BEFORE THE IOWA INDUSTRIAL COMMISSIONER JOYCE FULLER, Claimant, File No. 825099 vs. A R B I T R A T I 0 N BISHOP DRUMM CARE CENTER, D E C I S I O N Employer F I L E D and APR 21 1989 AETNA CASUALTY & SURETY CO., IOWA INDUSTRIAL COMMISSIONER Insurance Carrier, Defendants. STATEMENT OF THE CASE This is a proceeding in arbitration brought by Joyce Fuller, claimant, against Bishop Drumm Care Center, employer (hereinafter referred to as Drumm), and Aetna Casualty & Surety Co., insurance carrier, defendants, for workers' compensation benefits as a result of an alleged injury on April 17, 1986. On August 22, 1988, a hearing was held on claimant's petition and the matter was considered fully submitted at the close of this hearing. The parties have submitted a prehearing report of contested issues and stipulations which was approved and accepted as a part of the record of this case at the time of hearing. Oral testimony was received during the hearing from claimant and Beatrice,Hood. The exhibits received into the evidence at the hearing are listed in the prehearing report except for exhibit G which was excluded from the evidence. According to the prehearing report, the parties have stipulated to the following matters: 1. On April 17, 1986, claimant received an injury which arose out of and in the course of employment with Drumm. 2. Claimant is seeking.temporary total disability or healing period benefits only from June 16, 1986 to the present time. Defendants agree that she was not working during this time. 3. If the injury is found to have caused permanent disability, the type of disability is a scheduled member disability to the lower extremity. 4. Claimant's rate of weekly compensation in the event of an award of weekly benefits shall be $154.09. ISSUES The parties submitted the following issues for determination in this proceeding: I. Whether there is a causal relationship between the work injury and the claimed disability; and, II. The extent of claimant's entitlement to weekly benefits for disability. STATEMENT OF THE FACTS The following.is a brief statement highlighting the more pertinent evidence presented. Whether or not specifically referred to in this statement, all of the evidence received at the hearing was independently reviewed and considered in arriving at this decision. Any conclusions in the following statement should be viewed as preliminary findings of fact. Claimant is 54 years of age. Claimant testified that she worked for Drumm as a licensed practical nurse from June 1985 until her termination "for cause" in June 1986. The reason for the termination was not discussed at hearing except that claimant admits that it was not related to the work injury. The circumstances surrounding the work injury are not in dispute. Claimant fell and twisted her left ankle while serving food to residents of the care facility. Claimant returned to work and lost no time from work until her termination. However, she states that she continued to experienced swelling and pain and difficulties walking and standing in the weeks following the injury. Claimant's superior at Drumm, Beatrice Hood, testified that she observed no problems with claimant with walking and standing prior to her termination and that claimant was not observed wearing any elastic bandage as claimed by claimant. Hood also stated that the LPNs must walk and stand for very long periods of time in the performance of their work. Claimant had said that she wore an elastic bandage only occasionally at work after pain would develop. Claimant testified that she was in good health prior to the work injury. She had no prior chronic problems with her feet. In a conversation with an insurance claims representative following the accident, she stated that she had slipped on ice in March 1986 but fully recovered without continuing problems. She fell a few years earlier while working at Woodward State Hospital but she could not remember which foot was involved. She denied receiving any prior worker's compensation benefits. Defendants' brief asserts that claimant admitted in answers to interrogatories to a subsequent ankle injury in May 1986. Claimant denied such an injury at hearing and the answers to interrogatories were not offered into the evidence. Claimant testified that she did not seek immediate medical treatment following the injury as she was a LPN and thought she could treat a simple sprained ankle. However, she stated when the pain and swelling continued for almost two months, she sought treatment from the Mercy Medical Clinic and gave a history of an ankle injury in mid April. Claimant testified that she noticed the pain and swelling more when she was off work while walking in search of a job. Claimant denies any intervening injury. Claimant was primarily treated at the Mercy Clinic by John C. Tapp, D.O., a family practice physician. Claimant's ankle swelling was noted by Dr. Tapp who diagnosed chronic ankle strain. When claimant's symptoms persisted, Dr. Tapp referred claimant to an orthopedic surgeon, Martin Dubansky, M.D. On July 23, 1986, claimant requested a note from the clinic regarding her ability to work for the purposes of receiving welfare benefits. An associate of Dr. Tapp, Don Green, M.D., prepared a note which stated, according to his notes, that claimant is "unable to work according to the amount of pain she was having." It is also noted by Dr. Green that claimant became angry when he suggested that she get the note from Dr. Dubansky who had seen her on July 14. Dr. Green noted that he checked with Dubansky's office and there had been no reference in Dr. Dubansky's notes that she should be off work. He apparently had talked to someone in Dubansky's office and not to Dr. Dubansky himself. However, according to Green's notes, there is no question that he prepared a release from work note which claimant apparently gave to the local welfare office to receive food stamps. According to Dr. Dubansky, he first examined claimant in July 1986 and noted "a little tightness in the dorsiflexion of the foot...." He recommended use of an elastic bandage with an outer heel wedge and prescribed Naprosyn. Claimant's symptoms of swelling and pain persisted and in September 1986, Dr. Dubansky took a stress film test which indicated some calcification of the ligaments on the medial and lateral side of the ankle. However, he was unsure if this was the result of the work injury or even whether the calcification was causing claimant's problems. In December 1986, Dr. Dubansky stated to claimant that he was unable to determine the cause of her problems and could not offer further treatment. In a letter to claimant's attorney, Dr. Dubansky causally relates his care and treatment to the work injury of April 1986 by claimant's history of an injury at that time, but he felt that he could not give an impairment rating because he was unable to determine the cause of her problems. In another letter to defense counsel, Dr. Dubansky stated as follows: "If she was able to work and then a couple days or so after she terminated her work to suddenly get worse would be a most unusual circumstance in my particular understanding of the problem." Dr. Tapp stated in his letter to claimant's counsel that by history, he assumed that claimant's painful ankle was related to the April injury, but he stated to defense counsel that it would be unusual for a sprained ankle to get progressively worse after the accident without some precipitating event. On cross-examination, claimant admitted that during the time she claimed to be unable to work she performed some yard work, lawn mowing, shoveling of snow, cleaning of hallways, sweeping and vacuuming and mopping floors for her landlord. She also attended the state fair. Claimant was last treated approximately one and a half years before the hearing. Claimant's appearance and demeanor at hearing indicated she was testifying in a candid and truthful manner. APPLICABLE LAW AND ANALYSIS I. The claimant has the burden of proving by a preponderance of the evidence that the work injury is a cause of the claimed disability. A disability may be either temporary or permanent. In the case of a claim for temporary disability, the claimant must establish that the work injury was a cause of absence from work and lost earnings during a period of recovery from the injury. Generally, a claim of permanent disability invokes an initial determination of whether the work injury was a cause of permanent physical impairment or permanent limitation in work activity. However, in some instances, such as a job transfer caused by a work injury, permanent disability benefits can be awarded without a showing of a causal connection to a physical change of condition. Blacksmith v. All-American, Inc., 290 N.W.2d 348, 354 (Iowa 1980); McSpadden v. Big Ben Coal Co., 288 N.W.2d 181 (Iowa 1980). The question of causal connection is essentially within the domain of expert medical opinion. Bradshaw v. Iowa Methodist Hospital, 251 Iowa 375, 101 N.W.2d 167 (1960). The opinion of experts need not be couched in definite, positive or unequivocal language and the expert opinion may be accepted or rejected, in whole or in part, by the trier of fact. Sondag v. Ferris Hardware, 220 N.W.2d 903 (Iowa 1974). 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 v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965). Furthermore, if the available expert testimony is insufficient along to support a finding of causal connection, such testimony may be coupled with nonexpert testimony to show causation and be sufficient to sustain an award. Giere v. Asse Haugen Homes, Inc., 259 Iowa 1065, 146 N.W.2d 911, 915 (1966). Such evidence does not, however, compel an award as a matter of law. Anderson v. Oscar Mayer & Co., 217 N.W.2d 531, 536 (Iowa 1974). To establish compensability, the injury need only be a significant factor, not be the only factor causing the claimed disability. Blacksmith, 290 N.W.2d 348, 354. In the case of a preexisting condition, an employee is not entitled to recover for the results of a preexisting injury or disease but can recover for an aggravation thereof which resulted in the disability found to exist. Olson v. Goodyear Service Stores, 255 Iowa 1112, 125 N.W.2d 251 (1963). In the case sub judice, claimant has shown by the greater weight of evidence that she suffers from permanent impairment as found by Thomas Bowers, L.P.T. Claimant has limited range of motion. Dr. Dubansky refused to give a rating only because he could not find the cause of the problem. This does not controvert a clear objective finding by Bowers of functional impairment. Also, all documents indicate in the notes an objective finding of swelling months after the incident. With reference to causal connection, claimant's credibility is important. As she is found credible, her denial of subsequent injury and of increased worsening of symptoms substantiates her case. Claimant explains that she felt that she could handle a simple sprained ankle and only sought medical treatment when she realized the symptoms unusually persisted. This appears to be a plausible explanation for her delay in treatment. Admittedly, both Dr. Tapp and Dr. Dubansky felt that it was unusual for a sprained ankle to persist, but generally workers' compensation cases do involve the "unusual" as most people do not get hurt and most fully recover from their work injuries. The lack of observations by Hood of problems while claimant was still working at Drumm can be explained by claimant in that she was not wearing the bandage all the time. Although claimant may have performed a few isolated activities for her landlord, this does not appear to be the same type of activity required of an LPN according to the testimony of Hood. In the last analysis, both Dr. Tapp and Dr. Dubansky causally connect the problems claimant was having in the summer and fall of 1986 with her left ankle to the April injury by relying upon the history of injury provided by claimant. As claimant is found credible, their causal connection opinions prevail. II. Claimant must establish by a preponderance of the evidence the extent of weekly benefits for permanent disability to which claimant is entitled. Permanent partial disabilities are classified as either scheduled or unscheduled. A specific. scheduled disability is evaluated by the functional method; the industrial method is used to evaluate an unscheduled disability. Martin v. Skelly Oil Co., 252 Iowa 128, 133, 106 N.W.2d 95, 98 (1960); Graves v. Eagle Iron Works, 331 N.W.2d 116 (Iowa 1983); Simbro v. DeLong's Sportswear, 332 N.W.2d 886, 997 (Iowa 1983). when the result of an injury is loss to a scheduled member, the compensation payable is limited to that set forth in the appropriate subdivision of Code section 85.34(2). Barton v. Nevada Poultry Co., 253 Iowa 285, 110 N.W.2d 660 (1961). "Loss of use" of a member is equivalent to 'loss' of the member. Moses v. National Union C.M. Co., 194 Iowa 819, 184 N.W. 746 (1922). Pursuant to Code section 85.34(2)(u) the industrial commissioner may equitably prorate compensation payable in those cases wherein the loss is something less than that provided for in the schedule. Blizek v. Eagle Signal Company, 164 N.W.2d 84 (Iowa 1969). From the evidence submitted, Bowers objectively measured claimant's range of motion and found a nine percent permanent partial impairment to the lower extremity. According to his report, this lack of range of motion clearly was related to claimant's symptomatology of persistent swelling in the left ankle. Admittedly, Dr. Dubansky did not provide a rating because he could not provide a scientific explanation for claimant's problems. The lack of an explanation by medical science for a disability is not grounds to deny that a disability exists when there was no problem before the injury and the same symptoms persisted since the time of injury. Therefore, it is found as a matter of fact that the work injury of April 17, 1986, is more likely than not a cause of a nine percent loss of use of claimant's lower extremity. Based upon such a finding, claimant is entitled as a matter of law to 19.8 weeks of permanent partial disability benefits under Iowa Code section 85.34(2)(o) which is nine percent of 220 weeks, the maximum allowable for an injury to the leg in that subsection. As claimant has established entitlement to permanent partial disability, claimant is entitled to weekly benefits for healing period under Iowa Code section 85.34 from the date of injury until she returns to work; until she is medically capable of returning to substantially similar work to the work she was performing at the time of the injury; or, until it is indicated that significant improvement from the injury is not anticipated, whichever occurs first. This agency has held that a return to work does not prevent subsequent healing period benefits. Lawyer & Higgs, Iowa Workers' Compensation -- Law & Practice, section 13-3; Willis v. Lehigh Portland Cement Company, I-2 Iowa Industrial Commissioner Decisions 485 (1984); Clemens v. Iowa Veterans Home, I-1 Iowa Industrial Commissioner Decisions 35 (1984); and, Riesselman v. Carrol Health Center, III Iowa Industrial Commissioner Report 209 (Appeal Decision 1982). The circumstances of claimant's termination from Drumm are not important to her eligibility for healing period benefits in this case. Claimant was under treatment from a qualified physician from June 16, 1986 through December 29, 1986 at which time Dr. Dubansky felt he could no longer treat claimant. During this time claimant was not working and it was anticipated by her physicians that claimant would improve from treatment. Admittedly, Dr. Dubansky did not specifically take claimant off work but claimant was not working at the time and, apparently, he did not feel the need to specifically set this out in his reports. Claimant was continually advised by her physicians to avoid blows and activity to aggravate the injury. As Hood testified, claimant walked extensively at Drumm and this would deter from healing. Therefore, claimant will be awarded healing period benefits during her period of medical treatment for the work injury following her termination. FINDINGS OF FACT 1. Claimant was a credible witness. 