Supplementary Paper on Chronic Musculoskeletal Pain In the Injured

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					                          Submission #142


MFL Occupational Health Centre, Inc.

     Supplementary Paper on
   Chronic Musculoskeletal Pain
       In the Injured Worker




           Submitted to



      Workers Compensation
Public Review Hearings in Manitoba



Prepared by Rob Chase MD FRCPC
TABLE OF CONTENTS


1.     Occupational Disease............................................................................................. 5
     1.1   WCB policy on degenerative spinal disease as an “occupational disease”....... 5
     1.2   The etiology of degenerative spinal disease: Case study OPLL ....................... 6
     1.3   Current adjudication practice implications......................................................... 7
2.     Injury Disability and Chronic Musculoskeletal Pain................................................. 8
   2.1     The Exclusion of Chronic Pain in Impairment Ratings ...................................... 9
   2.2     The Problem with Chronic Pain Syndrome ..................................................... 10
3.     The Tension between Claims Costs and Prevention ............................................ 10
4.     Practicing Tertiary Prevention at the End of a Failed Claim.................................. 11
5.     Recommendations................................................................................................ 13
     Recommendation #1: Definition of pre-existing condition. ..................................... 13
     Recommendation #2: Policy on the work-relatedness of degenerative conditions of
     the spine. ............................................................................................................... 13
     Recommendation #3: Disputes between insurers over cases of indisputable
     disability. ................................................................................................................ 13
     Recommendation #4: The role of Medical Review Panel....................................... 14
     Recommendation #5: Ethical and health audit of failed WCB claimants with chronic
     MSK pain. .............................................................................................................. 14
     Recommendation #6: Proposing Tertiary Prevention intervention research on
     alternative models to manage chronic MSK pain in injured workers. ..................... 14




                                                                                                                                  2
INTRODUCTION
This is a supplement to the MFL Occupational Health Centre’s (MFLOHC) submission.
My medical work at the MFLOHC since 1997 has been with injured Manitoba workers
with ongoing medical issues, pain impairments, and issues of entitlement to WCB
benefits or services. Of more than 300 such patients, I estimate a third have been
unemployed since their closed WCB claim, many on welfare. Of those, half have coped
poorly with chronic pain in much diminished circumstances, many personal, social and
economic free fall. Over the past decades there are hundreds, likely thousands, of such
unfortunate personal stories in the province.

The focus of this paper is on aspects of the greatest cause of workplace injury and the
disability of working population of Manitoba: musculoskeletal injuries (MSI), e.g. acute
strains, sprains, contusions, to more chronic conditions of musculoskeletal (MSK) pain,
activity impairments, and disability. The opinions expressed below are my own, in an
effort to reflect the collective experience of many injured workers on whose behalf I
have worked as a physician and advocate.

The subject matter is how the Workers Compensation Act is interpreted into and
practice. It is our concern that current practices are not in the spirit of the Act and the
and effectiveness and ethics of which are to be questioned.

For injured workers who fail to return to employment, and are left with chronic MSK pain
from hazardous work and injury, the WCB process has not been effective. The social
and economic cost from the downward spiral of life circumstances attending a failed
recovery can be dramatic. The primary casualty is the once active, productive worker,
but the impact affects household and social economy.

The MFLOHC’s caseload of injured workers is disproportionate to the typical doctors
office because of the accessibility and screening for occupational health issues.
Patients are often those coping poorly with musculoskeletal pain, functional
impairments, emotional distress (anger, depression, helplessness). Particularly for
those in dire economic straits, they often lack resources personal resource and coping
skills and access to social and health support services. A significant proportion of claims
are contentious with allegations and evidence of hazardous work practices, failures in
reporting, stress and conflict in the workplace (e.g. co-worker or supervisor
harassment), sub-par medical care (e.g. lack of continuity) and disjointed disability
management (repeated work returns work with pain recurrences). By not accepting the
claim, issues of negligence, and poor workplace and medical practice compounding the
case are expediently not addressed, leaving the worker having to contend with the
consequences.

