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                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            TERESA CRONICAN,              :
 
                                          :
 
                 Claimant,                :
 
                                          :       File Nos. 959311
 
            vs.                           :                 959312
 
                                          :
 
            MERCY HOSPITAL,               :
 
                                          :     A R B I T R A T I O N
 
                 Employer,                :
 
                 Self-Insured,            :       D E C I S I O N
 
                 Defendant.               :
 
                                          :
 
            ___________________________________________________________
 
            
 
                              STATEMENT OF THE CASE
 
            
 
                 This case came on for hearing on January 30, 1992, at 
 
            Council Bluffs, Iowa.  This is a proceeding in arbitration 
 
            wherein claimant seeks compensation for temporary partial 
 
            disability and medical benefits and a transfer of care as a 
 
            result of alleged injuries occurring on March 16, 1989 and 
 
            September 25, 1989.  The record in the proceedings consist 
 
            of the testimony of claimant and joint exhibits 1 through 
 
            55.
 
            
 
                                      issues
 
            
 
                 The issues for resolution are:
 
            
 
                 1.  Whether claimant is entitled to temporary partial 
 
            disability benefits for the period beginning August 23, 1991 
 
            to the present;
 
            
 
                 2.  Whether claimant's temporary partial disability, 
 
            medical bills and eating disorder are causally connected to 
 
            her injuries of March 16, 1989 and/or September 25, 1989;
 
            
 
                 3.  Whether claimant is entitled to 85.27 medical 
 
            benefits.  These bills are set out in exhibits 47, 48 and 49 
 
            and are related to claimant's eating disorder.  Within this 
 
            issue is whether claimant is entitled to care and treatment 
 
            for her eating disorder and whether claimant is entitled to 
 
            have pain clinic treatment and, if authorized, whether that 
 
            pain clinic care should be transferred to the University of 
 
            Nebraska's pain management clinic at defendant's expense.  
 
            The parties agreed that if causal connection is found in 
 
            this case it would resolve the medical bills currently in 
 
            dispute.
 
            
 
                 The issue of permanency has been bifurcated.
 
            
 
                     
 
            
 
            
 
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            findings of fact
 
            
 
                 The undersigned deputy, having heard the testimony and 
 
            considered all the evidence, finds that:
 
            
 
                 Claimant is a 25-year-old high school graduate who also 
 
            has a degree in therapeutic recreation from the College of 
 
            St. Mary's.  She currently is enrolled in a dependent 
 
            counseling program at Metro Community College and is 
 
            attending the University of Nebraska, Omaha, program in 
 
            counseling.  Claimant worked part-time as a work study while 
 
            in college and later worked beginning in 1986 at Mercy 
 
            Hospital part-time.  Her position was as a recreational 
 
            therapeutic assistant working with mental health patients, 
 
            both adults and adolescents, in skilled nursing care and 
 
            chemical dependency.  Upon her graduation from the College 
 
            of St. Mary's in May of 1988, defendant employer offered 
 
            claimant a full-time job as a therapeutic recreation 
 
            specialist and claimant eventually was switched to a 
 
            certified therapeutic recreation specialist.  Her job was 
 
            primarily working with the chemically dependent among adults 
 
            and adolescents.  She related her basic duties in this 
 
            position.
 
            
 
                 Claimant recalled what happened on March 16, 1989, in 
 
            which she landed on the side of her right foot and ankle and 
 
            fell to the floor in pain.  At the time of this injury, she 
 
            was working with patients of the defendant employer playing 
 
            basketball.  She indicated she weighed approximately 135 
 
            pounds and was 5 feet 10 inches tall at that time.  Although 
 
            claimant worked the next two days, she related that her 
 
            ankle was getting worse with increasing pain and was still 
 
            swelling up.  She went to the emergency room at Mercy 
 
            Hospital in Council Bluffs.  Claimant related her medical 
 
            treatment.  She was put on crutches and therapy and 
 
            medication were prescribed.  Claimant continued to work 
 
            while on crutches but was not getting any better, so 
 
            eventually defendant employer called in an orthopedic 
 
            specialist, a Dr. Agarwal.  After reviewing the x-rays, the 
 
            doctor put claimant in a hard cast covering the edge of her 
 
            toes up to below the knee.
 
            
 
                 Claimant continued working full days.  Some time around 
 
            May of 1989, claimant saw Dr. Agarwal for the last time and 
 
            indicated she became very upset by the information the 
 
            doctor gave her.  She said he indicated to her that she 
 
            would probably never again walk normal and suggested she go 
 
            for a second opinion.  Claimant sought a second opinion from 
 
            Timothy C. Fitzgibbons, M.D., an orthopedic specialist in 
 
            Omaha, Nebraska.  She first saw Dr. Fitzgibbons around June 
 
            6, 1989.  She indicated that her right ankle and leg was 
 
            very swollen, discolored and was highly sensitive to a point 
 
            where claimant indicated even a brush such as with a piece 
 
            of paper would cause intense pain in her foot.  Claimant 
 
            indicated a series of nerve blocks was recommended as it 
 
            appeared she had a reflex sympathetic dystrophy.
 
            
 
                 Claimant testified that during this period of time from 
 
            March 16, 1989 to June 6, 1989, she was in immense pain and 
 

 
            
 
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            her eating habits changed whereby she had no appetite and 
 
            nothing sounded good to eat and they really changed after 
 
            the doctor told her she would never walk normal again in her 
 
            life.  She emphasized that she had no desire to eat and her 
 
            total concentration was trying to rehabilitate the ankle.  
 
            She indicated she was nor purging but just did not eat or 
 
            think about eating and her weight dropped approximately 15 
 
            to 20 pounds.
 
            
 
                 Claimant indicated that a Dr. Rosenberg performed three 
 
            separate series of nerve blocks on an outpatient basis at 
 
            Bergan Hospital.  She indicated the nerve blocks are a 
 
            series of shots done on three separate days and are done 
 
            toward the right side of her back, the first series being to 
 
            the mid or lower back, the second the mid-back to the hip, 
 
            and the third was an epidural block in the spine.  Claimant 
 
            related some of the problems that resulted from the shot in 
 
            her spine.  Claimant described the problem she was 
 
            continuing to have (Tr., p. 28).  Eventually, it was 
 
            suggested to the claimant that she see a nutritionist.  She 
 
            believed it was Thomas E. Connolly, M.D., that suggested it.  
 
            Claimant then was put on a calorie system that works off of 
 
            points and she had a calorie target.  She indicated that if 
 
            she did not eat as required, they would supplement her diet 
 
            with "Ensure" which is a high calorie drink that has a lot 
 
            of vitamins and minerals in it.  Claimant started drinking 
 
            this while in the hospital and her discharge from the 
 
            hospital was contingent upon her continuing to eat this and 
 
            reach a certain number of calories.
 
            
 
                 Claimant went back to see Dr. Fitzgibbons on July 10, 
 
            1989.  Claimant was asked about the notes in Dr. 
 
            Fitzgibbons' record indicating that claimant had headaches 
 
            in the past and some stress situations and had been seeing a 
 
            psychologist, apparently for stress management.  Claimant 
 
            emphasized she had never seen a psychologist before March 
 
            16, 1989, nor was she seeing one on March 16, 1989.  
 
            Claimant insisted she had no idea how Dr. Fitzgibbons got 
 
            that note in his records concerning a psychologist or stress 
 
            management.  Claimant's only explanation was that she did 
 
            take a stress management class in school and went to 
 
            workshops through her work and perhaps he might have 
 
            misunderstood or misinterpreted that (Tr., p. 34).
 
            
 
                 Claimant was working part-time from July 9 through 
 
            August 28, 1989, but was still having problems eating as she 
 
            did not have an appetite and no one was monitoring what she 
 
            was eating and she could not get herself to eat because she 
 
            hurt so much.  She was not seeing a nutritionist at that 
 
            time.
 
            
 
                 Claimant was referred to Dr. Fitzgibbons' diagnosis of 
 
            claimant having a lumbosacral strain in her low back.  
 
            Claimant did not know how that happened but indicated it 
 
            could have happened from being on crutches for so long or 
 
            the trauma from the nerve blocks.  She indicated she had not 
 
            lifted anything heavy, she was not in a car accident, nor 
 
            did she have any slips and falls during that period.
 

 
            
 
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                 On August 30, 1989, claimant had an evaluation done at 
 
            the eating disorders program at the University of Nebraska.  
 
            Claimant indicated that while in the hospital it was 
 
            suggested she was malnourished.  Claimant then had an 
 
            evaluation by a nutritionist, a therapist, a psychotherapist 
 
            and Dr. Pearson.  Claimant indicated that from August 28, 
 
            1989 until September 25, 1989, the time she hurt her back, 
 
            she had continued the outpatient therapy at the eating 
 
            disorders clinic.  Claimant indicated that she was still in 
 
            therapy at that time and was working out at the Bergan Mercy 
 
            Clinic and using a Biodex machine to strengthen her ankle, 
 
            etc. (Tr., p. 40).  She described various other exercises 
 
            and equipment she was using to help her recover from her 
 
            ankle injury.  She was back to full-time work at this point.  
 
            Claimant indicated that prior to March 16, 1989, she had 
 
            never seen a psychiatrist or a psychologist, has never been 
 
            treated on an inpatient or outpatient basis for mental 
 
            health problems of any kind, and has never been diagnosed as 
 
            having an eating disorder. She has never had any problems 
 
            with eating, refusing food or hiding food.  Claimant did say 
 
            she was in an accident when she was 15 years old but it 
 
            appears that she recovered from this and there is no residue 
 
            from this injury that has anything to do with the alleged 
 
            injuries or claimant's condition herein.
 
            
 
                 On September 25, 1989, claimant was at work and was 
 
            scheduling outside games when she bent down to pick up 
 
            equipment on defendant employer's premises.  On picking up 
 
            some metal horseshoes, she raised up and her back felt like 
 
            it ripped from the top to below the belt line on the right 
 
            side and she let go of the weights and incurred immense 
 
            pain.  She indicted she had never had this kind of back pain 
 
            before.  She indicated she could hear and feel it rip.  
 
            Claimant recalled that from September 25 (Monday), she 
 
            worked until Friday, the 29th, at which time she was really 
 
            bad when she came to work and could hardly move.  She 
 
            indicated she saw the employee health nurse who indicated 
 
            that claimant was unable to work that day and that she would 
 
            be taking that day off.
 
            
 
                 Claimant said that at that point, she was still losing 
 
            weight and was being threatened with admission.  She 
 
            indicated she was restricting and would not eat a lot.  She 
 
            indicated she was in a period of self-starvation and was in 
 
            a lot of pain.  She indicated that when she did not eat, she 
 
            did not feel the pain as much and that was the reason she 
 
            didn't eat.  She indicated that her exercising was 
 
            considered purging and that she was doing her physical 
 
            therapy.
 
            
 
                 Claimant was referred to Dr. Fitzgibbons' office notes 
 
            of October 2 that indicate they had already made 
 
            arrangements for claimant to be admitted at the University 
 
            of Nebraska Medical Center eating disorders program.  
 
            Claimant said a psychotherapist at the eating disorder 
 
            clinic by the name of Amanda made the arrangements.  
 
            Claimant went ahead and admitted herself to the eating 
 

 
            
 
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            disorders program.  She was not certain whether the workers' 
 
            compensation people knew she was doing this.  She was not 
 
            sure they knew about the eating disorder.  Claimant 
 
            continued her physical therapy while in the eating disorder 
 
            program.  She related her activity in this program and what 
 
            she did.  It was obvious she still did not want to eat.  
 
            Claimant indicated that her pain was bothering her and 
 
            indicated to them that the lower her weight was the less 
 
            pain she felt.  Claimant indicated that when she was at a 
 
            low weight she felt a sense of euphoria and it was on those 
 
            occasions that she felt good.
 
            
 
                 Claimant indicated she was an inpatient for 
 
            approximately eight weeks, being discharged around November 
 
            26, 1989.  Claimant indicated she felt her treatment was 
 
            beneficial and that she struggled a lot in treatment.  She 
 
            indicated she went back to work full-time and continued with 
 
            therapy with the disorder personnel.  Claimant indicated 
 
            that she was still in the eating disorder therapy with 
 
            Amanda in December 1989, when she walked by one of the 
 
            nutritionist offices and they asked if she had seen a 
 
            nutritionist recently.  She was set up with another 
 
            nutritionist and was placed back into the hospital around 
 
            March 12, 1990.
 
            
 
                 Claimant indicated from the first of the year 1990 to 
 
            March 12, she was working full-time but was not seeing 
 
            anybody for the back or ankle even though she was in a lot 
 
            of pain.  She indicated she had been prescribed a TENS unit 
 
            while she was in the hospital and it was beneficial.  
 
            Claimant related how painful her ankle was and that she was 
 
            frustrated with her pain cycles and her eating habits were 
 
            bad.
 
            
 
                 Claimant indicated that on March 12, 1990, she came to 
 
            the emergency room at the University of Nebraska as they 
 
            were unable to find vital signs of a pulse.  Claimant 
 
            testified that just prior to that time she was taking in way 
 
            below the 1200 calories that would be necessary for a body 
 
            to function if one was doing nothing at all.  Claimant was 
 
            then placed on a cardiac monitor at the hospital due to her 
 
            irregular heartbeat and inability to find a pulse.  Claimant 
 
            indicated she was not admitted to the eating disorder 
 
            department because she was too much of a medical risk as her 
 
            life was in danger at that time.
 
            
 
                 Claimant was in the hospital approximately a week and 
 
            she related her actions and nature of her treatment in 
 
            relation to her eating disorder at that time.  Claimant 
 
            recalled that she was down to approximately 108 pounds 
 
            around March 12, 1990.  Claimant indicated that after she 
 
            was in the cardiac section for approximately a week, she was 
 
            then sent to the eating disorder part of the hospital around 
 
            March 19, 1990, and was there approximately eight weeks 
 
            again, being discharged around May 25, 1990 (Transcript, 
 
            page 57).  Claimant indicated that her eating disorder is 
 
            cyclical in nature and the higher her pain goes the more 
 
            frustrated she gets with the pain and the less she eats.  
 

 
            
 
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            Claimant indicated that she was discharged because her 
 
            benefits ran out.  Claimant indicated that just before her 
 
            discharge they were running G.I. tests on her.  She 
 
            indicated that in order to run these tests, she was unable 
 
            to eat for twelve hours.  She indicated that as a result of 
 
            these tests, it put her back into the mold of craving and 
 
            starvation again and that she got a high from starving.  She 
 
            indicated that they made her fast for these tests.  She 
 
            related that she told them she had a desire to starve again 
 
            and to restrict and this desire came back pretty fast.  
 
