Page 1 before the iowa industrial commissioner ____________________________________________________________ : LAURIE A. GEBEL, : : Claimant, : : vs. : File No. 916790 : KITCHENS OF SARA LEE, : A R B I T R A T I O N : Employer, : D E C I S I O N : and : : TRAVELERS INSURANCE COMPANY, : : Insurance Carrier, : Defendants. : ____________________________________________________________ statement of the case This is a proceeding in arbitration brought by the claimant, Laurie A. Gebel, against her employer, Kitchens of Sara Lee, and its insurance carrier, Travelers Insurance Company, to recover benefits under the Iowa Workers' Compensation Act as a result of an injury sustained on October 29, 1988. This matter came on for hearing before the undersigned deputy industrial commissioner at Waterloo, Iowa, on November 27, 1991. A first report of injury has been filed. The record consists of claimant's exhibits 1 through 27 and defendants' exhibits 28 through 36, as well as of the testimony of claimant, of Lee Gebel, of Tony J. Gotto, of Barbara Bierbaum, and of Kevin Lamphier. issues Pursuant to the hearing assignment order, the prehearing report and the oral stipulation of the parties, the parties have stipulated to the following: that claimant's weekly rate is $233.78, given that she was married and entitled to three exemptions at the time of her injury; that claimant has received all healing period or temporary total disability benefits to which she is entitled with those beginning on October 29, 1988; and, that the commencement date for any permanent disability, should permanent partial disability be awarded, would be either March 16, 1990, or August 21, 1990. The parties have further stipulated that claimant did receive an injury arising out of and in the course of her employment on the alleged injury date and that a causal relationship exists between that injury and claimed permanent disability as well as claimed healing period or temporary total disability. Additionally, the parties agree that, under the American Page 2 Medical Association Guides to the Evaluation of Permanent Impairment, the combined value of the ratings of claimant by Peter C. Amadio, M.D., is 56 percent of the body as a whole. Also, the employer has agreed to pay the section 85.27 expenses listed in claimant's exhibits 18 and 19. The issue remaining to be decided is the nature and extent of claimant's permanent partial disability benefit entitlement, if any, including the question of whether claimant is an odd-lot worker under the Guyton doctrine. findings of fact The deputy, having heard the testimony and reviewed the documentary evidence, finds: Claimant is a 26-year-old married woman with one child. She is a high school graduate who has taken a limited course in dietary aide work but otherwise has no specialized training. Her primary work history was as a production worker with Kitchens of Sara Lee where she began at a salary of $5.39 per hour and left with a salary of $7.04. At Sara Lee, claimant also had a benefit package including vacation pay, health and dental insurance and a pension fund. Claimant has also worked part time and full time in nursing homes as a nurse's aide, dietary aide, laundress and cook. Claimant opined that each of those tasks involved a need for either repetitious work with the hands or strength in the hands and that she would be precluded from doing such work today. Claimant began work at Sara Lee in 1985. She initially worked in roll make-up and then worked in the savory department. Each job involved repetitious hand movements with claimant generally being required to package 70 items per minute. Claimant worked 8-10 hours per day, 5 or 6 days per week. In October 1988, claimant advised the Sara Lee nurse that her hands were swollen. Other symptoms included numbness and throbbing, sharp pain. Claimant saw William W. Eversmann, M.D., in November 1988. He advised splints for both work and home activities. Claimant's condition did not improve and she had carpal tunnel releases performed on April 26, 1989, and May 31, 1989. Claimant returned to work on a four-hour-per-day basis in July 1989. Claimant indicated that her condition worsened upon her work return. On September 7, 1989, claimant saw Peter C. Amadio, M.D., a board-certified hand surgeon with Mayo Clinic. Dr. Amadio again took claimant off work. Claimant has not since returned to work. Dr. Amadio diagnosed claimant's condition as bilateral failed carpal tunnel syndrome and bilateral thoracic outlet syndrome. Thoracic outlet surgery was performed on the right in July 1990. Vascular studies showed objective improvement, but claimant had no subjective improvement in her symptomatology. For that reason, left thoracic outlet surgery was not performed. Colleen M. Galegher Johnson performed a work capacity Page 3 evaluation with claimant in July 1990. In her deposition, Johnson reported that claimant's grip strength bilaterally was less than one percent of the norm for a 24-year-old female and her test was in the lowest possible range, that being less than 10 percent of the norm for a 24-year-old female. Fine motor skills also were less than one percent of the norm for a 24-year-old female. Claimant was unable to complete three tests of nuts and bolts assembly on account of her pain. She was unable to carry 10 pounds for greater than 50 feet and, in the course of doing so, complained of pain bilaterally in the arms and shoulders. On a push-pull test, claimant could push and pull 15 pounds of force to start movement and then 13 pounds to sustain movement. Claimant could lift floor to knuckle 5 pounds and knuckle to shoulder 5 pounds. Her estimated maximum safe lifting weight would be no more than 3 pounds between knuckle and shoulder level with nothing above the shoulder. A functional capacity evaluation was discontinued after approximately one hour, that is, two cycles, as claimant could not handle the fine motor activities involved. In her deposition of November 15, 1991, Johnson opined that there was no level of work claimant would be able to perform, given the results of the July 1990 testing and that claimant would not be able to perform sedentary level work. Johnson opined that claimant could not operate a computer, use a 10-key adding machine, make change or carry 5- or 10-pound items or lift cooking utensils filled with food. She also indicated claimant could not carry small children for extended periods of time. Johnson also opined that claimant would be incapable of washing her car at a self-service car wash using a high-pressure hose or using such a hose above her head and that claimant would not be able to dry and wash a car for an hour and fifteen minutes while using her right hand in a circular motion. In his deposition of November 15, 1991, Dr. Amadio opined that claimant's symptoms had not subsided since September 9, 1991, and he does not anticipate they will subside to a point where claimant can be gainfully employed. Dr. Amadio further opined that claimant cannot perform services of a quality and dependability that would be useful in a reasonably stable job market. Dr. Amadio doubted that claimant could serve as a restaurant hostess. Gordon Moore, M.D., a board-certified psychiatrist with the Mayo Clinic, evaluated claimant briefly on August 7, 1990. He felt claimant had an adjustment disorder with mixed features. He described such as not a preexisting psychiatric disorder but as an emotional response based on one's coping style to a set of stressors. Dr. Moore agreed that coping style itself is preexisting. Both Drs. Moore and Amadio have recommended that claimant enter the Mayo Pain Management Center after her litigation is resolved. Claimant's hands were visibly swollen and distorted at time of hearing. Claimant has difficulty fixing her own hair. Her sister assisted her in doing so on the date of hearing. Claimant can place laundry in a washing machine but cannot carry laundry. Claimant cooks simple meals, but Page 4 her three-year-old son must assist by operating an electric can opener for her. Claimant and her spouse have purchased a dishwasher as claimant is unable to do dishes. Claimant can vacuum with breaks in between. Claimant's family assists with housework. Claimant can drive approximately ten miles. Grasping a steering wheel causes hand and arm numbness. Claimant lies down approximately 5-10 times per day in order to relieve her pain. Claimant can write one check and a small note before experiencing symptoms requiring her to stop. She can hold a telephone to her ear with her neck for approximately five minutes. Kevin Lamphier, an investigator formerly with Gordon Gratias Private Investigations, observed claimant washing her car with a pistol grip sprayer which she held in her right hand and controlled with her left on approximately November 3, 1991. Claimant also operated a change machine and dried and cleaned the interior of her car for approximately one and one-fourth hours subsequent to washing it. Lamphier indicated claimant held both hands above her head while using the high-pressure water hose. Lamphier's report indicates that claimant pulled into the car wash at 10:57 a.m. and left the car wash at 11:06 a.m. Given that claimant had to make change and tend to her preschooler in that time, such does not represent a significant period of grasping with the hands or reaching overhead. Claimant arrived at her home at 11:09 a.m. and started drying her car at 12:10 p.m. Such represents a break of approximately one hour and, while it is likely claimant prepared lunch for herself and her child during that time, it is not altogether inconsistent with claimant's testimony that claimant needed a break prior to starting to dry the car after having washed the car. At hearing, claimant testified that she had been indoors for so long that she decided to see if she could wash the car. Claimant indicated that, after drying the car, her hands felt heavy and throbbed. She indicated it took a day or two after the car washing for her hands to return to normal. Claimant was a credible witness. Tony J. Gotto, personnel manager at Sara Lee, reported that the company's policy is to attempt to return workers to work within their medical restrictions. He indicated that, on claimant's work return, work was provided within Dr. Eversmann's assigned restrictions. Gotto indicated he was not aware of any restrictions from Dr. Amadio. Gotto stated claimant would be considered for reemployment if she should apply, but than agreed that there was no work at Sara Lee that does not require use of the hands and arms. Light-duty work at Sara Lee consists of cutting chocolate curls or putting chocolate bars into machines and other self-paced activities. Barbara Bierbaum, a rehabilitation specialist with a background in business but without specialized training as a rehabilitation specialist, testified at