The employee appeals (1) whether the opinions of the independent medical expert, relied upon by the judge, are supported by adequate foundation; (2) whether the judge erred in concluding the opinions of the employee’s treating physician were not entitled to substantial weight because they were largely based upon the employee’s subjective statements rather than objective findings; (3) whether the judge applied the appropriate legal standard in analyzing entitlement to permanent partial disability benefits for reflex sympathetic dystrophy/complex regional pain syndrome (RSD/CRPS); (4) if not, whether the employee was entitled to additional permanent partial disability benefits under the appropriate standard; (5) whether the judge erred in denying permanent total disability from May 2, 1998, through July 19, 2011; and (6) whether the judge properly determined the employee unreasonably refused stellate ganglion blocks^[1] to treat his RSD.  We affirm.

The employee began his employment as a millwright with the employer in the fall of 1995.  On May 21, 1996, the employee sustained an admitted crush injury to his left great toe/foot.  The employee was seen by Dr. Thomas Patnoe who operated on the toe on May 30, 1996.  Following the surgery, the employee experienced persistent swelling and sensitivity to light touch in his left foot and leg and was unable to return to work.

On July 15, 1996, Dr. Robert Barnett performed an independent medical examination at the request of the employer and insurer.  Dr. Barnett noted chronic edema (swelling), absence of motion, and a great deal of sensitivity and pain throughout the left leg and foot.  The doctor diagnosed RSD and recommended aggressive physical therapy to treat the condition.

The employee returned to see Dr. Patnoe on July 22 and 30, 1996.  Dr. Patnoe noted swelling in the leg and foot, mottling (skin discoloration) of the leg, changes in skin texture, tenderness to very light touch, and little or no active motion of the toes.  X-rays revealed osteopenia (bone loss) in the foot consistent with RSD.  He agreed with Dr. Barnett’s diagnosis of RSD and discussed treatment options with the employee, stressing the importance of physical therapy.  Dr. Patnoe also discussed the potential benefits of sympathetic blocks with the employee, but the employee indicated he had a needle phobia and was not interested in having injections in any form.

On August 19, 1996, the employee was seen by Dr. Jack Bert at the request of the case manager.  Dr. Bert indicated the treatment of choice for RSD was aggressive physical therapy and sympathetic blocks.  The employee stated that needles frightened him and would not consider a block.  Dr. Bert opined the employee should do extremely well with a sympathetic block which the doctor believed “could literally cure his symptoms completely,” and posited the employee was essentially refusing treatment for his condition.  (Er. Ex. 7.)

On October 28, 1996, Dr. Patnoe noted the employee’s symptoms seemed to be worsening, but stated they were “beyond the window of opportunity for sympathetic blocks.”  (Ee. Ex. 2.)  Dr. Bert disagreed.  On December 2, 1996, Dr. Patnoe stated he had little additional treatment he could offer the employee, stated the employee was at maximum medical improvement (MMI), and agreed with the case manager’s recommendation of a functional capacities evaluation (FCE).

A rehabilitation consultation was performed by QRC Dee Koskela on February 17, 1997.  The QRC concluded the employee would not be able to return to his work as a millwright and was, therefore, a qualified employee for purposes of rehabilitation services. Rehabilitation services, consisting primarily of medical monitoring, were initiated.

The employee was seen by Dr. Jack Drogt at the request of the employer and insurer on February 18, 1997.  The doctor noted the employee walked with a marked limp with an aversion to weight-bearing on the left side.  The left foot and ankle were swollen, slightly reddened, shiny, and puffy; and there was tenderness to light touch involving the foot and ankle.  Dr. Drogt concluded the employee’s subjective symptoms were substantiated by objective findings and the employee had significant impairment as a result of RSD.  It was Dr. Drogt’s opinion that the employee should be offered counseling to address his aversion to needles, and he opined there was an excellent chance that additional treatment would relieve his disabling symptoms.  Dr. Drogt further opined the employee was capable of sedentary work with restrictions of no frequent standing, walking, or climbing.

Based on a functional capacities evaluation completed on March 4-5, 1997, Dr. Patnoe released the employee to return to sedentary work on March 12, 1997.  Restrictions included sitting 8 hours, standing and walking 4 hours with frequent positional changes, and rest breaks.  Bending, stooping, kneeling, pushing/pulling, lifting and carrying were significantly limited due to compromised stability and balance, with no squatting, crawling, climbing, crouching, or balancing.  Dr. Patnoe noted the employee’s physical abilities were quite limited, and stated the employee might not be able to tolerate work even within these restrictions on a long term basis.

