On December 23, 2011, the Ontario Court of Appeal overturned the trial judge’s decision in Kusnierz v. The Economical Mutual Insurance Co. that psychological impairments should be combined with physical impairments to determine whether a motor vehicle accident victim has sustained a catastrophic impairment. This decision will likely impact the current definition of “catastrophic” impairment under the SABS and could lead to potential modifications to the definition.

This article will review the current definition of a catastrophic impairment as well as some relevant judgments pertaining to combining physical and psychological impairments using the AMA Guides to the Evaluation of Permanent Impairment, 4th Edition.

Current definition of a “Catastrophic” impairment under the SABS

Under section 2 (1.2)(f) and(g) of Bill 198 of the SABS (section 3(2)(e) and (f) of the current SABS), a person meets the definition of “catastrophic” where they sustained:
(f) . . . an impairment or combination of impairments that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 per cent or more impairment of the whole person; or
(g) . . . an impairment that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in a class 4 impairment (marked impairment) or class 5 impairment (extreme impairment) due to mental or behavioural disorder.

The AMA Guides to the Evaluation of Permanent Impairment, 4th Edition (the “Guides”)

The Guides provide a method by which medical practitioners may assess impairment and assign a percentage rating to the impairment. In circumstances where an individual is suffering from two or more impairments, the impairments are combined under a “Combined Values Chart” in the Guides. If the combined value of the impairments reaches a total of 55% or more, the individual meets the SABS definitions of a catastrophic impairment.

Chapters 3 to 13 of the Guides deal with physical impairment. Chapter 14 deals with mental or behavioural impairment. Mental or behavioural impairment is not assessed on a percentage scale. Rather, it is assessed on a scale that ranks impairment from class 1 to class 5. If the individual is suffering from a class 4 (marked impairment) or a class 5 (extreme impairment) impairment, then the individual is suffering from a catastrophic impairment. This is assessed in four domains of function: activities of daily living, social functioning, work adaptation and concentration, persistence and pace.

As previously mentioned, the 4th Edition does not include percentage measures of impairment for mental or behavioural impairment under chapter 14. However, the chapter does reference percentage levels used in earlier editions under Table #3 “Emotional or Behavioural Impairment”. This table describes a five category rating system of No, Mild, Moderate, Marked, and Severe Impairment with associated percentage ranges in which Mild Limitation = 0 -14%, Moderate Limitation = 15% -29%, Marked Limitations = 30% – 49%, and Severe Limitation (of almost all functions)= 50% – 70%.

Whether in fact the Guides was intended to allow for combining of physical and psychological impairment has been argued in the courts and has been a contentious topic of debate.

Previous Judgments

Below are two notable cases where the issue of combining physical and psychological impairments was considered.

Desbiens v. Mordini

In this case, Superior Court Justice Spiegel concluded that a mental impairment could be assigned a whole body impairment percentage for the purpose of (f).

In 1986 Mr. Desbiens fell off a roof and was rendered paraplegic at T11-12. In November 1, 1999 a car struck him while he was wheeling down a sidewalk. The main issue at the trial before Justice Spiegel was whether as a result of additional injuries sustained in the car accident, Mr. Desbiens was entitled to Catastrophic designation under Sections 5 (1) f) and g) of the SABS regulation.

Justice Spiegel found that without taking into consideration Desbien’s paraplegia he had suffered a 40% whole body impairment as a result of the motor vehicle accident. The injuries included a spiral fracture of the femur. Justice Spiegel agreed with the plaintiff’s assertion that Mr. Desbien’s MVA related impairments must be considered in the context of his paraplegia and that a 40% impairment to a paraplegic is “qualitatively much worse than to an able bodied person”. He found Desbiens catastrophically impaired under Subsection f) for this reason. In addition, he found that Desbiens also met the 55% threshold under subsection f) when his psychological impairments (25%) were combined with his musculoskeletal impairments (40%) in the appropriate manner.

Justice Spiegel in Desbiens felt it appropriate to use the percent measures in the earlier editions, to allow the combination of physical impairment with mental or behavioural impairment. In doing so, the courts allowed experts to provide clinical judgment in the assessment of the level of mental or behavioural impairment in percentage terms.

Kusnierz v. The Economical Mutual Insurance Co.

In the case, Robert Kusnierz was a passenger in a vehicle involved in an accident on December 24, 2001. As a result of the accident, Mr. Kusnierz suffered numerous injuries, including a below knee amputation of the left leg. He also suffered from psychological problems including depression.

The main question argued in this case was whether assigning of percentage ratings for Mr. Kusnierz’s psychological impairments was permissible and if these ratings could be combined with the percentage ratings for the physical impairments.

Secondly, the court assessed Mr. Kusnierz’s impairments alone, to determine if he had met the threshold for a catastrophic impairment.

Justice Lauwers noted that in Chapter 14 of the Guides, mental or behavioural impairments are not expressed in percentages, as there is no empirical evidence to support any method for assigning a percentage of psychiatric impairment of the whole person. He rejected that the reference to percentages in previous editions gives assessors permission to use them in the assessment of catastrophic impairment. He argued that the Guides are based on the assessment of objective and verifiable impairment and does not permit the introduction of clinical judgment in the assessment of a percentage level of impairment for a mental or behavioural disorder.

The judge made the following conclusions:
I find that it is not permissible under the SABS to assign percentage values to mental and behavioural disorders under Chapter 14 of the Guides (which is referred to in clause 2(1.1)(g) of the SABS), and then combine them with the percentage values derived from impairments assessed under the other chapters of the Guides (referred to in clause 2(1.1)(f) of the SABS) in determining whether an individual meets the catastrophic impairment threshold of “55 per cent or more impairment of the whole person” prescribed by clause 2(1.1)(f) of the SABS.

Kusnierz v. The Economical Mutual Insurance Co. Ontario Court of Appeal Decision (December 23, 2011)
On Dec. 23, 2011, the Ontario Court of Appeal ruled in Kusnierz v. The Economical Mutual Insurance Co. that psychological impairments should be combined with physical impairments to determine whether a car accident victim has suffered a catastrophic impairment. Therefore, the Court reversed the decision of Mr. Justice Lauwers, who had held that assessors could not combine psychological and physical impairment scores to determine an injured person’s Whole Person Impairment (WPI) score.