            Claimant emphasized notwithstanding this, she was still 
 
            discharged on May 29, 1990.  Claimant indicated the reason 
 
            for the discharge at that time was because her insurance ran 
 
            out (Tr., p. 59).  Actually, it was because her health 
 
            insurance carrier decided her condition was work related.
 
            
 
                 At that time, claimant did not go back to work because 
 
            she was told that she was placed on leave of absence and her 
 
            position was filled by a recent graduate who had taken her 
 
            place as a temporary part time initially.  Claimant said 
 
            defendant employer made no effort to place her in a 
 
            different position even though she applied a couple of 
 
            different times.  Claimant indicated that she didn't work 
 
            the summer of 1989 but was continuing outpatient treatment 
 
            for her eating disorder.  
 
            
 
                 Claimant said she started seeing W. Michael Walsh, 
 
            M.D., an orthopedist, in September of 1990.  she indicated 
 
            the reason she went to him is that he was related more with 
 
            sports injuries.  Claimant said that Dr. Walsh was not 
 
            treating her for the eating disorder but wanted to maintain 
 
            contact with the eating disorders so that she could get 
 
            treatment in one package instead of different people doing 
 
            their own thing (Tr., p. 61).  Claimant continued treatment 
 
            with Dr. Walsh which mainly involved physical therapy and 
 
            various exercises and continued on an outpatient basis with 
 
            treatment of her eating disorder.  Claimant indicated that 
 
            Dr. Walsh recommended the pain management clinic because of 
 
            her reflex sympathetic dystrophy.
 
            
 
                 Claimant said the defendant employer or anyone through 
 
            them would approve claimant going to the pain clinic.  
 
            Claimant indicated she eventually went anyway for an 
 
            evaluation as she had been informed that if the evaluation 
 
            showed a need for such pain management, the treatment might 
 
            be okayed for workers' compensation purposes (Tr., p. 63).  
 
            Claimant's pain clinic evaluation was May 29, 1991.
 
            
 
                 On or around June 1, 1991, claimant began working 
 
            full-time at Boys Town.  She described her duties.  Around 
 
            August 23, 1991, claimant then continued working but only 
 
            part time.  Claimant understood that this would be the 
 
            situation when she took the job.  It appears that around the 
 
            fall of 1991, claimant was going to the University of 
 
            Nebraska, Omaha, and also was going to the Metro Community 
 
            College for her counselor degree taking approximately 12 to 
 
            15 hours there.  Claimant indicated that her ankle currently 
 
            hurts a lot and sometimes it is cold, sometimes warmer, and 
 

 
            
 
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            the color changes off and on.  She indicated the pain 
 
            travels up her leg and then will go down.  Her back is also 
 
            aggravated.  She indicated she received a burn as a result 
 
            of sleeping on a heating pad.  Claimant indicated her eating 
 
            disorder at this time is fluctuating.  Right now she 
 
            indicates her weight is okay but her metabolism is very low 
 
            and she is on an eating range of 17 to 20 points, 16 points 
 
            or 1200 calories being the bear minimum (Tr., p. 69).  
 
            Claimant emphasized that she would like to go to a pain 
 
            management clinic because they have more experience working 
 
            with chronic conditions and more experience working with 
 
            reflex sympathetic dystrophy.  She indicated they tried 
 
            different methods for the rehabilitation of the injury with 
 
            the ankle and the back.  She also emphasized that she wanted 
 
            to continue treating for her eating disorder even though she 
 
            understands the insurance company has currently cut that 
 
            off.
 
            
 
                 Claimant's private health insurance was paying for her 
 
            eating disorder bills but they have cut payment off as they 
 
            now feel it is a workers' compensation-related matter.  The 
 
            workers' compensation company has indicated that it is not 
 
            workers' compensation related.  It is obvious to the 
 
            undersigned that the claimant is in a situation that is 
 
            often common in which a claimant is caught between the 
 
            health insurance company and the workers' compensation 
 
            carrier or self-insured whereby they claim each other should 
 
            be paying the medical bills and as a result, claimant gets 
 
            no treatment at all unless the person can first pay out of 
 
            their own pocket, which usually is not plausible.  It would 
 
            appear in this case that it would be beneficial to the 
 
            claimant and ultimately to the other parties involved that 
 
            care continue for this claimant so that she would, in fact, 
 
            get well and not regress.
 
            
 
                 It is obvious that the defendants or other health 
 
            carriers do not see this as necessary even though in the end 
 
            it may cost one or the other substantially more than had 
 
            they taken the proper care of the claimant.  The law does 
 
            provide that one or the other would be reimbursed for any 
 
            expenses they may have paid if they had proceeded and were 
 
            later found not responsible assuming they followed the 
 
            proper procedure and legal provisions of the law.
 
            
 
                 It appears claimant is still getting treatment for her 
 
            eating disorder with Amanda, who is a psychotherapist, and 
 
            the claimant is incurring bills for this treatment.
 
            
 
                 Claimant said that she was sent by defendant to Behrouz 
 
            Rassekh, M.D., on January 2, 1992 for an evaluation and 
 
            examination of her back and ankle.  She described his 
 
            examination as to her back.  She indicated during the 
 
            examination when she was attempting to bend, the doctor 
 
            pushed her farther than she was able to go and she fell 
 
            forward as her knees gave out.  She indicated that this hurt 
 
            (Tr., p. 76, 77).  She indicated he then examined her ankle 
 
            and touched it with an instrument that looked like a tuning 
 
            fork and she had an extreme reaction regarding her right 
 

 
            
 
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            ankle bone.  She said the pain was so immense, she burst 
 
            into tears.  She asked him not to do it again and said she 
 
            pleaded with him not to touch her ankle.  She indicated she 
 
            told him she was exercising a lot and related the doctor 
 
            told her if she didn't continue exercising and using the 
 
            ankle it would fuse from lack of use and that she would lose 
 
            the use of it.  Claimant indicated that advice affected her 
 
            again very much as she was thinking she would lose the use 
 
            of her ankle.  Claimant related the nature and the time she 
 
            would do her exercises.
 
            
 
                 On cross-examination, claimant was questioned in 
 
            reference to Jerrad J. Hertzler, M.D., and his report in 
 
            which he indicated claimant had seen a psychologist or 
 
            psychiatrist before March 1989.  Claimant said that was 
 
            inaccurate.  She indicated that he asked her about stress 
 
            and she said that she had attended workshops, etc., and that 
 
            type of information on stress management (Tr., p. 85-89).
 
            
 
                 Claimant then was referred to joint exhibit 22, page 7, 
 
            in which the psychotherapist notes of Amanda indicated that 
 
            she believed claimant saw a psychiatrist or psychologist 
 
            before.  Claimant indicated she was not aware of these notes 
 
            but emphasized that she had not seen a psychologist or 
 
            psychiatrist before.
 
            
 
                 It appears to the undersigned, regarding the notes and 
 
            references on joint exhibit 7 and joint exhibit 22, page 7, 
 
            that defendant is relying upon these to try to indicate a 
 
            preexisting mental condition in the claimant prior to March 
 
            16, 1989, and that claimant's current problems and eating 
 
            disorder were preexisting conditions and not caused by any 
 
            of the alleged injuries.  Claimant then was asked on 
 
            redirect examination as to whether the notes of Dr. 
 
            Fitzgibbons concerning claimant possibly being under the 
 
            care of a psychologist or psychiatrist are correct.  
 
            Claimant said these notes are incorrect (Tr., p. 89).
 
            
 
                 Claimant indicated that the pain management program is 
 
            a four week program and understood that pursuant to her 
 
            evaluation they wanted her to go into that program (Jt. Ex. 
 
            46, p. 17).
 
            
 
                 W. Michael Walsh, M.D., an orthopedic surgeon, 
 
            testified through his deposition (Jt. Ex. 44) on November 
 
            12, 1991, that he first saw claimant on September 4, 1990, 
 
            through a referral from a workers' compensation adjuster.  
 
            He related claimant's history and complaints of pain and the 
 
            location.  It appears Dr. Walsh thought claimant had a 
 
            reflex sympathetic dystrophy of the right leg.  He described 
 
            that as an alteration of the sympathetic nerve flow into an 
 
            injured area.  He indicated these nerves control such things 
 
            as temperature and blood supply to an extremity.  He 
 
            indicated for reasons unknown the sympathetic nervousness 
 
            system gets out of whack and begins to get too much 
 
            sympathetic nerve inflow to the extremity and thus produces 
 
            this characteristic clinical syndrome that is referred to as 
 
            reflex sympathetic dystrophy.  He indicated that the biggest 
 
            tip-off is that the pain is out of proportion for the injury 
 

 
            
 
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            that was sustained. He indicated that oftentimes there are 
 
            color changes, bluishness, the skin changes, the shiny 
 
            atrophy appearance to the extremity appears, sometimes 
 
            swelling throughout the extremity or in the joints and 
 
            sometimes stiffness occurs.  He indicated that this 
 
            condition is usually triggered by trauma, but that the exact 
 
            physiologic mechanism which causes this syndrome is unknown 
 
            (Jt. Ex. 44, pp. 8 and 9).  He indicated that the way he 
 
            interprets claimant's situation is that she started out with 
 
            a sprained ankle and this ripened into a reflex sympathetic 
 
            dystrophy.
 
            
 
                 He was questioned as to claimant's back problem.  He 
 
            did say that she developed a back problem in the course of 
 
            dealing with this particular injury.  He indicated that back 
 
            pain is not a part of clinical syndrome but claimant, like 
 
            other patients with reflex sympathetic dystrophy, was 
 
            walking around in a very abnormal fashion for a prolonged 
 
            period of time and one typically sees back complaints 
 
            stemming from that (Jt. Ex. 44, p. 11).  The doctor 
 
            indicated that when he saw the claimant on October 3, 1990, 
 
            her second visit, he was going to coordinate her treatment 
 
            of the ankle with treatment of her eating disorder.  He 
 
            indicated that he was not aware of any existing literature 
 
            that would indicate that the eating disorder is a sequela of 
 
            reflex sympathetic dystrophy.
 
            
 
                 The doctor leaves the impression that he has been 
 
            trying for some time to direct claimant to a pain management 
 
            program at the University of Nebraska Medical Center and 
 
            that claimant did have the initial evaluation from the 
 
            program dated May 29, 1991.  He also indicated that he knew 
 
            the claimant had gone to have some sympathetic nerve blocks 
 
            in her leg which are also part of the treatment for reflex 
 
            sympathetic dystrophy.
 
            
 
                 The doctor reiterated that he still is of the opinion 
 
            that claimant would be a good candidate for a pain 
 
            management program (Jt. Ex. 44, p. 15).  Dr. Walsh gave 
 
            several reasons why he thinks this program would be 
 
            beneficial to the claimant, namely, but not necessarily 
 
            limited to, the fact that these programs would take a 
 
            multi-disciplinary approach in that they have anesthesi
 
            ologists, physical therapists and psychologist involved to 
 
            handle the various aspects on a unified approach in handling 
 
            this type of condition.  Dr. Walsh said that reflex 
 
            sympathetic dystrophy is curable and the cure rate is 
 
            directly related to how quickly one jumps on it.  He 
 
            indicated any delay in getting started on the program is not 
 
            in the claimant's favor.  Nerve blocks are critical as 
 
            prognostic features (Jt. 44, p. 17).  The doctor indicated 
 
            that he did not believe there is a causal connection between 
 
            claimant's reflex sympathetic dystrophy and her eating 
 
            disorder.  He indicated he wasn't aware of any connection 
 
            between those two items.
 
            
 
                 The doctor indicated that he is writing a chapter that 
 
            deals with reflex sympathetic dystrophy in relation to a 
 

 
            
 
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            sports injury book and that his article deals with the knee 
 
            cap problems.  The doctor acknowledged that it is not 
 
            predictable who is going to have reflex sympathetic 
 
            dystrophy and who isn't when there has been some type of 
 
            traumatic event that occurs before the reflex sympathetic 
 
            dystrophy.  The doctor further acknowledged that the 
 
            fraternity still has problems with not only the sympathetic 
 
            nervous system itself, but the whole nervous system and it 
 
            is still very theoretical in its basis (Jt. Ex. 14, p. 22).
 
            
 
                 Dr. Walsh indicated that claimant showed a loss of bone 
 
            mineral and that there was a remark on the osteoporosis 
 
            which showed up on claimant's x-ray.  It appears that this 
 
            is typical in reflex sympathetic dystrophy conditions.  He 
 
            indicated that the reflex sympathetic dystrophy itself is 
 
            combined to the leg and that claimant's altered gait pattern 
 
            which results from the reflex sympathetic dystrophy would be 
 
            the biochemical reason to flare up one's back or leg or any 
 
            other part of the body linked to it mechanically.  The 
 
            doctor believes this is a legitimate sequela to the reflex 
 
            sympathetic dystrophy because it alters one's gait (Jt. Ex. 
 
            44, p. 32).
 
            
 
                 Dr. Fitzgibbons' notes of October 2, 1989, indicate a 
 
            question of psychological ramifications to the claimant's 
 
            problems as well as an eating disorder.  This appears for 
 
            the first time in his notes but he does indicate that he and 
 
            other doctors earlier that summer were concerned about 
 
            claimant having anorexia (Jt. Ex. 30, p. 5).  The doctor's 
 
            notes on July 10, 1989 indicate that he felt claimant's 
 
            accident of March 16, 1989, which caused her ankle sprain 
 
            did cause her eventual secondary sympathetic dystrophy and 
 
            was the reason claimant had the spinal blocks and was the 
 
            reason claimant got spinal headaches (Jt. Ex. 30, p. 3).
 
            
 
                 Dr. Fitzgibbons' notes of October 2, 1989, reflect 
 
            claimant's additional injury in which she hurt her back 
 
            approximately one week prior (Jt. Ex. 30, p. 6).  Dr. 
 
            Fitzgibbons's notes of November 14, 1989 reflect his 
 
            frustration in which he states:  "I really think we have 
 
            just done every test possible to look at all these 
 
            ramifications of her low back pain and her reflex 
 
            sympathetic dystrophy."  He further indicated in his notes 
 
            that there was psychological ramifications on her ability to 
 
            cope with her ankle and back symptoms.  He thought the 
 
            eating disorder goes along with all of this.  His notes 
 
            reflect he told her that she would have pain every day and 
 
            she would have to learn a way to come home and handle this 
 
            pain, either with a warm tub bath, ice packs, or something.
 