In March 1997, the QRC noted the employee was unable to complete a vocational evaluation due to inability to tolerate sitting for any length of time.  She reported the employee did not think he would be able to tolerate the sitting required for a desk job and did not think he could sit in a class or be in groups where his foot being bumped was possible.  The QRC recommended a consultation with an RSD expert.

The employee reached 90 days post MMI in May 1997.  On May 1, 1997, the employee filed an application for Social Security disability benefits.

The employee was seen by Dr. Todd Hess at United Pain Center in St. Paul on June 11, 1997.  Dr. Hess noted the employee’s phobia to needles.  The doctor reported the employee stated that since blocks were not 100 percent certain, he refused to go through the needles it would require, and that he was going to do nothing more for his condition but just accept the pain and have no more treatment.  Dr. Hess discussed with the employee that with aggressive treatment, RSD was very treatable, and that physical therapy along with pain medications and injections was the established treatment protocol.  The doctor further explained they could do injections under sedation.  The employee adamantly refused.  As an alternative, Dr. Hess proposed a number of medications, ultimately selecting Guanethidine for the employee’s RSD treatment.  Dr. Hess recommended that the employee obtain a primary physician in Eveleth for medication monitoring.

In a report dated August 15, 1997, QRC Koskela noted the employee was without income of any sort and had not followed up with Dr. Hess due to financial difficulty in returning to St. Paul.  The employee was discharged from the pain center program with a recommendation to obtain a copy of the list of recommended medications and follow up with a local physician.  Dr. Hess indicated he believed the employee’s condition was manageable and the likelihood of reduction of symptoms was great if the employee participated in the medication protocol.

The employee began treating with Dr. Brian Pfeifer at the East Range Clinic in September 1997.  The employee reported he had horrendous pain in the left leg and foot, was not able to walk effectively, was unable to sit for any length of time, and was unable to get around even for personal needs due to his RSD.  The employee had discontinued the Guanethidine due to minimal improvement and blurred vision.  Dr. Pfeifer also noted the employee did not wish blocks due to a severe fear of needles, and started the employee on Nortriptyline.  The doctor stated the employee should remain off work.

On December 10, 1997, the employee was examined by Dr. William Lohman at the request of the employer and insurer.  On examination, Dr. Lohman’s findings were normal except for the left leg and foot.  The doctor noted the skin there was mottled and dusky, there was diffuse mild swelling, the skin texture was thin and shiny, there was marked allodynia (skin pain) to cutaneous (skin) stimulation, active motion in the ankle was nil, passive motion was markedly reduced and accompanied by marked pain in the foot, and light touch sensation was decreased over the toes.  Dr. Lohman concluded the employee had RSD supported by history, physical, and x-ray findings.  The doctor opined the employee’s prognosis for further recovery was extremely poor based on the duration of his symptoms and his refusal to consider injection therapy.  Dr. Lohman believed the employee was capable of sedentary work so long as he was allowed to change positions as needed and keep the foot elevated while seated, coupled with the restrictions of no stooping, squatting, kneeling, crawling, or ladder climbing, minimize stair climbing, and limit lifting and carrying to 10 pounds or less with one hand.

After reviewing extensive surveillance videotapes of the employee, Dr. Lohman completed a supplementary report on January 26, 1998.  The doctor concluded the employee was exaggerating the amount of disability caused by his RSD, and needed no limitations on standing, walking, or sitting, could stoop, squat, kneel, and crawl, could lift at least 50 pounds and carry at least 35 pounds.  Dr. Lohman concluded the employee needed no further treatment.  He further opined the employee qualified for permanent partial disability, but only 6.5 percent for mild RSD.

In a report dated January 7, 1998, David Berdahl, a rehabilitation consultant, provided a labor market survey that looked at employment opportunities in the employee’s labor market, compatible with the employee’s work history, and consistent with the March 1997 FCE approved by Dr. Patnoe.  Mr. Berdahl noted the employee had 22 years of experience in car sales with solid customer service and communications skills.  Based on the survey, Mr. Berdahl expected the employee would be able to find suitable sedentary work if he conducted a serious job search with rehabilitation assistance.

