TIMMOTHY P. CLARK III, Employee, v. DR. PEPPER SEVEN UP BOTTLING CO. and KEMPER INS. CO., Employer-Insurer/Appellants.
WORKERS= COMPENSATION COURT OF APPEALS
NOVEMBER 1, 2002
EVIDENCE - EXPERT MEDICAL OPINION; MEDICAL TREATMENT & EXPENSE - SURGERY. Where opposing medical opinion did not constitute a definitive position regarding the compensability of the surgery at issue, and where the physician upon whose opinion the judge relied was clearly Aaware of@ the employee=s psychiatric difficulties and of the complexities of the condition with which he had been diagnosed, the compensation judge=s award of recommended spinal fusion surgery was not clearly erroneous and unsupported by substantial evidence.
CAUSATION - CONSEQUENTIAL INJURY; CAUSATION - SUBSTANTIAL EVIDENCE. Where it was evident that the employee=s foot drop condition was being treated as consequence of the employee=s work-related low back injury, and where there was evidence that the employee=s shoulder condition had resulted from a trip and fall consequent to his foot drop condition, the issue of the causation of the employee=s shoulder condition was not one of medical causation such as would require reliance on expert medical evidence, and the compensation judge=s finding of a shoulder injury as alleged was not clearly erroneous and unsupported by substantial evidence, even absent clear supporting expert medical evidence.
MEDICAL TREATMENT & EXPENSES - REASONABLE & NECESSARY. Where the cost of recommended pool therapy was not unreasonable given the therapy=s finite recommended duration and specific goals and the additional apparent parameter imposed on the therapy by affirmance of the judge=s grant of spinal fusion surgery, the compensation judge=s award of pool therapy in treatment of the employee=s work-related low back condition was not clearly erroneous and unsupported by substantial evidence.
Determined by Pederson, J., Wilson, J. and Johnson, C. J.
Compensation Judge: Jeanne E. Knight
WILLIAM R. PEDERSON, Judge
The employer and insurer appeal from the compensation judge's award of low back surgery, of benefits for a consequential shoulder injury, and of pool therapy. We affirm.
On July 6, 2000, Timmothy Clark sustained a work-related injury to his low back while building a display at a grocery store in the course of his employment as a route driver with the American Bottling Company. Mr. Clark [the employee] was twenty-nine years old on the date of his injury. The employee continued to work subsequent to his injury, but symptoms of low back pain, bilateral radicular pain, and left leg paresthesias developed, until on July 30, 2000, he was seen on an emergency basis by Dr. Marcia Saul, who diagnosed lumbar spasm strain with radiculopathy and possible herniated disc. On August 1, 2000, the employee saw physiatrist Dr. Michael McGrail, who ordered an MRI scan, which, conducted on August 4, 2000, was read to reveal moderate disc degeneration and a moderate-sized disc herniation at L4-5. Dr. McGrail restricted the employee from working, and American Bottling Company [the employer] admitted liability for the injury and commenced payment of benefits.
The employee=s symptoms subsequent to his injury eventually came to include urinary incontinence and bilateral lower extremity pain and numbness, and his related medical records are extensive and complex, with reports and other evidence of care by over twenty different physicians and psychologists. On August 14, 2000, the employee was seen by neurosurgeon Dr. Muzaffar Siddiqui, who recommended considering surgery. Dr. McGrail referred the employee to neurosurgeon Dr. Walter Bailey, and the employee requested of the employer=s insurer that any required surgery be performed closer to his home than Dr. Bailey=s facility. The insurer apparently recommended neurosurgeon Dr. Daniel Ahlberg, who ordered additional scans. The scans, conducted on August 15, 2000, were read to reveal a A[l]arge central disk herniation@ at the L4-5 level, Awith disk material filling the anterior 50% of the spinal canal.@
The employee first saw Dr. Ahlberg on August 25, 2000, complaining to him of low back and bilateral leg pain. Noting that the employee=s bowel and bladder functions remained normal, Dr. Ahlberg diagnosed a herniated disc at L4-5 and a relatively small spinal canal and recommended surgery. After examining the employee on August 30, 2000, Dr. Bailey concurred in the need for surgery, and on September 12, 2000, the employee underwent a lumbar foraminotomy/facetectomy, laminectomy, and discectomy at L4-5, performed by Dr. Ahlberg. On September 13, 2000, the employee underwent a post-surgical lumbar myelogram with CT scan, which was read to reveal Aa laminectomy defect on the left at L4-5 which seems to be filled with air-type density extending into the left lateral recess of the spinal canal at this level,@ together with a narrowing of the thecal sac and moderately severe narrowing of the spinal canal at that level. In a discharge summary dated September 17, 2000, Dr. Ahlberg reported that, following his surgery, the employee had
complained of total numbness and total inability to move his legs. A workup was undertaken and it was felt that he likely represented a post-operative conversion hysteria. An MRI scan of the lumbar spine was done which did not reveal any definite evidence for significant epidural hematoma or other postoperative complications.
