The employer and insurer appeal from the finding that the employee’s work injury resulted in a cervico-disequilibrium syndrome.  The employee cross-appeals from the finding that certain treatment for visual symptoms was not related to the work injury, and from the finding that the services provided by her QRC from August 20, 2013, through February 2014 were not reasonable and necessary.  We affirm.

The employee, Susan Sebghati, has worked as an art teacher at Rogers High School for more than 25 years.  About ten years ago she began a second job as a part-time water fitness instructor for the employer, Life Time Fitness.

On October 6, 2012, the employee was teaching a water fitness class for the employer when she slipped and fell on the pool deck.  She landed on her right hip and elbow.  Although she did not strike her head, she testified that her neck “snapped back and then snapped forward” in a whiplash motion.  She experienced immediate pain in her neck and forehead and not long after this also developed a bad headache.

The employee was seen at Park Nicollet Urgent Care on October 9, 2012, where she complained of light-headedness, nausea, difficulty with concentration, and neck pain.  She reported that she had a fairly immediate onset of headaches following her injury along with trouble with her vision for about 10 to 15 minutes.  She was diagnosed with a cervical strain and mild concussion and taken off work until October 13, 2012.  She was also referred for physical therapy and advised to follow up at the occupational medicine department.  The employee returned to Park Nicollet Urgent Care on October 12 and 19, 2012.  She was given an injection of Toradol and prescriptions for Vicodin, Flexeril, and Ibuprofen.  On both dates the chart notes indicate “no vision change.”  The diagnosis was cervical muscle strain.

On October 22, 2012, the employee began treating with Dr. Mary Arneson at Park Nicollet’s occupational medicine department.  She complained of blurred vision and confusion, and problems with her sense of taste.  Dr. Arneson attributed this to over-sedation with Flexeril and Tramadol and recommended that the employee discontinue those medications.  When the employee returned to Dr. Arneson on October 24, 2012, she reported that her vision, memory, and concentration had been improving since she was off the medications.  Dr. Arneson’s assessment was of a neck strain.

At a follow-up appointment with Dr. Arneson on November 7, 2012, the employee again complained of severe headaches and difficulty with vision.  Her neurological exam was normal.  Dr. Arneson ordered a brain MRI and suggested that the employee see an eye specialist.  The employee scheduled an eye examination for the following day but then cancelled the appointment.

On November 13, 2012, the employee left a voice mail message at Sizen Vocational Services inquiring about vocational rehabilitation.  The following day, November 14, 2012, QRC Stanley Sizen returned the employee’s telephone call and the employee decided to proceed with a rehabilitation consultation.  The employee and Mr. Sizen decided that Mr. Sizen would accompany her to her next medical appointment with Dr. Arneson and that the rehabilitation consultation would be held on the same day.

At her appointment with Dr. Arneson on November 16, 2012, the employee complained of difficulty concentrating, visual blurring, and poor dexterity.  In his rehabilitation case notes, Mr. Sizen recorded that he “explained to Dr. Arneson that whiplash . . . can also cause a brain injury.”  He also suggested to the doctor that the employee should be referred for a neurological consultation.  Dr. Arneson stated that she had not diagnosed a brain injury because the employee’s neurological examination was normal and there had been no head trauma or loss of consciousness at the time of the injury.  She also considered a neurological referral inappropriate while the results were still pending from the MRI scan.

The employee underwent an MRI of her head and brain on November 17, 2012.  The scan was read as normal with no acute changes.  Small, mild vessel ischemic changes were present but were thought to reflect her past history of migraine headaches.  Dr. Arneson met with the employee and Mr. Sizen on December 19, 2012, to review the MRI results.  Referrals for neurological consultation and for a headache clinic were discussed.  Dr. Arneson wanted to try the employee on migraine-specific headache medications before deciding whether to make a headache clinic referral.  However, she agreed to refer the employee for a neurological evaluation.

On December 17, 2012, the employee was still complaining of nausea, sleep disruption, photophobia, noise sensitivity, exercise intolerance, poor concentration, and headache, and was now also complaining of intermittent tinnitus in the left ear.  Dr. Arneson’s chart note indicates that the employee and Mr. Sizen were “extremely adamant that the injury could have produced brain damage” and that Mr. Sizen offered her printed material which cited whiplash as a possible cause of concussion and post-concussive syndrome.  Dr. Arneson agreed to refer the employee for a neurological consultation.