On March 19, 1998, the employee began treating with Dr. Fred Lux, a neurologist at East Range Clinic, on a referral from Dr. Pfeifer.  On examination, the doctor noted hair changes, increased coloration and blotchy spots, some decrease in temperature, and extreme sensitivity to touch in the left lower extremity, along with some acrodermatosis (inflammation of the skin) or neurogenic dermatitis on the left leg.  He noted temperature and coloration differences between the right and left sides.  His impression was left lower extremity RSD “apparently marching to other extremities (right side).”  (Ee. Ex. 4.)  The employee related his fear of needles to Dr. Lux and declined the use of blocks as treatment.  Dr. Lux recommended a Catapres (clonidine) transdermal patch instead.  Dr. Lux did not believe the employee could work.

By report dated March 19, 1998, QRC Koskela noted “the employee continues to believe that any type of work is not feasible because of his overall tolerance is so limited.”  (Ee. Ex. 13.)  He reported his best pain management technique was to minimize his activity.

On March 24, 1998, a hearing was held before Compensation Judge Donald Erickson.  The sole issue was the extent of the employee’s permanent partial disability for RSD to the left foot and ankle.  The employee’s claims for permanent partial disability in excess of 6.5 percent were denied in a Findings and Order issued June 25, 1998.  (Affirmed in a decision issued by this court on February 19, 1999.)

The employee continued to treat with Dr. Lux.  On June 15, 1998, he concluded that given the chronicity of the employee’s condition, future care would be focused primarily on pain management and attempting to improve the employee’s function to some degree.  Dr. Lux opined the employee would not be able to work even in a sedentary job.  By report dated July 28, 1998, QRC Koskela reported that Dr. Lux did not believe the employee would be able to participate in any meaningful job activities and would not be able to resume working in any capacity.  The QRC spoke to the claims representative on July 21 and reported that “Both parties are in agreement, at this time, additional rehabilitation services are not feasible as Mr. Niemi does not appear to be a qualified employee any more as the likelihood of his being able to return to work and benefit from rehabilitation services does not exist.”  (Ee. Ex. 13.)

The employee returned to see Dr. Lux periodically through the date of hearing in this matter.  The employee first reported symptoms in his hands in September 1998.  The doctor was unsure whether this was another condition or an extension of his RSD, but noted no changes or deficits in the upper extremities on examination.  Also at this visit, the employee requested a wheelchair to help him with his joint pain and arthritis.  Dr. Lux denied the request because of employee’s age (45) and his belief that cardiovascular activity was necessary.  By April 1999, the employee’s treatment consisted of weekly clonidine patches, naproxen, and Ultram for pain.  The doctor’s examination and objective findings remained focused on the left lower extremity.  Dr. Lux continued the employee off work and follow-up appointments were scheduled every six months.

Dr. Lux moved to Noran Neurological Clinic in Minneapolis in 2001 and the employee continued to treat with him there.  On March 14, 2001, Dr. Lux noted chronic RSD affecting primarily the left lower extremity, but, subjectively, “now marching into his left arm.”  (Ee. Ex. 7.)  Examination revealed objective findings consistent with RSD in the left foot and leg.  Neurontin was added to the employee’s medication regimen.

On April 10, 2002, the employee received a favorable decision upon remand from the federal District Court awarding him Social Security disability benefits retroactive to August 28, 1998, based on RSD of the left lower extremity and hypertension.

The employee was seen by Dr. Lux through September 2003 with little change in his condition.  He did not return thereafter until April 21, 2005, reporting he had not been doing well lately, and that he had had to go to court to get medical coverage reinstated.  On examination, Dr. Lux noted immobility of the left foot with mottling, blanching, and a patchy cyanotic (bluish discoloration) appearance, and tenderness to light touch.  The employee reported his condition had spread to the left hand and left hip, but the doctor wondered whether this was arthropathy rather than RSD.  His examination of the employee’s extremities other than the left lower extremity was normal.  Following a September 15, 2006, appointment, the employee began seeing Dr. Lux on an annual basis.  Over the next several years, Dr. Lux indicated the employee’s RSD had progressed, spreading, at various times, to his right leg and right and left upper extremities.  On September 10, 2010, Dr. Lux recorded the employee was having problems with pain below the neck level with symptoms and findings on the right hand, and in his arms, feet and legs bilaterally.  Upon physical examination, the employee appeared well nourished, well hydrated and in no acute distress.  He denied back pain, joint pain, joint swelling, muscle cramps, muscle weakness, stiffness, or arthritis.

