The employee appeals the compensation judge’s finding that the employee is not permanently and totally disabled.  We affirm.

Julianne Sanden, the employee, was born in 1955.  She is a high school graduate who completed two post-high school education programs, an administrative assistant associate degree and a medical assistant certification.  Over the years, the employee mostly worked in manual and assembly-type labor jobs as well as desk work.  She moved to Minnesota in 1996, and at the time of the hearing was residing in Fergus Falls, Minnesota.

On September 16, 1996, the employee sustained an injury to her neck and right shoulder while working for Northern Contours making cabinet doors and operating a press.  Northern Contours and its insurer, RTW, Inc., admitted liability and paid various benefits, including a 10 percent permanent partial disability for a right C5-6 disc herniation.  The employee continued to work at Northern Contours for another six years after the 1996 injury.  She stopped seeking medical treatment for the cervical spine in 2011.  At the hearing, the employee testified that her cervical spine is occasionally symptomatic.

In late 2006 or early 2007, the employee began working for The Work Connection,^[1] the employer, then self-insured with claims managed by RTW, Inc.  The employee’s first assignment was assembly work at a manufacturing plant.  On November 9, 2007, while working on assignment, the employee injured her low back as she pulled a 75 to 80 pound pallet off the top of a stack of wooden pallets.  She immediately experienced symptoms of severe low back pain and spasms, along with radiating pain into her legs.  The employer admitted liability for the injury and the employee began medical treatment for her low back under the direction of her family physician, Dr. David Sanderson at Fergus Falls Medical Group.

The employee continued conservative medical treatment following the low back injury, including physical therapy and steroid injections.  On February 1, 2008, the employee underwent a lumbar spine MRI scan that revealed a broad based herniation at L4-5 extending into the right neural foramina as well as degenerative changes at multiple levels of the lumbar spine.^[2]  Dr. Sanderson recommended a physical medicine and rehabilitation consultation and referred the employee to Dr. James Andrews.^[3]  On March 5, 2008, the employee consulted with Dr. Andrews.  Dr. Andrews reviewed the February 1, 2008, MRI and noted the employee was working four hours per day with lifting restrictions.  He diagnosed lumbar radiculopathy and recommended physical therapy, anti-inflammatory medications, and work restrictions.  Dr. Andrews also noted that if the employee did not improve, he would consider a transforaminal epidural steroid injection at the L4-5 nerve root levels.  He also mentioned that the employee would obtain a sequential stimulator to assist with her back spasms.

The employee continued to work for the employer on a different assignment and on April 16, 2008, the employee returned to Dr. Andrews, reporting ongoing pain and trouble working.  On May 14, 2008, with no change in the employee’s symptoms, Dr. Andrews recommended a lumbar epidural steroid injection.  On May 25, 2008, Dr. Andrews performed a left L4-5 transforaminal epidural steroid injection which provided the employee with notable relief.  The employee returned to work within her restrictions, but the work duties required some lifting beyond her restrictions and the employee’s back symptoms returned.  During this time, she also developed a radicular-type pain down the left leg.  Dr. Andrews continued the same restrictions and recommended a repeat lumbar epidural injection.  In July 2008, Dr. Andrews performed the employee’s second epidural steroid injection.  The second injection provided minimal, short-term relief.  The employee continued to work within the four-hours-per-day work restrictions and was recommended to pursue a surgical consultation with Dr. Sunny Kim at Central Minnesota Spine Center.

