must be satisfied;
(b) the diagnosis must have been present for at least one year;
(c) it must have been verified by more than one examining physician, and
(d) other possible diagnoses must have been excluded.
We accept there is evidence (b) that the diagnosis had been present for more than a year and (c) that the diagnosis had been made by other physicians. The respondent does not submit to the contrary.
Requirement (d) that other possible diagnoses must have been excluded amounts to a requirement that the Medical Assessor exclude other diagnoses. Contrary to the appellant’s submission, it is not satisfied merely by other specialists or investigations excluding other diagnoses.
The Medical Assessor did not offer any alternative diagnosis to explain all the signs and symptoms he elicited. He diagnosed trigger finger in the right ring finger as at the date of injury, but did not suggest this continued, or that it had ever explained any symptoms apart from those in the right ring finger. “Psychosomatic overlay” is not a diagnosis. It is shorthand for the suggestion that there are unspecified, non-organic causes for subjective pain or other symptoms.
Though he did not offer an alternative diagnosis, he did not say that other diagnoses were excluded. This amounted to a failure to take into account a relevant consideration, and itself amounts to error. The omission also leaves us in a position where we are not able to discern, from the reasons, whether other diagnoses have been or have not been excluded by the Medical Assessor. That insufficiency of reasons also demonstrates error.
Table [17.1]
The first task of the Medical Assessor was to examine the worker and determine whether each of the four criteria in Table 17.1 were satisfied. Those criteria were as follows.
1. Continuing pain, which is disproportionate to any causal event.
2. Must report at least one symptom in each of the four following categories:
• Sensory: Reports of hyperaesthesiae and/or allodynia.
• Vasomotor: Reports of temperature asymmetry and/or skin colour changes and/or skin colour asymmetry.
• Sudomotor/oedema: Reports of oedema and/or sweating increase or decrease and/or sweating asymmetry.
• Motor/trophic: Reports of decreased range of joint motion and/or motor dysfunction (tremor, dystonia) and/or trophic changes (hair, nail, skin).
3. Must display at least one sign* at time of evaluation in all of the following four categories:
• Sensory: Evidence of hyperalgesia (to pin prick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement).
• Vasomotor: Evidence of temperature asymmetry and/or asymmetric skin colour changes.
• Sudomotor/oedema: Evidence of oedema and/or sweating asymmetry.
• Motor/trophic: Evidence of decreased active joint range of motion and/or motor dysfunction (tremor, dystonia) and/or trophic changes (hair, nail, skin).
4. There is no other diagnosis that better explains the signs and symptoms.
*A sign is included only if it is observed and documented at time of the impairment evaluation.
Criterion (1)
Criterion (1) is continuing pain which is “disproportionate to any causal event”. Though the Medical Assessor did not consider the worker to be “genuine”, he did not expressly deny that she experienced pain. On the contrary, he suggested psychosomatic overlay, which implies that pain was felt, though without sufficient physical cause to explain its intensity. He described it at [10c] as “subjective pain” – in other words, pain felt by the worker, without sufficient physical cause. At [7], he said he did not believe that “what she tried to present to me is consistent with the mechanism of injury …”. We interpret “what she tried to present to me” as including complaints of pain, among other things, recorded above in his reasons. Reading his reasons as a whole, including these particular passages, we interpret him to mean that the pain was disproportionate to the mechanism of injury.
In our view, the findings of the Medical Assessor satisfied criterion (1).
Criterion (2)
The respondent says that criterion (2) was not satisfied, because there were no complaints (reports) of symptoms under the third category, Sudomotor/oedema. That is, no reports “of oedema and/or sweating increase or decrease and/or sweating asymmetry”. The respondent does not dispute that there were reports of symptoms under the other three headings in criterion (2), as indeed there were.
The Medical Assessor noted the worker’s complaints that her right hand was “cold, darker in colour”, though the worker complained of no “differences” in sweating. We interpret the word “differences” to mean greater or less swelling in one limb than the contralateral limb. The Medical Assessor did not record whether the worker reported sweating “asymmetry”, or whether she complained of swelling in the right hand, as distinct from a clinical finding to that effect on examination.
There is no evidence that the Medical Assessor asked the worker about these symptoms. If he did, he did not record her responses. The omission to mention them in his reasons results in our not knowing whether this particular criterion was satisfied, and in our being unable to discern whether there was error in the assessment of CRPS1.
