BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         _________________________________________________________________
 
                     
 
         HELEN MAXINE CHRISMAN,     
 
                     
 
              Claimant,   
 
                     
 
         vs.         
 
                                                  File No. 812528
 
         RIVER HILLS CARE CENTER,   
 
                                                    A P P E A L
 
              Employer,   
 
                                                 D E C I S I O N
 
         and         
 
                     
 
         LIBERTY MUTUAL INSURANCE   
 
         COMPANY,    
 
                     
 
              Insurance Carrier,    
 
              Defendants.      
 
         _________________________________________________________________
 
         The record, including the transcript of the hearing before the 
 
         deputy and all exhibits admitted into the record, has been 
 
         reviewed de novo on appeal.  The decision of the deputy filed 
 
         December 27, 1990 is affirmed and is adopted as the final agency 
 
         action in this case.
 
         Claimant shall pay the costs of the appeal, including the 
 
         preparation of the hearing transcript.
 
         Signed and filed this ____ day of November, 1992.
 
         
 
         
 
                                       ________________________________
 
                                               BYRON K. ORTON
 
                                         INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. H. Edwin Detlie
 
         Attorney at Law
 
         114 North Market St.
 
         Ottumwa, Iowa 52501
 
         
 
         Mr. Walter F. Johnson
 
         Attorney at Law
 
         P.O. Box 716
 
         Ottumwa, Iowa 52501-0716
 
         
 
 
            
 
 
 
 
 
 
 
 
 
                                             9998
 
                                             Filed November 10, 1992
 
                                             Byron K. Orton
 
            
 
                      BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
            HELEN MAXINE CHRISMAN,     
 
                        
 
                 Claimant,   
 
                        
 
            vs.         
 
                                                   File No. 812528
 
            RIVER HILLS CARE CENTER,   
 
                                                    A P P E A L
 
                 Employer,   
 
                                                  D E C I S I O N
 
            and         
 
                        
 
            LIBERTY MUTUAL INSURANCE   
 
            COMPANY,    
 
                        
 
                 Insurance Carrier,    
 
                 Defendants.      
 
            ____________________________________________________________
 
            
 
            9998
 
            
 
                 Summary affirmance of deputy's decision filed December 
 
            27, 1990.
 
            
 
 
            
 
            Page   1
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            HELEN MAXINE CHRISMAN,        :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :         File No. 812528
 
            RIVER HILLS CARE CENTER,      :
 
                                          :      A R B I T R A T I O N
 
                 Employer,                :
 
                                          :         D E C I S I O N
 
            and                           :
 
                                          :
 
            LIBERTY MUTUAL INSURANCE      :
 
            COMPANY,                      :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ____________________________________________________________
 
            
 
                              statement of the case
 
            
 
                 This is a proceeding in arbitration upon claimant's 
 
            petition filed February 15, 1989.  Claimant allegedly 
 
            sustained a back injury during the course of her duties as a 
 
            nurse's aide while helping to lift a patient on November 20, 
 
            1985.  She now seeks benefits under the Iowa Workers' 
 
            Compensation Act from her employer, River Hills Care Center, 
 
            and its insurance carrier, Liberty Mutual Insurance Company.
 
            
 
                 Hearing on the arbitration petition was had in Ottumwa, 
 
            Iowa, on March 28, 1990.  The record consists of joint 
 
            exhibits 1 through 71, claimant's exhibit 1, defendants' 
 
            exhibits 1 through 3 and the testimony of claimant and her 
 
            daughter, Debbie Aubrey.
 
            
 
                                      issues
 
            
 
                 Pursuant to the prehearing report, the parties have 
 
            stipulated:  that an employment relationship existed between 
 
            claimant and River Hills Care Center at the time of the 
 
            alleged injury; that if claimant has suffered permanent 
 
            disability relating to the alleged injury, it is an 
 
            industrial disability to the body as a whole; that the 
 
            proper rate of weekly benefits is $96.32; that defendants 
 
            voluntarily paid 160 weeks, 2 days of compensation at the 
 
            stipulated rate prior to hearing.
 
            
 
                 Issues presented for resolution include:  whether 
 
            claimant sustained an injury on November 20, 1985, arising 
 
            out of and in the course of her employment; whether the 
 
            alleged injury caused either temporary or permanent 
 
            disability, the extent of each and the commencement date of 
 
            the latter; the extent of claimant's entitlement to medical 
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            
 
            
 
            benefits (it was stipulated that the fees charged for 
 
            medical services or supplies are fair and reasonable, but 
 
            disputed as to whether those expenses were incurred for 
 
            reasonable and necessary treatment, were causally connected 
 
            to the work injury, or were authorized by defendants); 
 
            whether claimant is entitled to permanent total disability 
 
            under the "odd-lot" theory of recovery; whether claimant is 
 
            entitled to penalty benefits under Iowa Code section 86.13; 
 
            taxation of costs.
 
            
 
                 Because defendants have denied that claimant sustained 
 
            an injury arising out of and in the course of employment, it 
 
            is held that they are not entitled to raise a defense to 
 
            medical expenses based on lack of authorization.  Barnhart 
 
            v. MAQ, Inc., I Iowa Industrial Commissioner Report 16 
 
            (1981).
 
            
 
                                 findings of fact
 
            
 
                 The undersigned deputy, having heard the testimony and 
 
            considered all of the evidence, finds:
 
            
 
                 Claimant, age 50 at the time of hearing, completed the 
 
            eleventh grade, but has not since obtained a diploma or 
 
            General Equivalency Diploma.  However, she received 
 
            certification through a nurse's aide course at Indian Hills 
 
            Community College in about 1979.
 
            
 
                 Claimant's work history is fairly limited.  From the 
 
            1950's through 1979, she provided day care in her home and 
 
            was self-employed as a house cleaner, generally light 
 
            cleaning in various residences.  On March 26, 1979, she 
 
            began employment as a nurse's aide with River Hills Care 
 
            Center and continued that work through the subject injury.  
 
            River Hills Care Center is now defunct and the facility has 
 
            been taken over by a successor business.  Claimant has made 
 
            no effort to work since.
 
            
 
                 Claimant is 5 feet 3 inches tall and stated that she 
 
            weighed some 185-190 pounds at hearing and had for the 
 
            previous four years.  Medical records show that claimant has 
 
            long had a weight problem, weighing over 220 pounds in 1982 
 
            and having undergone gastric bypass surgery.  When she saw 
 
            D. Dale Emerson, M.D., on November 21, 1985, she weighed 175 
 
            pounds and was weighed at 173 pounds by Dr. Emerson on the 
 
            following day.  On November 29, she weighed 171 pounds.  
 
            Through June 24, 1986, Dr. Emerson's last chart note, her 
 
            weight remained fairly stable from 171-178 pounds.
 
            
 
                 Claimant described the work injury as occurring while 
 
            she and another nurse's aide were attempting to lift a 
 
            patient who became combative.  Claimant slipped and fell on 
 
            her left knee, but began suffering pain in the right leg and 
 
            low back.  Dr. Emerson's initial impression was of muscle 
 
            strain.
 
            
 
                 Radiologist Greg Raecker, D.O., performed radiological 
 
            and computerized tomography testing on February 7, 1986.  No 
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
            
 
            
 
            abnormalities were seen.  Radiologist J. J. Gleich, M.D., 
 
            performed a bone scan on February 19, 1986.  No 
 
            abnormalities were seen.  Radiologist T. R. Thurman, M.D., 
 
            performed a bone scan on May 9, 1986.  No abnormalities were 
 
            seen.  Further radiographic studies done by Dr. Thurman on 
 
            June 23, 1986 (of the pelvis and hip region) were 
 
            unremarkable with no arthritic changes noted.  
 
            Electromyography performed on October 28, 1986 by Mark Ross, 
 
            M.D., or D. Morris, M.D., at the University of Iowa 
 
            Hospitals and Clinics was normal.  Computerized tomography 
 
            and a lumbar myelogram were performed at the University of 
 
            Iowa Hospitals and Clinics and were read by Robert M. 
 
            Farner, M.D., and Ronald P. Mueller, M.D., on October 28, 
 
            1986.  No abnormalities were seen.  Magnetic resonance 
 
            imaging of the lumbar spine was performed by D. L. Roberson, 
 
            M.D., on November 13, 1987.  Interosseous lypomas were seen 
 
            at L2, L3 and probably T12, but the MRI scan of the lumbar 
 
            spine was otherwise normal.  Richard F. Neiman, M.D., 
 
            reviewed x-rays and CT scans from the University of Iowa and 
 
            felt that they suggested an abnormality at approximately 
 
            L5-S1.  He felt the CT scan showed a deformity, but that 
 
            myelogram and x-rays did not.  Dr. Neiman then did EMG 
 
            testing on November 15, 1987 and found an abnormal H-wave 
 
            reflex on the left side (but noted claimant's pain symptoms 
 
            were on the right side only) and was unsure as to the 
 
            correlation.  Dr. Neiman's opinions are discussed at more 
 
            length below.
 
            
 
                 Claimant was seen by Donald D. Berg, M.D., on March 20, 
 
            1986.  Dr. Berg noted that x-rays and CT scans showed no 
 
            evidence of a herniated disc and wrote to Dr. Emerson of his 
 
            clinical impression of lumbosacral strain with some right 
 
            sciatic pain, some bursitis.  He at that time felt 
 
            claimant's prognosis to be good, but noted that her recovery 
 
            had been slowed due to excessive weight.  Dr. Berg's 
 
            clinical impression of May 8, 1986 was of lumbosacral strain 
 
            and right sciatica associated with her fall at the nursing 
 
            home.  Claimant was admitted to St. Joseph Health and 
 
            Rehabilitation Center on May 6 and was discharged on May 17.  
 
            Final diagnosis was a right sciatica and lumbosacral strain, 
 
            improved with bed rest, physical therapy and 
 
            anti-inflammatory medication.  Dr. Berg anticipated 
 
            returning claimant to light work in one week.  On May 27, 
 
            Dr. Berg noted that claimant's sciatic pain was resolving, 
 
            but markedly improved and released her to return to work 
 
            with a 50-pound lifting limit.  Dr. Berg felt she should not 
 
            increase that limit for a six-month period.
 
            
 
                 Dr. Berg testified by deposition on May 26, 1989.  He 
 
            is a board-certified orthopaedic surgeon.  He noted that 
 
            myelogram, MRI, CT scan, x-rays, EMG's and bone scans all 
 
            failed to disclose any structural abnormalities whatsoever.
 
            
 
                 Dr. Berg felt that claimant's condition had 
 
            "stabilized" as of May 27, 1986, and that he did not see her 
 
            again until May 4, 1989.  It was his impression that she 
 
            suffered a back strain and had muscle spasms with some 
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            
 
            
 
            sciatic pain.  On May 4, 1989, claimant stated that she 
 
            continued to suffer back pain and pain radiating into the 
 
            right leg more than the left.  She weighed 192 pounds on 
 
            that date (almost a 20-pound increase).  Dr. Berg testified:
 
            
 
                 Q.  Doctor, with a person who has no objective 
 
                 findings through the sophisticated tests that 
 
                 you've mentioned, but who appears to have muscle 
 
                 spasms, what is the consequence or what happens 
 
                 with people having that condition who continue to 
 
                 gain weight such as she has?
 
            
 
                 A.  Well, usually they don't get better.  I mean, 
 
                 they continue to have pain.  They continue to have 
 
                 problems with muscle tightness.  And they 
 
                 sometimes will get worse.
 
            
 
                 Q.  What have you found over the years as to the 
 
                 possibility of total recovery from muscle spasms 
 
                 with loss of weight from someone that's grossly 
 
                 overweight?
 
            
 
                 A.  Usually, they usually get better.
 
            
 
                 Q.  How much overweight is she?
 
            
 
                 A.  Well, 192 pounds, I would say it would be good 
 
                 for her to lose 40 to 50 pounds.
 
            
 
                 Q.  Do you have any equation of any kind of what 
 
                 the consequence on pressure on one's back is with 
 
                 an overweight situation of approximately 50 
 
                 pounds?
 
