The Appeal CommissionThe Workers Compensation Act of Manitoba

Introduction

This appeal deals with the causal relationship between the worker’s back and sleep complaints and his September 2004 compensable injury.

Background

The worker works as an acoustic ceiling mechanic. This job requires him to install acoustic ceiling tiles often in an extended position with his arms over his head. The size and weight of the tiles can vary from 30 to 70 pounds and may require use of a scaffold or a ladder.

On September 30, 2004, the worker injured his back after pulling skids of ceiling tiles. He was diagnosed with a thoracolumbar and lumbar sprain/strain and was authorized to return to light duty work effective October 18, 2004; this consisted of performing his regular duties with the exception of heavy lifting. On October 23, 2004, he re-injured his back when he lifted ceiling tiles weighing approximately 45 pounds. He went off work and was referred for a lumbar CT scan and assessment by a sports medicine specialist.

The sports medicine specialist saw the worker on December 1, 2004. He thought that the worker had suffered mechanical and possibly discogenic back pain or a disc herniation. He referred the worker for a course of physiotherapy treatment. The initial assessment by the physiotherapist was done on December 3, 2004. The physiotherapist noted that the worker was agitated and could not find any comfortable position for his back; he complained that it was hard to sleep, sit, stand or lie down.

A CT of the lumbar spine dated December 15, 2004 revealed a broad central disc bulging in the L4-5 area in association with ligamentous hypertrophy and degenerative change in the apophyseal joints.

On January 13, 2005, a WCB medical advisor reviewed the file. She commented that the degenerative changes and disc bulging at the L4-5 did not appear to be significant. She noted that the sports medicine specialist had recommended modified duties of no lifting greater than 15 pounds and no repeated or sustained bending or twisting with the ability to change position as needed. She cautioned that the worker may not be able to resume his regular duties after his course of physiotherapy given his diagnosis.

The worker’s ongoing subjective complaints were noted in the physiotherapist’s February 1, 2005 discharge report. He noted that the worker’s nagging back pain was not relieved by rest, exercise or changing positions and that the worker did not sleep well at night due to pain. He said the worker’s pain did not seem mechanical in nature. On February 8, 2005, the physiotherapist told a WCB staff representative that both he and the sports medicine specialist felt the worker’s back pain was unrelated to his back but was radiating there from a possible abdominal injury or something else. Subsequent diagnostic tests ruled out this hypothesis.

The worker was then called in for an examination at the WCB on March 21, 2005. The WCB medical advisor that examined the worker found him to be tender along both of the paraspinal muscle areas in the lumbar spine. She thought that his symptoms were musculoskeletal in nature but that his recovery had been prolonged and he was not yet ready to return to even modified duties as he was still unable to find a comfortable position to relieve his back pain. She recommended further physiotherapy and thought that after this course of treatment he would be able to start light duties with restrictions of no lifting greater than 20 pounds, no repetitive or sustained forward flexing or twisting and the ability to change positions as required.

On April 26, 2005, the physiotherapist noted that the worker’s low back pain was preventing him from getting comfortable and that it interrupted his sleep. The worker had pain at end range of all trunk movement. The diagnosis rendered was non-specific mechanical low back pain.

On May 13, 2005, the WCB medical advisor commented that she expected that the worker would be recovered after four to six weeks of physiotherapy.

On May 31, 2005, the family physician outlined a return to work program starting June 20, 2005 with light duties including no overhead lifting, with the worker gradually increasing his hours of work until he was back at full regular duties by August 1, 2005.

On June 8, 2005, the treating physiotherapist reported that the worker’s back pain and sleep pattern were improving but the pain was still constant. Right hip flexor deficits continued but were improving. Further core strengthening was required.

On June 27, 2005, the worker told his case manager that things were going well with his return to work but he did not go in to work for two days. He said his back got really sore on Thursday night and he had not slept well since. The case manager spoke to the employer on the same day who expressed some concern about the worker’s complaints. He indicated that the job the worker was doing was the lightest work. He also indicated that the worker had used “the excuse of not being able to sleep many times pre-dating this accident”. The worker denied this allegation both to the case manager and at the hearing.

At the hearing the worker testified that prior to returning to work his back was still burning but bearable. The work he returned to was his regular work of installing ceilings mainly just tiling but also doing some grid installation.

On June 28, 2005, the physiotherapist called the WCB case manager to indicate that he had seen the worker and noted objective findings of apparent spasm. He thought that the worker might have a hip flexor problem that flared up the preceding week. He also noted the worker’s complaints of being unable to sleep. This was also the opinion of a second chiropractor who noted tight and tender lumbar paraspinal muscles.

In a narrative report dated June 29, 2005, the family physician reported that the worker complained bitterly of significant flare-up of pain involving his right lower back and flank region. He also noted significant insomnia secondary to ongoing pain. On examination, the only findings were complaints of muscle tenderness on palpation in the right lumbar region. In summary, the physician said he was at a loss to explain why the worker was unable to continue on with even a light duty course of work. He felt the worker needed to be working in a progressive manner in an attempt to ease his symptomatology. The worker was prescribed medication to assist with sleep and pain.