The inadequacy of reasons also demonstrates error, necessitating the setting aside of the Medical Assessment Certificate.
Criterion (3)
Criterion (3) requires that the worker display at least one sign in each of four categories, corresponding to the four headings in criterion (3). They are Sensory, Vasomotor, Sudomotor/oedema and Motor/trophic. The Medical Assessor observed swelling in the right hand, and decreased active joint range of motion. That satisfied at least one requirement in respect of each of the third and fourth categories, “Sudomotor/oedema” and “Motor/trophic”.
The first category, “Sensory”, required at least one sign of hyperalgesia to pin prick and/or allodynia to light touch and/or deep somatic pressure and/or joint movement. There is no evidence that the Medical Assessor tested for hyperalgesia. Though he elicited passive movement of joints, he did not record whether this resulted in allodynia. There is no evidence of any specific testing for allodynia. The reasons do not disclose whether the worker had hyperalgesia or allodynia. They are insufficient to inform the Appeal Panel as to whether the first category, “Sensory”, was satisfied or not. This demonstrates error.
The second category, “Vasomotor”, required at least one sign of temperature asymmetry and/or asymmetric skin colour changes. As indicated, on examination the Medical Assessor could find no difference in temperature. We interpret that as a finding that temperature asymmetry was absent.
With respect to colour changes, he found the right hand was a bit darker on the dorsum but not on the ventral side, but did not make any finding, or even express a view, as to whether this amounted to asymmetry of skin colour. That results in our not being able to discern his path of reasoning with respect to the “Vasomotor” category. His reasons are inadequate to enable us to discern whether this category was satisfied or not satisfied. The insufficiency of reasons demonstrates error.
Criterion (4)
Criterion [4] requires that there be “no other diagnosis that better explains the signs and symptoms”. As indicated, the Medical Assessor did not offer a diagnosis which better explained all the signs and symptoms of which report was made to him, or which were revealed by clinical examination. He did not make any finding as to whether any such diagnosis was available, as he was obliged to do in considering criterion (4), and therefore did not exclude any other diagnosis. That failure also demonstrates error, necessitating the setting aside of the Medical Assessment Certificate.
Other grounds of appeal
For all those reasons, the Appeal Panel was satisfied that the assessment was affected by demonstrable error, necessitating the setting aside of the Medical Assessment Certificate. It was unnecessary to consider the further grounds of appeal.
Report of Dr Bodel
It was not possible to correct the identified errors without further examination. The Appeal Panel referred the worker for examination to Medical Assessor Bodel, who is a medical member of the Appeal Panel. He examined her on 4 April 2023. His report follows.
“1. The worker's medical history, where it differs from previous records
I have carefully read the history as recorded by Dr Yiu-Kuy Ho, the Approved Medical Specialist in this circumstance, who assessed her clinically on 13 October 2022.
I have been through the history carefully with Ms Simpson and she indicates that this accurately reflects the mechanism of injury as outlined.
You will be aware that she was putting together some flatpack kitchen cabinets at a high school. When lifting one of the doors, she felt a painful popping sensation in the ring finger of the right hand when she hyperextended that finger while manipulating this piece of the cabinet.
She had increasing pain and over a period of time, she developed swelling. She was later seen at the Shoalhaven District Hospital where x-rays were taken. No definite fracture was seen but there was some concern of a possible hairline fracture, although that was not absolutely confirmed. She had appropriate conservative care and physiotherapy.
She was later seen by Dr Tawfik, an Orthopaedic Hand Surgeon who felt that there was, ‘Tenosynovitis of the right ring finger involving the flexor tendons with trigger finger’ for which she then had a steroid injection. Dr McGrath then performed nerve conduction studies and EMG studies which were normal.
Later, she was referred to a pain clinic. She saw Professor Jaeger regarding concerns of a C7 nerve root lesion but no definite neurological compromise was observed.
She also saw Dr Paul Jarman, an Orthopaedic Surgeon, regarding shoulder pathology and stiffness, and he advised conservative care.
She was then seen by Vascular Surgeons, Dr Arthur Stanton and Dr Andrew Bullen regarding the possibility of a diagnosis of thoracic outlet syndrome, but this was not confirmed.
Dr Tawfik advised her to use an elbow brace to keep her elbow extended at night but that did not help.
