The employee appeals the compensation judge’s findings that disputed medical treatment was precluded by the terms of a stipulation for settlement entered into by the parties in 2003 and was not due to a consequential injury resulting from the employee’s 1983 injury, and that an inhaler was not reasonable and necessary medical treatment for the employee’s condition.  We affirm.

On January 28, 1983, Barbara Headley, the employee, sustained a work-related low back injury when she transferred a patient while working as a physical therapist for Datron Inc, the employer, which was insured for workers’ compensation liability at that time by Hartford Insurance, the insurer.  The employee was diagnosed with two herniated discs at L4-5 and L5-S1, and has had extensive medical treatment, including eleven back surgeries related to her work injury between 1987 and 2002.  She underwent lumbar spine fusions and implantation of a spinal cord stimulator, which was later removed because it was not working properly.  According to the employee, the removal of the stimulator caused her to have chronic mid-back pain as well as her chronic low back pain.

The employee is a self-employed physical therapist who is recognized as an expert in her field.  She treats patients, researches and publishes professional articles, and presents lectures.  The employee has been treating with Dr. Christopher Ryan, a physiatrist, since September 2000.  This treatment includes medication, physical therapy, osteopathic manipulation, and acupuncture.  In the summer of 2004, the employee began to have difficulty with her voice, which was hoarse and strained, limiting her ability to lecture.  Dr. Ryan indicated that this seemed to be related to her thoracic spine pain, and stated, in his July 2, 2004, chart note that “I believe that her thoracic spine pain is responsible for the attenuation of her voice due to her inability to take a deep breath.”  Dr. Ryan first recommended a Medrol Dose Pack and Zantac.  Dr. Ryan also prescribed an inhaler, which did not alleviate the employee’s difficulty speaking.  In his August 20, 2004, chart note, Dr. Ryan stated:

The parties entered into a stipulation for settlement in September 2003, which was finalized by an award on stipulation served and filed February 3, 2004.  As part of that settlement, the employee agreed “that she is entitled to no further low back physical therapy or passive treatment modalities” and that she would qualify for additional physical therapy only in the event of another consequential injury.  The stipulation also limited the employer and insurer’s reimbursement for Dr. Ryan’s treatment to expenses related to a monthly 30-minute treatment plus “two 60 minute visits annually for the purposes of reviewing and evaluating the employee’s pharmacological care.”  The stipulation also stated that the “employee’s only ongoing entitlement is for reasonable and necessary medical expenses to her low back and her bilateral shoulder problems together with future Roraff fees.”^[1]

In addition to treating with Dr. Ryan since 2000, the employee treated at the Boulder Osteopathic Center, and with Dr. Lisa Rittel, an osteopath.  In the summer of 2005, the employee began having back pain while sitting in her home office which prevented her from sitting for more than five to ten minutes at a time and limited her ability to work.  The employee consulted with Dr. Ryan and purchased an ergonomic chair which has significantly increased her ability to sit and work.

By medical request filed on August 17, 2005, the employee claimed various medical expenses including those related to purchase of an ergonomic chair, an inhaler, and orthotics, and to treatment with Dr. Ryan, with Dr. Rittel from January 11, 2005, through January 4, 2006, and at the Boulder Orthopedic Center from September 20 through October 11, 2004.  The employer and insurer objected, claiming the various expenses were not reasonable and necessary or causally related to the employee’s work injury, and that the medical treatment was precluded by the 2003 stipulation for settlement.  The employer and insurer paid or agreed to pay some of the claimed expenses before the hearing.  In her findings and order served and filed on January 31, 2006, the compensation judge awarded the costs of the ergonomic chair, concluding that the employee carefully studied chair options that met her needs and also obtained Dr. Ryan’s approval for that specific chair.  The judge also awarded payment for purchase of the orthotics.  The compensation judge denied the costs of the inhaler and of the treatment with Dr. Rittel, the Boulder Orthopedic Center, and Dr. Ryan in excess of reasonable charges for a half hour visit monthly and two half hour visits annually.  The employee appeals.

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.  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.

