BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
            CRAIG ALLEN GULLETT,       
 
                        
 
                 Claimant,                     File No. 825147
 
                        
 
            vs.                                 A P P E A L
 
                        
 
            GEO. A. HORMEL & CO.,              D E C I S I O N
 
                        
 
                 Employer,   
 
                 Self-Insured,    
 
                 Defendant.       
 
            ____________________________________________________________
 
            
 
            The record, including the transcript of the hearing before 
 
            the deputy and all exhibits admitted into the record, has 
 
            been reviewed de novo on appeal.
 
            
 
                                       ISSUES
 
            
 
            The issues on appeal are:  Whether there is a causal 
 
            connection between claimant's work injury on July 3, 1986 
 
            and his current alleged permanent disability; the extent of 
 
            claimant's industrial disability, if any; the extent of 
 
            claimant's healing period, if any; the rate of weekly 
 
            benefits; and whether defendant is liable for the medical 
 
            care provided by Alex Macy, D.C.
 
            
 
                              FINDINGS OF FACT
 
            
 
            The findings of fact contained in the proposed agency 
 
            decision filed July 27, 1993 are adopted as set forth below.  
 
            Segments designated by brackets ([ ]) indicate language that 
 
            is in addition to the language of the proposed agency 
 
            decision.
 
            
 
                 Claimant was born on August 17, 1953, and at the time 
 
            of the hearing was 39 years of age.  He is right hand 
 
            dominant.
 
            
 
                 At the time claimant worked for the defendant, George 
 
            A. Hormel & Co. (hereinafter referred to as defendant or 
 
            Hormel), in addition to his high school diploma, he had 
 
            successfully completed one year of building trade classes 
 
            and a six-month welding course, earning certificates in both 
 
            disciplines.  Claimant started taking courses at the Indian 
 
            Hills Community College in Ottumwa, Iowa, in September of 
 
            1991, and at the time of the hearing he anticipated 
 
            graduating in May of 1993 with an A.A.S. degree in laser 
 
            optometrics.  He has received very good grades in his course 
 
            work at Indian Hills Community College (Defendant's Exhibits 
 
            X and Y).
 
            
 
                 Piecing together claimant's medical treatment was 
 
            challenging in light of the way the exhibits were organized 
 
            and claimant's own testimony.  First of all, defendant's 
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            exhibits H and I were not considered as they were records 
 
            that were considered in the original arbitration decision.
 
            
 
                 The first relevant medical records are dated August 3, 
 
            1987, wherein Donald Berg, M.D., stated that he had 
 
            evaluated the claimant on July 31, 1987.  Dr. Berg was under 
 
            the impression that claimant exhibited signs of bilateral 
 
            carpal tunnel syndrome as claimant complained of having pain 
 
            in his hand and forearms which increased with activity.  
 
            Claimant had a positive Phalen's test and Tinel's test.  Dr. 
 
            Berg recommended bilateral carpal tunnel surgery (Def. Ex. 
 
            K).
 
            
 
                 Carpal tunnel release surgery on the right wrist was 
 
            performed on September 21, 1987.  Dr. Berg was the surgeon, 
 
            and he also noted marked synovitis and performed a 
 
            synovectomy while repairing the carpal tunnel.  
 
            Postoperatively, claimant developed spasms and cramping in 
 
            both arms and legs.  Dr. Berg did not feel this was related 
 
            to the carpal tunnel problems and was probably not related 
 
            to any work-related injury.  He did feel that the 
 
            synovectomy was a direct result of the wrist problems.  Dr. 
 
            Berg also performed the left carpal tunnel release, which 
 
            was performed on October 12, 1987.  Again, Dr. Berg also 
 
            noted significant synovitis and performed a synovectomy.  He 
 
            believed that claimant would be able to return to work eight 
 
            months post the last surgery, or sometime in mid-December 
 
            1987.  However, claimant had come under the care of Marc 
 
            Hines, M.D., and Dr. Berg had not provided any follow-up 
 
            treatment to the claimant (Def. Ex. E).
 
            
 
                 The next records indicate that Dr. Hines provided a 
 
            report to Dale Emerson, M.D., regarding the results of an 
 
            EMG and nerve conduction velocity test.  The results of the 
 
            nerve conduction study showed no significant abnormalities 
 
            but only minimal slowing of the left median and right median 
 
            digital sensory distal latencies of each wrist.  Dr. Hines 
 
            was under the impression that this problem was the result of 
 
            the carpal tunnel surgeries.  The EMG showed some 
 
            denervation in either the C-8 or T-1 dermatome or a 
 
            combination of mild denervation from residual carpal tunnel 
 
            and ulnar denervation below the elbow.  Dr. Hines 
 
            recommended an evaluation at the Mayo Clinic and prescribed 
 
            Percodan for chronic pain symptoms (Def. Ex. M).
 
            
 
                 Paul Scanlon, M.D., a specialist in thoracic diseases 
 
            and internal medicine, provided the evaluation at the Mayo 
 
            Clinic in Rochester, Minnesota.  His report, dated March 23, 
 
            1988, indicates that claimant complained about pain in his 
 
            hands, arms, shoulders, neck and around the ears.  He was 
 
            able to receive minimal relief from Percodan but felt he was 
 
            unable to work.  Dr. Scanlon's review of claimant's past 
 
            medical history was essentially negative.  Current 
 
            complaints included discouragement, depression, and 
 
            nervousness.  A neurological consultation by J.P. Campbell, 
 
            M.D., resulted in a diagnosis of bilaterally positive 
 
            thoracic outlet maneuvers.  Dr. Campbell was under the 
 
            impression that claimant had a chronic pain disorder and 
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
            recommended an evaluation by the pain management center and 
 
            disability impairment unit.  An EMG showed no evidence of 
 
            median neuropathy at the wrist and no evidence of active 
 
            cervical or lumbosacral radiculopathy.  Claimant's 
 
            evaluation at the pain management center was summarized as 
 
            finding that claimant was not objectively disabled but 
 
            rather that his pain behavior was fueled by anger, a sense 
 
            of injustice and consequent legal proceedings.  Dr. Scanlon 
 
            recommended further impairment evaluations (Def. Ex. N).
 
            
 
                 In April of 1988, claimant underwent a neurological 
 
            examination performed by Randy Winston, M.D.  He found 
 
            positive Tinel's signs at the elbows, but not at the wrists.  
 
            He performed the Roos maneuver, which was negative (Cl. Ex. 
 
            4).
 
            
 
                 Next, claimant underwent a neuropsychological 
 
            evaluation administered by Jeff Martzke.  The examination 
 
            which was performed on April 21, 1988, confirmed that 
 
            physicians were unable to find a physiologic cause for 
 
            claimant's reported discomfort.  Throughout the report, Mr. 
 
            Martzke indicates that although claimant denies a sense of 
 
            anxiety, he appeared anxious.  Mr. Matzo conducted two 
 
            tests, the Beck Depression Inventory and the Minnesota 
 
            Multiphasic Personality Inventory.  On the first test, 
 
            claimant scored a 12 which indicates a depressive 
 
            symtomatology.  This diagnosis would include insomnia, 
 
            anorexia, loss of interest, irritability, crying spells, 
 
            suicidal ideation, memory or concentration deficits, 
 
            indifference or social withdrawal.  However, claimant denied 
 
            any of the symptoms other than not being able to sleep well.  
 
            The MMPI yielded results that included considerable 
 
            defensiveness, psychopathic deviants and nervousness and 
 
            hypochondriacal symptoms (Def. Ex. O).
 
            
 
                 In May of 1988, claimant was evaluated by Richard 
 
            Neiman, M.D., presumably at the request of Dr. Hines.  
 
            Claimant's primary complaints were of pain in the hands, 
 
            wrists, elbows, shoulders, and neck area.  An examination 
 
            revealed minor limitations and flexion, extension and 
 
            lateral rotation of the neck and ultimately found no 
 
            deficits neurologically.  Dr. Neiman felt claimant suffered 
 
            from fibromyocitis and did not detect any evidence of 
 
            thoracic outlet syndrome.  He did indicate that claimant's 
 
            current difficulty of pain was far outside the range of any 
 
            carpal tunnel symptoms and recommended Indocin and a trial 
 
            routine of traction (Def. Ex. P).
 
            
 
                 Also in May of 1988, claimant returned to Dr. Winston.  
 
            He concurred that if claimant had thoracic outlet syndrome, 
 
            the condition was related to his work at Hormel (Cl. Ex. 4).
 
            
 
                 The next medical records indicate that Dr. Hines 
 
            referred claimant to David Roos, M.D., a physician in 
 
            Denver, Colorado.  Dr. Hines suspected thoracic outlet 
 
            syndrome.  The Roos maneuver (an eponymic name) is used to 
 
            diagnose a thoracic outlet syndrome (Def. Ex. Q).
 
            
 
                 Claimant met with Dr. Roos on December 1, 1988.  
 
            Claimant continued to complain of extreme pain in his hands, 
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            wrists, arms, shoulders and upper chest.  Dr. Roos diagnosed 
 
            bilateral thoracic outlet syndrome related to claimant's 
 
            work as a meat cutter with Hormel.  He recommended surgical 
 
            decompression of the lower nerves of the brachial plexus by 
 
            transaxillary first rib resection.  The first decompression 
 
            of the right thoracic outlet was performed January 6, 1989, 
 
            and the second surgical decompression of the left thoracic 
 
            outlet was performed on March 2, 1989.  Dr. Roos also 
 
            indicated claimant had contracted fibromyalgia from 
 
            long-standing muscle spasms (Def. Ex. R; Cl. Ex. 2).
 
            
 
                 In April of 1989, claimant was referred back to Dr. 
 
            Hines to be evaluated for possible cubital tunnel entrapment 
 
            syndrome.  Dr. Roos felt that if Dr. Hines concurred in this 
 
            diagnosis, claimant was to be referred to an orthopedic or 
 
            neurosurgeon to undergo ulnar nerve transfer at the elbows.  
 
            This diagnosis was made in conjunction with Dr. Roos' 
 
            operation for recurrent carpal tunnel syndrome which was 
 
            also performed at the time of the surgical decompression of 
 
            the left thoracic outlet (Cl. Ex. 2).
 
            
 
                 The undersigned is unable to find this evaluation by 
 
            Dr. Hines.
 
            
 
                 The next medical records indicate that in February of 
 
            1990, claimant underwent both right and left total anterior 
 
            scalenectomies performed by Dr. Roos.  He was given several 
 
            prescription medications including Vicodin for pain control; 
 
            Percocet for anxiety; Flexeril for muscle spasms; and, 
 
            Sinequan for relaxation and sleep (Cl. Ex. 2).
 
            
 
                 In April of 1990, Dr. Roos sent a letter to Barbara 
 
            Chaldy of the Management Consulting and Rehabilitation 
 
            Services, Inc., a letter indicating that claimant would be 
 
            unable to return to work as a meat cutter.  He was 
 
            restricted to light physical activities with both upper 
 
            extremities and was not to lift any more than 20 pounds.  He 
 
            was to perform infrequent bending or stooping, reaching, 
 
            pushing or pulling activities (Cl. Ex. 2).
 
            
 
                 In October of 1990, claimant underwent another 
 
            evaluation performed by Dr. Roos.  An examination showed 
 
            full range of motion of the cervical spine and sensory tests 
 
            showed normal sensations in both upper extremities.  Again, 
 
            Dr. Roos diagnosed fibromyalgia of the neck and shoulder 
 
            muscles, tendonitis of the anterior shoulder and arthritis 
 
            of both wrist in the base of the thumbs.  Dr. Roos felt 
 
            claimant was unable to return to work because of persistent 
 
            pain in his hands, wrists and shoulders.  He believed 
 
            claimant fully disabled from the use of his hands, wrists, 
 
            arms, and shoulders due to fibromyalgia (Def. Ex. W; Cl. Ex. 
 
