The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is presently appealing decisions made by the Review Office of the Worker's Compensation Board ("WCB") that there is no entitlement to ongoing benefits and treatment. A hearing was held on November 20, 2013 to consider the matter.

Issue

Whether or not the worker is entitled to wage loss benefits beyond February 11, 2011;

Whether or not the worker is entitled to medical aid treatment beyond June 27, 2011; and

Whether or not the worker requires compensable work restrictions beyond June 27, 2011.

Decision

That the worker is not entitled to wage loss benefits beyond February 11, 2011;

That the worker is not entitled to medical aid treatment beyond June 27, 2011; and

That the worker does not require compensable work restrictions beyond June 27, 2011.

Background

On January 13, 2011, the worker was coming down off a foot stool when she missed a step and fell. The worker said she braced her fall by putting her right arm forward and landed on her right arm and felt pain in her right wrist.

Immediately after the accident, the worker sought medical attention at a hospital facility with complaints of tenderness in the distal radius and ulna. The worker was diagnosed with an undisplaced fracture of the distal radius although a right wrist x-ray was unremarkable. The claim for compensation was accepted by the WCB and benefits were paid to the worker.

Ongoing medical reports showed that the worker continued to complain of extreme pain in both her wrist and hand which she related to the fall at work.

On February 28, 2011, a WCB case manager wrote the worker to advise that based on a review of the medical information on file, he was unable to provide further wage loss benefits after February 11, 2011. The case manager stated:

"Your adjudicator confirmed with your treating physician on February 11, 2011 that you could return to one handed (left hand) duties, if your employer could accommodate. Your employer confirmed that they could accommodate that restriction the same day. You were informed on February 11, 2011 that if you choose to not attend the modified duty job made available to you, no further wage loss benefits could be provided.

To date, you have chosen not to return to work and have not participated in the above note (sic) modified duty job. You have also secured the opinion of your family doctor who stated you cannot work at this time; however, your family doctor has provided no objective or measureable findings to provide why you are unable to work at this time.

Given the medical information on file, on a balance or probability, I feel you are capable of working within one handed duties provided by your employer. As you have chosen to not work this modified duty job, I cannot provide any wage loss benefits for any time missed from work."

File records showed that the worker returned to modified duty work on March 2, 2011 but stopped work on March 4, 2011 due to arm/wrist pain. The worker's wage loss benefits were reinstated based on medical information which stated that the worker should remain off work.

On March 17, 2011, a sports medicine specialist reported that the worker fell while coming off a ladder and had almost instantaneous pain in her right wrist, the scaphoid triangle. The worker underwent repetitive x-rays and an MRI of her wrist and these tests never identified bony injury as far as he could discern. The worker had been immobilized in a thumb spica cast and since the cast was removed, the worker was unable to gain any significant return of range of motion. The worker complained of severe allodynia in the medial aspect of her right wrist and severe pain and numbness in her entire hand. There was an extension of this allodynia over the entire forearm and arm. The examination showed allodynia, extremely limited range of motion, hyperalgesia, swelling, temperature and color changes. The diagnosis was early Complex Regional Pain Syndrome ("CRPS") Type 1.

On March 22, 2011, a WCB medical advisor reviewed the file and offered the following opinions:

• the probable initial diagnosis was an undisplaced fracture of the distal radius. This was consistent with the typical mechanism of injury described as falling on an outstretched wrist and having clinical tenderness to the distal radius and snuff box as noted by the treating emergency physician and the treating sports medicine physician. This diagnosis was made despite a documented fracture noted radiologically. The medical advisor noted that a hair line fracture often may not show up on the initial assessment. 

• the typical recovery norms for an uncomplicated upper extremity fracture was 8 to 12 weeks. 

• the current diagnosis was CRPS. This was consistent with the treating sports medicine specialist opinion of March 4, 2011 citing disproportionate pain to clinical findings. 

• One-handed duties would be appropriate at this time. The response to the brachial plexus infiltration and physiotherapy will guide further revision of the current workplace restrictions.

