5180 3 Filed August 15, 1989 DAVID E. LINQUIST BEFORE THE IOWA INDUSTRIAL COMMISSIONER SCOTT C. MCKELVEY, Claimant, File No. 772870 vs. A P P E A L BURLINGTON MEDICAL CENTER, Employer, D E C I S I 0 N and ST. PAUL INSURANCE COMPANY, Insurance Carrier, Defendants. 51803 Deputy's award of 20 percent permanent partial disability of the right arm affirmed on appeal. BEFORE THE IOWA INDUSTRIAL COMMISSIONER SCOTT C. MCKELVEY, Claimant, File No. 772870 vs. A R B I T R A T I O N BURLINGTON MEDICAL CENTER, D E C I S I O N Employer, F I L E D and FEB 21 1989 ST. PAUL INSURANCE COMPANY, INDUSTRIAL SERVICES Insurance Carrier, Defendants. INTRODUCTION This is a proceeding in arbitration brought by Scott C. McKelvey against Burlington Medical Center, his former employer, and its insurance carrier, St. Paul Insurance Company. The case was heard and fully submitted at Burlington, Iowa on July 6, 1988. The record in the proceeding consists of testimony from Scott C. McKelvey and exhibits 1 through 15. ISSUES The only issue for determination is the extent of permanent partial disability affecting McKelvey's right arm as a result of the August 20, 1984 injury. SUMMARY OF EVIDENCE The following is a summary of evidence presented in this case. Of all the evidence received at the hearing, only that considered most pertinent.to this decision is discussed. Conclusions about what the evidence showed are inevitable with any summarization. The conclusions in the following summary should be considered to be preliminary findings of fact. There is no material dispute with regard to the circumstances of McKelvey's injury and its treatment. The only dispute is the extent of the resulting permanent partial disability. Scott C. McKelvey was working as a maintenance person for Burlington Medical Center during the summer of 1984. On August 20, 1984, he was driving a dump truck. When he tried to dump a load of dirt, the bed would not raise high enough to dump the dirt which it was carrying. Claimant inspected, found a cable which was binding, reached in, pulled the cable and the bed of the truck came down on his arm. He suffered a severe crush injury to his arm with a comminuted fracture of his humerus. The posterior triceps muscle was severed. The radial and ulnar nerves were crushed (exhibit 15, pages 15-17). Exhibit 7, a report from Jerry L. Jochims, M.D., dated September 4, 1984 adequately summarizes the first few days of claimant's treatment and recovery and is hereafter set forth: As you are well aware, on August 20, 1984, Mr. Scott McKelvey was brought to the Burlington Medical Center emergency room after a traumatic incident while employed by the Burlington Medical Center. To the best of my understanding, it appears as if he had his arm caught between the I-beam support at the base of a truck box, and the I-beam support of the truck chassis frame, when the hydraulic mechanism somehow was tripped or failed, and the truck box, which was hoisted up, collapsed down compressing his right upper arm between the two pieces of metal. With the significant amount of compression force involved, he sustained a complete loss of neural and arterial function to the arm, as well as a very comminuted fracture of the right humerus. On his arrival at the Burlington Medical Center, his condition was stabilized with intravenous fluids and antibiotics, as well as pain medications. While being supported initially, we did place gentle manipulative traction on his arm, and were able to get the pulses to return in his right forearm. Subsequent to this, I indicated him for an open reduction internal fixation of the humerus fracture and an exploration of the neural structures so as to allow for debridement of this open fracture and release of any of the neural tissue which might be encompassed in the fracture. His surgery was undertaken the night of August 20, 1984, and my partner Dr. Duane Nelson assisted on that surgery. He thereafter was followed in the Burlington Medical Center emergency room until August 28, 1984, at which time he appeared to have gone through his initial shock and primary healing phase. We did do a secondary surgical procedure four days after his admission for the purpose of delayed primary closure of his wound, which was too tight to close the night of his surgery, and also to re-inspect the radial nerve. His injury to date is as described above, and it should be noted that although the nerves are intact to the best of our ability to explore his arm through a posterior wound, we do know that the radial nerve is in total continuity, not having been transected as well as the ulnar nerve. We did not explore or dissect anteriorly to identify the median nerve, but at about one month post injury, our plan is to proceed with nerve conduction tests. It would appear that he does have deep pain sensation in all nerve groups and that although the nerve tissue itself was not transected, it was merely severely contused in a type of injury called a neuropraxia. I have no idea at this time as to the type of recovery we will anticipate, nor the date upon which he might be able to return to work. Obviously, at this point his functional impairment is with a complete loss of use of his right arm from the shoulder distally, and I hope that return of function will be progressive. We have seen where the loss of function in an extremity such as this takes as long as 3-4 months to recover, and I would not be surprised that he will require at least 3-4 months for recovery. It should be noted that his triceps muscle on the radial border was also totally transected by the compressive force, and loss of muscle function is certainly a possibility as well. Hopefully, because of his youth, his recuperative powers are optimal. (Exhibit 7, pages 1 and 2) Dr. Jochims' office notes are found in exhibit 1. The notes show a gradual yet positive course of recuperation. The note dated March 29, 1985 indicates that claimant has had an almost miraculous improvement with his radial nerve functioning at about 80% strength. The ulnar and median nerves had previously recovered much of their