hearing. She indicated that job possibilities for claimant included teacher's aide, group worker, production inspector, office Page 5 worker, cashier, teller, motel reservationist and day care worker. Bierbaum agreed that she based her job considerations on claimant's interests as ascertained through an interview with claimant and on a medical note of Ann Schutt, M.D., of September 21, 1989, which note stated that claimant would be permitted to return to non-repetitive, light-duty work without her arms overhead or at shoulder level when claimant's symptoms subsided. Bierbaum agreed that she had made no determination that claimant's symptoms had subsided when she used the report of Dr. Schutt as a work release. Bierbaum further agreed that, without knowledge of claimant's current restrictions, she does not know if claimant could perform any jobs found or perform jobs in the competitive job market. Bierbaum did not know if claimant could make change or count money on a regular basis. She did not believe that claimant could work as a full-time computer operator. Bierbaum was not aware of claimant's need for assistance with her own child or of claimant's need to rest 5-10 times per day. Jobs Bierbaum located for claimant required drives of 18-40 miles each way. Bierbaum agreed she had not checked with claimant as regards claimant's ability to drive long distances prior to locating such jobs. Bierbaum's testimony is given less weight, given her lack of understanding of claimant's current work restrictions, physical disabilities, and inability to drive for sustained periods. Bierbaum located two job openings in group work and nursing homes which Bierbaum felt claimant could do. One involved cleaning and the other involved hand work possibly pushing wheelchairs. Claimant was advised by the administrator that it was not likely she would be able to perform the cleaning work. Thomas W. Magner, a certified rehabilitation counselor, evaluated claimant and issued a report on October 28, 1991. Magner opined that, given claimant's situation and her lack of transferrable skills, claimant would not be able to work on a regular competitive basis. Claimant apparently graduated 82nd in a class of 172 students and had received grades ranging from A through C in high school. Dr. Amadio last physically examined claimant on March 27, 1991. She then had full range of motion in the hands, pinch strength of 1.5 kilometers bilaterally and a grip strength of 4 kilometers bilaterally without atrophy. Both hands were cool to touch and red and sweating. Dr. Eversmann, in a clinical note of March 6, 1990, indicated that claimant had a seven percent permanent partial impairment of the right upper extremity and a five percent permanent partial impairment of the left upper extremity equalling four percent of the body as a whole on the right and three percent of the body as a whole on the left for, under the combined values chart, seven percent of the body as a whole. Apparently, that amount relates to the bilateral carpal tunnel condition only and not to the thoracic outlet condition. W. C. Koenig, Jr., M.D., a physical medicine and Page 6 rehabilitation specialist, evaluated claimant and issued a report on November 29, 1990. His impression was that claimant was status post-carpal tunnel release and status post-right thoracic outlet surgery. Dr. Koenig opined that claimant had a 5 percent permanent partial impairment of each upper extremity as the result of her carpal tunnel syndrome and a 30 percent permanent partial impairment of the upper extremity as the result of her failed thoracic outlet surgery, equalling 40 percent permanent partial impairment of the upper extremity or 25 percent partial "disability" of the body as a whole. Page 7 conclusions of law Functional impairment is an element to be considered in determining industrial disability which is the reduction of earning capacity, but consideration must also be given to the injured employee's age, education, qualifications, expe rience and inability to engage in employment for which the employee is fitted. Olson v. Goodyear Serv. Stores, 255 Iowa 1112, 125 N.W.2d 251 (1963); Barton v. Nevada Poultry, 253 Iowa 285, 110 N.W.2d 660 (1961). A finding of impairment to the body as a whole found by a medical evaluator does not equate to industrial disability. Impairment and disability are not synonymous. The degree of industrial disability can be much different than the degree of impairment because industrial disability references to loss of earning capacity and impairment references to anatomical or functional abnormality or loss. Although loss of function is to be considered and disability can rarely be found without it, it is not so that a degree of industrial disability is proportionally related to a degree of impairment of bodily function. Factors to be considered in determining industrial dis ability include the employee's medical condition prior to the injury, immediately after the injury, and presently; the situs of the injury, its severity and the length of the healing period; the work experience of the employee prior to the injury and after the injury and the potential for rehabilitation; the employee's qualifications intellectually, emotionally and physically; earnings prior and subsequent to the injury; age; education; motivation; functional impairment as a result of the injury; and inability because of the injury to engage in employment for which the employee is fitted. Loss of earnings caused by a job transfer for reasons related to the injury is also relevant. Likewise, an employer's refusal to give any sort of work to an impaired employee may justify an award of disability. McSpadden v. Big Ben Coal Co., 288 N.W.2d 181 (Iowa 1980). These are matters which the finder of fact considers collectively in arriving at the determination of the degree of industrial disability. There are no weighting guidelines that indicate how each of the factors are to be considered. Neither does a rating of functional impairment directly correlate to a degree of industrial disability to the body as a whole. In other words, there are no formulae which can be applied and then added up to determine the degree of industrial disability. It therefore becomes necessary for the deputy or commissioner to draw upon prior experience as well as general and specialized knowledge to make the finding with regard to degree of industrial disability. See Christensen v. Hagen, Inc., Vol. 1 No. 3 State of Iowa Industrial Commissioner Decisions 529 (App. March 26, 1985); Peterson v. Truck Haven Cafe, Inc., Vol. 1 No. 3 State of Iowa Industrial Commissioner Decisions 654 (App. February 28, 1985). Page 8 Compensation for permanent partial disability shall begin at the termination of the healing period. Compensation shall be paid in relation to 500 weeks as the disability bears to the body as a whole. Section 85.34. In Guyton v. Irving Jensen Co., 373 N.W.2d 101 (Iowa 1985), the Iowa court formally adopted the "odd-lot doctrine." Under that doctrine a worker becomes an odd-lot employee when an injury makes the worker incapable of obtaining employment in any well-known branch of the labor market. An odd-lot worker is thus totally disabled if the only services the worker can perform are "so limited in quality, dependability, or quantity that a reasonably stable market for them does not exist." Guyton, 373 N.W.2d at 105. The burden of persuasion on the issue of industrial disability always remains with the worker. When a worker makes a prima facie case of total disability by producing substantial evidence that the worker is not employable in the competitive labor market, the burden to produce evidence of suitable employment shifts to the employer, however. If the employer fails to produce such evidence and if the trier of fact finds the worker does fall in the odd-lot category, the worker is entitled to a finding of total disability. Guyton, 373 N.W.2d at 106. Even under the odd-lot doctrine, the trier of fact is free to determine the weight and credibility of evidence in determining whether the worker's burden of persuasion has been carried, and only in an exceptional case would evidence be sufficiently strong as to compel a finding of total disability as a matter of law. Guyton, 373 N.W.2d at 106. Claimant has made a prima facie showing that the only services claimant could perform are so limited in quality, dependability, or quantity that a reasonably stable market for them does not exist. Claimant has virtually no effective use of her upper extremities. She lives in a rural area where the job market is already limited. She can drive for no more than ten miles without experiencing difficulties with her upper extremities. Those facts in themselves would seriously limit the job market available for claimant. In addition, claimant cannot perform the light-weight maneuvers required to make change, operate a keyboard, operate a credit card machine or otherwise perform sedentary level clerical tasks. She has difficulty writing. Her advisable lifting and carrying limit is three pounds. She has limited education; none of the vocational and occupational evaluators who worked with claimant advised retraining. Ms. Galegher Johnson opined that, based on the Dictionary of Occupational Titles, there was no sedentary level work that claimant could do. One can conclude then that retraining is not advised in that, even with retraining, claimant's inability to use her upper extremities precludes successful employment. Defendants have not sustained their burden of showing that work is available for claimant. Mr. Gotto testified that she would be considered for re-hiring at Kitchens of Page 9 Sara Lee, but then conceded that there are no jobs at Sara Lee that do not require use of the hands and arms. Nothing in this record suggests that claimant could fairly be required to use her hands and arms in sustained work. Defendants did observe claimant engaging in an activity which required some gripping and some overhead work as well as circular movement of the hand. Claimant's testimony that she attempted to wash her car as a result of her frustration with her inactivity was credible, however. Additionally, the ability to engage in such an activity on one day at one's own pace and with time to recover from the discomfort it produces is not fairly comparable to the demands of sustained employment in the competitive labor market. Likewise, Ms. Bierbaum's testimony did not show that claimant had the capacity to enter the labor market competitively. Defendants have failed in their burden to go forward and show that competitive employment is actually available to claimant. Given such, and given claimant's circumstances as a whole, it is concluded that claimant is an odd-lot worker under the Guyton doctrine and is for that reason entitled to an award of permanent total disability benefits. order