The Court of Appeal disagreed with the trial judge for a number of reasons, notably adopting the judge’s reasons in Desbiens:

Firstly, as has been noted, the definition of “impairment” as meaning “a loss or abnormality of a psychological, physiological or anatomical structure or function” is extremely broad. Indeed it is difficult to conceive of a more inclusive definition.

Secondly, clause (f) ensures that persons who do not suffer any of the specific injuries or conditions described in the other clauses of ss. 5(1), but nevertheless have an impairment, or a combination of impairments, that is so severe that they are among those with the greatest need for health care are able to recover the expenses of that health care. In effect the legislature, with clause (f), included a catch-all provision for the benefit of those who were likely in the greatest need of health care.

Thirdly, in order to ensure that no impairments were overlooked in determining whether the requirements of clause (f) and (g) were met, the analogous impairment provision, ss. 5(3) was included. This provision comes into play where an impairment is sustained that is not listed in the Guides.

Fourthly, there is nothing in the text of the Regulation that suggests that a combination of physiological and psychological impairments is not permitted. Indeed clause (f) permits any combination of impairments, both physical and psychological. The only requirement is that these impairments must result in a 55% WPI “in accordance with” the Guides. While the definition in clause (g) does not include mild or moderate psychological impairments there is nothing in the Regulation that prohibits such impairments from being considered under clause (f). If the intention were to exclude psychological impairments from clause (f), the insertion of the word “physiological” before the word “impairment[s]” would easily have achieved that purpose. [Emphasis in original.]

Justice MacPherson concluded the following:
[I]t seems unfair to deny to persons with combined physical and psychiatric impairments the enhanced benefits that are available to persons with similarly extensive impairments that fall entirely into one category or another.

Commentary

This recent decision will no doubt be a catalyst for the government to consider potential modification to the catastrophic definition. In an advisory report in April 2011, it was suggested that physical and psychological impairments should not be combined. The Kusnierz decision has no doubt created uncertainty for accident victims, health care professionals and insurers with respect to the interpretation of the catastrophic definition. Despite this uncertainty, the intent of catastrophic benefits is to assist the most seriously injured accident victims and this should remain the primary focus of any legislative reform. This is increasingly important today given that the benefits for non-catastrophic victims were reduced post September 2010. Of further interest is that more recent editions of the AMA Guides do allow for combining impairment rating but do not follow the approach taken in Desbiens. The percentages for psychological impairments reference by Desbiens in the 4th Edition of the Guides are significantly higher than the percentages used in the newer editions.

Catastrophic impairment continues be an interesting area of the SABS and the recent ruling by the Ontario Court of Appeal will likely lead to many new developments.

How many employers have taken the time to survey their employee population on any given issue?  Most employers would not know where to start in terms of the questions to pose to employees, as well as how to collect and process the data that is returned from survey participants.

Importance of Surveying Employees

Employee surveys are an important tool that organizations use to solicit employee feedback.  Surveys can be morale boosting for those who may not have or may not feel that they have other opportunities to confidentially express their views.  Surveys provide a way to improve levels of productivity and commitment by identifying the root causes of workplace attitudes and issues.  Employee satisfaction surveys allow for increased productivity, job satisfaction, and loyalty through their reporting by identifying root causes of employee satisfaction and targeting specific areas.  Engagement surveys measure the extent to which employees are passionate about the work that they do and how emotionally committed to their organization and their coworkers they may be.

The organization itself may also benefit by conducting a more comprehensive organizational assessment survey.  Listening to employees’ insights and suggestions for improvement provides the organization with valuable information that can be acted upon to increase satisfaction in the workplace.  Employees leaving the organization can also provide valuable feedback through employee exit interviews.

Survey Types

Employee Attitude Surveys – Assess the feelings or emotions of employees within the workplace on a variety of topics specific to your organization.

Employee Engagement Surveys – Analyze passion and commitment about employees’ work, company, and coworkers with an employee engagement survey.

Employee Opinion Surveys – Uncover the beliefs or conclusions held by employees thorough an employee opinion survey.

Employee Satisfaction Survey – Most commonly used by employers, this survey provides access to employees’ needs and wants within the workplace and provides employees an opportunity to express feedback on specific situations unique to their workplace.

Absence and Disability Management Survey – Measuring the true cost of absence through a calculation of average days lost for your organization, including a myriad of other casual absence, short and long term disability calculations.

Back to Basics – In-House vs. Outsourced Surveys

Organizations often make an attempt at surveying employees and developing surveys in-house.  There can be significant hazards associated with unprofessional attempts to conduct surveys in-house.

Few organizations have experience creating and reporting back on data from employee surveys.  Surprisingly, few organizations run surveys at all and those that do often outsource to other companies in order to avoid handling the project in-house.

Benefits of Outsourcing

Confidentiality/Quality of Data –

The quality of survey data is crucial if an organization hopes to make any definitive judgments with the data.  It really does not matter how large the data sample is – if the responses you are receiving do not accurately reflect the feelings of your employees, the data you have will not be usable.

Some studies have illustrated that employees may be less likely to answer truthfully when they know the information is being gathered by their employer.  If this is accurate, data collected in-house may be far less relevant, if relevant at all to your organization.  At the very least, you may have to change the way you look at “good results” considerably, which could harm the integrity of your data.

Experience –

Organizations experienced in creating, conducting, and reporting on survey data are the best suited to providing a comprehensive report.  Such organizations have researchers on staff that are able to analyze data to determine if there is something relevant that can be used from survey data.

When an organization does not have someone trained in conducting surveys, they run the risk of conducting the survey, analyzing and reporting incorrectly thus providing no useful information.

Staff Burden –

Finally, your organization may not have someone on staff that can handle an additional amount of work.  That is yet another reason that it may be in your organization’s best interest to outsource the survey project to a professional organization that is best suited to assist.

The best run surveys are those that are able to collect relevant data in a confidential manner, and report this data back to the organization in a useful format.

A.R.S. understands that operating a professional, confidential survey is crucial to a healthy productive workplace.  Effective reporting is key to organizational change.

For additional information regarding A.R.S.’ professional employee survey consulting and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

Shoulder impingement (or sub-acromial impingement) occurs when the space between the acromion process (bony extension of the shoulder blade that extends laterally, over the shoulder joint) and the rotator cuff tendons becomes narrowed. At such a time, the acromion can rub against, or ‘impinge’, the underlying soft tissue structures, causing irritation, injury and pain.