When the WCB claim closes, or if it is not approved in the first place, the claim
inevitably becomes adversarial; for many the WCB process is one of high frustration
and disappointment. The claims process itself readily contributes to stress and
disability. The medical term ‘iatrogenic’, as one calls the adverse results or


                                                                         Page 3 of 15
complications of surgical or medical treatment, is useful to describe the further injury
and setback to recovery this causes.

The unmet needs for disability management, treatment, and social services, invariably
falls to the denied worker, his/her household and Manitoba’s ‘safety net’, as it exists for
health care and social welfare assistance.

From the vantage point of the government of Manitoba, responsible for the rights, social
welfare, and health care of the population, the present review of the WCB is an
opportunity to re-appraise how WCB handles chronic MSK disability in it s policies and
practice and re-assess its impact direct and indirect, positive and negative. I believe
there are alternative policy and case management approaches that can improve the
health outcomes and reduce the social and economic costs of injury disability borne by
insurers and society at large.

I highlight four issues deserving of attention:
    1. Degenerative Spinal Diseases as Occupational Diseases.
    2. Disability from Chronic Pain from work related MSK injuries and conditions.
    3. Iatrogenic disability from the compensation process affects health and
        psychosocial outcomes; the need for tertiary prevention in ‘end-stage’ WCB
        claimants.
    4. Appraising the WCB claims process for chronic MSI injury and pain: how to
        integrate prevention (‘tertiary prevention’); research interventions to evaluate
        health outcomes.

After some discussion of each, I conclude with ideas in the form of recommendations for
the consideration of the Workers Compensation Act Review Committee.

Rob Chase MD, FRCPC (Community Medicine)
Musculoskeletal Occupational Physician,
MFL Occupational Health Centre, Winnipeg




                                                                        Page 4 of 15
1.      Occupational Disease

The first MFLOHC paper and presentation1 discusses that the definition of
“occupational diseases” used by WCB may not be consistent with the science in the
field2. The current WCB policy to deem a disease occupational when occupational
factors are deemed the dominant cause of the disease requires a difficult level of proof
for multifactorial diseases, in which workplace and non-workplace exposures interact in
the development of disease. Concerns that the level of Permanent Partial Impairment
awards was also discussed.


        1.1   WCB policy on degenerative spinal disease as an “occupational
              disease”

Degenerative disease in peripheral joints (e.g. traumatic arthritis of knees, elbows
shoulders) may be compensable under WCB if it resulted from severe work injuries.

Less accepted are cases of repetitive overuse leading to disease or chronic pain with
ongoing impairments. Without a documented history of an accident event, proving the
cases requires high level of epidemiological evidence substantiated by detailed,
convincing work histories. In practice, the ‘repetitive strain injuries’ that are accepted
are processed as injuries, with or without recurrence, not as an occupational disease.

In the case of degenerative diseases of the spine3, WCB generally maintains the
position that they are non-occupational in origin, on the basis of the epidemiology
showing e.g. DDD is age-related, occurs in non-working populations, with significant
hereditary and lifestyle factors.

To overturn this presumption in a ruling on an individual claim with epidemiologic
evidence would require occupational studies of high complexity e.g. similar job
characteristics, and health outcomes, and controlling for numerous other variables. In
practice, when the diagnosis is determined not to be an “occupational disease”4,
evidence of how the worker’s hazardous job and injury history obviously contributed is
not considered. This often undermines the medical and surgical opinions of the
worker’s doctors, and the expert opinion of the Medical Review Panel.