On January 8, 2013, Dr. Mary Staab, a neurologist with the Noran Clinic, saw the employee for the neurological consultation.  The neurological examination was normal and no vestibular dysfunction was seen on bedside testing.  The employee noted that her neck pain had improved significantly under therapy and with muscle relaxants.  Dr. Staab felt that the employee’s symptoms were consistent with a post-concussive syndrome, but that such a diagnosis would be questionable for an injury in which the employee did not strike her head or lose consciousness.  She noted that other causes that needed to be considered included chronic daily headache, migraine headache, or mood disturbance.  She referred the employee to the National Dizzy and Balance Center for an evaluation and prescribed Topamax for headache.

The employee was evaluated by Dr. Samira K. Zoberi at the National Dizzy and Balance Center on January 29, 2013.  In testing, the employee was seen to veer and show dizziness and imbalance when ambulating if horizontal head motion was added, but not with vertical head motion.  There was a positive Romberg test with tandem stance.  Dr. Zoberi concluded that the employee likely had a vestibular deficit and ordered further testing.

When the employee returned to Dr. Staab on February 4, she reported significant reduction in her headaches after starting the Topamax.  She still had complaints of dizziness and concentration.  Dr. Staab referred the employee to the Sister Kenny Brain Injury Program for a neuropsychological evaluation.

On February 14, 2013, the employee was seen by Dr. Apte-Kakade at the National Dizziness and Balance Center after participating in diagnostic testing there on February 7 and 13.  She had abnormal scores on her functional gait evaluation which the doctor considered to be consistent with a central vestibular deficit as well as post-concussive syndrome.  Vestibular rehabilitation therapy was recommended.

On February 27, 2013, the employee returned to see Dr. Arneson, again accompanied by Mr. Sizen.  Mr. Sizen told the doctor that both Dr. Staab and Dr. Apte-Kakade had diagnosed concussion or post-concussive syndrome, and asked why she wasn’t making the same diagnosis.  Dr. Arneson stated she did not consider that diagnosis appropriate in the absence of either head trauma or objective evidence.  She further noted that the employee’s symptoms were expanding rather than diminishing in scope, which she did not believe to be consistent with a concussive injury.  Mr. Sizen’s records state that he “explained [to] Dr. Arneson that research and literature indicates that whiplash was a cause of a TBI [traumatic brain injury]/concussion.”  Dr. Arneson wrote in her notes that “I resent being pressured by Mr. Sizen in this way . . . I do not want him coming to my office.”

The employee underwent a neuropsychological evaluation with Dr. Susanne Cohen at the Noran Clinic on April 16, 2013.  The employee was found to be fully oriented, with superior performance on visual construction tests and a strong cognitive profile.  Dr. Cohen concluded there was no residual cognitive impairment.  However, she noted that her physical symptoms, including dizziness, visual convergence, and headaches, interfered with her cognitive efficiency and stamina.  She agreed with the referral to the Sister Kenney Institute Brain Injury Program.  She also referred her to Dr. Rubenfeld, a neuro-ophthalmologist.

The employee saw Dr. Khalafalla Bushara, a neurologist, on May 21, 2013 for an examination on behalf of the employer and insurer.  Her neurological exam again showed no deficits.  Dr. Bushara concluded that the employee’s work injury had resulted in a mild myoligamentous strain of the cervical spine, now resolved.  He also opined that cervicogenic headaches from her strain/sprain injuries had temporarily exacerbated her pre-existing migraine headaches.  He found no objective evidence for a concussion or any head injury, or of inner ear problems.  In his view, the employee’s vision complaints were due to ageing, and there was no basis for her subjective cognitive complaints.  He found the ongoing continuation of symptoms of dizziness and memory problems inconsistent with a mild concussion.  He thought that the employee’s complaints of dizziness, fogginess, and loss of balance might be associated with her known history of depression, anemia, and Hashimoto’s disease.  Dr. Bushara opined that the employee had reached maximum medical improvement from her work injuries without any need for work restrictions.

The employee continued treatment at the National Dizzy and Balance Center and with Dr. Staab.  On April 6, 2013, a chart note from the National Dizzy and Balance Center notes that she has been diligent in therapy and slowly improving.

The employer and insurer denied payment for further ongoing medical expenses based on the medical opinion of Dr. Bushara.  The employee filed a medical request on May 8, 2013, asking for payment of medical bills and authorizations for further evaluation and treatment.

