LAURETTA F. BORRESCH, Employee/Appellant, v. STEVENS CMTY. MED. CTR. and AIG DOMESTIC CLAIMS, Employer-Insurer, and CENTRAL MINN. NEUROSCIENCES, CENTER FOR PAIN MGMT., PA, and MN DEP’T OF EMPLOYMENT & ECON. DEV., Intervenors.
WORKERS’ COMPENSATION COURT OF APPEALS
FEBRUARY 8, 2008
CAUSATION - PRE-EXISTING CONDITION. Where the employee had a significant pre-injury history of treatment to her neck, low back, right shoulder, and arms bilaterally, where the employee had returned unrestricted to her job after her pre-injury cervical fusion prior to her work injury but had continued to complain of ongoing neck and low back pain up through the date of her work injury, and where the employee had offered no objective evidence of new pathology to her neck, low back, or right shoulder after the date of the work injury, the compensation judge’s conclusion that the employee did not prove more than a left shoulder injury was not clearly erroneous and unsupported by substantial evidence, notwithstanding the employee’s testimony that her overall pain was substantially greater after the work injury than it was before the injury.
TEMPORARY TOTAL DISABILITY - WORK RESTRICTIONS; PERMANENT TOTAL DISABILITY - SUBSTANTIAL EVIDENCE. Where it was impossible to determine which, if any, of the employee’s restrictions were related to her compensable left-shoulder work injury and which, if any, were related to her noncompensable neck, low back, bilateral arm and wrist, and right-shoulder conditions, and where it was not entirely clear that those restrictions were a substantial contributing factor in the employee’s unemployment, the compensation judge’s finding that the employee failed to prove specific work restrictions related to her left shoulder injury was not clearly erroneous and unsupported by substantial evidence, although the employee had been subject to renewed written restrictions from essentially the date of her work injury to the date of the hearing, and although the judge’s finding was arguably in conflict with another, unappealed, finding of the judge.
MEDICAL TREATMENT - REASONABLE & NECESSARY; MEDICAL TREATMENT & EXPENSE - DIAGNOSTIC TESTING. Where the recommended cervical nerve block appeared not to have been intended to rule out the possibility of a cervical cause for the employee’s shoulder symptoms so much as to actually treat those symptoms under an affirmative presumption that they originated in the employee’s cervical spine, where contemporaneous records of the referring doctor suggested that that presumption was also the basis for the referral as well as for the repeat EMG recommended by the referring doctor, the compensation judge’s conclusion that the employee failed to prove that her left shoulder work injury substantially contributed to her need for a cervical nerve block, for her examination by the recommending doctor, or for a repeat EMG was not clearly erroneous and unsupported by substantial evidence.
Determined by: Pederson, J., Johnson, C. J., and Rykken, J.
Compensation Judge: Bradley J. Behr
Attorneys: Deanna M. McCashin, Schoep & McCashin, Alexandria, MN, for the Appellant. Steven E. Sullivan, Johnson & Condon, Minneapolis, MN, for the Respondents.
WILLIAM R. PEDERSON, Judge
The employee appeals (1) from the compensation judge's denial of compensation for cervical, lumbar, and right shoulder injuries, (2) from the judge’s finding that the employee failed to prove that she has specific work restrictions related to her left shoulder injury and the judge’s consequent denial of wage replacement benefits, and (3) from the judge’s denial of payment of certain medical expenses. We affirm.
Lauretta Borresch, the employee in this matter, obtained training as a certified nursing assistant [CNA] in 1998 and began working in that capacity for Stevens Community Medical Center, the employer in this matter, in about 1999. Ms. Borresch’s relevant medical history is long and complex. In June of 1992, she evidently sustained injuries to her neck and back consequent to a motor vehicle accident, after which she underwent several weeks of physical therapy. Nine years later, in July of 2001, consequent to recurring symptoms, she underwent lumbar and cervical MRI scans, which revealed in the lumbar region degenerative disc disease with the suggestion of possible impingement and in the cervical region disc bulges, protrusions, or herniations from C3 through C7, some of which were impinging on the spinal cord. Ms. Borresch underwent treatment of these by therapeutic injection and physical therapy, but she evidently experienced renewed symptoms, in the left side of her neck and left shoulder, in November of 2001, in the process of lifting a patient in the course of her work as a CNA with Stevens Community Medical Center.
In early February 2002, on referral from her family physician, Dr. Michael Busian, Ms. Borresch was examined by neurosurgeon Dr. Anthony Bottini regarding her neck and left upper extremity symptoms, which she claimed had been present for several years and had grown severe over the course of the past year. Ms. Borresch was complaining about that same time also of pain and paresthesias in both of her hands and wrists, and Dr. Bottini anticipated both neck and carpal tunnel surgery, pending results of an EMG. Ms. Borresch underwent the EMG on February 7, 2002, which revealed mild carpal tunnel syndrome on the left and mild to moderate carpal tunnel syndrome on the right. Dr. Bottini evidently performed a two-level anterior discectomy and fusion with instrumentation at C5-6 and C6-7 on about February 12, 2002, and a right carpal tunnel decompression either on that same date or two days later. Ms. Borresch was apparently off work for about two months following these surgeries and was then released by Dr. Busian to return to work, apparently restricted at first from lifting over forty pounds and from doing any repetitious overhead work and evidently released eventually to work without restrictions.
