BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
                                          
 
            KIMBERLY WILLIAMS,            :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :      File No. 894805
 
            GLENWOOD STATE HOSPITAL       :
 
            SCHOOL,                       :    A R B I T R A T I O N
 
                                          :
 
                 Employer,                :      D E C I S I O N
 
                                          :
 
            and                           :
 
                                          :
 
            STATE OF IOWA,                :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ___________________________________________________________
 
            
 
                              STATEMENT OF THE CASE
 
            
 
                 This is a contested case proceeding upon a petition in 
 
            arbitration filed by claimant Kimberly Williams against 
 
            defendants Glenwood State Hospital and the State of Iowa.  
 
            Ms. Williams sustained a work related back injury on August 
 
            17, 1988, and now seeks permanent disability benefits under 
 
            the Iowa Workers' Compensation act.
 
            
 
                 A hearing was held in Council Bluffs, Iowa on June 1, 
 
            1994.  The record consists of joint exhibits 1-17 and the 
 
            testimony of claimant, Cherilyn Leversee and Billy Ray 
 
            Williams.
 
            
 
                                      ISSUES
 
            
 
                 The parties have stipulated to the following:
 
            
 
                    1.  Claimant sustained injury arising out of 
 
                    and in the course of employment on August 
 
                    17, 1988;
 
            
 
                    2.  The injury caused both temporary and 
 
                    permanent disability;
 
            
 
                    3.  Entitlement to healing period benefits 
 
                    is no longer in dispute;
 
            
 
                    4.  Permanent disability should be 
 
                    compensated industrially;
 
            
 
                    5.  The correct rate of weekly compensation 
 
                    is $248.31; and,
 
            
 
                    6.  Entitlement to medical benefits is no 
 
                    longer in dispute (defendants agreed at 
 
                    hearing to cover certain unpaid charges).
 

 
            
 
            Page   2
 
            
 
            
 
            
 
                 The sole issue to be resolved is the extent of 
 
            claimant's industrial disability, whether it be partial or 
 
            total.
 
            
 
                                 FINDINGS OF FACT
 
            
 
                 Kimberly Williams, 34 years of age at hearing, left 
 
            school after the tenth grade.  Ms. Williams was a poor 
 
            student and was placed in some remedial classes.  Even now, 
 
            her literacy skills are weak.  Claimant's only further 
 
            education consists of certification in first aid and CPR.  
 
            Claimant does appear to have average intelligence, an 
 
            opinion shared by psychiatrist Michael J. Taylor, M.D.  
 
            Clinical psychologist Mary Ann Strider, PHD, reported that 
 
            testing showed an IQ only in the borderline range, but 
 
            believed this finding could be inaccurate in light of 
 
            emotional problems claimant has suffered, mostly as a result 
 
            of the work injury.
 
            
 
                 Claimant's work experience has been generally unskilled 
 
            and in the medium category of physical requirements.  
 
            Claimant has worked as a waitress, meat cutter, grocery 
 
            cashier and factory worker.
 
            
 
                 Claimant accepted work in 1984 as a residential 
 
            treatment worker ("RTW") at the Glenwood State Hospital 
 
            School, a facility operated by the State of Iowa to serve 
 
            children with severe handicaps.  Glenwood is a total care 
 
            facility.
 
            
 
                 Claimant suffered back injuries in 1986 and 1987, but 
 
            was able to return to full duty on both occasions.  However, 
 
            she developed severe pain on the stipulated day of injury 
 
            from lifting, transferring and bathing clients.
 
            
 
                 Development of these symptoms (lower back, buttock and 
 
            leg pain) set off an incredibly extensive series of medical 
 
            procedures, beginning with conservative treatment and ending 
 
            in four major surgical interventions.  So far, that is.
 
            
 
                 Ms. Williams underwent surgery on April 25, 1990.  A 
 
            bilateral L5-S1 laminotomy and exploration of the spinal 
 
            canal and foramina was performed without evidence of 
 
            significant abnormality; the treating surgeon, H. Randal 
 
            Woodward, M.D., went on to perform a two level transverse 
 
            process and posterior spine fusion from L3 to L5.  This 
 
            procedure failed to relieve symptoms.  Claimant next 
 
            underwent an anterior (that is, through the abdomen) 
 
            interbody fusion at L3-L5, followed by a separate posterior 
 
            fusion at the same two levels one week later, on October 14.  
 
            These procedures involved installation of pins and rods as 
 
            stabilizers.
 
            
 
                 Unfortunately, these procedures also failed to relieve 
 
            symptoms.  Dr. Woodward performed yet another major 
 
            procedure on April 14, 1993.  This major surgery included 
 
            both anterior and posterior approaches.  Anteriorly, a 
 
            fusion with bone graft was performed at L5-S1, while the 
 
            posterior procedure included removal of the previous spinal 
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
            "hardware" and extension of the fusion to a third level, 
 
            L5-S1.  A new internal fixation device was installed.
 
            
 
                 All of these procedures have failed.  Indeed, as 
 
            discussed below, two other back specialists recommend 
 
            further surgery, although these specialists disagree on what 
 
            procedure should be attempted next.  Claimant, however, has 
 
            lost faith in the medical community's ability to relieve her 
 
            suffering and is most reluctant to undergo any further 
 
            surgery at this time.  Considering how painful recuperation 
 
            from each prior procedure was, and the modest probability of 
 
            success, one cannot fairly view this reluctance as 
 
            unreasonable.
 
            
 
                 Dr. Woodward writes that it would not appear that 
 
            claimant will be able to return to any gainful employment in 
 
            the foreseeable future.  He rates impairment at 26 percent 
 
            of the whole person due to the injury, surgery and residual 
 
            problems in the low back and lower extremities.  Dr. 
 
            Woodward also believes installation of a dorsal column 
 
            stimulator is a potential further treatment, and, on the 
 
            basis that the only way to find out is to try, recommends 
 
            proceeding with pain therapy treatment at the University of 
 
            Iowa Spine Treatment Center.  However, he noted a lack of 
 
            conviction that the program will result in marked 
 
            improvement or allow claimant to return to gainful 
 
            employment.
 
            
 
                 Claimant has seen numerous physicians since the date of 
 
            injury, but the earliest opinions and impairment ratings can 
 
            no longer be considered current due to the multiplicity of 
 
            surgical experiences in the years since.
 
            
 
                 Kip A. Burkman, M.D., evaluated claimant in January 
 
            1984.  His impression is of failed low back syndrome, 
 
            chronic pain syndrome, including reactive depression, and a 
 
            component of deconditioning.  He recommends trial of a TENS 
 
            unit (previously tried unsuccessfully), reconditioning 
 
            exercises and possible candidacy for a chronic pain program.
 
            
 
                 Dr. Patrick W. Bowman has suggested the possibly of a 
 
            dorsal column stimulator implant.
 
            
 
                 James Weinstein, D.O., of the University of Iowa 
 
            Hospitals Spine Diagnostic and Treatment Center, has 
 
            suggested surgical removal of the metal fixation devices 
 
            previously installed by Dr. Woodward.  Claimant is also 
 
            reluctant to accept this advice.
 
            
 
                 Claimant has also suffered psychologically as a result 
 
            of her long ordeal.  Psychiatrist Michael L. Egger, M.D., is 
 
            of an opinion "consistent with" Dr. Woodward's view that 
 
            claimant is not functionally capable of returning to work.  
 
            He rates psychological impairment by itself at approximately 
 
            25 percent of the whole person based on a reactive pattern 
 
            of depression relating to the injury and chronic pain 
 
            syndrome resulting from the injury.
 
            
 
                 Another psychiatrist, Michael J. Taylor, M.D., has 
 
            diagnosed claimant as suffering major depressive disorder, 
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            single episode, which he finds directly related to ongoing 
 
            pain and disability.  He assess impairment according to AMA 
 
            guidelines, in the range of 10-20 percent, but believes 
 
            claimant is psychiatrically capable of competitive 
 
            employment.
 
            
 
                 Claimant is still seeing Dr. Egger for treatment of her 
 
            psychological condition.  Currently, she suffers constant 
 
            pain in the back and legs, although the intensity may vary 
 
            from day to day.  She has problems sleeping, can walk only 
 
            perhaps one block, and must frequently alternate between 
 
            sitting, standing and reclining.
 
            
 
                 Given her current condition, claimant knows of no work 
 
            she can now do.  This is an opinion shared by two vocational 
 
            rehabilitation specialists whose opinions appear in this 
 
            record: Cherilyn Leversee and James Rogers.  Mr. Rogers 
 
            concluded that claimant's employability was "nil," and 
 
            believed she was unlikely to benefit from vocational 
 
            assistance due to pain and depression.  Ms. Leversee agrees 
 
            that claimant can no longer perform medium category jobs 
 
            (all of her work history), and concedes that she is entirely 
 
            incapable of working, at this time.  However, Ms. Leversee 
 
            points out that claimant could perhaps return to work if she 
 
            attends the University of Iowa Spine Clinic successfully.  
 
            Ms. Leversee notes that claimant requires better 
 
            conditioning, less dependence on pain killing medications 
 
            and remedial education.
 
            
 
                                CONCLUSIONS OF LAW
 
            
 
                 Total disability does not mean a state of absolute 
 
            helplessness.  Permanent total disability occurs where the 
 
            injury wholly disables the employee from performing work 
 
            that the employee's experience, training, education, 
 
            intelligence and physical capacities would otherwise permit 
 
            the employee to perform.  See McSpadden v. Big Ben Coal Co., 
 
            288 N.W.2d 181 (Iowa 1980); Diederich v. Tri-City Ry. Co., 
 
            219 Iowa 587, 258 N.W. 899 (1935).
 
            
 
                 A finding that claimant could perform some work despite 
 
            claimant's physical and educational limitations does not 
 
            foreclose a finding of permanent total disability, however.  
 
            See Chamberlin v. Ralston Purina, File No. 661698 (App. 
 
            October 29, 1987); Eastman v. Westway Trading Corp., II Iowa 
 
            Industrial Commissioner Report 134 (App. 1982).
 
            
 
                 It is clear that claimant is currently unable to work 
 
            due to residual pain, functional limitations and 
 
            psychological impairment.  It is abundantly clear that 
 
            claimant is entitled to permanent total disability benefits 
 
            unless a different result is mandated by her unwillingness 
 
            to undergo additional surgery, to proceed with the in-house 
 
            program recommended by the University of Iowa Spine team, or 
 
            because deconditioning plays a role in her disability.
 
            
 
                 In assessing the impact of these negative factors, one 
 
            must look at the entire picture.  Claimant has been in pain 
 
            since 1988, frequently in very severe pain.  This includes 
 
            recuperation from four major surgical procedures, two of 
 

 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
            which involved an approach to the spine through the abdomen.  
 
            Recovery entailed a restrictive and uncomfortable body cast.  
 
