The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") that responsibility should not be accepted for their injections after August 30, 2021. A file review was held on March 8, 2022 to consider the worker's appeal.

Issue

Whether or not responsibility should be accepted for the worker’s injections after August 30, 2021.

Decision

Responsibility should not be accepted for the worker’s injections after August 30, 2021.

Background

This claim has been the subject of a previous appeal as detailed in the February 19, 2008 Appeal Commission Decision No. 28/08. The background will therefore not be repeated in its entirety.

On October 29, 1982, the worker sustained injuries to their neck and back when they slipped and fell on a set of stairs at work. The WCB accepted the worker’s claim, and the payment of various benefits began. In September 1983, the WCB determined the worker could return to modified duties and by December 17, 1983, the worker had returned to their full pre-accident duties. After returning to work in December 1983, the worker reported ongoing discomfort and pain while performing their normal job duties and continued to see their chiropractor for treatment to relieve those symptoms.

By Review Committee decision of February 7, 1985, the WCB accepted continuing responsibility for the worker’s ongoing head and neck complaints. Following the Review Committee decision, there was minimal activity on the file until July 2005 when the claim was reactivated by the worker. In a letter dated September 16, 2005, the worker reported that since the accident in 1982, they had suffered from “a sore stiff neck, headaches, and other troubles.” The WCB authorized further treatment as medical aid.

On March 27, 2007, the worker was examined by a WCB medical advisor for the purposes of establishing a Permanent Partial Disability (“PPD”) rating. The WCB determined that as of March 27, 2007, the worker had a 6.2% PPD rating based on the loss of range of motion in their cervical spine. The worker disagreed with the effective date of the PPD award and filed an appeal with Review Office, contending that the effective date should be October 29, 1982. In a decision dated September 25, 2007, Review Office confirmed that the effective date of the PPD award was correct as the effective date of a PPD is the date that the impairment was first accurately measured and prior to March 27, 2007, there was insufficient evidence to determine that there was a permanent measurable loss of range of motion of the neck. On November 28, 2007, the worker’s representative filed an appeal with the Appeal Commission and on February 19, 2008, Appeal Commission Decision No. 28/08 determined the March 27, 2007 date was correct.

The worker requested and received limited coverage for massage therapy and acupuncture between 2007 and 2008. On October 22, 2008, the worker’s treating physician requested the WCB authorize the provision of trigger point injections which were providing the worker with relief from their symptoms. The WCB authorized the request for six trigger point injections on November 12, 2008. On November 17, 2008, the WCB received a copy of a report to the worker’s treating physician from a pain management physician and on November 24, 2008, authorization for the injections was transferred to the pain management physician. The WCB extended the authorization for five additional treatments on July 9, 2009.

On August 21, 2009, the worker advised the WCB they were retiring from their employment effective September 26, 2009 and relocating out of province.

On October 23, 2009, the WCB received a report from the worker’s new pain management physician requesting authorization for further trigger point injections, and on October 30, 2009, the WCB authorized a six-week trial. On December 18, 2009, the treating physician requested an extension of the trigger injections for an additional 12-18 weeks and the WCB approved that request on January 6, 2010. A further extension for 6 injections was granted on May 17, 2010. Additional extensions were granted on November 3, 2010, March 2, 2011, July 19, 2011, October 26, 2011 and August 26, 2012. On January 17, 2013, the WCB advised the treating pain management physician that it would authorize 12 injections per year for a two-year period. On April 9, 2015, a further 12 injections were approved. After review of the worker’s file and information received by the worker’s treating physician, on April 5, 2016 a WCB medical advisor provided that the soft tissue injections should continue at a rate of one per month, for a total of twelve per year with a yearly review, as the injections were providing “…significant symptomatic benefit….”

