The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

An Appeal Panel hearing was held on August 16, 2000, at the request of a union representative, acting on behalf of the claimant. The Panel discussed this appeal on August 16, 2000.

Issue

Whether or not the claimant is entitled to benefits or services beyond May 25, 1999.

Decision

That the claimant is not entitled to benefits or services beyond May 25, 1999.

Background

In December 1997, the claimant filed a claim for workers compensation benefits with respect to left shoulder, neck, arm and back complaints which she related to her duties on a packing assembly line in November 1997. The claim was accepted by the Workers Compensation Board (WCB) and benefits commenced on November 20, 1997. Medical information on file showed the following:

• on October 15, 1997, a chiropractor diagnosed the claimant as follows: chronic moderate cervical dysfunction, chronic moderate left shoulder strain, acute left lateral epicondylitis and regional myofascial pain syndrome.
• on December 2, 1997, a general practitioner diagnosed the claimant with left arm, shoulder, and chest strain and he subsequently referred the claimant for physiotherapy treatments. The claimant made several attempts to return to work on a graduated basis but was unsuccessful due to pain complaints.
• a December 16, 1997 cervical spine x-ray report read as follows: "The disc spaces are well preserved. Minimal spurring is seen emanating from the C5 body. Facet joints are well preserved with no evidence of bony central canal stenosis."
• following examination on March 31, 1998, a WCB medical advisor concluded that the claimant was now developing adhesive capsulitis of the left shoulder girdle. The claimant had various areas of pinpoint tenderness on the muscles. The medical advisor stated that the claimant was unable to perform any work duties at this time.
• on July 16, 1998, the claimant was assessed by a physical medicine and rehabilitation specialist. His impression following examination was that the claimant's symptoms appeared to be related to left shoulder girdle dysfunction. The main finding was left bicipital tendonitis. The specialist's opinion was that the findings did not suggest a rotator cuff tendonopathy or labral injury. There were other soft tissue findings, however the specialist felt that the current treatment should be directed at the tendonitis. In a follow-up report dated August 19, 1998, the specialist indicated that the claimant's symptoms had not changed significantly.
• on September 3, 1998, a WCB medical advisor reviewed the medical reports and was of the opinion that further physiotherapy treatment was warranted with respect to the claimant's bicipital tendonitis.
• a report was received from a second physical medicine and rehabilitation specialist who saw the claimant on August 20, 1998. His clinical impression was that the claimant had myofascial neck and left shoulder pain syndrome affecting her pectoralis major, trapezius, sternocleidomastoid, deltoid and rotator cuff muscles. The claimant was also seen by the specialist on September 21, 1998 and September 28, 1998. Clinically, the specialist reported that the claimant had no active trigger points of the muscles of the chest, shoulder girdle and neck. The claimant had no evidence of any nerve root or peripheral nerve compression and no evidence of inflammatory arthritis or tendinitis of the left shoulder joint.
• on December 29, 1998, the claimant was assessed by a WCB physical medicine and rehabilitation consultant. The consultant noted there was a history of gradual onset of symptomatology with no specific injury reported in the left arm, shoulder and upper chest. Several evaluations on the file noted that the claimant had some bicipital tendonitis present in the left shoulder. The claimant appeared to have some muscle origin symptomatology. The consultant was unable to identify any active myofascial pain syndrome activity. The consultant commented that as the claimant had been off regular work since November 1997, he was uncertain as to the significance of the current symptomatology as he would have expected resolution of any prior tendonitis off work demands, assuming these were implicated as the cause of her symptomology. The consultant further concluded that the claimant was currently not totally disabled and could perform light work activities with restrictions.
• on April 16, 1999, the treating general practitioner noted that the claimant complained of extreme pain in her upper shoulder and top of left trapezius. The claimant indicated her left neck and chest wall pain was better and that extension of her arm felt better. The physician commented that the claimant felt she could not go back to her previous job.
• at the request of primary adjudication, the WCB's physical medicine and rehabilitation consultant reviewed the case on May 6, 1999. The consultant was of the opinion that the claimant had shown improvement between the December 1998 WCB examination and the medical report of April 16, 1999. He noted there were no objective findings shown on the report. The consultant was of the view that resolution of the claimant's symptoms would have been expected long ago. On a balance of probabilities, he felt the claimant's current symptoms were not related to her work injury and that restrictions were not required.

