Mary Ann Rosenketter v. Integram St. Louis Section

(Affirming Award and Decision of Administrative Law Judge)

Injury No.: 95-129017

Employee: Mary Ann Rosenketter

Employer: | Integram St. Louis Section |

Additional Party: Treasurer of Missouri as Custodian

of Second Injury Fund

Date of Accident: September 15, 1995

Place and County of Accident: Franklin County, Missouri

The above-entitled workers' compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review as provided by section 287.480 RSMo. Having reviewed the evidence and considered the whole record, the Commission finds that the award of the administrative law judge is supported by competent and substantial evidence and was made in accordance with the Missouri Workers' Compensation Act. Pursuant to section 286.090 RSMo, the Commission affirms the award and decision of the administrative law judge dated May 13, 2005. The award and decision of Administrative Law Judge Leslie E. H. Brown, issued May 13, 2005, is attached and incorporated by this reference.

The Commission further approves and affirms the administrative law judge's allowance of attorney's fee herein as being fair and reasonable.

Any past due compensation shall bear interest as provided by law.

Given at Jefferson City, State of Missouri, this 21st day of March 2006.

LABOR AND INDUSTRIAL RELATIONS COMMISSION

NOT SITTING

William F. Ringer, Chairman

Alice A. Bartlett, Member

John J. Hickey, Member

Attest:

Secretary

FINAL AWARD

1. Are any benefits awarded herein? Yes
2. Was the injury or occupational disease compensable under Chapter 287? Yes
3. Was there an accident or incident of occupational disease under the Law? Yes
4. Date of accident or onset of occupational disease: September 15, 1995
5. State location where accident occurred or occupational disease was contracted: Franklin County, MO
6. Was above employee in employ of above employer at time of alleged accident or occupational disease? Yes
7. Did employer receive proper notice? Yes
8. Did accident or occupational disease arise out of and in the course of the employment? Yes
9. Was claim for compensation filed within time required by Law? Yes
10. Was employer insured by above insurer? Yes
11. Describe work employee was doing and how accident occurred or occupational disease contracted: Working in Cut \& Sew, and slippedon a tag and fell.
12. Did accident or occupational disease cause death? No Date of death? ---
13. Part(s) of body injured by accident or occupational disease: Right ankle, right knee
14. Nature and extent of any permanent disability: 12 % of right knee
15. Compensation paid to-date for temporary disability: $\ 0.00
16. Value necessary medical aid paid to date by employer/insurer? $\ 2,752.37
17. Value necessary medical aid not furnished by employer/insurer? $\ 0.00
18. Employee's average weekly wages: $\ 479.60
19. Weekly compensation rate: $\$ 319.73 / \ 257.29
20. Method wages computation: By agreement of the parties

1. Amount of compensation payable:

Unpaid medical expenses: --- --- weeks of temporary total disability (or temporary partial disability)

12\% right ankle ( 155 week level) permanent partial disability from Employer, or $\qquad \ 4,785.59

---weeks of disfigurement from Employer

1. Second Injury Fund liability: No

TOTAL: $\quad \ 4,785.59

1. Future requirements awarded: None

Said payments to begin as of date of this Award and to be payable and be subject to modification and review as provided by law.

The compensation awarded to the claimant shall be subject to a lien in the amount of 25 % of all payments hereunder in favor of the following attorney for necessary legal services rendered to the claimant:

Ray Gerritzen, Attorney for Claimant

Employee: Mary Rosenkoetter

Injury No: 95-129017

Before the DIVISION OF WORKERS' COMPENSATION

Department of Labor and Industrial Relations of Missouri

Jefferson City, Missouri

Dependents:

Employer: | Integram St. Louis Section |

Insurer: | CNA Insurance Company/RSKCo |

This is a hearing setting for five cases involving the claimant, Mary Rosenkoetter, Injury Numbers 94-168476, 95129017, 97-483041, 98-175851, and 99-123209. In all five cases, the claimant, Mary Rosenkoetter appeared on her own behalf, and through counsel, Attorney Ray Gerritzen ${ }^{[1]}$. In all five cases, the employer/insurer appeared by and through counsel, Attorney Tim Tierney. In four cases (Injury Numbers 95-129017, 97-483041, 98-175851, and 99123209), the Second Injury Fund appeared by and through Assistant Attorney General M. Jennifer Sommers.

The parties entered into certain stipulations, and agreements as to the complex issues to be presented in these

hearings. Memorandums of Law were filed by the parties.

On or about September 15, 1995: a. the claimant while in the employment of Integram St. Louis Section sustained an injury by accident arising out of and in the course of her employment occurring in Franklin County, Missouri; b. the employer and employee were operating under and subject to the provisions of the Missouri Workers' Compensation Law; c. the employer's liability was insured by CNA Insurance Company/RSKCO[2]; d. the employee's average weekly wage was $\ 479.60, the rate being $\ 319.73 over $\ 257.29.

e. The employer had notice of the injury. f. A Claim for Compensation was filed within the time prescribed by law. g. No temporary total disability benefits have been paid. h. Medical aid was provided in the total amount of \$2,752.37

1. Medical causation
2. Future medical care
3. Nature and extent of permanent partial disability
4. Liability of the Second Injury Fund

No. A: Deposition transcript of Bruce Schlafly, M.D., taken July 9, 2002 on behalf of the claimant, with attachments of: Exhibit A-1, the curriculum vitae of Bruce Schlafly, M.D.; A-2, the March 1, 2001 report of Dr. Bruce Schlafly, M.D. (8 pages); A-3, November 12, 2001 report of Bruce Schlafly, M.D. (1 page); A-4, four photographs taken by Dr. Bruce Schlafly of another patient, not Mary Ann Rosenkoetter, who had persistent problems following prior endoscopes carpal tunnel release and required repeat carpal tunnel release using the standard technique, Exhibit A-3 has the description; A5, the medical literature provided by Bruce Schlafly, M.D. titled, quote, The Results of Revision Carpal Tunnel Release Following Previous Open Versus Endoscopes Surgery". A-6, the medical literature by Dr. Bruce Schlafly entitled "Persistent or Recurrent Carpal Tunnel Syndrome Following Prior Endoscopes Carpal Tunnel Release"; A-7, operative report of the December 7, 2001 left carpal tunnel release performed by Dr. Bruce Schlafly at St. Anthony's Medical Center; A-8 is the December 12, 2001 report of Dr. Bruce Schlafly (1 page); A-9, the May 6, 2002 report of Dr. Bruce Schlafly (2 pages); A-10, the operative report of the March 4, 2002 right carpal tunnel release performed by Bruce Schlafly, M.D., at St. Anthony's Medical Center; A-11, the statement of services of Hand Surgery Associates, P.C./Bruce Schlafly, M.D., in the amount of $\ 3,120.00 for services rendered November 12, 2001 through March 8, 2002; A-12, numerous letters addressed to Bruce Schlafly, M.D., and deposition notices of Dr. Bruce Schlafly relative to his carpal tunnel syndrome treatments. (Admitted subject to the objections therein.) (Ruling: Employer/Insurer's and Second Injury Fund's objections to Exhibit A-4 on grounds of, inadequate foundation has been laid, is overruled.)

No. B: Certified medical records of Calvin Medical Center

No. C: Certified medical records of Hand Therapy Network, certified March 15, 2001 (12 pages)

No. D: Certified medical records of HealthLine Corporate Health Services Metro St. Louis certified October 12, 1999 (72 pages)

No. E: Certified medical records of Karl A. Jacob, M.D. certified October 9, 1999 (43 pages)

No. F: Medical records of Dr. John Kef alas, M.D. certified October 7, 1999

No. G: Certified medical records of Missouri Baptist Medical Center certified January 19, 2000 (219 pages)

No. H: Deposition transcript of Dr. Poetz taken on behalf of the employee on April 28, 2003 (with attachment H-1, the doctor's June 10, 2002 report, 10 pages) [Admitted into evidence subject to the objections therein)

No. I: Certified medical records of St. John's Mercy Hospital in Washington, Missouri, certified May 4, 2000 (14 pages)

No. J: Certified medical records of St. John's Mercy Hospital in Washington, Missouri certified November 17, 1999 (8 pages)

No. K: Certified medical records of St. John's Mercy Hospital, Washington, Missouri certified July 16, 1997 (28 pages)

No. L: Certified medical records of Lesson Heights Orthopaedic \& Arthroscopic Associates certified November 10, 1999 ( 90 pages)

No. M: Medical bill of Pathology Associates, P.C., for services rendered December 7, 2001 and March 4, 2002 in the amount of $\ 41.00

No. M-1: Collection letter of Diversified Collection Services showing that $\ 27.00 of Exhibit M was turned over to collection

No. N: Medical bill of South County Anesthesia for services rendered December 7, 2001 in the amount of $\ 480.00 No. N-1: Medical bill of South County Anesthesia for services rendered on March 4, 2002 (the second surgery performed by Dr. Schlafly) in the amount of $\ 420.00

No. O: Medical bill of South County Radiologists, Inc. in the amount of $\ 20.00

No. P: Medical bill of St. Anthony's Medical Center for services rendered on December 7, 2001 in the amount of $\ 2,351.97

No. P-1: Surgical bill

No. Q: Prescription receipt of Heartland Discount Pharmacy in the amount of $\ 5.86 for Cephalexin, 500 milligrams prescribed by Bruce Schlafly, M.D.

No. R and R-1: Deposition transcript of Dr. John Crane, M.D. taken on April 8, 2004, and an August 18, 2003 report by Dr. Crane (Limited admission for these exhibits, only as to the issue of future medical care)

No. S: March 4, 2002 medical bill of St. Anthony's Medical Center, \$2,421.74

No. 1: Deposition transcript of Dr. R. Peter Mirkin, M.D. taken on behalf of the employer/insurer on 12/13/02 (Admitted subject to the objections therein)

No. 2: Deposition transcript of R. Evan Crandall, M.D. taken on behalf of employer/insurer on December 11, 2002 (Admitted subject to objections therein)

No. 3: Deposition transcript of Dr. Wayne Stallings, M.D. taken on behalf of the employer/insurer on 12-4-02 (Admitted subject to the objections therein)

No. 4: Certified records of Dr. George O. Sort, M.D.

No. 5: Records of Dr. Clark, D.C.

No. 6: Correspondence between the law offices of Gerritzen \& Gerritzen and Evans \& Dixon pertaining to the issue as to whether surgery had been authorized and when it had been authorized (a. November 20, 2001 letter from Paul Keeven to Mr. Gerritzen; b. November 16, 2001 letter by Mr. Gerritzen to Paul Keeven of Evans \& Dixon; c. October 15, 2001 letter from Mr. Gerritzen to Paul Keeven of Evans \& Dixon; d. October 5, 2001 letter from Paul Keeven to Mr. Gerritzen; e. April 23, 2001 letter of Michael Gerritzen to Paul Keevenn)

No. 7: First Workers' Compensation Claimant's Report dated 10-7-95, signed by Miss Rosenkoetter

No. 8: Deposition transcript of Dr. Wayne Stallings, M.D. taken on behalf of the employer/insurer on 4-28-04 (Admitted subject to the objections therein)

No exhibits.

Under Missouri law, the employee carries the burden of proving all essential elements of the claim, including causation. Lawrence v. Joplin R. VII School District, 834 S.W.2d 789 (Mo. 1992). The employee must establish a causal connection between the accident and the claimed injuries. Fischer v. Archdioceses of St. Louis, 791 S.W.2d 195 (Mo.App. 1990).

A claimant must show not only causation between the accident and the injury but also that a disability resulted and the extent of such disability. Smith v. National Lead Co., 228 S.W.2d 407, 412(4) (Mo.App.1955). While proof of cause of injury is sufficiently made on reasonable probability (Smith v. Terminal Transfer Company, 372 S.W.2d 659, 664(7) (Mo.App.1963)), proof of permanency of injury requires reasonable certainty. Davis v. Brezner, 380 S.W.2d 523, 588(6-- 9) (Mo.App.1964). Whatever may be the quantum of proof the law imposes on a given issue in a compensation case, however, such proof is made only by competent substantial evidence and may not rest on surmise or speculation. Griggs v. A. B. Chance Co., 503 S.W.2d 697, 703 (Mo.App. 1973).

"For an injury to be compensable the evidence must establish a causal connection between the accident and the injury. The testimony of a claimant or other lay witness can constitute substantial evidence of the nature, cause and extent of the disability when the facts fall within the realm of lay understanding.

"An injury may be of such a nature [however] that expert opinion is essential to show that it was caused by the accident to which it is ascribed." (Citations omitted) Griggs, 503 S.W.2d at 704.

"...an injury may be of such a nature that expert opinion is essential to show that it was caused by the accident to which it is ascribed. When the condition presented is a sophisticated injury that requires surgical intervention or other highly scientific techniques for diagnosis, and particularly where there is a serious question of pre-existing disability and its extent, the proof of causation is not within the realm of lay understanding..." Knipp v. Nordyne, Inc. 969 S.W.2d 236, 240 (Mo.App. 1998)

"Medical causation not within common knowledge or experience, must be established by scientific or medical evidence showing the cause and effect relationship between the complained of condition and the asserted cause." Selby v. Trans World Airlines, Inc., 831 S.W.2d 221, 222 (Mo.App. 1992).

"A medical expert's opinion must have in support of it reasons and facts supported by competent evidence which will give the opinion sufficient probative force to be substantial evidence." (citations omitted) Pippin v. St. Joe Minerals Corp., 799 S.W.2d 898, 904 (Mo.App. 1990)

The claimant, Rosenkoetter, (who was found to be a basically credible witness though easily confused on historical facts at times), alleges that on September 15, 1995 she was working in Cut and Sew at Integram St. Louis Section (Integram) and some tags had been dropped on the floor and she was coming around the table and stepped on one. It is real slick, Rosenkoetter testified, and I slipped and fell towards the table, trying to grab it, I fell to the concrete floor, and especially on my right knee and my foot was kind of turned under me and it hurt my right ankle and jarred my back. At that time, my ankle was really hurting, my back was throbbing, and I started limping, she said. I told the foreman, the claimant stated, and he said to try some ice on my ankle and my knee and didn't say nothing about my back. I had never had any problems with my right knee, right ankle or my back prior to slipping on this tag in 1995, the claimant said. I kept getting pain down the back of my right leg and my knee, and I was limping for two weeks before I could get them to finally decide to send me to a doctor, Rosenkoetter testified. My employer sent me to HealthLine where they wrapped my knee; they didn't take any x-rays or nothing, said it was just sprained and to put ice on my back, and that was it, Rosenkoetter stated. I returned to HealthLine because I still had the pain, the claimant said, and I asked for a second opinion on my back and the doctor got mad and said I refused to be seen and took my papers out to the front desk. I said I'm not leaving because I didn't refuse to be seen, and she says if you can act like a patient then come back in here, the claimant testified, so I went back in the office and she said I didn't need a second opinion on my back. The HealthLine doctor never did anything about my back, right knee and right ankle, Rosenkoetter testified, and this ended the company's tendered treatment. Rosenkoetter stated that she went to the doctor on her own, explaining that her back just kept hurting so bad that she couldn't stand the pain no more. And one night I sat down on the toilet and I couldn't get up, it was that bad, the claimant said, this was about a month after it had happened. My husband carried me to the chiropractor, Dr. Clark, Rosenkoetter stated, and Dr. Clark put some heat and therapy on my back and told me to go home and try to relax, and I was back the next day for another treatment and the next day, Rosenkoetter said, because I could hardly walk because the pain in my back was really bad and at that time it was going down the back of both of my legs all the way to my heel. I saw Dr. Clark about three times, I think, the claimant stated, and then I went to Dr. Calvin, my regular doctor, and he set me up an appointment with Dr. Jacobs, a neurologist. Dr. Jacobs took x-rays, and I had to go to the hospital for some nerve tests, MRI, Rosenkoetter testified, and then the doctor wanted to do surgery right away. Surgery was ultimately done on my back, the claimant said, about a month after I first went to Dr. Jacobs.

