Administrative practice document: Maintenance treatment for musculoskeletal injuries

On this page:

  1. Administrative practice document: Maintenance treatment
  2. Key principles
  3. Definitions
  4. Introduction
  5. What is maintenance treatment?
  6. Monitoring health recovery
  7. When is maintenance treatment appropriate?
  8. Medical evidence and rationale
  1. Work and functional abilities
  2. Home exercise program
  3. Previous treatment attempts
  4. Expected outcomes
  5. Communication of decisions
  6. Conclusion
  7. Document history
  8. Scheduled review

Note: This is not a policy; it is a supplementary document to illustrate how the WSIB will administer the Workplace Safety and Insurance Act, 1997, (WSIA), and Policies Entitlement to Health Care (Policy 17-01-02) and Choice and Change of Health Professional (Policy 17-01-03), as they relate to maintenance treatment. If there is a conflict between this Administrative Practice Document and the WSIA and/or WSIB policy, the decision-maker will rely on the WSIA and/or WSIB policy, as the case may be. The practice and approach is applicable to musculoskeletal injuries, not psychological or mental stress injuries, or cases that are managed in the Serious Injury Program.

Key principles

  • People are entitled to receive benefits for injuries and illnesses that arise out of and in the course of employment.
  • When deciding if a person is entitled to benefits, decision-makers determine if the injury or illness is related to their work.
  • Decision-makers gather relevant information and look at the evidence to make decisions.
  • The WSIB makes its decisions based on legislation, policy, and the individual merits and justice of each case.

Definitions

Person with injury or illness – a person who experiences a workplace injury or illness is described in the WSIA and in WSIB policy as a “worker” or “injured worker”. In this document we’ll use “person with injury or illness”, or just “person”.

Impairment – a physical or functional abnormality or loss, including disfigurement, which results from an injury and any psychological damage arising from the abnormality or loss.

Maximum medical recovery (MMR) – a plateau in recovery has been reached and it is not likely that there will be any further significant improvement in the work-related injury/disease.

Permanent impairment – impairment that continues to exist after the worker reaches MMR.

Significant improvement – a marked degree of improvement in the work-related injury/disease that is demonstrated by a measurable change in clinical findings (for example, a significant increase in the range of motion in the area of injury).

Significant deterioration – a marked degree of deterioration in the work-related impairment that is demonstrated by a measurable change in clinical findings (for example, a significant decrease in the range of motion in the area of injury).

Introduction

Section 33 (1) and (2) of the Workplace Safety and Insurance Act (WSIA) state,

A worker who sustains an injury is entitled to such health care as may be necessary, appropriate and sufficient as a result of the injury and is entitled to make the initial choice of health professional for the purposes of this section.

The Board may arrange for the worker’s health care or may approve arrangements for his or her health care. The Board shall pay for the worker’s health care.

Decision-makers at the WSIB decide what benefits and services a person can receive, under the WSIA. When a claim is allowed, the person can get health care that is necessary, appropriate, and sufficient, based on the nature of the injury or illness, to help them recover.

Once a person reaches MMR, it is generally accepted that the injured or ill person has received sufficient health care because additional treatment is not expected to result in any further significant improvement. The WSIB considers any treatment requested after MMR is reached (provided there is no significant deterioration) to be maintenance treatment. Health care following a significant deterioration is not considered maintenance treatment.

This document explains what maintenance treatment is and how we decide who can receive it based on section 33 of the WSIA and the health care principles in our policy on Entitlement to Health Care (Policy 17-01-02) and Choice and Change of Health Professional (Policy 17-01-03). Although the policies don’t talk about maintenance treatment directly, decision-makers use the guidelines in the policies to make decisions.

What is maintenance treatment?

Someone who is entitled to benefits under the WSIA is entitled to health care that is necessary, appropriate and sufficient as a result of the injury or illness. We will approve health-care treatments that we consider to be rehabilitation programs. Rehabilitation programs are intended to help a person get better, restore their quality of life and get them back to safe and suitable work.

Treatment requested after an injured or ill person reaches MMR with a permanent impairment (with no evidence of a significant deterioration) is generally referred to as maintenance treatment. This type of treatment is typically recommended by a health care professional if they believe it will help the injured or ill person. The goal of maintenance treatment is to preserve function, recovery, and quality of life by preventing deterioration of the work-related impairment, rather than rehabilitation. Maintenance treatment may also be recommended to help the person use less medication.

Monitoring health recovery

If someone gets injured or becomes ill at work, their doctor and other health care professionals who are providing treatment have to send us medical information. This includes the diagnosis, how long recovery may take, and the recommended treatment.

Decision-makers review the case file and all of the medical information to decide what benefits and services the person can get. They monitor medical information, help the person get back to work safely, and support them as they recover. According to the Better at Work principle, it’s best for most people to return to a safe and suitable job as soon as possible after a workplace injury or illness, with support from their health care provider.

When deciding what treatments an injured or ill person should receive, decision-makers check if the treatments are necessary, appropriate and sufficient. Usually, treatments are needed if they improve the person’s functional abilities and make it easier for them to return to work.

When someone has reached MMR, decision-makers have to understand if there is medical evidence that the person has an ongoing impairment because of the work-related injury or illness. If someone has a permanent work-related impairment, our return-to-work team can help identify a job they can do that is safe and suitable. This might be with their current employer in a different job or with a new employer.

Where there is no medical evidence of a permanent work-related impairment after MMR is reached, the injured or ill person is usually considered to have fully recovered from the work-related injury.

When is maintenance treatment appropriate?

