BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         _________________________________________________________________
 
                     
 
         GERALD GREGORY,       
 
                     
 
              Claimant,   
 
                     
 
         vs.         
 
                                               File No. 719227
 
         PORK PLACE,      
 
                                                A P P E A L
 
              Employer,   
 
                                               D E C I S I O N
 
         and        
 
                     
 
         ALLIED INSURANCE COMPANY,       
 
                     
 
              Insurance Carrier,    
 
              Defendants.      
 
         _________________________________________________________________
 
         The record, including the transcript of the hearing before the 
 
         deputy and all exhibits admitted into the record, has been 
 
         reviewed de novo on appeal.  The decision of the deputy filed 
 
         March 23, 1993 is affirmed and is adopted as the final agency 
 
         action in this case.
 
         
 
         Claimant shall pay the costs of the appeal, including the 
 
         preparation of the hearing transcript.
 
         
 
         Signed and filed this ____ day of September, 1993.
 
         
 
         
 
         
 
         
 
                                     ________________________________
 
                                              BYRON K. ORTON
 
                                          INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. William D. Scherle
 
         Attorney at Law
 
         803 Fleming Bldg.
 
         218 Sixth Ave.
 
         Des Moines, Iowa 50309
 
         
 
         Mr. Stephen W. Spencer
 
         Mr. Joseph M. Barron
 
         Attorneys at Law
 
         P.O. Box 9130
 
         Des Moines, Iowa 50306-9130
 
         
 
 
            
 
 
 
 
 
 
 
                                           5-1803
 
                                           Filed September 24, 1993
 
                                           BYRON K. ORTON
 
                      
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
           
 
            GERALD GREGORY,       
 
                        
 
                 Claimant,   
 
                        
 
            vs.         
 
                                               File No. 719227
 
            PORK PLACE,      
 
                                                A P P E A L
 
                 Employer,  
 
                                               D E C I S I O N
 
            and         
 
                        
 
            ALLIED INSURANCE COMPANY,       
 
                        
 
                 Insurance Carrier,    
 
                 Defendants.      
 
            ____________________________________________________________
 
           
 
            5-1803 -  Non-precedential
 
            Claimant failed to show a sufficient change of condition to 
 
            warrant review-reopening.
 
            
 
 
            
 
            Page   1
 
            
 
            
 
            
 
            
 
            
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
                                          :
 
            GERALD GREGORY,               :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :       File No. 719227
 
            PORK PLACE,                   :
 
                                          :        R E V I E W -
 
                 Employer,                :
 
                                          :      R E O P E N I N G
 
            and                           :
 
                                          :       D E C I S I O N
 
            ALLIED INSURANCE COMPANY,     :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ___________________________________________________________
 
            
 
            
 
                          STATEMENT OF THE CASE
 
            
 
                 This is a proceeding in review-reopening brought by 
 
            Gerald Gregory, claimant, against Pork Place, employer, and 
 
            Allied Insurance Company, insurance carrier, defendants, for 
 
            the recovery of further workers' compensation benefits as 
 
            the result of an injury on November 12, 1982.  A memorandum 
 
            of agreement pursuant to Iowa Code section 86.13 for this 
 
            injury was filed and approved on August 4, 1988.  On Febru
 
            ary 9, 1993, a hearing was held on claimant's petition and 
 
            the matter was considered fully submitted at the close of 
 
            this hearing. 
 
            
 
                 The parties have submitted a prehearing report of con
 
            tested issues and stipulations which was approved and 
 
            accepted as a part of the record of this case at the time of 
 
            hearing.  The oral testimony and written exhibits received 
 
            during the hearing are set forth in the hearing transcript.
 
            
 
                 In the hearing report submitted prior to hearing, it 
 
            was stipulated that the providers of the requested medical 
 
            expenses would testify as to their reasonableness and defen
 
            dants are not offering contrary evidence.
 
            
 
                                   ISSUES
 
            
 
                 The parties submitted the following issues for determi
 
            nation in this proceeding:
 
            
 
                  I.  The extent of claimant's entitlement to further 
 
            disability benefits.
 
            
 
                 II.  The extent of claimant's entitlement to further 
 
            medical benefits.
 
            
 
                                 FINDINGS OF FACT
 
            
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
                 Having heard the testimony and considered all of the 
 
            evidence, the deputy industrial commissioner finds as 
 
            follows:
 
            
 
                 On or about the 2nd day of August, 1988, claimant and 
 
            defendants entered into a settlement agreement wherein the 
 
            parties agreed that claimant suffered numerous injuries on 
 
            November 12, 1982, including but not limited to his back, 
 
            both legs, both upper extremities and hearing loss.  Based 
 
            in part upon a combined 53 percent permanent partial impair
 
            ment rating to the body as a whole from the ratings of Bruce 
 
            Butler, M.D., Timothy Fitzgibbons, M.D., and J. F. Pallanch, 
 
            M.D., claimant was paid weekly benefits for permanent dis
 
            ability equivalent to a 62 percent industrial disability as 
 
            a result of the work injuries.  Claimant was not represented 
 
            by counsel in this settlement but the terms of the agreement 
 
            were approved by a deputy industrial commissioner on August 
 
            4, 1988. 
 
            
 
                 At the time of the work injury, claimant was employed 
 
            as an assistant manager of a hog confinement operation.  The 
 
            injury occurred as a result of electrocution when claimant 
 
            made contact with a high tension power line and then fell 
 
            some 18-20 feet.  Claimant sustained entrance and exit 
 
            wounds over the hands and knees; compression fractures at 
 
            various levels in the thoracic spine; and burns on the upper 
 
            and lower extremities.  Prior to the settlement, claimant 
 
            had surgeries to his right hand and knee.  Claimant also had 
 
            injuries to his right shoulder.  Claimant also suffered 
 
            hearing loss and tinnitus prior to the settlement according 
 
            to Phala Helm, M.D., in a report issued in April 1988.  
 
            Finally, claimant suffered from emotional depression prior 
 
            to settlement but responded to treatment and recovered 
 
            according to claimant's testimony at hearing.
 
            
 
                 Claimant bases his claim for review-reopening in part 
 
            on new complaints in his left knee which resulted in arthro
 
            scopic surgery in 1990 upon a diagnosis of degenerative 
 
            arthritis and chondromalacia related to the original 1982 
 
            injury.  The causal connection of this condition to the 
 
            injury was established by the uncontroverted views of the 
 
            treating physician, Keith Swanson, M.D.  Claimant testified 
 
            that his knee condition has improved since the surgery.
 
            
 
                 Claimant further complains of a lot more pain in the 
 
            back and neck since the settlement along with more frequent 
 
            headaches.  Claimant also was diagnosed as suffering from 
 
            symptoms of pain and numbness compatible with carpal tunnel 
 
            syndrome in  1990 according to Tim Fitzgibbons, M.D.  How
 
            ever, further electrical testing failed to confirm either 
 
            carpal tunnel syndrome or cervical radiculopathy.  Also, an 
 
            MRI test in 1990 revealed kyphsis or curvature of the tho
 
            racic spine most likely due to the original injury.  In Jan
 
            uary, 1993, claimant was rated as suffering an additional 7 
 
            percent permanent impairment from a 20.63 percent loss of 
 
            hearing.  Finally, a clinical psychologist, in January 1993, 
 
            reports that claimant is suffering from progressively worse 
 
            depression requiring further psychotherapy and medication 
 
            treatment.
 
            
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
                 First, it is found that all of the new or additional 
 
            complaints involving claimant's left knee, hands, mid-back, 
 
            hearing and depression are causally related to the November 
 
            12, 1982 injury. This is based upon uncontroverted views of 
 
            the treating physicians.  However, it could not be found 
 
            from the evidence presented that these additional complaints 
 
            and symptoms constitute a significant change of physical or 
 
            mental condition from that which existed at the time of the 
 
            August 1988 settlement.
 
            
 
                 Other than claimant's self-serving testimony, the only 
 
            evidence that there is additional permanent impairment comes 
 
            from the lay testimony of a fellow teacher who states that 
 
            he appears worse than before.  One physician gives an 
 
            impairment rating for the loss of hearing.  The only profes
 
            sional evaluation of claimant's physical impairments and 
 
            capabilities comes from Thomas Bower, LPT, in January 1993.  
 
            Bower agrees with the ratings given prior to the 1988 set
 
            tlement.  Although claimant did undergo surgery on his left 
 
            knee, no physician opines that this increases his impair
 
            ment.  Indeed, claimant testified his knee improved after 
 
            surgery.
 
            
 
                 With reference to the additional hearing loss, such a 
 
            deteriorating hearing condition was anticipated and consid
 
            ered probable prior to the 1988 settlement according to a 
 
            report from John Pallanch, M.D., in September 1987.  Most 
 
            damaging to claimant's case for change of condition was the 
 
            letter report from Phala Helm, M.D., at the University of 
 
            Texas.  Dr. Helm opined in April 1988 that claimant's condi
 
            tions over time will probably deteriorate.
 
            
 
                 Although there is little question that claimant is suf
 
            fering serious emotional problems from the observations of 
 
            claimant by this deputy at hearing, which is verified by the 
 
            medical evidence, nothing has been submitted that would 
 
            indicate that this depression would not improve with addi
 
            tional treatment in the same time and manner as his prior 
 
            depression improved after treatment.
 
            
 
                 Lastly, there has been no showing that claimant has 
 
            suffered any non-physical change in his earning capacity 
 
            since the settlement related to this original injury.  
 
            Claimant was a public school teacher in August 1988 and he 
 
            remains a teacher today at higher salary levels.  Claimant 
 
            testified that he has had to give up some of his coaching 
 
            and other teaching activities but it could be found that 
 
            this was due to the work injuries or due to non-work injury 
 
            factors attributable to claimant's personality and back
 
            ground.  Claimant certainly has received less than stellar 
 
            performance appraisals from his superiors since 1988 but his 
 
            job has not been shown to be in jeopardy.  Claimant remains 
 
            a teacher today and at least, at this point in time, it is 
 
            likely he will continue in this capacity for the foreseeable 
 
            future.
 
            
 
                                CONCLUSIONS OF LAW
 
            
 
                  I.  In a review-reopening proceeding, claimant has the 
 
            burden of establishing by a preponderance of the evidence 
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            that he suffered a change of condition or a failure to 
 
            improve as medically anticipated as a proximate result of 
 
            his original injury, subsequent to the date of the award or 
 
            agreement for compensation under review, which entitles him 
 
            to additional compensation.  Deaver v. Armstrong Rubber Co., 
 
            170 N.W.2d 455 (Iowa 1969).  Meyers v. Holiday Inn of Cedar 
 
            Falls, 272 N.W.2d 24 (Iowa Ct. App. 1978).  Such a change of 
 
            condition is not limited to a physical change of condition.  
 
            A change in earning capacity subsequent to the original 
 
            award which is proximately caused by the original injury 
 
            also constitutes a change in condition under Iowa Code sec
 
            tion 85.26(2) and 86.14(2).  See McSpadden v. Big Ben Coal 
 
            Co., 288 N.W.2d 181, (Iowa 1980); Blacksmith v. All-Ameri
 
            can, Inc. 290 N.W.2d 348 (Iowa 1980).  A slight change not 
 
            resulting in any new physical restrictions on claimant's 
 
            employment is not a change of condition sufficient to sup
 
            port an award of additional industrial disability.  Doyle v. 
 
            Land O'Lakes, Inc., (Appeal Decision, Filed November 30, 
 
            1987).  Also, a deterioration of condition anticipated at 
 
            the time of settlement or prior award is not a sufficient 
 
            change of condition to warrant review-reopening.  Anderson 
 
            v. J. I. Case Co., IAWC 17 (Appeal Decision 1989).
 
            
 
                 In the case sub judice, claimant demonstrated that his 
 
            complaints since the settlement are work-related but they 
 
            are either not unanticipated or are not a permanent alter
 
            ation in his functional capabilities.  Therefore, claimant 
 
            is not entitled to a review-reopening.
 
            
 
                 II.  Pursuant to Iowa Code section 85.27, claimant is 
 
            entitled to payment of reasonable medical expenses incurred 
 
            for treatment of a work injury.  Claimant is entitled to an 
 
            order of reimbursement if he has paid those expenses.  
 
            Otherwise, claimant is entitled only to an order directing 
 
            the responsible defendants to make such payments directly to 
 
            the provider.  See Krohn v. State, 420 N.W.2d 463 (Iowa 
 
            1988).
 
            
 
                 In the case at bar, claimant seeks reimbursement for 
 
            two medical evaluations by Thomas Bower and Robert 
 
            Updegraff.  Both appear to only be evaluations for the pur
 
            pose of this litigation, not additional treatment.  There
 
            fore, claimant has not shown entitlement to reimbursement 
 
            for these expenses.
 