The worker was then referred for brachial plexus blocks in combination with physiotherapy treatment. Arrangements were also made for the worker to see a neurologist.

In early May 2011, the physiotherapist advised the WCB that she was concerned over the worker's lack of progress with treatment. Without anesthetic block, the worker refused to move her hand or wrist. The physiotherapist felt that there could be a strong psychological component to this.

On May 31, 2011, the worker was seen by a psychologist at the WCB's request. His report is on file dated June 15, 2011. 

On June 7, 2011, the worker was seen at a call-in examination by a WCB medical advisor for assessment of her right wrist/arm condition. Based on the worker's symptoms and findings, the medical advisor commented that the evidence did not support a diagnosis of CRPS. The worker had seven blocks with no improvement and reported an actual worsening of her symptoms. If this was CRPS, some improvement would be expected within that intense treatment.

The medical advisor said she could not provide a current diagnosis based on the worker's presentation and could not account for the worker's symptoms or findings on the basis of a wrist sprain or the reported mechanism of injury. There was no evidence of a structural abnormality on which to place any workplace restrictions. Any need for restricted activity was related to reported symptoms alone.

On May 20, 2011, the employer submitted to Review Office that the worker should not have been paid wage loss benefits beyond January 20, 2011.

On June 16, 2011, Review Office determined that wage loss benefits should not have been paid beyond February 11, 2011. Review Office commented that there was a multitude of medical opinions on file regarding both the original diagnosis as well as the matter of whether or not the worker was fit for modified duties. On February 11, 2011, the worker's treating physician was contacted by the WCB adjudicator and it was stated that the worker was capable of working modified duties using her left hand as long as she did not use her right hand. Review Office concluded that the worker should not have been absent from the workplace beyond February 11, 2011 and therefore the employer was entitled to relief of the costs charged to their firm regarding wage loss benefits.

On June 27, 2011, the worker was advised of the WCB's decision to end benefits as of June 27, 2011. The case manager referred to the medical opinion expressed by the WCB medical advisor that the evidence was not supportive of a diagnosis of CRPS. The case manager also referred to the psychological assessment that was performed in May 2011 which stated that the worker's ongoing symptoms were related to pre-existing and or underlying emotional/psychological conditions.

In November 2011, the worker's union representative submitted to Review Office that the worker had not recovered physically from the effects of her injury and that her emotional and psychological conditions still needed to be addressed by a professional who could assist in the resolution of her concerns. The union representative referred to a July 4, 2011 report from the treating sports medicine specialist that the worker was suffering from a lifelong disabling disease following a workplace injury and that this statement, in itself, had not been rebutted by a contrary medical opinion. The union requested that the worker be provided with services that would mitigate the effects of her workplace injury, the impressions she had of herself and how the injury had impacted on her life.

On December 20, 2011, Review Office referred the worker's file back to primary adjudication to address new medical information dated July 4, 2011.

In the report dated July 4, 2011, the sports medicine specialist stated:

I believe your decision to not cover this patient after a work place related injury is irreprehensible. I believe this is not justified given her medical history. She suffers from a severe debilitating condition called complex regional pain syndrome. This is a lifelong disabling disease following a work place related injury….Today on examination she has severe allodynia and changes consistent with swelling and edema, abnormal hair growth and significant allodynia and decreased range of motion. This patient is unable to work secondary to her work place related injury.

On January 22, 2012, a WCB medical advisor advised primary adjudication that the report of July 4, 2011 provided no new information to allow for a change in opinion from the call-in examination. The medical advisor noted that the worker sustained a sprain injury to her wrist from the January 13, 2011 work place injury. There was no evidence of structural abnormality on MRI and the normal recovery is in the 8 week range. The worker's presentation at the June call-in examination was not consistent with a sprain. The clinical findings from the call-in examination were not consistent with a specific anatomic diagnosis. The worker had pain from her neck to her fingertips and that cannot be explained on the basis of a wrist sprain. The medical advisor stated there was no medical relationship between the injury and the worker's ongoing upper extremity complaints. She said the worker did not meet the criteria for the diagnosis of CRPS. She also stated: "Furthermore, our understanding of CRPS has increased with literature reviews and medical studies, which raise the concern that this is not a credible dx [diagnosis], particularly in an insurance setting. The dx and treatment provided are not compatible with current evidence based treatment guidelines."