            
 
                 A.  Well, it's not a one-to-one ratio.  I forgot 
 
                 the exact ratio.  But I do know that in certain 
 
                 position when you are lifting, it can go up four 
 
                 or five times, you know, because of your weight.  
 
                 You know, I don't know exactly.
 
            
 
                 Q.  Do some doctors feel that there is a 
 
                 ten-to-one ratio in that?
 
            
 
                 A.  Certain types of lifting, yes.
 
            
 
                 Q.  And would the consequence of that be, if that 
 
                 is a fact, that it would be the equivalent of 
 
                 carrying a 500 pound load for an individual who is 
 
                 50 pounds overweight?
 
            
 
                 A.  Sure.
 
            
 
            (Dr. Berg deposition, page 18, line 1 through page 19, line 
 
            10)
 
            
 
                 And:
 
            
 
                 Q.  Doctor, in layman's language, what is this 
 

 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
            
 
            
 
                 woman suffering from, if anything, insofar as her 
 
                 allegations of back pain are concerned?
 
            
 
                 A.  Well, I think she's strained her back 
 
                 originally, and has gotten into a situation where 
 
                 she, you know, has gained some weight and lost the 
 
                 flexability [sic] in her back and has gotten into 
 
                 a chronic -- situation of chronic back pain.
 
            
 
                 Q.  And is that a condition which she could 
 
                 alleviate in whole or in part?
 
            
 
                 A.  I still think so, yes.
 
            
 
                 Q.  In what way?
 
            
 
                 A.  Weight loss, I think flexability [sic] 
 
                 exercises, going to physical therapy.  I think 
 
                 maybe going to voc. rehab and getting into 
 
                 activities, maybe that don't require doing heavy 
 
                 lifting.
 
            
 
                 Q.  What has your experience been over the last 14 
 
                 years as a Board certified orthopedic surgery with 
 
                 people having a condition such as this claimant 
 
                 has who cooperate with a systematic exercise 
 
                 program and a loss of weight such as you've 
 
                 described?
 
            
 
                 A.  It's pretty rare that somebody doesn't get to 
 
                 the point where they can go back and go to work.
 
            
 
                 Q.  And would they in that situation in some 
 
                 likelihood or all likelihood or whatever you feel 
 
                 develop a situation where there would be no 
 
                 functional impairment at all relative to the 
 
                 condition which you found on May 4, 1989?
 
            
 
                 A.  Yes.  That's true.
 
            
 
                 Q.  Is there anything structurely [sic] wrong with 
 
                 this lady at all?
 
            
 
                 A.  Not that I can find in my evaluations, no.
 
            
 
            (Dr. Berg deposition, page 20, line 15 through page 21, line 
 
            24)
 
            
 
                 Dr. Berg did not believe that claimant needed any 
 
            surgical intervention.  He was of the view that claimant had 
 
            sustained an impairment to the body as a whole equivalent to 
 
            three percent by reason of the subject work injury.  This 
 
            was based on American Medical Association guidelines.  It 
 
            was further his view that, as of May 4, 1989, claimant could 
 
            continuously engage in eight-hour work days, although she 
 
            perhaps would have some episodes of her back tightening up.  
 
            He would limit claimant to lifting 30 pounds and it would be 
 
            good to avoid bending and doing a lot of frequent twisting 
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            
 
            
 
            "to start this off."  He felt that claimant could bend, 
 
            squat, crawl, climb and reach over the shoulder up to 50 
 
            percent of the time, but not continuously.
 
            
 
                 Dr. Berg found no evidence of disc protrusion or 
 
            herniation of any nature.  When asked whether he was 
 
            familiar with the concept of "internal disruption" of the 
 
            disc, he indicated that he was, but that it was not involved 
 
            in this case.
 
            
 
                 Dr. Berg wrote on June 26, 1990, that he believed 
 
            claimant's limitations should be against lifting beyond 
 
            25-30 pounds and to avoid frequent twisting and bending of 
 
            the back.  He felt lifting and carrying over 25 pounds on a 
 
            frequent basis would probably give claimant problems, as 
 
            would standing for a full eight-hour day without breaks.  
 
            Overall, he believed claimant could do lighter sedentary 
 
            work.
 
            
 
                 Claimant was seen by Jack W. Brindley, M.D., on June 
 
            25, 1986.  He found it difficult to make a definite 
 
            diagnosis and referred her to the University of Iowa 
 
            facility.  In a letter of November 17, 1986, Dr. Brindley 
 
            stated he was not in a position to know if claimant had 
 
            improved or whether she suffered permanent impairment.
 
            
 
                 At the University of Iowa, claimant was seen by Dr. 
 
            Mumford and William O. Shaffer, M.D.  Based on an impression 
 
            of possible right-sided L5-S1 herniated disc with L5-S1 
 
            radiculopathy, claimant was scheduled for an epidural 
 
            steroid injection which was performed on August 21, 1986.  
 
            Discharge summary from the University of Iowa dated October 
 
            29, 1986 showed diagnosis of mechanical low back pain with 
 
            no organic pathology and was executed by William O. Shaffer, 
 
            M.D., and Cathy C. Wilson, M.D.
 
            
 
                 Dr. Shaffer saw claimant for follow-up on May 8, 1987.  
 
            Diagnostic studies again showed no instability and there was 
 
            normal myelogram, CT and EMG's.  His impression was of back 
 
            and right leg pain of unknown etiology.  "Disability" was 
 
            estimated at 5-10 percent.  In a letter of March 25, 1987 to 
 
            claimant's counsel, Dr. Shaffer wrote of his impression of 
 
            low back pain with no organic diagnosis.  He stated it would 
 
            be difficult to hypothesize how long claimant's healing 
 
            period would continue since there was no organic diagnosis 
 
            on which to prognosticate.  "If she is unable to work at 
 
            this time I doubt that she will ever be able to return to 
 
            work for as much behavioral impairment as an actual physical 
 
            impairment."  With respect to functional limitations, Dr. 
 
            Shaffer recommended a functional capacity evaluation be 
 
            performed in the physical therapy department.
 
            
 
                 Claimant was thereupon evaluated for the rehabilitation 
 
            program on July 22, 1987.  J. N. Weinstein, M.D., Associate 
 
            Professor of the Spine Treatment and Research Center of the 
 
            University of Iowa Hospitals and Clinics, wrote claimant on 
 
            August 3, 1987 that her physical exam and diagnostic studies 
 
            were essentially negative and that he had reviewed her 
 

 
            
 
            Page   7
 
            
 
            
 
            
 
            
 
            
 
            
 
            evaluation for the low back pain rehabilitation program with 
 
            the spine team and had the following comments:
 
            
 
                 1.  I would estimate your permanent partial 
 
                 impairment to be 2 percent of your body as a 
 
                 whole.
 
            
 
                 2.  I do not feel that you would be a good 
 
                 candidate for the program due to your current 
 
                 physical limitations, some of which appear to be 
 
                 the result of self-limitation.  At this time, you 
 
                 would not be able to complete all parts of the 
 
                 physical therapy as you have be [sic] limited 
 
                 flexibility, leg strength and trunk strength.
 
            
 
                 Dr. Weinstein's chart notes of July 22, 1987 contain 
 
            the following passage:
 
            
 
                 * * * She states she has considered some type of 
 
                 vocational change but not thought seriously about 
 
                 it.  She is honest in saying "I would not mind at 
 
                 all being a homemaker for the rest of my life" if 
 
                 she could be financially secure.  She would work 
 
                 only if she had for [illegible] by 22 mos post 
 
                 injury and does not see herself as anywhere near 
 
                 ready to return to work at this time.  Her 
 
                 attitude seems to be that she will  evaluate 
 
                 vocational after all of her comp is settled.
 
            
 
                 Claimant was seen by Richard F. Neiman, M.D., a 
 
            board-certified neurologist, on two occasions:  July 6, 1987 
 
            and October 10, 1988.  Dr. Neiman testified by deposition on 
 
            April 13, 1989.
 
            
 
                 On July 6, 1987, Dr. Neiman wrote Drs. Shaffer and 
 
            Emerson (as referring physicians) that x-rays of the 
 
            lumbosacral spine with flexion and extension revealed no 
 
            significant abnormalities and that EMG testing was planned.  
 
            He found claimant to exhibit several objective signs of back 
 
            pain radiating to the leg.  Claimant had a suggestive foot 
 
            drop on the right and there was a two centimeter diminution 
 
            in the size of the calf on the right side.  In addition, 
 
            claimant had a positive result when tested with straight leg 
 
            raising of the opposite leg, known as Fajersztajn's test, 
 
            one which the doctor believed beyond the sophistication of 
 
            most patients to demonstrate on an hysterical basis.
 
            
 
                 Claimant complained of pain in the lower back into the 
 
            right buttocks accentuated by activity.  No other physical 
 
            findings were made, and Dr. Neiman agreed that no objective 
 
            test has revealed any structural abnormality.  Dr. Neiman 
 
            suggested the possibility that claimant might suffer 
 
            internal derangement of a disc, itself apparently a rather 
 
            new concept, but agreed that he could not make that 
 
            diagnosis to a reasonable degree of medical certainty.
 
            
 
                 Dr. Neiman believed claimant to be approximately 50 
 
            pounds overweight and suggested weight reduction.  
 

 
            
 
            Page   8
 
            
 
            
 
            
 
            
 
            
 
            
 
            Cross-examined on that issue, he testified:
 
            
 
                 Q.  Has there been any weight reduction of any 
 
                 kind?
 
            
 
                 A.  I don't know.  AT least as far as the last 
 
                 visit, there was no evidence of weight reduction.  
 
                 The weight was essentially the same, 189 to start 
 
                 with, 190 when I saw her the second time.
 
            
 
                 Q.  Doctor, what effect does that have on someone 
 
                 who claims to have backache, back problems?
 
            
 
                 A.  Well, there is a law of physics as far as 
 
                 leverage force.  Ten pounds of excessive abdominal 
 
                 weight produces about a hundred pounds of stress 
 
                 on the back.  Doesn't mean that she has 500 pounds 
 
                 of excessive stress of the back, but she probably 
 
                 has between 200, 250 pounds excessive stress of 
 
                 the back because of her weight.
 
            
 
                 Q.  Would that be just like carrying a 250-pound 
 
                 weight on your back?
 
            
 
                 A.  Well, it's not the same, but it's like 
 
                 carrying around a large baby with the fluid in 
 
                 this regard, so certainly many pregnant women have 
 
                 considerable amount of back discomfort.
 
            
 
                 Q.  If she has no objective findings of any kind 
 
                 and all of her problems appear to be subjective 
 
                 complaints, are those subjective complaints likely 
 
                 to continue as long as she retains this sort of 
 
                 weight?
 
            
 
                 A.  Well, certainly they're not helped at all with 
 
                 this weight, and they're aggravated by the weight 
 
                 itself.
 
            
 
                 Q.  What about her failure to perform any type of 
 
                 exercises such as you prescribed.  Did you 
 
                 prescribe those from the very start also?
 
            
 
                 A.  Yes.
 
            
 
                 Q.  What effect will that have if she fails to do 
 
                 that the balance of her life?
 
            
 
                 A.  Again, we are kept in the upright position 
 
                 between -- to balance the muscles in the back and 
 
                 those in the front, her abdominal muscles.  Her 
 
                 abdominal muscle tone was not the best, and her 
 
                 back muscles stay fairly strong and you're 
 
                 literally arching the back, pushing her backwards 
 
                 and putting more stress on the back, and our 
 
                 normal exercise program is designed to increase 
 
                 the abdominal muscle tone to restore a more equal 
 
                 balance as far as her back.
 

 
            
 
            Page   9
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
                 Q.  What you're saying is this lady is making a 
 
                 lot of her own problems.
 
            
 
                 MR. DETLIE:  I would object to that as -- as a 
 
                 misparaphrasing the testimony.
 
            
 
                 Q.  Is that a correct statement, Doctor?
 
            
 
                 A.  I think we can say that because of her 
 
                 noncompliance with weight reduction and exercise 
 
                 that she certainly is accentuating the amount of 
 
                 discomfort that she has.  I honestly think if she 
 
                 would lose the weight and work on an exercise 
 
                 program that her pain could improve.
 