On January 27, 2009, the employee underwent a lumbar spinal fusion from L3 to L5 performed by Dr. Kim.  During a two-week follow up on February 13, 2009, the employee reported that her severe leg pains were gone.  But, gradually, the pre-surgery symptoms returned in her lower back and leg, and the employee continued to experience intermittent flare-ups with significant radicular pain.  During a follow up visit in June 2009, Dr. Kim noted the hardware seen by x-ray was intact and there was evidence of fusion.  On June 10, 2009, Dr. John Axelson, Medical Director for the employer’s administrator RTW, wrote to Dr. Kim as follows:

By fall 2009, the employee was in physical therapy and released to continue with sedentary part-time work restrictions.  By September 25, 2009, x-rays taken revealed a stable fusion;^[6] however, the employee continued to report lower back pain into the left lower extremity but no leg pain.  On November 20, 2009, Dr. Kim released the employee to light-duty lifting no more than 10 pounds eight hours per day for the next three months and to be able to change positions every 15 minutes.  Dr. Kim recommended another month of physical therapy and a Med-X program.^[7]  The employee continued treating with narcotic pain relievers.  In February 2010, she was diagnosed with depression and medication was prescribed to treat this condition.  By May 7, 2010, Dr. Kim noted that the Med-X program had provided good objective results and found the employee at maximum medical improvement with a permanent 10-pound lifting restriction.  The employee remained symptomatic.

During the periods Dr. Kim released the employee to return to work in 2009 and in 2010, the employee was provided rehabilitation assistance with QRC Ken Moberg.^[8]  In the summer of 2010, the employee and her QRC began exploring subsidized employment with the Experience Works organization.  The employee was not eligible for the subsidized employment program until she turned 55 years old in October 2010.^[9]

In November 2010, the employee began working part-time through Experience Works performing light clerical-type duties.  The employee worked four hours per day, five days per week.  The employee was physically capable of performing the job duties with occasional assistance from co-workers.^[10]  The employee continued to seek medical treatment for her pain and to restrict her activities.  On November 5, 2010, Dr. Kim referred the employee to Northwest Industrial Rehabilitation Services for physical therapy.  In February 2011, the employee returned to Dr. Kim, who recommended removal of the hardware from the lumbar fusion surgery.  Dr. Kim emphasized that the employee should not work more than four hours per day on a very light-duty basis with a 10-pound lifting restriction.  In March 2011, the employee discontinued working with Experience Works to have the fusion hardware surgically removed.  By the time the employee was released to return to work, her position through Experience Works had been eliminated because the funding for the position had run out.^[11]

On March 22, 2011, Dr. Kim performed an operation to remove the employee’s hardware from the spinal fusion.  The surgery did not provide the employee relief.  During a follow up appointment on April 20, 2011, Dr. Sanderson noted the employee was still having severe low back pain and agreed that the employee could try acupuncture.  On April 22, 2011, Dr. Kim took the employee off work and recommended additional physical therapy and acupuncture.  During a follow up with Dr. Kim on May 20, 2011, the employee reported improvement with acupuncture but worsening after physical therapy.  Dr. Kim recommended ongoing acupuncture.  The employee returned to Dr. Kim on June 17, 2011, reporting severe pain in the left low back and into the left hip, requiring a fentanyl patch.  Dr. Kim referred the employee to Dr. Andrews for a consultation on spinal cord stimulation.  The employee remained off work at the direction of Dr. Kim.

At a consultation with Dr. Andrews on July 1, 2011, the employee discussed the stimulator and the possibility of metal allergies.  Dr. Andrews did not recommend the spinal cord stimulator due to the employee’s reported metal allergy.  The employee continued to seek treatment.  During a follow up with Dr. Kim on July 18, 2011, the employee noted significant amounts of low back and left hip pain but denied any significant leg pain.  The employee had been attending a health club and reported that exercise did not increase her low back pain.  Dr. Kim noted that the employee had better range of motion and reported feeling stronger after exercising.  Dr. Kim continued the employee on off-work status but stated in his report that he would see her in one month and would recommend a functional capacity evaluation to assess permanent restrictions once the employee plateaued.^[12]  On August 16, 2011, Dr. Kim recommended that the employee reconsider the spinal cord stimulator implant to treat her chronic pain and that the employee seek an evaluation with an allergy specialist. The employee did not pursue Dr. Kim’s recommendations.