2. Additional history since the original Medical Assessment Certificate was performed
There has been no additional history of injury or other factors in regard to the Right Upper Extremity since Dr Ho did his assessment in October 2022
Current symptoms:
· Severe pain in the whole of the right upper limb.
· Numbness and tingling in all digits of the right hand.
Treatment:
· She is taking Panadol and Nurofen.
· She is doing physiotherapy exercise.
· She has been under the care of a pain specialist.
Whole Person impairment:
The level of Whole Person Impairment as expressed by Dr You Key Ho in his Medical Assessment Certificate dated 20 October 2022 is correct, with a final level of Whole Person Impairment of 0% WPI.
3. Findings on clinical examination
The clinical findings have been recorded by Dr Ho in his Medical Assessment Certificate. He has recorded some restriction of shoulder movement which is ‘significantly stiff’, but the left-hand side has a full range of movement in all directions.
He also makes the observation that there is also very restricted range of elbow, wrist and hand movement on the right-hand side, and that throughout the whole consultation, she kept her right arm ‘with her hand hanging down.’ That is again the position that she adopted here today, although I was able to encourage her to show some movement of the shoulder, the elbow, the wrist and the hand, although the range of movement is very stiff, as recorded by Dr Ho.
In his examination section, he also made the observations in regard to signs or potential signs of CRPS when he has recorded the following facts:
‘I cannot find any difference in temperature, or skin texture and sweating pattern. The right hand may be a bit swollen and looks a little bit darker in colour on the dorsum, but not on the ventral side. I cannot see any atrophic changes of the soft tissue, despite the fake nails, the hair looks the same, and I certainly cannot comment on the nails.’
He also reports that,
‘Most importantly on tape measurement, she told me she is right-handed, but the right arm and right forearm are slightly bigger than the left and cannot be consistent with a Right Upper Limb that has no such dysfunction, as she tried to describe in the past three years and certainly on passive movement.’
That recorded set of clinical findings is very similar to the clinical presentation here today. When encouraged to elevate the arm, which is very difficult for her to achieve, the dusky appearance to the right arm does improve.
You will be aware that holding the arm motionless does cause some swelling and the dusky appearance, but there are none of the true signs associated with the clinical diagnosis of CRPS, as required by Table 17.1 on page 81 of the WorkCover Guidelines.
The specifics of the findings from Table 17.1 on Page 81 are as follows:
1.The claimant clearly does have complaints which ‘are disproportionate to the cause of the event’ in regard to her right upper limb.
2.Her verbal complaint to satisfy all four dot points in Section 2 of the table with complaints of hyperaesthesiae allodynia, are complaints about temperature differential between the right and left arm and skin colour changes. She also has pseudo motor complaints about oedema and increased sweating patterns on the injured right side. She has complaints of stiffness in the whole of all of the joints at the right upper limb and no specific complaints about hair, nail or skin.
3.In this section, she does appear to have evidence of allodynia (to light touch) and this appears to be present all over the limb, but particularly in the region of the right wrist and hand. I find it difficult to verify this however although it does appear to be subjectively present.
In regard to the vasomotor abnormalities, there is no palpable temperature differential between the right arm and the left arm. I have already commented on the asymmetric skin colour change, as her right arm, when held dependent, does appear dusky when compared to the left but after a period of elevation, the appearance returns to normal. I believe that there is no objective sign of vasomotor abnormality on clinical testing here today.
Similarly, in regards to the third dot point (pseudo motor/oedema) there is no evidence of swelling or abnormal sweating pattern between the right and left arm.
In the motor and trophic changes, she has a grossly restricted range of active joint movement throughout the whole of the right upper limb and it is my view that this is probably inconsistent but she does demonstrate that, and will not allow any significant active movement. I have not tested passive movement because of her pain levels but I would concede that there is therefore, a positive finding in this 4th dot point.
There is no other diagnosis that better explains the signs and symptoms.
I would say that in Section 3 which is the objective attempt to validate CRPS, she does appear to have possible signs in point 1 and point 4 but there are no signs to justify a positive clinical finding in the vasomotor section or the pseudomotor section and therefore, she fails the requirements to be assessed under this table.
The reason for my re-examination today, as determined by the Appeal Panel, was to determine the presence of absence of signs for CRPS. I confirm, as indicated by Dr Ho, that there are no objective signs of CRPS on clinical assessment here today.