This condition commonly occurs with sports and/or jobs that involve overhead activities, though pain may also occur as the result of an injury whereby the arm is jolted upwards. In this case, the head of the humerus (arm) pushes upward, against the acromion, ‘pinching’ the overlying soft tissue structures.

Pain is usually felt towards the front of the shoulder, and movements become painful, especially elevation of the shoulder.

Neer Impingement Stages =

Stage 1: Involves Edema and/or Hemorrhage
Stage 2: Involves Pathological changes such as Fibrosis and Irreversible changes to the Tendon
Stage 3: Involves Tendon Rupture or Tear with presence of degeneration

Basic Phases of Rehab

1) Pain Control, Reduction of Inflammation (first 24-72 hours) and Activity Modification
— RICE (rest, ice, compression, elevation)
— Modalities (electrical therapy, ice, etc.)
— Massage

2) Restore Normal Motion after Pain and Inflammation are managed

— Stretches for shoulder and joint capsule

— Codman’s Pendulum Exercises: patient adopts a prone position on a bench, or stands bent forward with the good arm used as a support, while the injured arm hangs freely and perpendicular to the floor. Start with small circles, clockwise and counter-clockwise. Graduate to holding a light weight.

— Figure 8′s: same position as above, but perform figure 8′s with affected arm.

3) Strength Exercises (aim for 15-20 reps, 2-3 sets/day, 3 -5 days/week; stop if painful)

= ISOMETRICS (performed statically, as opposed to dynamically, such that joint angle and muscle length do not change during contraction) are performed through the shoulder’s ranges of movement

= ISOTONICS (performed dynamically such that the muscle length changes, though tension remains constant)

— Supraspinatus: the shoulder is flexed 90o, then horizontally abducted 45o. Then the patient lowers and raises the arm in this diagonal plane with the thumb pointing up and elbow pointing down. The patient is instructed to raise through to about 45o, not to 90o.

— External Rotation: patient lies on the unaffected side with a rolled-up towel under the armpit of the affected arm. The Up arm (affected arm) is bent to 90o at the elbow and the forearm is resting across chest. The patient keeps their UP arm at their side while slowly raising the forearm (via external rotation) to shoulder level. The forearm is slowly lowered and the movement is repeated for sets of repetitions.

— Internal Rotation: patient lies on the affected side with DOWN arm (affected arm) bent to 90o at the elbow. The patient then roll the shoulder inward, raising the DOWN forearm up to the chest (via internal rotation). The forearm is slowly lowered and the movement is repeated for sets of repetitions.

— Posterior Rotator Cuff: patient lies prone, on a bench, with arms straight out in a thumb up position. The arms are lowered until perpendicular with the floor, then elevated until nearly parallel to the floor. The movement is repeated for sets of repetitions.

— Supine Protraction: patient lies supine, on a bench, with arms perpendicular to body. The patient then makes a small ‘reaching’ motion while keeping the back flat on the bench. The reaching position is held for a few seconds and then released. The movement is repeated for sets of repetitions.

The above ISOTONIC exercises are performed against gravity and then the patient may be graduated to similar activities with the use of rubber bands and/or small weights. Such activities may also be performed while standing.

4) Proprioception (ability to sense where your own body parts are in space)

— PNF (Proprioceptive Neuromuscular Facilitation) helps stimulate the muscle/tendon stretch receptors for muscle length-tension re-education. The tissue is stretched to end-point or until ‘pain’ is beginning, then the patient contracts. The contraction aids in producing further relaxation for a brief time after contraction that is used to facilitate an increased stretch (provided by practitioner). Proprioceptive exercises vary, and they often also include use of an exercise ball, such as with having the patient move a ball to form letters of the alphabet, against the wall, with the hand of the affected side (eyes open/eyes closed).

Prognosis = Excellent for young individuals with acute, early stage impingement.

Expected recovery times may vary, though typically, inflammation subsides within 7-10 days, and complete recovery is expected within 12 weeks. If full recovery has not been achieved in such a timeframe, further investigation and/or non-conservative treatments may be required.

References

Belzer, J. and Durkin, R. Common Disorders of the Shoulder. Primary Care (1996);
23 (2): 365-388.
Fongemie, A., Buss, D., and Rolnick, S. Management of Shoulder Impingement Syndrome and Rotator Cuff Tears. American Family Physician (February, 1998); 57 (4).
Lally, S. Soothe Your Shoulder and Knee Pain. Prevention (1990); 4 (7): 33-43.
Nelson, L. Exercise and Fitness: Rehabilitation Protocols for the Shoulder. Chiropractic Journal (!992); 6 (5): 34.
Unidentified Author. Four Exercises to Strengthen the Muscles of Your Rotator Cuff. American Family Physician (February, 1998); 57 (4): 680.
Wolin, P. and Tarbet, J. Rotator Cuff Injury: Addressing Overhead Overuse. The Physician and Sportsmedicine (1997); 25 (6).

Written by Dr. Swain, B.Sc.(Hons), D.C., CICE
Certified Functional Abilities Evaluator
Certified Training in Impairment Rating (AMA Guides, 6th Edition)
Certified Independent Chiropractic Examiner

There is an elusive connection between an individual experiencing workplace stress and the occurrence of anxiety related illnesses including depression.

Psychologically Safe Workplaces

Canadian employers have been required by law to protect their employees’ physical health and safety in the workplace.  For the first time in Canadian history, employers are obligated to create and maintain not only a physically safe workplace, but also a psychologically safe work environment.

What is a Psychologically Safe Workplace?

A psychologically safe workplace is one that does not permit harm to an employee’s mental health in careless, negligent, reckless or intentional ways.  This kind of workplace is one in which every practical effort has been made to avoid reasonably foreseeable injury to the mental health of employees.

A report prepared for the Mental Health Commission of Canada – “Stress at Work” explains that a growing number of case law precedents, legislation changes and tribunal deliberations support a trend toward envisioning the duty to provide a psychologically safe workplace as an implicit term of the employment contract.

The law has imposed an increasingly restrictive limitation on management rights by requiring that the employer and management of work must lead to no lasting harm to employee mental health, which may impact an employee’s ability to function at work or outside of the workplace.  Interestingly, the overall implications are similar in both union and non-union workplaces.