In a decision dated January 24, 2012, the case manager advised the worker that the medical report of July 4, 2011 did not contain any new medical information or findings that the WCB had not already considered. The case manager stated that he disagreed with any opinion submitted by the treating physician regarding a cause and effect relationship between the accident of January 13, 2011 and any ongoing right arm issues. On February 10, 2012, the worker's union representative requested that the file be returned to Review Office to consider his appeal.

In a submission to Review Office dated March 23, 2011, (which should be March 23, 2012) the employer's representative outlined their position that the adjudicative decision of June 27, 2011 should be upheld. A copy of the employer's submission was provided to the worker's union representative for comment and his response is on file dated April 12, 2012.

On May 3, 2012, Review Office determined that wage loss benefits were not payable beyond February 11, 2011 and the WCB did not have responsibility for medical treatment or compensable restrictions beyond June 27, 2011.

Review Office stated that it preferred the opinion of the WCB medical advisor as the medical advisor had done a considerable amount of research into CRPS and had access to all the medical evidence on the claim which the sports medicine specialist did not have.

Review Office stated that it agreed with the position taken by the WCB medical advisor and the case manager and found that the cause of the worker's loss of earning capacity beyond June 27, 2011, did not have a relationship to the worker's compensable injury of January 13, 2011. Review Office indicated that it would not alter its prior decision regarding wage loss benefits beyond February 11, 2011. Review Office noted that left-handed modified duties were available to the worker and that she should have been able to perform those duties.

In February 2013, the worker's union representative provided Review Office with a report from an anesthesiologist to support that the worker's benefits should be reinstated. The union representative stated:

"Following his examination of [the worker] and after reviewing the clinical notes from [the sports medicine physicians], he noted that she displayed many of the classic signs and symptoms of a patient with CRPS. He stated the following: "I would have to conclude that complex regional pain syndrome is certainly an appropriate and reasonable diagnosis under this situation." He also stated that insofar as her prognosis was concerned, "contrary to what was written by the Workman's (sic) Compensation Physician, this usually is a protracted course and can be lifelong." He also related her CRPS condition to her compensable accident on January 13, 2011."

The union representative suggested that Review Office seek the opinion of a third party doctor with experience in treating patients with CRPS if it was unsure how much weight to give to the medical opinions on file.

On February 11, 2013, Review Office determined that the diagnosis and information provided by the anesthesiologist was consistent with the information that was available at the time it made its earlier decisions of June 21, 2011 and May 3, 2012.

On August 15, 2013, an appeal was filed with the Appeal Commission with respect to Review Office's decisions of June 16, 2011 and May 3, 2012 and an oral hearing was held on November 20, 2013.

Following the hearing, the appeal panel met to discuss the case and it requested additional information prior to rendering a decision on the issues under appeal. The additional information consisted of information from the WCB as to the guidelines they use in the assessment and diagnosis of Complex Regional Pain Syndrome and a report by an independent medical examiner with respect to the worker's right upper arm condition. The information was shared with the parties for their review and comments. On June 24, 2014, the panel met further to discuss the case and rendered its final decisions.

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.

The worker has an accepted claim. She is seeking additional wage loss benefits and medical aid benefits. She is also asking whether compensable restrictions should be in place after June 27, 2011.

Relevant provisions of the Act include: 

• ss. 4(1) provides that 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. 

• ss. 39(1) provides that wage loss benefits will be paid: “…where an injury to a worker results in a loss of earning capacity…” 

• ss. 39(2) 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. 

• ss. 27(1) empowers the WCB to provide such medical aid as the WCB considers necessary to cure and provide relief from an injury.

Worker's Position

The worker was represented by a union representative. The representative provided a written submission, and gave an oral summary of the submission. He answered questions from the panel. The worker's representative advised that the worker has a basic command of English but is unable to read or write in English. He advised that she did not require the assistance of an interpreter. The worker answered questions from her representative and the panel. She was assisted by her daughter.