4. Results of any additional investigations since the original Medical Assessment Certificate
This claimant has no additional medical investigations. She has, however, provided me with a typewritten two-page report outlining her persisting symptoms, which include the discolouration of the hands, fingers and forearm, and the swelling in the fingers, hand and forearm, the tingling and pins and needles from the fingertips to the shoulder and neck. She implies that this involves all surfaces of the whole of the right arm in a non-dermatomal distribution.
She reports a sleep disturbance, waking from sleep every 2-3 hours. She reports sensitivity on palpation of any part of the hand, and she does report that today when clinically assessed. She also states that she cannot grip the steering wheel with her right hand.
She cannot lift more than 1kg with the right hand. She cannot use a knife or spoon properly. She cannot hang clothes on the clothesline. She states that her right middle finger locks and that her right hand and arm are always colder than the left.
I again confirm that I have carefully palpated both arms and am unable to confirm that difference in actual skin temperature between the right and left hand. She describes the pain as, ‘intense pain and a burning sensation.’ She reports numbness and dry, itchy skin.
She has also listed the Activities of Daily Living that she cannot do because of her pain and that includes washing her hair, getting dressed, brushing her teeth, holding a phone, holding the steering wheel, cutting food or making sandwiches, lifting the laundry basket, hanging out the washing or putting the clothes into the washing machine or on a clothesline, and writing and painting.
She has listed the various specialists whom she has seen for treatment and that is consistent with the history as known. This does include IME assessments from Dr Powell and Dr Johns.
The physiotherapists are listed and the other treatments tried, including pain management treatments such as injections of cortisone (ganglion block injections or scalene injections), Melatonin, Lyrica, Pamidronate infusion at Wollongong Hospital in December 2022, and the mirror box therapy and TENS machine. She has found none of these of any value.
She lists the medication that she is taking which includes four Panadol tablets per day, four Nurofen tablets per day, 200mg of Celebrex as well as Telmisartan for her blood pressure.
5. Opinion
On behalf of the Appeal Panel, I have assessed this claimant clinically to determine the presence of absence of objective signs of CRPS. As I have indicated above, none of those signs are visible.
She has symptoms suggestive that she does indeed have a complex regional pain syndrome or neuropathic pain experience in the Right Upper Limb but there are none of the signs required for the application of Table 17.1 on page 81 of the Guidelines to make a diagnosis and rating of impairment in according with the WorkCover Guidelines.”
Further examination and report
On 22 December 2023, Medical Assessor Bodel conducted a further examination, to make further clinical observations and measurements. His report following that examination follows.
“1. The workers medical history, where it differs from previous records
I have again reviewed this lady’s medical history. I have nothing further to add to the findings in my previous examination on behalf of the Appeal Panel.
I have carefully read the history as recorded by Dr Yiu-Kuy Ho, the Approved Medical Specialist in this circumstance, who assessed her clinically on 13 October 2022.
I have been through the history carefully with Ms Simpson and she indicates that this accurately reflects the mechanism of injury as outlined.
You will be aware that she was putting together some flatpack kitchen cabinets at a high school. When lifting one of the doors, she felt a painful popping sensation in the ring finger of the right hand when she hyperextended that finger while manipulating this piece of the cabinet.
She had increasing pain and over a period of time, she developed swelling. She was later seen at the Shoalhaven District Hospital where x-rays were taken. No definite fracture was seen but there was some concern of a possible hairline fracture, although that was not absolutely confirmed. She had appropriate conservative care and physiotherapy.
She was later seen by Dr Tawfik, an Orthopaedic Hand Surgeon who felt that there was, ‘Tenosynovitis of the right ring finger involving the flexor tendons with trigger finger’ for which she then had a steroid injection. Dr McGrath then performed nerve conduction studies and EMG studies which were normal.
Later, she was referred to a pain clinic. She saw Professor Jaeger regarding concerns of a C7 nerve root lesion, but no definite neurological compromise was observed.
She also saw Dr Paul Jarman, an Orthopaedic Surgeon, regarding shoulder pathology and stiffness, and he advised conservative care.
She was then seen by Vascular Surgeons, Dr Arthur Stanton and Dr Andrew Bullen regarding the possibility of a diagnosis of thoracic outlet syndrome, but this was not confirmed.