2. On April 17, 1986, claimant suffered an injury to the left ankle which arose out of and in the course of employment with Drumm. This injury was a persistent sprained ankle. 3. The work injury of April 17, 1986, was a cause of a period of total disability from work from June 16, 1986 through December 29, 1986 at which time claimant reached maximum healing. During this period of time, claimant was not working and receiving treatment from a qualified physician and it was anticipated she would improve from such treatment. However, she did not fully recover. 4. The work injury of April 17, 1986, was a cause of a nine percent permanent partial impairment to the leg. Due to a persistent swelling of tissue, claimant has a permanent loss of active range of motion. However, claimant had full use of her ankle before the work injury and did not reinjure her ankle after the injury. Claimant's symptoms following the injury has remained the same until the present time. CONCLUSIONS OF LAW Claimant has established under law entitlement to the benefits awarded below. ORDER 1. Defendants shall pay to claimant nineteen point eight (19.8) weeks of permanent partial disability benefits at the rate of one hundred fifty-four and 09/100 dollars ($154.09) per week from December 30, 1986. 2. Defendants shall pay to claimant healing period benefits from June 16, 1986 through December 29, 1986 at the rate of one hundred fifty-four and 09/100 dollars ($154.09) per week. 3. Defendants shall pay accrued weekly benefits in a lump sum and shall receive credit against this award for all benefits previously paid. 4. Defendants shall pay interest on weekly benefits awarded herein as set forth in Iowa Code section 85.30. 5. Defendants shall pay the costs of this action pursuant to Division of Industrial Services Rule 343-4.33. 6. Defendants shall file activity reports on the payment of this award as requested by this agency pursuant to Division of Industrial Services Rule 343-3 1. Signed and filed this 21st day of April, 1989. LARRY P. WALSHIRE DEPUTY INDUSTRIAL COMMISSIONER Copies To: Mr. Robert W. Pratt Attorney at Law 1913 Ingersoll Ave. Des Moines, Iowa 50309 Mr. Glenn Goodwin Attorney at Law 4th Floor Equitable Bldg. Des Moines, Iowa 50309 1803 Filed April 21, 1989 LARRY P. WALSHIRE BEFORE THE IOWA INDUSTRIAL COMMISSIONER JOYCE FULLER, Claimant, File No. 825099 vs. A R B I T R A T I 0 N BISHOP DRUMM CARE CENTER, D E C I S I 0 N Employer, and AETNA CASUALTY & SURETY CO., Insurance Carrier, Defendants. 51803 - Non-precedential Claimant awarded healing period and permanent disability benefits for a scheduled loss of use to the left leg injury. BEFORE THE IOWA INDUSTRIAL COMMISSIONER CARL A. ANDERSON, Claimant, File No. 825104 vs. A R B I T R A T I O N HON INDUSTRIES/PRIME MOVER CO., D E C I S I O N Employer, and F I L E D THE HARTFORD INSURANCE COMPANY; FEB 14 1989 Insurance Carrier, IOWA INDUSTRIAL COMMISSIONER Defendants. STATEMENT OF THE CASE This is a proceeding in arbitration brought by Carl A. Anderson, claimant, against Hon Industries/Prime Mover Co., employer, and The Hartford Insurance Company, insurance carrier, to recover benefits under the Iowa Workers' Compensation Act as a result of an alleged injury of July 12, 1984. This matter came on for hearing before the undersigned deputy industrial commissioner July 12, 1988. The record was considered fully submitted at the close of the hearing. The record in this case consists of the testimony of claimant, Bob Wieskamp, Charles Coulter, Dale Jones, Arthur Williams, Michael Black and Michael Ryan; claimant's exhibits 1 through 18, inclusive; and defendants' exhibits A through D, inclusive. ISSUES Pursuant to the prehearing report and order submitted and approved July 12, 1988, the following issues are presented for resolution: 1. Whether claimant sustained an injury which arose out of and in the course of his employment on July 12, 1988; 2. Whether the alleged work injury is the cause of the disability on which claimant now bases his claim; 3. The extent of claimant's entitlement, if any, to weekly disability benefits including temporary total disability/healing period benefits and permanent partial disability benefits; and, 4. Claimant's entitlement to medical benefits under Iowa Code section 85.27. Also disputed is defendants' assertion of a notice issue under Iowa Code section 85.23. This issue, however, was not listed as an issue on the hearing assignment order and, accordingly, the undersigned is without jurisdiction to consider it. See Joseph Presswood v. Iowa Beef Processors, (Appeal Decision filed November 14, 1986) holding an issue not noted on the hearing assignment order is an issue that is waived. FACTS PRESENTED Claimant testified that on July 12, 1984, he reported for work at his usual time and began working at 6:00 a.m. Claimant reported he took his break at approximately 9:15 a.m. during which time he ate an individual size cherry pie. Claimant stated he felt fine and returned to his welding booth where at approximately 10:00, he began to experience symptoms of indigestion or a stomach ache. Claimant recalled he took some "Tums" which "did not agree with" him, that he raised his welding hood to wipe his brow, that he felt dizzy and went and stood in front of the blower fan to get some air. Claimant testified he then returned to work, began to again experience dizziness along with pain and nausea and went into the center aisle where he hollered he needed help. Claimant recalled he was lying on the floor when the emergency medical technicians came and that he was transferred by ambulance to Muscatine Hospital where he was diagnosed as having suffered a heart attack. Claimant described the condition of the plant and particularly his work area that day as hotter than outside which he felt was "extremely hot" and that because of the arrangement of the blowers no air could get into the welding department. Claimant estimated the outside temperature to have been approximately 92 degrees. Claimant stated that on July 12 he was working on an OE-15, which was a rush job in that it had to be welded (claimant's job), cleaned, painted and assembled by the next Friday. Claimant testified he eventually returned to work in February 1985 in the assembly area but began to experience back problems, that he eventually left work again until approximately August 1985 and that he has worked ever since. Claimant described his current position of making electrical cables as a composite of many other jobs which was specifically created for him but which is less physically demanding than the welding job he previously held. Claimant stated that his current position pays approximately $.75 to $1.00 less per hour. Claimant explained he can walk approximately 100 yards at a time, that he can lift 30 pounds often, 75 pounds occasionally, that he cannot work above his head, cannot bend or stoop and must alternate sitting and standing. Claimant estimated his weight on July 12, 1984 to have been approximately 360 pounds and stated that he weighs more than that currently. Bob Wieskamp, who identified himself as having been a welder/welding lead man for approximately nine years while employed with defendant employer, testified he is familiar with the OE-15 lift and had trained claimant on how to weld it. Mr. Wieskamp estimated that completed the OE-15 weighs from 150 to 200 pounds and that it is necessary to move it around by hand in order to get into the various positions needed to weld. Mr. Wieskamp testified he was familiar with the welding area which he described as the hottest part of the plant with "no ventilation in the [welding] booth." Mr. Wieskamp explained that claimant was operating a "mig" welder which uses shielding gas for a continuous weld and that as a consequence of using that type of gas a welder cannot have very much air movement. Mr. Wieskamp recalled that it was "real hot" inside the plant on July 12, 1984 because he originally felt that claimant had been overcome by the heat. Mr. Wieskamp acknowledged there is a hoist in the welding booth which is used to lift heavy objects but that the hoist would only be practical to be used for the initial and final lifting of the OE-15 and not to move it around while it is being assembled. Charles Coulter, who identified himself as an 11 plus year employee of defendant employer's welding department, testified he was acting as welding foreman on July 12, 1984 and had assigned claimant the job of welding the lift frame. Mr. Coulter asserted this was not a rush job even if it had to be done by Friday since it generally takes less than a day to weld an OE-15 frame and July 12 was a Tuesday or Wednesday. Mr. Coulter recalled that after he returned from his break on July 12 he saw claimant "just standing there" and in response to claimant's comment that he was not feeling well, instructed claimant to go sit down. Mr. Coulter offered that 10 to 15 minutes later he went into the booth and was not made aware in any way that claimant was in any distress but that approximately five minutes later claimant was on the floor needing help. Mr. Coulter recalled July 12 being an "average" summer day between 82 and 85 degrees, not extremely or exceedingly hot since extra breaks had not been given. Dale Jones, an employee of defendant employer, testified to seeing claimant on the bench with his hand on his chest in pain approximately five to ten minutes after break. Mr. Jones recalled the temperature being in the mid 80's, not a lot above normal and on cross-examination acknowledged it is usually hot in the welding booth since welders wear extra clothes. Arthur Williams, who identified himself as defendant employer's plant superintendent, testified that he saw claimant during a "pass through" the morning of July 12 but had no conversation with him. Mr. Williams recalled that the temperature was normal for that time of year, in the 80 degree range, and that it was not exceptionally warm particularly since the early morning hours are the coolest in the plant. Mr. Williams opined that the OE-15's are "not that difficult to weld," that the job was not rush or critical and that welding an OE-15 was no more stressful than doing cylinders, which had been claimant's usual job. Mr. Williams explained that claimant's current job is fairly light duty with no heavy exertion, that he is not aware of any current restrictions imposed on claimant, that claimant is a good steady worker who did a quality job on weldments and that he is not aware of any reason why claimant could not continue to do his job. Mike Black, who identified himself as defendant employer's personnel manager, testified to his recollection of the circumstances surrounding claimant's transfer to the hospital and that the day was warm with no recollection of it being extremely or excessively hot. Mr. Black explained that it is his responsibility to monitor all workers' compensation claims and that it was not until March 1986 that he became aware claimant was asserting an injury arising out of and in the course of his employment. Mr. Black stated that although he was not aware claimant was under any medical restrictions, any restrictions imposed would not jeopardize claimant's current employment. Michael Ryan, who identified himself as a welder employed by defendant employer, testified claimant called out to him that he was feeling ill and that once claimant explained he was feeling chest pains he left to get help, assuming claimant was having a heart attack. Mr. Ryan explained claimant developed the chest pains while sitting down on the bench resting. Mr. Ryan described the day as very warm but not sweltering and not unbearably hot. Philip A. Habak, M.D., Cardiologist, who saw claimant on referral from Marc Sink, M.D., of Muscatine Health Center, succinctly summarized claimant's medical care in a letter dated March 18, 1988 as: At 10:15 AM, the paramedics were called and he was taken to the hospital. He was then found to be suffering from an anteroseptal myocardial infarction. He suffered from ventricular tachycardia and was cardioverted twice. During his stay in the hospital, he developed post-infarction pericarditis and subsequently had peripheral embolization to the left lower extremity requiring endarterectomy. Subsequently, the patient continued to complain of chest discomfort and was transferred to Davenport for further cardiac