            
 
                 Costs are assessed against claimant.
 
            
 
                                      ORDER
 
            
 
                 1.  Claimant's petition for review-reopening is dis
 
            missed with prejudice.
 
            
 
                 2.  Claimant shall pay the costs of this action pur
 
            suant to rule 343 IAC 4.33.
 
            
 
            
 
                 Signed and filed this ____ day of March, 1993.
 
            
 
            
 
            
 

 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
            
 
            
 
                                          ______________________________
 
                                          LARRY P. WALSHIRE
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr. William D. Scherle
 
            Attorney at Law
 
            803 Fleming Building
 
            Des Moines, Iowa  50309
 
            
 
            Mr. Stephen W. Spencer
 
            Mr. Joseph M. Barron
 
            Attorneys at Law
 
            405 6th Avenue  STE 700
 
            Des Moines, Iowa  50309
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                              5-1803
 
                                              Filed March 23, 1993
 
                                              LARRY P. WALSHIRE
 
            
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
                                          :
 
            GERALD GREGORY,               :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :       File No. 719227
 
            PORK PLACE,                   :
 
                                          :        R E V I E W -
 
                 Employer,                :
 
                                          :      R E O P E N I N G
 
            and                           :
 
                                          :       D E C I S I O N
 
            ALLIED INSURANCE COMPANY,     :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ___________________________________________________________
 
            
 
            
 
            
 
            5-1803 -  Non-precedential
 
            Claimant failed to show a sufficient change of condition to 
 
            warrant review-reopening
 
            
 
 
        
 
 
 
 
 
                       BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
        
 
        
 
        SUSAN (LITTLE) LENZ BLUME,
 
           Claimant,
 
        
 
        vs .
 
        
 
        FARMLAND FOODS,
 
        
 
           Employer,                    File Nos. 719256 & 653710
 
        
 
        and                              A P P E A L
 
        
 
        AETNA CASUALTY & SURETY        D E C I S I O N
 
        COMPANY,
 
        
 
           Insurance Carrier,
 
           Defendants.
 
        
 
        
 
                                 STATEMENT OF THE CASE
 
                                                
 
        Defendants appeal and claimant cross-appeals from an arbitration 
 
        and review-reopening decision awarding permanent partial 
 
        disability benefits as the result of alleged injuries on November 
 
        1, 1980 and October 12, 1982.
 
        
 
        The record on appeal consists of the transcript of the 
 
        arbitration and review-reopening proceeding; and claimant's 
 
        exhibits A, B and C. Both parties filed briefs on appeal.
 
        
 
                                      ISSUES
 
        
 
        Both defendants' issue on appeal and claimant's issue on 
 
        cross-appeal address the nature and extent of claimant's 
 
        disability.
 
        
 
                                 REVIEW OF THE EVIDENCE
 
        
 
        The arbitration and review-reopening decision adequately and 
 
        accurately reflects the pertinent evidence and it will not be 
 
        totally set forth herein.
 
        
 
        Briefly stated, claimant worked for Farmland Foods since 1977. 
 
        Her duties consisted of work on a meat packing line, where she 
 
        used an electric "wizard" knife during 1980 and 1981. Claimant's 
 
        work involved the repetitive use of her hands, arms and 
 
        shoulders.
 
        
 
        BLUME V. FARMLAND FOODS
 
        Page 2
 
        
 
        
 
        In September of 1980, claimant sought treatment for pain in her 
 
        right upper forearm. James Flood, M.D., the company doctor, 
 
        placed claimant on light duty for one week. On November 16, 1980, 
 
        claimant's right ring finger became locked in one position. 
 
        Claimant visited Dr. Flood again and was referred to Timothy C. 
 
        Fitzgibbons, M.D., an orthopedic surgeon.
 
        
 
        Dr. Fitzgibbons diagnosed stenosing tenosynovitis. Claimant 
 
        underwent surgery to release the locked finger and after the 
 

 
        
 
 
 
 
 
        surgery claimant experienced pain in her right shoulder and 
 
        swelling and numbness of the right hand. Claimant was also found 
 
        to have a nerve entrapment of the right hand and wrist, resulting 
 
        in numbness.
 
        
 
        Claimant was released back to light duty on January 26, 1981. In 
 
        February 1981, claimant was discharged by Dr. Fitzgibbons. Dr. 
 
        Fitzgibbons noted at that time that claimant might have to seek 
 
        alternative work if her symptoms persisted.
 
        
 
        In May of 1981, claimant returned to Dr. Fitzgibbons with pain in 
 
        the right hand, wrist and forearm. Dr. Fitzgibbons removed 
 
        claimant from work, particularly from working with a wizard 
 
        knife.
 
        
 
        In August of 1981, claimant again returned to Dr. Fitzgibbons 
 
        with a recurrence of her symptoms. Dr. Fitzgibbons diagnosed 
 
        deQuervain's tenosynovitis, administered steroid injections, and 
 
        took claimant off work. A second release surgery was performed in 
 
        August of 1981 as well. When this surgery failed to relieve 
 
        claimant's symptoms, Dr. Fitzgibbons indicated he could help 
 
        claimant no further and released her to light duty on November 2, 
 
        1981 for six weeks to be followed by regular duty.
 
        
 
        In October of 1982, claimant experienced pain in her right 
 
        shoulder. Claimant was treated by Dr. Flood and also by Clifford 
 
        M. Danneel, M.D., and William R. Hamsa, Jr., M.D., with a 
 
        diagnosis of right shoulder bursitis and placed on light duty for 
 
        one month.
 
        
 
        On March 8, 1983, claimant continued to experience symptoms and 
 
        returned to Dr. Fitzgibbons. Dr. Fitzgibbons opined that 
 
        claimant's right wrist, right forearm, and right shoulder pain 
 
        and right shoulder bursitis were exacerbations of claimant's 
 
        earlier problem, stemming from repetitive overuse of her hands, 
 
        arms and shoulders during her work at Farmland. Dr. Fitzgibbons 
 
        assigned claimant a seven percent permanent partial impairment of 
 
        the right upper extremity and returned claimant to light duty 
 
        work on March 27, 1983.
 
        
 
        Claimant next treated with Thomas P. Ferlic, M.D., in June 1983. 
 
        Dr. Ferlic diagnosed scarring o' the radial nerve and stenosing 
 
        tenosynovitis of the right wrist and performed
 
        
 
        BLUME V. FARMLAND FOODS
 
        Page 3
 
        
 
        
 
        surgery in August of 1983. In September 1983, Dr. Ferlic opined 
 
        that claimant would not have any permanent impairment after her 
 
        third surgery. Later, Dr. Ferlic stated that claimant had 
 
        returned to her status prior to the third surgery and that "no 
 
        permanent disability should result as a result of the surgery." 
 
        Defendants' exhibit A, page 21.
 
        
 
        In May 1987, claimant was examined by a neurosurgeon, Horst 
 
        Blume, M.D., who assigned claimant a 13 percent permanent partial 
 
        impairment of the right hand.
 
        
 
        The record showed that claimant was compelled to leave work 
 
        temporarily because of her pain on November 16, 1980; May 5, 
 
        1981; August 31, 1981; November 17, 1982; March 8, 1983; and 
 
        August 29, 1983. Claimant continues to work at her employment 
 
        with Farmland Foods.
 
        
 
        The parties stipulated that claimant received injuries on 
 

 
        
 
 
 
 
 
        November 1, 1980 and October 12, 1982 that arose out of and were 
 
        in the course of her employment with Farmland Foods; claimant is 
 
        not seeking any further temporary total disability or healing 
 
        period benefits; claimant's rate is $217.37 per week for the 
 
        November 1, 1980 injury and $225.78 per week for the October 12, 
 
        1982 injury; the fees of Dr. Horst G. Blume are fair and 
 
        reasonable and causally connected to the work injury.
 
        
 
                                 APPLICABLE LAW
 
        
 
        Iowa Code section 85.34(2)(m) states: "The loss of two-thirds of 
 
        that part of an arm between the shoulder joint and the elbow 
 
        joint shall equal the loss of an arm and the compensation 
 
        therefore shall be weekly compensation during two hundred fifty 
 
        weeks."
 
        
 
        The right of a worker to receive compensation for injuries 
 
        sustained which arose out of and in the course of employment is 
 
        statutory. The statute conferring this right can also fix the 
 
        amount of compensation to be paid for different specific 
 
        injuries, and the employee is not entitled to compensation except 
 
        as provided by the statute. Soukup v. Shores Co., 222 Iowa 272, 
 
        268 N.W. 538 (1936).
 
        
 
        Permanent partial disabilities are classified as either scheduled 
 
        or unscheduled. A specific scheduled disability is evaluated by 
 
        the functional method; the industrial method is used to evaluate 
 
        an unscheduled disability. Martin v. Skelly Oil Co., 252 Iowa 
 
        128, 133, 106 N.W.2d 95, 98 (1560); Graves v. Eagle Iron Works, 
 
        331 N.W.2d 116 (Iowa 1983); Simbro v. DeLonq's Sportswear, 332 
 
        N.W.2d 886, 887 (Iowa 1983).
 
        
 
        When the result of an injury is loss to a scheduled member, the 
 
        compensation payable is limited to that set forth in the
 
        
 
        BLUME V. FARMLAND FOODS
 
        Page 4
 
        
 
        
 
        appropriate subdivision of Iowa Code section 85.34(2). Barton v. 
 
        Nevada Poultry Co., 253 Iowa 285, 110 N.W.2d 660 (1961).
 
        
 
        "Loss of use" of a member is equivalent to "loss" of the member. 
 
        Moses v. National Union C.M. Co., 194 Iowa 819, 184 N.W. 746 
 
        (1922).
 
        
 
        The "cumulative injury rule" may apply when disability develops 
 
        over a period of time. The compensable injury is held to occur at 
 
        the later time. For time limitation purposes, the injury in such 
 
        cases occurs when, because of pain or physical disability, the 
 
        claimant can no longer work. McKeever Custom Cabinets v. Smith, 
 
        379 N.W.2d 368 (Iowa 1985).
 
        
 
                                      ANALYSIS
 
        
 
        On appeal, both claimant and defendants raise the issue of the 
 
        extent of claimant's disability. The medical testimony of Dr. 
 
        Ferlic consisted of a prediction of no "disability" following 
 
        claimant's third and final surgery. The reports from Dr. Ferlic 
 
        are unclear as to whether he is referring to a lack of impairment 
 
        altogether, or, as stated in his report, a lack of impairment as 
 
        a result of the third surgery. Dr. Ferlic stated he expected 
 
        claimant to return to her pre-operative state following the 
 
        surgery. The record clearly shows that claimant's pre-operative 
 
        state prior to the third surgery did involve impairment of 
 
        claimant's right hand.
 

 
        
 
 
 
 
 
        
 
        Claimant's testimony establishes that she does continue to 
 
        experience pain in her right hand. The testimony of Dr. Blume, 
 
        who examined claimant subsequent to Dr. Ferlic, confirms an 
 
        ongoing disability. Dr. Cotton's examination of claimant was for 
 
        headaches and did not address the right upper extremity. Dr. 
 
        Fitzgibbons, who first examined claimant, assigned a permanent 
 
        impairment rating of seven percent of the upper right extremity. 
 
        Dr. Fitzgibbons examined claimant at a point in time much prior 
 
        to her treatment by Dr. Ferlic and her examination by Dr. Blume. 
 
        In addition, Dr. Fitzgibbons did not examine claimant after her 
 
        third surgery.
 
        
 
        Claimant clearly has a loss of function of her right hand. This 
 
        loss of function affects her ability to perform her work. 
 
        However, claimant is able to continue with her job at Farmland 
 
        Foods. Claimant is determined to have a permanent physical 
 
        impairment of seven percent of the right arm. The opinion of Dr. 
 
        Fitzgibbons, although giving a corresponding result of seven 
 
        percent impairment, is given limited weight in light of the 
 
        remoteness in time of that opinion in relation to claimant's 
 
        present condition. The conclusion that claimant has seven percent 
 
        permanent impairment of the right arm is reached after analysis 
 
        of all of the evidence in the record.
 
        
 
        BLUME V. FARMLAND FOODS
 
        Page 5
 
        
 
        
 
        That portion of the deputy's decision that set claimant's rate at 
 
        $217.37 per week, established a cumulative injury date of August 
 
        31, 1981, and ordered defendants to pay the costs of the medical 
 
        examination of Dr. Blume were not raised as issues on appeal. 
 
        Therefore, the deputy's decision in regard to those matters 
 
        stands affirmed.
 
        
 
                                 FINDINGS OF FACT
 
        
 
        1. Claimant worked for defendant Farmland Foods on a meat packing 
 
        line.
 