            2).
 
            
 
                 In January of 1991, Dr. Hines evaluated claimant for 
 
            purposes of rendering an opinion on his permanent 
 
            impairment.  He noted that claimant was continuing to have 
 
            considerable difficulties with ordinary activities of daily 
 
            living.  It was difficult, due to pain in his shoulders, 
 
            elbows and wrists to perform activities such as self-care 
 
            and personal hygiene.  Claimant encountered pain when he 
 

 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
            elevated his arms above his shoulders and had difficulties 
 
            writing and typing or using his arms and wrists for more 
 
            than five minutes.  Claimant also had pain in his shoulders 
 
            and neck while lying down, and often woke up several times 
 
            during the night due to the pain.  Getting out of a chair 
 
            caused pain in his shoulders and arms, and driving bothered 
 
            his wrists, shoulders and neck.  Dr. Hines concurred with 
 
            Dr. Roos' assessment that claimant had almost complete 
 
            inability to use his hands and arms without pain, and had 
 
            severe impairment of the use of his hands, arms, wrists and 
 
            shoulders.  Dr. Hines goes on to state:
 
            
 
                 Unfortunately, this type of pain is not 
 
                 specifically ratable using the AMA Guides; they do 
 
                 not give specific rating procedures for this type 
 
                 of diffuse fibromyalgia and/or arthritic type of 
 
                 situation.  I would feel, therefore, a great deal 
 
                 of lack of confidence in rating Mr. Gullett, were 
 
                 it not for the fact that he has been to multiple 
 
                 centers, in multiple areas of the state and even 
 
                 out of state, with recurrent consultation always 
 
                 leading to the same group or set of diagnoses... I 
 
                 therefore concur with Dr. Roos's opinion that 
 
                 these have caused near total disability in his 
 
                 arms, although the permanent impairment rating per 
 
                 se certainly must take into account that he has 
 
                 considerable continued use of his arms and hands 
 
                 on a daily basis, although from the standpoint of 
 
                 any ability to use these for repetitive activity, 
 
                 they are basically useless.
 
            
 
            (Cl. Ex. 2)
 
            
 
                 Dr. Hines was able to use various tables in the AMA 
 
            Guides to assess claimant as having a 39 percent impairment 
 
            to the whole person.  Dr. Hines indicated that fibromyalgia 
 
            and the type of arthritis that claimant had were not 
 
            specifically rated in the Guides.  His rating is based upon 
 
            impairment due to pain, discomfort or loss of sensation 
 
            which may prevent activity ranges.  Apparently, this 
 
            methodology is endorsed by authors of the Guides (Cl. Ex. 
 
            2).
 
            
 
                 In January and February of 1991, claimant received 
 
            medical attention from Mary Radia, M.D.  She specializes in 
 
            the treatment of arthritic conditions, and after and 
 
            examination and reviewing claimant's medical history she was 
 
            able to diagnose myofascial pain syndrome predominantly in 
 
            the right upper extremity.  She also stated that claimant 
 
            had incidental bursitis but no evidence of inflammatory 
 
            disease.  Later, Dr. Radia believed that claimant did not 
 
            have arthritis but rather showed manifestations of his 
 
            neurologic impingement (Cl. Ex. 3).
 
            
 
                 In May of 1991, Dr. Hines again examined claimant and 
 
            found that he was continuing to have permanent pain in his 
 
            neck, shoulders and arms.  Dr. Hines recommended continued 
 
            prescription therapy of Lortabs and claimant was to follow 
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            up with Dr. Hines every six months for an indefinite period 
 
            of time.  Also, claimant was not to perform any lifting of 
 
            more than 30 pounds (Cl. Ex. 1).
 
            
 
                 In August of 1991, claimant saw Douglas Reagan, M.D., 
 
            for an evaluation.  After reviewing his medical history and 
 
            performing an examination, Dr. Reagan indicated that 
 
            claimant had sustained a 12 percent permanent impairment to 
 
            the right upper extremity and an 8 percent impairment to the 
 
            left upper extremity.  He was unable to render any opinions 
 
            with respect to impairment to claimant's shoulder because 
 
            this is not his area of expertise.  Dr. Reagan's ratings are 
 
            based on the complaint of pain and the surgeries claimant 
 
            has undergone (Def. Ex. S).
 
            
 
                 In October of 1991, Dr. Hines provided yet another 
 
            report with respect to claimant's condition.  He had 
 
            reviewed several reports, including Dr. Roos' report dated 
 
            October 23, 1990; Dr. Reagan's report dated August 5, 1991; 
 
            and, his own reports dated January 2, 1991 and May 24, 1991.  
 
            At this time, he formed an opinion that claimant's 
 
            work-related injury and restriction were related directly to 
 
            his thoracic outlet syndrome and carpal tunnel syndrome.  He 
 
            believed all of these problems were related to claimant's 
 
            work situation at Hormel.  He also indicated that the 
 
            problems were exacerbated and worsened by the work 
 
            activities as a carpenter.  Dr. Hines also reiterated that 
 
            the fibromyalgia of the neck, shoulder muscles, tendonitis 
 
            of the anterior shoulder region and the arthritis of the 
 
            joints of the wrists and base of the thumbs were significant 
 
            conditions secondary to the chronic process that began with 
 
            work at Hormel (Cl. Ex. 1).
 
            
 
                 In March of 1992, claimant was sent to Thomas Bower, a 
 
            licensed physical therapist.  He underwent an extensive 
 
            evaluation, and Mr. Bower reviewed his medical records, 
 
            although it is unclear as to which medical records Mr. Bower 
 
            examined.  At this evaluation, claimant continued to 
 
            complain of persistent numbness and tingling in his upper 
 
            extremities.  Repeat nerve conduction studies demonstrated 
 
            completely normal median motor and sensory conductions.  
 
            Similar findings were noted for the ulnar nerve as well as 
 
            the cubital tunnel across the ulnar groove.  While Mr. Bower 
 
            believed that previous functional capacity evaluations 
 
            showed the claimant to demonstrate disportionate responses 
 
            relative to pain therefore indicating a very high propensity 
 
            of symptom magnification, after testing his lifting and 
 
            endurance capabilities, Mr. Bower felt any symptoms were 
 
            still a result of the thoracic outlet problem.  Claimant was 
 
            able to lift 30 pounds from floor to chest height, carry 29 
 
            pounds a distance of 25 feet, and push/pull 85 pounds.  
 
            These activities elicited pain to be on a level 7 from an 
 
            ascending scale from 0 to 10.  Endurance assessment revealed 
 
            that claimant was able to complete all of the assigned 
 
            activities for the full time allotment.  A lift track 
 
            analysis, which is a computerized analysis, wherein the 
 
            patient is videotaped performing specific tests, and Mr. 
 

 
            
 
            Page   7
 
            
 
            
 
            
 
            
 
            Bower wondered whether claimant was yielding his maximum 
 
            effort in overall lifts.  However, the test indicated that 
 
            claimant was able to lift a maximum of 62.7 pounds, a weight 
 
            obviously higher than what claimant was able to perform at 
 
            the time of the evaluation.  In any event, Mr. Bower stated 
 
            that claimant had sustained a 24 percent impairment to the 
 
            whole body as a result of the thoracic outlet problem.  This 
 
            is based on loss of sensation and reduced fine movements in 
 
            motor control.  While reluctant, Mr. Bower also limited 
 
            claimant to lift a maximum of 30 pounds, and placed him into 
 
            a light to light/medium work classification (Def. Ex. T).
 
            
 
                 Dr. Hines reviewed Mr. Bower's evaluation, and while he 
 
            was unable to accept the results of the nerve conduction 
 
            studies and EMGs because Mr. Bower is not a physician, he 
 
            did not express disagreement with the percentage of 
 
            impairment rendered by Mr. Bower (Cl. Ex. 1).
 
            
 
                 In November of 1992, Dr. Neiman was also called upon to 
 
            render an opinion with respect to claimant's permanent 
 
            impairment.  After an examination which revealed weakened 
 
            hand grips, full range of motion of the neck and test 
 
            results of nerve conduction studies which found denervation 
 
            involving the C-8 nerve root distribution involving the 
 
            clinical pattern, sensory loss and motor weakness, Dr. 
 
            Neiman was able to use the AMA guidelines for the thoracic 
 
            outlet syndrome.  After combining all of the percentages 
 
            given to claimant for both upper extremities, Dr. Neiman 
 
            used the combination tables and opined that claimant had 
 
            sustained a 26 percent permanent impairment of the whole 
 
            person.  He also was of the opinion that the multiple 
 
            surgeries including the thoracic outlet was directly related 
 
            to his work at Hormel (Def. Ex. U).
 
            
 
                 In an interesting change of direction, Dr. Hines in 
 
            March of 1993 stated that he was unable to judge whether 
 
            Hormel was more contributory to claimant's condition than 
 
            carpentry work.  However, he believed that Hormel was only 
 
            one of the initiating factors in claimant's current 
 
            symptomatology.  Apparently, this opinion was based on the 
 
            assumption that claimant had performed extensive carpentry 
 
            work, and Dr. Hines then refuted his letter and on April 29, 
 
            1993, stated that if claimant had merely supervised the 
 
            carpentry work and had not done the actual work it changed 
 
            his conclusions.  He believed that any work of a repetitive 
 
            nature would be the contributing factor but supervision then 
 
            would not be a contributing factor to claimant's 
 
            symptomatology (Def. Ex. V; Cl. Ex. 1).
 
            
 
                 [The parties orally stipulated that all of the medical 
 
            care and expenses were authorized except for those related 
 
            to Dr. Macy's treatment (Tr., pp. 77-78).  Dr. Macy 
 
            testified in his deposition (Cl. Ex. 5) that claimant had 
 
            been referred to him by Dr. Hines.  There is a reference in 
 
            the deposition to a note by Dr. Hines on November 17, 1987 
 
            that Dr. Hines had asked claimant to see Dr. Macy (Cl. Ex. 
 
            5, pp. 21-22).  The note referred to in the deposition is 
 
            not contained in claimant's exhibit 1.  Dr. Macy began 
 

 
            
 
            Page   8
 
            
 
            
 
            
 
            
 
            treating in 1981.  He treated claimant on a weekly or 
 
            monthly basis from November 1987 through April 1993.  Doug 
 
            Eckermann, a third-party administrator for defendant 
 
            employer, testified to his knowledge that neither he nor 
 
            defendant employer had authorized treatment by Dr. Macy.  
 
            However, he admitted that he did not remember that Dr. Hines 
 
            had recommended that claimant be provided chiropractic 
 
            care.]
 
            
 
                 Other exhibits used by the defendant include claimant's 
 
            tax records, an application for a building permit, 
 
            photographs of various job sites, and other photographs and 
 
            summaries of what the defendant argues are claimant's 
 
            extensive carpentry activities (Def. Exs., B, C, D, G and 
 
            J).
 
            
 
                 [In the prior arbitration proceeding the parties 
 
            stipulated that claimant was married and entitled to three 
 
            exemptions.  It was found that claimant's gross weekly 
 
            earnings at the time of his injury was $368.09.  It was also 
 
            found that his rate of compensation was $233.54.]
 

 
            
 
            Page   9
 
            
 
            
 
            
 
            
 
                               CONCLUSIONS OF LAW
 
            
 
            The conclusions of law contained in the proposed agency 
 
            decision filed July 27, 1993 are adopted as set forth below.  
 
            Segments designated by asterisks (*****) indicate portions 
 
            of the language from the proposed agency decision that have 
 
            been intentionally deleted and do not form a part of this 
 
            final agency decision.  Segments designated by brackets ([ 
 
            ]) indicate language that is in addition to the language of 
 
            the proposed agency decision.
 