1
  MFL Occupational Health Centre, Inc. Presentation to Workers Compensation Public Review Hearings
in Manitoba June 1, 2004 presented by Carol Loveridge, Executive Director.
2
  Dr. Allan Kraut MD provided further elaboration on this in his “Brief to the Workers Compensation Act
Review Committee submitted June 2, 2004 (attached)
3
  e.g., spinal stenosis, a common end result of degenerative disc disease
4
  In the epidemiology of occupational low back injuries, it is well-known that among the predictors for
back injury, the highest one is history of a previous back injury. However, this compelling fact on
incidence does not readily translate into the methodology of investigating spinal disease causation in the
occupational medical literature.


                                                                                   Page 5 of 15
Consequently, should an injured worker’s back condition from an unresolved strain be
given the additional diagnosis of osteoarthritis5, the diagnosis may be sufficient reason
to deny further coverage and responsibility for recurrences and poor work tolerance.
Diagnosis of degenerative disc disease or osteoarthiritis may often be by default, based
on radiographic imaging unrelated to clinical assessment; relevant soft tissue injury
diagnoses may not be considered valid or “objective” in the standard orthopedic
assessment.

Ironically, a series of previous significant back injuries at work, recognized in WCB
claims history, can be used as a ‘pre-existing’ condition disallowing a new claim
involving the same body part, despite a consistent history of aggravation and
impairment by the worker and his/her physicians.

When chronic musculoskeletal pain has been the primary problem throughout the injury
history, reversing claim acceptance by changing the diagnosis discounts the worker’s
common sense experience. At this stage the only recourse is to argue on the basis of
diagnosis, e.g. through convening a Medical Review Panel.

The rationale for current WCB policy and its practice should be questioned on two
grounds:
   • medical research is now understanding that some degenerative spinal diseases,
      can be caused by mechanical overuse.
   • exclusion of chronic pain as an impairment


    1.2 The etiology of degenerative spinal disease: Case study OPLL

        Case: A middle aged male labourer at a large heavy manufacturing
        workplace installed 30-50 metal frames, requiring repetitive forceful
        movements in awkward neck and shoulder positions. His tall height was
        miss matched to the restricted positions he worked in, certainly a factor in
        the degree of strain and force load applied on the neck. 4 years into the
        job, he developed symptoms and signs of spinal cord compression in the
        neck. His MRI demonstrated “moderate to severe cervical spondylitic
        changes with posterior disc protrusion and thickening, likely ossification of
        the posterior longitudinal ligament (OPLL) accentuating the degree of
        spinal stenosis [cervical stenosis]”.          He required surgery for
        decompression and vertebral fusion. His WCB claim and authorization for
        surgery was denied, against the opinion of his surgeon and medical
        doctors. The worker’s group disability insurer has refused to accept
        responsibility; One year later he is significantly disabled, subsisting on
        welfare with no coverage for support services for treatment or
        rehabilitation, and in bad psychological condition.

5
  E.g. on the basis of x-rays showing changes, including those that were entirely asymptomatic prior to
the strain injury.


                                                                                  Page 6 of 15
For this case I reviewed the medical literature on Ossification of the posterior
longitudinal ligament (OPLL). I highlight two papers on the etiology (causation) of
OPLL:

        In her review of the diagnosis and surgical management of cervical OPLL,
        Epstein (2002)6 notes that up to 25% of patients with cervical myelopathy (spinal
        cord and nerve compression effects) have ossification of the posterior
        longitudinal ligament, rather than spondylotic (degenerative vertebral joint) and
        stenotic (narrowing) myelopathy or disc disease alone. The posterior longitudinal
        ligament runs up the back of the vertebral column and lies within the spinal canal.
        In cases of cervical myelopathy from OPLL, the ligament hypertrophies (grows
        larger) with increased fibrous cell growth and deposition of collagen. This is
        followed by progressive mineralization (calcification) and slow transformation of
        the ligament into tissue similar to bone.