evaluation. Coronary anteriography was then performed and revealed marked elevation in the left ventricular and diastolic pressure. There was severe coronary artery disease with 70% stenosis of the proximal left anterior descending coronary artery. The circumflex and right coronary artery systems were normal. There was a recent antero-apical myocardial infarction with a left ventricular aneurysm. Medical treatment was then pursued. The patient, however, was hospitalized one month later with an abscess in the left inguinal area at the site of the embolectomy. The abscess was incised and the patient was doing quite well until 4 days later he developed sudden numbness involving both lower extremities. He was examined and no pedal pulses were found on either side. Sensations improved over the next several minutes. The patient was then transferred to Davenport a second time. Ischemia of the left lower extremity was noted. He was then taken to the catheterization laboratory and after baseline anteriography was performed through the right femoral approach, streptokinase was administered starting at the dose of 10,000 units per hour. The patient was returned to the intensive care unit and the streptokinase infusion was continued for 30 hours and had to be terminated eventually on account of a febrile reaction. Following the infusion it was noted that the patient developed good pulses on the right side while on the left side pedal pulses were still absent. Peripheral arteriograms were repeated on, September 11th, and demonstrated a thrombus in the distal left external iliac artery and proximal left common femoral artery. There was a thrombus in the distal common femoral artery and proximal superficial femoral artery with near total occlusion of the deep femoral system, occlusion of the left popliteal artery with reconstitution of flow was also present. The patient was subsequently anti-coagulated with Heparin and was eventually maintained on Coumadin. On account of difficulty drawing blood for a prothrombin time, a port-a-cath was then inserted. He did well subsequently, but developed an infection in the port-a-cath with bacteremia and osteomyelitis. He was hospitalized in Iowa City at that time and was maintained on antibiotics for 6 weeks. More recently, the patient has felt better and has been able to work without significant chest pains or shortness of breath. The patient notes that his left leg does not hurt as long as he goes at his own pace and walks slowly. The patient has learned to live within the limits of his disability. He has no history of rheumatic fever or scarlet fever and denies hypertension and diabetes. (Claimant's Exhibit 3) On November 30, 1987, Dr. Habak opined: I have since reviewed Mr. Anderson's records. It appears that he suffered from a myocardial infarction or heart attack while performing relatively strenuous activities at work. Although underlying coronary artery disease must be present to lead to the patient's heart condition. [sic] It is apparent the heart attack was precipitated or accelerated by the activity the patient was involved at that time. It is also possible that this activity would have accelerated the coronary event Mr. Anderson suffered from on July 12th, 1984. Thus, in my opinion, Mr. Anderson's heart attack was precipitated by the exertion performed at work and this may have been aggravated by the fact that he continued to work after the onset of symptoms. (Cl. Ex. l) When questioned by defendants' counsel, Dr. Habak acknowledged claimant never personally described to him specifically what activity he was performing at work when his problems developed and that the information he got concerning claimant's work came from claimant's counsel. Dr. Habak concluded his opinion by testifying: Q. Your opinion that you gave me then in your letter of November 30th of '87, have you heard anything here that would substantially change that opinion? A. Well, I think that letter was based on my assumption that he was doing a moderately heavy exertion in a warm environment. Q. Okay. A. And it sounds from what Mr. Shepler said that this may not be entirely or at least it requires additional checking into. Q. That would be a matter, I guess, that the judge would have to determine. A. Yeah. Q. But if it's established that this was true, that he was exerting himself moderately and it was a hot environment, then the judge would be justified in accepting -- A. Could I say as.to why I made this statement? Q. Sure. A. At least why my opinion was such. I may perhaps pass this on and you can review what I have underlined in yellow. That might explain my general feeling there. Q. I think that's fair enough and I think that what you're saying is that the facts that we've discussed have to be decided by the judge at the hearing? A. Obviously, yes. (Philip A. Habak Deposition; Cl. Ex. 2, pp. 51-52)) Dr. Habak then provided counsel with an excerpt entitled "Assessment of Causality" from an unknown source. On July 3, 1986, Marc Sink, M.D., Internal Medicine, who saw claimant after his admission to Muscatine Hospital, opined: The cause for Mr. Anderson's heart attack was atherosclerorotic heart disease. I do not feel this was a work-related phenomenon. Mr. Anderson had or has multiple risk factors for coronary disease including the following: l) smoking; 2) family history; 3) massive obesity. (Defendants' Exhibit A) APPLICABLE LAW AND ANALYSIS An employee is entitled to compensation for any and all personal injuries which arise out of and in the course of the employment. Section 85.3(1). The claimant must prove by a preponderance of the evidence that his injury arose out of and in the course of his employment. Musselman v. Central Telephone Co., 261 Iowa 352, 154 N.W.2d 128 (1967). In the course of employment means that the claimant must prove his injury occurred at a place where he reasonably may be performing his duties. McClure v. Union, et al., Counties, 188 N.W.2d 283 (Iowa 1971). Arising out of suggests a causal relationship between the employment and the injury. Crowe v. DeSoto Consolidated School District, 246 Iowa 402, 68 N.W.2d 63 (1955). The supreme court of Iowa in Almquist v. Shenandoah Nurseries, 218 Iowa 724, 254 N.W. 35 (1934) at 731-32, discussed the definition of personal injury in workers' compensation cases as follows: While a personal injury does not include an occupational disease under the workmen's Compensation Act, yet an injury to the health may be a personal injury [Citations omitted.] Likewise a personal injury includes a disease resulting from an injury....The result of changes in the human body incident to the general processes of nature do not amount to a personal injury. This must follow, even though such natural change may come about because the life has been devoted to labor and hard work. Such result of those natural changes does not constitute a personal injury even though the same brings about impairment of health or the total or partial incapacity of the functions of the human body. .... A personal injury, contemplated by the Workmen's Compensation Law, obviously means an injury to the body, the impairment of health, or a disease, not excluded by the act, which comes about, not through the natural building up and tearing down of the human body, but because of a traumatic or other hurt or damage to the health or body of an employee. [Citations omitted.] The injury to the human body here contemplated must be something, whether an accident or not, that acts extraneously to the natural processes of nature and thereby impairs the health, overcomes, injures, interrupts, or destroys some function of the body, or otherwise damages or injures a part or all of the body. As cited above in Crowe, there must be a causal relationship between the employment and the alleged injury. The claimant has the burden of proving by a preponderance of the evidence that the injury of July 12, 1984 is causally related to the disability on which he now bases his claim. Bodish v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965). Lindahl v. L.O. Boggs, 236 Iowa 296, 18 N.W.2d 607 (1945). A possibility is insufficient; a probability is necessary. Burt v. John Deere Waterloo Tractor Works, 247 Iowa 691, 73 N.W.2d 732 (1955). The question of causal connection is essentially within the domain of expert testimony. Bradshaw v. Iowa Methodist Hospital, 251 Iowa 375, 101 N.W.2d 167 (1960). Expert medical evidence must be considered with all other evidence introduced bearing on the causal connection. Burt, 247 Iowa 691, 73 N.W.2d 732. The opinion of experts need not be couched in definite, positive or unequivocal language. Sondag v. Ferris Hardware, 220 N.W.2d 903 (Iowa 1974). However, the expert opinion may be accepted or rejected, in whole or in part, by the trier of fact. Id. at 907. Further, the weight to be given to such an opinion is for the finder of fact, and that may be affected by the completeness of the premise given the expert and other surrounding circumstances. Bodish, 257 Iowa 516, 133 N.W.2d 867. See also Musselman, 261 Iowa 352, 154 N.W.2d 128. While a claimant is not entitled to compensation for the results of a preexisting injury or disease, the mere existence at the time of a subsequent injury is not a defense. Rose v. John Deere Ottumwa Works, 247 Iowa 900, 908, 76 N.W.2nd 756, (1956). If the claimant had a preexisting condition or disability that is aggravated, accelerated, worsened or lighted up so that it results in disability, claimant is entitled to recover. Nicks v Davenport Produce Co., 254 Iowa 130, 115 N.W.2d 812, (1962). When an aggravation occurs in the performance of an employer's work and a causal connection is established, claimant may recover to the extent of the impairment. Ziegler v. United States Gypsum Co., 252 Iowa 613, 620, 106 N.W.2d 591, (1960). The Iowa Supreme Court cites, apparently with approval, the C.J.S. statement that the aggravation should be material if it is to be compensable. Yeager v. Firestone Tire & Rubber Co., 253 Iowa 369, 112 N.W.2d 299 (1961); 100 C.J.S. Workmen's Compensation section 555(17)a. As the question of causal connection is essentially within the domain of expert testimony, review is first given to the medical records and testimony submitted. Initially, it is accepted that there can be no dispute that claimant had a myocardial infarction on July 12, 1987, that the myocardial infarction occurred while he was at work, and that cardiovascular disease was the underlying cause and the cardiovascular disease itself was not caused by the work. Therefore, the issue may more properly be phrased as whether or not the work aggravated, accelerated, worsened or lightened up claimant's underlying cardiovascular disease so as to precipitate the myocardial infarction which occurred on July 12, 1984. Dr. Sink, who was claimant's initial treating physician, opined that the cause of claimant's heart attack was atherosclerotic heart disease which was not a work-related phenomenon. Although Dr. Sink's credentials are not subject to question, he does not appear to have the cardiac training that Dr. Habak has exhibited. Dr. Sink specifically opined that claimant's heart attack was not a work-related phenomenon. Dr. Habak originally opined that claimant's underlying coronary artery disease was accelerated and his heart attack was precipitated by the activity claimant was involved in at work. Yet, Dr. Habak got no work history from claimant as to the work claimant was actually doing at the time of the onset of his symptoms. Dr. Habak was operating on the understanding that claimant suffered his heart attack "while performing relatively strenuous activities at work." Yet, as Dr. Habak's deposition progressed, it is clear to the undersigned that Dr. Habak had no clear understanding of what claimant was doing at the time of the onset of his symptoms. Dr. Habak's final opinion appears to be that if the undersigned should conclude claimant was engaged in "moderately heavy exertion in a warm environment" then the myocardial infarction would be causally connected to the work. While it is a well set principle in Iowa law that the expert's opinion need not be couched in definite, positive or unequivocal language, the undersigned finds Dr. Habak's opinion to be so equivocal as to fail to constitute any dependable opinion on the question of causal connection. As cited above in Burt, a possibility of causal connection is insufficient, a probability is necessary. Dr. Habak's opinion allows only for the possibility that the heart attack was precipitated by the work performed. This does not constitute an opinion within a reasonable degree of medical certainty and does not lead the undersigned to the conclusion that the myocardial infarction was probably caused by the work. As such, the undersigned cannot rely on the opinion. Dr. Habak does attempt to explain his equivocation by referring to the excerpt entitled "Assessment of Causality." However, without some reference to the source of these three pages, without the complete article, without some reference to exactly what Dr. Habak was pointing out, the validity of the information found therein simply cannot be evaluated. Therefore, it is concluded that claimant has failed to meet his burden of establishing that a medical causation exists between his myocardial infarction and his employment and it cannot be concluded that the work on July 12, 1984 acted extraneously to the natural processes of nature so as to impair claimant's health as contemplated by Almquist, supra. The evidence in this case would show that it just as likely claimant would have suffered the myocardial infarction had he not been working. As the court stated in Newman v. John Deere Ottumwa Works, 372 N.W.2d 199 (Iowa 1985) with regard to a nervous injury: "We find no cases which permit recovery when employment merely provides a stage" for the injury. The undersigned here would conclude that the employment merely provided a stage for claimant's heart attack. Accordingly, claimant has failed to establish he sustained an injury which arose out of and in the course of his employment and he shall take nothing further from these proceedings. The other issues raised, therefore, need not be addressed. FINDINGS OF FACT Wherefore, based on all of the evidence presented, the following findings of fact are made: 1. While at work on July 12, 1984, claimant began experiencing symptoms consistent with those of a heart attack. 