The employee appeals the compensation judge’s finding that the employee’s April 2012 work injury had resolved as of September 12, 2012, and therefore was not a substantial contributing factor to her disability, need for treatment, or work restrictions since that date, and the finding that the employee was not a qualified employee for rehabilitation services.  We affirm.

On April 16, 2012, Regina Huderle, the employee, sustained an admitted low back injury while working as a nursing assistant for Sanford Health, the employer, after frequently assisting a heavy patient out of bed over three consecutive nights.  The employer was insured for workers’ compensation liability by Dakota Truck Underwriters.  The employee treated for constant low back pain with Dr. Thomas Hanson, a chiropractor.^[1]  Dr. Hanson diagnosed lumbar sprain/strain, thoracic sprain/strain, and muscle spasm.  She was initially released to work without restrictions.  The employee reported pain radiating into her legs on April 18, 2012.  Dr. Hanson took the employee off work and added cervical spine sprain/strain and headaches to the employee’s diagnosis.  The employee reported some improvement the next day.  On April 23, 2012, the employee called Dr. Hanson reporting very little low back pain, and was released to return to work without restrictions.  The employer and insurer admitted liability and paid temporary total disability benefits and medical expenses.

On April 30, 2012, the employee treated with Dr. Mark J. Carlson at Sanford Clinic in Bemidji, Minnesota, for persistent and worsening low back pain and leg pain.  Dr. Carlson assigned work restrictions of no bending, stooping, or twisting and no lifting or carrying over 10 pounds, and ordered physical therapy.  The employee was off work from April 20 through May 8, 2012, and received temporary total disability benefits.  Physical therapy began on May 1, 2012.  On May 9, the employee returned to light-duty work and experienced a flare-up of her low back symptoms with a burning sensation in her back.

On May 14, the employee reported continuing low back numbness and pain radiating into her legs.  Dr. Carlson stated that the employee had sustained a muscle strain with myofascial pain in the surrounding area and continued the employee’s restrictions.  Dr. Carlson did not rule out radicular pain, but noted no evidence of weakness or progressive neurologic impairment.  A week later, the employee reported improvement and her restrictions were lessened to allow rare bending and twisting and lifting/carrying up to 15 pounds.  Physical therapy was continued.  On May 24, the employee reported worsening low back pain aggravated in physical therapy with shooting pain down her leg.  Dr. Carlson reinstated the employee’s previous restrictions and ordered x-rays and an MRI scan.  The June 1, 2012, MRI indicated mild disc degeneration at L4-5 and L5-S1 with small tears within the posterior annular fibers of the intervertebral discs, and no significant central spine stenosis or neural foraminal narrowing.  The MRI report noted that the findings could account for the acute symptoms of low back pain.

On June 14, 2012, the employee returned to Dr. Carlson, reporting increased back pain after working four to five hours.  Dr. Carlson reviewed the employee’s MRI results and stated that the employee’s radiating pain could be referred or myofascial pain.  He noted that the low back pain was possible secondary to the annular tear, but that it could be degenerative and progressive over time rather than due to an acute injury, and that there was no evidence of radicular findings.  Physical therapy and work restrictions continued with frequent position changes added.

On June 18, 2012, Dr. Carlson referred the employee to Dr. Maxwell Gessner at the Sanford Bemidji Pain Management Clinic, who treated the employee with a lumbar epidural steroid injection at L5-S1 on July 2.  A few weeks later, the employee reported no significant improvement from the injection and increased pain after working four to six hours.  Dr. Carlson prescribed Gabapentin, continued the employee’s physical therapy, and changed the employee’s work restrictions to working a maximum of six hours per day.  The possibility of additional injections was discussed, but there is a note in the record that no further care or injections would be approved by the insurer’s administrator.  Dr. Carlson opined at that time that the employee was not back to her pre-injury condition.  He also stated that he did not think that the minor abnormalities indicated on her MRI could all be attributed to her April 2012 work injury or that the abnormalities were the source of her symptoms at that time.

On June 28, 2012, the employer and insurer filed a notice of intention to discontinue temporary total disability benefits, based on the employee’s return to work for the employer at full wage.

On August 9, 2012, the employee saw Dr. Carlson again and reported significant pain relief from the medication.  She requested that her work restrictions be modified to allow an eight-hour work day, which Dr. Carlson agreed to do.  The restrictions from that date allowed eight hours of work per day, frequent position changes, and up to 10 - 15 pounds of lifting/carrying, and were listed as being in effect through September 15, 2012.  On September 12, 2012, the employee called the Sanford Clinic with questions regarding medication and requesting an extension of her restrictions.  On September 18, 2012, Dr. Carlson extended the employee’s restrictions without any changes.  It does not appear that the employee was at the clinic that day.  The employee did not treat with Dr. Carlson of Bemidji after that date.