Ms. Borresch apparently continued to experience left-side neck, shoulder, and arm pain over the course of the next year, and she was eventually referred to neurosurgeon Dr. Jeffrey Gerdes, who examined her on April 10, 2003. After reviewing her MRI scan, Dr. Gerdes referred Ms. Borresch for physical therapy and contemplated ordering a CT scan if her symptoms had not subsided within a month. After a month, Ms. Borresch complained that her symptoms were now on the right, with no reduction in her shoulder pain, and Dr. Gerdes ordered a CT scan of her cervical spine. The scan was conducted on May 29, 2003, and was read to reveal status post fusion from C5 through C7 and moderate to severe left-side foraminal stenosis at C4-5, evidently consequent to an osteophytic spur at that level. On June 23, 2003, Dr. Busian noted that the employee “continues to have significant neck and shoulder pain whenever she has to work. If she does not work the pain is less.” A left C5 nerve block on June 30, 2003, produced no immediate relief, and Ms. Borresch complained afterward of throbbing and burning in the back of her left shoulder. Dr. Gerdes reported on July 28, 2003, however, that Ms. Borresch’s neck symptoms did ultimately resolve nearly completely for three weeks, and he accordingly recommended surgical repair at C4-5. Eventually, on October 27, 2003, Dr. Gerdes performed a discectomy and fusion with instrumentation at that level, to relieve the effects of what was diagnosed as C4-5 spondylosis. Ms. Borresch was off work for a little over a month, and on December 8, 2003, Dr. Gerdes released her to full time work restricted from lifting over twenty pounds, indicating that she was released to work without any restrictions effective January 8, 2004. Ms. Borresch did not, however, return to work at all until about January 11, 2004, when she returned to part-time apparently light-duty work for the employer, evidently returning within about a month thereafter to full time work at her full duties as a CNA.
On March 12, 2004, Ms. Borresch was injured while helping to lift a patient in the course of her employment with Stevens Community Medical Center. She was fifty-nine years old on the date of her injury and was earning a weekly wage of $325.39. Ms. Borresch [the employee] experienced no immediate symptoms at the time of the injury, but within twenty-four hours she began complaining of neck pain, low back pain, and bilateral shoulder pain. On March 18, 2004, the employee sought treatment at Prairie Medical Associates, where she was seen by certified nurse practitioner Cynthia Pallesen, who released her to work restricted from lifting over twenty pounds and referred her for physical therapy. Stevens Communit y Medical Center [the employer] and its insurer acknowledged liability for a work-related injury to the employee’s left shoulder and commenced payment of benefits, including wage loss benefits and treatment expenses. In April of 2004, the employee began receiving rehabilitation assistance from qualified rehabilitation consultant [QRC] Ione Tollefson, with reference to “persisting symptoms of pain in the left side of her neck and down across her shoulder and into her shoulder blade,” which the employee related to a work injury on March 12, 2004.
Physical therapy and subacromial and subdeltoid bursal injections were apparently not successful in relieving the employee’s neck and left shoulder symptoms, and the employee was referred to Alexandria Orthopaedic Associates, P. A., where she was examined on April 22, 2004, by Dr. T. J. Kennedy. Upon examination of the employee’s shoulder, Dr. Kennedy found “full [range of motion] of the shoulder, no sign of any impingement, no pain with adduction of the arms across the chest” and “[n]o sign of any rotator cuff insufficiency.” He diagnosed neck pain probably secondary to segmental instability of the cervical spine and administered an injection into the employee’s shoulder to rule out AC joint degenerative disease as a possible factor. The injection evidently only increased the employee’s pain, and the employee was subsequently restricted from working by Nurse Practitioner Pallesen and referred back for consultation with Dr. Gerdes. On June 22, 2004, in a letter to the employee’s attorney, Dr. Busian indicated that, having reviewed the medical record of the employee’s neck symptoms in 2001, he did “not find convincing evidence o[f] relationship between [the employee’s] work duties and her neck difficulty . . . . Her employment duties very likely aggravated a pre-existing condition.” Upon examination of the employee on July 23, 2004, Dr. Gerdes concluded that the employee was not a candidate for further neck surgery, released her to work restricted from lifting over twenty pounds, and referred her to physiatrist Dr. Leslie Hillman.