THEREFORE, IT IS ORDERED: Defendants pay Laurie A. Gebel permanent total disability benefits at the rate of two hundred thirty-three and 78/100 dollars ($233.78) per week throughout the period of her disability with benefits to commence on the date of injury. Defendants receive credit for benefits previously paid. Defendants pay accrued amounts in a lump sum together with interest pursuant to Iowa Code section 85.30. Costs are assessed against defendants pursuant to rule 343 IAC 4.33. Defendants file claim activity reports as requested by this agency pursuant to rule 343 IAC 3.1. Signed and filed this ______ day of ____________, 1992. ______________________________ HELENJEAN M. WALLESER DEPUTY INDUSTRIAL COMMISSIONER Copies To: Mr. John Riccolo Mr. David L. Baker Attorneys at Law Suite 1140, The Center Page 10 425 Second Street SE Cedar Rapids, Iowa 52401 Mr. John D. Standafer Attorney at Law 101 East Main Street West Union, Iowa 52175 Mr. Rustin T. Davenport Mr. C. Bradley Price Mr. Mark A. Wilson Attorneys at Law 30 4th Street NW P.O. Box 1953 Mason City, Iowa 50401 1804; 3701; 4100 Filed February 28, 1992 HELENJEAN M. WALLESER before the iowa industrial commissioner ____________________________________________________________ : LAURIE A. GEBEL, : : Claimant, : : vs. : File No. 916790 : KITCHENS OF SARA LEE, : A R B I T R A T I O N : Employer, : D E C I S I O N : and : : TRAVELERS INSURANCE COMPANY, : : Insurance Carrier, : Defendants. : ____________________________________________________________ 1804; 4100 Twenty-six-year-old female claimant with bilateral carpal tunnel syndrome and bilateral thoracic outlet syndrome, three-pound lifting restriction below the shoulder, and de minimis grip strength found to be an odd-lot worker. 3701 Surveillance testimony and photos showing claimant using an air-powered hose to wash her car and showing claimant wiping the car were countered by claimant's testimony regarding difficulties she experienced subsequent to engaging in the activity. before the iowa industrial commissioner ____________________________________________________________ : WILLENE C. TITUS, : : Claimant, : : vs. : : File No. 916954 HUSH PUPPY SHOES, a/k/a : 926960 TODD'S NATURALIZERS, : : A P P E A L Employer, : : D E C I S I O N and : : AMERICAN MOTORISTS INSURANCE, : : Insurance Carrier, : Defendants. : ___________________________________________________________ The record, including the transcript of the hearing before the deputy and all exhibits admitted into the record, has been reviewed de novo on appeal. The decision of the deputy filed July 25, 1991, is affirmed and is adopted as the final agency action in this case. Defendants shall pay the costs of the appeal, including the preparation of the hearing transcript. Signed and filed this ____ day of March, 1992. ________________________________ BYRON K. ORTON INDUSTRIAL COMMISSIONER Copies To: Mr. David D. Drake Attorney at Law West Towers Office 1200 35th Street Suite 500 West Des Moines, Iowa 50265 Mr. Paul C. Thune Attorney at Law 218 6th Avenue, Suite 300 P O Box 9130 Des Moines, Iowa 50306 9998 Filed March 20, 1992 BYRON K. ORTON DRR before the iowa industrial commissioner ____________________________________________________________ : WILLENE C. TITUS, : : Claimant, : : vs. : : File No. 916954 HUSH PUPPY SHOES, a/k/a : 926960 TODD'S NATURALIZERS, : : A P P E A L Employer, : : D E C I S I O N and : : AMERICAN MOTORISTS INSURANCE, : : Insurance Carrier, : Defendants. : ___________________________________________________________ 9998 Summary affirmance of deputy's decision filed July 25, 1991. 1803 Filed February 28, 1992 MICHAEL G. TRIER before the iowa industrial commissioner ____________________________________________________________ : JUDY BANKS, : : Claimant, : File Nos. 898516 : 917001 vs. : 976638 : WOODWARD STATE HOSPITAL : A R B I T R A T I O N SCHOOL, : : D E C I S I O N Employer, : : and : : STATE OF IOWA, : : Insurance Carrier, : Defendants. : ____________________________________________________________ 1803 Claimant, with admitted injury, awarded 30 percent permanent partial disability. The decision discusses the impact of training obtained after the end of the healing period upon the employer's permanent partial disability liability. Page 1 before the iowa industrial commissioner ____________________________________________________________ : MICHAEL M. MORENO, : : Claimant, : : vs. : : File No. 917096 SIPCO, : : A R B I T R A T I O N Employer, : : D E C I S I O N and : : CITY INSURANCE COMPANY, : : Insurance Carrier, : Defendants. : ____________________________________________________________ introduction This is a proceeding in arbitration brought by the claimant, Michael Moreno, against his employer, Swift Independent Packing Company, and its insurance carrier, City Insurance Company, to recover benefits under the Iowa Workers' Compensation Act as a result of an injury sustained on April 12, 1989. This matter came on for hearing before the undersigned deputy industrial commissioner at Des Moines, Iowa on March 5, 1991. A first report of injury was filed on May 15, 1989. The record consists of the testimony of claimant, of Leona Martin, of William D. Green, and of Peter C. Crivara as well as of joint exhibits 1 through 43 and claimant's exhibit A. issues Pursuant to the prehearing order and the oral stipulations of the parties at hearing, the parties stipulated that claimant did receive an injury which arose out of and in the course of his employment; that claimant's injury was causally related to claimed temporary total or healing period disability; that claimant is entitled to healing period or temporary total disability benefits from April 12, 1989 to February 17, 1990; that any entitlement to permanent partial disability benefits would commence on February 18, 1990; that claimant's rate of weekly compensation is $200.01; and, that costs for claimant's medical care were fair and reasonable. Issues remaining to be decided are: whether a causal relationship exists between claimant's injury and claimed permanent disability; the extent of any permanent disability; whether claimant is an odd-lot worker under the Guyton doctrine; and, whether claimant is entitled to payment of certain medical costs under section 85.27. Page 2 findings of fact The deputy, having heard the testimony and considered the evidence, finds: Claimant is 58 years old and has completed the tenth grade. He has worked primarily as a heavy laborer, either in the steel manufacturing or meat packing industry. He also has experience as a truck driver and in janitorial work. Claimant has attended 21 hours of barber school and barbered part-time from approximately 1976 until 1982. Claimant left barbering on account of lack of income, declining eyesight, and pain in the upper dorsal spine region and in the lateral aspect of the right elbow. Claimant began working at Swift Packing on May 31, 1988. He worked in the inedible room where he separated lungs, spleens, and livers into different tubs. Claimant could have done his job at Swift under a 20-pound weight limitation. The job involves standing and walking throughout the day, however. It involves no above-shoulder activity. All lifting is done with an electric hydraulic crawler. Claimant fell on a wet surface at work on April 12, 1989. He struck his neck on a metal cart and struck his right elbow on another object. He sustained a hyperabduction injury to the elbow and shoulder and as of April 14, 1989, had discomfort from the neck going to both shoulders and down the right extremity into the right thumb (joint exhibit 3). X-rays of the cervical spine of April 14, 1989 showed severe degenerative arthritis with a reversal of the normal curve, ridging, and marked degeneration. An olecranon spur was found on the right elbow. The right shoulder was essentially normal. Claimant was again seen on April 20, 1989 where the impression was of severe cervical degenerative arthritis, questionably post-traumatic with radiculopathy, with possible superimposed carpal tunnel syndrome and possible ulnar tunnel syndrome on the right upper extremity. Claimant was referred for physical therapy and to see Douglas R. Koontz, M.D., a neurologist. Plain x-rays showed congenital blocked vertebrae at C2-3 with degenerative changes at C5, 6 and 7 with fusion. The x-ray report suggested some compression of those vertebrae from old trauma as a cause of the fusion. Abnormal kyphosis was apparent at 5, 6 and 7. An MRI study confirmed the above and did not show any cervical stenosis, foraminal encroachment or disc rupture. An EMG showed nerve root irritation on the right at the C5-6 level. Dr. Koontz did not believe that claimant's condition could appropriately be treated surgically. On May 22, 1989, claimant first reported pain in his left shoulder and arm (exhibit 3; exhibit 40). In July 1989, claimant experienced sharp, stabbing pain in the mid-thoracic area after he bent over to set down a Page 3 dish of dog food. David Berg, D.O., claimant's treating physician, characterized the dog dish incident as a new injury in that it happened at home and claimant never complained of thoracic back pain prior to that incident. On August 18, 1989, claimant could not straighten up while attempting to get out of a car. He was experiencing difficulty with straightening up when apparently Dr. Berg saw him on August 22, 1989. Dr. Berg opined that claimant's current problems stem from the degenerative condition of his neck and upper back and that he has neither continuing problems or symptoms nor permanent restrictions or impairment as a result of his April 12, 1989 incident. Dr. Berg stated that needed work restrictions were due to the degenerative nature of his cervical and thoracic spine and that such restrictions would be related to what he would tolerate with claimant having good days and bad days. Dr. Berg reported that the degenerative changes and fusion found on x-ray on April 17, 1989 could not possibly have happened in the five days since claimant's April 12, 1989 work incident. Dr. Berg later opined claimant had a ten percent impairment to the body as a whole as a result of severe degenerative disc disease without herniation and that one-half of that impairment was due to the April 12, 1989 incident. Dr. Berg could not relate claimant's left side complaints on May 22, 1989 to the April 12, 1989 work incident (exhibit 40). On July 12, 1989, Dr. Berg prescribed osteopathic therapy for claimant's back and shoulder pain. Between that date and August 2, 1989, claimant received manipulative treatment at the University of Osteopathic Medicine with David R. Boesler, D.O. Claimant apparently saw Dr. Boesler on 15 separate occasions for manipulative treatment. Peter D. Wirtz, M.D., an orthopedist, initially saw claimant on December 27, 1989. He opined that claimant suffered a ligamentous strain to his