            
 
                 After the first arbitration decision, which found a 
 
            work-related injury, claimant was paid weekly workers' 
 
            compensation benefits from September 29, 1987 through 
 
            February 23, 1988.  Benefits were denied from March 1, 1988 
 
            until December 20, 1988, when claimant received back 
 
            payments totaling $10,331.18 and then began receiving weekly 
 
            benefits until November 5, 1991.  Weekly benefits to date 
 
            total $51,312.53 (Def. Ex. F, pp. 6-9).
 
            
 
                 The defendant submitted evidence which predates the 
 
            date of the arbitration hearing, March 30, 1987.  A 
 
            review-reopening proceeding is defined under Iowa Code 
 
            section 86.14(2):
 
            
 
                    2.  In a proceeding to reopen an award for 
 
                 payments or agreement for settlement as provided 
 
                 by section 86.13, inquiry shall be into whether or 
 
                 not the condition of the employee warrants an end 
 
                 to, diminishment of, or increase of compensation 
 
                 so awarded or agreed upon.
 
            
 
                 Review-reopening does not contemplate a 
 
            re-determination of the condition of the employee that was 
 
            determined by the previous award.  Stice v. Consolidated 
 
            Ind. Coal Co., 228 Iowa 1031, 1035, 291 N.W. 452 (1940).
 
            
 
                 The first issue to be addressed is whether claimant's 
 
            injury is a proximate cause of his disability.
 
            
 
                 The claimant has the burden of proving by a 
 
            preponderance of the evidence that the injury is a proximate 
 
            cause of the disability on which the claim is based.  A 
 
            cause is proximate if it is a substantial factor in bringing 
 
            about the result; it need not be the only cause.  A 
 
            preponderance of the evidence exists when the causal 
 
            connection is probable rather than merely possible.  
 
            Blacksmith v. All-American, Inc., 290 N.W.2d 348 (Iowa 
 
            1980); Holmes v. Bruce Motor Freight, Inc., 215 N.W.2d 296 
 
            (Iowa 1974).
 
            
 
                 The question of causal connection is essentially within 
 
            the domain of expert testimony.  The expert medical evidence 
 
            must be considered with all other evidence introduced 
 
            bearing on the causal connection between the injury and the 
 
            disability.  The weight to be given to any expert opinion is 
 
            determined by the finder of fact and may be affected by the 
 
            accuracy of the facts relied upon by the expert as well as 
 
            other surrounding circumstances.  The expert opinion may be 
 
            accepted or rejected, in whole or in part.  Sondag v. Ferris 
 
            Hardware, 220 N.W.2d 903 (Iowa 1974); Anderson v. Oscar 
 

 
            
 
            Page  10
 
            
 
            
 
            
 
            
 
            Mayer & Co., 217 N.W.2d 531 (Iowa 1974); Bodish v. Fischer, 
 
            Inc., 257 Iowa 516, 133 N.W.2d 867 (1965).
 
            
 
                 While there can be no serious dispute that claimant has 
 
            sustained a permanent disability, the threshold issue is 
 
            whether claimant participated in extensive carpentry work 
 
            which was therefore the cause of his medical problems.  
 
            Conversely, if his work at Hormel caused all of the medical 
 
            conditions, then he is entitled to permanent partial 
 
            disability benefits from the employer.
 
            
 
                 All of the physicians associated with the case who have 
 
            rendered extensive treatment to claimant are of the opinion 
 
            that his problems began with the carpal tunnel syndrome 
 
            which was caused by his work as a meat cutter at Hormel.  
 
            The defendant argues that claimant is not credible, and that 
 
            he performed extensive carpentry work from the time of his 
 
            termination until the present, and although there was some 
 
            animosity on the claimant's part, claimant did not perform 
 
            an extensive amount of carpentry work.  That work which was 
 
            performed by the claimant consisted of supervision of 
 
            carpentry/construction work; installation of door locks; 
 
            limited hammering activities; and, job site preparation.  
 
            [Dr. Berg who was an authorized doctor performed surgery of 
 
            the carpal tunnel releases.  It was Dr. Hines' opinion that 
 
            the slowing of the left median and right median digital 
 
            sensory distal latencies of each wrist were due to the 
 
            carpal tunnel surgeries.  Dr. Neiman thought that claimant 
 
            suffered from fibromyocitis and he did not detect any 
 
            evidence of thoracic outlet syndrome.  It was Dr. Winston's 
 
            opinion that if claimant had thoracic outlet syndrome, the 
 
            condition was related to claimant's work.  Dr. Roos 
 
            diagnosed bilateral thoracic outlet syndrome related to 
 
            claimant's work and recommended surgery.  Dr. Hines' opinion 
 
            may have changed but he clearly was of the opinion that 
 
            claimant's work with defendant employer was a contributing 
 
            factor to claimant's current condition.  Dr. Neiman also 
 
            related claimant's multiple surgeries to his work with 
 
            defendant employer.
 
            
 
                 The weight of the expert medical opinion in this case 
 
            is that claimant's work with defendant employer was a cause 
 
            of claimant's current disability.  Claimant's work with 
 
            defendant employer need not be the sole cause of his 
 
            disability.  It only
 
            
 
            
 
            Page  11
 
            
 
            
 
            
 
            
 
            has to be a substantial factor.  Defendant employer's 
 
            argument regarding last injurious exposure is misplaced.  
 
            The question is whether claimant's work with defendant 
 
            employer was a substantial factor in bringing about his 
 
            current disability.  Claimant was treated for conditions 
 
            that authorized doctors felt were work related.  That 
 
            treatment included surgeries which resulted in a permanent 
 
            functional impairment.  Even though claimant may have had 
 
            other activities that aggravated his condition, the record 
 
            in this case shows that his work with defendant employer was 
 
            a substantial factor in causing his permanent disability.]  
 
            As a result, it is found that claimant's permanent 
 
            disability is causally related to his employment with 
 
            Hormel.
 
            
 
                 *****
 
            
 
                 [The next issue to be resolved is the extent of 
 
            claimant's industrial disability.]
 
            
 
                 Functional impairment is an element to be considered in 
 
            determining industrial disability which is the reduction of 
 
            earning capacity, but consideration must also be given to 
 
            the injured employee's age, education, qualifications, expe
 
            rience and inability to engage in employment for which the 
 
            employee is fitted.  Olson v. Goodyear Serv. 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.  Impairment and disability are not synonymous.  
 
            The degree of industrial disability can be much different 
 
            than the degree of impairment because industrial disability 
 
            references to loss of earning capacity and impairment 
 
            references to anatomical or functional abnormality or loss.  
 
            Although loss of function is to be considered and disability 
 
            can rarely be found without it, it is not so that a degree 
 
            of industrial disability is proportionally related to a 
 
            degree of impairment of bodily function.
 
            
 
                 Factors to be considered in determining industrial dis
 
            ability include the employee's medical condition prior to 
 
            the injury, immediately after the injury, and presently; the 
 
            situs of the injury, its severity and the length of the 
 
            healing period; the work experience of the employee prior to 
 
            the injury and after the injury and the 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
 
            
 
            
 
            Page  12
 
            
 
            
 
            
 
            
 
            the employee is fitted.  Loss of earnings caused by a job 
 
            transfer for reasons related to the injury is also relevant.  
 
            Likewise, an employer's refusal to give any sort of work to 
 
            an impaired employee may justify an award of disability.  
 
            McSpadden v. Big Ben Coal Co., 288 N.W.2d 181 (Iowa 1980).  
 
            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.  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 as well as 
 
            general and specialized knowledge to make the finding with 
 
            regard to degree of industrial disability.  See Christensen 
 
            v. Hagen, Inc., Vol. 1 No. 3 State of Iowa Industrial 
 
            Commissioner Decisions 529 (App. March 26, 1985); Peterson 
 
            v. Truck Haven Cafe, Inc., Vol. 1 No. 3 State of Iowa 
 
            Industrial Commissioner Decisions 654 (App. February 28, 
 
            1985).
 
            
 
                 Compensation for permanent partial disability shall 
 
            begin at the termination of the healing period.  
 
            Compensation shall be paid in relation to 500 weeks as the 
 
            disability bears to the body as a whole.  Section 85.34.
 
            
 
                 At the time of the hearing, claimant was 39 years of 
 
            age.  Apparently, much of his adult working life has been 
 
            spent as a carpenter, and claimant worked as a meat cutter 
 
            for less than one month.  Unfortunately, that one month has 
 
            forced claimant to pursue a completely different line of 
 
            work than that in which he had extensive experience.  
 
            However, claimant has been able to commit himself to 
 
            learning a different trade and has performed brilliantly in 
 
            his school work.  Likewise, 90 to 95 percent of the students 
 
            who successfully complete the laser optometrics program find 
 
            employment and earn salaries in the mid-$20,000 range.
 
            
 
                 The employer has done virtually nothing to help 
 
            claimant other than provide some medical treatment.  
 
            Likewise, they have paid weekly benefits but only after 
 
            being ordered to do so.  They have not provided claimant 
 
            with any type of vocational rehabilitation and, in fact, 
 
            promptly terminated claimant when he began to have medical 
 
            difficulties.  This termination was, of course, predicated 
 
            on his lack of ability to perform adequately the meat cutter 
 
            job.
 
            
 
                 It would be hard not to accept as true claimant's 
 
            description of the pain he feels.  While the agency 
 
            routinely does not rely solely on claimant's descriptions of 
 
            pain, there is some objective support for his complaints.  
 
            Claimant has undergone numerous surgeries and has been 
 
            exposed to long healing periods.
 
            
 
                 [It was Dr. Roos' and Dr. Hines' assessment that 
 

 
            
 
            Page  13
 
            
 
            
 
            
 
            
 
            claimant had severe impairment of the use of his arms and 
 
            shoulders.  Dr. Reagan assigned claimant a 12 percent 
 
            permanent impairment rating to the right upper extremity and 
 
            an eight percent permanent impairment rating to the left 
 
            upper extremity.  Dr. Neiman opined that claimant had 
 
            sustained a 26 percent permanent impairment rating of the 
 
            whole person.  It is clear from the entire record that 
 
            claimant has permanent functional impairment.]
 
            
 
                 After considering all of the factors that comprise an 
 
            industrial disability, it is found that claimant has 
 
            sustained a 40 percent industrial disability.
 
            
 
                 [The next issue to be resolved is the extent of 
 
            claimant's healing period.
 
            
 
                 Iowa Code section 85.34(1) provides that healing period 
 
            benefits are payable to an injured worker who has suffered 
 
            permanent partial disability until (1) the worker has 
 
            returned to work; (2) the worker is medically capable of 
 
            returning to substantially similar employment; or (3) the 
 
            worker has achieved maximum medical recovery.  The healing 
 
            period can be considered the period during which there is a 
 
            reasonable expectation of improvement from the disabling 
 
            condition.  See Armstrong Tire & Rubber Co. v. Kubli, 312 
 
            N.W.2d 60 (Iowa App. 1981).  Healing period benefits can be 
 
            interrupted or intermittent.  Teel v. McCord, 394 N.W.2d 405 
 
            (Iowa 1986).
 
            
 
                 Defendant argues that claimant's healing period ended 
 
            in May 1990.  Claimant makes no argument on appeal as to the 
 
            correct end of healing period.  The party who would suffer 
 
            loss if an issue were not established has the burden of 
 
            proving that issue by a preponderance of the evidence.  Iowa 
 
            R. App. P. 14(f).  Dr. Roos indicated in April 1990 that 
 
            most patients who have the type of surgery claimant had 
 
            could embark on a rehabilitation and training 2-3 months 
 
            after the surgery (Cl. Ex. 2).  Claimant's surgery was 
 
            February 2, 1990.  The tone of Dr. Roos' letter was that as 
 
            of April 17, 1990 claimant was capable of returning to 
 
            certain work with restrictions.  It was sometime after this 
 
            that claimant received impairment ratings.  The record in 
 
            regards to when the healing period ended is not well 
 
            presented.  Dr. Roos opinion will be relied upon.  
 