            Claimant's unwillingness to undergo further surgical 
 
            intervention at this time is reasonable.  She has had four 
 
            failed back surgeries, and medical recommendations as to a 
 
            fifth procedure vary from installation of a dorsal column 
 
            stimulator to removal (and presumably reinstallation) of the 
 
            internal fixation devices.  Claimant cannot bend, since her 
 
            spine is fused at three levels.  She cannot sleep, cannot 
 
            lift but a few pounds, and must change positions almost 
 
            constantly.  She has suffered disabling psychological 
 
            problems, which understandably interfere with her motivation 
 
            to undergo further surgery or the rehabilitative program 
 
            recommended at the University of Iowa Hospitals.  The 
 
            treating surgeon, Dr. Woodward, is himself skeptical that 
 
            this program is likely to have positive results.  The fact 
 
            that claimant is physically deconditioned at this point is 
 
            hardly surprising, given her inability to engage in active 
 
            exercise.
 
            
 
                 Considering all these factors, it must be concluded 
 
            that Kimberly Williams is at this time totally disabled from 
 
            remunerative employment, and likely to remain so for the 
 
            foreseeable future.  The concept of "permanent" disability 
 
            does not embrace the idea of absolute perpetuity; permanency 
 
            means for an indefinite or indeterminable period.  Wallace 
 
            v. Brotherhood of Locomotive Fireman and Engineman, 230 Iowa 
 
            1127, 300 N.W. 322 (1941).  Claimant has shown good 
 
            motivation, and it is to be hoped that she at some time will 
 
            regain earning capacity, whether through passage of time, 
 
            further surgery, or participation in the University of Iowa 
 
            program.  If so, review-reopening is available to 
 
            defendants.  But on this record, claimant is entitled to 
 
            permanent total disability benefits now and for the 
 
            foreseeable future.
 
            
 
                                      ORDER
 
            
 
                 THEREFORE, IT IS ORDERED:
 
            
 
                 Defendants shall pay permanent total disability 
 
            benefits at the rate of two hundred forty-eight and 31/100 
 
            dollars ($248.31) from August 17, 1988 and continuing during 
 
            such time as claimant remains under a total industrial 
 
            disability.
 
            
 
                 Defendants shall have credit for all benefits 
 
            voluntarily paid.
 
            
 
                 Costs are assessed to defendants.
 
            
 
                 Signed and filed this ____ day of June, 1994.
 
            
 
            
 
                                          
 
                                          ________________________________
 
                                          DAVID RASEY
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            
 
            Copies To:
 
            
 
            Mr Sheldon M Gallner
 
            Attorney at Law
 
            803 Third Avenue
 
            PO Box 1588
 
            Council Bluffs Iowa 51502
 
            
 
            Ms Joanne Moeller
 
            Assistant Attorney General
 
            Tort Claims Division
 
            Hoover State Office Building
 
            Des Moines Iowa 50319
 
            
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                                 5-1804
 
                                                 Filed June 20, 1994
 
                                                 DAVID RASEY
 
            
 
                   BEFORE THE IOWA INDUSTRIAL COMMISSIONER
 
            ____________________________________________________________
 
                                          
 
            KIMBERLY WILLIAMS,            :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :      File No. 894805
 
            GLENWOOD STATE HOSPITAL       :
 
            SCHOOL,                           A R B I T R A T I O N
 
                                          :
 
                 Employer,                :      D E C I S I O N
 
                                          :
 
            and                           :
 
                                          :
 
            STATE OF IOWA,                :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ___________________________________________________________
 
            
 
            5-1804
 
            Permanent total disability benefits were awarded.
 
            
 
 
            
 
            Page   1
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            VICTOR McCALL,                :
 
                                          :
 
                 Claimant,                :         File No. 894908
 
                                          :
 
            vs.                           :      A R B I T R A T I O N
 
                                          :
 
            OSCAR MAYER FOODS CORPORATION,:         D E C I S I O N
 
                                          :
 
                 Employer,                :
 
                 Self-Insured,            :
 
                 Defendant.               :
 
            ____________________________________________________________
 
            
 
                              statement of the case
 
            
 
                 Victor McCall filed a June 15, 1989 original notice and 
 
            petition in arbitration seeking workers' compensation 
 
            benefits from defendant employer Oscar Mayer Foods 
 
            Corporation.  He alleges injury to his back and body as a 
 
            whole arising out of and in the course of employment.
 
            
 
                 This cause came on for hearing in Des Moines, Iowa, on 
 
            November 21, 1990.  Claimant's exhibits 1 through 10 and 
 
            defendant's exhibits A through G were received into 
 
            evidence.  Claimant, Marilyn McCall and Tom McCann testified 
 
            personally.  Claimant also testified by deposition, as did 
 
            Peter D. Wirtz, M.D., Steven Sohn, M.D., and Ernest Found, 
 
            M.D.
 
            
 
                                      issues
 
            
 
                 The parties stipulated that claimant sustained an 
 
            injury arising out of and in the course of his employment on 
 
            July 14, 1988, that the injury caused temporary disability, 
 
            that the appropriate rate of weekly benefits is $252.98 and 
 
            that 1.143 weeks of benefits were voluntarily paid at that 
 
            rate prior to hearing.
 
            
 
                 Issues presented for resolution include:
 
            
 
                 1.  Whether there exists a causal relationship between 
 
            the work injury and any subsequent permanent impairment;
 
            
 
                 2.  The nature and extent of claimant's temporary and 
 
            permanent disability; and,
 
            
 
                 3.  The extent of claimant's entitlement to medical 
 
            benefits under Iowa Code section 85.27.
 
            
 
                                 findings of fact
 
            
 
                 The undersigned deputy industrial commissioner, having 
 
            heard the testimony and considered all of the evidence, 
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            finds:
 
            
 
                 Victor McCall, 31 years old at hearing, attained a 
 
            General Equivalency Diploma in 1980 and is a journeyman 
 
            carpenter following a four-year apprenticeship.  His 
 
            assertion in company personnel records (exhibit F-148) that 
 
            he holds a Ph.D. degree, "and many more," was doubtless 
 
            intended for humorous effect.  Following high school, he 
 
            worked in restaurants, a printing company, as a day camp 
 
            supervisor, as a janitor and as a carpenter.
 
            
 
                 Claimant began a stormy employment relationship with 
 
            Oscar Mayer Foods Corporation, a meat packing concern, on 
 
            February 11, 1985.  He worked one year as a ham boner and 
 
            thereafter on the cut floor doing various jobs, most of 
 
            which required repetitive lifting and bending.
 
            
 
                 Personnel records show that claimant was frequently 
 
            involved in matters of employee discipline.  He was on a 
 
            number of occasions warned or suspended for various 
 
            infractions, typically attendance and incidents of alleged 
 
            horseplay (throwing meat and the like).  Claimant was 
 
            discharged from employment for horseplay on September 30, 
 
            1985, rehired thereafter, and again discharged for horseplay 
 
            on April 27, 1987.  The latter separation was held to 
 
            disqualify claimant for job insurance benefits by a decision 
 
            dated May 29, 1987.
 
            
 
                 Nonetheless, claimant was again rehired effective June 
 
            8, 1987.  Thereafter, further disciplinary actions were 
 
            taken in early 1988.  Mr. McCall was given a verbal warning 
 
            for workmanship on March 29 and one for excessive 
 
            absenteeism on May 16.  On June 1, claimant was given a 
 
            three-day disciplinary suspension for absenteeism and, on 
 
            June 3, a written warning for alleged insubordination.  
 
            Claimant was given another one-day disciplinary suspension 
 
            for alleged insubordination on June 14 and a warning based 
 
            on attendance on June 22, 1988.  Claimant was counseled 
 
            (another individual was suspended) in yet another dispute 
 
            involving alleged insubordination on July 12, 1988, or two 
 
            days before the work injury.  It might also be noted that 
 
            claimant's employment history is replete with numerous 
 
            grievance procedures.  As shall be seen, these problems came 
 
            to a boil six weeks after the work injury.
 
            
 
                 Dr. Sohn, a family practice physician, testified by 
 
            deposition on September 13, 1990.  He has for some years 
 
            acted as a company physician for Oscar Mayer Foods 
 
            Corporation.  His chart notes indicate that claimant was 
 
            first seen on October 30, 1986, almost two years before the 
 
            injury.  Claimant at that time complained of right-side low 
 
            back discomfort and the doctor's assessment was of low back 
 
            strain secondary to repetitive stress on that side.  On 
 
            January 20, 1987, claimant was seen with complaints of pain 
 
            in the right chest wall area for the preceding three weeks.  
 
            When claimant was seen again on January 27, chest wall 
 
            tenderness was improving.
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
                 In his testimony, claimant indicated that the work 
 
            injury occurred while he was engaged in pushing loins (14-22 
 
            pounds) and turning bellies, a job that required twisting 
 
            and throwing loins from a tub to a conveyor belt.  Mr. 
 
            McCall indicated he felt a sharp pain in his side which he 
 
            pointed out as at belt level, just over the right hip at his 
 
            lower back/side.  In his deposition testimony of September 
 
            6, 1989, claimant variously described this incident as 
 
            gradual in nature and as a very sharp pain in the back as if 
 
            he had been poked with a sharp object.  Contemporaneous 
 
            personnel notes state that claimant, while being instructed 
 
            as to his job duties, indicated that his "back or side" 
 
            hurt.  Those notes, submitted by both parties, appear to 
 
            show that the words "or side" were added as an afterthought.  
 
            In any event, it is indicated that the supervisor took no 
 
            action because claimant subsequently went to the doctor, 
 
            this being Dr. Sohn.
 
            
 
                 Chart notes of July 14 show that claimant was 
 
            complaining of pain in the right lateral chest wall which 
 
            occurred while he was sorting loins and that it hurt to move 
 
            or take a deep breath.  Assessment was of muscle strain 
 
            injury with spasm.  However, Dr. Sohn's chart notes of July 
 
            18 reflect that claimant returned "for followup [sic] of 
 
            pain in the back and lower rib area."  The area of 
 
            tenderness over the lower ribs on the right was described as 
 
            improved.  On August 8, chart notes reflect that claimant 
 
            complained of diffuse pain throughout the back and 
 
            shoulders.  On August 12, as claimant continued to complain 
 
            of pain throughout the back, he was placed on light duty for 
 
            one week's time with no bending, stooping or lifting greater 
 
            than ten pounds.  On August 17, claimant continued to 
 
            complain of severe pain throughout the back and now, in both 
 
            shoulders.  However, he could not pinpoint any specific 
 
            areas of pain.  Assessment was of myofascial pain syndrome.
 