Dr. Hillman examined the employee on August 10, 2004, and referred her for an MRI scan of the left shoulder, to rule out a rotator cuff tear/impingement. The MRI, taken on September 9, 2004, was read to reveal AC joint arthrosis with mild hypertrophic changes, together with various other mild, moderate, and indistinct abnormalities. Dr. Hillman ultimately diagnosed a partial rotator cuff tear and degeneration of the left AC joint and referred the employee back to Alexandria Orthopaedic Associates, where she was examined on October 12, 2004, by Dr. Patrick Hurley. Dr. Hurley diagnosed a partial rotator cuff tear/strain with AC arthrosis and subacromial impingement, and he injected the employee’s shoulder with cortisone. The injection apparently did not provide any lasting relief, and on November 10, 2004, Dr. Hurley referred the employee to his partner Dr. Jefferson Brand for surgical repair.
In a letter dated December 14, 2004, Dr. Brand wrote “To Whom it May Concern” that the employee was scheduled to have shoulder surgery, noting, “I have discussed with [the employee] that she may have permanent restrictions after this shoulder surgery on the order of not lifting more than 30-40 pounds to chest level.” On December 28, 2004, Dr. Brand performed on the employee’s left shoulder an arthroscopic subacromial decompression with excision of the distal clavicle, and the employer and insurer ultimately admitted a permanent injury to the employee’s left shoulder and paid permanent partial disability compensation for a 5% whole-body impairment, together apparently with the costs of physical therapy through February of 2005. Dr. Brand had restricted the employee from all work until March 7, 2005, and on March 1, 2005, he extended the employee’s restriction from working until April 15, 2005. On March 11, 2005, the employee underwent an MRI scan of her left shoulder, pursuant to left shoulder pain that persisted following her decompression surgery. The scan was read to reveal a partial thickness tear and superficial fraying of the supraspinatus tendon, but no convincing full-thickness tear or retraction. On April 18, 2005, Dr. Brand released the employee to work until June 18, 2005, restricted to sedentary light duty, with no lifting over ten pounds to chest level, no overhead activity, and no work to the side. On June 29, 2005, he extended those restrictions until August 25, 2005.
On July 14, 2005, the employee was examined for the employer and insurer by orthopedic surgeon Dr. Richard Strand. In his report on July 19, 2005, Dr. Strand diagnosed degenerative disc disease of the cervical and lumbar spine, bilateral carpal tunnel syndrome, and impingement syndrome of the left shoulder, status post-arthroscopic decompression. Dr. Strand opined in part that the employee’s work incident on March 12, 2004, resulted at most in a cervical strain that was a temporary aggravation, lasting no more than four weeks, of a pre-existing degenerative cervical disc disease. He concluded that there was no evidence of any current significant shoulder injury. It was Dr. Strand’s further opinion that the work incident that the employee complained of in November of 2001, together with the employee’s pre-existing degenerative disc disease and a congenital spinal stenosis, caused the employee’s need for Dr. Bottini’s two-level fusion and related permanent partial disability in February 2002, together with all of the employee’s subsequent treatment, restrictions, and wage loss, other than during a four- to six-week period immediately following her March 12, 2004, work-related aggravation. He concluded that the November 2001 injury was a permanent one, with regard to which the employee reached maximum medical improvement [MMI] by May 14, 2002. It was Dr. Strand’s further opinion that the employee’s left wrist and low back complaints were unrelated to any work injury and that her shoulder condition was “in no way related to her work situation.” Finally, it was Dr. Strand’s opinion that the employee had reached MMI with respect to “all of her claimed injuries” within four weeks of her March 12, 2004, aggravation. Dr. Strand’s report to that effect was served on the employee and her attorney on July 28, 2005. Later, on September 16, 2005, Dr. Strand wrote to the insurer’s attorney, clarifying his opinion that it was without any restrictions that the employee would have been able to return to work four weeks after her March 12, 2004, injury.
In August 2005, Dr. Brand ordered a functional capacity evaluation [FCE] and continued the employee’s work restrictions essentially unchanged until November 11, 2005, adding that the employee should also avoid repetitive activity. On October 6, 2005, he continued the employee’s restrictions again, until December 15, 2005, noting that the employee was permitted to work six hours a day five days a week. On November 17 and 18, 2005, the employee underwent the ordered FCE, which indicated in part, under a primary diagnosis of status post arthroscopic left subacromial decompression and secondary diagnoses of left wrist pain, neck pain, and stiffness, that the employee had significant deficits in elevated work, deep static crouching, prolonged standing, step ladder climbing, and balance while walking on a narrow surface. The testing indicated further that the employee could work full time within certain weight restrictions, including a restriction from lifting forty-pounds floor to waist more than occasionally. On December 7, 2005, after an examination in follow-up to the employee’s shoulder decompression surgery, Dr. Brand opined that the employee had reached MMI on that date with regard to that procedure, and he indicated that he had discussed that conclusion with the employee and QRC Tollefson. On that same date, Dr. Brand issued a Report of Workability, on which he indicated that the employee would be able to work with restrictions “per FCE” from December 7, 2005, to May 8, 2006.