            Claimant's healing period ended April 17, 1990.
 
            
 
                 The next issue to be resolved is claimant's rate of 
 
            weekly benefits.  The rate found in the arbitration decision 
 
            was $233.54.  It is not known how the amount was determined 
 
            but it was erroneously calculated.  The proper rate for an 
 
            injury sustained on July 3, 1986 for a married individual 
 
            entitled to three exemptions with a gross weekly earnings of 
 
            $368.09 is $233.98.  See Guide to Iowa Workers' Compensation 
 
            Claim Handling published by this agency, dated July 1986.
 
            
 
                 The last issue to be resolved is whether the medical 
 
            services by Dr. Macy are to be paid by defendant.  The 
 
            parties stipulated that Dr. Hines was an authorized 
 
            physician.  He referred claimant to Dr. Macy for care.  Dr. 
 
            Macy's care was thus authorized.  Defendant employer is 
 

 
            
 
            Page  14
 
            
 
            
 
            
 
            
 
            liable for payment of Dr. Macy's treatments after the date 
 
            of referral (November 17, 1987).]
 
            WHEREFORE, the decision of the deputy is affirmed.
 
            
 
                                      ORDER
 
            
 
            THEREFORE, it is ordered:
 
            
 
                 That defendant shall pay unto claimant two hundred 
 
            (200) weeks of permanent partial disability benefits at the 
 
            rate of two hundred thirty-three and 98/100 dollars 
 
            ($233.98) per week commencing on April 17, 1990.
 
            
 
                 That defendant shall pay accrued weekly benefits in a 
 
            lump sum and shall receive credit against the award for 
 
            weekly benefits previously paid.
 
            
 
                 That defendant shall pay the costs of treatment by Dr. 
 
            Macy beginning November 17, 1987.
 
            That claimant and defendant shall share equally the costs of 
 
            the appeal including transcription of the hearing.  
 
            Defendant shall pay all other costs.
 
            
 
                 That defendant shall file an activity report upon 
 
            payment of this award as required by the agency pursuant to 
 
            rule 343 IAC 3.1.
 
            Signed and filed this ____ day of March, 1994.
 
            
 
            
 
            
 
            
 
                                   ________________________________
 
                                    BYRON K. ORTON
 
                                    INDUSTRIAL COMMISSIONER
 
            
 

 
            
 
            Page  15
 
            
 
            
 
            
 
            
 
            Copies To:
 
            
 
            Mr. H. Edwin Detlie
 
            Attorney at Law
 
            114 N Market St.
 
            Ottumwa, Iowa 52501
 
            
 
            Mr. Richard C. Bauerle
 
            Mr. Lloyd E. Keith
 
            Attorneys at Law
 
            P O Box 218
 
            Ottumwa, Iowa 52501
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                               5-1803
 
                                               Filed March 31, 1994
 
                                               Byron K. Orton
 
            
 
                       BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
            CRAIG ALLEN GULLETT,       
 
                        
 
                 Claimant,                     File No. 825147
 
                        
 
            vs.                                 A P P E A L
 
                        
 
            GEO. A. HORMEL & CO.,              D E C I S I O N
 
                        
 
                 Employer,   
 
                 Self-Insured,    
 
                 Defendant.       
 
            ____________________________________________________________
 
            
 
            
 
            5-1803
 
            Claimant awarded 40 percent industrial disability.  He 
 
            worked at a meat cutting job for approximately one month, 
 
            and developed carpal tunnel, ulnar tunnel and thoracic 
 
            outlet syndromes.  He underwent numerous surgeries, but has 
 
            not had a successful recovery.
 
            Claimant has been a carpenter most of his working life, but 
 
            since the injuries has not been able to perform this type of 
 
            work, he went to school, and has successfully completed a 
 
            laser-technology program, which boasts a 90-95 percent job 
 
            placement history.
 
            The employer fired claimant, and did nothing to help his 
 
            recovery or job training/placement.
 
            
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                    BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         CRAIG ALLEN GULLETT,
 
         
 
              Claimant,                               File No. 825147
 
         
 
         VS.
 
                                                    A R B I T R A T I 0 N
 
         
 
         GEORGE A. HORMEL & Co.,
 
         
 
              Employer,                                D E C I S I 0 N
 
              Self-Insured,
 
              Defendant.
 
         
 
                                   INTRODUCTION
 
         
 
              This is a proceeding in arbitration brought by Craig A. 
 
         Gullett, claimant, against George A. Hormel & Company, a 
 
         self-insured employer for the recovery of benefits as the result 
 
         of an alleged injury on July 3, 1986.  This matter was heard 
 
         before the undersigned at the courthouse in Ottumwa, Wapello 
 
         County, Iowa on March 30, 1987.  It was considered fully 
 
         submitted at the conclusion of the hearing.  The record consists 
 
         of the testimony of claimant, Mary Brooks and Mike McClain; 
 
         claimant's exhibits 1 through 14 and defendant's exhibits A and 
 
         B.
 
         
 
                             STIPULATIONS AND ISSUES
 
         
 
              Pursuant to the pre-hearing report and order approving same, 
 
         the parties stipulated that there was an employer-employee 
 
         relationship between the claimant and the employer at the time of 
 
         the alleged injury; that the claimant did receive an injury 
 
         arising out of and in the course of his employment on July 3, 
 
         1986; that the claimant is married and entitled to three 
 
         exemptions; that the fees charged for medical services were fair 
 
         and reasonable and were reasonably necessary for the treatment of 
 
         the condition; that the defendant is entitled to credit in the 
 
         amount of $85.83 under section 85.38(2) for medical expenses paid 
 
         in connection with the injury; and, that each party has actually 
 
         paid items of cost which they seek to be assessed in this 
 
         proceeding.
 
         
 
              The issues to be resolved in this proceeding are whether or 
 
         not the injury suffered by claimant was the cause of any 
 
         temporary disability and/or permanent disability; the extent of 
 
         any temporary disability or permanent disability suffered by the 
 
         claimant; the nature of the disability suffered by the claimant; 
 
         the rate of compensation to which claimant is entitled; and, 
 
         whether or not claimant is entitled to medical expenses under the 
 
         provisions of section 85.27. The issue of whether or not
 
         the defendant should be assessed penalties for unreasonable 
 
         denial or delay of payment of benefits remains asserted.
 
         
 

 
         
 
         
 
         
 
         GULLETT V. GEORGE A. HORMEL & CO.
 
         Page   2
 
         
 
         
 
                            EVIDENCE PRESENTED
 
         
 
              Claimant testified that he began his employment with the 
 
         defendant on May 5, 1986.  Claimant's employment was in the ham 
 
         boning job where it was his duty to remove bones from hams with 
 
         an air knife.  Claimant stated he is right-handed.
 
         
 
              Claimant advised that, prior to beginning his employment 
 
         with the defendant, he had experienced no problems with either of 
 
         his hands.  He stated that on or about July 3, 1986, he began to 
 
         experience severe pain in his hands.  He went to see the company 
 
         nurse who stated that he would be able to see the company doctor 
 
         when the doctor visited the plant that day.  Claimant stated that 
 
         he had been to see the nurse prior to July 3, 1986 with the same 
 
         problem.
 
         
 
              Claimant said he saw Winn Gregory, M.D. on July 3, 1986 
 
         following referral from the nurse.  He was advised by Dr. Gregory 
 
         to return to work which he did for about an hour at which time a 
 
         company official appeared and terminated him from his employment. 
 
          Claimant has not been employed by defendant since.
 
         
 
              Claimant was then referred to Donald D. Berg, M.D. whom he 
 
         saw on July 15, 1986.  Dr. Berg diagnosed tendonitis and 
 
         prescribed medication for claimant's problems.  Upon claimant's 
 
         failure to improve, he was referred by Dr. Berg to Richard F. 
 
         Neiman, M.D. whom he saw in August of 1986.
 
         
 
              Claimant stated that Dr. Neiman treated him with medication, 
 
         with some treatment at the YMCA, and with wrist splints.  
 
         Claimant said his condition did not improve greatly and that he 
 
         continues to suffer problems with his hands.
 
         
 
              Claimant stated that after his discharge from the 
 
         defendant's he obtained employment as a self-employed carpenter.  
 
         Claimant said he checked with the doctors about doing light-duty 
 
         work and, although they generally recommended against it, he felt 
 
         he had no choice in order to earn a living.  Claimant continued 
 
         to work as a carpenter throughout the summer and had been 
 
         continuing to do so at the time of the hearing.  Claimant stated 
 
         that in August, September, and October, 1986 he drew unemployment 
 
         compensation which he was allowed to do because he was working 
 
         less than 20 hours per week as a carpenter.  Claimant outlined in 
 
         considerable detail the nature and type of work he had done since 
 
         leaving employment with the defendant.
 
         
 
              Claimant testified that at the time of his discharge he was 
 
         earning $8.82 per hour and that he had begun his employment at 
 
         the rate of $8.55 per hour.
 
         
 
              Claimant was questioned considerably on cross-examination 
 
         about the nature of the carpentry work he was performing after 
 
         his discharge by the defendant.  Claimant described his 
 
         employment as a carpenter as light-duty work involving mostly 
 
         finishing work and very little hammering and heavy lifting.  
 
         Claimant said he has also experienced arm, shoulder and neck 
 
         pain.
 

 
         
 
         
 
         
 
         GULLETT V. GEORGE A. HORMEL & CO.
 
         Page   3
 
         
 
         
 
         
 
              Mary Brooks testified that she is employed as a nurse at the 
 
         defendant's and has been so for nine years.  She stated that 
 
         claimant first presented himself with a complaint of pain in the 
 
         right elbow on June 25, 1986.  She reported that he returned 
 
         again on July 3, 1986 with complaints of pain in the elbow, arms, 
 
         hands and wrist.  She said he was seen by Dr. Gregory that day 
 
         who gave claimant some medication and directed him to return to 
 
         work.  She said the company files contained no other reports from 
 
         Dr. Gregory.  Ms. Brooks testified that all new employees at the 
 
         plant are handed wrist bands with an explanation as to their use.  
 
         She also stated that claimant's visit with Dr. Neiman in August 
 
         of 1986 was arranged by the defendant.
 
         
 
              Mike McClain testified that he is employed as a personnel 
 
         manager by the defendant and has been so since 1978.  He stated 
 
         that during claimant's period of employment claimant was a 
 
         probationary employee.
 