On May 28, 2013, the employee saw Kyle Harvison, Ph.D., a neuropsychologist at the Sister Kenny Brain Injury Clinic.  The employee complained of confusion, distractibility, vision disorder, decreased appetite, heightened sense of smell, light and noise sensitivity, slight dizziness, and anxiety.  Dr. Harvison felt that the employee would not have sustained a higher cortical injury in the absence of a history of blunt head trauma and post-fall amnesia.  Dr. Harvison concluded that the employee had instead sustained a central vestibular injury along with her neck injury.  He thought that an interaction of stress, fatigue, and somatic symptoms with injury-related factors might explain the persistence of some of the employee’s symptoms.

Dr. Marian Rubenfeld, a neuro-ophthalmologist, saw the employee for her ongoing vision complaints starting in July 2013.  Dr. Rubenfeld recorded that employee complained of photophobia, light sensitivity, convergence insufficiency, and paresis.  Testing showed a normal appearing optic nerve and 20/20 visual acuity, but the employee needed a mild astigmatic presbyopic (nearsightedness) correction.  Dr. Rubenfeld diagnosed a convergence insufficiency associated with a traumatic brain injury.  She prescribed special glasses with prisms to assist the employee in reading and other close work.  She also recommended work station changes with decreased lighting levels, and released the employee from hall monitor duties at the high school.

On June 24, 2013, the employer and insurer filed a rehabilitation request seeking termination of Mr. Sizen’s rehabilitation services on the basis that the work injury had completely resolved and that the employee no longer had work restrictions related to her injury.

An administrative conference on the employee’s medical request was held on July 22, 2013, at the Department of Labor and Industry, and a conference on the employer and insurer’s rehabilitation request was held on July 24, 2013.

On August 20 and August 23, 2013, the Department of Labor and Industry issued its decisions and orders on the medical and rehabilitation requests.  In the medical request, the department determined that the employee did not sustain a concussion or develop post-concussion syndrome as a result of the work injury.  Medical bills for treating those conditions were denied but the expenses associated with the evaluating the possible causes of the employee’s symptoms were allowed.  Dr. Rubenfeld’s examination was found unrelated to the work injury.  With respect to the rehabilitation request, the department referenced its decision on the medical request and noted that the employee had been released to return to work without restrictions, so that vocational rehabilitation was no longer required.  The department also found that there was no further need for medical management by Mr. Sizen, and ordered that he cease activity on the claim and file a notice of rehabilitation closure.

The employee requested a formal hearing before a compensation judge.  Because the order terminating his services was under formal reconsideration, Mr. Sizen continued to provide “minimal” medical monitoring and medical management services.

When the employee returned to Dr. Rubenfeld on October 30, 2013, she reported that the prismatic glasses had assisted her in reading up close, but that she was still having difficulty with computer screens and with sensitivity to light.  Dr. Rubenfeld diagnosed a closed head injury with accommodation paresis, presbyopia, convergence insufficiency, and photophobia.  She recommended occupational therapy emphasizing fixation, saccades, pursuit, convergence, and ambient focal training.

The employee returned to Dr. Tarrel at the Noran Clinic on September 28, 2013.  At that time, she was continuing to report disequilibrium, headache, environmental overstimulation and neck pain.  Dr. Tarrel again diagnosed “persisting effects of traumatic brain injury” and cervical disequilibrium syndrome.  He recommended a chiropractic neurologist.  On his recommendation, the employee commenced treatment at Pietila Chiropractic.

On October 17, 2013, the employee was seen on behalf of the employer and insurer by Dr. Oleg Froymovich, an otolaryngologist.  Dr. Froymovich found no peripheral vestibular damage in the employee’s inner ear that could contribute to the employee’s dizziness.  He also discussed cervicogenic dizziness, noting that some medical studies had associated that disorder to a whiplash injury.  Dr. Froymovich felt that the earlier assessment performed by Dr. Apte-Kakade pointed to central imbalance/disequilibrium issues.

On November 13, 2013, Dr. Tarrel provided a brief narrative report at the request of the employee’s attorney.  He opined that the employee continued to suffer from persistent dizziness due to cervical disequilibrium syndrome, and that she had sustained a traumatic brain injury/concussion as a result of her slip and fall.

The employee was seen for an independent medical opinion about her visual complaints on December 18, 2013 by Dr. Alan Weingarden, a neuro-ophthalmologist.  Dr.  Weingarden diagnosed age-related presbyopia and cataracts, both unrelated to the October 6, 2012, injury.  In his view, the employee’s light sensitivity was due to her cataracts, her difficulty with close focusing was age related, and her convergence was within the normal range.  He saw no examination findings that suggested head injury, traumatic brain injury, or concussion.  In his view, the duration of the employee’s symptoms was also inconsistent with concussion injuries, the vast majority of which would resolve within six months.  He did not consider the employee to be subject to any restrictions related to her visual complaints.

The compensation judge found that the employee’s work injury had resulted in ongoing headaches and a cervico-disequilibrium condition, but that she had not sustained traumatic brain injury, concussion, or post-concussion syndrome.  The judge further found that the work injury was not the cause of the employee’s visual symptoms, tinnitus, cognitive dysfunction, mood changes, or changes in her sense of taste.  The medical treatment for these problems was not found compensable.       The compensation judge also found that QRC services from July 22, 2013, through February 17, 2014, were not reasonable or necessary.  The employer and insurer appeal from the finding that the employee’s work injury resulted in headaches and a cervico-disequilibrium syndrome.  The employee cross-appeals from the denial of payment for the services of Dr. Rubenfeld and of QRC Sizen.

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.”^[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]  Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.^[3]  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.”^[4]

“[A] decision which rests upon the application of a statute or rule to essentially undisputed facts generally involves a question of law which [the Workers’ Compensation Court of Appeals] may consider de novo.”^[5]

The compensation judge found that the employee’s work injury had resulted in ongoing symptoms of headaches and cervico-disequilibrium resulting in dizziness, imbalance, and associated nausea, continuing through the date of hearing.  The employer and insurer argue that the evidence fails to support a finding of any ongoing condition requiring medical treatment or restrictions.

In her memorandum, the compensation judge noted that the employee had reported ongoing dizziness and imbalance since the work injury.  She accepted the opinion of Dr. Froymovich, who related these symptoms to a cervico-disequilibrium condition.  The judge’s memorandum further notes that she relied in part on the opinion of Dr. Tarrel, who had also diagnosed the employee with cervico-disequilibrium.  We note that Dr. Apte-Kakade also suggested that “cervicogenic dizziness might be an additional finding.”  As to headaches, the judge noted in her findings that she again relied on the ongoing nature of the employee’s headache complaints following the work injury, together with the expert opinions of Dr. Arneson, Dr. Staab and Dr. Tarrel.

This court will generally affirm the decision of the compensation judge based on the choice between expert opinions, so long as the accepted opinions have adequate foundation.^[6]  The appellants contend on appeal that the medical opinions of Dr. Froymovich, Dr. Tarrel, and Dr. Apte-Kakade had inadequate foundation and were insufficient to sustain the judge’s findings.  We note, however, that each of these experts took a medical history and performed an examination or testing.  This court has stated on many occasions that this level of knowledge about the subject matter affords adequate foundation for an expert medical opinion.^[7]

The appellants argue that the opinions of Dr. Apte-Kakade and Dr. Tarrel do not provide support for the finding of cervico-disequilibrium in that both physicians mentioned cervico-disequilibrium only as a secondary or provisional diagnosis, and the compensation judge did not accept the primary diagnoses they offered of a post-concussive syndrome or brain injury.  It is well-settled that a compensation judge may rely on part of a medical expert’s opinion and is not obligated to accept such an opinion on an all or none basis.^[8]

The appellants next argue that because Dr. Froymovich is an otolaryngologist, a diagnosis of cervico-disequilibrium was outside his medical field of expertise and therefore insufficiently reliable to support the compensation judge’s finding.  Competence to render an expert opinion depends on both the degree of the witness’s scientific knowledge and the extent of the witness’s practical experience with the matter at hand.  Dr. Froymovich noted in his report that while cervico-disequilibrium is outside of the scope of otolaryngology, he had found “an awareness of such disorder [to be] part of my thorough work up of dizziness in any individual.”  The compensation judge could reasonably conclude that Dr. Froymovich was qualified to render an opinion on cervico-disequilibrium.  The question of whether his medical specialty diminished the value of his opinion is one which goes primarily to the weight of the opinion, a matter entrusted to the compensation judge.

The compensation judge cited the opinions of Dr. Staab, Dr. Arneson, and Dr. Tarrel as support for her finding that the work injury caused the employee’s headaches.  The appellants argue that the opinions of Dr. Staab and Dr. Arneson were somewhat equivocal about causation for the headaches, and that neither tied the employee’s headaches to an underlying diagnosis or an explanation related to the work injury.  However, while a failure to explain the mechanism of injury or the underlying reasons for the opinion may go to the weight to be afforded the opinion by the compensation judge, it does not render the opinion without foundation.^[9]

With respect to Dr. Tarrel, the employer and insurer argue that his opinion associated the employee’s headaches with a diagnosis of a traumatic brain injury/concussion, a condition which the compensation judge expressly found did not result from the work injury.  Again, however, we note that a compensation judge is not required to adopt all parts of an expert opinion.^[10]

For all the reasons stated above, we conclude that the compensation judge’s findings had substantial support in the record, and affirm.

Dr. Weingarden provided an expert medical opinion in which he explained in detail why he had concluded that the employee’s visual complaints were unrelated to the work injury.  The compensation judge’s memorandum states that she found Dr. Weingarden’s opinion persuasive.  Accordingly, the judge denied the expenses for treatment for visual problems rendered by Dr. Rubenfeld.

On cross-appeal, the employee argues that Dr. Weingarden’s opinion “is utterly implausible” in light of the timing of her visual complaints, which, she alleges, began at the time of injury and have continued since that time.  Instead, she argues, the compensation judge should have adopted the opinion of Dr. Rubenfeld, who performed specialized tests not performed by Dr. Weingarden and provided a detailed explanation of how the mechanism of the employee’s injury caused her symptoms.  She further points out that Dr. Rubenfeld’s treatment was effective in alleviating her symptoms, and argues that this strongly suggests that Dr. Rubenfeld’s opinion and diagnosis was more likely correct than was Dr. Weingarden’s opinion.

We are not persuaded that the evidence about the timing of the employee’s symptoms renders Dr. Weingarden’s opinion “utterly implausible” so as to require that we reject the opinion and reverse the compensation judge on this issue.  We note that the evidence does not so clearly establish ongoing visual symptoms starting with the date of the injury as the employee suggests.  At the first medical appointment for her work injury, the employee stated that she had experienced trouble with her vision for fifteen minutes after her fall at work, but that it “seemed okay” after that.  Chart notes indicate that the employee reported no vision changes at the next two medical appointments.  She complained of blurred vision when first seen by Dr. Arneson on October 22, 2012, but Dr. Arneson attributed this to over-medication with Flexeril and Tramadol, and after the employee was taken off these medications she reported to Dr. Arneson that her vision had been improving.

As we have noted above, the choice of expert opinion was in the discretion of the compensation judge and that the judge’s choice of expert opinion here was not unreasonable.  As to the testing performed by Dr. Rubenfeld, the compensation judge accepted Dr. Weingarden’s opinion that this particular testing was not commonly accepted by the neuro-ophthalmologic community.  In any event, whether such testing was used by each doctor is a matter going primarily to the weight, rather than the sufficiency, of the expert testimony.  We therefore affirm the finding that the employee’s visual complaints were not related to the work injury.

The compensation judge denied vocational rehabilitation expenses for the employee’s QRC for the period from August 20, 2013, through February 2014.  The employee argues that the QRC nonetheless provided services that assisted her through medical monitoring and in a successful return to work in her job as a school teacher.  In particular, this assistance included facilitating implementation of the visual restrictions placed on the employee by Dr. Rubenfeld.

A rehabilitation provider may be paid only for necessary and reasonable services rendered in accordance with the statute and rules governing vocational rehabilitation under the Workers’ Compensation Act.  A dispute about the reasonableness and necessity of such services “shall be determined by the commissioner or a compensation judge.”^[11]  In the present case, the judge expressly found that:

We note that rehabilitation services were ended by an administrative decision from the Department of Labor and Industry issued on August 23, 2013, which was itself predicated in part on an August 20, 2013, decision concluding that the employee had no ongoing medical restrictions from the work injury.  Mr. Sizen thereafter provided what he characterized as “minimal” medical monitoring and medical management services, pending the results of the employee’s request for a formal hearing on the same issue at the Office of Administrative Hearings.  Mr. Sizen’s records thereafter show only a very little time expended either for medical monitoring or in assisting with the implementation of restrictions.  Much of the time billed after August 20, 2013, was associated with preparing for the hearing.  For the reasons stated above, we conclude that the compensation judge’s determination on this issue was supported by substantial evidence in the record, and affirm.