Dr. Kim authorized a functional capacity evaluation (FCE) on September 16, 2011.  In October 2011, Dr. Kim continued the employee off work and recommended physical therapy and acupuncture.  The employee underwent a two-day FCE at Northwest Industrial Rehabilitation Services on October 27-28, 2011.^[13]  The employee was found able to tolerate sedentary part-time work four hours per day.  Overall, the employee had good use of her upper extremities with good bilateral hand strength and coordination.  She could tolerate sitting with lumbar support and the ability to move at will, and was limited in standing and walking tolerances, up to a total of one hour per day.  Lifting and carrying were limited to five pounds occasionally, lifting up to 10 pounds four times per day, and carrying up to 15 pounds three to four times per day.  On November 3, 2011, the QRC sent a copy of the FCE to Dr. Kim, who responded on November 8, 2011, approving the results of the FCE.^[14]

In December 2011, the employee began treatment with Dr. Lonnie Berger, who recommended the employee participate in a pain management evaluation.  Dr. Berger continued the prescriptions for narcotic medications, specifically morphine, and referred the employee for a pain management evaluation and treatment.  Two months later, the employee changed her primary care provider from Dr. Berger to Dr. Erik Lokken.  Dr. Lokken managed the employee’s pain medications.

The employer made a written job offer to the employee on March 2, 2012.  The job was a part-time administrative assistant position for four hours per day and the hourly rate was $13.75 per hour.  The job offer identified the duties and the physical requirements of the position and also stated that the employer was “willing to accommodate current restrictions.”^[15]  The employee did not accept the job offer.  At the time of the hearing, an employer representative testified that the job was still available to the employee.  On March 5, 2012, Dr. Lokken took the employee off work^[16] pending a neurosurgical consultation, without knowledge of the October 2011 FCE.^[17]  On August 16, 2012, QRC Moberg sent a letter to Dr. Lokken seeking to clarify Dr. Lokken’s opinions on the employee’s work abilities.^[18]  The QRC provided Dr. Lokken with a copy of the FCE, and mistakenly advised Dr. Lokken that the employee unsuccessfully attempted a return to clerical work after the 2011 FCE.^[19]

In March 2012, the insurer approved a pain clinic evaluation.  The employee testified at hearing that she would consider medical treatment through a pain clinic, but had not made any effort to pursue the treatment.  The employee continued to seek treatment from multiple providers.  Dr. Andrews and Dr. Lokken referred the employee to a neurosurgeon for a surgical consultation.  A repeat lumbar MRI was obtained on March 16, 2012.  The MRI showed that mild to moderate central canal stenosis had developed at the L2-3 disc level since the previous study.

In June 2012, the employee consulted with neurosurgeon Dr. Gregory Sherr at Central Neurosciences.  During the physical examination, Dr. Sherr noted no tenderness of the spine or paraspinous muscles and negative straight leg raise test bilaterally.  The employee reported significant bilateral lower extremity symptoms and mid lumbar severe pain syndrome despite a solid appearing fusion on MRI.  Dr. Sherr diagnosed the employee’s condition as a failed back surgical syndrome with multilevel degenerative disease.^[20]  Dr. Sherr referred the employee back to Dr. Andrews for discussion on a spinal cord stimulator.  Another option mentioned was surgery involving extension of the fusion and additional decompression.  The employee returned to see Dr. Andrews on August 7, 2012.  Dr. Andrews noted that the employee was absolutely against the stimulator and recommended the employee seek a surgical consultation.  On September 24, 2012, the employee returned to Dr. Kim, who reviewed the March 2012 MRI and recommended a lumbar epidural steroid injection at L2-3 and, if no relief, he offered an extension of the prior fusion to address the L2-3 level.  Dr. Kim stated that he would not have released the employee to light duty work four hours per day had he realized that the employee was developing severe spinal stenosis at L2-3.