function. On June 14, 1985, Dr. Jochims evaluated claimant for the purpose of providing a permanent partial impairment rating. Dr. Jochims found claimant to have triceps muscle weakness for which he assigned a ten percent impairment rating. Dr. Jochims also assigned a five percent impairment rating to the radial nerve and to the median nerve based upon hypesthesia. The total rating provided by Dr. Jochims was a 20% permanent partial impairment of the right upper extremity. At the time, Dr. Jochims had some reservations regarding whether or not the fractured humerus was completely united (exhibit 1, pages 5 and 6; exhibit 15, pages 5 and 6). Dr. Jochims last examined claimant on June 6, 1986. At that time, claimant displayed very minimal weakness in triceps strength, but the neurological function was normal. X-rays demonstrated total consolidation of the humerus fracture (exhibit 1, page 7). Dr. Jochims stated that the condition of claimant's arm had actually improved between June of 1985 and June 1986 (exhibit 15, pages 6 and 7). Claimant's right upper arm exhibits quite marked notable scars and pigment changes. An indented portion is clearly observable. Claimant was examined by Barry Lake Fischer, M.D., on October 17, 1986. Upon observing the deformities and performing range of motion and strength testing, Dr. Fischer concluded that claimant had a 41% permanent partial disability of his right arm (exhibit 14, pages 19 and 20). Claimant testified at hearing that he has restricted range of motion which causes him problems in movements such as scratching his back. He stated that the motion of his right hand and fingers is impaired in comparison to his left. Claimant stated that he has a dull pain in his upper right arm at the area of injury when he performs strenuous activities or when he engages in movements such as throwing a ball or playing tennis. Claimant is right-handed. APPLICABLE LAW AND ANALYSIS Scott C. McKelvey suffered an extremely severe injury to his right upper arm. When the condition of the arm as it existed a few days following the injury is compared to its present condition, the amount of recuperation that occurred is nothing short of miraculous. The workers' compensation system exists by virtue of statute. The statute does not provide a recovery for matters such as pain and suffering, or disfigurement which does not impair function (except for disfigurement of the face). The right of a worker to receive compensation for injuries sustained which arose out of and in the course of employment is statutory. The statute conferring this right can also fix the amount of compensation to be paid for different specific injuries, and the employee is not entitled to compensation except as provided by the statute. Soukup v. Shores Co., 222 Iowa 272, 268 N.W. 598 (1936). Where an injury is limited to a scheduled member, the loss is measured functionally, not industrially. Graves v. Eagle Iron Works, 331 N.W.2d 116 (Iowa 1983). The claimant has the burden of proving the degree of disability that resulted from his injury. The nature of the injury that occurred could readily have left claimant with a very severe disability. While the current disability and impairment in claimant's right arm is certainly not minimal or inconsequential, it is far less than what might have occurred. Dr. Jochims, claimant's treating physician, rated a 20% impairment in 1985. Dr. Jochims has indicated that the degree of impairment has probably been reduced somewhat due to subsequent unanticipated recovery. Dr. Fischer assigned a 41% disability. The testimony from claimant regarding his ability to engage in activities such as throwing a ball:or playing tennis is corroborative of Dr. Jochims' rating. Individuals with a 40% impairment of an arm are not commonly able to perform those types of activities. Further, Dr. Jochims is the treating physician and is more familiar with this case than is Dr. Fischer. For these reasons, the assessment made by Dr. Jochims is accepted as being correct. Claimant is therefore entitled to receive 50 weeks of compensation for permanent partial disability representing a 20% permanent partial disability of the right arm under the provisions of Iowa Code section 85.34(2)(m). The entire amount of the award has been previously paid voluntarily by the defendants. In view of the fact that claimant has been fully paid, the costs of this proceeding will be assessed against claimant. Costs are determined in accordance with Division of Industrial Services Rule 343-4.33. Costs related to depositions can be assessed only if the deposition is introduced into evidence at trial. Woody v. Machin, 380 N.W.2d 727 (Iowa 1986). Expert witness fees are limited to the statutory amount provided by Code section 622.72 for expert witnesses. Accordingly, defendants are entitled to recover costs in the amount of $59.00 for the court reporter fees for Dr. Fischer's deposition, $155.00 for reporter fees for Dr. Jochims' deposition and $150.00 as an expert witness fee for Dr. Jochims at his deposition. The total is $364.00. FINDING OF FACT 1. Scott C. McKelvey has a 20% permanent partial disability of his right arm as a result of the injuries he sustained on August 20, 1984. CONCLUSIONS OF LAW 1. This agency has jurisdiction of the subject matter of this proceeding and its parties. 2. Scott C. McKelvey is entitled to receive 50 weeks of compensation for permanent partial disability representing a 20% permanent partial disability of his right arm under the provisions of Code section 85.34(2)(m). 