The worker's representative outlined the worker's injury, the sequence of diagnoses in the worker's case and the treatments provided. He noted that the worker's treating physicians all agreed that the worker suffered from Complex Regional Pain Syndrome (CRPS) He noted that a WCB medical advisor also agreed with this diagnosis but that a different WCB Medical Advisor who examined the worker on June 7, 2011 did not support this diagnosis.

The worker's representative provided a detailed explanation of CRPS including references to British Columbia Worksafe Guidelines (BC Guidelines) on this condition. He noted that the evidence-based guidelines indicate:

• CRPS is usually precipitated by noxious stimulation or immobilization in the periphery, although the amount of tissue damage may be minimal. 

• CRPS is generally accepted as a neurologic disorder affecting both central and peripheral nervous systems. 

• The exact pathophysiology is still unclear. 

• Pathophysiology may vary from one patient to another.

The worker's representative also referred to other resources including the International Association for the Study of Pain definition of CRPS and the Canadian RSD network description of the condition. The worker's representative submitted that CRPS is an injury to the nervous system, not a musculoskeletal injury. The worker's representative noted the BC Guidelines list the most commonly agreed upon symptoms that typify a person with CRPS.

The worker's representative submitted that:

"In this claim the WCB medical advisor who was ultimately assigned to this file is a non-believer in Complex Regional Pain Syndrome. Even though she admits to having absolutely no experience with Complex Regional Pain Syndrome patients, she has strongly and inflexibly opined that CRPS is not a legitimate medical diagnosis in an insurance setting. This is a position that is inconsistent with other docs from the WCB in the Health Care Department."

The worker's representative disagreed with the medical advisor's comments and findings from the June 7, 2011 call in examination. He noted that the medical advisor concluded: 

• that since the treating physiotherapist reported that the worker had near full passive range of motion following brachial plexus blocks, the worker's inability to actively move her arm was voluntary and not due to her medical condition 

• that the worker could not have CRPS because she did not show improvement after the brachial plexus block therapy.

The worker's representative noted that subsequent to the call-in examination, the WCB medical advisor purported to research the CRPS medical condition. He noted that she referred extensively to the America Medical Association and American Association of Orthopedic Surgeons information. With respect to her conclusion that the worker did not meet the criteria for diagnosis of CRPS according to the AMA guidelines, he noted that this conclusion was based upon the medical advisor's personal observations during the call-in exam and is contrary to the observations of numerous other medical reports which note signs and symptoms which would support the diagnosis of CRPS.

Regarding the worker's return to work, her representative noted that she reported to work on March 1, 2011, worked for approximately two and one half hours but had to stop due to increasing pain. She returned to work on March 4, 2011 but was sent home by the employer. He advised that: 

• her physician changed his opinion and concluded that she was not able to work.

• the June 1, 2011 physiotherapy discharge report did not approve the return to work. 

• a specialist provided a note dated May 25, 2011 that the worker is unable to work using her right hand and that she may have difficulty concentrating and working due to her ongoing pain. 

• another physician provided a report dated July 12, 2013 which indicated that "Since this is a type of neuropathic pain in her dominant hand, it would be unusually cruel to suggest that she could go back to work at this time."

The worker's representative stated:

"To sum up, [the worker] had a compensable accident on January 13th, 2011. In the opinion of one athletic therapist, one sports medicine specialist, one experienced physiotherapist at [clinic], three experienced pain clinic specialists at two different pain clinics, and one WCB medical consultant, [the worker's] on-going compensable diagnosis is Complex Regional Pain Syndrome."

He submitted that a fair assessment of all the evidence in the file supports a retroactive restoration of full WCB benefits for the worker.

In answer to questions, the worker advised that her current physician has prescribed 2 medications. The physician also advised her to continue with her home physiotherapy which involves her fingers and massage. She advised that her physician told her that her arm will never get better.

