United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

N.C., Appellant

and

DEPARTMENT OF VETERANS AFFAIRS, 

SEATTLE VA MEDICAL CENTER, 

Seattle, WA, Employer

__________________________________________

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Docket No. 21-0934

Issued: February 7, 2022

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

JANICE B. ASKIN, Judge

PATRICIA H. FITZGERALD, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On June 3, 2021 appellant filed a timely appeal from a January 25, 2021 merit decision of 

the Office of Workers’ Compensation Programs (OWCP). Pursuant to the Federal Employees’

Compensation Act1(FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction over 

the merits of this case.2

1

5 U.S.C. § 8101 et seq.

2 The Board notes that,following the January 25, 2021 decision, OWCP received additional evidence. However, 

the Board’s Rules of Procedure provides: “The Board’s review of a case is limited to the evidence in the case record 

that was before OWCP at the time of its final decision. Evidence not before OWCP will not be considered by the 

Board for the first time on appeal.” 20 C.F.R. § 501.2(c)(1). Thus, the Board is precluded from reviewing this 

additional evidence for the first time on appeal. Id.
2

ISSUE

The issue is whether appellant has met his burden of proof to establish that the acceptance 

of his claim should be expanded to include headaches as consequential to the accepted June 11, 

2018 employment injury.

FACTUAL HISTORY

On June 21, 2018 appellant, then a 41-year-old pharmacy technician, filed a traumatic 

injury claim (Form CA-1) alleging that on June 11, 2018 he sustained neck and upper shoulder 

strains while lifting a partial case of fluid bags. He stopped work on June 18, 2018 and returned 

on June 20, 2018. OWCP accepted the claim for cervical spine ligament sprain, and right arm, 

upper arm, and shoulder strains. 

In progress notes dated July 19, 2018 and a duty status report (Form CA-17) of even date, 

Melinda L. Franklin, advanced registered nurse practitioner (ARNP), diagnosed cervical 

radiculopathy and referred appellant for physical therapy. 

OWCP received a July 21, 2018 emergency department note by Sabine L. Prince, an

ARNP, who noted appellant had experienced worsening cervical pain following neck traction 

performed by a physical therapist. 

In a July 23, 2018 letter, William Wainwright, a physical therapist, noted that cervical 

traction had been performed and that appellant reported no change in symptoms during treatment. 

Following this treatment, appellant reported severely increased symptoms including decreased 

range of motion, and had sought further emergency care. 

Ms. Franklin, in progress notes dated July 26, 2018, noted appellant’s emergency 

department visit following traction performed during physical therapy on July 21, 2018. She 

related that appellant’s physical therapy was placed on hold due to his poor tolerance to both light 

manual and cervical therapy treatment. 

OWCP received progress notes dated August 13 and 17, 2018 from Ms. Franklin. In the 

August 17, 2018 notes, Ms. Franklin noted that appellant had related that he began having 

headaches two weeks prior in the occipital and posterior neck regions, and that his headaches were 

worsening. She noted that she had explained to appellant that headaches could be multifactorial 

and were not uncommon with cervical spondylosis.

In August 27, 2018 progress notes, Ms. Franklin related that appellant continued to report 

headaches, which he believed were injury related, but that she had explained to him that headaches 

could be multifactorial and not necessarily related to cervical spondylosis. In October 1, 2018 

progress notes, Ms. Franklin opined that appellant’s headaches were not employment related.

In progress notes dated November 14, 2018, Dr. Matthew C. Keifer, a Board-certified 

internist, reported that appellant was seen for work-related neck and shoulder pain and headaches 

following a work injury. He noted that appellant developed headaches two hours after a cervical 

traction session. Appellant related being seen in the emergency department in late July and again 

in August for complaints of headaches. Both computerized tomography (CT) scans performed 
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during his emergency department visits were negative. Dr. Keifer opined that appellant had 

developed an onset of headaches following treatmentfor work-related shoulder and neck disorders. 