3. Since defendants' liability has been fully satisfied by voluntary payments made prior to the time of hearing, the costs of this action should be assessed against claimant. ORDER IT IS THEREFORE ORDERED that claimant take nothing further from this proceeding as his entitlement to compensation was fully paid voluntarily by the defendants prior to hearing. IT IS FURTHER ORDERED that the costs of this action are assessed against claimant pursuant to Division of Industrial Services Rule 343-4.33 as follows: Cynthia Varelli, Dr. Fischer's deposition $59.00 Linda M. Flakne, Dr. Jochims' deposition 155.00 Expert witness fee, Dr. Jochims 150.00 Total $364.00 Signed and filed this 21st day of February, 1989. MICHAEL G. TRIER DEPUTY INDUSTRIAL COMMISSIONER Copies To: Mr. Patrick A. Tallon Attorney at Law 25 East Washington, Suite 835 Chicago, Illinois 60602 Mr. Greg A. Egbers Attorney at Law 600 Union Arcade Building 111 East Third Street Davenport, Iowa 52801-1550 1402.40, 1803, 2207 Filed February 21, 1989 MICHAEL G. TRIER BEFORE THE IOWA INDUSTRIAL COMMISSIONER SCOTT C. MCKELVEY, Claimant, vs. File No. 772870 BURLINGTON MEDICAL CENTER, A R B I T R A T I 0 N Employer, D E C I S I 0 N and ST. PAUL INSURANCE COMPANY, Insurance Carrier, Defendants. 1402.40, 1803, 2907 Claimant awarded 20% permanent partial disability of the arm consistent with the treating physician's rating, inspite of a higher rating from an examining physician. Defendants admitted liability and had previously paid the full amount awarded. Costs were assessed against claimant. BEFORE THE IOWA INDUSTRIAL COMMISSIONER EARL LOWE, Claimant, File No. 772890 vs. LAS VEGAS CEMENT COMPANY, A R B I T R A T I 0 N Employer, D E C I S I 0 N and F I L E D MARYLAND CASUALTY COMPANY, MAR 24 1989 Insurance Carrier, IOWA INDUSTRIAL COMMISSIONER Defendants. STATEMENT OF THE CASE This is a proceeding in arbitration brought by Earl Lowe, claimant, against Las Vegas Cement Company, employer, and Maryland Casualty Company, insurance carrier, to recover benefits under the Iowa Workers' Compensation Act as a result of an injury sustained on July 27, 1984. This matter came on for hearing before the undersigned deputy industrial commissioner May 5, 1988 and was considered fully submitted at the close of the hearing. The record in this case consists of the testimony of claimant, Delores Lowe, and joint exhibits 1 through 7, inclusive. ISSUES Pursuant to the prehearing report and order submitted and approved May 5, 1988, the following issues are presented for resolution. 1. Whether the injury of July 27, 1984 is the cause of the disability on which claimant now bases his claim; 2. Claimant's entitlement to weekly benefits including temporary total disability/healing period benefits and permanent partial disability benefits; 3. The applicability of the odd-lot doctrine; and 4. Claimant's entitlement to certain benefits under Iowa Code section 85.27. FACTS PRESENTED Claimant sustained an injury on July 27, 1984 which arose out of and in the course of his employment when, while loading trusses onto a flat bed truck on which steel beams had already been loaded, the trusses slipped, claimant fell onto the ground on his back and one of the trusses landed on claimant crushing his pelvis. Claimant testified he was hospitalized for two weeks, that it was over a week before he could "get up and around" and then only in a corset brace that "held [him] together" and that he used a walker for about a month thereafter until he began using a cane. Claimant explained he underwent physical therapy and did home exercises as prescribed by his physician, Marvin Dubansky, M.D. Claimant testified that in approximately April 1986, Dr. Dubansky sent him to Iowa City because he was having back pain (described as sometimes severe and sometimes not) and trouble with his pelvis and bladder. Claimant stated that Dr. Dubansky,, around the same time, suggested he try to return to work and that he then went to work for a contractor friend laying forms for sidewalks, doing drywall and odd jobs. Claimant stated that this venture proved completely unsuccessful as the bending required resulted in "terrible pains," that it was difficult for him to stretch, reach out and twist and difficult for him to work above his head. Claimant estimated he worked off and on for about a week and during this week had worked only one full day. Claimant denied having any symptoms with reference to his back prior to this injury although he acknowledged he had suffered from some muscle soreness at times after a long day's work. Claimant testified that currently he can stand anywhere from 15 to 30 minutes, cannot bend over except for a "few seconds," that he cannot walk over 15 minutes without pain and that sitting, without frequently changing position, bothers him. Claimant opined that his back has gotten worse since April 1986 and that since the injury he has never been pain-free, although some days are worse than other. Claimant does not believe he is capable of working a 40 hour week or an 8 hour day because he cannot move well enough to do a good job. Claimant acknowledged he did not do well when he went through vocational rehabilitation programs because his pain made it difficult for him to concentrate and he would not be able to set his own pace. Claimant testified he has cooperated with vocational rehabilitation counselors and sought work both through the counselors and on his own but has been unsuccessful in that endeavor. Claimant opined that his age coupled with his injury makes it particularly difficult for him to acquire work and that even if he were in good health his age would be a barrier to securing employment. Claimant admitted he had one contract to paint and repair a fence but that the job took so long to complete he could not make any money on it and that his current plans are to set up a woodworking shop at his home. On cross-examination, claimant testified he worked for Delavan as a machine operator until the union was decertified, but after this separation from employment he had trouble finding other employment, and that during this time he worked on his own doing remodeling/repair work until he was able to secure a series of basically short-term labor positions. Claimant estimated his earnings in 1981 as $2,100, in 1982 as $3,000, and in 1983 as $7,000. Claimant revealed he does do some housework and yard work and that his wife retired in November 1987 on social security disability. Delores Lowe testified claimant, prior to his injury, was a robust, strong, healthy, hard working individual who could provide a living for his family but that he is a different person since