BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         DEANA ASKELSON,
 
         
 
              Claimant,
 
         
 
         vs.                                          File No. 771130
 
         
 
         J & M INC. OF BADGER,                     A R B I T R A T I O N
 
         
 
              Employer,                               D E C I S I O N
 
         
 
         and
 
                                                         F I L E D
 
         UNITED FIRE & CASUALTY COMPANY,
 
                                                        MAR 29 1989
 
              Insurance Carrier,
 
              Defendants.                           INDUSTRIAL SERVICES
 
         
 
         
 
                                   INTRODUCTION
 
         
 
              This is a proceeding in arbitration brought by the claimant, 
 
         Deana Askelson, against her employer, J & M Inc. of Badger, and 
 
         its insurance carrier, United Fire & Casualty Company, to recover 
 
         benefits under the Iowa Workers' Compensation Act as a result of 
 
         an injury sustained on July 23, 1984.  This matter came on for 
 
         hearing before the undersigned deputy industrial commissioner at 
 
         Fort Dodge, Iowa on January 18, 1989.  A first report of injury 
 
         was filed on August 6, 1984.  A final report was received on 
 
         March 5, 1985 which final report indicates that claimant was paid 
 
         14 weeks of temporary total/healing period benefits and 12.5 
 
         weeks of permanent partial disability benefits as well as medical 
 
         benefits in the amount of $19,245.68.  The record in this 
 
         proceeding consists of the testimony of claimant, of Kelly 
 
         Gonder, of Norman E. Moon, and of Herbert Kersten, M.D., as well 
 
         as of claimant's exhibits 1 through 7 and defendants' exhibits A 
 
         through K as identified on the parties' respective exhibits 
 
         lists.
 
         
 
                                  ISSUES
 
         
 
              Pursuant to the prehearing report and the oral stipulations 
 
         of the parties at hearing, the parties stipulated that claimant 
 
         sustained an injury on July 23, 1984 which arose out of and in 
 
         the course of her employment which was the cause of temporary and 
 
         permanent disability for which claimant has been paid all 
 
         temporary total/healing period and permanent partial disability 
 
         benefits to which she is entitled.  The parties agreed that the 
 
         only issue remaining to be decided is whether claimant is 
 
         entitled to payment of certain medical costs, that is, costs for 
 
         treatment with Douglas S. Parks, M.D., at Iowa Methodist Medical 
 
                                                
 
                                                         
 
         Center and related care as care authorized by the defendants, as 
 
         care reasonable and necessary for the treatment of claimant's 
 
         condition, and as care, the costs of which are fair and 
 
         reasonable.
 
         
 
                         REVIEW OF THE EVIDENCE
 
         
 
              Claimant is a 24-year-old single woman with one child.  She 
 
         sustained burns on the right side of her face, right side of her 
 
         neck, chest and breast as well as on her stomach and the right 
 
         side of her trunk and right underarm when a broiler exploded 
 
         during the course of her work as a cook for the defendant 
 
         employer.  Immediately subsequent to the injury, claimant was 
 
         hospitalized at Trinity Regional Hospital for approximately two 
 
         months during which time Herbert Kersten, M.D., a Dr. LeValley, 
 
         and a Dr. Miller treated claimant . Claimant testified that she 
 
         received skin grafts and physical therapy intended to relieve 
 
         tightness and pulling of the scar tissue in the upper arm area. 
 
         She stated that her skin grafts did not increase right arm 
 
         mobility, but "greatly improved" the skin's appearance.
 
         
 
              Claimant expressed her belief that her face was discolored 
 
         subsequent to her burn injury and reported that she was 
 
         self-conscious about her burn following her hospital release.  No 
 
         visible scarring or discoloration was observed on claimant's face 
 
         at hearing.  Claimant reported that she could wear clothing on 
 
         the burned areas of her body only subsequent to her hospital 
 
         release, but that clothing irritated the burned areas.  She 
 
         stated that discomfort prevented her from wearing a bra.
 
         
 
              Claimant reported that she saw Ralph Cram, M.D., at the 
 
         University of Iowa Burn Unit in January, 1985.  She stated that 
 
         Dr. Cram recommended dermabrasion treatment at least two years 
 
         subsequent to her injury.  Claimant later saw Gerald P. Kealey, 
 
         M.D., at the University of Iowa Burn Unit.  She reported that Dr. 
 
         Kealey did not recommend dermabrasion as her scarring was too 
 
         deep.  He did give her names of physicians qualified to perform 
 
         dermabrasion, however.  Claimant subsequently saw Douglas Parks, 
 
         M.D., who performed tissue expansion procedures at Iowa Methodist 
 
         Hospital.  Claimant stated that the procedures were carried out 
 
         in the right lower arm, in the chest below the breast and on the 
 
         right side of her trunk in an attempt to normalize the skin's 
 
         appearance.  She agreed that all areas on which the procedures 
 
         were performed were covered with clothing save for the lower arm. 
 
         Claimant reported that the tissue expansion procedures had 
 
         increased her movement in the arm and had improved her appearance 
 
         although the effect on her appearance had not been as beneficial 
 
         as she had hoped.  She reported that the procedures had decreased 
 
         her problems with not being outgoing and that she no longer found 
 
         clothing irritating although it was still uncomfortable to wear a 
 
         bra.
 
         
 
              Claimant agreed that she had not advised defendants that she 
 
         was treating with Dr. Parks, but for a casual conversation with 
 
         her own insurance agent.  She stated that Dr. Parks' bill as well 
 
                                                
 
                                                         
 
         as the anesthesiologist's bill remain unpaid.  She agreed that 
 
         defendants had paid all Trinity Regional Hospital and University 
 
         of Iowa medical bills and agreed that she had advised the insurer 
 
         of her Trinity and University of Iowa care.
 
         
 
              Kelly Gonder identified herself as a friend of claimant and 
 
         reported that prior to her injury, claimant had been outgoing, 
 
         but subsequent to her injury, claimant's personality changed.  
 
         She reported that claimant has now "gotten better" insofar as she 
 
         is able to interact with persons other than her close friends.  
 
         She reported that claimant continues to wear long-sleeved shirts 
 
         in hot summer weather.
 
         
 
              Norman E. Moon testified that he is supervisor for workers' 
 
         compensation claims with the insurance carrier.  He reported that 
 
         the insurer had relied upon August 12, 1985 and December 18, 1985 
 
         letters of Drs. Cram and Kealey respectively stating that 
 
         claimant required no further treatment but for possible 
 
         dermabrasion.  He reported the insurer was first aware that 
 
         claimant was treating with Dr. Parks when defendants' counsel 
 
         inquired regarding mileage payments for treatment with Dr. Parks.  
 
         Moon indicated that neither claimant nor her counsel ever 
 
         contacted the insurer regarding care with Dr. Parks even though 
 
         claimant's workers' compensation claim had been filed in 
 
         September, 1986.
 
         
 
              Herbert Kersten, M.D., identified himself as a general 
 
         surgeon practicing in the Fort Dodge area since 1952.  Dr. 
 
         Kersten stated that, while hospitalized at Trinity Regional 
 
         Hospital, claimant had had contracture in the anterior fold of 
 
         the right axilla which he characterized as shrinkage of scar 
 
         tissue in front of the fold that goes from the chest to the right 
 
         arm.  The arm was manipulated and stretched and then dressed away 
 
         from the body in order to minimize the web formation.  Dr. 
 
         Kersten stated that such contractures are usually but not always 
 
         permanently controllable.  Dr. Kersten stated that, after 
 
         claimant's skin grafts had healed, claimant had normal arm 
 
         motion, but needed to stretch the arm tissue uncomfortably to 
 
         achieve that motion.  Dr. Kersten testified that, following 
 
         claimant's graft, she had minimal scarring on her face and neck, 
 
         but did have significant scarring on the chest wall and arm.  Dr. 
 
         Kersten reported that claimant had second degree burns on her 
 
         face, neck and arm and extensive third degree burns on the side 
 
         of her chest and near the breast.  Dr. Kersten stated that a 
 
         graft over a third degree burn is essentially numb, but does 
 
         produce permanent impairment of sensation.
 
         
 
              Dr. Kersten characterized claimant's tissue expansion 
 
         procedure as corrective plastic surgery primarily done to correct 
 
         impaired function and not primarily done for appearance's sake.
 
         
 
              Dr. Kersten reported that he had examined claimant on 
 
         January 9, 1989.  He reported that claimant's chest area 
 
         extending under the arm and into the back was "close to normal 
 
         except for appearance."  He stated there was no visible 
 
                                                
 
                                                         
 
         contracture, but minimal scarring.  He characterized the risk of 
 
         future contracture as a "diminishing probability as time goes 
 
         by."  Dr. Kersten stated that the tissue expansion procedure does 
 
         not really improve the skin's appearance, but for eliminating the 
 
         underlying contracture so that the skin adapts a more normal 
 
         contour.  Dr. Kersten opined that, if the record shows that 
 
         contracture was again trying to form, the tissue expansion 
 
         procedure was justified.  He opined that severe burns permanently 
 
         change the body's appearance and thereby affect an individual's 
 
         self-image and confidence.  He stated it was appropriate to work 
 
         with those changes in dealing medically with a burn victim.
 
         
 
              On August 12, 1985, Albert E. Cram, M.D., reported that 
 
         under the AMA Guides to the Evaluation of Permanent Impairment 
 
         for skin disorders, claimant had a class 2 impairment 
 
         representing a 12% permanent impairment of the whole person.  He 
 
         stated he did not anticipate any additional or future surgical 
 
         procedure, but had prescribed an overhead pulley system to help 
 
         claimant exercise the burn contracture in the axilla which 
 
         contracture he characterized as extremely mild.  On January 31, 
 
         1985, he recommended claimant be considered for dermabrasion two 
 
         years post surgery.
 
         
 
              On December 18, 1985, Gerald P. Kealey, M.D., Assistant 
 
         Professor of Surgery at the University of Iowa, reported that 
 
 
 
                         
 
                                                         
 
         claimant's burn injury to the right anterolateral thorax was 
 
         fully healed and that she had no loss of motion of the right 
 
         shoulder. He reported that she had no scar contracture or loss of 
 
         function of the right upper extremity, but did have some 
 
         hypopigmentation of the grafted area over the right breast and 
 
         right anterior chest.  He stated that claimant had no complaints 
 
         of itching or dryness and that there was no evidence of 
 
         hypertrophic scarring. Dr. Kealey reported claimant as wishing to 
 
         consider dermabrasion for cosmesis some time in the future.
 