            
 
                 Q.  So in those two respects at least, she is not 
 
                 cooperating?
 
            
 
                 A.  She is noncompliant as far as those two 
 
                 issues, yes.
 
            
 
            (Dr. Neiman deposition, page 23, line 24 through page 26, 
 
            line 11)
 
            
 
                 Dr. Neiman suggested a swimming program, but claimant 
 
            refused on the basis of a personal phobia.  It appears there 
 
            was a tragic drowning in her family history.  However, 
 
            claimant has not undertaken any other exercise program 
 

 
            
 
            Page  10
 
            
 
            
 
            
 
            
 
            
 
            
 
            either.
 
            
 
                 Nonetheless, Dr. Neiman expressed the view that 
 
            claimant did have real pain and that it was speculative to 
 
            consider how much her current pain would be reduced through 
 
            weight loss.  Dr. Neiman also discussed his belief that 
 
            claimant's psychological condition of depression is 
 
            secondary to persistent back pain.  Dr. Neiman agreed that 
 
            back pain was not necessarily the sole cause of depression, 
 
            but certainly felt it was a major aggravating factor.  He 
 
            further pointed out that depression itself can cause a 
 
            psychomotor retardation which can interfere with a number of 
 
            life activities, presumably including claimant's ability to 
 
            cooperate with treatment modalities such as exercise or 
 
            weight loss.
 
            
 
                 Dr. Neiman felt that claimant had reached maximum 
 
            healing on October 10, 1988, as pain had been fairly stable 
 
            and did not seem to be getting better or worse.  He further 
 
            specified his belief that the back pain itself was causally 
 
            related to the lifting incident that is the subject of this 
 
            litigation.  He rated claimant as having sustained a five 
 
            percent impairment of the whole body.
 
            
 
                 On October 30, 1988, Dr. Neiman filled out a functional 
 
            capacity form indicating that claimant could sit, stand or 
 
            walk four hours continuously with rests (in his deposition 
 
            indicating his expectation that claimant would improve to 
 
            eight hours), that she never lift over 51 pounds and only 
 
            occasionally up to 30, and that she only occasionally carry 
 
            11-20 pounds or bend, squat, crawl, climb, or reach above 
 
            shoulder level.  He suggested mild restrictions against 
 
            unprotected heights, being around moving machinery, exposure 
 
            to marked changes in temperature and humidity and exposure 
 
            to dust, fumes and gases.  However, it does not seem that 
 
            all these restrictions are causally related to the work 
 
            injury itself.
 
            
 
                 Claimant was referred by her attorney to a 
 
            psychiatrist, L. Elaine Ham, D.O.  After an initial visit on 
 
            February 6, 1989, Dr. Ham assessed claimant as:
 
            
 
                 Axis I:  (1) Major depressive episode (2) Probable 
 
                 codependency
 
            
 
                 Axis II:  Suspect personality disorder dependent 
 
                 type
 
            
 
                 Dr. Ham continued seeing claimant.  Her chart notes 
 
            reflect that claimant has in the past and now had a number 
 
            of personal problems, including a tendency to engage in 
 
            relationships with alcoholic men and her son being convicted 
 
            of robbery.  On August 21, 1989, Dr. Ham wrote to Social 
 
            Security Disability Determination Services (claimant has 
 
            unsuccessfully sought Social Security disability benefits) 
 
            that claimant suffered from chronic depression secondary to 
 
            her chronic pain and that the prognosis for her improvement 
 
            was poor.  She felt claimant to be disabled and incapable of 
 

 
            
 
            Page  11
 
            
 
            
 
            
 
            
 
            
 
            
 
            gainful competitive employment.
 
            
 
                 Dr. Ham's chart notes repeatedly employ the phrase 
 
            "totally disabled from gainful competitive employment," 
 
            indicating to this reader that those notes were written 
 
            specifically with Social Security disability in mind.  Dr. 
 
            Ham's chart notes of February 21, 1989 note that she 
 
            specifically urged claimant to apply for Social Security 
 
            disability and that she should qualify based on depression 
 
            and physical problems.
 
            
 
                 Dr. Ham is a Diplomate of the National Board of 
 
            Examiners for Osteopathic Physicians and Surgeons and is 
 
            board-eligible in psychiatry for purposes of the American 
 
            College of Neuropsychiatrists.  In a questionnaire as to 
 
            mental residual functional capacity, apparently for Social 
 
            Security purposes, Dr. Ham found claimant to be markedly 
 
            impaired in many respects (e.g., ability to relate to 
 
            others, constriction of interests, ability to carry out very 
 
            short and simple instructions, the ability to accept 
 
            instructions, etc.) and moderately impaired in others (e.g., 
 
            deterioration in personal habits, the ability to simple 
 
            work-related decisions, the ability to ask simple questions, 
 
            etc.).
 
            
 
                 Claimant was also seen for psychiatric evaluation by 
 
            Michael J. Taylor, M.D.  Dr. Taylor reported a diagnosis of 
 
            major depressive disorder, recurrent, and stated to the 
 
            extent claimant's current back discomfort was related to the 
 
            work injury, her disorder had been aggravated.  However, he 
 
            opined that there was absolutely no indication of any 
 
            permanent psychiatric impairment and that there was every 
 
            reason to believe that with appropriate treatment, there 
 
            would be absolutely no psychiatric functional limitations to 
 
            claimant returning to her usual and customary employment.
 
            
 
                 In a letter of March 21, 1990, Dr. Ham responded to Dr. 
 
            Taylor's report, agreeing with everything except that there 
 
            was no permanent psychiatric impairment.  She felt that 
 
            claimant would have chronic mild depressive symptoms which 
 
            would become aggravated with stress and that to attempt 
 
            full-time work with her degree of physical discomfort would 
 
            cause a worsening of depressive symptoms.
 
            
 
                 Claimant was offered vocational assistance with Jack 
 
            Reynolds, rehabilitation consultant.  However, claimant did 
 
            not meaningfully seek to rehabilitate herself.  Claimant 
 
            decided against seeking to obtain her GED and against 
 
            pursuing training in the bookkeeping field.  She was not 
 
            interested in pursuing job placement.  In a report of 
 
            December 21, 1988, Reynolds complained that claimant had not 
 
            followed through with GED training or testing, had not 
 
            pursued classes in income tax preparation, had not contacted 
 
            her counselor at the Iowa Division of Vocational 
 
            Rehabilitation (Paul Halferty), had not looked for 
 
            employment, had not involved herself in exercise programs, 
 
            no longer wished to pursue training, had made no attempt to 
 
            learn how to drive an automobile, and spent the majority of 
 

 
            
 
            Page  12
 
            
 
            
 
            
 
            
 
            
 
            
 
            her time in her house, except for occasional walks of a few 
 
            blocks.
 
            
 
                 It might be noted that claimant testified to the 
 
            ability to walk only two blocks, but continues to live four 
 
            blocks from a bus stop, even though she does not and has 
 
            never driven an automobile.
 
            
 
                 Paul Halferty, Ottumwa area counselor for the Division 
 
            of Vocational Rehabilitation Services, wrote claimant's 
 
            attorney as follows on December 13, 1988:
 
            
 
                 I am in possession of your letter of December 12 
 
                 regarding Helen Maxine Chrisman.  Assuming that 
 
                 she does decide to call for an appointment I will 
 
                 be happy to talk with her.  I do wish, however, to 
 
                 clarify the reasons which led to the closing of 
 
                 the file on August 12, 1988.  The reason was not a 
 
                 difference of an opinion between Maxine and I as 
 
                 to what she would be capable of working on for 
 
                 rehabilitation, but that Maxine wasn't doing 
 
                 anything at all.  She did not keep appointments, 
 
                 she did not start her GED work.  She wouldn't even 
 
                 look into to [sic] starting her GED work, just 
 
                 absolutely did nothing that I could see.  Under 
 
                 those circumstances we simply do not have a client 
 
                 to work with and have little choice but to close 
 
                 the file.
 
            
 
                                conclusions of law
 
            
 
                 Claimant has the burden of proving by a preponderance 
 
            of the evidence that she received an injury on November 20, 
 
            1985 which arose out of and in the course of her employment. 
 
            McDowell v. Town of Clarksville, 241 N.W.2d 904 (Iowa 
 
            1976); Musselman v. Cent. Tel. Co., 261 Iowa 352, 154 N.W.2d 
 
            128 (1967). 
 
            
 
                 The injury must both arise out of and be in the course 
 
            of the employment.  Crowe v. DeSoto Consol. School Dist., 
 
            246 Iowa 402, 68 N.W.2d 63 (1955) and cases cited at pp. 
 
            405-406 of the Iowa Report.  See also Sister Mary Benedict 
 
            v. St. Mary's Corp., 255 Iowa 847, 124 N.W.2d 548 (l963) and 
 
            Hansen v. State of Iowa, 249 Iowa 1147, 91 N.W.2d 555 
 
            (1958).
 
            
 
                 The words "out of" refer to the cause or source of the 
 
            injury.  Crowe v. DeSoto Consol. School Dist., 246 Iowa 402, 
 
            68 N.W.2d 63 (1955). 
 
            
 
                 The words "in the course of" refer to the time and 
 
            place and circumstances of the injury.  McClure v. Union, 
 
            et al., Counties, 188 N.W.2d 283 (Iowa 1971); Crowe v. 
 
            DeSoto Consol. School Dist., 246 Iowa 402, 68 N.W.2d 63 
 
            (1955).
 
            
 
                 The claimant has the burden of proving by a 
 
            preponderance of the evidence that the injury of November 
 

 
            
 
            Page  13
 
            
 
            
 
            
 
            
 
            
 
            
 
            20, 1985 is causally related to the disability on which she 
 
            now bases her 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 
 
            Hosp., 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. Cent. Tel. Co., 261 
 
            Iowa 352, 154 N.W.2d 128 (1967).
 
            
 
                 Claimant's credible testimony establishes that she 
 
            suffered a falling incident as she described while assisting 
 
            a patient on November 20, 1985.  The incident was promptly 
 
            reported and claimant sought medical attention the following 
 
            day.  There is no question but that she was engaged in the 
 
            course of her normal duties when this incident occurred.  
 
            Claimant has met her burden of proof in establishing that 
 
            she sustained an injury arising out of and in the course of 
 
            her employment.
 
            
 
                 Various physicians in this record have attributed 
 
            claimant's onset of symptoms to the lifting incident.  No 
 
            contrary evidence appears of record.  Claimant has 
 
            established that the work incident is causally related to 
 
            both temporary and permanent disability, although there is 
 
            conflict in the evidence as to the extent of permanent 
 
            disability.
 
            
 
                 Under Iowa Code section 85.34(1), healing period is 
 
            compensable beginning on the date of injury and until the 
 
            employee has returned to work, it is medically indicated 
 
            that significant improvement from the injury is not 
 
            anticipated, or until the employee is medically capable of 
 
            returning to substantially similar employment, whichever 
 
            first occurs.
 
            
 
                 Claimant has never returned to work.  It is unclear 
 
            from the record whether she would have been able to return 
 
            to the same position with a 50-pound lifting restriction on 
 
            May 27, 1986, but this date was, at least, the date upon 
 
            which her condition "stabilized" in Dr. Berg's opinion and 
 
            seems in retrospect to have been something of a high-water 
 
            mark, as claimant's sciatic pain was resolving and markedly 
 
            improved.  Afterwards, she gained substantial weight and her 
 

 
            
 
            Page  14
 
            
 
            
 
            
 
            
 
            
 
            
 
            condition appears to have deteriorated, at least as shown by 
 
            more restrictive medical limitations imposed years later.  
 
            It is held that claimant is entitled to healing period 
 
            benefits from the date of injury until May 27, 1986, a total 
 
            of 27 weeks.
 
            
 
                 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, expe
 
            rience 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 disabil
 
            ity.  This is so as impairment and disability are not syn
 
            onymous.  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 dis
 
            ability include the employee's medical condition prior to 
 
            the injury, immediately after the injury, and presently; the 
 
            situs of the injury, its severity and the length of healing 
 
            period; the work experience of the employee prior to the 
 
            injury, after the injury and potential for rehabilitation; 
 
            the employee's qualifications intellectually, emotionally 
 
            and physically; earnings prior and subsequent to the injury; 
 
            age; education; motivation; functional impairment as a 
 
            result of the injury; and inability because of the injury to 
 
            engage in employment for which the employee is fitted.  Loss 
 
            of earnings caused by a job transfer for reasons related to 
 
            the injury is also relevant.  These are matters which the 
 
            finder of fact considers collectively in arriving at the 
 
            determination of the degree of industrial disability.
 