the injury. Mrs. Lowe stated claimant had a negligible medical history prior to this injury and that he did not complain of pain anytime after returning from work prior to the injury. Mrs. Lowe described claimant as having to lean his arms on the sink to wash dishes, to have to sit down to dry them, that he cannot make a bed alone and that, although he tries, sometimes cannot finish the house or lawn work. Mrs. Lowe stated that claimant does not complain and most generally keeps things to himself. Marvin Dubansky, M.D., orthopedic surgeon, testified he first saw claimant on July 27, 1984 at the request of Carlton N. Vannatta, M.D., claimant's family physician, and that after taking x-rays found claimant to have a fracture of the right ilium and pubis and "some damage to the right sacroiliac joint." Dr. Dubansky recommended bed rest and gradual ambulation, physical therapy and referral to other physicians until December 1985 when he referred claimant to the University of Iowa Hospitals and Clinics because of claimant's complaints with reference to his back. Dr. Dubansky concurred with the diagnosis rendered at the University of Iowa of degenerative spondylolisthesis and spinal stenosis and related those conditions to the injury of July 24, 1984 stating: "I think that he had an injury and then he gradually developed this because I don't think on our initial films we recognized a degenerative spondylolisthesis as such." (Exhibit 2, Dubansky Deposition, page 22) Dr. Dubansky went on to testify that: So because on my December film I found no evidence of degenerative spondylolisthesis or any kind of spondylolisthesis and then in April they reported one and he had a 500-pound steel girder or something hit him, has trouble and he'd had continuing trouble, I would say that there is a causal relationship between that girder and eventually the presence of the degenerative spondylolisthesis. Now, one could say, yes, this could develop because many people that we are -- the majority of the people we see with degenerative spondylolisthesis have never had any severe injury of this type, but on the other hand you have a man who had this thing fall on him. He's had continued trouble since that time and eventually has shown up with a degenerative spondylolisthesis. So that I would say the chances are that he had an injury. Now, we -- it takes time for degeneration to take place, and it would very well be he had the injury and the full manifestation showed up. I don't know. the time of injury was in Q. July of '84. A. -- July of '84 and this is April. So there were nine months or so before -- no. It was over nine months. It was a year and a half or more that they found the degenerative spondylolisthesis. I have films that don't show it, so that I would say that somebody who had an injury and has had continued symptoms clear through that there's probably a causal relationship between the two, although I cannot stand here and say it would never have happened if he didn't have something drop on him. (Ex. 2, Dubansky Dep., pp. 24-25) Dr. Dubansky's office notes of September 30., 1985 read: I feel as a result of the fracture of the pelvis and subsequent difficulties I think he's reach [sic] full medical recovery as far as I can do and I have nothing more I can recommend for him. Circulation in his legs are all right. He's been seen by a neurosurgeon who could not find any neurosurgical changes and I think this is a result of the severe compression fractures of the pelvis that he has permanent pain, impairment and there is nothing more I can do. No future appointments have been given. (Ex. 1, p. 118) On October 11, 1985, Dr. Dubansky opined claimant "has approximately 10% impairment of the body as a whole as a result of the fracture of his pelvis" and explained this rating as "sort of a guess because I don't know what 10 percent means really and I don't know what any percent means either." Dr. Dubansky testified he expected claimant to fully or nearly fully recover from the fractured pelvis and opined that claimants' present inability to work is as a result of claimant's back problems. Dr. Dubansky referred claimant to C. A. Tom Foreman, M.D., urologist, on August 24, 1984 because claimant's "complaints were of voiding difficulty; including nocturia about every hour with post voiding dribbling, urgency with urge incontinence." Dr. Foreman found claimant's condition had improved by November 14, 1984 and opined that claimant's voiding difficulties were definitely caused by claimant's work accident. However, on March 19, 1986, Hugh C. Dick, M.D., urologist, who practices with Dr. Foreman, advised defendant insurance carrier: [T]he patient came to my office on 28 February 1986 with complaints of post voiding dribbling and urinary urgency. He underwent out-patient panendocystoscopy @ Mercy Hospital on 5 March 1986 for urological evaluation to see if he indeed had stricture due to his previous work injury. However, no stricture was found, final diagnosis ,being prostatic enlargement, which I feel is not related to his injury. (Jt. Ex. 1, p. 6) Claimant was seen by Stuart R. Winston, M.D., on June 20 and again on June 27, 1985 at the request of Dr. Dubansky. On June 27, Dr. Winston opined: His cranial nerves, on examination, are normal and the remainder of the examination fails to show any weakness, lack of strength, cerebellar signs. His reflexes are symmetric and perhaps the ankle jerk is reduced slightly on the right. There is no Babinski sign. Electrodiagnostic studies were performed which were normal, and lumbosacral spine films show no evidence of any recent or remote injury. He does have some degenerative diseases at L2-3. I sought to.reassure the patient since his numbness and discomfort seem to be improving, that there still is room for continued improvement. I would certainly think with the nature of the trauma to the pelvic floor that he probably did have some involvement of the lumbosacral plexis, but we cannot document any ongoing problem, and have reassure him along these lines. (Ex. 1, p. 100) On April 8, 1986, claimant was admitted to