Dr Tawfik advised her to use an elbow brace to keep her elbow extended at night but that did not help.
2. Additional history since the original Medical Assessment Certificate was performed
There is no further additional medical history since I saw her last on behalf of the Appeal Panel.
There has been no additional history of injury or other factors in regard to the Right Upper Extremity since Dr Ho did his assessment in October 2022.
The previous additional history is contained as follows:
Current symptoms:
•Severe pain in the whole of the right upper limb
•Numbness and tingling in all digits of the right hand
Treatment:
•Panadol and Nurofen
•Physiotherapy exercise
•Under the care of a pain specialist
Whole Person impairment:
The level of Whole Person Impairment as expressed by Dr Yu Key Ho in his Medical Assessment Certificate dated 20 October 2022 is correct, with a final level of Whole Person Impairment of 0% WPI.
3. Findings on clinical examination
I have fully examined Katrina Simpson’s neck, right shoulder, and arm. I attach for the Panel’s perusal photographs for which I was given verbal permission, which demonstrate both arms. They do not identify the claimant. She also signed my claimant information form which indicates that, amongst other things:
‘I hereby give consent to MedAssess Australia to collect, hold, use and disclose my personal and health information contained in the assessment report to be released to the referring party, or as otherwise required by law.’
Once we have dealt with this matter, the photographs will be deleted, and I would recommend that they should be done also on your behalf.
Ms Simpson has a good range of neck flexion, extension and rotation in all directions and there is no asymmetry of neck movement. She has no visible sign of colour change in the right upper limb, which was present when I saw her last.
I have taken the temperature of her forearm and arm using an ‘infrared thermometer’, which we use routinely on every patient to check that they are afebrile when they attend for examination. The temperature was 36.3 on the right arm and 36.2 on the left.
Ms Simpson has tattoos on the right arm and the upper part of the left arm, which predate her injury. Clear inspection shows no colour change and no abnormal loss of hair in the right arm or hand, and particularly there are small fine hairs over the back of all of the fingers, which are the same on the right arm and the left arm.
Unfortunately, she has acrylic nails in place, and it is impossible to genuinely check the status of her nails in this circumstance. There is no abnormal sweating pattern. Today she does complain of some discomfort on palpation of the arm, but gentle manipulation during examination has not caused the same response that she demonstrated when I saw her last.
She has no evidence of allodynia to deep somatic pressure or joint movement. There is no hyperalgesia to pin prick, which was tested with a neurotip, although with the plastic guard still in place. From the vasomotor point of view from signs, there is no temperature differential as I have verified above. There are no asymmetric colour changes or skin changes which were present when I saw her last.
Today, I asked her to lie on the examination couch for a period of about 10 minutes or so while I reviewed the history before examining her clinically. There is no swelling. I measured the forearm and the arm above the elbow which is 33cm on the right-hand side and 32.5cm on the left-hand side. On the forearm below the elbow, it measures 26.5cm on the right-hand side and 26.5cm on the left-hand side.
When she attempts to make a fist, she cannot make a complete fist. Gentle palpation of the extensor muscle bellies, and the volar muscles indicate that both antagonist and agonist muscles are contracting together. This is a significant inconsistency in her clinical progress.
It can also be noted on the photographs that when she attempts to squeeze my fingers, I do feel pressure and the range of movement in flexion is increased in that movement which she actively did without discomfort.
On clinical findings seen here today, she has no single sign of vasomotor abnormality, pseudomotor or oedema abnormality, or motor or trophic changes. The only possibility of a positive sign in accordance with Table 17.1 is the altered sensation.
Ms Simpson therefore, probably has neuropathic pain but has no clinical evidence of CRPS (complex regional pain syndrome) to accommodate a rating under that title in accordance with Table 17.1 on page 81.
4. Results of any additional investigations since the original Medical Assessment Certificate
When I saw Ms Simpson last, she did provide a few pages of a typewritten list of her persisting symptoms which I referred to at the time of my last examination. I include that reference in this re-assessment for clarity.
5. Opinion
On formal re-examination to assess the level of Whole Person Impairment associated with CRPS, I find today quite convincingly, that there are insufficient objective signs of CRPS to make that diagnosis.
She has symptoms strongly suggestive of neuropathic pain, but not a complex regional pain syndrome. She has only one possible, but not definite, sign from Table 17.1 at Item 3 (the sensory loss) and no positive findings of vasomotor, pseudomotor or motor and trophic changes as required by that table.”