On September 25, 2000, the employee had a follow-up visit with Dr. Ahlberg, who reported on that date that the employee had Aimproved dramatically@ since his discharge from the hospital on September 17, 2000. On September 27, 2000, however, the employee saw Dr. Bailey again, who reported that the employee had Ahad no improvement since his operation,@Adid not like the way Dr. Ahlberg dealt with him in the 2 minutes that he saw him post-operatively,@ and Awould like me to take over his care.@
On October 8, 2000, the employee injured himself again, when he tripped and fell as he was coming out of his bathroom at home. He was taken by ambulance to an emergency room, where he reported that his fall had resulted from numbness and weakness in his left leg consequent to his July 2000 work injury. The employee was admitted to the hospital, and on October 9, 2000, he underwent lumbar x-rays and a lumbar myelogram with CT scan, which were read to reveal mild spinal canal narrowing at L4-5. Findings on thoracic and sacral MRI scans conducted the following day were read as essentially normal, and on October 11, 2000, the employee also saw urologist Dr. George Haikel regarding a urinary retention problem that had apparently developed in the hospital, possibly related to his spinal injury. Dr. Haikel recommended self-catheterization, but the employee refused. In a discharge summary on October 12, 2000, Dr. Bruce Lomax, who had referred the employee to Dr. Haikel, noted that the employee=s urinary retention problem had A[m]ysteriously@ disappeared overnight, after he had once again refused catheterization the night before.
On October 16, 2000, the employee saw Dr. Ahlberg again, who concluded that the employee Aappears to be continuing to improve,@ reiterating his Aworking diagnosis of a postoperative conversion hysteria.@ On November 8, 2000, however, the employee returned to see Dr. Bailey with continuing complaints of primarily left leg pain and continuing urinary incontinence, and Dr. Bailey ordered another lumbar MRI scan. The scan, which was performed on November 13, 2000, was read to reveal postoperative changes at L4-5 without significant neural impingement.
On January 4, 2001, the employee saw urologist Dr. Thomas Stormont concerning difficulties voiding his bladder, which he indicated had begun about four months earlierBthe month of his surgery with Dr. Ahlberg. Dr. Stormont concluded that the problem was most likely neurogenic and ordered tests. On March 2, 2001, Dr. Stormont reported that tests had verified that diagnosis and that the employee had elected to defer recommended catheterization and further studies pending any recommended further surgery.
On April 6, 2001, the employee saw physiatrist Dr. Richard Timming, on referral from Dr. Bailey. Upon examination, Dr. Timming diagnosed (1) chronic low back pain and left lower extremity pain and numbness, with loss of bladder and sexual function, (2) left foot drop, (3) loss of total sensation of his left lower extremity below the hip, (4) chronic low back and radiating right lower extremity pain, neurogenic bladder with loss of sexual function, (6) possible chronic pain syndrome, and (7) possible contributing psychological factors. Dr. Timming recommended a psychological consultation with Dr. Ellen Snoxell, together with MMPI testing. On May 7, 2001, the employee saw psychologist Dr. Ellen Snoxell, on referral from Dr. McGrail. Dr. Snoxell administered an MMPI, from which she found Ano indications of psychotic symptoms, malingering or a somatization disorder.@ Dr. Snoxell concluded in part that the employee
may hold unrealistic hopes that a Asimple@ solution will be found to completely ameliorate his symptoms and he will not have to change his behavior in any way. If surgery is not an option, he would be a very good candidate for a multidisciplinary pain program with a strong behavior emphasis.
