The employer and insurer appeal from the compensation judge’s findings that (1)  the employee has a 22.5 percent permanent partial disability for cervical pain syndrome, thoracic pain syndrome and lumbar pain syndrome; (2) that the employee’s medical treatment was reasonable and necessary; and (3) that the chiropractic treatment was in conformance with the treatment parameters.  We affirm as modified.

On the afternoon of June 13, 2011, the employee, Francisco Ochoa, was working for the employer, Aspen Ridge Lawn Maintenance, removing grass and putting down new sod.  He was pushing a loaded wheelbarrow up a narrow plank to dump the contents in the back of a truck.  He was near the top of the ramp when the wheelbarrow tipped to the side.  The employee and the wheelbarrow fell onto the street below with the employee landing on his left side.

The employee was seen at the Minnesota Occupational Health Clinic on June 17, 2011.  His primary complaints were to the left arm and elbow, left trapezius muscle, and left lower back.  The doctor prescribed pain medication, and assigned light-duty restrictions.  The employee returned to Minnesota Occupational Health on June 23, 2011, complaining of persistent pain in the left upper shoulder into the neck, left arm pain, and left low back pain.  The doctor noted the employee was not working at the time, and continued light-duty restrictions of no lifting or carrying over 10 pounds, pushing/pulling up to 25 pounds, avoid excessive bending, twisting, and kneeling, and limit overhead reaching.

The employee began treating at Back in Balance Chiropractic Clinic on July 1, 2011.  He described left trapezius and upper back pain going down the left arm, low back pain radiating down the left leg, and neck pain into the mid-back area.  On examination, Deborah Jerikovsky, D.C., noted severe neck, thoracic, and lumbar pain, a significant decrease in range of motion in the neck, and moderate loss of range of motion in the thoracic and lumbar spine, and spasm rated as a 7 in the neck and mid-back and 5 in the lumbar spine.  The employee was treated with chiropractic manipulation, electrical muscle stimulation (EMS), and ice and heat, and was provided restrictions of no lifting over 10 pounds, avoid prolonged repetitious neck flexion or extension, alternate sitting, standing and walking every 30 minutes, avoid repetitious use of arms above shoulder level, no bending, no pushing/pulling over 15 pounds, and no heavy cleaning, housekeeping, or carrying.

The employee received chiropractic treatment at Back in Balance three times a week for the next six weeks and twice a week for the following three weeks.  The treatment records reflect slow improvement, especially in the neck, left shoulder, and mid-back, with decreasing pain, improving range of motion, and less spasm.  In addition to chiropractic treatment, the employee was given instruction in exercises and icing to be performed on his own.  The employee continued, however, to experience significant low back pain and symptoms and, on August 24, 2011, Dr. Jerikovsky made a referral to the Center for Diagnostic Imaging for a lumbar MRI scan.  The scan performed on September 19, 2011, showed mild disc degeneration from T12-L1 through L5-S1, with bulging discs at L2-3, L3-4, and L5-S1 with no herniation, stenosis or impingement.  The employee received two additional treatments on September 21 and September 30, 2011.  Proper lifting mechanics and low back care were reviewed with the employee.

The employee received treatment at Back in Balance once a week from October 1 through November 5, 2011.  The records show continued improvement, including decreasing spasm and increasing range of motion in the cervical, thoracic and lumbar spine.  The employee returned on December 5, 2011, reporting that his neck was good and left shoulder was better, but his low back was bothering him.  A re-evaluation was performed on December 14, 2011.  The doctor noted bilateral tightness in the shoulder and neck and tightness in the mid-back.  Cervical range of motion was normal except for mild limitation of lateral flexion and rotation.  Tension was also noted in the lumbar spine with mild limitation of lumbar flexion.  The employee received two additional treatments in December.  On December 28, the employee reported he was happy with his treatment, but felt he was about the same as he had been at the last treatment.  The employee was discharged from care and was to return as needed.

