JENNIFER E. KALLESTAD, Employee/Appellant, v. OLD DUTCH FOODS, INC., and CHUBB & SON GROUP, Employer-Insurer, and BLUE CROSS BLUE SHIELD OF MINN., TWIN CITIES BAKERY WORKERS HEALTH & WELFARE FUND, PRIMARY BEHAVIORAL HEALTH CLINICS, INC., and TWIN CITIES SPINE, Intervenors.
WORKERS’ COMPENSATION COURT OF APPEALS
FEBRUARY 27, 2009
CAUSATION - TEMPORARY INJURY; CAUSATION - PSYCHOLOGICAL INJURY. Substantial evidence, including expert opinion, supported the compensation judge’s decision that the employee’s work-related low back injury was merely temporary and that the employee’s subsequent psychological condition and need for treatment were not causally related to the employee’s work-related back injury.
Determined by: Wilson, J., Rykken, J., and Johnson, C.J.
Compensation Judge: Patricia J. Milun
Attorneys: John J. Horvei, Attorney at Law, St. Paul, MN, for the Appellant. Thomas F. Coleman and Whitney L. Teel, Cousineau McGuire, Minneapolis, MN, for the Respondents.
DEBRA A. WILSON, Judge
The employee appeals from the compensation judge’s decision denying benefits related to the employee’s ongoing low back and psychological problems and need for treatment. The employee also asks this court to consider new causation evidence on appeal. We deny the employee’s request that we reconsider new evidence, and we affirm the compensation judge’s decision.
The employee was born on August 29, 1953, and was 54 years old on the date of hearing. She attended special education classes and earned poor grades but ultimately graduated from high school. Testing over time disclosed full-scale IQ scores between 69 and 76, and the employee has significant trouble reading and writing. Her work history consists primarily of factory work and other unskilled employment.
The employee has a history of depression dating back to at least the early 1990s. Treatment included several hospitalizations for severe depression and anxiety, and the employee apparently made at least one suicide attempt. Precipitating traumatic incidents noted in the employee’s mental health records include a sexual assault, emotional abuse by her husband, a stormy divorce, the death of a son in an automobile accident, and significant financial problems.
In 1994, the employee was hired to work on the packaging line at Old Dutch Foods, Inc. [the employer]. The work was relatively light but required a moderate amount of bending, twisting, and repetitive upper extremity use. She sustained several work-related injuries during the course of her employment there, including a slip-and-fall injury in 1995, after which she treated for neck and thoracic pain, a back injury in 2001, allegedly occurring when the employee was struck in the back by a heavy gate, and a knee injury in 2003. The employee was ultimately able to return to her usual job, without restrictions or ongoing treatment, following each of these injuries. Medical records reflect that the employee also received treatment for a multitude of other conditions and injuries, both before and during her employment with the employer.
In late October of 2004, the employee was seen by Dr. Thomas Barringer, complaining of having experienced pain in the “posterior right upper pelvis” for the past two years, with “some pain that goes down the leg.” Dr. Barringer noted pain and tenderness at about the SI level of the employee’s spine, and he recommended an MRI scan “because of some atypical features, including waking at night and worsening after two years.” However, before the test could be performed, the employee sustained an injury at work.
On November 9, 2004, the employee slipped and fell on a wet cement floor at work, landing on her back and striking her head on the floor. That same day she was seen at Columbia Park Medical Group for head and low back pain. Two days later, she was evaluated at the clinic by Dr. Sean Flood, from whom she had received treatment for a previous injury. After a few weeks, the employee reported experiencing bilateral leg pain. She was subsequently treated with medication and physical therapy and was off work intermittently due to her symptoms into December of 2004.
On January 7, 2005, the employee returned to see Dr. Flood, who indicated that she was “much improved,” with minimal back pain, and that she was no longer using any medication related to her low back condition. Orthopedic, sensory, and motor testing were all normal, and Dr. Flood’s assessment was “lumbosacral strain, low back pain with sacroilitis, all vastly improved.” He further indicated that the employee was at maximum medical improvement, that she could work without restrictions, and that she had 0% permanent partial disability due to her injury.
