AWIL MOHAMED, Employee, v. VIRACON, INC., and INSURANCE CO. OF THE STATE OF PA./SEDGEWICK CMS, Employer-Insurer/Appellants, and PRIMARY BEHAVIORAL HEALTH CLINIC, Intervenor.
WORKERS’ COMPENSATION COURT OF APPEALS
JANUARY 4, 2013
PERMANENT PARTIAL DISABILITY - PSYCHOLOGICAL CONDITION. Substantial evidence supports the compensation judge’s award of a 27% permanent partial disability for the employee’s psychological condition based on the employee’s treating psychologist’s rating pursuant to Weber v. City of Inver Grove Heights, 461 N.W.2d 918, 43 W.C.D. 471 (Minn. 1990) by analogy to Minn. R. 5223.0360, subp. 7.D., items (2) and (3).
PERMANENT TOTAL DISABILITY - SUBSTANTIAL EVIDENCE. Substantial evidence, including the adequately founded opinion of the employee’s treating psychologist, a licensed psychologist that conducted vocational psychometric testing, and a qualified rehabilitation consultant, supports the compensation judge’s finding that the employee has been permanently and totally disabled since his work-related accident on December 18, 2008.
Affirmed in part and reversed in part
Determined by: Johnson, J., Wilson, J. and Hall, J.
Compensation Judge: Kathleen Behounek
Attorneys: Michael G. Schulz, Sommerer & Schultz, Minneapolis, MN, for the Respondent. Thomas V. Maguire, Brown & Carlson, Minneapolis, MN, for the Appellants.
THOMAS L. JOHNSON, Judge
The employee, Awil Mohamed, was born in Somalia and moved with his family to Kenya at approximately age 8. He attended school through the second grade in Somalia and again in Kenya for approximately one and one-half years. The employee emigrated to the United States in October 2001. After arriving in the United States, the employee attended English as a second language classes and learned to read and write English on a limited basis.
The employee lived in Owatonna, Minnesota, after coming to the United States. He had two jobs prior to his employment with the employer doing meat processing and assembly work. The job duties were physical and required the use of both hands.
The employer began working for the employer, Viracon, Inc., in December 2007, assembling windows. He used both hands and was required to lift up to 30 to 40 pounds on a repetitive basis. On December 18, 2008, the employee suffered an injury to his right hand when it was caught in rollers and pulled into a window processing machine. The employee sustained a severe crush injury to the hand with degloving of the index finger, neurovascular damage to the thumb, and a fracture dislocation through the proximal interphalangeal (PIP) joint of the middle finger. The employee was transported to the Mayo Clinic where emergency surgery including a partial amputation of the right index finger, fasciotomies, a carpal tunnel release, and stabilization of the middle finger was performed.
The employee came under the care of Dr. Alexander Shin, an orthopedic surgeon and director of the Hand Clinic at the Mayo Clinic. The employee underwent five additional surgeries between December 21, 2008, and January 6, 2009, including partial amputation of the thumb, a revision amputation of the index finger at the metacarpophalangeal (MCP) joint, pinning of the middle finger, and a skin graft in the dorsal aspect of the thumb and hand.
In January 2009, the third party claims administrator, Sedgwick CMS, referred the case to Mary Aydt, a registered nurse and qualified rehabilitation consultant (QRC), for a rehabilitation consultation and medical management. The employee was living with his father in the Twin Cities during his recovery, and met with Ms. Aydt on January 13, 2009. He reported burning pain in the right hand and was taking Oxycodone and Vicodin for pain.
The employee participated in physical and occupational therapy two to three times a week to address markedly decreased motion and stiffness and sensitivity and pain in his hand and fingers. The employee had two additional surgeries in February 2009. In March 2009, Dr. Shin stated the employee would not be able to return to his preinjury job. Two more surgeries were performed in April 2009, including removal of the skin graft due to infection. On May 6, 2009, Dr. Shin, concerned about the degree of pain the employee was experiencing, referred him Dr. Keith Bengston for a pain consultation. Dr. Bengston noted the employee had severe sensitivity at the index finger stump and constant pain in the palm of the hand at the base of the thumb. He prescribed Tramadol for pain as needed.
