The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decisions made by the Workers Compensation Board ("WCB") to deny responsibility for trigger point needling to treat his myofascial pain and to deny the costs associated with three prescriptions for medication. A file review was held on July 24, 2014 to consider these matters.

Issue

Whether or not responsibility should be accepted for the myofascial trigger point needling treatment; and

Whether or not responsibility should be accepted for the medications Venlafaxine, Baclofen and Cyclobenzabrine.

Decision

That responsibility should not be accepted for the myofascial trigger point needling treatment; and

That responsibility should be accepted for the medication Venlafaxine; and

That no responsibility should be accepted for Baclofen and Cyclobenzabrine.

Decision: Unanimous

Background

The worker filed a claim with the WCB for right elbow difficulties that began in October 2002 which he related to "overuse and repetitive work, 12 hour shifts." The claim for compensation was initially accepted based on the diagnosis of right lateral epicondylitis but the compensable diagnosis changed to radial tunnel syndrome. Despite surgical intervention, the worker was left with chronic denervation of the right posterior interosseous nerve ("PIN") which the WCB accepted as being related to the workplace injury.

On August 2, 2012, the worker was seen by a physical medicine and rehabilitation specialist for right upper extremity complaints. The specialist reported that some of the worker's pain arose from multiple trigger points found in the right upper extremity muscles and myofascial trigger point needling was suggested as a form of treatment.

On October 24, 2012, the treating neurologist reported that the worker's main pain was still in the right extensor forearm, the area of the surgery for the nerve entrapment. He stated that this pain alone would make it difficult for the worker to do any type of repetitive work with the arm. He stated "There is likely an additional myofascial pain in the right arm which has developed subsequently, which likely is related..."

On October 31, 2012, a WCB orthopedic consultant reviewed the medical reports dated August 2, 2012 and October 24, 2012 and stated: "...the ongoing impairment of the right PIN is related to the workplace injury. This is the residual effect of the radial tunnel syndrome. The myofascial features described by [the physical medicine and rehabilitation specialist] are not related to the workplace, on a balance of probabilities, as there is no objective medical evidence to confirm a causal relationship."

On November 21, 2013, the WCB orthopedic consultant again reviewed the worker's file and stated:

1. Venlafaxine (Effexor) is for treatment of anxiety and depression, and would not have a direct relationship with the workplace injury.
2. Cyclobenzaprine (Flexeril) is used to counteract muscle spasms, not the result of PIN deficiency.
3. Baclofen is used to counteract muscle spasms that are not the result of PIN deficiency.

In decisions dated November 26 and 28, 2013, the worker was advised that the WCB would not accept responsibility for trigger point needling or for the medications Venlafaxine, Cyclobenzaprine or Baclofen as the treatments and medications were not required for his compensable injury. The worker disagreed and an appeal was filed with Review Office.

On February 19, 2014, Review Office determined that no responsibility should be accepted for the myofascial trigger point needling as there was insufficient medical evidence to support a causal relationship between the diagnosis of myofascial pain and the compensable injury. This decision was based on the WCB medical opinion outlined on October 31, 2012.

Review Office also determined that no responsibility should be accepted for Venlafaxine, Cyclobenzaprine or Baclofen. Review Office noted that the worker's muscle spasms had not been accepted as related to the compensable injury and that the WCB could not cover the costs of the medications prescribed to treat same. The worker stated that Venlafaxine was prescribed due to the amount of pain in his upper right extremity. Review Office found the medical evidence on file did not support that Venlafaxine was prescribed for pain control.

On March 17, 2014, the worker filed an appeal with the Appeal Commission regarding the decisions made by Review Office on February 19, 2014 and a file review was arranged.

Following the file review held on July 24, 2014, the appeal panel requested additional medical information from three treating physicians. The reports were later received and were provided to the worker for comment. On October 22, 2014, the panel met further to discuss the case and rendered decisions on the issues under appeal.

Reasons

Applicable Legislation:

The Appeal Commission and its panels are bound by The Workers Compensation Act (the “Act”), regulations and policies of the Board of Directors.

When a worker suffers personal injury by accident arising out of and in the course of employment, compensation is payable to the worker pursuant to subsection 4(1) of the Act. Provision of medical aid to injured workers is payable in accordance with subsection 27(1) of the Act which provides as follows:

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.