On November 18, 2019, the WCB requested a narrative report from the worker’s treating physician. The December 19, 2019 report outlined the physician’s opinion that the worker should continue with the injections as the worker’s pain “…comes back quite dramatically” without the injections. On October 6, 2020, a WCB medical advisor undertook an in-depth review of the worker’s file. The medical advisor noted the treatment of the worker’s injury after the October 29, 1982 workplace accident, and that the file evidence indicated the worker returned to work in December 1983 after their symptoms subsided. The medical advisor also noted the worker’s treating neurosurgeon on June 24, 1985 indicated the worker had an “entirely normal” neurological examination. The medical advisor commented upon the worker’s lack of contact with the WCB between 1985 and 2005, when the worker reported ongoing neck difficulties, but that they had not missed any work due to those difficulties. The WCB medical advisor concluded the worker’s original diagnosis was “…probably back contusion, with a head contusion/neck strain possible” and went on to opine that the diagnostic investigations on the file did not provide evidence the worker sustained a cervical spine fracture or a cervical spine dislocation, with no cervical spine instability indicated. The WCB medical advisor noted “There also is no evidence of any organically based neurological sequelae to have resulted from the fall.”

In response to the WCB medical advisor’s opinion, the worker’s WCB case manager, on October 7, 2020, requested a further opinion on whether the monthly injections were required in relation to the October 29, 1982 workplace accident. On February 9, 2021, the WCB medical advisor indicated a virtual call-in examination was being arranged to determine the worker’s status. In a file note dated March 16, 2021, the WCB case manager confirmed the worker indicated they were not interested in participating in the virtual call-in examination and requested the WCB provide them and their treating healthcare providers with clarification of why the examination was being arranged.

On May 4, 2021, the WCB medical advisor provided a further opinion that the WCB could no longer medically support the worker’s injections as their neck symptoms were not medically accounted for in relation to the workplace accident and factors other than the workplace accident could account for those symptoms. Further, the medical advisor stated the quantity of injections provided to the worker exceeded conventional treatment for the worker’s subjective complaints and despite the years-long course of injections, there was no evidence of sustained improvement in the worker’s symptoms and function. On May 20, 2021, the WCB advised the worker that the WCB would no longer provide funding for the monthly soft tissue injections but, due to the length of time the worker had been receiving those injections, a weaning period of three months was provided, to end on August 31, 2021.

The worker requested reconsideration of the WCB’s decision to Review Office on August 4, 2021. In their submission, the worker noted they had a permanent impairment which required ongoing treatment and that the injections provided pain relief. On September 29, 2021, the employer provided a submission in support of the WCB’s decision, a copy of which was provided to the worker. Review Office determined on October 6, 2021 that responsibility should not be accepted for the worker’s injections after August 31, 2021. Review Office accepted the WCB medical advisor’s opinions and concluded the evidence on the worker’s file did not support the need for further coverage for injections.

The worker filed an appeal with the Appeal Commission on November 30, 2021. A file review was arranged for March 8, 2022.

Reasons

Applicable Legislation and Policy

The question on appeal relates to the worker’s entitlement to medical aid benefits. The Workers Compensation Act, CCSM 1970 c.W200, as amended, (the “Act”) in effect on the date of the accident provides in s 4(1) that where in any industry within the scope of the Act, personal injury by accident arising out of and in the course of employment is caused to a worker, compensation shall be paid by the WCB as set out in the Act.

With respect to medical treatment, the Act provides in s 24(1) that:

In addition to other compensation provided by this Part, the board may provide for the injured workman such medical, surgical and hospital treatment, transportation, nursing, attendant care, medicines,…as it may deem reasonably necessary at the time of the injury, and thereafter during the disability, to cure and relieve from the effects of the injury; and the board may adopt rules and regulations with respect to furnishing medical aid to injured workmen entitled thereto, and for the payment thereof.

The Act goes on to provide in s 24(11) that medical aid “…furnished or provided…shall at all times be subject to the supervision and control of the board.”

The WCB has established Policy 44.120.10, Medical Aid, (the “Policy”) as applying to all decisions related to medical aid on or after January 1, 2019. The general principles that govern the WCB’s funding of medical aid are set out in the Policy and include the following:

• The Board is responsible for the supervision and control of medical aid funded under the Act or this policy. 