In June 2009, the employee moved permanently to the Twin Cities. He began physical therapy at NovaCare Rehabilitation, working on improving functional use of the right hand. He continued to need assistance with activities of daily living. On September 29, 2009, the employee underwent yet another surgery consisting of a ray resection and neurectomy of the index finger, MCP capsulotomies and pinning of the third and fourth fingers, and debridement and partial amputation of the thumb. He continued in physical therapy to address pain, stiffness, and functional use of the hand.
On November 12, 2009, the physical therapist suggested referral to a psychologist to help with emotional problems stemming from the accident. The employee was seen by Dr. Shin on November 23, 2009, who noted the employee continued to have significant discomfort in the radial aspect of the third finger and severe pain to light touch consistent with neuroma formation. The doctor also noted the employee was having issues with post-traumatic stress and was interested in seeing a psychologist or psychiatrist. Dr. Shin imposed work restrictions of no use of the right hand for the next six weeks, and prescribed Tramadol.
During November 2009, Ms Aydt explored a return to work with the employer and vocational testing was completed. The employee needed considerable explanation regarding instructions for the tests and completed the testing very slowly. Barriers to a return to work were identified including no realistic transferable job skills within his physical capacities, below average aptitudes in all tested areas, and cultural and language barriers.
The employee was seen by Dr. Keith Kramlinger, a psychiatrist at the Mayo Clinic, on December 2, 2009. The employee was noted to have had persistent pain and significantly restricted movement in his hand since the work accident. The employee reported anxiety and depression arising from disruptive dreams regarding the accident as well as frequent daytime triggered reminiscences. Dr. Kramlinger diagnosed post-traumatic stress disorder (PTSD) with mild depression and anxiety.
On December 23, 2009, the employee was seen in consultation by Dr. Mary Jurisson at the Mayo Clinic. Dr. Jurisson urged the employee to get a psychologist lined up as quickly as possible as his anxiety affected his pain. She also suggested referral to a pain rehabilitation program and a trial of medications for neuropathic pain management such as anti-depressants or the anti-epileptic category of drugs, as well as topical pain agents.
On January 1, 2010, Ms. Aydt reported that a job offer had been provided by the employer, but the employee was concerned about driving from the Twin Cities to Owatonna and stated he was scared to go back to Viracon due to bad memories about the accident. On January 19, 2010, Dr. Shin indicated the employee had improved with the most recent surgeries and limited the employee to work using the right hand as a helper hand with a 5 pound or less lifting, pushing or pulling limit, and no operation of power equipment. The employee was to continue with hand therapy.
A screening evaluation at the Mayo Clinic pain rehabilitation center on January 28, 2010, identified depression, anxiety and PTSD present since the accident. A three week program at the center was recommended. On January 30, 2010, the employee was admitted to the Fairview University of Minnesota Medical Center. He was expressing suicidal thoughts, had lost weight, and was not sleeping at night. He was isolative and would not interact with others including his family. PTSD and depression were diagnosed. The employee refused anti-depressant medication but was willing to try Trazedone for sleep.
The employee returned to see Dr. Jurisson on March 23, 2010. He described persistent, chronic pain and recent cold sensitivity in the hand. The doctor suggested use of a Lidoderm patch and participation in the pain clinic, as well as separate treatment for the employee’s PTSD and depression. Dr. Jurisson concurred with the employee’s work restrictions, but added no significant cold exposure, and recommended waiting until the employee had worked with a psychologist before returning to work due to his profound anxiety related to his previous work.
The employee was seen by Dr. John Rauenhorst, a psychiatrist, on March 24, 2010, at the request of the employer and insurer. By report dated April 1, 2010, Dr. Rauenhorst noted the employee reported an intense emotional reaction to the injury with intrusive recollections of the event, including nightmares, avoidance behaviors, and increased vigilance, as well as signs of increased anxiety. Dr. Rauenhorst agreed with the diagnosis of PTSD, but felt the employee’s PTSD was resolving, stating that most PTSDs resolve spontaneously, even without treatment. The doctor stated the employee continued to have some mild symptoms with some difficulty in social or occupational functioning. He agreed the employee should not do work requiring contact with potentially dangerous machinery, and stated the employee should not be placed in a position where he would have to move away from his family for at least a year, as his family was his major emotional support. Dr. Rauenhorst further opined the employee had reached maximum medical improvement (MMI) and did not have any ratable permanent partial disability from a psychiatric standpoint.