The employee returned on February 10, 2012, reporting low back and neck/shoulder pain, especially on the left side.  The doctor noted mild pain in the cervical and lumbar spine, and moderate limitation of motion and moderate spasm in the cervical, thoracic, and lumbar spine.  The employee was again released to return as needed following treatment.  The employee next returned to Back in Balance on June 13, 2012, reporting persistent left-sided low back pain going down the left leg, and persistent neck and upper back pain.  The doctor noted 5/10 pain in the cervical and thoracic spine, and 6/10 pain in the lumbar spine.  There was a moderate decrease in range of motion in the cervical and lumbar spine and mild loss of motion in the thoracic spine.  Spasm was noted as a 6 in the cervical spine, 5 in the thoracic spine, and 4 in the lumbar spine.  Dr. Jerikovsky referred the employee to the Noran Neurological Clinic for further evaluation.

The employee was seen by Dr. Adam Todd at the Noran Clinic on August 24, 2012.  The employee’s neurological examination was normal.  Dr. Todd noted the November 2011 MRI scan showed some mild disc bulging, but no other abnormalities.  The doctor stated the history and his examination were consistent with a musculoligamentous injury of the neck and back with possible facet joint injuries.  Dr. Todd concluded that most of the employee’s lumbar pain was the result of a permanent soft tissue injury.  The doctor provided a trial of a muscle relaxant and advised the employee to continue chiropractic care with Dr. Jerikovsky.  The doctor also referred the employee for a cervical MRI scan.

The cervical scan, performed on September 1, 2012, revealed a small disc herniation at C5-6 causing a slight effacement of the ventral aspect of the spinal cord, and mild to moderate degenerative disc disease with disc bulging and posterior spurring at C3-4, C4-5, and C6-7.  In a phone note, Dr. Todd opined the employee’s pain was mostly musculoskeletal, and he advised the employee to continue chiropractic care.

The employee returned to Back in Balance Chiropractic Clinic and continued to receive chiropractic care from December 15, 2012, through April 27, 2013.  On April 27, Dr. Jerikovsky noted the neck and upper back were tight and tense, there was mild pain in the lumbar spine, and there was mildly decreased range of motion and spasm (3-4) in the cervical, thoracic, and lumbar spine.  Dr. Jerikovsky provided new restrictions of no lifting over 40 pounds, no repetitious lifting from floor to waist, and alternate sitting, standing and walking every 60 minutes.

By letter dated May 6, 2013, Dr. Jerikovsky provided permanent partial disability ratings for the employee of 10 percent for the cervical spine, 2.5 percent for the thoracic spine, and 10 percent for the lumbar spine.  In a Health Care Provider Report dated May 8, 2013, Dr. Jerikovsky stated the employee had a 22.5 percent permanency to the body as a whole, and that maximum medical improvement (MMI) had been reached as of April 27, 2013.

The employer and insurer requested a records review from Dr. William Tontz, an orthopedic surgeon, through the Medical Review Institute of America in Salt Lake City, Utah.  The only record received and reviewed by Dr. Tontz was the August 24, 2012, note of the employee’s visit with Dr. Todd.  On that record, Dr. Tontz concluded there were no objective findings to support a diagnosis of a cervical or lumbar strain.  He further opined there was no indication for an MRI scan of the cervical spine as the employee had a normal neurological examination and there were no “red flags” to warrant advanced imaging.  Dr. Tontz also stated that, per the Minnesota schedule, there was no permanent partial disability.

In a claim petition filed on May 22, 2013, the employee alleged an injury to the spine on August 13, 2011, and sought a 22.5 percent permanent partial disability, and payment of medical expenses to Back in Balance Chiropractic Clinic and Noran Neurological Clinic, along with medical mileage.  The employer and insurer admitted an injury to the spine on June 13, 2011, but denied liability for the benefits claimed.

The case was heard by Compensation Judge Penny Johnson on April 8, 2014.  In a Findings and Order served and filed on April 30, 2014, the compensation judge found (1) the employee was entitled to payment for a 22.5 percent permanent partial disability for cervical pain syndrome, thoracic pain syndrome, and lumbar pain syndrome; (2) that chiropractic treatment through June 13, 2012, was reasonable and necessary; (3) that no additional chiropractic treatment beyond the first 12 weeks plus 12 additional treatments was reasonably required as a result of the work injury; and (4) that medical care provided to the employee at Noran Clinic, including a cervical MRI scan, was reasonable and necessary.  The employer and insurer appeal.

