Decision #100/17 - Type: Workers Compensation
The worker is appealing the decision made by the Workers Compensation Board ("WCB") that his right shoulder condition was not related to his compensable injury and therefore he was not entitled to full wage loss benefits after July 8, 2016 or for the costs associated Ketorloc and Celebrex. A hearing was held on June 27, 2017 to consider the worker's appeals.
Whether or not the worker is entitled to full wage loss benefits after July 8, 2016; and
Whether or not responsibility should be accepted for the medications Ketorloc and Celebrex.
That the worker is not entitled to full wage loss benefits after July 8, 2016; and
That responsibility should not be accepted for the medications Ketorloc and Celebrex.
On September 27, 2012, the worker was holding a knife in his left hand to flip meat. When he used his right hand to flip the meat over, he accidentally stabbed the knife into his right palm. The compensable diagnoses listed on the claim file were sensory loss at the right thumb and index finger, neuropathic pain in the right hand and right foot and major depressive disorder.
On May 17, 2016, Compensation Services wrote the worker to confirm the details regarding his return to work program that was scheduled to start on May 16, 2016. The job duties performed by the worker would be shaving hogs. The WCB considered these job duties to be consistent with the following work restrictions:
• Avoid working at night
• No sustained/resisted grasping with right hand
• Seated duties intermittently as tolerated
• Alternate sitting and standing duties approximately every 15 to 20 minutes
• Work in a warm environment
In a memo to file dated May 26, 2016, the case manager noted that the worker returned to work on May 17, 2016 and was taken to the new job station on the kill floor. The worker was certain that the job was "completely difficult" but did not want to refuse right away and went to give it a try. After a couple of hours, he started to feel tired and dizzy from working on a raised station. He said he "blacked out," lost his balance and fell to the ground scraping his knee. The worker advised that the new job was "very dangerous" and when asked to elaborate on the hazards, he said the station was elevated and he fell with a knife in his hand. The knife could have gone into his stomach or he could have injured someone else. He said his right hand is sore from keeping it in a metal mesh glove. The worker asked the case manager to provide him with a different job as the kill floor job was completely unbearable for him. He asked that his employer find him a job that was 'less dangerous" and started at 3 p.m. versus 7 a.m. The worker went on to advise that he did not feel capable of working 4 hours per day but he had been doing so only out of love for his family that he had to provide for. The worker stated that he did not want to upset his employer and was willing to work on the kill floor at four hours shifts only "until he can do more."
In a letter dated May 30, 2016, Compensation Services advised the worker that he was not entitled to full wage loss benefits beyond May 16, 2016 since his employer had offered suitable full time modified/sedentary duties on the kill floor. The case manager opined that the offered permanent light duty accommodation was safe, appropriate and unlikely to lead to further injury. The job was located in a warm environment, he was not required to use his injured hand and he had the opportunity to sit or stand as tolerated. The position accommodated his temporary medical restriction to avoid working at night and allowed him to work day shifts. Given these findings, Compensation Services indicated that the worker was fit for the proposed light duties on a full time basis.
In a report dated June 16, 2016, the worker's treating pain management physician noted that the worker:
…continues to suffer from pain in his hand as well as his shoulder and leg. This has been secondary to his workplace-related injury. Despite this pain, I have previously approved a graduated return to work program. We had started with four hours shifts.
His current pain and symptoms have not improved with this graduated return to work. His pain has been aggravated especially since the change in his work that occurred on May 17. I have now instructed that he stop working. His pain and symptoms are not improved with the graduated work program. He has clearly exacerbated his health issues by continuing to work, at my previous recommendation. This gentlemen is in severe pain. He now has symptoms of rotator cuff injury. He fell at work on May 17 onto his knees as well as his shoulder…At this stage, I am very confident that this gentleman is unable to work and have long term disability secondary to his workplace-related injury.
On June 30, 2016, the pain management physician spoke with the case manager. He said the worker should be considered "permanently disabled" and he instructed the worker to stop working. He understood from the worker's description of his duties that the job was dangerous and he continued to injure himself. The physician indicated that the worker likely injured his rotator cuff from the recent fall and that a right shoulder MRI was being arranged.