In the not too distant past, acts of harassment and bullying resulting in psychological harm could give rise to legal actions for mental injury; we have now arrived at a point where even the negligent and chronic infliction of excessive work demands can certainly be the subject of such claims, under certain conditions.

Navigating the Workplace

In a rapidly transforming and uncertain environment, understanding the process and results of this change will be a manager’s key to responding effectively.

Managers and supervisors alike must pay be aware of the fact that making positive changes to the workplace will not only protect their employees, but will also enhance the competitiveness and overall workplace environment as a whole.

Recognizing anxiety and depression and the effects of each in the workplace are crucial.  The following illustrates both anxiety and depression:

Anxiety

Stress itself is not an illness, and in and of itself is not even necessarily harmful.  Because every person experiences stress differently, each individual’s reaction to stress can vary widely and can result in crippling anxiety for some. More than one quarter of the population will suffer from some type of anxiety disorder during their lifetime. Anxiety disorders are the most treatable of all mental disorders with 80% who undergo cognitive behaviour therapy report recovering after just one year.

There are a variety of anxiety disorders including:

• Generalized anxiety disorder which is characterized by chronic worrying, nervousness and exaggerated fears. This disorder is usually accompanied by physical symptoms that may include headaches, shaking, twitching, hot flushes, breathlessness, dizziness, nausea or insomnia;
• Social Anxiety Disorder is often noted by an extreme fear of being humiliated or ‘shown up’ in front of others;
• Obsessive Compulsive Disorder results in continual unwanted thoughts and rituals that the sufferer has no control over.

Depression

More than one million Canadians suffer from some form of a depressive illness. Over a lifetime as many as 12% of men and 24% of women experience at least one major depressive episode. Unfortunately less than one third of these individuals seek assistance from a doctor, despite the fact that treatment is successful in 70-80% of people who seek help. Depression is caused by a variety of issues, including traumatic life events, the impact of their own personal style (often introverted, dependent, high worriers, untrusting or inflexible), genetics, the absence of social support or often an imbalance of brain chemistry which comes on without a preceding traumatic event.

Symptoms of depression may include: reduced interest or pleasure in activities, changes in appetite, weight and sleep patterns, sad, dark mood, a feeling of lethargy, fatigue or restlessness, difficulty concentrating, feeling that life is purposeless and empty, irrational feelings of guilt, and thoughts of death or suicide.

Additional Support

Where an employer has a number of employees on extended absences related to anxiety and depression related illnesses, there is a high cost involved in continuing to operate the business profitably.

In workplaces where there is a combination of high stress activity and unresolved employee relation problems there seems to be an increased number of employees on medical leave for depression and anxiety. Workplace stress is rarely the only factor in an individual’s illness. Usually there is a combination of home life issues, coupled with a highly stressful work environment and together the situation is more than some individuals are able to manage.

Time Away vs. Staying at Work

As a percentage, how many employees are taking time away from the workplace when they experience anxiety or depression symptoms?  It has been found that most employees do not take extended sick leave absences; continuing to work during this time.

What kind of productivity can be expected from employees who stay in the workplace, ignoring anxiety and depression symptoms?  Low productivity is often exhibited together with less than optimal relations between affected employees, their co-workers and management.

The Workplace as a Source of Support

What can an employer do in terms of supporting vulnerable employees?

Employee Assistance Plans (EAPs) have increased in popularity and have become an invaluable tool in assisting employees experiencing a variety of workplace and personal issues.  Providing support to employees is crucial as there is statistical evidence that shows for each extended absence from work due to depression, there is an exponential increase in the likelihood of the illness reoccurring. This means that each time an employee is away from the workplace on sick leave for a depressive type illness, the chance of the employee leaving the workplace for the same illness increases by approximately 20%. Returning to work after such an absence is emotionally traumatic, and so the duration of the absence may increase each time the employee is away from the workplace.

• Talk to your employee.  Describing your observations and expressing your concern for their health is a good first step;
• Share information about the your internal EAP and discuss the benefits of this program;
• Assess the level of stress within your operation, are their unresolved issues contributing to a high stress environment?
• Take action to resolve the issues at play at your workplace.

A.R.S. understands that the costs involved in managing absence and offering appropriate support is crucial to healthy productive workplace.  Effective counselling and Employee Assistance Plans (EAP) are essential.

For additional information regarding A.R.S.’ EAP – Optimal Health Solutions and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

What some employers neglect to take into consideration is the home or “away from work” life of their employees.  While a healthy work environment is a good first step to ensuring optimal productivity and balance for employees, a healthy home life is just as important.

Healthy, productive employees are essential to every workplace.  It is important to recognize that situations and issues in an employee’s personal life will affect their ability to perform in the workplace.  Likewise, unresolved issues and stressors in the workplace can carry over to an employee’s home life.  The end result of this cycle is decreased overall health for the employee, and a decreased ability to perform in the workplace.

Employees today are managing a variety of personal situations while attempting to perform at the workplace.  Day care, elder care, addiction, financial and a variety of other stressors are affecting your employees and in some cases may be contributing to casual absenteeism in the workplace, which can ultimately develop into long-term absence.

As an employer you are not able to manage a healthy home life for employees, but you can offer tools that will encourage the best management of this home life as possible.

Psychological Healthcare

As Canadians we are accustomed to publicly funded provincial hospital insurance plans that provide excellent physical healthcare through a network of doctors and hospitals. Employer-sponsored extended healthcare insurance policies reimburse employees for some expenses not covered by the provincial plan.

Unfortunately, when we face emotional, interpersonal or psychological problems, the traditional healthcare delivery system can be of little assistance.  It can be difficult to locate a qualified professional, and often the accessibility and cost prevent us from getting the help we need.

Healthy Human Resources 

Personal problems can and ultimately do become personnel problems.  Investment in corporate wellness is likely to be the most significant factor that will influence the quality of work, productivity, attendance and retention of your staff.  By addressing the personal needs of your employees, you can create a healthier corporate environment.

Employee Assistance Plans (EAP)

EAPs have been in existence for many years, with varying degrees of success.  With some very good intentions employers have adopted EAPs for their employees, usually in combination with some sort of group insurance plan.