            
 
                 There are no weighting guidelines that indicate how 
 
            each of the factors are to be considered.  There are no 
 
            guidelines which give, for example, age a weighted value of 
 
            ten percent of the total value, education a value of fifteen 
 
            percent of total, motivation - five percent; work experience 
 
            - thirty percent, etc.  Neither does a rating of functional 
 
            impairment directly correlate to a degree of industrial 
 
            disability to the body as a whole.  In other words, there 
 
            are no formulae which can be applied and then added up to 
 
            determine the degree of industrial disability.  It therefore 
 
            becomes necessary for the deputy or commissioner to draw 
 
            upon prior experience, general and specialized knowledge to 
 
            make the finding with regard to degree of industrial dis
 
            ability.  See Peterson v. Truck Haven Cafe, Inc., (Appeal 
 
            Decision, February 28, 1985); Christensen v. Hagen, Inc., 
 

 
            
 
            Page  15
 
            
 
            
 
            
 
            
 
            
 
            
 
            (Appeal Decision, March 26, 1985).
 
            
 
                 This case presents problems in determining industrial 
 
            disability.  Although claimant has seen numerous physicians 
 
            and undergone extensive sophisticated testing, including 
 
            magnetic resonance imaging, myelography and computerized 
 
            tomography, there is absolutely no objective evidence of any 
 
            structural abnormality.  Claimant appears to have sustained 
 
            some nature of soft tissue injury, a strain or sprain, which 
 
            has never fully resolved.  The testimony of Dr. Neiman and 
 
            Dr. Berg indicates that in the ordinary course of affairs, 
 
            claimant would have been expected to make a full or nearly 
 
            full recovery.  Unfortunately, claimant was about 30 pounds 
 
            overweight at the time of the injury and has gained 
 
            approximately 20 pounds since then (and in particular, since 
 
            May 27, 1986).  In addition to gaining substantial weight 
 
            (on the order of a 10 percent increase), claimant has 
 
            completely refused to take any steps whatsoever towards her 
 
            own rehabilitation.  Although an exercise program was 
 
            suggested by Dr. Neiman, swimming or otherwise, claimant has 
 
            done nothing.  She has missed appointments.  She has decided 
 
            against pursuing a GED or other education.  She candidly 
 
            told Dr. Weinstein that she would not at all mind being a 
 
            homemaker for the rest of her life if she could be 
 
            financially secure.
 
            
 
                 The best evidence in this case indicates that claimant 
 
            had greatly improved by May 27, 1986, and could have 
 
            reasonably been expected to continue to improve but for her 
 
            self-limitation, weight gain and refusal to participate in 
 
            such necessary rehabilitative steps as an exercise program.  
 
            As a result, her pain has become worse (both Dr. Neiman and 
 
            Dr. Berg gave graphic testimony of the "leverage" effect of 
 
            increased abdominal weight as a back stressor) and the 
 
            increased pain has contributed to her depression.
 
            
 
                 There can be little doubt but that for many people 
 
            accomplishing a large weight loss is easier said than done.  
 
            Yet, who should bear the financial burden when excessive 
 
            weight is directly related to industrial disability?  In 
 
            fact, it cannot even be said that claimant's problem is due 
 
            to a failure to lose weight, but rather that she gained very 
 
            significant weight after her physical condition "stabilized" 
 
            in the words of Dr. Berg.
 
            
 
                 In many cases this writer considers motivation to be 
 
            perhaps a less significant factor in assessing industrial 
 
            disability than certain others, especially medical 
 
            restrictions.  Industrial disability is a measure of the 
 
            loss of earning capacity, and motivation often is more 
 
            directly related to loss of actual earnings rather than 
 
            earning capacity.  But in this case, claimant's lack of 
 
            motivation is so extreme that it is, itself, by far the 
 
            greatest cause of her current state of ill-being and 
 
            unemployed status.  Even though the medical evidence is that 
 
            claimant's depression was exacerbated or aggravated by her 
 

 
            
 
            Page  16
 
            
 
            
 
            
 
            
 
            
 
            
 
            pain, the continuing pain itself appears most probably 
 
            related to her increased weight and failure to participate 
 
            in therapeutic exercise.
 
            
 
                 It is, of course, to some degree speculative to 
 
            consider what claimant's condition might have been had she 
 
            lost (or at least not gained) weight and otherwise attempted 
 
            to assist in her own rehabilitation.  Yet, it would be 
 
            patently unjust to defendants to permit claimant to in 
 
            effect create her own disability through an unwillingness to 
 
            rehabilitate herself and then send defendants the bill for a 
 
            claimed permanent total disability.  Claimant may indeed be 
 
            totally disabled as she claims, but it appears to be a 
 
            disability mostly of her own making.
 
            
 
                 Accordingly, it appears that the fairest result in this 
 
            case is to evaluate claimant's industrial disability based 
 
            on her condition at the end of the healing period discussed 
 
            above.  She at that time had a medical restriction against 
 
            lifting in excess of 50 pounds, although Dr. Berg apparently 
 
            felt this might improve within the next six months.  This 
 
            restriction might well prevent claimant from returning to 
 
            work as a nurse's aide, but would not necessarily interfere 
 
            with her previous career choices as day care provider and 
 
            self-employed light housecleaner.  In fact, had claimant 
 
            exercised and kept her weight down, she might have no 
 
            medical restriction whatsoever at this point.
 
            
 
                 Considering all these factors then, and the record in 
 
            general otherwise, it is held that claimant has sustained a 
 
            permanent partial disability equivalent to 20 percent of the 
 
            body as a whole, or 100 weeks.
 
            
 
                 As the parties stipulated that defendants voluntarily 
 
            paid 160 weeks, 2 days of compensation at the stipulated 
 
            rate prior to hearing, claimant has already been paid 
 
            benefits in excess of her entitlement.
 
            
 
                 Claimant also seeks compensation under Iowa Code 
 
            section 85.27 for a bill apparently owing to McWilliams Drug 
 
            totalling $434.00, apparently incurred largely for 
 
            psychoactive medications.  The only evidence is a dunning 
 
            letter from a debt collector.  Defendants have disputed 
 
            whether the expenses were incurred for reasonable and 
 
            necessary medical treatment or causally connected to the 
 
            work injury.  It is claimant's burden of proof to establish 
 
            the necessity of this treatment and the causal connection, 
 
            and the record presented is simply too sparse to meet that 
 
            burden of proof.
 
            
 
                                      order
 
            
 
                 THEREFORE, IT IS ORDERED:
 
            
 
                 Claimant shall take nothing further from these 
 
            proceedings.
 
            
 
                 The costs of this action shall be assessed to 
 

 
            
 
            Page  17
 
            
 
            
 
            
 
            
 
            
 
            
 
            defendants pursuant to 343 IAC 4.33.
 
            
 
                 Signed and filed this ______ day of ____________, 1990.
 
            
 
                 
 
            
 
                 
 
                 
 
                                          ______________________________
 
                                          DAVID RASEY
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr. H. Edwin Detlie
 
            Attorney at Law
 
            114 North Market Street
 
            Ottumwa, Iowa  52501
 
            
 
            Mr. Walter F. Johnson
 
            Attorney at Law
 
            111 West Second Street
 
            P.O. Box 716
 
            Ottumwa, Iowa  52501
 
            
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                           1402.60; 1802; 1803
 
                           Filed December 27, 1990
 
                           DAVID RASEY
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            HELEN MAXINE CHRISMAN,        :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :         File No. 812528
 
            RIVER HILLS CARE CENTER,      :
 
                                          :      A R B I T R A T I O N
 
                 Employer,                :
 
                                          :         D E C I S I O N
 
            and                           :
 
                                          :
 
            LIBERTY MUTUAL INSURANCE      :
 
            COMPANY,                      :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ____________________________________________________________
 
            
 
            1802; 1803
 
            Claimant proved she suffered back injury -- a strain or 
 
            sprain -- but no medical tests showed any structural 
 
            abnormality.  She recuperated well for six months, but 
 
            afterwards gained substantial weight and took no steps 
 
            whatsoever to assist in her own rehabilitation.  Her 
 
            condition deteriorated and she developed depression.
 
            Healing period held to end when claimant reached a "high 
 
            water mark" six months after injury and her industrial 
 
            disability was assessed as of that point (medical 
 
            restrictions subsequently were more limiting, but this was 
 
            found to be due to her weight gain and failure to exercise).
 
            
 
            1402.60
 
            Record was too sparse to support award of disputed medical 
 
            benefits where the only evidence was a dunning letter from a 
 
            debt collector.
 
            
 
 
 
 
 
 
 
 
                BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
_________________________________________________________________
 
          
 
     HAROLD C. LEOHR, JR.,    
 
          
 
          Claimant,         
 
          
 
     vs.               
 
                                          File No. 812964
 
     R & A TRUCKING,          
 
                                           R E M A N D
 
          Employer,         
 
                                          D E C I S I O N
 
     and               
 
          
 
     THE TRAVELERS COMPANY,   
 
          
 
         Insurance Carrier,        
 
         Defendants.       
 
_________________________________________________________________
 
This matter is on remand from the Iowa District Court for Black 
 
Hawk County.
 
 
 
                              ISSUE
 
 
 
The issue on remand is the extent of claimant's healing period.
 
 
 
                            FINDINGS OF FACT
 
 
 
Claimant injured his right hand on December 4, 1985.  Claimant was 
 
eventually referred to William F. Blair, M.D.  Dr. Blair testified that 
 
it was his opinion on April 22, 1986 that claimant's hand had healed to 
 
the extent that significant improvement was not expected.  At that time 
 
Dr. Blair felt he could render an opinion on permanent partial disability.  
 
(Exhibit 1, page 9, lines 15-25).  Dr. Blair released claimant to return 
 
to work on June 1, 1986.  Dr. Blair also testified that when he examined 
 
claimant on August 7, 1987 that there had not been any significant change 
 
in his condition since May 6, 1986.
 
 
 
In a letter dated April 22, 1986 Dr. Blair wrote:  "I anticipate a 
 
return to work date of June 1, 1986. ...  Mr. Leohr has probably not 
 
reached his total maximum healing, as additional small amounts of 
 
increases in active range of motion and grip strength are a possibility.  
 
However, for all practical purposes I believe his healing period has 
 
ended."
 
 
 
At the time of the hearing claimant had not returned to work.  Also, 
 
he was not medically capable of returning to substantially similar 
 
employment.
 
 
 
                          CONCLUSIONS OF LAW
 
 
 
Iowa Code section 85.34(1) provides that healing period benefits are 
 
payable to an injured worker who has suffered permanent partial disability 
 
until (1) the worker has returned to work; (2) the worker is medically 
 
capable of returning to substantially similar employment; or (3) the 
 
worker has achieved maximum medical recovery.  The healing period can 
 
be considered the period during which there is a reasonable expectation 
 
of improvement from the disabling condition.  See Armstrong Tire & Rubber 
 
Co. v. Kubli, 312 N.W.2d 60 (Iowa App. 1981).  Healing period benefits 
 
can be interrupted or intermittent.  Teel v. McCord, 394 N.W.2d 405 (Iowa 
 
1986).
 
 
 
The question to be resolved in this case is when claimant achieved 
 
maximum medical recovery.  The evidence of Dr. Blair indicates that 
 
 
 
 
 
 
 

 
claimant reached maximum medical improvement on April 22, 1986.  
 
However, the district court in its ruling has ruled that a decision 
 
ending the healing period on that date was in error.  Although that 
 
appears to be the proper date, the district court decision in this 
 
case is the law of this case.  For the sake of judicial expediency 
 
and efficiency, this agency will acquiesce to the court's ruling.
 