the University of Iowa Hospitals and Clinics on referral from Dr. Dubansky and underwent a myelogram, CT, EMG, NCV, and urology evaluation. The orthopedic diagnosis was established as "degenerative spondylolisthesis Lumbar 4-5 with spinal stenosis Lumbar 4-5." (Ex. 1, p. 135) Neurological evaluation showed no evidence of neurogenic bladder. Claimant had an epidural steroid injection April 17, 1986 which he later advised the doctors "were of no benefit." Clinical notes dated July 10, 1986, state: IMPRESSION: The patient suffers from low back pain with impairment of his back aggravated by his injury. It is probable that the patient may in the future need a decompression of the L5 nerve roots but we do not feel that it is indicated at this time. We feel that his back impairment amounts to a 10 percent impairment of the body,as a whole in addition to his impairment from the pelvic fractures. We will see the patient on a PRN basis. (Ex. 1, p. 141) In a report dated December 16, 1986, Jack E. Reynolds, M.D., C.R.C., rehabilitation consultant with Resource Opportunities, Inc., wrote: On December 15, 1986, the consultant received a phone call from Dr. Marvin Dubansky. Dr. Dubansky stated that he did not need to see Mr. Lowe at this time and that he felt written work restrictions would not be appropriate. It was his opinion that the client's limitations are primarily up to him and what he can handle. Thy physician did state that he would recommend no heavy manual labor including no climbing, repetitive lifting, pushing or pulling and that Mr. Lowe would need to change positions between sitting and standing on an as needed basis. The consultant discussed the potential for a tool repair/assembly position with Ace Tool and a desk clerk position or a light maintenance positions. Dr. Dubansky stated that these types of occupations may be appropriate for the client under the right circumstances. Dr. Dubansky agreed that upon obtaining a job offer for the client he would be willing to see Mr. Lowe at that time to discuss the position and the appropriateness of that job. (Ex, 6, p. 3) Claimant attended the Iowa State Vocational Rehabilitation facility beginning January 5, 1987. The final report of the facility counselor states: This evaluator does feel that the client put.forth good efforts and attempted to meet competitive employment expectations in regard to his work habits. The disability did seem to interfere with the evaluation. The client did make numerous complaints of discomfort, walked bent over holding his back. The client left the area early on two occasions and had three additional days absent due to what he stated was back problems. The client, in my opinion, does not appear to have physical tolerance for machine operation tasks. (It appears that bending to inspect the tasks is the problem.) The client tried two parts lists and then declined further involvement. In my opinion the best performance can on low level (bench) electrical task. The client declined further interest in building inspection tasks due to physical. This evaluator questions if the client's physical tolerance would be appropriate for an 8-hour day. (Even if the task were bench repair oriented.) The only area I can suggest (part-time) would be Electrical Tool Repairer, 729.281-022, Repairer Hand tools, 701.381-010. (Both jobs are classified as light physical in the Dictionary of Occupational Titles. (Ex 5, p. 16) 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(l). The claimant has the burden of proving by a preponderance of the evidence that the injury of July 27, 1984 is causally related to the disability on which he now bases his claim. Bodish v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965). Lindahl v. L.O. Boggs, 236 Iowa 296, 18 N.W.2d 607 (1945). A possibility is insufficient; a probability is necessary. Burt v. John Deere Waterloo Tractor Works, 247 Iowa 691, 73 N.W.2d 732 (1955). The question of causal connection is essentially within the domain of expert testimony. Bradshaw v. Iowa Methodist Hospital, 251 Iowa 375, 101 N.W.2d 167 (1960. 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). The parties do no dispute that on July 27, 1984 claimant sustained an injury which arose out of and in the course of his employment which, at a minimum, caused claimant to sustain a fractured pelvis. What appears to be principally an issue is whether this injury was the cause of claimant's complaints concerning his back and his urinary difficulties. There does not appear to be any question that it is claimant's back that is the major cause of his disability and that the pain as the result thereof is currently preventing claimant from gainful employment. Dr. Dubansky has opined that there is a causal connection between claimant's injury and the spinal stenosis and/or spondylolisthesis with which claimant has been diagnosed. Dr. Dubansky was unequivocal in his testimony that "I would say that there is a causal relationship between that girder and eventually the presence of the degenerative spondylolisthesis." (Jt. Ex. 2, p. 24) In addition, Dr. Lehmann, from the University of Iowa Hospitals and Clinics, stated that claimant suffers from low back problems with impairment of his back aggravated by his injury. While a claimant is not entitled to compensation for the results of a preexisting injury or disease, the mere existence at the time of a subsequent injury is not a defense. Rose v. John Deere Ottumwa Works, 247 Iowa 900, 908, 76 N.W.2nd 756, (1956). If the claimant had a preexisting condition or disability that is aggravated, accelerated, worsened or lighted up so that it results in disability, claimant is entitled to recover. Nicks v Davenport Produce Co., 254 Iowa 130, 115 N.w.2d 812, (1962). When an aggravation occurs in the performance of an employer's work and a causal connection is established, claimant may recover to the extent of the impairment. Ziegler v. United States Gypsum Co., 252 Iowa 613, 620, 106 N.W.2d 591, (1960). Defendants argue that based on an admission note that claimant had experienced "neck/back pains/stiffness/swelling