A few weeks later, on December 29, 2005, on referral from Dr. Brand, the employee saw pain specialist Dr. Sam Elghor, at the Douglas County Hospital Center for Pain Management, regarding continuing complaints of pain in the left side of her neck and her left shoulder blade. In his report on that date, Dr. Elghor noted that the employee had had neck problems for several years and was status post C5-C7 fusion in 2002 and C4-C5 fusion in 2003. He noted also that the employee’s pain had been “particularly severe since March of 2004,” but he made no reference to her work injury on March 12 of that year. Dr. Elghor noted further, upon examination, that he “explained to [the employee] that there is a strong possibility that at least some of this pain is arising from her cervical facet joint,” and on that basis he recommended a “left C2-C5 diagnostic medial branch block.” He explained, “If that provides significant pain relief, i.e. more than 50%, then she will be a candidate for radiofrequency left C2-C5 facet joint denervation.”
On March 20, 2006, Dr. Strand issued a follow-up to his July 19, 2005, report. In the follow-up report, he reiterated that the employee was able to return to work without restrictions four weeks after her March 12, 2004, work injury, that the employee’s left shoulder condition was due to chronic impingement from a genetic abnormality and not to the March 12, 2004, incident, and that, even were the left shoulder injured in that incident, all disability related to that incident would have been resolved four weeks after the incident. On March 28, 2006, Dr. Brand completed a Health Care Provider Report, certifying that the employee had reached MMI on December 7, 2005, from her injury of March 12, 2004, having sustained a 5% whole-body impairment under two subparts of Minnesota Rules 5223.0450, which rates permanent partial disability in the shoulder and upper arm. The report does not indicate either a diagnosis or a history of the injury. On the following day, March 29, 2006, the employee ceased working for the employer, for reasons that are here in dispute.
On April 3, 2006, the employer issued to the employee a written offer of a permanent new position with the employer, as a part-time night clerk at an hourly wage of $9.50, with medical and life insurance benefits. The job description attached to the offer indicated that the job was generally sedentary and that lifting would be limited to ten pounds occasionally and negligible amounts frequently. The cover letter requested that the employee call the employer within a week with her decision “as to whether you will accept this position or terminate your employment with [the employer].” Two days later, on April 5, 2006, and at the request of the employee, the employer also put in writing “the fact that the light duty work you were performing is no longer available effective Thursday, March 30, 2006,” reiterating its offer of the night clerk position “that fits within your current restrictions.” After evidently reviewing the offer with QRC Tollefson and Dr. Brand on April 10, 2006, the employee declined the job on grounds that it was not within her physical abilities. In a Report of Workability on that same date, April 10, 2006, Dr. Brand indicated that, through June 10, 2006, the employee was “unable to do night clerk job” but “may do sedentary work, non-repetitive” with “minimal keyboarding.” On May 9, 2006, Dr. Brand extended those restrictions to August 9, 2006.
Subsequent to her termination, the employee applied for and was awarded unemployment compensation for twenty-six weeks. On May 15, 2006, the employee commenced about five months of job search activities under the direction of placement specialist Donna Tomczak. On June 1, 2006, the employer and insurer served Dr. Brand’s March 28, 2006, Health Care Provider Report on the employee and her attorney, also issuing on that same date a Notice of Benefit Payment and payment to the employee of permanent partial disability benefits for a 5% whole-body impairment. On June 6, 2006, in a letter to the insurer, Dr. Brand indicated that he was referring the employee back to Dr. Gerdes, for evaluation of her “neck, shoulder, and elbow pain,” which “[a]t this time appears to be related to her work injury” of March 12, 2004, “but she needs further evaluation by Dr. Gerdes for this.” On July 10, 2006, he extended the employee’s restrictions to October 10, 2006.
On July 14, 2006, the employee filed a claim petition, alleging entitlement to either temporary or permanent total disability benefits consequent to her work injury on March 12, 2004, continuing from March 28, 2006, the last day that the employee worked for the employer, together with continuing rehabilitation benefits. In addition to claiming benefits consequent to the admitted left shoulder injury, the employee also claimed benefits consequent to injuries to her neck, left arm, and back on that same date. In their answer to the claim petition on August 8, 2006, the employer and insurer admitted the left shoulder injury but denied liability for any neck, left arm, or back injury.
On October 13, 2006, Dr. Brand further restricted the employee, from working more than four hours a day. By about the end of October 2006, the services of placement specialist Tomczak were discontinued, and on November 6, 2006, QRC Tollefson filed a rehabilitation request, seeking payment of $4,127.75 in outstanding bills for rehabilitation services that she had provided for the employee since June 15, 2006. On November 10, 2006, Dr. Brand discussed with the employee possibly obtaining a repeat EMG, and he recommended that she follow up with Dr. Gerdes. Three days later, on November 13, 2006, in a letter to the insurer, QRC Tollefson concluded that the employee was permanently and totally disabled due to her work injuries of March 12, 2004. She indicated that her conclusion was based on the following: (1) continuing symptoms of debilitating pain in the employee’s neck and both upper extremities; (2) work restrictions that severely limit what the employee can do; (3) the employee’s limited transferable skills; (4) the employee’s inability to find suitable gainful employment after a diligent search and comprehensive research of her labor market, in full cooperation with Ms. Tomczak; and (5) the inadvisability of retraining.