         
 
              On November 19, 1984, Dr. Kersten reported that claimant's 
 
         major sequelae of her burns were scarring of the chest wall, arm, 
 
         breast and contracture of the right axillary fold.  He reported 
 
         that her graft donor sites had healed well with faint scarring 
 
         which would be permanent.  The first and second degree burns on 
 
         the right side of her face and neck were reported as having 
 
         healed with very faint residual scarring that may fade further, 
 
         but which will leave some permanent scarring.  He reported that 
 
         the deeper burns on the right anterior chest, right breast, right 
 
         axilla and right inner and anterior arm were all well healed with 
 
         considerable cosmetic scarring and with the development of an 
 
         early contracture along the right axillary fold.  He then thought 
 
         that such would require revision the following Spring.  On 
 
         January 29, 1985, Dr. Kersten advised claimant that she should 
 
         wait for her scars to stop shrinking before undergoing skin 
 
         grafting and revision.  He stated, "[t]he bands which are forming 
 
         can then be correct [sic]."
 
         
 
              On November 23, 1987, Dr. Parks of Plastic-Reconstructive, 
 
         Cosmetic & Hand Surgery, reported that claimant had significant 
 
         residual scarring on her chest, arm, and back.  He further 
 
         reported the following:
 
         
 
              She originally had some skin grafting done but now she has 
 
              significant residual scarring on her chest, arms and back. 
 
              At this time she presents to have this burn revised.
 
         
 
              I counselled her in the various techniques available and at 
 
              this time tissue expansion under the normal skin next to the 
 
              burn area with expansion of the skin and excising the burn 
 
              and pulling this normal skin up seemed most appropriate in 
 
              her case.  This she desires to have done to reconstruct her 
 
              chest wall to a more normal looking appearance.  This should 
 
              allow her to function more effectively.
 
         
 
              In an office note of March 10, 1988, Dr. Parks stated:
 
         
 
              ...the object is to get normal looking skin to cover most of 
 
              her back and side so she would look better in her clothes 
 
              and feel better.
 
         
 
              In a note to United Fire & Casualty Company dated November 
 
         10, 1987, Dr. Parks stated the following in response to Norman E. 
 
         Moon's request that he advise who had referred claimant to him as 
 
         a patient:
 
                                                
 
                                                         
 
         
 
              Pt was referred by my office manager, as her surgeon in Iowa 
 
              City was gone.
 
         
 
              Medical bills outstanding are apparently a bill of 
 
         Associated Anesthesiologists in the amount of $930.00; a bill of 
 
         Dr. Parks in the amount of $5,297.50; and, bills of Iowa 
 
         Methodist Medical Center in the amounts of $30.90 and $3,477.25.  
 
         On claimant's exhibit list, claimant lists an Iowa Methodist 
 
         Medical Center bill in the amount of $2,100.36.  No exhibit 
 
         documenting such charge was submitted into evidence, however.  
 
         Claimant, by way of her exhibit 11, states that she has traveled 
 
         2,750 miles to Des Moines as expenses in this matter.
 
         
 
                       APPLICABLE LAW AND ANALYSIS
 
         
 
              Our only issue is whether claimant is entitled to payment of 
 
         her medical costs and medical mileage expenses related to the 
 
         tissue expansion procedures which Dr. Parks performed.
 
         
 
              Section 85.27 provides that employers furnish employees 
 
         reasonable surgical, medical, and hospital services and supplies 
 
         when an injury arises out of and in the course of the employment. 
 
         Medical treatment provided need not reduce impairment or 
 
         disability.  Zimmerman v. L. L. Pelling Co., II Iowa Industrial 
 
         Commissioner Report, 462, 463 (App. Decn. 1982).  The section 
 
         also provides that claimant shall be paid reasonable and 
 
         necessary transportation expenses incurred in the course of 
 
         receiving such medical services.  The employer has the right to 
 
         chose the care. "The employee has the burden of showing the 
 
         treatment is related to the injury.  Proof of the necessity of 
 
         the treatment may be found in the claimant's own testimony."  
 
         Lawyer and Higgs, Iowa Workers' Compensation--Law and Practice, 
 
         section 15-1.
 
         
 
              Where a designated physician refers a claimant to another 
 
         physician, the designated physician acts as the employer's agent. 
 
         It is not necessary then for defendants to authorize such 
 
         referral.  See Kittrell v. Allen Memorial Hospital, 34th Biennial 
 
         Report of the Iowa Industrial Commissioner, 164 (1979).
 
         
 
              Webster's Ninth New Collegiate Dictionary defines 
 
         "reasonable" as agreeable to reason; not extreme or excessive; 
 
         moderate; fair.
 
         
 
              Defendants first contend that claimant's treatment with Dr. 
 
         Parks was not reasonable and necessary.  We note that section 
 
         85.27 expressly states only that the treatment must be 
 
         reasonable, not that such be necessary.  Nor can it be inferred 
 
         from the section or from the common definition of reasonable that 
 
         treatment must be absolutely necessary before such is permissible 
 
         as reasonable treatment.  Claimant reports that the tissue 
 
         expansion procedure which Dr. Parks performed increased her arm 
 
         movement. Objective records would suggest that claimant received 
 
         relatively little, if any, benefit by way of increased arm 
 
                                                
 
                                                         
 
         movement given the extremely mild contracture which Dr. Cram 
 
         reported in August of 1985 and the lack of any loss of motion in 
 
         either the right shoulder or the right upper extremity which Dr. 
 
         Kealey reported in December 1985.  Hence, it appears that the 
 
         real benefit, if any, derived from the tissue expansion procedure 
 
         related to claimant's appearance and self-image.  Indeed, while 
 
         Dr. Kersten testified that the tissue expansion procedure was 
 
         primarily corrective plastic surgery and to increase claimant's 
 
         arm movement, Dr. Parks who performed the tissue expansion 
 
         procedure apparently felt that the primary purpose was for 
 
         cosmesis.  Dr. Parks stated, "The objective is to get normal 
 
         looking skin to cover most of her back and side so she would look 
 
         better in her clothes and feel better."
 
         
 
              Defendants apparently assert that if the primary purpose was 
 
         cosmesis, the treatment was not reasonable.  They appear to rely 
 
         upon the fact that the areas affected can generally be covered 
 
         with clothing.  Defendants argument is not well taken.  A sense 
 
         that one's body appears normal and need not be constantly covered 
 
         is generally important to most individuals' well being.  Dr. 
 
         Kersten reported that changes in physical appearance and 
 
         resulting changes in self-image and individual confidence were 
 
         typical sequelae following burn injuries.  He opined that it was 
 
         appropriate [medically] to work with such changes.  Both claimant 
 
         and Kelly Gonder testified that claimant had a decrease in 
 
         self-confidence and decreased ability to interact with 
 
         individuals other than close personal friends following her burn 
 
         injury.  Both reported improvement in claimant's self-confidence 
 
         and in her ability to interact interpersonally following the 
 
         tissue expansion procedures.  Such occurred even though the 
 
         results of the procedure were not cosmetically as effective as 
 
         claimant had hoped.  Hence, the tissue expansion procedure 
 
         benefited claimant overall in that it increased her 
 
         self-perception of her physical appearance and thereby increased 
 
         her psychic well-being.
 
         
 
              Additionally, claimant reported that she had had irritation 
 
         of her burned skin from her clothing following her injury.  She 
 
         reported that this improved subsequent to the tissue expansion 
 
         procedure.  While Dr. Kersten reported that third degree burn 
 
         areas are essentially numb, we cannot say that it is not possible 
 
         that third degree burn areas would be irritated through contact 
 
         with clothing.  Therefore, the tissue expansion procedure was 
 
         reasonable treatment for such irritation.
 
         
 
              Defendants also argue that the tissue expansion procedure 
 
         was not authorized.  Mr. Moon testified that he relied upon Dr. 
 
         Kealey's and Dr. Cram's opinions that the only potential 
 
         procedure which claimant might undergo would be dermabrasion.  
 
         Claimant testified that Dr. Kealey did not recommend 
 
         dermabrasion.  He did report her desire to have such treatment, 
 
         however, and did give her the name of surgeons who perform such.  
 
         As defendants correctly note, Dr. Cram had indicated that 
 
         dermabrasion would be appropriate.  Additionally, Dr. Kersten had 
 
         suggested in November, 1984, that revision for contracture would 
 
                                                
 
                                                         
 
         be necessary the following Spring.  Nothing in the record 
 
         indicates that defendants expressly advised claimant that they 
 
         would not permit treatment either by way of revision of the 
 
         contracture or by way of dermabrasion primarily for cosmesis.  
 
         Dr. Kealey, whom defendants apparently authorized claimant to 
 
         see, gave claimant Dr. Parks' name.  In the absence of an 
 
         expressed advisement of defendants that cosmesis treatment was 
 
         not authorized, Dr. Kealey's reference to Dr. Parks may be 
 
         considered a treating physician's referral to another physician.  
 
         Dr. Parks elected tissue expansion procedure over dermabrasion as 
 
         a means of cosmetically improving claimant's appearance.  The 
 
         right to chose care does not extend to defendants the right to 
 
         substitute their nonmedical judgment as to appropriate treatment 
 
         for the judgment of a qualified and authorized physician.  We 
 
         find the tissue expansion procedure authorized as Dr. Kealey 
 
         referred claimant to Dr. Parks and Dr. Parks elected to perform 
 
         tissue expansion procedure over dermabrasion in order to achieve 
 
         the contemplated result of improving claimant's overall 
 
         appearance and level of functioning.
 
         
 
              Defendants also contended that the cost of claimant's tissue 
 
         expansion procedure was not fair and reasonable.  While minimal 
 
         evidence was presented on that point, that evidence presented 
 
         suggests that the costs were fair and reasonable and typical of 
 
         costs in the state of Iowa for similar procedures.  No contrary 
 
         evidence was offered.  The costs are found to be fair and 
 
         reasonable and defendants are ordered to pay those costs, but for 
 
         the Iowa Methodist Medical Center cost of $2,100.36 which cost is 
 
         not supported by appropriate documentation.
 
         
 
                              FINDINGS OF FACT
 
         
 
              WHEREFORE, IT IS FOUND:
 
 
 
                       
 
                                                         
 
         
 
              Claimant sustained burns on the right face, right neck, 
 
         chest and breast as well as her stomach and her right trunk and 
 
         right underarm when a broiler exploded during the course of her 
 
         employment as a cook for defendants.
 
