APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER:
20250015
OBJECTING PARTY:
WORKER
REPRESENTED by:
WORKER REPRESENTATIVE
RESPONDENT PARTY:
EMPLOYER
HEARING:
HEARING IN WRITING
HEARD by:
L. DIAZ, APPEALS RESOLUTION OFFICER
DATED:
NOVEMBER 14, 2024
ISSUE
The worker objects to the Case Manager’s March 8, 2024 decision which concluded the worker had reached Maximum Medical Recovery (MMR) effective August 25, 2021, without a permanent impairment evidence for their concussion injury.
BACKGROUND
On June 26, 2020, while employed as a Drywall and Stucco worker, the worker fell from scaffolding three stories high onto the ground, sustaining injuries to their bilateral wrists and the back of their head.
Entitlement in the claim was accepted for bilateral wrist fractures and a head laceration/concussion. The worker has been paid full loss of earnings (LOE) benefits since their injury under the claim.
The worker underwent open reduction internal fixation (ORIF) on June 26, 2020, and subsequently underwent physiotherapy treatment. They first underwent assessment on October 8, 2020 at the Upper Extremity Specialty Program (UESP) and were diagnosed with the following: 1. Bilateral distal radius fracture – status post ORIF, 2. Left ulnar styloid non-union, 3. Cubital tunnel syndrome with ulnar neuropathy, intrinsic wasting and altered sensation, 4. Left – EPL tendon rupture, 5. Subluxation right distal radial ulnar joint, 6, post injury stiffness – general.
The worker then commenced treatment with Dr. Semler, Psychologist, though the WSIB Community Mental Health Program (CMHP).
On November 17 and 19, 2020, the worker underwent assessment at the Neurology Specialty Program (NSP) following which it was noted the worker had not had a graduated and progressive rehabilitation program for the mild traumatic brain injury (mTBI). The following diagnoses were confirmed: associated neck strain, headaches, sleep impairment, and panic attacks since the injury. Diagnosis under
consideration was Panic Attack. Treatment in the form of physical therapy, occupational therapy and psychological/psychotherapy was recommended.
On August 25, 2021, the worker was discharged from the NSP. It was recommended the worker be referred to the WSIB Mental Health Specialty Program for assessment and treatment.
In April 2022, entitlement was also accepted for Psychotraumatic Disability for the diagnosis of Adjustment Disorder with Mixed Anxiety and Depressed Mood.
The worker’s treatment with Dr. Semler through the CMHP progressed, and they were also assessed and treated by Dr. Attia at a local mental health centre effective October 19, 2022. The worker has also undergone assessment at CBI Occupational Therapy Mental Health.
Case Manager’s decision
In a March 8, 2024 decision, the Case Manager determined the worker’s concussion had resolved effective August 25, 2021, without a permanent impairment or restrictions evident for their concussion.
Worker’s position
The worker’s representative did not provide a submission for consideration. Rather, his completed Appeal Readiness Form merely indicated ‘PI’ (permanent impairment).
AUTHORITY
Operational Policy Manual
Published
11-01-05, Determining Permanent Impairment
November 3, 2014
ANALYSIS
I find there the worker reached MMR for their concussion, without evidence of an ongoing related impairment. In arriving at this decision, I had regard for the file information and the applicable policy and legislation.
Policy 11-01-05, Determining Permanent Impairment, records the following, in part:
A work-related impairment is considered permanent when it continues to exist after maximum medical recovery (MMR) has been reached.
A recovery from the work-related injury/disease is considered to have been made if there is no evidence of an ongoing work-related impairment at the time MMR is reached.
Determining ongoing impairment
Once MMR has been determined, decision-makers consider whether there is an ongoing impairment based on the clinical evidence.
The WSIB considers
a physical abnormality to be a change to or damage to a body part or organ system
a physical loss to be a loss of some or all of a body part or organ system
a functional abnormality to be a malfunction of a body part or organ system
a functional loss to be a loss of some or all of the functioning of a body part or organ system
a disfigurement to be an altered or abnormal appearance such as an alteration of color, shape, structure, or a combination of these, and
psychological damage to be the loss of or abnormal psychological functioning.
In order to determine whether the evidence supported an ongoing impairment in relation to the worker’s concussion, all file medical reports were reviewed, with particular focus upon all NSP reports, the UESP Psychiatry Assessment report of March 3, 2021, the local mental health centre reports, and the CMHP reports. Of importance, I note the worker’s treatment for their accepted psychological condition continues and that they continue to be paid full LOE on the basis they remain psychologically unable to return to work.
The November 17, 2020 NSP assessment report confirmed the following: “48-year-old male with mTBI and bilateral radius fractures June 26, 2020. He continues to receive treatment for his bilateral wrists but has not had a graduated and progressive rehabilitation program for the mTBI. … There is associated neck strain, headaches, sleep impairment and panic attacks since the injury. … he continues to receive treatment for his bilateral wrist injuries but has not had a graduated and progressive rehabilitation program for the mTBI. He perhaps has two additional surgeries planned for his wrist injuries; and he will begin the Neurology Specialty Treatment Program to address his mTBI once he has had an initial recovery from a pending right wrist surgery.” Symptoms included headaches, blurry vision, dizziness, panic attacks, sleep disturbance, fatigue, concentration issues, pain and stiffness in various areas, and mood issues.