On September 12, 2012, the employee was evaluated by another doctor, also named Dr. Mark J. Carlson, an orthopedist from Duluth, Minnesota (hereinafter the IME doctor), at the employer and insurer’s request.  The IME doctor opined that on April 12, 2012, the employee had sustained a temporary sprain/strain of the lumbar spine which had resolved by June 14, 2012, was at maximum medical improvement, had no permanent partial disability, and any ongoing care was related to her chronic low back condition, not her April 2012 work injury.

In October 2012, the employee started treating for low back pain with chiropractor Dr. Larry Stember.  Dr. Stember reviewed the employee’s MRI results and opined that the employee’s work injury caused the annular tears and contributed to disc degeneration and ongoing chronic myofascial injury to the lumbosacral region with a right radicular component.  He assigned restrictions of light-duty work, eight hours per day, no transfers, and no lifting over 15 pounds.  The employee treated with Dr. Stember numerous times through January 2013.  In December 2012, the employee moved from her light-duty nursing assistant position to a clerical position as a registration service assistant with the employer.  In this position, the employee could sit or stand as needed but her pain would be a four out of ten at the end of a work day.  By April 2013, the employee was working without a wage loss based on her weekly wage.

On February 13, 2013, the employee returned to Dr. Thomas Hanson, the chiropractor she initially visited after the April 2012 work injury, for low back pain described as a dull ache into her leg, and was treated with adjustments and ultrasound therapy.  Later in 2013, the employee moved to another clerical position as a patient access specialist with the employer, which allowed her to also walk short distances on occasion.  The employee was working in this position without a wage loss at the time of the hearing.

In a March 24, 2014, report, Dr. Stember opined that the employee had a 12 percent permanent partial disability rating for her lumbar spine, which was solely caused by the employee’s April 2012 work injury.  After a functional capacities evaluation in April 2014, Dr. Stember assigned restrictions of eight hours of work per day, four hours sitting or walking and two hours standing, and no lifting/carrying over ten pounds or pushing/pulling over 15 pounds.

On April 9, 2014, the employee filed a claim petition for temporary partial disability benefits, permanent partial disability benefits, medical expenses, and rehabilitation services.  The employer and insurer denied the claim.  The employee was reevaluated by the IME doctor on June 4, 2014.  He reiterated his position that the employee had sustained a temporary sprain/strain of the lumbar spine which had resolved by June 14, 2012, and agreed that the employee needed work restrictions, but opined that the need was not related to her work injury.  He also opined that she had zero percent permanent partial disability.  The employee underwent a rehabilitation consultation with QRC Julie Quanrud on October 2, 2014.  The QRC determined that the employee was a qualified employee for rehabilitation services since she had work restrictions and was working in a different position at a reduced hourly wage for more hours per week, even though the employee had no wage loss based on her weekly wage.

A hearing was held on April 16, 2015.  The compensation judge found that the employee’s April 2012 work injury had resolved without residuals as of September 12, 2012, the date of the independent medical examination, and therefore that the injury was not a substantial contributing factor to her disability, need for treatment, or work restrictions since that date.  The judge also found that she was entitled to temporary partial disability benefits for wage loss up to September 12, 2012, that the employee was not entitled to permanent partial disability benefits, and that the employee was not a qualified employee for rehabilitation services.  The employee appeals.

In reviewing cases on appeal, the Workers’ Compensation Court of Appeals must determine whether “the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.”  Minn. Stat. § 176.421, subd. 1.  Substantial evidence supports the findings if, in the context of the entire record, “they are supported by evidence that a reasonable mind might accept as adequate.”  Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984).  Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed.  Id. at 60, 37 W.C.D. at 240.  Similarly, “[f]actfindings are clearly erroneous only if the reviewing court on the entire evidence is left with a definite and firm conviction that a mistake has been committed.”  Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).  Findings of fact should not be disturbed “unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of the evidence or not reasonably supported by the evidence as a whole.”  Id.

The employee appeals the compensation judge’s finding that the employee’s April 2012 work injury had resolved as of September 12, 2012, and therefore that the injury was not a substantial contributing factor to her disability, need for treatment, or work restrictions after that date.^[2]  We affirm.