2. Claimant was hospitalized and found to be suffering an anteroseptal myocardial infarction. 3. Claimant was found to have severe coronary artery disease with 70 percent stenosis of the proximal left anterior descending coronary artery. 4. Marc Sink, M.D., Internal Medicine, opined that claimant's heart attack was not a work-related phenomenon but was caused by arterial sclerotic heart disease. 5. Philip A. Habak, M.D., Cardiologist, rendered varying opinions on the issues of causal connection. 6. Dr. Habak's opinion was so equivocal so as to fail to constitute a dependable opinion on the question of causal connection. 7. Claimant has failed to show that his myocardial infarction constituted an injury arising out of and in the course of his employment. CONCLUSION OF LAW Therefore, based on the principles of law previously stated, the following conclusion of law is made: Claimant failed to establish he sustained an injury on July 12, 1984 which arose out of and in the course of his employment or that the illness with which he has been diagnosed is causally related to his employment. ORDER THEREFORE, it is ordered: Claimant shall take nothing as a result of these proceedings. Costs are assessed against defendants pursuant to Division of Industrial Services Rule 343-4.33. Signed and filed this 14th day of February, 1989. DEBORAH A. DUBIK DEPUTY INDUSTRIAL COMMISSIONER Copies to: Mr. David W. Newell Attorney at Law 323 East Second Street P.O. Box 175 Muscatine, IA 52761 Mr. Larry L. Shepler Attorney at Law Ste 102, Executive Sq. 400 Main St. Davenport, IA 52801-1550 1108.10; 1402.20; 2202 Filed February 14, 1989 Deborah A. Dubik BEFORE THE IOWA INDUSTRIAL COMMISSIONER CARL A. ANDERSON, Claimant, File No. 825104 vs. A R B I T R A T I O N INDUSTRIES/PRIME MOVER CO., Employer, D E C I S I O N and THE HARTFORD INSURANCE COMPANY, Insurance Carrier, Defendants. 1108.10; 1402.20; 2202 Claimant's heart attack not found to be an injury arising out of or in the course of his employment. Medical evidence was insufficient to establish causation. BEFORE THE IOWA INDUSTRIAL COMMISSIONER LARRY GEMMING, Claimant, FILE NO. 825105 vs. A R B I T R A T I O N CONSOLIDATED PACKAGING CORP., D E C I S I O N and LIBERTY MUTUAL INSURANCE COMPANY, Insurance Carrier, Defendants. INTRODUCTION This is a proceeding in arbitration brought by the claimant, Larry Gemming, against his employer, Consolidated Packaging Corp., and its insurance carrier, Liberty Mutual Insurance Company, to recover benefits under the Iowa Workers' Compensation Act as a result of an injury sustained May 8, 1986. This matter came on for hearing before the undersigned deputy industrial commissioner in Burlington, Iowa, on March 18, 1987. The record was considered fully submitted at close of hearing. A first report of injury was filed June 18, 1986. The record in this proceeding consists of the stipulations of the parties and of defendants' exhibits 1 through 3. Claimant appeared through his counsel but not personally. Defendants' exhibit 1 is the deposition of Edward J. DeLashmutt, M.D., taken December 1, 1986. Defendants' exhibit 2 is a medical report of Artemio C. Santiago, M.D., of June 26, 1986. Defendants' exhibit 3 is.an employee absentee report for claimant. ISSUES At hearing, the parties stipulated that claimant received an injury on May 8, 1986 which arose out of and in the course of his employment. They stipulated that claimant's injury was causally related to temporary total disability to claimant from June 26, 1986 to August 11, 1986. They further stipulated that claimant has been paid all temporary total disability benefits due him at the stipulated rate of $234.15. They further stipulated that claimant has been paid all medical benefits due claimant and that claimant has no permanent partial impairment causally related to his injury and that claimant is not entitled to any award of industrial disability as a result of his injury. The parties asked that an order be entered relative to the above GEMMING V. CONSOLIDATED PACKAGING CORP. Page 2 stipulations. REVIEW OF THE EVIDENCE Claimant sustained a left inguinal hernia, both direct and indirect. Each can be associated with lifting. Dr. DeLashmutt operated on claimant on June 27, 1986 and released him to return to work on August 11, 1986. Dr. DeLashmutt testified that claimant should be able to return to his presurgery employment provided that he bends with his knees as opposed to bending over without relaxing the muscles. He opined that claimant did not have any permanent "disability" on account of his hernia repair. Per the stipulation of the parties and per exhibit 3, claimant has returned to work since August 11, 1986 and has continued to work but for vacation time and time off for reasons other than his hernia repair. APPLICABLE LAW AND ANALYSIS The evidence presented is consistent with the stipulations reached by the parties as regards the legal issues. Therefore, an analysis is not warranted. FINDINGS OF FACT THEREFORE, IT IS FOUND: Claimant sustained a left inguinal hernia on or about May 18, 1986. Claimant received surgical repair of the hernia on June 27, 1986. Claimant was released for work on August 11, 1986. Claimant has continued to work for his employer from that date but for vacation time or time missed for reasons other than his inguinal hernia. Claimant sustained no permanent partial impairment as a result of the inguinal hernia. CONCLUSIONS OF LAW THEREFORE, IT IS CONCLUDED: Claimant has not established that his injury of May 8, 1986 is causally related to any permanent partial disability on which he bases his claim. Claimant is not entitled to an award Of permanent partial disability benefits. ORDER THEREFORE, IT IS ORDERED: That claimant take nothing further from this proceeding. GEMMING V. CONSOLIDATED PACKAGING CORP. Page 3 Claimant pay the costs of this proceeding pursuant to Division of Industrial Services Rule 343-4.33, formerly Industrial Commissioner Rule 500-4.33. Signed and filed this 31st day of March, 1987. HELEN JEAN WALLESER DEPUTY INDUSTRIAL COMMISSIONER Copies to: Mr. James P. Hoffman Attorney at Law P.O. Box 1066 Middle Road Keokuk, Iowa 52632 Mr. Walter F. Johnson Attorney at Law P.O. Box 716 111 W. Second St. Ottumwa, Iowa 52501 NO HEADNOTE NUMBER Filed 3-31-87 Helen Jean Walleser BEFORE THE IOWA INDUSTRIAL COMMISSIONER LARRY GEMMING, Claimant, VS. File No. 825105 CONSOLIDATED PACKAGING CORP., 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. Claimant did not appear for hearing. Counsel stipulated no permanent partial disability due claimant. Order entered so stating. BEFORE THE IOWA INDUSTRIAL COMMISSIONER FRANCES E. GRANT, Claimant, vs. File No. 825107 ROYAL NEIGHBORS OF AMERICA, A R B I T R A T I O N Employer, D E C I S I O N and CHUBB GROUP, Insurance Carrier, Defendants. INTRODUCTION This is a proceeding in arbitration brought by the claimant, Frances E. Grant, against her employer, Royal Neighbors of America, and its insurance carrier, The Chubb Group of Insurance Companies, to recover benefits under the Iowa Workers' Compensation Act as the result of an injury sustained July 9, 1984. This matter came on for hearing before the undersigned deputy industrial commissioner at Davenport, Iowa on February 25, 1988. A first report of injury was filed on November 30, 1987. The record in this proceeding consists of the testimony of claimant, of Don Leroy Grant and of Delores Guy, as well as of joint exhibits 1 through 25. ISSUES Pursuant to the pre-hearing report, the parties stipulated that claimant's rate of weekly compensation, in the event of an award, is $146.48; that claimant has not returned to work since her injury; that the provider of medical services would testify that medical costs were fair and reasonable; that claimant did receive an injury which arose out of and in the course of her employment on the alleged injury date; and, that there is a causal relationship between that injury and temporary total disability, which temporary total disability has been paid in the amount of 75.6 weeks. The issues remaining for resolution are: 1. Whether there is a causal relationship between the alleged injury and claimed permanent partial disability; 2. Whether claimant is entitled to benefits and the nature and extent of such benefit entitlement, including any entitlement to additional temporary total disability or any GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 2 entitlement to permanent partial disability and including the related question of whether claimant is an odd-lot employee under the Guyton doctrine; and, 3. Whether claimant is entitled to payment of certain medical expenses under section 85.27 as expenses related to reasonable and necessary medical care causally related to claimant's injury and authorized by defendants. REVIEW OF THE EVIDENCE Claimant was born on May 11, 1936 and is married with five grown children. Apparently, one child died in a house fire in 1982. Claimant has completed eighth grade and has worked in a machine job as a punch press operator. She characterized such as a sitting job in which she lifted weights of five pounds. Claimant has also worked as a waitress, a dietary aide and a cook. She.was last employed at Royal Neighbors as the second cook in which job she did cleanup, food preparation and prepared the evening and any special meals for the 30 home residents and the home staff. Claimant stated that, at that job, she was required to lift large pans and trays of meat and potatoes. She reported that she generally stood, although she might sit while preparing vegetables. Claimant agreed that there were elevators between floors and that carts were available for transporting items. Claimant was apparently off work in November, 1981 as a result of back pain. She also injured herself at home in January, 1984 in a fall. She subsequently saw Mickey J. Burt, D.C., on April 6, 1984. Claimant testified that, on July 9, 1984, she fell to her knees at work. She indicated that subsequent to that fall, she had back pain and headache which worsened throughout the day. She reported that she could hardly walk the next day, that her whole body hurt and that she subsequently did not work, but did see Dr. Burt. Claimant continues to treat with Dr. Burt. She has also been examined by Eugene Collins, M.D., a neurosurgeon, on two occasions at the direction of the insurance carrier. Claimant testified that Dr. Burt has never released her to work. She indicated that the insurer no longer pays the costs of her chiropractic care with Dr. Burt. Claimant characterized herself as continuing to have pain in the legs, the low back, the thoracic back and the neck. She claims that she has a zigzag pattern of lights in her eyes which developed after her fall at work, but agreed that no eye specialist has ever related such to the work fall. Claimant agreed that she had seen Patrick Campbell, M.D., a psychiatrist, for depression subsequent to the death of her son and her mother, but reported that she had last seen Dr. Campbell in 1985. Dr. Campbell had prescribed Xanax for claimant. Claimant voluntarily stopped taking that medication within four or five weeks of hearing. GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 3 Claimant reported that she now washes dishes, sweeps and scrubs floors, makes beds and vacuums two times per week as well as launders approximately once per week in her home. She reported that she does so even though she can stand for only two or three minutes and then must sit for fifteen minutes to rest. Claimant reported that she does arm and leg lifts every day and rides her stationary bicycle each day, but reported that she rides for only five minutes before resting. Claimant opined that she could not tolerate the lifting and standing involved in her work at Royal Neighbors and could do neither waitressing nor factory work. Claimant agreed that she has not contacted Royal Neighbors concerning a work return and that she has not sought other work. She attributed her lack of such activity to the absence of a medical release and her limited education. She agreed that she has also not sought vocational rehabilitation. Claimant could not remember telling the vocational rehabilitation specialist that she was planning to quit her Royal Neighbors employment. She reported that she had not complained about sexual harassment taking place at work until two days prior to her fall, but characterized that harassment as being a very troubling incident. Claimant's husband, Don Leroy Grant, substantiated claimant's testimony concerning her current life activities. Delores Guy, personnel director at Royal Neighbors, reported that, under Royal Neighbors' management policies, an employee must first use sick leave and then is placed on a 21-day unpaid employee status. The employee then must use any vacation leave and then receives 105 days of unbenefited leave of absence. Subsequent to the use of that 105 days, the individual is automatically terminated. She testified that claimant was terminated under that policy. She reported that claimant did have sick leave and leave of absence remaining prior to her fall and stated that, subsequent to the fall at work, all time off was counted as sick leave. Eugene Collins, M.D., a neurosurgeon, testified by way of his deposition taken January 28, 1988. Dr. Collins indicated that he first saw claimant on October 23, 1984 at which time she had decreased range of motion in the neck and low back, but lacked evidence of radiculopathy or myelopathy. The doctor reported that claimant's findings at that time were mostly consistent with strain or flexion/extension injury of the lumbar spine and possibly of the neck region. He referred claimant to R. J. Chesser, M.D., who performed EMG and nerve conduction studies on November 7, 1984. Dr. Collins indicated that Dr. Chesser found a nominal EMG without evidence of radiculopathy or peripheral denervating process in either lower extremity. Claimant also had normal nerve conduction values with no findings evidencing peripheral neuropathy. Dr. Collins recommended that claimant be referred to a phychiatrist for work hardening. Dr. Collins next saw claimant