        
 
        2. Claimant's duties involved the repetitive use of her hands and 
 
        arms and the use of a "wizard knife."
 
        
 
        3. Claimant experienced pain and numbness in her right hand and 
 
        the "locking" of her right ring finger after using the wizard 
 
        knife.
 
        
 
        4. Claimant was diagnosed as suffering deQuervain's tenosynovitis 
 
        of the right hand.
 
        
 
        5. Claimant's condition was limited to the right upper extremity 
 
        and did not extend beyond the shoulder joint.
 
        
 
        6. Claimant's condition was first diagnosed as permanent in 
 
        November of 1981.
 
        
 
        7. Claimant's date of injury is August 31, 1981.
 
        
 
        8. Claimant received medical ratings of permanent partial 
 
        impairment of seven percent of the right upper extremity and 13 
 
        percent of the right hand.
 
        
 
        9. Claimant underwent three surgeries to relieve her right hand 
 
        and arm condition.
 
        
 

 
        
 
 
 
 
 
        10. Claimant remained employed at Farmland Foods at the time of 
 
        the hearing and continued to experience pain and a lack of full 
 
        movement in her right hand and arm.
 
        
 
        11. Claimant's rate is $217.37 per week.
 
        
 
                                 CONCLUSIONS OF LAW
 
        
 
        Claimant suffered a cumulative injury on August 31, 1981 that 
 
        arose out of and was in the course of her employment with 
 
        defendant. Farmland Foods.
 
        
 
        Claimant has an impairment of seven percent of the right arm as a 
 
        result of her work injury of August 31, 1981.
 
        
 
        WHEREFORE, the decision of the deputy is affirmed.
 
        
 
        BLUME V. FARMLAND FOODS
 
        Page 6
 
        
 
        
 
                                      ORDER
 
                                                
 
        THEREFORE, it is ordered:
 
        
 
        1. That defendants shall pay to claimant seventeen point five 
 
        (17.5) weeks of permanent partial disability benefits at a rate 
 
        of two hundred seventeen and 37/100 dollars ($217.37) per week 
 
        from November 2, 1981.
 
        
 
        2. That defendants shall pay claimant the total sum of two 
 
        hundred and no/100 dollars ($200.00) as reimbursement for the 
 
        evaluation by Dr. Blume.
 
        
 
        3. That defendants shall pay accrued weekly benefits in a lump 
 
        sum.
 
        
 
        4. That defendants shall pay interest on weekly benefits awarded 
 
        herein from November 2, 1981.
 
        
 
        5. That defendants shall pay the costs of this action pursuant to 
 
        Division of Industrial Services Rule 343-4.33.
 
        
 
        6. That defendants shall file an activity report upon payment of 
 
        this award 25 requested by this agency pursuant to Division of 
 
        Industrial Services Rule 343-3.1.
 
        
 
        
 
        Signed and filed this 27th day of December, 1988.
 
        
 
        
 
                                        DAVID E. LINQUIST
 
                                     INDUSTRIAL COMMISSIONER
 
        
 
        
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                    BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         _________________________________________________________________
 
         
 
         
 
         FRANK ROCHWICK, JR.,
 
         
 
              Claimant,
 
                                                 FILE NO. 719389
 
         VS.
 
                                               A R B I T R A T I 0 N
 
         KNUTSON CONSTRUCTION CO.,
 
                                                 D E C I S I 0 N
 
              Employer,
 
         
 
         and
 
                                        
 
         U.S. INSURANCE GROUP,
 
         
 
              Insurance Carrier,
 
              Defendants.
 
         _________________________________________________________________
 
         
 
         
 
                                   INTRODUCTION
 
         
 
              This is a proceeding in arbitration brought by Frank 
 
         Rochwick, Jr., against his employer, Knutson Construction 
 
         Company, and its insurance carrier, U.S. Insurance Group.  
 
         Claimant alleges that he sustained a compensable injury to his 
 
         back on October 20, 1982 and seeks an award of compensation for 
 
         healing period, permanent disability and payment of medical 
 
         expenses.  The issues presented by the parties at the time of 
 
         hearing are determination of claimant's entitlement to 
 
         compensation for healing period; his entitlement to compensation 
 
         for permanent disability; determination of the correct rate of 
 
         compensation; and whether or not the employer is liable for 
 
         payment of a recently incurred medical expense in the amount of 
 
         $19.00.
 
         
 
              The case was heard at Davenport, Iowa on May 29, 1986 and 
 
         was fully submitted upon conclusion of the hearing.  The record 
 
         in the proceeding consists of testimony from claimant, claimant's 
 
         exhibits 1 through 13, and defendants' exhibits A through F.
 
         
 
                            SUMMARY OF  EVIDENCE
 
         
 
              The following is only a brief summary of pertinent evidence.  
 
         All evidence received at hearing was considered when deciding the 
 
         case.
 
         
 
              Frank Rochwick is a 53 year old married man who has one 
 
         minor son.  Claimant resides at Riverside, Iowa.
 
         
 
              Claimant's formal education ended with the fourth grade in 
 
         Los Angeles, California.  Following that time, he spent 
 
         approximately half of his life in penal institutions until he was 
 
         paroled from the Iowa Men's Reformatory when he was approximately 
 
         35 years of age.  Claimant testified that his ability to read, 
 
         write and perform mathematical computations is limited.
 
         
 

 
              Following his release from the Iowa Men's Reformatory, 
 
         claimant became a concrete finisher and practiced that trade for 
 
         approximately 17 years.  The work, which generally consists of 
 
         pouring and finishing concrete, requires occasional shoveling of 
 
         cement, and finishing it with trowels.  Claimant stated,that the 
 
         heavy part is striking off, a process which involves bending over 
 
         or squatting down and pushing and pulling wet cement.  Claimant 
 
         had worked as a foreman for a cement crew where he supervised a 
 
         few as two or as many as 15 other cement finishers.  He stated 
 
         that a foreman is a worker as well as a supervisor in the cement 
 
         industry.
 
         
 
              Claimant's work experience includes general construction 
 
         labor, work in an institutional kitchen, shoe repair, refereeing 
 
         sports events and work in a laundry.
 
         
 
              Claimant testified that on October 20, 1982 he was working 
 
         as a cement finisher involved in construction of the new 
 
         University of Iowa basketball arena.  He testified that while 
 
         walking through mud between buildings he slipped on a metal rod 
 
         and fell, striking his back on the edge of an eight inch concrete 
 
         slab.  Claimant testified that he laid there briefly and then 
 
         stood up using a wall for support.  He testified that when he 
 
         attempted to work he found himself twisting when he bent over.  
 
         He reported the incident to a supervisor and sought medical care 
 
         from D. G. Settler, M.D., in Kalona, Iowa.  Claimant testified 
 
         that he was then experiencing pain in his back which extended 
 
         into his left leg.  He reported that he had suffered a sprained 
 
         back on other occasions but that the prior events had not left 
 
         any permanent problems and that he was not under a doctor's care 
 
         at the time when he fell.
 
         
 
              Dr. Settler treated claimant with diathermy and 
 
         anti-inflammatory medications.  When claimant's complaints did 
 
         not resolve, Dr. Settler referred claimant to Michael M. Durkee, 
 
         M.D., an orthopedic surgeon in Iowa City, Iowa. (Exhibit 2).
 
         
 
              Claimant was examined by Dr. Durkee on December 8, 1982.  
 
         Dr. Durkee found claimant's left knee jerk reflex and the 
 
         strength of the left quadricep to be reduced.  He also noted 
 
         sensory changes throughout the entire left lower extremity.  
 
         X-rays showed claimant to have slight degenerative changes 
 
         throughout his back and with well maintained vertebral bodies and 
 
         with normal disc spaces except that the L3-4 space appeared to be 
 
         narrowed. 
 
         
 
               Treatment in the nature of bedrest and prescription 
 
         medication was directed. (Ex. 4).
 
         
 
              Dr. Durkee diagnosed claimant's condition as a left L4 nerve 
 
         root impingement.  Claimant was started on exercise therapy under 
 
         the directions of Stan Christensen, a physical therapist at the 
 
         Pain Management Center in Iowa City, Iowa.  Reports from 
 
         Christensen and Dr. Durkee showed that claimant was making some 
 
         improvement until he reported twisting and hurting himself in 
 
         early March, 1983. (Ex. 3, page 1, Ex. 4, pages 3 & 4) Claimant 
 
         continued treating with Mr. Christensen but without making 
 
         significant improvement.  On April 23, 1983, Dr. Durkee, in a 
 
         report to the insurance carrier stated:
 
         
 
              ...He is adamant that he does not wish to consider 
 
              surgery.  This includes chymopapain.  I see no sense in 
 
              proceeding with further work up.  We will finalize his 
 
              disability.
 

 
         
 
         
 
         
 
         ROCHWICK V. KNUTSON CONSTRUCTION CO.
 
         Page   3
 
         
 
         
 
         
 
         
 
         
 
              On examination he still has findings compatible with a 
 
              left L4 nerve root impingement.  His rating at the 
 
              present time is felt to be compatible [sic] with 
 
              moderate persistent pain and stiffness aggravated by 
 
              heavy lifting with necessary modification of 
 
              activities.  He is given a 15% whole body permanent 
 
              [sic] physical impairment and loss of physical function 
 
              to the whole body. (Ex. 5)
 
         
 
              Claimant continued receiving physical therapy from Mr. 
 
         Christensen through May 6, 1983. (Ex. 3, p. 2) He then saw Dr. 
 
         Durkee again on August 31, 1983 and again on September 21, 1984.  
 
         On neither of the subsequent visits was any actual care or 
 
         treatment indicated by the doctor's notes.  At the visit of 
 
         September 21, 1984, Dr. Durkee stated: "...His physical 
 
         examination is basically unchanged from his previous visits.  He 
 
         seems to be stabilized.  He doesn't seem to be improving.  He 
 
         states he is worse.  I feel he has actually reached maximum 
 
         benefit time-wise [sic] as far as recuperation."  When seen on 
 
         February 28, 1985, an estimated functional capacity form which 
 
         appears in the record as claimant's exhibit 10 was completed but 
 
         it does not appear that treatment of any other type was 
 
         performed.
 
         
 
              On January 16, 1984, claimant was evaluated by Harry Honda, 
 
         M.D. Dr. Honda found claimant to be free from paravertebral 
 
         muscle spasm, weakness or atrophy of the lower extremities and 
 
         scoliosis of the lumbar spine.  He found claimant to walk 
 
         normally.  Dr. Honda did, however, identify diminished pain 
 
         perception in the left foot and in the lower left leg.  Under the 
 
         direction of Dr. Honda, a CT scan of the lumbar spine was 
 
         performed which showed only hypertrophy of the facet joint 
 
         without any disc herniation.  He diagnosed claimant as having an 
 
         L5 radiculopathy of uncertain origin.  He noted that claimant's 
 
         facet joint problem could have been aggravated by the work 
 
         accident.  (Ex. 6 & 8)
 
         
 
              In 1983 claimant was involved in a motor vehicle accident.  
 
         He testified that the injury sustained did not include his back. 
 
          Dr. Settler also concluded that the injury had no effect upon 
 
         claimant's back. (Ex. 7)
 
         
 
              Since the injury claimant has also experienced cardiac 
 
         problems and digestive tract problems.  Claimant testified that 
 
         he did not feel that those problems were related to the injury of 
 
         October 20, 1982 and the evidence in the record does not contain 
 
         any indication that the medical personnel who have treated 
 
         claimant have felt that the ulcer or cardiac problems are in any 
 
         way related to the October 20, 1982 injury.
 
         
 
              Claimant was evaluated by G. Brian Paprocki, a vocational 
 
         consultant.  Paprocki felt that claimant was essentially 
 
         unqualified to perform any work except unskilled physical labor.  
 
         He felt that claimant's physical restrictions as indicated by Dr. 
 
         Durkee restricted him from a substantial number of jobs within 
 
         that classification.  He also felt that claimant's age, prison 
 

 
         
 
         
 
         
 
         ROCHWICK V. KNUTSON CONSTRUCTION CO.
 
         Page   4
 
         
 
         
 
         record, lack of education and minimal transferrable work skills 
 
         from past employments were a serious impediment to gainful 
 
         employment.  Paprocki felt that claimant was capable of 
 
         performing competitive employment but that locating suitable 
 
         employment could require professional assistance and that the 
 
         employment would undoubtedly provide a rate of earnings much less 
 
         than what claimant had earned as a cement finisher. (Ex. 1)  
 
         Paprocki did not provide information concerning job availability 
 
         in the Riverside and Iowa City areas for individuals with 
 
         claimant's abilities and restrictions.
 
