THOMAS D. JOHNSON, Employee, v. YELLOW TRANSP., SELF-INSURED, Employer/Appellant, and ST. ANTHONY MED. CTR., Intervenor.

 

WORKERS= COMPENSATION COURT OF APPEALS

OCTOBER 21, 2005

 

No. WC05-165

 

HEADNOTES

 

CAUSATION - PSYCHOLOGICAL INJURY; EVIDENCE - EXPERT MEDICAL OPINION; MEDICAL TREATMENT & EXPENSE - REASONABLE & NECESSARY.  Where it was supported by expert medical opinion and the expressly credited testimony of the employee, the compensation judge=s conclusion that the employee=s preexisting psychiatric condition had substantially deteriorated as a result of his work-related physical injuries was not clearly erroneous and unsupported by substantial evidence, and the judge=s consequent award of related medical benefits, including electroconvulsive therapy, was affirmed.

 

Affirmed.

 

Determined by: Pederson, J., Johnson, C. J., and Rykken, J.

Compensation Judge: Paul D. Vallant

 

Attorneys: David B. Kempston, Law Office of Thomas D. Mottaz, Anoka, MN, for the Respondent.  Michael J. Patera, Michael J. Patera, Chartered, Buffalo, MN, for the Appellant.

 

 

OPINION

 

WILLIAM R. PEDERSON, Judge

 

The self-insured employer appeals from the compensation judge's conclusion that the employee=s pre-existing psychiatric/psychological condition was substantially aggravated by the employee=s work injury of March 7, 2003, and that the employee was entitled to various medical and related benefits as a consequence.  We affirm.

 

BACKGROUND

 

The record of the orthopedic and psychiatric/psychological treatment undergone by Thomas Johnson prior to the 2003 work injury that is here at issue is substantial and complex and warrants detailed summary.  Apparently in about 1964, at about age fifteen, Mr. Johnson underwent electroconvulsive therapy [ECT] in an effort to resolve behavioral problems that he was evidently manifesting both at home and at school.  He lived apparently without notable disability for nearly thirty years thereafter, until June of 1993, when he was treated for right knee and shoulder injuries sustained in a work-related motor vehicle accident.  On August 15, 1994, Mr. Johnson commenced treatment with orthopedist Dr. Mark Keohane for a different work-related injury, to his left shoulder, which he had sustained about five weeks earlier in his work as an over-the-road truck driver and which had not responded to physical therapy, medication, or altered work patterns.  Dr. Keohane recommended repair of the left rotator cuff and performed an acromioplasty fairly soon after that date.  Dr. Keohane subsequently prescribed medication and physical therapy and eventually released Mr. Johnson to return to work on February 6, 1995.

 

On February 16, 1995, less than two weeks after his release to return to work, Mr. Johnson recommenced treatment with Dr. Keohane for bilateral shoulder and low back injuries that he had sustained in a slip and fall on some ice in the course of his work.  Dr. Keohane prescribed physical therapy, but the pain persisted, and on March 6, 1995, he recommended further left shoulder surgery, which he evidently then performed.  Mr. Johnson=s medical records had been noting symptoms of depression and sleeplessness and sexual dysfunction since the beginning of the year, and eventually Dr. Keohane referred him to St. Joseph=s Health Center for psychiatric treatment.  At St. Joseph=s, on April 1, 1995, Mr. Johnson came under the care of psychiatrist Dr. John Canale, who diagnosed major unipolar depression and commenced a regiment of antidepressants.  Mr. Johnson=s physical and psychological conditions appeared to improve, and on May 18, 1995, Dr. Keohane released him to return to work without restrictions, although treatment with Dr. Canale continued.

 

Mr. Johnson=s shoulder pain returned, and on September 21, 1995, Dr. Keohane assigned to Mr. Johnson a rating Asomewhere in the vicinity of 30% permanent physical impairment of the left shoulder.@  By December of 1995, Mr. Johnson=s right shoulder pain had apparently grown as severe as his left shoulder pain, and on December 25, 1995, on referral from Dr. Keohane, Mr. Johnson was seen for a second opinion by orthopedist Dr. Richard Hulsey.  Dr. Hulsey agreed with Dr. Keohane=s diagnosis of rotator cuff tears bilaterally and recommended surgical repair, beginning with the right shoulder, concluding that it was unsafe for Mr. Johnson to drive a truck for the time being.  Dr. Hulsey performed the right shoulder surgery in early January of 1996, following which symptoms of the left shoulder rotator cuff tear evidently increased.