Although Dr. Blair indicated there would be little increase in 
 
improvement after April 22, 1986, he nonetheless did not anticipate a 
 
return to work until June 1, 1986.  Because claimant was not released 
 
to return to work until June 1, 1986, under the facts and law of this 
 
case, claimant did not reach maximum medical improvement until June 1, 
 
1986.  Therefore, claimant's healing period ended on June 1, 1986.
 
 
 
                                  ORDER
 
 
 
THEREFORE, it is ordered:
 
 
 
That defendants are to pay unto claimant healing period benefits from 
 
December 4, 1985 until June 1, 1986, at the rate of one hundred 
 
sixty-two and 40/100 dollars ($162.40) per week.
 
 
 
That defendants shall pay accrued weekly benefits in a lump sum.
 
 
 
That defendants shall pay interest on unpaid weekly benefits awarded 
 
herein as set forth in Iowa Code section 85.30.
 
 
 
That defendants shall file claim activity reports as required by this 
 
agency pursuant to rule 343 IAC 3.1(2).
 
 
 
Signed and filed this ____ day of June, 1993.             
 
                                     ________________________________                        
 
 
 
                                             BYRON K. ORTON                   
 
                                         INDUSTRIAL COMMISSIONER
 
 
 
Copies To:
 
 
 
Mr. Robert D. Fulton
 
Attorney at Law
 
P.O. Box 2634
 
Waterloo, Iowa 50704
 
                                                           
 
Mr. Scott E. McLeod
 
Attorney at Law
 
P.O. Box 2457
 
Cedar Rapids, Iowa 52406
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                   BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         HAROLD C. LEOHR, JR.,
 
         
 
              Claimant,                            File No. 812964
 
         
 
         vs.                                         A P P E A L
 
         
 
         R & A TRUCKING,                           D E C I S I O N
 
         
 
              Employer,                               F I L E D
 
         
 
         and                                         NOV 30 1989
 
         
 
         THE TRAVELERS COMPANY,            IOWA INDUSTRIAL COMMISSIONER
 
         
 
              Insurance Carrier,
 
              Defendants.
 
         
 
         
 
                            STATEMENT OF THE CASE
 
         
 
              Claimant appeals from an arbitration decision awarding 
 
         healing period and permanent partial disability benefits.
 
         
 
              The record on appeal consists of the transcript of the 
 
         arbitration hearing; joint exhibits 1 through 3, 5 through 8 and 
 
         10 through 12; and claimant's exhibits 4 and 9.  Both parties 
 
         filed briefs on appeal.
 
         
 
                                  ISSUES
 
         
 
              Claimant states the issues on appeal are:
 
         
 
               I.  Whether the deputy industrial commissioner erred in not 
 
         awarding the claimant a running award for healing period benefits 
 
         and whether the deputy industrial commissioner erred in not 
 
         entering an order authorizing the claimant to obtain further 
 
         medical treatment from Dr. Delbridge or other qualified hand 
 
         surgeons to relieve his pain syndrome and to get maximum function 
 
         of the hand.  In the alternative if the industrial commissioner 
 
         should determine that there should not be a running award, the 
 
         issue is whether the deputy industrial commissioner was correct 
 
         in setting the end of the healing period as April 22, 1986 as 
 
         opposed to June 1, 1986.
 
         
 
              II.  Whether the deputy industrial commissioner erred in 
 
              holding that the industrial commissioner is bound by the 
 
              impairment ratings of the physicians in assessing disability 
 
              for scheduled injuries and whether the industrial 
 
              commissioner is required to make an independent assessment 
 
              of the extent of disability resulting from a scheduled 
 
              injury based on loss of use of the member.
 
         
 
                                                
 
                                                         
 
                              REVIEW OF THE EVIDENCE
 
         
 
              The arbitration decision filed October 26, 1988 adequately 
 
         and accurately reflects the pertinent evidence and it will not be 
 
         reiterated herein.
 
         
 
                                 APPLICABLE LAW
 
         
 
              The citations of law in the arbitration decision are 
 
         appropriate to the issues and evidence.
 
         
 
                                   ANALYSIS
 
         
 
              The analysis of the evidence in conjunction with the law in 
 
         the arbitration decision is adopted.
 
         
 
              Claimant is correct in stating that the industrial 
 
         commissioner and deputy industrial commissioners are not bound by 
 
         the impairment ratings of physicians in assessing disability for 
 
         scheduled injuries.  However, a review of the deputy's decision 
 
         reveals that she properly considered the law and the evidence 
 
         presented.  In this case the deputy and the undersigned 
 
         determined a physicians rating of impairment to be correct.  That 
 
         does not mean that evidence in another case might point to a 
 
         different conclusion.
 
         
 
                              FINDINGS OF FACT
 
         
 
              1.  Claimant was employed as a mechanic's helper with R & A 
 
         Trucking.
 
         
 
              2.  Claimant is right-hand dominant.
 
         
 
              3.  Claimant sustained an injury arising out of and in the 
 
         course of his employment at R & A Trucking on December 4, 1985 
 
         when his right hand became entangled in a dual semi-tractor tire 
 
         show chain.
 
         
 
              4.  Claimant sought treatment with John Moes, M.D.; Dr. 
 
         Ahrenholz; Dale G. Phelps, M.D.; and William F. Blair, M.D.
 
         
 
              5.  Claimant was examined by Bruce L. Sprague, M.D., and 
 
         Arnold E. Delbridge, M.D.
 
         
 
              6.  Dr. Blair is an Associate Professor of Orthopaedic 
 
         Surgery at the University of Iowa Hospitals and Clinics with a 
 
         subspeciality of hand surgery.
 
         
 
              7.  Dr. Sprague is associated with Surgery of the Hand and 
 
         Upper Extremity.
 
         
 
              8.  Dr. Delbridge has a practice limited to orthopaedic and 
 
         hand surgery.
 
         
 
              9.  Drs. Sprague and Blair do not believe that further 
 
                                                
 
                                                         
 
         surgical intervention and medical treatment would benefit 
 
         claimant, but subsequently felt that, given claimant's rather 
 
         extensive pain syndrome, he was unlikely even with surgery to 
 
         gain additional function of the hand.
 
         
 
              10.  The record is unclear as to whether claimant has 
 
         sympathetic dystrophy of the hand.
 
         
 
              11.  Claimant does have a significant pain experience in the 
 
         hand.
 
         
 
              12.  Additional surgery and medical treatment would not 
 
         significantly benefit claimant and is not reasonable and 
 
         necessary alternate care for claimant.
 
         
 
              13.  Claimant has significant loss of his gripping, pushing, 
 
         pulling, prehension of pinching functions in the hand.
 
         
 
              14.  The AMA guides do not account for the function of 
 
         pinch, grip, hook, and push in determining impairment.
 
         
 
              15.  The AMA guides primarily assess range of motion in 
 
         determining impairment.
 
         
 
              16.  Losses of such functions do not necessarily not 
 
         correlate at least reasonably well with losses of range of 
 
         motion.
 
         
 
              17.  Dr. Delbridge's impairment rating took into account 
 
         claimant's purported sympathetic dystrophy whereas Dr. Blair's 
 
         impairment rating did not.
 
         
 
              18.  Claimant's purported sympathetic dystrophy could well 
 
         be an attempt to account for claimant's significant pain in the 
 
         hand.
 
         
 
              19.  Claimant has a loss of use of the right hand of 65 
 
         percent.
 
         
 
              20.  Claimant has not returned to work and is not medically 
 
         capable of returning to substantially similar employment.
 
         
 
              21.  Claimant achieved maximum medical healing on April 22, 
 
         1986.
 
         
 
                             CONCLUSIONS OF LAW
 
         
 
              Claimant has not established that he is entitled to 
 
         additional medical care as recommended by Dr. Delbridge as 
 
         reasonable and necessary medical care.
 
         
 
              Claimant has established that he is entitled to healing 
 
         period benefits from his injury date through April 22, 1986.
 
         
 
              Claimant has established that he is entitled to permanent 
 
                                                
 
                                                         
 
         partial disability benefits of 65 percent of the right hand.
 
         
 
              WHEREFORE, the decision of the deputy is affirmed.
 
         
 
                                      ORDER
 
         
 
              THEREFORE, it is ordered:
 
         
 
              That defendants pay claimant permanent partial disability 
 
         benefits for an additional one hundred twenty-three point five 
 
         seven one (123.571) weeks at the rate of one hundred sixty-two 
 
         and 40/100 dollars ($162.40) with those payments to commence on 
 
         April 23, 1986.
 
         
 
              That defendants pay claimant healing period benefits at the 
 
         rate of one hundred sixty-two and 40/100 dollars ($162.40 from 
 
         December 4, 1985 through April 22, 1986.
 
         
 
              That defendants pay accrued amounts in a lump sum.
 
         
 
              That defendants.pay interest pursuant to Iowa Code section 
 
         85.30.
 
         
 
              That defendants pay the costs of the hearing proceeding and 
 
         claimant pay the costs on appeal including the cost of the 
 
 
 
                             
 
                                                         
 
         transcription of the hearing proceeding pursuant to Division of 
 
         Industrial Services Rule 343-4.33.
 
         
 
              That defendants file claim activity reports as requested by 
 
         this agency pursuant to Division of Industrial Services Rule 
 
         343-3.1.
 
         
 
              Signed and filed this 30th day of November, 1989.
 
         
 
         
 
         
 
         
 
         
 
         
 
                                               DAVID E. LINQUIST
 
                                            INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. Robert D. Fulton
 
         Attorney at Law
 
         P.O. Box 2634
 
         Waterloo, Iowa  50704
 
         
 
         Mr. Scott E. McLeod
 
         Attorney at Law
 
         P.O. Box 2457
 
         Cedar Rapids, Iowa  52406
 
 
 
 
 
 
            
 
 
 
 
 
                  
 
 
 
                                                 5-1802
 
                                                 Filed June 25, 1993
 
                                                 Byron K. Orton
 
            
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
           
 
            HAROLD C. LEOHR, JR.,      
 
                        
 
                 Claimant,   
 
                        
 
            vs.         
 
                                                File No. 812964
 
            R & A TRUCKING,       
 
                                                  R E M A N D
 
                 Employer,   
 
                                               D E C I S I O N
 
            and         
 
                        
 
            THE TRAVELERS COMPANY,     
 
                        
 
                 Insurance Carrier,    
 
                 Defendants.      
 
            ____________________________________________________________
 
            
 
            5-1802
 
            
 
            On remand from district court it was determined that 
 
            claimant's healing period ended when he reached maximum 
 
            medical improvement.  Under the facts and law of this case 
 
            claimant reached maximum medical improvement when the 
 
            treating doctor anticipated claimant would return to work.
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                            1803 - 2500 - 2700
 
                                            Filed November 30, 1989
 
                                            DAVID E. LINQUIST
 
         
 
                 BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         HAROLD C. LEOHR, JR.,
 
         
 
              Claimant,
 
         
 
         vs.
 
                                                 File No. 812964
 
         R & A TRUCKING,
 
                                                   A P P E A L
 
              Employer,
 
                                                  D E C I S I 0 N
 
         and
 
         
 
         THE TRAVELERS COMPANY,
 
         
 
              Insurance Carrier,
 
              Defendants.
 
         
 
         
 
         
 
         1803
 
         
 
              Claimant awarded permanent partial disability benefits of 65 
 
         percent of the right hand.  Rating of physicians utilized even 
 
         though based on AMA Guides which largely evaluate loss of range 
 
         of motion and which do not generally evaluate other losses of 
 
         hand function.
 
         
 
         2500 - 2700
 
         
 
              Claimant denied request for additional surgery where surgery 
 
         not shown to likely produce significant improvement in function 
 
         of injured hand.  Deputy affirmed on appeal.
 
         
 
         
 
         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         HAROLD C. LEOHR, JR.,
 
         
 
              Claimant,
 
         
 
         vs.
 
                                                    File No.  812964
 
         
 
         R & A TRUCKING,
 
                                                 A R B I T R A T I O N
 
              Employer,
 
                                                    D E C I S I O N
 
         and
 
         
 
         THE TRAVELERS COMPANY,
 
         
 
              Insurance Carrier,
 
              Defendants.
 