on March 30, 1985. At that time, claimant had increased range of motion of both the neck and the lower back, but continued to have mild point tenderness over the spinal region. Claimant once again had a nonfocal objective neurological exam. GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 4 Dr. Collins opined that he felt there was a strong possibility claimant could return to work in August, 1985 subsequent to Dr. Burt's evaluation. He opined that claimant's healing had plateaued at approximately May 30, 1985. Dr. Collins opined that, with injuries such as claimant's, the majority of individuals will have improved within one year of injury. Dr. Collins stated that he found nothing on May 30, 1985 indicating that claimant was totally, permanently disabled from performing useful industrial work and that claimant could return to her previous job without problems. He did opine that claimant may well have problems lifting greater than 50 pounds on a repetitive basis, however. Dr. Collins opined that claimant's complaints in part were caused by her fall at work. Mickey G. Burt, D.C., testified by way of his deposition taken February 17, 1988. He initially saw claimant on April 6, 1984 subsequent to her January, 1984 fall at home. Her complaints then were of backache, leg tingling, dizziness, headaches and eye difficulties. His impression was of instability in the low back. Conservative chiropractic care was initiated. Claimant was seen through July 5, 1984. On July 5, 1984, claimant's predominant complaint was of pain and discomfort in the thoracic back with burning sensation in the chest when she ate. Dr. Burt stated that, at that time, he did believe claimant would have low back pain as her low back condition appeared to be stabilizing. On July 10, 1984, Dr. Burt's associate, D. Bernard, D.C., saw claimant. At that time, claimant apparently complained of a great deal of discomfort in the thoracic and cervical spine. On August 14, 1984, claimant was provided a low back support. The record is silent as to when claimant began to have low back complaints. Dr. Burt opined that such complaints as well as leg complaints were directly from claimant's fall at work. Dr. Burt reported that he continued to treat claimant through 1985 and that she continued to improve. He reported that, as of July, 1985, he felt claimant's condition was not progressing at a satisfactory rate or had either stagnated or stabilized. A complete neurological exam and x-rays were undertaken. Dr. Burt testified that he found radiculitis involving the sciatic nerve and other pertinent nerves relating to the low back with irritation or ongoing inflammatory condition. He reported that the irritation and inflammatory condition also involved the hip joints and sacroiliac joints. He reported that, subsequent to that exam, that is, as of July 24, 1986, he felt claimant would not significantly improve. Dr. Burt reported that he continues to treat claimant in order to keep her low back stable and to avoid increased neurological disruption or deterioration. Dr. Burt testified that, as of the time of his deposition, claimant's low back was not as painful as it was in July, 1986, but that claimant continued to have intermittent radiating pain in the low back and legs. Dr. Burt characterized claimant's condition as spondylolisthesis of the fifth lumbar, Grade I. He characterized such as producing 20% permanent partial impairment GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 5 to the body as a whole under the AMA guides. The doctor opined that such was directly attributable to claimant's fall at work and stated that he arrived at that conclusion after evaluating x-rays taken prior to the fall. Dr. Burt defined spondylolisthesis as an anterior displacement of the vertebral body and separation of the anterior motor unit and the posterior motor unit resulting in a fracture at the pars interarticulais. He indicated that he first noted the condition on April 6, 1984. He opined that it was directly attributable to the work fall and stated that he had arrived at that conclusion after evaluating x-rays taken prior to the fall. The doctor stated that, after the fall of July 9, 1984, there was anterior displacement of the fifth lumbar vertebra and a widening of the gap between the fracture line. He reported that the fracture line was: ... a hairline measuring possibly one millimeter, and it separated to approximately four to five millimeters after that fall, indicating to us that there was a tearing of the disc, allowing the vertebra to move at an anterior motion. The doctor reported there was also a tearing of the anterior longitudinal ligaments as well as separation of the two motor units causing rearrangement or distortion of the intervertebral foramen. The doctor stated that that situation "can create all kinds of complications on the neurology of that area." The doctor indicated that it was never possible to stabilize the fifth lumbar and end the anterior displacement. He further stated that it was never possible to shorten the gap between the anterior and posterior motor units which [the doctor] felt was directly caused by the fall at work. Dr. Burt opined that the healing phase necessary for recovery of ligamentous structure is generally approximately six months. He felt that claimant's psychological problems added additional stresses and made her case more complex and difficult and thereby were a contributing factor in her [slow] healing process. The doctor stated that claimant had fallen on her patio at home on December 4, 1986 and subsequently had increased symptoms of a burning sensation. The doctor stated that this was a definite exacerbation or aggravation of her condition, but subsequently stated that it did not increase or worsen the preexisting condition as claimant had neither leg pain nor low back pain in March, 1987. Dr. Burt indicated that he knew claimant was a cook at a care facility. He characterized such as involving cooking for several hundred people and opined it would be difficult for claimant to do the lifting, carrying or standing involved. Claimant's left leg is apparently shorter than her right. On April 9, 1984, Dr. Burt prescribed an insert for the left leg. On April 26, 1985, Brent C. Nielsen, O.D., reported that he had examined claimant's vision on March 15, 1985. He stated that, refractively, claimant was hyperopic and presbyopic. Muscle balance tests revealed high exorphoria (convergence insufficiency) at distance and near. He reported that her vision GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 6 reserves to deal with such were very low creating poor fusion. William B. Hoffmann, M.D., Diplomat--American Board of Ophthalmology, examined claimant on March 21, 1985. On March 22, 1985, he noted an impression of hyperopia and presbyopia, but no other ocular pathology. He recommended a CT scan, given claimant's persistent headaches. A brain CT scan with contrast of April 1, 1985 was reported as normal and showing no evidence of focal abnormality, shift of the midline structure or enlargement of the ventricles. On September 30, 1985, the Chubb Group of Insurance Companies notified claimant that her temporary total disability benefits would be terminated effective October 30, 1985, given Dr. Collins' report that she had no objective findings of injury neurologically and that she had reached maximum healing. On March 14, 1986, the Chubb Group of insurance Companies advised Dr. Burt that claimant's benefits were terminated on October 30, 1985 and that he would be paid costs of care to that date. The doctor had apparently submitted a bill totaling $530.72 of which $434.72 was paid by the insurer. Douglas L. Nelson, M.S., CRC, CIRS, of North Central Rehabilitation Service, reported that claimant had worked as a second cook who assisted in lunch and prepared dinner for nursing home residents. He characterized the physical demands of that work as light to medium, demanding up to 50 pounds of maximum lifting with frequent lifting or carrying of objects weighing up to 25 pounds. Standing and walking were characterized as required in excess of 75% of the time. Dexterous use of the arms and hands for reaching, holding and grasping were important job factors. Mr. Nelson later characterized claimant as a vocationally skilled individual in the field of food service work, specialized as a cook. He characterized her as very concerned with her physical status and concerned that she would not be able to tolerate the standing and walking required in her former jobs. Complicating the orthopaedic concerns was claimant's rather extensive psychiatric history. Additionally, the employer indicated that claimant had had extended absences from work due to other health reasons. Mr. Nelson's initial impression was that claimant would be more suited to an employment setting which minimized interpersonal contact, particularly with authority figures. She appeared to be best suited for a position where she had distinct and refined responsibilities with minimal changes in responsibilities. Mr. Nelson later indicated that claimant verbally expressed a desire to return to vocational productivity, but that her treating physician had not encouraged her to do so. Claimant apparently indicated she would not go back to work for Royal Neighbors, even if offered a job. She apparently indicated that she was going to quit anyway, prior to her injury because of significant employee-employer difficulties. Claimant was reported to have questioned whether the employer would have to pay her compensation for the rest of her life if she were unable to return to a position as a cook. Mr. Nelson subsequently reported that claimant continued to complain of numerous symptoms which her doctor of chiropractic GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 7 did not document or substantiate, including inability to read, constant headaches, loss of balance, lack of strength in her legs and inability to bear weight on her left heel. On April 10, 1985, Mr. Nelson reported that claimant objectively regarded herself as incapable of performing any productive activity and stated that minimal progress had been made with regard to vocational counseling. He characterized claimant as remaining extremely bitter towards all parties involved, except for Dr. Burt. He later reported that claimant was performing no exercises beyond walking one-half to one block per day and that no attention was being given to control of her weight or to weight loss which might be contributing factors to her low back discomfort. The balance of the evidence was reviewed and considered in the disposition of this matter. APPLICABLE LAW AND ANALYSIS Our first concern is whether a causal relationship exists between the alleged injury and claimed permanent partial disability. The claimant has the burden of proving by a preponderance of the evidence that the injury of July 9, 1984 is causally related to the disability on which she now bases her claim. Bodish v. Fischer, Inc., 257 Iowa 516, 1,33 N.W.2d 867 (1965). Lindahl v. L. 0. Boggs, 236 Iowa 296, 18 N.W.2d 607 (1945). A possibility is insufficient; a probability is necessary. Burt v. John Deere Waterloo Tractor Works, 247 Iowa 691, 73 N.W.2d 732 (1955). The question of causal connection is essentially within the domain of expert testimony. Bradshaw v. Iowa Methodist Hospital, 251 Iowa 375, 101 N.W.2d 167 (1960). However, expert medical evidence must be considered with all other evidence introduced bearing on the causal connection. Burt, 247 Iowa 691, 73 N.W.2d 732. The opinion of experts need not be couched in definite, positive or unequivocal language. Sondag v. Ferris Hardware, 220 N.W.2d 903 (Iowa 1974). However, the expert opinion may be accepted or rejected, in whole or in part, by the trier of fact. Id. at 907. Further, the weight to be given to such an opinion is for the finder of fact, and that may be affected by the completeness of the premise given the expert and other surrounding circumstances. Bodish, 257 Iowa 516, 133 N.W.2d 867. See also Musselman v. Central Telephone Co., 261 Iowa 352, 154 N.W. 2d 128 (1967). While a claimant is not entitled to compensation for the results of a preexisting injury or disease, the mere existence at the time of a subsequent injury is not a defense. Rose v. John Deere Ottumwa Works, 247 Iowa 900, 908, 76 N.W.2d 756, 760-761 (1956). If the claimant had a preexisting condition or disability that is aggravated, accelerated, worsened or lighted up so that it results in disability, claimant is entitled to recover. Nicks v. Davenport Produce Co., 254 Iowa 130, 115 N.W.2d 812, 815 (1962). We note initially that claimant had preexisting problems in GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 8 her spinal region. She had been off work on account of back pain in 1981 and had fallen at home in January, 1984. She had seen Dr. Burt for that condition from April 4, 1984 through July 5, 1984. His impression at that time was of instability of the low back. After July 5, 1984, claimant saw Dr. Burt on July 10, 1984. That was the day following her work incident. Her complaints at that time were quite similar to her complaints of July 5, 1984 as both involved complaints in the thoracic area. Additionally, on July 10, 1984, claimant was apparently indicating she was having discomfort in the cervical area. Given the similarity of claimant's complaints one day after the fall with her complaints of four days prior to the fall, it is reasonably questionable whether such complaints related to claimant's work fall. The first notice of low back complaints following the work fall is notice that on August 14, 1984 claimant was provided a low back support. The absence of earlier notes of such complaints and the fact that such complaints are only noted more than a month following the work incident raises questions as to the relationship of the low back complaints to the work fall. We believe it reasonable to presume that the low back support would not have been prescribed unless the complaints had been ongoing for at least some period of time, however. Additionally, Dr. Burt has opined that there is a relationship between claimant's current complaints of low back pain and her work incident. He states that his opinion is based on reviewing x-rays taken