The employee testified that she subsequently performed her usual job for the employer but that she continued to experience low back pain, an account corroborated at hearing by family members and a former coworker. The employee’s supervisor testified, however, that the employee did not complain to him of ongoing low back pain, that he saw no limping or any other signs that the employee was experiencing symptoms, and that none of the employee’s coworkers had informed him about any problems that the employee might have been having with her back. In any event, it is undisputed that, after her January 7, 2005, appointment with Dr. Flood, the employee did not seek further treatment for low back symptoms for nearly a year.
On July 12, 2005, the employer terminated the employee for excessive absenteeism. Later that same day, the employee was also terminated from a second, part-time job at an automobile dealership when she was involved in a minor motor vehicle accident. Her claim for unemployment compensation was apparently denied. She subsequently defaulted on her Chapter 13 bankruptcy plan and was forced to move out of her home and live with her daughter.
The employee testified that she was very upset by the loss of her jobs and resulting financial problems, and, in August of 2005, she was admitted to Mercy Hospital for treatment of depression. Records indicate that the employee specifically denied having any physical complaints at the time of her admission to the hospital. She continued with outpatient psychiatric treatment after her discharge, and records from this treatment contain few if any references to low back complaints over the next several months. Rather, records refer repeatedly to the employee’s loss of her jobs and related financial stress.
In December of 2005, the employee sought treatment for tailbone pain and “feelings that it is running down part of her right thigh,” which, records indicate, the employee believed might be due to a work injury, l“in which she fell most recently in 06/2005.” The pain down her leg was noted to have been present for the past week. The employee was also complaining of numbness in both hands. The following month, on January 10, 2006, the employee was seen by Dr. Danny Dunsworth. Dr. Dunsworth’s notes from this evaluation read in part as follows:
The patient is a 52-year-old female who comes in complaining of pain and discomfort in her lower lumbar area. She states that she has had this for months after she fell landing on her back and buttocks area. She did not hit her head. She had no loss of consciousness. This occurred in June of 2005, she believes. She did not see any physicians. However, she states that recently she has had difficulty standing, walking and sitting. It is getting somewhat worse and then she has some discomfort into her right buttocks and to the right upper leg area. This occurs off and on. She denies any severe numbness going into her legs. She has tried some Motrin which has not been helping her, and when she stands long periods of time the pain becomes worse. She has been using some heat which does alleviate some of the discomfort. She has also been trying some Naprosyn which does not help as much. The patient has difficulty in ambulating as well as bending and twisting. She has not had any back surgery. However, she has had some previous back injuries in the past.
The employee subsequently underwent a CT and an MRI scan of her lumbar spine and was evaluated or treated for low back and leg symptoms by several other physicians, including Drs. Joseph Flake and Manual Pinto. The scans disclosed multilevel degenerative changes and/or bulging discs. When the employee complained of increasing symptoms despite conservative treatment, Dr. Pinto recommended a multilevel fusion procedure. The employee also continued to receive treatment for psychological problems, and, over time, the employee’s psychological treatment records began to contain more frequent references to low back pain and resulting disability, in addition to continued references to the effects of the employee’s loss of employment.
The employee claimed entitlement to various benefits as a result of the November 9, 2004, low back injury, including wage loss benefits, rehabilitation assistance, permanent partial disability benefits, and medical expenses, including expenses relating to the fusion surgery proposed by Dr. Pinto. The employee also claimed that she had developed a psychological condition, namely, chronic pain syndrome and depression, as a result of the November 9, 2004, incident. The employer and insurer admitted that the employee had sustained a work-related injury on November 9, 2004, but asserted that the injury was merely temporary and was not a substantial contributing cause of the employee’s condition or disability for the period at issue. The employer and insurer also denied that the employee had developed a psychological condition as a result of the injury. Seven witnesses testified at the two-day hearing, including the employee, the employee’s sister, a former coworker, the employee’s ex-husband, the employee’s former supervisor, and a QRC. Other evidence submitted at hearing included the employee’s extensive medical records and deposition testimony from Drs. John Cronin, Thomas Gratzer, Paul Wicklund, and Robert Wengler.