        Ohishi7 investigated the hypothesis that mechanical stress on the posterior
        longitudinal ligament plays an important role in the progression of OPLL. Their
        experiments looked at the different responses of live cells from the ligaments of
        OPLL and non-OPLL patients, that when cultured in the lab were subjected to
        mechanical bending and stretching applied by a computer-controlled stepping
        motor. The mechanically stressed cells produced hormone regulating bone
        formation and induced product of RNA and proteins associated with bone cells.
        This is consistent with the transformation of the spinal ligament tissue into bone-
        like tissue (“osteogenic differentiation”).

This research demonstrates that cumulative mechanical stress can induce the
degenerative changes seen in OPLL. This finding may be relevant to other cases of
spinal stenosis in the neck and elsewhere e.g. hypertrophy of the ligamentum flavum in
the low back. In this case, it adds scientific evidence to the strong clinical picture that
the workers occupational repetitive neck straining and forceful exertions contributed
significantly to the worker’s degenerative spinal disease.


    1.3 Current adjudication practice implications

Current WCB practice is based on the position that overuse and recurrent strain does
not cause a degenerative spinal disease such as cervical stenosis. Such a condition is
deemed ‘pre-existing’ not occupational; it then becomes reason to deny entitlement for
permanent impairments, not as evidence of the work or injury history impact on health.



6
   Epstein N. Diagnosis and surgical management of cervical ossification of the posterior longitudinal
ligament. The Spine Journal, 2(2000);436-449.
7
   Oshishi H, Furukawa KL, et al. Role of prostaglandin I2 in the gene expression induced by mechanical
stress in spinal ligament cells derived from patients with ossification of the posterior longitudinal ligament.
Journal of Pharmacology and Experimental Therapeutics 2003; 305:818-824.


                                                                                      Page 7 of 15
The current practice of WCB policy in failing to consider the work-relatedness in cases
of degenerative spinal disease does not reflect current science. Nor does it reflect the
clinical impressions of the surgeons and doctors of many injured workers. As a result
there is widespread skepticism among the medical community that “the Board does not
listen to doctors”.


2.       Injury Disability and Chronic Musculoskeletal Pain

Chronic pain is likely the most litigated issue in WCB process. Based on my experience
with injured workers, the second, closely related, issue I wish to highlight is how
musculoskeletal pain conditions are handled by WCB, particularly in the end stages of
claims management.

For denied claimants, their option is appeal for medical review. For some, a Medical
Review Panel is convened to address a list of questions posed by WCB advisors; this
may take place years after the claim was active and when critical decisions in the
management of the claimant’s case were taken. However, the information gathered by
the MRP and their expert opinion is subject to interpretation by the insurer (WCB) as
applied to its internal construction of the issues, which as illustrated above, may not be
consistent with medical science, or common sense.

This is an example of the medicalization of the injured worker’s circumstances and
suffering. When, as is often the case, the appeal is denied on medical grounds (e.g. the
assigned diagnosis is a ‘pre-existing’ condition, thereby cutting off benefits and
treatments), many feel understandably betrayed and disbelieved.

In medical terminology, this situation constitutes a major iatrogenic complication, i.e. an
adverse, complicating condition that results from medical treatment or management
the worker sees her/himself doubly victimized, by the accident and then ‘the system’

         “Excessive or exaggerated pain behaviours can be a response to feeling
         discounted or mistrusted, so that one must emphasize symptoms to
         persuade physicians of their reality, magnification can be an iatrogenic
         phenomenon that occurs when an individual feels mistrusted or poorly
         cared for.”8

The reality is that such claims are often complex with multiple issues and complications
such as allegations of harassment, poor medical management, and stressors for the
worker beyond injury and work. The insurer’s primary concern to limit their long term
cost exposure runs counter to the injured worker’s personal experience how the injury
or hazardous work history precipitated much misfortune and his/her pressing need for
the supports and service being denied.



8
    AMA Guides to the Evaluation for Permanent Impairment. 5th Ed, Section 18.4 p 583.


                                                                                 Page 8 of 15
It is important to integrate a balance of the ethical dimension of pain and disability
management with the medical aspects. This tension underlies the dilemma of many
adjudicators and case managers inside WCB as it does those exerting themselves on
behalf of the denied claimant.