            
 
                 Claimant was last seen by Dr. Sohn on September 2, 
 
            1988.  Chart notes reflect complaints of increasing pain 
 
            across the back.  As had been the case in the past, claimant 
 
            had full range of motion.  Neurological examination was 
 
            normal.  Assessment was of diffuse back pain without 
 
            objective findings.  Claimant had at this point been seen 
 
            twice by Dr. Wirtz.  At his request, Dr. Sohn referred him 
 
            to Joseph F. Fellows, M.D., an orthopaedic surgeon (claimant 
 
            was actually seen by another physician in that office, 
 
            Ronald K. Bunten, M.D.) and released with no work 
 
            restrictions.  On September 3, Dr. Sohn wrote to defendant 
 
            that after repeat evaluation and testing, he could find no 
 
            objective cause for complaints of back pain and that 
 
            claimant was able to return to full duties at the plant 
 
            without restriction.
 
            
 
                 In his deposition testimony, Dr. Sohn noted that 
 
            claimant's initial complaints of pain were along the right 
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            chest wall and that he made no initial complaints of the 
 
            spine, including the neck.  Claimant did not relate his pain 
 
            to any specific injury or accident, but it was just more of 
 
            a strain from accumulated exertion.  Dr. Sohn also specified 
 
            that claimant's symptoms on August 8 were different than 
 
            they had been before, although he was at that time fit to 
 
            return to work (except that, as chart notes indicate, he was 
 
            then apparently on disciplinary suspension).
 
            
 
                 Defendant takes the position that claimant's initial 
 
            injury was only to the rib area and that later reports of 
 
            symptomatology in the back, neck and shoulders are 
 
            unrelated.  Dr. Sohn was vague as to whether a causal nexus 
 
            to the latter complaints existed in that he testified it 
 
            would be "guess work" as to whether August complaints were 
 
            brought on by the July incident, but he later indicated that 
 
            pain to the back muscles was considered related in that 
 
            closely related muscle groups can be affected by splinting 
 
            or compensating for pain in one group.
 
            
 
                 Dr. Sohn did not attempt to rate claimant's disability.  
 
            However, he testified that he generally agreed with Dr. 
 
            Wirtz that claimant's problem was muscular in origin, that 
 
            it should only last 4-6 weeks and that later exacerbations 
 
            were not related to any one prior incident, but rather, the 
 
            most proximal incident of injury to a later examination.  
 
            Nonetheless, he also testified at page 22 of his deposition 
 
            that he believed claimant's back complaints were related to 
 
            employment.  From the context, it appears that Dr. Sohn 
 
            refers to back complaints during the time he was treating 
 
            claimant.
 
            
 
                 Generally speaking, there is much in Dr. Sohn's 
 
            testimony to comfort both parties to this contested case.
 
            
 
                 Claimant was seen by Dr. Wirtz on August 24, 1988.  Dr. 
 
            Wirtz is a board-certified orthopaedic surgeon and testified 
 
            by deposition on December 8, 1989.  History given to Dr. 
 
            Wirtz was of symptoms over four years developing in the 
 
            right lower back approximately one year prior to the 
 
            examination.  Dr. Wirtz found no spasm and range of motion 
 
            was normal.  Review of cervical and lumbar x-rays was 
 
            normal.  Diagnosis was of muscular strain in the right lower 
 
            back area with a possibility of facet degeneration at L3 
 
            (which was eventually ruled out following x-rays on 
 
            September 15, 1989).  Although no medications were 
 
            prescribed, Dr. Wirtz recommended that claimant restrict 
 
            activities that would aggravate subjective symptoms of 
 
            muscle pain in the back, to work in a more upright position 
 
            and limit forced bending and twisting of the back.
 
            
 
                 Dr. Wirtz saw claimant again on August 31, 1988 for 
 
            continued complaints of muscular pains.  As no bone or 
 
            neurological condition was found that would restrict 
 
            activities, claimant was merely advised to minimize bending 
 

 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            activities of the back and check back as needed.  On the 
 
            same day, Dr. Wirtz wrote defendant that claimant had no 
 
            condition from an orthopaedic point of view that would 
 
            restrict his activities.
 
            
 
                 Dr. Wirtz saw claimant again at the request of 
 
            defendant's attorney on September 15, 1989.  Diagnosis was 
 
            of recurring muscular strain symptoms.  X-rays were normal.  
 
            The doctor concluded that any muscle strain in existence on 
 
            September 15, 1989 was not related to the work incident of 
 
            the previous year.
 
            
 
                 In the meantime, claimant's disciplinary adventures 
 
            continued.  A memorandum dated August 29 indicated that 
 
            claimant was instructed by supervisor Ed O'Connor not to 
 
            take unscheduled breaks.  On August 30, he was instructed 
 
            that he was not to use barrels as a chair, but O'Connor 
 
            reported claimant's response as, "You guys never give up, 
 
            you've always gotta be fucking with me; well, I'm not gonna 
 
            give up either, and you ain't seen nothing yet."  The 
 
            balance of this memorandum (exhibit F-109) indicates a 
 
            relatively heated exchange with, perhaps, even a hint of 
 
            threatened violence ("if you don't like it, maybe you should 
 
            move away from me.").  On the same day, claimant left work 
 
            before the end of his shift, complaining of disabling pain.  
 
            On August 31, he was also absent and failed to report in (as 
 
            required) before the start of his shift.  On September 1, he 
 
            appeared for work, but also left early following a 
 
            conference in which he was informed that he would be 
 
            gradually brought up to speed on his regular job over a 
 
            several-day interval.  On September 2, after Dr. Sohn joined 
 
            Dr. Wirtz in concluding that no medical restrictions were 
 
            necessary given the absence of objective findings, the 
 
            previous absences were deemed unexcused by defendant and 
 
            claimant was discharged.  This discharge was determined by 
 
            Job Service of Iowa to be for disqualifying job misconduct; 
 
            unemployment benefits were denied.
 
            
 
                 Claimant then remained unemployed until accepting a 
 
            position as a food preparation worker for Woodward State 
 
            Hospital on March 17, 1989.  This employment relationship 
 
            also proved stormy and he was discharged on August 21, 1989.  
 
            The exit evaluation indicated a number of complaints 
 
            Woodward had with claimant's job performance, but in 
 
            particular, he was discharged for refusal to wear a beard 
 
            net in the course of his food preparation duties.  Between 
 
            July 30 and August 20, he was instructed to cover his beard 
 
            nine separate times, received a letter of clarification 
 
            after the sixth instance and a written reprimand after the 
 
            seventh instance.  The ninth instance resulted in discharge.  
 
            The significance of this history may be seen in claimant's 
 
            deposition testimony.  Asked why he had been discharged, 
 
            claimant testified:
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
                 A.  Beard net is one of the policies they have.  I 
 
                 forgot to put my beard net on.  They discharged me 
 
                 since I was on probation.
 
            
 
            (Defendant's exhibit B, page 22, lines 23 through 25)
 
            
 
                 It is wholly unbelievable that claimant "forgot" to 
 
            wear his beard net on nine occasions in only three weeks, 
 
            particularly when he received a letter of clarification and 
 
            a written reprimand before being discharged.  Without 
 
            question, claimant's deposition testimony was, at the very 
 
            least, misleading.  He would have this agency believe that 
 
            his discharge from Woodward State Hospital was for an act of 
 
            mere negligence as opposed to, as the record makes clear, 
 
            repeated acts of direct insubordination.  Considering this 
 
            instance along with demeanor while testifying and the record 
 
            as a whole, it is found that claimant lacks substantial 
 
            credibility as a witness.
 
            
 
                 Claimant thereafter was employed by a sanitation 
 
            company to clean machines for a well-known meat packing 
 
            concern with a pressure hose.  He was also discharged from 
 
            this employment after approximately four months, allegedly 
 
            because he missed work as the result of an injured leg.  
 
            Claimant then worked for several months stacking and 
 
            wrapping boxes for an ice cream company, for one or two 
 
            weeks as a stocker and shelver for a supermarket business 
 
            and, for about three months, as a laborer for a construction 
 
            company.  This job involved building forms, pouring concrete 
 
            and the like.  Lifting requirements were up to 50 pounds.  
 
            Claimant indicated he was laid off from this work at the end 
 
            of the construction season and that he was unemployed at the 
 
            time of hearing.
 
            
 
                 Claimant states that his back is now uncomfortable, but 
 
            generally all right unless he tries to lift or bend 
 
            strenuously.  He complains of inability to bend, jog, 
 
            bicycle, participate in sports to the extent he previously 
 
            could, and that he also has less energy.  He is not 
 
            currently on any medication, last being prescribed medicines 
 
            by Dr. Sohn in 1988.
 
            
 
                 As will be recalled, Dr. Sohn referred claimant to Dr. 
 
            Fellows at claimant's request.  He was eventually seen by 
 
            Dr. Bunten of the same office for examination on October 3, 
 
            1988.  Dr. Bunten arranged a CT scan of the lumbar spine, 
 
            but this proved normal.  On October 17, 1990, Dr. Bunten 
 
            wrote that based on his one examination there was no obvious 
 
            permanent partial impairment, although the assessment was 
 
            incomplete after only one visit.
 
            
 
                 Claimant was seen by William R. Boulden, M.D., on 
 
            October 27, 1988.  Dr. Boulden believed claimant's muscles 
 
            were out of shape, leaving him with residual myofascial pain 
 
            and tightness which should reverse with physical therapy and 
 

 
            
 
            Page   7
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            exercise.
 
            
 
                 Claimant was thereafter seen by the Spine Diagnostic 
 
            and Treatment Center of the University of Iowa Hospitals and 
 
            Clinics in March 1989.  The primary physician to evaluate 
 
            claimant, Ernest M. Found, M.D., testified by deposition on 
 
            October 9, 1990.  Dr. Found is a board-certified orthopaedic 
 
            surgeon.
 
            
 
                 Dr. Found testified that no objective signs were found 
 
            that might explain claimant's continued complaints of 
 
            discomfort.  In a contemporaneous report dated March 1, 
 
            1989, he stated that no permanent functional disability was 
 
            expected at that time.  Although Dr. Found made it clear 
 
            that he is not entirely satisfied with the Guides to the 
 
            Evaluation of Permanent Impairment published by the American 
 
            Medical Association, he agreed that under the guides, 
 
            impairment rating would necessarily be zero.  He noted that 
 
            initial complaints of costochondral pain would normally not 
 
            be related to later complaints of back pain and that it was 
 
            difficult to exactly pinpoint a precise pathological entity 
 
            as responsible for continued subjective complaints of pain.
 