In a report dated July 15, 2016, the pain management physician stated:
1. I strongly suggested to the patient that he stop working and that WCB accepts full responsibility of his long term permanent disability.
2. At minimum, this patient needs to stop working at this current location and be moved back to the laundry area which he found he was better able to do than his current position.
3. We will continue to manage his pain with Celebrex as well as Cymbalta. I have renewed these prescriptions for him. I understand from the patient that he fell recently at work and had to attend the emergency department at…
On July 21, 2016, an occupational health physician provided a narrative report regarding the worker's hand injury, job tasks and current clinical findings. The specialist outlined the view that the light duties performed by the worker worsened his pain condition with multiple psychological and workplace stressors.
A WCB medical advisor reviewed the file on August 19, 2016 and stated, in part, "Full file review does not produce any evidence to support that there is a patho-anatomic dx [diagnosis] to the shoulder otherwise related to the C/I [compensable injury]. If the pain is referred from the hand, no specific treatment or accommodation is required to the shoulder in relation to the C/I."
In a decision dated September 12, 2016, Compensation Services wrote to the worker to advise that based on review of the current information, his claim for right shoulder pain and any associated disability is not accepted in relation to his compensable injury. His claim remained accepted on a limited basis for a right hand injury (sensory loss in right thumb and index finger), right foot secondary neuropathic condition and a secondary diagnosis of depression.
The worker was further advised that there was no entitlement to full wage loss benefits for his current leave from work effective July 8, 2016 as there was no evidence to support total disability. The worker was entitled to partial wage loss benefits based on his ability to work 8 hours per day in the assigned light duties within his permanent restrictions.
The case manager stated:
While [the pain management physician's] expertise is highly appreciated, I will concur with the medical opinion provided by WCB Healthcare. The WCB upper extremity plastic surgery consultant has examined you twice, once with the Senior Medical Advisor. She has spoken to the treating specialist about her opinion and documented that accordingly. Her opinion is supported by a detailed rationale. [The pain management physician's] latest letter does not provide any objective medical evidence to negate the consultant's opinion. In accordance with the medical opinion on file, at this time there is no reason to change the decision based on opinions previously provided by WCB Healthcare with regards to work abilities. It is the position of WCB Compensation Services that you are capable of working full time light duties as long as they are within your permanent restrictions. As we have discussed in our meetings, in my opinion the currently assigned alternate duties of hog shaver are suitable as they fully match your workplace restrictions.
A WCB medical advisor noted in a memorandum dated October 19, 2016 that based on the compensable diagnoses of Major Depressive Disorder and Sensory loss at the right thumb and index finger and neuropathic pain at the right hand and right foot, there did not appear to be an indication related to the compensable injury for the use of nonsteroidal anti-inflammatory medication. As such, the use of Ketorolac and Celebrex was not related to the compensable injury and was not eligible for WCB financial support.
In a decision dated October 24, 2016, Compensation Services advised the worker that his prescriptions for Ketorolac and Celebrex were not related to his compensable injury and therefore was not be eligible for WCB financial support.
On November 7, 2016, the worker's advocate wrote Review Office and requested reconsideration of the decisions dated September 12 and October 24, 2016. The advocate referred to medical opinions on file dated September 15 and September 29 from the pain management physician and from the occupational health physician to support that the worker continued to deteriorate from his compensable injuries and that he was now experiencing secondary pain in his right shoulder which the doctors have indicated are related to his compensable injury. The advocate argued that the employer failed to provide the worker with work that was not detrimental to help improving his health. The advocate also was of the view that the WCB should cover the expenses related to Ketorolac and Celebrex as the medications were prescribed by his treating physicians.
On December 8, 2016, the employer's advocate submitted to Review Office that they supported the decisions made by the WCB based upon the totality of evidence including the nature of light duties provided, the objective medical evidence and the opinions of WCB medical consultants.
In a decision dated January 4, 2017, Review Office determined that there was no entitlement to full wage loss benefits beyond July 8, 2016 and there was no entitlement to Ketorloc and Celebrex.