After a person has reached MMR, if a health care professional requests treatment, decision-makers will gather information to understand why. Decision-makers need to understand if the treatment is needed due to the work-related injury or illness. They may also contact the health care professional to discuss a plan for reducing and then stopping treatment, before continuing with a home exercise program (if necessary).

We only consider maintenance treatment for people who have a permanent impairment from a work-related injury or illness. A decision-maker may approve maintenance treatment if medical evidence shows it is needed to meet one or more of the following goals:

  • helps the injured or ill person to continue working in a job that fits their abilities
  • helps them to continue participating in a training plan
  • reduces their pain and/or decreases their use of medication

  • maintains their level of functioning

    teaches them how to manage their condition by themselves

For decision-makers to consider a request for maintenance treatment, the health care professional must submit a written request that includes:

  • the diagnosis
  • how the person has responded to treatment so far
  • the history of attempts to reduce or stop treatment
  • the person’s current functional abilities, including range of motion, strength, pain score, and other outcome measures
  • the proposed treatment plan, including how often and how long the treatment will take, and the reasons why maintenance treatment is needed
  • the goal of the treatment and the expected end date
  • the expected outcome
  • a plan for discharge to a home exercise program, if applicable

When deciding whether to approve maintenance treatment, decision-makers consider the following factors:

Medical evidence and rationale

  • Is there current and specific medical information to support the treatment?
  • Is the health care professional’s rationale clearly described and clinically supported?
  • Is the treatment recognized by the WSIB?
  • Are there other treatment options that might be more appropriate and have not yet been tried?

Work and functional abilities

  • Will the treatment help the injured or ill person keep working in a suitable job or continue in their training plan?
  • Is another assessment needed to ensure that the current work is appropriate and matches the person’s permanent functional abilities?

Home exercise program

  • Has the person received a home exercise program before?
  • Has the person been following home exercises to help prevent or manage their symptoms?

Previous treatment attempts

  • Have there been attempts to stop the treatment? Did stopping the treatment make it hard for the person to maintain their functional level or return-to-work status?
  • If the person could not maintain their function or return-to-work status, could this be because of unsuitable work?

Expected outcomes

  • Is it expected that the treatment will reduce the person’s pain and allow them to use less medication?
  • Is it expected that the treatment will help the person maintain their level of function? For example, will it help them do daily activities, walk certain distances, or lift and carry objects?
  • Will the treatment teach or support the person to manage their condition independently? For example, does it include new home exercises or other suggested ways to modify activities?
  • Has the treatment prevented the symptoms getting worse and met that expectation?  If so, do you expect the proposed treatment to do the same?

Before we consider a maintenance treatment request, a decision-maker will identify if there are new injuries or a significant deterioration in the work-related injury or illness. If there are, then maintenance treatment is not appropriate.

In cases where there is no new injury or significant deterioration in the work-related injury or illness, a decision-maker will decide if maintenance treatment is allowed.

In every case, the decision-maker will collect and review the relevant information to decide if the person is entitled to maintenance treatment. If there is different or conflicting medical information or opinions about the benefits of the requested maintenance treatment, the decision-maker will assess and weigh the information or opinions as described in the administrative practice document on weighing of medical evidence.

In cases where maintenance treatment is allowed, funding will be approved for no longer than one year. We will review an updated report from the health care professional at that time to determine if ongoing maintenance treatment is still necessary and appropriate.

Communication of decisions

When a decision-maker has made a decision on a claim, they will tell the injured or ill person and their health care professional verbally whenever possible. Decisions will also be communicated in writing. The decision letter will:

  • identify the issue,
  • summarize the facts of the case,
  • explain the entitlement rules that apply to the issue (legislative and/or policy criteria, or standards),
  • explain the reason for the decision and how the entitlement rules were or were not met according to Entitlement to Health Care (Policy 17-01-02)
  • only reference evidence that is relevant to the decision, and
  • include the deadline for appealing the decision if the person disagrees with it.

The decision-maker will communicate decisions in plain language, so the injured or ill person and their health care professional fully understand the decision and the reasons for the decision. The reasoning should outline the evidence that was considered in the decision-making process.

When making a decision about a request for maintenance treatment, the decision-maker will explain the evidence considered, and how it relates to the factors and objectives mentioned in this document. If there is conflicting information or medical opinions, they will clearly explain in the decision letter how it’s been assessed and weighed.

If the request for maintenance treatment is approved, the decision letter will clearly specify the type of treatment, how often and how long the treatment is approved, and the expected outcome. The letter will also explain what information is needed if additional maintenance treatment is requested.

Conclusion

When an injured or ill person reaches MMR after a work-related injury or illness, more treatment is usually not needed, as it is unlikely to result in further recovery. To allow additional treatment, the decision-maker needs to identify if the injured or ill person has suffered a significant deterioration of their condition.  If it is confirmed that there has been no significant deterioration, further treatment is considered maintenance treatment and may be considered only in cases where the injured or ill person has a permanent work-related impairment.

We may approve maintenance treatment when there is evidence that shows the requested treatment will be helpful to the injured or ill person to maintain their condition and prevent a significant deterioration. Based on the factors for consideration, the decision-maker must be satisfied that the maintenance treatment will achieve one or more of the objectives explained in this document.

Determining entitlement for maintenance treatment requires a thorough review of the request and the information in the file record. Where there isn’t enough information, the decision-maker will gather additional relevant information from the person with injury or illness, their employer, and health care professionals, as needed, and review each case on its own merits.

When reviewing differing medical opinions, decision-makers will refer to the administrative practice document on weighing of medical evidence.

Document history:

December 2025 – replaces December 2020 document

December 2020 – reviewed

April 2015 - replaces the Best Approaches Guide on Maintenance Treatment, December 2005

Scheduled review:

December 2030