both before and subsequent to the work incident. Even given Dr. Burt's testimony, we find it difficult, given claimant's previous history, to wholly attribute claimant's low back problems to her work fall, however. Dr. Collins, a neurosurgeon, examined claimant twice. Upon examination, he GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 9 found objective signs of some limitation of range of motion, both in the neck and in the lumbar area. He opines that claimant's complaints, in part, were caused by her work incident, even though he also found claimant overall had a nonfocal objective neurological examination. The evidence, while mixed at best, does support Dr. Collins' finding that at least a portion of claimant's lumbar and cervical complaints relate to her work incident. Claimant has not shown objective evidence that her numerous other complaints relate to her work injury. The examinations of Dr. Hoffmann and Dr. Nielsen as well as the brain CT scan do not show either a head or a visual condition objectively or any relationship of any such condition to the work incident. Claimant has complaints of fatigue, excessive weakness, loss of balance, lack of leg strength and an inability to bear weight on the left heel. The record does not substantiate that such complaints relate to the work incident. Furthermore, given claimant's absence of any objective neurological findings, many of the complaints are simply not consistent with the nature of her injury. It appears more possible that such either relate to claimant's discrepancy in lower leg length or relate to claimant's psychological state which the record reveals was one of considerable stress and anxiety. In any event, claimant has not shown objective evidence of a relationship of such complaints to her work injury. Claimant, at best, has shown some relationship between her work fall and her current cervical and low back complaints. We next consider the question of the nature and extent of claimant's benefit entitlement, including any entitlement to additional temporary total disability or any entitlement to permanent partial disability and including the related question of whether claimant is an odd-lot worker under the Guyton doctrine. 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). Continuing to receive medical care which is maintenance in nature does not extend the healing period beyond the point where claimant actually stopped improving. Armstrong Tire & Rubber Co. v. Kubli, Iowa App. 312 N.W.2d 60 (Iowa 1981); Derochie v.City of Sioux City, II Industrial Commissioner Report, 112 (1982). The employer terminated claimant's temporary total disability benefits on October 30, 1985. Dr. Collins has opined that claimant's healing had plateaued at approximately May 30, 1985. He also opined that the majority of individuals will have improved within one year of an injury such as claimant's. Dr. Burt stated that claimant continued to improve throughout 1985, but that her condition had stabilized on July 24, 1986. He also reported that claimant's psychological state could have GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 10 contributed to her slow progress, given that the healing phase necessary for recovery of ligamenous structure is generally approximately six months. Dr. Burt continues to treat claimant in order to keep her low back stable and to avoid increased neurological disruption or deterioration. While Dr. Burt opined that claimant did not reach maximum healing until July, 1986, there is no objective evidence in the record of significant change in claimant's objective findings in that time frame or of significant change or even of change in claimant's life activities during that period which would suggest that her level of well-being had increased from May 30, 1985 through July 24, 1986. Given the absence of any such evidence, we rely on the testimony of Dr. Collins that an appropriate healing phase for an injury such as claimantOs would be approximately one year. For that reason, we believe that claimant had received her full entitlement to temporary total or healing period benefits when such benefits were terminated on October 30, 1985. We now reach the permanency question and the Guyton doctrine question. Functional disability is an element to be considered in determining industrial disability which is the reduction of earning capacity, but consideration must also be given to the injured employee's age, education, qualifications, experience and inability to engage in employment for which he is fitted. Olson v. Goodyear Service Stores, 255 Iowa 1112, 125 N.W.2d 251 (1963). Barton v. Nevada Poultry, 253 Iowa 285, 110 N.W..2d 660 (1961). A finding of impairment to the body as a whole found by a medical evaluator does not equate to industrial disability. This is so as impairment and disability are not synonymous. Degree of industrial disability can in fact be much different than the degree of impairment because in the first instance reference is to loss of earning capacity and in the later to anatomical or functional abnormality or loss. Although loss of function is to be considered and disability can rarely be found without it, it is not so that a degree of industrial disability is proportionally related to a degree of impairment of bodily function. Factors to be considered in determining industrial disability include the employee's medical condition prior to the injury, immediately after the injury, and presently; the situs of the injury, its severity and the length of healing period; the work experience of the employee prior to the injury, after the injury and potential for rehabilitation; the employee's qualifications intellectually, emotionally and physically; earnings prior and subsequent to the injury; age; education; motivation; functional impairment as a result of the injury; and inability because of the injury to engage in employment for which the employee is fitted. Loss of earnings caused by a job transfer for reasons related to the injury is also relevant. These are matters which the finder of fact considers collectively in arriving at the determination of the degree of industrial disability. There are no weighting guidelines that indicate how each of the factors are to be considered. There are no guidelines which give, for example, age a weighted value of ten percent of the GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 11 total value, education a value of fifteen percent of total, motivation - five percent; work experience - thirty percent, etc. Neither does a rating of functional impairment directly correlate to a degree of industrial disability to the body as a whole. In other words, there are no formulae which can be applied and then added up to determine the degree of industrial disability. It therefore becomes necessary for the deputy or commissioner to draw upon prior experience, general and specialized knowledge to make the finding with regard to degree of industrial disability. See Peterson v. Truck Haven Cafe, Inc., (Appeal Decision, February 28, 1985); Christensen v. Hagen, Inc., (Appeal Decision, March 26, 1985). In Guyton v. Irving Jensen Co., 373 N.W.2d 101 (Iowa 1985), the Iowa court formally adopted the "odd-lot doctrine." Under that doctrine a worker becomes an odd-lot employee when an injury makes the worker incapable of obtaining employment in any well known branch of the labor market. An odd-lot worker is thus totally disabled if the only services the worker can perform are "so limited in quality, dependability, or quantity that a reasonably stable market for them does not exist. The burden of persuasion on the issue of industrial disability always remains with the worker. However, when a worker makes a prima facie case of total disability by producing substantial evidence that the worker is not employable in the competitive labor market, the burden to produce evidence of suitable employment shifts to the employer. It the employer fails to produce such evidence and the trier of fact finds the worker does fall in the odd-lot category, the worker is entitled to a finding of total disability. Id. Even under the odd-lot doctrine, the trier of fact is free to determine weight and credibility of evidence in determining whether the worker's burden of persuasion has been carried, and only in an exceptional case would evidence be sufficiently strong to compel a finding of total disability as a matter of law. Id. In Guyton, the court also stated the following regarding determination of a worker's industrial loss. The question is more than the one posed by the commissioner concerning what the evidence shows Guyton "can or cannot do." The question is the extent to which the injury reduced Guyton's earning capacity. This inquiry cannot be answered merely by exploring the limitations on his ability to perform physical activity associated with employment. It requires consideration of all the factors that bear on his actual employability. See New Orleans (Gulfwide) Stevadores v. Turner, 661 F.2d 1031, 1042 (5th Cir.1981) (are there jobs in the community that the worker can do for which he could realistically compete?) Id. For workmenOs (sic) compensation purposes total disability does not mean a state of absolute helplessness, but means disablement of an employee to earn wages in the same kind of work, or work of a similar nature, that he was trained for, or accustomed to perform, or any other kind of work which a person of his [sic] mentality and attainments could do. Franzen v. Blakley, 155 Neb. 621, 51 N.W.3d 833 (1952). Total GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 12 and permanent disability contemplates the inability of the workman (sic) to perform any work for which he (sic) has the experience or capacity to perform. Shaw v. Gooch Feed Mill Corp., 210 Neb. 17, 312 N.W.2d 682 (1981). Initially, claimant has not shown that she is an odd-lot worker under the Guyton doctrine. While claimant has not returned to work, this record does not support the finding that claimant's lack of any work return relates to her work injury. The record is replete with instances of claimantOs lack of good feelings about her employer. While claimant may well have had good reason to bear ill will toward the employer and while the evidence shows that claimant was ultimately terminated under the employer's automatic termination policy, claimant's failure to contact the employer about reemployment and her statements to Vocational Consultant Nelson suggest that claimant did not intend to return to employment with this employer. Claimant, lacking such intent, can not fairly state that her inability to return to work for the employer wholly relates to the employer's conduct. Additionally, claimant has not sought other work. Claimant attributes her failure to do so to her lack of a medical release from Dr. Burt and her lack of sufficient formal education. The insurer notified claimant on September 30, 1985 that Dr. Collins felt she had reached maximum healing. The record does not show that claimant made any attempts to discuss such with Dr. Burt, her treating physician, or otherwise entertain the possibility that she could resume some kind of meaningful employment. Likewise, Vocational Consultant Nelson's report indicates that claimant does have transferable job skills despite her limited education. Claimant apparently has made no attempt to utilize such skills to find additional employment. While Dr. Burt believes claimant could not return to work as a cook in the care facility, Dr. Collins believes that she could, albeit she might have some difficulties dealing with weights of greater than 50 pounds. The record indicates that Dr. Burt did not have a fair understanding of claimantOs duties as he greatly exaggerated the number of meals claimant would be required to prepare. Such suggests that his understanding of the weights she would be lifting would also be suspect. In any event, claimant's prior skills could well be utilized in other work such as cook's helper or dietary aide and she might well be able to return to factory small parts assembly work. Claimant has attempted none of these. Given the above, it cannot be stated that claimant has demonstrated that her work injury has made her incapable of obtaining employment in any well-known branch of the labor market. Claimant has not shown that her injury has placed her in a position where the only services she can perform are so limited in quality, dependability, or quantity that a reasonably stable market for them does not exist. Likewise, claimant has not shown permanent total disability under more traditional standards. She has not shown disablement to earn wages in the same kind or similar work for which she is trained or accustomed to perform, nor has she shown that she is unable to obtain other work for which she has the mentality and attainments. Claimant's degree of permanency, if any, must be assessed under traditional factors. We note initially that claimant had a GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 13 history of spinal problems prior to the injury. Such were present after the injury and continue to the present. As noted, medical opinion is that some of these relate to the work injury. Despite claimantOs absence of a work return following her work incident, however, it cannot be said that there was an extreme change in her condition subsequent to the injury. The record indicates that claimant had had numerous work absences from medical conditions prior to the injury; her complaints subsequent to the injury were substantially similar to complaints prior to the injury; her psychological state prior to and subsequent to the injury were such as to affect appropriate healing and apparently work return as well. For that reason, while claimant's state of well-being changed subsequent to the injury and on account of the injury, that change, and that portion of claimant's present state of ill-being, properly attributable to her injury is modest at best. Claimant's work experience both prior to and after her injury is substantially the same. As noted above, claimant does have transferable skills and the objective evidence suggests that, were claimant so motivated, she could seek and find employment using such skills. Claimant's potential for rehabilitation appears