The employee was seen by Dr. Peter Wilson, a psychologist at the Mayo pain clinic, on April 9, 2010. The doctor noted the employee had areas of exquisite tenderness throughout the scarred area of the right hand, and particularly over the long finger MCP joint, the area of the resected index finger, and in the first web space. The employee described neuropathic pain and vascular changes. Dr. Wilson discussed pain management with the employee and recommended a trial of pregabalin (Lyrica) for pain control and Doxazosin for his vascular complaints.
On April 12, 2010, the employee began treatment with Dr. John Cronin, a psychologist, at the Primary Behavioral Health Clinic. An initial psychological assessment and testing was completed. The employee reported nightmares about the accident and replaying the accident in his head over and over. His self-esteem was low, he didn’t feel safe or that he could take care of himself, and he relied on his brothers for emotional and financial support. Dr. Cronin diagnosed a pain disorder with both psychological factors and a general medical condition.
On April 19, 2010, the employee was seen by Dr. Jack Schaffer for a psychological evaluation. The employee presented with a depressed flat affect, describing social isolation, difficulty sleeping, weight loss, low self-esteem, and suicidal ideation. Dr. Schaffer conducted a series of standardized tests, noting the employee struggled greatly with the written tests. The doctor opined the employee suffered from PTSD with considerable depression. In Dr. Schaffer’s opinion, the employee lacked the psychological skills to be able to manage his disability effectively. He felt it crucial that the employee receive psychological treatment and stated that such treatment would take some period of time.
The employee returned to Dr. Shin on April 23, 2010, with persistent pain and hypersensitivity in the web space between the thumb and the middle finger after the ray resection, radiating into the middle finger, and contracture at the PIP joint of the third finger preventing him from opening his hand fully. An injection was performed to try to reduce the pain in the hand.
The employee was seen by Dr. Cronin or his associates on at least four occasions between April 22 and June 7, 2010. A battery of psychological and vocational tests were administered, and the employee received psychotherapy. In a report dated June 11, 2010, Dr. Cronin stated the employee met the criteria for a pain disorder with both psychological factors and a general medical condition, PTSD, and major depression, recurrent, unspecified. The doctor opined the employee’s psychological symptoms were a direct result of the work injury and that the employee was in need of further psychological and psychiatric care. In Dr. Cronin’s opinion, the employee was not capable of a successful return to work at that time due to his psychological condition. Dr. Cronin assigned a permanent partial disability of 28% using a Weber rating, referencing Minn. R. 5223.0360, subp. 7.D., stating the employee fell between category 2, “mild emotional disturbance” and category 3 “requires some supervision on a daily basis.”
On July 2, 2010, the employee underwent another surgery performed by Dr. Shin, a resection of the neuroma and protection of the digital nerve to the middle finger with a neural tube. The employee reported some reduced nerve pain following the surgery. On August 3, 2010, Dr. Jurisson noted the employee’s pain in the original area was much better, but he was now experiencing pain in the dorsal metacarpal area. Dr. Jurisson restarted the employee’s Lyrica and Lidoderm patches, and restricted the employee from driving motor vehicles due to the pain medication.
Physical therapy was reinstituted, and the employee continued to see Dr. Cronin approximately once a month for psychotherapy. He continued to use Tramadol, Lyrica, and Lidoderm patches for pain, and continued treatment at the Mayo Clinic for persistent pain and hypersensitivity in the hand and in the dorsal area of the middle finger. On January 13, 2011, Dr. Shin performed another surgery, a neurolysis of the superficial radial nerve and tendon transfer to reduce pain and increase extension at the middle finger PIP joint. The surgery was not particularly helpful, and the employee reported persistent pain in the hand in the surgical area.