On May 8, 2001, the employee=s physical therapist, Lee Korthof, concluded that an ankle/foot orthotic device would probably not help the employee, given that he Aslides his foot along floor & is unable/unwilling to ever pick his (L) foot up from floor.@ Mr. Korthof concluded that the rehabilitation potential was Apoor with physical therapy alone. [The employee] would be better served by enrolling in a multi-disciplinary chronic pain program.@ On May 11, 2001, the employee underwent a lumbar CT scan with contrast, which was read to reveal a disc bulge at L4-5 that was seen to contact the nerve root after it had exited the neural foramina. On May 16, 2001, the employee saw Dr. Bailey, who concluded that the compression was very minimal and anticipated Aa slow but definite recovery.@
On May 16, 2001, the employee also apparently saw Dr. Timming, who referred the employee for physical therapy for an onset of left foot drop, noting as a precaution that there was a Arisk [of] fall@ and that a goal of treatment should be Asafe walking.@ The employee returned to see Dr. Timming again on May 29, 2001, primarily with regard to what Dr. Timming diagnosed as A[c]hronic left partial foot drop with loss of sensation from the groin to the foot.@ The employee was discharged from physical therapy due to nonattendance on June 18, 2001, and two days later, on June 20, 2001, he saw Dr. Timming again, reporting that he had tripped and fallen about two weeks earlier and had landed on his right side and that he had subsequently had increased low back pain and an onset of right shoulder discomfort.
On July 25, 2001, with the employee still failing to make any progress with regard to his symptoms of pain in his low back and both lower extremities, numbness in his left lower extremity, loss of bladder control, gait abnormality, partial left foot drop, and right shoulder pain, Dr. Timming recommended that the employee be reexamined by Dr. Bailey as to the prospects of neurosurgery, continuing meanwhile with pool therapy.
On August 23, 2001, the employee was examined by orthopedic surgeon Dr. John Stark, to whom the employee complained of severe back pain, bilateral leg weakness, and bladder and sexual dysfunction. Upon review of the employee=s medical record and various radiological studies, Dr. Stark indicated that it was Aevident from the record and the imaging studies that problems were immediately evident following the surgery@ on September 12, 2000. Upon a physical examination of the employee as well, Dr. Stark assessed a Acontusion/neuropraxia to the passive L5 and lower sacral roots, resulting in bladder and sexual difficulty,@ consequent to the employee=s surgery at L4-5, together with A[u]ntreated right lateral recess stenosis aggravated by vertical collapse caused by enucleation of the disc.@ The doctor noted also that the employee had Aa severe functional deficit for a 31-year-old@ and Aprofound numbness and weakness below the knees and profound bladder abnormalities and sexual dysfunction,@ explaining that Athe loss of disc space height has caused not only an aggravation of the lateral recess stenosis on the right, but probably foraminal stenosis bilaterally.@ A week later, on August 30, 2001, Dr. Stark advised the employee to consider a spinal fusion. On September 4, 2001, the employee sought a second opinion from Dr. Bruce Young, who declined to concur in the recommended fusion surgery.
On October 4, 2001, the employee filed a medical request, alleging entitlement to payment for the recommended fusion surgery, a shoulder MRI scan, certain medication, pool therapy, and related mileage, all consequent to his low back injury on July 6, 2000. On October 11, 2001, the employer and insurer filed a denial of that request. On that same date, Dr. McGrail wrote a letter ATo Whom It May Concern,@ indicating in part that it was his opinion that the employee Astill requires pool therapy in order to improve overall physical conditioning and musculature strength as well as prevent further deconditioning, which is secondary to the back injury [he has] sustained on July 6,@ 2000. The following day, October 12, 2001, Dr. Timming also wrote a letter, this to the employee=s QRC Cheryl Reinerson, agreeing that continuing the employee=s warm water pool therapy, for two to three months, was not only medically indicated for the employee but Aalso very cost effective.@
On October 15, 2001, the employee was examined for the employer and insurer by psychiatrist Dr. Thomas Gratzer. After interviewing the employee, reviewing his medical records, and administering an MMPI, Dr. Gratzer diagnosed in part Aconversion disorder,@ together with Apersonality disorder not otherwise specified with dependent and compulsive features.@ It was Dr. Gratzer=s opinion that the employee did not have any psychiatric difficulties arising from his July 2000 work injury, that the employee=s Aconversion disorder symptoms are a relative contraindication for future back surgery,@ and that Ait would be imperative for any orthopedic surgeon considering surgery to be aware of [the employee=s] psychiatric difficulties.@ On October 22, 2001, psychologist Marvin Logel, Ph.D., who had interpreted the employee=s MMPI for Dr. Gratzer, wrote a lengthy and detailed report to the employer and insurer=s attorney, in which he stated that the test=s validity scale results suggested Aa conscious attempt to distort the test findings in order to influence the outcome of the examination.@
On October 25, 2001, Dr. Stark, also, endorsed warm pool therapy for the employee, indicating that it would be useful in treating specifically the employee=s bladder control problems and the dysesthetic sensations and weakness in his lower extremities, in addition to offering weight relief, gentle strengthening opportunities, and cutaneous stimulation.
On November 16, 2001, the employee was examined for the employer and insurer by orthopedic surgeon Dr. John Dowdle. Upon interview and examination of the employee and review of his medical records, Dr. Dowdle diagnosed (1) degenerative disc disease at L4-5, (2) status post central herniation at L4-5 with a lumbar laminectomy and disc excision at that level on the left, (3) significant functional overlay with subjective complaints in excess of objective findings, (4) neurogenic bladder, and (5) reported sexual dysfunction. It was Dr. Dowdle=s opinion in part that pool therapy, Aincluding exercises in a hot tub, a cooler pool and/or hot showers/baths,@ was not medically necessary, that the employee Acan do exercises at home in a regular tub.@ Apparently with reference to the recommended fusion surgery, Dr. Dowdle concluded also that the employee=s Aspinal canal is of normal size and not causing a compressive lesion@ and that A[a] substantial portion of [the employee=s] illness is psychological or psychogenic in nature, and that needs to be addressed in order to be able to improve his situation.@
On January 15, 2002, Dr. Stark testified by deposition. It was Dr. Stark=s conclusion that the employee=s current low back and lower extremity problems were probably due to the fact that Dr. Ahlberg had Aprobably over retracted the nerve root, giving [the employee] cauda equina syndrome, creating instability, which resulted in collapse and redundancy, and the stenosis which we are now looking at,@ leaving less room for the nerve root to exit. Dr. Stark expressly disagreed with Dr. Bailey=s conclusion that the employee=s May 2001 Myelogram CT did not reveal a significant compression on the employee=s L4 nerve root, expressly agreeing instead with the reading radiologist=s conclusion to the contrary. Dr. Stark testified further, Abased on my impression as an orthopedist who sees this kind of thing all day and in a lot of angry, frustrated patients, I didn=t see anything about [the employee] that suggested he had a conversion hysteria.@ Dr. Stark opined also that, even if the employee=s MMPI results indicated that he was a highly defensive individual, the employee would not be disqualified as a surgical candidate Afrom a surgical emergency like this.@ Dr. Stark conceded that the employee may have benefitted more from the recommended pool therapy earlier in his condition, when that therapy would have been more valuable as a weight-relieving measure to relieve the collapsed disc, such therapy being now perhaps more of a comfort measure. Indicating that he had confirmed his position by sending out the employee=s scans to be read by a radiologist, Dr. Stark concluded that Dr. Dowdle was A[f]lat-out wrong@ in concluding that the employee=s scans revealed no residual or persistent tightness in the employee=s spinal canal. With regard to the relationship between the employee=s psychological condition and his physical low back condition, Dr. Stark ultimately concluded, AI don=t care if [the employee is] confused or angered, frustrated or psychotic, I don=t care. I would still take care of his orthopedic problem so that he=s not paralyzed or impaired in his bladder and his sexual function.@
The matter came on for hearing on January 18, 2002. Issues at hearing included whether the recommended fusion surgery was reasonable and necessary, whether it was premature to consider surgery before addressing psychiatric issues, whether the employee=s right shoulder injury was consequential to the employee=s work injury, and whether pool therapy was reasonable and necessary. The employee testified at hearing that he had been completely numb from the waist down following his surgery on September 12, 2000, that he had no sensation of any sort. He testified that the feeling in his right leg eventually returned before his discharge from the hospital, leaving only pain, but that feeling in his left leg remained nearly gone and that he suffered from incontinence. He testified that when he complained to Dr. Ahlberg about this result Dr. Ahlberg spent a total of only three or four minutes with him, after keeping him in the waiting room for an hour and a half past his appointment time, and did not examine him at all, repeatedly ignoring his complaints of multiple post-surgery pain and other problems. The employee testified also that, in late May or early June 2001, he had gotten up at 3:00 a.m. to stretch, due to his back pain, and had tripped and fallen due to the numbness he had been experiencing in his left foot. He testified that, in trying to avoid hitting a corner of a wall, he had twisted as he fell and taken his full weight on his shoulder. By findings and order filed March 18, 2002, the compensation judge concluded in part that the proposed fusion surgery was reasonable and necessary, that no need had been shown for additional psychological or psychiatric treatment, that the employee=s shoulder injury was a consequence of his work injury, and that pool therapy was reasonable and necessary. The employer and insurer appeal.