            
 
                 James Weinstein, M.D., is director of the Spine 
 
            Diagnostic and Treatment Center.  The record, particularly 
 
            the testimony of Dr. Found and Dr. Weinstein's letter of 
 
            March 14, 1989, indicates that he did not actually see 
 
            claimant, but did participate in staffing the case as 
 
            director of the spine center.  Dr. Weinstein's March 14 
 
            letter suggests that mid- and low-back pain radiating into 
 
            the right hip and pelvic area was "absolutely real" and 
 
            suggested lifting restrictions of approximately 50-60 pounds 
 
            no more than four times per hour, and a repetitive lifting 
 
            limit of 25-30 pounds.  Although claimant's pain was real, 
 
            "we feel that there is nothing seriously wrong with your low 
 
            back.  All of our indications would point towards a chronic 
 
            musculoskeletal type of strain which is very amenable to a 
 
            positive and active rehabilitation approach."  Dr. Weinstein 
 
            stated that the low back pain claimant was experiencing was 
 
            not doing any damage to the lower back, but simply causing 
 
            discomfort.  He was hopeful that with proper exercise and 
 
            conditioning, claimant's condition would continue to 
 
            improve.  With that in mind, increased activity was 
 
            recommended.
 
            
 
                 In a subsequent letter to claimant's attorney dated 
 
            July 18, 1989, Dr. Weinstein related claimant's back 
 
            condition to the subject injury, indicated that healing 
 
            period "has ended March 14, 1989," and assessed a five 
 
            percent permanent partial impairment rating of the body as a 
 
            whole.
 
            
 
                 In his deposition testimony, Dr. Found testified that 
 
            he had no reason to disagree with the medical restrictions 
 
            suggested by Dr. Weinstein nor any particular objection to 
 

 
            
 
            Page   8
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            that physician's impairment rating (although it appeared to 
 
            Dr. Found that "functional disability would probably be 
 
            quite minimal").
 
            
 
                                conclusions of law
 
            
 
                 The parties have stipulated to the existence of an 
 
            injury arising out of and in the course of employment as 
 
            alleged.  Similarly, causal relationship to temporary 
 
            disability is stipulated, but not the extent thereof.  The 
 
            parties further dispute the existence of a causal 
 
            relationship between the work injury and claimed permanent 
 
            disability.
 
            
 
                 The supreme court of Iowa in Almquist v. Shenandoah 
 
            Nurseries, 218 Iowa 724, 731-32, 254 N.W. 35, 38 (1934) 
 
            discussed the definition of personal injury in workers' 
 
            compensation cases as follows:
 
            
 
                 While a personal injury does not include an 
 
                 occupational disease under the Workmen's 
 
                 Compensation Act, yet an injury to the health may 
 
                 be a personal injury.  [Citations omitted.]  
 
                 Likewise a personal injury includes a disease 
 
                 resulting from an injury. . . . The result of 
 
                 changes in the human body incident to the general 
 
                 processes of nature do not amount to a personal 
 
                 injury.  This must follow, even though such 
 
                 natural change may come about because the life has 
 
                 been devoted to labor and hard work.  Such result 
 
                 of those natural changes does not constitute a 
 
                 personal injury even though the same brings about 
 
                 impairment of health or the total or partial 
 
                 incapacity of the functions of the human body. 
 
            
 
                    . . . .
 
                 
 
                 A personal injury, contemplated by the Workmen's 
 
                 Compensation Law, obviously means an injury to the 
 
                 body, the impairment of health, or a disease, not 
 
                 excluded by the act, which comes about, not through the 
 
                 natural building up and tearing down of the human body, 
 
                 but because of a traumatic or other hurt or damage to 
 
                 the health or body of an employee.  [Citations 
 
                 omitted.]  The injury to the human body here 
 
                 contemplated must be something, whether an accident or 
 
                 not, that acts extraneously to the natural processes of 
 
                 nature, and thereby impairs the health, overcomes, 
 
                 injures, interrupts, or destroys some function of the 
 
                 body, or otherwise damages or injures a part or all of 
 
                 the body.
 
            
 
                 The claimant has the burden of proving by a 
 
            preponderance of the evidence that the injury of July 14, 
 
            1988 is causally related to the disability on which he now 
 
            bases his claim.  Bodish v. Fischer, Inc., 257 Iowa 516, 133 
 

 
            
 
            Page   9
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            N.W.2d 867 (1965).  Lindahl v. L. O. Boggs, 236 Iowa 296, 18 
 
            N.W.2d 607 (1945).  A possibility is insufficient; a 
 
            probability is necessary.  Burt v. John Deere Waterloo 
 
            Tractor Works, 247 Iowa 691, 73 N.W.2d 732 (1955).  The 
 
            question of causal connection is essentially within the 
 
            domain of expert testimony.  Bradshaw v. Iowa Methodist 
 
            Hosp., 251 Iowa 375, 101 N.W.2d 167 (1960). 
 
            
 
                 However, expert medical evidence must be considered 
 
            with all other evidence introduced bearing on the causal 
 
            connection.  Burt, 247 Iowa 691, 73 N.W.2d 732.  The opinion 
 
            of experts need not be couched in definite, positive or 
 
            unequivocal language.  Sondag v. Ferris Hardware, 220 N.W.2d 
 
            903 (Iowa 1974).  However, the expert opinion may be 
 
            accepted or rejected, in whole or in part, by the trier of 
 
            fact.  Id. at 907.  Further, the weight to be given to such 
 
            an opinion is for the finder of fact, and that may be 
 
            affected by the completeness of the premise given the expert 
 
            and other surrounding circumstances.  Bodish, 257 Iowa 516, 
 
            133 N.W.2d 867.  See also Musselman v. Cent. Tel. Co., 261 
 
            Iowa 352, 154 N.W.2d 128 (1967).
 
            
 
                 While a claimant is not entitled to compensation for 
 
            the results of a preexisting injury or disease, the mere 
 
            existence at the time of a subsequent injury is not a 
 
            defense.  Rose v. John Deere Ottumwa Works, 247 Iowa 900, 
 
            908, 76 N.W.2d 756, 760-61 (1956).  If the claimant had a 
 
            preexisting condition or disability that is aggravated, 
 
            accelerated, worsened or lighted up so that it results in 
 
            disability, claimant is entitled to recover.  Nicks v. 
 
            Davenport Produce Co., 254 Iowa 130, 115 N.W.2d 812, 815 
 
            (1962).
 
            
 
                 This record certainly contains evidence supporting a 
 
            conclusion either way on the crucial issue of causal nexus 
 
            between claimed impairment and the work injury.  However, it 
 
            is concluded that claimant has failed to meet his burden of 
 
            proof on the issue.  It should be recalled that claimant has 
 
            a preexisting history of right side and back problems.  His 
 
            credibility is suspect and the record indicates that he 
 
            harbors ill will towards defendant.  When claimant first 
 
            presented to Dr. Sohn, his sole, or at least primary, 
 
            complaint was of costochondral pain.  Later, complaints 
 
            ranged from the low back radiating to the leg to the neck 
 
            and shoulders.  Claimant's subsequent absenteeism and 
 
            refusal to work is consistent with the existence of an 
 
            injury, but equally consistent with his previous history of 
 
            absenteeism and insubordination (and, for that matter, his 
 
            subsequent history).
 
            
 
                 Dr. Sohn, the primary treating physician, released 
 
            claimant to return to work without restriction and did not 
 
            anticipate permanent impairment.  Dr. Wirtz, the other 
 
            physician who saw claimant shortly following the work 
 

 
            
 
            Page  10
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            injury, concurred.  Except for muscle spasm only when 
 
            claimant was first seen by Dr. Sohn, there is no objective 
 
            sign of injury to explain claimant's continued complaints.  
 
            Neither Dr. Bunten nor Dr. Boulden anticipated further 
 
            impairment.  When claimant was evaluated by the University 
 
            of Iowa spine team, Dr. Found found no objective signs and 
 
            anticipated no permanent impairment.  Dr. Weinstein, who 
 
            apparently did not see claimant at all (although, as 
 
            director of the spine team, he participated in staffing the 
 
            case) suggested medical restrictions that would not bar 
 
            claimant from performing the same work at Oscar Mayer 
 
            (throwing loins of less than 30 pounds repetitively) and 
 
            imposed a five percent impairment rating, but anticipated 
 
            that his condition would improve.  Claimant's reported 
 
            symptoms appear far out of proportion to objective evidence 
 
            of impairment.  Pain, absent objective findings, is not 
 
            equivalent to impairment.  Waller v. Chamberlain Mfg., II 
 
            Iowa Industrial Commissioner Report 419 (1981).
 
            
 
                 Considering all these factors, this writer finds 
 
            himself unconvinced that claimant has sustained permanent 
 
            impairment or industrial disability causally related to the 
 
            original work injury.  It is to be recalled that claimant 
 
            subsequently held at least one construction job involving 
 
            substantial lifting over 50 pounds which he was able to 
 
            perform successfully, although he complained of residual 
 
            back pain.  Claimant has not met his burden of proof on the 
 
            issue.
 
            
 
                 The record is unclear as to the extent of claimant's 
 
            entitlement to temporary total disability.  As of August 8, 
 
            1988, Dr. Sohn released claimant to return to work without 
 
            restriction.  Even though Dr. Sohn recommended that claimant 
 
            be put on 50 percent or light duty on August 12, it is hard 
 
            to tell what days he missed as a result of those 
 
            restrictions as opposed to various disciplinary actions.  It 
 
            is stipulated that defendant voluntarily paid eight days of 
 
            compensation at the stipulated rate prior to hearing.  
 
            Claimant has not shown entitlement beyond that period.
 
            
 
                 The parties dispute claimant's entitlement to medical 
 
            expenses set forth in his exhibits 3, 6, 7 and 8 (defendant 
 
            agreed to pay the expenses set forth in exhibit 10 at 
 
            hearing).  Those expenses, each of which post-date the end 
 
            of claimant's entitlement to temporary total disability, 
 
            have not been established as causally related to the subject 
 
            work injury.
 
            
 
                           
 
            
 
            
 
            Page  11
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            order
 
            
 
                 THEREFORE, IT IS ORDERED:
 
            
 
                 Claimant shall take nothing from this proceeding.
 
            
 
                 The costs of this action are assessed to defendant 
 
            pursuant to rule 343 IAC 4.33.
 
            
 
                 Signed and filed this ______ day of ____________, 1991.
 
            
 
                 
 
            
 
                 
 
                 
 
                                          ______________________________
 
                                          DAVID RASEY
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr. Robert E. McKinney
 
            Attorney at Law
 
            480 6th Street
 
            P.O. Box 209
 
            Waukee, Iowa  50263
 
            
 
            Mr. Harry W. Dahl
 
            Attorney at Law
 
            974 73rd Street
 
            Suite 16
 
            Des Moines, Iowa  50312
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                           5-1803
 
                           Filed May 14, 1991
 
                           DAVID RASEY
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            VICTOR McCALL,                :
 
                                          :
 
                 Claimant,                :         File No. 894908
 
                                          :
 
            vs.                           :      A R B I T R A T I O N
 
                                          :
 
            OSCAR MAYER FOODS CORPORATION,:         D E C I S I O N
 
                                          :
 
                 Employer,                :
 
                 Self-Insured,            :
 
                 Defendant.               :
 
            ____________________________________________________________
 
            
 
            5-1803
 
            Claimant failed to prove work injury caused permanent 
 
            disability.
 