Regarding her current pain level on a scale of 1 to 10, she advised that she is at 10. She said it never goes under 10 but when she sleeps she does not feel the pain. She said her hand turns colors such as pink, white, black, and red. It is also wet. She added that:

"Fever. It’s burning inside of me and I’m going up to my shoulder to my neck, it’s frozen, like I can’t move."

The worker advised that she wore a cast for 4 months and then used a sling. With respect to nerve blocks, the worker stated that blocks numbed her arm so she didn't feel her arm. She could not recall whether she had a block prior to her examination by the WCB medical advisor.

The worker's representative made a further submission in response to the independent medical examination which the appeal panel ordered. The worker's representative disagreed with the examiner's opinion. However he noted that the examiner did find the worker presented with some of the signs and symptoms that would support a diagnosis of CRPS.

The worker's representative submitted that:

"On a balance of probabilities the medical evidence supports that [worker] had CRPS in 2011 and if there are now doubts that her current disability is related to this condition then it becomes necessary to determine when this change may have occurred".

Employer's Position

The employer was represented by an employer advocate. The employer representative reviewed the claim history including the worker's attempt to return to work. He noted that the issue in this claim is the compensability of a CRPS diagnosis to a mechanism of injury. He said this is a minor event that was deemed to have caused a wrist sprain and it should have resulted in rehabilitation within six to eight weeks.

The employer representative submitted that:

"Just in closing it is still the Employer’s position that Complex Regional Pain Syndrome is not caused by work. The National Institute of Neurological Disorders and Stroke says that Complex Regional Pain Syndrome is a chronic condition that is believed to be the result of dysfunction of the central and peripheral nervous systems. It also goes on to state that a CRPS is frequently triggered by an injury, however, it doesn’t say that it is caused by an injury.

The term describes – this term describes all patients with such symptoms but with no underlying nerve injury. See, the CRPS can strike at any age. If affects both men and women. However, it is more common in young women and again, this is unrelated to the workplace.

On this – the National Institute of Neurological Disorders and Stroke lists underneath what causes CRPS and it clearly states doctors aren’t sure what causes CRPS. There’s theories, however, it looks like there’s many triggering points, but a general cause is not known, and in this case certainly the workplace injury could not cause something that – well, there’s no evidence to show that no mechanism of injury caused Complex Regional Pain Syndrome."

The employer representative noted that the worker has not returned to work and submitted that it would be unfair for the employer to incur costs when they do everything to mitigate these minor injuries that do occasionally occur within the workplace.

Analysis

There are 3 issues before the panel; however, the primary focus of the discussions at the hearing was on whether the worker 's condition meets the diagnosis for CRPS and whether it is related to her workplace injury.

Given the complexity of the medical matters under consideration, the panel elected to obtain an opinion from an independent specialist to assist it with addressing the appeal. The panel asked the independent specialist to examine the worker, review her medical file and answer the following questions:

1. What was the diagnosis(es) resulting from the fall? 

2. What is the current diagnosis(es) relating to the worker's right upper extremity complaints? 

3. To what point in time can this diagnosis(es) be traced back? 

4. What are the medical findings in support of the current diagnosis(es)? 

5. In your opinion, is there a relationship between the current difficulties experienced by the worker and the fall of January 13, 2011? Please provide the rationale in support of your conclusions. 

6. Does the worker require any physical restrictions in relation to the workplace injury? If so, please outline the restrictions. 

7. Would the physical restrictions be considered temporary or permanent in nature? 

8. What are your recommendations for future treatment?

The panel considered the independent specialist's report dated April 30, 2014. The panel is satisfied that the specialist was qualified to undertake the examination; was acquainted with the current literature and practices with respect to the diagnosis and treatment of CRPS; reviewed all medical reports on the worker's WCB claim file; and examined the worker. The panel found the analysis to be thoughtful and thorough and accepts the opinions offered by the independent specialist.

Specifically the panel accepts the independent specialist's opinions as follows:

1. Original diagnosis(es) resulting from the fall at work: 

"...on the basis of the information available, a nonspecific diagnosis of wrist pain and swelling, is the most specific diagnosis that can be made with respect to the original condition that existed after her fall rather, than a specific diagnosis.