The November 30, 2020 NSP Psychology assessment by Dr. Ebrahimian confirmed the occupational diagnoses of Adjustment Disorder Associated with Mixed Anxiety and Depressed Mood, Irritability, and Query Somatic Symptom Disorder, with Predominant pain, Acute. Psychological treatment was recommended.
The March 3, 2021 UESP Psychiatry assessment by Dr. Grenier documented the worker was unable to successfully return to work from a mental health perspective given their ongoing depressed and anxiety symptoms, which included sleep disturbance, panic attacks, fatigue, concentration and short-term memory difficulties, decreased motivation, somatic preoccupation, fear avoidance, and catastrophization. Ongoing treatment was recommended.
The April 27, 2021, June 2, 2021, June 30, 2021, and August 4, 2021 NSP reports recommended ongoing treatment.
The NSP treatment discharge report of August 25, 2021 provided the following information:
“(The worker) initiated OT treatment at a frequency of once per week on May 12, 2021, as part of the multi-disciplinary NSP. He was discharged from OT treatment with this writer on August 16, 2021. (The worker) attended treatment consistently, and was largely engaged in treatment sessions; however, engagement and progression of functional ability was negatively impacted by psychological factors, particularly low mood, significant anxiety and intrusive thoughts, and frequent panic attacks. OT treatment focused on mTBI symptoms management education, basic
psychoeducation and review of stress management strategies, and functional goal setting for behavioural reactivation.”
The following additional information was provided with respect to the worker’s activities of daily living and functional tasks:
From a functional perspective, (the worker) is independent with his self-care tasks, including dressing and bathing. He no longer receives supervision or assistance from his wife for showering. (The worker) reported that his wife organizes and reminds him to take his medications, as he often forgets. Writer suggested trialing a dosette for medication management, as this can be filled once per week on Sundays and can help address difficulty recalling whether he took his medication or not. (The worker) reported that he assists with light housekeeping tasks as able, such as vacuuming or carrying in light grocery items, though identifies bilateral wrist pain as a barrier. (The worker) reported that he accompanies his wife/family on community outings, such as grocery shopping and taking his children to the park, community pool, and other play areas. (The worker) reported increased anxiety in public places as a barrier to going out into the community independently. (The worker) reported that he feels comfortable going on walks around his immediate neighbourhood independently, though not in busier public places
(I.e. grocery store, shopping centres, etc.). In terms of childcare responsibilities, (the worker) helps get his children dressed in the morning, and takes them to the park/community pool, accompanied by his wife. He reported that he is unable to pick-up his children or engage in more physical play, due to bilateral wrist pain. From a driving perspective, (the worker) is currently driving short distances (approx. 10 minutes) independently or with his wife in the vehicle with him. He reports increased anxiety as both a driver and passenger of the vehicle as an ongoing barrier to progressing driving tolerance. Writer has reviewed education regarding exposure therapy as an approach to address driving anxiety. He was encouraged to practice driving regularly and to gradually progress the length of time driving to decrease driving anxiety over time; however, he has been unable to progress past 10-15 minutes of driving thus far.
It was noted the worker presented with significant anxiety, including panic attacks, obsessive thoughts, and significant fear-avoidance behaviors. Given the severity of the worker’s mental health difficulties and the fact that their psychological dysfunction had become the major obstacle in their recovery and potential return to work, it was recommended that the worker be transferred to the WSIB Mental Health Specialty Program for further treatment.
In summary, when comparing the worker’s symptoms documented in the November 17, 2020 NSP assessment to the August 25, 2021 NSP discharge report, I note the worker’s residual symptoms were predominantly psychological. I note the worker no longer reported blurred vision, and there were no reports of nausea, vomiting, or vertigo, which are symptoms typically associated with an mTBI.
The difficulty in this particular case with determining whether the worker achieved MMR for their concussion is that some typical ongoing concussion symptoms, i.e. concentration, headaches, sleep difficulties, may overlap with psychological symptoms. I find the medical evidence supports this is the case with this particular worker. I am persuaded the worker attained MMR effective August 25, 2021 for their mTBI as this report confirmed the worker’s progression was predominantly hampered by their psychological functioning.
In summary, I find the medical evidence supports the worker recovered from their mTBI effective August 25, 2021, without evidence of a permanent impairment, and that any ongoing psychological symptoms are predominantly related to the worker’s accepted psychological condition in the claim for which the worker has ongoing entitlement.
CONCLUSION
I conclude the worker recovered from their mTBI (concussion) effective August 25, 2021, without evidence of a permanent impairment, and that any ongoing psychological symptoms are predominantly related to the worker’s accepted psychological condition in the claim for which they have ongoing entitlement.
The objection is denied.
DATED NOVEMBER 14, 2024
L. Diaz
Appeals Resolution Officer Appeals Services Division