with heavy lifting" that claimant suffered from some preexisting back problems. Claimant did candidly acknowledge that at times he was stiff and sore after a hard day's work. However, the record, as a whole, fails to,support defendants' position and, even if it would be shown that claimant suffered from some sort of preexisting back condition, claimant has established that the injury of July 27, 1984 materially aggravated this condition so as to bring claimant to the condition to which he now finds himself. Accordingly, the greater weight of medical evidence would establish a causal connection between claimant's injury of July 27, 1984 and claimant's underlying back problems. The undersigned must conclude that the same holds true with regard to claimant's urinary problems. The record is clear that when claimant was first admitted to the hospital following the injury there was concern over claimant's inability to void to the point that a catheter was inserted. Throughout claimant's recuperation, he was treated by Dr. Foreman who "definitely" found claimant's problems to be caused by the accident. It was not until almost two years after claimant's injuries that Dr. Dick diagnosed claimant as having a prostatic enlargement, unrelated to the injury. Claimant received instructions from his visit to the University of Iowa Hospitals and Clinics which undoubtedly improved his condition. In addition, Dr. Dubansky has stated that the spinal stenosis, which has already been found to be causally connected to the work injury, can result in problems with bladder incontinence. Therefore, the greater weight of medical evidence would establish that claimant's injury of July 27, 1984 was the precipitating factor in claimant's bladder problems and accordingly was the proximate cause thereof. The primary issue for resolution is the extent of claimant's industrial disability. Claimant asserts that he is permanently and totally disabled either under Iowa Code section 85.34(3) or under the applicability of the odd-lot doctrine as found in Guyton v. Irving Jensen Co., 373 N.W.2d 101 (Iowa 1985). Under the odd-lot doctrine, which was formally adopted by the Iowa Supreme Court in Guyton, supra, a worker becomes an odd-lot employee when an injury makes the worker incapable of obtaining employment in any well-known branch of the labor market. An odd-lot worker is thus totally disabled if the only services the worker can perform are so limited in quality, dependability, or quantity that a reasonably stable market for them does not exist. Id., citing Lee v. Minneapolis Street Railway Company, 230 Minn.315, 320, 41 N.W.2d 433, 436 (1950). The rule of odd-lot allocates the burden of production of evidence. If the evidence of degree of obvious.physical impairment, coupled with other facts such as claimant's mental capacity, education, training or age, places claimant prima facie in the odd-lot category, the burden should be on the employer to show that some kind of suitable work is regularly and continuously available to the claimant. Certainly in such a case it should not be enough to show that claimant is physically capable of performing light work and then round out the case for non-compensable by adding a presumption that light work is available. Guyton, 373 N.W.2d at 105. When a worker makes a prima facie case of total disability by producing substantial evidence that the worker is not employable in the competitive labor market, the burden to produce evidence of suitable employment shifts to the employer. If the employer fails to produce such evidence and the trier of fact finds the worker falls in the odd-lot category, the worker is entitled to a finding of total disability. Even under the odd-lot doctrine, the trier of fact is free to determine the weight and credibility of the evidence in determining whether the worker's burden of persuasion has been carried. Only in an exceptional case would evidence be sufficiently strong to compel a finding of total disability as a matter of law. Guyton, 373 N.W.2d at 106. The court went on to state: The commissioner did not in his analysis address any of the other factors to be considered in determining industrial disability. Industrial disability means reduced earning capacity. Bodily impairment is merely one factor in a gauging industrial disability. Other factors include the worker's age, intelligence, education, qualifications, experience, and the effect of the injury on the worker's ability to obtain suitable work. See Doerfer Division of CCA v. Nicol, 359 N.W.2d 428, 438 (Iowa 1984). When the combination of factors precludes the worker from obtaining regular employment to earn a living, the worker with only a partial functional disability has a total disability. See McSpadden v. Big Ben Coal Co., 288 N.W.2d 181, 192 (Iowa 1980. The undersigned would conclude that claimant's situation falls far short of that presented in the Guyton case. It cannot be concluded that the evidence in this case would establish that the only services that claimant can perform are so limited in quality, dependability or quantity that a reasonably stable market for them does not exist. Claimant clearly has transferable skills. Dr. Dubansky has agreed that claimant is capable of employment and claimant's search for employment does not begin to compare to that done in Guyton. Jack Reynolds has identified jobs which are available in the job market which are suited to claimant's capabilities even in light of his restrictions. Therefore, claimant has failed to establish he is an odd-lot employee. Claimant has, however, suffered an industrial disability as a result of the work injury of July 27, 1984. Both Doctors Dubansky and Lehmann have rendered opinions on claimant's impairment and the undersigned does not dispute that claimant has a permanent partial impairment as a result of the injury. 