On October 11, 2012, Dr. Rick Davis, an orthopedic surgeon, performed an independent medical evaluation at the employer’s request.^[21]  At the time of the evaluation, the employee reported severe pain in the lower back and left upper buttock that has persisted since her surgery.  During the physical examination, he noted tenderness to palpation of the lumbar spine, severely limited range of motion secondary to pain, and identified the employee’s area of pain that develops while standing and walking at the L4-5 and L5-S1 levels that radiated into the upper buttock on the left side over the iliac crest and left sacroiliac joint.  Dr. Davis noted no sciatic notch tenderness, negative straight leg raise on the right, and on the left a reproduction of left-sided back pain.  The neurological examination was normal.  Dr. Davis reviewed all medical records and personally reviewed radiographs of the October 1, 2009, lumbar spine MRI and the March 16, 2012, lumbar spine MRI.^[22]

Dr. Davis was of the opinion that the November 9, 2007, work injury was more likely than not a substantial cause of the employee’s low back and left upper buttock pain.  Dr. Davis was also of the opinion that the employee could be developing symptomatic left sacroiliac joint arthropathy.  He noted that the radiographs revealed evidence of significant left sacroiliac joint sclerosis and disease and recommended a diagnostic injection to determine whether the sacroiliac joint was the pain generator, as opposed to the failed lumbar spine surgery, causing the persistent low back and left upper buttock pain.  Dr. Davis also noted that the employee was on high doses of narcotic medication and had developed a narcotic tolerance and elements of opioid hyperalgesia.^[23]  He recommended the employee wean down to minimal short-acting narcotics to better assess her true pain levels and anatomic sources of pain.  Once the weaning process is completed, he recommended a guided sacroiliac joint injection.^[24]  Dr. Davis opined that the employee’s symptoms did not correlate with the progression of spinal stenosis and neurologic compression at L2-3.  Finally, Dr. Davis was of the opinion that the revision lumbar fusion procedure recommended by Dr. Kim would not be appropriate given the lack of a clinical correlation to the imaging studies and the employee’s history of depression and anxiety.  Dr. Davis was also of the opinion that the employee was capable of working consistent with the restrictions identified in the October 2011 FCE and was at maximum medical improvement.

During the 2009 and 2010 job search process, the QRC explored and discussed retraining, but after the October 2011 FCE, the QRC made no attempt to explore or discuss retraining.^[25]  The employee has not conducted any job search on her own since March 2011, nor has the QRC considered job placement activities with other rehabilitation services since the October 2011 FCE.^[26]

The employee filed an amended claim petition on September 12, 2011, against Northern Contours and RTW, Inc., for the 1996 work injury and against the self-insured employer for the 2007 work injury, seeking permanent total disability benefits and an additional 10 percent permanent partial disability.  The self-insured employer paid the claimed permanent partial disability.^[27]  On April 17, 2013, the employee filed a medical request for approval of an MRI scan and a referral from Dr. Lokken to Dr. Alejandro Mendez for a neurosurgical evaluation.  The employer approved this request before the hearing began on May 14, 2013; the hearing was continued.  A lumbar spine MRI was obtained on June 5, 2013.  The MRI showed severe generalized spinal canal stenosis and spondylolisthesis at L2-3, moderate narrowing of the intervertebral foramina at that level, and abnormalities at other disc levels.  Based on the employee’s symptoms and tests, therapeutic injections were again recommended.  The employee had not undergone the treatment by the second hearing date.

The hearing resumed on June 24, 2013, before Compensation Judge Kathleen Behounek.  In her findings and order served and filed September 10, 2013, the compensation judge determined that the employee met the statutory threshold for permanent total disability under Minn. Stat. § 176.101, subd. 5, but that the employee was not permanently and totally disabled.  The employee appeals.