On November 16, 2006, the employee filed a medical request, seeking approval of the repeat EMG testing of her left upper extremity that Dr. Brand had suggested, and in a medical response filed November 22, 2006, the employer and insurer objected to that request. On January 18, 2007, QRC Tollefson filed a second rehabilitation request, now seeking a total of $5,772.21 in payment of all unpaid bills for rehabilitation services that she had rendered to the employee from June 15, 2006, through January 15, 2007. An administrative conference was held on January 23, 2007, regarding the medical and rehabilitation requests in the matter, and on February 8, 2007, mediator/arbitrator Donna Olson issued orders approving both requests.
QRC Jan Lowe had met with the employee on January 3, 2007, for a vocational evaluation at the request of the employer and insurer, and on February 12, 2007, she issued her report. In that report, Ms. Lowe concluded generally that the employee’s “overall functioning is in the middle average range of vocational development with the exception of her fine finger dexterity” and that she was “best suited for positions where she is performing clerical tasks as a service to others.” Ms. Lowe indicated further that, “[c]onsidering her vocational qualifications and physical capacities as cited . . . in the Functional Capacities Evaluation, [the employee] is employable [at work including] Retail Sales Associate, Hotel Desk Clerk, Light cleaner, Dietary Aide, Food Worker, and Home Health Aide.” She went on to opine that, “[w]ithout restriction[,] as opined by Dr. Strand, [the employee] can do any type of work for which she is otherwise vocationally qualified.” QRC Lowe included in her report a labor market survey, identifying a broad range of jobs available to the employee in her geographical area, concluding, based in part on the employee’s job search logs, that “[t]here is no evidence indicating [that the employee] has performed a reasonably diligent search for employment.”
On March 6, 2007, the employer and insurer filed timely requests for formal hearing on both of the February 8, 2007, administrative decisions, and on March 19, 2007, Dr. Brand subsequently extended the employee’s restrictions into September of 2007. Issues in the employer and insurer’s requests for formal hearing were consolidated with the issues raised in the employee’s claim petition, and the matter came on for hearing on April 11, 2007. Issues at the hearing included the following: (1) whether the employee had sustained work-related personal injuries to her cervical spine, lumbar spine, or right shoulder on March 12, 2004; (2) the nature and extent of any left shoulder injury sustained by the employee on March 12, 2004; (3) whether the employee was temporarily totally disabled from March 29 to September 1, 2006, as a result of any such work injury; (4) whether the employee was barred from receipt of temporary total disability benefits for refusing an offer of gainful employment; (5) whether the employee had reached MMI from the effects of her alleged work injuries; (6) whether the employee had demonstrated a reasonable and diligent job search; (7) whether the employee had sufficient permanent partial disability to satisfy the threshold requirement for claiming permanent total disability under the statute; (8) whether the employee had been permanently and totally disabled since March 29, 2006, consequent to her alleged work injuries; (9) whether the intervenors’ claims should be denied because of their failure to appear at hearing; (10) whether the employee’s treatment at Central Minnesota Neuroscience [CMN] and the Center for Pain Management, PA [CPM], had been reasonable and necessary; (11) whether the named intervenors were entitled to reimbursement; and (12) whether $5,978.31 in unpaid bills for rehabilitation services provided to the employee by QRC Tollefson were reasonable, necessary, and causally related to the employee’s work injury.
Evidence submitted at hearing included substantial testimony from the employee, from QRC Tollefson, who essentially reiterated conclusions that she had voiced in her letter of November 13, 2006, from QRC Lowe, who essentially reiterated conclusions that she had voiced in her report of February 12, 2007, and from Karla Larson, personnel director at the employer. By findings and order filed June 11, 2007, the compensation judge concluded in part the following: (1) that the employee had demonstrated sufficient permanent partial disability related to her cervical spine and left shoulder to satisfy the threshold for permanent total disability benefits; (2) that the employee’s evaluation of neck and left shoulder pain at CMN on four specified dates had been reasonable and necessary and CMN was entitled to reimbursement for its reasonable and necessary treatment; and (3) that the employee was “likely to be precluded from returning to her preinjury job, partially as a result of her 3/12/04 injury” and was “likely to benefit from rehabilitation assistance”and that QRC Tollefson was entitled to payment of the outstanding charges for rehabilitation assistance that she had rendered to the employee. By those same findings and order, however, the judge concluded in part also as follows: (1) that the employee had failed to prove that she sustained injury to her cervical spine, right shoulder, low back or hands and arms bilaterally as a consequence of her employment on March 12, 2004; (2) that the employee had failed to prove “that she has specific work restrictions related to her 3/12/04 left shoulder injury”; (3) that the employee was not entitled to temporary total or permanent total disability benefits; (4) that the employee had failed to prove entitlement to the repeat EMG recommended by Dr. Brand; and (5) that intervenors Department of Employment & Economic Development [DEED] and CPN were not entitled to reimbursement for, respectively, unemployment benefits paid to the employee or treatment rendered or recommended by Dr. Elghor. The employee appeals.