• The Board determines the appropriateness and necessity of medical aid provided to injured workers in respect of the compensable injury. 

• In determining the appropriateness and necessity of medical aid, the Board considers: 

o Recommendations from recognized healthcare providers; 

o Current scientific evidence about the effectiveness and safety of prescribed/recommended healthcare goods and services; 

o Standards developed by the WCB Healthcare Department. 

• The Board promotes timely and cost-effective access to medical aid. 

• Workers are entitled to select their own health care provider, subject to the Board's control and supervision of medical aid. 

• The Board's objectives in funding medical aid are to promote a safe and early recovery and return to work, enable activities of daily living, and eliminate or minimize the impacts of a worker's injuries. 

… 

• The Board will refuse or limit the funding of any medical aid it considers excessive, ineffective, inappropriate or harmful.

Worker’s Position

The worker represented themself in the appeal and provided a written submission to the panel dated March 1, 2022.

The worker’s position is that the injections have reduced their pain, neck stiffness and headaches and in general, have contributed to their increased wellbeing and function. The worker’s position is that their symptoms are the result of the compensable workplace injury sustained in 1982 and as a result, the treatment of those symptoms by periodic injections should be funded by the WCB.

The worker stated in their submission that they continue to suffer the effects of their workplace injury and that of all therapies tried in the past, none has been as effective in treating their symptoms as the injections.

The worker indicated these injections have allowed them discontinue all oral medications such that they only rely upon medication received by a transdermal pain patch, and the injections. The worker stated “These injections have turned my life of pain, and misery around, and allowed me to live my life, with pain, but manage it….I am “managing” my neck injury with a pain patch, and monthly injections. I am very happy with my progress, treatment, and outcome of receiving these injections.”

In sum, the worker’s position is that the injections continue to provide relief of symptoms that arise out of their compensable workplace injury sustained on October 29, 1982 and therefore, the WCB should accept responsibility for their injections after August 30, 2021.

Employer’s Position

The employer was represented in the hearing by its workers compensation coordinator who provided a written submission on behalf of the employer for consideration by the appeal panel, dated March 1, 2022.

The employer’s position is that the decisions of the WCB and Review Office are correct in finding that no responsibility should be accepted for the worker’s injections after August 30, 2021. The employer believes that the evidence is clear that the injections have not resulted in the relief contemplated by the Act and Policy and therefore, the WCB correctly ended responsibility for the injections.

As set out in the written submission, the employer acknowledges that in November 2008, the WCB accepted responsibility for the trigger point injections in relation to the worker’s compensable injury and that such responsibility was to be periodically reviewed by the WCB. Initially, the rationale provided for those injections was to relieve the worker’s symptoms so that they could continue working in their position with the employer without the need to increase other pain relief medication. After the worker’s retirement in September 2009, the worker moved out of province and received treatment from a new pain management physician who continued to report that the worker would receive 3-5 weeks relief from the injections and to recommend that the worker receive injections each 4 weeks.

The employer’s representative noted a WCB medical advisor opinion of December 14, 2012 that “There does not appear to be any reasonable medical rationale for this claimant to receive any further repeating series of injections to the muscles of [their] neck as related to the reported claim of October 29, 1982 (now of greater than 30 years remote.)” The employer’s representative noted that despite this opinion, the WCB case manager continued to authorize ongoing injections, stating in a memo to file dated January 17, 2013 that:

“While there does not appear to be a measurable objective basis to authorize ongoing injections, whether or not the injections are covered by WCB for “maintenance”, is a decision to be made in Case Management, taking into account the entire claim. The WCB Medical advisor will only comment on the requirement of the [treatments] and any measurable benefit they may be providing, which is not present here.”

The employer’s position is that the WCB case manager’s subsequent decision to authorize continuing injections “on a therapeutic maintenance basis” is in error in that it does not properly apply the Act and the Policy and provides for continuation of treatment for which there is no measurable benefit to the worker. Further, there is no subsequent medical rationale provided to continue these injections beyond that date.