Given the claimant stated that she tried to return to work immediately, and given the relatively innocuous mechanism of injury, it is unlikely that she perceived that she was at serious risk to her life and limb. As such, it is improbable that this incident resulted in psychological trauma."

2. Current diagnosis(es) relating to the worker's right upper extremity complaints:

"In the claimant's particular situation, her primary complaint is diffuse right upper limb pain and range of motion loss. In the first instance, the development of diffuse entire right upper limb chronic pain and range of motion loss, is unanticipated following a relatively innocuous mechanism of injury such as a fall on an outstretched hand (FOOSH) from a low height.

With respect to the working diagnosis of CRPS, it is unusual that her pain is completely relieved at night during sleep yet present throughout the waking hours with no change in intensity throughout her waking hours. This on/off phenomena is not a typical feature of CRSPS (sic).

It is also unusual that the claimant has almost complete loss of active range of motion at the shoulder, elbow and hand; yet does not show any evidence of tissue atrophy or soft tissue contracture. In addition, unlike the proposed diagnostic criteria for CRPS, she does not specifically complain of symptoms of temperature change, color change, altered sweating or trophic/motor changes.

With respect to the criteria for CRPS previously listed, there is no objective evidence of hyperesthesia. Rather, she has a complete anesthesia to all modalities throughout the right upper limb across a nonanatomic sensory pattern extending from the acromion to the fingertips. It is therefore irreconcilable how she perceives very light palpation as painful during very gentle palpation of her bony prominences or soft tissues, but not during the sensory examination. In addition, she reports pain distally with palpation of the shoulder girdle in a pattern that does not conform to a physiologic referral pattern.

From a purely neurologic perspective, complete absence of sensation, indicative of a neurologic lesion is incompatible with preserved reflexes, unless once (sic) suspects a lesion in the brain, brainstem or spinal cord. In the absence of these latter conditions (no one on file has suggested these diagnoses, nor does it fit with her clinical presentation), her absence of sensation does not make physiological sense.

Again with respect to the diagnostic criteria for CRPS, the claimant does not currently present with objective evidence of vasomotor dysfunction in the form of altered skin color, temperature or asymmetry. In addition, she does not currently display objective evidence of sudomotor dysfunction in the form of edema. The mild difference in palmar sweating from right to left is likely within the range of normal.

While she does present with loss of range of motion, it appears likely that the majority of this range of motion loss is due to voluntary guarding rather than soft tissue contracture or muscle paralysis. In particular, it is noted on several occasions that she "passively" moves the right upper limb with her left hand, only to actively engage right upper limb muscles at the same time during motion. The end-feel documented by the examiner is inconsistent with capsular or muscular contracture as would be expected in an individual with sustained range of motion loss. As such, there is no objective physiological basis to explain why the claimant does not move her right upper limb at the shoulder, elbow, forearm, wrist and hand.

Therefore, on a balance of probabilities, the clinical presentation does not meet the diagnostic criteria for CRPS.

It is noted that the claimant was seen by [Dr. name], a clinical psychologist, who opined that the claimant's clinical presentation was consistent with a somatization disorder, conversion disorder, or pain disorder. All three of these conditions are classified as one of the somatoform disorders which represent a group of conditions that present with physical symptoms that suggest a physiological basis. However, the subsequent clinical evaluation reveals that the presenting complaints are not adequately explained by organic pathology. An essential effect of these conditions is the presence of clinically significant distress or impairment in social, occupational or other areas of functioning.

Based on the clinical presentation, including the current evaluation and that inferred from the file record, it is medically probable that the claimant has one of the somatoform disorders. The specific sub-classification of a somatoform disorder is deferred to a mental healthcare practitioner."

3. Relationship between current difficulties experienced by the worker and the accident on January 13, 2011:

"As has been mentioned previously, it is improbable that the claimant sustained a substantial bony or ligamentous injury as evidenced by the negative imaging studies. Nevertheless, if she did sustain a subtle fracture or ligamentous injury, it was sufficiently occult that it was not detected on 2 x-rays or a subsequent MRI scan. As such, the claimant did not sustain an anatomic disruption of tissue that is still awaiting repair.