On March 17, 2011, Dr. Shin stated there was no additional surgery that could be done, and referred the employee for a functional capacities evaluation (FCE) to determine what he could and could not do with his right hand. Dr. Shin’s final diagnoses were amputation of the tip of the thumb through the level of the DIP joint; radial and ulnar nerve injuries to the thumb and the superficial branch of the radial nerve; amputation of the index finger with traumatic neuromas of the index, radial, and ulnar digital nerve; traumatic nerve injury to the terminal branches of the median nerve; and crush injury to the middle finger PIP joint resulting in flexion contraction. Dr. Shin reviewed a job description and videotape of a file clerk position with the employer, and opined that if the FCE was consistent with the job description, the job would be appropriate from a medical/physical standpoint. The employee was released from the care of Dr. Shin and a referral was made to Dr. Frank Wei in the Twin Cities for continued care.
The employee was seen by Dr. Wei, a physical medicine and rehabilitation specialist, on April 4, 2011. Dr. Wei noted the employee was using a Lidoderm patch, Lyrica and Tramadol. He recommended the employee try increasing the Lyrica or adding another medication to help with his neuropathic pain.
The employee completed a three day FCE on April 21, 2011. The employee reported he lived with his family and needed help to fasten buttons and zippers, open jars and beverage bottles, carry heavy objects, and drive. He essentially performed most activities with his non-dominant left hand, using the right hand as a helper to his left hand to anchor or stabilize objects. Work restrictions were assigned of crawling and climbing seldom; reaching above the shoulder on the right occasionally; pushing/pulling 40 pounds seldom, 20 pounds occasionally; no carrying or lifting over 5 pounds; and no grasping, pinching, or fine manipulating with the right hand. It was recommended that issues regarding drowsiness while taking pain medication be addressed.
The employee was seen by Dr. Cronin on May 10 and June 13, 2011. The employee reported the insurance company wanted him to return to work at Viracon, but he was scared of going back. Dr. Cronin continued the employee off work due to his ongoing level of pain and psychological condition, and further opined that, due to the trauma of the crush injury, the employee should not return to any type of work at Viracon. In a letter report dated July 20, 2011, Dr. Cronin stated he continued to provide psychological treatment to the employee, and maintained that the type of physical injury the employee suffered on December 18, 2008, was consistent with the emotional sequela that developed including chronic pain, depression, anxiety, and PTSD. Dr. Cronin assessed a permanent partial disability rating of 27%, using the same Weber criteria used previously. The doctor further stated that, in his opinion, the employee was psychologically restricted from gainful employment at this point in his life due to his work injury.
On August 4, 2011, QRC Mary Aydt reported that based on Dr. Cronin’s letter, the employee would not be returning to work with the employer. Job search with a placement vendor was initiated on August 17, 2011.
The employee continued to treat with Dr. Cronin, Dr. Shin, and Dr. Wei between September and December 2011. At some point, Dr. Wei took the employee off Lyrica and started the employee on Cymbalta. On November 10, 2011, Dr. Shin completed a Health Care Provider Report assigning a permanent partial disability of 53.7% based on Minn. R. 5223.0080, 5223.0090, and 5223.0480 (1993).
On January 6, 2012, Dr. David Falconer examined the employee at the request of the employer and insurer. By report dated February 24, 2012, Dr. Falconer provided a permanent partial disability rating of 39.9%, pursuant to Minn. R. 5223.0540, 5223.0480, and 5223.0410 (2008), and stated the employee would benefit from chronic pain management under the direction of Dr. Wei for the foreseeable future. Dr. Falconer concurred with the work restrictions outlined in the FCE, stating the employee would need to pursue vocational and other activities that were largely one-handed with his left, non-dominant hand. The doctor did not feel the employee was permanently totally disabled from a medical/physical standpoint.