         
 
              Claimant also met with Douglas B. Schoenborn, M.A., CRC, 
 
         CRIS.  Schoenborn, based upon essentially the same information as 
 
         relied upon by Paprocki, found that there were numerous unskilled 
 
         positions available in the labor market that would offer some 
 
         type of employment to claimant.  He listed a number of positions 
 
         in his report, exhibit B, but did not make any specific 
 
         recommendations.
 
         
 
              Claimant testified that he currently carries nitroglycerin 
 
         for his heart and takes medication for his ulcer.  He stated that 
 
         he is not on prescription medication for his back but does take 
 
         four or five Tylenol daily for it.  He testified that he 
 
         continues to perform the exercises recommended by Dr. Durkee.
 
         
 
              Claimant testified that he has not returned to work, has not 
 
         sought employment and was never instructed to return to work by 
 
         any of his doctors.  He generally confirmed his physical 
 
         capabilities and restrictions as indicated by Dr. Durkee in 
 
         exhibit 10.  In particular, he stated that driving as much as 50 
 
         miles produces pain in his low back and upper buttocks.  He 
 
         stated that his ability to mow the lawn is limited to 
 
         approximately 15 minutes before a rest becomes necessary.  He 
 
         reported that he has tried to finish cement on three different 
 
         occasions but has been unable to due to pain.  Claimant reported 
 
         that he formerly hunted and hiked and bowled but has ceased those 
 
         activities due to the problems with his back and leg.  Claimant 
 
         testified that he has continued to be engaged in a long term 
 
         remodeling project of his home but that his son carries sheetrock 
 
         and that claimant himself avoids lifting anything heavy.  
 
         Claimant testified that his wife is employed at the University of 
 
         Iowa Laundry.  He stated that there is no work available in 
 
         Riverside,,Iowa.  Claimant related that in the past his prison 
 
         record had been a detriment to obtaining employment.
 
         
 
              Claimant testified that he has steadfastly refused any 
 
         surgical treatment for his back condition.  He has refused to 
 
         allow a myelogram to be performed.  Claimant testified that he 
 
         has a sister in California who was nearly paralyzed through what 
 
         was purported to be minor surgery on her spine.  He reported that 
 
         he observed people who were paralyzed by spinal procedures 
 
         performed at a state hospital in California.  Claimant stated 
 
         that Dr. Honda had not recommended surgery.  Claimant related 
 
         that he has seen bad results from surgery with other construction 
 
         workers and that the doctors have not given him any promises or 
 
         assurances of a good result from surgery.
 
         
 
              Claimant reported that he has not looked for any of the 
 
         types of work recommended by Schoenborn.  He stated that he has 
 

 
         
 
         
 
         
 
         ROCHWICK V. KNUTSON CONSTRUCTION CO.
 
         Page   5
 
         
 
         
 
         not looked for work related to the cement finishing industry and 
 
         has not looked for any other types of work because he does not 
 
         know of anything he could do.  He related, however, that he has 
 
         tended bar and discussed operating a tavern with a friend.  He 
 
         testified that he has also considered opening an army surplus 
 
         store.  Claimant felt that in general his back is a little better 
 
         now than it was when he started seeing Dr. Durkee and that 
 
         swimming in his pool at home is about the only activity which 
 
         seemed to help his back condition.  Claimant reported that he has 
 
         not looked into financing for entering business on his own and 
 
         that he has no capital with which to start a business.
 
         
 
                         APPLICABLE LAW AND ANALYSIS
 
         
 
              It was stipulated by the parties in the  prehearing  report
 
         that claimant was injured as he alleged.  It was further 
 
         stipulated that a causal connection existed between the injury 
 
         and permanent disability with which claimant is now afflicted.
 
         
 
              Claimant's entitlement to compensation for healing period 
 
         under section 85.34(l) is at issue.  Since claimant has not 
 
         returned to work his healing period terminates at the time when 
 
         it was medically indicated that significant improvement from the 
 
         injury was not anticipated.  It is evident that claimant has not, 
 
         and will not, become medically capable of performing the type of 
 
         work which he performed as a cement finisher at the time of 
 
         injury.  The healing period ends at the time the physician 
 
         determines that further improvement is not anticipated.  It is 
 
         not ended at the time when hindsight shows that further 
 
         improvement ceased to occur.  Thomas v. William Knudson & Son, 
 
         Inc., 349 N.W.2d 124, 126 (Iowa App. 1984).  Armstrong Tire & 
 
         Rubber Co. v. Kubli, 312 N.W.2d 60, 65 (Iowa App. 1981).  When 
 
         Dr. Durkee evaluated claimant on April 20, 1983, he indicated 
 
         that he did not expect any further significant improvement in 
 
         claimant's condition. (Ex. 5) The fact that he later confirmed 
 
         that earlier determination on May 18, 1984 does not extend the 
 
         healing period entitlement.  Claimant's physical therapy 
 
         treatment with Mr. Christensen was ended on May 6, 1983. (Ex. 3) 
 
         It is therefore concluded that claimant's entitlement to healing 
 
         period ended on April 20, 1983 and that his entitlement to 
 
         compensation for permanent partial disability became payable 
 
         commencing on April 21, 1983 in accordance with section 
 
         85.34(2).
 
         
 
              If claimant has an impairment to the body as a whole, an 
 
         industrial disability has been sustained.  Industrial disability 
 
         was defined in Diederich v. Tri-City Railway Co., 219 Iowa 587, 
 
         593, 258 N.W. 899, 902 (1935) as follows: "It is therefore plain 
 
         that the legislature intended the term 'disability' to mean 
 
         'industrial disability' or loss of earning capacity and not a 
 
         mere 'functional disability' to be computed in the terms of 
 
         percentages of the total physical and mental ability of a normal 
 
         man."
 
         
 
              Functional impairment is an element to be considered in 
 
         determining industrial disability which is the reduction of 
 
         earning capacity, but consideration must also be given to the 
 
         injured employee's age, education, qualifications, experience and 
 
         inability to engage in employment for which he is fitted.  Olson 
 

 
         
 
         
 
         
 
         ROCHWICK V. KNUTSON CONSTRUCTION CO.
 
         Page   6
 
         
 
         
 
         v. Goodyear Service Stores, 255 Iowa 1112, 1121, 125 N.W.2d 251, 
 
         257 (1963).
 
         
 
              Claimant is limited physically and academically.  His 
 
         employability is further impaired by his criminal record and 
 
         limited work experience.  On the other hand, the criminal record 
 
         is now sufficiently remote that its effect upon his employability 
 
         would be expected to be much less than it was 15 years ago.  
 
         Claimant's level of functioning as exhibited at hearing and as 
 
         evidenced by the fact that he has successfully supervised other 
 
         employees, is well above what one would normally expect of a 
 
         person with only a fourth grade education.  The fact that 
 
         claimant was able to function as a foreman is an indication that 
 
         his ability to read blueprints and plans may be somewhat better 
 
         than his testimony would otherwise lead one to believe.  The law 
 
         recognizes a duty on the part of an injured worker to mitigate 
 
         damages, so to speak, by obtaining prompt medical treatment and 
 
         by cooperating with reasonable medical care.  McKeever Custom 
 
         Cabinets v. Smith, 379 N.W.2d 368 (Iowa 1985); Stufflebean v. 
 
         City of Fort Dodge, 233 Iowa 438, 9 N.W.2d 281 (1943).  Although 
 
         claimant has been reluctant to undergo surgery, that reluctance 
 
         is not found to be unreasonable.  As a practical matter, the 
 
         record fails to contain any clear concise recommendation for 
 
         performance of any particular surgical procedure.  The lengths to 
 
         which a person will go in order to obtain relief from their 
 
         symptoms is a factor which can be considered when evaluating the 
 
         severity and extent of those symptoms.
 
         
 
              Claimant is not physically capable of working as ' a cement 
 
         finisher, but is employable as indicated by Paprocki and 
 
         Schoenborn.  He has no demonstrated aptitude for academic 
 
         pursuits and at age 53 the feasibility of major retraining is 
 
         limited.  His future employment is limited to sedentary or light 
 
         work which requires minimal reading, writing or math.  Such work 
 
         typically provides a relatively low rate of pay.  When all 
 
         applicable factors are considered, it is found that claimant has 
 
         a 35 percent permanent partial disability of the body as a whole 
 
         when the same is evaluated industrially.
 
         
 
              The rate of compensation is a subject of dispute in this 
 
         case.  Claimant's earnings during the 13 weeks proceeding the 
 
         injury in accordance with section 85.36(6) are determined from 
 
         exhibit F. The weeks considered are those identified at lines 27 
 
         through 41 of the exhibit except for lines 38 and 39.  This is in 
 
         keeping with the rule that the 13 weeks are weeks during which 
 
         the employee actually worked.  Schotanus v. Command Hydraulics, 
 
         Inc., I Iowa Industrial Commissioner Report, 294 (1981);  Lewis 
 
         v. Aalf's Manufacturing Co., I Iowa Industrial Commissioner 
 
         Report, 206 (1980).  Computations based upon the amount paid and 
 
         hours worked shows claimant's hourly rate of pay to have been 
 
         $14.67 per hour.  During the 13 applicable weeks he worked 468 
 
         hours which provides a total renumeration of $6,865.56. When 
 
         divided by 13 the average weekly earnings are $528.12. It should 
 
         be noted that Rule 500-8.2 is applied in making these 
 
         computations and that the total amount listed does not include a 
 
         premium for overtime pay but rather applies it at the normal 
 
         hourly rate.  With the stipulated status of married with three 
 
         exemptions the 1982 benefit booklet shows the correct rate of 
 
         compensation to be $313.82 per week.
 

 
         
 
         
 
         
 
         ROCHWICK V. KNUTSON CONSTRUCTION CO.
 
         Page   7
 
         
 
         
 
         
 
              Claimant seeks payment from defendants for a medical expense 
 
         in the amount of $19.00 incurred with Dr. Durkee for the 
 
         examination of September 21, 1984.  It is not unreasonable that a 
 
         treating physician would reevaluate a patient after a long period 
 
         of time has elapsed in order to monitor whether or not the 
 
         condition is changing.  Defendants will therefore be held 
 
         responsible for payment of the same.
 
         
 
                              FINDINGS OF FACT
 
         
 
              1.  On October 20, 1982 claimant was a resident of the State 
 
         of Iowa employed by Knutson Construction Company in the State of 
 
         Iowa.
 
         
 
              2.  Claimant was injured on October 20, 1982 when, while in 
 
         the course of his employment, he slipped on a rod and fell 
 
         striking his back on a concrete slab.
 
         
 
              3.  At the time of injury claimant was employed by Knutson 
 
         working as a cement finisher.
 
         
 
              4.  Following the injury claimant was medically incapable of 
 
         performing work in employment substantially similar to that he 
 
         performed at the time of injury from October 20, 1982 until April 
 
         20, 1983 when it became medically indicated that further 
 
         significant improvement from the injury was not anticipated.
 
         
 

 
         
 
         
 
         
 
         ROCHWICK V. KNUTSON CONSTRUCTION CO.
 
         Page   8
 
         
 
         
 
              5.  Claimant is generally found to be a credible witness but 
 
         he is found to have understated his intellectual abilities to a 
 
         moderate degree.
 
         
 
              6.  Claimant worked 468 hours during the 13 weeks that he 
 
         worked prior to the week in which the injury occurred.  His rate 
 
         of pay was $14.67 per hour.
 
         
 
              7.  Claimant's evaluation by Dr. Durkee on May 18, 1984 
 
         constituted reasonable medical care in the nature of a follow-up 
 
         examination for the purpose of monitoring claimant's condition.  
 
         The charge in the amount of $19.00 made for the evaluation is 
 
         fair and reasonable.
 
         
 
              8.  Claimant has a 15 percent permanent functional 
 
         impairment of the body as a whole due to the condition of his 
 
         back.  He has a limited education, limited reading, writing and 
 
         math skills and limited physical capabilities.  Claimant's prior 
 
         work experience appears to be limited generally to moderate to 
 
         heavy physical labor.  Claimant has experience, however, in 
 
         several fields and appears to be of at least average intelligence 
 
         and emotionally stable.  He has not appeared interested in 
 
         returning to gainful employment unless it is employment of the 
 
         type which pays the level of wages that he earned as a cement 
 
         finisher.  He has not made a good faith effort to find work that 
 
         is appropriate to his abilities and restrictions.
 
         
 
              9.  Claimant has a 35 percent permanent partial disability 
 
         of the body as a whole when the same is evaluated industrially.
 
         
 
              10.  Claimant's cardiac condition and ulcer are not related 
 
         to the injury of October 20, 1982.
 
              11.  Claimant's refusal to undergo a myelogram or surgery if 
 
         the same were to be strongly recommended by his treating 
 
         physicians is not unreasonable and does not constitute a failure 
 
         to minimize or mitigate damages.
 