In a decision issued on August 6, 2008, the compensation judge determined, in part, that the November 9, 2004, work injury was merely temporary and had resolved by January 7, 2005. The judge also concluded that the November 2004 work injury was not a substantial contributing cause of the employee’s subsequent psychological condition, chronic pain syndrome, or need for related treatment. The employee appeals.
STANDARD OF REVIEW
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 (2008). 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, 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 evidence or not reasonably supported by the evidence as a whole.” Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).
1. New Evidence
In connection with her appeal, the employee submitted a letter from Dr. Manual Pinto, addressing the issue of causation, dated October 29, 2008, more than two months after the compensation judge issued her decision, and an undated causation letter from Dr. Dunsworth, which was similarly not submitted to the compensation judge. In an affidavit, the employee indicated that she had insisted to her attorney that he attempt to have these reports considered for purposes of her appeal.
This court is generally limited to reviewing the record as submitted to the compensation judge, Minn. Stat. § 176.421 subd. 1(3), and the employee has offered no legal or factual basis to justify our consideration of the new evidence. The reports at issue are merely cumulative, in that the employee submitted other expert testimony and reports on causation to the compensation judge. We therefore reject the employee’s request to have the additional evidence considered on appeal.
2. Causation - Low Back
Medical evidence as to causation for the employee’s low back condition is extensive and includes the employee’s treatment records and the deposition testimony and reports from Dr. Wicklund and Dr. Wengler. Dr. Wengler concluded that the employee is suffering from multilevel degenerative disc disease and herniations at two or three lumbar levels, and he tied this condition to the employee’s November 9, 2004, fall at work. Dr. Wicklund, on the other hand, concluded that the employee has only minimal degenerative disc disease, appropriate to her age, that her pain complaints are not related to any orthopedic findings, and that her low back condition is not causally related to the November 9, 2004, incident.
In her findings, the compensation judge found Dr. Wengler’s opinion unpersuasive, explaining that Dr. Wengler had been unaware that a lumber MRI scan had been recommended only weeks before the employee’s November 9, 2004, injury. The judge also observed that Dr. Wengler had based his opinion “predominantly” on “the employee’s representation . . . that her back pain was caused by the work injury of November 9, 2004.” Then, after explaining her view of Dr. Wengler’s opinions, the compensation judge found as follows:
The Compensation Judge accepts the medical opinions of Dr. Flood as well as the medical opinions contained in the records from Columbia Park Medical Group over the medical opinions of Dr. Wengler and finds the employee sustained a temporary aggravation to the lumbar spine on November 9, 2004, that resolved by January 7, 2005.
In a footnote to this same finding, the judge went on to explain,
The evidence presented at hearing failed to establish that an underlying pathology was present and causally related to a designated work injury. The absence of medical treatment to the back for over ten months is significant. On December 8, 2005, the employee was seen for complaints of pain that are, more likely than not, a development of a new onset of right leg pain rather than a recurrence of a long standing problem that was permanently aggravated by either work-related injury.
The judge did not expressly accept or reject the opinion of Dr. Wicklund.
On appeal, the employee argues that the compensation judge erred in rejecting testimony from three witnesses indicating that the employee continued to experience low back pain after her last visit with Dr. Flood on January 7, 2005; that the judge erred in rejecting Dr. Wengler’s opinion; and that the office records and opinions of Dr. Flood through January 7, 2005, have no “foundation” relative to diagnoses and treatment rendered by other providers after that date. The employee also suggests, repeatedly, that, because she was not involved in any “intervening” incident after January 7, 2005, her subsequent low back symptoms must be related to her November 9, 2004, fall. We are not persuaded.