The employee was examined by Dr. William Fleeson on August 19, 2010, at the request of his attorney.  Dr. Fleeson interviewed and examined the employee and reviewed extensive medical records.  The doctor noted the employee was a very poor historian and was unable to provide detailed information about his symptomatology.  The employee reported that his RSD was spreading to other areas and that everything from his neck down had RSD.  Dr. Fleeson noted his physical examination of the employee was somewhat curtailed due to the employee’s rather extreme reactions and reports of pain during the examination process.  The doctor observed a swollen distal phalanx on the ring finger with an infection along the edge of the fingernail.  There was no mottling of the hands or arms and no observable abnormality of color, temperature, or skin trophic elements.  Examination of the lower extremities and feet was unsatisfactory, however, the left foot was observably smaller and cooler than the right, was purplish and mottled, the employee stated he could not move his toes, and there appeared to be muscle wasting.  There was no perceptible temperature change or observable mottling on the right.  Dr. Fleeson concluded the employee had RSD/CRPs, with documented spreading RSD symptoms, along with an emotional/psychological component.  He anticipated the employee’s RSD would at best remain as it was, but more likely than not would worsen over time with more members being involved.  Dr. Fleeson opined the employee was not capable of full-time employment and seemed to have internalized the disability status reflected in his medical records for the past 15 years.

On July 19, 2011, the employee was examined by Dr. Loren Vorlicky at the request of the employer and insurer.  By report dated August 3, 2011, Dr. Vorlicky agreed the employee had RSD/CRPS of the left lower extremity, but stated there was no evidence to support the notion that he had RSD “from the neck down.”  The doctor noted the employee would not permit examination of his lower extremities.  Dr. Vorlicky further stated he was “unaware of migratory symptoms associated with RSD,” but asserted the employee had a completely normal examination of his upper extremities, and based on his observation, the right lower extremity appeared normal.  The doctor stated that typically RSD is not a progressive migrating entity and he believed the employee had reached a plateau or “burnout stage” by early 1997.  (Er. Ex. 12.)  Dr. Vorlicky further opined the employee was capable of working in a sit down, sedentary-type job with walking and standing limited to less than one hour; had not been and was not permanently and totally disabled; and had permanent partial disability of 6.5 percent relative to the left lower extremity attributable to the work injury.

On October 7, 2011, Dr. Lux stated the employee seemed more immobile than before.  He observed clear swelling in the employee’s right hand at the interphalangeal and metacarpophalangeal joints.  Dr. Lux reiterated that he did not believe the employee was capable of working.

An independent vocational assessment was completed by Scott Campbell, a certified case manager and QRC, on behalf of the employee.  In a report dated December 22, 2011, Mr. Campbell stated the employee described RSD spread throughout his body from the neck down.  The employee described his self-perceived extensive limitations for Mr. Campbell.  Mr. Campbell noted the employee had not worked since 1996, that his RSD/CRPS symptoms had worsened over the years, and that the employee’s activities of daily living were extremely circumscribed.  Mr. Campbell concluded it would be highly unlikely the employee would be able to secure or sustain any type of gainful employment given his current medical status.

Dr. Vorlicky examined the employee a second time on March 30, 2012.  By report dated April 11, 2012, the doctor described essentially normal findings in both lower and both upper extremities, with the exception of tenderness to palpation on both feet, left greater than right.  He noted some swelling in the right hand index finger and some clubbing of the left hand ring finger.  Dr. Vorlicky concluded the employee had subjective complaints of left lower extremity pain that were out of proportion to any objective findings, and stated he could find no evidence of RSD/CRPS of the left foot/lower extremity at the time of his exam.  He continued to maintain he was unaware of any migratory findings of RSD and had not seen any individual who had RSD involving one extremity which spread to another extremity.  It was Dr. Vorlicky’s opinion that the employee could work without restrictions relative to time on his feet in a standard 8-hour day.  Dr. Vorlicky was aware of Dr. Lohman’s medical opinions.