            
 
 
            
 
            Page   1
 
            
 
            
 
            
 
            
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            MICHAEL L. PAPALE,            :
 
                                          :
 
                 Claimant,                :
 
                                          :
 
            vs.                           :
 
                                          :      File No. 894922
 
            WAYNE CARNEY PAINTING,        :
 
                                          :    A R B I T R A T I O N
 
                 Employer,                :
 
                                          :      D E C I S I O N
 
            and                           :
 
                                          :
 
            AETNA LIFE AND CASUALTY       :
 
            COMPANY,                      :
 
                                          :
 
                 Insurance Carrier,       :
 
                 Defendants.              :
 
            ___________________________________________________________
 
            On January 26, 1990, Michael Papale, (claimant) filed a 
 
            petition as a result of an injury to claimant's lungs back 
 
            occurring on July 26, 1988.  Wayne Carney Painting (Wayne 
 
            Carney) was identified as employer and Aetna Casualty 
 
            (Aetna) was identified as the workers' compensation insurer 
 
            for Wayne Carney (collectively defendants).  On April 1, 
 
            1991, these matters came on for hearing in Davenport Iowa.  
 
            The parties appeared as follows:  the claimant in person and 
 
            by his counsel Joseph M. Bauer of Des Moines, Iowa and Wayne 
 
            Carney and Aetna by their counsel Linda Frischmeyer of Rock 
 
            Island, Illinois.  
 
            The record in this proceeding consisted of the following:
 
            1.  The live testimony of the claimant, Susan Papale and  
 
            Wayne Carney.
 
            2.  Joint exhibits 1-25
 
            3.  Claimant's exhibit A.
 
            At the close of all evidence, the case was deemed fully 
 
            submitted.
 
            stipulations
 
            
 
                 The parties stipulated to the following matters at the 
 
            time of the hearing:
 
            a.  An employer-employee relationship existed between 
 
            claimant and employer at the time of the alleged injury.
 
            b.  The claimant sustained an injury on July 26, 1988, which 
 
            arose out of and in the course of employment.
 
            c.  The alleged injury is a cause of temporary disability.
 
            d.  The type of permanent disability, if the injury is found 
 
            to be a cause of permanent disability, is industrial 
 
            disability to the body as a whole.
 
            e.  The commencement date for permanent partial disability, 
 
            is November 26, 1988.
 

 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            f.  The rate of compensation, in the event of an award, is 
 
            $230.14 per week.  At the time of the injury, claimant was 
 
            married and had three dependants.  He is entitled to four 
 
            exemptions.
 
            g.  The parties agree that if the providers of medical 
 
            services were called to testify the providers of the 
 
            services would testify that the fees were fair and 
 
            reasonable and incurred for necessary medical treatment.  
 
            Defendants would not offer contrary evidence.
 
            h.  Defendants have paid 79 and 6/7 weeks of workers' 
 
            compensation benefits to claimant at the rate of $230.14 per 
 
            week prior to hearing and are claiming a credit therefore.
 
            i.  There are no bifurcated claims.
 
            j.  Incorporated by this reference is the supplemental to 
 
            the prehearing report regarding the testimony of Steve 
 
            Brehmer, and Don Pruitt regarding Material Safety Data 
 
            Sheets for Diamond Vogel products and Glidden Paint 
 
            Products.
 
            k.  The amount of costs to assess in this matter is not in 
 
            dispute.  Costs total $165.50.
 
            Issues
 
The issues for resolution are as follows:
 
            1.  Whether a causal relationship exists between claimant's 
 
            claimed injuries and the claimed disability and the nature 
 
            and extent of any entitlement to benefits, if any.
 
            2.  Whether claimant is entitled to medical benefits, 
 
            including a determination of causal connection to the work 
 
            injury and the causal connection of this condition to a work 
 
            injury.
 
FINDINGS OF FACT
 
            After considering all of the evidence and the arguments of 
 
            counsel, the undersigned makes the following findings of 
 
            fact and conclusions of law.
 
            
 
                 1.  At the time of the hearing, claimant was 37 years 
 
            old.  On the date of injury, claimant was 35 years old.  
 
            Claimant is a high school graduate and has attended post 
 
            graduate courses.  He attended Hamilton Technical College 
 
            for five months.  
 
            
 
                 2.  Claimant has had a checkered employment history.  
 
            Between 1973 and 1983 claimant has held 19 different jobs 
 
            and these jobs have lasted for less than one year.  Claimant 
 
            has experience as a self employed painter and construction 
 
            worker.  Claimant has built furniture, worked as a prep cook 
 
            for a restaurant, optical technician, bookkeeper and 
 
            scheduler, a supervisor for mentally retarded clients, and a 
 
            grounds maintenance person.  Claimant began his working 
 
            career in Salt Lake City, Utah, and then moved to Iowa in 
 
            1981.  Claimant has experienced several lengthy periods of 
 
            unemployment during his working career.
 
            
 
                 3.  Claimant began to work for Wayne Carney Painting in 
 
            1986.  Claimant worked for Wayne Carney until February of 
 
            1988.  Claimant then left to work for another painting 
 
            contractor, Jay Jennings, for two months in 1988, April and 
 
            May.  During the time that claimant worked for Jay Jennings, 
 
            he was working with lacquer paints.  This is an oil based 
 
            paint or stain that has a stronger odor than regular paint 
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
            and can be a sensitizing agent for someone with an asthmatic 
 
            condition.  (Exhibit 21, Page 4).  During the time that 
 
            claimant was employed by Wayne Carney, claimant did not use 
 
            lacquer paints in his work.  However, claimant did use other 
 
            paints including oil and latex based paints.  Additionally, 
 
            claimant applied thinner, paint stripper, and used 
 
            turpentine in the course of his employment.  As a painter, 
 
            and previously, as a wood worker, claimant had been exposed 
 
            to substantial amounts of dust while working.
 
            
 
                 4.  On July 26, 1988, claimant was working in a small 
 
            bathroom.  He was sanding off paint from the ceiling and the 
 
            walls and experienced heaviness in his chest.  Breathing 
 
            became difficult and he started to wheeze.  Claimant 
 
            reported his breathing problem to Wayne Carney at the end of 
 
            the working day.  That evening, claimant went to the 
 
            emergency room at Mercy Hospital in Davenport reporting 
 
            difficulty breathing.  At the time claimant was seen in the 
 
            emergency room, he indicated that he had had an eight year 
 
            history of intermittent breathing difficulties.  He further 
 
            indicated that he had been on Proventil until six months ago 
 
            when he stopped using this inhaler on his own decision.  
 
            
 
                 5.  There was some dispute in the evidence regarding 
 
            whether claimant in fact had bronchial asthma prior to the 
 
            incident on July 26, 1988.  It is apparent from medical 
 
            records in evidence that claimant has a longstanding 
 
            bronchial asthma condition.  Dr. Troxell's records indicate 
 
            that claimant suffered from significant asthma attacks for 
 
            the last six years. (Ex. 7, p. 3).
 
            
 
                 6.  After claimant was seen in the emergency room at 
 
            Mercy Hospital, claimant returned to work on August 1, 1988 
 
            and worked Tuesday and Wednesday.  Claimant did not return 
 
            to work for Wayne Carney Painting thereafter.
 
            
 
                 7.  Claimant was examined by Dr. Askhay Mahadevia on 
 
            August 25, 1988.  Dr. Mahadevia is board certified in 
 
            internal medicine and by the American Board of Pulmonary 
 
            Medicine.  He is a pulmonary medicine specialist.  At the 
 
            time of the examination on August 25, 1988, Dr. Mahadevia 
 
            concluded that claimant was suffering from chronic bronchial 
 
            asthma with significant aggravation by occupational 
 
            exposure.  At the time of the August 25, 1988 examination, 
 
            claimant indicated to Dr. Mahadevia that he was still 
 
            working as a painter.  However, claimant was not working for 
 
            Wayne Carney Painting at the time of that visit.
 
            
 
                 8.  Dr. Mahadevia continues to follow claimant in 
 
            connection with his bronchial asthma condition.  Dr. 
 
            Mahadevia has opined that claimant's bronchial asthma was 
 
            aggravated by exposure to various paint fumes at work.  
 
            Initially, Dr. Mahadevia indicated that claimant had no 
 
            permanent impairment arising from his bronchial asthma 
 
            condition.  However, he retreated somewhat from that 
 
            position and indicated that he had given claimant an 
 
            impairment rating of between zero and fifteen percent, 
 
            depending on the claimant's condition on any given day.  
 
            When contemplating the functional impairment rating 
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            assigned, Dr. Mahadevia indicated that this rating was based 
 
            on an average of claimant's worst days and his best days.  
 
            Dr. Mahadevia indicated that claimant's exposure to paint 
 
            fumes had probably made him more sensitive to other 
 
            triggering factors in the environment.  However, claimant 
 
            had various non work related and non paint related triggers 
 
            that would cause asthmatic attacks before his paint 
 
            exposure.(1)  Dr. Mahadevia also indicated that claimant's 
 
            bronchial asthma condition did not change his underlying 
 
            lung condition.  Dr. Mahadevia also opined that claimant's 
 
            exposure to certain paint related products had no connection 
 
            with other sensitizing agents that also triggered claimant's 
 
            bronchial asthma.  Dr. Mahadevia indicated that claimant was 
 
            reactive to those other things before he was exposed to 
 
            paint fumes.  However, Dr. Mahadevia further indicated that 
 
            claimant's reactivity may have gotten worse as a result of 
 
            his exposure.
 
            
 
                 9.  Dr. Mahadevia indicated that during the fall and 
 
            early winter of 1988, he continued to treat claimant for his 
 
            bronchial asthma condition.  Dr. Mahadevia indicated that 
 
            claimant improved significantly to a point where claimant 
 
            was feeling like he did before he began taking medication.  
 
            In connection with the impairment rating Dr. Mahadevia gave, 
 
            it was impossible for him to assign a proportionate shares 
 
            to claimant's preexisting condition attributable to 
 
            bronchial asthma and the increased reactivity that the 
 
            claimant suffers as a result of his exposure to paint and 
 
            other fumes from his work as a painter.  Dr. Mahadevia 
 
            indicated that as a result of claimant's incident at work it 
 
            is more likely that he will have frequent episodes of asthma 
 
            attacks.  Dr. Mahadevia also indicated that once claimant is 
 
            removed from an environment that contains paint fumes and 
 
            the associated chemical odors connected with painting, then 
 
            his reactivity to other catalyst for bronchial asthma should 
 
            return to baseline.  Because of claimant's sensitivity to 
 
            paint fumes, Dr. Mahadevia has restricted claimant from 
 
            returning to an environment where he is exposed to paint 
 
            fumes, varnishes, lacquer, turpentine, or thinner.
 