         
 
              Claimant was hospitalized for two months during which time 
 
         she received skin grafts and physical therapy intended to relieve 
 
         tightness and pulling of the scar tissue of the upper arm area.
 
         
 
              Claimant's face and neck burns were first and second degree 
 
         burns; her other burns were second and third degree burns.
 
         
 
              Claimant has no readily discernible scarring or 
 
         discoloration about her face or neck.
 
         
 
              Subsequent to her burn injury, clothing irritated the burned 
 
         areas on claimant's body.
 
         
 
              Claimant had an extremely mild contracture in the anterior 
 
         fold of the right axilla.
 
         
 
              Claimant had no loss of motion in the right upper extremity 
 
         or the right shoulder on account of her mild contracture.
 
         
 
              Claimant did experience pain in achieving normal range of 
 
         motion.
 
         
 
              Subsequent to her burn injury, claimant was self-conscious 
 
         about her appearance and withdrew from interpersonal interaction 
 
         with all but close friends.
 
         
 
              Changes in physical appearance and resulting change in 
 
         self-image and confidence are normal sequelae following a burn 
 
         injury.
 
         
 
              It is appropriate to treat such changes medically.
 
         
 
              Dr. Kersten recommended revision of claimant's contracture 
 
         in November, 1984.
 
         
 
              Dr. Cram opined that dermabrasion for cosmesis would be 
 
         appropriate approximately two years subsequent to claimant's 
 
         injury.
 
         
 
              Dr. Kealey also reported claimant wished to consider 
 
         dermabrasion for cosmesis some time in the future.
 
         
 
              Dr. Kealey supplied claimant with names of physicians 
 
         capable of performing dermabrasion.
 
         
 
              Dr. Parks' name was among those Dr. Kealey supplied 
 
         claimant.
 
         
 
              Dr. Kealey was an authorized physician.
 
                                                
 
                                                         
 
         
 
              Defendants did not expressly instruct claimant that she 
 
         could not undergo dermabrasion for cosmesis.
 
         
 
              Dr. Kealey's supplying claimant with Dr. Parks' name was a 
 
         referral to a subsequent physician by an authorized physician.
 
         
 
              Dr. Parks made a medical determination that tissue expansion 
 
         was more appropriate than dermabrasion for claimant's condition.
 
         
 
              Defendants authorized claimant's tissue expansion 
 
         procedure.
 
         
 
              Costs with Associated Anesthesiologists, with Dr. Parks, and 
 
         with Iowa Methodist Medical Center as well as medical mileage 
 
         costs are within the norm for such costs within the state of 
 
         Iowa.
 
         
 
                                CONCLUSIONS OF LAW
 
         
 
              THEREFORE, IT IS CONCLUDED:
 
         
 
              Claimant has established that her treatment with Dr. Parks 
 
         and related treatment was reasonable and necessary treatment for 
 
         her burn injury; was authorized by defendants; and, that the 
 
         costs of such treatment were fair and reasonable.
 
         
 
              Claimant has established that she is entitled to payment of 
 
         costs with Associated Anesthesiologists, with Dr. Parks and with 
 
         Iowa Methodist Medical Center, in the amounts listed in the order 
 
         below.
 
         
 
              Claimant has established that she is entitled to payment at 
 
         the appropriate rate for 2,750 miles traveled in the course of 
 
         treating her work-related injury with tissue expansion 
 
         procedure.
 
         
 
                                   ORDER
 
         
 
              THEREFORE, IT IS ORDERED:
 
         
 
              Defendants pay the following medical costs:
 
              Associated Anesthesiologists                $ 930.00
 
              Douglas Parks, M.D.                         5,297.50
 
              Iowa Methodist Medical Center               3,508.15
 
         
 
              Defendants pay claimant mileage expenses totalling two 
 
         thousand seven hundred and fifty (2,750) miles at the rate of 
 
         twenty-four cents ($.24) per mile totalling six hundred sixty and 
 
         00/100 dollars ($660.00).
 
         
 
              Defendants pay costs pursuant to Division of Industrial 
 
         Services Rule 343-4.33.
 
         
 
              Defendants file a final payment report when this award is 
 
                                                
 
                                                         
 
         paid.
 
         
 
              Signed and filed this 29th day of March, 1989.
 
         
 
         
 
         
 
         
 
         
 
         
 
                                         HELENJEAN WALLESER
 
                                         DEPUTY INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. William H. Habhab
 
         Attorney at Law
 
         1216-A Central Avenue
 
         Fort Dodge, Iowa  50501
 
         
 
         Mr. Neven J. Mulholland
 
         Attorney at Law
 
         600 Boston Centre
 
         P.O. Box 1396
 
         Fort Dodge, Iowa  50501
 
         
 
         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                
 
 
            
 
 
 
 
 
                             
 
                                  
 
                                              2505, 2700
 
                                              Filed March 29, 1989
 
                                              HELENJEAN WALLESER
 
         
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         DEANA ASKELSON,
 
         
 
              Claimant,
 
         
 
         vs.                                         File No. 771130
 
         
 
         J & M INC. OF BADGER,                   A R B I T R A T I O N
 
         
 
              Employer,                              D E C I S I O N
 
         
 
         and
 
         
 
         UNITED FIRE & CASUALTY COMPANY,
 
         
 
              Insurance Carrier,
 
              Defendants.
 
         
 
         
 
         
 
         2505, 2700
 
         
 
              Claimant sustained third degree burns on her right trunk, 
 
         right underarm and on and about her right chest and breast which 
 
         burns arose out of and in the course of her employment.  
 
         Subsequent to appropriate hospitalization and medical treatment 
 
         including skin grafts and physical therapy, claimant had 
 
         significant scarring in those areas.  She also had extremely mild 
 
         contracture in the anterior fold of the right axilla.  Claimant 
 
         underwent tissue expansion procedure to improve the appearance of 
 
         the burned area.  Defendants argued that such procedure was not 
 
         reasonable and necessary care and was not authorized.  One 
 
         physician had advised dermabrasion for cosmesis while another 
 
         authorized physician had reported claimant's desire for 
 
         dermabrasion for cosmesis and had given claimant the names of 
 
         physicians who could perform dermabrasion.  The recommended 
 
         physician with whom claimant elected to treat chose to perform 
 
         the tissue expansion rather than dermabrasion.  Held that 
 
         claimant's treatment for cosmesis was reasonable treatment in 
 
         that it improved claimant's self-perception of her physical 
 
         appearance and permitted her to better interact interpersonally, 
 
         areas in which she had experienced problems subsequent to her 
 
         burn injury.  Held that defendants who were aware of the 
 
         recommendation for dermabrasion and who had not expressly advised 
 
         claimant that they would not permit that procedure could not 
 
         argue they had not authorized the tissue expansion procedure when 
 
         the physician whom claimant saw on referral from an authorized 
 
         physician elected to perform that procedure to accomplish the 
 
                                                
 
                                                         
 
         same result as had been contemplated by the recommended 
 
         dermabrasion.  Held on the limited evidence available that the 
 
         costs of claimant's tissue expansion procedure were within the 
 
         norm in the state of Iowa and were fair and reasonable costs.
 
         
 
         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                
 
 
        
 
 
 
 
 
        
 
                                            2505, 2700
 
                                            Filed March 29, 1989
 
                                            HELENJEAN WALLESER
 
        
 
                    BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
        
 
        
 
        DEANA ASKELSON,
 
        
 
            Claimant,
 
        
 
        vs.                                               File No. 
 
        771130
 
        
 
        J & M INC. OF BADGER,                             A R B I T R A 
 
        T I O N
 
        
 
            Employer,                                    D E C I S I O 
 
        N
 
        
 
        and
 
        
 
        UNITED FIRE & CASUALTY COMPANY,
 
        
 
            Insurance Carrier,
 
             Defendants.
 
             
 
        
 
        
 
        2505, 2700
 
        
 
             Claimant sustained third degree burns on her right trunk, 
 
             right underarm and on and about her right chest and breast which 
 
             burns arose out of and in the course of her employment. 
 
             Subsequent to appropriate hospitalization and medical treatment 
 
             including skin grafts and physical therapy, claimant had 
 
             significant scarring in those areas. She also had extremely mild 
 
             contracture in the anterior fold of the right axilla. Claimant 
 
             underwent tissue expansion procedure to improve the appearance of 
 
             the burned area. Defendants argued that such procedure was not 
 
             reasonable and necessary care and was not authorized. One 
 
             physician had advised dermabrasion for cosmesis while another 
 
             authorized physician had reported claimant's desire for 
 
             dermabrasion for cosmesis and had given claimant the names of 
 
             physicians who could perform dermabrasion. The recommended 
 
             physician with whom claimant elected to treat chose to perform 
 
             the tissue expansion rather than dermabrasion. Held that 
 
             claimant's treatment for cosmesis was reasonable treatment in 
 
             that it improved claimant's self-perception of her physical 
 
             appearance and permitted her to better interact interpersonally, 
 
             areas in which she had experienced problems subsequent to her 
 
             burn injury. Held that defendants who were aware of the 
 
             recommendation for dermabrasion and who had not expressly advised 
 
             claimant that they would not permit that procedure could not 
 
             argue they had not authorized the tissue expansion procedure when 
 
             the physician whom claimant saw on referral from an authorized 
 
             physician elected to perform that procedure to accomplish the 
 
             same result as had been contemplated by the recommended 
 
             dermabrasion. Held on the limited evidence available that the 
 
             costs of claimant's tissue expansion procedure were within the 
 
             norm in the state of Iowa and were fair and reasonable costs.
 
             
 

 
        
 
 
 
 
 
        
 
 
            
 
 
 
 
 
 
 
 
 
                      
 
                      BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         MILLIE DRAPER, n/k/a BRUHN,
 
         
 
              Claimant,                              File Nos. 771230
 
                                                               806153
 
         vs.
 
                                                   A R B I T R A T I O N
 
         WILSON FOODS CORPORATION,
 
                                                      D E C I S I O N
 
              Employer,
 
              Self-Insured,                              F I L E D
 
              Defendant.
 