The employer’s representative submitted that the panel should place significant weight on the May 4, 2021 opinion of the WCB medical advisor that despite having undergone some 157 individual sessions of typically multiple soft tissue injections over more than ten years, with concurrent initiation of opioids in 2009 and increased opioid dosing thereafter, there is no evidence that the worker has sustained any meaningful benefit from the injections in terms of symptoms and function.

In sum, the employer’s position is that the evidence does not support a finding that the proposed treatment has provided or will provide sustained and beneficial relief to the worker from the symptoms of the workplace injury and therefore the WCB should not accept responsibility for the worker’s injections after August 30, 2021.

Analysis

The question for the panel to determine is whether the WCB should accept responsibility for the worker’s injections after August 30, 2021. For the worker’s appeal to be granted, the panel would have to determine that the treatment is reasonably necessary to cure and relieve from the effects of the compensable workplace injury of October 29, 1982. As outlined in the reasons that follow, the panel was not able to make such a finding and therefore the worker’s appeal is denied.

In determining the question on appeal, the panel considered whether the evidence supports a finding that the injection treatments to address the worker’s ongoing and painful neck symptoms are related to the effects of the compensable workplace injury and if so, whether the proposed treatment is reasonably necessary to cure and relieve from the effects of that injury. The panel accepts and finds that the worker continues to experience painful neck symptoms but must find that there is a causal relationship between those ongoing symptoms and the injury of October 29, 1982 and if there is such a relationship, that the proposed medical aid is reasonably necessary.

The panel carefully reviewed the medical evidence and claim file history. The worker sustained injury on October 29, 1982 on falling on stairs, landing on their back and striking their head on a stair. The early suspected diagnosis was of a C1 vertebral fracture or dislocation, but this was ruled out as noted in a January 24, 1983 report to the WCB from a treating physician. The worker subsequently experienced cervical pain and headache as well as some seizure episodes which were medically investigated. By December 3, 1982 the treating physician reported the worker was experiencing less neck pain and minor headache. In April 1983, the worker was still complaining of some muscle “twitching” and minor headaches. Upon further investigation, the treating physician, in a June 9, 1983 report, concluded that there was no “organic basis for this patient’s symptoms and I think they are presumably the result of the previous injury and spasms” the worker experienced following the accident. On assessment by a neurologist in August 1983, the worker’s symptoms were described as including “blanking out, headaches and neck muscle spasms” suggestive of a nonorganic functional disorder, and there was no evidence of any neurologic abnormality. By November 1983, the worker reported continuing low-level pain in their upper neck and back, but no further spasms or blanking out episodes and noted that chiropractic treatment was helping. The worker returned to work on full duties as of December 17, 1983.

A January 24, 1984 cervical spine x-ray indicated altered cervical lordosis with minor scoliosis. The WCB continued to fund chiropractic treatment through to April 1984 and by June, the worker again reported an increase in pain symptoms in their neck and resumed chiropractic treatment. The WCB continued to investigate the worker’s symptoms through 1984, with further x-rays taken on December 27, 1984, indicating a stable cervical spine. Early in 1985, the WCB accepted that the worker’s continuing symptoms were related to the workplace accident and authorized continuing treatment. The worker was examined by another neurologist in June 1985 who reported that the worker had occasional episodes of neck stiffness and pain, aggravated by turning the neck and exacerbated when sleeping, but not symptoms “referrable to the central nervous system” and an entirely normal neurological examination, noting only some restriction in the worker’s forward bending. The neurologist also confirmed that the prior imaging confirms there was no evidence of “any cervical spine fracture, subluxation, or instability.”