limited by her psychological problems and her absence of insight into her condition as well as by her limited formal education. However, such is balanced by the fact that claimant has current job skills which she could well be utilizing. Claimant is a middle-aged worker. As she has not returned to work, we have no evidence of what earnings would be subsequent to her injury. Claimant was employed in minimum-skill positions prior to injury and likely would return to such positions, however. Therefore, the record does not support a finding that claimant's potential for earnings has been significantly reduced by her work injury. On the other hand, claimant's 50-pound weight restriction will limit her from some jobs she might have obtained prior to her injury. As noted, claimant appears to have continuing psychological problems which impede her functioning in the world. Those problems apparently affect her motivation to work. While we sympathize with claimant's position, her absence of motivation for psychological reasons unrelated to her work incident must be considered in assessing claimant's loss of earning capacity. Likewise, while claimant's employer terminated her, pursuant to an automatic termination policy, the employerOs unwillingness to accommodate the work-related nature of claimant's long-term absence is also a factor to be considered in assessing industrial disability. Additionally, no physician has imposed permanent partial impairment ratings for claimant. As noted above, the similarity of claimant's complaints before and subsequent to her work incident would suggest that the impairment attributable to the work incident is modest. Likewise, Dr. Collins has indicated claimant could return to her former employment. As claimant's only objective restriction is the 50-pound lifting restriction and as claimant has not shown other significant infringement on her earning capacity subsequent to her work injury, we find that the record supports a finding of a loss on earning capacity of 10% on account of the work injury. We next consider the question of payment of medical costs. Section 85-27 provides that the employer must provide reasonable and necessary medical care for an injury for which the employer is liable. In turn, the employer is allowed to choose GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 14 the care provided. The employee may seek alternate care in an emergency situation, however. Apparently, the costs at issue are unpaid costs of Dr. Burt rendered after September 30, 1985. On March 14, 1986, the insurer advised Dr. Burt that he would not be paid costs of care to claimant after the date her benefits were terminated, that is, October 30, 1985. The insurer then paid Dr. Burt $434.72 representing partial payment of a total bill of $530.72. Nothing on this record suggests that Dr. Burt could have been made aware that treatment he had rendered was not authorized by the employer prior to the date of the March 14, 1986 letter. Likewise, nothing suggests that claimant was advised that care from Dr. Burt would not be allowed prior to March 14, 1986. Payment of those costs for care of Dr. Burt rendered prior to that notice is therefore appropriate. Payment of the additional $96.00 of the submitted bill is ordered. It is unclear on this record whether Dr. Burt is claiming payment or whether claimant is claiming a right to reimbursement of costs with Dr. Burt subsequent to March 14, 1986. We note, however, that Dr. Burt was advised on March 14, 1986 that his care of claimant was no longer authorized. This record has not shown that such care was reasonable and necessary care related to claimant's compensable condition and sought in an emergency situation. Therefore, claimant is not entitled to any reimbursement of costs with Dr. Burt after March 14, 1986. FINDINGS OF FACT WHEREFORE, IT IS FOUND: GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 15 Claimant was off work on account of back pain in 1981. Claimant fell at home in January, 1984. Claimant saw Dr. Burt, a chiropractic physician, on April 6, 1984 and through July 5, 1984 subsequent to that home fall. Dr. Burt's impression on April 6, 1984 was of instability of the low back. On July 5, 1984, claimant had complaints in the thoracic spine. Claimant fell at work on July 9, 1984. Claimant saw Dr. Burt on July 10, 1984 with complaints in the thoracic and cervical area. Claimant did not return to work subsequent to the July 9, 1984 fall. On August 14, 1984, a low back support was provided claimant. Dr. Burt continues to treat claimant. Dr. Collins, a neurosurgeon, examined claimant twice. Dr. Collins found limited range of motion in the low back and the cervical area. Dr. Collins overall found that claimant had a nonfocal objective neurological exam. Claimant's low back and cervical complaints, in part, relate to her work incident. Claimant has no visual or eye condition objectively related to her work injury as evidenced by examinations of Dr. Hoffmann and Dr. Nielsen and as evidenced by brain CT scan. Claimant has had psychological problems, both prior to and subsequent to her work injury. Claimant has complaints of fatigue, excessive weakness, loss of balance, lack of leg strength and inability to bear weight on the left heel. Such complaints are not consistent with the nature of claimant's injury, given the absence of neurologically objective findings. Claimant has a length discrepancy in the lower extremities. Claimant's employer terminates' claimant under a standard policy requiring automatic termination after substantial employee absence. That claimant was off on a work-related injury was not considered in assessing the appropriateness of automatic GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 16 termination under the policy. Claimant has not contacted the employer regarding return to employment. Claimant has not sought vocational rehabilitation. Claimant has not sought other employment. Claimant had difficulties with the employer prior to her work injury and was considering voluntary termination of her employment prior to the work injury. Claimant is a middle-aged worker. Claimant has completed the eighth grade. Claimant has prior work experience as a punch press operator, a waitress, a dietary aide and a cook. Claimant worked at Royal Neighbors as a second cook preparing meals for approximately 30 residents and staff. Claimant's job required sitting, standing and lifting of pans and trays of meat and potatoes. Claimant had access to an elevator for between floor activities and carts were available for conveying items. Claimant currently would have difficulty with lifting 50 pounds or more. Claimant has had a modest change in her cervical and low back conditions on account of her work incident. No doctor has assigned claimant a permanent partial impairment rating. Claimant is not well-motivated to return to work or to seek vocational rehabilitation. Claimant has transferable work skills in the food preparation area. Claimant has sustained a loss of earnings of 10%. Claimant is not an odd-lot worker. The normal recovery period for an injury such as claimant's is six months to one year. Claimant had reached maximum medical healing as of May 30, 1985. Dr. Burt was advised that his care was no longer authorized on March 14, 1986. Care of Dr. Burt after March 14, 1986 was unauthorized care and is not shown to have been reasonable and necessary care sought in an emergency. GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 17 CONCLUSIONS OF LAW THEREFORE, IT IS CONCLUDED: Claimant has established a causal relationship between her July 9, 1984 work injury and claimed permanent partial disability. Claimant has not established that she is entitled to additional temporary total disability benefits on account of her July 9, 1984 work injury. Claimant has established that she is entitled to permanent partial disability on account of the July 9, 1984 work injury in the amount of 10%. Claimant has not established that she is an odd-lot worker under the Guyton doctrine. Claimant is entitled to payment of medical expenses with Dr. Burt in the amount of $530.72. The insurer is entitled to credit in the amount of $434.72 for previous payment of such costs. ORDER THEREFORE, IT IS ORDERED: Defendants pay claimant permanent partial disability benefits for fifty (50) weeks at the rate of one hundred forty-six and 48/100 dollars ($146.48) commencing the first day after the last date of payment for temporary total disability. Defendants pay accrued amounts in a lump sum. Defendants pay interest pursuant to Iowa Code section 85.30 as amended. Defendants pay costs at care with Dr. Burt in the amount of five hundred thirty and 72/100 dollars ($530.72) with credit to defendants for payment already made in the amount of four hundred thirty-four and 72/100 dollars ($434.72). Defendants pay costs of this action pursuant to Division of Industrial Services Rule 343-4.33. Defendants file a Final Payment Report when this award is paid pursuant to Division of Industrial Services Rule 343-3.1. Signed and filed this 28th day of September, 1988. HELENJEAN WALLESER DEPUTY INDUSTRIAL COMMISSIONER GRANT V. ROYAL NEIGHBORS OF AMERICA PAGE 18 Copies To: Mr. Elliott R. McDonald, Jr. Attorney at Law 3432 Jersey Ridge Road P.O. Box 2746 Davenport, Iowa 52809 Mr. Thomas J. Shields Attorney at Law 600 Davenport Bank Building Davenport, Iowa 52801 1108.50, 1802, 1803, 1804 2206, 2505, 4100 Filed September 28, 1988 HELENJEAN WALLESER BEFORE THE IOWA INDUSTRIAL COMMISSIONER FRANCES E. GRANT, Claimant, vs. File No. 825107 ROYAL NEIGHBORS OF AMERICA, A R B I T R A T I O N Employer, D E C I S I 0 N and CHUBB GROUP, Insurance Carrier, Defendants. 1108.50, 1802, 1803, 1804, 2206, 2505, 4100 Middle-aged female claimant with modest increase in functional limitations following work injury and job skills she could continue to utilize although within 50-pound lifting restriction awarded 10% permanent partial disability. Claimant who had not sought other work following work injury and automatic termination following exhaustion of extended long-term leave of absence not an odd-lot worker. Chiropractic physician's medical costs to be paid until point where insurer informed physician his services were no longer authorized. BEFORE THE IOWA INDUSTRIAL COMMISSIONER MARGARET A. OLSEN, Claimant, FILE NO. 825115 VS. A R B I T R A T I 0 N FRUEHAUF CORP., D E C I S I 0 N Employer, and CNA INSURANCE, Insurance Carrier, Defendants. STATEMENT OF THE CASE This is a proceeding in arbitration brought by Margaret A. Olsen, claimant, against Fruehauf Corporation, employer (hereinafter referred to as Fruehauf), and CNA Insurance, insurance carrier, for workers' compensation benefits as a result of an injury on June 19, 1986. On March 2, 1988, a hearing was held on claimant's petition and the matter was considered fully submitted at the close of the hearing. The parties have submitted a prehearing report of contested issues and stipulations which was approved and accepted as a part of the record of this case at the time of hearing. Oral testimony was received during the hearing only from claimant. The exhibits received into the evidence at the hearing are listed in the prehearing report. According to the prehearing report, the parties have stipulated to the following matters; 1. On June 19, 1966, claimant received an injury which arose out of and in the course of employment at Fruehauf. 2. Claimant's rate of weekly compensation in the event of an award of weekly benefits from this proceeding shall be $243.23 per week. 3. Claimant is entitled to healing period benefits from June 20, 1986 through December 9, 1987 and claimant has been paid these benefits. 4. If permanent disability benefits are awarded, they shall begin as of December 10, 1987. 5. All requested medical benefits have been or will be paid by defendants. OLSEN V. FRUEHAUF CORP. Page 2 ISSUES The only issues submitted by the parties for determination in this proceeding is the extent of claimant's entitlement to weekly benefits for permanent disability. SUMMARY OF THE EVIDENCE The following is a summary of evidence presented in this case. For the sake of brevity, only the evidence most pertinent to this decision is discussed. Whether or not specifically referred to in this summary, all of the evidence received at the hearing was considered in arriving at this decision. As will be the case in any attempted summarization, conclusions about what the evidence offered may show are inevitable. Such conclusions, if any, in the following summary should be considered as preliminary findings of fact. Claimant testified that prior to the injury she worked for Fruehauf for 13 years as an assembler. Fruehauf manufactures semi-trailers. Claimant continues to work at Fruehauf at the present time but since her return to work after the work injury she has been placed in a light duty janitor job. Due to physician imposed work restrictions, claimant cannot return to assembly work. Claimant testified that she earned $9.97 per week ($20,000.00 annually) at the time of the work injury in this case. Claimant states that her current job normally pays $.18 per hour less than the assembly wages but that she continues to receive assembly wages at the present time. However, claimant testified that management at Fruehauf has told her that her current job and wages are only a temporary arrangement. The facts surrounding the work injury are not in dispute. Claimant testified that on the date of the injury her upper body was accidently crushed between two semi-trailers that were being constructed at Fruehauf. Claimant was immediately transported to the hospital where she was admitted with a diagnoses of fractured ribs, fractured left and right scapular and laceration of the right ear. Hospital records indicate that claimant suffered severe pain from the injury. Claimant was discharged from the hospital care on June 29, 1986. Claimant was initially treated by Duane Nelson, M.D., an orthopedic surgeon. This treatment involved pain medication, fitting claimant with a figure 8 clavical strap and gradual increase in activity including physical therapy. however, despite this treatment claimant's recovery was slow and she continued to complain of bilateral shoulder and arm pain. Claimant remained off