         
 
                            CONCLUSIONS OF LAW
 
         
 
              1.  This agency has jurisdiction of the subject matter of 
 
         this proceeding and its parties.
 
         
 
              2.  The injury claimant sustained to his back on October 20, 
 
         1982 arose out of and in the course of his employment with 
 
         Knutson Construction Company.
 
         
 
              3.  Claimant's healing period entitlement under section 
 
         85.34(l) is 26 1/7 weeks commencing October 20, 1982.
 
         
 
              4.  Claimant's disability, when evaluated industrially is 35 
 
         percent permanent partial disability of the body as a whole which 
 
         entitles him to receive 175 weeks of compensation payable 
 
         commencing April 21, 1983.
 
         
 
              5.  Claimant's rate of compensation is $313.82 per week for 
 
         both healing period and permanent partial disability.
 
         
 
              6.  Defendants are responsible for payment of claimant's 
 
         medical expenses with Dr. Durkee in the amount of $19.00 under 
 

 
         
 
         
 
         
 
         ROCHWICK V. KNUTSON CONSTRUCTION CO.
 
         Page   9
 
         
 
         
 
         the provisions of section 85.27 of the Code.
 
         
 
              7.  Where a worker's refusal to undergo certain types of 
 
         medical treatment is not unreasonable the extent of his permanent 
 
         disability is evaluated under the circumstances known to exist.  
 
         No reduction or adjustment of the award due to the refusal to 
 
         undergo recommended care is warranted.
 
         
 
                                   ORDER
 
         
 
              IT IS THEREFORE ORDERED that defendants pay claimant 
 
         twenty-six and one-seventh (26 1/7) weeks of compensation for 
 
         healing period at the rate of three hundred thirteen and 82/100 
 
         dollars ($313.82) per week commencing October 20, 1982.
 
         
 
              IT IS FURTHER ORDERED that defendants pay claimant one 
 
         hundred seventy-five (175) weeks of compensation for permanent 
 
         partial disability at the rate of three hundred thirteen and 
 
         82/100 dollars ($313.82) per week payable commencing April 21, 
 
         1983.
 
         
 
              IT IS FURTHER ORDERED that defendants pay claimant nineteen 
 
         and no/100 dollars ($19.00) in medical expenses under the 
 
         provision of section 85.27.
 
         
 
              IT IS FURTHER ORDERED that defendants receive credit for the 
 
         one hundred seventeen and three-sevenths (117 3/7) weeks of 
 
         compensation previously paid at the rate of three hundred nine 
 
         and 78/100 dollars ($309.78) per week, said credit to be in the 
 
         total amount of thirty-six thousand three hundred seventy-seven 
 
         and 16/100 dollars ($36,377.16). The entire amount of the award 
 
         for permanent partial disability is past due and owing and shall 
 
         be paid to claimant in a lump sum together with interest pursuant 
 
         to section 85.30.
 
         
 
              IT IS FURTHER ORDERED that defendants pay the costs of this 
 
         action pursuant to Industrial Commissioner Rule 500-4.33.
 
         
 
              IT IS FURTHER ORDERED that defendants file a claim activity 
 
         report as requested by this agency pursuant to Rule 500-3.1.
 
         
 
         
 
                Signed and filed this 24th day of September, 1986.
 
         
 
         
 
         
 
         
 
         
 
                                          MICHAEL G. TRIER
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
         
 
         
 
         Copies To:
 
         
 
         Mr. John H. Westensee
 
         Attorney at Law
 
         Plaza Office Building
 
         Rock Island, Illinois 61201
 
         
 

 
         
 
         
 
         
 
         ROCHWICK V. KNUTSON CONSTRUCTION CO.
 
         Page  10
 
         
 
         
 
         Ms. Dorothy L. Kelley
 
         Attorney at Law
 
         1000 Des Moines Building
 
         Des Moines, Iowa 50309-2462
 
         
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                                 1402.40; 1802; 1803
 
                                                 2501; 2700; 3001
 
                                                 Filed September 24,  
 
                                                 1986
 
                                                 MICHAEL G. TRIER
 
         
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         _________________________________________________________________
 
         
 
         
 
         FRANK ROCHWICK, JR.,
 
         
 
              Claimant,
 
                                                 FILE NO. 719389
 
         VS.
 
                                               A R B I T R A T I 0 N
 
         KNUTSON CONSTRUCTION CO.,
 
                                                 D E C I S I 0 N
 
              Employer,
 
         
 
         and
 
         
 
         U.S. INSURANCE GROUP,
 
         
 
              Insurance Carrier,
 
              Defendants.
 
         _________________________________________________________________
 
         
 
         
 
         1402.40; 1802; 1803; 2501; 2700; 3001
 
         
 
              Fifty-three year old former cement worker who suffered a 
 
         back injury in a fall was held not to have acted unreasonably in 
 
         refusing to undergo surgical treatment of his back condition 
 
         where the same was not strongly recommended by the physicians and 
 
         he observed other individuals who had less than favorable results 
 
         following back surgery.  Claimant's healing period was terminated 
 
         at the time the physician assessed a final impairment rating and 
 
         offered no further treatment.  The healing period was not 
 
         extended further even though, approximately one year later, that 
 
         same physician stated in a report that the claimant had reached 
 
         maximum medical recuperation.  Claimant's disability was fixed at 
 
         35 percent, industrially, where it was evident that he would not 
 
         be able to return to his prior employment and that any employment 
 
         that he would obtain would most likely provide a significantly 
 
         lower rate of earnings.  Claimant's rate of compensation was 
 
         computed based upon the hours he actually worked during the 
 
         preceding 15 weeks, prior to the injury.    Two of the 15 weeks 
 
         were excluded where claimant did not perform any work during 
 
         those weeks.
 
         
 
 
 
 
 
 
 
                                                
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         DARREL L. CRAIN,
 
         
 
              Claimant,                             File No. 719428
 
         
 
         vs.
 
                                                      A P P E A L
 
         NEVADA RURAL FIRE PROTECTION
 
         ASSOCIATION,                               D E C I S I 0 N
 
         
 
              Employer,
 
                                                       F I L E D
 
         and
 
                                                      FEB 26 1988
 
         AID INSURANCE SERVICE,
 
                                              IOWA INDUSTRIAL COMMISSIONER
 
              Insurance Carrier,
 
              Defendants.
 
         
 
         
 
                                STATEMENT OF THE CASE
 
         
 
              Defendants appeal from an arbitration decision awarding 
 
         claimant healing period benefits, medical expenses and permanent 
 
         partial disability benefits as a result of an injury on September 
 
         29, 1982.
 
         
 
              The record on appeal consists of the transcript of the 
 
         arbitration proceeding; joint exhibits 1 through 9; claimant's 
 
         exhibits 1 through 6; and defendants' exhibits A through D.  Both 
 
         parties filed briefs on appeal.
 
         
 
                                      ISSUES
 
         
 
              1.  Whether claimant's disability is causally related to his 
 
         injury of September 29, 1982;
 
         
 
              2.  The extent of claimant's disability; and
 
         
 
              3.  Whether defendants are responsible for payment of 
 
         certain medical bills for claimant.
 
         
 
                             REVIEW OF THE EVIDENCE
 
         
 
              The arbitration decision adequately and accurately reflects 
 
         the pertinent evidence and it will not be totally reiterated 
 
         herein.
 
         
 
              Briefly stated, claimant was employed by B & D Auto Parts of 
 
         Nevada, Iowa.  His work involved bending, stooping, lifting up to 
 
         50 pounds at a time, and driving approximately 300 miles per 
 
         week. Claimant also served as a volunteer fireman for defendant 
 
                                                       
 
                                                                
 
         Nevada Rural Fire Protection Association.
 
         
 
              In 1976, claimant was responding to a fire alarm and ran 
 
         into a parked car.  He did not lose any time from work as a 
 
         result of this injury, but did experience pain in his back.  In 
 
         February of 1980, he visited John A. Grant, M.D., who discovered 
 
         a ruptured disc at the L4-5 level on the left.  A laminectomy was 
 
         performed by Dr. Grant and the disc was excised.  Claimant was 
 
         off work for three months, then resumed his work.  Claimant 
 
         testified he had no further problems until August 1981, when he 
 
         reported to Dr. Grant back and leg pain, especially after 
 
         driving.
 
         
 
              In March 1982, claimant experienced a slip on the ice while 
 
         getting ready to make a delivery for B & D Auto Parts.  He again 
 
         experienced pain and complained of difficulty in riding in a car. 
 
         Claimant told Dr. Grant his back problem had "never settled" 
 
         since September 1981.  Dr. Grant performed a myelogram, which 
 
         showed "some deformity of the nerve root at the L4-5 level."  
 
         Claimant was treated with epidural block and released back to 
 
         work.
 
         
 
              On September 29, 1982, claimant was assisting at a rural 
 
         fire when he slipped on grass made wet by a portable water tank 
 
         he was operating.  Claimant experienced immediate pain and had to 
 
         lie down.  Claimant's fellow firefighters, Steven Herr and Harold 
 
         Mitchell, both observed claimant in pain immediately after the 
 
         fall.  Although he drove home, his wife testified he could not 
 
         undress himself.  Claimant returned to his job the next day, but 
 
         three days later he could not dress himself for work.
 
         
 
              Steven Herr opined that claimant had a reputation for 
 
         truthfulness.  Harold Mitchell testified that claimant made parts 
 
         deliveries to his business, and that prior to September 29, 1982, 
 
         claimant had no visible difficulty with lifting while carrying 
 
         out those deliveries.
 
         
 
              Claimant stated that after the fall, he experienced 
 
         increased back and leg pain, as well as left testicle pain.  
 
         Claimant was hospitalized by Dr. Grant for two weeks and treated 
 
         with traction, heat, medication and injections.  Claimant 
 
         testified that after his March 1982 slip, injections relieved his 
 
         pain, but after his September 1982 fall, injections did not 
 
         help.
 
         
 
              On November 22, 1982, claimant underwent a second myelogram, 
 
         which Dr. Grant stated showed an irregularity of the L4-5 nerve 
 
         root, but "the degree of irregularity is much less than it was on 
 
         the examination of 3/18/82."  He stated that "this appearance may 
 
         be due to postoperative change.  It is also possible that there is 
 
         a fragment of nucleus pulposus which is extended laterally and is 
 
         less evident than it was previously."  On December 9, 1982, 
 
         claimant underwent a CT scan, which, according to George H. 
 
         Holmes, M.D., had "no recurrent disc protrusion identified."  
 
         Another CT scan was conducted on December 28, 1982 and Dr. Grant 
 
                                                       
 
                                                                
 
         stated that a bulge at the L4-5 level and scar tissue was noted.  
 
         In December 1982, Dr. Grant stated that claimant "was going to try 
 
         to return to work, although he was still having trouble."  
 
         However, by January 14, 1983, Dr. Grant felt "he should not return 
 
         to work until able to resume most of his regular employment."
 
         
 
              On January 24, 1983, Dr. Grant stated:  "It appears to me 
 
         that the cause of his current difficulties are directly related 
 
         to the September, 1982 injury but what percentage of the current 
 
         symptoms are directly due to the fall and what percentage might 
 
         be due to aggravation of pre-existing problems is impossible to 
 
         state."
 
         
 
              Claimant stated that he continued to experience both pain 
 
         and a "catch" in his back.  Claimant indicated that since no 
 
         relief for his discomfort had been obtained, he asked Dr. Grant 
 
         for a referral to Mayo Clinic for a second opinion.  An 
 
         electromyography was conducted at Mayo Clinic on February 17, 
 
         1983.  A psychiatric examination of claimant at Mayo Clinic on 
 
         February 21, 1983 concluded:  "He does not appear to...be 
 
         exaggerating or dramatizing his symptomatology."
 
         
 
              On February 28, 1983, Dr. Grant stated:
 
         
 
              I had a great deal of difficulty trying to sort out what 
 
              percentage of his current symptoms are due to the fall and 
 
              what percentage might be due to aggravation of a 
 
              pre-existing problem.  On that basis I will quote verbatim 
 
              from the "Manual for Orthopedic Surgeons In Evaluating 
 
              Permanent Physical Impairment" and perhaps try and establish 
 
              from this what percentage of his current difficulties are 
 
              due to the situation before the fall and what are due to the 
 
              condition after the September, 1982 fall.  In this booklet 
 
              which I use quite frequently the "surgical excision of disc, 
 
              no fusion, good results, no persistent sciatic pain" there 
 
              is awarded a 10% whole body permanent physical impairment 
 
              and loss of physical function of the whole body.  The next 
 
              step in this sequence states that "surgical excision of a 
 
              disc, no fusion, moderate persistent pain and stiffness 
 
              aggravated by heavy lifting with necessary modification of 
 
              activities" leads to a percent whole body permanent physical 
 
              impairment and loss of physical function of the whole body 
 
              of 20%.  It would be my feeling that based on these 
 
              considerations he had a 10% impairment as a result of his 
 
              original surgery leading up to the time of the subsequent 
 
              fall.  I would then estimate that the fall has produced the 
 
              rather persistent pain and stiffness and placed him in a 
 
              category of 20% partial permanent physical impairment.  As 
 
              you must realize this is an estimate based on my judgement 
 
              [sic] but it is the closest I can come to trying to break 
 
              down the differences.
 