Regarding the issue related to wage loss benefits, Review Office agreed with a WCB medical advisor's opinion (outlined on August 19, 2016) which stated:
…a WCB upper extremity plastic surgery consultant has examined the worker twice, once with the Senior Medical Advisor. She has spoken to the treating specialist about her opinion and documented that accordingly. Her opinion is supported by a detailed rationale. [The pain management physician's] latest letter does not provide any objective medical evidence to negate the consultant's opinion.
Review Office noted that the WCB medical advisor commented upon 18 different prior medical reports and stated that there had been no mention of a specific shoulder diagnosis in relation to the compensable injury until May 2016. Therefore, there was no diagnosis that would be directly related to the workplace injury.
Review Office also referenced the following comments made by the consultant:
…To summarize, the worker has complained of intermittent shoulder pain throughout the claim. It is assumed that this has been related to referral of his hand pain. Full file review does not produce any evidence to support that there is a patho-anatomic dx to the shoulder otherwise related to the C/I. If the pain is referred from the hand, no specific treatment or accommodation is required to the shoulder in relation to the C/I.
Review Office stated it agreed with the above opinion as it could not find evidence to suggest otherwise. It concluded that the worker's right shoulder problems were not considered to be a consequence of the original compensable right hand injury.
Regarding the prescribed medication, Review Office was unable to find evidence to suggest that the medication was required to provide relief from the compensable injury and it placed weight on the following WCB medical opinion:
…there does not appear to be an indication related to the compensable injury for the use of nonsteroidal anti-inflammatory medication. Therefore the use of Ketorolac (nonsteroidal anti-inflammatory medication) as well as Celebrex (Cox II inhibitor nonsteroidal anti-inflammatory medication) is not related to the compensable injury…
On January 1, 2017, the worker's advocate appealed Review Office's decision to the Appeal Commission and an oral hearing was arranged.
The Appeal Commission and its panels are bound by The Workers Compensation Act (the “Act”), regulations and policies of the WCB's Board of Directors.
The worker has an accepted claim for an injury arising from a 2012 workplace accident. With respect to the first issue, the worker maintained that he was not able to return to work after July 8, 2016 because of his original injury and surgery. He is also appealing the WCB decision that denied responsibility for certain difficulties which he asserts are related to the compensable injury. He is seeking further benefits in relation to his accident of September 27, 2012.
Under subsection 4(1) of the Act, where a worker suffers personal injury by accident arising out of and in the course of employment, compensation shall be paid to the worker by the WCB.
Subsection 39(1) of the Act provides that wage loss benefits will be paid: "…where an injury to a worker results in a loss of earning capacity…" Subsection 39(2) of the Act provides that the WCB will pay wage loss benefits until such a time as the worker’s loss of earning capacity ends, or the worker attains the age of 65 years.
WCB Policy 43.20.25, Return to Work with the Accident Employer (the "Return to Work Policy"), outlines the WCB's approach to the return to work of injured workers through modified or alternate duties with the accident employer. The Policy provides that most of the time the worker, employer and collective bargaining agent (where applicable) will make their own arrangements. The WCB encourages these permanent or transitional arrangements and will work with all parties to help the worker safely return to work.
The Return to Work Policy describes suitable modified or alternative work as follows:
Suitable work is that which the worker is medically able to do, does not aggravate or enhance the injury, and will provide benefits to both the worker and the employer.
Suitable work is permanent or transitional employment that takes into account the worker's pre-accident employment, aptitudes, skills, and what work is available. It also considers any safety concerns for the worker or co-workers. To determine if the worker is medically able to perform suitable work, the WCB will compare the worker's compensable medical restrictions and capabilities to the demands of the work.
With respect to the second issue under appeal, the worker maintained that certain prescriptions are required for treatment of his compensable injuries.
Subsection 27(1) provides that the WCB may provide the worker with such medical aid as the board considers necessary to cure and provide relief from a work injury.
The worker was represented by an advocate at the hearing, and was also provided with a translator who provided the worker with word-for-word translation of the whole hearing. A physician with an interest in occupational health ("occupational health physician") was also in attendance on behalf of the worker and provided evidence and commentary during the presentation made on behalf of the worker, and later answered questions from the panel.