This court’s standard of review for workers’ compensation cases is well established.  We will uphold the factual findings of the compensation judge if they are supported by substantial evidence and were reached through application of the correct legal standard.^[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.^[2]  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.^[3]  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.”^[4]

The compensation judge adopted the ratings provided by Dr. Jerikovsky and awarded permanent partial disability of 22.5 percent, consisting of 10 percent for a cervical pain syndrome, 2.5 percent for thoracic pain syndrome, and 10 percent for lumbar pain syndrome.  The employer and insurer contend that the weight of the evidence supports a rating of 0 percent permanent partial disability based on the opinion of Dr. Tontz and the record of Dr. Todd,^[5] and argue the opinion of Dr. Jerikovsky lacks foundation and lacks support in the chiropractic records.  We disagree for the reasons stated below.

Both Minn. R. 5223.0370, subp. 3.C.(2), cervical pain syndrome, and Minn. R. 5223.0390, subp. 3.C.(2), lumbar pain syndrome, provide a 10 percent rating for symptoms of pain or stiffness in the cervical or lumbar spine region, respectively, substantiated by persistent objective clinical findings, that is, involuntary muscle tightness or decreased range of motion, with any MRI scan abnormality not specifically addressed elsewhere.  Minn. R. 5223.0380, subp. B., thoracic pain syndrome, provides a 2.5 percent rating for symptoms of pain or stiffness in the thoracic spine region, substantiated by persistent objective clinical findings, that is, involuntary muscle tightness, regardless of radiographic abnormality.

The compensation judge found that the chiropractic records document persistent reduced range of motion, involuntary muscle tightness, and spasm in the cervical, thoracic, and lumbar spine, and that the employee has MRI abnormalities in the cervical and lumbar spine at multiple vertebral levels.^[6]

The employer and insurer argue the Back in Balance treatment notes are inadequate and lack specific documentation with respect to range of motion findings and spasm.  We disagree.  The chart notes document, for each visit, the level of pain in the cervical, thoracic, and lumbar spine, graded as mild, moderate, or severe, the degree of loss of range of motion (ROM) for each level of the spine, graded as mild, moderate, or severe, and the amount of spasm at each spinal level, indicated by numbers, from 0 (blank) and going up as high as 7.^[7]  The chart notes also indicate specific instances of tension, tightness, and stiffness in the cervical, thoracic and lumbar spine.  This is sufficient to support the compensation judge’s determination that the employee established persistent pain or stiffness with involuntary muscle tightness or decreased range of motion at all three levels.

The employer and insurer argue, additionally, that although the MRI scans showed degenerative changes, there is no evidence that the degeneration was caused by the work accident or that the degenerative changes caused the employee’s condition or symptoms.  They assert that Dr. Todd found nothing of significance in the MRI scans and concluded the employee had a soft tissue injury only.

The compensation judge concluded the employee’s spinal degenerative disease was not all causally related to the work injury, but he did not have a symptomatic spinal condition before the work injury.  The compensation judge acknowledged that Dr. Jerikovsky did not explain the relationship between the MRI abnormalities and the employee’s condition and symptoms, but it is clear from the compensation judge’s findings and her memorandum that she believed that the work injury aggravated the employee’s underlying degenerative condition, contributing to his chronic symptoms.

It is the role of the compensation judge to draw reasonable inferences from the evidence, and she was entitled to interpret the employee’s medical records so as to conclude that the employee’s condition was consistent with a cervical and lumbar pain syndrome.  Dr. Todd interpreted the MRI scans as showing degenerative changes in both the lumbar and cervical spine and concluded the employee’s pain was primarily musculoskeletal,^[8] that is, relating to the skeleton and the muscles.  A finding as to the rating of permanent partial disability is one of ultimate fact.^[9]  The judge was entitled to accept Dr. Jerikovsky’s rating for these conditions, and there is substantial support in the record for her determination.  We therefore affirm the compensation judge on the award of permanent partial disability.