         
 
         (Jt. Ex. J4, P. 19)
 
         
 
              On April 18, 1983, Dr. Grant opined:
 
                                                       
 
                                                                
 
         
 
                   Based on the way this man appears to me, I feel he has 
 
              a 20 percent partial permanent physical impairment and loss 
 
              of physical function of the body as a whole.  This is an 
 
              impairment rating, not a disability rating.
 
         
 
                   ...I certainly think that it would be advisable for him 
 
              to look into some type of further training for a more 
 
              sedentary occupation requiring less lifting, less repeated 
 
              bending, and less highway travel....Personally, I would 
 
              think it unlikely that he will ever return to the type of 
 
              work he was doing before and that the most advantageous 
 
              approach to this man would be attempted training at a more 
 
              sedentary type activity.
 
         
 
         (Jt. Ex. J4, p. 20)
 
         
 
              On June 21, 1983, the Mayo Clinic, through Dr. White, 
 
         released claimant to work at sedentary jobs.  The claimant 
 
         testified that at that point, he did not feel capable of 
 
         returning to work, had no relief from his pain, could not stand 
 
         physical activity, and travel was hard on him.  He stated he 
 
         could no longer do household chores such as mowing or gardening.  
 
         His wife testified that claimant wanted to return to his work at 
 
         B & D, but was not capable of doing so.  Claimant was engaged in 
 
 
 
                             
 
                                                                
 
         walking and swimming therapy throughout the summer of 1983.  Dr. 
 
         Grant advised claimant in August 1983 that he did not recommend 
 
         surgery, and that there would be no significant improvement.
 
         
 
              On October 5, 1983, claimant was examined by Dr. Peter Wirtz 
 
         for purposes of determining his continuing eligibility for 
 
         disability insurance benefits.  Dr. Wirtz reported:
 
         
 
                   This patient has chronic symptoms in his back secondary 
 
              to his laminectomy and congenital anomalies.  In light of 
 
              his congenital anomalies and the back surgery, he has a 
 
              restriction of activity from heavy lifting, twisting and 
 
              bending.  Weight limitation would be 25 to 30 pounds, as 
 
              well as the same for pushing and pulling.
 
         
 
                   This patient's back does not limit standing, walking or 
 
              sitting activities.  Jarring activities such as car or truck 
 
              activities would be limited only as far as intermittent 
 
              resting for walking and bending.
 
         
 
                   Orthopaedic impairment is based upon surgery and he has 
 
              had an L4-5 laminectomy which would be a 5% impairment of 
 
              the body.  This is directly related to his 1980 surgery.  
 
              The patient, likewise, has congenital anomalies which 
 
              pre-existed this problem and would be another 5% impairment 
 
              of the body as a whole because they continue to restrict his 
 
              functional ability.
 
         
 
                   Injuries since his accident, on a periodic basis, are 
 
              an aggravation of a pre-existing problem.  Each episode of 
 
              [sic] has healed itself without any increase in his 
 
              impairment.
 
         
 
         (Jt. Ex. J6, p. 2)
 
         
 
              Claimant continued to complain of a "catch" in his back and 
 
         testicular pain, and stated that he had not experienced either of 
 
         these symptoms prior to his fall of September 29, 1982.
 
         
 
              On October 20, 1983, Kenneth Heithoff, M.D., stated:
 
         
 
              INTERPRETATION:  C.T. scan of the lumbar spine shows 
 
              evidence of previous surgery at the L5-S1 level on the left.  
 
              There is a small to moderate size disc herniation at the 
 
              L5-S1 level on the left which extends caudally to underlie 
 
              the left S1 nerve root.  The left S1 nerve root is 
 
              compressed against the ligamentum flavum and lamina of S1.
 
         
 
              The L3-4 and 4-5 levels are normal.
 
         
 
              CONCLUSIONS:  Small recurrent free fragment disc herniation 
 
              L5-S1 on the left with 1 mm. of caudal migration.
 
         
 
         (Jt. Ex. J9, P. 1)
 
         
 
                                                       
 
                                                                
 
              It was noted in the record that claimant suffered a 
 
         congenital anomaly that could result in the labeling of the L4-5 
 
         disc as L5-S1.
 
         
 
              Dr. Grant referred claimant to the Low Back Institute and 
 
         Alexander Lifson, M.D., at claimant's request.  Dr. Lifson 
 
         reviewed claimant's CT scan and concluded:
 
         
 
              This study showed a soft tissue density at the level between 
 
              the last lumbar and the first sacral segment.  It is very 
 
              difficult for me to differentiate the possibility of a 
 
              recurrent disc herniation from postoperative fibrosis.
 
         
 
                   If Darrel has a recurrent disc at this level, I believe 
 
              it could be responsible for irritation of the S2 nerve root 
 
              and resulting testicular pain.  To clarify this diagnosis, 
 
              we would like to obtain a metrizamide enhanced CT scan of 
 
              the lumbar spine which can be done on an outpatient basis.
 
         
 
         (Jt. Ex. J9, p. 6)
 
         
 
              Dr. Lifson also stated in his deposition that claimant's 
 
         fall of September 29, 1982 aggravated or exacerbated his 
 
         preexisting condition.
 
         
 
              An enhanced CT scan, however, could not be conducted due to 
 
         a toxic reaction by claimant.  Consequently, claimant received a 
 
         percutaneous radiofacet nerve block, which claimant indicated 
 
         relieved the symptoms to a degree.
 
         
 
              On December 7, 1983, claimant began to seek employment 
 
         again. At a seminar to obtain job seeking skills, he found he 
 
         could not sit comfortably through the seminar.  Claimant was 
 
         given a lengthy list of possible job placements compiled by North 
 
         Central Rehabilitation Services of Des Moines, and claimant 
 
         investigated these.
 
         
 
              Dr. Grant reiterated his diagnosis on July 15, 1984, stating 
 
         "[F]rom my standpoint his percentage of partial permanent 
 
         physical impairment and loss of physical function to the whole 
 
         body remains as described on February 28, 1983.  I feel this is 
 
         an impairment rating that will not change despite the fact that 
 
         he may obtain some degree of relief with the treatment that was 
 
         given."
 
         
 
              On March 2, 1984, Dr. Lifson performed surgery on claimant's 
 
         back.  He found evidence of a "very extensive" amount of epidural 
 
         fibrosis, and removed a herniated disc fragment that was 
 
         compressing the nerve root against the layer of scar tissue.  Dr. 
 
         Lifson stated in his deposition that the nerve impingement 
 
         claimant suffered could be caused by either the epidural fibrosis 
 
         from his 1980 surgery or by disc herniation.  He stated that the 
 
         disc herniation could have been caused by a number of factors, 
 
         including injury, disease, or even slight activity such as 
 
         coughing or sneezing.
 
                                                       
 
                                                                
 
         
 
              Dr. Grant reviewed the results of the above procedures, and 
 
         stated on March 24, 1984:
 
         
 
              [I]t appeared to me that the cause of his current 
 
              difficulties directly relate to the September, 1982 injury. 
 
              I have also reviewed the consultation report from Doctor 
 
              Lifson that had been sent to you on March 8, 1984.  Based 
 
              on his statements I really do not feel my opinion is going 
 
              to change much.  The findings at surgery suggest that 
 
              following the initial operative procedure he had adhesions 
 
              which may have been present but asymptomatic.  It is then 
 
              very possible that the fall he sustained both in March of 
 
              1982 and September of 1982 have aggravated existing 
 
              adhesions producing the intractable pain he described.  We 
 
              still are faced with the uncertainty of what percentage of 
 
              his current symptoms relate to each separate incident.  I 
 
              still feel that his current difficulties are directly 
 
              related to the September, 1982 injury as the major source 
 
              of symptoms because his March, 1982 injury responded to 
 
              symptomatic treatment so well and was not associated with 
 
              much difficulty until the reinjury of September 30, 1982.
 
         
 
         (Jt. Ex. J4, p. 25)
 
         
 
              Dr. Grant also expressed the opinion that claimant was not a 
 
         malingerer.
 
         
 
              In April or May 1984, claimant stepped into an elevator and 
 
         again felt the sudden onset of pain in his groin, back and leg. 
 
         Claimant described the pain as being the same as that experienced 
 
         after the September 29, 1982 fall although he did not 
 
         re-experience the catch in his back.
 
         
 
              Another CT scan was performed on May 30, 1984, and Dr. 
 
         Heithoff stated:
 
         
 
              [T]here is epidural and perineural fibrosis extending into 
 
              the central spinal canal lateral to the fat graft.  There is 
 
              evidence of a prior discectomy with removal of a portion of 
 
              the plate of L5.  There is a strong suggestion of a 
 
              recurrent free fragment L5-S1 disc herniation underlying the 
 
              left S1 nerve root and the fat graft.  Since this may also 
 
              represent perineural fibrosis, a metrizamide enhanced CT 
 
              scan is necessary to distinguish between the two 
 
              possibilities since the disc visualized at the site of the 
 
              previous discectomy is low in attenuation values; and an 
 
              isodense disc herniation cannot be excluded.
 
         
 
         (Jt. Ex. J9, p. 27)
 
         
 
              On June 18, 1984, Dr. Lifson again performed surgery and 
 
         found no disc herniation but a significant amount of prior 
 
         epidural fibrosis.  Following this surgery, claimant indicated 
 
         his symptoms improved but not to the same extent as following his 
 
                                                       
 
                                                                
 
         March 1984 surgery.
 
         
 
              Both Dr. Grant and Dr. Lifson stated in their depositions 
 
         that it is difficult to distinguish between epidural fibrosis, or 
 
         scarring, and recurrent disc herniation.
 
         
 
              On October 25, 1984, the Institute For Low Back Care 
 
         assessed claimant's limitations as follows:
 
         
 
              The patient states he is able to sit for forty-five minutes 
 
              before feeling an increased discomfort in his low back.  
 
              With breaks he states he could sit for up to four hours.  
 
              The patient reports discomfort in his low back after walking 
 
              approximately thirty-five minutes.  He states with breaks he 
 
              could walk for up to six hours.  The patient states he is 
 
              able to drive a car.  He states he is able to drive a manual 
 
              shift.  He denies any difficulty operating the pedals with 
 
              either foot.  He denies any upper extremity gross motor 
 
              coordination difficulties.
 
         
 
              FLEXIBILITY:  Active range of motion of the lumbar spine is 
 
              as follows:
 
         
 
                     Flexion              0  to  60  
 
                     degrees
 
                     Right side bending   0  to  15  
 
                     degrees
 
                     Left side bending    0  to  15  
 
                     degrees
 
                     Right rotation       0  to  20  
 
                     degrees
 
                     Left rotation        0  to  20  
 
                     degrees
 
 
 
                             
 
                                                                
 
                     Extension            0  to  15  
 
                     degrees
 
         
 
                 ....
 
         
 
                   SUMMARY:  Today the patient reports intermittent left 
 
              lower extremity discomfort.  He says this is exacerbated by 
 
              activities which include forward flexion and heavy lifting. 
 
              He has participated well in caring for his low back in that 
 
              he has lost considerable weight since his first time seen. 
 
              He now expresses an interest in returning to work in 
 
              whatever capacity is available for him.  Strength testing 
 
              showed a grade of normal throughout.  He was able to lift 
 
              30 pounds and carry 40 pounds with slight report of 
 
              discomfort. His overall endurance is decreased, and he is 
 
              in need of a reconditioning program.  With care given to 
 
              limit the amount of repetitive forward flexion and heavy 
 
              lifting the patient should do well.
 
         
 
         (Jt. Ex. J9, pp. 40, 41)
 
         
 
              On October 30, 1984, Dr. Lifson opined:
 
         
 
              Darrel Crain was first seen at The Institute for Low Back 
 
              Care on 10/20/83.  In consideration of the past history, the 
 
              initial and follow-up physical examinations, and patient's 
 
              response to treatment, and the condition in which we found 
 
              him at the time of the last examination on 7/31/84, he has a 
 
              25 percent permanent partial disability to the spine.
 