 

On May 10, 1996, Dr. Robert Geekie, Mr. Johnson's family physician since at least 1992, who was treating Mr. Johnson primarily for hypertension, noted that Mr. Johnson was Aon an unbelievable amount of medication.@  A[F]rom the psychiatrist [h]e is on Ambien, Klolopin, Amitriptyline and Paxil.  From me he is on Zantac, 150 twice a day, Normodyne, 100 mg twice a day.  From the orthopedist he takes Roxicet and Propoxphene.@  On June 24, 1996, Dr. Keohane released Mr. Johnson to return to his truck driving job on July 8, 1996, and Mr. Johnson evidently did so for about three months, before going off work again on October 14, 1996, to undergo surgery on his left shoulder.  On January 13, 1997, Dr. Hulsey released Mr. Johnson to work at light duty, restricted from lifting over five pounds and from performing any overhead work involving his shoulders, and Mr. Johnson apparently returned to work sometime in March of 1997.  On July 7, 1997, Dr. Hulsey rated Mr. Johnson=s permanent partial disability at 25% of the whole body related to his left shoulder and at 20% of the whole body related to his right shoulder.  Meanwhile, Dr. Canale continued to treat Mr. Johnson=s psychiatric condition periodically through October 1998, for various symptoms including general depression, difficulty sleeping, sexual dysfunction, irritability, and fatigue, employing a variety of psychotropic medications.

 

On January 18, 2000, Mr. Johnson was treated again for work-related bilateral shoulder and back injures, sustained in a five or six foot fall from the engine compartment of his truck.  Consequent medication left him unable to drive to work any longer, so on February 14, 2000, Dr. Keohane restricted him from all work.  Subsequent to his January 2000 injuries, Mr. Johnson was treated by Dr. Keohane with two months of physical therapy, which evidently only increased his pain, and with a TENS unit and an injection, which apparently provided only transient relief.  Mr. Johnson=s depression returned, and in April of 2000 Dr. Keohane began recommending that he see a psychiatrist again.  On August 9, 2000, Dr. Hulsey concluded that Mr. Johnson=s rotator cuffs were no longer repairable and that it was unlikely that he would be able to return to over-the-road trucking driving, secondary to his shoulder injuries alone.  About six months later, however, on February 19, 2001, Dr. Keohane did release Mr. Johnson to return to driving work on May 1, 2001.

 

Mr. Johnson=s depression apparently only increased, and on March 13, 2001, he commenced treatment with psychiatrist Dr. Michael Stotler at Associates in Behavioral Health, who diagnosed Major Depressive Disorder with chronic pain, rotator cuff injuries, three ruptured discs, hypertension, obesity, hypercholesterol, and carotid artery stenosis.  Dr. Stotler=s records indicate that Mr. Johnson was isolative and withdrawn, had a reduced sex drive, was crying easily, was having difficulty sleeping, had a reduced appetite, had a passive death wish, had decreased concentration, and was irritable and angry.  Eventually, on January 7, 2002, Mr. Johnson was treated for yet another work-related back injury, after slipping on some ice and falling onto his buttocks, but on February 18, 2002, he returned again to his regular truck driving job without restrictions.  Subsequent to his return to work, Mr. Johnson continued to treat with Dr. Stotler, complaining of various symptoms of depression and anxiety and occasionally expressing a passive death wish.

 

On March 7, 2003, Mr. Johnson sustained multiple work-related injuries when the truck that he was driving in the course of his employment with Yellow Transportation hit some ice and overturned.  Mr. Johnson [the employee] was fifty-three years old on that date and was earning a weekly wage of apparently $1,096.32.  On the date of his injury, the employee was admitted to North Memorial Medical Center, where he was treated and then discharged on March 10, 2003, under a diagnosis of left-side rib fractures, L1 through L4 transverse process fractures, low back pain, bilateral shoulder pain, and contusions.  About a week later, on March 19, 2003, the employee returned to see Dr. Stotler, with whom he had been continuing to treat periodically since March of 2001, who diagnosed depressive disorder without severe psychosis.  Yellow Transportation [the employer] received proper notice of the injury and admitted workers= compensation liability.  In a report to the employer on March 27, 2003, Dr. Keohane stated, AIt does not appear as if the [employee] is capable of returning to any gainful employment at this point@ and AI believe [that his] concern over his health is such that it is not likely that he will be able to concentrate on a job at this point, until it seems assured that his physical ailments will get better again.@  The employee has not returned to work since the date of his March 7, 2003, work injury.