neck in his April 12, 1989 injury, which strain had resolved. He reported that the injury had not left claimant with a change in his cervical disc condition and indicated that degenerative changes in claimant's cervical spine were not in themselves limiting to claimant's physical ability to use his upper extremities or back in gainful employment. On September 28, 1990, Dr. Wirtz reported that ligamentous strains and related aggravation of preexisting problems generally resolve over a period of treatment. He stated that repeated symptoms relate to repeated activities causing such symptoms. Dr. Wirtz believes that claimant has a five percent impairment of the body as a whole based on the fact that claimant has a degenerative disc in his cervical spine without neurological pressure (exhibit 39). He also stated that, of claimant's present condition, only ten percent would relate to the April 12, 1989 incident (exhibit 39). On September 24, 1990, James L. Blessman, M.D., of the Page 4 Mercy Iowa Occupational Medicine Clinic, opined that claimant had a temporary aggravation of quite severe preexisting arthritis of the spine in his April 12, 1989 injury and that claimant had no permanent impairment as a result of the injury. Martin S. Rosenfeld, D.O., evaluated claimant apparently on January 7, 1991. Dr. Rosenfeld opined that, under the Orthopaedic Academy Guidelines to Physical Impairment, claimant had a 20 percent permanent physical impairment to the body as a whole as a result of the April 12, 1989 injury with preexisting factors taken into account (exhibit 30). Robert A. Hayne, M.D., saw claimant for examination on July 7, 1975, July 29, 1975 and July 12, 1977. At the time of those examinations, claimant presented complaints of pain over the top of the shoulders extending into the shoulder plain area. He at times experienced pain in the right upper extremity (exhibit 33). Dr. Hayne saw claimant for examination on September 24, 1973. Claimant gave a history of injuring his neck and shoulder regions in an incident in 1966 where his shoulders were suddenly thrown forward and upward in an accident while loading a case of hides on a scale. Symptoms persisted for approximately two weeks. In 1968, claimant pulled excessively on a carcass and experienced recurrent pain in the shoulders and in the right shoulder blade region. Claimant was off work for 14 weeks subsequent to that incident. During that time, he experienced pain in the right upper extremity with paresthesia of the fingers of the right hand. In 1970, claimant suddenly twisted his neck region at work and experienced recurrent pain in the right scapular region. He was off work for five weeks subsequent to that incident (exhibit 33). X-rays of the cervical spine of September 24, 1973 showed the 5th and 6th cervical interspaces to be narrowed with rather advanced degenerative arthritis changes. Hypertrophic spurs were present at those levels, which spurs encroached upon the right intervertebral foramina at the interspace between the 5th and 6th cervical segments. Mild wedging of the 6th cervical segment apparently degenerative was also found. Dr. Hayne, in a letter of October 2, 1973, diagnosed claimant's condition then as intervertebral disc degeneration at the 5th and 6th cervical interspaces with encroachment on the 6th cervical nerve root on the right side at the level of the intervertebral foramina at the 5th cervical interspace on the right side. Prognosis was guarded. Dr. Hayne opined that claimant's symptoms appeared to be directly related to the accidents he described as having occurred dating back to 1966 (exhibit 33). The opinions of Doctors Berg, Blessman and Wirtz that claimant's current problems relate to his preexisting degenerative condition and do not relate to his April 12, 1989 work incident which has resolved are accepted as more consistent with the objective findings and more consistent with claimant's overall medical history as detailed in Dr. Hayne's reports. Dr. Rosenfeld's causation testimony is Page 5 rejected as inconsistent with the record presented. Claimant had lumbar back surgery in the mid-1960's. Claimant has had cataract surgery and has had surgery for a detached retina. Claimant has tinnitus which interferes with his ability to discriminate speech. Claimant does not believe that he could now do the work he did at Swift given his problems with his back, his neck and his shoulder blades. Claimant performs household duties for his family, which consists of himself, his wife, two daughters and apparently three grandchildren. He vacuums, cooks, and makes beds. He also does laundry. His daughters carry laundry to and from the basement for him, however. Claimant made no contact with Monfort while off work. Monfort terminated claimant on May 8, 1990 after making a decision that claimant voluntarily quit by abandonment by not returning to work within two months of his release for work. When injured, claimant earned $6.85 per hour and had fringe benefits including life insurance, sick and accident insurance, dental insurance, paid vacations, raises on a six-month basis, and a discount on any meat purchased. An employee at claimant's work status today would earn $7.35 per hour at Swift/Monfort. Regular attendance is required for all Swift jobs. Leona E. Martin, M.S., a rehabilitation consultant, opined that claimant is not able to be employed due to pain which distracts his attention and interrupts his activities. She believed that the activities in which claimant engages to tolerate his constant pain, that is, resting, use of hot packs, and pacing the floor, are not permissible in competitive employment (exhibit 32). conclusions of law Initially, claimant contends that a causal relationship exists between claimant's injury and his claimed permanent disability. The claimant has the burden of proving by a preponderance of the evidence that the injury of April 12, 1989 is causally related to the disability on which he now bases his claim. Bodish v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965). Lindahl v. L. O. Boggs, 236 Iowa 296, 18 N.W.2d 607 (1945). A possibility is insufficient; a probability is necessary. Burt v. John Deere Waterloo Tractor Works, 247 Iowa 691, 73 N.W.2d 732 (1955). The question of causal connection is essentially within the domain of expert testimony. Bradshaw v. Iowa Methodist 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 Page 6 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). Claimant has not established the requisite causal connection between his work injury and claimed permanent disability. The greater weight of medical evidence supports the conclusion that, at best, claimant sustained a temporary aggravation of his preexisting condition in his April 12, 1989 work incident. His continuing problems and reaggravations have their roots in his long-term problems initially documented by Dr. Hayne in 1973. With the exception of Dr. Rosenfeld, none of claimant's physicians directly relate his current condition to the work incident. Dr. Rosenfeld was an examining physician only and his report does not document that he had access to all of claimant's medical records, including the earlier records of Dr. Hayne. Likewise, while Doctors Berg and Wirtz gave opinions as to impairment which would appear to infer some relationship between the April 12, 1989 work incident and claimant's current condition, those ratings are given little weight as to the causation issue in that in each case they are inconsistent with the overall opinion testimony of the physicians as regards causal relationship between the April 12, 1989 work incident and claimant's continuing problems. Therefore, it is concluded that claimant has not established a causal relationship between his April 12, 1989 work injury and his claimed permanent disability. As claimant has not established a causal relationship between the work injury and permanent disability, no determination as to the extent of any such disability need be made and it need not be determined whether claimant would be an odd-lot worker under the Guyton doctrine. We address the section 85.27 question. Claimant seeks reimbursement for mileage expenses in the amount of $167.16. Both section 85.27 and section 85.39 permit mileage costs for appropriate medical treatment or evaluation, respectively. Given such, claimant is entitled to reimbursement for his mileage expenses as outlined. We note that claimant apparently saw Dr. Rosenfeld for evaluation and not for treatment. However, defendants have Page 7 not objected on that basis and in the absence of any objection on the grounds that Dr. Rosenfeld's evaluation of claimant is not appropriately reimbursable under section 85.39, unnumbered paragraph 2, mileage expenses for that evaluation are ordered paid. Similarly, the undersigned does not find express references in the record as regards treatment by Stephen Eckstat, D.O., and Ronnie Hawkins, M.D. Defendants have not objected as regards either the causal relationship or the authorization of either physician. Therefore, medical mileage related to treatment by such physicians is ordered paid. Claimant also seeks payment of costs with the University of Osteopathic Medicine and Health Sciences in the amount of $592.00. Such costs relate to claimant's manipulative therapy with David R. Boesler, D.O. Defendants apparently object to payment of the costs on the ground that the costs were not authorized. We note that section 85.27 permits the employer to choose claimant's care where the employer has accepted liability for claimant's injury. We find defendants' objection to payment of the costs ill- founded on two grounds, however. Initially, the record indicates that whether claimant received an injury arising out of and in the course of his employment remained an issue until stipulated to at time of hearing. Indeed, the parties did not agree to attempt to stipulate on that matter at time of prehearing; the hearing assignment order filed October 12, 1990 does not reflect any agreement to attempt to stipulate. Hence, defendants cannot argue they had a right to control claimant's medical care during a time when they denied liability for his injury. Furthermore, assuming arguendo that defendants did have some right to control claimant's care, the record clearly establishes that Dr. Berg, who was claimant's treating physician, apparently retained by the employer, recommended osteopathic manipulation to claimant and referred him to a physician at the University of Osteopathic Medicine and Health Sciences for manipulative therapy. When such therapy was not available with the originally-designated physician at the University, the University set claimant up for treatment with Dr. Boesler. Under the facts presented, neither the University nor claimant can be said to have acted unreasonably and outside the referral of Dr. Berg. For that