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.^[28]  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.^[29]  Fact findings are clearly erroneous if the reviewing court, looking at the entire evidence, is left with a definite and firm conviction that a mistake has been committed.^[30]  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.”^[31]

The employee contends that the compensation judge erred in determining that the employee was not permanently and totally disabled.  The employee maintains that the conclusions of the independent medical examiner, Dr. Davis, are inconsistent with the imaging studies and the medical opinions and conclusions of the employee’s treating physicians.  The employee further contends the compensation judge’s decision is based, for the most part, upon a conclusion that various treatment options available to the employee to address her pain are likely to result in long-term improvement in her symptoms and functional abilities.  The employee points out that this line of reasoning is without medical opinion in the record to support the likelihood or probability that any of the procedures would improve the employee’s level of functioning, nor has she refused to partake in various recommended treatment.  The employee contends that the compensation judge’s decision is contrary to established case law which holds that reasonable refusal of medical treatment is not grounds for denying permanent total disability benefits and is clearly erroneous and unsupported by the record as a whole.

The self-insured employer argues that substantial evidence supports the compensation judge’s finding that the employee has failed to establish she was permanently and totally disabled from sustained gainful employment as of the date of the hearing.  Under the standard of review set forth in Hengemuhle, we affirm.

The employee contends that her symptoms had worsened and that she had been taken off work at the time the employer made the job offer.  Prior to that job offer, she had worked in subsidized, temporary employment that was intended to try to return her to gainful employment.  The employee points to the fact that she had ongoing physical problems with the job at Experience Works and claims she was not physically capable of performing her job duties.  The employee maintains an exhaustive job search was conducted and, in this case, further search would have been pointless.

Whether an employee’s disability, based upon either a medical or vocational analysis, totally incapacitates her from working in an occupation which brings an income is a question of fact for the compensation judge.^[32]  The Minnesota Supreme Court has held repeatedly in workers’ compensation cases that conflicts in medical and vocational opinions must be resolved by the compensation judge.^[33]  The fact remains that a compensation judge is free to accept a medical opinion which has reasonable support in the evidence.  In the present case, the compensation judge accepted Dr. Davis’s opinion that the employee is capable of working within the restrictions outlined in the October 2011 functional capacity evaluation (FCE), and rejected the employee’s doctor’s more limited restrictions.  No objection had been raised to the validity or accuracy of the FCE.  Dr. Davis’s medical opinion is based on (1) the lack of correlation between the employee’s clinical symptoms and the findings on imaging studies; (2) the perceived lack of management of the employee’s narcotic use and the effects of narcotics on chronic pain coupled with anxiety and depression; and (3) the treatment options available, including therapeutic injections and pain management treatment recommended by her treating physicians.  These factors provide a substantial basis for the compensation judge’s reliance on Dr. Davis’s opinions, including the ability to work and the employee’s work restrictions.  There is no dispute that since the FCE, no job search activity has taken place and the employer’s job offer was made at a time when the FCE restrictions and release to return to work were in place.  While different inferences could be drawn from the evidence, there is sufficient support in the record for the compensation judge’s determination that the employee is currently capable of returning to work within the restrictions identified in the FCE and that the job offered by the employer in March 2012 is within the employee’s restrictions and her labor market.^[34]

The employee has a long and complex medical history, and the work restriction issues are intertwined with the issues of permanent total disability and appropriate medical treatment.  Although raised as an issue by the employee on appeal, we note the employer did not argue at the hearing or on appeal that the employee’s permanent total disability claim failed because of unreasonable refusal of medical treatment.  The employee was advised that participation in a chronic pain program may benefit the employee in improvement of her symptoms and functional abilities.  The judge was again persuaded by Dr. Davis’s opinion, given the numerous treatment options that remained open to the employee and were recommended by her treating physicians.  The judge did not find that the employee was directed to attend the pain program and by failing to make a good faith effort to participate in the program the employee unreasonably refused medical treatment.  Nor did the judge make an explicit statement that the employee’s failure to participate in a chronic pain program or further medical recommendations was an unreasonable refusal of medical treatment.  Rather, she was persuaded by Dr. Davis’s opinion on future medical care and treatment, given the lack of correlation between clinical symptoms to findings on imaging studies, the management of narcotic use, and the treatment options available.  In her memorandum, the judge stated as follows: