The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") that they are not entitled to benefits in relation to the diagnosis of Chronic Pain Syndrome. A hearing was held on August 15, 2023 to consider the worker's appeal.

Issue

Whether or not the worker is entitled to benefits in relation to the diagnosis of Chronic Regional Pain Syndrome.

Decision

The worker is entitled to benefits in relation to the diagnosis of Chronic Regional Pain Syndrome.

Background

The WCB accepted the worker’s claim for an injury at work on July 6, 2010 when they tripped and fell down some stairs, landing on their right wrist. The worker sought medical treatment and received a diagnosis of soft tissue injury, but due to ongoing pain and instability complaints, the worker saw an orthopedic surgeon on January 17, 2011, who diagnosed midcarpal instability and recommended 12 weeks of splinting to stabilize the midcarpal joint. On April 18, 2011, the treating orthopedic surgeon opined the worker had “…failed nonoperative treatment” and recommended surgery with pinning. That surgery took place on May 27, 2011 and was followed by an additional surgery on July 11, 2012.

In a post-surgical follow-up on July 26, 2012, the orthopedic surgeon noted the worker’s report of symptoms “…consistent with complex regional pain with very significant discomfort even to light tough over the dorsal aspect of the wrist” and referred the worker to a pain management clinic for assessment regarding complex regional pain syndrome (“CRPS”).

On August 23, 2012, the pain clinic physician recorded the worker’s history of falling at work, sustaining an extension-type injury to their right wrist. The physician noted that after two surgeries the worker continued to report symptoms of sensitivity to touch in the dorsum region of the wrist next to the surgical scars, “…significant mechanical allodynia with severe restriction of movement…”, and weakness in hand grip on the right. The physician also noted the worker’s report of some mottling of their hand, but the physician did not note color or temperature changes. On examining the worker, the pain clinic physician found “…there was disuse atrophy of the forearm and hand. There was no excessive nail growth and no excessive hair. There were no color changes, no edema. There was dysesthesia over the scars on the dorsum of her hand and mechanical allodynia of her wrist. Range of motion of her wrist was reduced significantly with decreased strength of her hand grip.” The physician went on to note their belief the worker did not have CRPS and opined as to a possible neuropathic component around the scarring. The physician recommended continued physiotherapy to attempt to increase range of motion in the wrist and a change in medication, including pain relief injections.

Following a call-in examination with a WCB medical advisor on March 13, 2013, the WCB referred the worker to a plastic surgeon for a further opinion. The plastic surgeon, on May 23, 2013, provided an opinion that further surgical intervention would not help the worker with their symptoms, but they recommended a further MRI study. The MRI study of the worker’s right wrist of June 14, 2013 noted “No definite abnormalities seen.” After receiving the results of the MRI study, the WCB arranged a referral to an upper extremity orthopedic specialist. On November 13, 2013, the orthopedic specialist reported that:

…the patient’s right wrist range of motion is approximately 50% of the contralateral left wrist. The patient has pain with extremes of motion. The patient has normal functioning fingers and thumb. The incisions have healed well with no evidence of infection. The patient has pain throughout [their] wrist, but specifically overlying the incisions, both volarly and dorsally. The patient does not have an obvious Tinel’s sign. There is no vasomotor changes in her wrist.

The orthopedic specialist provided that no further surgical intervention would help the worker with their pain, which appeared to be neuropathic and noted the worker was taking pain medication that appeared to be working. The specialist recommended the worker continue with the medication and recommended other modalities such as massage, acupuncture and stretching exercises for pain improvement.

At the request of the WCB, the worker attended a second call-in examination on January 23, 2014. The WCB medical advisor outlined permanent restrictions of no tasks requiring firmly resisted grasping with the right hand and activities which would predictably involve direct forcible contact with the right dorsal wrist scar. On June 17, 2014, the WCB provided the restrictions to the employer who, on June 20, 2014 advised the WCB as the worker’s employment had been terminated for non-compensable injury related issues, they could not accommodate the worker. The WCB then referred the worker for vocational rehabilitation services.

Through the course of the vocational rehabilitation, the worker reported pain in their right wrist, with numbness and tingling. After the vocational rehabilitation plan concluded on November 16, 2015, the worker moved out of the province.

The treating physician referred the worker for a nerve conduction study due to their ongoing complaints. In the report from the nerve conduction study of November 1, 2016, the treating neurologist recorded the worker's report of bilateral numbness since April 2016, which radiated up to their elbows. These symptoms were noted to be episodic and coinciding with increased use of the worker’s hands. The neurologist also noted the worker's 6-year history of right wrist pain "…which developed into CRPS (chronic regional pain syndrome)." On examining the worker, the neurologist indicated:

Surgical scar on the dorsal aspect of the right wrist. Slight discolouration to the right hand and distal arm which was not seen on the left. No temperature asymmetric noted. No allodynia or hyperesthesia noted in the hands. No trophic changes in the hands. Normal Cervical spine, shoulders and elbows range of motion and asymptomatic.

The neurologist opined that "The neuromuscular examination is normal, the nerve conduction studies are normal and there is no evidence of CTS (carpal tunnel syndrome) or ulnar neuropathy. No concerning central or peripheral nervous system pathology is appreciated." The neurologist recommended use of wrist splints if the worker experienced recurring symptoms.

On November 24, 2017, the worker contacted the WCB to advise they sustained a left shoulder injury while employed in another province and had filed a claim with that province's disability insurer. The worker indicated their belief their left shoulder injury was related to their right wrist injury. On April 5, 2018, the WCB advised the worker that it would not accept responsibility for their left shoulder difficulties in relation to this claim.

On May 11, 2018, the worker contacted the WCB to discuss their claim and advise of their belief that the diagnosis of CRPS was a result of the compensable right wrist injury. The WCB case manager advised the worker that the diagnosis of CRPS was not accepted as compensable in this claim. On May 14, 2018, the treating family physician provided a report to the WCB noting the worker "…deteriorated clinically again during this past winter…" and was seeking funding from the WCB for a "comprehensive treatment program" for CRPS.

At the request of the WCB, the worker attended a call-in examination with a WCB plastic surgery consultant on July 9, 2018. On examining the worker, the WCB consultant opined that medical information and findings did not establish that the worker met the criteria for diagnosis of CRPS, noting the worker had improved in terms of range of motion, demonstrated ability to write with their right hand, and grip strength. The consultant went on to state that "…if CRPS develops in relation to a specific injury or surgery, it would be anticipated that it would develop in relatively close temporal proximity to same. On review of the file, CRPS was first mentioned subsequent to 2014, over two years following the right wrist arthroscopic surgery." On August 29, 2018, the WCB advised the worker it did not accept responsibility for a diagnosis of CRPS in relation to their compensable right wrist workplace injury.

On October 5, 2018, the worker requested Review Office reconsider the WCB's decision, providing a detailed chronology of the events since the workplace accident and their subsequent medical treatment, as well as medical articles related to CRPS and documents in support of their diagnosis from their treating healthcare providers. On November 2, 2018, Review Office determined the WCB would not accept responsibility for the diagnosis of CRPS, accepting the WCB plastic surgery consultant’s opinion that the worker did not meet the diagnostic criteria.

The worker's representative filed an appeal with the Appeal Commission on April 26, 2023 and a hearing was arranged. Following the hearing, the appeal panel requested additional medical information, which was provided to the interested parties for comment before the appeal panel met again on June 20, 2024, to discuss the case and render its decision on the issue under appeal.

Reasons

Applicable Legislation

The Appeal Commission and its panels are bound by The Workers Compensation Act (the "Act"), regulations and policies of the WCB's Board of Directors. The provisions of the legislation in effect at the time of the accident are applicable.

Section 4(1) of the Act 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. Payment of wage loss benefits is addressed in s 4(2) of the Act, which sets out that where a worker is injured in an accident, wage loss benefits are payable for their loss of earning capacity resulting from the accident, and s 39(2) provides that such benefits are payable until the loss of earning capacity ends, as determined by the board or the worker attains the age of 65 years. Section 27(1) of the Act allows the WCB to "…provide a worker with such medical aid as the board considers necessary to cure and provide relief from an injury resulting from an accident."

Worker’s Position

The worker appeared in the hearing with representation by a worker advisor, who made an oral submission in support of the worker’s appeal and addressed questions to the worker. The worker offered evidence through answering questions posed by the worker advisor and by members of the appeal panel.

The worker’s position is that the evidence confirms they developed CRPS by December 2012, approximately five months following the surgery in July 2012, which was required to repair the injury to the worker’s right wrist sustained in the accident of July 6, 2010. The worker advisor submitted that the evidence from the treating pain specialist confirms that they were treating the worker for CRPS since 2012 and that although the specialist initially concluded that the worker’s symptoms related to neuropathic pain, the specialist noted that neuropathic pain is on a continuum with CRPS, and that the worker progressed from neuropathic pain syndrome to CRPS over time.

The worker advisor submitted that the panel should rely upon the evidence and opinion of the treating pain specialist and give greater weight to their evidence than to that of the WCB plastic surgery consultant. The worker advisor noted that the WCB plastic surgery consultant erred in stating there was no diagnosis of CRPS noted in the medical records until after 2014, pointing to references beginning in 2012. The worker advisor submitted there is no requirement in the Act, regulations or WCB policies that requires a diagnosis to be made within a specific time frame.

The worker advisor summarized the medical evidence, including clinical findings and reported symptoms, that supports the worker’s diagnosis, applying the Budapest criteria as described by the worker’s treating pain clinic physician, and noting that it is not surprising that the physician did not on first assessment diagnose CRPS, given that symptoms of CRPS have variable progression over time and different modalities of treatment need to be trialed before making a diagnosis.

The worker confirmed in their evidence that they continue to experience symptoms of CRPS, including pain they described as burning, throbbing, searing, and pulsating, which increases with use of their right wrist. The worker confirms they experience symptoms of clamminess and colour changes as well.

Employer’s Position

The employer did not participate in the appeal.

Analysis

The question on appeal requires the panel to determine whether the worker’s diagnosis of CRPS is causally connected to the injury sustained on July 6, 2010 and as such, compensable under the provisions of the Act. For the worker’s appeal to succeed the panel would have to find that the worker developed CRPS because of their compensable right wrist injury and that the worker is entitled to benefits in relation to that condition. As detailed in the reasons that follow, the panel was able to make such a finding and therefore the worker’s appeal is granted.

In considering the question before us, the panel reviewed the medical reporting and opinions from the worker’s treating providers as well as the opinions and findings of the WCB medical advisors who reviewed those reports and assessed the worker in call-in examinations. The panel noted that a diagnosis of CRPS was first queried by the treating orthopedic surgeon in their post-operative follow-up report of July 26, 2012. At that time, the surgeon noted the worker’s description of “…a symptom complex consistent with complex regional pain with very significant discomfort even to light touch over the dorsal aspect of the wrist” and referred the worker to a pain clinic.

The panel considered that the treating pain clinic physician, on initial assessment in August 2012, concluded that the worker did not have CRPS, but “…some neuropathic component around [their] scars.” By December 7, 2012, the treating pain clinic physician described the worker’s symptoms as burning pain that increases with activity, mottling of the wrist, dysesthesia of the scar and mechanical allodynia of the wrist, and noted that “Unfortunately, [the worker] has a condition that can have long-term effects, so it is difficult at this time to outline what the prognosis is. [The worker] does have chronic pain and by its very nature it is a long-term disease.” The panel also noted the pain clinic physician’s chart notes indicate a diagnosis of right wrist CRPS from May 2014 onwards, and from August 2012 through to May 2014, those chart notes detail ongoing efforts to provide appropriate pain relief for the worker’s symptoms, with various medications and doses trialed. Subsequent communications from the pain clinic physician confirm their assessment that the worker was being treated for CRPS.

The panel further noted that upon reviewing the December 7, 2012 report, a WCB medical advisor concluded, on January 30, 2013, that “Based on the medical reports this worker has CRPS….” In their notes from the call-in examination of the worker of March 13, 2013, the WCB medical advisor concluded that “This worker has residual effects of causalgia of the dorsal surface of [their] right wrist and also of the volar surface to some degree. There is also causalgia in the distribution of the radial nerve to the right thumb and also discomfort on ulnar deviation with some ulnar impact on the right wrist.” The panel also noted that the file documentation indicates the WCB medical advisors undertook frequent and regular reviews of the worker’s medications as prescribed by the pain clinic physician to address the worker’s CRPS and continued to approve the medications as prescribed for that condition.

The panel also considered that after the worker’s 2016 move to another province, a new pain clinic physician confirmed the diagnosis of CRPS and continued to prescribe medications consistent with the diagnosis, which the WCB continued to fund. This physician also referred the worker for further investigation of bilateral hand paresthesia that developed over the course of the summer of 2016 while the worker was moving. By the time of that consultation in November 2016, the paresthesia was asymptomatic, but the diagnosis of CRPS continued.

The panel reviewed the July 9, 2018 WCB call-in examination of the worker by a WCB plastic surgery consultant who stated that the diagnosis of CRPS Type 1 was noted on file for the first time in 2015; however, as outlined above, that is not consistent with the medical reporting on file. Based on the examination findings, the WCB plastic surgery consultant concluded that “…the criteria to establish a diagnosis of CRPS were not fulfilled” and noted that if CRPS develops in relation to a specific injury or surgery, it would be expected to develop in “relatively close temporal proximity to same.”

The panel also considered the subsequent reporting from the initial pain clinic physician, who resumed treating the worker in 2019 after their return to Manitoba. The physician confirmed in a letter to the WCB dated November 19, 2019 that:

“This patient indeed does have what I believe is complex regional pain syndrome. [The worker] has allodynia, dysesthesia, colour changes and temperature changes of [their] right wrist and hand. We have been treating [them] as complex regional pain syndrome for many years. The fact that there is no reference to complex regional pain syndrome is certainly an oversight.”

In further correspondence dated June 19, 2020, the treating pain clinic physician confirmed their opinion that “The complex regional pain syndrome occurred on the site that the injury occurred, that is, the right wrist.” The panel also reviewed the report from the treating pain clinic physician requested upon conclusion of the hearing. In the report of May 18, 2024, the physician sets out the following:

“On review of my initial notes…I note at that time I felt the patient had neuropathic pain. It is unclear from my notes…as to when I felt that [their] diagnosis changed. It is widely felt that complex regional pain syndrome and neuropathic pain syndrome are part of a continuum….

The diagnosis of complex regional pain syndrome is often diagnosed using the Budapest criteria. With regards the self reporting section of the Budapest criteria the patient needs to report at least 1 symptom in 3 out of 4 categories. [The worker] met 3 of the 4 self reporting criteria that being ongoing pain disproportionate to the initial injury. Hyperalgesia and allodynia. Reporting of skin colour changes. Lastly [the worker] reported weakness of the right wrist.

With regards the physical examination component of the Budapest criteria refers to having at least 1 or more signs in two of 4 categories. On examination [the worker] has hyperalgesia and allodynia of the wrist. [The worker] has skin color (redness) changes of the wrist. [The worker] has weakness of the wrist.

With these features I believe [the worker] has CRPS.”

The panel accepts and relies upon the evidence of the treating pain clinic physician who first assessed the worker approximately one month after the second surgery and continued to treat the worker until 2016 and then resumed treating the worker in 2019. We find that the progression of the worker’s symptoms after August 2012, as documented in the November 1, 2012 and December 7, 2012 reports, is consistent with the pain clinic physician’s statement that CRPS and neuropathic pain syndrome are on a continuum and is consistent with the variable symptom progression that is characteristic of CRPS.

The panel is further satisfied that the worker developed symptoms consistent with the diagnosis of CRPS at the site of the original compensable injury and that those symptoms were first queried as being in relation to a diagnosis of CRPS within weeks of the surgery. While the diagnosis was not confirmed on first assessment, it was ultimately confirmed by the treating pain clinic physician in Manitoba and later confirmed by the second treating pain clinic physician. This diagnosis was also confirmed by a WCB medical advisor following a call-in examination of the worker in 2013 and their review of the file evidence to that point. The panel further noted the absence of any evidence before us of any other injury or cause, neither prior to the workplace accident, nor since the accident, that could potentially explain the worker’s development of CRPS in their right wrist.

Where there is a difference of opinion in terms of the medical conclusions reached by the treating and consulting physicians, the panel prefers and gives greater weight to the opinions of the treating physicians, who are specialists in treatment of pain disorders.

Based on the evidence before us, and on the standard of a balance of probabilities, the panel is satisfied that the worker developed CRPS as a consequence of the compensable workplace injury of July 6, 2010, and that as a result the worker required further medical aid in relation to that diagnosis and continued to sustain a loss of earning capacity. Therefore, the worker is entitled to benefits in relation to the diagnosis of Complex Regional Pain Syndrome. The appeal is granted.

Panel Members

K. Dyck, Presiding Officer
J. Peterson, Commissioner
R. Ripley, Commissioner

Recording Secretary, J. Lee

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

Signed at Winnipeg this 26th day of July, 2024