            
 
                 10. Claimant's records were reviewed by Peter S. 
 
            Jerome, M.D., a pulmonary and critical care specialist.  Dr. 
 
            Jerome provided a fairly thorough definition of bronchial 
 
            asthma.(2)  ,   Dr. Jerome concluded after a review of 
 
            claimant's medical records and depositions of claimant and 
 
            Dr. Mahadevia, that claimant in fact suffered an aggravation 
 
 
 
 
 
 
 
 
 
 
 
 
 
            (1).  Claimant testified that triggering events included 
 
            excessive talking and laughing, waling, cold air, fresh 
 
            carpet, fresh cut wood, newspaper ink, plastics, cigarette 
 
            smoke, reaching with his hands overhead, cleaning fluids, 
 
            high humidity, hair spray, cheap perfumes, gas fumes and 
 
            roughhousing with his children.
 
            (2).  Bronchial asthma is a disease characterized by an 
 
            increased responsiveness of the trachea and bronchi to 
 
            various stimuli and manifested by wide spread narrowing of 
 
            the airways that changes in severity either spontaneously or 
 
            as a result of treatment.  Bronchial asthma is a reversal 
 
            airways obstruction.
 
            
 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
            of his bronchial asthma on exposure to pungent solvents, 
 
            paints, plaster and wood dust.  However, Dr. Jerome does not 
 
            believe that this exposure caused any permanency.  Dr. 
 
            Jerome also believes that claimant's exposure to non 
 
            specific agents such as the paint fumes, solvents, and 
 
            various dusts would have caused increased sensitivity to 
 
            specific chemicals or items.  He did agree, however, that 
 
            patients who are having an aggravation of bronchial asthma 
 
            tend to be more sensitive to various agents during a 
 
            particular time when the asthma has been aggravated.  Dr. 
 
            Jerome concludes his review of claimant's condition and 
 
            records by recommending that claimant avoid tobacco and 
 
            occupations associated with the potential environmental 
 
            pollutants including paint fumes.  Dr. Jerome believed that 
 
            claimant had not been sensitized not by the exposure to 
 
            paint, dust, and turpentine and thinner products used by 
 
            Wayne Carney.  Dr. Jerome based his conclusion on his review 
 
            of the material safety data sheets which did not show a 
 
            sensitizing chemical such as diisocyanate group of 
 
            sensitizing agents in the paint used by Wayne Carney Paint.
 
            
 
                 11. Claimant was also seen by James L. Gillilland, 
 
            D.O., an allergist and clinical immunologist.  After an 
 
            examination, Dr. Gillilland also agreed that claimant had 
 
            bronchial asthma that had been brought on by his work 
 
            environment.  (Ex. 3, p. 2).  Dr. Gillilland believes that 
 
            the sensitizing agent may have come from the polyurethane 
 
            varnishes that claimant was working with.  However, on the 
 
            date of the incident at Wayne Carney Painting, claimant was 
 
            working in a bathroom where there were no paint fumes and he 
 
            was still wheezing.  He opined that the cause of claimant's 
 
            incident on July 26, 1988, was due to the irritant effect 
 
            from the sawdust or mold spores that gather in bathrooms.  
 
            Dr. Gillilland was also of the opinion that claimant's work 
 
            setting had a direct relation in bringing on his asthma and 
 
            he should avoid this type of environment in the future.  Dr. 
 
            Gillilland did not assign a functional impairment rating to 
 
            claimant's condition.
 
            
 
                 12. Claimant's health history is significant for low 
 
            back problems and ulcers.  Additionally, claimant was a 
 
            substance abuser for approximately ten years.  Medical 
 
            evidence indicates that claimant took a variety of 
 
            controlled substances with his last use in 1985 when 
 
            claimant discontinued smoking marijuana.  Claimant's prior 
 
            drug use is not mentioned in any of the histories provided 
 
            to any of his treating or evaluating physicians in 
 
            connection with his bronchial asthma condition.  Claimant 
 
            was not using marijuana at the time he was employed by Wayne 
 
            Carney Painting.  
 
            
 
                 13. After claimant left employment with Wayne Carney, 
 
            he found a subsequent job in November of 1988 with the 
 
            Shoefixers at the North Park Mall in Davenport.  Claimant 
 
            stayed with Shoefixers for one month.  Claimant quit this 
 
            employment in December of 1988 because he indicated that the 
 
            chemicals used at the Shoefixers induced asthmatic symptoms.  
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            However, claimant did not report this symptoms to Dr. 
 
            Mahadevia and he did not report that he was in any distress 
 
            during that time period.  Claimant did not seek any medical 
 
            attention for his reaction to the chemicals at the Shoefixer 
 
            in 1988.
 
            
 
                 14. Claimant's next employment was with the Mississippi 
 
            Valley Blood Bank.  Claimant began work there in March of 
 
            1989.  Claimant was hired as a mobile technician and was in 
 
            the process of being trained as a phlebotomist.  However, 
 
            when claimant was exposed to bleach it affected his 
 
            bronchial asthma condition.  Claimant has filed a workers' 
 
            compensation claim for aggravation of his bronchial asthma 
 
            condition as a result of his exposure to bleach on the job 
 
            at Mississippi Valley Blood Bank.  
 
            
 
                 15. As an accommodation, Mississippi Valley Blood Bank 
 
            transfered claimant to a driving position.  Dr. Mahadevia 
 
            agreed that claimant could perform this job with the use of 
 
            inhalers and medication.  Claimant would have to take simple 
 
            precautions and continue his oral and inhaled bronchial 
 
            dilator therapy.  (Ex. 19, p. 6).  However, claimant decided 
 
            that he could not continue in this employment and so 
 
            voluntarily resigned.
 
            
 
                 16. Claimant's next employment was for Normandeau 
 
            Associates.  Normandeau was hired to do an environmental 
 
            study for a hydroelectric plant.  Claimant was to assist 
 
            with catching fish.  Claimant stayed in this employment for 
 
            two and a half months, complaining of stomach pain, night 
 
            work and shortness of hours.  Additionally, claimant 
 
            indicated that he had breathing problems with this 
 
            employment but he did not seek any medical assistance for 
 
            this condition.
 
            
 
                 17. Claimant's next employment was with Schwartz 
 
            Construction Company, a builder who constructed log homes.  
 
            Claimant was hired as a carpenter's helper and laborer.  He 
 
            stayed on this job for approximately one and one half 
 
            months.  In this job, claimant was covered with sawdust; a 
 
            circumstance that  would bring on breathing problems.  
 
            Claimant's next employment was with HayCroft Construction.  
 
            In this job, claimant was tearing off old roofs and putting 
 
            on new roofs.  Additionally, claimant was doing concrete 
 
            work.  In doing this work, claimant indicated that he had 
 
            breathing problems when he was around hot tar roof.  
 
            Additionally, claimant complained that he had breathing 
 
            problems when he smelled burning leaves in the fall.  At the 
 
            time of the hearing, claimant was off work because he had 
 
            torn a knee ligament and while in therapy had pulled a 
 
            muscle in his back.
 
            
 
                 18. On average, at these various jobs, claimant has 
 
            earned between $6.00 and $8.00 per hour.
 
            
 
                 19. Claimant has also been suffering from symptoms of 
 
            depression.  Claimant consulted with Dr. Hayes, a 
 
            psychologist for his depression symptoms.  Dr. Hayes could 
 
            not say when claimant's depression began and what caused the 
 
            initial depression.  Dr. Hayes indicated that claimant's 
 

 
            
 
            Page   7
 
            
 
            
 
            
 
            
 
            major depressive episode with anxiety was difficult to link 
 
            to claimant's job situation as a painter.
 
            
 
                 20. After claimant had been injured, claimant decided 
 
            to take some courses at the American Institute of Commerce 
 
            in Davenport.  Claimant was interesting in developing 
 
            drafting skills and he signed up for a CAD drafting course.  
 
            He was awarded financial aid but he dropped out due to 
 
            financial problems.
 
            
 
                 21. Claimant has not always been truthful in his job 
 
            applications.  At the time claimant began seeing Dr. Hayes, 
 
            claimant was employed at the Mississippi Valley Blood Bank.  
 
            He continued his work as a driver.  He did not disclose his 
 
            depression to the vocational rehabilitation counselor that 
 
            had been hired by the defendants, nor did he make any 
 
            references to his depression of his depression to Dr. 
 
            Mahadevia, his treating pulmonologist.  When claimant was 
 
            working for Normandeau, he indicated that he had not been 
 
            under a doctor's care in the past six months.  Additionally, 
 
            he indicated that he was in a good state of health.  
 
            Claimant also failed to give a complete job history for the 
 
            Normandeau employment.  He indicated that the last position 
 
            he had held was with Wayne Carney Painting in Davenport, 
 
            Iowa.  He failed in include references to the Shoefixers and 
 
            the Mississippi Valley Blood Bank at the time of his 
 
            application February 21, 1990.
 
            
 
                 22. In assessing claimant's ability to participate in a 
 
            formal education, it is apparent from the records from the 
 
            American Institute of Commerce, that claimant is in need of 
 
            some remedial assistance in the areas of reading and 
 
            mathematics.  However, it does not appear that claimant is 
 
            incapable of pursuing advanced educational courses if he 
 
            obtains the proper assistance.
 
            
 
                 23. At the time of the hearing, claimant had various 
 
            unpaid medical bills which included the following:
 
            
 
                 Charles Hays, Ph.D.                 $520.00
 
            William Nissen M.D.                      $105.00
 
            Pulmonary Associates                      $31.50
 
            St. Lukes Hospital                     $1,258.00
 
            St. Lukes Hospital                       $623.75
 
            Vera French Community Health Ctr     $68.60
 
            
 
                                          TOTAL:   $2,606.85
 
            
 
                 The services for Ira French Community Mental Health 
 
            were incurred on March 1, 1990.  The first part of this bill 
 
            was paid by insurance coverage maintained by claimant's 
 
            wife.  Additionally, Susan Papale's insurance covered the 
 
            bill for Dr. Nissen.  The bill for Dr. Mahadevia's services 
 
            date from August 3, 1988 to June 2, 1989.  Finally, the bill 
 
            at St. Luke's Hospital for sleep monitoring, and various 
 
            testing, done June 7, 1989 and ordered by Dr. Mahadevia 
 
            totaled $648.75.
 

 
            
 
            Page   8
 
            
 
            
 
            
 
            
 
            CONCLUSIONS OF LAW
 
            1.  Whether a causal relationship exists between claimant's 
 
            claimed injuries and the claimed disability and the nature 
 
            and extent of any entitlement to benefits, if any.
 