From June 1985 to July 2005, there is no medical documentation or reporting in relation to the compensable workplace injury. The worker contacted the WCB in July 2005 indicating ongoing neck pain treated with massage therapy as well as headaches and seeking WCB support for the massage therapy. The worker’s treating physician reported occasional neck pain with stiffness and reduced range of motion, treated with massage therapy. The WCB determined that the worker’s continuing symptoms relating to the area of injury were compensable and authorized further massage therapy for symptomatic relief. Based on the treating physician’s report that the worker’s neck movement was restricted, the WCB assessed the worker for a permanent partial disability award in March 2007 and found a permanent reduction in the worker’s cervical range of motion. The WCB continued to provide massage therapy treatment to the worker for treatment of their neck pain symptoms through to 2008. In 2008 the WCB also provided coverage for a series of acupuncture treatments. On September 8, 2008 the WCB physiotherapist advisor provided an opinion that these treatments were providing only temporary relief but not any sustained benefit to the worker, noting that it would benefit the worker to continue yoga and regular stretches to control their symptoms of “chronic neck myofascial pain.”

In October 2008 the worker’s treating physician requested that the WCB authorize provision of monthly trigger point injections for pain management, which seemed to be effective in that the worker had been able to eliminate pain medications. A WCB medical advisor reviewed the request and noted that although the worker was likely at maximum medical improvement as evidenced by the permanent partial impairment assessment, continuation of the trigger point injections would be appropriate if these injections brought about “significant symptomatic improvement” and permitted the worker to maintain their level of functioning.

The treating physician referred the worker to a pain management physician who first assessed the worker on November 17, 2008. The report from that consultation indicates that the worker had a C1/C2 dislocation arising out of the 1982 workplace injury. The report described the previous medical management of the worker’s symptoms as having provided only “temporary symptomatic relief” but no lasting benefit. On examination the pain management physician formed an impression that the worker was “suffering with a post-traumatic chronic mechanical neck pain syndrome” and that the worker’s headaches appeared “to be cervicogenic in nature likely attributable to the hypertonic paracervical muscles identified.” The physician recommended further local anesthetic injections with a longer acting local anesthetic, initially on a weekly basis for 6 weeks, and noted that if this did not successfully “break the daily pain and muscle spasm cycle that has unfortunately developed” and provide more lasting benefit to the worker, then consideration should be given to a trial of botox injections targeting the same muscle groups. The WCB medical advisor agreed that these injections might provide a more lasting benefit to the worker and were related to the effects of the compensable injury.

Initially, the medical reports from the treating pain management physician indicated positive outcomes for the worker, indicating a significant reduction in pain symptoms immediately following the injections and a lasting benefit, without any adverse side effects or changes in other medications. On January 23, 2009 the physician reported a change in the worker’s pain medications. On March 9, 2009, the physician reported the worker indicated significant improvement in pain symptoms, sleep and functional abilities and that they would be returning to work on March 11, 2009. No further injections were requested at that time but on April 21, 2009 the physician requested approval for five more treatments “to help control” the worker’s pain and improve their functional abilities so that the worker could continue working without the need to increase narcotic analgesic consumption. The WCB approved this request on July 9, 2009 and the injections were administered in July and August, 2009 with the worker again reporting significant symptomatic relief.

The WCB assessed the worker again for permanent partial disability on June 16, 2009. At that time, the worker noted some soreness in their neck during certain activities and that they were working modified duties due to another unrelated condition. The worker reported continued reliance upon the pain medications prescribed by the treating pain management physician as necessary as well as participating in yoga, frequently changing positions of their neck and avoiding risk taking. There was no change in the degree of impairment noted as compared to the previous assessment two years earlier.

In October 2009 the worker was assessed by a new pain management physician after moving to another province. This physician noted in the patient history that the worker had sustained a fracture of the C1 vertebra in October 1982. The physician reported their diagnostic impression as “a classic example of chronic post traumatic pain resulting from trauma of [the worker’s] fall in 1982. Neck and bilateral sternocleidomastoid symptoms are mechanical/myofascial in nature. [The worker’s] cervicogenic headaches are attributed to the hypertonic paracervical muscles identified.” The physician outlined a plan for further injections over up to 6 weeks to again attempt to break the worker’s pain cycle and suggested a trial of botox injections if these were not successful. The worker’s pain medications were continued. The physician concluded that the worker’s prognosis was guarded given the 25 plus years of symptoms and “their refractoriness to treatment thus far.”