Medical records in evidence revealed that Rosenkoetter was treated at Healthline (Cl's. D) beginning on 9/15/95, and the record stated that Rosenkoetter was being seen for complaints of pain and intermittent swelling in the right ankle and right knee as a result of twisting and slipping on a piece of paper at work on 8/25/95; a 9/15/95 x-ray report, indicating a date of injury of $8 / 25 / 95$, noted exams of the right knee and the right ankle, and results for both were negative/no bone or joint abnormality evident; the record reflected a diagnosis after examination on 9/15/95 of - Mild sprain right ankle, and Strain right knee. The Healthline record reflected additional treatment of the right knee and right ankle for the 8/25/95 injury through 10/6/95; the diagnosis remained - Sprain right ankle, and Strain right knee; written in the record was that the injury was consistent with work activities of the alleged 8/25/95 incident; the last entry of 10/6/95 included that the injuries to the right ankle and right knee were improving and that therapy sessions were set up, and that Rosenkoetter was continued on light duty. The records of Dr. Clark, D.C. (Emp./Ins. 5) reflected the next treatment of Rosenkoetter,

beginning on 10-15-95, and this entry included: "Pat(ient) working today painting floors in flexed or stooped position. Sat down 2-3 hours ago \& got pain - left low back and hip and leg. Constant since then to left ankle."; the 10/15/95 further included - "Off work Bed". The record indicated that Rosenkoetter was seen and treated again the next day (10/16), seen and treated on 10/17 and had worked that day; she was seen and treated on 10/18, and it was noted that Rosenkoetter had not gone to work that day. The next entry of 10/19/95 entry, apparently written by Dr. Glen Calvin, D.O. stated that Rosenkoetter presented that day with severe pain in the lumbar spine running down her left leg, and that they agreed that her disability began on 10-15-95; it was written that she had the potential for having a ruptured disk in the lumbar spine; the 10/19/95 entry further stated that Rosenkoetter needed a work disability form from her primary doctor as work would not accept the chiropractor's. The chiropractor ordered radiological studies which were performed at St. John's Hospital (See Cl's. J and Emp./Ins. 5) on 10/23/95; the 10/23/95 radiological report noted a history of - "... rule out disc. Patient has low back pain radiating to the left leg for approximately 2 weeks". Dr. Clark's record included an approximate 1994 entry in which it was written that Rosenkoetter reported a chief complaint of - auto accident in 1987, worse last 6 months with pain in the small of back and hip and legs. The records of Dr. Karl Jacob, M.D. (Cl's. E) indicated that he was the next to see Rosenkoetter; the Initial Office Examination report of 10/30/95 included a history of: Rosenkoetter "...slipped at work on a tag that was on the floor, twisted her right ankle and her right knee and had pain immediately. This occurred three weeks ago. The patient developed left low back, hip and leg pain after sitting for a long period of time." A myelogram CT scan was ordered by Dr. Jacob. Dr. Jacob's records reflect that he performed surgery on the claimant's back on 12/14/95.

In this case, it is found that the issue of the cause of the claimant's, Rosenkoetter's, back injury/condition with surgery on 12/14/95 is a sophisticated matter in that the medical evidence reveals that extensive testing and surgery was required, thus the proof of causation is not within the realm of lay understanding and medical expert opinion is necessary.

Considering the expert medical opinions, the claimant offered Dr. Bruce Schlafly's (Cl's. A) who noted a history of injury of: A major injury at work on or about 8/25/95 where Rosenkoettter slipped on a slick paper tag on the floor "and fell to the concrete floor, landing on her knees and back and also apparently twisting her right ankle"; the next day she was experiencing considerable low back pain with swelling at the right ankle and she sought medical attention; I see medical records where she was evaluated at the Healthline clinic on 9/15/95 for the injury, where her complaints involving her right ankle and right knee were noted and x-rays were negative, and she was given a diagnosis of mild sprain of her right ankle and strain of the right knee; she says that her back was not properly evaluated at Healthline and she had to obtain on her own treatment from her personal physician, Dr. Calvin, who on 10/19/95 noted that she had severe pain along the lumbar spine with pain radiating into the left leg, and diagnosed a ruptured disc and referred her to Dr. Jacob. Dr. Jacob ordered an MRI scan of the lumbar spine that revealed degenerative change, and then ordered a lumbar myelogram with CT scan which showed changes such as narrowing of the lateral recess on each side at L4-5; her symptoms continued, and Dr. Jacob operated on her on 12/14/95 at which time he found displacement at L3-4 and L4-5 with spinal stenosis at these level; following surgery Rosenkoetter noticed numbness in the dorsum of the left forearm, and electrical studies Dr. Jacob had performed on 5/6/96 were negative. Prior to the 8/25/95 fall at work, she tells me that she had no problems with her low back, Dr. Schlafly wrote. Dr. Schlafly opined - "Mrs. Rosenkoetter slipped and fell at work on or about 8/25/95, injuring her low back. This work injury is the substantial factor in the cause of her low back condition that necessitated Dr. Jacob's surgical treatment." On cross examination, Dr. Schlafly stated that his review of Healthline's records following the 8/25/95 incident revealed that Healthline did not record complaints referable to the back at that time; the doctor agreed that Healthline recorded complaints with respect to the right ankle and the knee. It was noted that Dr. Schlafly wrote that Rosenkoetter relayed to him that her back was not properly evaluated at Healthline; Dr. Schlafly was shown a workers' compensation report signed by Rosenkoetter on 10/7/95[4] (Emp./Ins. 7), and Dr. Schlafly agreed that there was nothing on the 10/7/95 report indicating any complaints of problems with the back and agreed that this report would be consistent with the Healthline records. Dr. Schlafly (who agreed that Rosenkoetter had told him she had not had any prior back problems before the 8/25/95 fall on the tag) was shown the October 1995 record of Dr. Calvin in which it was written that Rosenkoetter had had an auto accident in 1987, care for last two years, worse last six months, pain in small of back and hip and legs; Dr. Schlafly agreed that if this was true then Rosenkoetter had problems with her low back from 1987 for the next six years, and since the record was an October 1995 record this would indicate that before August of 1995 Rosenkoetter was having problems with her low back; Dr. Schlafly agreed that this would be inconsistent with the history Rosenkoetter had given him. Dr. Schlafly agreed, during cross examination, that the medical records indicated that treatment Rosenkoetter received during the interval of 8/25/95 up until the reference to injuring her back on 10/15/95 in Dr. Calvin's record did not include the back; the doctor admitted that he did not have medical records that record any complaints of pain, ache, discomfort, involving the back or the legs between 8/25/95 and 10/15/95. Dr. Schlafly admitted that he did not know about any 10/15/95 injury. During cross examination, Dr. Schlafly was shown the October 23, 1995 CT scan of the lumbar spine, and stated that "(P)robably" the findings on the scan, if the scan had been done six months earlier, would have been present; the findings would have been present before 8/25/95. (Schlafly Dp.

pg. 41) In regards to the calcified bulging disc seen on the October 23, 1995 CT scan, "I wasn't sure" if it would have been seen prior to 8/25/95, the doctor said. (Schlafly Dp. pg. 42) Dr. Schlafly was asked - would you anticipate that somebody who sustained an acute herniation of a disc could go a month-and-a-half without treatment and/or complaints? "Unlikely", Dr. Schlafly answered. (Schlafly Dp. pg. 43)

The claimant also offered the expert medical opinion of Dr. Robert P. Poetz, D.O. (Cl's. H) who evaluated Rosenkoetter and wrote in his June 10, 2002 evaluation report that he saw Rosenkoetter on October 26, 2001 for evaluation of work related injuries occurring while employed with Magna Interior Systems of America as a factory worker for eight years. Dr. Poetz discussed work related injuries relayed by Rosenkoetter, which included: August 25, 1995 slipped on a paper tag which caused her to twist her right ankle and knee before falling onto a table, with ongoing occasional pain and swelling at the ankle and knee, and on September 15, 1995 was seen at Healthline and diagnosed with mild right ankle sprain and right knee sprain, and physical therapy was recommended; also reported was that after the incident Rosenkoetter developed lower back, left hip and left leg pain; treatment for the back included radiological studies, and surgery. Dr. Poetz' diagnoses were: 1) 8/25/95 - Right ankle sprain; and right knee sprain. 2) 8/25/95 Lumbar strains with degenerative disc disease; lumbar spondylosis with myelopathy, severe L3-4, L4-5; displacement disc, lumbar L3-4, L4-5 left and cicatrix of the nerve roots L4 and L5 left; Status post lumbar decompression laminectomy with laser magnification and microdissection L3-4 and L4-5 left. 3) Lumbar degenerative disc disease and spinal stenosis, L3-4, L4-5, pre-existing. On cross examination, Dr. Poetz agreed that Rosenkoetter's initial treatment in regards to the 8/25/95 injury where Rosenkoetter slipped on a paper tag and injured herself was at Healthline, and at that time she had complaints about the right knee and ankle and x-rays were taken of the right knee and ankle. The doctor agreed that the first treatment was on 9/15/95, and that in his review of the initial Healthline reports he did not find any history or complaint of injury to the low back. Dr. Poetz was asked how long after the incident before Rosenkoetter developed low back pain. "I don't know", Dr. Poetz answered. (Poetz Dp. pg. 69) The doctor was questioned assuming it was Rosenkoetter's signature on a Report of Injury dated 10/7/95, what were the injuries noted by Rosenkoetter on the form, and Dr. Poetz indicated "right ankle and ankle". Agreeing that there was no reference to the back as of 10/7/95, Dr. Poetz testified - "No. It says, sprained right ankle and ankle". (Poetz Dp. pg. 7) The doctor was asked his opinion as to the mechanism in this case of injury to the back for the 1995 problem Rosenkoetter had with her back, and Dr. Poetz answered:

"Well, I think that she had indicated in the history there, that she developed this knee and ankle twisting, she continued to have an ankle and knee pain, and eventually after the incident, she developed lower back pain, left hip pain and leg pain.

"And she said she felt that it was related.

"I think that she indicated that she felt that it, it came as a result of it, it was part of the, the ongoing complaint of pain in the knee and the ankle." (Poetz Dp. pg 74)

Dr. Poetz agreed that Rosenkoetter did not provide him any history of additional trauma or repetitive activities that caused her to develop pain with her back. The doctor was queried if he had been provided with any history of Rosenkoetter doing some work painting floors in a stooped position and developing pain complaints in the back as of 10/15/95. "Not to my knowledge", the doctor answered. (Poetz Dp. pg. 75) The doctor agreed that when Rosenkoetter eventually started undergoing diagnostic studies for the back it was through x-rays of the lumbar spine which were done about a month and a half after the incident where she slipped on a tag. Dr. Poetz agreed that the findings of the radiographic studies were pre-existing conditions to 1995 with the exception of the following findings on diagnostic studies which may or may not have been pre-existing: the marked narrowing of the left neuroforamina as a result of calcified focal area of disc protrusion. Dr. Poetz stated that the spondylosis (dysfunction of the spinal canal) found when Rosenkoetter was operated on was in part a degenerative condition that occurs over time or a pre-existing condition. Explaining other causes of the spondylosis, Dr. Poetz testified: "Multiple injuries or recent injury to exacerbate it". Poetz Dp. pg. 79) The doctor stated that the stenosis at L3 L4-5, and left lateral recessed stenosis at 3-4 and L4-5 "would all be preexisting, but the degree of preexisting and the degree of exacerbation is indeterminable". (Poetz Dp. pg 79)

Dr. R. Peter Mirkin, M.D. offered expert medical opinion on behalf of the employer/insurer. (Emp./Ins 1) The doctor stated that he examined Rosenkoetter on several occasions (during the time period of March 1998 - July, 2002). "I reviewed extensive records including records from Dr. Jacob, Dr. Rende, Dr. Calvin, physical therapy notes, records from Healthline", the doctor said. (Mirkin Dp. pg. 6) Dr. Mirkin gave his opinion from his review of x-rays and diagnostic studies:

"It was my conclusions this was a lady with very severe degenerative disease in her lumbar spine who underwent a

laminectomy. When I first saw her, she really was not having radicular pain. Later on, she was starting to have some recurrent pain, and I recommended that if she had persistent pain that it be reevaluated by MRI or myelogram. (Mirkin Dp. pp. 7-8)

Dr. Mirkin stated that the findings seen on the radiographic studies would occur over years. Dr. Mirkin testified as to his diagnoses for Rosenkoetter: "It's my opinion this is a lady with severe degenerative spine disease who underwent a decompression procedure by Dr. Jacobs and still suffers from the effects of her degenerative arthritis disease." (Mirkin Dp. pg. 8) Testifying that it was his opinion Rosenkoetter's severe spine disease was not medically causally related to her employment with Integram, Dr. Mirkin explained:

"As we stated before, this is something that occurs over a long period of time. Her initial complaints after her work injury were of knee pain and I believe some ankle pain, and she didn't even talk about back problems. So, you know, I would expect a patient who had an acute injury to have back complaints immediately." (Mirkin Dp. pg. 9)