In January 2012, Michael Richardson, a licensed psychologist, completed a psychological-vocational evaluation of the employee. The employee reported mental health symptoms including helplessness, hopelessness, anxiety, depression, apathy and pessimism, and Mr. Richardson concluded the employee demonstrated symptoms of PTSD with major depression. He also observed the employee had issues with chronic pain that limited his activities of daily living. Psychometric tests were administered, including the Wechsler Adult Intelligence Scale (WAIS) and the Conners Continuous Performance Test-II. According to Mr. Richardson, the employee’s scores on measures of nonverbal intellectual abilities were uniformly poor, with deficits commonly observed in students with learning problems. Mr. Richardson opined that due to the employee’s mental health problems and intellectual limitations, the employee had limited resiliency, coping strategies, and problem-solving abilities. In his opinion, the employee had significant, permanent cognitive deficits that posed a substantial barrier to employment, vocational training, or postsecondary education, and Mr. Richardson opined the employee was not currently capable of gainful employment.
In January 2012, L. David Russell performed an independent vocational evaluation at the request of the employer and insurer. Mr. Russell performed vocational testing, interviewed the employee, and reviewed medical and rehabilitation records. By report dated April 4, 2012, Mr. Russell opined the employee had some transferable work skills based on his past work history, and concluded the employee was employable in various sedentary capacities. Mr. Russell did not believe the employee was permanently and totally disabled from employment, stating the employee was young and had made no significant efforts to return to the workforce. In Mr. Russell’s opinion, the rehabilitation services provided were poorly structured and ineffective, and he recommended several means by which the employee’s vocational rehabilitation might be improved.
The employee was seen by John Richardson, a QRC, for a vocational evaluation at the request of his attorney. By report dated March 6, 2012, Mr. Richardson observed that the employee had problems taking the vocational tests he administered to him. He interviewed the employee, reviewed the results of the testing and evaluation performed by Mr. Michael Richardson, and reviewed the employee’s medical and vocational records. In Mr. John Richardson’s opinion, there were very few jobs available within the physical restrictions of the employee, as demonstrated by the limited scope of the job leads provided to the employee in the course of his job search, complicated by the employee’s intellectual deficits, lack of education, and significant mental health problems. In his opinion, the employee was unlikely to benefit from further rehabilitation services, and he believed the employee was permanently and totally disabled.
Dr. Cronin was deposed on April 25, 2012. He noted that he had not seen the employee since September 14, 2011, so he could not give an opinion as to whether the employee was better or worse since that time. Dr. Cronin stated, however, that the employee continued to have the same diagnoses: chronic pain syndrome, PTSD, and major depressive disorder when he last saw him. Given the passage of time since the injury, and his lack of successful response to treatment, Dr. Cronin opined the employee’s psychological condition was permanent. Based on his diagnosis and review of the employee’s medical records, as well as a hypothetical provided by the employee’s attorney, Dr. Cronin opined that, from a psychological standpoint, he did not believe the employee was capable of gainful employment.
By note dated April 27, 2012, Mary Aydt, the employee’s QRC, opined that, from a vocational standpoint, the employee was employable. She observed the employee had not begun his job search until August 17, 2011, and had required ongoing assistance and instruction. Given the numerous challenges and barriers, Mr. Aydt opined the limited period of time during which the employee conducted his job search was not sufficient, and that the employee would benefit from continued job search.
In a findings and order served and filed on June 29, 2012, a compensation judge at the Office of Administrative Hearings found the employee had sustained a permanent partial disability to the right hand of 53.7%, adopting the opinion of Dr. Shin. The judge further found the employee sustained a permanency of 27% for a psychological injury, pursuant to the rating of Dr. Cronin, and found the employee had been permanently and totally disabled from gainful employment since December 19, 2008, as a result of his work-related injury of December 18, 2008. The employer and insurer appeal.
1. Permanent partial disability to the right hand
The compensation judge adopted Dr. Shin’s assignment of a 53.7% permanent partial disability for the physical injuries to the employee’s right hand. The employer and insurer assert Dr. Shin incorrectly applied an old law rating based on the permanency schedule in effect from 1985 to 1993. The employee concedes that Dr. Shin incorrectly rated the employee under the 1993 schedule, and stipulates to the 39.9% permanent partial disability rating provided by Dr. Falconer. Finding11 is accordingly reversed.
2. Permanent partial disability for psychological injury
The employer and insurer assert that substantial evidence does not support the compensation judge’s award of permanent partial disability for a psychological condition based on Dr. Cronin’s rating, and argue the judge misapplied the Weber case in assigning permanency on the facts in this case.