                                                        MAY 24 1989
 
         
 
                                                    INDUSTRIAL SERVICES
 
         
 
         
 
                             STATEMENT OF THE CASE
 
         
 
              These are proceedings in arbitration brought by claimant 
 
         Millie Draper against self-insured defendant employer Wilson 
 
         Foods Corporation to recover benefits under the Iowa Workers' 
 
         Compensation Act as the result of injuries sustained on May 25, 
 
         1984 (771230) to the left shoulder and on May 8, 1985 (806153) to 
 
         the right shoulder.  This matter came on for hearing before the 
 
         undersigned in Storm Lake, Iowa, on January 3, 1989.  The matter 
 
         was considered fully submitted at the close of hearing.  Both 
 
         parties subsequently filed briefs.
 
         
 
              The record in the proceeding consists of claimant's exhibits 
 
         1 through 63, defendant's exhibit A, and the testimony of the 
 
         following witnesses:  Claimant, Dan Hasty, Ron Libolt, Tim Bruhn 
 
         and Dwayne Aduddell.
 
         
 
                                      ISSUES
 
         
 
              Pursuant to the prehearing report submitted by the parties 
 
         and approved by the deputy in case number 806153, the parties 
 
         have stipulated:  To the existence of an employment relationship 
 
         at the time of the injury; that claimant sustained an injury on 
 
         May 8, 1985, arising out of and in the course of that employment; 
 
         that the injury caused temporary disability of two weeks plus two 
 
         days; that the appropriate rate of weekly compensation is 
 
         $195.33; that defendant is entitled to credit for 2 weeks 2 days 
 
         of temporary total disability and 12.5 weeks of permanent partial 
 
         disability voluntarily paid claimant at the stipulated rate.
 
         
 
              The following issues in case number 806153 are presented for 
 
         determination:  Whether the work injury caused permanent 
 
         disability; the extent of claimant's entitlement to compensation 
 
         for permanent disability, if liability be found; whether 
 
                                                
 
                                                         
 
         claimant's disability, if any, is a scheduled member disability 
 
         or an industrial disability to the body as a whole; the extent of 
 
         claimant's entitlement to medical benefits under Iowa Code 
 
         sections 85.27 and 85.39; taxation of costs.
 
         
 
              In file number 771230, the parties stipulated:  To the 
 
         existence of an employment relationship at the time of the 
 
         injury; that claimant sustained an injury on May 25, 1984 arising 
 
         out of and in the course of that employment; that the injury 
 
         caused temporary disability during a period of recovery; that the 
 
         appropriate rate of weekly compensation is $195.33; that 
 
         defendant is entitled to credit for 56 5/7 weeks of temporary 
 
         total disability and 67.5 weeks of disputed compensation paid 
 
         voluntarily to claimant at the stipulated rate.
 
         
 
              In case number 771230, the following issues are presented 
 
         for determination:  Whether the work injury caused permanent 
 
         disability; the extent of claimant's entitlement to temporary 
 
         total disability or healing period benefits (claimant contending 
 
         that the healing period ended on January 5, 1987 and employer 
 
         contending that the healing period ended July 7, 1986); the 
 
         extent of claimant's entitlement to compensation for permanent 
 
         disability; whether permanent disability, if found, is a 
 
         scheduled member disability or an industrial disability to the 
 
         body as a whole; the commencement date for permanent partial 
 
         disability, if awarded; the extent of claimant's entitlement to 
 
         medical benefits under Iowa Code sections 85.27 and 85.39; 
 
         taxation of costs.
 
         
 
                              REVIEW OF THE EVIDENCE
 
         
 
              Claimant testified that she was born on February 3, 1955; 
 
         therefore, she had nearly reached her 34th birthday by the date 
 
         of hearing.  She indicated that she graduated from high school in 
 
         1973 with very good grades.  Since then, she has held positions 
 
         with only two employers.  She worked approximately six years for 
 
         a farm equipment manufacturer, being engaged in factory chores 
 
         such as painting and assembly.  She resigned that employment to 
 
         begin work with defendant Wilson Foods effective June 7, 1979.
 
         
 
              Wilson Foods is a meat packing company that operates a pork 
 
         plant in Cherokee, Iowa.  Claimant began her work boxing hot 
 
         dogs, but after three months was transferred to the kill floor 
 
         where she worked until 1986.  Her hours varied from as few as 36 
 
         hours per week during a business downturn in 1983 to as many as 
 
         60 per week. On the kill floor, claimant cleaned chitterlings, 
 
         tied and washed guts, and for the last three to four years worked 
 
         as a middle gut puller.  This involved pulling a membrane apart 
 
         approximately 125 times per hour.  The motion used is not unlike 
 
         a swimmer doing the breast stroke.
 
         
 
              Claimant developed pain in the left shoulder on May 25, 1984 
 
         while pulling guts.  The pain began in her shoulder blade then 
 
         moved to the front of the shoulder joint and down her upper arm, 
 
         but also into the body toward her breastbone.  She first saw the 
 
                                                
 
                                                         
 
         plant nurse, then was referred to Keith Garner, M.D., the company 
 
         physician, who diagnosed muscle strain.
 
         
 
              Dr. Garner eventually referred claimant to John Connolly, 
 
         M.D. She was seen by Dr. Connolly on August 2, 1984.  Dr. 
 
         Connolly wrote on that date:
 
         
 
              When I examined her, she was a cooperative young lady with 
 
              no evidence of deformity in the shoulder.  The shoulder 
 
              joint was tender on external rotation and abduction, but she 
 
              had no signs of rotator cuff tendonitis; that is, she had no 
 
              pain on resisted external rotation and abduction.  I did, 
 
              however, feel on palpating and maneuvering the left shoulder 
 
              that I could subluxate the head of the humerus anteriorly.  
 
              This caused a click and reproduced her symptoms, and, in 
 
              fact, brought tears to her eyes.
 
         
 
              I think your diagnosis was correct, that she does have 
 
              anterior shoulder subluxation.  This is not a muscular 
 
              problem and I do not think would be amenable to merely 
 
              exercises.  I think she has stretched out the front of the 
 
              glenoid labrum and this needs to be repaired.  I discussed 
 
              this with her and she wanted to go ahead and have something 
 
              done with it as soon as possible since she is so 
 
              symptomatic. She says the popping out is occurring at least 
 
              once or twice per day, so we will have her admitted to the 
 
              hospital next week and perform the shoulder repair on 
 
              Tuesday.  I will keep you informed of her progress.
 
         
 
              Dr. Connolly performed surgery on claimant's left shoulder 
 
         on August 7, 1984.  The surgery was known as a Bankart repair of 
 
         the left shoulder based on a diagnosis of osteochondritis 
 
         dissecans, left humeral head, anterior subluxation, left 
 
         shoulder.  Dr. Connolly's surgical notes show:
 
         
 
              ... A shoulder-strap incision, extending from just lateral 
 
              to the coracoid and over the top of the shoulder extending 
 
              for approximately 4 inches, was completed.  The skin and 
 
              subcutaneous tissues were sharply incised and hemostasis was 
 
              maintained with electrocautery.  Deltoid was displaced 
 
              laterally with a thin slip displaced medially.  The 
 
              deltapectoral was incised longitudinally and the coracoid 
 
              process was identified.  The conjoined tendon was released 
 
              at the coracoid process and the anterior aspect of the 
 
              shoulder joint was identified.  Subscapularis was released 
 
              off its insertion into the lesser tuberosity and the capsule 
 
              was incised and separated from the subscapularis.  
 
              Examination of the inner aspect of the joint revealed the 
 
              following pathological changes:  l) There was a 2 cm. x 1 
 
              cm. loose, articular cartilage piece which was removed from 
 
              the joint. There was a 2xl cm. area over the 
 
              anterior-superior aspect of the humeral head which was 
 
              covered with fibrocartilage but depressed approximately 3mm.  
 
              There was a large Bankart lesion over the anterior aspect of 
 
              the glenoid.  Following this, a Bankart repair was done 
 
                                                
 
                                                         
 
                   utilizing the Hall drill to place two holes in the anterior 
 
              aspect of the glenoid.  2-0 Tevdek sutures were placed here 
 
              and the capsule was tied snuggly down to the arm so as to 
 
              limit external rotation at neutral.  Subscapularis was 
 
              imbricated over this and the arm was noted to be unable to 
 
              externally rotate past neutral.
 
         
 
              Upon final discharge, Dr. Connolly's discharge summary makes 
 
         reference to a diagnosis of recurrent anterior subluxation of the 
 
         left shoulder with osteochondritis dissecans of the left humeral 
 
         head.  The surgical procedure is referred to as Bankart repair 
 
         with imbrication of the subscapularis tendon on the left side. 
 
         The wound was healing well and claimant was discharged with 
 
         follow-up in one week recommended.
 
         
 
              Claimant described the incision as located in the crease 
 
         where the arm meets the body and noted that Dr. Connolly 
 
         prescribed exercises such as touching both arms to a clasp behind 
 
         her head, although she was unable to do so.
 
         
 
              Claimant also testified that she believes her shoulder has 
 
         not improved in the four years following surgery.
 
         
 
              In a letter to Dr. Garner dated February 28, 1985, Dr. 
 
         Connolly indicated that claimant should be able to return to work 
 
 
 
 
 
                             
 
                                                         
 
         within the next month to see if the shoulder could hold up and 
 
         anticipated that claimant would have a permanent functional 
 
         impairment to the shoulder of 15%.  Following further complaints, 
 
         Dr. Connolly wrote again to Dr. Garner on July 25, 1985, 
 
         indicating that claimant at that time still wished to return to 
 
         work, that her left shoulder was continuing to improve, and 
 
         recommending that claimant return to work on a half-day basis.
 
         
 
              Claimant also saw Scott B. Neff, D.O., from March, 1986 
 
         until April, 1987.  Dr. Neff's letter to Dr. Garner of March 24, 
 
         1986 indicated that claimant was having myofascial pain in the 
 
         right scapula and posterior aspect, but that he would not produce 
 
         any symptoms or signs of instability.  He found claimant normal 
 
         on the right side with muscle soreness and no impingement.  He 
 
         noted that claimant was at that time working a maximum of five 
 
         hours per day. Dr. Neff mentioned his intent to prescribe a TENS 
 
         unit, which he eventually did.  He further noted that "job change 
 
         might be a good idea."  Claimant continued working part-time 
 
         until May 22, 1986, when Dr. Neff took her off work because of 
 
         continued myofascial soreness; Dr. Neff found crepitus with 
 
         forward flexion and extension.
 