            
 
                 Joint exhibit 36 is a letter from Paul H. Pearson, 
 
            M.D., professor emeritus and senior consultant, of the 
 
            eating disorders program at the University of Nebraska 
 
            Medical Center.  In his July 18, 1990 letter, he rendered an 
 
            opinion relating to the causal relationship between 
 
            claimant's work-related injury of March 16, 1989 and her 
 
            eating disorder.  He stated in part:
 
            
 
                 1. The cause(s) of anorexia nervoso and/or bulimia 
 
        
 
            
 
            
 
            Page  11
 
            
 
            
 
            
 
            
 
                    are unknown in specific.
 
            
 
                 2. The medical literature, and my own experience, 
 
                    document a causal relationship between trauma 
 
                    or illness and the subsequent development of 
 
                    the signs and/or symptoms of an eating disorder 
 
                    in some patients, i.e., to use your words, the 
 
                    injury or illness seems to "set in motion" the 
 
                    signs/symptoms of the eating disorder.
 
            
 
                 3. From my review of the medical records and the 
 
                    history I took from Teresa Cronican on August 
 
                    30, 1989, I would state that with a reasonable 
 
                    degree of medical probability Teresa Cronican's 
 
                    eating disorder was "set in motion" by the 
 
                    injury and its subsequent complications.
 
            
 
            (Jt. Ex. 36)
 
            
 
                 Joint exhibit 37 reflects a letter of April 12, 1991, 
 
            from Dr. Walsh, M.D., of the Sports Medicine Center.  On 
 
            page 3 of this exhibit, he notes that he felt the most 
 
            appropriate referral for the claimant would be the pain 
 
            management program at the University of Nebraska Medical 
 
            Center.  He also felt that some additional sympathetic 
 
            blocks in her right leg as well as addressing the 
 
            psychological component of her complaints could be tried.  
 
            He further opined that he believed claimant's work injuries 
 
            were the cause of her present physical disability (Jt. Ex. 
 
            37, p. 3).
 
            
 
                 Joint exhibit 38 is a physical therapy screening 
 
            evaluation dated May 29, 1991, in which the assessment made 
 
            by the center indicated that claimant was physically 
 
            appropriate to participate in the pain management program 
 
            and that due to the possible complications from the eating 
 
            disorder, it would be necessary for the pain program 
 
            psychologist to evaluate the feasibility of having the 
 
            claimant participate in the pain management center program.  
 
            Joint exhibit 39 is the psychological pain assessment at the 
 
            University of Nebraska Medical Center.  Joint exhibit 39, 
 
            page 6, indicates that the evaluator felt that claimant 
 
            could participate in their pain management center program or 
 
            continue to be followed by the eating disorder program at 
 
            the University of Nebraska Medical Center.
 
            
 
                 Joint exhibit 40, her discharge summary dated December 
 
            6, 1991, reflects that it was recognized some time ago 
 
            claimant would probably be a good candidate for the pain 
 
            program.  However, due to the problems with litigation and 
 
            coverage for the pain clinic, she has as of that time not 
 
            been accepted into the pain program.  She indicated she was 
 
            continuing ongoing treatment of an eating disorder at the 
 
            eating disorder program at the University of Nebraska 
 
            Medical Center.
 
            
 
                 Joint exhibit 41 is a January 3, 1992 letter written by 
 
            Dr. Rassekh, a neurologist, in which he wrote defendant's 
 
            attorney after the attorney referred the claimant to him for 
 
            an evaluation.  He indicated that the patient had a normal 
 

 
            
 
            Page  12
 
            
 
            
 
            
 
            
 
            neurological examination and he did not find any objective 
 
            findings to explain the pain of the patient.  He indicated 
 
            he believed the patient needed more psychotherapy other than 
 
            other formal surgical or medical treatment.  He indicated 
 
            the pain clinic may be more beneficial on the psychotherapy 
 
            aspect of this patient.
 
            
 
                 The parties agreed that both the March 16, 1989 and the 
 
            September 25, 1989 injuries arose out of and in the course 
 
            of claimant's employment and that there was some causal 
 
            connection as to temporary disability.
 
            
 
                 Although the defendant points to some instances in 
 
            which it believes shows claimant had psychological problems 
 
            prior to March 16, 1989, there was no indication that if, in 
 
            fact, there was some psychological problems, they were 
 
            causing claimant problems.  Claimant denies any prior 
 
            treatment or diagnosis for psychological problems prior to 
 
            March 16, 1989.  The undersigned realizes that often items 
 
            are found in a doctor's notes in which there is either an 
 
            obvious misinterpretation or misunderstanding.  The 
 
            undersigned believes that when there are possible references 
 
            where the doctor may have referred to the fact that claimant 
 
            indicated she had seen a psychologist or psychiatrist, they 
 
            are either a misunderstanding or misinterpretation of what 
 
            she told him.  Claimant has been in school and has taken 
 
            courses involving stress management, etc., and it is easy to 
 
            see where this might have been misinterpreted.  The fact is 
 
            that the undersigned sees no indication of any psychological 
 
            problems being treated or any eating disorder that the 
 
            claimant had prior to March 16, 1989.
 
            
 
                 The medical evidence clearly shows that claimant's 
 
            eating disorder began after she had her ankle injury on 
 
            March 16, 1989.  It seems undisputed that claimant has a 
 
            reflex sympathetic dystrophy condition which was caused by 
 
            her right ankle injury on March 16, 1989.
 
            
 
                 It is clear the doctors consider the causes or the 
 
            nature of the reflex sympathetic dystrophy to be somewhat a 
 
            mystery and that it has some unknown etiologies within the 
 
            medical profession.  Dr. Walsh indicated that he did not 
 
            think an eating disorder would be a sequela of reflex 
 
            sympathetic dystrophy.  Likewise, his expertise appears to 
 
            be related more to his experience with the knee and a 
 
            resulting reflex sympathetic dystrophy.  He did not 
 
            specifcially rule it out nor did he specifically say a 
 
            trauma, itself, could not trigger an eating disorder.
 
            
 
                 The undersigned finds that whether an eating disorder 
 
            is a sequela to reflex sympathetic dystrophy, it is not as 
 
            crucial to find as whether claimant's ankle injury, itself, 
 
            resulted in or triggered an eating disorder in the claimant.  
 
            In other words, did the eating disorder result from the 
 
            March 16, 1989 injury, itself, and not whether the eating 
 
            disorder resulted from the reflex sympathetic dystrophy 
 
            which resulted or was caused, itself, by the March 16, 1989 
 
            ankle injury.
 
            
 
                 The undersigned finds that claimant's eating disorder 
 

 
            
 
            Page  13
 
            
 
            
 
            
 
            
 
            is causally related to claimant's March 16, 1989 injury.  
 
            The undersigned finds that this eating disorder has been 
 
            further aggravated by claimant's work injury of September 
 
            25, 1989, in which claimant injured her lower back.  The 
 
            undersigned finds that this aggravation is a contributing 
 
            and continuing aggravation to her eating disorder and pain, 
 
            but that the eating disorder itself was triggered and 
 
            substantially caused by the March 16, 1989 right ankle and 
 
            foot injury and that said eating disorder developed 
 
            subsequent to the ankle and foot injury.  
 
            
 
                 Dr. Pearson causally connected claimant's eating 
 
            disorder to her March 16, 1989 injury.  He is an expert on 
 
            eating disorders (Jt. Ex. 36).
 
            
 
                 Dr. Walsh said that reflex sympathetic dystrophy is 
 
            curable.  He indicated the cure rate is directly related to 
 
            how quickly one jumps on it (Jt. Ex. 44, p. 17).
 
            
 
                 It is apparent to the undersigned that with the dispute 
 
            behind the scenes as to claimant's care and who was going to 
 
            pay for what, the ultimate discontinuance of at least some 
 
            payment of medical bills by the claimant's health carrier 
 
            who is alleging that the matter is now workers' 
 
            compensation, and the denial by the workers' compensation 
 
            carrier or defendant that the injury is not work related as 
 
            far as the eating disorder problem, the claimant is in 
 
            somewhat of a state of limbo and is not receiving the care 
 
            she should receive.  It is obvious that between the two 
 
            insurance entities, claimant should be getting the care to 
 
            help solve her problems which in the end is apparent, could 
 
            substantially reduce the ultimate cost to one or the other 
 
            or both.  Claimant is caught in the middle.  This conduct is 
 
            not condoned as there are procedures under the law if there 
 
            is such a dispute in which claimant could get the care she 
 
            deserves and the other entities could fight the dispute 
 
            among themselves under the proper procedure if they could 
 
            not resolve it among themselves.
 
            
 
                 The undersigned finds that claimant deserves treatment 
 
            for her eating disorder and pain management.  It appears 
 
            from Dr. Walsh that the Nebraska Medical Center Pain Clinic 
 
            is able to provide the multiplicity of disciplines to help 
 
            claimant in her total problems in both pain management and 
 
            treatment of the eating disorder.  Claimant has been treated 
 
            in the pain clinic and the undersigned finds that this 
 
            treatment and any necessary treatment for her eating 
 
            disorder should continue at defendant's expense until such 
 
            time it is apparent that no further medical treatment is 
 
            determined to be necessary by qualified confident specialist 
 
            in the area.
 
            
 
                 Claimant contends that she should be entitled to 
 
            temporary partial disability benefits from August 23, 1991 
 
            to the present, as she not reached sufficient healing 
 
            period.  Defendant contends that claimant is not entitled to 
 
            any temporary partial disability benefits from said date 
 
            because it believes claimant's problem probably involves an 
 
            eating disorder which is a preexisting condition or at least 
 

 
            
 
            Page  14
 
            
 
            
 
            
 
            
 
            the roots are preexisting, and that there is no causal 
 
            connection to claimant's eating disorder and the injuries 
 
            and it is this eating disorder that prevents claimant from 
 
            working at least full-time.
 
            
 
                 The undersigned finds that claimant is entitled to 
 
            temporary partial disability benefits beginning August 23, 
 
            1991 and continuing as long as it is medically indicated 
 
            that the claimant is not capable of returning to employment 
 
            substantially similar to the employment in which the 
 
            claimant was engaged at the time of her injury but is able 
 
            to perform other work consistent with the employee's 
 
            disability, all in accordance with Iowa Code section 
 
            85.33(2).
 
            
 
                 Regarding the 85.27 medical issue, in light of the 
 
            above findings, defendant shall pay those bills represented 
 
            by joint exhibits 47, 48 and 49.  Defendant shall also pay 
 
            for claimant's bills incurred as a result of her treatment 
 
            for her ankle and foot injury and any pain management and 
 
            eating disorder treatment.  The undersigned has already 
 
            indicated that said pain management and eating disorder 
 
            treatment should be at the University of Nebraska Medical 
 
            Center, where claimant has received some treatment in the 
 
            past and is apparently currently receiving some treatment.
 
            
 
                 Regarding claimant's September 25, 1989 injury, both 
 
            parties agreed that claimant incurred a back injury which 
 
            arose out of and in the course of her employment.  The 
 
            undersigned finds that claimant's problems resulting from 
 
            her March 16, 1989 injury are contributing and obviously are 
 
            not helping the cure or resolution of claimant's problems 
 
            resulting from her September 25, 1989 injury.  It appears to 
 
            the undersigned that with proper treatment, as has been 
 
            referred to and hereinafter ordered, it may also solve or 
 
            alleviate or decrease claimant's ultimate problems resulting 
 
            from her September 25, 1989 injury.
 
            
 
                 Since the determination of permanency is not an issue 
 
            herein in either of these injuries, and since the permanent 
 
            partial disability issue has been bifurcated, the 
 
            undersigned need not go into any further discussion or 
 
            detail regarding that issue.
 
            
 
                                conclusions of law
 
            
 
                 The claimant has the burden of proving by a 
 
            preponderance of the evidence that the injuries of March 16, 
 
            1989 and September 25, 1989 are causally related to the 
 
            disability on which she now bases her claim.  Bodish v. 
 
            Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965).  Lindahl 
 
            v. L. O. Boggs, 236 Iowa 296, 18 N.W.2d 607 (1945).  A 
 
            possibility is insufficient; a probability is necessary.  
 
            Burt v. John Deere Waterloo Tractor Works, 247 Iowa 691, 
 
            73 N.W.2d 732 (1955).  The question of causal connection is 
 
            essentially within the domain of expert testimony.  Bradshaw 
 
            v. Iowa Methodist Hospital, 251 Iowa 375, 101 N.W.2d 167 
 
            (1960). 
 
            
 
                 However, expert medical evidence must be considered 
 

 
            
 
            Page  15
 
            
 
            
 
            
 
            
 
            with all other evidence introduced bearing on the causal 
 
            connection.  Burt, 247 Iowa 691, 73 N.W.2d 732.  The opinion 
 
            of experts need not be couched in definite, positive or 
 
            unequivocal language.  Sondag v. Ferris Hardware, 220 N.W.2d 
 
            903 (Iowa 1974).  However, the expert opinion may be 
 
            accepted or rejected, in whole or in part, by the trier of 
 
            fact.  Id. at 907.  Further, the weight to be given to such 
 
            an opinion is for the finder of fact, and that may be 
 
            affected by the completeness of the premise given the expert 
 
            and other surrounding circumstances.  Bodish, 257 Iowa 516, 
 
            133 N.W.2d 867.  See also Musselman v. Central Telephone 
 
            Co., 261 Iowa 352, 154 N.W.2d 128 (1967).
 
            
 
                 Iowa Code section 85.27 provides, in part:
 
            
 
                    For purposes of this section, the employer is 
 
            obliged to furnish reasonable services and supplies to treat 
 
            an injured employee, and has the right to choose the care.  
 
            The treatment must be offered promptly and be reasonably 
 
            suited to treat the injury without undue inconvenience to 
 
            the employee.  If the employee has reason to be dissatisfied 
 
            with the care offered, the employee should communicate the 
 
            basis of such dissatisfaction to the employer, in writing if 
 
            requested, following which the employer and the employee may 
 
            agree to alternate care reasonably suited to treat the 
 
            injury.  If the employer and employee cannot agree on such 
 
            alternate care, the commissioner may, upon application and 
 
            reasonable proofs of the necessity therefor, allow and order 
 
            other care.  In an emergency, the employee may choose the 
 
            employee's care at the employer's expense, provided the 
 
            employer or the employer's agent cannot be reached 
 
            immediately.
 
            
 
                 Iowa Code section 85.33(2) provides:
 
            
 
                    "Temporary partial disability" or "temporarily, 
 
                 partially disabled" means the condition of an 
 
                 employee for whom it is medically indicated that 
 
                 the employee is not capable of returning to 
 
                 employment substantially similar to the employment 
 
                 in which the employee was engaged at the time of 
 
                 injury, but is able to perform other work 
 
                 consistent with the employee's disability.  
 