         
 
                                   
 
                                   INTRODUCTION
 
         
 
              This is a proceeding in arbitration brought by the claimant, 
 
         Harold C. Leohr, Jr., against his employer, R & A Trucking, and 
 
         its insurance carrier, The Travelers Company, to recover benefits 
 
         under the Iowa Workers' Compensation Act as the result of an 
 
         injury sustained December 4, 1985.  This matter came on for 
 
         hearing before the undersigned deputy industrial commissioner at 
 
         Waterloo, Iowa on October 8, 1987.  A first report of injury was 
 
         filed on January 2, 1986.  The record in this proceeding consists 
 
         of the testimony of claimant and of Sandra K. Leohr as well as of 
 
         joint exhibits 1 through 3, 5 through 8 and 10 through 12 and 
 
         claimant's exhibits 4 and 9.  Defendants' objections to 
 
         claimant's exhibit 9 are overruled.
 
         
 
                                      ISSUES
 
         
 
              Pursuant to the pre-hearing report, the parties stipulated 
 
         that claimant's rate of compensation is $162.40; that claimant 
 
         did receive an injury which arose out of and in the course of his 
 
         employment; and, that there is a causal relationship between that 
 
         alleged injury the claimed disability.  The parties stipulated 
 
         that claimant's disability is a scheduled member loss to the 
 
         right hand, but indicated that the issues remaining to be decided 
 
         are the nature and extent of any such loss and whether claimant 
 
         is entitled to additional treatment under section 85.27.  
 
         Claimant reasserted his request to bifurcate the claim for 
 
         additional medical entitlement with the issue of permanency to be 
 
         determined at a later date.
 
         
 
                            REVIEW OF THE EVIDENCE
 
         
 
              Claimant was a mechanic's helper with the employer, R & A 
 
         Trucking.  As such, he washed trucks with a steam and pressure 
 
         hose.  He also changed oil and lubricated trucks.  Claimant is 
 
         right-hand dominant.  The pressure hose required him to grip with 
 
         his nondominant left hand while using his right hand to control 
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE   2
 
         
 
         
 
         the trigger mechanism.  Claimant used screwdrivers and hammers in 
 
         his work.  Claimant was injured on December 4, 1985 when his 
 
         right hand became entangled in a dual semi-tractor tire snow 
 
         chain.  The hand and chain were pulled under the front dual while 
 
         the semi was operating.
 
         
 
              Claimant initially treated with John Moes, M.D., who 
 
         attempted to refasten the skin.  Claimant saw        Ahrenholz,  
 
         M.D., for skin dressing on seven occasions from December 6, 1985 
 
         through December 31, 1985.  He subsequently saw Dale G. Phelps, 
 
         M.D., on his own.  Dr. Phelps referred claimant to William F. 
 
         Blair, M.D., who prescribed physical therapy and finger braces.  
 
         Claimant also saw Bruce L. Sprague, M.D., at the insurer's 
 
         request and Arnold E. Delbridge, M.D., at his counsel's request.  
 
         Claimant testified that the insurer has not authorized the 
 
         treatment Dr. Delbridge recommended.
 
         
 
              At hearing, claimant demonstrated his loss of use of his 
 
         hand.  Claimant is unable to perform a full pinch mechanism with 
 
         his small, ring or middle fingers.  Claimant can perform a 
 
         limited pinch mechanism with his thumb and index finger, although 
 
         the prescribed mechanism is such that the palm of the thumb 
 
         slides to the side of the index finger.  He cannot perform the 
 
         normal pinch mechanism wherein the palm of both digits would 
 
         meet.  Claimant does use the thumb and index finger mechanism to 
 
         pick up coins, pins and pencils.  Claimant is able to write with 
 
         a "claw-like" motion.  Claimant can grasp a hammer awkwardly 
 
         between the thumb and index finger.  He uses a screwdriver in a 
 
         similar manner.  Claimant cradled a suitcase handle in the palm 
 
         of his hand.  He is unable to grasp in a normal manner.  
 
         Claimant's fingers are very painful to touch.
 
         
 
              Claimant worked from 30-35 hours per week in the spring 
 
         prior to hearing painting trim on an apartment building.  
 
         Claimant reported that he held the one and one-half inch brush 
 
         between his thumb and index finger and that he would hold any 
 
         larger brush in the same manner.  Claimant has not tried painting 
 
         with a larger brush, however.  Claimant drives a Datsun 
 
         stick-shift pickup.  He uses the heel of his hand to shift the 
 
         vehicle.  Claimant changes oil in his own truck and reported he 
 
         could wash the truck since he uses only rags to do so.  Claimant 
 
         reported that he is able to grasp his own lawnmower by using a 
 
         closed lefthand fist and the pinch mechanism of the right thumb 
 
         and index finger.  He reported that he had helped to saw 
 
         Christmas trees in 1986.  Claimant has not.tried driving any 
 
         larger trucks.  He is not registered with Job Service, but 
 
         reported that he would undertake vocational rehabilitation 
 
         following medical treatment and that he has looked into such.
 
         
 
              Claimant's wife, Sandra K. Leohr, substantiated claimant's 
 
         testimony and his demonstrated loss of use of his right hand.
 
         
 
              William F. Blair, M.D., testified by way of his deposition 
 
         taken August 20, 1987.  Dr. Blair is Associate Professor of 
 
         Orthopaedic Surgery at the University of Iowa Hospitals and 
 
         Clinics.  His subspecialty is hand surgery.  The doctor saw 
 
         claimant on March 11, 1986 with a stiff, contracted finger with 
 
         inadequate dorsal skin coverage.  He reported he recommended 
 
         physical therapy and anti-inflammatory medications.  The doctor 
 
         reported that neither claimant's range of motion nor the physical 
 
         functioning of claimant's hand significantly improved while the 
 
         University of Iowa Hospitals and Clinics treated claimant.  
 
         Claimant apparently was discharged from the University's care on 
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE   3
 
         
 
         
 
         May 6, 1986.  The doctor opined that claimant's healing period 
 
         ended on April 22, 1986.  He stated that he had never prescribed 
 
         further surgery for claimant and did not recommend such.
 
         
 
              Claimant was released for work on June 1, 1986.  Dr. Blair 
 
         assigned a 58% permanent partial impairment of the right hand at 
 
         approximately that time.  He agreed that the impairment rating 
 
         was arrived at through use of the AMA guides and considered 
 
         claimant's loss of range of motion, but did not consider 
 
         claimant's injury's effect on his daily life activities.  Dr. 
 
         Blair opined that claimant should still be able to put air in 
 
         tires with a hose and should be able to use a pressurized hose to 
 
         wash trucks.  He agreed that he envisioned both activities as 
 
         one-handed activities with the second hand assisting.  He agreed 
 
         he had not considered the possibility that claimant would need to 
 
         actually drive trucks if he were to work as a truck washer.  Dr. 
 
         Blair opined that claimant could work on a caged platform, but 
 
         stated claimant would possibly have difficulty grasping and 
 
         gripping with the right hand if a free hand were needed for 
 
         balance or support.  The doctor opined claimant would be unable 
 
         to handle a hammer right-handedly, but possibly could handle a 
 
         shovel with modifications, although not proficiently.  The doctor 
 
         reported that he again envisioned such as a one-handed job with 
 
         the second hand used only for assistance.  Dr. Blair opined that 
 
         claimant should be able to drive both a car and pickup, but felt 
 
         that the vibration from operating heavy equipment could create a 
 
         pain syndrome problem.  He reported claimant physically could 
 
         drive a dumptruck with modifications on the gear shift knobs and 
 
         with power steering.
 
         
 
              Dr. Blair was skeptical that a pain clinic would benefit 
 
         claimant.  He felt that the nature of claimant's pathology and 
 
         claimant's demonstrated distress from the injury were factors 
 
         making any benefit less likely.
 
         
 
              The doctor stated he felt surgery was not recommended as a 
 
         result of both the nature and complexity of claimant's problem.  
 
         He described claimant's problem as a combination of fixed joint 
 
         fractures, tendon adhesions and insufficient dorsal skin.  He 
 
         felt claimant had a dysfunctional pain syndrome with pain in the 
 
         hand interfering with use of the hand.  He also felt that 
 
         claimant was distressed and angry with the employer and insurer.  
 
         He opined that, in his experience, persons displaying such an 
 
         emotional state are not optimum candidates for surgery.  The 
 
         doctor stated,  ... as I view his circumstance, no simple, easy, 
 
         relatively low-risk options...are available to us to improve his 
 
         hand." (Exhibit 1, page 16).  He opined that any medical 
 
         treatment to improve the hand would involve a relatively major 
 
         operative procedure with prolonged rehabilitation.
 
         
 
              Dr. Blair did not believe that claimant had reflex 
 
         sympathetic dystrophy.
 
         
 
              The doctor described the hand's important functions, aside 
 
         from range of motion, as gripping, pushing, pulling, prehension 
 
         or pinching.  He stated that a particular function's importance 
 
         is relative to the task one wishes to accomplish.  He agreed that 
 
         the small, ring and large fingers are most important in gripping. 
 
          He stated that claimant has very minimal grip capacity with 
 
         those fingers, but can grip to a very limited extent.  He 
 
         reported claimant has almost no measurable pinch strength, though 
 
         he can proximate the thumb to the side of the index finger.  Dr. 
 
         Blair agreed that the AMA guides' range of motion measurements 
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE   4
 
         
 
         
 
         for determining impairments do not account very well for what 
 
         goes on at the base of the thumb and that that activity is 
 
         critical to the pinch function.  He agreed that the guides do not 
 
         account for the function of pinch, grip, hook, and push in 
 
         determining impairment.
 
         
 
              The doctor opined that any surgery to pull the ring finger 
 
         out into a more extended position would not translate into much 
 
         greater functional capacity to push objects, although it had the 
 
         potential for giving claimant a flatter hand surface.  He stated 
 
         the procedure described for surgery was not one he would attempt 
 
         in the same circumstances, observing:
 
         
 
              Q.  So you do not believe an operative intervention to 
 
              get the ring finger out of the palm in some way 
 
              probably by a combination of tendon grafts and repair 
 
              and fusion of the PIP joint could be accomplished with 
 
              Mr. Leohr?
 
         
 
              A.  I would have to think very, very careful about that 
 
              to be precise, but what's ominous about the plan -- 
 
              first it's not precisely described.  I can't tell what 
 
              is connected and grafted where, extensors or flexors; 
 
              and there's no indication in that description of in 
 
              what sequence these activities are going to be 
 
              performed.  But one of the principles of tendon 
 
              reconstruction is first obtaining an optimum range of 
 
              passive motion across which the tendon graft is made.  
 
              In Leohr's case he has significant contractures of all 
 
              joints, MP, PIP and DIP joints.  It's not logical to be 
 
              tendon grafting across contracted joints until the 
 
              contractures are first addressed.
 
         
 
              Further, it's an extremely unusual clinical 
 
              circumstances, one which would simultaneously 
 
              reconstruct tendons and fuse joints in the same 
 
              fingers.  Like with all these considerations in mind, I 
 
              find the recommendation itself most puzzling and it 
 
              becomes increasingly puzzling to me how that would 
 
              benefit Mr. Leohr.
 
         
 
              Q.  It it could free it from the hand, if it could free 
 
              the fingers from the, hand, you could see how it would 
 
              benefit him?
 
         
 
              A.  Getting back to our previous comments on realistic 
 
              expectation, it is not clear to me, given the 
 
              complexity and the severity of the problems in his 
 
              hand, how some small incremental amounts of improved 
 
              extension in that finger is going to significantly 
 
              improve Mr. Leohr's ability to function, driving truck, 
 
              whatever.
 
         
 
              Q.  And that's how you made your decision, on that 
 
              basis?  You look at the chance of success vis-a-vis 
 
              what you would look at as a functional improvement and 
 
              then you arrived at your decision?
 