         
 
              Dr. Neff's letter to Dr. Garner of June 16, 1986 noted that 
 
         CAT scan and arthrogram show postsurgical changes with no 
 
         evidence of any surgical lesion.  He was of the view that 
 
         claimant was certainly having muscular soreness with job change 
 
         and position change, but felt this should be temporary.  Dr. Neff 
 
         expressed the view that claimant had muscle soreness on the right 
 
         also.  He noted flattening along the head of the left humerus as 
 
         compatible with the previous dislocation and recommended a 
 
         restriction from external rotation on the left side.
 
         
 
              Dr. Neff's letter of June 23, 1986 noted claimant's right 
 
         shoulder had a full range of motion with minimal symptoms, noted 
 
         also that the left arm showed postsurgical changes, and released 
 
         claimant to work the next Monday (a standard calendar shows this 
 
         to be June 30, 1986), but noting further that "it would be a good 
 
         idea for her to avoid a job which entails repetitive 
 
         time-after-time similar occupation."
 
         
 
              Claimant was also seen on June 23, 1986 for a functional 
 
         evaluation of the left shoulder by Thomas W. Bower, L.P.T.  Mr. 
 
         Bower noticed that claimant demonstrated a markedly reduced left 
 
         upper extremity strength with normal strength in the other 
 
         extremities.  With reaching, claimant was able to push overhead a 
 
         weight of only 10 pounds.  His summary:
 
         
 
              It appears this patient is going to be markedly limited in 
 
              her activities [sic] that require greater than 70 to 75 
 
              degrees of shoulder elevation.  This is going to markedly 
 
              restrict the amount of weight or repetitious activity that 
 
              she can perform above this range of motion.  She should 
 
              have, in my opinion, no difficulty in performing activities 
 
              at waist height.  It appears, again in my opinion that the 
 
              activities she was performing prior to her surgery, should 
 
                                                
 
                                                         
 
                   present no difficulties.
 
         
 
              I would establish a weight maximum for lifting of 45 pounds 
 
              as well as it is performed at no higher level than 33 
 
              inches. Overhead work should be excluded completely from any 
 
              job description.  Pushing and pulling appears not to be a 
 
              restrictive quality.
 
         
 
              I have advised the patient that she should be able to 
 
              perform those duties as long as they are at waist height.  
 
              Whether repetitious activity at high speed work will cause 
 
              problems, may have to be evaluated in the future.
 
         
 
              On June 30, 1986, Dr. Neff rated claimant's impairment of 
 
         the left shoulder at eight percent of the left upper extremity. 
 
         However, Dr. Neff saw claimant again on October 20, 1986, and 
 
         found that claimant's shoulder had become markedly worse with 
 
         significant restriction of motion.  Claimant had a definite 
 
         tenderness over the subacromial bursa.  He considered the 
 
         shoulder definitely abnormal and recommended a range of motion 
 
         treatment of the left shoulder under anesthetic to lyse 
 
         adhesions.
 
         
 
              A range of motion under anesthetic and intraoperative 
 
         arthrogram using fluoroscopy was performed by Dr. Neff on October 
 
         23, 1986.  Unfortunately, motion obtained was minimal.  Dr. Neff 
 
         wrote Dr. Garner on November 20, 1986, noting that even though he 
 
         had tried hard, he was unable to break or free or lyse any of the 
 
         adhesions about the left shoulder.  Dr. Neff noted that he did 
 
         not believe claimant's situation was improvable and that it 
 
         certainly had not changed since the original shoulder surgery.
 
         
 
              Dr. Neff wrote to Dr. Garner again on January 5, 1987 after 
 
         seeing claimant again for follow-up.  He believed at that time 
 
         that claimant had reached a stable situation with regard to the 
 
         left shoulder and further improvement was unlikely.  He 
 
         recommended that the ]eft arm be used at or below shoulder level. 
 
         With regard to claimant's right shoulder, he indicated that 
 
         claimant was having more and more difficulty especially because 
 
         of the necessity to lift boxes above shoulder height and do most 
 
         of the work with the right shoulder.  He recommended that 
 
         claimant continue working, and noted that one or both arms should 
 
         be used at or below shoulder height.  On January 12, 1987, Dr. 
 
         Neff wrote Dr. Garner again, opining that claimant had sustained 
 
         a 15% impairment to the left upper extremity as a result of her 
 
         shoulder surgery and could not be expected to significantly 
 
         improve.  Dr. Neff characterized his rating as "permanent."  
 
         However, Dr. Neff wrote again in a subsequent undated letter 
 
         noting that Dr. Garner had understandable confusion about the 
 
         earlier rating and noted that based on Mr. Bower's further range 
 
         of motion studies and Cybex curves, he opined that claimant now 
 
         had a 27% impairment to the left upper extremity which was "not 
 
         convertible" to a body as a whole rating.
 
         
 
              Dr. Neff also wrote with Mr. Bower to claimant's attorney on 
 
                                                
 
                                                         
 
         January 14, 1987, noting that claimant's functional capacity 
 
         evaluation demonstrated a 5% impairment to the right upper 
 
         extremity and a 27% impairment to the left upper extremity. 
 
         Further:  "[t]hese would be specific scheduled members and would 
 
         not be converted into a body as a whole since the injury itself 
 
         does not encompass the body as a whole."  On April 27, 1987, Dr. 
 
         Neff rather confusingly reiterated the permanent impairment "as 
 
         stated in the communication of 12 January 1987."  If it was truly 
 
         his intent to reduce claimant's impairment rating back to 15% as 
 
         per that communication, as opposed to his undated but subsequent 
 
         correction, no explanation for the change was given.  Dr. Neff 
 
         also indicated that he did not believe there was any way to 
 
         improve claimant's function and did not recommend further 
 
         surgery. He also thought it was a good idea for claimant to work 
 
         with a counselor regarding changing jobs.
 
         
 
              Claimant also testified that she saw Richard Murphy, M.D., 
 
         an orthopaedic surgeon, on two occasions.  She indicated that Dr. 
 
         Murphy had not prescribed further treatment, but had recommended 
 
         that she leave the meatpacking industry.  Dr. Murphy wrote on 
 
         September 20, 1985 to claimant's attorney after evaluation.  He 
 
         opined that claimant had sustained a total 27% impairment of the 
 
         upper extremity (as he made reference to shoulder surgery, this 
 
         is presumably the left upper extremity).  After a follow-up 
 
         evaluation, Dr. Murphy wrote again to claimant's attorney on May 
 
         8, 1986.  He noted that x-rays of the right shoulder showed no 
 
         evidence of acute or chronic bony changes and diagnosed chronic 
 
         tendonitis with full range of motion in the right shoulder.  He 
 
         was of the view that claimant had not at that time sustained any 
 
         degree of permanent impairment to the right shoulder, but 
 
         reiterated that based on range of motion measurements, claimant 
 
         had sustained a 27% impairment of the left upper extremity.
 
         
 
              Claimant also saw A. J. Wolbrink, M.D., an orthopaedic 
 
         surgeon.  His letter to claimant's attorney of July 1, 1986 noted 
 
         that claimant had pain in both shoulders (predominately anterior 
 
         in the left) and noted crepitation in the left shoulder upon 
 
         range of motion examination.  "Tenderness was predominately about 
 
         the acromion and not the AC joint."  There was also crepitation 
 
         but only mild pain in the right shoulder, which seemed to have 
 
         essentially normal strength. X-rays of the left shoulder showed 
 
         depression of the central portion of the humeral head and some 
 
         irregularity, while the right shoulder was normal.  Dr. Wolbrink 
 
         opined that claimant had a significant impairment of the left 
 
         shoulder due to post-traumatic arthritis and mild impairment due 
 
         to tendonitis in the right shoulder.  He opined that claimant had 
 
         a 23% permanent impairment of the left shoulder (extrapolated to 
 
         a whole person impairment of 14%) and less than a 5% impairment 
 
         of the right shoulder.  In notes of October 28, 1986, Dr. 
 
         Wolbrink noted his impression of chronic tendonitis of the left 
 
         shoulder and suggested that claimant's problems could not be 
 
         expected to entirely settle down and that claimant should not be 
 
         overly vigorous with an exercise program.
 
         
 
              Claimant also testified credibly that Dr. Wolbrink 
 
                                                
 
                                                         
 
         affirmatively advised her to leave her employment in the 
 
         meatpacking industry.
 
         
 
              Claimant also saw Stephen G. Taylor, M.D., on two or three 
 
         occasions.  In a report of July 21, 1987, Dr. Taylor noted that 
 
         x-rays showed some mild glenohumeral arthritis and a central 
 
         defect in the humeral head.  He had an impression of 
 
         post-traumatic arthritis, left shoulder with ankylosis.  He noted 
 
         that surgical intervention to decompress the subacromial space 
 
         and possibly an arthrotomy to release adhesions offered a 
 
         possibility of a better range of motion and reduction of pain, 
 
         but that success could certainly not be assured.
 
         
 
              Dr. Taylor referred claimant to the Mayo Clinic in 
 
         Rochester, Minnesota, where she was seen by Robert H. Cofield, 
 
         M.D., an orthopaedic surgeon.  Dr. Cofield recommended continued 
 
         conservative treatment on his interpretation that claimant had a 
 
         mild to moderate arthritic problem of the glenohumeral joint with 
 
         moderate impairment of shoulder function.
 
         
 
              Dr. Cofield's notes of January 21, 1988 find claimant 
 
         suffering a mild atrophy of the left supraspinatus and deltoid 
 
         muscles with range of motion limitation and subacromial and 
 
         glenohumeral crepitus.  His impression was of degenerative 
 
         arthritis status post loose body removal and Bankart repair.  Dr. 
 
         Cofield noted that claimant had changed her work to one that 
 
         involves use of her arms and her hands in front of her and seemed 
 
         able to do that all right.  There was no indication of residual 
 
         instability of the shoulder joint.
 
         
 
              Claimant testified that Dr. Cofield advised he could do a 
 
         shoulder replacement, but was hesitant to do so due to claimant's 
 
         age, that he advised her to keep up medications and physical 
 
 
 
                             
 
                                                         
 
         therapy and to continue to work, but claimant understood this 
 
         recommendation to be that she work within Dr. Neff's 
 
         restrictions. She also noted that Dr. Neff has never told her 
 
         that restrictions against repetitive work had been lifted.  She 
 
         indicated that Dr. Neff advised her to continue working, but made 
 
         clear that she had restrictions concerning the range of motion of 
 
         her shoulder in addition to avoidance of repetitive work.  In 
 
         advising her as to the range of motion restrictions, claimant 
 
         further testified that Dr. Neff asked her to visualize a box-like 
 
         area in front of her person in which work with her hands could be 
 
         performed, but not otherwise.  Claimant has not seen Dr. Neff 
 
         since mid-1987.  She testified that she declined surgery offered 
 
         by Dr. Neff to remove scar tissue and bone spurs, primarily 
 
         because he believed that the scar tissue and bone spurs would 
 
         redevelop despite surgical intervention.
 
         
 
              With regard to claimant's right arm, she testified that it 
 
         was first injured on May 8, 1985.  She blames overusing the arm 
 
         in an attempt to protect the left shoulder.  At the time, she was 
 
         employed in a part-time position pulling small guts.  Claimant 
 
         testified that at present, she suffers pain in the shoulder blade 
 
         and down her arm approximately one-half way to her elbow and not 
 
         across the front of the body toward her breastbone.  This pain is 
 
         intermittent, although she has never regained full range of 
 
         motion in the right arm.
 
         
 
              Claimant believes that she has lost strength in both upper 
 
         extremities estimating a 3%-4% loss to the right arm and 10% to 
 
         the left.  As an example, she testified that she was unable to 
 
         lift an eight-pack of soda pop bottles with the left arm.  She 
 
         normally takes two pain medications and one anti-inflammatory 
 
         medication on a daily basis.
 
         
 
              Claimant is now continuing to work for defendant on the 
 
         "service board."  This is at her own election.  Service board 
 
         employees are floated around to many different jobs as the need 
 
         might arise and do not "own" any particular job.  For example, 
 
         claimant's husband has less seniority, but works full-time 
 
         because he owns a regular job.
 
         
 
              In 1988, claimant worked in maintenance, press, pump, 
 
         pace-boning, sausage and McDonald loins.  She felt that these 
 
         jobs were mostly within the restrictions set forth by Dr. Neff, 
 
         perhaps to the extent of 75%.  It is claimant's intent to 
 
         continue working until least June, 1989 so as to gain eligibility 
 
         for a ten-year seniority pension.
 
         
 
              Claimant is now earning substantially less money than was 
 
         the case before her first injury.  On cross-examination, it was 
 
         made known that this was in large part due to a new union 
 
         contract that took effect in 1985 or 1986.  Wages apparently were 
 
         lowered from $10.69 per hour to $6.50, although they have since 
 
         risen to $8.50.
 
         
 
              Claimant indicated that the pulling guts job was eliminated 
 
                                                
 
                                                         
 
         when the kill floor was closed in May, 1986.  She had returned to 
 
         the same job on a part-time basis following her April, 1985 
 
         return to work.  After the kill floor was shut down, claimant 
 
         returned to work in approximately July, 1986, but did not then 
 
         own a job due to the reorganization.  Claimant had injured her 
 
         shoulder on the McDonald loins job in May, 1986 immediately after 
 
         the kill floor had shut down; she was taken off work until July, 
 
         1986 and then continued employment until October when she 
 
         underwent the unsuccessful manipulation at the hands of Dr. Neff.  
 
         Dr. Neff did not release her until approximately eight weeks 
 
         after that manipulation.
 
         
 
              Claimant agreed on cross-examination that she has not bid 
 
         for other jobs since beginning her service board work following 
 
         the return to work after the failed manipulation.
 
         
 
              Claimant agreed that she did not in 1988 take herself off 
 
         work by reason of shoulder problems, although she stabbed her 
 
         forearm in an unrelated incident and was off work for 
 
         approximately seven weeks.  She agreed that she last saw Dr. 
 
         Cofield in August, 1988 and that he advised her to return to 
 
         work; as claimant had advised Dr. Cofield of Dr. Neff's 
 
         restrictions, it was her understanding that his advice to return 
 
         to work was in accordance with those restrictions.
 
         
 
              Dan Hasty testified that he is a physical therapist employed 
 
         at Cherokee Hospital, who also does work for defendant, and has 
 
         been so employed for 11 1/2 years.  His formal education     
 
         includes a bachelors degree in general science, training as a 
 
         physical therapist, passing a licensing examination and 
 
         undergoing 20 hours of annual continuing education.  For the last 
 
         five and one-half years, Hasty has worked with injured employees 
 
         of defendant and for the last two and one-half years has gone to 
 
         defendant's plant three times per week to provide services.
 
         
 
              Mr. Hasty indicated that he had seen claimant some 12 weeks 
 
         after the August, 1984 surgery upon Dr. Garner's prescription.  
 
         He has treated claimant regularly for left shoulder problems with 
 
         heat, ice, ultrasound, electricity, range of motion exercises and 
 
         strengthening exercises.  He has also worked with claimant's 
 
         right shoulder, but to a much lesser extent.  He described the 
 
         right shoulder as having limitations, but not nearly so severe, 
 
         and actually somewhat mild.  A courtroom demonstration of 
 
         claimant's limited range of motion was undertaken.  Claimant has 
 
         only 80 degrees motion in front of her body parallel to the floor 
 
         (of a possible 180 degrees) and 45-50 degrees (of 90 degrees) 
 
         active range of motion in external rotation.
 
         
 
              Ron Libolt testified that he is a union vice-president for 
 
         this unionized plant.  He stated that there are now approximately 
 
         500 employees, and that claimant's seniority number is 359.  Jobs 
 
         are bid on the basis of seniority.
 
         
 
              He described claimant as a member of the service board, or 
 
         "floaters" who substitute for employees who call in sick or are 
 
                                                
 
                                                         
 
         on vacation.  Service board members have no choice as to which 
 
         job might be assigned.
 
         
 
              Mr. Libolt testified that he is familiar with all the jobs 
 
         defendant has for which claimant may be qualified.  He stated 
 
         that all of those jobs include repetitive motion.  Further, Mr. 
 
         Libolt stated that he knows of no jobs available to persons with 
 
         claimant's level of seniority that would allow an individual to 
 
         work in a "small box in front" of the body as described by Dr. 
 
         Neff to claimant.  He indicated that defendant has consistently 
 
         attempted to assign claimant to jobs beyond her restrictions, 
 
         although claimant has often tried those jobs anyway.  However, he 
 
         conceded on cross-examination that he was aware that the 
 
         physician claimant saw at Mayo Clinic advised that claimant could 
 
         continue doing the same job.
 
         
 
              Tim Bruhn testified that he is now married to claimant and 
 
         works himself for defendant on the ham boning line.  His 
 
         seniority is approximately 60 days less than claimant's.
 
         
 
              Mr. Bruhn worked all of 1988 at a repetitive job on a 
 
         full-time basis, although he has less seniority than claimant.
 
         
 
              Mr. Bruhn testified that claimant frequently wakes up at 
 
         night in pain, as he knows since he has lived with her for 
 
         approximately eight years.  He indicated that claimant no longer 
 
         plays softball and volleyball due to her shoulder problems.
 
         
 
              Dwayne Aduddell testified that he is defendant's employment 
 
         manager.  He described how to interpret defendant's exhibit A, 
 
         which is an attendance summary.  He testified that service board 
 
         employees sometimes have the option to pass up work.  On 
 
         cross-examination, he conceded that claimant could have had the 
 
         job now held by Tim Bruhn,.but for her injuries.
 
         
 
              Dr. Richard Murphy testified by deposition taken April 10, 
 
         1986.  He testified that he had estimated the impairment of the 
 
         left upper extremity at 27%, and that he made use of the American 
 
         Medical Association's Guides to the Evaluation of Permanent 
 
         Impairment in so doing.  He agreed that the 27% impairment 
 
         translated into a 16% impairment of the whole person.  A review 
 
         of the guides shows that this conversion is accurate.  His 
 
         examination consisted of taking x-rays, taking claimant's 
 
         history, and performing a physical examination.
 
         
 
              Dr. Adrian Wolbrink also testified by deposition taken 
 
         November 17, 1988.  He agreed that he had first seen claimant on 
 
         June 30, 1986.  Based upon the history he took, the examination, 
 
         and x-rays, he agreed that he basically concurred with Dr. 
 
         Connolly's diagnosis.  As to causation, Dr. Wolbrink testified:
 
         
 
              Q.  All right.  Doctor, Millie Draper would testify in this 
 
              matter that she is approximately 33 years old at the present 
 
              time, that she commenced working in a meat packing plant 
 
              known as Wilson Foods sometime in the calendar year 1979, 
 
                                                
 
                                                         
 
                   that she had no physical symptoms, pain, or injuries known 
 
              to her with her left or right shoulder, and that she worked 
 
              eight hours a day for approximately five years, up to May 
 
              1984, where she did repetitive motion with her hands in a 
 
              job called pulling guts out in front of her where she 
 
              basically put both of her hands in fairly close proximity 
 
              out in front of her, with the hog gut, and basically 
 
              straightened it out, pulling those arms out away in 
 
              something that I believe would approximate a breast type 
 
              swimming stroke.
 
         
 
              And my statement to you, Doctor, is do you have an opinion 
 
              as to whether that activity performed for that length of 
 
              time would be a substantial factor in producing this 
 
              subluxation of the shoulder that Doctor Connolly has 
 
              referred to in his letter, which I have elated to you?
 
         
 
         (Claimant's exhibit 52, page 7, line 11 through page 8, line 6)
 
         
 
              * * *
 
         
 
              A.  Yes, I do have an opinion.
 
         
 
         (Claimant's exhibit 52, page 8, line 13)
 
         
 
              * * *
 
         
 
         
 
              Q.  And what is your opinion, sir?
 
         
 
         (Claimant's exhibit 52, page 8, line 15)
 
         
 
              * * *
 
                             
 
                                                         
 
         
 
              A.  My opinion would be that there would be a material 
 
              aggravation from that activity for this shoulder problem.
 
         
 
         (Claimant's exhibit 52, page 8, lines 17-19; objection by Mr. 
 
         Sayre omitted)
 
         
 
              Claimant testified on direct examination that the facts 
 
         posed in this question were all accurate.
 
         
 
              Dr. Wolbrink also testified to his opinion that if claimant 
 
         went back to the same repetitive type of activity after the 
 
         Bankart repair was performed, that repetitive activity would 
 
         again further aggravate the shoulder.  He further testified that 
 
         given the Bankart repair and the restriction of motion he found 
 
         afterwards, and also on the assumption that claimant would relate 
 
         that she had pain in the scapular area in the back of the 
 
         shoulder, the repetitive activity and the Bankart repair and 
 
         restriction of motion would be causative of that pain.
 