STANDARD OF REVIEW
In reviewing cases on appeal, the Workers= Compensation Court of Appeals must determine whether Athe findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.@ Minn. Stat. ' 176.421, subd. 1 (1992). Substantial evidence supports the findings if, in the context of the entire record, Athey are supported by evidence that a reasonable mind might accept as adequate.@ Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, A[f]actfindings are clearly erroneous only if the reviewing court on the entire evidence is left with a definite and firm conviction that a mistake has been committed.@ Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975). Findings of fact should not be disturbed, even though the reviewing court might disagree with them, Aunless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.@ Id.
1. Fusion Surgery
In reliance on the expert medical opinion of Dr. Stark over that of Dr. Dowdle, the compensation judge concluded that it was reasonable and necessary for the employee to undergo the recommended fusion surgery without any additional psychological or psychiatric treatment. The employer and insurer assert that the judge, in so concluding, apparently ignored the opinions of other medical and psychological experts, including the opinions of psychiatrist Dr. Gratzer and psychologists Drs. Logel and Snoxell as to the employee=s psychological condition and the opinions of Drs. Ahlberg, Lomax, Bailey, and others as to the employees physical condition. They argue that ADr. Gratzer is of the opinion that the employee is not currently a surgical candidate@ and that the employee suffers from a conversion disorder that Amust be addressed before any type of additional surgical intervention.@ They argue that Drs. Logel and Snoxell concur in Dr. Gratzer=s diagnosis and that these three doctors Aare the only individuals with expertise in the issue of conversion disorder and how this condition impacts the appropriateness of surgery.@ With regard to the employee=s physical condition, they argue that, even if we were to accept the judge=s position that the recommended surgery is not premature prior to treatment of the employee=s psychological condition, and even though the judge did make reference to the opinion of Dr. Dowdle, there is no evidence that the judge reviewed the opinions of Drs. Ahlberg, Bailey, Lomax, and others prior to concluding that the fusion surgery at issue was even physically necessary. We are not persuaded.
It was Dr. Gratzer=s opinion that the employee=s Aconversion disorder symptoms are a relative contraindication for future back surgery@ (emphasis added) and that Ait would be imperative for any orthopedic surgeon considering surgery to be aware of [the employee=s] psychiatric difficulties@ (emphasis added). Neither of these assertions constitutes a definitive position regarding the compensability of the surgery at issue. Moreover, Dr. Stark was clearly Aaware of@ the employee=s psychiatric difficulties and of the complexities of the conversion disorder condition with which he had been diagnosed, and it was his expert opinion that those difficulties and that diagnosis did not affect the reasonable necessity of the surgery at issue in this case. Dr. Stark conceded that there might be circumstances where a psychological condition might diminish the reasonableness of proceeding with surgery, but it was his opinion that such circumstances did not here exist. Nor is there basis for reversal of the judge=s award in the fact that the judge did not mention contrary physicians other than Dr. Dowdle. See Rothwell v. Minnesota Dep't of Natural Resources, slip op. (W.C.C.A. Dec. 6, 1993) (a compensation judge has no obligation to acknowledge specifically in his decision every item of medical evidence received). See also Pelto v. USX Corp., slip op. (W.C.C.A. Dec. 16, 1993). A trier of fact's choice between experts whose testimony conflicts is usually upheld unless the facts assumed by the expert in rendering his opinion are not supported by the evidence, Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985). Concluding that Dr. Stark did not premise his opinion on unsupported facts, we will not reverse the judge=s award of fusion surgery on grounds that the judge improperly relied on the opinion of Dr. Stark. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
2. Consequential Shoulder Injury
At Finding 10, the compensation judge concluded that, A[i]n approximately June 2001, the employee arose at 3 a.m. due to low back pain. As he walked down the hall, his left foot caught and he fell,@ injuring his right shoulder. Apparently on the basis of that finding, the judge ordered, at Order 2, that the employer and insurer should provide medical treatment required to treat the employee=s right shoulder, apparently including a recommended MRI scan and recommended physical therapy. The employer and insurer contend that Aneither the employee nor any of his treating or examining doctors are able to provide any real evidence that this condition relates to [the employee=s] low back condition,@ that A[n]o doctor has actually opined to a reasonable degree of medical certainty that it was the condition of the employee=s back that cause him to trip.@ They argue that Ait is simply speculation on the part of the employee that his back condition had anything to do with the injury to his shoulder@ and, citing Carroll v. Univ. of Minnesota, slip op. (W.C.C.A. May 4, 1999), that A[t]his speculation cannot serve as the basis for an award of benefits.@ We are not persuaded.
