Opinion ID: 1302330
Heading Depth: 3
Heading Rank: 3

Heading: The Board Erred in Denying Tolbert's 1993 and 1994 Claims.

Text: Tolbert filed one claim in February 1993 and two claims in June 1994, asserting that the repetitious keyboarding she performed for Alascom was causing swelling, numbness, and pain in her hands and arms. Tolbert initially asserted that these symptoms were caused by aggravation of her pre-existing carpal tunnel syndrome. [15] Ultimately, however, she was able to present little evidence to support this theory. But she did present considerable evidence indicating that the problems she experienced stemmed from work-related episodes of tendinitis. At the hearing on her claims, Tolbert described suffering from work-related problems with her hands on February 22, 1993, June 1, 1994, and June 14, 1994. She presented extensive expert testimony suggesting that the problems she experienced were work related. Dr. Lipke, Tolbert's treating physician and primary witness, testified about carpal tunnel syndrome and tendinitis, describing the differences between the two conditions. According to Dr. Lipke, carpal tunnel is the narrow passageway in the wrist between the wrist bones and the transverse carpal ligament. The flexor tendons and the median nerve must pass through this tunnel to reach the fingers. Although the causes of carpal tunnel syndrome vary, one cause is repetitious trauma. Repetitious motion, coupled with the normal aging process, can cause pain in, and swelling of, the tendons resulting in tendinitis. Tendinitis can, by putting pressure on the median nerve, in turn, lead to carpal tunnel syndrome. Tendinitis is a temporary condition and generally will resolve without causing carpal tunnel syndrome. But if the pressure is persistent enough, nerve dysfunction, pain, numbness, and tingling in the fingerscollectively called carpal tunnel syndromewill result. Scar tissue may eventually form on the nerve, which can, when combined with external pressure, continue to irritate the nerve even after the tendinitis resolves. Once the carpal tunnel syndrome becomes sufficiently severe, surgery is necessary to release it. Carpal tunnel release surgery consists of cutting the ligament that forms part of the carpal tunnel, thereby releasing the pressure on the median nerve. Dr. Lipke also addressed the issue of Tolbert's diagnosis. He commented that, in Tolbert's case, nerve conduction studies revealed no aggravation of her carpal tunnel syndrome. In Dr. Lipke's view, Tolbert's problems were more likely attributable to tendinitis. Specifically, Dr. Lipke testified that repetitive motions like keyboarding can cause and aggravate tendinitis, that Tolbert's symptoms were consistent with tendinitis, and that tendinitis could be objectively confirmed if volumetric tests showed abnormal swelling. Volumetric testing of Tolbert's hands did in fact reveal abnormal swelling. Dr. Ferris conducted two volumetric tests on Tolbert. The first simulated Tolbert's job as she had described it, but Dr. Ferris later deemed this test unreliable because he learned that Tolbert had exaggerated the amount of keyboarding she usually performed. Dr. Ferris personally designed the second test after speaking with Alascom about the kinds of work Tolbert actually did and after observing Tolbert's work being performed by other Alascom workers. Dr. Ferris testified that this second test accurately simulated Tolbert's job conditions. In both tests, Tolbert's hands swelled abnormally. Dr. Ferris, like Dr. Lipke, found the results of the volumetric testing significant because the tests had been designed to mimic Tolbert's actual work conditions and they produced abnormal swelling. In Dr. Ferris's view, the objective signs of swelling substantiated Tolbert's subjective complaints of hand pain. Moreover, swelling to the degree he observed would cause pain and decrease the amount of function that [Tolbert] would feel comfortable with carrying out. He indicated that he believed that Tolbert's hands would continue to swell as long as she persisted in the sorts of activities required by her job. Although Dr. Ferris said that Tolbert's hand swelling was not necessarily tendinitis and might be a sort of passive edema related to carpal tunnel syndrome, he recognized that his opinion on this issue was speculative, and he deferred to Dr. Lipke's diagnosis of tendinitis, because, in Dr. Ferris's view, Dr. Lipke had more expertise in diagnosing the condition. Two other experts presented evidence at Tolbert's hearing: Drs. Sack and Fu. Their testimony aimed primarily at negating the possibility that Tolbert's problems had been caused by an aggravation of her carpal tunnel syndrome. Both agreed that her work had not caused any substantial permanent aggravation in her carpal tunnel syndrome. Dr. Fu testified that Tolbert was left with mild residual nerve entrapment after her carpal tunnel release surgeries and, as a result, her symptoms might increase with activity. But he did not explain what symptoms he expected her to have. He acknowledged the presence of some form of temporary aggravation and reaggravation of pain and discomfort when Tolbert engages in repetitive hand activities. But beyond disputing Tolbert's claim of aggravated carpal tunnel syndrome and mentioning the possibility of some residual symptoms that might occur in the absence of aggravation, Dr. Fu did not specify what Tolbert's problem might or might not be. While he did testify that she still objectively showed some decrease of sensations involving both hands and increased sensitivity along her wrist, he drew no inferences from these symptoms. As for the swelling in Tolbert's wrists, he failed to account for it at all. Like Dr. Fu, Dr. Sack also unequivocally testified that he did not believe that Tolbert's carpal tunnel syndrome had been aggravated. But he, too, was silent with respect to tendinitis and did not account for Tolbert's swelling. He testified that Tolbert's carpal tunnel syndrome, even after surgery, would cause a bit of symptomatology. But he did not describe what symptoms he had in mind; nor did he deny that Tolbert might also be suffering from tendinitis.