On cross examination by the claimant, Dr. Mirkin agreed that the only film studies he ever reviewed were x-rays he had taken, and thus the first films he would have reviewed would have been films taken in 1998, approximately $21 / 2-23 / 4$ years after the injury. Dr. Mirkin agreed it was his opinion that based on her history, Rosenkoetter had radicular symptoms prior to the surgery by Dr. Jacobs in 1995, the radicular symptoms returned, and to a certain extent have been off and on ever since. On redirect, Dr. Mirkin was given a hypothetical question in regards to degenerative findings that may or may not be related to the surgical procedure and degenerative findings that would have predated the surgical procedure; Dr. Mirkin was given the following facts - assume that the original injury was on or about 9/15/95, and that prior to the surgical procedure on 12/14/95, she underwent a lumbar CT scan that was administered on 10/23/95, further assume that the radiologist's interpretation of that CT scan was that axial images centered through the disc spaces from L2-3 through L5, S were obtained, there were uniformed calcified disc bulging at L2-3, there was disc bulging at L3-4 with a focal area of calcified disc protrusion laterally to the left, hypotrophy in this region as well contributed to the narrowing of the left lateral neuroforamina, there was uniform disc bulging at L4-5 with calcification, facet hypertrophy at that level as well and at all image levels, narrowing was noted at the disc space at L3-4 and L4-5, and no focal herniations of soft disc material were identified; the doctor was asked - assuming those to be accurate conclusions, would that effect his opinion regarding medical causation in any way? Dr. Mirkin answered:

"Certainly that CAT scan report substantiates my opinion that this is a degenerative condition. Those are all degenerative findings. In fact, the radiologist clearly points out there is not an acute disc rupture there. They are all calcified degenerative bulges, protrusions as well as facet hypertrophy, and that's a classic description of an arthritic condition of the back." (Mirkin Dp. pg. 36) (Ruling: Claimant's objections on grounds of, Seven Day Rule and nonresponsive, are overruled. Mirkin Dp. pp. 36 and 37)

The doctor was further queried with the hypothetical facts; he was asked, assuming the same facts to be true and assuming Rosenkoetter did have an injury on or about 9/15/94, would one expect in that period from 9/15/95 through 10/23/95 the development of facet hypertrophy and calcified disc bulging basically from L2-3 all the way down to L5, S1 as a result of the traumatic event. Dr. Mirkin answered: "Absolutely not. These are all changes that take years to evolve." (Mirkin Dp. pg. 37) (Ruling: Claimant's objection on grounds of, Seven Day Rule, is overruled. Mirkin Dp. pg. 37)

Considering the expert medical opinions in light of the medical and other evidence presented, firstly, it is found Dr. Schlafly's opinion on causation is not supported by the substantial weight of the evidence. The doctor's opinion is based on a history not supported by the medical treatment records in that: a. the treatment records do not establish that Rosenkoetter began experiencing symptoms the next day after the 1995 work incident which included considerable low back pain; b. Dr. Schlafly admitted that he was not aware of a 10/15/95 incident of Rosenkoetter of painting floors that was noted in Dr. Clark's record of 10/15/95, the 10/15/95 record further including a notation that this was the date of the back injury. It should be noted that it is further found that it is not clear from the evidence, including the records of Dr. Clark, D.C., [the claimant's admitted personal doctor, where noted was the 10/15/95 incident of -- "Pat(ient) working today painting floors in flexed or stooped position. Sat down 2-3 hours ago \& got pain - left low back and hip and leg. Constant since then to left ankle."], whether or not the 10/15/95 event occurred at the claimant's place of employment of Integram or elsewhere; from the evidence ${ }^{[5]}$ such a determination would be purely speculative. It is found that Dr. Schlafly's opinion lacks sufficient probative force in that the doctor's opinions do not have in support of it facts supported by competent evidence, and thus is found not to be substantial evidence on the issue of medical causation. It is found that Dr. Poetz' opinion on causation is also not supported by the substantial weight of the evidence in that this doctor stated that his opinion was based on the history relayed by the claimant, admittedly a poor historian; Dr. Poetz admitted that he did not know how long after the slipping on a tag on the floor incident Rosenkoetter developed low back pain; Dr. Poetz agreed that Rosenkoetter did not provide him any history of additional trauma or repetitive

activities that caused her to develop pain with her back, the doctor admitted that he had no knowledge of the 10/15/95 event that was reflected in the treatment records. It is found that Dr. Poetz' opinions are not supported by the competent evidence and thus his opinion does not have sufficient probative force to be substantial evidence. It is found that the substantial weight of the medical evidence supports the opinion of Dr. Mirkin on causation, and his opinion is considered to be of sufficient probative force to be substantial evidence. It is found that the substantial weight of the competent evidence, including Dr. Mirkin's opinion, does not establish a medical causal connection between the work related incident of slipping on a tab and the claimant's back injury/condition with surgery performed on 12/14/95.

Further, it is found that there is no dispute among the medical expert opinions and their opinions are supported by the substantial weight of the medical evidence, that as a result of the slipping on the tab incident occurring at work on September 15, 1995, the claimant suffered injuries of - sprain of the right ankle and strain of the knee.

It has been determined in this Award that as a result of the slipping on the tab at work incident on September 15, 1995, the claimant sustained injuries of - sprain of the right ankle and strain of the knee.

The claimant testified about ongoing problems with her knee and ankle, such as every once in a while her right ankle flares up and will swell. The claimant gave no testimony about ongoing medical treatment as a result of these work related injuries. The claimant testified that she was released from treatment by Healthline for the injuries sustained in the 1995 slipping on a tab incident. Healthline records, which reflected a diagnosis of Sprain right ankle, and Strain right knee, further reflected in the last treatment entry of 10/6/95 that the injuries were resolving, and that Rosenkoetter would be scheduled of physical therapy sessions (which she had previously not attended). The claimant testified that she did not recall Healthline asking her to come back for anything else. There were no further treatment records in evidence indicating treatment of Rosenkoetter's right knee and ankle as a result of the 1995 work related incident; there was no expert medical opinion of a need for future medical care in regards to the 1995 work related injuries to the right ankle and knee.

The Workers' Compensation Act does not require that there be evidence of the specific medical treatment or procedures that will be necessary in the future as that may put an impossible and unrealistic burden upon the employee; but evidence of future medical care must flow from the injuries causally related to the compensable accident before the employer is to be held responsible. See, generally, Sifferman v. Sears, Roebuck and Co., 906 S.W.2d 823, 828 (Mo.App. S.D. 1995).

As there is no evidence of a need for future medical care for the injuries found to be medically/causally related to the 1995 work related accident, future medical care is denied.

The claimant testified about ongoing problems with her right knee and ankle as a result of the 1995 work related injury, stating that her knee and ankle had quit hurtingfor a while after she had back surgery in December 1995, but that once in a while her right ankle flares up, and it will swell. The evidence reveals subsequent, unrelated injuries and/or problems with the claimant's knee(s). Dr. Schlafly, who evaluated the claimant on the claimant's behalf, stated the following opinion: "My opinion is that she carries a 10 percent permanent partial disability of the right ankle as a result of the right ankle sprain sustained when she fell at work on 8/25/95. I do not find any significant disability of her knees....". Dr. Poetz also evaluated the claimant on her own behalf, and stated that as a direct result of the injuries sustained in the 1995 work related accident, Rosenkoetter had sustained the following disabilities: 15\% permanent partial disability to the lower right extremity as measured at the right ankle, and 15\% permanent partial disability to the lower right extremity as measured at the right knee. During cross examination, Dr. Poetz agreed that Rosenkoetter did not provide him with a history of injury to the left knee ${ }^{[6]}$, and when queried, wasn't it correct that he found crepitus in the knee bilaterally, Dr Poetz answered "Yes". (Poetz Dp. pg. 67) The doctor further agreed that there was no indication that one knee was worse than the other on exam. No atrophy of the lower extremities was found and there was normal range of motion at the level of the knees, the doctor agreed. Dr. Poetz was asked - on your exam of the right knee what is it that you found that was different than your exam of the left knee. "None", the doctor answered. (Poetz Dp. pg. 68) Dr. Mirkin evaluated the claimant on behalf of the employer/insurer, and stated that he evaluated her back, only; he did not assess her for any other possible ailments.

It is found that both Dr. Schlafly and Dr. Poetz offered probative opinions on the issue of permanent partial disability in that their opinions are found to be based on a review of records pertaining to the treatment for the 1995 work related injury, however, it is found that Dr. Poetz testimony indicates that he did not review all treatment records, thus his opinion is given less weight. It is found, considering the evidence that the substantial weight of the credible evidence supports an award of permanent partial disability as a result of the September 15, 1995 work related injury of slipping on a tab of: 12 % permanent partial disability of the right ankle. This would be: $12 \% \times 155 weeks =18.6 weeks; 18.6 weeks x \$ 257.29 / week =\ 4785.59.

The parameters of Second Injury Fund liability in permanent partial disability cases is set forth in Section 287.220.1 RSMo 1993, which states in pertinent part:

All cases of permanent disability where there has been previous disability shall be compensated as herein provided. Compensation shall be computed on the basis of the average earnings at the time of the last injury. If any employee who has a preexisting permanent partial disability whether from compensable injury or otherwise, of such seriousness as to constitute a hindrance or obstacle to employment or to obtaining reemployment if the employee becomes unemployed, and the preexisting permanent partial disability, if a body as a whole injury, equals a minimum of fifty weeks of compensation or, if a major extremity injury only, equals a minimum of fifteen percent permanent partial disability, according to the medical standards that are used in determining such compensation, receives a subsequent compensable injury resulting in additional permanent partial disability so that the degree or percentage of disability, in an amount equal to a minimum of fifty weeks compensation, if a body as a whole injury or, if a major extremity injury only, equals a minimum of fifteen percent permanent partial disability..... (Emphasis added)

In this case, the percentage of permanent partial disability for the subsequent compensable injury, the 1995 work related injury as a result of the claimant slipping on a tag, was found to be 12 % permanent partial disability. This is below the threshold set for consideration of any Second Injury Fund liability, and thus Second Injury Fund liability is denied.

Mary Ann Rosenkoetter, the claimant, testified that she was born on June 30, 1945. My highest education is eleven and a half years schooling and thirty-eight hours of college, she said, I was about two months to graduate. I never graduated from high school, the claimant said. A college I went to was Jeffco for a while, Rosenkoetter said, and I took different classes for blueprint reading and math and machine and welding. I also went to East Central in Union, Missouri where I took horticulture; and I can't recall what else I took there, the claimant stated. I did not get a degree from either one of the colleges, she said. The longest time I would have gone to East Central was a couple semesters, I think, Rosenkoetter stated.

I first went to work when I was eighteen, I think, the claimant testified. As far as I can recall I worked in a factory where you made beer signs and advertisement signs, she said. I have done factory work, school custodian, and storeroom clerk all of my life, the claimant stated. I worked at East Central for a year as a school custodian, and I think it was in about 1993 or 1994, while I was working at Integram. I don't remember how many years I did factory work, the claimant said, it's been several years. As a storeroom clerk; I read the blueprints and inspected machine parts and gave out parts out of the storeroom; this was at Bull Moose Tube where I worked about fourteen months, Rosenkoetter stated. I first went to work for Integram in 1991, I think, the claimant said, and I went to work in maintenance which entailed cleaning all the bathrooms on the production side, sweeping floors, polishing the floors or cleaning them, and then just all around maintenance work.

Concerning my November 23, 1994 injury to my left hand and ring finger, Rosenkoetter testified, at that time I had gone from the maintenance to production, and they made seats for Chrysler cars and minivans. I was working on a Saturday, overtime; I was working at the dump area - that's where all the seats come from the overhead down in the bin, then you take the parts out of there and you pack them in the boxes, the claimant testified. And I had two seats come down, front seats, cushions, and I grabbed both of them and I went to turn around to put them in the box and it hit the edge of the box, the one cushion in my left hand, and it started to fall to the floor and I started to grab it, and when I did, it has a metal pan on the bottom and my hand went in the middle of that circle in the middle of the pan, and when it did that it just sliced right down my hand, between my little finger and my ring finger, the claimant said, it went down my hand quite a ways, about an inch. I was bleeding pretty bad and they decided I needed to go to the hospital; so someone from

The hospital I was taken to was St. John's in Washington, Missouri, the claimant said. In the emergency room, they cleaned it all out, gave me a tetanus shot, and put, I think, three stitches in it, she said, the stitches were from the inside of my finger down about an inch down my hand. I went back to work, and as far as I recall, I was there the next day, Rosenkoetter said.

Continuing problems are that I have numbness on the inside of my little finger, the claimant said. Whenever I drive or use a broom, or anything that goes across my hand there, it really hurts it; it aches in the winter; it hurts when I put my hand on a jar to open it; I can't bend my little finger on my left hand out like the other one, I can't close it all the way like my other hand, Rosenkoetter testified. I can't pick up a heavy skillet or anything like I used to be able to because the strength just isn't there anymore, the claimant said, and anything that rubs on that, if you do it very long at a time, well, it gets sore. I just can't grip as well anything with the left hand, she said. Rosenkoetter displayed her left hand, and it was noted that there was a line scar that went about an inch into the hand between the ring and little finger. It was further noted that the claimant was unable to touch the little finger to the hand by about a fourth of an inch.

Concerning the September 15, 1995 accident at Integram, the claimant testified, that night I was working in Cut and Sew. We have to take leather covers and put them on the foam, and it was always hurry up, hurry up, hurry up, and some tags got dropped on the floor, and I was coming around the table and I stepped on one, and it's real slick on one side, and I slipped and fell towards the table, trying to grab it, I fell to the concrete floor, and especially on my right knee and my foot was kind of turned under me and it hurt my right ankle and jarred my back, the claimant stated. At that time, my ankle was really hurting, my back was throbbing, and I started limping; I was trying to find the foreman, Rosenkoetter said. I finally found the foreman and told him what happened, she stated, and he said to try some ice on my ankle and my knee, and didn't say nothing about my back. I had never had any problems with my right knee, right ankle or my back prior to slipping on this tag in 1995, the claimant said. I tried the ice like the foreman said, Rosenkoetter stated. I did not lose any time from work, she said. I kept getting pain down the back of my right leg and my knee, and I was limping for two weeks before I could get them to finally decide to send me to a doctor.

My employer sent me to HealthLine where they wrapped my knee; they didn't take any x-rays or nothing, said it was just sprained and to put ice on my back, and that was it, Rosenkoetter stated. I returned to HealthLine because I still had the pain, and my husband went with me that day, and the doctor said my knee was fine, and I asked for a second opinion on my back and the doctor got mad and said I refused to be seen and took my papers out to the front desk. I said I'm not leaving because I didn't refuse to be seen, and she says if you can act like a patient then come back in here, the claimant testified, so I went back in the office and she wouldn't let my husband go back in there and she said I didn't need a second opinion on my back. The HealthLine doctor never did anything about my back, right knee, and right ankle, the claimant said, and this ended the company's tendered treatment. Rosenkoetter stated that she did not recall HealthLine asking her to come back for anything else, or recall the company sending her somewhere else; she went to the doctor on her own and had the surgery, she said.