        2.1   The Exclusion of Chronic Pain in Impairment Ratings

WCB policy on pain has been that it is a subjective experience that cannot be
objectively measured, unlike the measurable loss of range in a joint or spine, the
absence of a limb by amputation, weakness from paralysis, or hearing loss. Therefore
pain (e.g. pain of soft tissue origin) is not typically factored into impairment ratings. This
has generally been standard policy of compensation boards elsewhere for decades.
The American Medical Association’s Guide to the Evaluation of Permanent Impairment
has been the principal reference for impairment ratings used by physicians and insurers
across North America.

However, in its fifth and most recent edition (2003), the Guide underwent landmark
revisions on the subject Pain Impairment. It presents extensively on the need to include
pain as an intrinsic aspect of impairment assessment and disability ratings; it recognizes
the challenge this may pose to scientific medicine’s ability to account for pain by
obvious pathophysiological changes.

      Pain is an essential determinant of the incapacitation of many individuals who
      undergo impairment evaluation… ”The notion that all impairments should be
      verifiable by objective assessment is administratively necessary for an entitlement
      program. Yet this notion is fundamentally at odds with a realistic understanding of
      how dieses and injury operate to incapacitate people. Except for a very few
      conditions, such as loss of a limb, blindness, deafness, paralysis, or coma, most
      diseases and injuries do not prevent people from working by mechanical failure.
      Rather people are incapacitated by a variety of unbearable sensations when they
      try to work.” 9

Chapter 18 on Pain assessment (attached) was completely revised to include a method
for evaluating chronic pain and how they can be integrated with the other conventional
impairment rating methods. A practical approach for performing impairment ratings on
individuals with ambiguous or controversial syndromes such as myofascial pain
syndrome, fibromyalgia and “disputed neurogenic” thoracic outlet syndrome. is
outlined.10




9 AMA Guides Chapter 18 p 567
10
   The public policy dimensions of chronic pain, so central to WCB, are also being confronted by insurers
and providers nationwide: e.g. new practice guidelines for Ontario emergency room physicians to not
deny treatment for pain when pain is the chief complaint.


                                                                                 Page 9 of 15
        2.2 The Problem with Chronic Pain Syndrome
At the heart of the controversy are cases of chronic pain syndrome (CPS) with which an
injured worker may be labeled when they continue to have high levels of pain and
activity related disability, “out of proportion to the physical findings related to the injury
event”: The classification of CPS is characterized by:

   1. Intense and unremitting pain is the predominant clinical symptom.
   2. Pain is attributed to the unresolved effects of their physical injury.
   3. Appropriate therapeutic interventions have failed.
   4. Pain is continuous, progressive, and results in marked disability in occupation,
      social and recreational areas of functioning.
   5. Disability exceeds expected durations and is disproportionate to the organic
      pathology identified (usually conservatively defined by a standard orthopedic
      assessment insensitive to soft-tissue pain conditions (e.g. myofascial pain).

Many injured workers may initially feel vindicated when their situation is recognized as
CPS, as it may reflect their experience in terms they understand. There may now be
coverage for e.g. anti-depressant medication or psychological counseling for a period.
However, with CPS as the main diagnosis too often previous support for therapy and
rehabilitation for the physical aspects of the condition are curtailed. CPS ‘self-defines’
that ‘appropriate therapeutic interventions have failed’ whereas, in many cases, there
were problems providing basic treatment under reasonable conditions for recovery,
attention given to return to safe work, etc.

Practice by WCB Manitoba has been to send some entitled chronic pain claimants to an
expensive multidisciplinary pain program in Canmore, Alberta. I am unclear why
resources within the province have not been mobilized to address the need- perhaps
distrust of local service providers, and the logic that the high cost of the out-of-province
program justifies restricting enrolment to a rare event. I know several patients who
attended the Canmore program and shortly thereafter were cut off e.g. on the basis of
video surveillance evidence.