The Board found that there was no medical testimony indicating [that Tolbert] suffered a work-related injury on February 22, 1993, June 1, 1994 or June 14, 1994. Accordingly, it concluded that Tolbert failed to establish the preliminary link necessary to trigger the presumption of compensability. Tolbert challenges this finding. Alaska Statute 23.30.120 presumes that workers' compensation claims are compensable. But this presumption does not apply automatically; we have held that the worker must show a preliminary link between the injury and the job. [16] To establish such link, the claimant need not present substantial evidence that his or her employment was a substantial cause of ... disability. [17] Rather, an offer of some evidence that the claim arose out of the worker's employment is sufficient. [18] For purposes of determining whether the claimant has established the preliminary link, only evidence that tends to establish the link is consideredcompeting evidence is disregarded. [19] Likewise, credibility plays no part in the process: In making its preliminary link determination, the board need not concern itself with the witnesses' credibility. [20] At her hearing, Tolbert reported work-related problems with her hands occurring on February 22, 1993; June 1, 1994; and June 14, 1994. She presented a great deal of expert testimony suggesting that the problems she experienced were work related. Dr. Lipke testified that keyboarding can cause and aggravate tendinitis, that Tolbert's symptoms were consistent with tendinitis, and that tendinitis could be objectively confirmed if volumetric tests showed abnormal swellingwhich, in Tolbert's case, they did. Considering the overwhelming medical evidence supporting a work-related injury, and given the minimal showing required to establish the preliminary link and the irrelevance of credibility at this phase of the inquiry, we hold that there was sufficient evidence to establish the preliminary link and give rise to the presumption of compensability. Thus, the Board erred in finding that Tolbert did not produce some evidence linking her injuries to her job.
Once the preliminary link has been established, it is the employer's burden to overcome the presumption [of compensability] by coming forward with substantial evidence that the injury was not work related. [21] Substantial evidence is evidence that a reasonable mind, viewing the record as a whole, might accept as adequate to support the Board's decision. [22] We have explained this standard as follows: To overcome the AS 23.30.120(a) presumption of compensability, an employer must present substantial evidence that either (1) provides an alternative explanation which, if accepted, would exclude work-related factors as a substantial cause of the disability; or (2) directly eliminates any reasonable possibility that employment was a factor in causing the disability. [23] If the employer successfully rebuts the presumption of compensability, the presumption drops out, and the employee must prove all of the elements of the case by a preponderance of the evidence. [24] Here, the Board found that, even if Tolbert had established the preliminary link, Alascom would have overcome the presumption of compensability with the testimony of Dr. Sack and Dr. Fu. But, again, the thrust of both doctors' testimony was that Tolbert had experienced no permanent aggravation of her carpal tunnel syndromethey scarcely referred to the issue of tendinitis. And while the doctors mentioned the possibility that Tolbert's prior carpal tunnel syndrome might continue to manifest itself in a bit of symptomatology, neither specified what symptoms might occur or characterized such symptomatology as a likely cause of Tolbert's recent problems. In short, although Dr. Sack and Dr. Fu did point to a possible alternative cause for Tolbert's pain, they did not describe this alternative as its probable cause or otherwise attempt to rule out Dr. Lipke's diagnosis of work-related tendinitis. We have previously recognized that, for purposes of overcoming the presumption of compensability, medical testimony cannot constitute substantial evidence if it simply points to other possible causes of an employee's injury or disability, without ruling out work-related causes. [25] Because Dr. Sack's and Dr. Fu's testimony does nothing more than point to other possible causes, it fails to rebut the presumption of compensability. [26]
The Board alternatively concluded that Tolbert failed to prove her claims by a preponderance of the evidence because she failed to prove that her wrist injuries would not have occurred but for the work. Though the Board accepted Dr. Lipke's testimony that the swelling in Tolbert's hands indicated a problem with tendinitis and that Tolbert's work at Alascom aggravated this condition, it nevertheless found that her activities at home also might have aggravated the condition. Therefore, the Board reasoned, Tolbert had failed to establish that, but for her work, she would not have been disabled. But this reasoning conflicts with our prior holdings on substantial-factor causation. We have said that, when two or more forces operate to bring about an injury and each of them, operating alone, would be sufficient to cause the harm, the 'but for' test is inapplicable because it would tend to absolve all forces from liability. [27] In such cases, it is necessary to ask whether the work-related injury was a substantial factor in causing the disability: If one or more possible causes of a disability are [work related], benefits will be awarded where the record establishes that the [work-related] injury is a substantial factor in the employee's disability regardless of whether a [non-work-related] injury could independently have caused disability. [28] The but for standard applied by the Board required Tolbert to prove that her work-related injury was the sole cause of and not merely a substantial factor in causingher disability. Because the standard applied by the Board conflicts with the substantial-factor test, which we have held applicable in cases like Tolbert's, we reject the Board's alternative ground for concluding that Tolbert failed to prove her claims.
As yet another independent ground for denying Tolbert relief, the Board concluded that her 1993 and 1994 claims were not compensable because they were legally precluded. Finding that Tolbert's tendinitis was as longstanding as the underlying carpal tunnel syndrome, the Board reasoned that any claims relating to her tendinitis were barred by res judicata following our 1992 decision affirming the denial of Tolbert's original claims for carpal tunnel syndrome. But this holding conflicts with the Board's finding that tendinitis is a temporary (albeit recurring) condition. Under these circumstances, claim preclusion does not apply.