My back just kept hurting so bad that I couldn't stand the pain no more, and one night I sat down on the toilet and I couldn't get up, it was that bad, she said, this was about a month after it had happened. My husband carried me to the chiropractor, Dr. Clark, she said. Dr. Clark put some heat and therapy on my back and told me to go home and try to relax, and I was back the next day for another treatment, and the next day, Rosenkoetter said, because I could hardly walk because the pain in my back was really bad and at that time it was going down the back of both of my legs all the way to my heel. I saw Dr. Clark about three times, I think, the claimant said, and then I went to Dr. Calvin, my regular doctor, and he set me up an appointment with Dr. Jacobs, a neurologist.

Dr. Jacobs took x-rays, and I had to go to the hospital for some nerve tests, MRI, Rosenkoetter said, and then the doctor wanted to do surgery right away. Surgery was ultimately done on my back, the claimant said, about a month after I first went to Dr. Jacobs. The surgery was done by Dr. Jacobs at Missouri Baptist in about November of 1995, she said, and it was done on my low back on the left side of my spine. Rosenkoetter agreed that this was where she had been having the pain. Dr. Jacobs took out a disc and put a stabilizer in my back and fused some bones, I think, together, the claimant said. The affect the surgery had on me, the claimant said, is that my legs don't work right; there is a piece of bone that came off of my spine and runs into the nerve of my leg and that's what is the constant pain all the time. After the surgery I was in bed for a month, the claimant said, I could get up to go to the bathroom, but I couldn't stand to be up any longer than just a few minutes. And then I got a little bit stronger where I could go to the kitchen and come back, and I got so I could sit up and eat at the table for a few minutes, and every little bit, you know, got a little better and a little better where I could walk a little more, Rosenkoetter said.

The claimant testified about ongoing problems with her back and leg. I have constant pain all the time in the low back in the same area where it originally started when I had the slip on the tag, she said. Sometimes the pain is pretty bad, Rosenkoetter stated, it keeps me from sleeping, and I live on pain pills all the time. With walking, the claimant said, I can make it maybe fifty, sixty feet, but I can't sweep the floor unless I stop three or four times and then come back to it, and mopping is very hard. I am not able to do any activities without repercussions from it; the pain is -- if I do too much then I'm in bed for a couple days for it to get better again, unless I'm going for therapy on my back, she said.

From the time of the 1995 work accident up to the time of surgery I was back at work some days, Rosenkoetter said. I would take off my vacation days; I even got in trouble for taking off days because I just couldn't do it, I done what I could do; I took off TPT days where they had people work for you; I took vacation days and everything I could take off to keep from having to work, the claimant stated. I have no idea how many days I was off work before the surgery, she said.

I was never able to work like I could work before the accident when I slipped on the tag, Rosenkoetter testified. Before I slipped on the tag there'd be weeks that I would work more overtime hours than my regular hours; and I was always going in early on the second shift; and I couldn't do that afterwards, she said.

After the surgery, I was off work close to fourteen months, I think, the claimant said, when I went back to work it would have been close to Christmas of 1996. When I went back to work it was hard on my back, Rosenkoetter stated, I went home the first night that I went back. It's hard on my back to lift the stuff and just to be able to walk from station to station and get back in the routine of anything, she said, this along with bending was hard. It was just made me real sore to start back after not being able to do anything for so long, the claimant said, and the bending over the re-work table would hurt my back, and I couldn't do the lifting; I'd go home every night and couldn't hardly stand it from the lifting the heavy seats and stuff, and bending over the boxes. And then I'd have so long a time to get from one station to the other and to be on time, Rosenkoetter said. Walking was from the inspection table to re-work, which wasn't but about five feet, but then you had to go from there all the way into the back, which was maybe sixty, seventy feet, she said, and it was all on level concrete which wasn't real good either.

My knee and ankle had quit hurting for a while after I had my back surgery, the claimant said, but every once in a while my right ankle flares up. It swells, and in here it's swollen all the time, she said, it's swollen today. From the time I went back to work in November of 1996 until the accident of November 18, 1997 with the bench seat, the claimant said, the difference in my ability to work at Integram was that it slowed down a lot. I just didn't do as many parts as I used to; I wouldn't help other people, I just couldn't do that no more, Rosenkoetter said.

I also lost a business interest because of the 1995 accident at Integram, the claimant said. I had several mobile homes; some of them were located in trailer parks and three were on pieces of ground in Union, she said. The times that I worked both jobs, the sixteen hours a day, was to pay for these so that I would have something to retire with, and I made all the payments myself and I done all the repairs myself, she said. After I slipped on the tag I had to sell them all because I couldn't do the repairs or keep them up anymore, Rosenkoetter said, I used to be able to tear them down and set them up myself and I couldn't do any of that anymore after the 1995 accident to my back.

Also before the 1995 accident at Integram where I slipped on the tag, I had my own motorcycle, and I rode it all the time, Rosenkoetter testified. And when I got married, my husband lives on a farm, and I would go with him all day and helped cut wood, I had my own saw; helped him plow the fields, cut the hay, put the hay up, all those things. I can't do none of that anymore, the claimant said. I have always been an active person, I have always been independent, Rosenkoetter stated, I always depended on myself to make my living and to do the things I needed done, I never had to go and ask anybody. But after I got hurt, I sold my bike; it had sat in the shed for two years. I just couldn't do that stuff anymore, she said. My chainsaws, I sold them, the claimant said.

On November 18, 1997 at Integram I had one of the larger seats, and I took it to the box and bent over to put it in, and I got a real sharp pain in my right lower back, Rosenkoetter testified. The size of these seats, I think they seated three, the claimant said, it was the bottom seat, and I guess they're maybe as long as about two to two and a half feet wide. I think we made all the seats for the minivans, she said. The pain in my low back was in the same area as where I had had the surgery, Rosenkoetter said. Agreeing that some time after this, but not that night, the pain went down her leg.

I have constant pain all the way down my leg to my heel still today, the claimant said. I'm going to therapy now because I can't hardly get around; my legs just don't work as well, and I fell going up my steps, two steps, that I have gone up them a thousand times before. I fell, broke my tibia in my left leg because I thought my foot was up high enough

for the step, she said, also I stepped over a little fence, maybe nine inches tall, and I fell again. I have come out of the barn and when I stepped on the step then my ankle just turned; I just think my legs are up high enough, but they aren't, the claimant stated. I have slipped in a hole in the yard and fell, Rosenkoetter stated, and my last thing last week I fell and hurt my arm, all I was doing was walking on the driveway, but my right leg wouldn't come when I was stepping and I just went face down. I attribute these falls at home to my back and my legs, they just don't work right, she said. The claimant was asked if this came from the 1995 accident on the tag, the 1997 accident with the bench seat, or both. The 1995, she answered. When asked if they got worse in 1997, Rosenkoetter responded - They just seem to be getting worser all the time; the pain never goes away.

After the November 1997 incident I stood there for a while and when it eased down a little bit, I went and told the foreman that I'd hurt my back bending over in the box, Rosenkoetter testified. The foreman called the nurse and she brought some Aleve pills and told me to take them, and I must have been allergic to them, I had a reaction because I couldn't breathe very well, she said. And then the next day I went to see Dr. Calvin and I had a knot come up in my hip and he gave me muscle relaxers and some pain medicine, and he has a therapy machine in his office and I got therapy there, the claimant stated. She was asked how long did she get therapy, and Rosenkoetter responded - I was off work for about a week, I think.

When I went back to work after about a week, I just had the pain all the time, the claimant said, it was just miserable because my back hurt and the more places that I went to do the job, then it was just hard. I was not able to do the same amount of work like I used to, she said. Giving an example, Rosenkoetter testified that the fork truck drivers would bring the seats in big boxes and you'd have to bend over and get an armful and put them on the bins for the air bag blower, and that's what was really hard because of the bending and lifting the bunch of seat covers, so I always tried to trade that off with anybody that I could get to trade with.

Since November 18, 1997, every so often my ankle will start aching, I'll be limping around for a while, then it'll get better, the claimant said. It hurts me to walk if I walk a ways, she stated, and sometimes it aches at night; when it gets cold, it hurts. The pain is about a five or a six out of ten, she said. Concerning how far she can walk before the ankle starts swelling up, Rosenkoetter stated that as soon as she gets on her feet it starts swelling.

The claimant testified about the treatment she is getting now. I've been going to Dr. Calvin, Rosenkoetter said, and I go to the therapy at BJC in Union, Missouri twice a week now because of the pain in my right back. When I go Thursday they're supposed to fit me for a cane, she said. This is the second week that I have been going to the BJC Health Care, going twice a week, the claimant stated. I'm getting the cane so when I'm walking it'll help me sturdy myself, maybe keep me from falling, she said. Medicare is paying for this, the claimant stated.

Rosenkoetter was asked how was her right knee by now, in 1997. It would be all right for a while and it would get sore if I turned it a certain way, she answered. It has bothered me off and on since the original problems with it in 1995, she said. It will get sore; and when I straighten it back and forth, it will pop, the claimant stated. I don't have a stick shift car or anything anymore because it's too hard for the clutch, I always get an automatic, Rosenkoetter added. It was noted that the clutch is the left foot, and the claimant stated that she can't work a clutch because her left knee also hurts. Rosenkoetter agreed that both knees hurt. The left knee has been hurting for about two or three years, she said. I don't know what caused this, she said, except maybe when I fell at home and I broke my tibia bone. The claimant was further queried as to how her left foot was originally injured. Just from my back when I fell on the tag, it just doesn't work, she stated, when I raise it up, I think it's up, but my leg isn't, it doesn't come up like it used to. This has been true since 1995, the claimant said.

Testifying about what she can no longer do as a result of the 1997 work accident involving the bench seat, Rosenkoetter testified that it is just about the same things that she couldn't do before, when she hurt her back originally in 1995. I can't sweep and mop like I used to; I can't go work in the fields; I can't ride my bike; it's just pain all the time, she said.

I was fired by Integram in 1999, the claimant stated, and the reason they gave was because I was off when I hurt my leg; and they changed the contract and they said the insurance papers -- when I hurt my knee, I went on sick leave and I went and got my papers to fill out; it's after I fell and went to the hospital and the doctor said I shouldn't work. So I went to the bone specialist, and I got my insurance papers and I didn't know how to fill them out because they were different, and I called the H.R. and Mary Jo said she would help me fill them out, and she told me what to put down. And I went to the doctor, the bone specialist, Dr. Kefalas, and I had an immobilizer on my knee and a gel cast on my ankle and I was on crutches; and I think that was on a Wednesday, and Thursday I had called work, I had all my phone bills because it was long distance, and I had called them on a Friday and I asked them in H.R. at Integram if there's anything

else that I had to do, and she said no, that's all I have to do, the claimant testified. On the Thursday the doctor had faxed my medical papers from his office to work; they had them, but she lied to me, she said there was nothing else to do and that wasn't true, the claimant said. They said they fired me because I didn't come in and fill out new papers; that's why we went, the union man and me, before the arbitration board. It was whoever's the boss down there at Integram, the general foreman, I guess, who said I didn't fill out the papers right, the claimant stated, because they said I was fired because I didn't do my paperwork right. But they already had the doctor's papers there in front of them and then when we went to the arbitration I had my phone bills and everything, and they had three or six women from the H. R. Department sit there and lie, it didn't make any difference what I said, and my union worker denied me the right to have counsel, said he was going to represent me, so I didn't even get to have a lawyer there, Rosenkoetter testified. This was right after they fired me and then went through three steps, and the fourth step was to go before the arbitrator. They denied my unemployment, and I went to the hearing for unemployment and their woman said that was absurd that I would quit my job at fifteen something an hour, and she gave me my unemployment, the woman from Jeff City, the claimant stated.

The claimant testified about her daily routine now. I try to do my dishes in the morning, and get my husband off to work, and make his lunch, she said, and try to sweep the floor, that takes me a while because I quit and go back, and sometimes l'll sit on the porch, or sometimes I watch TV for a while. I can't sit very long, can't stand very long, the claimant stated, I sit for maybe about forty-five minutes or so, then I got to get up and walk around. With standing it's really hard for me to bend over the sink to do the dishes, Rosenkoetter said, l'll stand for a while, depends on what I'm doing. I think the longest I can stand is about an hour or so, I guess, she said. I can't walk very far, the claimant said, l'd walk from the house to the barn and turn the water faucet on for the cows but last time I went out there, I fell, this was last week. I fell because of my leg, Rosenkoetter stated, I had bad pains in my right hip and lower back for the last month and a half, and when I went to step it was just real bad pain, I couldn't bring my foot up and I just fell face down in the gravel. But I got a bone on the left side that catches on my hip bone, and I can feel it, I can feel it rubbing, the claimant said.

On cross examination by the employer/insurer, Rosenkoetter agreed that the first time her case was set for hearing, exhibits were entered into evidence on the record and then on that date she had indicated that she didn't feel like she was able to testify. My nerves was really bad that day, she said. The claimant was asked if she had felt competent to testify on direct examination the day before. I got nervous, but the medicine the doctor gives me helps me, Rosenkoetter answered. I'm not real good today, she stated, but I feel I am competent to testify today.

The claimant was asked about her 1985 motor vehicle accident. I had a small car, an Omni, she stated, and a lady came up on the right side, and she clipped the front of the car and threw me into the median, and I wound up hitting my head pretty hard on the Mirror and broke it and caused me to have a concussion and messed up a nerve in the back of my neck, and there was a bone out of place in the side of my head. I went to a doctor for about seventeen months; I couldn't drive, I would lose track of time, I get lost, I'd be sitting at home and l'd just lose three or four hours, she stated, and I couldn't stand to smell white bread, I couldn't see the trees going by or I had to wear sunglasses. Problems that have continued are with direction, the claimant said, getting turned around and getting lost sometimes. I just don't go far from home and usually my husband takes me if I have to; this is because I get turned around sometimes, but not all the time. Concerning my memory, Rosenkoetter said, as far as everyday things, it's all right. I've never been any good at dates, she said, I can remember what happened, but I can't for, say, remember every day. When queried if she was confident all the history she gave on direct exam was accurate, Rosenkoetter responded - I tried the best I can remember. The claimant was queried, if some of the medical records showed a slightly different history as opposed to what she testified to on direct examination, would she dispute what's in the medical records? I don't know; I done the best I could to remember all the dates; I'm just not good at dates, the claimant answered.