reason also, defendants are appropriately liable for treatment of claimant at the University. Page 8 order THEREFORE, IT IS ORDERED: Defendants pay claimant medical mileage expenses equalling seven hundred ninety-six (796) miles at a rate of twenty-one cents ($.21) per mile in a total amount of one hundred sixty-seven and 16/100 dollars ($167.16). Defendants pay claimant medical costs with the University of Osteopathic Medicine and Health Sciences in the amount of five hundred ninety-two and 00/100 dollars ($592.00). Claimant take nothing further by way of weekly benefit payments from this proceeding. Claimant and defendants share equally costs of this action pursuant to rule 343 IAC 4.33. Defendants file claim activity reports as required by the agency pursuant to rule 343 IAC 3.1. Signed and filed this ______ day of ____________, 1991. ______________________________ HELENJEAN WALLESER DEPUTY INDUSTRIAL COMMISSIONER Copies To: Mr. Robert W. Pratt Attorney at Law 6959 University Avenue Des Moines, Iowa 50311 Mr. Stephen W. Spencer Mr. Timothy W. Wegman Attorneys at Law Suite 300, Fleming Building P.O. Box 9130 Des Moines, Iowa 50306-9130 1108.50; 2500; 2700 Filed March 28, 1991 HELENJEAN WALLESER before the iowa industrial commissioner ____________________________________________________________ : MICHAEL M. MORENO, : : Claimant, : : vs. : : File No. 917096 SIPCO, : : A R B I T R A T I O N Employer, : : D E C I S I O N and : : CITY INSURANCE COMPANY, : : Insurance Carrier, : Defendants. : ____________________________________________________________ 1108.50 No causation found between claimant's work injury and his permanent disability where medical evidence demonstrated the permanent condition related to longstanding degenerative problems. 2500; 2700 Defendants are liable for costs of osteopathic manipulation rendered claimant after referral from treating physician. Page 1 before the iowa industrial commissioner ____________________________________________________________ _____ : CHERYL K. GARDNER, : : Claimant, : File No. 917134 : vs. : A P P E A L : SECOND INJURY FUND, : D E C I S I O N : Defendant. : ____________________________________________________________ _____ The record, including the transcript of the hearing before the deputy and all exhibits admitted into the record, has been reviewed de novo on appeal. issues Because neither party filed a brief on appeal this matter will be considered generally without any specified errors. The issues considered by the deputy were: 1) whether claimant is entitled to benefits pursuant to the Second Injury Fund Act. findings of fact The findings of fact contained in the proposed agency decision filed April 30, 1992 are adopted as final agency action. conclusions of law The conclusions of law contained in the proposed agency decision filed April 30, 1992 are adopted as final agency action. WHEREFORE, the decision of the deputy is affirmed. order THEREFORE, it is ordered: That defendant is liable for seventy-seven point four (77.4) weeks of Fund benefits commencing on July 13, 1991, the day after the settlement agreement was filed and at the stipulated rate of two hundred thirty-seven and 70/l00 ($237.70) per week. That accrued benefits are to be paid in a lump sum together with statutory interest at the rate of ten percent (10%) per year pursuant to section 85.30, Iowa Code, as amended, and commencing on the date of this decision. That defendant, Second Injury Fund, shall pay the costs of this matter including the transcription of the hearing. That defendant shall file a claim activity report as requested by this division and pursuant to rule 343 IAC 3.1. Signed and filed this ____ day of December, 1992. Page 2 ________________________________ BYRON K. ORTON INDUSTRIAL COMMISSIONER Copies To: Mr. James E. Shipman Attorney at Law 115 3rd St. SE, Ste 1200 Cedar Rapids, Iowa 52401 Ms. Joanne Moeller Assistant Attorney General Tort Claims Division Hoover State Office Bldg. Des Moines, Iowa 50319 9998 Filed December 22, 1992 BYRON K. ORTON MAM before the iowa industrial commissioner ____________________________________________________________ _____ : CHERYL K. GARDNER, : : Claimant, : File No. 917134 : vs. : A P P E A L : SECOND INJURY FUND, : D E C I S I O N : Defendant. : ____________________________________________________________ _____ 9998 Summary affirmance of deputy's decision filed April 30, 1992. Page 1 before the iowa industrial commissioner ____________________________________________________________ : CHERYL K. GARDNER, : : File No. 917134 Claimant, : : A R B I T R A T I O N vs. : : D E C I S I O N SECOND INJURY FUND, : : Defendant. : : ___________________________________________________________ STATEMENT OF THE CASE This is a proceeding in arbitration upon the petition of claimant, Cheryl K. Gardner, against the Second Injury Fund of Iowa. Claimant had filed a proceeding in arbitration against her former employer. However, claimant and the Iowa Insurance Commissioner entered into an agreement for settlement which was approved by then Deputy Industrial Commissioner, Deborah Dubik, on July 12, 1991. The case involving the Second Injury Fund was heard on April 6, 1992, at the Linn County courthouse. The record consists of the testimony of claimant. The record also consists of the testimony of Carol Myers, manager of the Casey's Store in Mechanicsville, Iowa. Additionally, the record consists of joint exhibits 1, 2 and 3 and defendant's exhibit A. issues The issues to be determined are: 1) whether claimant is entitled to benefits pursuant to the Second Injury Fund Act. findings of fact The deputy, having heard the testimony and considered all the evidence, finds: Claimant is 51 years old. She is single and is the owner of the farm where she resides. Claimant rents the farm ground to someone who works the land. Claimant is a 1959 graduate from high school. Subsequent to her graduation, claimant worked as an assembly line worker. She commenced her employment with Farmstead Foods in 1964. She con tinued her employment until March 1, 1990. On that date, Farmstead Foods ceased doing business. During her employment period, claimant held a variety of positions. For approximately one-half of her tenure, claimant trimmed pig cheeks. She also operated the snout wheel. Both jobs involved the rapid use of her hands and arms. Defendant acknowledges that claimant sustained bilateral Page 2 carpal tunnel syndrome on March 15, 1989, and that the injury arose out of and in the course of her employment. Additionally, the Fund stipulated that the correct impairment rating equates to two percent of each upper extremity. (Joint Exhibit 1, page 8) On March 26, 1985, claimant sustained an injury to her right ankle. John Koch, M.D., opined that claimant's right knee was also affected by the ankle injury. He opined that claimant sus tained a 33 percent impairment to the right lower extremity. Defendant stipulates to this impairment rating. Also on July 21, 1987, claimant sustained an injury to her left eye. According to Winthrop S. Risk's, M.D., report of June 7, 1989, claimant has sustained a 100 percent loss to the left eye. At the time of the hearing, claimant had been working part-time at the Casey's store in Mechanicsville, Iowa. During November of 1990, claimant commenced her employment with the store. She was hired as a pizza maker. She has performed all duties with the exception of cashiering. Claimant testified that her eyesight prevented her from seeing the cash register well enough. Claimant testified she must use a magnifying glass to even read a newspaper. Claimant did not believe she could check merchandise because of her eyesight. She had been requested to train on the cash register, but claimant refused. Claimant's supervisor, Carol Myers, testified that claimant's starting wage was $4.35 per hour and that claimant worked 12-13 hours per week. Ms. Myers also testified that if claimant would check items, she could work more hours every week. Claimant has testified she is capable of driving to and from the Casey's store. She has also testified the drive is 2-3 miles. According to claimant's testimony, she has applied for sev eral positions subsequent to her employment at Casey's. One of the positions involves maintenance work at Cornell College. Claimant has not contacted the Commission for the Blind for any training or assistance. Page 3 conclusions of law Claimant alleges she is entitled to benefits from the Second Injury Fund. Section 85.64 governs Second Injury Fund liability. Before liability of the Fund is triggered, three requirements must be met. First, the employee must have lost or lost the use of a hand, arm, foot, leg or eye. Second, the employee must sustain a loss or loss of use of another specified member or organ through a compensable injury. Third, permanent disability must exist as to both the initial injury and the second injury. The Second Injury Fund Act exists to encourage the hiring of handicapped persons by making a current employer responsible only for the amount of disability related to an injury occurring while that employer employed the handicapped individual as if the indi vidual had had no preexisting disability. See Anderson v. Second Injury Fund, 262 N.W.2d 789 (Iowa 1978); Lawyer and Higgs, Iowa Workers' Compensation-Law and Practice, section 17-1. The Fund is responsible for the difference between total disability and disability for which the employer at the time of the second injury is responsible. Section 85.64. Second Injury Fund v. Neelans, 436 N.W.2d 335 (Iowa 1989); Second Injury Fund v. Mich. Coal Co., 274 N.W.2d 300 (Iowa 1970). Interest accrues on benefits the Fund pays commencing on the date of the decision. Second Injury Fund of Iowa v. Braden, 459 N.W.2d 467 (Iowa 1990). A deputy is entitled to determine the nature of claimant's injury and entitlement to compensation from the evidence pre sented, regardless of particular theories pled. Shank v. Mercy Hospital Medical Center, File No. 719627 (Appeal Decision Filed August 28, 1989). It is the determination of the undersigned that claimant has a 60 percent industrial disability. Claimant now only works 12 hours per week at minimum wage. Prior to the closing of the plant she had worked 40 hours per week at $9.84 per hour. Claimant has lost the use of one eye. She cannot perform a job where there is any reading involved. Claimant is motivated but she lacks transferable skills and training. Claimant's age is a negative factor. In the instant case, claimant has sustained three separate injuries. The first injury is to the right ankle and knee. The second injury is a total loss of the left eye. The third injury is a bilateral carpal tunnel injury. The injuries are all perma nent in nature. Section 85.64 is applicable. The following for mula is used to determine the Second Injury Fund's liability: 300 weeks - Industrial