The employee first argues that the compensation judge erroneously relied on a flawed medical opinion from the IME doctor, Dr. Carlson of Duluth, in making his causation determination.  The employee claims that the IME doctor’s opinion was not reliable, claiming that since the last medical record referenced in his reports was dated July 12, 2012, the doctor did not have access to any medical records generated after that date before giving his opinion.  As a result, the employee argues that the IME doctor was unable to review the continuum of treatment the employee received after that date with Dr. Carlson of Bemidji and Dr. Stember.

The record does not support the employee’s assertion regarding the IME doctor’s access to medical records.  A letter sent to the IME doctor, dated May 19, 2014, indicates that he was sent multiple medical records, including Dr. Carlson’s records in their entirety through September 18, 2012, and Dr. Stember’s records through March 2014.  The last treatment record from Dr. Stember in the employee’s exhibit was dated January 9, 2013.  The background letter sent to the IME doctor before the June 4, 2014, examination detailed the employee’s medical treatment and also included treatment through April 2014.  While the IME doctor’s June 20, 2014, report states that the last medical record available for his review was dated July 12, 2012, the report also includes references to Dr. Carlson’s assignment of restrictions in September 2012, which is the last of Dr. Carlson’s records for the employee, and Dr. Stember’s evaluation of the employee, which occurred in October 2012.  The IME doctor also noted Dr. Stember’s permanent partial disability rating, which was listed in a March 2014 report.  The IME doctor examined the employee, took her history, and reviewed her medical records in 2012 and in 2014, including records dated after July 12, 2012, and therefore he did not miss reviewing any continuum of care being provided to the employee after July 2012 as alleged by the employee.  The compensation judge did not err by relying on the IME doctor’s opinion.

The employee argues that substantial evidence does not support the compensation judge’s findings that the employee’s April 2012 work injury was not a substantial contributing factor in the employee’s disability, need for treatment after September 2012, or her restrictions.  The employee claims that the employer and insurer have the burden of proving that the employee’s injury resolved as of September 12, 2012.  We disagree.  The employee has the burden of proof in establishing entitlement to compensation and in showing that claimed medical expenses are reasonable, necessary, and causally related to the work injury.  Minn. Stat. § 176.021, subd. 1; see also Adkins v. Univ. Health Care Ctr., 405 N.W.2d 231, 233, 39 W.C.D. 898, 900 (Minn. 1987).

The employee asserts that her work injury had not resolved as of September 12, 2012, and that treatment after that date should be compensable.  An employer and its insurer are responsible for an employee’s reasonable and necessary medical expenses where the employee’s need for treatment is due in substantial part to the work injury.  See Minn. Stat. § 176.135, subd. 1; Keane v. Critical Care Servs., Inc., 72 W.C.D. 709, 713-14 (W.C.C.A. 2012), summarily aff’d (Minn. Dec. 12, 2012).  The work injury need not be the sole cause of the need for treatment but may be a substantial contributing factor in the employee’s condition.  See Salmon v. Wheelabrator Frye, 409 N.W.2d 495, 497-98, 40 W.C.D. 117, 122 (Minn. 1987) (citing Roman v. Minneapolis Street Railway Co., 268 Minn. 367, 129 N.W.2d 550, 23 W.C.D. 573 (1964)).  Whether a work injury is a substantial contributing factor in the need for medical treatment is a question of causation and a question of fact for the compensation judge.  See Felton v. Anton Chevrolet, 513 N.W.2d 457, 50 W.C.D. 181 (Minn. 1994).

The employee claims that there is nothing in the record to support the compensation judge’s choice of the date that the employee’s work injury had resolved and that the compensation judge should have relied on Dr. Stember’s opinion that the employee’s ongoing disability was solely caused by the employee’s April 12, 2012, work injury.

Although this court is required to look at all the evidence in performing its review, it generally upholds the findings based on conflicting evidence or evidence from which more than one inference might reasonably be drawn.  Redgate v. Sroga’s Standard Serv., 421 N.W.2d 729, 734, 40 W.C.D. 948, 957 (Minn. 1988).  The IME doctor opined that the employee’s temporary sprain/strain of the lumbar spine had resolved by June 14, 2012, that she was at maximum medical improvement, and that any ongoing care was related to her chronic low back condition, not her April 2012 work injury.  The judge accepted the IME doctor’s opinion that the employee’s work injury had resolved by June 14, 2012, and in his memorandum, explained that he chose the date of resolution September 12, 2012, because that was the date the IME doctor first examined the employee.  In addition, other evidence supports that the employee’s condition had improved by September 2012.  The employee last treated with Dr. Carlson at the Sanford Clinic in Bemidji in August 2012, and physical therapy records from that clinic stopped in August 2012.  The record also shows that the employee reported significant pain relief from the medication and was released to work an eight-hour work day in August 2012.  The employee’s restrictions from her treating doctor as of September 18, 2012, allowed eight hours of work per day, frequent position changes, and up to 10 - 15 pounds of lifting/carrying, and the employee was able to work within these restrictions.  Further, the employee’s chiropractic treatment from October 2012 through January 2013 was similar to treatment she had received before her work injury.