            Claimant urges that the asthma attack of July 26, 1988, 
 
            resulted from his two year exposure to paint fumes.  His 
 
            exposure came about while working for Wayne Carney.  In 
 
            accordance with Langford v. Kellar Excavating Grading, Inc., 
 
            191 N.W.2d 667 (Iowa 1971), since the exposure to paint 
 
            fumes is the substantial factor in sensitizing claimant to 
 
            further aggravation of his bronchial asthma, defendants are 
 
            liable for causing permanent disability to claimant 
 
            entitling him to industrial benefits.  Defendants contend 
 
            that claimant suffered an aggravation of a preexisting 
 
            condition that did not cause a permanent injury to 
 
            claimant's lungs.  Claimant's subsequent aggravations are 
 
            not attributable to the exposure experienced at Wayne 
 
            Carney.  
 
            
 
                 The claimant has the burden of proving by a 
 
            preponderance of the evidence that the injury of July 26, 
 
            1988, is causally related to the disability on which he now 
 
            bases his claim.  Bodish v. Fischer, Inc., 133 N.W.2d 867, 
 
            868 (Iowa 1965);  Lindahl v. L. O. Boggs, 18 N.W.2d 607, 
 
            613-14 (Iowa 1945).  A possibility is insufficient; a 
 
            probability is necessary.  Burt v. John Deere Waterloo 
 
            Tractor Works, 73 N.W.2d 732, 738 (Iowa 1955).  The question 
 
            of causal connection is essentially within the domain of 
 
            expert testimony.  Bradshaw v. Iowa Methodist Hospital, 101 
 
            N.W.2d 167,171 (Iowa 1960). 
 
            
 
                 Expert medical evidence must be considered with all 
 
            other evidence introduced bearing on the causal connection.  
 
            Burt, 73 N.W.2d at 738.  The opinion of the experts need 
 
            not be couched in definite, positive or unequivocal 
 
            language.  Sondag v. Ferris Hardware, 220 N.W.2d 903, 907 
 
            (Iowa 1974).  Moreover, the expert opinion may be accepted 
 
            or rejected, in whole or in part, by the trier of fact.  
 
            Sondag, 220 N.W.2d at 907.  Finally, 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 material circumstances.  Bodish, 133 N.W.2d 
 
            at 870; Musselman, 154 N.W.2d at 133.  The Supreme Court has 
 
            also observed that greater deference is ordinarily accorded 
 
            expert testimony where the opinion necessarily rests on 
 
            medical expertise.  Sondag, 220 N.W.2d at 907.
 
            Furthermore, if the available expert testimony is 
 
            insufficient alone to support a finding of causal 
 
            connection, such testimony may be coupled with nonexpert 
 
            testimony to show causation and be sufficient to sustain an 
 
            award.  Giere v. Aase Haugen Homes, Inc.,  146 N.W.2d 911, 
 
            915 (1966).  Such evidence does not, however, compel an 
 
            award as a matter of law.  Anderson v. Oscar Mayer & Co., 
 
            217 N.W.2d 531, 536 (Iowa 1974).  To establish 
 
            compensability, the injury need only be a significant 
 
            factor, not be the only factor causing the claimed 
 

 
            
 
            Page   9
 
            
 
            
 
            
 
            
 
            disability.  Blacksmith v. All-American, Inc., 290 N.W.2d 
 
            348, 354 (Iowa 1980); Langford, 191 N.W.2d at 670.
 
            While a claimant is not entitled to compensation for the 
 
            results of a preexisting injury or disease, the mere 
 
            existence at the time of a subsequent injury is not a 
 
            defense.  Rose v. John Deere Ottumwa Works, 76 N.W.2d 756, 
 
            760-61 (Iowa 1956).  If the claimant had a preexisting 
 
            condition or disability that is aggravated, accelerated, 
 
            worsened or lighted up so that it results in disability, 
 
            claimant is entitled to recover. Gosek v. Garmer and Stiles 
 
            Co., 158 N.W.2d 731, 737 (Iowa 1968);  Barz v. Oler, 133 
 
            N.W.2d 704, 707 (Iowa 1965); Olson v. Goodyear Service 
 
            Stores, 125 N.W.2d 251, 256 (Iowa 1963); Nicks v. Davenport 
 
            Produce Co., 115 N.W.2d 812, 815 (Iowa 1962);  Yeager v. 
 
            Firestone Tire & Rubber Co., 112 N.W.2d 299, 302 (Iowa 
 
            1961); Ziegler v. United States Gypsum Co., 106 N.W.2d 591, 
 
            595 (Iowa 1960); Almquist v. Shenandoah Nurseries, 254 N.W. 
 
            35,38 (Iowa 1934).
 
            When an aggravation occurs in the performance of an 
 
            employer's work and a causal connection is established, 
 
            claimant may recover to the extent of the impairment caused 
 
            by the aggravation.  Barz, 133 N.W.2d at 707; Olson, 125 
 
            N.W.2d at 256; Yeager, 112 N.W.2d at 302; Ziegler, 106 
 
            N.W.2d at 595; Almquist, 254 N.W. at 38.
 
            In this instance, all of the doctors agreed that claimant's 
 
            preexisting asthma was aggravated by his exposure to paint 
 
            fumes while on the job.  The question becomes whether the 
 
            exposure to dust on July 26, 1988 as the triggering event 
 
            for a bronchial asthma attack lighted up claimant's 
 
            sensitivity to paint fumes traceable to claimant's job as a 
 
            painter thereby causing a permanent disability.  Dr. 
 
            Madadevia, the primary treating physician indicated that 
 
            claimant had developed a sensitivity to paint fumes as a 
 
            result of his exposure to this environment on the job.  This 
 
            conclusion was corroborated by Dr. Gillilland.  Dr. 
 
            Mahadevia gave claimant a permanent functional impairment 
 
            between 0 and 15 percent depending upon claimant's 
 
            activities.  However, both Dr. Jerome and Dr. Mahadevia 
 
            indicated that the exposure and the subsequent asthma attack 
 
            did not cause permanent lung damage.(3)    However, Dr. 
 
            Mahadevia did indicate that once claimant becomes sensitized 
 
            to a substance the substance will continually cause an 
 
            asthma attack upon exposure.  Here, claimant was sensitized 
 
            to paint fumes that upon re-exposure results in an asthma 
 
            attack.  As a consequence of the sensitization, claimant is 
 
            restricted from returning to an environment where there are 
 
            paint fumes, solvents, or turpentine.  This is the most 
 
            compelling evidence of permanency.  Since the most 
 
            substantial factor in claimant's sensitization process 
 
            occurred while he was working for Wayne Carney, Wayne Carney 
 
 
 
 
 
 
 
            (3).  By its very nature bronchial asthma is a reversible 
 
            airway obstruction disease.  Over time and with sufficient 
 
            aggravations, the diseases can lose its reversibility and 
 
            cause permanent damage to the lungs.  This has not occurred 
 
            in the claimant.
 
            
 
            
 
            Page  10
 
            
 
            
 
            
 
            
 
            is responsible for claimant's permanent partial disability.
 
            However, Dr. Mahadevia did not indicate that claimant was in 
 
            a heightened state of reactivity constantly as a result of 
 
            the exposure to paint fumes.  Nor did he indicate that since 
 
            claimant had become sensitized to paint fumes that he was 
 
            necessarily more reactive to other substances.  He was 
 
            reactive to other substances before his exposure to paint 
 
            fumes and that level of reactivity has not changed.  Dr. 
 
            Mahadevia explained that claimant would be more reactive to 
 
            other substances in combination with an exposure to paint 
 
            fumes.  Once claimant's episode with paint fumes had passed 
 
            his reactivity level would return to its normal position for 
 
            claimant which is heightened due to his asthma and not the 
 
            exposure to paint fumes.  The subsequent aggravations to 
 
            claimant's asthma were not caused by claimant's exposure to 
 
            paint fumes.  Those aggravations were caused by substances 
 
            on those jobs and are separate injuries not chargeable to 
 
            Wayne Carney.
 
            Where claimant has an impairment to the body as a whole, an 
 
            industrial disability has been sustained.  Industrial 
 
            disability was defined in Diederich v. Tri-City Railway Co., 
 
            258 N.W.2d 899, 902 (Iowa 1935) as loss of earning capacity 
 
            and not a mere `functional disability' to be computed in the 
 
            terms of percentages of the total physical and mental 
 
            ability of a normal person.  The essence of an earning 
 
            capacity inquiry then, is not how much has the claimant been 
 
            functionally impaired, but whether that impairment, in 
 
            combination with the claimant's age, education, work 
 
            experience, pre and post injury wages, motivation and 
 
            ability to get a job within the stated restrictions, if any 
 
            restrictions have been imposed, have caused a loss of 
 
            earning capacity.  Olson v. Goodyear Service Stores, 125 
 
            N.W.2d 251, 257 (Iowa 1963); Diederich v. Tri-City Railway 
 
            Co., 258 N.W. 899, 902 (Iowa 1935);  Peterson v. Truck Haven 
 
            Cafe, Inc., 1 Iowa Industrial Comm'r Dec. No. 3, 654, 658 
 
            (1985); Christening v. Hague, Inc., 1 Iowa Industrial Comm'r 
 
            Dec. No. 3, 529, 534-535 (1985). 
 
            There are no weighting guidelines that indicate how each of 
 
            the factors are to be considered.  Nor is there any formulae 
 
            which can be applied and then added up to determine the 
 
            degree of industrial disability to the body as a whole.  It 
 
            therefore becomes necessary for the deputy or commissioner 
 
            to draw upon prior experience and general and specialized 
 
            knowledge to make a finding with regard to the degree of 
 
            industrial disability.  See, Peterson, 1 Iowa Industrial 
 
            Commissioner Decisions No. 3, at 658; Christening, 1 Iowa 
 
            Industrial Commissioner Decisions No. 3, at 535.
 
            
 
                 At the time of the injury, claimant was 35 years old.  
 
            He has demonstrated that he is able to work with his 
 
            disability.  The medical evidence does not support 
 
            claimant's contention that his continuing inability to hold 
 
            down long term employment is attributable to his 
 
            sensitization to paint fumes.  Dr. Mahadevia indicated that 
 
            claimant's continuing problem in that regard stems from his 
 

 
            
 
            Page  11
 
            
 
            
 
            
 
            
 
            preexisting asthma.  While claimant was working for 
 
            Mississippi Valley Blood Bank, Dr. Mahadevia specifically 
 
            approved claimant's work environment.  Claimant voluntarily 
 
            quit that employment without discussing the decision with 
 
            Dr. Mahadevia.  Likewise, claimant quit his employment with 
 
            Normandeau Associates for a variety of reasons but did not 
 
            seek medical assistance for the apparent aggravation to his 
 
            asthma.  Moreover, claimant's past work history does not 
 
            suggest that claimant stays with any job for any length of 
 
            time.  Claimant held 19 jobs in the space of 10 years.  He 
 
            changed jobs while working for Wayne Carney.  Claimant has 
 
            worked in manual labor jobs since he began working and this 
 
            injury has not foreclosed claimant from opportunities in 
 
            this area.  Claimant would have been working at the time of 
 
            the hearing but for an injury to his knee and back.  On 
 
            claimant's last job he was earning $8.00 per hour.  Prior to 
 
            that time, claimant was earning about $6.00 per hour.  Due 
 
            to his young age, his industrial disability is not as 
 
            serious as it would be for an older employee.  Becke v. 
 