Worker’s Position

The worker was self-represented in the appeal. The worker's position was that both the trigger point needling and the medications were treatment related to his compensable injury. In the fall of 2011, the worker started to see a doctor at a Pain Clinic on the referral of his surgeon. The prescriptions for which he was claiming were given for his pain. As treatment proceeded at the Pain Clinic, multiple medications were tested on a trial basis. The worker was first prescribed Baclofen and the next was Cyclobenzaprine. Neither of these medications accomplished the goal of pain relief. Soon after, the worker was prescribed Venlafaxine. It was not until the worker tried Gabapentin that he noticed some pain relief. The WCB did accept responsibility for the Gabapentin medication. The worker submitted that although only the Gabapentin was successful, all of the medications were part of the claim.

With respect to the trigger point needling given by the physical medicine and rehabilitation specialist, it was submitted that the Appeal Commission in an earlier decision had stated that the worker should have at least attempted an accommodated position offered by the employer. The worker was now performing these duties but the trigger point needling was still ongoing and on occasion, the worker had to leave work to attend treatment.

Analysis

The issue before the panel is whether or not responsibility should be accepted for the myofascial trigger point needling treatment and whether or not responsibility should be accepted for the medications Venlafaxine, Baclofen and Cyclobenzabrine. In order for the worker's appeal to succeed, the panel must be satisfied that the treatment and/or medications are necessary to cure and provide relief from the injury resulting from an accident. We are able to make this finding with respect to the Venlafaxine.

The worker's accepted compensable diagnosis is the residual chronic denervation of the right PIN following surgery. The worker is also receiving myofascial trigger point needling treatment which is being administered by a physical medicine and rehabilitation specialist. In response to a request from the panel, the specialist provided a report dated August 29, 2014 which outlined his treatment of the worker. The myofascial trigger point needling administered by the specialist started in December 2012 with the right upper extremity muscles but then extended to the other quadrants of the worker's body. The worker's diagnosis was described as including "myofascial pain in the right and left neck, shoulders, upper extremities, torso, lower back and buttock."

The worker is only entitled to coverage for symptoms which are caused by the worker's PIN condition and its sequelae. On a balance of probabilities, we find that the widespread myofascial trigger point treatment administered by the specialist from December 2012 to August 2014 cannot be considered a sequelae of the chronic denervation of the PIN. We accept the October 31, 2012 opinion of the WCB medical advisor that the myofascial features described by the specialist are not related to the workplace injury.

As a result, the panel finds that responsibility should not be accepted for the myofascial trigger point needling treatment. The worker's appeal on this issue is dismissed.

With respect to the medications, the panel's understanding is that although the worker submitted that the Baclofen and Cyclobenzabrine were prescribed for the purpose of pain relief, the WCB Medical Advisor indicated that these are medications intended to counteract muscle spasms. Information from the Pain Clinic confirmed that these medications were trialed for hyperreactive muscles. The file records show that in early 2011, the worker was being investigated for fasciculations involving areas of his arm and leg musculature. In a report dated July 7, 2011, a treating neurologist determined that the features of generalized muscle twitching were not related to the accident of 2009 and were not in his opinion compensable. In Appeal Commission Decision 123/13, a previous panel determined that the medical evidence did not support a causal relationship between the symptoms of weakness and fasciculations in all four extremities and the worker's compensable injury. On a balance of probabilities, the panel finds that the Baclofen and Cyclobenzabrine medications were prescribed for these non-compensable fasciculations and responsibility should not be accepted for same.

With respect to the Venlafaxine, the WCB Medical Advisor identified that this medication is used for treatment of anxiety and depression. In a letter dated September 26, 2014, the worker's family physician advised that he prescribed the Venlaxafine in January 2012 and that it was being prescribed as an adjuvant for pain control. His assessment was that the medication may have helped slightly, but was not successful in treatment of the worker's medical condition. As at the time of the letter, the worker continued to be prescribed refills of the Venlafaxine.

Even though the Venlafaxine is described as only "helping slightly," the family physician continues to prescribe the medication for pain control. The WCB does accept responsibility for other pain medications being taken by the worker, including Gabapentin. Although Venlafaxine may not typically be prescribed as an adjuvant for pain control, this is the reason it is being prescribed in the worker's case. The panel accepts on a balance of probabilities that the Venlafaxine is necessary to provide relief from the worker's residual chronic denervation of the right PIN and therefore responsibility should be accepted for this medication. The worker's appeal is allowed for the Venlafaxine.

Panel Members

L. Choy, Presiding Officer
A. Finkel, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

L. Choy - Presiding Officer

Signed at Winnipeg this 4th day of December, 2014