         
 
              A.  That along with other factors too.
 
         
 
              Q.  The patient himself?
 
         
 
              A.  Yes.
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE   5
 
         
 
         
 
         
 
         (Exhibit 1, page 36, line 10 through page 38, line 2)
 
         
 
              On April 22, 1986, Dr. Blair advised that claimant avoid 
 
         activities requiring manipulation of small parts, tight pinch 
 
         between the fingers and thumb, and the handling of parts or tools 
 
         that require sustained tight grip with the right hand.  He 
 
         advised that claimant avoid climbing activities, the suspension 
 
         of parts or equipment above shoulder level and work with a 
 
         20-pound, bimanual weight lifting restriction.  The doctor then 
 
         rated claimant's impairment at 58% of the hand, but agreed that 
 
         the determination of impairment was somewhat difficult, given the 
 
         complexity of the injury and the losses of active motion in 
 
         multiple joints including the wrist and  all  fingers.
 
         
 
              On March 3, 1986, Dr. Phelps reported that claimant had what 
 
         looked like Sudeck's [atrophy] and that he also had x-ray 
 
         evidence of reflex sympathetic dystrophy with motteling of the 
 
         bone.  Dr. Phelps is a general orthopaedic surgeon.
 
         
 
              Bruce L. Sprague, M.D., of Surgery of the Hand and Upper 
 
         Extremity, apparently saw claimant on July 23, 1986.  He 
 
         reported:
 
         
 
              On examination today, the patient has full range of 
 
              motion of the elbow, forearm, and wrist of the right 
 
              upper extremity.  He has normal thumb and has full 
 
              extension of the MP, PIP, and DIP joints of the index 
 
              finger with flexion of the MP joint to 70 degrees, 
 
              flexion of the PIP joint to 90 degrees, and the DIP 
 
              joint to 30 degrees.  He has very limited motion 
 
              involving the MP, PIP, and DIP joints of the long 
 
              finger, and the ring finger has a flexure contracture 
 
              of 90 degrees at the PIP joint with no motion at the MP 
 
              joint or DIP joint.  The little finger has flexion of 
 
              30 degrees at the MP joint with limited flexion of 30 
 
              degrees at the PIP joint and no flexion at the DIP 
 
              joint.  He has dysesthesia involving the dorsum of the 
 
              right hand of the long, ring, and little fingers.
 
         
 
              I feel that, because of this gentleman's dysesthesia, 
 
              that no reconstructive surgery is going to be very 
 
              beneficial, and at this point, I feel that the rating 
 
              given by Dr. Blair at the University is a fair one and 
 
              is the best avenue in order to settle this problem.  I 
 
              do not feel that he is a rehabilitative candidate, and 
 
              I do not feel that further medical treatment would be 
 
              beneficial.
 
         
 
              Arnold E. Delbridge, M.D., whose practice is limited to 
 
         orthopaedic and hand surgery, saw claimant on June 3, 1986.  He 
 
         then described claimant's right hand as essentially useless, even 
 
         as a helping hand, because of a flexed ring finger that gets in 
 
         the way of anything he wants to grasp in his palm.  He described 
 
         the flexion as probably due to extensor disruption and subsequent 
 
         flexion contracture of the PIP joint in particular and of the MP 
 
         joint secondarily of the right ring finger.  The doctor reported 
 
         that claimant would like to have something done with his hand to 
 
         improve function, it possible, and stated that that would be very 
 
         difficult, although there were several things that could be done 
 
         which might enhance function.  The doctor proposed the following 
 
         treatments: (1) sympathetic blocks done by anesthesia to relieve 
 
         the element of reflex sympathetic dystrophy that was present, if 
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE   6
 
         
 
         
 
         possible; (2) vigorous physical therapy to get all of the 
 
         mobility possible out of the remaining good joints; (3) operative 
 
         intervention to get the ring finger out of the palm in some way 
 
         probably by a combination of tendon grafts and repair and fusion 
 
         of the joint at the PIP joint; (4) utilization of a TENS unit and 
 
         other pain relieving modalities as well as anti-inflammatories in 
 
         addition to physical therapy to get as much function out of his 
 
         hand as possible; and, (5) appropriate career counseling, if 
 
         necessary.  The doctor reported that, once claimant's finger was 
 
         repositioned so that he could use his hand better, claimant may 
 
         be able to return to some type of mechanic work, although he 
 
         would continue to have problems in not being able to reach in 
 
         tight areas with the right hand.  The doctor stated claimant had 
 
         chronic pain syndrome and needed vigorous treatment, even though 
 
         with vigorous treatment, significant compromise might remain.  He 
 
         stated that, if treatment, rehabilitation and career counseling 
 
         were not pursued vigorously, the patient could well be 
 
         unemployable in the future.
 
         
 
              Dr. Delbridge once again saw claimant on October 5, 1987.  
 
         On October 6, 1987, he reported that claimant had a 45% 
 
         impairment of the upper extremity based on loss of motion of the 
 
         wrist and fingers and additionally had severe hypersensitivity 
 
         problems over his ulnar fingers in his upper extremity.  He 
 
         stated that claimant continued to have reflex sympathetic 
 
         dystrophy of the right upper extremity as well as considerable 
 
         scarring on the dorsum of the hand where he had had skin loss.  
 
         The doctor reported that claimant had an additional 25% 
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE   7
 
         
 
         
 
         impairment of the right upper extremity as the result of the 
 
         reflex sympathetic dystrophy and the extensive scarring.  He 
 
         reported that claimant's permanent impairment of the right upper 
 
         extremity was 59% when 25% and 45% were combined on the AMA 
 
         guides' combined values charts.
 
         
 
              The doctor opined that, while initially he had felt claimant 
 
         would receive some benefit from straightening, particularly the 
 
         PIP joint of his ring finger, with claimant's rather extensive 
 
         pain syndrome he was unlikely even with surgery to gain much 
 
         additional function of the hand.  He recommended that claimant's 
 
         reflex sympathetic dystrophy be brought under control in order 
 
         that his fingers be operated upon to position them in such a way 
 
         that he could use the hand as a helping hand more effectively.  
 
         The doctor opined it was unlikely that claimant would improve 
 
         significantly in terms of function with the exception that, if 
 
         the fingers were brought into a better position, he would have 
 
         less impairment and there would be some hope of bringing his 
 
         reflex sympathetic dystrophy under control.  He stated:
 
         
 
              I am not optimistic that it could be brought under very 
 
              good control, however.
 
         
 
              The balance of the evidence was reviewed and considered in 
 
         the disposition of this matter.
 
         
 
                           APPLICABLE LAW AND ANALYSIS
 
         
 
              Our first concern is whether claimant is entitled to 
 
         additional medical treatment.  Claimant seeks additional medical 
 
         treatment by way of some sort of medical intervention which would 
 
         straighten his hand further as well as relieve his constant pain.  
 
         Section 85.27, unnumbered paragraphs 1 and 4 provide:
 
         
 
              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.
 
         
 
              * * *
 
         
 
              For purposes of this section, the employer is obliged 
 
              to furnish reasonable services and supplies to treat an 
 
              injured employee, and has the right to choose the care.  
 
              The treatment must be offered promptly and be 
 
              reasonably suited to treat the injury without undue 
 
              inconvenience to the employee.  If the employee has 
 
              reason to be dissatisfied with the care offered, the 
 
              employee should communicate the basis of such 
 
              dissatisfaction to the employer, in writing if 
 
              requested, following which the employer and the 
 
              employee may agree to alternate care reasonably suited 
 
              to treat the injury.  If the employer and employee 
 
              cannot agree on such alternate care, the commissioner 
 
              may, upon application and reasonable proofs of the 
 
              necessity therefor, allow and order other care.  In an 
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE   8
 
         
 
         
 
              emergency, the employee may choose the employee's care 
 
              at the employer's expense, provided the employer or the 
 
              employer's agent cannot be reached immediately.
 
         
 
              Having viewed claimant's hand and its limitations at 
 
         hearing, and having evidenced claimant's obvious pain on account 
 
         of his condition, we are sympathetic with claimant's desire for 
 
         further medical treatment.  Unfortunately, we do not believe that 
 
         claimant has established that such treatment would be of such 
 
         significant benefit to him as to constitute reasonable and 
 
         necessary care under our Act.  Initially, Drs. Sprague and Blair, 
 
         an examining and a treating physician, respectively, both of whom 
 
         are orthopaedic hand specialists, do not believe that claimant 
 
         would benefit significantly if at all from reconstructive 
 
         surgery.  Each does not believe that further medical treatment is 
 
         warranted.  Additionally, Dr. Blair does not believe that 
 
         claimant has reflex sympathetic dystrophy.  Likewise, the record 
 
         taken as a whole does not clearly establish the presence of that 
 
         condition.  Dr. Delbridge initially opined that sympathetic 
 
         blocks to deal with the reflex sympathetic dystrophy which he 
 
         believed was present would be appropriate.  He also advised 
 
         vigorous physical therapy, use of a TENS unit, and operative 
 
         intervention.  He later opined that, with claimant's rather 
 
         extensive pain syndrome, claimant was unlikely even with surgery 
 
         to gain much additional function of the hand, however.  Hence, 
 
         the physician whose opinions are most in keeping with claimant's 
 
         desire for additional treatment also ultimately offers little 
 
         hope that additional medical intervention would significantly 
 
         assist claimant.  Furthermore, as Dr. Blair pointed out in his 
 
         deposition as quoted in the review of the evidence above, the 
 
         precise nature of the operative intervention proposed was not 
 
         presented on this record.  Without such, one must agree with Dr. 
 
         Blair that "the recommendation [for surgery] itself [is] most 
 
         puzzling and it becomes increasingly puzzling .... how that would 
 
         benefit [claimant]."  Therefore, while we sympathize greatly with 
 
         claimant's plight, we must respectfully decline his request for 
 
         additional medical treatment as claimant has not established that 
 
         such treatment is reasonable and necessary treatment and 
 
         appropriate alternate care under our Act.
 
         
 
              We reach the question of benefit entitlement.
 
         
 
              As claimant has not established that he is entitled to 
 
         additional medical treatment and a running award of healing 
 
         period benefits., we must initially determine whether claimant 
 
         has reached maximum medical improvement.
 
         
 
              Section 85.34(l), Code of Iowa, provides that healing period 
 
         benefits are payable to an injured worker who has suffered 
 
         permanent partial disability until (1) he has returned to work; 
 
         (2) is medically capable of returning to substantially similar 
 
         employment; or, (3) has achieved maximum medical recovery.  The 
 
         industrial commissioner has recognized that healing period 
 
         benefits can be interrupted or intermittent.  Willis v. Lehigh 
 
         Portland Cement Company, Vol. 2-1, State of Iowa Industrial 
 
         Commissioner Decisions, 485 (1984).
 
         
 
              Claimant has not returned to work and is not medically 
 
         capable of returning to substantially similar employment.  As no 
 
         further treatment would likely be beneficial to claimant, he has 
 
         reached maximum medical improvement, however.  Dr. Blair has 
 
         opined that claimant's healing period ended on April 22, 1986.  
 
         He released claimant for work on June 1, 1986 and assigned a 
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE   9
 
         
 
         
 
         permanent partial impairment rating at approximately that time.  
 
         Claimant was discharged from the University's care on May 6, 
 
         1986.  Under various scenarios, any of the above events could be 
 
         taken as demonstrating the point of maximum medical improvement.  
 
         Each is in close proximity to the others also.  We have the 
 
         doctor's express opinion that the healing period ended on April 
 
         22, 1986.  We believe that the point of maximum medical 
 
         improvement is essentially an issue of medical evidence properly 
 
         within the province of the doctor's expertise.  Therefore, we 
 
         defer to the doctor.  Claimant is entitled to healing period 
 
         benefits from his injury date through April 22, 1986.
 
         
 
              We next reach the question of the nature and extent of 
 
         claimant's permanency entitlement.  The parties have stipulated 
 
         that claimant's injury is a scheduled member injury to the right 
 
         hand.  The fighting issue is whether the permanent partial 
 
         impairment ratings assigned by the doctors and generally derived 
 
         through use of the AMA Guides to Evaluation of Impairment are 
 
         appropriate in this case.  Claimant argues forcefully that the 
 
         guides' reliance on loss of range of motion for determination of 
 
         impairment represents an inappropriate standard for evaluating 
 
         claimant's actual loss of use or function in his hand.
 
         
 
              Section 85.34(2)(1) provides that 190 weeks of compensation 
 
         shall be paid for the loss of a hand.
 