Regarding the first issue, the advocate stated that the WCB should accept responsibility for ongoing wage loss benefits after July 8, 2016. She noted that the worker did have permanent damage from the September 27, 2012 workplace accident and subsequent surgery, resulting in numbness in the right hand and neuropathic pain originating from the right hand, as well as neuropathic pain affecting his right foot. The advocate also asserted that the worker's current right shoulder difficulties are related to his right hand injury and subsequent activities over the following years.
The advocate noted that the worker had been receiving wage loss benefits for four hours per day and was on a graduated return to program that was increasing his hours when he had increased symptoms, and had been advised by his physicians that he should not continue to work as of July 8, 2016. She framed the issue as follows: "The question is if [the worker] can be accommodated by the employer in meaningful employment for the remainder of the work day given the nature of his injury and his neuropathic pain he suffers."
The position advanced by the advocate is that the worker's total removal from work was recommended by his treating pain management physician and by an occupational health physician, and referred to several reports and letters that referred to the worker's ongoing neuropathic pain that had not responded to treatment and had not resulted in functional improvement, and that the worker was unable to work without increasing the neuropathic pain that he was experiencing.
As to the worker's right shoulder difficulties, the advocate's position was that the worker was now suffering from secondary localized pain in the right shoulder that is a consequence of the 2012 injury. At the hearing, the occupational health physician referred to his earlier reports that suggested that the worker had been required to participate in modified duties too soon after the original accident and after the surgery that required him to stand for long periods of time. With his significant and chronic neuropathic pain, the worker was working with his right arm dangling and he was also guarding his right arm, leading to the worker developing myofascial pain in a number of muscles in his right shoulder and surrounding area. The physician was able to identify a number of trigger points that would cause referral pain down the worker's right arm and up into the neck.
The advocate also referred to comments by the worker's pain management specialist that the worker suffered post-traumatic stress disorder from the initial incident as well as some negative experiences at his workplace, as additional factors in his belief that the worker is not likely to be able to return to full-time work.
In conclusion, the advocate suggested that it was the modified duties plus factors in the workplace that led to the enhancement of hand complaints and dysfunction. The worker now has neuropathic pain, chronic pain, myofascial dysfunction into his shoulder and neck, and significant psychological impacts (depression, intimidation, etc.) The worker is a vulnerable worker with little chance of employment outside of his accident employer.
Regarding the second issue, the position advanced on behalf of the worker was that the two medications had been prescribed by the worker's treating physician and should therefore be covered by the WCB. As well, the pain management specialist has noted that the worker continues to benefit by the combination of Celebrex and Cymbalta.
The employer was represented by an advocate and its Benefits Coordinator. It was the employer's position that the worker was not entitled to full wage loss benefits after July 8, 2016. The advocate noted that eight WCB medical advisors from a variety of healthcare disciplines have reviewed or examined the worker, and asked the panel to accept their opinions.
The advocate referred to the November 5, 2014 call-in examination by a WCB plastic surgeon consultant with a specialty in upper extremities, who noted inconsistencies in her examination of the worker compared to earlier findings by a physiotherapist that could not be explained on a patho-anatomic basis. The consultant also noted that the worker indicated that he could not carry items with his right hand but was later observed carrying a large backpack with his right hand.
The advocate also referred to a March 1, 2016 call-in examination by the same consultant who found full range of motion of the shoulder, elbows and wrists, and advised that there was no contraindication for the worker to work 8 hours/day, even in the presence of the worker's known neuropathic pain condition.
As well, the advocate commented that there were no psychological restrictions added by the WCB psychiatrist consultant, after a WCB psychologist consultant had examined the worker, leading to the WCB's acceptance of the worker's depression as a compensable condition.
The advocate noted that the pain management specialist had taken the worker off work because of his pain complaints but later noted only modest decreases in pain but attributing other factors such as his emotional distress with WCB. There were no objective findings of total disability, just subjective complaints. She also noted that the worker's right shoulder issues have not been accepted by any WCB medical advisors as being causally related to the worker's compensable injury.