The January 7, 2005, treatment notes and MMI opinion of Dr. Flood reasonably indicate that it was his opinion that the employee had effectively recovered from her November 2004 work injury by that date. All findings on examination were normal. While the employee and other witnesses testified that the employee continued to experience symptoms thereafter, the fact remains that the employee worked her usual job without restrictions or additional low back treatment until her termination for absenteeism in July of 2005. Even after her termination, the employee did not seek treatment for any low back symptoms for at least five more months, she specifically denied any physical problems on her psychiatric admission in August of 2005, and her subsequent psychiatric treatment records contain few if any references to low back pain until early 2006. It is reasonably inferable from her extensive treatment records that the employee does not generally hesitate to seek medical care when she is experiencing symptoms. As such, the employee’s failure to seek treatment for low back symptoms, over the course of nearly a year, can be viewed as significant.
As for the employee’s other arguments, the compensation judge was not required to comment on the testimony of the employee’s relatives or coworkers, she was entitled to find Dr. Wengler’s opinion unpersuasive for the reasons specified,  and the fact that the employee was not involved in any intervening incident does not automatically establish that her low back condition was causally related to her fall at work. It is again noteworthy in this regard that an MRI had been recommended, because of a reported two-year history of symptoms, only a couple of weeks prior to the employee’s work injury.
Finding substantial evidence in the record as a whole to support it, we affirm the judge’s finding that the employee’s November 9, 2004, work-related low back injury was merely temporary, ending on January 7, 2005, in accordance with the report of Dr. Flood.
3. Causation - Psychological Condition
As previously noted, the employee has a history of treatment for psychological problems dating back to at least the early 1990s. Following her termination from employment in July of 2005, she resumed psychiatric care, and she was hospitalized for several days, for psychiatric treatment, in August of 2005. Records relating to this treatment were submitted into evidence, as were the deposition testimony and reports of Dr. Cronin and Dr. Gratzer.
Dr. Cronin testified that the employee is suffering from a pain disorder associated with both psychological factors and a general medical condition, that is, chronic pain syndrome, as well as a dysthymic disorder, that is, a lower-grade, long term depression. He further concluded that these conditions were causally related to the November 9, 2004, work injury. In contrast, Dr. Gratzer diagnosed the employee with major depression, recurrent but in remission, and a long-standing, generalized anxiety disorder, both of which diagnoses he found to be unrelated to the work injury. Explaining his decision as to the lack of causal link between the employee’s psychological condition and the work injury, Dr. Gratzer testified as follows:
I would say that one issue would be that she didn’t have depressive symptoms following the work injury. Number two, she wasn’t seeking medical treatment for back pain complaints at the time she developed depression in July, 2005. Number three, her psychiatric records make minimal reference to back complaints when treating for her depression. Number four, her depression started on July 15, 2005 when she in fact was terminated and she identifies that as the stress leading to her depression, and that’s consistent with her records, and number six, her depression remitted in the spring of 2006 and has remained stable since that time.
It’s my understanding that she currently is having back pain complaints at a time when her depression is in remission, again indicating a lack of temporal correlation, so my opinion would be that the back injury of 11-9-04 was not a substantial contributing factor to her major depression.
As to what he did attribute the employee’s depression, Dr. Gratzer explained,
Well, I think the pattern is that if she developed depression principally in connection with interpersonal loss which could include job termination, her ex-husbands or death of her son, to a lesser extent the records might indicate a depression in the context of financial stresses and perhaps gambling problems.
Her pattern is not that she developed depression in the context of work injuries. It is more that she develops in the context of interpersonal loss, and that’s what you would expect, because her mixed personality traits, she struggles I think with issues of - - by her own account with issues of loneliness, lack of support, being somewhat of a people pleaser, so issues of interpersonal loss probably bring out these dynamics in her childhood where she has a less than ideal childhood and parental pathology, so that is a trigger for her depression in the past and I believe was a trigger for her current depression with the job termination.
In findings relevant to this issue, the compensation judge expressly concluded that there was no evidence that the employee had depressive symptoms, after her November 9, 2004, work injury, until her termination from both of her jobs in July of 2005; that, more likely than not, the employee developed depression “in the context of interpersonal loss and not work-related injuries”; and that low back pain from a work injury “was not contemporaneous with the psychosocial stressors that triggered a major depressive episode or chronic pain syndrome.”