An EAP will help both your employees and your corporation reach their potentials. The increasing popularity of EAPs shows that corporations are beginning to realize the need to invest in healthy human resources.

The purpose of an EAP is to improve the psychological health of your employees and to provide the information and supports needed by all family members.   An EAP will assist employees in resolving their individual, marital, family and job performance situations.   As a result, their productivity and attendance will show improvement.

A.R.S.’ EAP –“Optimal Health Solutions”

As a national provider of Absence and Disability Management services across Canada, A.R.S. is pleased to offer a unique EAP solution to both employers and employees alike.  Optimal Health Solutions provides our employer clients and their valued employees with the dedicated personal attention and service required to meet the various needs in the workplace, and at home.

The A.R.S. Optimal Health Solutions plan specializes in providing counselling services to employees and family members with the intention of improving their overall health, productivity in the workplace, and quality of life.

The A.R.S. Optimal Health Solutions plan will provide access to qualified professionals who are trained to assist in the resolution of personal and work related situations.

The A.R.S. Optimal Health Solutions plan is unique in that we are able to deliver EAP services from PhD level Psychologists only.  These Psychologists are professionals with the highest qualification in the field of human behaviour and personal situational resolution.

Effective counselling focuses on assisting the employee deal effectively with change and stress in their personal, career and family lives.

As an employer, your managers, supervisors and human resource staff will be able to focus on work performance. They will no longer feel the need to struggle with the personal problems of their staff.

Optimal Health Solutions Provides:

• Direct Access:  Upon assigning a Registered Psychologist to an individual, he or she may contact this professional directly;
• Quick Response:  The first counselling session will take place as soon as possible;
• Direct Treatment:  If supplementary or long-term care are required, we are pleased to offer appropriate referrals;
• Availability:  Our staff is available to take referrals 24 hours per day, 7 days per week.

About A.R.S.

A.R.S. understands that the costs involved in ineffective management of employees’ personal situations are crucial to employers. Effective counselling and Employee Assistance Plans (EAP) are essential.

For additional information regarding Optimal Health Solutions and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

On first blush, this makes sense.  An employer pays premium for a short-term disability benefit regardless of whether employees use or do not use the benefit itself.  Premiums increase year to year regardless of use, although with extensive use they can certainly increase at alarming rates.

In the last ten to fifteen years in Canada it has become popular to switch from fully to self-insured short-term disability plans, mainly for perceived financial gain.  Making a change is fine, but it also makes sense to analyze the costs of a self-insured short-term disability program.

Many employers consider self-insuring because they feel their claims have not been substantial enough to warrant paying the premium for a fully-insured program.  Before any employer can make this decision it is important to analyze the following factors:

1. Actual short-term disability claims paid:  Has your organization tracked and accurately recorded the cost of these claims?  Most organizations are unaware of what they have paid out in short-term disability claims dollars.
2. Proof of Loss:  Most employers require some form of proof of loss (burden of proof) before an employee can access a casual absence or short-term disability plan.  How does this differ from what an insurer may require?  The differences are staggering.  An insurer will require supporting medical data, together with completion of a short-term disability claim form.  Most employers who self-insure have virtually no way to accurately manage the length or medical component of a claim.
3. Sick Days/Sick Time:  A number of employers offer some sort of sick pay that is utilized prior to a short-term disability claim, and they often allow employees to access this service in the days/weeks prior to a claim.  Medical management of this sick time is crucial, and this is often an area where employers lose track of a claim before it ever even begins.  Will you allow employees to utilize vacation days prior to a medical claim?  What are the ramifications of this action and what policies do you have in place to manage this process?

A “Hybrid” Approach – Third-Party Case Management

The objective of any short-term disability plan is to ensure that disabled employees receive pay and/or benefits during the period they are unable to work and that any return to work program is managed effectively returning the employee to their pre-disability job.

The “hybrid” approach involves the introduction of an independent third-party case management service that would accurately and effectively manage all short-term disability claims, according to a predetermined set of criteria.

Third-party case management provides considerable savings as fees are only paid when a claim is incurred, as opposed to a fully-insured plan where premiums are paid regardless of the number of claims submitted and paid.  As the employer managing a third-party plan you are also responsible for the dollars paid for each claim paid in accordance with the terms of your contract.

Third-party case management is also attractive in that it provides accurate and expert adjudication, medical management, and full supports for all graduated return to work programs.

The Right Choice

The right choice for your organization can be determined by studying and auditing claim dollars paid out versus the cost of the premiums to insure this liability.

The following questions are important when considering a truly self-insured program:

• What functions do you want your internal HR department performing?
• Are you following all of the current legislation in terms of privacy with regard to claims payment?
• The risks involved in a bad claims year – can your organization continue to support a program in a year where your claims may double or triple in cost?
• What liability is involved in making an incorrect decision?
• What are your internal processes where a contentious claim is concerned?  Do you have staff internally capable of defending a claim decision?

About A.R.S.

A.R.S. understands that the costs involved in managing and adjudicating short-term disability claims are important to employers.  Effective adjudication, claims management and accurate claims payments are crucial.

A.R.S. offers a comprehensive third-party claims management program that can assist employers both in managing cost and claims management.

For additional information regarding third-party claims management and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

A SPRAIN refers to a common injury to a LIGAMENT, typically involving a stretch that results in one of 3 grades of injury. A Grade 1 sprain is mild in nature, while a Grade 3 sprain involves complete tissue tearing. Typically, a Grade 1 injury of this nature involves having torn a few fibres of a ligament. Onset is acute and only minor weakness, swelling and/or loss of function results. With such an injury, there is no expected pain on isometric contraction (ligament tissue is inert), but there is pain associated with ‘stretching’ the tissue. A Grade 2 sprain typically involves partial tearing of a ligament. Onset is acute, while weakness may be ‘minor to moderate’, swelling may be moderate and loss of function is ‘moderate to major’. With such an injury, there is no expected pain on isometric contraction (ligament tissue is inert), but there is pain associated with ‘stretching’ the tissue. Finally, in the scenario of a Grade 3 injury, all fibres of a ligament are torn. Onset is acute and weakness is expected to be ‘minor to moderate’. Swelling and loss of function are expected to be ‘moderate to major’. In a Grade 3 injury, early detection of a palpable defect may also be possible. In this scenario, it is possible for there to be no pain with stretching given that complete tearing has occurred (though other surrounding tissues may have incurred grade 1 or 2 injuries simultaneously, which would result in pain associated with ‘stretching’).