In progress notes dated December 30, 2018 and April 2, 2019, Dr. Lee-Loung Liou, a 

Board-certified neurologist, reviewed diagnostic tests and reported a normal neurological 

examination without any sensory or motor deficit. Appellant related new headaches?, and neck 

and right shoulder pain symptoms, which he attributed to an employment injury and traction during 

physical therapy. Dr. Liou noted a December 30, 2018 magnetic resonance imaging (MRI) scan 

of appellant’s brain was negative for structural contribution to appellant’s intermittent headache 

complaints.

In a January 11, 2019 addendum, Dr. Keifer reported he had been asked to prescribe 

medication for appellant’s headaches; however, he was unsure of the reasoning for using migraine 

headache medication for what may not be a vascular headache. 

In progress notes dated January 16 and April 9, 2019, Digna H. Walker, an ARNP, related 

that appellant had persistent headaches of unknown origin and cervical strain. 

In progress notes dated January 23, 2019, Dr. Keifer diagnosed cervical strain with 

persistent recurrent headaches of unclear etiology. He reported that appellant’s recurrent

headaches began after he underwent neck traction in physical therapy. Dr. Keifer also noted that 

appellant’s neurologist speculated that the headaches could be attributed to stimulation of the neck 

nerve tissue.

Dr. Keifer, in progress notes dated February 6, 2019, notedthat appellant was experiencing 

headache episodes about four times a day, lasting seven to eight minutes. He attributed appellant’s 

headaches to cervical traction undertaken to relieve an employment-related neck/shoulder injury. 

OWCP continued to receive progress notes dated February 20 and March 14, 2019,

wherein Dr. Keifer diagnosed employment-related headache and neck strain. 

In a development letter dated October 3, 2019, OWCP informed appellant that the evidence 

was insufficient to warrant expansion of the acceptance of his claim to include headaches. It 

advised him regarding the medical evidence to submit and afforded him 30 days to provide this 

information. 

In an October 9, 2019 physical therapy report,Royce R. Larson, a physical therapist, noted 

a diagnosis of chronic tension-type headaches. 

By decision dated November 20, 2019, OWCP denied expansion of the acceptance of 

appellant’s claim to include consequential headaches. It found that the evidence of record was 

insufficient to establish causal relationship between his headaches and the accepted employment 

injury-related cervical traction therapy. 

Subsequently, OWCP received physical therapy reports from Mr. Larson dated

September 5 and October 29, 2019 for treatment of chronic tension-type headaches. 
4

In progress notes dated December 3, 2019, Dr. Liou noted that appellant had been referred 

for treatment to a headache clinic on April 2, 2019. Appellant related that his headaches 

dramatically worsened after he had neck traction during physical therapy in July 2018. Dr. Liou

noted that appellant had no headaches prior to his injury, which developed immediately after the 

work injury and following traction performed during physical therapy. He opined that appellant’s 

history strongly suggested that appellant’s employment injury was the cause of his headaches. 

On March 17, 2020 appellant requested reconsideration and submitted additional evidence. 

Dr. Liou, in progress notes dated June 3, 2020, reported that appellant was currently 

receiving treatment for his headaches from an employing establishment physician. He noted that

appellant’s headache symptoms and neck and shoulder were associated with an employment 

injury.

On March 20, 2020 OWCP referred appellant for a second opinion evaluation. In a report 

dated September 28, 2020, Dr. Linda Wray, an OWCP second opinion physician, Board-certified 

in neurology, reviewed appellant’s medical record, and a statement of accepted facts (SOAF). She 

opined that appellant’s headaches were unrelated to the accepted June 11, 2018 employment 

injury. Based on her examination findings, Dr. Wray found no evidence of cervical radiculopathy 

or other neurologic impairment. She explained that there was no documentation of any specific 

injury or physical condition caused by the traction,which would account for appellant’s symptoms. 

Moreover, Dr. Wray related that on physical examination appellant had no evidence of tenderness 

or spasm over the cervicodorsal spine, skull base, or greater occipital nerve. Appellant had a

completely normal examination. In addition, none of his MRI scans, CT scans, and 

electrodiagnostic testing documented any pathology related or not, which would explain his

ongoing symptoms. Dr. Wray found appellant’s prognosis for his headache complaints unknown 

based on the lack of any apparent explanation or etiology relating them to the traction incident or 

employment injury. The more likely cause of appellant’s headaches was his use of high-dose of 

over-the-counter analgesics on a daily basis, making it likely that he had overuse/rebound 

headache. 