Assessment of the Appeal Panel
The task of the Appeal Panel is to correct the following errors which were identified in the reasons of Medical Assessor Ho:
(a) Failure to determine whether other diagnoses are excluded: Guidelines, [17.5], criterion (d).
(b) Failure to determine whether there were reports of at least one symptom “of oedema and/or sweating increase or decrease and/or sweating asymmetry”: Table 17.1, Criterion (2), 3rd category “Sudomotor/oedema”.
(c) Failure to determine whether the worker displayed at least one sign of “hyperalgesia (to pin prick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)” – Table 17.1, Criterion 3, first category “Sensory”.
(d) Failure to determine whether the worker displayed “asymmetric skin colour changes” – Table 17.1, Criterion 3, second sub-criterion “Vasomotor”.
(e) Failure to determine whether “there is no other diagnosis that better explains the signs and symptoms”: Table 17.1, Criterion 4.
Having regard to Medical Assessor Bodel’s expertise as an orthopaedic surgeon and clinical experience, the Appeal Panel accepts the accuracy of his clinical findings.
With respect to (a) above, in his most recent report Medical Assessor Bodel diagnosed neuropathic pain (as distinct from nociceptive pain) not amounting to CRPS. In his earlier report, he had expressed the following conclusion:
“She has symptoms suggestive that she does indeed have a complex regional pain syndrome or neuropathic pain experience in the Right Upper Limb but there are none of the signs required for the application of Table 17.1 on page 81 of the Guidelines to make a diagnosis and rating of impairment in according with the WorkCover Guidelines.”
The “symptoms” to which he referred differed to some extent from one examination to another. In his first report, he had noted “possible signs in point 1 and point 4”. He was referring to allodynia to light touch (point 1 – Sensory) and grossly restricted movement of the right upper limb (point 4 – Motor/trophic). By the time of the second examination, allodynia was no longer present. There was also some evidence of skin colour differential on first examination (though whether this satisfied the relevant criteria is a different matter), which disappeared with movement. There was none at all on the second examination.
In our view, having regard to the clinical findings on both examinations, and to the fact that the findings on the later examination are the more current, the diagnosis of neuropathic pain not amounting to CRPS is appropriate. In reaching that view, we accept the clinical findings of Medical Assessor Ho, except to the extent that we have found error, and to that extent accept the latest clinical findings of Medical Assessor Bodel. Neuropathic pain not amounting to CRPS is a diagnosis, even if the neural source of the pain is not, or cannot be, identified with precision. It is a diagnosis which is necessarily distinct from CPRS, and inconsistent with it. In the presence of such a diagnosis, it cannot be said that other diagnoses are excluded. Criterion (d) in [17.5] of the Guidelines is not satisfied.
With respect to (b) above – reports of at least one symptom “of oedema and/or sweating increase or decrease and/or sweating asymmetry” – Medical Assessor Bodel found that there were such complaints. Criterion (2) in Table 17.1, 3rd category “Sudomotor/oedema”, is satisfied.
With respect to (c) above – whether the worker displayed at least one sign of “hyperalgesia (to pin prick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)” – Medical Assessor Bodel found that she did display allodynia on first examination, but that it was no longer present on the second. Adopting the later and more current clinical finding, we are satisfied that Criterion 3, Table 17.1, first category “Sensory”, is not satisfied.
With respect to (d) above – whether the worker displayed “asymmetric skin colour changes” – Medical Assessor Bodel ultimately found on further examination that such changes were not present. Criterion 3, Table 17.1, second sub-criterion “Vasomotor”, is not satisfied.
With respect to (e) above – whether “there is no other diagnosis that better explains the signs and symptoms” – in our view the diagnosis of neuropathic pain not amounting to CRPS better explains the signs and symptoms than does CRPS. Criterion 4 of Table 17.1 is not satisfied.
For those reasons, the Appeal Panel is satisfied that not all the criteria for CRPS are satisfied. It follows that the requirements of the Guidelines at [17.5] are not met, and a finding of CRPS cannot be made.
Though our reasons differ from those of Medical Assessor Ho, and are based to some extent on the results of different examinations, the result is the same. The Medical Assessment Certificate of Medical Assessor Ho is confirmed.
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