The advocate also commented on the worker's representative's position that the worker couldn't work successfully since his injury in 2012. She reviewed the extensive return to work history between the worker and the employer, which involved long periods of employment and adjustments to the worker's modified duties over time, as required. She advised that the employer had a long history of a well-developed modified duties program, not just for WCB claims but also because of its general obligations to accommodate injuries and disabilities under human rights legislation. She noted as well that the WCB case manager who was involved with the worker had visited the employer's plant many times and was very familiar with the various modified duties available for injured workers. The advocate asked that the panel therefore place considerable weight on the case manager's comments in her May 26 and September 1, 2016 memos where she stated that the hog shaving position completely matched the worker's restrictions and was absolutely appropriate. The advocate noted that the position does not require significant dexterity; it is not fast paced; the worker can sit or stand; can keep his right hand on his lap if he desired; can use either hand; and that there are protective barriers around the work area. She also noted that the Physical Demands Analysis for the position indicates that no forceful effort is required, and that the position is used for other injured workers and for women who are in the final stages of pregnancy.
Issue 1: Entitlement to full wage loss benefits after July 8, 2016
For the worker's appeal to be successful, the panel would need to find that that the worker was totally disabled from performing his modified work duties with the accident employer as of July 8, 2016, because his modified duties were outside the compensable medical restrictions for the worker's right hand and right foot injuries. It is also open for the panel to find that the worker's right shoulder difficulties are causally related to the worker's 2012 injury, and that the associated work restrictions for this condition, together with the previous compensable restrictions, resulted in the modified duties falling outside the worker's expanded restrictions, or that the worker had become unable to work at all.
After due consideration of the evidence on file and at the hearing, as well as the submissions made at the hearing, the panel was unable to make these findings, for the reasons that follow.
A significant part of the worker's submission dealt with the question of whether the worker's right shoulder difficulties should be added as a compensable condition, as part of the 2012 claim; if so, the condition would potentially lead to additional compensable restrictions that would in turn affect our analysis of the appropriateness of the modified duties that had been offered to the worker. Accordingly, the panel first turned its attention to the work-relatedness of the worker's right shoulder difficulties.
The position advanced on behalf of the worker was that the worker has a myofascial pain condition in the shoulder/shoulder girdle area that is attributable to the worker's guarding of his right arm while doing modified duties for full shifts and/or the arm dangling by his side while performing his job duties. This position was supported by the occupational health physician. In the alternative, the worker has a rotator cuff injury associated with his job duties. This position was supported by the worker's pain management physician. The panel does not accept either position, and finds that the worker's right shoulder condition is not compensable, with particular weight placed on the following evidence:
• The worker's pain management specialist had been treating the worker on a continuous basis since November 27, 2014. At that time, there were limited findings in the right shoulder area, with minor loss of range of motion, and "weak resistance with all shoulder muscle groups, approximately 4/5 but this is mostly pain limited in nature." The panel notes that there was no shoulder-specific diagnosis provided, outside of the commonly described neuropathic pain radiating up from the hand to the elbow and into the shoulder and neck. The panel further notes that the worker had been receiving physiotherapy treatment throughout this period from July 2013 (four weeks after surgery) to his discharge on December 10, 2014. At the time of discharge, the worker had full should range of motion bilaterally and no concerns identified by the physiotherapist beyond the referrals to the Pain Clinic for his neuropathic pain. Subsequent reports by the pain management specialist up to June 2016 do not refer to any local shoulder issues.
• On June 16, 2016, the specialist first reported a significant change in symptoms, stating that "This gentleman is in severe pain. He now has symptoms of rotator cuff injury. He fell at work on May 17 onto his knees as well as the shoulder." The panel notes that this is the first mention on the claim of a localized physical injury to the shoulder, and that it is attributed to a single traumatic event and not to anything in the previous four year claim history. At the hearing, the worker referenced a fainting incident and subsequent fall at work on May 17, 2016. The panel notes that there has been no argument advanced by the worker with the WCB as to how this fall might be related to this claim or to a new claim, and the panel declines to address these arguments given the absence of Review Office decisions on those points.