Rosenkoetter agreed, during cross examination by the employer/insurer, that she has had two injuries to her back. I don't remember the month of the first injury, September or June, she said, and it was in 1995. She agreed that she had testified earlier this first injury was as a result of stepping on a tag and slipping. Indicating that she had continued working and finished her shift that day, Rosenkoetter stated - When I fell it was almost time for the shift to be over. Agreeing that she had returned to work at Integram the next day, the claimant said that she had to. It was noted that Rosenkoetter had testified that she had requested treatment but it took them a while to get her to a treating doctor. They said to put ice on it, she responded. When queried that she continued to work at Integram up until the time she was first seen by a treating doctor, Rosenkoetter responded - As far as I know, I don't know if I had any days to take off or not. The first treatment was about ten days after the tag incident, the claimant said. She was queried if she had attempted to go to a doctor on her own during those first ten days. We were told to go to the foreman and the foreman would set up an appointment for me to go to HealthLine, because with an injury at work you had to go to the workmen's comp doctor, the claimant answered. The claimant was queried, you waited ten days to get treatment? I kept telling the

foreman - it's hurting, and he said he'd get me an appointment, and after ten days then he finally got me an appointment, she answered.

During cross examination, Rosenkoetter was questioned about the first back injury stipulated to by the parties as to have occurred on September 15, 1995. The claimant was referred to Employer/Insurer's Exhibit No. 7 (first workers' compensation claimant's report dated 10-7-95); Rosenkoetter stated that it looked like her signature at the bottom of this form. It was noted that Exhibit No. 7 reflected that Rosenkoetter had hurt herself on 8-25-95. I don't know if I filled that out the night I got hurt or I filled it out after, I don't remember, the claimant answered, all I know is I went in the office after I found the foreman and I told him, and he filled out a paper. It was September 15th that I got wrote down, the claimant stated, I think that's the date that I hurt my back. Rosenkoetter stated that as far as she could recall, between the time she did hurt herself - be it June, August, or September - in the time she first received treatment she continued to work at Integram. When queried, wasn't it correct that the first place she received treatment was Healthline, the claimant responded - First treatment I got was putting ice on it; that's what the foreman told me to do. She agreed that the first hospital, emergency room, or clinic, or doctor that she was seen by was at Healthline. Agreeing that from the time of the injury up until the time she went to Healthline she continued to work at Integram doing her regular duties without restrictions. I had to, I didn't have no days off, Rosenkoetter answered. She agreed that when she went to Healthline the doctor took a history from her and asked her what body parts were hurt. From the time I got hurt until ten days later when I went to that doctor, yes, I had problems with my back, the claimant said. When the doctor asked what body parts I had hurt I told her - my ankle, my knee, and my back, the claimant stated. When queried, so if the only history in those medical records is that you injured your ankle and your knee that would be inconsistent with your recollection, Rosenkoetter responded - The doctor told me there wasn't nothing wrong with my back. Concerning the "first workers' compensation claimant's report" dated 10-7-95, Rosenkoetter agreed that she had signed it, but further stated - I don't remember filling it out. She admitted that at the time she signed and dated this report it was filled out. I don't recall if I had an opportunity to review the report before I signed and dated it, she said. It was noted that the 10-7-95 report specifically made inquiry as to what were her injuries; at the hearing, the claimant noted that it stated "right ankle and ankle", and admitted that she did not see on the report any reference to an injury to the back. After HealthLine the next place I received treatment for my back was when they sent me to Dr. Clark, the claimant said, and for three days he got me to where I could walk again, then I went to Dr. Calvin. From that time where I slipped on the tag in June or August or September up until the time I went to Dr. Clark, I did not have any new injuries to my back, Rosenkoetter said.

The claimant was queried during cross examination if she had ever worked painting floors at Integram. Not that I can recall; she answered, the only painting they done was to paint a yellow line on the -- when they were off for model to change over, and I don't even remember if I even done that or not. Rosenkoetter said that she did not recall if she would have been painting at Integram on October 14 and 15, 1995; she agreed that October 14 and 15, 1995 was a weekend, and assuming that to be the case, she would not have been working at Integram. Rosenkoetter agreed that Dr. Clark was a doctor that she picked on her own, and she stated that she supposed Dr. Clark took a history from her as to how she had injured herself when she went to him on October 15, 1995. I told him I sat on the toilet and I couldn't get up, Rosenkoetter stated. The claimant was queried if it would be consistent with her recollection if Dr. Clark's record of 10-15-95 reflected that she relayed that she had been painting floors in a flexed stooped position and after sitting down two to three hours ago she had an onset of pain in the left low back, hip, and leg. I don't know where he got the painting floors at, Rosenkoetter responded. I know what I told the doctor, I don't know what he wrote down, she said. The claimant agreed that Dr. Calvin was a doctor she had picked on her own, the company did not send her to Dr. Calvin. Dr. Calvin is my main doctor, Rosenkoetter said. The history I told Dr. Calvin as to how I had hurt my back, Rosenkoetter stated, was that I just sat down and I couldn't get up. The claimant stated that it was at Leslie Depot, a bar and eating place where they have live music on the weekends, where she had attempted to use the restroom and was unable to get up. No one had talked to me about a need for surgery on my back until I went to Dr. Calvin, the claimant said. Rosenkoetter was questioned about physical therapy records indicating that she missed the first physical therapy session on 10-17-95 for her knee because of an injury to her back sustained over the weekend. I wasn't in no accident since I hurt my back until I sat on the frigging commode and couldn't get up; there was no accident in between there, I just sit down and I couldn't get up, Rosenkoetter responded.

The claimant stated that as far as she knew, she had never been to Dr. Clark prior to the 10-15-95 injury to her back. She was queried if it would be inconsistent with her recollection if Dr. Clark's records from 1994 indicated that she had been involved in a motor vehicle accident and that she had pain in the small of her back, and hip, and legs that was worse in the last six months. I only been in two car accidents, the claimant responded. Rosenkoetter agreed that Dr. Jacob is the physician who operated on her back. Dr. Calvin sent me to Dr. Jacob, the claimant said. I don't know if Healthline had discharged me from their care prior to my seeing Dr. Jacob, Rosenkoetter stated. She was queried if, prior to her seeing Dr. Jacob, had anyone at Integram ever said to her that they were done with treating her, that they were not going to treat her legs or back anymore. I don't recall that, the claimant answered. Dr. Jacob's bills were paid

through my group insurance, Rosenkoetter said. The claimant agreed that she was off for some time after this back surgery, and when asked if she believed upon her return to work in June of 1996 did she feel she was able to return to work, the claimant responded - I didn't have no choice.

Rosenkoetter stated, during cross examination, on 11-18-97 she hurt her right back when she put the bench seat in the box, and that from the first date of injury to her back up to 11-18-97 she did not recall having any other injuries to her back. At the time of the second back injury I was working full duty without restrictions, as far as I know, Rosenkoetter said. For this second accident on 11-18-97 Integram might have sent me Dr. Rende who was supposed to be a back doctor, Rosenkoetter said. The claimant was asked if she had treated for a relatively short period of time for this second 11-18-97 injury. When I hurt my back at work, Rosenkoetter answered, the next day I went to Dr. Calvin, and I think I was seen by someone else, and I had a knot right across from my spine, and they took me off work for a week and gave me muscle relaxers to see if that would help it. The claimant was asked if she had been seen by Dr. Calvin prior to 11-18-97 for problems with her back, such as six months preceding, and the claimant answered - I go to Dr. Calvin for most everything. I don't remember if I went to Dr. Calvin for complaints or problems with my back in the six months preceding the 11-18-97 incident, the claimant said. I could have but I don't remember going to Dr. Calvin on 5-29-97 for complaints of strain in the upper back and neck, and severe muscle spasm after lifting liquid soap, Rosenkoetter said, sometimes I turn just right or if I'd pick up a basket of clothes or anything then I strain my back. It was noted that Dr. Calvin's record included a 9-16-97 entry reflecting that Rosenkoetter had advised him that she had strained her back while lifting heavy pots at a family reunion and that she had been diagnosed with acute lumbar sacral strain and severe muscle sprain; the claimant responded - If that's what it says. The claimant was asked if Dr. Calvin in September, 1997 had referred her to Dr. Jacob. I'd already been going to Dr. Jacob, Rosenkoetter answered, I don't know how many times I saw Dr. Jacob after the surgery for the 1995 injury. I had another MRI done and I had other nerve tests done after that because the top of my arm is numb, and the inside of my left leg is numb on certain parts; that's from 1995, it's been that way ever since I come out of surgery, the claimant said. She agreed that this would have been present at the time Dr. Poetz examined her, but stated that she did not know if she would have expressed these complaints and problems to Dr. Poetz; if he would have asked me, she said.

The claimant agreed that she was involved in a motor vehicle accident in October, 2003. My daughter suggested that she and I go down to visit my other daughter and we went down there, and I rested while I was there, and we spent the day and had dinner. We started back home, and I was driving on Highway A, and there was a road on the right side and the man was coming the other way, and he decided he was going to turn and he was drunk, no insurance, two babies in the car and his wife; I didn't have time to stop, and I tried to miss him but it didn't work, Rosenkoetter said. The people in the other car, and my daughter and myself were injured in the accident, she said, no one was killed in the accident. Explaining about her injuries, Rosenkoetter stated that the air bag went off and she was going sideways and it hit her shoulder, and her hand hit something and broke a bone in her left hand, and her knee hit something on the door somehow. I wasn't casted, Rosenkoetter stated, it seems like my bones don't break across but rather they break down, and they put five, I don't know what you call it, it had a metal piece on the bottom and you wrapped it there; I had to wear that for a month. I did not have any problems with my neck or anything else as a result of this injury, she said.

During cross examination by the employer/insurer, Rosenkoetter stated that she last worked at Integram on March 15, 1999, the claimant said. I had to quit anyway, the claimant answered, my health just keep getting worse.

Rosenkoetter agreed on cross examination that the problem that came up that led to the whole paperwork mess and that eventually led to her termination was an injury that she had to her left leg that occurred at her home. I had several injuries happen at my house, my legs wouldn't work right; I wasn't never sure if my foot was high enough or if I was stepping right, it just didn't work right, the claimant stated. The first time I fell on some steps I broke my tibia, she said. When I fell on 3-17-99, I didn't fall because I was dizzy or disoriented, I fell because of the problems with my legs that I know was due to my back, the claimant stated. I told Dr. Jacob, the one who did the surgery, that my legs just didn't work right, and he said there's nothing more that he could do for me, the claimant stated. I went to my bone doctor, Dr. Kef alas, for treatment when I fell at home on 3-15-99, she said.

The claimant was queried if it would be inconsistent with her memory of how she was injured if Dr. Kefalas's notes of 3-17-99 indicated that she became dizzy at home and fell. When I came out of the barn I thought my foot was on the step, but it wasn't, and I stepped in a hole and the ground was uneven and I went down, the claimant responded. It was noted that Rosenkoetter had said that she fell on the steps. The first time I got hurt after the surgery I was going up the steps and my foot caught on the steps because it wasn't up high enough and I fell and I broke my tibia bone, the claimant answered, and then I come out of the barn and I thought my foot was on the step but it wasn't, it went sideways, and I fell, and fell in the hole in the yard. I don't know if the fall into the hole in the yard was on 3-15-99, the claimant said. Dr. Kafalas took me off work for the 3-15-99 injury, the claimant said, I had a mobilizer on my knee, I was on crutches, and I

had a metal-with-gel-cast on the inside of my ankle. The claimant was asked if it sounded accurate that as reflected in the doctor's record he kept her off work through 4-7-99; and she answered that she did not remember the date, but she thought it was in sometime in April. Rosenkoetter denied that at that time she attempted to return to work. The doctor looked at my knee and stuff and x-rays and said that I should not work on it, to stay on the crutches, and that's what I did. The claimant was queried,

It was noted, during cross examination by the employer/insurer, that the claimant had testified that as a result of all of her conditions she had been inhibited in her ability to engage in activities around the farm, and Rosenkoetter was asked how long had she had that limitation. Ever since I fell on the tag, the claimant answered. Rosenkoetter was queried if she would question the accuracy of Dr. Sertl's record which contained a history that she had injured her left leg riding a tractor in September of 1998. I would try to do stuff; I didn't have as much wrong with me then; it was just all the stuff just piles up; I still try to do stuff, it just don't work, the claimant said.

On cross examination by the Second Injury Fund, Rosenkoetter stated that after recovering from her broken tibia injury that occurred in the Summer of 1998, she was working full job duties on her regular scheduled hours up to the time she hurt her right knee and she was fired from Integram. My regularly scheduled hours were to start at eleven p.m. and I think we got off at seven-ten. The time I worked at Integram my job title was Foam Production, the claimant said, and agreed that there were other people who worked with her who did the same jobs she did. The only time that there was more than one person at a work station doing the same job was at the dump where the cushions would come down and you'd inspect them and then put them in boxes, the claimant said. Agreeing that there were other shifts at Integram besides the one she worked, Rosenkoetter stated that there might have been three shifts including a day shift, and she worked on evening shift one time. I imagine there was somebody else doing that same foam production job that I was doing on those other two shifts, the claimant said. I started in foam production in 1991, I don't remember the month, the claimant said, and worked there until I left Integram. During this time period I was doing the same job duties throughout the whole time, she said. Discussing this job in more detail, Rosenkoetter agreed that she worked with the foam seats that went in minivans. The bench seats were quite long; I have no idea what they would weigh, I really don't, she said. I also lifted all the cushions backs or the cushion part; there was child seat cushions, and the cut and sew was the foam buns with other covers on them and heaters in them. The cushions had a metal pan on them, so they might have been the heaviest, I really don't know, the claimant stated. The whole work-day was spent on my feet, she said. Rosenkoetter stated that she was doing bending with just about every position there, and explained that they rotated to different stations. I don't think I ever had to do any squatting or kneeling in doing my job duties, the claimant said, not unless you dropped something. Rosenkoetter denied that during the last six months that she was physically working at Integram she was doing the same job duties that she had been doing since she'd been in foam production beginning in 1991. I wouldn't help nobody anymore, and I was lucky to get my job done, she stated. I would trade off because lifting covers was really hard on me because you'd have to lift like ten or so at a time, and then you had to bend over in the boxes and lift the heavy lids off the boxes; it was really hard on my back, the claimant testified.

Before I had slipped on that tab and had the surgery I worked a lot of overtime, Rosenkoetter testified, I would usually go in early and sometimes l'd stay over late, and there for a while I made more overtime hours than I did regular hours. I don't remember if I worked any overtime after the slip on the tag on the floor, the claimant said.

Rosenkoetter agreed, during cross examination by the Second Injury Fund, that at the time that she was terminated from Integram she was on sick leave for her leg. The doctor kept me off work for a period of time for my leg at that time, the claimant agreed, and this was about April of 1999. It was my intention to return to my job at Integram after I recovered from this leg injury, the claimant said. The claimant was queried if it was correct that one of the reasons she filed a grievance at the time Integram let her go in April of '99 was because she had planned and wanted to return to her job at Integram. No, Rosenkoetter answered, I filed a grievance because the lady in the H.R. lied, she said I didn't have to fill out anymore papers, and that's why I lost my job. The claimant agreed that when she filed the grievance she was trying to get her job back.