The worker submits that their ongoing symptoms are causally related to the 1982 compensable workplace injury, noting that the WCB accepted this causal relationship from 2005 onward, providing the worker with medical aid including massage therapy, acupuncture, pain medication, trigger point injections and ultimately, the local anesthetic injections that are subject of this appeal. The worker stated that the injections provide ongoing relief in addressing the continuing symptoms of the workplace injury.

Having reviewed the file evidence, the panel is challenged to come to the same conclusion. There is little clinical evidence in the worker’s WCB claim file to support the conclusion reached that there was a causal link between the worker’s symptomatic presentation in 2005 and their injury in 1982. We note the lack of evidence of continuity of symptoms from 1985 to 2005 and no evidence of any medical care or medical treatment provided from 1985 to 2005. When the worker did seek medical treatment on July 27, 2005, it was primarily to obtain a referral for massage therapy and the worker indicated to the WCB that they saw the physician only for “about 10 minutes”. At that time, the worker indicated that they attended for massage therapy regularly. The worker described having “little neck problems over the years” and that they lived with the pain, self-treating with over-the-counter pain relievers, massage therapy and yoga. The worker also described headaches that begin in their neck and neck stiffness.

Although the worker sought further medical treatment for their neck and headache symptoms and the WCB provided further coverage for such treatment after 2005, the panel notes that the worker was not disabled from employment in this period. In fact, the file evidence confirms that the worker was sufficiently recovered from their workplace injury to return to their full regular duties with the pre-accident employer for more than 20 years following the accident and continued in their employment until their retirement in September, 2009.

The panel also considered the detailed file review and opinions provided by the WCB medical advisor, in a memo to file dated July 28, 2020 (put to file October 6, 2020) and in another memo to file dated May 4, 2021. The July 28, 2020 memo indicates the medical advisor’s conclusion that the original diagnosis “…was a probable back contusion with a head contusion/neck strain possible” and that there was no evidence “…that a cervical spine fracture occurred with the original fall…nor that there was any cervical spine dislocation…”, and also no evidence of any cervical spine instability or neurological sequelae from the fall. In the May 4 2021 memo, the WCB medical advisor also noted that the worker’s medical and employment history supports a conclusion that the worker materially recovered from the October 29, 1982 workplace injury by June 24, 1985. Further, the medical advisor outlined that the worker’s neck symptoms since 2008 were diagnosed as “post-traumatic chronic mechanical neck pain syndrome or mechanical/myofascial neck pain” on the basis of an understanding of the worker’s medical history as including cervical spine dislocation or fracture, which is not confirmed by the evidence. Taken in combination with the worker’s clinical status to 1985 and the worker’s continuing employment from 1985-2005 without requirement for medical intervention, the medical advisor concluded the post-2008 diagnoses were “not substantiated” in relation to the 1982 workplace accident. Further, the medical advisor noted that the worker’s reported symptoms are common symptoms of “non-specific neck pain” and the diagnostic labels attached to the worker’s condition are themselves “non-specific” and may be caused by a “variety of widely medically acknowledged factors” such as “structural changes within the neck, postural factors and a sleep disturbance.” The medical advisor noted evidence of such factors in the worker’s medical history, including multilevel degenerative changes in their cervical spine, anterior head carriage and sleep disturbance.

The panel accepts and relies upon these opinions of the WCB medical advisor based on two separate reviews of the worker’s entire claim file and medical history, including diagnostic imaging.

On the standard of a balance of probabilities, the panel is satisfied that the evidence does not support the worker’s position that nearly 40 years following the workplace injury, their ongoing symptoms can be causally related to their 1982 workplace injury. However, the panel also considered whether, if there was such a causal link, the requested continuation of injection treatments is reasonably necessary to cure and relieve from the effects of that injury.