                 "Temporary partial benefits" means benefits 
 
                 payable, in lieu of temporary total disability and 
 
                 healing period benefits, to an employee because of 
 
                 the employee's temporary partial reduction in 
 
                 earning ability as a result of the employee's 
 
                 temporary partial disability.  Temporary partial 
 
                 benefits shall not be considered benefits payable 
 
                 to an employee, upon termination of temporary 
 
                 partial or temporary total disability, the healing 
 
                 period, or permanent partial disability, because 
 
                 the employee is not able to secure work paying 
 
                 weekly earnings equal to the employee's weekly 
 
                 earnings at the time of injury.
 
            
 
                 It is further concluded that:
 
            
 
                 Claimant's work injury to her right ankle and foot on 
 

 
            
 
            Page  16
 
            
 
            
 
            
 
            
 
            March 16, 1989, caused her to develop an eating disorder.
 
            
 
                 Claimant's March 16, 1989 work injury caused claimant 
 
            to incur a reflex sympathetic dystrophy in her right lower 
 
            extremity.
 
            
 
                 Claimant's work-related March 16, 1989 injury caused 
 
            claimant to incur an eating disorder which resulted in 
 
            claimant incurring a substantial amount of bills, as set out 
 
            in joint exhibits 47, 48 and 49, which are to be paid by the 
 
            defendant.
 
            
 
                 Defendant shall pay for the continuing care of the 
 
            claimant for treatment of her ankle and foot injury, 
 
            resulting eating disorder, and her reflex sympathetic 
 
            dystrophy.  This treatment would include claimant going to 
 
            the pain management center at the University of Nebraska 
 
            Medical Center to receive the multiplicity of disciplines 
 
            medically for treatment of claimant's pain management, 
 
            reflex sympathetic dystrophy, and eating disorder.
 
            
 
                 Because of claimant's March 16, 1989 work injury, 
 
            claimant is entitled to temporary partial disability 
 
            benefits beginning August 23, 1991, and continuing as long 
 
            as it is medically indicated that claimant is not capable of 
 
            returning to employment substantially similar to the 
 
            employment she was engaged at the time of her injury, but is 
 
            able to perform other work consistent with claimant's 
 
            disability.  This is all in compliance with Iowa Code 
 
            section 85.33(2).
 
            
 
                 Claimant's stipulated rate is $218.45.
 
            
 
                 Claimant's work injury of September 25, 1989, has not 
 
            resulted of itself in claimant incurring an eating disorder, 
 
            but said injury has contributed to claimant's continuing 
 
            problems originally brought about by her March 16, 1989 
 
            injury.
 
            
 
                 Claimant's current entitlement to temporary partial 
 
            disability benefits materially and substantially flow from 
 
            her March 16, 1989 injury and not from her September 25, 
 
            1989 work injury although the latter may be contributing 
 
            thereto.
 
            
 
                 Any issue of permanency has been bifurcated as to both 
 
            of the above injuries and is not being addressed herein.
 
            
 
                 Defendant shall pay claimant's mileage incurred to date 
 
            (Jt. Ex. 54) and any future mileage consistent with this 
 
            decision.
 
            
 
                           
 
            
 
            
 
            Page  17
 
            
 
            
 
            
 
            
 
            order
 
            
 
                 THEREFORE, it is ordered:
 
            
 
                 That claimant is entitled to temporary partial 
 
            disability benefits beginning August 23, 1991, and are to 
 
            continue as long as it is medically indicated that claimant 
 
            is not capable of returning to employment substantially 
 
            similar to the employment to which she was engaged at the 
 
            time of her injury but is able to perform other work 
 
            consistent with the claimant's disability, all in accordance 
 
            with Iowa Code section 85.33(2), at the stipulated rate of 
 
            two hundred eighteen and 45/100 dollars ($218.45) per week.
 
            
 
                 That defendant shall pay for all of claimant's medical 
 
            bills that are represented by joint exhibits 47, 48 and 49, 
 
            and to further pay for additional medical bills incurred as 
 
            a result of the continuing treatment of claimant, including 
 
            treatment at the University of Nebraska Medical Center pain 
 
            clinic program.  This would also involve treatment of 
 
            claimant's pain management, and eating disorder.
 
            
 
                 That defendant shall pay for claimant's mileage 
 
            incurred to date as shown on joint exhibit 54 and any future 
 
            mileage consistent with this decision.
 
            
 
                 Nothing is further ordered at this time regarding 
 
            claimant's September 25, 1989 work injury.
 
            
 
                 That defendants shall pay accrued weekly benefits in a 
 
            lump sum and shall receive credit against the award for 
 
            weekly benefits previously paid.
 
            
 
                 That defendants shall pay interest on benefits awarded 
 
            herein as set forth in Iowa Code section 85.30.
 
            
 
                 The files are to be returned to docket for the 
 
            determination of the bifurcated issue.
 
            
 
                 That defendants shall pay the costs of this action, 
 
            pursuant to rule 343 IAC 4.33.
 
            
 
                 That defendants shall file an activity report upon 
 
            payment of this award as required by this agency, pursuant 
 
            to rule 343 IAC 3.1.
 
            
 
                 Signed and filed this ____ day of February, 1992.
 
            
 
            
 
            
 
                                          ______________________________
 
                                          BERNARD J. O'MALLEY
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            
 
            Copies to:
 
            
 
            Mr Jacob John Peters
 
            Attorney at Law
 
            233 Pearl St
 

 
            
 
            Page  18
 
            
 
            
 
            
 
            
 
            P O Box 1078
 
            Council Bluffs IA 51502
 
            
 
            Mr James E Thorn
 
            Attorney at Law
 
            310 Kanesville Blvd
 
            P O Box 398
 
            Council Bluffs IA 51502
 
            
 
            
 
                 
 
            
 
 
            
 
            Page   1
 
            
 
            
 
            
 
            
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            TERESA CRONICAN,              :
 
                                          :
 
                 Claimant,                :
 
                                          :       File Nos. 959311
 
            vs.                           :                 959312
 
                                          :
 
            MERCY HOSPITAL,               :
 
                                          :     A R B I T R A T I O N
 
                 Employer,                :
 
                 Self-Insured,            :       D E C I S I O N
 
                 Defendant.               :
 
                                          :
 
            ___________________________________________________________
 
            
 
                              STATEMENT OF THE CASE
 
            
 
                 This case came on for hearing on January 30, 1992, at 
 
            Council Bluffs, Iowa.  This is a proceeding in arbitration 
 
            wherein claimant seeks compensation for temporary partial 
 
            disability and medical benefits and a transfer of care as a 
 
            result of alleged injuries occurring on March 16, 1989 and 
 
            September 25, 1989.  The record in the proceedings consist 
 
            of the testimony of claimant and joint exhibits 1 through 
 
            55.
 
            
 
                                      issues
 
            
 
                 The issues for resolution are:
 
            
 
                 1.  Whether claimant is entitled to temporary partial 
 
            disability benefits for the period beginning August 23, 1991 
 
            to the present;
 
            
 
                 2.  Whether claimant's temporary partial disability, 
 
            medical bills and eating disorder are causally connected to 
 
            her injuries of March 16, 1989 and/or September 25, 1989;
 
            
 
                 3.  Whether claimant is entitled to 85.27 medical 
 
            benefits.  These bills are set out in exhibits 47, 48 and 49 
 
            and are related to claimant's eating disorder.  Within this 
 
            issue is whether claimant is entitled to care and treatment 
 
            for her eating disorder and whether claimant is entitled to 
 
            have pain clinic treatment and, if authorized, whether that 
 
            pain clinic care should be transferred to the University of 
 
            Nebraska's pain management clinic at defendant's expense.  
 
            The parties agreed that if causal connection is found in 
 
            this case it would resolve the medical bills currently in 
 
            dispute.
 
            
 
                 The issue of permanency has been bifurcated.
 
            
 
                     
 
            
 
            
 
            Page   2
 
            
 
            
 
            
 
            
 
            findings of fact
 
            
 
                 The undersigned deputy, having heard the testimony and 
 
            considered all the evidence, finds that:
 
            
 
                 Claimant is a 25-year-old high school graduate who also 
 
            has a degree in therapeutic recreation from the College of 
 
            St. Mary's.  She currently is enrolled in a dependent 
 
            counseling program at Metro Community College and is 
 
            attending the University of Nebraska, Omaha, program in 
 
            counseling.  Claimant worked part-time as a work study while 
 
            in college and later worked beginning in 1986 at Mercy 
 
            Hospital part-time.  Her position was as a recreational 
 
            therapeutic assistant working with mental health patients, 
 
            both adults and adolescents, in skilled nursing care and 
 
            chemical dependency.  Upon her graduation from the College 
 
            of St. Mary's in May of 1988, defendant employer offered 
 
            claimant a full-time job as a therapeutic recreation 
 
            specialist and claimant eventually was switched to a 
 
            certified therapeutic recreation specialist.  Her job was 
 
            primarily working with the chemically dependent among adults 
 
            and adolescents.  She related her basic duties in this 
 
            position.
 
            
 
                 Claimant recalled what happened on March 16, 1989, in 
 
            which she landed on the side of her right foot and ankle and 
 
            fell to the floor in pain.  At the time of this injury, she 
 
            was working with patients of the defendant employer playing 
 
            basketball.  She indicated she weighed approximately 135 
 
            pounds and was 5 feet 10 inches tall at that time.  Although 
 
            claimant worked the next two days, she related that her 
 
            ankle was getting worse with increasing pain and was still 
 
            swelling up.  She went to the emergency room at Mercy 
 
            Hospital in Council Bluffs.  Claimant related her medical 
 
            treatment.  She was put on crutches and therapy and 
 
            medication were prescribed.  Claimant continued to work 
 
            while on crutches but was not getting any better, so 
 
            eventually defendant employer called in an orthopedic 
 
            specialist, a Dr. Agarwal.  After reviewing the x-rays, the 
 
            doctor put claimant in a hard cast covering the edge of her 
 
            toes up to below the knee.
 
            
 
                 Claimant continued working full days.  Some time around 
 
            May of 1989, claimant saw Dr. Agarwal for the last time and 
 
            indicated she became very upset by the information the 
 
            doctor gave her.  She said he indicated to her that she 
 
            would probably never again walk normal and suggested she go 
 
            for a second opinion.  Claimant sought a second opinion from 
 
            Timothy C. Fitzgibbons, M.D., an orthopedic specialist in 
 
            Omaha, Nebraska.  She first saw Dr. Fitzgibbons around June 
 
            6, 1989.  She indicated that her right ankle and leg was 
 
            very swollen, discolored and was highly sensitive to a point 
 
            where claimant indicated even a brush such as with a piece 
 
            of paper would cause intense pain in her foot.  Claimant 
 
            indicated a series of nerve blocks was recommended as it 
 
            appeared she had a reflex sympathetic dystrophy.
 
            
 
                 Claimant testified that during this period of time from 
 
            March 16, 1989 to June 6, 1989, she was in immense pain and 
 

 
            
 
            Page   3
 
            
 
            
 
            
 
            
 
            her eating habits changed whereby she had no appetite and 
 
            nothing sounded good to eat and they really changed after 
 
            the doctor told her she would never walk normal again in her 
 
            life.  She emphasized that she had no desire to eat and her 
 
            total concentration was trying to rehabilitate the ankle.  
 
            She indicated she was nor purging but just did not eat or 
 
            think about eating and her weight dropped approximately 15 
 
            to 20 pounds.
 
            
 
                 Claimant indicated that a Dr. Rosenberg performed three 
 
            separate series of nerve blocks on an outpatient basis at 
 
            Bergan Hospital.  She indicated the nerve blocks are a 
 
            series of shots done on three separate days and are done 
 
            toward the right side of her back, the first series being to 
 
            the mid or lower back, the second the mid-back to the hip, 
 
            and the third was an epidural block in the spine.  Claimant 
 
            related some of the problems that resulted from the shot in 
 
            her spine.  Claimant described the problem she was 
 
            continuing to have (Tr., p. 28).  Eventually, it was 
 
            suggested to the claimant that she see a nutritionist.  She 
 
            believed it was Thomas E. Connolly, M.D., that suggested it.  
 
            Claimant then was put on a calorie system that works off of 
 
            points and she had a calorie target.  She indicated that if 
 
            she did not eat as required, they would supplement her diet 
 
            with "Ensure" which is a high calorie drink that has a lot 
 
            of vitamins and minerals in it.  Claimant started drinking 
 
            this while in the hospital and her discharge from the 
 
            hospital was contingent upon her continuing to eat this and 
 
            reach a certain number of calories.
 
            
 
                 Claimant went back to see Dr. Fitzgibbons on July 10, 
 
            1989.  Claimant was asked about the notes in Dr. 
 
            Fitzgibbons' record indicating that claimant had headaches 
 
            in the past and some stress situations and had been seeing a 
 
            psychologist, apparently for stress management.  Claimant 
 
            emphasized she had never seen a psychologist before March 
 
            16, 1989, nor was she seeing one on March 16, 1989.  
 
            Claimant insisted she had no idea how Dr. Fitzgibbons got 
 
            that note in his records concerning a psychologist or stress 
 
            management.  Claimant's only explanation was that she did 
 
            take a stress management class in school and went to 
 
            workshops through her work and perhaps he might have 
 
            misunderstood or misinterpreted that (Tr., p. 34).
 
            
 
                 Claimant was working part-time from July 9 through 
 
            August 28, 1989, but was still having problems eating as she 
 
            did not have an appetite and no one was monitoring what she 
 
            was eating and she could not get herself to eat because she 
 
            hurt so much.  She was not seeing a nutritionist at that 
 
            time.
 
            
 
                 Claimant was referred to Dr. Fitzgibbons' diagnosis of 
 
            claimant having a lumbosacral strain in her low back.  
 
            Claimant did not know how that happened but indicated it 
 
            could have happened from being on crutches for so long or 
 
            the trauma from the nerve blocks.  She indicated she had not 
 
            lifted anything heavy, she was not in a car accident, nor 
 
            did she have any slips and falls during that period.
 

 
            
 
            Page   4
 
            
 
            
 
            
 
            
 
            
 
                 On August 30, 1989, claimant had an evaluation done at 
 
            the eating disorders program at the University of Nebraska.  
 
            Claimant indicated that while in the hospital it was 
 
            suggested she was malnourished.  Claimant then had an 
 
            evaluation by a nutritionist, a therapist, a psychotherapist 
 
            and Dr. Pearson.  Claimant indicated that from August 28, 
 
            1989 until September 25, 1989, the time she hurt her back, 
 
            she had continued the outpatient therapy at the eating 
 
            disorders clinic.  Claimant indicated that she was still in 
 
            therapy at that time and was working out at the Bergan Mercy 
 
            Clinic and using a Biodex machine to strengthen her ankle, 
 
            etc. (Tr., p. 40).  She described various other exercises 
 
            and equipment she was using to help her recover from her 
 
            ankle injury.  She was back to full-time work at this point.  
 