On September 20, 2013, Dr. Lux reported the employee was having more mobility issues and his condition was getting worse.  The doctor noted more edema in both hands and minimal movement in his right hand, with clubbing of his fingernail beds but no acrocyanosis (bluish discoloration).  He referred the employee to rheumatology as he though the employee might have arthritis or an autoimmune disorder superimposed on his RSD.

In supplementary reports, dated May 23, 2013, and November 1, 2013, Dr. Fleeson responded to Dr. Vorlicky’s reports and reviewed medical articles provided by the employee’s attorney.  Dr. Fleeson stated the eight articles provided in May were from reliable and accepted sources, were consistent with his knowledge of, and personal experience with, RSD and supported the contention that RSD may migrate to other limbs.  He disagreed with the opinions of Dr. Vorlicky.  Additional articles provided in October included a meta-analysis that concluded there was little evidence to support the effectiveness of lumbar sympathetic blocks for the treatment of CRPS.  Dr. Fleeson stated the published materials generally correlated with his clinical experience with the use of blocks which he stated had a spotty success rate, with sometimes partial relief, sometimes none, but typically short relief.  Dr. Fleeson additionally opined the employee was suited only for sporadic, short hours of work with restrictions that would prevent significant gainful employment.

A deposition was taken of Dr. Lux on October 18, 2013.  Dr. Lux testified the employee’s RSD has migrated to both arms and both legs.  He stated he has treated many people over time for RSD, has seen patients with migration of their symptoms from the original injury site, and that migration from one limb to another is very common.  He reviewed the same literature provided to Dr. Fleeson and agreed it is considered reliable in the field and was consistent with his experience.  Dr. Lux additionally testified that stellate ganglion blocks are one of the treatments used to treat patients with RSD, however, in his view, the treatment is controversial because not many patients actually achieve success with the treatment.  He stated it is an invasive procedure with significant risks, including the risk that doing a block would worsen the RSD/CRPS.  Dr. Lux testified that by the time he first saw the employee in March 1998, the window of opportunity for treating with a sympathetic block had closed.  Moreover, he did not believe that it was likely that the employee would have improved even if he had had blocks commencing in August 1996.

On January 1, 2011, the employee filed a claim petition alleging injuries in the nature of “left foot/RSD” and seeking permanent total disability benefits from and after March 25, 1998, and permanent partial disability for RSD in all four extremities.  The matter was heard on November 5 and 6, 2013, before Compensation Judge Baumgarth in Duluth.  At the hearing, the employee amended the effective date of the claimed permanent total disability to May 2, 1998, and amended his claim for permanency to 19.5 percent for the left lower extremity, 9.75 percent for the right lower extremity, and 20.25 percent each for the left and right upper extremities.  In a Findings and Order served and filed January 9, 2014, the judge found (1) the employee’s left lower extremity RSD had not migrated to the other extremities; (2) the employee unreasonably refused stellate ganglion blocks to treat his RSD; (3) the employee had sustained no additional permanent partial disability; and (4) the employee failed to establish he has been permanently and totally disabled since May 2, 1998.  The employee appeals.

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 (2012).  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).

The compensation judge accepted and adopted the opinion of Dr. Vorlicky in finding the employee’s left lower extremity RSD had not migrated to other extremities.  (Finding 22.)  The employee argues the opinion of Dr. Vorlicky is so flawed as to lack foundation and the judge should not have admitted his reports and testimony over the objections of the employee’s counsel.  The employee contends that Dr. Vorlicky indicated that he had not seen RSD migration in his own practice and admitted he was unaware that RSD symptoms could migrate.  Lacking adequate scientific knowledge and experience relating to RSD/CRPS, the employee argues that Dr. Vorlicky missed or discounted symptoms in the employee’s extremities during his examination, and therefore, lacked adequate foundation to provide an opinion in this case.

The exclusion of expert medical testimony lies within the sound discretion of the trier of fact.  Generally, the competency of a witness to provide expert medical testimony depends both upon the degree of the witness’s scientific knowledge and the extent of the witness’s practical experience with the matter which is the subject of the offered testimony.  Reinhardt v. Colton, 337 N.W.2d 88, 93 (Minn. 1983).  Dr. Vorlicky is a board certified orthopedic surgeon.  He testified that he has treated a number of people with RSD/CRPS in his own practice.  He took a history from the employee and examined the employee on two occasions, reviewed all of the employee’s treatment records, including those of Dr. Lux and Dr. Lohman, and reviewed the previous independent medical examination reports.  As a general rule, this level of knowledge establishes a doctor’s competence to render an expert opinion.  See Grunst v. Immanuel-St. Joseph Hospital, 424 N.W.2d 66, 68, 40 W.C.D. 1130, 1132-33 (Minn. 1988).