The employee=s symptoms of foot drop in this case were being treated by Dr. Timming in the same context with several other symptoms directly related to the employee=s low back condition. The issue of the causation of the employee=s shoulder condition here is therefore not exclusively one of medical causation. Here the compensation judge credited the employee=s testimony that he tripped and fell as a result of his chronic foot numbness, which was being treated implicitly as a back-related symptom, and that, in the process of his fall, his body twisted and he took the full weight of the fall on his right shoulder. Because assessment of a witness=s credibility is the unique function of the trier of fact, see Brennan v. Joseph G. Brennan, M.D., 425 N.W.2d 837, 839-40, 41 W.C.D. 79, 82 (Minn. 1988), citing Spillman v. Morey Fish Co., 270 N.W.2d 781, 31 W.C.D. 187 (Minn. 1978), and because the judge=s crediting of the employee=s testimony on this issue was not otherwise unreasonable, we affirm the judge=s conclusion that the employee sustained a compensable injury to his right shoulder consequent to his admitted work injury. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
3. Pool Therapy
The compensation judge concluded at Finding 17 that the pool therapy at issue was reasonable and necessary in treatment of the employee=s work injury. Quoting Buda v. Pillsbury, 38 W.C.D. 516, 518 (W.C.C.A. 1986), the employer and insurer contend that the reasonable and necessary standard for treatment compensability requires that Athe cost of each treatment is rated against the amount and duration of the relief obtained.@ Citing that same case, they argue that A[i]t is insufficient to conclude, merely, that the treatment as a whole was needed and reasonable.@ They go on to list some twelve factors cited in case law for determining the reasonableness and necessity of chiropractic care, applying three of them specifically to the facts of this case, contending (1) that there is no evidence of a reasonable treatment plan, (2) that the cost of the treatment is not justified in light of the amount of relief provided, and (3) that the pool therapy appears to have had no beneficial impact on the employee=s ability to work. We are not persuaded.
We would underscore first that warm pool therapy has been expressly recommended for the employee by three medical doctorsBDr. McGrail, Dr. Timming, and Dr. Stark. While Dr. Stark in his deposition was certainly less than emphatic about the necessity of the therapy, it is clear that he considered it reasonably constructive. Moreover, the fact remains that in October 2001 Dr. McGrail concluded that the employee still Arequires@ the therapy and Dr. Timming found the treatment both Amedically indicated@ and Avery cost effective.@ While any treatment Aplan@ regarding the pool therapy may remain somewhat vague, it is clear from Dr. McGrail=s conclusion, that the employee Astill requires pool therapy in order to improve overall physical conditioning and musculature strength@ (emphasis added), that Dr. McGrail sees the therapy as both temporary and oriented to particular goals, and it is clear from Dr. Timming=s recommendation that the prescription is of a limited duration. With regard to the cost of the therapy in light of the relief provided, we note the employee=s testimony as to his relief in light of Dr. Timming=s express conclusion that the therapy is Avery cost effective@ (emphasis added). This latter conclusion apparently implies comparison to alternative measures for healing and Afor reducing [the employee=s] pain but also for improving his functional status,@ the latter being a comment also on the relationship between the therapy and the employee=s potential for returning to work
Although we acknowledge that $600 a month for about twenty-two therapy sessions each month is a substantial financial consideration, it is not an unreasonable amount given the finite duration and goals of Dr. Timming=s and Dr. McGrail=s recommendations and given the apparent parameter imposed on such therapy by our affirmance of the judge=s grant of fusion surgery for the employee. We conclude that it was not unreasonable for the compensation judge to rely on the opinions of Drs. McGrail, Timming, and Stark over contrary opinions by other physicians with regard to the pool therapy at issue. See Nord, 360 N.W.2d at 342-43, 37 W.C.D. at 372-73. Therefore we affirm the compensation judge=s award of that therapy. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
 At the time of Dr. Timming=s October 12, 2001, letter to QRC Reinerson, the employee had been participating in pool therapy five days each week.