By decision dated November 4, 2020, OWCP denied modification. 

OWCP subsequently received progress notes dated November 2, 2020 from Dr. Liou, 

notingthat appellant’s MRI scan of the brain was negative for structural contribution to appellant’s 

headaches. 

On November 13, 2020 appellant requested reconsideration. 

In support of his request for reconsideration, appellant submitted progress notes dated 

October 29, 2020 from Dr. Donald A. Bright, a Board-certified neurologist. Dr. Bright noted 

appellant’s chronic headache disorder and long-term current use of anticoagulant. He reviewed 

and disagreed with Dr. Wray’s opinion on the cause of appellant’s headaches as he opined that 

appellant’s cervicogenic headaches were due to the cervical traction used to treat appellant’s 

employment-related cervical sprain. In support of this conclusion,Dr. Bright explained that, while 

cervical traction is normally safe, it can strain or sprain cervical ligaments and fascia. He also 
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related that appellant did not have osteoarthritis, significant disc herniation, or other causes of 

cervicogenic headaches.

By decision dated January 25, 2021, OWCP denied modification. 

LEGAL PRECEDENT

Where an employee claims that a condition not accepted or approved by OWCP was due 

to an employment injury, he or she bears the burden of proof to establish that the condition is 

causally related to the employment injury.3

Causal relationship is a medical question that requires rationalized medical opinion 

evidence to resolve the issue.4 A physician’s opinion on whether there is a causal relationship 

between the diagnosed condition and the implicated employment factor(s) must be based on a 

complete factual and medical background.5 Additionally, the physician’s opinion must be 

expressed in terms of a reasonable degree of medical certainty, and must be supported by medical 

rationale, explaining the nature of the relationship between the diagnosed condition and appellant’s 

employment injury.6

When an injury arises in the course of employment, every natural consequence that flows 

from that injury likewise arises out of the employment, unless it is the result of an independent 

intervening cause attributable to a claimant’s own intentional misconduct.7 Thus, a subsequent 

injury, be it an aggravation of the original injury or a new and distinct injury, is compensable if it 

is the direct and natural consequence of a compensable primary injury.8

ANALYSIS

The Board finds that appellant has not met his burden of proof to establish that the 

acceptance of his claim should be expanded to include headaches as consequential to the accepted 

June 11, 2018 employment injury 

OWCP received a number of reports from Dr. Keifer and Dr. Liou. They attributed 

appellant’s headaches to the traction used to treat appellant’s employment-related cervical strain. 

While both physicians provided affirmative opinions that supported causal relationship, they did 

3

J.R., Docket No. 20-0878 (issued July 26, 2021); R.J., Docket No. 17-1365 (issued May 8, 2019); Jaja K. 

Asaramo, 55 ECAB 200, 204 (2004).

4

J.R., id.; E.M., Docket No. 18-1599 (issued March 7, 2019); Robert G. Morris, 48 ECAB 238 (1996).

5

J.R., id.; M.V., Docket No. 18-0884 (issued December 28, 2018); Victor J. Woodhams, 41 ECAB 345, 352 (1989).

6

Id.

7

See J.R., id.; S.M., Docket No. 19-0397 (issued August7, 2019);Mary Poller, 55 ECAB 483, 487 (2004); Arthur 

Larson & Lex K. Larson, The Law of Workers Compensation 10-1 (2006).

8

J.R., id.; A.T., Docket No. 18-1717 (issued May 10, 2019); SusanneW. Underwood (Randall L. Underwood), 53 

ECAB 139 (2001).
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not offer a rationalized medical explanation to support their opinions. Medical evidence that 

provides a conclusion, but does not offer a rationalized medical explanation regarding the cause 

of an employee’s condition, is of limited probative value on the issue of causal relationship.9 Thus,

the opinions of Dr. Keifer and Dr. Liou are insufficient to meet appellant’s burden of proof.