 

On April 14, 2003, Dr. Keohane reported to the employer in part that it was his Aimpression that at least part of [the employee=s] current absence of his rotator cuff is related to his previous injury.  The [employee], however, does have increased functional impairment after his accident by comparison to how he was right before the accident, so there is at least some injury there.@  On June 16, 2003, the employee was reexamined, at the request of the employer, by Dr. Hulsey, who diagnosed early rotator cuff tear arthropathy in both shoulders, with massive rotator cuff tears.  Upon review of the employee=s MRI scans, Dr. Hulsey noted that A[t]here is absolutely no rotator cuff remaining,@ noting also, however, that, while A[t]he accident of 3/7/03 aggravated his underlying synovitis and pain,@ the employee Ahas had the massive tears for a long time and they were not caused by his most recent accident.@  Dr. Hulsey opined that surgery would not provide much relief to the employee or improve his function, that it was highly unlikely that the employee would return to any type of commercial driving due to limitations in his use of his arms, that the employee would be unable to do any significant lifting, and that Athese restrictions will be permanent.@  Dr. Hulsey went on to rate the employee=s permanent partial disability at 25% of the whole body, estimating that 20% was related to the employee=s ongoing, Aprogressive@ problem and that 5% was related to the work injury of March 7, 2003.

 

On June 18, 2003, two days after his appointment with Dr. Hulsey, the employee was examined also by osteopath Dr. Michael Chabot, who diagnosed lumbosacral strain, sacroiliitis, history of chronic back pain, history of chronic rotator cuff tears and bilateral shoulder pain, and depression.  It was Dr. Chabot=s opinion that the majority of the employee=s back complaints were related to sacroiliac dysfunction and that the work injury of March 7, 2003, may have exacerbated this underlying condition.  Dr. Chabot recommended sacroiliac injections, physical therapy, antiinflammatory medication, and a bone scan to rule out a stress fracture, noting also that the employee appeared to demonstrate significant symptom magnification.  On July 7, July 31, and August 18, 2003, respectively, Dr. Keohane continued to hope that the employee Awill be able to return to full time active driving for his van line,@ that Awithin a reasonable period of time, perhaps he could try and drive his truck again,@ and that it was Areasonable to assume that this [employee] could return to truck driving.@

 

Subsequent to his March 7, 2003, work injury, the employee had continued to treat with Dr. Stotler for increasing depression-related symptoms, and the doctor=s treatment notes for December 16, 2003, finally indicate an intent to Aconsider ECT@ for the employee for the first time since the employee=s youth.  On December 22, 2003, in a letter ATo Whom It May Concern,@ Dr. Stotler stated that A[s]ubsequential to the motor vehicle accident on March 7, 2003 in Minnesota, the condition of [the employee] has worsened to the severe state of depression seen today.@

 

On January 21, 2004, the employee was examined for the employer by orthopedist Dr. James Doll, who concluded in part that the employee=s Asubjective complaints clearly outweigh his objective findings with multiple inconsistencies on physical examination, suggesting a nonorganic basis for his subjective complaints.@  On that finding, Dr. Doll discouraged reliance on narcotic medications and recommended strict compliance with a home exercise plan, a regimen of physical therapy, use of a medical muscle relaxant, and referral for a psychiatric evaluation to explore his capacity to work at his regular job.

 

About half a year later, on July 13, 2004, Dr. Stotler reported in a letter to the employee=s attorney that A[t]he severity [of the employee=s Major Depressive Disorder] has worsened as a result of the added stress that stems from his financial concerns and also from his loss of physical ability.@  He concluded that Athe work related injury has substantially aggravated the pre-existing psychiatric condition and constitutes a substantial contributing cause to the worsening of his depression.@  In that same report, Dr. Stotler affirmatively recommended a trial of ECT, indicating that without it he did not expect the employee to be able to work due to his disabling depression symptoms.  On July 22, 2004, Dr. Geekie wrote a letter ATo Whom It May Concern,@ in which he indicated that he seen the employee about two weeks earlier and that A[h]e seems to be deteriorating both physically as well as psychologically,@ acknowledging in that same letter, however, that he had no specialization in either the employee=s physical disability or his psychiatric disability.  On July 27, 2004, the employee filed materials supplementing a medical request filed on May 19, 2004, in which he sought payment of certain outstanding psychiatric/psychological treatment expenses, including approval of the ECT recommended by Dr. Stotler.