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 of the employee prior to the injury, after the injury and potential for rehabilitation; the employee's qualifications intellectually, emotionally and physically; earnings prior and subsequent to the injury; age; education.motivation; functional impairment as a result of the injury; and inability because of the injury to engage in employment for which the employee is fitted. Loss of earnings caused by a job transfer for reasons related to the injury is also relevant. These are matters which the finder of fact considers collectively in arriving at the determination of the degree of industrial.disability. There are no weighting guidelines that indicate how each of the factors are to be considered. There are no guidelines which give, for example, age a weighted value of ten percent of the total value, education a value of fifteen percent of total, motivation - five percent; work experience - thirty percent, etc. Neither does a rating of functional impairment directly correlate to a degree of industrial disability to the body as a whole. In other words, there are no formulae which can be applied and then added up to determine the degree of industrial disability. It therefore becomes necessary for the deputy 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). Claimant is currently 60 years old with a high school education and some education at the college level. At age 60, it cannot be the subject of much dispute that claimant has already worked more years than he would anticipate working in the future. In light of his age, claimant's loss of future earnings from employment due to his disability is not as severe as would be the case of a younger individual. See Becke v. Turner-Busch, Inc., 34 Biennial Report, Iowa Industrial Commissioner 34 (1979). Claimant identified himself as a machinist by trade who worked at Delavan Manufacturing Company until a strike and decertification of the union forced claimant to seek employment elsewhere. Claimant candidly acknowledged that he had great difficulties securing other employment after that and he was probably unemployed more than he was employed after leaving Delavan. Claimant has not had any regular steady employment since his separation from employment with Delavan and had earnings over the three years prior to his injury in the total amount of $12,100. Claimant's position with defendant employer was again temporary in nature. Defendant cannot be held responsible for conditions other than those related to the injury. Claimant clearly has transferable skills and although he may not now be capable of performing all of the jobs for which he is fitted, he is not excluded from that employment completely and has not lost all of the knowledge gained from his years of working experience. Dr. Dubansky has not prohibited claimant from all employment and has approved of certain positions recommended to claimant. Claimant's restrictions on employability are essentially self-imposed although Dr. Dubansky acknowledged claimant would have difficulty bending, twisting and working over head. Considering then all the elements of industrial disability, it is determined that claimant has a permanent partial disability of 35 percent for industrial purposes entitling claimant to 175 weeks of permanent partial disability benefits. Iowa Code section 85.34(1) provides that if an employee has suffered a personal injury causing permanent partial disability, the employer shall pay compensation for a healing period from the day of the injury until (1) the employee returns to work; or (2) it is medically indicated that significant improvement from the injury is not anticipated; or (3) until the employee is medically capable of returning to substantially similar employment. Based on the testimony of Dr. Dubansky, it is determined that claimant's healing period ended on September 30, 1985. Nothing in the record would indicate that claimant's condition changed or that claimant improved subsequent to September 30, 1985 to lead the undersigned to conclude that claimant had not reached his maximum medical recovery by this date. Therefore" claimant is entitled to 61.571 weeks of healing period benefits for the period of July 27, 1984 through September 30, 1985, inclusive. Iowa Code section 85.27 provides, in part: The employer, for all injuries compensable under this chapter or chapter 85A, shall furnish reasonable surgical, medical, dental, osteopathic, chiropractic, podiatric, physical rehabilitation, nursing, ambulance and hospital services and supplies therefor and shall allow reasonably necessary transportation expenses incurred for such services. The employer shall also furnish reasonable and necessary crutches, artificial members and appliances but shall not be required to furnish more than one set of permanent prosthetic devices. The final issue for resolution is claimant's entitlement to medical expenses at the University of Iowa Hospitals and Clinics as found in joint exhibit 7. There is no dispute that Dr. Dubansky is claimant's primary authorized treating physician and further that claimant was referred to the University of Iowa by Dr. Dubansky. As it has been found that claimant's work injury of July 27, 1984 was the proximate cause of claimant's urological and orthopedic problems, it must be concluded that defendants are liable for the costs of this treatment. Therefore, defendants shall bear the costs of the treatment at the University of Iowa as found in joint exhibit 7. FINDINGS OF FACT WHEREFORE, based on all of the evidence presented, the following findings of fact are made: 1. Claimant sustained an injury which arose out of and in the course of his employment on July 27, 1984 when, while loading trusses onto a flat bed truck on which steel beams had already been loaded, the trusses slipped with one of them landing on claimant. 2. Claimant was hospitalized and upon admission to the hospital had difficulty voiding and a catheter was put in place. 3. Claimant had complaints of back pain upon admission to the hospital and was found to have a fracture of the right ilium and pubis and some damage to the right sacroiliac joint upon taking x-rays. 4. Claimant was originally treated conservatively and eventually referred by his primary treating physician to the University of Iowa Hospitals and Clinics where claimant was diagnosed as having.degenerative spondylolisthesis and spinal stenosis which was aggravated by the injury. 