         
 
         (Jt. Ex. J9, p. 42)
 
         
 
              Claimant received employment assistance from Kathryn Bennett 
 
         of North Central Rehabilitation Services.  Claimant contacted 
 
         numerous potential employers, found employment with an auto 
 
         dealer and is currently earning approximately $12,400 annually as 
 
         a service advisor.  His employer is satisfied with his work and 
 
         eventually claimant could earn up to $20,000 in his present 
 
         position.  Kathryn Bennett further stated that claimant was 
 
         cooperative and motivated toward finding work.  His present work 
 
         does not require bending, lifting, or stooping.  She described 
 
         him as a difficult job placement in light of his strict 
 
         limitations and three surgeries.
 
         
 
              Claimant also stated that he attempted to drive a truck to 
 
         Montana in October 1984, but found that shifting the gears of the 
 
         truck produced back pain.  He testified that since his September 
 
         1982 fall, he cannot lift more than 20 pounds, cannot stand 
 
         longer than one to two hours without a break, sit comfortably, or 
 
         drive more than 100 miles without stopping.  He also indicates he 
 
         now has testicular pain, and has developed a fear of falling as a 
 
         result of his three back surgeries.
 
         
 
              Claimant's exhibit 1, a ruling on a social security 
 
         disability claim, was not considered on appeal in that a 
 
                                                       
 
                                                                
 
         determination of eligibility for social security disability 
 
         benefits is based on criteria not appropriate to this case.  The 
 
         parties stipulated that claimant's rate of compensation is 
 
         $379.61.
 
         
 
                                 APPLICABLE LAW
 
         
 
              The claimant has the burden of proving by a preponderance of 
 
         the evidence that the injury of September 29, 1982 is causally 
 
         related to the disability on which he now bases his claim.  
 
         Bodish v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965).  
 
         Lindahl v. L. O. Boggs, 236 Iowa 296, 18 N.W.2d 607 (1945).  A 
 
         possibility is insufficient; a probability is necessary.  Burt v. 
 
         John Deere Waterloo Tractor Works, 247 Iowa 691, 73 N.W.2d 732 
 
         (1955).  The question of causal connection is essentially within 
 
         the domain of expert testimony.  Bradshaw v. Iowa Methodist 
 
         Hospital, 251 Iowa 375, 101 N.W.2d 167 (1960).
 
         
 
              However, expert medical evidence must be considered with all 
 
         other evidence introduced bearing on the causal connection.  
 
         Burt, 247 Iowa 691, 73 N.W.2d 732.  The opinion of experts need 
 
         not be couched in definite, positive or unequivocal language.  
 
         Sondag v. Ferris Hardware, 220 N.W.2d 903 (Iowa 1974).  However, 
 
         the expert opinion may be accepted or rejected, in whole or in 
 
         part, by the trier of fact.  Id. at 907.  Further, the weight to 
 
         be given to such an opinion is for the finder of fact, and that 
 
         may be affected by the completeness of the premise given the 
 
         expert and other surrounding circumstances.  Bodish, 257 Iowa 
 
         516, 133 N.W.2d 867.  See also Musselman v. Central Telephone 
 
         Co., 261 Iowa 352, 154 N.W.2d 128 (1967).
 
         
 
              While a claimant is not entitled to compensation for the 
 
         results of a preexisting injury or disease, the mere existence at 
 
         the time of a subsequent injury is not a defense.  Rose v. John 
 
         Deere Ottumwa Works, 247 Iowa 900, 908, 76 N.W.2d 756, 760-761 
 
         (1956).  If the claimant had a preexisting condition or 
 
         disability that is aggravated, accelerated, worsened or lighted 
 
         up so that it results in disability, claimant is entitled to 
 
         recover.  Nicks v. Davenport Produce Co., 254 Iowa 130, 115 
 
         N.W.2d 812, 815 (1962).
 
         
 
              When an aggravation occurs in the performance of an 
 
         employer's work and a causal connection is established, claimant 
 
         may recover to the extent of the impairment.  Ziegler v. United 
 
         States Gypsum Co., 252 Iowa 613, 620, 106 N.W.2d 591, 595 
 
         (1960).
 
         
 
              The Iowa Supreme Court cites, apparently with approval, the 
 
         C.J.S. statement that the aggravation should be material if it is 
 
         to be compensable.  Yeager v. Firestone Tire & Rubber Co., 253 
 
         Iowa 369, 112 N.W.2d 299 (1961); 106-C.J.S. Workmen's 
 
         Compensation 555(17)a.
 
         
 
              Our supreme court has stated many times that a claimant may 
 
         recover for a work connected aggravation of a preexisting 
 
                                                       
 
                                                                
 
         condition.  Almquist v. Shenandoah Nurseries, 218 Iowa 724, 254 
 
         N.W. 35 (1934).  See also Auxier v. Woodward State Hosp. Sch., 
 
         266 N.W.2d 139 (Iowa 1978); Gosek v. Garmer and Stiles Co., 158 
 
         N.W.2d 731 (Iowa 1968); Barz v. Oler, 257 Iowa 508, 133 N.W.2d 
 
         704 (1965); Olson v. Goodyear Service Stores, 255 Iowa 1112, 125 
 
         N.W.2d 251 (1963); Yeager, 253 Iowa 369, 112 N.W.2d 299; Ziegler, 
 
         252 Iowa 613, 106 N.W.2d 591.
 
         
 
              If claimant has an impairment to the body as a whole, an 
 
         industrial disability has been sustained.  Industrial disability 
 
         was defined in Diederich v. Tri-City Railway Co., 219 Iowa 587, 
 
         593, 258 N.W. 899, 902 (1935) as follows:  "It is therefore plain 
 
         that the legislature intended the term 'disability' to mean 
 
         'industrial disability' or loss of earning capacity and not a 
 
         mere 'functional disability' to be computed in the terms of 
 
         percentages of the total physical and mental ability of a normal 
 
         man."
 
         
 
              Functional disability is an element to be considered in 
 
         determining industrial disability which is the reduction of 
 
         earning capacity, but consideration must also be given to the 
 
         injured employee's age, education, qualifications, experience and 
 
         inability to engage in employment for which he is fitted.  Olson, 
 
         255 Iowa 1112, 125 N.W.2d 251.  Barton v. Nevada Poultry, 253 
 
         Iowa 285, 110 N.W.2d 660 (1961).
 
         
 
              A finding of impairment to the body as a whole found by a 
 
         medical evaluator does not equate to industrial disability.  This 
 
         is so as impairment and disability are not synonymous.  Degree of 
 
         industrial disability can in fact be much different than the 
 
         degree of impairment because in the first instance reference is 
 
         to loss of earning capacity and in the later to anatomical or 
 
         functional abnormality or loss.  Although loss of function is to 
 
         be considered and disability can rarely be found without it, it 
 
         is not so that a degree of industrial disability is 
 
         proportionally related to a degree of impairment of bodily 
 
         function.
 
         
 
              Factors to be considered in determining industrial 
 
         disability include the employee's medical condition prior to the 
 
         injury, immediately after the injury, and presently; the situs of 
 
         the injury, its severity and the length of healing period; the 
 
         work experience of the employee prior to the injury, after the 
 
         injury and potential for rehabilitation; the employee's 
 
         qualifications intellectually, emotionally and physically; 
 
         earnings prior and subsequent to the injury; age; education; 
 
         motivation; functional impairment as a result of the injury; and 
 
         inability because of the injury to engage in employment for which 
 
         the employee is fitted. Loss of earnings caused by a job transfer 
 
         for reasons related to the injury is also relevant.  These are 
 
         matters which the finder of fact considers collectively in 
 
         arriving at the determination of the degree of industrial 
 
         disability.
 
         
 
              There are no weighting guidelines that indicate how each of 
 
                                                       
 
                                                                
 
         the factors are to be considered.  There are no guidelines which 
 
         give, for example, age a weighted value of ten percent of the 
 
         total value, education a value of fifteen percent of total, 
 
         motivation - five percent; work experience - thirty percent, etc. 
 
         Neither does a rating of functional impairment directly correlate 
 
         to a degree of industrial disability to the body as a whole.  In 
 
         other words, there are no formulae which can be applied and then 
 
         added up to determine the degree of industrial disability.  It 
 
         therefore becomes necessary for the deputy or commissioner to 
 
         draw upon prior experience, general and specialized knowledge to 
 
         make the finding with regard to degree of industrial disability.  
 
         See Peterson v. Truck Haven Cafe, Inc., (Appeal Decision, 
 
         February 28, 1985); Christensen v. Hagen, Inc., (Appeal Decision, 
 
         March 26, 1985).
 
         
 
              Defendants cannot deny liability in a workers' compensation 
 
         case and also guide the course of treatment or select the medical 
 
         care the injured worker receives.  Barnhart v. MAQ Incorporated, 
 
         I Iowa Industrial Commissioner Reports 16 (Appeal Decision 
 
         1981).
 
         
 
              A cause is proximate if it is a substantial factor in 
 
         bringing about the result.  It need not be the only cause. 
 
         Blacksmith v. All-American, Inc., 290 N.W.2d 348 (Iowa 1980).
 
         
 
              Apportionment is appropriate where a prior injury or illness 
 
         independently produces some ascertainable portion of the ultimate 
 
         industrial disability which exists following the current injury. 
 
         Varied Enterprises, Inc. v. Sumner, 353 N.W.2d 407 (Iowa 1984).
 
         
 
                                    ANALYSIS
 
         
 
              On September 29, 1982, claimant slipped and fell while 
 
                  
 
                                                       
 
                                                                
 
         working as a volunteer fireman.  Two other firemen witnessed the 
 
         incident and confirmed claimant's statement that he immediately 
 
         experienced severe back pain and had to lie down.  Claimant 
 
         stated that he also experienced leg pain and left testicular 
 
         pain, and a "catch" in his back subsequent to the accident, and 
 
         that these symptoms had not been present prior to his fall.  
 
         Subsequent to his fall, he can no longer perform the lifting or 
 
         bending duties of his job.  Claimant's co-firemen indicated 
 
         claimant was a truthful person, and the Mayo Clinic psychiatric 
 
         report indicated claimant was not exaggerating his symptoms.  
 
         Although claimant had two back injuries and one back surgery 
 
         prior to September 29, 1982, these incidents did not result in 
 
         any inability to perform his duties for B & D Auto Parts other 
 
         than discomfort while driving.  All of the above nonexpert 
 
         testimony tends to confirm a causal relationship between 
 
         claimant's present impairment and his injury of September 29, 
 
         1982.
 
         
 
              Dr. Grant expressed the medical opinion on January 24, 1983 
 
         that claimant's impairment was caused by his fall on September 
 
         29, 1982.  He reiterated that opinion on March 24, 1984, after 
 
         reviewing the results of Dr. Lifson's surgery.  Both Dr. Grant 
 
         and Dr. Lifson opined that claimant's fall of September 29, 1982 
 
         aggravated or exacerbated his preexisting condition.
 
         
 
              There is medical testimony in the record that claimant's 
 
         back condition could be caused by a disc herniation compressing 
 
         the nerve root or by epidural fibrosis, or scarring, from his 
 
         surgery in March 1982, or a combination of these causes.  
 
         Defendants argue that claimant's impairment is the result of 
 
         scarring from the 1980 surgery and not the September 1982 fall.  
 
         Both Dr. Grant and Dr. Lifson indicated that epidural fibrosis 
 
         and disc herniation are very difficult to distinguish on a CT 
 
         scan without enhancement. Enhancement was not possible here due 
 
         to a toxic reaction.
 
         
 
              Dr. Lifson indicated that if claimant's condition was caused 
 
         by a recurrent disc herniation, that herniation could be caused 
 
         by more than one factor.  He listed injury, as well as slight 
 
         activities such as coughing, sneezing, or bending to tie shoes as 
 
         possible causes.  Claimant testified he had had no incident of 
 
         excessive coughing.  The surgery conducted in March 1984 did 
 
         confirm the presence of disc herniation as well as extensive 
 
         scarring.
 
         
 
              Dr. Grant expressed an inability to assign a percentage of 
 
         causation to either contributing factor.  He reaffirmed his 
 
         opinion that claimant's current impairment was caused by the 
 
         September 29, 1982 fall based on his observations that claimant's 
 
         condition improved considerably after the March 1982 surgery but 
 
         has not improved subsequent to the September 29, 1982 fall.  He 
 
         concluded the present condition was not a result of the scarring 
 
         from the prior surgery but was the result of the September 29, 
 
         1982 fall.
 
         
 
                                                       
 
                                                                
 
              Dr. Wirtz opined that although claimant's injuries 
 
         aggravated his preexisting condition, no further impairment 
 
         resulted.  The opinions of Dr. Grant were based on examinations 
 
         of claimant on numerous occasions, as well as the surgery he 
 
         performed on claimant.  His opinion remained unchanged even with 
 
         the benefit of updated information from Dr. Lifson.  Dr. Wirtz 
 
         examined claimant only once.  The opinions of Dr. Grant will be 
 
         given the greater weight.  Claimant's injury of September 29, 
 
         1982 was a substantial cause of his present impairment.
 