A STRAIN refers to a common injury to a MUSCLE or TENDON, typically involving a stretch or twist of the tissue that results in one of 3 grades of injury. A Grade 1 strain is mild in nature, while a Grade 3 strain involves rupture of tissue from bony attachment or complete tissue tearing. Typically, a Grade 1 injury of this nature involves having torn a few fibres of a muscle. Onset is acute and only minor weakness, swelling and/or loss of function results. With such an injury, there is minor pain expected with both stretch of the tissue and with isometric contraction. A Grade 2 strain typically involves partial tearing of a muscle. Onset is acute, while weakness may be ‘moderate to major’, and reflex inhibition may be noted. Spasm of muscle, swelling and loss of function may be ‘moderate to major’. Pain would be noted with stretching the tissue and increased further with isometric contraction. Finally, in the scenario of a Grade 3 injury, all fibres of a muscle are torn. Onset is acute and weakness is expected to be ‘moderate to major’. Swelling would be expected to be ‘moderate to major’ and loss of function would be expected to be ‘major’. Reflex inhibition would be expected. In this scenario, pain with isometric contraction would be little to none, and stretching of the tissue may also fail to provoke pain (though other surrounding tissues may have incurred grade 1 or 2 injuries simultaneously, which would result in pain associated with ‘stretching’). In a Grade 3 injury, detection of a palpable defect may also be possible, depending on the muscle that has been injured.

Written by Dr. Swain, B.Sc.(Hons), D.C., CICE
Certified Functional Abilities Evaluator
Certified Training in Impairment Rating (AMA Guides, 6th Edition)
Certified Independent Chiropractic Examiner

About A.R.S.
Assessment Rehabilitation Services Inc. (A.R.S.) partners with physicians and specialists across Canada to assist claimants with sprains and strains. The goal of A.R.S. is to design a treatment plan with the claimant in mind, a plan that will support a safe and speedy recovery that will allow the claimant to return to the workplace.

For additional information regarding sprains and strains and all other Insurance Services offered by A.R.S. please contact:
Warren Hamer – Director of Marketing
warren@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

Fibromyalgia is a syndrome comprised of multiple soft tissue tender points (soreness seems isolated to muscles and ligaments), musculoskeletal pain (not in joints like arthritis), and stiffness in multiple regions. This condition may also cause fatigue, sleep problems, depression and concentration difficulty.

Symptoms:

- Pain (discomfort in ligaments and muscles, not joints). Usually worse in morning. Described as burning, aching, soreness, bruised feeling.
- Fatigue (it seems no amount of rest is helpful for some). Often have trouble falling asleep, awake frequently, and simply cannot wake feeling refreshed.
- Fibrofog (mental fogginess, unclear thinking, memory difficulties)
- Headaches, nervousness, dizziness, frequent awakenings due to discomfort, difficulty falling asleep and intestinal disturbances have also been noted.
- Almost ½ of all fibromyalgic patients report soft-tissue swelling and/or numbness/tingling.

What Causes it?

- no specific cause has been isolated
- Fibromyalgia is about 4-7 times more common in women than in men

Theories of Causation:

1) Altered Neurotransmitter Levels.
a. Serotonin: plays a role in controlling pain, regulating sleep and warding off depression. Serotonin deficiency may be seen in fibromyalgic patients.
b. Substance P: fibromyalgic patients may have 2-3 times more Substance P than the normal individual. Substance P heightens the nerve’s sensitivity to pain. Thus, high levels can cause non-noxious stimuli to be perceived as painful.
c. Adenosine Triphosphate: reduced concentration in red blood cells may be seen in fibromyalgic patients.

2) Lack of deep sleep. Muscle recovery occurs during stage 4 deep sleep. Fibromyalgia patients tend not to enter stage 4, therefore, they do not get the necessary recuperation. Normal participants in research, who have been deprived of stage 4 deep-sleep tended to develop reversible symptoms similar to FMS.

3) Immune Disorders (especially autoimmune problems like leaky gut syndrome)

4) Neuro-Endocrine Abnormalities.
a. Hypothalamic-Pituitary-Adrenal Axis Dysfunction: this axis is critical for proper stress-adaptation responses. Some believe that there are 5 key, measurable abnormalities associated with HPA axis dysfunction – (1) low free cortisol in 24-hour urine sample, (2) loss of normal circadian rhythm with elevated evening cortisol levels, (3) insulin-induced hypoglycemia due to increased ACTH, (4) low growth hormone levels, and (5) insufficient adrenal release of glucocorticoids (stress response mediators).

5) Inherited

6) Viral Infections

7) Reactive Fibromyalgia Syndrome (arises after illness, trauma, etc.)

8 ) Muscle Metabolic Abberations

9) Various Psychopathologies

10) Abnormal Central Processing

11) Genetic Predisposition

12) Leaky Gut Syndrome: due to inflammation of the gut lining, the intestine is more permeable than normal. As such, various waste products, bacteria, fungi, toxins, undigested protein, etc. more easily enter the bloodstream. The immune system will produce antibodies against the larger invading molecules and eventually against proteins and previously well tolerated foods. The antibodies trigger inflammatory reactions as they accumulate in tissues and react with the corresponding foods/proteins. If the inflammatory process occurs in the muscles and organ systems, many experts believe that this may result in an autoimmune derived Fibryomyalgia Syndrome. Leaky Gut Syndrome is also implicated in the development of several mineral deficiencies.

Examinations/Tests:

- Unfortunately, no single test is capable of determining whether or not someone has fibromyalgia. The diagnosis is made by a thorough history and physical examination. Other tests (blood, xray, etc) may be requested to rule out other illnesses that may mimic fibromyalgia.

The American College of Rheumatology originally created clear diagnostic criteria for the diagnosis of fibromyalgia, which were introduced in 1990:

1) Diffuse muscle pain, located on both sides of the body, above and below the waist, present for longer than 3 months

2) Pain must occur at a minimum of 11 out of 18 defined tender points when digital pressure of 4 kg per unit area of force is applied (includes areas such as cervical skeleton, shoulders, buttock, lower back and below waist).