Disability from all impairments -(200 x .33 = 72.6) weeks preexisting disabilities -(140 x .100 = 140) weeks - 10 weeks amount of disability for which Page 4 _____ defendant employer was responsible 77.4 amount of weeks for which the Fund is responsible. The formula as aforementioned is computed as: 300 weeks -140 weeks - 72.6 weeks - 10 weeks 77.4 amount of weeks for which the Fund is responsible. The Fund is properly brought into this suit. order THEREFORE, IT IS ORDERED: Defendant is liable for seventy-seven point four (77.4) weeks of Fund benefits commencing on July 13, 1991, the day after the settlement agreement was filed and at the stipulated rate of two hundred thirty-seven and 70/l00 ($237.70) per week. Accrued benefits are to be paid in a lump sum together with statutory interest at the rate of ten percent (10%) per year pur suant to section 85.30, Iowa Code, as amended, and commencing on the date of the filing of this action. Costs are taxed to defendant. Defendant shall file a claim activity report as requested by this division and pursuant to rule 343 IAC 3.1. Signed and filed this ____ day of April, 1992. ______________________________ MICHELLE A. McGOVERN DEPUTY INDUSTRIAL COMMISSIONER Page 5 Copies To: Mr. James E. Shipman Attorney at Law 1200 MNB Building Cedar Rapids, Iowa 52401 Ms. Joanne Moeller Assistant Attorney General Tort Claims Division Hoover State Office Building Des Moines, Iowa 50319 5-3200; 3202 Filed April 30, 1992 MICHELLE A. McGOVERN before the iowa industrial commissioner ____________________________________________________________ : CHERYL K. GARDNER, : : File No. 917134 Claimant, : : A R B I T R A T I O N vs. : : D E C I S I O N SECOND INJURY FUND, : : Defendant. : : ___________________________________________________________ 5-3200; 3202 Claimant was entitled to Second Injury Fund benefits. BEFORE THE IOWA INDUSTRIAL COMMISSIONER ____________________________________________________________ DOROTHY HENSON, Claimant, vs. File Nos. 968594 CHAMBERLAIN MANUFACTURING 917346 CORPORATION, A R B I T R A T I O N Employer, D E C I S I O N and NATIONAL UNION FIRE INS., Insurance Carrier, Defendants. ___________________________________________________________ STATEMENT OF THE CASE These are proceedings in arbitration upon the petition of claimant, Dorothy Henson, against her employer, Chamberlain Manufacturing Corporation, and its insurance carrier, National Union Fire Insurance Company, defendants. The cases were heard on September 15, 1994 at the Pinecrest Building in Waterloo, Iowa. The record consists of the testimony of claimant. The record also consists of the testimonies of Charles Weidman, Max Hool, Christine K. Fidler and Gary Scoggin. Additionally, the record consists of certain exhibits. They are: joint exhibits 1-17 with the exception of 1-2, 1-6 and 1-7; defendants' exhibits A-C with the exception of C-5, C-18 and C-21B, and D-1, D-2, D-4, E, F, G, H, and I. The deputy industrial commissioner agreed, upon request, to take official notice of the administrative file of the Division of Industrial Services. After reviewing exhibit 20, the deputy industrial commissioner noted that the pages in the deposition were not placed in numerical sequence. The lack of organization of the deposition made it very difficult to read. The attorneys are advised to comply with paragraph 9 of the hearing assignment order. Failure to comply may result in sanctions. ISSUES The issues to be determined are: With respect to file number 917346 (the parties have stipulated that claimant sustained a work-related injury on May 16, 1989): 1) whether there is a causal relationship between the work injury and any permanent partial disability; 2) whether claimant is entitled to any temporary or permanent partial disability benefits; and, 3) whether claimant is entitled to penalty benefits pursuant to section 86.13 of the Iowa Code. With respect to file number 968594 (alleged injury date of December 10, 1990): 1) whether claimant sustained a work-related injury which arose out of and in the course of her employment; 2) whether there is a causal relationship between the work injury and any temporary or permanent partial disability; and, 3) whether claimant is entitled to any temporary or permanent partial disability benefits. FINDINGS OF FACT The deputy, having heard the testimony and considered all of the evidence, finds: Claimant is a credible witness. The undersigned deputy industrial commissioner has had ample time to observe claimant during the course of the proceedings. Claimant is a 56-year-old single woman. She obtained her GED in 1966. In 1978 claimant attended Hawkeye Technical College where she studied machine operations. From 1984-1986, claimant attended Northeast Iowa Community College where she obtained an Associate of Arts Degree in clerical skills. Then in 1992, claimant returned to Hawkeye Technical College. There she studied data entry operations. Claimant has held numerous positions throughout the course of her employment. She has worked in the bakery and restaurant business; she has worked as a bartender; and, she has been the part owner of a lounge. In 1978, claimant commenced employment with John Deere in Waterloo. There is no dispute; claimant had experienced previous injuries to her low back. The record contains evidence of back problems which date back to 1980. After each prior occurrence, claimant returned to her normal routine and activities. Claimant commenced her employment with the present defendant-employer on February 13, 1987. The parties have stipulated to the various dates of employment with this employer. Claimant's employment history is as follows: 2-13-87 date of hire 5-8-87 laid off work 10-19-87 recalled to work 2-10-89 laid off work 5-3-89 recalled to work 9-14-89 claimant returned to work per physician's release 9-15-89 laid off 8-26-90 recalled to work 8-16-91 final lay off from work Initially, claimant was hired for the "blue room" where she was assigned the task of running presses. Her duties included pushing rubber through the various presses and removing parts from the machines. Claimant was required to lift weights in excesss of 20 pounds. Later claimant was transferred to the "Chucker Department." Her job assignments included securing various parts for the equipment; checking machines; and, pushing large tubs containing parts. Claimant worked on an incentive plan. On May 16, 1989, claimant sustained an injury to her low back and left leg. At the time of the work injury, claimant was pushing a box across a conveyor line. She was standing on a platform. However, she twisted improperly and fell from the platform. Immediately after the incident occurred, claimant was escorted by a foreman from the work station and transported to the emergency room of the local hospital. Arnold E. Delbridge, M.D., treated claimant from May 24, 1989 through September 14, 1989. He released claimant to return to work on that date (Exhibit B-41, B-42). At a later point in time, Dr. Delbridge rated claimant as having a five percent permanent impairment to the body as a whole (Ex. 7-70). However, the rating was made after claimant had sustained a non-work-related injury to her neck. The neck injury was to claimant's cervical spine and was the direct result of a motor vehicle accident. The medical evidence does not support a finding that any cervical spine condition is related to claimant's employment with the present defendant-employer. John Milner-Brage, M.D., performed nerve conduction studies relative to claimant's low back injury. He noted in his report of May 31, 1989: ELECTRODIAGNOSTIC SUMMARY: Abnormal F-wave response on the left with a decreased response rate to 50%. The EMG revealed increased polyphasics at the tibialis anterior and flexor hallucis muscles. ELECTRODIAGNOSTIC IMPRESSION: Mild chronic left L5 radiculopathy. (Ex. 11-113) The evidence shows that defendants paid claimant weekly benefits for the low back injury from May 17, 1989 through July 2, 1989, and from July 10, 1989 through September 13, 1989. The total number of weeks paid is 15 weeks (Ex. H-133). Claimant testified that she sustained a work-related injury to her arms and that the injury occurred on December 10, 1990. Records kept in the regular course of business indicate the following, relative to work injuries in December of 1990: A. 12-6-90. "Contusion left index finger. Went to Dr. Tarr. Subungual hematoma. Evacuated. No lost time." (Ex. 20-12) A. 12-11-90. "W/C" stands for work comp. She went to occupational health. "Right lateral epicondylitis, left ulnar nerve impingement. Lost time." (Ex. 20-13) The administrative file at the Division of Industrial Services indicate that the following temporary total disability/healing period benefits were paid in file number 968594: 12-11-90 through 12-21-90 1-2-91 through 2-15-91 3-14-91 through 3-28-91 3-30-91 through 5-26-91 5-28-91 through 7-2-91 7-5-91 through 8-8-91 The total number of weekly benefits paid is 28.714 weeks. In January of 1991, Dr. Milner-Brage also conducted nerve studies of the left ulnar nerve. The physician authored a report following the studies. Dr. Milner-Brage opined: Mild left ulnar nerve compression at the Guyon canal (see diagram). CLINICAL DISCUSSION: This ulnar nerve compression represents a 50% conduction block of motor and sensory fibers. There is no evidence of axon loss. The site of compression is occurring at the distal wrist crease or the entrance to the Guyon canal. This injury is consistent with the activities the patient was carrying out on her job at Chamberlain. The patient should avoid all pressure over the ulnar side of the hand. She frequently pushes herself to the standing position using that side of her hand. She should use a closed fist in the future. Complete recovery should be expected and, in fact, the patient has noted improvement. She may experience increased paresthesias as the nerve block resolves. The recovery period may require an additional 6 to 8 weeks. (Ex. 11-116) Claimant sought medical treatment for her upper extremities at Allen Memorial Hospital. Kenneth McMains, M.D., diagnosed claimant as having: 1. R Lateral epicondylitis 2. L Ulnar nerve impingement syndrome (Ex. 2-11) Dr. McMains treated claimant conservatively. Claimant wore an elbow splint. The physician prescribed physical therapy and medications. He also began to treat claimant for low back pain and leg pain. As of August 12, 1991, Dr. McMains opined: 1. I believe Ms. Henson's back injury is related to her employment since she has been doing this type of work for five years, and part of that she worked at John Deere as maintenance. 2. Yes, patient was released to full activity on August 9, 1991. 3. Recommended treatment is using her non-steroidal and her Tagamet [sic] on a PRN basis. She is also to continue with her back support and flexibility exercises. 