In an October 29, 2020 report, Dr. Bright diagnosed chronic headache disorder. He opined 

that appellant’s cervicogenic headache had been caused by the cervical traction used to treat his 

employment-related cervical sprain. Dr. Bright explained that, while cervical traction was 

normally safe, it can result in the cervical ligaments and fascia strain or sprain and there was no 

other explanation for the cervicogenic headaches. The Board has held that a medical opinion 

should offer a medically-sound explanation of how the specific incident physiologically caused 

the diagnosed condition.10 Although Dr. Bright opined that the traction appellant underwent to 

treat his cervical sprain was the cause of his headaches, he did notsupport his opinion with medical 

rationale. This report, therefore, is insufficient to establish a consequential headache condition.

Appellant also submitted reports from ARNPs and physical therapists. As nurse 

practitioners and physical therapists are not considered physicians as defined under FECA, their 

medical findings and opinions are insufficient to establish entitlement to compensation benefits. 11 

OWCP also received diagnostic testing reports. The Board has held that diagnostic tests, 

standing alone, lack probative value on the issue of causal relationship as they do not address the 

relationship between the accepted employment factors, and a diagnosed condition.12 For this 

reason, these report were insufficient to meet appellant’s burden of proof.

OWCP referred appellant to Dr. Wray, a Board-certified neurologist, for second opinion 

evaluation. Dr. Wray reviewed appellant’s objective physical examination and diagnostic testing 

findings and found no evidence supporting a causal relationship between appellant’s headaches 

and the June 11, 2018 employment injury or the traction used to treat his cervical spine. She 

opined that the cause of appellant’s cervicogenic headache was instead his high-dose of over-thecounter analgesics on a daily basis. Dr. Wray provided a thorough review of the factual and 

medical background and accurately summarized the relevant medical evidence. Moreover, she 

provided detailed findings on examination and reached conclusions regarding appellant’s 

9 T.T., Docket No. 19-0319 (issued October 26, 2020); A.H., Docket No. 18-1632 (issued June 1, 2020).

10 M.G., Docket No. 21-0727 (issued October 15, 2021).

11 Section 8101(2) of FECA provides that a physician includes surgeons, podiatrists, dentists, clinical psychologists, 

optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined by state law. 

5 U.S.C. § 8101(2); 20 C.F.R. § 10.5(t). See Federal (FECA) Procedure Manual, Part 2 -- Claims, Causal 

Relationship, Chapter 2.805.3a(1) (January 2013); M.J., Docket No. 19-1287 (issued January 13, 2020); P.H., Docket 

No. 19-0119 (issued July 5, 2019); T.K., Docket No. 19-0055 (issued May 2, 2019); DavidP. Sawchuk, 57 ECAB 

316, 320 n.11 (2006) (lay individuals such as nurses, physician assistants, and physical therapists are not competent 

to render a medical opinion under FECA). See also W.Z., Docket No. 20-0191 (issued July 31, 2020) (a nurse 

practitioner is not considered a physician under FECA).

12 See S.O., Docket No. 21-0332 (issued September 24, 2021); W.M.,Docket No. 19-1853 (issued May 13, 2020);

L.F., Docket No. 19-1905 (issued April10, 2020).
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condition which comported with her findings. Consequently, Dr. Wray’s opinion is entitled to the 

weight of the evidence.

As appellant has not submitted rationalized medical evidence sufficient to establish that 

the acceptance of his claim should be expanded to include headaches as consequential to the 

accepted employment injury, the Board finds that he has not met his burden of proof.

Appellant may submit new evidence or argument with a written request for reconsideration 

to OWCP within one year of this merit decision, pursuant to 5 U.S.C. § 8128 (a) and 20 C.F.R. 

§§ 10.605 through 10.607.

CONCLUSION

The Board finds that appellant has not met his burden of proof to establish that the 

acceptance of his claim should be expanded to include headaches as consequential to the accepted 

June 11, 2018 employment injury 

ORDER

IT IS HEREBY ORDERED THAT the January 25, 2021 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: February 7, 2022

Washington, DC

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Alternate Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board