         
 
              Donald D. Berg, M.D. testified by way of deposition which 
 
         was marked as defendant's exhibit A. Dr. Berg stated that he is 
 
         an orthopaedic surgeon practicing in Ottumwa, Iowa.  He stated 
 
         that he first saw the claimant on July 15, 1986 at which time he 
 
         took a history disclosing the claimant had been employed at the 
 
         defendant's as a ham boner.  Claimant was complaining at that 
 
         time of arm pain.  According to the history given to the doctor 
 
         by claimant, claimant was employed in carpentry work between July 
 
         2 and July 15.  Dr. Berg said he examined claimant and diagnosed 
 
         tendonitis in the arms.  He prescribed medication of an 
 
         anti-inflammatory character and told him, if at all possible, not 
 
         to do a lot of work or use his arms.  Claimant apparently told 
 
         the doctor, however, that he needed money and had to work and so 
 
         was continuing to do carpentry work.  Dr. Berg stated that he did 
 
         not make a diagnosis of carpal tunnel syndrome, but did not 
 
         dispute the findings of Dr. Neiman.    It was Dr. Berg's opinion 
 
         that claimant's employment as a carpenter continued to aggravate 
 
         the tendonitis that was diagnosed.  The doctor stated that he 
 
         last saw the claimant in November, 1986, at which time he was 
 
         having continued complaints of pain in his arms, tenderness over 
 
         the forearms and numbness in his fingers.  It was Dr. Berg's 
 
         opinion that claimant's condition arose from both his employment 
 
         at Hormel and his carpentry work.  He said it would be difficult 
 
         to distinguish which of the two contributed most to the 
 
         condition.  He said he advised the claimant to not do carpentry 
 
         work.  The doctor also stated that he would not be surprised that 
 
         someone doing ham boning work would develop carpal tunnel 
 
         syndrome.  He indicated that claimant's recovery would have been 
 
         quicker had he not been involved in the carpentry work.
 
         
 
              Richard F. Neiman, M.D. testified by way of deposition which 
 
         was submitted as claimant's exhibit 1. Dr. Neiman stated that he 
 
         is a neurologist practicing in Cedar Rapids, Iowa.  He stated 
 
         that he first examined claimant on August 15, 1986 upon referral 
 
         from Dr. Berg in Ottumwa.  Dr. Neiman outlined the history which 
 
         was given to him by the claimant which was essentially that which 
 
         was given to Dr. Berg.  Dr. Neiman diagnosed carpal tunnel 
 
         syndrome on the right with borderline left carpal tunnel 
 
         syndrome.  Dr. Neiman also recommended that claimant limit the 
 
         use of his hands, but was advised that claimant felt he had to 
 

 
         
 
         
 
         
 
         GULLETT V. GEORGE A. HORMEL & CO.
 
         Page   4
 
         
 
         
 
         work in order to earn a living.  The doctor stated that, in his 
 
         opinion, approximately 80% of claimant's problem was attributable 
 
         to his employment at the defendant's and perhaps 20% related to 
 
         his work as a carpenter.  The doctor stated that there was a 
 
         clear causal relationship between claimant's employment and the 
 
         difficulty he was having with his hands.  He stated, however, 
 
         that had claimant not been employed at Hormel, he would not have 
 
         had the problem with his hands.  Dr. Neiman stated that he did 
 
         not have an opinion at that time as to whether or not claimant 
 
         suffered any permanent disability and indicated that it would be 
 
         best to wait and see whether or not claimant's condition 
 
         improved.  The doctor indicated that his following of the 
 
         claimant showed that improvement was slowly taking place.
 
         
 
              A review of the exhibits submitted by the parties 
 
         demonstrates essentially the same matters as were testified to by 
 
         claimant and by the doctors.  Statements from claimant's medical 
 
         treatment are included in the exhibits.  Defendant's exhibit B is 
 
         a statement of claimant's earnings while in the employ of the 
 
         defendant from May 11, 1986 through July 6, 1986.  The pay slip 
 
         indicates claimant's payment over a nine-week period.
 
         
 
                           APPLICABLE LAW AND ANALYSIS
 
         
 
              The claimant has the burden of proving by a preponderance of 
 
         the evidence that the injury of July 3, 1986 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. 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).
 
         
 
              Iowa Code section 85.33(l), which deals with temporary total 
 
         and temporary partial disability, states:
 
         
 
              Except as provided in subsection 2 of this section, the 
 
              employer shall pay to an employee for injury producing 
 
              temporary total disability weekly compensation benefits, as 
 
              provided in section 85.32, until the employee has returned 
 
              to work or is medically capable of returning to employment 
 
              substantially similar to the employment in which the 
 
              employee was engaged at the time of injury, whichever occurs 
 
              first.
 

 
         
 
         
 
         
 
         GULLETT V. GEORGE A. HORMEL & CO.
 
         Page   5
 
         
 
         
 
         
 
              This case presents an interesting fact pattern.  It is 
 
         evident that the claimant did, in fact, suffer an injury arising 
 
         out of and in the course of his employment.  It is also evident 
 
         that it was the clear recommendation of claimant's treating 
 
         physicians that he not work, in order to give his body a chance 
 
         to recuperate from the injury.  At the same time, however, 
 
         defendant did not pay claimant and, in fact, discharged him from 
 
         his employment and now claim to be relieved from their obligation 
 
         due to the fact that the claimant was required to seek 
 
         selfemployment in order to support himself and his family.  In 
 
         short, the defendant now seeks to benefit from its own refusal to 
 
         pay for what they have acknowledged they are responsible.  As a 
 
         consequence, claimant has suffered a continuing and ongoing 
 
         problem with his hands which has failed to clear up and which 
 
         continues to bother him.  Unfortunately, the law does not 
 
         contemplate such actions and an appropriate remedy for the 
 
         claimant is difficult to find.  The medical evidence clearly 
 
         establishes a causal relationship and he is entitled to prevail 
 
         on that point.  He consequently prevails on the issue of section 
 
         85.27 benefits.
 
         
 
              The sole issue in this case is whether or not claimant is 
 
         entitled to disability benefits as a result of his injury.  
 
         Certainly his return to work, even as a self-employed carpenter, 
 
         precludes his recovery of temporary total disability and the 
 
         record does not establish any permanent disability at this time.  
 
         At the same time, however, it is the purpose of the compensation 
 
         law to provide for the injured worker and his or her dependents 
 
         and it is contemplated that he have adequate time to recover from 
 
         the injuries.  Accordingly, it will be ordered that the defendant 
 
         shall commence payment of temporary total disability upon 
 
         notification by the claimant, filed with the office of the 
 
         industrial commissioner, that he has ceased his self-employment 
 
         as a carpenter.  Such payments should continue until claimant 
 
         achieves a maximum medical recovery or is capable of returning to 
 
         substantially similar employment to that which he was engaged in 
 
         at the time of the injury.  It is the specific purpose of this 
 
         decision to deny the defendant the benefit of having refused to 
 
         pay claimant compensation owed when they were aware of the fact 
 
         that claimant was not capable of employment.  Claimant shall be 
 
         entitled to file a review-reopening,petition at the conclusion of 
 
         his healing period if it becomes apparent at that time that he 
 
         has suffered permanent disability.
 
         
 
              Claimant's rate of compensation shall be based upon section 
 
         85.36(7). Utilizing defendant's exhibit B and applying that 
 
         section, claimant's gross weekly earnings at the time of his 
 
         injury were $368.09.  His rate of compensation is accordingly 
 
         $233.54.
 
                     FINDINGS OF FACT AND CONCLUSIONS OF LAW
 
         
 
              1.  On July 3, 1986 claimant suffered an injury arising out 
 
         of and in the course of his employment with the defendant.
 
         
 
              2.  Claimant's injury is carpal tunnel syndrome on the right 
 
         and borderline on the left.
 
         
 
              3.  Claimant's doctors recommended claimant not work in 
 

 
         
 
         
 
         
 
         GULLETT V. GEORGE A. HORMEL & CO.
 
         Page   6
 
         
 
         
 
         order to recover from his injury.
 
         
 
              4.  Due to defendant's discharge of claimant from employment 
 
         and refusal to pay compensation, claimant was nevertheless 
 
         required to work as a self-employed carpenter.
 
         
 
              5.  Claimant's self-employment has prolonged and aggravated 
 
         his condition.
 
         
 
              6.  Claimant has not achieved maximum medical recovery.
 
         
 
              7.  Due to defendant's continued failure to pay 
 
         compensation, claimant must continue self-employment.
 
         
 
              8.  Claimant needs to be off work to recover from his 
 
         injury.
 
         
 
              9.  The medical expenses incurred by claimant as set forth 
 
         in exhibits 3 through 7 are causally related to his injury.
 
         
 
             10.  Claimant's rate of compensation is $233.54.
 
         
 
             11.  It can not be determined at this time whether claimant
 
         suffered permanent disability.
 
         
 
             12.  Any aggravation of the injury which occurred as a result 
 
         of claimant's self-employment was proximately caused by 
 
         defendant's refusal to pay compensation.
 

 
         
 
         
 
         
 
         GULLETT V. GEORGE A. HORMEL & CO.
 
         Page   7
 
         
 
         
 
         
 
              IT IS THEREFORE CONCLUDED that claimant has proven by a 
 
         preponderance of the evidence that he is entitled to temporary 
 
         total disability benefits to recover from his injury upon ceasing 
 
         the self-employment he was required to undertake as a result of 
 
         defendant's refusal or failure to pay compensation.
 
         
 
              IT IS FURTHER CONCLUDED that claimant has proven by a 
 
         preponderance of the evidence that there is a causal relationship 
 
         between his injury and the medical expenses set forth in exhibits 
 
         3 through 7.
 
         
 
                                      ORDER
 
         
 
              IT IS THEREFORE ORDERED that the defendant pay unto claimant 
 
         temporary total disability benefits at his rate of $233.54 
 
         commencing immediately upon notice by claimant, filed with the 
 
         Division of Industrial Services, of his cessation of 
 
         self-employment.  Such benefits shall continue until the 
 
         conditions of section 85.33(l) are met.
 
         
 
              IT IS FURTHER ORDERED that the defendant pay all medical 
 
         expenses set forth in exhibits 3 through 7.
 
         
 
              IT IS FURTHER ORDERED that costs are taxed to the 
 
         defendant.
 
         
 
         
 
              Signed and filed this 29th day of 1987.
 
         
 
         
 
         
 
         
 
                                            STEVEN E. ORT
 
                                            DEPUTY INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. H. Edwin Detlie                   Mr. Richard Bauerle
 
         Attorney at Law                       Attorney at Law
 
         114 North Market Street               111 West Second Street
 
         Ottumwa, Iowa 52501                   P.O. Box 716
 
                                               Ottumwa, Iowa 52501
 
         
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                                   1108, 1402.40, 1402.60
 
                                                   1801, 2209, 2207
 
                                                   Filed June 29, 1987
 
                                                   STEVEN E. ORT
 
         
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
         
 
         
 
         CRAIG ALLEN GULLETT,
 
         
 
              Claimant,                           File No. 825147
 
         
 
         VS.
 
                                                A R B I T R A T I 0 N
 
         GEORGE A. HORMEL & Co.,
 
         
 
              Employer,                            D E C I S I 0 N
 
              Self-Insured,
 
              Defendant.
 
         
 
         
 
         
 
         
 
         1108, 1402.40, 1402.60, 1801, 2209, 2207
 
         
 
              In this case the employer admitted that the claimant 
 
         received a compensable injury.  The defendant also directed 
 
         medical and doctors advised claimant to stay off work.  Employer 
 
         fired claimant but did not pay temporary total disability.  
 
         Claimant started self-employment work and employer contended this 
 
         relieved them of liability because claimant's continued working 
 
         aggravated the condition and was against medical advise.
 
         
 
              Decision was that as soon as claimant stops self-employment, 
 
         employer is to start making temporary total disability payments 
 
         until he fully recovers.
 
 
 
         
 
 
            
 
               
 
            
 
            
 
            
 
                    BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
                                          :
 
            CRAIG ALLEN GULLETT,          :
 
                                          :      File No. 825147
 
                 Claimant,                :
 
                                          :
 
            vs.                           :       R E V I E W -
 
                                          :
 
            GEO. A. HORMEL & CO.,         :     R E O P E N I N G
 
                                          :
 
                 Employer,                :      D E C I S I O N
 
                 Self-Insured,            :
 
                 Defendant.               :
 
                                          :
 
            ___________________________________________________________
 
            
 
                             STATEMENT OF THE CASE
 
            
 
                 This is a proceeding in review-reopening brought by 
 
            claimant, Craig Gullett, against his former employer, Geo. 
 
