The Appeal CommissionThe Workers Compensation Act of Manitoba

The worker in this case suffered a significant abdominal injury in 2004, and continues to be on wage loss and medical aid benefits with the WCB. To date, his requests for the WCB to cover the purchase and installation costs of a whirlpool or hot tub in his home have been denied. The worker’s appeal deals with this limited issue.

The worker’s position:

The worker states that he has very serious pain management issues arising from his compensable injuries, as a result of which he is currently on a very long list of medications. He described a list of these medications at the hearing. He also advised that these medications are not effective in managing his condition, and that consideration is now being given to another treatment program. He expressed concerns that the array of medications he is on is affecting not only his quality of life but also his longevity.

The worker states that he has used a friend’s hot tub and found significant pain relief for a short period of time during and after the use of the tub. For this reason, he wants to have one installed in his home, so that it is available to him on an as-needed basis, up to 3 or 4 times a day. He states that it is the opinion of his two doctors, as well as a WCB psychologist consultant, that home hydrotherapy would provide him with pain relief and a reduction in the pain medications he is using. When asked at the hearing about the potential use of a whirlpool in a community facility, the worker noted that this was a poor alternative: He expected that he would need the whirlpool when he was experiencing exacerbations of his pain, and that it was not realistic to require at that time the significant travel time, as well as time dressing and undressing, that would be needed to reach a community-based facility.

The worker also asserts that he is not seeking a “top end” whirlpool, and that it would be a cost-effective expenditure by the WCB, given the high costs of his medications.

The employer’s position:

The employer’s representative supported the WCB’s prior decisions on this issue, and noted that the WCB had been generous in its accommodations of the worker to date. The representative further noted that while the worker’s current drug regime was quite expensive, there was not enough information on the file to demonstrate that the whirlpool was a cost-effective alternative.

Legislation:

Panels of the Appeal Commission are bound by the Act and any policies passed by the WCB Board of Directors.

Provision of medical aid is covered in WCB Policy 44.120.10. It provides, in part, that:

2. Medically Prescribed Treatments, Devices and Their Related Accessories

To minimize the impact of workers’ injuries and to encourage recovery and return to work, the WCB approves the use of many prescribed and recommended treatments and devices, including prescription drugs, over-the-counter medical supplies, braces, prosthetic devices, wheelchairs, dentures, hearing aids, eye glasses, contact lens and other devices.

b. Medically Recommended Treatments

i) Other medically recommended treatments include, but are not limited to, acupuncture, massage therapies, swimming, fitness therapies, obus forms, as well as new treatment modalities constantly being introduced to the market place.

ii) The WCB may approve the use of these treatments or medications subject to pre-approval by the WCB on a case-by-case basis. All such treatments must satisfy the WCB that their use will aid in the recovery of an injured worker or minimize the impact of the injury.

Analysis:

The panel notes at the outset that the worker in this case has a significant abdominal injury that has been compounded, unfortunately, by a well-entrenched (and compensable) chronic pain syndrome, depression, and post-traumatic stress condition. As described extensively in the file, the worker is under an extended array of pain and sleep medications. The panel also notes that even with these medications, the worker’s pain management has not stabilized, and further (and more serious) drug regimens are now under consideration.

It is against this backdrop that the worker is seeking to have a whirlpool made available to him by the WCB, in his home.

The WCB policy on medical aid contemplates that some medical treatments may be authorized, on a case by case basis, where “their use will aid in the recovery of an injured worker or minimize the impact of the injury.” The worker has characterized the whirlpool as providing him with “home hydrotherapy” treatment which helps to minimize the impact of the injury.

The panel finds this to be a useful characterization of the issue. In this case, the question embedded in the worker’s request for a whirlpool is: will or should the WCB (in this case, the panel through its decision) authorize a hydrotherapy program for the worker, and if so, is it appropriate that it be delivered at home, rather than at a community facility?

Dealing firstly with whether hydrotherapy is a covered treatment under WCB policy, the panel notes that the medical aid policy describes a number of treatments in the “medically recommended treatments” list, and that these treatments are not necessarily restorative in nature but will assist in alleviation of pain or maintenance of function. These include swimming (a form of hydrotherapy) and fitness therapies, and often result in workers receiving, for example, fitness passes in order to access those programs or facilities. The panel also notes that the list of treatments in this particular section of the policy is not exhaustive; the wording “includes but are not limited to...” suggests that other treatments can also be examined on a case by case basis.

In this case, the worker described to the panel that he has used a friend’s hot tub and finds significant pain relief firstly from being immersed in heated water, and secondly from the massaging effects from pointing the water jets at specific areas of his abdomen and groin that had been injured. The worker indicates that he contemplates using the whirlpool three to four times per day at home, on an as-needed basis, for pain management. The panel accepts the worker’s position that it would be untenable and impractical for him to travel to and from a community facility a number of times a day, to achieve the same result.

The panel notes that the worker’s two treating physicians (who are prescribing his various medications) are supportive of the worker’s appeal on this issue, and are of the opinion that the hydrotherapy will reduce pain and become part of his pain management regimen, and reduce his pain medications. There is no contrary medical opinion on this point.

While the panel acknowledges a formal cost-effectiveness analysis would be helpful (comparing the costs of a whirlpool with the cost savings from a reduced future drug program), it is not an essential consideration in the analysis or for that matter in the WCB medical aid policy, mainly because of the challenges involved in projecting medical aid costs in complex physical/psychological claims such as in the case at hand. In this regard, the panel notes that to date, the only pain relief for the worker comes from a steadily increasing use of pain and sleep medications, and that this continues to trend upwards four years post-injury. The challenge in medical management of this worker is ultimately to alter this progression.

The panel finds that the use of home hydrotherapy does add a first non-medication treatment option to the mix, and offers the potential of both economic and pain relief outcomes to the worker and to the claim. Only time will tell whether or how the trend line of medication costs or health outcomes will change from its use by the worker. In any event, the use of the whirlpool does also have practical implications for the worker in terms of pain relief and the minimization of the effects of the compensable injury.