            Claimant indicated that prior to March 16, 1989, she had 
 
            never seen a psychiatrist or a psychologist, has never been 
 
            treated on an inpatient or outpatient basis for mental 
 
            health problems of any kind, and has never been diagnosed as 
 
            having an eating disorder. She has never had any problems 
 
            with eating, refusing food or hiding food.  Claimant did say 
 
            she was in an accident when she was 15 years old but it 
 
            appears that she recovered from this and there is no residue 
 
            from this injury that has anything to do with the alleged 
 
            injuries or claimant's condition herein.
 
            
 
                 On September 25, 1989, claimant was at work and was 
 
            scheduling outside games when she bent down to pick up 
 
            equipment on defendant employer's premises.  On picking up 
 
            some metal horseshoes, she raised up and her back felt like 
 
            it ripped from the top to below the belt line on the right 
 
            side and she let go of the weights and incurred immense 
 
            pain.  She indicted she had never had this kind of back pain 
 
            before.  She indicated she could hear and feel it rip.  
 
            Claimant recalled that from September 25 (Monday), she 
 
            worked until Friday, the 29th, at which time she was really 
 
            bad when she came to work and could hardly move.  She 
 
            indicated she saw the employee health nurse who indicated 
 
            that claimant was unable to work that day and that she would 
 
            be taking that day off.
 
            
 
                 Claimant said that at that point, she was still losing 
 
            weight and was being threatened with admission.  She 
 
            indicated she was restricting and would not eat a lot.  She 
 
            indicated she was in a period of self-starvation and was in 
 
            a lot of pain.  She indicated that when she did not eat, she 
 
            did not feel the pain as much and that was the reason she 
 
            didn't eat.  She indicated that her exercising was 
 
            considered purging and that she was doing her physical 
 
            therapy.
 
            
 
                 Claimant was referred to Dr. Fitzgibbons' office notes 
 
            of October 2 that indicate they had already made 
 
            arrangements for claimant to be admitted at the University 
 
            of Nebraska Medical Center eating disorders program.  
 
            Claimant said a psychotherapist at the eating disorder 
 
            clinic by the name of Amanda made the arrangements.  
 
            Claimant went ahead and admitted herself to the eating 
 

 
            
 
            Page   5
 
            
 
            
 
            
 
            
 
            disorders program.  She was not certain whether the workers' 
 
            compensation people knew she was doing this.  She was not 
 
            sure they knew about the eating disorder.  Claimant 
 
            continued her physical therapy while in the eating disorder 
 
            program.  She related her activity in this program and what 
 
            she did.  It was obvious she still did not want to eat.  
 
            Claimant indicated that her pain was bothering her and 
 
            indicated to them that the lower her weight was the less 
 
            pain she felt.  Claimant indicated that when she was at a 
 
            low weight she felt a sense of euphoria and it was on those 
 
            occasions that she felt good.
 
            
 
                 Claimant indicated she was an inpatient for 
 
            approximately eight weeks, being discharged around November 
 
            26, 1989.  Claimant indicated she felt her treatment was 
 
            beneficial and that she struggled a lot in treatment.  She 
 
            indicated she went back to work full-time and continued with 
 
            therapy with the disorder personnel.  Claimant indicated 
 
            that she was still in the eating disorder therapy with 
 
            Amanda in December 1989, when she walked by one of the 
 
            nutritionist offices and they asked if she had seen a 
 
            nutritionist recently.  She was set up with another 
 
            nutritionist and was placed back into the hospital around 
 
            March 12, 1990.
 
            
 
                 Claimant indicated from the first of the year 1990 to 
 
            March 12, she was working full-time but was not seeing 
 
            anybody for the back or ankle even though she was in a lot 
 
            of pain.  She indicated she had been prescribed a TENS unit 
 
            while she was in the hospital and it was beneficial.  
 
            Claimant related how painful her ankle was and that she was 
 
            frustrated with her pain cycles and her eating habits were 
 
            bad.
 
            
 
                 Claimant indicated that on March 12, 1990, she came to 
 
            the emergency room at the University of Nebraska as they 
 
            were unable to find vital signs of a pulse.  Claimant 
 
            testified that just prior to that time she was taking in way 
 
            below the 1200 calories that would be necessary for a body 
 
            to function if one was doing nothing at all.  Claimant was 
 
            then placed on a cardiac monitor at the hospital due to her 
 
            irregular heartbeat and inability to find a pulse.  Claimant 
 
            indicated she was not admitted to the eating disorder 
 
            department because she was too much of a medical risk as her 
 
            life was in danger at that time.
 
            
 
                 Claimant was in the hospital approximately a week and 
 
            she related her actions and nature of her treatment in 
 
            relation to her eating disorder at that time.  Claimant 
 
            recalled that she was down to approximately 108 pounds 
 
            around March 12, 1990.  Claimant indicated that after she 
 
            was in the cardiac section for approximately a week, she was 
 
            then sent to the eating disorder part of the hospital around 
 
            March 19, 1990, and was there approximately eight weeks 
 
            again, being discharged around May 25, 1990 (Transcript, 
 
            page 57).  Claimant indicated that her eating disorder is 
 
            cyclical in nature and the higher her pain goes the more 
 
            frustrated she gets with the pain and the less she eats.  
 

 
            
 
            Page   6
 
            
 
            
 
            
 
            
 
            Claimant indicated that she was discharged because her 
 
            benefits ran out.  Claimant indicated that just before her 
 
            discharge they were running G.I. tests on her.  She 
 
            indicated that in order to run these tests, she was unable 
 
            to eat for twelve hours.  She indicated that as a result of 
 
            these tests, it put her back into the mold of craving and 
 
            starvation again and that she got a high from starving.  She 
 
            indicated that they made her fast for these tests.  She 
 
            related that she told them she had a desire to starve again 
 
            and to restrict and this desire came back pretty fast.  
 
            Claimant emphasized notwithstanding this, she was still 
 
            discharged on May 29, 1990.  Claimant indicated the reason 
 
            for the discharge at that time was because her insurance ran 
 
            out (Tr., p. 59).  Actually, it was because her health 
 
            insurance carrier decided her condition was work related.
 
            
 
                 At that time, claimant did not go back to work because 
 
            she was told that she was placed on leave of absence and her 
 
            position was filled by a recent graduate who had taken her 
 
            place as a temporary part time initially.  Claimant said 
 
            defendant employer made no effort to place her in a 
 
            different position even though she applied a couple of 
 
            different times.  Claimant indicated that she didn't work 
 
            the summer of 1989 but was continuing outpatient treatment 
 
            for her eating disorder.  
 
            
 
                 Claimant said she started seeing W. Michael Walsh, 
 
            M.D., an orthopedist, in September of 1990.  she indicated 
 
            the reason she went to him is that he was related more with 
 
            sports injuries.  Claimant said that Dr. Walsh was not 
 
            treating her for the eating disorder but wanted to maintain 
 
            contact with the eating disorders so that she could get 
 
            treatment in one package instead of different people doing 
 
            their own thing (Tr., p. 61).  Claimant continued treatment 
 
            with Dr. Walsh which mainly involved physical therapy and 
 
            various exercises and continued on an outpatient basis with 
 
            treatment of her eating disorder.  Claimant indicated that 
 
            Dr. Walsh recommended the pain management clinic because of 
 
            her reflex sympathetic dystrophy.
 
            
 
                 Claimant said the defendant employer or anyone through 
 
            them would approve claimant going to the pain clinic.  
 
            Claimant indicated she eventually went anyway for an 
 
            evaluation as she had been informed that if the evaluation 
 
            showed a need for such pain management, the treatment might 
 
            be okayed for workers' compensation purposes (Tr., p. 63).  
 
            Claimant's pain clinic evaluation was May 29, 1991.
 
            
 
                 On or around June 1, 1991, claimant began working 
 
            full-time at Boys Town.  She described her duties.  Around 
 
            August 23, 1991, claimant then continued working but only 
 
            part time.  Claimant understood that this would be the 
 
            situation when she took the job.  It appears that around the 
 
            fall of 1991, claimant was going to the University of 
 
            Nebraska, Omaha, and also was going to the Metro Community 
 
            College for her counselor degree taking approximately 12 to 
 
            15 hours there.  Claimant indicated that her ankle currently 
 
            hurts a lot and sometimes it is cold, sometimes warmer, and 
 

 
            
 
            Page   7
 
            
 
            
 
            
 
            
 
            the color changes off and on.  She indicated the pain 
 
            travels up her leg and then will go down.  Her back is also 
 
            aggravated.  She indicated she received a burn as a result 
 
            of sleeping on a heating pad.  Claimant indicated her eating 
 
            disorder at this time is fluctuating.  Right now she 
 
            indicates her weight is okay but her metabolism is very low 
 
            and she is on an eating range of 17 to 20 points, 16 points 
 
            or 1200 calories being the bear minimum (Tr., p. 69).  
 
            Claimant emphasized that she would like to go to a pain 
 
            management clinic because they have more experience working 
 
            with chronic conditions and more experience working with 
 
            reflex sympathetic dystrophy.  She indicated they tried 
 
            different methods for the rehabilitation of the injury with 
 
            the ankle and the back.  She also emphasized that she wanted 
 
            to continue treating for her eating disorder even though she 
 
            understands the insurance company has currently cut that 
 
            off.
 
            
 
                 Claimant's private health insurance was paying for her 
 
            eating disorder bills but they have cut payment off as they 
 
            now feel it is a workers' compensation-related matter.  The 
 
            workers' compensation company has indicated that it is not 
 
            workers' compensation related.  It is obvious to the 
 
            undersigned that the claimant is in a situation that is 
 
            often common in which a claimant is caught between the 
 
            health insurance company and the workers' compensation 
 
            carrier or self-insured whereby they claim each other should 
 
            be paying the medical bills and as a result, claimant gets 
 
            no treatment at all unless the person can first pay out of 
 
            their own pocket, which usually is not plausible.  It would 
 
            appear in this case that it would be beneficial to the 
 
            claimant and ultimately to the other parties involved that 
 
            care continue for this claimant so that she would, in fact, 
 
            get well and not regress.
 
            
 
                 It is obvious that the defendants or other health 
 
            carriers do not see this as necessary even though in the end 
 
            it may cost one or the other substantially more than had 
 
            they taken the proper care of the claimant.  The law does 
 
            provide that one or the other would be reimbursed for any 
 
            expenses they may have paid if they had proceeded and were 
 
            later found not responsible assuming they followed the 
 
            proper procedure and legal provisions of the law.
 
            
 
                 It appears claimant is still getting treatment for her 
 
            eating disorder with Amanda, who is a psychotherapist, and 
 
            the claimant is incurring bills for this treatment.
 
            
 
                 Claimant said that she was sent by defendant to Behrouz 
 
            Rassekh, M.D., on January 2, 1992 for an evaluation and 
 
            examination of her back and ankle.  She described his 
 
            examination as to her back.  She indicated during the 
 
            examination when she was attempting to bend, the doctor 
 
            pushed her farther than she was able to go and she fell 
 
            forward as her knees gave out.  She indicated that this hurt 
 
            (Tr., p. 76, 77).  She indicated he then examined her ankle 
 
            and touched it with an instrument that looked like a tuning 
 
            fork and she had an extreme reaction regarding her right 
 

 
            
 
            Page   8
 
            
 
            
 
            
 
            
 
    1/21/2S?der were 
 
            preexisting conditions and not caused by any of the alleged 
 
            injuries.  Claimant then was asked on redirect examination 
 
            as to whether the notes of Dr. Fitzgibbons concerning 
 
            claimant possibly being under the care of a psychologist or 
 
            psychiatrist are correct.  Claimant said these notes are 
 
            incorrect (Tr., p. 89).
 
            
 
                 Claimant indicated that the pain management program is 
 
            a four week program and understood that pursuant to her 
 
            evaluation they wanted her to go into that program (Jt. Ex. 
 
            46, p. 17).
 
            
 
                 W. Michael Walsh, M.D., an orthopedic surgeon, 
 
            testified through his deposition (Jt. Ex. 44) on November 
 
            12, 1991, that he first saw claimant on September 4, 1990, 
 
            through a referral from a workers' compensation adjuster.  
 
            He related claimant's history and complaints of pain and the 
 
            location.  It appears Dr. Walsh thought claimant had a 
 
            reflex sympathetic dystrophy of the right leg.  He described 
 
            that as an alteration of the sympathetic nerve flow into an 
 
            injured area.  He indicated these nerves control such things 
 
            as temperature and blood supply to an extremity.  He 
 
            indicated for reasons unknown the sympathetic nervousness 
 
            system gets out of whack and begins to get too much 
 
            sympathetic nerve inflow to the extremity and thus produces 
 
            this characteristic clinical syndrome that is referred to as 
 
            reflex sympathetic dystrophy.  He indicated that the biggest 
 
            tip-off is that the pain is out of proportion for the injury 
 

 
            
 
            Page   9
 
            
 
            
 
            
 
            
 
            that was sustained. He indicated that oftentimes there are 
 
            color changes, bluishness, the skin changes, the shiny 
 
            atrophy appearance to the extremity appears, sometimes 
 
            swelling throughout the extremity or in the joints and 
 
            sometimes stiffness occurs.  He indicated that this 
 
            condition is usually triggered by trauma, but that the exact 
 
            physiologic mechanism which causes this syndrome is unknown 
 
            (Jt. Ex. 44, pp. 8 and 9).  He indicated that the way he 
 
            interprets claimant's situation is that she started out with 
 
            a sprained ankle and this ripened into a reflex sympathetic 
 
            dystrophy.
 
            
 
                 He was questioned as to claimant's back problem.  He 
 
            did say that she developed a back problem in the course of 
 
            dealing with this particular injury.  He indicated that back 
 
            pain is not a part of clinical syndrome but claimant, like 
 
            other patients with reflex sympathetic dystrophy, was 
 
            walking around in a very abnormal fashion for a prolonged 
 
            period of time and one typically sees back complaints 
 
            stemming from that (Jt. Ex. 44, p. 11).  The doctor 
 
            indicated that when he saw the claimant on October 3, 1990, 
 
            her second visit, he was going to coordinate her treatment 
 
            of the ankle with treatment of her eating disorder.  He 
 
            indicated that he was not aware of any existing literature 
 
            that would indicate that the eating disorder is a sequela of 
 
            reflex sympathetic dystrophy.
 
            
 
                 The doctor leaves the impression that he has been 
 
            trying for some time to direct claimant to a pain management 
 
            program at the University of Nebraska Medical Center and 
 
            that claimant did have the initial evaluation from the 
 
            program dated May 29, 1991.  He also indicated that he knew 
 
            the claimant had gone to have some sympathetic nerve blocks 
 
            in her leg which are also part of the treatment for reflex 
 
            sympathetic dystrophy.
 
            
 
                 The doctor reiterated that he still is of the opinion 
 
            that claimant would be a good candidate for a pain 
 
            management program (Jt. Ex. 44, p. 15).  Dr. Walsh gave 
 
            several reasons why he thinks this program would be 
 
            beneficial to the claimant, namely, but not necessarily 
 
            limited to, the fact that these programs would take a 
 
            multi-disciplinary approach in that they have anesthesi
 
            ologists, physical therapists and psychologist involved to 
 
            handle the various aspects on a unified approach in handling 
 
            this type of condition.  Dr. Walsh said that reflex 
 
            sympathetic dystrophy is curable and the cure rate is 
 
            directly related to how quickly one jumps on it.  He 
 
            indicated any delay in getting started on the program is not 
 
            in the claimant's favor.  Nerve blocks are critical as 
 
            prognostic features (Jt. 44, p. 17).  The doctor indicated 
 
            that he did not believe there is a causal connection between 
 
            claimant's reflex sympathetic dystrophy and her eating 
 
            disorder.  He indicated he wasn't aware of any connection 
 
            between those two items.
 
            
 
                 The doctor indicated that he is writing a chapter that 
 
            deals with reflex sympathetic dystrophy in relation to a 
 

 
            
 
            Page  10
 
            
 
            
 
            
 
            
 
            sports injury book and that his article deals with the knee 
 
            cap problems.  The doctor acknowledged that it is not 
 
            predictable who is going to have reflex sympathetic 
 
            dystrophy and who isn't when there has been some type of 
 
            traumatic event that occurs before the reflex sympathetic 
 
            dystrophy.  The doctor further acknowledged that the 
 
            fraternity still has problems with not only the sympathetic 
 
            nervous system itself, but the whole nervous system and it 
 
            is still very theoretical in its basis (Jt. Ex. 14, p. 22).
 
            
 
                 Dr. Walsh indicated that claimant showed a loss of bone 
 
            mineral and that there was a remark on the osteoporosis 
 
            which showed up on claimant's x-ray.  It appears that this 
 
            is typical in reflex sympathetic dystrophy conditions.  He 
 
            indicated that the reflex sympathetic dystrophy itself is 
 
            combined to the leg and that claimant's altered gait pattern 
 
            which results from the reflex sympathetic dystrophy would be 
 
            the biochemical reason to flare up one's back or leg or any 
 
            other part of the body linked to it mechanically.  The 
 
            doctor believes this is a legitimate sequela to the reflex 
 
            sympathetic dystrophy because it alters one's gait (Jt. Ex. 
 
            44, p. 32).
 
            
 
                 Dr. Fitzgibbons' notes of October 2, 1989, indicate a 
 
            question of psychological ramifications to the claimant's 
 
            problems as well as an eating disorder.  This appears for 
 
            the first time in his notes but he does indicate that he and 
 
            other doctors earlier that summer were concerned about 
 
            claimant having anorexia (Jt. Ex. 30, p. 5).  The doctor's 
 
            notes on July 10, 1989 indicate that he felt claimant's 
 
            accident of March 16, 1989, which caused her ankle sprain 
 
            did cause her eventual secondary sympathetic dystrophy and 
 
            was the reason claimant had the spinal blocks and was the 
 
            reason claimant got spinal headaches (Jt. Ex. 30, p. 3).
 
            
 
                 Dr. Fitzgibbons' notes of October 2, 1989, reflect 
 
            claimant's additional injury in which she hurt her back 
 
            approximately one week prior (Jt. Ex. 30, p. 6).  Dr. 
 
            Fitzgibbons's notes of November 14, 1989 reflect his 
 
            frustration in which he states:  "I really think we have 
 
            just done every test possible to look at all these 
 
            ramifications of her low back pain and her reflex 
 
            sympathetic dystrophy."  He further indicated in his notes 
 
            that there was psychological ramifications on her ability to 
 
            cope with her ankle and back symptoms.  He thought the 
 
            eating disorder goes along with all of this.  His notes 
 
            reflect he told her that she would have pain every day and 
 
            she would have to learn a way to come home and handle this 
 
            pain, either with a warm tub bath, ice packs, or something.
 
            
 
                 Joint exhibit 36 is a letter from Paul H. Pearson, 
 
            M.D., professor emeritus and senior consultant, of the 
 
            eating disorders program at the University of Nebraska 
 
            Medical Center.  In his July 18, 1990 letter, he rendered an 
 
            opinion relating to the causal relationship between 
 
            claimant's work-related injury of March 16, 1989 and her 
 
            eating disorder.  He stated in part:
 
            
 
                 1. The cause(s) of anorexia nervoso and/or bulimia 
 
        
 
            
 
            
 
            Page  11
 
            
 
            
 
            
 
            
 
                    are unknown in specific.
 
            
 
                 2. The medical literature, and my own experience, 
 
                    document a causal relationship between trauma 
 
                    or illness and the subsequent development of 
 
                    the signs and/or symptoms of an eating disorder 
 
                    in some patients, i.e., to use your words, the 
 
                    injury or illness seems to "set in motion" the 
 
                    signs/symptoms of the eating disorder.
 
            
 
                 3. From my review of the medical records and the 
 
                    history I took from Teresa Cronican on August 
 
                    30, 1989, I would state that with a reasonable 
 
                    degree of medical probability Teresa Cronican's 
 
                    eating disorder was "set in motion" by the 
 
                    injury and its subsequent complications.
 
            
 
            (Jt. Ex. 36)
 
            
 
                 Joint exhibit 37 reflects a letter of April 12, 1991, 
 
            from Dr. Walsh, M.D., of the Sports Medicine Center.  On 
 
            page 3 of this exhibit, he notes that he felt the most 
 
            appropriate referral for the claimant would be the pain 
 
            management program at the University of Nebraska Medical 
 
            Center.  He also felt that some additional sympathetic 
 
            blocks in her right leg as well as addressing the 
 
            psychological component of her complaints could be tried.  
 
            He further opined that he believed claimant's work injuries 
 
            were the cause of her present physical disability (Jt. Ex. 
 
            37, p. 3).
 
            
 
                 Joint exhibit 38 is a physical therapy screening 
 
            evaluation dated May 29, 1991, in which the assessment made 
 
            by the center indicated that claimant was physically 
 
            appropriate to participate in the pain management program 
 
            and that due to the possible complications from the eating 
 
            disorder, it would be necessary for the pain program 
 
            psychologist to evaluate the feasibility of having the 
 
            claimant participate in the pain management center program.  
 
            Joint exhibit 39 is the psychological pain assessment at the 
 
            University of Nebraska Medical Center.  Joint exhibit 39, 
 
            page 6, indicates that the evaluator felt that claimant 
 
            could participate in their pain management center program or 
 
            continue to be followed by the eating disorder program at 
 
            the University of Nebraska Medical Center.
 
            
 
                 Joint exhibit 40, her discharge summary dated December 
 
            6, 1991, reflects that it was recognized some time ago 
 
            claimant would probably be a good candidate for the pain 
 
            program.  However, due to the problems with litigation and 
 
            coverage for the pain clinic, she has as of that time not 
 
            been accepted into the pain program.  She indicated she was 
 
            continuing ongoing treatment of an eating disorder at the 
 
            eating disorder program at the University of Nebraska 
 
            Medical Center.
 
            
 
                 Joint exhibit 41 is a January 3, 1992 letter written by 
 
            Dr. Rassekh, a neurologist, in which he wrote defendant's 
 
            attorney after the attorney referred the claimant to him for 
 
            an evaluation.  He indicated that the patient had a normal 
 

 
            
 
            Page  12
 
            
 
            
 
            
 
            
 
            neurological examination and he did not find any objective 
 
            findings to explain the pain of the patient.  He indicated 
 
            he believed the patient needed more psychotherapy other than 
 
            other formal surgical or medical treatment.  He indicated 
 
            the pain clinic may be more beneficial on the psychotherapy 
 
            aspect of this patient.
 
            
 
                 The parties agreed that both the March 16, 1989 and the 
 
            September 25, 1989 injuries arose out of and in the course 
 
            of claimant's employment and that there was some causal 
 
            connection as to temporary disability.
 
            
 
                 Although the defendant points to some instances in 
 
            which it believes shows claimant had psychological problems 
 
            prior to March 16, 1989, there was no indication that if, in 
 
            fact, there was some psychological problems, they were 
 
            causing claimant problems.  Claimant denies any prior 
 
            treatment or diagnosis for psychological problems prior to 
 
            March 16, 1989.  The undersigned realizes that often items 
 
            are found in a doctor's notes in which there is either an 
 
            obvious misinterpretation or misunderstanding.  The 
 
            undersigned believes that when there are possible references 
 
            where the doctor may have referred to the fact that claimant 
 
            indicated she had seen a psychologist or psychiatrist, they 
 
            are either a misunderstanding or misinterpretation of what 
 
            she told him.  Claimant has been in school and has taken 
 
            courses involving stress management, etc., and it is easy to 
 
            see where this might have been misinterpreted.  The fact is 
 
            that the undersigned sees no indication of any psychological 
 
            problems being treated or any eating disorder that the 
 
            claimant had prior to March 16, 1989.
 
            
 
                 The medical evidence clearly shows that claimant's 
 
            eating disorder began after she had her ankle injury on 
 
            March 16, 1989.  It seems undisputed that claimant has a 
 
            reflex sympathetic dystrophy condition which was caused by 
 
            her right ankle injury on March 16, 1989.
 
            
 
                 It is clear the doctors consider the causes or the 
 
            nature of the reflex sympathetic dystrophy to be somewhat a 
 
            mystery and that it has some unknown etiologies within the 
 
            medical profession.  Dr. Walsh indicated that he did not 
 
            think an eating disorder would be a sequela of reflex 
 
            sympathetic dystrophy.  Likewise, his expertise appears to 
 
            be related more to his experience with the knee and a 
 
            resulting reflex sympathetic dystrophy.  He did not 
 
            specifcially rule it out nor did he specifically say a 
 
            trauma, itself, could not trigger an eating disorder.
 
            
 
                 The undersigned finds that whether an eating disorder 
 
            is a sequela to reflex sympathetic dystrophy, it is not as 
 
            crucial to find as whether claimant's ankle injury, itself, 
 
            resulted in or triggered an eating disorder in the claimant.  
 
            In other words, did the eating disorder result from the 
 
            March 16, 1989 injury, itself, and not whether the eating 
 
            disorder resulted from the reflex sympathetic dystrophy 
 
            which resulted or was caused, itself, by the March 16, 1989 
 
            ankle injury.
 
            
 
                 The undersigned finds that claimant's eating disorder 
 

 
            
 
            Page  13
 
            
 
            
 
            
 
            
 
            is causally related to claimant's March 16, 1989 injury.  
 
            The undersigned finds that this eating disorder has been 
 
            further aggravated by claimant's work injury of September 
 
            25, 1989, in which claimant injured her lower back.  The 
 
            undersigned finds that this aggravation is a contributing 
 
            and continuing aggravation to her eating disorder and pain, 
 
            but that the eating disorder itself was triggered and 
 
            substantially caused by the March 16, 1989 right ankle and 
 
            foot injury and that said eating disorder developed 
 
            subsequent to the ankle and foot injury.  
 
            
 
                 Dr. Pearson causally connected claimant's eating 
 
            disorder to her March 16, 1989 injury.  He is an expert on 
 
            eating disorders (Jt. Ex. 36).
 
            
 
                 Dr. Walsh said that reflex sympathetic dystrophy is 
 
            curable.  He indicated the cure rate is directly related to 
 
            how quickly one jumps on it (Jt. Ex. 44, p. 17).
 
            
 
                 It is apparent to the undersigned that with the dispute 
 
            behind the scenes as to claimant's care and who was going to 
 
            pay for what, the ultimate discontinuance of at least some 
 
            payment of medical bills by the claimant's health carrier 
 
            who is alleging that the matter is now workers' 
 
            compensation, and the denial by the workers' compensation 
 
            carrier or defendant that the injury is not work related as 
 
            far as the eating disorder problem, the claimant is in 
 
            somewhat of a state of limbo and is not receiving the care 
 
            she should receive.  It is obvious that between the two 
 
            insurance entities, claimant should be getting the care to 
 
            help solve her problems which in the end is apparent, could 
 
            substantially reduce the ultimate cost to one or the other 
 
            or both.  Claimant is caught in the middle.  This conduct is 
 
            not condoned as there are procedures under the law if there 
 
            is such a dispute in which claimant could get the care she 
 
            deserves and the other entities could fight the dispute 
 
            among themselves under the proper procedure if they could 
 
            not resolve it among themselves.
 
            
 
                 The undersigned finds that claimant deserves treatment 
 
            for her eating disorder and pain management.  It appears 
 
            from Dr. Walsh that the Nebraska Medical Center Pain Clinic 
 
            is able to provide the multiplicity of disciplines to help 
 
            claimant in her total problems in both pain management and 
 
            treatment of the eating disorder.  Claimant has been treated 
 
            in the pain clinic and the undersigned finds that this 
 
            treatment and any necessary treatment for her eating 
 
            disorder should continue at defendant's expense until such 
 
            time it is apparent that no further medical treatment is 
 
            determined to be necessary by qualified confident specialist 
 
            in the area.
 
            
 
                 Claimant contends that she should be entitled to 
 
            temporary partial disability benefits from August 23, 1991 
 
            to the present, as she not reached sufficient healing 
 
            period.  Defendant contends that claimant is not entitled to 
 
            any temporary partial disability benefits from said date 
 
            because it believes claimant's problem probably involves an 
 
            eating disorder which is a preexisting condition or at least 
 

 
            
 
            Page  14
 
            
 
            
 
            
 
            
 
            the roots are preexisting, and that there is no causal 
 
            connection to claimant's eating disorder and the injuries 
 
            and it is this eating disorder that prevents claimant from 
 
            working at least full-time.
 
            
 
                 The undersigned finds that claimant is entitled to 
 
            temporary partial disability benefits beginning August 23, 
 
            1991 and continuing as long as it is medically indicated 
 
            that the claimant is not capable of returning to employment 
 
            substantially similar to the employment in which the 
 
            claimant was engaged at the time of her injury but is able 
 
            to perform other work consistent with the employee's 
 
            disability, all in accordance with Iowa Code section 
 
            85.33(2).
 
            
 
                 Regarding the 85.27 medical issue, in light of the 
 
            above findings, defendant shall pay those bills represented 
 
            by joint exhibits 47, 48 and 49.  Defendant shall also pay 
 
            for claimant's bills incurred as a result of her treatment 
 
            for her ankle and foot injury and any pain management and 
 
            eating disorder treatment.  The undersigned has already 
 
            indicated that said pain management and eating disorder 
 
            treatment should be at the University of Nebraska Medical 
 
            Center, where claimant has received some treatment in the 
 
            past and is apparently currently receiving some treatment.
 
            
 
                 Regarding claimant's September 25, 1989 injury, both 
 
            parties agreed that claimant incurred a back injury which 
 
            arose out of and in the course of her employment.  The 
 
            undersigned finds that claimant's problems resulting from 
 
            her March 16, 1989 injury are contributing and obviously are 
 
            not helping the cure or resolution of claimant's problems 
 
            resulting from her September 25, 1989 injury.  It appears to 
 
            the undersigned that with proper treatment, as has been 
 
            referred to and hereinafter ordered, it may also solve or 
 
            alleviate or decrease claimant's ultimate problems resulting 
 
            from her September 25, 1989 injury.
 
            
 
                 Since the determination of permanency is not an issue 
 
            herein in either of these injuries, and since the permanent 
 
            partial disability issue has been bifurcated, the 
 
            undersigned need not go into any further discussion or 
 
            detail regarding that issue.
 
            
 
                                conclusions of law
 
            
 
                 The claimant has the burden of proving by a 
 
            preponderance of the evidence that the injuries of March 16, 
 
            1989 and September 25, 1989 are causally related to the 
 
            disability on which she now bases her claim.  Bodish v. 
 
            Fischer, Inc., 257 Iowa 516, 133 N.W.2d 867 (1965).  Lindahl 
 
            v. L. O. Boggs, 236 Iowa 296, 18 N.W.2d 607 (1945).  A 
 
            possibility is insufficient; a probability is necessary.  
 
            Burt v. John Deere Waterloo Tractor Works, 247 Iowa 691, 
 
            73 N.W.2d 732 (1955).  The question of causal connection is 
 
            essentially within the domain of expert testimony.  Bradshaw 
 
            v. Iowa Methodist Hospital, 251 Iowa 375, 101 N.W.2d 167 
 
            (1960). 
 
            
 
                 However, expert medical evidence must be considered 
 

 
            
 
            Page  15
 
            
 
            
 
            
 
            
 
            with all other evidence introduced bearing on the causal 
 
            connection.  Burt, 247 Iowa 691, 73 N.W.2d 732.  The opinion 
 
            of experts need not be couched in definite, positive or 
 
            unequivocal language.  Sondag v. Ferris Hardware, 220 N.W.2d 
 
            903 (Iowa 1974).  However, the expert opinion may be 
 
            accepted or rejected, in whole or in part, by the trier of 
 
            fact.  Id. at 907.  Further, the weight to be given to such 
 
            an opinion is for the finder of fact, and that may be 
 
            affected by the completeness of the premise given the expert 
 
            and other surrounding circumstances.  Bodish, 257 Iowa 516, 
 
            133 N.W.2d 867.  See also Musselman v. Central Telephone 
 
            Co., 261 Iowa 352, 154 N.W.2d 128 (1967).
 
            
 
                 Iowa Code section 85.27 provides, in part:
 
            
 
                    For purposes of this section, the employer is 
 
            obliged to furnish reasonable services and supplies to treat 
 
            an injured employee, and has the right to choose the care.  
 
            The treatment must be offered promptly and be reasonably 
 
            suited to treat the injury without undue inconvenience to 
 
            the employee.  If the employee has reason to be dissatisfied 
 
            with the care offered, the employee should communicate the 
 
            basis of such dissatisfaction to the employer, in writing if 
 
            requested, following which the employer and the employee may 
 
            agree to alternate care reasonably suited to treat the 
 
            injury.  If the employer and employee cannot agree on such 
 
            alternate care, the commissioner may, upon application and 
 
            reasonable proofs of the necessity therefor, allow and order 
 
            other care.  In an emergency, the employee may choose the 
 
            employee's care at the employer's expense, provided the 
 
            employer or the employer's agent cannot be reached 
 
            immediately.
 
            
 
                 Iowa Code section 85.33(2) provides:
 
            
 
                    "Temporary partial disability" or "temporarily, 
 
                 partially disabled" means the condition of an 
 
                 employee for whom it is medically indicated that 
 
                 the employee is not capable of returning to 
 
                 employment substantially similar to the employment 
 
                 in which the employee was engaged at the time of 
 
                 injury, but is able to perform other work 
 
                 consistent with the employee's disability.  
 
                 "Temporary partial benefits" means benefits 
 
                 payable, in lieu of temporary total disability and 
 
                 healing period benefits, to an employee because of 
 
                 the employee's temporary partial reduction in 
 
                 earning ability as a result of the employee's 
 
                 temporary partial disability.  Temporary partial 
 
                 benefits shall not be considered benefits payable 
 
                 to an employee, upon termination of temporary 
 
                 partial or temporary total disability, the healing 
 
                 period, or permanent partial disability, because 
 
                 the employee is not able to secure work paying 
 
                 weekly earnings equal to the employee's weekly 
 
                 earnings at the time of injury.
 
            
 
                 It is further concluded that:
 
            
 
                 Claimant's work injury to her right ankle and foot on 
 

 
            
 
            Page  16
 
            
 
            
 
            
 
            
 
            March 16, 1989, caused her to develop an eating disorder.
 
            
 
                 Claimant's March 16, 1989 work injury caused claimant 
 
            to incur a reflex sympathetic dystrophy in her right lower 
 
            extremity.
 
            
 
                 Claimant's work-related March 16, 1989 injury caused 
 
            claimant to incur an eating disorder which resulted in 
 
            claimant incurring a substantial amount of bills, as set out 
 
            in joint exhibits 47, 48 and 49, which are to be paid by the 
 
            defendant.
 
            
 
                 Defendant shall pay for the continuing care of the 
 
            claimant for treatment of her ankle and foot injury, 
 
            resulting eating disorder, and her reflex sympathetic 
 
            dystrophy.  This treatment would include claimant going to 
 
            the pain management center at the University of Nebraska 
 
            Medical Center to receive the multiplicity of disciplines 
 
            medically for treatment of claimant's pain management, 
 
            reflex sympathetic dystrophy, and eating disorder.
 
            
 
                 Because of claimant's March 16, 1989 work injury, 
 
            claimant is entitled to temporary partial disability 
 
            benefits beginning August 23, 1991, and continuing as long 
 
            as it is medically indicated that claimant is not capable of 
 
            returning to employment substantially similar to the 
 
            employment she was engaged at the time of her injury, but is 
 
            able to perform other work consistent with claimant's 
 
            disability.  This is all in compliance with Iowa Code 
 
            section 85.33(2).
 
            
 
                 Claimant's stipulated rate is $218.45.
 
            
 
                 Claimant's work injury of September 25, 1989, has not 
 
            resulted of itself in claimant incurring an eating disorder, 
 
            but said injury has contributed to claimant's continuing 
 
            problems originally brought about by her March 16, 1989 
 
            injury.
 
            
 
                 Claimant's current entitlement to temporary partial 
 
            disability benefits materially and substantially flow from 
 
            her March 16, 1989 injury and not from her September 25, 
 
            1989 work injury although the latter may be contributing 
 
            thereto.
 
            
 
                 Any issue of permanency has been bifurcated as to both 
 
            of the above injuries and is not being addressed herein.
 
            
 
                 Defendant shall pay claimant's mileage incurred to date 
 
            (Jt. Ex. 54) and any future mileage consistent with this 
 
            decision.
 
            
 
                           
 
            
 
            
 
            Page  17
 
            
 
            
 
            
 
            
 
            order
 
            
 
                 THEREFORE, it is ordered:
 
            
 
                 That claimant is entitled to temporary partial 
 
            disability benefits beginning August 23, 1991, and are to 
 
            continue as long as it is medically indicated that claimant 
 
            is not capable of returning to employment substantially 
 
            similar to the employment to which she was engaged at the 
 
            time of her injury but is able to perform other work 
 
            consistent with the claimant's disability, all in accordance 
 
            with Iowa Code section 85.33(2), at the stipulated rate of 
 
            two hundred eighteen and 45/100 dollars ($218.45) per week.
 
            
 
                 That defendant shall pay for all of claimant's medical 
 
            bills that are represented by joint exhibits 47, 48 and 49, 
 
            and to further pay for additional medical bills incurred as 
 
            a result of the continuing treatment of claimant, including 
 
            treatment at the University of Nebraska Medical Center pain 
 
            clinic program.  This would also involve treatment of 
 
            claimant's pain management, and eating disorder.
 
            
 
                 That defendant shall pay for claimant's mileage 
 
            incurred to date as shown on joint exhibit 54 and any future 
 
            mileage consistent with this decision.
 
            
 
                 Nothing is further ordered at this time regarding 
 
            claimant's September 25, 1989 work injury.
 
            
 
                 That defendants shall pay accrued weekly benefits in a 
 
            lump sum and shall receive credit against the award for 
 
            weekly benefits previously paid.
 
            
 
                 That defendants shall pay interest on benefits awarded 
 
            herein as set forth in Iowa Code section 85.30.
 
            
 
                 The files are to be returned to docket for the 
 
            determination of the bifurcated issue.
 
            
 
                 That defendants shall pay the costs of this action, 
 
            pursuant to rule 343 IAC 4.33.
 
            
 
                 That defendants shall file an activity report upon 
 
            payment of this award as required by this agency, pursuant 
 
            to rule 343 IAC 3.1.
 
            
 
                 Signed and filed this ____ day of February, 1992.
 
            
 
            
 
            
 
                                          ______________________________
 
                                          BERNARD J. O'MALLEY
 
                                          DEPUTY INDUSTRIAL COMMISSIONER
 
            
 
            
 
            Copies to:
 
            
 
            Mr Jacob John Peters
 
            Attorney at Law
 
            233 Pearl St
 

 
            
 
            Page  18
 
            
 
            
 
            
 
            
 
            P O Box 1078
 
            Council Bluffs IA 51502
 
            
 
            Mr James E Thorn
 
            Attorney at Law
 
            310 Kanesville Blvd
 
            P O Box 398
 
            Council Bluffs IA 51502
 
            
 
            
 
                 
 
            
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                                          1108; 1801.1; 2500
 
                                          Filed February 14, 1992
 
                                          Bernard J. O'Malley
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            TERESA CRONICAN,              :
 
                                          :
 
                 Claimant,                :
 
                                          :       File Nos. 959311
 
            vs.                           :                 959312
 
                                          :
 
            MERCY HOSPITAL,               :
 
                                          :     A R B I T R A T I O N
 
                 Employer,                :
 
                 Self-Insured,            :       D E C I S I O N
 
                 Defendant.               :
 
                                          :
 
            ___________________________________________________________
 
            
 
            1108
 
            Found claimant's work injury to her right foot and ankle on 
 
            March 16, 1989 caused a reflex sympathetic dystrophy in her 
 
            right lower extremity and also that this injury triggered an 
 
            eating disorder in claimant.
 
            
 
            1801.1
 
            Found claimant is entitled to a running award for temporary 
 
            partial disability benefits for her March 16, 1989 work 
 
            injury.
 
            
 
            2500
 
            Found claimant is entitled to have her medical bills paid by 
 
            defendant for treatment of her eating disorder, future 
 
            treatment of this disorder, her reflex sympathetic 
 
            dystrophy, and pain management.
 
            
 
            1801.1
 
            Found claimant's September 25, 2989 low back work injury may 
 
            be contributing to claimant's current problems, but are not 
 
            the current cause of her eating disorder or entitlement to 
 
            temporary partial disability benefits.
 
            The issue of permanency was bifurcated as to both injuries.
 
            
 
 
         
 
         Page   1
 
         
 
         
 
         
 
         
 
         
 
                     before the iowa industrial commissioner
 
         ____________________________________________________________
 
                                       :
 
         LARRY DON DeGEEST,            :
 
                                       :        File No. 959317
 
              Claimant,                :
 
                                       :     A R B I T R A T I O N
 
         vs.                           :
 
                                       :        D E C I S I O N
 
         ROLSCREEN COMPANY,            :
 
                                       :
 
              Employer,                :
 
              Self-Insured,            :
 
              Defendant.               :
 
         ___________________________________________________________
 
         
 
         
 
                              STATEMENT OF THE CASE
 
         
 
              This is a proceeding in arbitration brought by Larry Don 
 
         DeGeest, claimant, against Rolscreen Company, self-insured 
 
         employer, to recover benefits under the Iowa Workers' Compensa
 
         tion Act as a result of an injury on May 7, 1990.  This matter 
 
         came on for hearing before the undersigned deputy industrial 
 
         commissioner on July 16, 1991, in Des Moines, Iowa.  The record 
 
         was considered fully submitted at the close of the hearing.  The 
 
         record in this case consists of claimant's testimony and joint 
 
         exhibits A through N.
 
         
 
                                      issues
 
         
 
              Pursuant to the prehearing report and order dated July 16, 
 
         1991, the parties have submitted the following issues for 
 
         resolution:
 
         
 
              1.  Whether claimant sustained an injury on May 7, 1990, 
 
         which arose out of and in the course of employment with employer;
 
         
 
              2.  Whether the alleged injury is a cause of temporary and 
 
         permanent disability;
 
         
 
              3.  The extent of entitlement to temporary and permanent 
 
         disability, if any; and,
 
         
 
              4.  Whether claimant's medical expenses are causally con
 
         nected to the work injury.
 
         
 
                                 findings of fact
 
         
 
              The undersigned has carefully considered all the testimony 
 
         given at the hearing, the arguments made, the documents described 
 
         in the exhibits herein, and makes the following findings:
 
         
 
              Claimant was born on June 4, 1941, and completed the 
 
         eleventh grade of school.  Claimant has worked for employer since 
 
         January 18, 1962.  For the past 16 years he has worked as a qual
 
         ity control technician.  This job requires extensive standing and 
 
         walking in the course of inspecting parts, units, ect.
 
         
 

 
         
 
         Page   2
 
         
 
         
 
         
 
         
 
              The pertinent medical evidence of record reveals that 
 
         claimant has had diabetes mellitus for the past 23 years.  He has 
 
         been on insulin therapy for the past 15 years.  He has had inter
 
         mittent problems over the years with ulcerations on his right 
 
         sole, painful callouses on his right foot and ulcers on his great 
 
         right toe.
 
         
 
              Carl W. Carlson, D.O., who has treated claimant for his 
 
         diabetic foot ulcers since at least 1980, has taken him on and 
 
         off work during a 10 year period due to diabetic foot ulcers 
 
         (Exhibit A).
 
         
 
              In February 1988, claimant saw Paul A. Schippers, podia
 
         trist, in conjunction with Dr. Carlson for treatment of painful 
 
         callouses on the right foot.  Claimant was off work for this 
 
         problem from February 17 through March 7, 1988 (Exs. A-B).  On 
 
         July 14, 1989, claimant was treated by Dr. Schippers for treat
 
         ment of an ulceration on his great right toe.  Dr. Schippers 
 
         referred claimant to Douglas Dorner, M.D., for further evaluation 
 
         on July 25, 1989.  He reported evidence of mal perforans ulcers 
 
         involving his right great toe and the third metatarsal head area 
 
         (Ex. C).  He referred claimant to Iowa Mobile Diagnostics for a 
 
         lower extremity arterial evaluation.  This was performed on July 
 
         27, 1989, and suggested some tibial occlusive disease (Ex. E).  
 
         Claimant was taken off work for this problem from July 19, 1989 
 
         until August 17, 1989 (Ex. B, page 4).
 
         
 
              On October 4, 1989, claimant presented to Gene Van Zee, 
 
         M.D., with an infected right great toe.  On examination he was 
 
         noted to have a very marked amount of cellulitis of the great toe 
 
         and dorsum of the foot.  He also had a large ulceration over the 
 
         plantar surface of the toe at the crease of the toe and foot.  
 
         The ulceration was marked by a significant foul smelling debris 
 
         which was debrided in order to make an assessment of the toe.  
 
         After debridement, the toe showed considerable necrosis down to 
 
         the bone and cellulitis.  He was also seen in consultation by 
 
         Bradley Adams, M.D., orthopedist, and it was mutually recommended 
 
         to hospitalize him for treatment with IV antibiotics.  He was 
 
         admitted to Pella Community Hospital on October 4, 1989, where he 
 
         was treated for cellulitis of his right foot secondary to 
 
         necrotic ulceration of the plantar surface of the right great 
 
         toe.  He was discharged on October 6, 1989 (Exs. F-H).
 
         
 
              Claimant testified that he made application with the company 
 
         to be placed on short term disability benefits from October 7, 
 
         1989 until February 7, 1990.  This is reflected in his personnel 
 
         records (Ex. L, p. 85).
 
         
 
              Despite being off work and off of his feet for four months, 
 
         claimant redeveloped an ulceration on the plantar aspect of the 
 
         second toe of the right foot in February 1990.  He was treated by 
 
         Dr. Adams and was off work and on short term disability pay from 
 
         March 10 through April 29, 1990.  At that time, Dr. Adams 
 
         released him to return to work without restrictions.
 
         
 
              Claimant testified that on April 29, 1990, Rolscreen offered 
 
         him a new job, checking lumber in the warehouse.  He worked 
 
         three-four days and was then put on a press in another building 
 
         where he had to stand constantly on his feet.  He lasted two days 
 
         at this job.
 

 
         
 
         Page   3
 
         
 
         
 
         
 
         
 
         
 
              In May 1990, claimant was treated by Dr. Adams due to a 
 
         breakdown of the plantar aspect of the right great toe with an 
 
         ulceration.  Silvadene dressing changes were initiated.  On July 
 
         9, 1990, Dr. Adams indicated that the ulceration was healing and 
 
         there were no signs of active infection.  Dr. Adams recommended 
 
         that claimant consider a more sedentary type of occupation or 
 
         terminating his work activities altogether (Ex. H, pp. 4-7).
 
         
 
              Claimant testified that on July 9, 1990, a sedentary job at 
 
         Rolscreen was made available to him.  However, he declined to 
 
         accept the employment because he still had an ulcer on his foot 
 
         and was unable to walk from the parking lot to the work site and 
 
         needed to elevate his foot during the course of the day.  
 
         Instead, claimant requested unpaid leave of absence.  Claimant 
 
         has been on extended unpaid leave of absence from the company 
 
         since May 7, 1990.  He is eligible to receive retirement benefits 
 
         in September 1991, on the 80 and out plan.
 
         
 
                                conclusions of law
 
         
 
              Claimant alleges that he sustained an injury on May 7, 1990, 
 
         which arose out of and in the course of employment with employer.  
 
         Claimant acknowledges a 29 year history of diabetes mellitus.  He 
 
         alleges that his condition has been aggravated by his work activ
 
         ity which required prolonged standing and walking on cement 
 
         floors.  
 
         
 
              It is claimant's burden of proof to show by a preponderance 
 
         of the evidence that his injury developed gradually from work 
 
         activity over a period of time, McKeever Custom Cabinets v. 
 
         Smith, 379 N.W.2d 368 (Iowa 1985), which finally compelled him 
 
         to cease working.
 
         
 
              The injury must both arise out of and be in the course of 
 
         the employment.  Crowe v. DeSoto Consol. Sch. Dist., 246 Iowa 
 
         402, 68 N.W.2d 63 (1955) and cases cited at pp. 405-406 of the 
 
         Iowa Report.  See also Sister Mary Benedict v. St. Mary's Corp., 
 
         255 Iowa 847, 124 N.W.2d 548 (l963) and Hansen v. State of Iowa, 
 
         249 Iowa 1147, 91 N.W.2d 555 (1958).
 
         
 
              The words "out of" refer to the cause or source of the 
 
         injury.  The words "in the course of" refer to the time and place 
 
         and circumstances of the injury.  See Cedar Rapids Community Sch. 
 
         V. Cady, 278 N.W.2d 298 (Iowa 1979); McClure v. Union, Et Al., 
 
         Counties, 188 N.W.2d 283 (1971); Crowe, 246 Iowa 402, 68 N.W.2d 
 
         63 (1955).  An employer takes an employee subject to any active 
 
         or dormant health impairments, and a work connected injury which 
 
         more than slightly aggravates the condition is considered to be a 
 
         personal injury.  Ziegler v. United States Gypsum Co., 252 Iowa 
 
         613, 620, 106 N.W.2d 591 (1960), and cases cited.
 
         
 
              The words "in the course of" refer to the time and place and 
 
         circumstances of the injury.  McClure, 188 N.W.2d 283 (Iowa 
 
         1971); Crowe, 246 Iowa 402, 68 N.W.2d 63 (1955).
 
         
 
              The record clearly demonstrates that claimant has a long 
 
         history of diabetes mellitus with frequent manifestations of foot 
 
         ulcerations, callouses and ulcers.  Claimant must prove by a pre
 
         ponderance of the evidence that his right foot injury arose out 
 

 
         
 
         Page   4
 
         
 
         
 
         
 
         
 
         of his employment.  He must show a nexus between his employment 
 
         and aggravation of his diabetic condition.  A determination that 
 
         an injury "arises out of" the employment contemplates a causal 
 
         connection between the conditions under which the work was per
 
         formed and the resulting injury; i.e., the injury followed as a 
 
         natural incident of the work.  Musselman v. Central Telephone 
 
         Co., 154 N.W.2d 128 (1967); Reddick v. Grand Union Tea Company, 
 
         296 N.W. 800 (1941).
 
         
 
              The medical evidence in this case is insufficient to show a 
 
         nexus between claimant's ulcers and his walking and standing on 
 
         cement floors at work.  Dr. Adams reported on July 1, 1991:  "I 
 
         do agree that Mr. DeGeest [sic] diabetic condition was not caused 
 
         by his work environment and he is susceptible to the ulcerations 
 
         and cellulitis of his feet because of his diabetic condition and 
 
         a person who is nondiabetic in my opinion would not be suscepti
 
         ble to these problems."  (Ex. H., p. 12).  He further stated:
 
         There is indeed no permanent impairment as a result of the 
 
         ulcerations.  The problem is the underlying diabetic condition.  
 
         This is why the restrictions were recommended with regards to his 
 
         standing activities as it seems that because of this diabetic 
 
         condition, prolonged standing or long periods of time with 
 
         downward pressure applied to the foot and toe region can cause 
 
         the ulcerations to develop.
 
         
 
         (Ex. H. p. 12).
 
         
 
              The medical evidence does not support claimant's contention 
 
         that his condition became so disabling on May 7, 1990, that he 
 
         could no longer continue working for employer.  Dr. Adams 
 
         released claimant to return to work on April 30, 1990 (Ex. H, 
 
         p. 2).  Although claimant experienced a recurrence of his ulcera
 
         tions and was treated with Silvadene and local wound care by Dr. 
 
         Adams, there is no reference to prohibiting claimant from working 
 
         on or about May 7, 1990.
 
         
 
              The greater weight of the evidence supports the finding that 
 
         claimant took a personal leave of absence on May 7, 1990 (Ex. L, 
 
         p. 5).  After voluntarily taking this leave, claimant's attorney 
 
         wrote to employer on May 22, 1990, alleging that claimant was 
 
         unable to properly perform his work and was therefore on medical 
 
         leave (Ex. L, p. l).  However, claimant's attorney was immedi
 
         ately notified that claimant was not off work because of any doc
 
         tor's orders.  On May 23, 1990, Mr. Mel Petersma advised 
 
         claimant's attorney that claimant had been released to return to 
 
         work on April 30, 1990 and that there was no medical information 
 
         in employer's possession that claimant was unable to work (Ex. L, 
 
         p. 4).
 
         
 
              At the hearing, claimant admitted he decided in May 1990, to 
 
         take an unpaid leave of absence until September 1991, so that he 
 
         could qualify for retirement under Rolscreen's retirement poli
 
         cies.  Claimant never provided employer with any medical informa
 
         tion indicating he was unable to work after May 7, 1990.  
 
         Claimant requested an extension of his voluntary leave of absence 
 
         on July 16, 1990, which was ultimately extended through January 
 
         1991 (Ex. J, pp. 42-45 & Exs. 2 & 3).
 
         
 
              Furthermore, when claimant was advised by employer that his 
 
         treating physician was recommending consideration of a more 
 

 
         
 
         Page   5
 
         
 
         
 
         
 
         
 
         sedentary type of activity, Rolscreen offered claimant such a job 
 
         beginning July 16, 1990, and claimant refused to accept this 
 
         employment (Ex. L, p. 2).  Claimant never tried the job offered 
 
         by employer (Ex. J, pp. 28-31).  Dr. Adams indicated the job pro
 
         posed by employer was well within his recommendations concerning 
 
         modified work activity to compensate for claimant's pre-existing, 
 
         diabetic condition (Ex. H, pp. 10 & 12).
 
         
 
              It is speculative to assume that claimant had a medical con
 
         dition which prohibited him working in May 1990.  It is also 
 
         speculative to assume that any alleged medical condition in May 
 
         1990, was the result of activity in the work environment.  
 
         Claimant testified that he engages in self-employed activity 
 
         operating a greenhouse.  That activity begins in February and 
 
         reaches it's peak in May.  Claimant testified that while he was 
 
         not working at Rolscreen during this period of time, he was in 
 
         fact running his greenhouse business.  In any event, while it is 
 
         possible that claimant's condition may have been aggravated by 
 
         his work activity,  medical evidence is insufficient to show a 
 
         nexus between such activity and the intermittent exacerbation of 
 
         his foot ulcers.  Furthermore, there is insufficient evidence to 
 
         show that claimant's condition ultimately forced him to quit all 
 
         work activity on May 7, 1990.  By claimant's own admission, he 
 
         filed for short term disability benefits and unpaid leave due to 
 
         a non-work related injury and for the sole purpose of qualifying 
 
         for retirement benefits (Ex. L, pp. 84-85).
 
         
 
              Thus, it is found that claimant has failed to establish by a 
 
         preponderance of the evidence that his right foot problem arose 
 
         out of his employment with employer.
 
         
 
              This issue is dispositive of the entire case and further 
 
         analysis is unnecessary.
 
         
 
                                      order
 
         
 
              THEREFORE, IT IS ORDERED:
 
         
 
              That claimant take nothing from this proceeding.
 
         
 
              That the parties pay their own costs pursuant to rule 343 
 
         IAC 4.33.
 
         
 
         
 
         
 
              Signed and filed this ____ day of August, 1991.
 
         
 
         
 
         
 
         
 
         
 
                                       ______________________________               
 
         JEAN M. INGRASSIA
 
                                       DEPUTY INDUSTRIAL COMMISSIONER
 
         
 
         Copies To:
 
         
 
         Mr. Harold B. Heslinga
 
         Attorney at Law
 
         118 N Market St
 

 
         
 
         Page   6
 
         
 
         
 
         
 
         
 
         Oskaloosa  IA  52577
 
         
 
         Mr. Cecil L. Goettsch
 
         Attorney at Law
 
         801 Grand Ave
 
         Suite 3700
 
         Des Moines  IA  50309
 
         
 
 
            
 
 
 
 
 
 
 
 
 
 
 
                           5-1400; 5-1402.20; 5-1402.30
 
                           Filed August 1, 1991
 
                           JEAN M. INGRASSIA
 
            
 
                     before the iowa industrial commissioner
 
            ____________________________________________________________
 
                                          :
 
            LARRY DON DeGEEST,            :
 
                                          :        File No. 959317
 
                 Claimant,                :
 
                                          :     A R B I T R A T I O N
 
            vs.                           :
 
                                          :        D E C I S I O N
 
            ROLSCREEN COMPANY,            :
 
                                          :
 
                 Employer,                :
 
                 Self-Insured,            :
 
                 Defendant.               :
 
            ___________________________________________________________
 
            
 
            
 
            5-1400; 5-1402.20; 5-1402.30
 
            Claimant, a quality control technician with employer since 
 
            January 18, 1962, has suffered from diabetes mellitus for 23 
 
            years.  He has a history or diabetic foot ulcers, callouses 
 
            and soft tissue infections.  He alleges that his condition 
 
            became so severe on May 7, 1990, that he was no longer able 
 
            to work.  The evidence shows otherwise.  The medical 
 
            evidence does not establish a disabling condition on May 7, 
 
            1990, which prohibited him from continuing to work.  There 
 
            are no medical reports supporting his claim.  His treating 
 
            physicians specifically stated that his diabetic condition 
 
            was not caused by his work environment and he is susceptible 
 
            to ulcerations and cellulitis of his feet because of his 
 
            diabetic condition.  Medical evidence does not establish by 
 
            a preponderance of the evidence a nexus between claimant's 
 
            employment and an aggravation of his condition.
 
            By his own admission, claimant, on May 7, 1990, voluntarily 
 
            requested short term disability leave and ultimately unpaid 
 
            leave until he qualified for company retirement in September 
 
            1991.
 
            Therefore, it was determined that claimant's condition did 
 
            not arise out of his employment with employer.  A nexus 
 
            between his employment and aggravation of his condition was 
 
            not established by a preponderance of the evidence.