Dr. Vorlicky acknowledged that case studies exist in the medical literature that describe migrating symptoms, but stated that he had never seen it.  Moreover, Dr. Vorlicky testified that other than the employee’s subjective complaints, he saw no objective evidence of RSD symptoms in any extremity other than the left leg.

According to both Dr. Vorlicky and Dr. Fleeson, the physiology of RSD/CRPS is not well understood.  Its progression and treatment, as demonstrated in this case, is controversial and not well defined, including the concept of migration of RSD symptoms to other extremities.  The arguments made by the employee go to the persuasiveness or weight to be accorded the doctor’s opinion rather than a lack of foundation.  See, e.g., Drews v. Kohl’s, 55 W.C.D. 33 (W.C.C.A. 1996).  The compensation judge did not err in adopting the opinion of Dr. Vorlicky in finding the employee’s left lower extremity RSD had not migrated to other extremities.

The employee argues that a medical opinion must rest on a factual basis and not mere conjecture.  He asserts the trier of fact’s choice of medical experts is “not upheld where the facts assumed by the expert in rendering his opinion are not supported by the evidence.”  Nord v. City of Cook, 360 N.W.2d 337, 343, 37 W.C.D. 364, 372-73 (Minn. 1985).  The employee argues that, in addition to assuming that RSD migration does not exist, Dr. Vorlicky - - and the judge - - ignored the documented objective findings of Dr. Lux over the 13 years he treated the employee.

The judge found the employee’s testimony not credible (finding 20) and that the opinions of Dr. Lux were predominantly based upon the statements of the employee (finding 21).  A close review of the medical records reveals that between May 1996 and January 1997, there were no references to RSD symptoms in other extremities.  At the employee’s first visit with Dr. Lux on March 19, 1998, the doctor recorded objective findings relative to the left lower extremity and assessed left lower extremity RSD, “apparently marching to other extremities (right side).”  The doctor referenced the employee’s complaints, but recorded no abnormal findings relative to the right leg.  On June 15, 1998, Dr. Lux commented, “luckily so far no additional extremities have been involved.”  (Ee. Ex. 4.)  These comments, among others, support the judge’s conclusion that the opinions of Dr. Lux were predominantly based upon the employee’s statements.

Dr. Lux recorded the employee’s subjective complaints of right foot/leg and hand and arm symptoms through 2007, however, Dr. Lux’s chart notes continue to reference objective findings on examination solely in the left foot and leg.  In September 1998, the employee reported paresthesia in his hands in the morning, but Dr. Lux noted no deformities or deficits in the upper extremities on examination.  In April 2000, Dr. Lux related that RSD was now marginal in the employee’s hands and he was having a hard time operating simple things like a remote control.  The doctor specifically reported, however, that there were no changes in coloration, temperature, or strength in the employee’s hands.  In March 2001, Dr. Lux reported that, subjectively, the employee was having more problems with his left arm, but again noted only left foot and leg findings on examination.  In March 2002, Dr. Lux stated the employee’s left hand looked a little pale and dry compared to the right with quite limited motion and a weak grasp, but that the employee’s symptoms were mostly circumscribed to his left leg.  In April 2005, Dr. Lux indicated the employee’s condition had spread to the left hand, but noted normal motor function, strength and sensation in the upper extremities.

Beginning in 2008, Dr. Lux’s chart notes indicate the employee’s RSD was progressing and had spread to both upper extremities and both feet.  The doctor recorded some weakness in the upper extremities on occasion, and on one occasion mottling discoloration in both feet.  On September 10, 2010, he noted variations in color in the employee’s arms, feet and legs, minor fractures in his elbow, and swelling and numbness in the interphalangeal joint of the ring finger of the right hand, all of which he believed were probably related to the employee’s RSD and/or osteoporosis from RSD.  The doctor again noted swelling of interphalangeal and metacarpophalangeal joints of the right hand and weakness in both upper extremities and both lower extremities in October 2011.  In October 2012, Dr. Lux assessed RSD and osteoarthritis.  He noted deformity and joint pain in the right hand. In September 2013, Dr. Lux noted more swelling and restricted movement in both hands and referred the employee to rheumatology.  He diagnosed increased arthritis and joint pain.  At his deposition, Dr. Lux agreed that what he was seeing in the hands could be arthritis and that additional testing would need to be done to determine whether the employee’s hand difficulties were arthritis or RSD.

