EVIDENCE – EXPERT MEDICAL TESTIMONY. Noting that a doctor makes no reference to an intervening incident in the employee’s medical history is part of the compensation judge’s weighing of evidence and does not constitute improper exclusion of evidence for lack of foundation by the compensation judge.
CAUSATION – SUBSTANTIAL EVIDENCE. Substantial evidence, including medical records and expert medical opinion, supports the denial of the employee’s claims in relation to a low back injury.
Compensation Judge: William J. Marshall
Attorneys: Ronald R. Envall, LaCourse, Poole & Envall, P.A., Duluth, Minnesota, for the Appellant. Mark A. Kleinschmidt, Cousineau, Waldhauser & Kieselbach, Mendota Heights, Minnesota, for the Respondents.
Affirmed.
PATRICIA J. MILUN, Chief Judge
The employee appeals the compensation judge’s findings related to the compensability of medical treatment received for employee’s low back condition. As substantial evidence supports the compensation judge’s findings, we affirm.
George Hakomaki, the employee, worked for Braun Intertec as a drilling assistant. In this position, the employee was required to perform significant lifting. On April 12, 2018, the employee was pouring a gelling agent from a 50-pound bag when he felt a pain in his low back. The employee applied ice and heat to his low back and took Tylenol and ibuprofen, but his pain symptoms continued. On April 23, 2018, the employee was examined by Brooke Harle, APRN, CNP. CNP Harle diagnosed the employee with acute midline low back pain. She imposed a five-pound lifting restriction on the employee and directed him to seek conservative treatment if the pain did not resolve with rest and medication (Naproxen and Flexeril).
On May 1, 2018, the employee was examined on a follow-up by CNP Harle. The employee described his back pain as worsening, despite following the work restrictions. The employee described the pain as centered in his mid to low back, and occasionally radiating down his right leg to mid-thigh. Imaging of the lumbar spine revealed narrowing of the L5-S1 disc space and mild narrowing of the right SI joint. CNP Harle referred the employee for physical therapy.
On May 9, 2018, Jakob Rikkola, PT, examined the employee. The employee described continuing pain in his mid to low back, increasing with bending, twisting, and lifting. PT Rikkola applied a number of range of motion (ROM) exercises and applied electrical stimulation with moist heat to the affected portion of the employee’s back. PT Rikkola assessed the employee’s rehabilitation potential as good. The employee was directed to attend physical therapy sessions twice per week. In follow-up sessions, the employee reported reduced pain and improved ROM. The employee received physical therapy treatments for eight weeks.
The employee reported continuing improvement in regular visits to CNP Harle. On May 15, 2018, the employee’s lifting restrictions were eased to 10 pounds. On May 29, 2018, the employee informed CNP Harle that his back pain had gotten better but recurred when the employee lifted more than 40 pounds. CNP Harle eased the employee’s lifting restriction to 30 pounds. By June 7, 2018, the employee discontinued icing his back and taking pain medications for his back condition. (Ex. H.)
On June 12, 2018, the employee reported to CNP Harle that his back pain continued and worsened when he lifted more than 30 to 40 pounds. The employee described the physical therapy sessions as “helping somewhat.” (Ex. G.) CNP Harle noted that the employee was exhibiting improved ROM and minimal pain with flexion, but some pain on extension. MRI scans were ordered, and the employee was directed to continue his physical therapy sessions. By June 15, 2018, the employee was experiencing a noticeable reduction in pain symptoms after “doing a lot of standing at work” and taking no pain medications. (Ex. H.)
On June 27, 2018, MRIs of the thoracic and lumbar spine showed mild disc degeneration at T7-T8 and no other abnormalities. On June 28, 2018, the employee reported an increase in back pain after lifting over 20 pounds and standing at work, despite taking his pain medication. By July 12, 2018, the employee reported significantly reduced back pain. By early July 2018, the employee’s lifting restriction had been raised to 40 pounds and he was working 40 hours per week.
The employee had a follow-up examination with CNP Harle on July 24, 2018. He described continuing improvement in his symptoms and expressed a desire to have his lifting restriction raised to 50 pounds, which was done. The employee’s treatment plan included Flexeril and Naproxen for pain as needed and continuing his physical therapy and home exercises. (Ex. G.) At physical therapy on July 31, 2018, the employee reported tolerating lifting 50 pounds well, and the only specific treatment provided was directed toward “minor right low thoracic muscle tension.” (Ex. H.)
On August 10, 2018, the employee attended a session of physical therapy and reported back soreness, which he attributed to a long truck drive to and from South Dakota. The employee displayed some difficulty in performing 50-pound lifts, which was attributed to not performing strengthening exercises during a week spent on vacation. (Ex. H.)
On August 14, 2018, the employee returned to CNP Harle. The employee described his condition as doing well until he lifted a motorcycle off a rider at Sturgis, South Dakota. The employee described worsening low back symptoms since that incident. CNP Harle continued the employee’s conservative care and referred him for examination by Stefan Kaiser, M.D. On August 27, 2018, Dr. Kaiser examined the employee. The chart note of that visit described the history of the work injury but made no mention of the motorcycle incident. Dr. Kaiser enrolled the employee in a work hardening program. (Ex. G.)
In November 2018, the employee reported improvement in functionality, but persistence of low back pain. Dr. Kaiser referred the employee to Obioma Igboko, MBBS, for lumbar medial branch blocks. On December 3, 2018, the employee underwent the branch block procedure at L4-S1 performed by Dr. Igboko. The employee reported no benefit from the procedure and described the blocks as being placed “too low.” Dr. Kaiser again recommended branch blocks, this time at T10 to L2. In subsequent visits, the employee described increasing pain.
