02-12WC. Patricia Jacobs v. Metz and Associates, Ltd. d/b/a Valley Vista.

• Court: Vermont

Vermont Workers Compensation 2012. 02-12WC. Patricia Jacobs v. Metz and Associates, Ltd. d/b/a Valley Vista Patricia Jacobs v. Metz and Associates, Ltd. d/b/a Valley Vista(January 11, 2012)STATE OF VERMONT DEPARTMENT OF LABORPatricia Jacobs v. Metz and Associates, Ltd. d/b/a Valley VistaOpinion No. 02-12WCBy: Jane Woodruff, Esq. Hearing Officer For: Anne M. Noonan CommissionerState File No. Z-01481OPINION AND ORDERHearing held in Montpelier, Vermont on September 19 and 20, 2011 Record closed on November 14, 2011APPEARANCES:Charles Powell, Esq., for ClaimantCorina Schaffner-Fegard, Esq., for DefendantISSUES: 1. Does Claimant suffer from chronic regional pain syndrome causally related to her accepted work injury? 2. Is Claimant entitled to a spinal cord stimulator trial as reasonable and necessary medical treatment for her accepted work-related injury? EXHIBITS Joint Exhibit I: Medical records Claimant's Exhibit 1: Dr. Lake's medical records Claimant's Exhibit 2: Harden RN et al., Proposed New Diagnostic Criteria for ComplexRegional Pain Syndrome, Pain Medicine, 2007; 8(4):326-331 Defendant's Exhibit A: Curriculum vitae, Dr. Leon Ensalada Defendant's Exhibit B: Curriculum vitae, Dr. Albert Drukteinis Defendant's Exhibit C: Video of Dr. Ensalada's Examination Defendant's Exhibit D: Video of Dr. Drukteinis' Examination CLAIM: Medical benefits pursuant to 21 V.S.A. § 640 Costs and attorney fees pursuant to 21 V.S.A. §678 FINDINGS OF FACT: 1. At all times relevant to these proceedings, Claimant was an employee and Defendant was her employer as those terms are defined in Vermont's Workers' Compensation Act. 2. Judicial notice is taken of all relevant forms contained in the Department's files relating to this claim. 3. Claimant worked for Defendant as a dietary aide. On December 17, 2007 she felt and heard a pop in her right wrist as she was loading a five-gallon crate of milk into a dispenser. Her wrist swelled and pain radiated up to her shoulder. The emergency room physician diagnosed tendonitis of the right wrist. Defendant accepted this injury as compensable and began paying workers' compensation benefits accordingly. Medical Treatment 4. Initially Claimant treated conservatively for her injury. Thereafter, between April 2008 and February 2009 she underwent three surgeries - first a carpal tunnel release, then surgical repair of a cartilage (TFCC) tear in her wrist, and finally an ulnar nerve decompression. After each surgery Claimant underwent additional conservative treatment, including physical and occupational therapy, injections and pain medications. Despite her full compliance with all treatment recommendations, none provided long-lasting relief of symptoms. To the contrary, Claimant's right upper extremity became increasingly painful. 5. By January 2010 Claimant's treating physician had concluded that she was suffering from chronic pain, at a level beyond what seemed reasonable for the surgeries she had undergone. Claimant thus was referred for pain management services to Dr. Lake, a board certified anesthesiologist. Dr. Lake concluded that Claimant was suffering from chronic regional pain syndrome (CRPS) in her right upper extremity. 6. CRPS is a disorder of the sympathetic nervous system. It is characterized by continuing regional pain that (a) occurs both spontaneously and with movement; (b) extends beyond the territory of a specific peripheral nerve; and (c) is disproportionate in time or degree to the usual course of any inciting injury.(fn1) 7. The signs and symptoms of CRPS tend to predominate at the far end of an affected extremity. Clinical findings indicative of the syndrome are generally categorized as follows:

* Sensory, including hyperesthesia (heightened sensitivity of skin to touch) and allodynia (pain from stimuli that are not normally painful);

* Vasomotor, including asymmetry of skin temperature and either changes and/or asymmetry of skin color;

* Sudomotor and edema, including edema and/or sweating changes and/or sweating asymmetry; and

* Motor/trophic, including decreased range of motion and/or motor dysfunction (weakness, tremor, involuntary muscle contractions) and/or trophic changes to hair, nails or skin.

8. The currently accepted diagnostic criteria for CRPS, as reflected in the AMA Guides to the Evaluation of Permanent Impairment (6th ed.), were developed in 2007 at an invitation-only conference in Budapest. Known as the Harden criteria(fn2), before diagnosing CRPS the clinician must make the following clinical findings:

* Continuing pain that is disproportionate to the inciting event;

* Patient reports at least one symptom in three of the four categories listed above;

* Patient displays at least one sign at the time of evaluation in two or more of the four categories listed above; and

* There is no other diagnosis that better explains the signs and symptoms.(fn3)

9. In Claimant's case, Dr. Lake's CRPS diagnosis was based on the following clinical findings:

* Significant color change in the outside region of the right wrist as compared to the left wrist;

* Hypersensitivity to touch (allodynia);

* Nail changes in the fourth and fifth digits on the right hand as compared with all other digits;

* Some limited strength with grip; and

* Hair changes in the right wrist area.

10. In addition to these observations, Dr. Lake also determined (a) that Claimant's pain was out of proportion to what ordinarily would be expected following her three right upper extremity surgeries; and (b) that no other diagnosis better explained her signs and symptoms. I find that Dr. Lake's CRPS diagnosis thus comported with the Harden criteria. 11. As treatment for Claimant's CRPS, initially Dr. Lake recommended a course of stellate ganglion nerve blocks. Unfortunately, these failed to provide any effective long-term pain relief. Given her prior history of cocaine and alcohol abuse during her teenage years...