         
 
              As to claimant's right shoulder, Dr. Wolbrink testified to 
 
         his opinion that claimant had tendonitis.  He was also of the 
 
         view that claimant's repetitive activity and employment would 
 
         constitute a material aggravation of the shoulder.  He was also 
 
         of the view that his opinions as to both shoulders were expressed 
 
         within a reasonable degree of medical probability.  Generally 
 
         speaking, (see page 14 of the deposition) it was Dr. Wolbrink's 
 
         position that repetitive work was causative of symptoms.
 
         
 
              With regard to Dr. Cofield's findings, Dr. Wolbrink was 
 
         questioned as follows:
 
         
 
              Q.  Doctor Cofield recites in his report again, Doctor, 
 
              little further on, that he finds some mild atrophy of the 
 
              left supraspinatus and deltoid muscles.
 
         
 
              What part of the body is that, Doctor? Can you demonstrate 
 
              for us?
 
         
 
              A.  The deltoid is a large muscle that fans out from the 
 
              clavicle, and then goes down over the shoulder.  The 
 
              supraspinatus goes on the back side from the -- attaching 
 
              from the humerus, and then along the shoulder blade, along 
 
              the top margin of the shoulder blade to about -- well, to 
 
              the medial border of the shoulder blade, which is adjacent 
 
              to the spine.
 
         
 
              Q.  Would this atrophy of the supraspinatus and deltoid 
 
              muscles also be a consequence of the repetitive work 
 
              activity, the Bankhart repair and the restriction of motion 
 
              that she had following the Bankhart repair?
 
         
 
              A.  Yes, it would be related to the problem.
 
         
 
         (Claimant's exhibit 52, page 15, line 13 through page 16, line 
 
                                                
 
                                                         
 
         5)
 
         
 
              Claimant submitted evidence as to expenses assessed to and 
 
         paid on her behalf.  Dr. Murphy submitted a bill of $240.00 on 
 
         November 28, 1986.  It was not itemized.  Physical Therapy 
 
         Consultants (Mr. Bower) submitted a bill for $55.00 on January 
 
         14, 1987 for claimant's disability rating.  Dorothea Pharris 
 
         submitted a bill of $61.90 on April 1, 1986 for Dr. Murphy's 
 
         deposition (as a court reporter).  The University of Nebraska 
 
         Medical Center submitted a bill for $15.00 on April 1, 1986 
 
         concerning a request for information.  Dr. Wolbrink submitted a 
 
         bill for $345.00 on November 17, 1988 for his deposition.  Harris 
 
         Reporting submitted a bill for $80.20 on December 5, 1988 for the 
 
         deposition fee.  All of these expenses were paid by claimant or 
 
         by her attorney.
 
         
 
                       APPLICABLE LAW AND ANALYSIS
 
         
 
              An employee is entitled to compensation for any and all 
 
         personal injuries which arise out of and in the course of the 
 
         employment.  Section 85.3(1).
 
         
 
              The supreme court of Iowa in Almquist v. Shenandoah 
 
         Nurseries, 218 Iowa 724, 254 N.W. 35 (1934) at 731-32, discussed 
 
         the definition of personal injury in workers' compensation cases 
 
         as follows:
 
         
 
              While a personal injury does not include an occupational 
 
              disease under the workmen's Compensation Act, yet an injury 
 
              to the health may be a personal injury [Citations omitted.] 
 
              Likewise a personal injury includes a disease resulting from 
 
              an injury....The result of changes in the human body 
 
              incident to the general processes of nature do not amount to 
 
              a personal injury.  This must follow, even though such 
 
              natural change may come about because the life has been 
 
              devoted to labor and hard work.  Such result of those 
 
              natural changes does not constitute a personal injury even 
 
              though the same brings about impairment of health or the 
 
              total or partial incapacity of the functions of the human 
 
              body.
 
         
 
                 ....
 
         
 
              A personal injury, contemplated by the Workmen's 
 
              Compensation Law, obviously means an injury to the body, the 
 
              impairment of health, or a disease, not excluded by the act, 
 
              which comes about, not through the natural building up and 
 
              tearing down of the human body, but because of a traumatic 
 
              or other hurt or damage to the health or body of an 
 
              employee.  [Citations omitted.]  The injury to the human 
 
              body here contemplated must be something, whether an 
 
              accident or not, that acts extraneously to the natural 
 
              processes of nature and thereby impairs the health, 
 
              overcomes, injures, interrupts, or destroys some function of 
 
              the body, or otherwise damages or injures a part or all of 
 
                                                
 
                                                         
 
                   the body.
 
         
 
              The claimant has the burden of proving by a preponderance of 
 
         the evidence that the injuries of May 25, 1984 and May 8, 1985 
 
         are causally related to the disability on which she now bases her 
 
         claims.  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).
 
         
 
              In his deposition, Dr. Wolbrink expressed his opinion that 
 
         both of claimant's shoulder injuries were caused by the 
 
         employment.  No other physician has expressed a contrary view. 
 
         While none of the other physicians directly opined that the work 
 
         injuries were causative of disability, it has also been 
 
         stipulated that the work injuries caused temporary disability, 
 
         and the record shows that at least three physicians have 
 
         recommended that claimant leave employment in the meatpacking 
 
         field.  It is therefore held that claimant's shoulder 
 
         disabilities were caused by her work injuries.
 
         
 
              To determine disability, it is necessary to discuss whether 
 
         claimant's injuries have been to scheduled members or to the body 
 
         as a whole.  It was held in Alm v. Morris Barick Cattle Co., 240 
 
         Iowa 1174, 38 N.W.2d 161 (1949) that the statutory scheduling of 
 
         an arm injury does not apply to a shoulder injury, nor is such an 
 
         injury scheduled in any other subsection.  Although the statute 
 
         has been amended and renumbered during the intervening years, 
 
         such is still the case.  See also, Lauhoff Grain Company v. 
 
         McIntosh, 395 N.W.2d 834 (Iowa 1986), holding that the statutory 
 
         definition of "leg" did not include the hip joint, that the 
 
         commissioner was not required to apply the leg schedule to a hip 
 
         impairment, and that if there was actual impairment of the hip, 
 
         rather than the leg, compensation should be based on an 
 
         industrial disability to the body as a whole.  Lauhoff Grain also 
 
         cited and quoted with apparent approval from Alm.
 
         
 
              The surgical procedure to claimant's left shoulder was 
 
         located in the crease between claimant's body and arm.  Claimant 
 
                                                
 
                                                         
 
         suffers pain in the body and has clinical findings of atrophy to 
 
         the left supraspinatus and deltoid muscles; these are muscles 
 
         that are connected in the body as a whole.  It cannot fairly be 
 
         said that claimant's disability on the left side is limited to 
 
         her arm, but clearly includes the joint itself and impairs the 
 
         body as a whole.  Although the evidence is less satisfactory as 
 
         to claimant's right shoulder injury, the evidence does reflect 
 
         that claimant's tendonitis is not merely limited to the arm.  It 
 
         is held that both injuries are to the body as a whole and not to 
 
         scheduled members.
 
         
 
              With regard to claimant's right shoulder, the parties have 
 
         stipulated to healing period or temporary total disability.  As 
 
         to the left side, the evidence is unclear as to claimant's 
 
         initial healing period following the work injury, as the dispute 
 
         relates to the period from June, 1986 to January, 1987.  Claimant 
 
         was held off work by reason of her disability from May 22, 1986 
 
         through June 30, 1986, and then returned to work.  However, it is 
 
         clear that Dr. Neff's manipulation of October 23, 1986 is 
 
         causally related to the work injury, since it constituted an 
 
         attempt to lyse adhesions resulting from the initial surgery.  
 
         Claimant was not found to have reached maximum recuperation from 
 
         this procedure until January 5, 1987.  Therefore, it is held that 
 
         claimant's healing period includes those two intervals.  It 
 
         appears from the stipulation that the initial healing period is 
 
         agreed by the parties to be 56 weeks 5 days for which claimant 
 
         was compensated.
 
         
 
              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 
 
 
 
                       
 
                                                         
 
         v. Goodyear Service Stores, 255 Iowa 1112, 125 N.W.2d 251 (1963). 
 
         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 latter 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 or 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).
 
         
 
              The record makes abundantly clear that claimant's injury to 
 
         the left shoulder is of substantially greater severity than her 
 
         injury to the right shoulder.  On an impairment basis, Dr. 
 
         Connolly found a 15% disability, Dr. Wolbrink found a 23% 
 
         disability, and Drs. Murphy and Neff each found a disability of 
 
         27%.  (The undersigned concludes that 27% was Dr. Neff's final 
 
         rating.)  As Dr. Neff was a primary treating physician and as his 
 
         evaluation coincides with that of Dr. Murphy, it is concluded 
 
                                                
 
                                                         
 
         that claimant has suffered a 27% functional impairment to the 
 
         left arm (as it was calculated by the respective physicians), 
 
         which, as has been seen, converts under the American Medical 
 
         Association's guides to a whole body impairment of 16%.
 
         
 
              Claimant has restrictions in effect concerning her left side 
 
         injury.  Dr. Neff restricted her against rotation of the arm on 
 
         June 16, 1986, and against repetitive work activity on June 23, 
 
         1986.  On January 5, 1987, he restricted claimant to working with 
 
         both arms above her shoulders.  In addition, he advised claimant 
 
         on a personal level that she should leave her employment in the 
 
         meatpacking field.  The 45-pound lifting restriction imposed by 
 
         Mr. Bower is not considered a medical restriction because Mr. 
 
         Bower is not a physician.  However, it is worth pointing out that 
 
         as a physical therapist working in conjunction with Dr. Neff on 
 
         the case, he agreed with the overhead work restriction and was 
 
         somewhat unsure as to whether restrictions against repetitious 
 
         work would be in order.
 
         
 
              It should be noted at this time that defendants' brief 
 
         attributes a quotation in exhibit 22 concerning claimant's 
 
         ability to perform her previous work to Dr. Neff.  A review of 
 
         the exhibit reveals that the quotation is actually that of Mr. 
 
         Bower.  The undersigned accepts claimant's testimony as credible 
 
         that Dr. Neff advised her to leave this employment.
 
         
 
              Drs. Murphy and Wolbrink each advised claimant to leave 
 
         employment in the meatpacking industry.  In addition, Dr. 
 