STANDARD OF REVIEW
In reviewing cases on appeal, the Workers’ Compensation Court of Appeals must determine whether “the 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, “they 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, “[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, “unless 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. Cervical, Lumbar, and Right Shoulder Injury
At Findings 10 and 11, the compensation judge concluded that the employee had failed to prove that she sustained injuries to her neck, right shoulder, and low back consequent to her work incident on March 12, 2004. In support of this conclusion, the judge found at Finding 6 that the employee had continued to experience neck, low back, and left scapular/shoulder symptoms from her October 27, 2003, surgery until just prior to the March 12, 2004, work incident and at Finding 15 that she had failed to prove that her current neck, low back, and bilateral hand and arm symptoms were related to that incident. The employee acknowledges that she had low back, neck, and shoulder complaints prior to her March 12, 2004, work injury, but she contends that she had returned to her pre-injury employment without restrictions at least a month prior to that work injury. She argues that the employee’s neck, low back, right shoulder, and bilateral hand and arm symptoms have intensified and become chronic since the work injury, from a level three pain level to a level nine or ten, and that the judge, in reaching his decision, failed to consider factors articulated in precedent case law for determining whether a work injury has permanently aggravated or accelerated a pre-existing condition. She argues that the post March 2004 FCEs, which address the employee’s neck and low back conditions as well as her left shoulder condition, document a substantial reduction in functional capacity since the employee’s release to work without restrictions in January of 2004. Along the same lines, she argues that the medical records immediately following the March 2004 injury and for eight months thereafter document substantial treatment for to the employee’s neck, bilateral shoulders, and low back, but that these appear to have been ignored by the compensation judge. She argues further that the only contrary medical opinion in the case is Dr. Strand’s conclusion that the employee sustained a temporary strain to her neck on March 12, 2004, which resolved no more than four weeks later - - which opinion, the employee argues, is unfounded and unsupported. She argues further that Dr. Strand himself, in his March 20, 2006, report, agreed that the employee eventually returned to work unrestricted after her 2002 and 2003 neck surgeries. Finally, she reminds the court that a work injury, to be compensable, need not be the only cause of a continuing condition, only a substantial contributing factor in it. We are not persuaded.
The burden is on the employee to prove by a fair preponderance of the evidence that she is entitled to workers’ compensation benefits. Minn. Stat. § 176.021, subd. 1 and 1a; Fischer v. Saga Corp., 463 N.W.2d 501, 501, 43 W.C.D. 559, 560 (Minn. 1990). In this case, there is evidence which, if accepted by the compensation judge, would support a finding of a neck, low back, and right shoulder injury. That evidence includes the employee’s testimony, the FCE, and the employee’s treatment records. The issue on appeal, however, is not whether the evidence of record will support a result different from that reached by the compensation judge but whether the evidence of record will support the result actually reached by the judge. See Minn. Stat. § 176.421, subd. 1. As indicated earlier, substantial evidence supports a finding of the judge if, in the context of the entire record, it is supported by evidence that a reasonable mind might accept as adequate. Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239. In this case, the judge’s conclusion was not unreasonable.
In a very thorough memorandum accompanying his findings and order, the compensation judge noted that the employer and insurer’s defense to the employee’s claims was primarily based on the employee’s significant preexisting medical history. Although the employee returned to her normal job duties following her October 27, 2003, fusion surgery, the judge noted that Dr. Gerdes had prescribed additional physical therapy in December 2003, based on the employee’s complaints of sharp and persistent left-side neck pain. And, importantly for the judge, the employee conceded on cross-examination that she continued to experience ongoing neck pain, left shoulder pain, and low back pain during the period following her surgery through early March 2004.
The judge noted also that the employee offered no objective evidence of new pathology to her cervical spine, lumbar spine, or right shoulder after March 12, 2004. The employee acknowledged that her pain after this incident was in the same areas as those where she had experienced pain previously, although she testified also that the level of that pain was greater. The judge was not required to accept the employee’s testimony as to the level of the pain. Assessment of the credibility of a witness is the unique function of the trier of fact. Even v. Kraft, Inc., 445 N.W.2d 831, 835, 43 W.C.D. 220, 225 (Minn. 1989); Brennan v. Joseph G. Brennan, M.D., P.A., 425 N.W.2d 837, 839-40, 41 W.C.D. 79, 82 (Minn. 1988).