 

On July 28, 2004, the employee was examined for the employer by orthopedist Dr. David Raskas, who diagnosed a major depressive disorder and a long history of low back problems, concluding that no current back complaints had anything to do with the employee=s March 7, 2003, work injury.  With regard to the employee=s neck complaints, Dr. Raskas recommended a cervical MRI for more certainty, but he stated provisionally that he did not believe that there was any need for further treatment.  Dr. Raskas indicated that he did not believe that the employee required any physical restrictions either, but he did conclude that the employee was currently incapable of working due to the medications he was taking, his severe depression, and his problems with balance.  Dr. Raskas stated that the employee=s symptoms Amay have been triggered by [the March 2003 work injury], but I do not believe they were caused by it,@ opining that the employee=s Apreexisting conditions combined with deterioration of his psychiatric condition are likely leading to his inability to work.@

 

On about August 28 or 29, 2004, the employee was treated on an emergency basis at St. Anthony=s Medical Center for Aseveral superficial lac[eration]s to bilat[eral] wrists@ and abdomen with a Adull kitchen knife.@  He was apparently hospitalized overnight for observation and released again on August 30, 2004.

 

The matter of the employee=s medical request was heard at an administrative conference on September 22, 2004.  In a decision filed October 15, 2004, the compensation judge denied the employee=s claim, citing foundational problems with the opinions of the employee=s treating physicians, in particular a lack of evidence that Dr. Stotler was fully aware of the employee=s extensive history of psychological/psychiatric problems and of his treatment for those problems.  On November 12, 2004, the employee filed a request for formal hearing.

 

In a report to the employer on November 4, 2004, Dr. Keohane noted that, A[i]n addition [to multiple physical problems], because of all the difficulties, [the employee] has had a lot of financial problems and marital problems that are related to his inability to go to work.@  Dr. Keohane indicated further that it was his Aconsidered opinion that [the employee] needs to be off work for another three months, and . . . that he have pain management evaluation and treatment.@  He opined also that the employee Adesperately needs psychiatric care,@ expressing concern that the employee Amay have additional suicide attempts, which may be successful.@

 

On November 17, 2004, in a letter to the employer=s attorney, Dr. Raskas diagnosed the employee=s March 7, 2003, low back work injuries as transverse process fractures and a temporary aggravation of a degenerative condition, both apparently resolved.  Dr. Raskas diagnosed the employee=s work-related neck injury as cervical spondylosis with cervical strain, the spondylosis preexisting and uncaused by the March 2003 work injury, the causally related strain now resolved.  Dr. Raskas again saw no need for physical restrictions, concluding that the employee=s past medical treatment had been reasonable and necessary up to six months after the work injury, at which time, the doctor concluded, the employee reached MMI.

 

The employee was examined for the employer on December 14, 2004, by psychologist Dr. Gitry Heydebrand, who, in her report on January 12, 2005,  diagnosed AMajor Depression, Moderate, Recurrent, without psychotic features.@  In that report, Dr. Heydebrand concluded in part that the employee=s March 2003 work injuries Amay . . . have contributed to an aggravation of his depressive symptoms to some degree as would many other stressors, but are not considered to have permanently aggravated his condition.@  Dr. Heydebrand concluded further that A[a] series of ECT may provide fairly rapid relief (if positive response occurs) but with risk of relapse,@ noting that the employee=s Acurrent depression appears to be exacerbated to some extent by his anger at perceived lack of response by the employer.@  Dr. Heydebrand concluded also that the employee had not yet reached MMI with regard to his March 2003 work injury, suggesting that diagnosis was complicated by the fact that the employee Adid not produce reliable and valid personality inventories due to an apparent unwillingness to cooperate.@

 