On redirect examination, Rosenkoetter was asked to explain what happened to her back when she slipped on the tag at work. I kind of twisted and then I tried to grab the table to keep from falling, but I couldn't hold onto it, and the table was here [indicating] and I grabbed it when I fell and went down. I hit this knee first and then the other knee, and my ankle was turned under me, and my hands hit the floor, too, she said. I never had any symptoms down the back of my legs before I slipped on the tag at Integram in 1995, the claimant said. I cannot recall any doctor telling me I had a disc injury in my back prior to this twist of my back, the claimant said. No doctor had ever recommended surgery on my back prior to my slipping on the tag at Integram, she stated. Before I started at Integram they sent me to a pre-employment physical with a doctor and x-rays were taken and everything of my back and I got the job, there wasn't nothing wrong or he would have told me; I don't think I would have got the job because he done one of the most thorough exams, the

claimant testified. Rosenkoetter agreed that this pre-employment physical was after her auto accident in 1985 because she started at Integram in 1991.

Prior to my slipping on the tag at Integram I worked overtime at one time every day, and then sometimes once or twice a week, the claimant stated during redirect. In the year before I slipped on the tag I worked two jobs, I worked sixteen hours a day, Rosenkoetter said. Agreeing that her life changed as a result of slipping on the tag at work, the claimant stated that she doesn't have a life no more. I had to sell my mobile homes and that was something I enjoyed, that was going to be my old age retirement.

After I hurt my back in 1995 when I fell on the tag I was never able to work the same as before then, the claimant stated. It wasn't only work, she said, it was my activities at home and just the things I enjoyed doing, couldn't do no more.

I honestly don't think I can work because of what happened at Integram; my back, it started the whole thing, the claimant stated, during redirect examination. And I think my weight problems is because of my back and my nerves and I can't get out and exercise, and now l've got diabetes because of it, Rosenkoetter added. Since 1995 when I hurt my back I have gained about forty-five pounds, she said.

The claimant agreed, during further cross examination that when she had the first injury to her back in 1995 that slowed her down at work; she agreed that also as a result of this she couldn't work as much overtime. Rosenkoetter was queried about Dr. Bedor's records which indicated on 5-28-98 that she was working ten to twelve hour days, six to seven days a week. My back was bad in May of 1998, she said, but if they said for you to work, you worked.

Joe Laffleur testified on behalf of the employer/insurer. I'm a human resource manager at Integram St. Louis Seating, and have been in that position for eight and a half years, Laffleur said. He agreed that in his position he deals with the union, UAW, at Integram, and stated that the union has been involved with this particular Integram plant since July of 1995. If one is to be employed at Integram as an assembly worker, they are required to be a member of that union, Laffleur stated. As the H.R. manager I am familiar with the company handbook which has been in existence since 1989, he said. Explaining how employees are made aware of this handbook, Laffleur stated that employees are given a copy of it when they're hired; when the union came in, the contract took the place of the handbook for the hourly employees; but prior to the union coming in, we had the handbook and it pertained to all the employees. Agreeing that the company has a hotline, Laffleur explained - We are owned by Magna International out of Toronto, and they have a phone number that employees can call if they can't get their issues resolved at the plant and it can be anonymous. The hotline has been in effect at least twenty-five to thirty years, he stated. Employees are made aware of the hotline by us telling them in the orientation that it's available to them, Laffleur said, plus we also have posters in the plant which talks about what the purpose of the hotline is, what the phone number is to call, and plus periodically we'll have representatives come down from Toronto and do a presentation in one of our monthly employee meetings. The posters are in the H.R. department where we do the orientation, plus they're out in the plant in several locations, Laffleur said. He agreed that as part of the company's benefits package for the employees, they have an EAP (Employee Assistance Program) program, and stated that this has been in effect since the plant opened in 1989. The services available through the EAP are that the employees can contact the EAP if they have financial issues, chemical dependency issues, emotional issues either for them or for anyone living in their household, Laffleur said. Agreeing that H.R. took an active role in making the employees aware of the EAP program, Laffleur stated that they have posters out in the plant that talks about it, everybody in H.R. has business cards from the EAP, plus periodically they'll have someone come in and do a presentation. He agreed that this is something that is in the handbook.

On cross examination by the claimant, Laffleur stated that he started at Integram in January of 1996. He agreed that, therefore, he is totally unaware of any orientation Rosenkoetter would have had when she went to work at Integram. Laffleur stated that he was aware that Rosenkoetter did have an orientation based on the company's records.

Dean Nordman does not still work for Integram, Laffleur stated, I haven't talked to Dean in five years, so, no, I do not know where he is.

Laffleur agreed that Integram keeps the records of pre-employment physicals, and that he had a record of Rosenkoetter's pre-employment physical. I have never looked at it, Laffleur said. I did not review Rosenkoetter's deposition, he said.

There are six hundred and fifty employees in the plant right now, Laffleur stated. He agreed that as human resources manager, he hires and fires people.

On redirect examination, Laffleur testified about the basis of his terminating Rosenkoetter in 1999. She terminated her seniority in accordance with the labor agreement because she failed to return from her leave of absence, Laffleur said, and agreed that the employer made no proactive attempt to terminate her. To my knowledge, Rosenkoetter was never written up for poor performance, and never written up for problems with quality or quantity of her work, Laffleur said. To my knowledge, in the grievance procedure, ability to perform her job duties was not an issue, he said.

On further cross examination by the claimant, Laffleur agreed that he had brought Rosenkoetter's personnel file with him to the hearing. He agreed that the file included write-ups of Rosenkoetter, and stated that there were all on attendance. I have no idea what the attendance records were for the six months prior to September 15, 1995, he said, we don't have those records prior to 1995.

On cross examination by the Second Injury Fund, Laffleur agreed that if someone has poor performance, it is possible for them to be disciplined at Integram, and if there's a discipline for poor performance it is it put in their personnel file. Rosenkoetter did not have any discipline forms in her file for poor performance, Laffleur said.

On further direct examination, Laffleur stated that the slips he had been asked about that were in Rosenkoetter's personnel file, he got them either from the supervisor -- the employee gives them to the supervisor and the supervisor gives them to us in H.R. Agreeing that somehow the employee directs the routing of these to the file, Laffleur added that the employee brings the note in. He agreed that it appeared Rosenkoetter was aware of the need to bring those forms in.

Medical records in evidence included the following:

1.Certified medical records of HealthLine Corporate Health Services Metro St. Louis (Claimant's Exh. D) indicated a majority of the treatment as employer (Integram) authorized treatment; the record concerned the treatment of Rosenkoetter for various complaints and injuries from March of 1994 through October of 1999.

The first entry of 3/18/94 indicated that Rosenkoetter presented for evaluation of her right wrist, with a history that the wrist had been bruised on two separate occasions in the past week; she was evaluated at the emergency room and x-rays were taken which were negative; the diagnosis was - wrist contusion and hematoma; it was written that Rosenkoetter was returned to regular duties, and that the company had flexible wrist supports which was recommended Rosenkoetter obtain and use. The next and subsequent entries included the following.

12/01/94 - treatment for an 11/23/94 laceration injury to Rosenkoetter's left palm as a result of cutting her hand on the sharp edge of a pan while working; exam findings included that the wound was quite deep, tenderness to palpation about the area, decreased grip secondary to pain, some numbness over the radial aspect of the left little finger near the area of the wound; some sutures were removed and others left in; Rosenkoetter was placed on restricted duty. 12/6/94 treatment for re-opening of wound subsequent to another doctor removing the sutures; Rosenkoetter was restricted to no use of the left hand. 12/16/94 - follow-up treatment to the laceration injury; the diagnosis remained - laceration left palm healing; Rosenkoetter was continued on restricted duty of use of left hand as tolerated. 1/4/95 - follow-up appointment for the laceration injury, it was noted that Rosenkoetter had been off work for sometime as she had recently lacerated a tendon which was non-occupational of the right hand; exam findings were improvement with the laceration but still some tenderness about the area of the wound and pain with forced abduction of the thumb and index finger; the diagnosis remained - laceration left palm healing, and Rosenkoetter was discharged from the clinic, full duty status. 9/15/95 (the next entry in the record) - complaints of pain to the left palm in the area of the previous laceration which was at the radial aspect of the base of the left little finger, and complaints of numbness along the radial aspect of the little finger with some pain along the scar area extending to the palm; the assessment after examination was - 1. Pain left palm status post laceration which is old, and 2. Flexor tendonitis left hand which is new; the plan was for hand therapy with scar management; Rosenkoetter was returned to full duty; it was indicated that this injury was consistent with the 11/23/94 incident. 10/6/95 - Rosenkoetter presented with complaints that her little finger drew up and the pain was unbearable; objective findings were - no swelling to the area of the healed laceration, no excessive scar tissue present, skin appears to move easily as if there is no adherence of the underlying tendons, excellent resisted flexion, full extension; it was noted that Rosenkoetter said she could not find anything wrong with her hand; the diagnosis was - pain left palm, no change; therapy for scar massage was ordered; written was a question as to whether injury was consistent with alleged 11/23/94 incident as the doctor wrote that she could really never find anything wrong with the hand other than Rosenkoetter's subjective complaints; Rosenkoetter was continued on full duty work status.

9/15/95 - Rosenkoetter was seen for complaints of pain and intermittent swelling in the right ankle and right knee as a result of twisting and slipping on a piece of paper at work on 8/25/95; an x-ray report, dated 9/15/95 and indicating a

date of injury of 8/25/95, indicated exams of the right knee and the right ankle, and results for both were - negative/no bone or joint abnormality evident; the diagnosis after examination was - Mild sprain right ankle, and Strain right knee; treatment was a Futuro wrap for the ankle and Genu-Medi for the knee and also ice, heat and medication; it was indicated that the injury was consistent with Rosenkoetter's work activities or the alleged incident; she was released to full duty. 9/25/95 - follow-up of sprain to the right ankle and strain to the right knee; it was written - "Although, her injury seemed mild on her last visit here she complains of continued pain and states she is not improved. She requests to only work 40 hours a week 8 hours a day. I told her that we would consider other restrictions instead and she was very unhappy with this."; diagnosis after examination was - Sprain right ankle, and Strain right knee; physical therapy was ordered; ordered was light duty work of seated duty for half a shift and self-paced walking; it was noted that the injury was consistent with work activities of the alleged 8/25/95 incident. 10/6/95 - follow-up of an injury to the right knee and right ankle; included in the entry was - "Upon my entrance to the room I asked the patient if she had improved and how she was feeling. She did not respond for several minutes. I asked her again how she was doing and she states I want to see a Specialist. I told her I did not think that was necessary at this time as she had yet to attend any of the therapy sessions that were ordered for her and that were apparently set up."; the entry indicated further friction, but eventual examination did occur, and the assessment was - Sprain right ankle - improved, and Strain right knee - improved; it was written that six visits of therapy was set up for Rosenkoetter, and medication was to be continued; light duty recommendation was continued.

11/19/97 - Rosenkoetter reports that the night before (entry noted a date of injury of 11/18/97) at about 11:35 p.m. at her work in the foam division of Integram she sustained a back injury when she leaned over to retrieve arrange some parts in a box and when she got back up she felt back pain and the pain is going down into her right leg; further written was Rosenkoetter reported that she had previous back injury, apparently nonoccupational, and that the back was stabilized with some stuff in the back, so I am presuming it might be metal such as Steffe plates or spinal fusion, however I do not have the details of this operative procedure; objective findings included - essentially normal posture, fairly overweight, able to forward flex fingertips coming to about the knee of just below the knee level bilaterally, mild tenderness in the lower lumbar spine, no paraspinal muscle spasm appreciated especially given her body habitus, reflexes in the knees as well as the ankles are hypoactive but present bilaterally, straight leg raising is negative to almost 80 degrees bilaterally seated, range of motion in the hips, knees and ankles appear essentially within normal limits; diagnosis was - Low back pain; work restrictions were placed of maximum lifting of 15 pounds, occasional stooping, crouching and crawling; it was written that the injury was consistent with work activities or alleged incident. 12/01/97 Rosenkoetter reports she is feeling a little bit better, that she felt well after the Thanksgiving weekend and was off a few days, however upon return to work she has redeveloped some of her back pain, denies any paresthesia or radicular symptoms; objective findings included - minimal if any tenderness in the lower lumbar spine, straight leg raising to 90 degrees seated bilaterally; the diagnosis was - Low back pain resolving; Ibuprofen and Flexeril was continued; Rosenkoetter was returned to full duty work, no restrictions.

1. Medical records of St. John's Mercy Hospital, Washington, Missouri (Claimant's Exh. J). A 10/23/95 radiology report reflected that studies had been ordered by Dr. Calvin, and the report noted a history of - rule out disc; has had low back pain radiating to the left leg for approximately 2 weeks. Plain film findings were: lumbar vertebral bodies are well aligned; anterior and posterior osteophytes noted at L2-3, L3-4, and L4-5; disc space narrowing, most severe at L5-S1; narrowing of the apophyseal joints, with subchondral sclerosis. CT scan through the disc spaces from L2-3 through L5-S1 resulted in the following findings:

There is uniform calcified disc bulging at L2-3. There is disc bulging noted at L3-4, with a focal area of calcified disc protrusion laterally to the left. Facet hypertrophy in this region as well contributes to narrowing of the left lateral neural foramina. There is uniform disc bulging at L4-5, with calcification. There is facet hypertrophy at this level as well, and at all imaged levels. Air noted within the disc space at L3-4 and L4-5. No focal herniations of soft disc material is identified. Recommend correlation of these findings with tomogram of the spine, to determine exact location before surgical intervention. For labeling purposes, a short ribbed $12^{\text {th }}$ thoracic vertebral body and sacralized 5th lumbar vertebral body are noted.

CONCLUSION: 1. Facet hypertrophy and calcified bulging discs noted all levels as described above, resulting in narrowing of the spinal canal. There is a calcified focal area of disc protrusion and/or osteophyte formation within the let lateral position at L3-4. This results in marked narrowing of the left nerual foramina. (No focal herniations of soft disc material is identified). (sic)

1. Records described as those of Dr. Clark, D.C. (Emp./Ins. 5) were mostly illegible, but indicated that in about 1994 Rosenkoetter reported a chief complaint of - auto accident in 1987, worse last 6 months with pain in the small of back and hip and legs.