Although the judge did not cite specific case law in analyzing whether the employee permanently aggravated her preexisting conditions, it is quite apparent from the judge’s lengthy memorandum that he did, in fact, carefully consider the nature and severity of the employee’s medical condition both before and after the incident of March 12, 2004. The judge noted that the employee presented a very complicated medical picture, with multiple surgeries, permanent disability, and acknowledgment of ongoing symptoms just prior to the injury in question. Given the employee’s troubling medical history, the judge found it important that the employee failed to present “a reasoned causation opinion based upon thorough review of all of the salient facts.” On that basis, and for the other reasons stated, the judge concluded that the employee had failed to prove by a preponderance of the evidence that her current symptoms of neck pain, low back pain, and right shoulder pain are substantially related to her March 12, 2004, work-related incident. Having thoroughly reviewed the entire record in this matter with a great deal of care, we conclude that this factual determination of the judge was not unreasonable, and so we affirm it. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
2. Specific Restrictions and Wage Replacement Related to the Left Shoulder Injury
At Finding 16, the compensation judge concluded that the employee had “failed to prove . . . that she has specific work restrictions related to her 3/12/04 left shoulder injury.” At Finding 13, the judge concluded also that the employee reached MMI from the effects of her left shoulder injury at her December 7, 2005, office visit with Dr. Brand, was effectively served with Dr. Brand’s opinion to that effect at the time of that visit, and so was not entitled to temporary total disability benefits after March 6, 2006. At Finding 17, the judge concluded that a significant portion of the employee’s job search had been directed toward jobs that she was clearly not qualified to perform. At Finding 18, the judge concluded also that the employee had failed to prove that she was unable to secure more than sporadic employment resulting in an insubstantial income as a substantial result of her March 12, 2004, injury and so was not entitled to permanent total disability benefits. Pursuant to these conclusions, the judge also concluded, at Finding 21, that intervenor DEED was not entitled to reimbursement for unemployment benefits paid from about May 14, 2006, to November 11, 2006. The employee contends that the judge’s denial of wage replacement benefits and reimbursement to DEED are unsupported by substantial evidence. With regard to the judge’s conclusion as to specific restrictions, she argues primarily that the judge’s finding is in conflict with the judge’s unappealed conclusion at Finding 25, that the employee is “likely to be precluded from returning to her preinjury job, partially as a result of her 3/12/04 injury,” also quoting Dr. Brand’s restrictions on two dates and anticipated restrictions on a third. With regard to the judge’s denial of temporary total disability benefits in particular, the employee argues that the judge committed an error of law in finding service of MMI by the doctor’s mere discussion of the topic with the employee at an office visit. With regard to the judge’s denial of permanent total disability benefits in particular, the employee argues that the she has always cooperated fully with rehabilitation assistance in her job search and that the adverse vocational examiner has provided no evidence that any position exists in the employee’s labor market that is within her physical restrictions. We are not persuaded.
Near the end of the section titled “3/12/04 Injury - Nature and Extent” in his very substantial and detailed memorandum, the compensation judge states as follows:
This is a very complicated medical picture with multiple surgeries, permanent disability and acknowledgment of ongoing left-sided neck pain just prior to the injury in question.
In the absence of a reasoned causation opinion based upon thorough review of all of the salient facts I cannot find that the employee has met her burden of proof.
While the context of this statement is the judge’s denial of the employee’s claim to benefits based on her neck, low back, and right shoulder condition, it appears also applicable to his conclusion, in Finding 16, that the employee “failed to prove . . . specific work restrictions related to her 3/12/04 left shoulder injury.” We acknowledge that the employee has been subject to continuously renewed restrictions from essentially the date of her work injury to the date of the hearing. It is impossible for us to determine, however, as it apparently was also for the judge, which, if any, of those restrictions are related to her compensable left-shoulder work injury and which, if any, are related to her neck, low back, bilateral arm and wrist, and right-shoulder conditions, which the judge affirmably found to be noncompensable. Nor is it entirely clear, given the very conflicting testimony of the two opposing medical experts, that those restrictions are a substantial contributing factor in the employee’s unemployment. The judge’s conclusion in Finding 16 does not appear to us to have been unreasonable.
We acknowledge also that there does, as the employee has argued further, appear to be some conflict between the judge’s award of rehabilitation benefits, based on a conclusion in Finding 25 that the employee is “likely to be precluded from returning to her preinjury job, partially as a result of her 3/12/04 injury,” and the judge’s conclusion in Finding 16 that the employee failed to prove specific restrictions related to her work injury. Our task here on review, however, is to assess whether substantial evidence exists to support the appealed conclusion in Finding 16, not the unappealed conclusion in Finding 25. The employer and insurer have not elected to contest the judge’s award of payment to QRC Tollefson for her services or his findings supportive of that award, and, as such, the evidentiary support for those findings is beyond the purview of this court. The judge’s findings as to MMI and job search, in Findings 13 and 14, respectively, are in effect rendered moot by our affirmance of the judge’s conclusion as to injury-related restrictions in Finding 16, and the judge’s denials of wage replacement are accordingly affirmed. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
3. Recommended EMG, Dr. Elghor’s Treatment, and the Recommended Cervical Nerve Block
At Finding 19, the compensation judge concluded that a repeat EMG of the employee’s left upper extremity, as recommended by Dr. Brand, was reasonable and necessary, but he concluded also that the need for one had not been shown to be substantially related to the employee’s work-related left shoulder injury of March 12, 2004. At Finding 24, the judge also found that Dr. Elghor’s December 29, 2005, treatment and recommendation of a C2-C5 medial branch block were similarly not shown to be related to the employee’s left shoulder injury, Dr. Elghor’s suspicion at the time having been that the employee’s neck and left shoulder pain originated in her cervical spine. The employee contends that both the proposed EMG and the actual and proposed treatment of Dr. Elghor are diagnostic in nature, intended to “rule out” possible nonwork-related causes of the employee’s symptoms, and that, according to precedent case law, such diagnostic medical treatment is compensable. We are not persuaded.