It appears that early on, pain and possibly swelling, were reported. It is unclear, why, in the presence of negative imaging studies, that continued immobilization was recommended for treatment of the claimant's right upper limb complaint. In particular, when the claimant was seen again in follow-up on February 17, 2011 at the [name] clinic (at just over 1 month since onset), it is likely that the result of the previous x-ray, noting that no fracture was evidence, was available on file. In addition since the diagnostic impression accounting for her lack of progress thus far included possibly early CRPS, it is unclear why additional immobilization was recommended.

As such, it appears that immobilization beyond February 17, 2011, was not justified on the basis of the objective medical available at that time. If it is accurate that the claimant was immobilized for four months as she states in her history, then the duration of immobilization appears to be greater than was clinically indicated. As such, to the extent that the claimant may have sustained soft tissue contracture or disuse atrophy, one could apportion some of the cause of the outcomes to her having been immobilized for a prolonged period.

Nevertheless, the current evaluation does not show objective evidence of tissue atrophy, swelling or contracture. As such, if these objective findings ever did exist, they have resolved. The fact that the claimant is currently unable to move her right upper limb is therefore not compatible with a complication of prolonged immobilization that may have previously existed.

When considering whether a medically probable cause and effect relationship exists, it is helpful to consider whether there is: 

• medically probable cause 

• medically probable effect 

• an appropriate temporal relationship between the cause and effect 

• an appropriate magnitude of the effect given the alleged cause

With respect to the above factors, the following is known: 

• the alleged cause is a FOOSH injury from a low height 

• the medically probable clinical effect is a somatoform disorder 

• the clinical effect followed the alleged cause 

• the degree of activity limitation and the duration of same in the absence of objective physical finding is unanticipated

It is medically improbable that the above mechanism of injury would cause a somatoform disorder. The degree of physical activity limitation is inconsistent with a (sic) injury resulting from a FOOSH injury.

Therefore, on a balance of probabilities, there does not appear to be a medically probable causal relationship between the current difficulties experienced by the claimant and the fall of January 13, 2011."

4. Physical restrictions in relation to the workplace injury:

"In the absence of a physical diagnosis accounting for her pain and range of motion loss, it does not make medical sense to recommend activity limitation or to restrict the claimant from moving her right upper limb. The only reason to advise the claimant not to move her right upper limb is for treatment of a psychogenic condition. The rationale, if any, for such a recommendation is deferred to a mental health practitioner."

The panel notes that in the opinion of the independent specialist the worker's condition does not meet the AMA Guidelines nor the BC Guidelines for CRPS.

In addition to the independent specialist's report the panel places weight on the opinion of the clinical psychologist, who opined that the worker's clinical presentation was consistent with a somatoform disorder.

The panel does not place weight upon the opinion of the WCB medical advisor who reported that she was unable to fully assess the worker's arm.

With respect to the issues before the panel, we find that:

Issue 1: whether the worker is entitled to wage loss beyond February 11, 2011 

The worker is not entitled to wage loss beyond February 11, 2011. The panel is not able, on a balance of probabilities, to identify a compensable medical condition arising from the worker's workplace injury which caused the worker's loss of earning capacity beyond that date, or made the return to work single arm duty placement outside the worker's functional abilities at that time.

Issue 2: whether the worker is entitled to medical aid benefits beyond June 27, 2011.

The worker is not entitled to medical aid benefits beyond June 27, 2011. The panel is not able, on a balance of probabilities, to identify a compensable medical condition arising from the worker's workplace injury which requires treatment beyond June 27, 2011.

Issue 3: whether the worker requires compensable work restrictions beyond June 27, 2011.

The worker does not require compensable work restrictions beyond June 27, 2011. The panel is not able to identify a compensable medical condition arising from the worker's workplace injury which supports the imposition of compensable work restrictions beyond June 27, 2011.

The worker's appeal is dismissed.

Panel Members

A. Scramstad, Presiding Officer
A. Finkel, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

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

Signed at Winnipeg this 22nd day of July, 2014