The judge also concluded that, while the employee suffers from a “chronic pain syndrome, superimposed on a major recurrent depressive disorder with mixed personality traits and borderline intellectual functioning,” the employee’s work injury of November 9, 2004, was not a substantial contributing cause of either the chronic pain syndrome or the major depression. Finally, the judge expressly accepted the causation opinion of Dr. Gratzer over that of Dr. Cronin.
On appeal, the employee argues primarily that, because Dr. Cronin and Dr. Gratzer rendered different diagnoses, and the compensation judge apparently accepted at least part of Dr. Cronin’s opinion concerning the specific nature of the employee’s psychological condition, the judge could not reasonably rely on the opinion of Dr. Gratzer for purposes of causation. That is, the employee contends that, because the compensation judge concluded that the employee is suffering from chronic pain syndrome, which Dr. Gratzer did not diagnose as one of the employee’s problems, Dr. Gratzer’s opinion cannot be used to justify the conclusion that the employee’s chronic pain syndrome is not related to her work injury. As the employee puts it, the “issue is whether [the employee] has suffered a consequential emotional reaction to her low back injury and continuing pain therefrom in the nature of chronic pain syndrome.” Furthermore, according to her brief, the employee is not claiming that her “major depression, recurrent,” is related to her work injury. While the employee’s argument on this issue is not entirely without merit, we conclude that the compensation judge’s decision is nevertheless supported by substantial evidence in the record as a whole.
First and perhaps foremost, the judge concluded that the physical effects of the employee’s work injury had ended by January 7, 2005, and we have affirmed her decision to that effect on appeal. As such, any orthopedically-based chronic pain that she later sought treatment for was not related to the work injury at issue. In other words, the “general medical condition” component of Dr. Cronin’s chronic pain syndrome diagnosis is not causally connected to the employee’s work injury. Second, Dr. Cronin specifically testified that his opinion on causation was based on the assumption that the employee had experienced chronic low back pain and leg pain ever since the November 9, 2004, injury, an assumption rejected by the judge.
In addition, contrary to the employee’s suggestion on appeal, the hearing record rather clearly indicates that the employee was in fact claiming that she had developed depression as a result of her work injury. And, because of the bulk of the employee’s psychological care immediately following her termination was directed toward that depression, it was not unreasonable for the compensation judge to focus on and make findings relevant to that condition.
The medical and psychiatric evidence in this case was extensive and complex, and we are sympathetic to the employee’s complaint about the compensation judge’s failure to include any memorandum explaining her decision. Clearly, further explanation would have been helpful. However, we conclude that the compensation judge’s findings are sufficient for review purposes, and the record as a whole reasonably supports the conclusion that, whatever the specific nature of the employee’s current psychological problems, those problems are not substantially related to the November 9, 2004, work injury. We therefore affirm the judge’s decision in its entirety.
 Testing also revealed a large cyst in the employee’s cerebellum. Records suggest that the employee’s impaired intellectual functioning may be related to this condition.
 Including such things as a shoulder injury, chest and arm pain, bronchitis, asthma, ankle sprain, fatigue, a concussion, tennis elbow, cervical dysplasia, and a foot injury.
 Under the employer’s attendance policy, employees are subject to termination for 10 unexcused absences in a 12-month period. The absence that put the employee over the limit was related to time off due to dental work. The employee’s job was a union position, and there is no argument that the employee was terminated improperly under the union contract or that her termination was in any way related to the November 2004 work injury.
 A compensation judge need not discuss every piece of evidence submitted at hearing. See, e.g., Smith v. The Press, slip op. (W.C.C.A. Apr. 27, 1995).
 And, we emphasize, the judge did not expressly reject Dr. Wengler’s opinion on foundation grounds but instead merely found it unpersuasive.
 Because of our findings on causation, we need not address certain other issues raised in the employee’s brief, such as maximum medical improvement and the compensability of the proposed fusion surgery.