Dr. Cronin assigned a permanency rating of 27% under Weber by analogy to Minn. R. 5223.0360, subp. 7.D., items 2 and 3, stating that, in his opinion, the employee fell between the two categories. He explained that
mild tends to be where you have an obvious dysfunction, but you’re still able to get out of bed, engage in some personal hygiene, maybe make a meal for yourself, and try to interact with life. Might not do such a hot job at it, but at least you try. . . . On the other end is when getting out of bed is an absolute chore. And the rest of it, interacting with people, going out, finding work, keeping a job, those sorts of things, very difficult to do.
(Ex. B at 41-42.) Dr. Rauenhorst disagreed, stating the employee did not have a pain disorder or depression, his PTSD was resolving, and the employee had no ratable permanency under the permanency schedule as the employee had no objective symptoms and his condition was not severe enough to rate in even the mildest category.
There is no provision in the permanency schedules for permanent partial disability due to a psychological injury. The purpose of a Weber rating is to approximate the functional loss suffered by an employee by comparing a non-scheduled disability to similar losses contained in the schedule. Minn. R. 5223.0360, subp. 7.D., has previously been applied in assessing permanency for a permanent psychological injury. See, e.g., Bissonette v. Koochiching Cnty., No. WC09-5029 (W.C.C.A. May 11, 2010); Makowsky v. St. Mary’s Med. Ctr., 62 W.C.D. 409 (W.C.C.A. 2002); Reyes v. Wal Mart, 61 W.C.D. 835 (W.C.C.A. 2001). Since, by definition, a non-scheduled injury falls outside the permanency schedules, there is no requirement that any particular category in the schedule be applied, or that the injury meet the specific requirements of any given category. Crain v. Riverview Healthcare Ass’n, slip op. (W.C.C.A. Nov. 9, 1998).
Dr. Cronin diagnosed a chronic pain syndrome, PTSD, and major depressive disorder. His diagnoses and opinions regarding permanency were based on clinical observation of the employee over an approximately two year period and psychometric testing including the Hopkins Symptom Checklist, the Cornell Index, Beck Depression Inventory, MMPI-2, and the Pain Report Recovery Index. The medical records provide clear evidence of significant and persistent chronic pain, and multiple providers indicated the employee’s psychological condition contributed to his chronic pain. Dr. Shaffer and Michael Richardson also concluded, based on psychometric testing and clinical observation, that the employee suffered from PTSD and significant depression. And, although he maintained the employee’s psychological condition was resolving, Dr. Rauenhorst also concluded the employee suffered from PTSD.
The employee testified he continued to experience the symptoms he treated for with Dr. Cronin. He described recurrent nightmares and intrusive thoughts about the accident during the day. He stated he was afraid to sleep alone or live on his own, and described an inability to help himself, feelings of low self-esteem, isolation, anger and depression, and avoidance behaviors. The medical records indicate the employee avoided use of his right hand due to chronic pain, and, as a result, continued to have difficulty with activities of daily living.
As a trained medical professional, based on the psychometric testing of the employee and his treatment and observations of the employee, Dr. Cronin was qualified to give an opinion regarding the permanent partial disability resulting from the employee’s psychological condition. Grunst v. Immanuel-St. Joseph Hosp., 424 N.W.2d 66, 68, 40 W.C.D. 1130, 1132-33 (Minn. 1988); Drews v. Kohl’s; 55 W.C.D. 33 (W.C.C.A. 1996). It is the compensation judge’s responsibility, when there are conflicting medical expert opinions, to choose the opinion the judge finds most persuasive. See Nord v. City of Cook, 360 N.W.2d 337; 37 W.C.D. 364 (Minn. 1985). There is adequate support in the record for the permanent partial disability rating provided by Dr. Cronin for the employee’s psychological condition and we, accordingly, affirm.
3. Permanent total disability
The employer and insurer contend that substantial evidence does not support the compensation judge’s finding that the employee is permanently and totally disabled. They assert the judge overlooked overwhelming and substantial medical and vocational evidence to the contrary in awarding the employee permanent total disability benefits. We are not persuaded.