            A. Hormel & Co., self-insured.  Claimant received a 
 
            work-related injury on July 3, 1986, which arose out of and 
 
            in the course of his employment.  This matter came on for a 
 
            hearing before the undersigned deputy industrial 
 
            commissioner on May 5, 1993, at Oskaloosa, Iowa.
 
            
 
                 The record in this case consists of the live testimony 
 
            from the claimant and Doug Eckermann, as well as deposition 
 
            testimony from Alex Macy, D.C., Donald Berg, M.D., Phillip 
 
            Lyon, Patricia Berger, and Richard Neiman, M.D.; claimant's 
 
            exhibits 1 through 5; and, defendants' exhibits A through Z.
 
            
 
                                      ISSUES
 
            
 
                 The parties submitted the following issues for 
 
            resolution:
 
            
 
                 1.  Whether there is a causal relationship between 
 
            claimant's injury and his disability;
 
            
 
                 2.  Whether claimant is entitled to temporary total or 
 
            healing period benefits, or permanent partial disability 
 
            benefits; and,
 
            
 
                 3.  Whether claimant is entitled to medical expenses 
 
            under Iowa Code section 85.27.  The defendants deny that the 
 
            treatment claimant received was reasonable and necessary, 
 
            and that the expenses were authorized by the defendants.
 
            
 
                           REVIEW-REOPENING DECISIONS
 
            
 
                 As noted, this is a proceeding in review-reopening.  
 
            Any initial determination regarding claimant's case was made 
 
            on June 29, 1987, the date the initial arbitration decision 
 
            was filed.  The initial findings of fact and conclusions of 
 
            law of the original arbitration decision are as follows:
 
            
 
                 1.  On July 3, 1986 claimant suffered an injury 
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
                 arising out of and in the course of his employment 
 
                 with the defendant.
 
            
 
                 2.  Claimant's injury is carpal tunnel syndrome on 
 
                 the right and borderline on the left.
 
            
 
                 3.  Claimant's doctors recommended claimant not 
 
                 work in order to recover from his injury.
 
            
 
                 4.  Due to defendant's discharge of claimant from 
 
                 employment and refusal to pay compensation, 
 
                 claimant was nevertheless required to work as a 
 
                 self-employed carpenter.
 
            
 
                 5.  Claimant's self-employment has prolonged and 
 
                 aggravated his condition.
 
            
 
                 6.  Claimant has not achieved maximum medical 
 
                 recovery.
 
            
 
                 7.  Due to defendant's continued failure to pay 
 
                 compensation, claimant must continue 
 
                 self-employment.
 
            
 
                 8.  Claimant needs to be off work to recover from 
 
                 his injury.
 
            
 
                 9.  The medical expenses incurred by claimant as 
 
                 set forth in exhibits 3 through 7 are causally 
 
                 related to his injury.
 
            
 
                 10.  Claimant's rate of compensation is $233.54.
 
            
 
                 11.  It can not be determined at this time whether 
 
                 claimant suffered permanent disability.
 
            
 
                 12.  Any aggravation of the injury which occurred 
 
                 as a result of claimant's self-employment was 
 
                 proximately caused by defendant's refusal to pay 
 
                 compensation.
 
            
 
                    IT IS THEREFORE CONCLUDED that claimant has 
 
                 proven by a preponderance of the evidence that he 
 
                 is entitled to temporary total disability benefits 
 
                 to recover from his injury upon ceasing the 
 
                 self-employment he was required to undertake as a 
 
                 result of defendant's refusal or failure to pay 
 
                 compensation.
 
            
 
                   IT IS FURTHER CONCLUDED that claimant has proven 
 
                 by a preponderance of the evidence that there is a 
 
                 causal relationship between his injury and the 
 
                 medical expenses set forth in exhibits 3 through 
 
                 7.
 
            
 
                 The defendant was ordered to pay claimant temporary 
 
            total disability benefits at his appropriate workers' 
 
            compensation rate ($233.54) commencing immediately upon 
 
            notice by claimant of his cessation of self-employment.  The 
 
            benefits would continue until the conditions of section 
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
            85.33(1) were met.
 
            
 
                                 FINDINGS OF FACT
 
            
 
                 The undersigned deputy, having reviewed all of the 
 
            evidence received, finds the following facts:
 
            
 
                 Claimant was born on August 17, 1953, and at the time 
 
            of the hearing was 39 years of age.  He is right hand 
 
            dominant.
 
            
 
                 At the time claimant worked for the defendant, George 
 
            A. Hormel & Co. (hereinafter referred to as defendant or 
 
            Hormel), in addition to his high school diploma, he had 
 
            successfully completed one year of building trade classes 
 
            and a six month welding course, earning certificates in both 
 
            disciplines.  Claimant started taking courses at the Indian 
 
            Hills Community College in Ottumwa, Iowa, in September of 
 
            1991, and at the time of the hearing he anticipated 
 
            graduating in May of 1993 with an A.A.S. degree in laser 
 
            optometrics.  He has received very good grades in his course 
 
            work at Indian Hills Community College (Defendant's Exhibits 
 
            X and Y).
 
            
 
                 Piecing together claimant's medical treatment was 
 
            challenging in light of the way the exhibits were organized 
 
            and claimant's own testimony.  First of all, defendant's 
 
            exhibits H and I were not considered as they were records 
 
            that were considered in the original arbitration decision.
 
            
 
                 The first relevant medical records are dated August 3, 
 
            1987, wherein Donald Berg, M.D., stated that he had 
 
            evaluated the claimant on July 31, 1987.  Dr. Berg was under 
 
            the impression that claimant exhibited signs of bilateral 
 
            carpal tunnel syndrome as claimant complained of having pain 
 
            in his hand and forearms which increased with activity.  
 
            Claimant had a positive Phalen's test and Tinel's test.  Dr. 
 
            Berg recommended bilateral carpal tunnel surgery (Def. Ex. 
 
            K).
 
            
 
                 Carpal tunnel release surgery on the right wrist was 
 
            performed on September 21, 1987.  Dr. Berg was the surgeon, 
 
            and he also noted marked synovitis and performed a 
 
            synovectomy while repairing the carpal tunnel.  
 
            Postoperatively, claimant developed spasms and cramping in 
 
            both arms and legs.  Dr. Berg did not feel this was related 
 
            to the carpal tunnel problems and was probably not related 
 
            to any work-related injury.  He did feel that the 
 
            synovectomy was a direct result of the wrist problems.  Dr. 
 
            Berg also performed the left carpal tunnel release, which 
 
            was performed on October 12, 1987.  Again, Dr. Berg also 
 
            noted significant synovitis and performed a synovectomy.  He 
 
            believed that claimant would be able to return to work eight 
 
            months post the last surgery, or sometime in mid-December 
 
            1987.  However, claimant had come under the care of Marc 
 
            Hines, M.D., and Dr. Berg had not provided any follow-up 
 
            treatment to the claimant (Def. Ex. E).
 
            
 
                 The next records indicate that Dr. Hines provided a 
 
            report to Dale Emerson, M.D., regarding the results of an 
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            EMG and nerve conduction velocity test.  The results of the 
 
            nerve conduction study showed no significant abnormalities 
 
            but only minimal slowing of the left median and right median 
 
            digital sensory distal latencies of each wrist.  Dr. Hines 
 
            was under the impression that this problem was the result of 
 
            the carpal tunnel surgeries.  The EMG showed some 
 
            denervation in either the C-8 or T-1 dermatome or a 
 
            combination of mild denervation from residual carpal tunnel 
 
            and ulnar denervation below the elbow.  Dr. Hines 
 
            recommended an evaluation at the Mayo Clinic and prescribed 
 
            Percodan for chronic pain symptoms (Def. Ex. M).
 
            
 
                 Paul Scanlon, M.D., a specialist in thoracic diseases 
 
            and internal medicine, provided the evaluation at the Mayo 
 
            Clinic in Rochester, Minnesota.  His report, dated March 23, 
 
            1988, indicates that claimant complained about pain in his 
 
            hands, arms, shoulders, neck and around the ears.  He was 
 
            able to receive minimal relief from Percodan but felt he was 
 
            unable to work.  Dr. Scanlon's review of claimant's past 
 
            medical history was essentially negative.  Current 
 
            complaints included discouragement, depression, and 
 
            nervousness.  A neurological consultation by J.P. Campbell, 
 
            M.D., resulted in a diagnosis of bilaterally positive 
 
            thoracic outlet maneuvers.  Dr. Campbell was under the 
 
            impression that claimant had a chronic pain disorder and 
 
            recommended an evaluation by the pain management center and 
 
            disability impairment unit.  An EMG showed no evidence of 
 
            median neuropathy at the wrist and no evidence of active 
 
            cervical or lumbosacral radiculopathy.  Claimant's 
 
            evaluation at the pain management center was summarized as 
 
            finding that claimant was not objectively disabled but 
 
            rather that his pain behavior was fueled by anger, an sense 
 
            of injustice and consequent legal proceedings.  Dr. Scanlon 
 
            recommended further impairment evaluations (Def. Ex. N).
 
            
 
                 In April of 1988, claimant underwent a neurological 
 
            examination performed by Randy Winston, M.D.  He found 
 
            positive Tinel's signs at the elbows, but not at the wrists.  
 
            He performed the Roos maneuver, which was negative (Cl. Ex. 
 
            4).
 
            
 
                 Next, claimant underwent a neuropsychological 
 
            evaluation administered by Jeff Martzke.  The examination 
 
            which was performed on April 21, 1988, confirmed that 
 
            physicians were unable to find a physiologic cause for 
 
            claimant's reported discomfort.  Throughout the report, Mr. 
 
            Martzke indicates that although claimant denies a sense of 
 
            anxiety, he appeared anxious.  Mr. Matzo conducted two 
 
            tests, the Beck Depression Inventory and the Minnesota 
 
            Multiphasic Personality Inventory.  On the first test, 
 
            claimant scored a 12 which indicates a depressive 
 
            symtomatology.  This diagnosis would include insomnia, 
 
            anorexia, loss of interest, irritability, crying spells, 
 
            suicidal ideation, memory or concentration deficits, 
 
            indifference or social withdrawal.  However, claimant denied 
 
            any of the symptoms other than not being able to sleep well.  
 
            The MMPI yielded results that included considerable 
 
            defensiveness, psychopathic deviants and nervousness and 
 
            hypochondriacal symptoms (Def. Ex. O).
 
            
 

 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
                 In May of 1988, claimant was evaluated by Richard 
 
            Neiman, M.D., presumably at the request of Dr. Hines.  
 
            Claimant's primary complaints were of pain in the hands, 
 
            wrists, elbows, shoulders, and neck area.  An examination 
 
            revealed minor limitations and flexion, extension and 
 
            lateral rotation of the neck and ultimately found no 
 
            deficits neurologically.  Dr. Neiman felt claimant suffered 
 
            from fibromyocitis and did not detect any evidence of 
 
            thoracic outlet syndrome.  He did indicate that claimant's 
 
            current difficulty of pain was far outside the range of any 
 
            carpal tunnel symptoms and recommended Indocin and a trial 
 
            routine of traction (Def. Ex. P).
 
            
 
                 Also in May of 1988, claimant returned to Dr. Winston.  
 
            He concurred that if claimant had thoracic outlet syndrome, 
 
            the condition was related to his work at Hormel (Cl. Ex. 4).
 
            
 
                 The next medical records indicate that Dr. Hines 
 
            referred claimant to David Roos, M.D., a physician in 
 
            Denver, Colorado.  Dr. Hines suspected thoracic outlet 
 
            syndrome.  The Roos maneuver (an eponymic name) is used to 
 
            diagnose a thoracic outlet syndrome (Def. Ex. Q).
 