4. Yes, above. I do not, at this time, feel she has any permanent work restrictions or permanency attributed to her work injury. (Ex. 2-34) In 1991 Dr. McMains referred claimant to Jitu D. Kothari, M.D. He treated claimant for several months. Dr. Kothari opined the following with respect to claimant's condition: Work hardening progress was reviewed. She has really not made any progress with the work hardening program. She continues to have back pain and left leg pain. On the other hand, based on the present clinical findings, and her MR Scan, etc., she is not a candidate for lumbar disc surgery. Review of her history with the patient indicates that she has this recurrent problem with back pain and left leg pain since 1989, and she has lost at least 6-7 months of work on account of her back problem. Work hardening program has also not improved her symptoms. As mentioned above, in my opinion, she is not a candidate for any major lumbar back surgery. My recommendation would be that either this patient have a permanent work restriction, such as no lifting beyond 15-20 pounds and no repetitive bending, twisting and turning, if her employer is willing to work with that, or, she would benefit from Vocational Rehabilitation. She will have further follow-up with Dr. McMains. ... Letter to Crawford & company stating that this patient has 7% permanent impairment and loss of physical function of the whole body on account of persistent low back pain and left leg pain since 1989. (Ex. 9-92) Claimant also received several injections for her epicondylitis. The injections were performed by Scott Marrs, D.O. (Ex. 10-103). In November of 1991, Dr. Maars opined that claimant should be on permanent light duty work restrictions (Ex. 10-106). Also in 1991, claimant sought a medical opinion from Hosung Chung, M.D. He examined claimant on November 5, 1991. His progress note provided no specific diagnosis. Rather, he only summarized the diagnoses of several other treating physicians. His progress note contained no additional information relative to claimant's work injury (Ex. 5-51). However, Dr. Chung did issue a report on November 5, 1991. In his report, he opined: Standing posture is straight. Low back movement is not significantly limited to any direction. Romberg is absent. Hell and tip-toe walking is well performed with both feet. She can make a full squat, but she is not able to get up by herself from squat position. Paravertebral muscles are not spastic or tender on either side. Midline tenderness is present at the midlevel of the lumbar spine. No tenderness on sacroiliac joint or sciatic notch on either side. No tenderness at the coccygeal tip, either. She has genu valgum deformity of knees. Straight leg raising is probably positive at about 60 degrees on the left side. No Bonnet's phenomenon on either side. Hip flexors and knee extensors are quite strong on both side [sic], and this is rather incongruent with her difficulty in getting up from squat position. No sensory loss on either side of lower limbs. Babinski is flexor bilaterally. No ankle clonus on either side. In summary, her neurological examination shows bilateral paracervical muscular spasm and tenderness, equivocal root stretch signs at the left leg and no discernable neurological deficit on either side of upper or lower limbs. She brought a single AP view of cervical spine, which was obtained at Covenant Medical Center on August 26, 1991. It shows no obvious bony abnormality. She also brought MRI of cervical spine, which was obtained at Covenant Medical Center on September 5, 1991. It demonstrates very minimal compromise of anterior subarachnoid space at C5-6 interspace on the left side. there [sic] is no abnormality on the right side of the cervical canal at any level. Mrs. Henson stated that she had a MRI of lumbar spine, but the films are not available for my review. In essence, this lady has cervical muscular strain and mild root stretch signs at the left leg. Her difficulty in getting up from squat position is somewhat bothersome, although I am not able to elicit definitive motor weakness of the proximal muscle groups of both lower extremities on individual muscle testing. If not yet done, MRI of lumbar spine might be in order to rule out any remote possibility of root compression. However, even if the MRI does demonstrate any abnormality, I do not think her condition warrants any surgical intervention at this point of time. I would recommend continuous conservative treatment. I will send her back to your care. I thank you for your referral. (Ex. A-26, 27) In 1993 claimant had an EMG which was conducted by Thomas D. Mulakkan, M.D. The neurologist determined: THE ABOVE STUDY IS ABNORMAL AND SHOWS MILD CARPAL TUNNEL SYNDROME OF THE RIGHT HAND NO PERIPHERAL NEUROPATHY OR CERVICAL OR LUMBAR RADICULOPATHY. IF THE PATIENT IS SYMPTOMATIC, A WRIST SPLINT MAY BE USEFUL. (Ex. 16, p. 136) Claimant returned to work in August of 1991. She worked for only a few days. She was laid off on August 16, 1991. There is testimony that claimant experienced difficulties during her final week of employment. Charles Weidman, production operations manager, testified there was no light duty work available within the plant. He described the work within the plant as hard physical labor. He reported he had observed claimant working in the plant after her work injury in 1989. It was his opinion that claimant had difficulties working and making her incentive pay after her first injury. Claimant testified that as of the date of the hearing, she was still experiencing some physical problems as a result of her work injuries. She reported she is unable to stand for long periods of time. She is unable to sit for very long before her left leg becomes numb. She can walk but not for great distances. She has a burning sensation in her left leg. She avoids lifting but she is capable of carrying bags of groceries. She has difficulties sleeping as her left leg becomes numb. Since her layoff from the plant in August of 1991, claimant has exhibited a strong motivation to return to work. She enrolled and completed course work in office skills at Hawkeye Community College. She also made numerous applications for employment. In addition, claimant worked as a temporary office worker at $5.00 per hour. CONCLUSIONS OF LAW The party who would suffer loss if an issue were not established has the burden of proving that issue by a preponderance of the evidence. Iowa R. App. P. 14(f). The claimant has the burden of proving by a preponderance of the evidence that the injury is a proximate cause of the disability on which the claim is based. A cause is proximate if it is a substantial factor in bringing about the result; it need not be the only cause. A preponderance of the evidence exists when the causal connection is probable rather than merely possible. Blacksmith v. All-American, Inc., 290 N.W.2d 348 (Iowa 1980); Holmes v. Bruce Motor Freight, Inc., 215 N.W.2d 296 (Iowa 1974). The question of causal connection is essentially within the domain of expert testimony. The expert medical evidence must be considered with all other evidence introduced bearing on the causal connection between the injury and the disability. The weight to be given to any expert opinion is determined by the finder of fact and may be affected by the accuracy of the facts relied upon by the expert as well as other surrounding circumstances. The expert opinion may be accepted or rejected, in whole or in part. Sondag v. Ferris Hardware, 220 N.W.2d 903 (Iowa 1974); Anderson v. Oscar Mayer & Co., 217 N.W.2d 531 (Iowa 1974); Bodish v. Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965). There is medical evidence to support a conclusion that claimant's work injury on May 16, 1989 is causally related to a permanent disability. Two well respected physicians have rated claimant as having between a five percent to seven percent functional impairment. The opinions of the two physicians are credible. Claimant has met her burden of proof. Dr. Khotari, the treating orthopedic surgeon, issued permanent restrictions for claimant. The permanent restrictions are listed in the findings of fact and will not be reiterated again. The restrictions are quite severe. Claimant has met her burden of proof. She has sustained permanent injuries to her low back as a result of her work injury on May 16, 1989. Functional impairment is an element to be considered in determining industrial disability which is the reduction of earning capacity, but consideration must also be given to the injured employee's age, education, qualifications, experience and inability to engage in employment for which the employee is fitted. Olson v. Goodyear Serv. Stores, 255 Iowa 1112, 125 N.W.2d 251 (1963); Barton v. Nevada Poultry, 253 Iowa 285, 110 N.W.2d 660 (1961). A finding of impairment to the body as a whole found by a medical evaluator does not equate to industrial disability. Impairment and disability are not synonymous. The degree of industrial disability can be much different than the degree of impairment because industrial disability references to loss of earning capacity and impairment references to anatomical or functional abnormality or loss. Although loss of function is to be considered and disability can rarely be found without it, it is not so that a degree of industrial disability is proportionally related to a degree of impairment of bodily function. Factors to be considered in determining industrial disability include the employee's medical condition prior to the injury, immediately after the injury, and presently; the situs of the injury, its severity and the length of the healing period; the work experience of the employee prior to the injury and after the injury and the potential for rehabilitation; the employee's qualifications intellectually, emotionally and physically; earnings prior and subsequent to the injury; age; education; motivation; functional impairment as a result of the injury; and inability because of the injury to engage in employment for which the employee is fitted. Loss of earnings caused by a job transfer for reasons related to the injury is also relevant. Likewise, an employer's refusal to give any sort of work to an impaired employee may justify an award of disability. McSpadden v. Big Ben Coal Co., 288 N.W.2d 181 (Iowa 1980). These are matters which the finder of fact considers collectively in arriving at the determination of the degree of industrial disability. There are no weighting guidelines that indicate how each of the factors are to be considered. Neither does a rating of functional impairment directly correlate to a degree of industrial disability to the body as a whole. In other words, there are no formulae which can be applied and then added up to determine the degree of industrial disability. It therefore becomes necessary for the deputy or commissioner to draw upon prior experience as well as general