3) Lab tests are within normal limits.

4) 3 out of 10 minor criteria are present: chronic anxiety/tension, fatigue, poor sleep, chronic headaches, numbness, subjective soft tissue swelling, irritable bowel syndrome, pain impacted by physical activity or weather conditions or anxiety/stress.

The American College of Rheumatology provisionally accepted new criteria for the diagnosis of fibromyalgia in 2010. The controversial ‘tender point’ evaluation has been replaced by a ‘symptom severity scale’ and a ‘widespread pain index’. To meet the criteria for a diagnosis, one must have seven or more pain areas on the pain index and a symptom severity score of 5 or more, or 3-6 pain areas and a symptom severity score of 9 or more. The new criteria continue to also include symptom duration of at least 3 months, and that other causes of the patient’s presentation are ruled out prior to establishing a diagnosis of ‘fibromyalgia’.

Treatment:

- there is no known cure
- a multidisciplinary approach is considered best
- current treatment is geared towards symptom relief

A) Regular, low impact aerobic exercise that is gradually increased in intensity. It is also important to include gentle flexibility exercises that progress to stretching all major muscle groups.

B) Pain Control Interventions: Heat, Electrotherapy, Ice, Massage, Stretching, Chiropractic Adjustments, Myofascial Release Therapy, Relaxation Training, Cognitive-Behavioral Techniques, etc.

C) Over the Counter and Prescribed Medications

D) Tender Point Injections

E) Vitamin D supplementation

F) S-Adenosylmethionine (SAM-e). Has anti-inflammatory, pain killing and anti-depressant effects.

G) Ascorbigen and Broccoli Powder. A few small studies have shown positive results.

H) 5-HTP (hydroxytryptophan) supplementation

I) Vitamins, Minerals, Antioxidants, Malic Acid – Magnesium combination, Amino Acids, Herbs

J) Sleep Diary can be helpful

K) Nutrition:
i. Food journal may be helpful
ii. Gradual weaning from caffeine and alcohol
iii. Remove tobacco, chemical-laden foods, refined sugars, white flour, processed foods and additives (MSG and Aspartame)
iv. Decrease carbohydrate intake and choose foods lower on the glycemic index
v. Increase vegetables, fish, fiber and green leafy and yellow vegetables.
vi. Because fibromyalgic patients may produce more free radicals, which lead to oxidative stress on the system, antioxidant supplements may also be recommended. Some think that a vegetarian diet may improve some symptoms.

L) Relaxin Therapy: Dr. Samuel Yue noted that many women with fibromyalgia experience symptom relief during pregnancy. With hormonal research, we know that the most apparent change in hormone production occurs with Relaxin (produced by the ovaries; 10 fold increase during pregnancy). Relaxin is responsible for ‘relaxing’ the soft tissue to the point where a woman’s pelvis will become mobile enough to allow passage of an infant. Research has shown promise in this area. While there are possible negative side-effects, the positive effects of this therapy are almost ‘anti-aging’ in nature (ex. Many things from better smell/taste sensation to more youthful looking skin to soft tissue relaxation! It actually helps to remodel the connective tissue towards a more youthful state).

Prevention:

No known way to prevent.

Prognosis:

Poor. Until we understand what causes and cures the disease, the outlook is not considered positive.

Most Common Differentials:

1. Myofascial Pain Syndrome
2. Chronic Fatigue Syndrome

Fibromyalgia is a generalized hypersensitivity associated with tender points in the muscles (not trigger points). The pain does not refer to distant areas when these tender points are compressed. Myofascial pain syndrome is associated with trigger points, which are specific areas in muscle tissue/fascia that are sensitive to compression AND refer symptoms to a ‘referral zone’. Trigger points are palpably detectable taut bands that undergo localized twitch response. Myofascial pain syndrome does not involve fatigue as one of its main criteria. It is more difficult to separate Chronic Fatigue Syndrome and Fibromyalgia because chronic ‘un-refreshed sleep’ will lead to fatigue and the resultant neuro-hypersensitivity, as well as other associated ailments/symptoms.

Important Consideration:

As quoted by the Fibromyalgia Network (http://www.fmnetnews.com/basics-news-criteria410.php), Dr. Wolfe (an author of the new preliminary diagnostic criteria), indicated that “The ACR diagnostic criteria should not be seen as an endorsement of the legitimacy and existence of fibromyalgia-the criteria are neutral on that point.” It was also indicated that while the new format of studying widespread pain is simple and inexpensive, it is not likely to result in the development of any new effective therapies or actual biomarkers for the condition.

Written by Dr. Swain, B.Sc.(Hons), D.C., CICE

About A.R.S.

Assessment Rehabilitation Services Inc. (A.R.S.) partners with physicians and specialists across Canada to assist claimants with fibromyalgia. The goal of A.R.S. is to design a treatment plan with the claimant in mind, a plan that will support a safe and speedy recovery that will allow the claimant to return to the workplace.

For additional information regarding fibromyalgia and all other Insurance Services offered by A.R.S. please contact:

Warren Hamer – Director of Marketing
warren@arsi.ca
Telephone: 416-510-2468 or Toll Free: 1-877-304-2239

Every year, an estimated 10 to 25% of Canadians may contract the flu, with children being two to three times more likely than their adult counterparts to come down with the flu virus.  Studies have shown that vaccinating children against flu protects the entire family and community at large against the spread of the flu virus.

Flu and Children

Take a moment to think about how children spend their time.  They play with other children in highly populated areas in schools, playgrounds, daycare centres and friends’ homes.  Children tend to have the highest rates of influenza, and younger children are also at high risk of complications associated with the flu.

Flu in the Workplace

Take a moment to think about your workplace.  As an adult, you travel to and from work.  Some of us ride public transit in close quarters, others carpool and some drive in a car alone, but we all end up at the same workplace; together.  Much like younger children, adults spend long hours with other adults during the workday, and on the trip to and from the workplace.

Employer Challenges

Employers face challenges in keeping productivity at an acceptable level during flu season, as well as ensuring that their employees are as healthy as they can possibly be.

Does your workplace suffer from higher than average absenteeism during flu season?  If you are like most employers the answer to this question is a resounding “yes”.