The employee underwent an independent medical examination (IME) with Stephen Barron, M.D., on behalf of the employer and insurer on December 18, 2018. Dr. Barron concluded that the employee suffered a mild thoracic and lumbar sprain from the April 12, 2018, work injury. Dr. Barron concluded that the employee reached maximum medical improvement (MMI) from the April 12, 2018, work injury on July 12, 2018, with no permanent partial disability (PPD) resulting from the injury. Dr. Barron also concluded that the April 12, 2018, work injury did not result in continuing work restrictions and that no further medical treatment was necessary. (Ex. 4.)
After receiving trigger point injections in the thoracolumbar paraspinals performed by Zach Beresford, M.D., on May 16, 2019, the employee described receiving about two days of “muscle relaxing effect” but no other relief.
The employee underwent procedures to remove kidney stones in March 2019. On June 11, 2019, Dr. Barron provided a supplement to his earlier opinion, noting that the two areas where pain was described were distinct. Dr. Barron attributed the employee’s ongoing pain complaints to the kidney stones and not to the employee’s April 12, 2018, work injury. (Ex. 4.)
On September 6, 2019, Dr. Kaiser provided a narrative opinion regarding the employee’s condition and treatment. Dr. Kaiser opined that the April 12, 2018, work injury was a substantial contributing cause of the employee’s conditions and ongoing need for medical treatment. Dr. Kaiser considered the treatment the employee received reasonable and necessary to treat the effects of the April 12, 2018, work injury. (Ex. F.)
The employee filed a claim petition seeking temporary partial disability (TPD) benefits, rehabilitation benefits, and payment for medical care. On October 23, 2019, the matter came on for hearing before a compensation judge. The issues were identified as: 1) the nature and extent of the employee’s April 12, 2018, low back injury; 2) the employee’s average weekly wage on the date of injury; 3) the employee’s entitlement to TPD benefits in two distinct periods; 4) the reasonableness, necessity and causal relationship of the medical treatment provided; and 5) whether MMI was reached as of July 2018.
The judge found: 1) the April 12, 2018, work injury was not a substantial contributing cause of the medical care that the employee received after July 24, 2018; 2) the employee was entitled to TPD benefits through July 24, 2018; 3) the employee was entitled to payment of medical benefits through July 24, 2018; and, 4) the MMI issue was moot. The employee was awarded benefits consistent with the findings. The remaining claims were denied. The employee appeals.
On appeal, the Workers’ Compensation Court of Appeals must determine whether “the findings of fact and order [are] clearly erroneous and unsupported by substantial evidence in view of the entire record as submitted.” Minn. Stat. § 176.421, subd. 1(3). Substantial evidence supports the findings if, in the context of the entire record, “they are supported by evidence that a reasonable mind might accept as adequate.” Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 59, 37 W.C.D. 235, 239 (Minn. 1984). Where evidence conflicts or more than one inference may reasonably be drawn from the evidence, the findings are to be affirmed. Id. at 60, 37 W.C.D. at 240. Similarly, findings of fact should not be disturbed, even though the reviewing court might disagree with them, “unless they are clearly erroneous in the sense that they are manifestly contrary to the weight of evidence or not reasonably supported by the evidence as a whole.” Northern States Power Co. v. Lyon Food Prods., Inc., 304 Minn. 196, 201, 229 N.W.2d 521, 524 (1975).
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. Krovchuk v. Koch Oil Refinery, 48 W.C.D. 607, 608 (W.C.C.A. 1993), summarily aff’d (Minn. June 3, 1993).
The employee contends that substantial evidence does not support the compensation judge’s decision that the April 12, 2018, work injury was no longer a substantial contributing cause of the employee’s low back condition after July 24, 2018. The employer and insurer maintain that the employee’s medical record and the opinion of Dr. Barron support the decision.
In this matter, the employee’s medical record shows uninterrupted improvement in his low back condition from May 1, 2018, through July 24, 2018. The employee’s lifting restrictions were repeatedly eased, and the employee was able to resume full-time work. The employee’s own reporting of symptoms through July 31, 2018, is consistent with an improving condition. The compensation judge could reasonably find from the record before him that the employee suffered a temporary injury which healed with no residual disability and no need of further medical treatment. Dr. Barron provided an expert medical opinion that this was the case. While Dr. Kaiser provided a contrary opinion, the choice between well-supported medical opinions is left to the compensation judge.[1]
The employee reported suffering increased low back pain symptoms following a lifting incident in August 2018. A reasonable inference from this fact is that the employee’s symptoms following the lifting incident did not result from the April 12, 2018, work injury. The determination of causation by the compensation judge is affirmed on appeal where that determination is supported by substantial evidence.[2]
The employee argues that the compensation judge improperly excluded the opinion of Dr. Kaiser for lack of foundation, without a foundation objection being made at the hearing. We disagree. The compensation judge merely explained in his memorandum that part of the reason for not crediting Dr. Kaiser’s opinion was due to the absence of any reference to the South Dakota lifting incident. This explanation goes to the weight given to a medical opinion, which is the province of the compensation judge.[3]
The medical record in this case, together with Dr. Barron’s opinion regarding the employee’s low back condition, constitutes substantial evidence supporting the judge’s determination that the employee’s April 12, 2018, work injury was not a substantial contributing cause of the employee’s condition after July 24, 2018. For this reason, we affirm.