The compensation judge was provided with competing medical opinions as to whether the work injury had resolved by September 2012 and whether subsequent treatment was causally connected to the work injury.  It is the function of the compensation judge to resolve conflicts in expert medical testimony.  See Nord v. City of Cook, 360 N.W.2d 337, 342, 37 W.C.D. 364, 372 (Minn. 1985).  This court generally upholds a compensation judge’s choice between expert medical opinions, unless the expert opinion assumes facts that are not supported by substantial evidence.  Id. at 342-43, 37 W.C.D. at 372-73.  In his findings and order, the compensation judge considered the evidence and determined that employee’s work injury had resolved by September 12, 2012, and was not a substantial contributing factor to the employee’s disability or need for treatment or restrictions after that date.  Substantial evidence supports this finding, and we affirm.

The employee also appealed the compensation judge’s finding that she was not a qualified employee for rehabilitation services.  The compensation judge found that the employee was not qualified for rehabilitation services because she had returned to suitable gainful employment with the employer and did not have a wage loss as of the time of the hearing.  “Rehabilitation is intended to restore the injured employee so the employee may return to a job related to the employee’s former employment or to a job in another work area which produces an economic status as close as possible to that the employee would have enjoyed without disability.”  Minn. Stat. § 176.102, subd. 1(b).

The employee argues that even though she is working without a wage loss, she is entitled to rehabilitation services since she is not physically capable of working at her pre-injury position.  For an employee to be eligible for rehabilitation services, the employee must meet the definition of “qualified employee.”  Minn. R. 5220.0130, subp. 1.  A “[q]ualified employee” is defined in part as an employee who “cannot reasonably be expected to return to suitable gainful employment with the date-of-injury employer.”  Minn.  R. 5220.0100, subp. 22.B.  The employer and insurer argue that the employee is working at suitable gainful employment with the date-of-injury employer, and therefore she is not a qualified employee under Minn. R. 5220.0100, subp. 22.B.

An employee’s eligibility for rehabilitation services is determined by comparing the employee’s “economic status” pre- and post-injury and applying the factors outlined in the statute and applicable rules.  Evaluation of the employee’s economic status includes comparison of the employee’s wages, fringe benefits such as health, life and disability insurance, the opportunity for future income and advancement, and other factors such as the employee’s age, education, interests, skills and employment history.  See Minn. R. 5220.0100, subp. 34 (suitable gainful employment provides an opportunity to restore the injured employee to an economic status as close as possible to that which the employee would have enjoyed without disability; consideration also given to other factors); Keklah v. Gebert's Floor Coverings, 511 N.W.2d 437, 50 W.C.D. 80 (Minn. 1994); Gackstetter v. Johnson/Midwest Coca Cola Bottling, 511 N.W.2d 439, 50 W.C.D. 51 (Minn. 1994).  Whether post-injury employment produces an economic status as close as possible to that which the employee would have enjoyed without disability is a question of fact for the compensation judge. See Erickson v. City of St. Paul, 67 W.C.D. 516, 523 (W.C.C.A. 2007).

The employee’s pre-injury job for the employer was as a nursing assistant working directly in patient care.  In her post-injury jobs, she has worked in clerical positions which met her restrictions and at the time of the hearing, resulted in no wage loss.  There is no evidence as to any differences in opportunity for future income or advancement between the positions or that the fringe benefits differ.  While the employee may prefer working directly with patients, her pre-injury job is not available to her because it is not within her restrictions.  See Adams v. Marvin Windows, 52 W.C.D. 585, 590 (W.C.C.A. 1995) (where the employee had returned to suitable gainful employment with the date-of-injury employer, substantial evidence supported the compensation judge’s finding that the employee was not a qualified employee for rehabilitation services), summarily aff’d (Minn. June 1, 1995).  Substantial evidence supports the compensation judge’s finding the employee had returned to suitable gainful employment with the employer and that she was not a qualified employee for rehabilitation services, and we affirm.