         
 
              Dr. Grant determined that there would be no improvement in 
 
         claimant's condition, and thus his disability is permanent. 
 
         Subsequent to his fall of September 29, 1982, he can no longer 
 
         bend or lift as he could before.  Dr. Wirtz stated that claimant 
 
         should not lift more than 20-30 pounds.  Claimant himself 
 
         testified he could not lift more than 20 pounds.  Both claimant's 
 
         testimony and that of Kathryn Bennett of North Central 
 
         Rehabilitation Services show that claimant's prior employment 
 
         with B & D Auto Parts did involve lifting weights up to 50 
 
         pounds. Claimant was able to perform those duties prior to the 
 
         injury of September 29, 1982, as shown by his testimony and that 
 
         of Harold Mitchell.  Claimant has therefore suffered a loss of 
 
         lifting ability as a result of his injury.
 
         
 
              Claimant also testified that since his injury of September 
 
         29, 1982, he cannot sit for longer than two hours at a time.  His 
 
         former employment with B & D Auto Parts required him to stand for 
 
         longer periods than two hours.
 
         
 
              Since his injury, claimant cannot drive over 100 miles 
 
         without a rest.  His employment at B & D required him to drive 
 
         approximately 300 miles per week.  However, there is evidence in 
 
         the record to indicate that claimant suffered an inability to 
 
         drive or ride long distances in a vehicle prior to his fall in 
 
         September 1982, and therefore this restriction is not 
 
         attributable to his September 1982 injury.
 
         
 
              Dr. Lifson rated claimant's condition as a 25 percent 
 
         impairment of the spine.  Dr. Grant opined claimant's prior 
 
         surgery and its effects would have given claimant a 10 percent 
 
         permanent partial impairment, and that after his fall of 
 
         September 29, 1982, claimant now has a permanent partial 
 
         impairment of 20 percent of the body as a whole.  He first gave 
 
         this opinion on February 28, 1983, reconfirmed it on April 18, 
 
         1983, and again reconfirmed it on January 15, 1984.
 
         
 
              It must be realized that functional impairment is only one 
 
         of the factors used in determining a person's industrial 
 
         disability.
 
         
 
              Claimant was 40 years old at the time of the hearing, with 
 
         one and one-half years of college education.
 
         
 
              The record also shows claimant attempted to return to work 
 
         after his fall, but found he could not perform his job duties. 
 
                                                       
 
                                                                
 
         Both he and his wife testified he wanted to return to work.  Dr. 
 
         Grant also opined that claimant was not a malingerer.  Kathryn 
 
         Bennett, of North Central Rehabilitation Services, testified that 
 
         claimant's motivation to find work was good.  Both his former 
 
         employer and his present employer were pleased with claimant's 
 
         performance.  The Mayo Clinic psychiatric report described 
 
         claimant's attitude as positive.  Although defendants urge that 
 
         claimant was a malingerer in order to maximize his receipt of 
 
         various public benefits, and did not seek employment until his 
 
         eligibility for those benefits had expired, the greater weight of 
 
         the evidence shows that claimant's motivation to return to work 
 
         was good.
 
         
 
              Claimant was unable to return to his prior employment 
 
         because of an aggravation or exacerbation of his preexisting 
 
         condition. His income from that position for a nine month period 
 
         of time up to his injury was $16,877.  By extrapolation, his 
 
         annual income was approximately $22,500.  His new employment is 
 
         at $12,400 annually.  The record shows a potential future income 
 
         of $20,000. Claimant has suffered and will continue to suffer a 
 
         loss of earning capacity as a result of his fall of September 29, 
 
         1982.
 
         
 
              Taking these factors and all other factors used in 
 
         determining person's earning capacity into account, claimant 
 
         presently has permanent partial industrial disability of 40 
 
         percent.
 
         
 
              Because defendants are only responsible for the extent the 
 
         September 29, 1982 injury aggravated claimant's preexisting 
 
         condition, a determination of claimant's preexisting disability 
 
         is necessary so that an apportionment can be made.
 
         
 
              Dr. Grant stated that claimant has a 10 percent functional 
 
         impairment of the body from his 1980 surgery.  Dr. Wirtz opined 
 
         that claimant had a preexisting 5 percent impairment from the 
 
         1980 surgery, and an additional 5 percent impairment from a 
 
         congenital disc defect.  Under either view, claimant had a 10 
 
         percent impairment of the body as a whole as a result of his 1980 
 
         surgery. Claimant also had a second back injury in March 1982.
 
         
 
              The 10 percent functional impairment rating is only one of 
 
         the factors to be considered.  The record shows that claimant was 
 
         able to return to his work at his job at B & D Auto Parts 
 
         subsequent to his 1980 surgery, but that he experienced some 
 
         discomfort in driving.  Driving up to 300 miles per week was one 
 
         of his job duties.  Considering these factors and all other 
 
         factors used in determining a person's earning capacity, 
 
         claimant's industrial disability prior to September 29, 1982 is 
 
         determined to have been 10 percent of the body as a whole.
 
         
 
              In that claimant's medical bills at the Low Back Institute 
 
         were the result of a referral by Dr. Grant, they were related to 
 
         his injury of September 29, 1982.  This conclusion is not 
 
         affected by the fact that claimant requested the referral.  Dr. 
 
                                                       
 
                                                                
 
         Grant made the referral in keeping with his medical judgment.  As 
 
         the bills are causally related to claimant's injury of September 
 
         29, 1982, defendants are responsible for them under Iowa Code 
 
         section 85.27. In addition, as defendants denied liability, they 
 
         cannot refuse payment because the bills were not authorized.
 
         
 
                                 FINDINGS OF FACT
 
         
 
              1.  Claimant was 40 years old at the time of the hearing.
 
         
 
              2.  Claimant completed high school and one and one-half 
 
         years of college.
 
         
 
              3.  Claimant worked as a salesman for B & D Auto Parts.
 
         
 
              4.  Claimant's B & D Sales job required him to lift up to 50 
 
         pounds and to travel approximately 300 miles per week.
 
         
 
              5.  Claimant injured his back in 1976 when responding to a 
 
         fire call as a volunteer firefighter.
 
         
 
              6.  Claimant underwent a laminectomy in February 1980, 
 
         resulting in a ten percent permanent partial impairment to the 
 
         body as a whole.
 
         
 
              7.  Claimant injured his back in March 1982 when he slipped 
 
         on some ice.
 
         
 
              8.  Claimant injured his back on September 29, 1982 while 
 
         working as a volunteer firefighter for the Nevada Rural Fire 
 
         Protection Association.
 
         
 
              9.  Claimant's fall on September 29, 1982 materially 
 
                      
 
                                                                
 
         aggravated claimant's preexisting back condition.
 
         
 
              10.  Subsequent to the fall on September 29, 1982, claimant 
 
         had a permanent partial impairment to the body as a whole of 20 
 
         percent.
 
         
 
              11.  Subsequent to September 29, 1982, claimant has back 
 
         pain and is physically unable to drive extensive distances, to 
 
         lift over 30 pounds, or bend on a regular basis.
 
         
 
              12.  Claimant can now only perform sedentary or light duty 
 
         jobs and currently works as a service advisor for an auto dealer 
 
         at an annual salary of $12,400.
 
         
 
              13.  Claimant earned more than $12,400 annually prior to his 
 
         injury on September 29, 1982.
 
         
 
              14.  Claimant is not a malingerer.
 
         
 
              15.  Claimant's physical condition is not likely to improve 
 
         significantly in the future.
 
         
 
              16.  Claimant reached maximum healing on June 21, 1983.
 
         
 
              17.  Claimant's stipulated weekly rate of compensation is 
 
         $379.61.
 
         
 
              18.  Claimant's medical bills relating to the Low Back 
 
         Institute are causally related to his injury and treatment.
 
         
 
              19.  Prior to September 29, 1982, claimant had a permanent 
 
         partial disability of 10 percent of the body as a whole.
 
         
 
              20.  As of the date of hearing, claimant had a permanent 
 
         partial disability of 40 percent of the body as a whole.
 
         
 
              21.  As a result of his injury of September 29, 1982, 
 
         claimant has a permanent partial impairment of 30 percent of the 
 
         body as a whole.
 
         
 
                              CONCLUSIONS OF LAW
 
         
 
              Claimant established by a preponderance of the evidence he 
 
         sustained an injury on September 29, 1982 that arose out of and 
 
         in the course of his employment with the Nevada Rural Fire 
 
         Protection Association.
 
         
 
              Claimant established by a preponderance of the evidence 
 
         there is a causal connection between his injury of September 29, 
 
         1982 and his claimed disability.
 
         
 
              Prior to September 29, 1982, claimant had a permanent 
 
         partial disability of 10 percent of the body as a whole.
 
         
 
              As of the date of hearing, claimant had a permanent partial 
 
                                                       
 
                                                                
 
         disability of 40 percent of the body as a whole.
 
         
 
              As a result of his injury of September 29, 1982, claimant 
 
         has a permanent partial impairment of 30 percent of the body as a 
 
         whole.
 
         
 
              WHEREFORE, the decision of the deputy is affirmed and 
 
         modified.
 
         
 
                                        ORDER
 
         
 
              THEREFORE, it is ordered:
 
         
 
              That defendants are to pay unto claimant one hundred fifty 
 
         (150) weeks of permanent partial disability benefits at a rate of 
 
         three hundred seventy-nine and 61/100 dollars ($379.61) per week 
 
         from June 21, 1983.
 
         
 
              That defendants are to pay unto claimant healing period 
 
         benefits at a rate of three hundred seventy-nine and 61/100 
 
         dollars ($379.61) per week from September 29, 1982 through June 
 
         20, 1983, less any days claimant actually worked during that 
 
         period.
 
         
 
              That defendants shall pay claimant's medical bills incurred 
 
         with the Low Back Institute.
 
         
 
              That defendants shall pay accrued benefits in a lump sum, 
 
         and pay interest pursuant to section 85.30, The Code.
 
         
 
              That defendants shall be given credit for benefits already 
 
         paid to claimant.
 
         
 
              That defendants are to pay the costs of this action.
 
         
 
              That defendants shall file claim activity reports, pursuant 
 
         to Division of Industrial Services Rule 343-3.1(2), as requested 
 
         by the agency.
 
         
 
              Signed and filed this 26th day of February, 1988.
 
         
 
         
 
         
 
         
 
         
 
         
 
         
 
                                               DAVID E. LINQUIST
 
                                            INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. Max Burkey
 
         Attorney at Law
 
         211 Shops Building
 
                                                       
 
                                                                
 
         Des Moines, Iowa  50309
 
         
 
         Mr. Cecil L. Goettsch
 
         Attorney at Law
 
         1100 Des Moines Building
 
         Des Moines, Iowa  50307
 
 
 
         
 
         
 
 
            
 
 
 
 
 
             
 
 
 
                                            1108.50-1803-1806-2501
 
                                            Filed February 26, 1988
 
                                            DAVID E. LINQUIST
 
         
 
                  BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         DARREL L. CRAIN,
 
         
 
              Claimant,                               File No. 719428
 
         
 
         vs.
 
                                                        A P P E A L
 
         NEVADA RURAL FIRE PROTECTION
 
         ASSOCIATION,                                 D E C I S I 0 N
 
         
 
              Employer,
 
         
 
         and
 
         
 
         AID INSURANCE SERVICE,
 
         
 
              Insurance Carrier,
 
              Defendants.
 
         
 
         
 
         1108.50
 
         
 
              Claimant proved a causal connection between his disability 
 
         and his work injury where the record showed claimant was able to 
 
         perform his work duties before the injury but not after, and 
 
         where medical testimony was to the effect that claimant's prior 
 
         back injuries were aggravated by his fall.
 
         
 
         1803 - 1806
 
         
 
              Claimant proved entitlement to disability benefits 
 
         equivalent to 30 percent of the body as a whole where the record 
 
         showed a loss of earnings, a lifting restriction, an inability to 
 
         stand or sit for any length of time and a rating of impairment of 
 
         40 percent of the body as a whole.  Claimant's prior injury was 
 
         determined to have resulted in a 10 percent industrial 
 
         disability, which was apportioned to give claimant 30 percent 
 
         industrial disability as a result of this injury.
 
         
 
         2501
 
         
 
              Defendants are responsible for claimant's medical bills 
 
         where defendants denied liability and where said medical bills 
 
         were the result of a referral by the treating physician, even 
 
         though claimant requested the referral.