The employee appeals the compensation judge’s denial of reimbursement for the inhaler which Dr. Ryan prescribed for the employee’s breathing difficulty without success.  The employee argues that there is no medical opinion concluding that the inhaler was not reasonable and necessary, and that Dr. Ryan’s opinion should not be disregarded since it is an uncontroverted medical opinion.  See Olson v. Midwest Printing Co., 347 N.W.2d 43, 46, 36 W.C.D. 623, 627 (Minn. 1984) (citing DeHaan v. Farmers Union Mktg & Processing Ass’n, 302 Minn. 552, 555, 225 N.W.2d 21, 23, 27 W.C.D. 683, 686 (1975)); see also Flansburg v. Giza, 284 Minn. 199, 201-02, 169 N.W.2d 744, 746, 25 W.C.D. 3, 6 (1969).  However, there is a difference between disregarding an unopposed medical opinion and rejecting it on the basis of other evidence.  Clark v. Archer Daniels Midland, slip op. (W.C.C.A. Feb. 14, 1994).  Such opinion is not necessarily conclusive upon the trier of fact, see Tuomela v. Reserve Mining Co., 299 Minn. 203, 204, 216 N.W.2d 638, 639, 27 W.C.D. 312, 313 (1974), where there is other evidence to consider.

The compensation judge found that the conditions for which Dr. Ryan prescribed the inhaler and which he felt were potential causes of the employee’s voice and breathing problems, such as back pain restricting her breathing, vocal cord irritation from reflux brought on by medications for the back condition, or vocal cord scarring from surgical intubations, were causally related to the employee’s work injury.  The compensation judge also found, however, that the inhaler was not reasonable and necessary medical treatment since Dr. Ryan did not explain how the inhaler would treat the thoracic pain, reflux, or the vocal scarring.  The judge also noted that the treatment was not proposed or endorsed by the employee’s otolaryngology specialists.  We also note that the employee testified that the inhaler had no effect on her symptoms.  The compensation judge rejected Dr. Ryan’s opinion concerning the need for the inhaler on the basis that it was not a reasonable treatment for the conditions presented.  The compensation judge was not bound to accept Dr. Ryan’s opinion, and we affirm the denial of payment for the inhaler.

The employee also appeals the compensation judge’s denial of the costs of treatment by Dr. Rittel and Boulder Osteopathic Center.  The 2003 stipulation for settlement precluded “passive treatment modalities” for her low back condition and additional physical therapy except in the event of another consequential injury.  The employee argues that this treatment was for a thoracic spine condition caused by the placement and removal of a spinal stimulator, and that this condition occurred as a consequence of her original injury.  The employee relied on the opinion of Dr. Ryan and also testified as to her symptoms.  The employee also argues that Dr. Rittel’s records also indicate the reason the employee first sought this treatment was for her ongoing thoracic spine condition and symptoms.  The employee argues that the compensation judge did not address the issue of whether the employee’s thoracic spine pain was an injury that developed as a consequence of her initial low back injury, and argues that there is no medical evidence to support a finding that the thoracic symptoms were not a consequence of the employee’s low back work injury.

Determination of medical causation is a factual determination to be made by a compensation judge upon consideration of the evidence.  Felton v. Anton Chevrolet, 513 N.W.2d 457, 50 W.C.D. 181 (Minn. 1994); Foster v. Metro Produce Distrib., 63 W.C.D. 218 (W.C.C.A. 2002).  A compensation judge is generally not bound by medical opinion when making factual determinations.  The compensation judge found that under the definitions set out in the Minnesota workers’ compensation treatment parameters the treatment provided by Boulder Osteopathic Center and Dr. Rittel was passive treatment, and the employee does not argue that the treatment provided was not passive in nature.  In addition, much of the treatment provided by Boulder Osteopathic Center from September 20 through October 11, 2004, and with Dr. Rittel from January 11, 2005, through January 4, 2006, was for the low back, which was precluded by the settlement as passive treatment, and not for the thoracic spine.  It appears from the records that treatment for the employee’s thoracic spine was provided in conjunction with, and not separate from, treatment for her neck, shoulders and low back.  The compensation judge specifically found that the treatment provided by Boulder Osteopathic Center and Dr. Rittel was not the result of a consequential injury.  (Finding 13.)  Substantial evidence supports the compensation judge’s findings that the treatment was not compensable under the terms of the stipulation, and we affirm.