In reviewing cases on appeal, the question is not whether there is evidence of record that would support a contrary decision, but whether there is substantial evidence, in the record as a whole, to support the findings of the compensation judge. Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 37 W.C.D. 235 (Minn. 1984). While recognizing that the employee is a young man, and would likely benefit emotionally from a return to work, the compensation judge noted the employee has not worked since the accident in December 2008, and accepted the opinion of Dr. Cronin that the employee is psychologically disabled and unable to work, and the opinions of Michael Richardson, a licensed psychologist, and John Richardson, a QRC, that given the employee’s language and cultural barriers, lack of education, limited intellectual abilities, and lack of transferable skills, combined with his significant physical restrictions - - essentially limiting the employee to one-handed work with his non-dominant hand - - the employee is permanently and totally disabled.
The employer and insurer argue the opinions of Dr. Cronin and Michael Richardson lack foundation. They assert that Dr. Cronin’s treatment notes are so vague as to be unreliable evidence, that he failed to review all of the employee’s medical records, and that he saw the employee on only two occasions. Based on the records submitted, it is clear that Dr. Cronin or his associates saw the employee on multiple occasions between April 2010 and September 2011 for testing and psychotherapy sessions. The doctor reviewed the reports of Dr. Shaffer, Michael Richardson, and Dr. Rauenhorst, and was provided an extensive hypothetical describing the employee’s medical, psychological, and vocational rehabilitation history. In addition to the medical records submitted, the transcribed depositions of Dr. Cronin were admitted into evidence. There is sufficient foundation in the record for Dr. Cronin’s opinions.
The appellants argue that the opinions of Michael Richardson are not reliable without knowing the extent of the medical records and rehabilitation records he reviewed to reach his opinion. Mr. Richardson was involved in a limited capacity, to provide testing requested by John Richardson, QRC, as part of the employee’s vocational evaluation. Michael Richardson is a licensed psychologist who administered a series of psychometric tests to the employee for the purpose of quantifying his intellectual and vocational abilities. Based on these tests, Mr. Richardson concluded the employee had significant cognitive deficits that would pose a substantial barrier to employment, vocational training, and the pursuit of postsecondary education. The opinion of Michael Richardson, based on the testing administered and his clinical experience, is sufficiently founded, and the compensation judge did not err in relying on it.
Finally, the compensation judge found the opinion of QRC John Richardson persuasive, that is, that further rehabilitation services were likely to be ineffective and unproductive, and that the employee was permanently and totally disabled from a vocational standpoint. The opinions of these experts, combined with the medical records and testimony of the employee, are sufficient to support the compensation judge’s determination that the employee has been permanently and totally disabled since December 18, 2008. We, accordingly, affirm.
 Tramadol is a centrally acting synthetic opioid analgesic used to treat moderate to moderately severe pain.
 Trazedone is an antidepressant of the serotonin antagonist and reuptake inhibitor (SARI) class. Trazedone also has anti-anxiety and sleep-inducing effects.
 Lyrica is an anti-epileptic drug used for neuropathic pain.
 See Weber v. City of Inver Grove Heights, 461 N.W.2d 918, 43 W.C.D. 471 (Minn. 1990); Minn. Stat. § 176.105, subd. 1(c).
 In all, the employee underwent 20 or 21 major and minor surgeries to the right hand between December 19, 2008, and January 13, 2011.
 Cymbalta is a serotonin-norepinephrine reuptake inhibitor (SNRI). It is effective for major depressive disorder and generalized anxiety disorder. It can also relieve the symptoms of painful peripheral neuropathy.
 Minn. R. 5223.0360, subp. 7.D., provides in pertinent part:
D. Emotional disturbances and personality changes must be substantiated by medical observation and supported by psychometric testing. . . .
(2) mild emotional disturbance is present at all times but can live independently and relate to others, 20 percent;
(3) moderate emotional disturbance is present at all times, and requires some supervision on a daily basis, 40 percent; . . .
 Minn. R. 5223.0360, subp. 7, applies to injuries causing organic brain dysfunction with anatomic loss or alteration, or objectively measurable neurological deficits.