On January 13, 2005, in a report to the employee=s attorney, Dr. Keohane stated in part that it was his understanding that the employee=s Awork injury of 2003 has aggravated his psychiatric condition, and although I am not a psychiatrist, the [employee] seems much worse off mentally now tha[n] he ever has been.@  Dr. Keohane indicated that, after observing and caring for the employee for the past ten years, it was his Aimpression that both his shoulders and low back were substantially aggravated by his [March 2003] tractor trailer accident.@  He stated that, prior to that accident, the employee had had Aa very reasonable outcome@ from his many work injuries and problems Aand had returned to gainful full time employment as a tractor trailer driver@ - - had Areached a nice plateau, I believe, and was able to return to gainful employment.@  Dr. Keohane went on to state that, in contrast, the employee Ahas not been able to return to work since [the March 2003 injury],@ and AI do not believe [that he] is employable in any condition.@  Dr. Keohane attributed the employee=s overall worsened condition to Athe substantial change in his mental attitude toward his work and his life@ and the fact that A[h]is general physical condition has worsened considerably,@ explaining that Athere is no question in my mind@ that this latter specifically physical worsening was caused by the work injury of March 7, 2003.  AObviously,@ he stated, Aall of [the employee=s] treatment through this office is medically necessary and caus[al]ly related to his March 7, 2003 motor vehicle accident.@

 

On January 14, 2005, having now considered a lengthy and detailed hypothetical furnished by the employee=s attorney and having reviewed the records of Dr. Canale, Dr. Stotler indicated that his opinion remained essentially unchanged - - that the employee=s work injury had substantially aggravated his preexisting psychiatric condition and constituted a substantial contributing cause of a worsening of his depression, which remained severe enough to preclude the employee from working.

 

The matter of the employee=s medical request came on for hearing on January 19, 2005, as of which date the employee had never returned to work or been released by his treating physicians to return to work since the March 7, 2003, date of his work injury.^[1]  Issues at hearing included the following: (1) whether the employee=s preexisting psychiatric/psychological condition was substantially aggravated by the employee=s March 7, 2003, work injury; (2) whether the employee=s psychiatric/psychological treatment at Associates in Behavioral Health, Ltd., was reasonable, necessary, and causally related to an alleged consequential psychiatric condition, and whether his psychiatric treatment at St. Anthony Medical Center was also causally related to that alleged consequential psychiatric condition; (3) whether the employee is entitled to reimbursement of out-of-pocket medical expenses related to the alleged consequential psychiatric condition; and (4) whether the proposed ECT is reasonable and necessary and whether it and prescribed psychotropic medications are causally related to the alleged consequential psychiatric condition.  At the hearing, the employee testified in part that his bilateral shoulder pain, back pain, neck pain, ability to function, and depression have all been significantly worse since his March 7, 2003, work injury.  By findings and order filed March 28, 2005, the compensation judge concluded in part that the employee=s preexisting psychiatric/psychological condition was substantially aggravated by the work injury of March 7, 2003, and that the employee was entitled to payment of all of the medical and related expenses at issue.  The employer appeals.

 

STANDARD OF REVIEW

 

In reviewing cases on appeal, the Workers= Compensation Court of Appeals must determine whether Athe findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.@  Minn. Stat. ' 176.421, subd. 1 (1992).  Substantial evidence supports the findings if, in the context of the entire record, Athey are supported by evidence that a reasonable mind might accept as adequate.@  Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984).  Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.  Id. at 60, 37 W.C.D. at 240.  Similarly, A[f]actfindings are clearly erroneous only if the reviewing court on the entire evidence is left with a definite and firm conviction that a mistake has been committed.@  Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).  Findings of fact should not be disturbed, even though the reviewing court might disagree with them, Aunless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.@  Id.

 

DECISION

 