         Wolbrink advised claimant to refrain from repetitive work with 
 
         both arms. While Dr. Cofield suggested that claimant could return 
 
         to work with her job restriction as she had supplied it, it was 
 
         claimant's understanding that this recommendation was based upon 
 
         Dr. Neff's limitations in writing and to claimant personally, 
 
         including his verbal restriction that claimant perform work only 
 
         in a "small box" directly in front of her person.
 
         
 
              Claimant has clearly shown motivation in continuing to work 
 
         for defendant despite these two injuries.  On the other hand, 
 
         defendant is entitled to credit for continuing to make work 
 
         available for claimant, although it is disputed as to whether 
 
         that work is actually within her physical limitations.  The 
 
         record tends to show that all of the work provided claimant was 
 
         at least close to the edge of those limitations, while some of 
 
         the work is more clearly beyond the scope of the limitations.
 
         
 
              Claimant's work history is somewhat limited, involving only 
 
         a factory job and various positions in the meatpacking industry. 
 
         Claimant has a high school diploma and appeared at hearing to be 
 
         of at least average intelligence.  Given her age, she appears 
 
         suited for and capable of further retraining.  Yet, there has 
 
         clearly been a diminution of her earning capacity because of the 
 
         restrictions placed upon her.  Upon considering all of the above 
 
         factors and the evidence in general, the undersigned concludes 
 
         that claimant has sustained a 25% industrial disability to the 
 
         body as a whole by reason of her May 25, 1984 left shoulder 
 
                                                
 
                                                         
 
         injury.
 
         
 
              The evidence as to claimant's right shoulder disability 
 
         shows that there is very little impairment or industrial impact. 
 
          Dr. Neff believed she had a five percent impairment, Dr. Murphy 
 
         believed she had no impairment, and Dr. Wolbrink believed she had 
 
         less than a five percent impairment to the right shoulder.  Only 
 
         Dr. Wolbrink has recommended restrictions, that being against 
 
         repetitive motion.  However, there are surely some positions for 
 
         which claimant must now appear disqualified that might involve 
 
         only repetitive motions of the right shoulder and none of the 
 
         left.  Therefore, the impairment to claimant's right shoulder 
 
         does constitute a separate and additional source of industrial 
 
         disability.  The undersigned concludes that the industrial 
 
         disability attributable to the May 8, 1985 injury to claimant's 
 
         right shoulder is three percent of the body as a whole.
 
         
 
              The final issue to be determined is that of assessment of 
 
         medical expenses and costs  Defendants' brief takes the position 
 
         that Dr. Murphy's bill was for an independent examination under 
 
         Iowa Code section 85.39, and that Dr. Wolbrink's bill is an 
 
         attempt to recover second benefits under section 85.39.  However, 
 
         a review of the face of that statement shows that Dr. Wolbrink's 
 
         charge was for his deposition.  There is no indication that 
 
         examination or other services are included.  Expert witness 
 
         testimony fees are not to exceed $150.00 per day, see Iowa Code 
 
         section 622.72.  Therefore, Dr. Wolbrink's charge will be 
 
         assessed to defendants only in the sum of $150.00.  Dr. Murphy's 
 
         bill is allowed as for an 85.39 examination and the statement of 
 
         Physical Therapy Consultants will be allowed as it is within the 
 
         expert witness limitation of 622.72, The Code.
 
         
 
                            FINDINGS OF FACT
 
         
 
              THEREFORE, based on the evidence presented, the following 
 
         ultimate facts are found:
 
         
 
              1.  At all times relevant, claimant was employed by 
 
         defendant Wilson Foods Corporation.
 
         
 
              2.  As stipulated, claimant suffered an injury arising out 
 
         of and in the course of that employment to her left shoulder on 
 
         May 25, 1984 (771230).
 
          
 
              3. As stipulated, claimant suffered an injury arising out of 
 
         and in the course of that employment to her right shoulder on May 
 
         8, 1985 (806153).
 
         
 
              4.  As stipulated, claimant was temporarily disabled from 
 
         working by reason of her right shoulder injury for two weeks and 
 
         two days, for which she has been fully compensated by defendant.
 
         
 
              5.  Claimant was temporarily disabled by reason of her left 
 
         shoulder injury from May 22, 1986 through June 30, 1986 (five 
 
         weeks, five days) and from October 23, 1986 through January 5, 
 
                                                
 
                                                         
 
         1987 (ten weeks, five days), totalling sixteen weeks, three days. 
 
         Claimant has been compensated for her initial healing period 
 
         following the injury, which the parties stipulated to be 56 
 
         weeks, 5 days.  In addition, defendant has paid 67.5 weeks of 
 
         compensation at the stipulated rate, although the parties dispute 
 
         as to whether the same should be credited as healing period or 
 
         permanent partial disability.
 
         
 
              6.  As stipulated, claimant's rate of compensation for each 
 
         injury is $195.33 per week.
 
         
 
              7 . With regard to each injury, claimant's disability 
 
         extends to the joint itself or further into the body as a whole.
 
         
 
              8.  Each of claimant's work injuries has caused her 
 
         permanent disability and a diminution of her earning capacity.
 
         
 
              9.  Claimant was a credible witness.
 
         
 
             10.  Claimant has been given physical limitations by reason 
 
         of her left shoulder injury as follows:  Rotation of the arm, 
 
         repetitive work activity, working with both arms above the 
 
         shoulders, and verbally by Dr. Neff, that claimant should work 
 
         only within a "small box" in front of her person and should 
 
         consider leaving the meatpacking industry.
 
         
 
              11.  Claimant has been given no restrictions by her treating 
 
         physician as to her right shoulder injury, although Dr. Wolbrink 
 
         has recommended against repetitive movement.
 
         
 
              12.  With regard to claimant's left shoulder, her physical 
 
         therapist has recommended that she be limited to lifting weights 
 
         not exceeding 45 pounds.
 
 
 
                            
 
                                                         
 
         
 
              13.  Dr. Murphy's bill is for a medical examination under 
 
         Iowa Code section 85.39; other disputed medical and court 
 
         reporter expenses are for expert witness fees or court reporting 
 
         and should be assessed as costs.
 
         
 
                                CONCLUSIONS OF LAW
 
         
 
              WHEREFORE, based on the principles of law previously stated, 
 
         the following conclusions of law are made:
 
         
 
              1.  Claimant sustained an injury to her left shoulder 
 
         arising out of and in the course of her employment on May 25, 
 
         1984 (771230).
 
         
 
              2.  Claimant sustained an injury to her right shoulder 
 
         arising out of and in the course of her employment on May 8, 1985 
 
         (806153).
 
         
 
              3.  Each of claimant's injuries was an injury to the body as 
 
         a whole.
 
         
 
              4.  Claimant's left shoulder injury directly caused a 
 
         healing period from May 22, 1986 through June 30, 1986 and from 
 
         October 23, 1986 through January 5, 1987, in addition to 
 
         undisputed healing period disability at the time of the injury 
 
         for which claimant has been compensated.
 
         
 
              5.  Claimant has established a permanent partial disability 
 
         of 25% of the body as a whole with regard to her left shoulder 
 
         injury; the commencement date is January 6, 1987, after the end 
 
         of her last healing period interval.
 
         
 
              6.  Claimant has sustained a permanent partial disability of 
 
         three percent of the body as a whole by reason of her right 
 
         shoulder injury; the commencement date being March 12, 1988 (as 
 
         per the parties' stipulation).
 
         
 
              7.  Claimant is entitled to a physical examination under 
 
         Iowa Code section 85.39 with respect to Dr. Murphy.
 
         
 
                                      ORDER
 
         
 
              THEREFORE, IT IS ORDERED:
 
         
 
              Defendant is to pay to claimant sixteen point four two nine 
 
         (16.429) weeks healing period benefits at the stipulated rate of 
 
         one hundred ninety-five and 33/100 dollars ($195.33) per week 
 
         totalling three thousand two hundred nine and 08/100 dollars 
 
         ($3,209.08) with respect to her left shoulder injury.
 
         
 
              Defendant is to pay unto claimant one hundred twenty-five 
 
         (125) weeks of permanent partial disability at the stipulated 
 
         rate of one hundred ninety-five and 33/100 dollars ($195.33) per 
 
         week, totalling twenty-four thousand four hundred sixteen and 
 
                                                
 
                                                         
 
         25/100 dollars ($24,416.25) with respect to her left shoulder 
 
         injury commencing January 6, 1987.
 
         
 
              Defendant is to pay unto claimant fifteen (15) weeks 
 
         permanent partial disability benefits at the stipulated rate of 
 
         one hundred ninety-five and 33/100 dollars ($195.33) per week, 
 
         totalling two thousand nine hundred twenty-nine and 95/100 
 
         dollars ($2,929.95), with respect to her right shoulder injury.
 
         
 
              Defendant shall be entitled to eighty (80) weeks credit 
 
         against these awards, totalling fifteen thousand six hundred 
 
         twenty-six and 40/100 dollars ($15,626.40).
 
         
 
              The bill of Richard P. Murphy, M.D., in the sum of two 
 
         hundred forty and 00/100 dollars ($240.00) shall be paid by 
 
         defendant under Iowa Code section 85.39.
 
         
 
              The balance of the expenses set forth in claimant's exhibit 
 
         63 shall be assessed as costs, except that Dr. Wolbrink's 
 
         statement in the sum of three hundred forty-five and 00/100 
 
         dollars ($345.00) shall be awarded only in the sum of one hundred 
 
         fifty and 00/100 dollars ($150.00).
 
         
 
              Any unpaid benefits which have accrued as of the date of 
 
         this decision shall be paid in a lump sum together with statutory 
 
         interest thereon pursuant to Iowa Code section 85.30.
 
         
 
              The costs of each action shall be assessed to defendant 
 
         pursuant to Division of Industrial Services Rule 343ù4.33.
 
         
 
              Defendant shall file claim activity reports in each file 
 
         number as requested by this agency pursuant to Division of 
 
         Industrial Services Rule 343-3.1.
 
         
 
              Signed and filed this 24th day of May, 1989.
 
         
 
         
 
         
 
         
 
                                        
 
                                         DAVID RASEY
 
                                         DEPUTY INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. Steve Hamilton
 
         Attorney at Law
 
         606 Ontario Street
 
         P.O. Box 188
 
         Storm Lake, Iowa  50588
 
         
 
         Mr. David L. Sayre
 
         Attorney at Law
 
         223 Pine Street
 
         P.O. Box 535
 
                                                
 
                                                         
 
         Cherokee, Iowa  51012