The record included treatment entries in October 1995 for low back complaints. A 10-15-95 treatment note included: "Pat(ient) working today painting floors in flexed or stooped position. Sat down 2-3 hours ago \& got pain - left low back and hip and leg. Constant since then to left ankle."; the 10/15/95 further included - "Off work Bed". The next entry of 10/16 included that Rosenkoetter was somewhat better that morning - range of motion and stability had increased, less spasm, L4-5 interspace tender and taut. The 10/17 entry included that Rsoenkoettere was feeling better, had mild to moderate ache in left leg without cramping or spasm, ?continued left leg numbness?; it was noted that Rosenkoetter had worked that day. The 10/18 entry included that Rosenkoetter had not gone to work; no leg cramping, stiff and taut at L45; weight bearing causes ?????.

The next entry of 10/19/95 entry, apparently written by Dr. Glen Calvin, D.O. stated that Rosenkoetter presented that day with severe pain in the lumbar spine running down her left leg, and that they would agreed that her disability began on 10-15-95. She has the potential for having a ruptured disk in the lumbar spine, it was written. In the handwritten entry dated 10/19/95, it was written that Rosenkoetter weighed 215 pounds and had a blood pressure reading of 148/102; also written was that Rosenkoetter had injured her back on 10-15-95 and was under Dr. Clark's care; it was written that Rosenkoetter needed a work disability form from her primary doctor as work would not accept Dr. Clark's. The 10/23/95 report of x-rays and a CT scan of the lumbar spine lumbar performed at St. John's Mercy Hospital. A last treatment note of 10/26/95, handwritten, apparently in Dr. Calvin's record indicated - disc lumbar spine, and pain in left leg continues.

1. Medical records of Karl A. Jacob, M.D. (Cl. Exh. E) began with a 10/30/95 initial office exam report; the doctor noted that Rosenkoetter was being seen for an injury that had occurred three weeks earlier when she had slipped at work on a tag that was on the floor, twisted her right ankle and her right knee and had pain immediately, and then developed left low back, hip and leg pain after sitting for a long period of time. Treatment by Dr. Clark, D.C. resulted in some improvement but then the left lower extremity pain reccured, Dr. Jacob wrote, she was seen by Dr. Calvin and was noted to have left low back, hip and leg pain radiating to the foot. Dr. Jacob's examination findings included: somewhat obese; on the left, weakness of abduction and adduction of the fifth finger, numbness in the ulnar distribution and weakness of opposition of the thumb on the left greater than on the right; low back - lumbosacral paravertebral muscle spasm, positive straight leg raising on the left at 30 degrees and positive straight leg raising on the right at 60 degrees related to the hamstring; right lower extremity motor, sensory and DTR exam are grossly normal; left lower extremity extremity pinprick hypalgesia in the L4 dermatome, knee reflex is diminished compared to the right, weakness of great toe and foot extensor. The impression on 10/30/95 was: 1. Lumbar spondylosis with myelopathy; 2. Displacement disc, L3-4, left suspected; 3. Foot drop, left; 4. Ulnar neuropathy, left greater than right; 5. Median neuropathy, left greater than right; 6. Transitional segment, L5-S1. Radiographic studies were performed; it was indicated in a Missouri Baptist Medical Center 11/16/95 Discharge Summary report that a post myelogram CT scan revealed multiple levels of lateral recess stenosis, bulging disc. It was noted that Rosenkoetter was going to consider surgery at a future date.

A 12/14/95 operative report reflected that on that date, Dr. Karl Jacob performed the following operation on Rosenkoetter:

Lumbar decompression laminectomy with laser magnification and microdissection L3-4, L4-5 left for posterior decompression of the dura and cauda equina by undercutting of the lamina and the spinous process space of L3, L4 and L5, lateral recessed decompression by resection of the medial $1 / 2$ of the facet joints of L3-4 and L4-5 and the medical one half of the pedicle base of L4 and L5, L4 and L5 nerve root foraminotomies, partial corpectomy. Posterior lateral caudal margin of the vertebral bodies of L3 and L4 and L5, microdissection and laser lysis of vascular adhesions of the anterior and lateral wall of the vertebral canal and L4 and L5 nerve root. Disk removal L3-4 and L4-5 and posterior interspinous stabilization L3, L4 and L5.

The post-operative diagnosis was: Lumbar spondylosis with myelopathy, severe, L3-4 and L4-5. Spinal stenosis, L3-4 and L4-5. Left lateral recessed stenosis, L3-4, L4-5. Displacement disk, lumbar L3-4, L4-5 left. Cicatrix of the nerve roots L4 and L5 left. A discharge summary indicated that Rosenkoetter was discharged from Missouri Baptist Medical Center on 12/17/95; in the Hospital Course section of the discharge summary, the following was included:

This 50 year old patient of Dr. Glen Calvin and Dr. Jerome Dwyer slipped at work on a tag that was on the floor. She twisted her right ankle, right knee, pain immediately in the left low back, hip and leg after sitting for a long period of time. She was seen by Dr. Clark for chiropractic evaluation. She was followed by Dr. Clark for the two days post injury. She was noted to have left low back, hip and leg pain. Denied bowel and bladder symptoms and was admitted for myelography on 11/15/95.

This revealed degenerative changes in addition to bulging disc and more focal protrusion lateralizing to the right within the canal at L2-3, however, she was symptomatic on the left; osteophytes produce lateral recess narrowing

on the left at L3-4 and L4-5. She had a transitional segment at L5-S1. The left lower extremity had pin prick hypalgesia in the L4 dermatome. Reflex was diminished on the left as was the ankle reflex. There was weakness of extensors of great toe, foot and extensor strength on the left compared to the right preoperatively. At the time of surgery, there was tremendous lateral recess stenosis at L3-4 and I4-5; total decompression of the nerve roots was carried out through the foramen. All cicatrix and vascular adhesions were removed from the anterior and lateral wall of the canal. Posterior decompression was accomplished by undercutting of the lamina and enlarged the size of the canal and a posterior Tycron interspinous stabilization was carried out at the end of the procedure between L3-4, L4-5.

A 1/17/96 follow-up entry reflected that Rosenkoetter was one month post left lumbar decompression laminectomy at L3-4 and L4-5 with posterior interspinous stabilization. It was noted that Rosenkoetter's leg pain had totally cleared. Medication was prescribed; it was written that Rosenkoetter was to return in one month and hopefully at that time she has lost enough weight that knee-shoulder flexion exercises could be started. A 2/26/96 entry included that despite all admonitions Rosenkoetter continued to gain weight rather than lose it. She is carrying too much weight for her back to tolerate it on a permanent basis, Dr. Jacob wrote, and further wrote that because of her weight she could not do the strengthening exercises.

In a 3/18/96 follow-up entry, it was written that Rosenkoetter seemed to be continuing to gain weight, and that she had complaints of discomfort in both lower extremities even when she walked just to go to the end of the driveway. Exam findings were: no muscle spasm; can flex to about 80 degrees without any radicular pain; a 90 degrees straight leg raising bilaterally in both lower extremities. It was further noted that Rosenkoetter was complaining about some sensory loss in the dorsum of the left forearm in the distribution of the cutaneous branch of the radial nerve since she awoke from surgery, numbness in this area was confirmed by pinprick, the doctor wrote. A radial never conduction test was scheduled. Dr. Jacob wrote in the 5/6/96 follow up entry that the radial nerve conduction time bilaterally was excellent and no problems. It was noted that Rosenkoetter still had numbness on the dorsum of the left forearm, but it was improving with time. Dr. Jacob finally wrote in the 5/6/96 entry the following:

The patient is discharged from follow-up as far as her lumbar spine is concerned. She is to do conditioning for approximately one month after which she can return to work with a 25 pound limit weight lifting restriction. She is to do no lifting that involves bending over at the waist. She should continue a weight loss program since I've told the patient and her husband who accompanied her to the examining room that this is vital to maintenance of her back over a long period of time. If she has any further difficulty in the future, we would be happy to see her again. Otherwise, she is discharged from current follow-up.

Dr. Jacob's record included additional treatment/examination reports beginning with a 06/18/97 re-examination report in which the doctor wrote:

This is a re-examination of this 51-year-old patient of Dr. Glen Calvin who has had right lower extremity pain progressive and involving the area of the distal thigh and the knee, as well as below the knee. A month and a half ago she saw Dr. Rende regarding the right knee. An MRI was negative and the orthopedist said that he thought the pain was related to the patient's back and referred her here.

The patient has had a rather precipitous weight gain since her last surgery for left-sided radicular pain which has now cleared. She has pain in the back of the right thigh and leg distally into the foot and ankle. This pain increases with walking. It does not increase with coughing, sneezing, bending or lifting. She has no bowel or bladder symptoms.

It was noted that Rosenkoetter had a family history of her mother being a diabetic. Examination findings on 6/18/97 included: right upper extremity motor, sensory and DTR exams are grossly normal; on the left, weakness of abduction and adduction of the fifth finger, numbness in the ulnar distribution and weakness of opposition of the thumb on the left greater than the right; chest, heart, lung and abdominal exams are grossly within normal limits; low back - lumbosacral paravertebral muscle spasm, right sciatic notch tenderness positive straight leg raising on the right in the sitting position at about 30 degrees, and negative straight leg raising on the left; left lower extremity motor, sensory and DTR exams are normal; right lower extremity knee reflex is hypoactive; ankle reflex fatigues; some weakness of dorsiflexion of the right foot and great toe and weakness of the quadriceps on the right compared to the left; Romberg, gait and station is difficult to evaluate because of the patient's weight, however she does a reasonable job of walking heel-to-toe. Dr. Jacob's written impression on 6/18/97 was: 1. Lumbar spondylosis with myelopathy; 2. Rule out displacement disc, lumbar, L3-4, right; and 3. Morbid obesity. An MRI of the spine was scheduled, and Rosenkoetter was to return for follow-up.

The next examination report in the record was dated 04/01/98, and Dr. Jacobs wrote that Rosenkoetter was a patient of Dr. Calvin who had reinjured her back at work three months ago bending over putting cushions in a box and heard a popping of her back and pain radiating to the right lower extremity. The pain became progressively worse in spite of conservative management, Dr. Jacob wrote, she can no longer work at her regular employment because of the pain. Dr. Jacob reported similar examination findings, and the diagnoses remained the same as on 6/18/97. There were no written treatment recommendations.

The next and last document in Dr. Jacob's record was a 5/24/99 report of an MRI of the lumbar spine. The history noted in the report was: "Lumbar surgery 3 years ago. Recent falls at work with low back pain and left lower extremity radicular pain." The written impression was:

1. Transitional lumbosacral segment which has been referred to as transitional $1^{\text {st }}$ sacral segment (appears to be sacralized bilaterally, there appears to be a rudimentary nonfunctional disk space cauded to the disk space);
2. Postsurgical changes on the left at L3-4 and L4-5; and
3. Severe degenerative disk disease at L3-4, L4-5 an L5-S1. Disk protrusion latralizes to the right within the canal at L5-S1. Abnormality extends laterally in the canal into the foramen on the left at L4-5 as discussed above. There is some encroachment left greater than right at L3-4.
4. Records of Dr. Glen D. Calvin, D.O. of Calvin Medical Center (Claimant's Exh. No. B) reflected treatment of Rosenkoetter for various ailments (i.e. cough, congestion, pharyngitis, otitis) during the period of March of 1996 through March of 1999. The following are examples of treatment entries. 2/10/97 - acute viral syndrome with secondary problems, symptoms are headaches, eye pain, cervical spine pain, back pain, sneezing, coughing; treatment included Ultram. 2/24/97 - complaints of severe headache and cough, patient states she is not able to work at this time; diagnosis was bronchial pneumonia or pulmonary vascular congestion, and Rosenkoetter was sent to Missouri Baptist Hospital under Dr. Shen's care. 2/28/97 - Rosenkoetter was seen for follow-up on Proventil inhaler. 3/3/97 combination of congestive heart failure, bronchitis, pneumonia and difficulty breathing, return to see Dr. Shen ASAP. 4/3/97 - seems to have an exacerbation of her right shoulder, I think she has a torn tendon of her right shoulder but she refuses to have an MRI, sending her to Dr. Stetson for work up, here with severe shoulder pain and severe degenerative arthritis in shoulder. 5/5/97 - complaints of pulled muscle in left side mid-back for 24 hours after lifting on carpeting; typed entry included that exam revealed severe spasm of the TS and neurological was essentially neg, and was started on Anaprox and Ultram for pain, and therapy. 5/9/97 - continued back pain; written was - "..she had surgery from Dr. Jacobs approx 2 years ago and she was told that there would be a possibility that she would have to have the other side operated on and she states that it has come to the pt. where she thinks that she needs to go back to see him because of the discomfort in the LS and (therapy) is not helping that much and also she is having a lot of family diff. And we will put her on Paxil" (sic); the diagnosis was - LS strain and Sit. Depression. 5/15/97 - treated for viral syndrome with ear infection, and given a slip for work. 5/29/97 - lifted on 5/27/97 two 15-lbs of liquid soap and strained upper back and neck and has severe muscle spasm on exam with cervical spine strain and upper back strain, physical therapy was given and medication of Ultram, and given slip to go back to work the next day. 6/16/97 - complaints of head and chest congestion, "will continue her on antibiotic and Claritin and we will give her breathing treatment today of Preventil and RTW on 6/23/98-She states that she is so run down that she cannot return to work". 6/30/97 complaints of continued sinus pressure and drainage for 24 hours which came on after working in hay field all day, treatment was continued Claritin and repeat round of antibiotics and RTW that evening if feeling fine. 9/16/97 - "Acute LS strain with muscle spasm and having problems with lifting and had stabilization rods put in her back and now she is lifting again and having severe pain"; handwritten 9/16/97 entry noted - mid and low back pain for 2 days, states strained while lifting heavy pots at family reunion on 9/14/97. 9/19/97 - treating her all week with an acute LS strain with previous surgery and back injuries, she is seeing Dr. Jacobs, we have been treating since 9/16 and allow her to RTW on 9/22 and ask if all possible that she do no heavy lifting but we will let her have a trail of work; "Some improvement, but DX is reoccurrence of an acute LS strain with symptoms of ruptured disc in the LS".