The Act provides that medical aid may be provided to cure and relieve from the effects of the injury during the disability. The Policy sets out that medical aid is provided to eliminate or minimize the impacts of a worker's injuries and that the WCB may refuse or limit the funding of any medical aid it considers excessive, ineffective, inappropriate or harmful.

For the WCB to provide medical aid, the treatment must be effective to eliminate or minimize impact of the workplace injury. In this regard, the panel notes that despite the worker having received some 157 injection treatments over the course of more than 13 years, from 2008 to 2021, there is no evidence of any sustainable benefit to the worker from those treatments. The treating physicians consistently recorded the worker’s report of short-term benefit in terms of reduction of symptoms, but as noted by the WCB medical advisor in their May 4, 2021 opinion:

“…although injections of local anesthetic into soft tissues are sometimes utilized on a short term basis to see if they might be associated with a sustained improvement of pain and function, the provision of recurrent multiple area injections of local anesthetic into soft tissues, to the degree that has occurred here, is well beyond the bounds of conventional treatment.

Notwithstanding the lack of an evidence basis for long term monthly injections of local anesthetic into soft tissues, for the injections [the worker] has undergone/is undergoing to be considered effective, the anticipated outcome would be for a sustained (more than several months) improvement of symptoms and correspondingly function associated with the injections. Based on the reports submitted by the treating physician, it is clear that the several year-long course of injections has not met this criterion.”

Further, the panel noted this treatment has been accompanied by an increased reliance upon other pain relief modalities. The medical records indicate that the worker’s treating pain management physician initially proposed injection therapy as a means to wean the worker from other oral medications with less desirable side effects. In fact, over time, the worker’s symptoms were not successfully managed with the injections alone and by 2009 the treating pain management physician had transitioned the worker to opioid medications in addition to the ongoing injection treatments. Further, and as set out in significant detail in the WCB medical advisor’s May 4, 2021 opinion, the worker’s opiate dosage increased over time, while the injection treatments also were provided with greater frequency and reduction in the reported duration of pain relief benefit to the worker. The medical advisor concluded that:

“Beyond the documented evidence that the serial injections [the worker] has undergone over the last decade + have not been associated with a sustained improvement of symptoms and function, the concurrent initiation of opioids (in 2009) and progressive increased dosing of opioids over the course of 10+ years superimposed on 157 individual sessions of typically multiple soft tissue injections obviates a meaningful benefit from the injections. Further soft tissue injections are similarly unlikely to be effective.”

The panel also noted the treating pain management physician’s December 19, 2019 statement that:

“Without the injections and/or the Butrans [the worker’s] pain comes back quite dramatically. In fact should [their] regular monthly injections be delayed even by a week or two, [the worker’s] neck stiffens up, increasing [their] pain…quite dramatically and becomes quite irritable. It is my professional medical opinion that [the worker] remain on the injections and the Butrans patch for the foreseeable future.”

The panel finds that the treating physician’s opinion does not support the basis for the initial approval of the worker’s injection treatments, which was to reduce the worker’s reliance upon other medications with more harmful side effects and increase the worker’s function. The opposite is true, such that the treating physician has stated the worker requires not only continuing the injections but also continuing use of an opioid based pain relief patch.

In these circumstances, the panel accepts and relies on the opinion of the WCB medical advisor that there is no evidence that the treatments already provided have offered any sustained benefit to the worker beyond the very short-term relief offered and cannot be expected to be effective in the future.

On the basis of the evidence before the panel and on the standard of a balance of probabilities, the panel is therefore satisfied that, even if the worker’s current symptoms are causally related to the compensable workplace injury, continuation of injection treatments is not reasonably necessary to cure and relieve from the effects of that injury.

The panel therefore concludes that responsibility should not be accepted for the worker’s injections after August 30, 2021. The worker’s appeal is denied.

Panel Members

K. Dyck, Presiding Officer
J. Peterson, Commissioner
M. Kernaghan, Commissioner

Recording Secretary, J. Lee

K. Dyck - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 7th day of April, 2022