We acknowledge that this court has awarded payment for diagnostic treatment that is designed to rule out non-work-related causes for an injured worker’s symptoms. See, e. g., Klaven v. Northwest Med. Ctr., slip op. (W.C.C.A. Sept. 24, 1991). Such a “rule-out” situation appears here, however, not to have been entirely the case. The cervical nerve block recommended by Dr. Elghor, for instance, appears not to have been intended to rule out the possibility of a cervical cause for the employee’s symptoms but instead to actually treat symptoms presumed to be originating in the employee’s cervical spine. It was clearly reasonable for the compensation judge to conclude that Dr. Elghor intended by the procedure to be treating a presumed origin of pain, not simply ruling out an alternative one, and contemporaneous records of Dr. Brand suggest that that also was the basis for Dr. Brand’s referral to Dr. Elghor in the first place.
Similarly, the judge indicated in his memorandum that the EMG also appeared to be intended to determine the source of the employee’s ongoing neck, arm, and wrist pain. He explained that, although Dr. Brand had noted positive impingement testing in the employee’s shoulder and an MRI had demonstrated some progression in the employee’s condition, it did not appear that Dr. Brand was considering any additional shoulder surgery. That inference by the judge was not unreasonable, given Dr. Brand’s recommendation at the time that the employee follow up with neurosurgeon Dr. Gerdes. The judge evidently believed that the EMG was directed solely toward evaluating symptoms which have not been demonstrated to be causally related to the March 12, 2004, injury. The judge’s conclusion that the employee failed to prove that her March 12, 2004, left shoulder injury substantially contributes to her need for a repeat EMG, a cervical nerve block, or her examination by Dr. Elghor was not unreasonable and so is affirmed. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
This is an extremely complex case medically, and it is clear from his extensive and detailed findings and order and memorandum that the compensation judge considered it very carefully and thoughtfully. It is in nearly every regard a very fact driven case, and we cannot say that the conclusions of the factfinder are unreasonable. Hence, we have affirmed. See Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.
 This incident, which is not referenced in any treatment record in evidence, is eventually reported in the July 19, 2005, independent medical evaluation report of Dr. Richard Strand in this matter, where it is identified as a specific injury reported to Dr. Strand by Ms. Borresch. Hearing was eventually held on March 30, 2006, on the employee’s entitlement to temporary benefits from the employer that is also here a party, based on a Gillette-type injury, see Gillette v. Harold, Inc., 257 Minn. 313, 101 N.W.2d 200, 21 W.C.D. 105 (1960), on July 1, 2001, and/or a specific injury on November 2, 2001. The employee’s claims in that litigation were denied in their entirety by findings and order filed June 6, 2006.
 We do not find the actual surgical reports in evidence, and references to the surgeries in other medical records are somewhat ambiguous. It appears from the medical record that the employee continued to be treated for carpal tunnel syndrome at least through November 27, 2006, when she complained on an “Ultimate Carpal Tunnel Syndrome Relief Program Application Form,” at Back to Health Acupuncture and Chiropractic Center, that, in addition to other pain throughout most of her body, she had very severe “pain from neck down both arms & wrists” and “wrist pain, bilateral.”
 See Footnote 1.
 The employee contends that she was terminated by the employer on grounds that it had no work for her within her restrictions; the employer and insurer contend that the employee gave notice on that date that she expected to be settling her case the following day and was no longer intending to continue work at the job.
 As the compensation judge notes in his memorandum, there is no office note from Dr. Brand in this regard, but both the employee and QRC testified to this effect, and in her case notes for April 10, 2006, QRC Tollefson reports that “[o]n this date I met with [the employee] and I consulted with Dr. Brand during her appointment with him,” that they “discussed [the employee’s] job search,” and that “[s]he has an interview scheduled tomorrow at the Salvation Army but she is concerned that these duties will not likely be within her restrictions.” There is no mention of the employer’s job offer in QRC Tollefson’s note, but in what appear to be case notes of placement specialist Donna Tomczak there is a note on April 4, 2006, to the effect that the employee “has received a job offer from the hospital and has discussed it with her QRC” and that they “[w]ill be discussing it with her physician during her 4/10/06 appointment.”
 Ultimately by a Findings of Fact and Decision dated July 5, 2006.