            
 
                 Claimant met with Dr. Roos on December 1, 1988.  
 
            Claimant continued to complain of extreme pain in his hands, 
 
            wrists, arms, shoulders and upper chest.  Dr. Roos diagnosed 
 
            bilateral thoracic outlet syndrome related to claimant's 
 
            work as a meat cutter with Hormel.  He recommended surgical 
 
            decompression of the lower nerves of the brachial plexus by 
 
            transaxillary first rib resection.  The first decompression 
 
            of the right thoracic outlet was performed January 6, 1989, 
 
            and the second surgical decompression of the left thoracic 
 
            outlet was performed on March 2, 1989.  Dr. Roos also 
 
            indicated claimant had contracted fibromyalgia from 
 
            long-standing muscle spasms (Def. Ex. R; Cl. Ex. 2).
 
            
 
                 In April of 1989, claimant was referred back to Dr. 
 
            Hines to be evaluated for possible cubital tunnel entrapment 
 
            syndrome.  Dr. Roos felt that if Dr. Hines concurred in this 
 
            diagnosis, claimant was to be referred to an orthopedic or 
 
            neurosurgeon to undergo ulnar nerve transfer at the elbows.  
 
            This diagnosis was made in conjunction with Dr. Roos' 
 
            operation for recurrent carpal tunnel syndrome which was 
 
            also performed at the time of the surgical decompression of 
 
            the left thoracic outlet (Cl. Ex. 2).
 
            
 
                 The undersigned is unable to find this evaluation by 
 
            Dr. Hines.
 
            
 
                 The next medical records indicate that in February of 
 
            1990, claimant underwent both right and left total anterior 
 
            scalenectomies performed by Dr. Roos.  He was given several 
 
            prescription medications including Vicodin for pain control; 
 
            Percocet for anxiety; Flexeril for muscle spasms; and, 
 
            Sinequan for relaxation and sleep (Cl. Ex. 2).
 
            
 
                 In April of 1990, Dr. Roos sent a letter to Barbara 
 
            Chaldy of the Management Consulting and Rehabilitation 
 
            Services, Inc., a letter indicating that claimant would be 
 
            unable to return to work as a meat cutter.  He was 
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            restricted to light physical activities with both upper 
 
            extremities and was not to lift any more than 20 pounds.  He 
 
            was to perform infrequent bending or stooping, reaching, 
 
            pushing or pulling activities (Cl. Ex. 2).
 
            
 
                 In October of 1990, claimant underwent another 
 
            evaluation performed by Dr. Roos.  An examination showed 
 
            full range of motion of the cervical spine and sensory tests 
 
            showed normal sensations in both upper extremities.  Again, 
 
            Dr. Roos diagnosed fibromyalgia of the neck and shoulder 
 
            muscles, tendonitis of the anterior shoulder and arthritis 
 
            of both wrist in the base of the thumbs.  Dr. Roos felt 
 
            claimant was unable to return to work because of persistent 
 
            pain in his hands, wrists and shoulders.  He believed 
 
            claimant fully disabled from the use of his hands, wrists, 
 
            arms, and shoulders due to fibromyalgia (Def. Ex. W; Cl. Ex. 
 
            2).
 
            
 
                 In January of 1991, Dr. Hines evaluated claimant for 
 
            purposes of rendering an opinion on his permanent 
 
            impairment.  He noted that claimant was continuing to have 
 
            considerable difficulties with ordinary activities of daily 
 
            living.  It was difficult, due to pain in his shoulders, 
 
            elbows and wrists to perform activities such as self-care 
 
            and personal hygiene.  Claimant encountered pain when he 
 
            elevated his arms above his shoulders and had difficulties 
 
            writing and typing or using his arms and wrists for more 
 
            than five minutes.  Claimant also had pain in his shoulders 
 
            and neck while lying down, and often woke up several times 
 
            during the night due to the pain.  Getting out of a chair 
 
            caused pain in his shoulders and arms, and driving bothered 
 
            his wrists, shoulders and neck.  Dr. Hines concurred with 
 
            Dr. Roos' assessment that claimant had almost complete 
 
            inability to use his hands and arms without pain, and had 
 
            severe impairment of the use of his hands, arms, wrists and 
 
            shoulders.  Dr. Hines goes on to state:
 
            
 
                 Unfortunately, this type of pain is not 
 
                 specifically ratable using the AMA Guides; they do 
 
                 not give specific rating procedures for this type 
 
                 of diffuse fibromyalgia and/or arthritic type of 
 
                 situation.  I would feel, therefore, a great deal 
 
                 of lack of confidence in rating Mr. Gullett, were 
 
                 it not for the fact that he has been to multiple 
 
                 centers, in multiple areas of the state and even 
 
                 out of state, with recurrent consultation always 
 
                 leading to the same group or set of diagnoses... I 
 
                 therefore concur with Dr. Roos's opinion that 
 
                 these have caused near total disability in his 
 
                 arms, although the permanent impairment rating per 
 
                 se certainly must take into account that he has 
 
                 considerable continued use of his arms and hands 
 
                 on a daily basis, although from the standpoint of 
 
                 any ability to use these for repetitive activity, 
 
                 they are basically useless.
 
            
 
            (Cl. Ex. 2)
 
            
 
                 Dr. Hines was able to use various tables in the AMA 
 
            Guides to assess claimant as having a 39 percent impairment 
 

 
            
 
            Page   7
 
            
 
            
 
            
 
            
 
            to the whole person.  Dr. Hines indicated that fibromyalgia 
 
            and the type of arthritis that claimant had were not 
 
            specifically rated in the Guides.  His rating is based upon 
 
            impairment due to pain, discomfort or loss of sensation 
 
            which may prevent activity ranges.  Apparently, this 
 
            methodology is endorsed by authors of the Guides (Cl. Ex. 
 
            2).
 
            
 
                 In January and February of 1991, claimant received 
 
            medical attention from Mary Radia, M.D.  She specializes in 
 
            the treatment of arthritic conditions, and after and 
 
            examination and reviewing claimant's medical history she was 
 
            able to diagnose myofascial pain syndrome predominantly in 
 
            the right upper extremity.  She also stated that claimant 
 
            had incidental bursitis but no evidence of inflammatory 
 
            disease.  Later, Dr. Radia believed that claimant did not 
 
            have arthritis but rather showed manifestations of his 
 
            neurologic impingement (Cl. Ex. 3).
 
            
 
                 In May of 1991, Dr. Hines again examined claimant and 
 
            found that he was continuing to have permanent pain in his 
 
            neck, shoulders and arms.  Dr. Hines recommended continued 
 
            prescription therapy of Lortabs and claimant was to follow 
 
            up with Dr. Hines every six months for an indefinite period 
 
            of time.  Also, claimant was not to perform any lifting of 
 
            more than 30 pounds (Cl. Ex. 1).
 
            
 
                 In August of 1991, claimant saw Douglas Reagan, M.D., 
 
            for an evaluation.  After reviewing his medical history and 
 
            performing an examination, Dr. Reagan indicated that 
 
            claimant had sustained a 12 percent permanent impairment to 
 
            the right upper extremity and an 8 percent impairment to the 
 
            left upper extremity.  He was unable to render any opinions 
 
            with respect to impairment to claimant's shoulder because 
 
            this is not his area of expertise.  Dr. Reagan's ratings are 
 
            based on the complaint of pain and the surgeries claimant 
 
            has undergone (Def. Ex. S).
 
            
 
                 In October of 1991, Dr. Hines provided yet another 
 
            report with respect to claimant's condition.  He had 
 
            reviewed several reports, including Dr. Roos' report dated 
 
            October 23, 1990; Dr. Reagan's report dated August 5, 1991; 
 
            and, his own reports dated January 2, 1991 and May 24, 1991.  
 
            At this time, he formed an opinion that claimant's 
 
            work-related injury and restriction were related directly to 
 
            his thoracic outlet syndrome and carpal tunnel syndrome.  He 
 
            believed all of these problems were related to claimant's 
 
            work situation at Hormel.  He also indicated that the 
 
            problems were exacerbated and worsened by the work 
 
            activities as a carpenter.  Dr. Hines also reiterated that 
 
            the fibromyalgia of the neck, shoulder muscles, tendonitis 
 
            of the anterior shoulder region and the arthritis of the 
 
            joints of the wrists and base of the thumbs were significant 
 
            conditions secondary to the chronic process that began with 
 
            work at Hormel (Cl. Ex. 1).
 
            
 
                 In March of 1992, claimant was sent to Thomas Bower, a 
 
            licensed physical therapist.  He underwent an extensive 
 
            evaluation, and Mr. Bower reviewed his medical records, 
 
            although it is unclear as to which medical records Mr. Bower 
 

 
            
 
            Page   8
 
            
 
            
 
            
 
            
 
            examined.  At this evaluation, claimant continued to 
 
            complain of persistent numbness and tingling in his upper 
 
            extremities.  Repeat nerve conduction studies demonstrated 
 
            completely normal median motor and sensory conductions.  
 
            Similar findings were noted for the ulnar nerve as well as 
 
            the cubital tunnel across the ulnar groove.  While Mr. Bower 
 
            believed that previous functional capacity evaluations 
 
            showed the claimant to demonstrate disportionate responses 
 
            relative to pain therefore indicating a very high propensity 
 
            of symptom magnification, after testing his lifting and 
 
            endurance capabilities, Mr. Bower felt any symptoms were 
 
            still a result of the thoracic outlet problem.  Claimant was 
 
            able to lift 30 pounds from floor to chest height, carry 29 
 
            pounds a distance of 25 feet, and push/pull 85 pounds.  
 
            These activities elicited pain to be on a level 7 from an 
 
            ascending scale from 0 to 10.  Endurance assessment revealed 
 
            that claimant was able to complete all of the assigned 
 
            activities for the full time allotment.  A lift track 
 
            analysis, which is a computerized analysis, wherein the 
 
            patient is videotaped performing specific tests, and Mr. 
 
            Bower wondered whether claimant was yielding his maximum 
 
            effort in overall lifts.  However, the test indicated that 
 
            claimant was able to lift a maximum of 62.7 pounds, a weight 
 
            obviously higher than what claimant was able to perform at 
 
            the time of the evaluation.  In any event, Mr. Bower stated 
 
            that claimant had sustained a 24 percent impairment to the 
 
            whole body as a result of the thoracic outlet problem.  This 
 
            is based on loss of sensation and reduced fine movements in 
 
            motor control.  While reluctant, Mr. Bower also limited 
 
            claimant to lift a maximum of 30 pounds, and placed him into 
 
            a light to light/medium work classification (Def. Ex. T).
 
            
 
                 Dr. Hines reviewed Mr. Bower's evaluation, and while he 
 
            was unable to accept the results of the nerve conduction 
 
            studies and EMGs because Mr. Bower is not a physician, he 
 
            did not express disagreement with the percentage of 
 
            impairment rendered by Mr. Bower (Cl. Ex. 1).
 
            
 
                 In November of 1992, Dr. Neiman was also called upon to 
 
            render an opinion with respect to claimant's permanent 
 
            impairment.  After and examination which revealed weakened 
 
            hand grips, full range of motion of the neck and test 
 
            results of nerve conduction studies which found denervation 
 
            involving the C-8 nerve root distribution involving the 
 
            clinical pattern, sensory loss and motor weakness, Dr. 
 
            Neiman was able to use the AMA guidelines for the thoracic 
 
            outlet syndrome.  After combining all of the percentages 
 
            given to claimant for both upper extremities, Dr. Neiman 
 
            used the combination tables and opined that claimant had 
 
            sustained a 26 percent permanent impairment of the whole 
 
            person.  He also was of the opinion that the multiple 
 
            surgeries including the thoracic outlet was directly related 
 
            to his work at Hormel (Def. Ex. U).
 