            Turner-Busch, Inc., Thirty-fourth Biennial Report of the 
 
            Industrial Commissioner 34 (Appeal Decision  1979); Walton 
 
            v. B & H Tank Corp., II Iowa Industrial Commissioner Report 
 
            426 (1981); McCoy v. Donaldson Company, Inc., file numbers 
 
            782670 & 805200 (Appeal Decision April 28, 1989).  
 
            Claimant's educational abilities demonstrate that he has the 
 
            capacity to be retrained if he is given some assistance.  
 
            Based upon the foregoing factors, all of the factors used to 
 
            determine industrial disability, and employing agency 
 
            expertise, it is determined that claimant sustained a 12% 
 
            industrial disability.
 
            With regard to the claim for psychological injury, there is 
 
            insufficient evidence in the record to show that claimant's 
 
            depressive episodes were precipitated by claimant's injury 
 
            at work.  Dr. Hays cannot say with any certainty what caused 
 
            claimant's mental problems.  Claimant has failed to satisfy 
 
            his burden and will take nothing from this proceeding 
 
            regarding the psychological injury.
 
            As a result of claimant's injury he is also entitled to 
 
            healing period benefits.  Healing period benefits may be 
 
            characterized as that period during which there is a 
 
            reasonable expectation of improvement of a disabling 
 
            condition and ends when maximum medical improvement is 
 
            reached. Armstrong Tire and Rubber Co. v. Kubli, 312 N.W.2d 
 
            60, 65 (Iowa Ct. App. 1981).  In discussing the concept of 
 
            healing period as contemplated by Iowa Code Section 85.34(1) 
 
            (1991) the Kubli Court observed that recuperation refers to 
 
            that condition in which healing is complete and the extent 
 
            of the disability can be determined. Kubli, 312 N.W.2d at 
 
            65.  The healing period ends when claimant returns to work.  
 
            Boyd v. Western Home, File No. 890207, Slip Op. at 2, (Iowa 
 
            Ind. Comm'r App. June 26, 1991);  Bertlshofer v. Fruehauf 
 
            Corporation, File Nos. 764496, 742752, Slip Op. at 6 (Iowa 
 
            Ind. Comm'r App. April 14, 1988).  The finding of a 
 
            termination of healing period necessarily precludes the 
 

 
            
 
            Page  12
 
            
 
            
 
            
 
            
 
            discussion of a running award.  Hoskins v. Quaker Oats, 2 
 
            Iowa Industrial Commissioner Decisions, No. 1, 181, 185 
 
            (App. 1985).  
 
            Claimant returned to work for the Shoe Fixers on November 
 
            26, 1988.  Claimant left this employment due to an 
 
            aggravation suffered at this employment rather than an 
 
            aggravation caused by exposure to paint fumes with Wayne 
 
            Carney.  His healing period ended at that point at the time 
 
            he resumed full time work.  Consequently, claimant is 
 
            entitled to healing period benefits from July 26, 1988 to 
 
            November 26, 1988.
 
            2.  Whether claimant is entitled to medical benefits, 
 
            including a determination of causal connection to the work 
 
            injury and the causal connection of this condition to a work 
 
            injury.
 
With regard to entitlement to medical benefits, 
 
            claimant urges that defendants are liable for medical bills 
 
            related to his current condition including his bills for 
 
            psychological care.  Defendants urge that they are only 
 
            responsible for medical care attributable to the injury 
 
            claimant suffered while he worked for Wayne Carney.  They 
 
            are not responsible for the cost of the subsequent 
 
            aggravations caused by other employments of the claimant or 
 
            the psychological services rendered to claimant.
 
            Under Iowa Code section 85.27(1991) an employer has the 
 
            responsibility to provide an injured worker with reasonable 
 
            medical care and has the right to select the care the worker 
 
            will receive.  The claimant has the burden of demonstrating 
 
            that the medical services obtained were related to the 
 
            injury in order to have the expenses reimbursed or paid.  
 
            Auxier v. Woodward State Hospital, 266 N.W.2d 139, 144 
 
            (Iowa 1978).  Additionally, in order for the employer to be 
 
            held responsible for claimant's medical expenses, claimant 
 
            must show that the treatment sought was either of an 
 
            emergency nature or was authorized.  Templeton v. Little 
 
            Giant Crane & Shovel, 1 Iowa Industrial Commissioner 
 
            Decisions No. 3, 702, 704 (App. 1985).  An employee may 
 
            engage medical services if the employer has expressly or 
 
            impliedly conveyed to the employee the impression that the 
 
            employee has authorization to proceed in this fashion.  2 
 
            Larson's Workmen's Compensation Section 61.12(g) (1990).  If 
 
            the treatment is unauthorized a claimant may still recover 
 
            if the treatment improves the claimant's condition and the 
 
            treatment ultimately mitigates defendants' liability.  
 
            Thomas v. Broadlawns Medical Center, File No. 81240, Slip 
 
            op. at pp. 6-8 (Iowa Ind. Comm'r October 31, 1990);  Butcher 
 
            v. Valley Sheet Metal, IV Iowa Industrial Commissioner 
 
            Report 49 (1983); Rittgers v. United Parcel Service, III 
 
            Iowa Industrial Commissioner Report 210 (1982).
 
            With regard to claimant's outstanding medical bills, a 
 
            review of these bills shows that the bills for Dr. Hays, Dr. 
 
            Nissen, and Vera French Community Health Center were 
 
            attributable to claimant's depression.  There is 
 
            insufficient evidence in the record to find a casual 
 
            connection between claimant's injury and his depression.  
 

 
            
 
            Page  13
 
            
 
            
 
            
 
            
 
            Defendants are not liable for those bills.
 
            The balance owed to Dr. Mahadevia appears to be for office 
 
            visits on April 21, 1989 and June 2, 1989.  By that time 
 
            claimant was working for Mississippi Valley Blood Center and 
 
            complaining of aggravations to his asthma condition 
 
            resulting from his exposure to bleach and other chemical 
 
            fumes on April 7, 1989.  There is insufficient evidence to 
 
            show that this incident is casually connected to claimant's 
 
            exposure on July 26, 1988.    Dr. Mahadevia did not offer 
 
            any opinion that the visits after March, 1989 were related 
 
            to the paint fume exposure at Wayne Carney.  Consequently, 
 
            defendants are not liable for this bill.
 
            The balance owed to St. Luke's hospital was for a variety of 
 
            tests and a hospital course directed by Dr. Mahadevia.  
 
            However, there is insufficient evidence to link this 
 
            admission with the injury suffered on July 26, 1988.  By 
 
            this time, claimant had complained of successive 
 
            aggravations of his asthma from a variety of work and 
 
            non-work related substances.  Additionally, claimant's 
 
            depression from unknown causes was contributing to his sleep 
 
            disorder.  Finally, claimant's ulcer condition was 
 
            evaluated.  The record in this case does not support the 
 
            causal link claimant requires to compel payment by 
 
            defendants for these bills.  Consequently, defendants are 
 
            not liable for the charges owed to St. Luke's Hospital.
 
            Since claimant has failed to show that these expenses were 
 
            causally connected to the injury suffered on July 26, 1988,  
 
            the other issues raised in connection with claimant's 
 
            entitlement to medical benefits are moot.
 
            order
 
            THEREFORE, it is ordered:
 
            1.  Wayne Carney and Aetna shall pay to claimant healing 
 
            period benefits for the period of time beginning on July 26, 
 
            1988 and ending on November 26, 1988 at the rate of two 
 
            hundred and thirty and 14/100 dollars ($230.14).  As these 
 
            benefits have accrued, they shall be paid in a lump sum 
 
            together with statutory interest thereon pursuant to Iowa 
 
            Code section 85.30 (1991).
 
            2.  Wayne Carney and Aetna shall pay to claimant permanent 
 
            partial disability benefits in the amount of twelve percent 
 
            (12%) with payment commencing on November 27, 1988 at the 
 
            rate of two hundred thirty and 14/100 dollars ($230.14).  As 
 
            these benefits have accrued, they shall be paid in a lump 
 
            sum together with statutory interest thereon pursuant to 
 
            Iowa Code section 85.30 (1991).
 
            3.  Wayne Carney and Aetna shall have a credit in the amount 
 
            of seventy-nine and six-sevenths (79 6/7) weeks against any 
 
            amounts owed.  
 
            4.  The costs of this action totaling one hundred sixty-five 
 
            and 50/100 dollars ($165.50) shall be assessed to Wayne 
 
            Carney and Aetna pursuant to rule 343 IAC 4.33.
 
            5.  Wayne Carney and Aetna shall file claim activity reports 
 
            as required by rule 343 IAC 3.1.
 
            Signed and filed this ____ day of August, 1991.
 

 
            
 
            Page  14
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
            
 
                      ________________________________
 
                      ELIZABETH A. NELSON
 
                      DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            Copies To:
 
            
 
            Mr Joseph M Bauer
 
            Attorney at Law
 
            100 Court Avenue Ste 203
 
            Des Moines Iowa 50309
 
            
 
            Ms Linda E Frischmeyer
 
            Attorney at Law
 
            1750 2nd Avenue
 
            PO Box 3250
 
            Rock Island Illinois 61204
 
            
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                      5-2205 - 5-2206
 
                      Filed August 13, 1991
 
                      ELIZABETH A. NELSON
 
            before the iowa industrial commissioner
 
            ____________________________________________________________
 
                      :
 
            MICHAEL L. PAPALE,  :
 
                      :
 
                 Claimant, :
 
                      :
 
            vs.       :
 
                      :      File No. 894922
 
            WAYNE CARNEY PAINTING,   :
 
                      :    A R B I T R A T I O N
 
                 Employer, :
 
                      :      D E C I S I O N
 
            and       :
 
                      :
 
            AETNA LIFE AND CASUALTY  :
 
            COMPANY,  :
 
                      :
 
                 Insurance Carrier,  :
 
                 Defendants.    :
 
            ___________________________________________________________
 
            
 
            5-2205, 5-2206
 
            Claimant aggravated a preexisting asthma condition while 
 
            working for a painting contractor.  Claimant was 37 at the 
 
            time of hearing.  He is capable of retraining.  Claimant 
 
            worked after the exposure to dust and paint fumes in other 
 
            occupations for wages between $6.00 and $8.00 per hour.  
 
            Claimant cannot return to an environment where he would be 
 
            exposed to paint fumes and other chemical odors related to 
 
            paint.  Claimant was awarded a 12 percent industrial 
 
            disability.