• The panel has, however, considered whether the worker's modified job duties were causative of a rotator cuff injury. The evidence discloses that the worker first returned to work to the hog shaving position on May 17, the day he later indicated was the date of onset of his rotator cuff symptoms. The panel has assessed the worker's job duties later in this analysis, noting that the worker primarily performed these duties with his left hand. The panel finds that the factors commonly associated with a repetitive use rotator cuff injury, namely overhead work or with arms outstretched in front, were not present in this case.
• The occupational health physician has proposed that guarding or disuse by the worker of his right arm over the course of years of performing modified duties has led to myofascial pain issues in the worker's right shoulder girdle and upper chest area. The panel notes that the physician first examined the worker four years after the workplace incident, and we therefore reviewed all the earlier medical information on the file to determine whether there was evidence to support this opinion. The panel finds that, prior to 2016, there are no earlier references anywhere by medical or treating healthcare practitioners of concerns or observations of guarding or disuse behaviours, or findings of associated loss of strength or muscle atrophy or range of motion that would typically be associated with disuse or guarding. Likewise, the worker did not make specific complaints of localized shoulder issues in his dealings with WCB staff or his employer, and there are no indications of observed shoulder issues by them. The panel further notes that a WCB medical advisor undertook a similar comprehensive review of the medical file on August 19, 2016 and found no earlier mention of a specific shoulder diagnosis. Further, the evidence discloses that the worker was in fact using his right hand and arm in his modified duties in the laundry area in 2014 and 2015, and that the issues regarding the suitability of that position had to do with his ability to stand and not with his ability to use his right hand/arm. The panel finds that the worker's actual job history is not consistent with the occupational health physician's position that the worker had a long history of working with his right arm dangling by his side or of guarding of his right hand and arm, leading the panel to place little weight on the occupational health physician's assertion regarding work-relatedness of the worker's myofascial pain issues.
The panel therefore finds, on a balance of probabilities, that the worker's right shoulder difficulties are not related to the worker's 2012 claim. Accordingly, there is no basis to establish compensable restrictions for the right shoulder condition.
As to the submission that there should be workplace restrictions because PTSD, intimidation, or emotional issues, the panel notes that the WCB has accepted only depression as a compensable psychological condition. We further note that these additional diagnoses have been proposed by the worker's pain management physician which were then reviewed by WCB medical advisors with greater expertise in psychological conditions and more familiarity with the diagnostic criteria for the condition. The panel places greater weight on those opinions and their conclusions that the diagnostic criteria for PTSD or other psychological injuries (beyond depression) were not met. Dealing finally with the worker's compensable hand and right lower leg conditions, the panel has first turned its attention to whether the worker's compensable restrictions were appropriate in May to July 2016, the period of time in which the worker had been placed in the hog shaver position.
At the outset, we note that the worker's restrictions had evolved over the course of the claim.
• In 2015, the worker had been working in positions in the cafeteria and laundry area. At that time, the worker and the employer were using compensable restrictions of: No sustained/resisted grasping with right hand, and work in a warm environment. An additional restriction was in place, to avoid work at night because of sleep quality issues associated with the medications that the worker was taking. The worker's position in the laundry involved folding gloves and handing out various items to other workers in the plant. This involved the use of the right hand.
• In July 2015, the worker went off work at the recommendation of his physician and later returned on September 1, 2015 to alternate duties in the laundry room at night that continued the restriction (approved by his pain management physician) of no sustained/repetitive grasping with the right hand. Later, the WCB determined that the laundry position required too much standing which affected the worker's right foot neuropathic pain condition. Accordingly, the worker's compensable restrictions were modified, adding: Seated duties intermittently as tolerated, and alternate sitting and standing duties approximately every 15 to 20 minutes. There was also a restriction added to avoid night shifts because of sleep-related issues.
• The panel notes that during the worker's path through various modified duties positions, no changes were made to the restrictions regarding the use of the right hand or arm. The last change was with respect to the worker's compensable foot issues, which was specifically accommodated for in the hog shaver position. Specifically, the right hand restriction remained as no sustained/resisted grasping.