Based on this record, the judge could reasonably conclude that the opinions of Dr. Lux were predominantly based on the employee’s subjective statements relative to his symptoms and condition in the right leg and upper extremities.  Accordingly, the judge did not err in finding Dr. Lux’s opinions less persuasive than Dr. Vorlicky’s on this basis.

The employee argues the judge applied an erroneous legal standard in concluding the employee did not establish RSD in limbs other than the left lower extremity.  In his memorandum, the judge stated that “[t]o support a diagnosis of RSD, the rules require that at least five of the following conditions persist concurrently in the affected member:  edema [swelling], local skin color change of red or purple, osteoporosis in underlying bony structures demonstrated by radiograph, local dyshidrosis [small blisters/eczema], local abnormality of skin temperature regulation, reduced passive range of motion in contiguous or contained joints, local alteration of skin texture of smooth or shiny, and typical findings of reflex sympathetic dystrophy on bone scan,”^[2] and stated that he found no documentation of these conditions being concurrently found “on successive examinations.”  (Mem. at 7.)

In Ellsworth v. Days Inn/Brutgers Equities, No. WC06-276 (W.C.C.A. June 8, 2007), this court stated the rule phrase “persist concurrently” may be read to imply appearance in a general period of time rather than in a specific moment of time, and concluded it was not unreasonable for a judge to rely on the doctors’ several diagnoses of RSD, notwithstanding the fact that the specified conditions were not present at the same moment in time.  Thus, the judge incorrectly stated or implied that five conditions must collectively be present “on successive examinations.”

Moreover, the requirements for a permanent partial disability rating do not necessarily apply to preclude a diagnosis of RSD, although they may be a useful index by which a judge may elect to accept such a diagnosis.  Specifically, to establish a diagnosis of RSD, an employee need not establish five of the eight listed conditions.  Stone v. Harold Chevrolet, 65 W.C.D. 102 (W.C.C.A. 2004), summarily aff’d. (Minn. Feb. 2, 2005); Ellsworth v. Days Inn/Brutgers Equities, No. WC06-276 (W.C.C.A. June 8, 2007).  There must, however, be an affirmative diagnosis of RSD in a limb based in part on objective personal observation of at least some of the RSD-relevant conditions.

As discussed above, the judge reasonably concluded the opinions of Dr. Lux were predominantly based on the employee’s reports of spreading symptoms in the right leg and upper extremities.  The evidence of objective observations of any of the eight listed conditions in the right leg or upper extremities is minimal.  There are recent objective findings relative to the hands, but even Dr. Lux was uncertain whether these findings represented arthritis or RSD.  Although the judge misapplied the legal standard for establishing RSD, the substantial evidence of record supports the judge’s determination that the employee failed to establish that the left lower extremity RSD had migrated to other extremities or portions of his body.

The employee contends the judge erred in denying permanent total disability from May 2, 1998, through July 19, 2011, the date of Dr. Vorlicky’s first report, because there was no contrary medical or vocational evidence on which to conclude the employee was employable during this time period.  The employee asserts that Dr. Lux’s chart notes provide the only contemporaneous medical evidence of the employee’s disability status during that time.  Dr. Lux opined the employee was not competitively employable throughout his treatment of the employee and did not release the employee to return to work.  The employee maintains that both vocational experts, Mr. Campbell and Mr. Berdahl, agreed that if Dr. Lux’s opinion was accepted, the employee was, and had been, unable to work since March 1998.

The judge found the employee’s testimony, particularly his testimony relating to the extent of his functional limitations, was not credible.  The judge concluded, as discussed above, that the opinions of Dr. Lux and Dr. Fleeson were predominantly based upon the statements of the employee, and rejected their opinions that the employee was not capable of gainful employment.  He accepted instead the vocational opinions of David Berdahl that the employee was, and is, capable of sedentary employment.