            
 
                 In an interesting change of direction, Dr. Hines in 
 
            March of 1993 stated that he was unable to judge whether 
 
            Hormel was more contributory to claimant's condition than 
 
            carpentry work.  However, he believed that Hormel was only 
 
            one of the initiating factors in claimant's current 
 
            symptomatology.  Apparently, this opinion was based on the 
 

 
            
 
            Page   9
 
            
 
            
 
            
 
            
 
            assumption that claimant had performed extensive carpentry 
 
            work, and Dr. Hines then refuted his letter and on April 29, 
 
            1993, stated that if claimant had merely supervised the 
 
            carpentry work and had not done the actual work. it changed 
 
            his conclusions.  He believed that any work of a repetitive 
 
            nature would be the contributing factor but supervision then 
 
            would not be a contributing factor to claimant's 
 
            symptomatology (Def. Ex. V; Cl. Ex. 1).
 
            
 
                 Other exhibits used by the defendant include claimant's 
 
            tax records, an application for a building permit, 
 
            photographs of various job sites, and other photographs and 
 
            summaries of what the defendant argues are claimant's 
 
            extensive carpentry activities (Def. Exs, B,C,D,G and J).
 
            
 
                         ANALYSIS AND CONCLUSIONS OF LAW
 
            
 
                 After the first arbitration decision, which found a 
 
            work-related injury, claimant was paid weekly workers' 
 
            compensation benefits from September 29, 1987 through 
 
            February 23, 1988.  Benefits were denied from March 1, 1988 
 
            until December 20, 1988, when claimant received back 
 
            payments totaling $10,331.18 and then began receiving weekly 
 
            benefits until November 5, 1991.  Weekly benefits to date 
 
            total $51,312.53 (Def. Ex. F, pp. 6-9).
 
            
 
                 The defendant submitted evidence which predates the 
 
            date of the arbitration hearing, March 30, 1987.  A 
 
            review-reopening proceeding is defined under Iowa Code 
 
            section 86.14(2):
 
            
 
                    2.  In a proceeding to reopen an award for 
 
                 payments or agreement for settlement as provided 
 
                 by section 86.13, inquiry shall be into whether or 
 
                 not the condition of the employee warrants an end 
 
                 to, diminishment of, or increase of compensation 
 
                 so awarded or agreed upon.
 
            
 
                 Review-reopening does not contemplate a 
 
            re-determination of the condition of the employee that was 
 
            determined by the previous award.  Stice v. Consolidated 
 
            Ind. Coal Co., 228 Iowa 1031, 1035, 291 N.W. 452 (1940).
 
            
 
                 The first issue to be addressed is whether claimant's 
 
            injury is a proximate cause of his disability.
 
            
 
                 The claimant has the burden of proving by a 
 
            preponderance of the evidence that the injury is a proximate 
 
            cause of the disability on which the claim is based.  A 
 
            cause is proximate if it is a substantial factor in bringing 
 
            about the result; it need not be the only cause.  A 
 
            preponderance of the evidence exists when the causal 
 
            connection is probable rather than merely possible.  
 
            Blacksmith v. All-American, Inc., 290 N.W.2d 348 (Iowa 
 
            1980); Holmes v. Bruce Motor Freight, Inc., 215 N.W.2d 296 
 
            (Iowa 1974).
 
            
 
                 The question of causal connection is essentially within 
 
            the domain of expert testimony.  The expert medical evidence 
 
            must be considered with all other evidence introduced 
 

 
            
 
            Page  10
 
            
 
            
 
            
 
            
 
            bearing on the causal connection between the injury and the 
 
            disability.  The weight to be given to any expert opinion is 
 
            determined by the finder of fact and may be affected by the 
 
            accuracy of the facts relied upon by the expert as well as 
 
            other surrounding circumstances.  The expert opinion may be 
 
            accepted or rejected, in whole or in part.  Sondag v. Ferris 
 
            Hardware, 220 N.W.2d 903 (Iowa 1974); Anderson v. Oscar 
 
            Mayer & Co., 217 N.W.2d 531 (Iowa 1974); Bodish v. Fischer, 
 
            Inc., 257 Iowa 516, 133 N.W.2d 867 (1965).
 
            
 
                 While there can be no serious dispute that claimant has 
 
            sustained a permanent disability, the threshold issue is 
 
            whether claimant participated in extensive carpentry work 
 
            which was therefore the cause of his medical problems.  
 
            Conversely, if his work at Hormel caused all of the medical 
 
            conditions, then he is entitled to permanent partial 
 
            disability benefits from the employer.
 
            
 
                 All of the physicians associated with the case who have 
 
            rendered extensive treatment to claimant are of the opinion 
 
            that his problems began with the carpal tunnel syndrome 
 
            which was caused by his work as a meat cutter at Hormel.  
 
            The defendant argues that claimant is not credible, and that 
 
            he performed extensive carpentry work from the time of his 
 
            termination until the present, and although the undersigned 
 
            did detect some animosity on the claimant's part, she 
 
            believes that claimant did not perform an extensive amount 
 
            of carpentry work.  That work which was performed by the 
 
            claimant consisted of supervision of carpentry/construction 
 
            work; installation of door locks; limited hammering 
 
            activities; and, job site preparation.  As a result, it is 
 
            found that claimant's permanent disability is causally 
 
            related to his employment with Hormel.
 
            
 
                 As claimant has sustained numerous bilateral scheduled 
 
            injuries, he also sustained a thoracic outlet syndrome which 
 
            is an unscheduled injury.  As a result, he is to be 
 
            compensated industrially.
 
            
 
                 Functional impairment is an element to be considered in 
 
            determining industrial disability which is the reduction of 
 
            earning capacity, but consideration must also be given to 
 
            the injured employee's age, education, qualifications, expe
 
            rience and inability to engage in employment for which the 
 
            employee is fitted.  Olson v. Goodyear Serv. 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.  Impairment and disability are not synonymous.  
 
            The degree of industrial disability can be much different 
 
            than the degree of impairment because industrial disability 
 
            references to loss of earning capacity and impairment 
 
            references 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.
 
            
 

 
            
 
            Page  11
 
            
 
            
 
            
 
            
 
                 Factors to be considered in determining industrial dis
 
            ability include the employee's medical condition prior to 
 
            the injury, immediately after the injury, and presently; the 
 
            situs of the injury, its severity and the length of the 
 
            healing period; the work experience of the employee prior to 
 
            the injury and after the injury and the 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.  Likewise, an employer's refusal to give any sort 
 
            of work to an impaired employee may justify an award of 
 
            disability.  McSpadden v. Big Ben Coal Co., 288 N.W.2d 181 
 
            (Iowa 1980).  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.  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 as well as 
 
            general and specialized knowledge to make the finding with 
 
            regard to degree of industrial disability.  See Christensen 
 
            v. Hagen, Inc., Vol. 1 No. 3 State of Iowa Industrial 
 
            Commissioner Decisions 529 (App. March 26, 1985); Peterson 
 
            v. Truck Haven Cafe, Inc., Vol. 1 No. 3 State of Iowa 
 
            Industrial Commissioner Decisions 654 (App. February 28, 
 
            1985).
 
            
 
                 Compensation for permanent partial disability shall 
 
            begin at the termination of the healing period.  
 
            Compensation shall be paid in relation to 500 weeks as the 
 
            disability bears to the body as a whole.  Section 85.34.
 
            
 
                 At the time of the hearing, claimant was 39 years of 
 
            age.  Apparently, much of his adult working life has been 
 
            spent as a carpenter, and claimant worked as a meat cutter 
 
            for less than one month.  Unfortunately, that one month has 
 
            forced claimant to pursue a completely different line of 
 
            work than that in which he had extensive experience.  
 
            However, claimant has been able to commit himself to 
 
            learning a different trade and has performed brilliantly in 
 
            his school work.  Likewise, 90 to 95 percent of the students 
 
            who successfully complete the laser optometrics program find 
 
            employment and earn salaries in the mid-$20,000 range.
 
            
 
                 The employer has done virtually nothing to help 
 
            claimant other than provide some medical treatment.  
 
            Likewise, they have paid weekly benefits but only after 
 
            being ordered to do so.  They have not provided claimant 
 
            with any type of vocational rehabilitation and, in fact, 
 
            promptly terminated claimant when he began to have medical 
 
            difficulties.  This termination was, of course, predicated 
 

 
            
 
            Page  12
 
            
 
            
 
            
 
            
 
            on his lack of ability to perform adequately the meat cutter 
 
            job.
 
            
 
                 It would be hard not to accept as true claimant's 
 
            description of the pain he feels.  While the agency 
 
            routinely does not rely solely on claimant's descriptions of 
 
            pain, there is some objective support for his complaints.  
 
            Claimant has undergone numerous surgeries and has been 
 
            exposed to long healing periods.
 
            
 
                 After considering all of the factors that comprise an 
 
            industrial disability, it is found that claimant has 
 
            sustained a 40 percent industrial disability.
 
            
 
                                      ORDER
 
            
 
                 THEREFORE, it is ordered:
 
            
 
                 That defendant shall pay unto claimant two hundred 
 
            (200) weeks of permanent partial disability benefits at the 
 
            rate of two hundred forty and 26/100 dollars ($240.26) per 
 
            week commencing on January 3, 1991.
 
            
 
                 That defendant shall pay accrued weekly benefits in a 
 
            lump sum and shall receive credit against the award for 
 
            weekly benefits previously paid.
 
            
 
                 That defendant shall pay interest on benefits awarded 
 
            herein as set forth in Iowa Code section 85.30.
 
            
 
                 That defendant shall pay the costs of this proceeding, 
 
            pursuant to rule 343 IAC 4.33.
 
            
 
                 That defendant shall file an activity report upon 
 
            payment of this award as required by the agency pursuant to 
 
            rule 343 IAC 3.1.
 
            
 
                 Signed and filed this ____ day of July, 1993.
 
            
 
            
 
            
 
            
 
                                          
 
                                        ________________________________
 
                                          PATRICIA J. LANTZ
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr H Edwin Detlie
 
            Attorney at Law
 
            114 N Market St
 
            Ottumwa IA 52501
 
            
 
            Mr Richard C Bauerle
 
            Mr Lloyd E Keith
 
            Attorneys at Law
 
            211 E 4th St
 
            P O Box 218
 
            Ottumwa IA 52501
 
 
 
 
            
 
        
 
             
 
 
 
                                                 5-1803
 
                                                 Filed July 27, 1993
 
                                                 Patricia J. Lantz
 
            
 
                     BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
                                          :
 
            CRAIG ALLEN GULLETT,          :
 
                                          :      File No. 825147
 
                 Claimant,                :
 
                                          :
 
            vs.                           :       R E V I E W -
 
                                          :
 
            GEO. A. HORMEL & CO.,         :     R E O P E N I N G
 
                                          :
 
                 Employer,                :      D E C I S I O N
 
                 Self-Insured,            :
 
                 Defendant.               :
 
                                          :
 
            ___________________________________________________________
 
            
 
            5-1803
 
            Claimant awarded 40% industrial disability.  He worked at a 
 
            meat cutting job for approximately one month, and developed 
 
            carpal tunnel, ulnar tunnel and thoracic outlet syndromes.  
 
            He underwent numerous surgeries, but has not had a 
 
            successful recovery.
 
            
 
            Claimant has been a carpenter most of his working life, but 
 
            since the injuries has not been able to perform this type of 
 
            work, he went to school, and has successfully completed a 
 
            laser-technology program, which boasts a 90-95% job 
 
            placement history.
 
            
 
            The employer fired claimant, and did nothing to help his 
 
            recovery or job training/placement.