In a decision letter dated May 19, 1999, the WCB's Rehabilitation & Compensation Services advised the claimant that wage loss benefits were not payable after May 25, 1999 as it was considered she had recovered from the effects of the compensable accident. The letter further indicated that there were minimal objective findings on file to suggest that the claimant was still suffering from the effects of her injury and that restrictions were no longer required as a direct result of the compensable injury.

On July 20, 1999, a union representative appealed the above decision to Review Office stating that the claimant had not totally recovered from her work related injury of October 15, 1997. In support of this position, a June 22, 1999 report from an occupational health physician was submitted. The union representative indicated that the claimant had terminated her employment with the accident employer as of June 18, 1999, to pursue other employment within her capabilities. The claimant was therefore requesting that the WCB continue wage loss benefits beyond May 25, 1999 until June 18, 1999, and to continue its responsibility for services in the form of treatment and rehabilitation beyond May 25th.

Following consultation with a WCB medical advisor on September 9, 1999, Review Office determined that the claimant was not entitled to benefits or services beyond May 25, 1999. Review Office based its decision on the following opinion and weight of medical evidence:

• the claimant's symptoms should have resolved after being away from the work force since November 1997. Her myofascial symptoms had been inconsistently documented throughout the duration of the worker's disability.
• when examined by a WCB medical advisor in December 1998, the claimant's symptoms were muscular in origin, and her primary limitations were symptoms based, and that even without treatment, her left shoulder tendonitis should have gradually resolved.
• the WCB healthcare advisor was unsure of the relationship of the worker's ongoing symptoms to the compensable injury and was unable to identify objective medical findings to support these symptoms.
• recent medical reports document the worker's current symptoms but do not contain objective medical findings.

On April 3, 2000, the union representative appealed Review Office's decision and an oral hearing was arranged.

Reasons

The issue in this appeal is whether or not the claimant is entitled to benefits or services beyond May 25, 1999.

The relevant subsections of the Workers Compensation Act (the Act) in this appeal are subsection 39(2) which provides for the duration of wage loss benefits and 27(1) which provides for medical aid.

Subsection 39(2) states:

Duration of wage loss benefits

39(2) Subject to subsection (3), wage loss benefits are payable until

a) the loss of earning capacity ends, as determined by the board; or

b) the worker attains the age of 65 years.

Subsection 27(1) states:

Provision of medical aid

27(1) The board may provide a worker with such medical aid as the board considers necessary to cure and provide relief from an injury resulting from an accident.

In this appeal we reviewed all the evidence on file and received at the hearing and find unanimously that the weight of the evidence, on a balance of probabilities, supports a finding that the claimant is not entitled to benefits or services beyond May 25, 1999. In reaching this conclusion we noted the following evidence. The claimant submitted a claim to the WCB in December 1997 contending that her work in a packing plant had led to problems in her left shoulder, neck, arm and back which had commenced in October 1997. The WCB accepted responsibility for the claim as a non-specific injury and benefits were paid from November 20, 1997 until May 25, 1999.

The claimant was initially seen by an attending chiropractor and subsequently seen by an attending physician. The attending physician diagnosed strain whereas the chiropractor indicated strain as well as a left lateral epicondylitis and a regional myofascial pain syndrome. The attending physician recommended that the claimant be examined by a WCB medical advisor. The claimant was examined by a WCB medical advisor on March 3, 1998. He noted reduced range of motion of the left shoulder and felt she might be developing adhesive capsulitis. He further noted pinpoint tenderness on the muscles and that the claimant was scheduled to see a physical medicine specialist. He felt she should not perform any work duties until she had been seen by this specialist.

The claimant was examined by a physical medicine specialist on July 16, 1998. The specialist indicated his main finding was left bicipital tendonitis and he noted other soft tissue findings. He prescribed non-steroidal anti inflammatories. Subsequently he noted little improvement and referred the claimant for physiotherapy treatment.

The claimant was seen by a second physical medicine specialist on August 20 and September 21 and 28, 1998. He found generalized tenderness of the soft tissues of the back, neck and shoulder joints but clinically no active trigger points of the same areas. (emphasis added). The specialist found no evidence of any nerve root compression or of inflammatory arthritis, or tendonitis of the left shoulder.