         
 
              Section 17A.14(5) provides that the agency's experience, 
 
         technical competence, and specialized knowledge may be utilized 
 
         in the evaluation of evidence.
 
         
 
              The Iowa Supreme Court has' recognized that the Act was 
 
              enacted to benefit the employee and the Act should be 
 
              liberally construed, but there is also a recognition in 
 
              scheduled injury cases of the legislatures privilege to 
 
              draw definite lines, which are necessarily arbitrary, 
 
              to guide the industrial commissioner.  The guidelines 
 
              are not subject to the commissioner's discretion.
 
         
 
         (Lawyer and Higgs, Iowa Workers' Compensation--Law and Practice, 
 
         section 13-4).
 
         
 
              Section 85.34(2)(u), second unnumbered paragraph, provides:
 
         
 
              If it is determined that an injury has produced a 
 
              disability less than that specifically described in 
 
              said schedule, compensation shall be paid during the 
 
              lesser number of weeks of disability determined, as 
 
              will not exceed a total amount equal to the same 
 
              percentage proportion of said scheduled maximum 
 
              compensation.
 
         
 
              Dr. Blair has assigned claimant a 58% permanent partial 
 
         impairment of the right hand.  He arrived at that rating through 
 
         use of the AMA guides considering claimant's loss of range of 
 
         motion, but not considering claimant's injury's effects on his 
 
         daily life activities.  Dr. Sprague has concurred with that 
 
         impairment rating.  He also considered claimant's loss of range 
 
         of motion as well as dysesthesia involving the dorsum of the 
 
         right hand of the long, ring, and little fingers.  Dr. Delbridge 
 
         has given claimant a 45% impairment of the upper extremity based 
 
         on loss of motion of the wrist and fingers and additionally 
 
         severe hypersensitivity problems over his ulnar fingers.  He gave 
 
         claimant an additional 25% impairment of the right upper 
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE  10
 
         
 
         
 
         extremity as a result of the reflex sympathetic dystrophy and 
 
         extensive scarring.  He reported that, under the combined values 
 
         charts, that resulted in a 59% right upper extremity impairment.  
 
         As claimant's injury is agreed to be limited to the hand and the 
 
         impairments which Dr. Delbridge cites are also to the hand, Dr. 
 
         Delbridge's rating equates to 65% permanent partial impairment of 
 
         the right hand.
 
         
 
              As noted, claimant forcefully argues that the issue is the 
 
         extent of disability and not simply the extent of impairment.  We 
 
         note, however, that the legislature has, through use of the 
 
         schedule, equated loss or loss of use with disability in the case 
 
         of scheduled member losses such as claimant's.  Hence, we find no 
 
         basis for the argument that compensating a scheduled loss through 
 
         a medically arrived at permanent partial impairment rating is 
 
         compensation which does not compensate for disability.  Claimant 
 
         further argues that the undersigned should assess claimant's loss 
 
         as demonstrated at hearing and arrive at an evaluation 
 
         substantially different from that of the various medical 
 
         practitioners in that the loss demonstrated at hearing related to 
 
         claimant's ability to function in daily life activities and in 
 
         activities which his original employment involved, whereas the 
 
         impairment ratings as arrived at by the physicians generally 
 
         concentrated on claimant's demonstratable loss of motion and 
 
         diagnosed medical conditions and not on his limitations of daily 
 
         life.  Claimant, in essence, asks that we substitute our judgment 
 
         for that of the physicians assessing claimant's impairment and 
 
         thereby his disability.  We agree that claimant has a substantial 
 
         loss of use of his hand.  We note that Dr. Blair has stated the 
 
         AMA guides do not account for loss of pinch function related 
 
         conditions.  We do not agree, however, that our subjective, 
 
         nonmedical judgment would result in a more accurate assessment of 
 
         claimant's actual loss of use than results under the AMA guides.  
 
         While, as claimant notes, the AMA guides rely primarily on loss 
 
         of range of motion in assessing the loss of use to the hand, no 
 
         showing has been made that the degree of that loss evaluation 
 
         does not correlate significantly with the degree of loss which 
 
         might be found by assessing other losses of function such as the 
 
         pinch, grip and grasping losses which claimant possesses.  We 
 
         will rely upon the doctors' assessments of impairment in 
 
         assessing claimants loss of use.  The doctors' assessments do not 
 
         differ substantially.  Drs. Blair and Sprague report 59% 
 
         impairment of the hand; Dr. Delbridge, 65% impairment of the 
 
         hand.  Dr. Delbridge takes into account reflex sympathetic 
 
         dystrophy which he believes is present, but which diagnosis is 
 
         not altogether established on the record as a whole.  Dr. Blair 
 
         discounts that condition's presence; Dr. Sprague has noted 
 
         claimant's dysesthesia.  Claimant has a great deal of pain and it 
 
         is proper to take pain into account when assessing impairment.  
 
         Dr. Delbridge's reference to sympathetic dystrophy could well be 
 
         an attempt to deal with claimant's pain syndrome.  Dr. Blair 
 
         apparently has not considered pain in arriving at his assessment.  
 
         We accept the impairment rating of Dr. Delbridge as the most 
 
         accurate assessment on the record of claimant's loss of use of 
 
         his hand.  Claimant is entitled to permanent partial disability 
 
         on account of his loss of use of the hand of 65% of the hand.  
 
         That rating entitles claimant to 123.5 weeks of permanent partial 
 
         disability benefits at the appropriate rate of $162.40.
 
         
 
                                 FINDINGS OF FACT
 
         
 
              WHEREFORE, IT IS FOUND:
 
         
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE  11
 
         
 
         
 
              Claimant was employed as a mechanic's helper with R & A 
 
         Trucking.
 
         
 
              Claimant is right-hand dominant.
 
         
 
              Claimant sustained an injury arising out of and in the 
 
         course of his employment at R & A Trucking on December 4, 1985 
 
         when his right hand became entangled in a dual semi-tractor tire 
 
         snow chain.
 
         
 
              Claimant sought treatment with John Moes, M.D.; ________ 
 
         Ahrenholz, M.D.; Dale G. Phelps, M.D.; and, William F. Blair, 
 
         M.D.
 
         
 
              Claimant was examined by Bruce L. Sprague, M.D., and Arnold 
 
         E. Delbridge, M.D.
 
         
 
              Dr. Blair is an Associate Professor of Orthopaedic Surgery 
 
         at the University of Iowa Hospitals and Clinics with a 
 
         subspecialty of hand surgery.
 
         
 
              Dr. Sprague is associated with Surgery of the Hand and Upper 
 
         Extremity.
 
         
 
              Dr. Delbridge has a practice limited to orthopaedic and hand 
 
         surgery.
 
         
 
              Drs. Sprague and Blair do not believe that further surgical 
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE  12
 
         
 
         
 
         intervention or further medical treatment would benefit 
 
         claimant.
 
         
 
              Dr. Delbridge initially felt that additional surgical 
 
         intervention and medical treatment would benefit claimant, but 
 
         subsequently felt that, given claimant's rather extensive pain 
 
         syndrome, he was unlikely even with surgery to gain additional 
 
         function of the hand.
 
         
 
              The record is unclear as to whether claimant has sympathetic 
 
         dystrophy of the hand.
 
         
 
              Claimant does have a significant pain experience in the 
 
         hand.
 
         
 
              Additional surgery and medical treatment would not 
 
         significantly benefit claimant and is not reasonable and 
 
         necessary alternate care for claimant.
 
         
 
              Claimant has significant loss of his gripping, pushing, 
 
         pulling, prehension or pinching functions in the hand.
 
         
 
              The AMA guides do not account for the function of pinch, 
 
         grip, hook, and push in determining impairment.
 
         
 
              The AMA guides primarily assess range of motion in 
 
         determining impairments.
 
         
 
              Losses of such functions do not necessarily not correlate at 
 
         least reasonably well with losses of range of motion.
 
         
 
              Dr. Delbridge's impairment rating took into account 
 
         claimant's purported sympathetic dystrophy whereas Dr. Blair's 
 
         impairment rating did not.
 
         
 
              Claimant's purported sympathetic dystrophy could well be an 
 
         attempt to account for claimant's significant pain in the hand.
 
         
 
              Claimant has a loss of use of the right hand of 65%.
 
         
 
              Claimant has not returned to work and is not medically 
 
         capable of returning to substantially similar employment.
 
         
 
              Claimant achieved maximum medical healing on April 22, 
 
         1986.
 
         
 
                                CONCLUSIONS OF LAW
 
         
 
              THEREFORE, IT IS CONCLUDED:
 
         
 
              Claimant has not established that he is entitled to 
 
         additional medical care as recommended by Dr. Delbridge as 
 
         reasonable and necessary medical care.
 
         
 
              Claimant has established that he is entitled to healing 
 
         period benefits from his injury date through April 22, 1986.
 
         
 
              Claimant has established that he is entitled to permanent 
 
         partial disability benefits of 65% of the right hand.
 
         
 
                                      ORDER
 
         
 
              THEREFORE, IT IS ORDERED:
 

 
         
 
         
 
         
 
         LEOHR V. R & A TRUCKING
 
         PAGE  13
 
         
 
         
 
         
 
              Defendants pay claimant permanent partial disability 
 
         benefits for an additional one hundred twenty-three point five 
 
         (123.5) weeks at the rate of one hundred sixty-two and 40/100 
 
         dollars ($162.40) with those payments to commence on April 23, 
 
         1986.
 
         
 
              Defendants pay claimant healing period benefits at the rate 
 
         of one hundred sixty-two and 40/100 dollars ($162.40) from 
 
         December 4, 1985 through April 22, 1986.
 
         
 
              Defendants pay accrued amounts in a lump sum.
 
         
 
              Defendants pay interest pursuant to section 85.30.
 
         
 
              Defendants pay costs pursuant to Division of Industrial 
 
         Services Rule 343-4.33.
 
         
 
              Defendants file Claim Activity Reports as required by the 
 
         agency pursuant to Division of Industrial Services Rule 343-3.1.
 
         
 
         
 
              Signed and filed this 26th day of October, 1988.
 
         
 
         
 
         
 
         
 
         
 
         
 
         
 
         
 
                                          HELENJEAN WALLESER
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. Robert D. Fulton
 
         Attorney at Law
 
         616 Lafayette Street
 
         P.O. Box 2634
 
         Waterloo, Iowa 50704-2634
 
         
 
         Mr. Scott E. McLeod
 
         Attorney at Law
 
         526 Second Avenue SE
 
         P.O. Box 2457
 
         Cedar Rapids, Iowa 52406
 
         
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                                 1803, 2500, 2700
 
                                                 Filed October 26, 1988
 
                                                 HELENJEAN WALLESER
 
         
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         HAROLD C. LEOHR, JR.,
 
         
 
              Claimant,
 
         
 
         vs.
 
                                              File No. 812964
 
         R & A TRUCKING,
 
                                           A R B I T R A T I O N
 
              Employer,
 
                                              D E C I S I O N
 
         and
 
         
 
         THE TRAVELERS COMPANY,
 
         
 
              Insurance Carrier,
 
              Defendants.
 
         
 
         
 
         
 
         1803, 2500, 2700
 
         
 
              Claimant denied request for additional surgery where surgery 
 
         not shown to likely produce significant improvement in function 
 
         of injured hand.
 
         
 
              Claimant awarded permanent partial disability of 65% of the 
 
         right hand.  Ratings of physicians utilized even though based on 
 
         AMA guides which largely evaluate loss of range of motion and 
 
         which do not generally evaluate other losses of hand function.
 
         
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                           5-1402.40
 
                           Filed November 5, 1990
 
                           DAVID RASEY
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            MARK C. GOODE,                :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :         File Nos. 798415
 
                                          :                   813084
 
            GEO. A. HORMEL & CO.,         :
 
                                          :      A R B I T R A T I O N
 
                 Employer,                :
 
                                          :         D E C I S I O N
 
            and                           :
 
                                          :
 
            LIBERTY MUTUAL INSURANCE      :
 
            COMPANY,                      :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ____________________________________________________________
 
            
 
            5-1402.40
 
            Claimant failed to prove shoulder injuries caused permanent 
 
            impairment.