The employer and insurer contend the compensation judge erred in finding that all chiropractic treatment, as well as the treatment at Noran Neurological Clinic, was reasonable, necessary, and in conformance with the treatment parameters.  We disagree for the reasons stated below.

Chiropractic care is permitted for up to twelve weeks, up to five times per week for the first one or two weeks, decreasing in frequency thereafter.^[10]  The compensation judge found that chiropractic treatment at Back in Balance resulted in gradually decreasing symptoms over time, that treatment frequency decreased over time, and that by the end of the first 12 weeks, the employee was treating one time per week.^[11]  The first 12 weeks ended on September 24, 2011.  There is no real dispute regarding the compensability of the first 12 weeks of chiropractic care, and there is substantial evidence to support payment of chiropractic expenses during this period.

Pursuant to Minn. R. 5221.6200, subp. 3.B.(1), an additional 12 chiropractic visits may be provided if all of the following apply:

The compensation judge found the employee completed an additional 12 treatments as of June 13, 2012, and found the chiropractic treatment through that date was reasonably required by the work injury.^[12]  The judge found the employee (1) was released to work and there was progressive improvement in his condition; (2) he was not regularly scheduled for chiropractic treatment after the initial treatment; (3) there was a treatment plan to improve his condition; (4) he was being taught active home exercises; and (5) the chiropractic treatment did not delay other needed treatment.

The employer and insurer argue the employee failed to meet any of the required factors in the treatment parameters, and assert that, as such, any treatment expenses after September 24, 2011, should be disallowed.  We disagree.  The employee returned to work after his injury.  The chiropractic records for treatment after September 21, 2011, up to June 13, 2012, which encompasses the 12 additional visits, show modest improvement in his condition, and at the very least, maintenance of the employee’s functional status through February 10, 2012.  Following a significant exacerbation in June 2012, the chiropractor referred the employee to Noran Neurological Clinic for further evaluation.  The employee was seen fairly regularly between October 1 and November 5, but was seen on an as-needed basis thereafter.  Treatment included instruction in home exercises and stretches and review of proper lifting mechanics and back care.  The treatment plan included a variety of chiropractic and physical therapy-type techniques addressing the most problematic areas of his back, care only as needed, and referral for diagnostic testing and to other medical providers as needed.  There is substantial evidence to support the compensation judge’s award of an additional 12 treatments beyond the initial 12 weeks.

In addition, despite typographical errors in the Findings and Order, it is clear the compensation judge found all chiropractic treatment beyond the first twelve weeks plus 12 additional treatments not compensable.  In finding 8, the compensation judge found the chiropractic office did not request prior approval for additional treatment, or provide prior notice of a basis to depart from the medical treatment parameters, pursuant to Minn. R. 5221.6200, subp. 3.B.(2), and Minn. R. 5221.6050, subp. 8, nor did the employee provide proof of a rare case exception.  Therefore, the judge found that no additional chiropractic treatment beyond the first 12 weeks plus 12 additional treatments was reasonably required as a result of the work injury.  Finding 7 and order 1 are therefore modified to show the correct date of June 13, 2012.

Finally, the employer and insurer argue that the employee’s referral to Dr. Todd at Noran Neurological Clinic for a consultation was not reasonable and necessary medical treatment.  The employee was referred to this clinic in June 2012 due to a significant exacerbation of his chronic cervical and low back pain.  At the August 24, 2012, consultation, Dr. Todd found the employee’s history and examination consistent with a musculoligamentous or musculoskeletal injury of the neck and back.  He reviewed the lumbar MRI scan, which had not been previously reviewed by a neurologist or orthopedic surgeon, and concluded there were no neurologically significant findings.  Dr. Todd believed the employee’s persistent cervical pain suggested a disc herniation or other structural abnormalities, and referred the employee for a cervical MRI scan.  The judge found the August 24, 2012, visit, the cervical MRI scan, and the telephone follow-up was reasonably required as a result of the work injury.  We find substantial evidence to support this finding, and we affirm.