3.      The Tension between Claims Costs and Prevention
As an insurance company, WCB is understandably concerned with limiting the financial
responsibility for financial and social costs inherent in chronic disability. This drives
claims management strategies more than do the principles of prevention, i.e., broader
efforts to prevent disability and unemployment beyond the narrow, time-limited definition
of insurer responsibility. Coverage under WCB claims practice, as with most insurance
companies, is limited by design and not because it works well from a health outcomes
perspective, e.g. as cost-effective service of health care.

The relative savings of a no fault (WCB) vs. a litigation-based system of compensation
is lost when chronic disability claims become subjected to lengthy appeal proceedings
with administrative and expenses (e.g. Medical Review Panels, video surveillance)
several-fold in excess of the costs of benefits and services. Presumably, such data and


                                                                        Page 10 of 15
its analysis is an internal WCB matter; it is however, very relevant to the present review
of the WCB. It would be of high interest to assess the cost-effectiveness of current
practice on a level playing field using standards of care and health outcome required by
some health care institutions.

It is helpful to recall that prevention can take place at different stages. Primary
prevention occurs before problems start: e.g. training a new employee in lifting
technique; secondary prevention occurs in the setting of known risks or early markers
for problems e.g., providing a worker recovered from a strain injury with ergonomic
changes, stretching program, etc. to prevent re-injury). Tertiary prevention, which is the
subject here, occurs at the stage where a disease or condition is already established
but further deterioration and disability can be prevented.


4.     Practicing Tertiary Prevention at the End of a Failed Claim
What is missing for many end stage WCB claimants is a life skills and chronic MSK pain
management skills course that directly assists the claimant, regardless of claim status:
   - that would address the worker’s physical pain and his/her ability to manage their
       symptoms through self-care,
   - that participation by the injured worker is not conditional on compliance with
       unrealistic return to work: e.g. when workers know they cannot return to their
       former workspace regardless of whether they had WCB support or not.
   - that is more helpful than judgmental, assisting the individual where they are at with
       coping skills, understanding their pain condition and how to better manage their
       pain and stress and other ways to help themselves.
   - that does not add to the protracted medicalization
   - that is delivered by independent service provider(s) the evaluation of which
       includes participant self-assessment outcomes and feedback from the claimant’s
       treating physician care provider
   - that is at a cost on scale with comparable outlays of treatment regimes provided by
       WCB to return a worker to productive work with their injury employer
   - that is provided based on need and the claimants preparedness to participate for
       his/her benefit, distinct from issues of entitlement or disentitlement in more
       adversarial medicolegal deliberations of their claim.

I put forward the need that such a service be considered based on my 7 years
experience in Manitoba as an occupational health physician for injured workers with
chronic MSK pain conditions. I have had the opportunity to trial various programs for
such workers, both in the workplace (hospital employees at Health Sciences Centre
(1998-2003, in part funded by WCB Manitoba’s Community Prevention Initiatives
Program) and in the past year at the MFLOHC. Refinement led to the Stretch Massage
Breathe (SMB) Program, a multidisciplinary course that provides the small group of
participants with:
       - workshops to provide education on the anatomic and physiological basis for
          musculoskeletal problems, combined with graduated instruction in yoga (of the




                                                                     Page 11 of 15
        Iyengar tradition, using props and modifications as appropriate), stabilization
        exercises, relaxation, mindful breathing, self-massage and other self-care ideas.
      - a treatment series of remedial massage for e.g. myofascial symptoms (e.g.
        muscle tenderness, tension and hyperactivity) and mind-body learning
        experience integrated into the home program and workshop activities
      - A manual and guided audiotapes for home exercises.

SMB program objectives are for participants to better understand their pain condition
through learning skills based on yoga (posture, relaxation breathing) massage therapy
and self-massage. The program offers a ‘body-awareness’ learning experience that has
significantly helped individuals both on the job and in everyday life. Worker participation
is voluntary and unlinked to WCB claims status. There is non-judgmental attention given
to both the work injury and other barriers, i.e. the whole personal. Since the first pilot in
1999 the program has been delivered with adaptations to 9 groups of 6-8 injured
workers with extensive evaluation11. Costs to deliver the program per participant are
$500- $800.

This is an example of the kind of program that many failed WCB claimants with chronic
MSK impairments would benefit from. Alternative programming compared with current
management practice could be creatively evaluated with qualitative and quantitative
(e.g. cost-benefit, cost-effectiveness) methods.

Bringing prevention back into the picture would call for a fundamental shift from current
practice. This could have many positive results: Possible effects include:
    - improve quality of life and self-management skills among a group of claimants with
         few resources and high need
    - litigation and further cycles of medicalization of a claimant’s circumstances would
         no longer be the only recourse for grieved claimants with chronic MSK pain. The
         adversarial climate attending such appeals could be diminished by the less
         conditional offering of a service found helpful by the injured worker.
    - facilitate more creative problem solving and less iatrogenic disability from the WCB
         claims process

To conclude, it is time WCB ‘think outside the box’ and re-consider preventive
approaches in managing end stage claims with chronic MSK pain impairments.




11
  A presentation on the Stretch Massage Breathe (SMB) program after its pilot year at
the MFLHOC will be presented Tuesday October 19


                                                                       Page 12 of 15
5.    Recommendations
From the material presented I put forward the following recommendations for the
consideration of the committee chairing the public review of WCB.

Recommendation #1: Definition of pre-existing condition.

That a worker’s history of previously accepted work injuries involving a particular body
part ( e.g. low back) should not be discounted as a ‘pre-existing condition’ that
disentitles the current claim relating to the same body part.

Recommendation #2: Policy on the work-relatedness of degenerative conditions
of the spine.

That the policy to categorically exclude recognition of cases of degenerative spinal
disease as occupational be changed. In cases of clearly evident disability, consideration
should be given to the extent that work contributed to injury and overuse as compared
to non-occupational contributing factors when determining the cause of musculoskeletal
injury.

Recommendation #3: Disputes between insurers over cases of indisputable
disability.

There are many cases where an injured worker with demonstrable disability ends up
without coverage because of disputes between disability insurers over coverage
responsibility.

Example: a worker is off work on WCB for treatment of a work injury. At this stage he
is involved in a motor vehicle accident (MVA); his compounded condition further
restricts him from returning to work. WCB states he has recovered from the effects of
his work injury and his residual disability is related to the MVA. However, MPIC states
his barrier to returning to work is related to his initial work injury, therefore, the
responsibility belongs to WCB. Having two insurers involved did not bring greater
security, The workers ends up without any coverage through no fault of the worker.

Recommendation: That when there is unequivocal disability from an injury related to
work, but coverage is disputed between insurers, WCB and public, or other private
disability insurers, it is recommended that services necessary for the worker to proceed
with basic treatment, rehabilitation and vocational opportunities not be withheld due to
contestation between WCB and another insurer.

There should be a mechanism by which the injured worker is not denied services and
disability costs due to the intransigence of insurers to apportion responsibility between
them. I propose two options. (1) A ‘human rights ombudsman’, or other impartial office,
at arms length from WCB may be required to apportion financial responsibility or (2) a




                                                                     Page 13 of 15
Medical Review Panel with a re-defined mandate and terms of reference (#4). Other
options may also be feasible.

Recommendation #4: The role of Medical Review Panel.

That there be a critical re-appraisal of the terms of reference and purpose of the Medical
Review Panel.

Currently, the Medical Review Panel’s expert opinion is sought on specific topics and is
interpreted narrowly according to WCB’s internal definitions e.g. excluding chronic pain
of soft tissue origin as impairment. There can be an over-reliance on medical
interpretation that is out of balance with other influential and contributing considerations
in the claim. The insurer is not bound to the MRP’s conclusions. To go to such expense
and effort “to get to the bottom” and have it not carried through contributes to iatrogenic
harm and is unethical.

Recommendation #5: Ethical and health audit of failed WCB claimants with
chronic MSK pain.

That there be a combined internal and external study with case reviews of failed WCB
claimants with chronic MSK pain (failed recovery, closed claims). The review should
examine health, employment and psychosocial outcomes beyond the limited data of
WCB the insurer.

For example, direct and indirect costs borne by the individual and household, other
insurer (private, EI, CPP) and provincial health care and social services could be
collected on a stratified sample of WCB failed claims

What is the proportion of disability in the population of Manitoba attributable to work
injuries and unsafe work? Survey methodology could be used of an age-appropriate
sample of Winnipeg welfare recipients e.g. 100 for their experience with WCB and/or
work injuries as precipitating cause of their eventual destitution.

Recommendation #6: Proposing Tertiary Prevention intervention research on
alternative models to manage chronic MSK pain in injured workers.

For a significant minority of WCB claimants current WCB interventions are not
necessarily effective or efficient. Ethically and economically, it is incumbent upon WCB
to consider intervention research to trial alternative approaches to end stage case
management . WCB funds community initiatives for prevention of work injuries; it should
also be prepared to re-consider the rationale and effects of its own practices.

I propose an experimental approach to compare health, psychosocial and claims
administrative outcomes across different case management strategies.




                                                                       Page 14 of 15
Study Design: Randomized control trial of chronic disability claimants into three different
study arms (1:control, 2: package of self-help supports; 3: alternative multidisciplinary
chronic pain program with provider(s) independent of insurer.
Participation voluntary; unlinked to WCB claim file/ status; supported by family doctor

Eligibility criteria might include : unsuccessful return to productive work with injury
employer, 3 years of unemployment from pain disability, activity related musculoskeletal
pain related to work injury and history;…

Study Proposal 50 subjects in each of 3 study arms: 150 total
      ARM 1. (control group) Standard Practice; no intervention 50 subjects

       ARM 2. Allocation of alternative approaches; cost equivalent to standard WCB
       physiotherapy series - ($600 per subject; 50 subjects); not necessarily
       conditional on return to work, compliance with WCB case plan
          -   Objective: provide support for alternative therapy or supports not previously tried
              but aimed to: improve coping with chronic pain / life skills… ; Improve quality of
              life,
          -   Participant selects type of treatment among various modalities- acupuncture,
              massage, athletic therapy, yoga, tai chi, swimming membership, under MD
              supervision; gives reasons for choice, expectations in a brief questionnaire and
              functional abilities measure (e.g. SF36)
          -   post-treatment, repeat questionnaire, and final report on helpfulness or not,

      ARM 3: Multidisciplinary pain management program e.g. adapted from SMB or
      another model; $700-1000/ subject, 50 subjects
Analysis
   - randomized controlled intervention trial
   - cost-effectiveness and cost benefit analysis feasible
   - pre and post quality of life indicators, brief status report,
   - case management / WCB cost analysis

The direct costs of the study would be in the range of $80,000, similar to costs of
convening 10 MRPs, or a few videosurveillance contracts and referrals to the Canmore
chronic pain program. An applied research project would provide direct service to 100
claimants (Arm 2 and 3 combined) with unmet needs. It would test how a qualitatively
different approach to case management can affect claims and health outcomes, e.g.
claimant satisfaction likelihood of appeal and litigation at claim’s end.

Attachments
   1. Curriculum vitae of Rob Chase
   2. Submissions to Public Review Committee by Dr. Allan Kraut and Carol
      Loveridge, MFLOHC
   3. Reprints of AMA Guide to Permanent Impairment
   4. Journal papers on OPLL (2)
   5. SMB program materials (2): description and informed consent; introductory
      chapter of SMB manual


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