On March 12, 1997, Dr. Patnoe, the employee’s surgeon and then treating physician, released the employee to return to work with sedentary-work restrictions.  Although Dr. Patnoe expressed some reservations about the employee’s long-term ability to work based on the FCE restrictions, no attempt was made to look for work within those restrictions.  On January 26, 1998, Dr. Lohman concluded, based upon his review of surveillance videotapes, that the employee was exaggerating his disability and was capable of employment with no limitations on standing, walking, or sitting, stooping, squatting, kneeling, and crawling, and could lift at least 50 pounds, and carrying at least 35 pounds.

In a report dated January 7, 1998, David Berdahl, a rehabilitation consultant, provided a labor market survey that looked at employment opportunities in the employee’s labor market, compatible with the employee’s work history, and consistent with the March 1997 FCE approved by Dr. Patnoe.  Mr. Berdahl noted the employee had 22 years of experience in car sales with solid customer service and communications skills.  Based on the survey, Mr. Berdahl anticipated the employee would be able to find suitable sedentary work if he conducted a serious job search with rehabilitation assistance.

The employee began treating with Dr. Lux, on March 19, 1998, at which time Dr. Lux took the employee off work.  On that date, QRC Koskela noted “the employee continues to believe that any type of work is not feasible because his overall tolerance is so limited.”  (Ee. Ex. 13.)  The employee stated his best pain management technique was to minimize his activity.  By June 15, 1998, Dr. Lux concluded the employee was so disabled by his RSD that he would not be able to work even in a sedentary job.  By report dated July 28, 1998, QRC Koskela reported that based on Dr. Lux’s opinion, “Both parties are in agreement, at this time, additional rehabilitation services are not feasible as Mr. Niemi does not appear to be a qualified employee any more as the likelihood of his being able to return to work and benefit from rehabilitation services does not exist.”  (Ee. Ex. 13.)  The employee has not returned to or looked for work since the injury.

On August 3, 2011, Dr. Vorlicky completed an IME report.  Based on his review of the employee’s treatment records, the employee’s deposition testimony, the history he took from the employee, and his examination of the employee, Dr. Vorlicky was of the opinion that the employee was capable of working in a sedentary, sit down-type job with walking and standing limited to less than one hour in an 8-hour day, and the use of a postop type shoe on the left foot.  The doctor further opined the employee had not been permanently and totally disabled from a medical standpoint and could have engaged in sedentary office-type work.

Mr. Berdahl met with the employee in January 2012, and conducted another labor market survey in October 2013.  He reviewed Mr. Campbell’s report, Dr. Fleeson’s reports, additional chart notes from Dr. Lux, and a physical therapy/pre-FCE report from Essentia Health.  Mr. Berdahl accepted that, medically, the employee was limited to sedentary work, primarily sitting down, with the ability to change positions.  He opined the employee is capable of hire in entry-level, non-physical work, such as customer service jobs, phone jobs, and things of that kind, and that there are jobs in the market consistent with his capabilities and work history.  Mr. Berdahl additionally testified that, basically, the employee just doesn’t believe he can physically work.

The result reached by the judge boils down to a choice between medical and vocational experts.  The judge concluded the employee had been and was capable of sedentary employment, and accepted Mr. Berdahl’s opinion that, based on his 1998 and 2013 reports, the employee is not, and was not permanently and totally disabled.  There is substantial evidence to support the judge’s decision on this issue and we affirm.

The judge found (1) the employee was advised by multiple physicians, both treating and independent medical experts, that stellate ganglion blocks were indicated for treatment of RSD in his left lower extremity, and was afforded multiple opportunities to proceed with sympathetic blocks as a part of his treatment; (2) the employee refused sympathetic blocks on each occasion and testified he did so because he has a needle phobia; (3) the blocks could have been given under sedation and the employee had been advised they could be given under sedation; and (4) the employee’s refusal to undergo the stellate ganglion blocks previously offered to him was unreasonable based on the opinions of Drs. Bert and Hess.

In any event, the issue may be moot given the judge’s finding, in reliance upon Mr. Berdahl’s opinion, that the employee failed to establish he was permanently and totally disabled from May 20, 1998, through the date of the hearing, that the employee was, and is, capable of sedentary employment.