work for almost two years. After Dr. Nelson moved from the area, claimant's care was transferred to another orthopedic surgeon in December, 1986, Koert R. Smith, M.D. At that time claimant was still complaining of lingering pain in the left shoulder. Claimant was also diagnosed as having carpal tunnel and cubical tunnel syndrome problems in the right extremity causing numbness and aching of the right extremity. Claimant returned to work on December 10, 1987 with restrictions imposed by Dr. Smith consisting of no vigorous lifting or over the head lifting or other extensive OLSEN V. FRUEHAUF CORP. Page 3 activity involving the left shoulder. In his deposition Dr. Smith opined that claimant has permanent defects from the injury consisting of a five percent permanent partial impairment to the left extremity. Dr. Smith did not believe that the carpal tunnel or cubical tunnel problems were much of a problem at this time. Despite his rating to the arm, Dr. Smith explained that the source of claimant's problems is a limited range of motion of the left shoulder due to residual pain from the fracture of the left scapula and injury to the surrounding ribs and muscle. Dr. Smith adds that this is more than an injury to the joint. The doctor explained that the injury goes to the upper body or back as the scapular forms a portion of the socket of a ball-socket shoulder joint. Dr. Smith stated that he does not anticipate significant improvement in claimant's condition in the future. Finally, Dr. Smith said that claimant could probably lift 25 to 30 pounds on an intermittent basis during the course of an average work day so long as she did not have to lift above her waist. Claimant testified that she has not made an effort to look for employment elsewhere because she does not feel anyone else would hire her. She stated at hearing that she is 50 years of age and has a high school education. She did not describe her work history other than her work at Fruehauf over the last 13 years. Little has been shown in the record with reference to claimant's rehabilitation potential as she has not been evaluated by a rehabilitation specialist. Claimant's appearance and demeanor at the hearing indicated that she was testifying truthfully. APPLICABLE LAW AND ANALYSIS I. The claimant has the burden of proving by a preponderance of the evidence that the work injury is a cause of the claimed disability. A disability may be either temporary or permanent. In the case of a claim for temporary disability, the claimant must establish that the work injury was a cause of absence from work and lost earnings during a period of recovery from the injury. Generally, a claim of permanent disability invokes an initial determination of whether the work injury was a cause of permanent physical impairment or permanent limitation in work activity. However, in some instances, such as a job transfer caused by a work injury, permanent disability benefits can be awarded without a showing of a causal connection to a physical change of condition. Blacksmith v. All-American, Inc., 290 N.W.2d 348, 354 (Iowa 1980); McSpadden v. Big Ben Coal Co., 288 N.W.2d 161 (Iowa 1980). The question of causal connection is essentially within the domain of expert medical opinion. Bradshaw v. Iowa Methodist Hospital, 251 Iowa 375, 101 N.W.2d 167 (1960). The opinion experts need not be couched in definite, positive or unequivocal language and the expert opinion may be accepted or rejected, in whole or in part, by the trier of fact. Sondag v. Ferris Hardware, 220 N.W.2d 903 (Iowa 1974). The weight to be given to such.an opinion is for the finder of fact, and that may be OLSEN V. FRUEHAUF CORP. Page 4 affected by the completeness of the premise given the expert and other surrounding circumstances. Bodish v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965). Furthermore, if the available expert testimony is insufficient alone to support a finding of causal connection, such testimony may be coupled with nonexpert testimony to show causation and be sufficient to sustain an award. Giere v. Aase Haugen Homes, Inc., 259 Iowa 1065, 146 N.W.2d 911, 915 (1966). Such evidence does not, however, compel an award as a matter of law. Anderson v. Oscar Mayer & Co., 217 N.W.2d 531, 536 (Iowa 1974). To establish compensability, the injury need only be a significant factor, not be the only factor causing the claimed disability. Blacksmith, 290 N.W.2d 348, 354. In the case of a preexisting condition, an employee is not entitled to recover for the results of a preexisting injury or disease but can recover for an aggravation thereof which resulted in the disability found to exist. Olson v. Goodyear Service Stores, 255 Iowa 1112, 125 N.W.2d 251 (1963). In the case sub judice, claimant contains that her injury extends beyond the arm. Although Dr. Smith only gives a rating to the arm, the question of whether the injury is to the body as a whole or to the arm is not a medical but a legal question. Admittedly, there is a conceptual problem in determining whether a disability should be measured functionally or industrially when a major body joint is involved. A shoulder injury can be a loss of an arm or a loss to the body as a whole and the determination depends upon the extent of injury. however, it is the anatomical situs of the injury, not the situs of the disability caused by the injury which determines whether or not to apply the schedules in Iowa Code section 85.34(2)(a-t). Lauhoff Grain Co. v. McIntosh, 395, N.W.2d 834 (Iowa 1986); Dailey v. Pooley Lumber Co., Iowa 758, 10 N.W.2d 569 (1943); Blacksmith, 290 N.W.2d 248 (Iowa 1980). Finally, it is well established in Iowa that a shoulder injury is an injury to the body as a whole and not to a scheduled member injury simply because of the function of those joints' impact on a scheduled member. Lauhoff, 395 N.W.2d 834 (Iowa 1986); Alm v. Morris Barick Cattle Co., 240 Iowa 1174, 38 N.W.2d 161 (1949); Nazarenus v. Oscar Mayer & Company, II Iowa Industrial Commissioner Report 281 (1962); Godwin v. Hicklin G.M. Power, II Iowa Industrial Commissioner Report 170 (1981). In the case at bar, the testimony of Dr. Smith is clear that the situs of the injury is into the body although the effect is only upon the arm. Therefore, claimant has sustained a body as a whole permanent injury. The exact percentage of the body as a whole impairment is unknown as Dr. Smith incorrectly rated the disability to the arm rather than to the body. However, given his permanent restrictions on claimant's activity, the extent of impairment certainly is not insignificant from an industrial disability standpoint as will be discussed below. II. Claimant must establish by a preponderance of the evidence the extent of weekly benefits for permanent disability to which claimant is entitled. As the claimant has shown that the work injury was a cause of a permanent physical impairment or limitation upon activity involving the body as a whole, the degree of permanent disability must be measured pursuant to Iowa Code section 85.34(2)(u). However, unlike scheduled member OLSEN V. FRUEHAUF CORP. Page 5 disabilities, the degree of disability under this provision is not measured solely by the extent of a functional impairment or loss of use of a body member. A disability to the body as a whole or an "industrial disability" is a loss of earning capacity resulting from the work injury. Diederich v. Tri-City Railway Co., 219 Iowa 587, 593, 258 N.W. 899 (1935). A physical impairment or restriction on work activity may or may not result in such a loss of earning capacity. The extent to which a work injury and a resulting medical condition has resulted in an industrial disability is determined from examination of several factors. These factors include the employeeOs 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. Olson, 255 Iowa 1112, 1121, 125 N.W.2d 251, 257 (1963). See Peterson v. Truck Haven Cafe, Inc., (Appeal Decision, February 8, 1985). Claimant's medical condition before the work injury was excellent and she had no functional impairments or ascertainable disabilities despite her age. Claimant was able to fully perform physical tasks involving repetitive lifting, bending, twisting, stooping and lifting above waist level and above her head. As a result of the painful injuries she can no longer do any of these tasks and must remain on a light duty status for the rest of her working life. Claimant's only employment history to the knowledge of this administrative law judge is the type of work she can no longer perform. Certainly,,claimant has suffered a very serious industrial disability or loss of earning capacity. Also, claimant is currently earning a substantial income. Claimant testified, however, that her current job is only temporary. This testimony is uncontroverted. Therefore, claimant's current employment is suitable but it is not stable. Finally, an actual loss of earnings is only one factor not the only factor in determining her industrial disability. The industrial disability is a loss of earning "capacity" not solely a loss of earnings. See Michael v. Harrison County, Thirty-Fourth Biennial Report of the Iowa Industrial Commissioner 218, 220 (1979). The availability of suitable employment outside of Fruehauf is an important consideration in awarding industrial disability benefits in this case. However, claimant made no attempt to look for suitable employment elsewhere. Also, she has not made use of the burden shifting aspects on this issue under the so-called "odd-lot doctrine." See Klein v. Furnas Electric Co., 384 N.W.2d 370, 375 (Iowa 1986); Guyton v. Irving Jensen Co., 373 N.W.2d 101, 105 (Iowa 1985). Therefore, claimant has not shown that suitable, sedentary light duty employment is not available to her outside of Fruehauf although it made indeed pay much less than her current factory work. OLSEN V. FRUEHAUF CORP. Page 6 Claimant is 50 years of age and in the middle of her working career. Her loss of future earnings from employment due to her disability is much more severe than would be the case for an older or younger individual. See Becke v. Turner-Busch, Inc., Thirty-Fourth Biennial Report of the Iowa Industrial Commissioner 34 (1979); Walton v. B & H Tank Corp., II Iowa Industrial Commissioner 428 (1981). Claimant has shown motivation to remain employed despite her chronic pain and difficulties. Although claimant has a high school education and exhibited average intelligence at the hearing, little was shown to indicate her potential for vocational rehabilitation. After examination of all the factors, it is found as a matter of fact that claimant has suffered a 30 percent loss of her earning capacity from her work injury. Based upon such a finding, claimant is entitled as a matter of law to 150 weeks of permanent partial disability benefits under Iowa Code section 85.34(2)(u) which is 30 percent of 500 weeks, the maximum number of allowable weeks for an injury to the body as a whole in that subsection. FINDINGS OF FACT 1. Claimant was a credible witness. 2. On June 19, 1986, claimant suffered an injury to both of her shoulders, ribs and ear which arose out of and in the course of employment with Fruehauf. 3. The work injury of June 19, 1986 was a cause of approxi- mately a two year period of temporary total disability from work. 4. The work injury of June 19, 1986 was a cause of a significant permanent partial impairment to the body as a whole and of permanent restrictions upon claimant's physical activity consisting of no frequent lifting over 25 to 30 pounds or any lifting overhead or above waist level. The work injury is to the left scapular which forms the socket of a ball and socket shoulder joint. This joint has permanent residual effect from the fracture which prevents full range of motion of the shoulder and loss of use to the arm and the shoulder. 5. The work injury of June 19, 1986 and the resulting permanent partial impairment and permanent work restrictions is a cause of a 30 percent loss of earning capacity. Claimant is unable to return to her assembly job that she held at the time of the work injury or to any other work which she has held in the past at Fruehauf. Claimant has a current job as a janitor earning substantially the same income as before is suitable but only a temporary arrangement. Claimant is 50 years of age and has a high school education. Suitable light duty work may be available to claimant outside of Fruehauf but at substantial less money than her factory work at Fruehauf. CONCLUSIONS OF LAW OLSEN V. FRUEHAUF CORP. Page 7 Claimant has established by a preponderance of the evidence entitlement to permanent partial disability benefits as awarded below. ORDER 1. Defendants shall pay to claimant one hundred fifty (150) weeks of permanent partial disability benefits at the rate of two hundred forty-three and 23/100 dollars ($243.23) per week from December 10, 1967. 2. Defendants shall pay accrued weekly benefits in a lump sum and shall receive a credit against this award for all permanent disability benefits previously paid. 3. Defendants shall pay interest on benefits awarded herein as set forth in Iowa Code section 85.30. 4. Defendants shall pay the costs of this action pursuant to Division of Industrial Services Rule 343-4.33 including the deposition costs of Dr. Smith in the amount of three hundred ninety-seven and 80/100 dollars ($397.80). 5. Defendants shall tile activity reports on the payment of this award as requested by this agency pursuant to Division of Industrial Services Rule 343-3.1. Signed and filed this 12th day of May, 1988. OLSEN V. FRUEHAUF CORP. Page 8 LARRY P. WALSHIRE DEPUTY INDUSTRIAL COMMISSIONER Copies To: Mr. James P. Hoffman Attorney at Law Middle Road Keokuk, Iowa 52632-1066 Mr. Elliott R. McDonald, Jr. Attorney at Law P. 0. Box 2239 Davenport, Iowa 52809 1803 Filed May 12, 1988 LARRY P. WALSHIRE BEFORE THE IOWA INDUSTRIAL COMMISSIONER MARGARET A. OLSEN, Claimant, FILE NO. 825115 VS. A R B I T R A T I 0 N FRUEHAUF CORP., D E C I S I 0 N Employer, and CNA INSURANCE, Insurance Carrier, Defendants. 1803 Claimant awarded 30 percent industrial disability for a shoulder injury. The fact that she was working and earning substantially the same money as before was taken into consideration but it was also found that the job was only temporary in nature.