The specialist recommended soft tissue treatment modalities followed by stretching, mobilization and conditioning exercises for the next 4 weeks followed by a return to gainful employment.

The claimant was subsequently reviewed by the first physical medicine specialist who noted marginal improvement since he last saw her and suggested that the claimant's main limitations were symptom based and that he had nothing further to suggest. The claimant was examined by a WCB specialist in physical medicine on December 28, 1998. He felt the claimant appeared to have some bicipital tendonitis of the left shoulder as well as some muscle-origin symptomatology. He noted that the current activity might represent resolving myofascial pain syndrome activity. (emphasis added). He also indicated:

" I was unable to identify on the current clinical examination any active myofascial pain activity.

As the claimant has been off regular work since November 1997, I am uncertain as to the significance of the current symptomatology as I would have expected resolution of any prior tendonitis off work demands, assuming these were implicated as the cause of the symptomatology.

However I cannot rule out some degree of aggravation of the tendonitis as a result of prior physiotherapy... .

I would also have expected better improvement and resolution of any residual muscle involvement to date as she has been away from any aggravating physical work demands and is doing a regular stretching exercise program... .

I would expect even with no further treatment directed at the tendonitis in the shoulder there should be gradual further improvement."

The specialist further found that the claimant was not totally disabled and could return to light duties with temporary left shoulder restrictions for 3 months. On a further review of the most recent medical information, on April 30, 1999, the WCB physical medicine specialist indicated that a resolution of the symptoms related to the injury would be expected because the claimant had not worked and that her current symptoms were unlikely to be related to the compensable injury and that restrictions related to the injury were not required.

In June 1999, the claimant was reviewed by a physician at an occupational health centre who noted shoulder symptomatology and ongoing myofascial discomfort and referred the claimant to a third physical medicine specialist.

The WCB physical medicine specialist indicated at this stage that that there was no medical evidence to support a relationship between the ongoing myofascial pain discomfort and the compensable event.

We note the third physical medicine specialist saw the claimant initially on September 30, 1999, some two years following the compensable accident. At this stage, he diagnosed myofascial pain syndrome with trigger points and indicated that there was a temporal relationship to the compensable event and that its chronic nature was due to the persistence of trigger points not eradicated by previous treatment.

We note the above evidence and conclude that the claimant's current left shoulder symptomatology is unrelated to the compensable event of October 1997. We placed weight on the opinions of the first consulting physical medicine specialist on October 6, 1998 who found no active trigger points of the muscles of the chest, shoulder girdle and neck and recommended 4 weeks treatment of soft tissues followed by stretching, mobilization and conditioning followed by a return to gainful employment.

We also place weight on the opinion of the WCB physical medicine specialist. He noted on December 29, 1998 that he was unable to identify, on clinical examination, any active myofascial pain syndrome activity; that the current activity might be resolving myofascial pain syndrome activity; and as the claimant had been off work duties since November 1997 that he would have expected resolution of any tendonitis related to work. Also, even with no further treatment directed at the tendonitis there should be gradual improvement. He further noted on April 30, 1999 following review of the latest medical information that current problems were likely not related to work and that restrictions were not required.

We find this to be the most consistent and contemporaneous evidence with respect to the compensable event. In regard to the later report by the third physical medicine specialist dated January 25, 2000 we placed much less weight on this evidence due to the length of time which had elapsed between the compensable event and the date of first examination. We find the postulation of a cause and effect relationship between the current symptoms and the compensable event on a temporal basis to be somewhat speculative in light of all the other evidence on file.

We therefore conclude that the weight of the evidence, on a balance of probabilities, does not support a relationship between the claimant's current symptoms and the compensable event of October 1997. We further find that any ongoing symptomatology and need for restrictions are not related to the compensable event and that the claimant has recovered from any residual problems related to the compensable event. On this basis the claimant is not entitled to any further benefits and services beyond May 25, 1999. Therefore the claimant's appeal is denied.

Panel Members

D.A. Vivian, Presiding Officer
A. Finkel, Commissioner
C. Monk, Commissioner

Recording Secretary, B. Miller

D.A. Vivian - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 4th day of October, 2000