• The worker's pain specialist asserts that the worker was experiencing increased right neuropathic pain in his new modified job duties on the shaver line. However, the panel notes:
o an absence of objective findings of any changes to the worker's hand or neuropathic pain condition in the ongoing reports by the pain management physician.
o the specialist's comments (supported by our own review of the medical file) that there has been actually no change in the VAS pain reports by the worker over the course of years leading up to the summer of 2016.
o the worker's evidence at the hearing that he performed the hog shaver job duties primarily with his left hand, which actually reduced the use of his right hand from his previous modified duties position in the laundry.
The panel therefore finds that the evidence does not provide a medical basis to change the compensable medical restrictions for the worker in mid-2016.
The panel then assessed whether the modified duties on the shaving line fell within the worker's compensable restrictions. We find that the modified duties were appropriate for the worker and within his compensable restrictions, based on:
• a short video of the modified duties which had been shared with all parties and the panel. The worker acknowledged that the job duties, as shown, accurately reflected what he had been doing from May 27 to July 8, 2016, in terms of location, sitting/standing, arm movements, and pacing.
• The worker agreed that it was a one-handed job and that he did it primarily with his left hand. He did sit and stand, and the pace was casual. There were two workers on each side of the hog line, which allowed him to do the work with whichever hand he preferred.
• While the worker's pain management specialist and occupational health physician suggested that the performance of this particular modified duties position led to the worker being totally disabled from work as of July 8, 2017, the panel has had the opportunity to clarify the worker's modified job duties to a degree not available to either of his physicians. The panel finds that the modified job duties in the hog shaver position actually demonstrated minimal to no use of the right hand and arm, and were fully within the worker's compensable restrictions.
After a review of all the evidence, the panel finds, on a balance of probabilities, that the worker's assertion that he is totally disabled is not causally related to his 2012 claim. The worker is not entitled to full wage loss benefits after July 8, 2016.
The worker's appeal on this issue is denied.
Issue 2: Responsibility for Ketorloc and Celebrex
The panel notes that the two medications are described as NSAIDS (non-steroidal anti-inflammatory drugs). In terms of timing, the first time a NSAID (Celebrex) was prescribed and referenced on the file was by the worker's treating pain management specialist on June 16, 2016, in response to the physician's findings and first report of an acute rotator cuff issue in the worker's right shoulder that had arisen suddenly in May 2016. The panel's general understanding is that this would be an appropriate medication for a musculoskeletal injury to the shoulder girdle.
Given our findings on Issue #1 that the right shoulder issues are not related to the worker's 2012 injury/claim, the panel finds that to the degree that the medications were prescribed for the worker's right shoulder condition, they should not be covered by the WCB.
The question remains as to whether the two NSAIDS are appropriate for the treatment of the worker's compensable neuropathic pain or depression diagnoses. The panel notes that before and after June 2016, the pain management specialist had been prescribing various anti-neuropathic and mental health medications, which the WCB would review and approve, from time to time, in consultation with a specific WCB medical advisor with an expertise in medication requests.
In this case, the WCB medical advisor reviewed the requests for coverage for Celebrex and Ketorloc, and provided opinions in October 2016 and November 2016 indicating that these medications were not prescribed for neuropathic or depression conditions, which were the worker's compensable conditions. Accordingly, he declined to support them being covered by the WCB.
At the hearing, the occupational health physician was asked for his comments as to whether these two medications were generally indicated for neuropathic pain issues or depression. The panel notes that the physician supported the prescriptions but did not provide a clear medical rationale for coverage, beyond a general comment that it was appropriate for the worker's physician to search broadly for anything that might reduce the worker's pain and to continue to prescribe the medication where there was a perception that helped.
The panel places greater weight on the more formal criteria and analysis provided by the WCB medical consultant and finds, on a balance of probabilities, that the Ketorloc and Celebrex medications should not be covered by the WCB.
The worker's appeal on this issue is denied.
A. Scramstad, Presiding Officer
A. Finkel, Commissioner
M. Kernaghan, Commissioner
Recording Secretary, B. Kosc
A. Scramstad - Presiding Officer
(on behalf of the panel)
Signed at Winnipeg this 11th day of July, 2017