5. Dr. Dubansky found claimant's spondylolisthesis and/or spinal stenosis to be as a result of claimant's work injury of July 27, 1984. 6. Claimant had been referred to a urologist because of bladder incontinence which condition is causally connected to the injury. 7. The services claimant can perform are not so limited in quality, dependability or quantity that a reasonably stable market for them does not exist. 8. Claimant is currently 60 years old with a high school education and some education at the college level. 9. Claimant is a machinist by trade who had steady employment with Delavan Manufacturing Company until a strike and decertification of the union forced him to seek employment elsewhere. 10. Claimant has been unable to secure regular steady employment since his separation from employment with Delavan and had earnings in 1981 of $2,100, 1982 of $3,000, and 1983 of $7,000. 11. Claimant has transferable skills from previous employment and although he may not now be capable of performing all of the jobs for which he is fitted he is not excluded from that employment completely and has not lost all of the knowledge gained from his years of work and experience. 12. Claimant's restrictions on his employability are essentially self-imposed. 13. Claimant does have difficulty bending, twisting and working over head. 14. Claimant has a permanent partial disability of 35 percent for industrial purposes. 15. Claimant's healing period ended September 30, 1985. 16. Claimant's treatment at the University of Iowa Hospitals and Clinics were necessitated because of the work injury. CONCLUSIONS OF LAW THEREFORE, based on the principles of law previously stated, the following conclusions of law are made: 1. Claimant's work injury of July 27, 1984 is the cause of the disability on.which he now bases his claim. 2. Claimant has failed to establish he is an odd-lot employee. 3. Claimant has established a permanent partial disability of 35 percent for industrial purposes. 4. Claimant has established a healing period of July 27, 1984 through September 30, 1985, inclusive. 5. Claimant has established the medical expenses incurred at the University of Iowa Hospitals and Clinics are causally connected to the work injury of July 27, 1984. ORDER THEREFORE, it is ordered: Defendants' shall pay unto claimant sixty-one point five seven one (61.571) weeks of healing period benefits at the stipulated rate of two hundred six and 42/100 dollars ($206.42) for the period from July 27, 1984 through September 30, 1985, inclusive. Defendants shall pay unto claimant one hundred seventy-five (175) weeks of permanent partial disability benefits at the stipulated rate of two hundred six and 42/100 dollars ($206.42) per week commencing October l, 1985. Defendants shall receive full credit for all disability benefits previously paid. Payments that have accrued shall be paid in a lump sum together with statutory interest thereon pursuant to Iowa Code section 85.30. Defendants shall pay all disputed medical expenses as found in joint exhibit 7. Defendants shall file a claimant activity report upon payment of this award. Costs of this action are assessed against defendants pursuant to Division of Industrial Services Rule 343-4.33. Signed and filed this 24th day of March, 1989. DEBORAH A. DUBIK DEPUTY INDUSTRIAL COMMISSIONER Copies to: Mr. James Waters Attorney at Law 323 E. Fifth Des Moines, IA 50309 Mr. Richard G. Book Attorney at Law 500 Liberty Bldg Des Moines, IA 50309 1108; 1402.40; 1803; 4100 Filed March 24, 1989 Deborah A. Dubik BEFORE THE IOWA INDUSTRIAL COMMISSIONER EARL LOWE, Claimant, File No. 772890 vs. LAS VEGAS CEMENT COMPANY, A R B I T R A T I 0 N Employer, D E C I S I 0 N and MARYLAND CASUALTY COMPANY, Insurance Carrier, Defendants. 1108; 1402.40; 1803 Claimant sustained an injury which arose out of and in the course of his employment when a steel beam from a truck fell on top of him crushing his pelvis. As a result of the injury, claimant also experienced back problems and bladder incontinence which were found to be causally connected to the original injury. Claimant awarded permanent partial disability benefits of 35 percent. 4100 Claimant failed to establish he was an odd lot employee as the services he can perform were not so limited in quality, dependability or quantity that a reasonably stable labor market for him did not exist. 5-2905;3102;2905 Filed December 23, 1991 BYRON K. ORTON WRM before the iowa industrial commissioner ____________________________________________________________ : ORLA JANE SMITH, : : Claimant, : : vs. : : File Nos. 853642/773001 FLEETGUARD, INC., : : A P P E A L Employer, : : D E C I S I O N and : : LIBERTY MUTUAL INSURANCE : COMPANY, : : Insurance Carrier, : Defendants. : ___________________________________________________________ 5-2905 At the time of the prior award, claimant was determined to be able to perform clerical work. Subsequent to the award, claimant's physician determined that she was not able to perform such work. Held that a physical change of condition had occurred, justifying a further award in review-reopening. 3102, 2905 A vocational rehabilitation expert's testimony was admitted. Defendants objected because the expert could have testified prior to the original award, but that evidence was not offered then. Defendants argued it could not, therefore, be offered on review-reopening. Held that, especially here where the expert did not conduct the evaluation of claimant until after the original award, the evidence was admissible for the limited purpose of showing a change of condition since the original award, but could not be used to alter the assessment of claimant's disability at the time of the original award as that had already been legally determined. The evidence was used only as it related to events occurring subsequent to the original award, and any portion purporting to assess claimant's condition at the time of the prior award were disregarded.