The compensation judge found that the employee=s preexisting psychiatric/psychological condition was substantially aggravated by the work injury of March 7, 2003, and on that basis he awarded payment of all of the medical benefits at issue.  The employer contends that the judge=s conclusion is unsupported by substantial evidence, arguing that the judge did not consider the following factors required by case law to be considered Awhen determining whether an aggravation of a pre-existing condition is temporary or permanent@:  (1) the nature and severity of the preexisting condition and the extent of restrictions and disability resulting therefrom; (2) the nature of the symptoms and extent of medical treatment prior to the aggravating incident; (3) the nature and severity of the aggravating incident and the extent of the restrictions and disability resulting therefrom; (4) the nature of the symptoms and extent of medical treatment following the aggravating incident; (5) the extent of the employee=s work duties and nonwork activities during the relevant period; and (6) medical opinions on the issue.  See McClellan v. Up North Plastics, slip op. (W.C.C.A. Oct. 18, 1994).  The employer argues that, in this case, the nature and severity of the preexisting condition have not deteriorated and have perhaps even improved subsequent to the March 7, 2003, work injury and that any restrictions that Dr. Stotler may have assigned to the employee Awere never communicated to the Employee and were generated for purposes of litigation only.@  The employer argues that there are no new medical findings on examination of the employee subsequent to March 7, 2003, and that the only difference between the employee=s condition prior to March 7, 2003, and his condition subsequent to that date is the employee=s subjective complaints of pain.  The employer argues that, even if we assume that there was a permanent physical injury on March 7, 2003, the physical effects of the injury were not at issue at the hearing below, no increase in psychiatric problems is evident in the employee=s medical records, and any hypothetical increase in physical permanency Ais not controlling for purposes of the psychiatric claim.@  The mere fact that the reports of Drs. Keohane and Stotler, separate from their treatment records, suggest that the employee=s emotional condition has Adeteriorated@ does not, the employer argues, constitute substantial evidence of substantial deterioration causally related to the work injury.  The employer argues further that the factual hypothetical relied upon the Drs. Stotler and Keohane Alacks significant aspects of Employee=s history@ and, finally, that, A[e]ven if there has been an emotional sequella, electroshock therapy has not been demonstrated to be reasonable or necessary.@  We are not persuaded.

 

As the employer appears to acknowledge, both Dr. Stotler and Dr. Keohane have issued essentially unambiguous opinions to the effect that the employee=s psychological condition has deteriorated since the date of his March 2003 work injury, effectively rendering him unable to work.  Further, as the compensation judge noted in unappealed Finding 15, Dr. Stotler unambiguously opined on July 13, 2004, that Athe work related injury has substantially aggravated the pre-existing psychiatric condition and constitutes a substantial contributing cause to the worsening of [the employee=s] depression.@  Moreover, as the judge noted in Finding 17, Dr. Keohane, while acknowledging that psychiatry was not his area of specific expertise,  unambiguously opined on January 13, 2005, that it was his understanding that the employee=s Awork injury of 2003 has aggravated his psychiatric condition, and . . . the [employee] seems much worse off mentally now tha[n] he ever has been.@  As demonstrated not only by Findings 15 and 17 but also in the judge=s memorandum, the compensation judge clearly relied on the causation opinions of Drs. Stotler and Keohane in reaching his decision in this matter.  This court has long granted substantial deference to conclusions of a compensation judge drawn in direct reliance on the opinion of a medical expert, so long as the factual premises underlying the expert=s opinion are supported by the evidence.  Cf. Nord v. City of Cook, 360 N.W.2d 337, 342-43, 37 W.C.D. 364, 372-73 (Minn. 1985) ("the trier of fact's choice between experts whose testimony conflicts is usually upheld [unless] the facts assumed by the expert in rendering his opinion are not supported by the evidence").  In this case there is no evidence that the opinions of either Dr. Stotler or Dr. Keohane are based on any false premises.  Moreover, A[t]here is no requirement in the law that a causation opinion be supported by diagnostic tests or measurable objective findings.@  Mauer v. Big Lake American Legion, slip op. (May 6, 1997).  Indeed, the truth of the expert=s opinion need not even be capable of demonstration.  Pommeranz v. State, Dep=t of Public Welfare, 261 N.W.2d 90, 91, 30 W.C.D. 174, 177 (Minn. 1977).  With regard to the sufficiency of the factual hypothetical provided to Dr. Stotler preparatory to his ultimate causation opinion, we would note that, while adequate foundation is necessary for a medical opinion to be afforded evidentiary value, the expert need not be made aware of every relevant fact.  Bossey v. Parker Hannifin, slip op. (W.C.C.A. Mar. 14, 1994).  Drs. Stotler and Keohane were well and long established in the treatment of the employee, and we will not discount their expert opinions for lack of sufficient foundation.  Accordingly, we affirm the judge=s conclusion that the employee=s March 7, 2003, work injury substantially aggravated his preexisting psychiatric condition and the judge=s consequent awards of the benefits here at issue, including the ECT recommended by Dr. Stotler.  See  Hengemuhle, 358 N.W.2d at 59, 37 W.C.D. at 239.