Challenges –

• Days lost to absenteeism and their associated financial costs;
• Lower morale in the workplace due to some employees performing the duties of others while they are away from the workplace;
• Absenteeism due to the flu breeds additional absenteeism…..

 Presenteeism –

• Some employees will feel obligated to attend the workplace regardless of their state of health.  This is a dangerous situation for a number of reasons.  For the sick employee, they are not able to tend to their health situation and will often remain ill for a longer period of time.  For the sick employee’s colleagues, influenza is easily spread which breeds further illness.

Strategic Partnership

A.R.S. Assessment Rehabilitation Services Inc. (A.R.S.) is pleased to partner with AstraZenca to offer a revolutionary flu vaccine – FluMist® to our employer clients and their valued employees by way of Flu Clinics beginning in the Fall of 2011.

AstraZeneca reports that FluMist® has a long standing history in the United States and as FluMist® is delivered as a nasal mist as opposed to the traditional flu ‘vaccine’, many employers and individuals are opting to take advantage of this product beginning in 2011.

FluMist^® is a preservative-free vaccine that uses live virus strains recommended by the World Health Organization (northern hemisphere) for this influenza season that are weakened so as not to cause the flu.

Available in the U.S. since 2003, FluMist^® has been studied in more than 140,000 people and more than 39 million doses have been manufactured and distributed in the U.S. alone.

To help protect against seasonal influenza, FluMist^®, the only needle-free vaccine, is available this fall through Flu Clinics in conjunction with A.R.S. and AstraZeneca.

With FluMist®, adults and children can feel reassured that they can be protected against influenza with a safe and effective vaccine, without having to experience the discomfort that comes with the traditional injectable vaccine.

Influenza Vaccination Clinics

In the last few years employers are gaining a better understanding of the importance of vaccinating employees (and in some cases their families) and the positive effect this can have on their workplace from both a financial and morale perspective.

About A.R.S.

A.R.S. understands that absence, presenteeism and all associated costs related to influenza are concerning to employers.  Today, immunizing employees and their families is easier and more cost effective than ever.

A.R.S. can arrange for flu clinics on your time schedule – if you have employees working regular hours, shift work or any combination of the two we can accommodate.  A.R.S. can deliver a flu clinic from a few hours in length to a full day where required.

Our registered nurses are willing and able to attend your workplace on your schedule.  An effective flu clinic and immunization program will help to ensure that your employees and their families are as healthy as they can be.

For additional information regarding Flu Clinics and all other Employer Services offered by A.R.S. please contact:

Mary Crunkleton – Director of Employer Services
mary@arsi.ca
Telephone:  416-510-2468 or Toll Free:  1-877-304-2239

Typically associated with trigger points that can present themselves in the form of painful knots or lumps, the pain can cause restricted movement, sleep disturbances, and guarding, which is a natural protective response that helps to prevent further injury. Although myofascial pain is not a fatal condition, it can cause a significant reduction in quality of life and is a major cause of time lost from work.

There are many causes of myofascial pain, from muscle injuries to strain on a particular muscle, ligament or tendon. Other causes may include injury to intervertebral disc, repetitive motion, general fatigue, and atrophy.

When it comes to diagnosing myofascial pain, locating trigger points is one of the most important parts of the physical examination. There are four types of trigger points that can be distinguished:

1) Active Trigger Point – This will be an extremely tender area of the muscle that is connected to local or regional pain.  An active trigger point as a palpable, taut band or nodule within the tissue that is hyperirritable.  The area is painful with direct compression and may produce referred pain and tenderness, local twitch response, motor dysfunction and/or autonomic phenomena.  The subjective symptoms from an active trigger point are present constantly.  Pain referral is characteristic of a trigger point and helps to differentiate a trigger point from a local tender point (painful at site of palpation only).

2) Latent Trigger Point – This is an inactive area that has the potential to act like a trigger point.

3) Secondary Trigger Point – When a muscle becomes overloaded, typically caused from guarding, it can induce a secondary trigger point in another muscle.

4) Satellite Myofascial Point – This is an extremely irritable area in a muscle that becomes inactive when a key (reference point) trigger point is inactivated.  The satellite trigger point is induced neurogenically or mechanically by the activity of a key trigger point.

A skilled examiner can provide an accurate assessment of claimants with myofascial pain. The physical examination requires close observation and should include such things as:

Measuring Range Of Motion

This is another important part of the physical examination and should be completed very carefully with the use of a goniometer or digital inclinometer, if at all possible.

Observing How the Claimant Performs the Motion

Probably the most important aspect of the physical examination relates to observing how the patient moves. Normal motion will be observed when the patient is concentrating on other things, so observing how they turn to talk to an interpreter, get on and off the exam table and turn over on the table may be more beneficial than asking them directly to show you their range of motion.

Spontaneous motion is the type of motion we use in our daily lives to bend and twist and walk. It is a natural motion that we develop in childhood and allows us to function without concern at work and at play.

When we have been injured in some way we tend to be protective of that motion and be careful how we bend and twist and turn and function in our daily routine. This protective response, or guarding, is a natural reaction to help prevent further pain and injury. Unfortunately, advising a patient to be careful may only reinforce this protective response.

The problem begins when the guarding instinct is carried on after the initial injury has been resolved. This lack of natural spontaneous motion requires excessive muscle contraction to continue the protection. By carefully observing how a claimant moves, it will be easy to discover this guarded, slow, and often tremulous motion.

Guarding, even over a short period of time, will often result in muscle fatigue and muscle pain, which in turn results in a chronic pain problem. There is nothing wrong with the muscles, they are just doing what they are being asked to do and not allowed to do what they were trained to do from childhood.

In summary the physical examination should look for trigger points, note the range of motion and observe how spontaneous motion is performed, with the goal to encourage activities that will allow for the return of spontaneous motion, rather than primarily treating the muscle pain on its own.

About A.R.S.

Assessment Rehabilitation Services Inc. (A.R.S.) partners with physicians and specialists across Canada to assist claimants with myofascial pain. The goal of A.R.S. is to design a treatment plan with the claimant in mind, a plan that will support a safe and speedy recovery that will allow the claimant to return to the workplace.

For additional information regarding myofascial pain and all other Insurance Services offered by A.R.S. please contact:

Warren Hamer – Director of Marketing

warren@arsi.ca

Telephone:  416-510-2468 or Toll Free:  1-877-304-2239