On June 30, 2005, the case manager told the worker to return to his graduated return to work program starting July 4, 2005 and to use the same schedule that was outlined in the original plan outlined on June 8, 2005.

On July 11, 2005, the worker advised the WCB that he was working four hours per day and was managing okay. He started to experience back symptoms at the end of the four hours but was doing well.

On July 18, 2005, the second chiropractor indicated that the worker’s pain was decreasing and his function was increasing. He noted the worker was treated four times to date and was doing well with little difficulty at work six hours per day. No further treatment was scheduled. On August 1, 2005, the worker returned to full time duties.

On August 26, 2005, the worker told the WCB that he had been fine working regular duties until the preceding week when his back got sore again. He thought it was related to carrying acoustic panels up stairs that weighed about 30 pounds. He missed work again on August 29, 2005 but then returned to work and was continuing to work while in pain. An August 29, 2005 medical report notes that the worker presented with mechanical low back pain complaining of having “pulled” his lower back tiling. The doctor noted tender paraspinal muscles as well as tenderness at the L1-L5.

At the hearing the worker testified that by this point his lower right back was “burning furious” and the more he worked the more he felt it. He explained at great lengths the various jobs he did, his body mechanics and the back symptoms he experienced.

On September 7, 2005, the family physician referred the worker to a physician at a pain clinic noting that the worker complained of significant flare-ups of lower back pain with minimal activity.

Then on September 12, 2005, the worker advised the WCB that he quit work as he could not do it anymore and was unable to sleep. He said things were never right after he returned to work and that he just gradually began to get worse. On the same day, the employer advised the WCB that the worker had been given the lightest jobs working mostly with acoustic panels and fibreglass jobs. The worker had however made ongoing complaints about his back. The employer commented however that the worker had personal stressors in his life.

At the hearing the worker testified that the day he quit he was in a great deal of pain but tried nonetheless to work. On the way home when his employer called him, he quit. He denied having any personal stressors.

The worker was called in for an examination by the WCB on September 29, 2005. The examining physical medicine and rehabilitation consultant felt the worker’s initial injury was likely a simple muscular strain involving the lumbar paravertebral muscles of the quadratus lumborum, more to the right. He also thought that the diagnostic tests revealed some pre-existing degeneration of the lumbar spine. On the current examination there did not appear to be a definite pathoanatomic diagnosis to explain the worker’s persistent symptoms. He commented however that some of the symptom persistence could relate to the lack of any general fitness or aerobic fitness activities that involve the affected area. He suggested a return to work with an exercise program, acupuncture and active release treatment on an as-needed basis. With respect to his sleep problems, he recommended an increase in medication with the anticipation that the sleep dysfunction would improve and resolve.

On October 17, 2005, the worker told his case manager that he was in such severe pain that he could not sleep.

In an October 19, 2005 report from the pain clinic, the physician stated the worker’s low back pain may be multifactorial in origin but was likely muscular or musculoligamentous in origin. She felt the degree of findings seemed out of keeping for the degree of pain reported and thought that the worker’s sleep disorder and depressed mood might be contributing to it. She thought that if the worker’s sleep problem was addressed, it should take care of the mood disorder and that treatment of the worker’s back would then be successful, allowing him to return to work.

On December 7, 2005, a WCB medical advisor commented that it was difficult to relate the worker’s sleep disorder to the compensable injury. The diagnosis had been non-specific low back pain. This should not cause a significant sleep disturbance especially more than one year post injury. She felt there were other stressors and factors which were more likely the cause of the worker’s sleep disturbance.

The physician from the pain clinic disagreed with this opinion. In a December 15, 2005 report she stated that the worker had no pre-existing sleep disorder prior to his September 2004 injury and felt that it was directly related to his compensable injury. She added that with respect to his physical status, his examination was relatively benign but he did display a significant degree of difficulty with extension at the waist and extension at the hips – the exact movements required of a ceiling tile installer. She thought that the mechanism of injury caused a strain to his right pelvic hip flexors which contributed to some pelvic lumbar instability which was the cause of his low back pain. She added that the remaining deficit continued to impair him from returning to work specifically because of the degree of extension called for in his job. She commented that given that the worker’s sleep had improved with medication, he would be suited to re-enter a rehabilitation program with accent on stretching, strengthening and stabilizing his back area as well as possibly active release treatment.

In a further report dated April 18, 2007, which was provided at the request of the appeal panel, the physician from the pain clinic outlined her various examinations and findings from December 2005 to May 17, 2006. She noted a continuity of paraspinal quadratus lumborum tenderness that, although there was some improvement with the sleep and mood restored, were aggravated with his lumbar extension activities. She added:

“Because the activities which reproduced his discomfort are very specific and repetitive to the tasks of a ceiling installer, this likely resulted in some limitation of his ability to do those job duties.”

At the hearing the worker testified that the medication prescribed by the physician at the pain clinic helped him to sleep. He continued with his physiotherapy exercises and then had trigger point injections into his right quadratus lumborum. He said that after this treatment he was able to return to his regular duties without any further problems.