and specialized knowledge to make the finding with regard to degree of industrial disability. See Christensen v. Hagen, Inc., Vol. 1 No. 3 State of Iowa Industrial Commissioner Decisions 529 (App. March 26, 1985); Peterson v. Truck Haven Cafe, Inc., Vol. 1 No. 3 State of Iowa Industrial Commissioner Decisions 654 (App. February 28, 1985). Compensation for permanent partial disability shall begin at the termination of the healing period. Compensation shall be paid in relation to 500 weeks as the disability bears to the body as a whole. Section 85.34. Since claimant's injury is to her low back, and the injury is permanent in nature, it is the determination of this deputy industrial commissioner that claimant is entitled to an industrial disability. Claimant, as aforementioned, has permanent restrictions placed upon her. They are severe. She is precluded from lifting more than 15-20 pounds. She is to avoid repetitive activities. While claimant had returned to work for various periods of time, she has had difficulties meeting her job quotas, and "from pulling her own load." Her difficulties were observable by her co-workers. Claimant was laid off from her job. She has never been called to return to work. Defendants have been unwilling to accommodate claimant. Claimant's age is a negative factor in finding other employment. She is 56-years-old. It is difficult for workers in her age group to find competitive employment. Claimant has made application for many office type positions. She has made every effort to seek employment. She did obtain employment at Pries Manufacturing and she admitted she voluntarily quit because the job was too strenuous for her. Claimant has persisted. She has found work as a temporary worker. However, her current wages are substantially less than what she had earned with the present defendant. All she earns now is $5.00 to $5.50 per hour. Formerly, she earned $336.59 per week. As a temporary worker, claimant has no fringe benefits. When she was employed with the present defendant, she had vacation pay and holiday pay. It is clear to this deputy that claimant has sustained not only a loss of actual earnings but she has also sustained a loss of earning capacity. It is the determination of the undersigned that claimant is entitled to a 40 percent permanent partial disability. Two hundred weeks of benefits are due to her from August 9, 1991, the date she was able to finally return to work. Her weekly benefits are payable at the stipulated rate of $204.71 per week. The next issue to address is the issue of healing period benefits. Section 85.34(1) provides that healing period benefits are payable to an injured worker who has suffered permanent partial disability until (1) the worker has returned to work; (2) the worker is medically capable of returning to substantially similar employment; or (3) the worker has achieved maximum medical recovery. The healing period can be considered the period during which there is a reasonable expectation of improvement of the disabling condition. See Armstrong Tire & Rubber Co. v. Kubli, 312 N.W.2d 60 (Iowa Ct. App. 1981). Healing period benefits can be interrupted or intermittent. Teel v. McCord, 394 N.W.2d 405 (Iowa 1986). Claimant is entitled to healing period benefits from the period of March 30, 1991 through August 8, 1991. Her low back problems at that time related to her injury in 1989. Her symptoms were the same. She was treated over a course of several months with physical therapy and work hardening with the goal of a return to work. Claimant was able to return to work. She is entitled to 18.857 weeks of healing period benefits at the stipulated rate of $204.71 per week. The final issue to address is the issue of penalty benefits pursuant to section 86.13 of the Iowa Code, as amended. Section 86.13 permits an award of up to 50 percent of the amount of benefits delayed or denied if a delay in commencement or termination of benefits occurs without reasonable or probable cause or excuse. The standard for evaluating the reasonableness of defendants' delay in commencement or termination is whether the claim is fairly debatable. Where a claim is shown to be fairly debatable, defendants do not act unreasonably in denying payment. See Stanley v. Wilson Foods Corp., File No. 753405 (App. August 23, 1990); Seydel v. Univ. of Iowa Physical Plant, File No. 818849 (App. Decn., November 1, 1989). Penalty benefits are denied in the present case since there is a fairly debatable claim. Not all of the medical providers agreed there was a permanent impairment. Claimant is not entitled to penalty benefits. The parties have stipulated to the costs of litigation. The remaining issues deal with file number 968594 The first issue to address is whether claimant sustained an injury which arose out of and in the course of her employment. The claimant has the burden of proving by a preponderance of the evidence that the alleged injury actually occurred and that it arose out of and in the course of employment. McDowell v. Town of Clarksville, 241 N.W.2d 904 (Iowa 1976); Musselman v. Cent. Tel. Co., 261 Iowa 352, 154 N.W.2d 128 (1967). The words "arising out of" refer to the cause or source of the injury. The words "in the course of" refer to the time, place and circumstances of the injury. Sheerin v. Holin Co., 380 N.W.2d 415 (Iowa 1986); McClure v. Union County, 188 N.W.2d 283 (Iowa 1971). Claimant engaged in repetitive type activities which necessitated the use of her right and left upper extremities. Her diagnoses have been vague with the exception of the right carpal tunnel syndrome. There is objective evidence to establish that she has a mild case of carpal tunnel syndrome. She has received no functional impairment ratings with respect to either upper extremity. She is restricted to permanent light duty but light duty is not defined by any medical provider. This deputy understands that "light duty work" is a nebulous phrase. It is nonspecific. It is the determination of the undersigned that claimant has sustained temporary disabilities to her left upper extremity and to her right hand and right upper extremity. She has sustained a permanent partial disability to her right wrist only. The right of an employee to receive compensation for injuries sustained is statutory. The statute conferring this right can also fix the amount of compensation payable for different specific injuries. The employee is not entitled to compensation except as the statute provides. Soukup v. Shores Co., 222 Iowa 272, 268 N.W. 598 (1936). Compensation for permanent partial disability begins at termination of the healing period. Section 85.34(2). Permanent partial disabilities are classified as either scheduled or unscheduled. A specific scheduled disability is evaluated by the functional method; the industrial method is used to evaluate an unscheduled disability. Simbro v. Delong's Sportswear, 332 N.W.2d 886 (Iowa 1983); Graves v. Eagle Iron Works, 331 N.W.2d 116 (Iowa 1983); Martin v. Skelly Oil Co., 252 Iowa 128, 106 N.W.2d 95 (1960). A wrist injury generally is an injury to the hand, not the upper extremity. The hand extends to the distal end of the radius and ulna, including the carpus or wrist. Elam v. Midland Mfg., II Iowa Industrial Commissioner Report 141 (App. 1981). It is the determination of the undersigned that claimant has sustained a one percent permanent partial disability to the hand. Under section 85.34(l). She is entitled to 19 weeks of permanent partial disability benefits at the stipulated rate of $270.05 per week. Said benefits shall commence as of April 1, 1991. This is the time when she received medical treatment for her upper extremities. Claimant is entitled to temporary total/healing period benefits for the following periods: 12-11-90 through 12-21-90 1-2-91 through 2-15-91 3-14-91 through 3-28-91. She is not entitled to temporary or healing period benefits for: 3-30-91 through 5-26-91 5-28-91 through 7-3-91 7-5-91 through 8-8-91 The above periods reflect the time claimant was in the healing period as a result of the 1989 work injury. Claimant is entitled to temporary total/healing period benefits for 10.143 weeks at the stipulated rate of $270.05 per week. With respect to this file, the parties have stipulated to the costs of the litigation. ORDER THEREFORE IT IS ORDERED: With respect to file number 917346: Defendants shall pay unto claimant two hundred (200) weeks of permanent partial disability benefits at the stipulated rate of two hundred four and 71/l00 dollars ($204.71) per week and commencing from August 9, 1991. Defendants shall also pay unto claimant eighteen point five-seven-one (18.571) weeks of healing period benefits at the stipulated rate of two hundred four and 71/l00 dollars ($204.71) per week for the following periods: 3-30-91 through 8-8-91 With respect to file number 968594: Defendants shall pay unto claimant nineteen (19) weeks of permanent partial disability benefits at the stipulated rate of two hundred seventy and 05/l00 dollars ($270.05) per week and due and payable from April 1, 1991. Defendants shall also pay unto claimant ten point one-four-three (10.143) weeks of temporary total/healing period benefits at the stipulated rate of two hundred seventy and 05/l00 dollars ($270.05) per week and due and payable for the following periods: 12-11-90 through 12-21-90 1-2-91 through 2-15-91 3-14-91 through 3-28-91. She is not entitled to temporary total disability/healing period benefits for: 3-30-91 through 5-26-91 5-28-91 through 7-3-91 7-5-91 through 8-8-91 Defendants shall take credit for all benefits previously paid to claimant. Accrued benefits are to be paid in a lump sum together with statutory interest at the rate of ten percent (10%) per year. Costs are taxed to defendants pursuant to rule 343 IAC 4.33. Defendants shall file a claim activity report as requested by this division and pursuant to rule 343 IAC 3.1. Signed and filed this ____ day of January, 1995. _____________________________ MICHELLE A. McGOVERN DEPUTY INDUSTRIAL COMMISSIONER Copies To: Mr. J. Scott Bayne Mr. Thomas L. Staack Attorneys at Law 3151 Brockway Rd PO Box 810 Waterloo IA 50704 Mr. Kevin R. Rogers Mr. Jeffrey J. Greenwood Attorneys at Law 528 W Fourth St PO Box 1200 Waterloo IA 50704 5-1800; 5-1803 Filed January 13, 1995 MICHELLE A. McGOVERN BEFORE THE IOWA INDUSTRIAL COMMISSIONER ____________________________________________________________ DOROTHY HENSON, Claimant, vs. File No. 968594 CHAMBERLAIN MANUFACTURING 917346 CORPORATION, A R B I T R A T I O N Employer, D E C I S I O N and NATIONAL UNION FIRE INS., Insurance Carrier, Defendants. ___________________________________________________________ 5-1800; 5-1803 Claimant sustained a permanent partial disability to her back in the amount of 40 percent. Claimant sustained a 1 percent permanent partial disability to her hand as a result of a right carpal tunnel injury.