The next entry in Dr. Calvin's record after 9/19/97 was an 11/20/97 entry in which the following was written: "Seen with c/o of LS pain and goes down into the rt. leg. States hurt this while bending and lifting a box while at work". Examination findings were: some LS pain radiating into the rt. lower extremity, palpation of LS area reveals a fairly moderate to large sized lipoma which produces more pain and especially into the rt. lower extremity; therapy was started and referral to Dr. Rao for possible excision of lipoma of the rt. LS area. 12/4/97 - complaints of bad pain in the lower rt. present for some time, is under the care of Dr. Jacobs for this who is thinking about surgery apparently on the back, here today due to the unrelenting discomfort, would like to put her on Ultram until she can get in to see Dr. Jacobs; DX probable ruptured disc of the LS. 1/6/98 - here with acute pyeloneuphritis, needs slip for work and to return in near future; no other significant findings. 1/9/98 - no show for appt. 1/27/98 - complaints of vomiting, fever, cough, body aches, ear pain, sore throat; referred to Dr. Chen due to chronic nature of the positive findings; DX was - 1. acute otitis

media, 2. acute pharyngitis, and 3. bronchitis. 1/30/98 - doing much better however still has resolving cough; DX resolving bronchitis and otitis. 2/10/98 - complaints of vertigo, chills, fever and ear pain for last 2 days; has been putting up with these symptoms now since Jan 23, started on Lorbid and referred to an ENT specialist.

After 2/10/98, the next entry was dated 4/9/98, and included - "Here today with an acute anxiety episode with chronic problems with carpal tunnel, chronic degenerative back disease, possible ruptured disc", has some previous stabilization surgeries; "We recommend that she have further work up if her workman's comp. will approve of it"; she will be placed on BuSpar for mild anxiety; no other significant findings. 5/19/98 - treated for diagnosis of fungal infection of the right foot; 5/28/98 - advised to stay off feet; 6/9/98 referred to pediatrist and kept off work until then. The next entry of 6/16/98 indicated - treated for DX of Acute pharyngitis, and Sinusitis.

9/1/98 - complaints of pain and edema in left knee for 1 day; this is a re-injury 6/98 with Dr. Kefalas; patient noticed symptoms after pushing in brake on a tractor; the typed 9/1/98 entry included that this was a reinjury from a fracture, that she had a knee brace in place for patella support, x-rays were negative, and the diagnosis was - contusion of the left knee. The claimant was treated for Bronchitis on 11/24/98 and 12/8/98, and for Sinusitis and Resolving bronchitis on 12/18/98.

The next entry of 1/6/99 included in the handwritten section - "c/o of left hip pain. No known injury. X-6 months."; the typed 1/6/99 entry stated that Rosenkoetter presented with low back pain radiating into the left hip, x-rays showed degenerative disease in the hip socket, it was written that she "has severe osteoarthritis, scoliosis of the spine" and she has had previous surgery in the past; the plan was evaluation by an orthopedist. January 1999 entries (2) concerned treatment for Chronic bronchitis and for Acute viral gastritis. 2/2/99 - complaints of lower back pain for one day, noticed after picking up laundry basket; the typed 2/2/99 entry noted - complaints of left lower back pain, physical exam reveals spasm in LS area more on the left than right and no neurological deficits; therapy was to be started, and Rosenkoetter was to be returned back to work that evening; the DX was - LS strain. The final entries of 3/3/99 and 3/9/99 concerned treatment for symptoms of bronchitis and pharyngitis.

6.Medical records of Dr. John Kef alas, M.D. (Claimant's Exh. No. F) concerned the treatment of Rosenkoetter from 2/26/98 - 5/5/99. The 2/26/98 entry reflected the chief complaint as - right knee injury. It was written that Rosenkoetter relayed that while at home she had fallen sustaining a twisting injury to the right knee. The diagnosis after x-ray and physical examination was - Acute right knee injury with probable patellofemoral subluxation possible, and Quadriceps tendon injury and possible meniscal injury. Rosenkoetter was placed in a neoprene sleeve, was taken off work, and was to return in 2 weeks. The next entry of 3/12/98 included that Rosenkoetter relayed her knee symptoms were slightly improved, and that she had re-injured her right long finger recently at home. The plan was to observe the right long finger with instructions for digital motion, and for the knee continued use of the neoprene sleeve, quad and hamstring strengthening exercises, and return in 5 weeks; it was written that Rosenkoetter could return to regular duty at work as of $3 / 23 / 98$.

The next entry of 6/17/98 noted that Rosenkoetter reported that on 6/16/98 she had missed a step and fell on her wood porch at her home, landing directly on the anterior aspect of the left knee. It was noted that radiographs from her emergency room visit the day before showed a question of a possible proximal left tibial plateau fracture; the diagnosis was left tibial plateau fracture, and the plan was a continuation of non-weight bearing with a walker, starting therapy for this, a knee immobilizer, return in 2 weeks, and no work. In the next entry of 7/1/98, examination findings were: left knee is minimally tender over the proximal tibia, no effusion, nontender anteriorly over the patella, tender over the medial joint line, neurologic function is unchanged (the distal neurovascular function is normal). It was written that repeat radiographs failed to reveal any obvious tibial plateau fractures. The plan was to continue weight bearing as tolerated, a neoprene sleeve, and follow up in 3 weeks. In the next entry of 7/22/98, it was written that Rosenkoetter relayed her symptoms were slowly improving; the plan was for weight bearing as tolerated, weaning herself from the walker, continue using the knee splint, physical therapy for range of motion and strengthening, no work, and return in 4 weeks. In the 8/19/98 entry it was written that Rosenkoetter still noted achiness in the knee. Exam findings were - no effusion, full extension and flexion to 90 degrees, collateral ligament are stable, and tender over the patellofemoral joint and medial pes bursa. The plan was continuing strengthening on her own, Motrin, a new Ace bandage was applied, follow-up in 6 weeks, and Rosenkoetter was returned to regular duty at work on 8/20/98. A 12/4/98 entry stated that per patient's disability form she was now seeing Dr. G. Sort at Orthopedic Associates.

The next entry of 3/17/99 noted Rosenkoetter relayed that on 3/15/99 while at home she sustained an injury to the left knee, ankle and foot after she fell after becoming dizzy. Further written was: "She states she twisted her left ankle and knee. Denies back pain or any other musculoskeletal complaints. She states the dizziness has improved.". The following examination findings were noted on 3/17/99:

Exam today shows her spine is nontender. Shoulders, elbows and wrists had good motion, no pain. Pelvis is stable. Right hip, knee and ankle had good motion, no pain. The left hip is nontender and had good motion. The left knee skin is intact. She is tender over the medial tibial plateau as well as the MCL. Nontender over either medial or lateral joint line. Good quad control. Distal neurovascular function is intact. She is tender over the anterior talofibular ligament of the left ankle. Nontender medially over the deltoid. Nontender over the hindfoot, midfoot or forefoot. She had good digital motion.

It was noted that radiographs of the left knee, the left ankle and the left foot showed no obvious fractures. The impression was: 1. Left knee contusion, 2. Left ankle sprain, and 3. Left foot sprain. The treatment plan was the application of an aircast and a knee immobilizer, Celebrex was prescribed, no work, and follow-up in 2 weeks. The 4/7/99 entry included that Rosenkoetter relayed she had removed the knee immobilizer as her left knee had improved; she was still using the aircast on the left and still noted left heel and ankle pain. Examination findings on 4/7/99 included: ambulating with a slight antalgic gait; spine is nontender to palpation; hips had good motion, no pain; left knee had full extension, lacking about 5 degrees, flexes about 120 degrees; collateral ligaments are stable; still tender over the MCL; still tender over the ATF; also tender with medial and lateral compression of the calcaneus. The treatment plan was to continue with Aircast, if symptoms in the heel persisted then repeat radiographs of calcaneus, follow up in 4 weeks, new prescription of Celebrex, and return to regular duty at work on 4/7/99. The 5/5/99 entry, the last entry, indicated that Rosenkoetter missed the appointment.

Dr. Bruce Schlafly, M.D. testified by deposition on behalf of the claimant. (Claimant's Exh. A) The doctor identified his treatment reports which had been marked as deposition exhibits, and it was agreed and stipulated to by the parties that Dr. Schlafly would testify per his reports (See Schlafly Dp. pp. 4-8).

Dr. Schlafly's examination/treatment reports, addressed to the claimant's attorney Ray Gerritzen, began with a March 1, 2001 report in which the doctor wrote that he had examined Rosenkoetter on that date and had reviewed very extensive medical records; Dr. Schlafly noted that he did not have at that time the records of Dr. Phillips and Dr. Crandall. Dr. Schlafly wrote that Rosenkoetter had relayed a history of working full-time at Integram for eight years until she lost her job two years ago in March of 1999, and she had been unemployed since then. Dr. Schlafly noted that Rosenkoetter relayed that she had been in good health when she started working for Integram, even riding her motorcycle to work; it was noted that she relayed she had a motor vehicle accident around 1985 which produced a concussion and some type of whiplash injury to her neck. She says she had symptoms related to her head and neck for several years, but they eventually resolved and at this time she has only minimal complaints involving the neck, the doctor wrote, and I saw x-rays of the neck done 6/15/95 which showed only some curvature of the neck suggesting some muscle spasm at that time. The doctor wrote that Rosenkoetter spent her first $11 / 2$ years at Integram performing maintenance work, but then was switched to the production line where they made seats for the Chrysler mini vans.

Dr. Schlafly noted in his March 1, 2001 report injuries Rosenkoetter had suffered, which incldued: a. A laceration to the left hand in 11/94 at work with wound problems and persistent pain at the scar, and the symptoms were attributed to flexor tendonitis; she relays continuing pain at the scar with gripping, residual numbness in the left small finger and loss of hyperextension of the left small finger from the location of the laceration. b. A major injury at work on or about 8/25/95 where she slipped on a slick paper tag on the floor "and fell to the concrete floor, landing on her knees and back and also apparently twisting her right ankle"; the next day she was experiencing considerable low back pain with swelling at the right ankle and she sought medical attention; I see medical records where she was evaluated at the Healthline clinic on 9/15/95 for the injury, where her complaints involving her right ankle and right knee were noted and x-rays were negative, and she was given a diagnosis of mild sprain of her right ankle and strain of the right knee; she says that her back was not properly evaluated at Healthline and she had to obtain on her own treatment from her personal physician, Dr. Calvin, who on 10/19/95 noted that she had severe pain along the lumbar spine with pain radiating into the left leg, and diagnosed a ruptured disc and referred her to Dr. Jacob. Dr. Jacob ordered an MRI scan of he lumbar spine that revealed degenerative change, and then ordered a lumbar myelogram with CT scan which showed changes such as narrowing of the lateral recess on each side at L4-5; her symptoms continued, and Dr. Jacob operated on her on 12/14/95 at which time he found displacement at L3-4 and L4-5 with spinal stenosis at these level; following surgery Rosenkoetter noticed numbness in the dorsum of the left forearm, and electrical studies Dr. Jacob had performed on 5/6/96 were negative. Prior to the 8/25/95 fall at work, she tells me that she had no problems with her low back, Dr. Schlafly wrote. c. Strained her back while working in November, 1997 as a result of bending over to put a seat in a box and felt pain in her low back on the right side of spine; Dr. Jacob had an MRI of the lumbar spine performed on 5/24/99 which showed some post-op changes with severe degenerative disc disease at L3-4, L4-5, and L5-S1 as well as rightsided disc protrusion at L5-S1; no surgery was performed; Rosenkoetter continues to experience pain from the injury at the right side of the lower lumbar spine with some intermittent right leg pain, the doctor wrote. d. Dr. Schlafly noted that when Rosenkoetter visited the Healthline clinic in 11/97 she had complaints of pain and parasthesia in the hands, and on

2/19/98 she was told to obtain electrical studies on her hands; Healthline noted that she was to see Dr. Phillips and Dr. Crandall for her hands; Rosenkoetter said electrical tests were done and she was advised she has carpal tunnel syndrome worse in the left hand than the right hand; she was treated in nonoperative fashion; she relays she continues to experience numbness and tingling in her hands. g. Dr. Kefalas, in the summer of 1998, treated her for a possible fracture involving the left proximal tibia after she fell at home; she states injury forced her off work for $11 / 2$ months, but she healed well from the injury. f. 3/15/99 - she again fell at home sustaining contusion and sprains of the left knee and ankle; Dr. Kefalas treated conservatively including Celebrex and released her to return to work on 4/07/99 but by that time she had lost her job.

Examination findings on March 1, 2001 for Rosenkoetter in regards to her upper and lower extremities, her hips and her back were discussed by Dr. Schlafly in his report. In the Analysis Section of his March 1, 2001 report, Dr. Schlafly included the following:

Mrs. Rosenkoetter slipped and fell at work on or about 8/25/95, injuring her low back. This work injury is the substantial factor in the cause of her low back condition that necessitated Dr. Jacob's surgical treatment. In my opinion, Mrs. Rosenkoetter has a 42.5 percent permanent partial disability of the body as a whole referable to the low back as a result of this injury, which necessitated Dr. Jacob's surgical treatment. She has an additional 7.5 percent permanent partial disability of the body as a whole referable to the low back on the basis of the work injury of 11/97 that resulted in strain with right lower extremity symptoms. The MRI scan that was then performed on 5/24/99 suggested a disc problem to the right side at L5-S1, and Mrs. Rosenkoetter should return to the care of Dr. Jacob for further evaluation and treatment as necessary of her low back. It is possible that further surgery may be required. As a result of her low back condition, she cannot engage in work that requires her to lift more than 20 lbs., or to perform activities such as bending, stooping, twisting, or squatting.

........As of today, I do not find any significant disability resulting from the prior motor vehicle accident and injuries of her head and neck.

My opinion is that she carries a 10 percent permanent partial disability of the right ankle as a result of the right ankle sprain sustained when she fell at work on 8/25/95. I do not find any significant disability of her knees or left ankle, or right index finger. With regard to the tender scar from the work related laceration in the left hand dating back to 11/94, my opinion is that this has produced a 25 percent permanent partial disability of the left small finger ( 22 week level), as well as an additional 7.5 percent permanent partial disability of the left hand. This is in addition to the disability in the left hand from the left carpal tunnel syndrome.

I do not find significant disability involving her shoulders, hips, or elbows, and at this time I cannot confirm any significant industrial disability related to her eyes, heart, or lungs. I would defer to a psychiatrist as to the extent of any psychiatric disability from work related depression.

Given the problems with her hands, she is not fit for work that requires heavy, repetitive gripping, pushing, and pulling with her hands, or use of vibrating tools.

On cross examination by the employer/insurer, Dr. Schlafly agreed that he is a hand specialist; "I limit my surgical practice to hand and upper extremity, yes", the doctor said. (Schlafly Dp. pg. 18)

On cross examination, Dr. Schlafly stated that his review of Healthline's records following the 8/25/95 incident revealed that Healthline did not record complaints referable to the back at that time; the doctor agreed that Healthline recorded complaints with respect to the right ankle and the knee. It was noted that Dr. Schlafly wrote that Rosenkoetter relayed to him that her back was not properly evaluated at Healthline; Dr. Schlafly was shown a workers' compensation report signed by Rosenkoetter on 10/7/95, and Dr. Schlafly agreed that there was nothing on the 10/7/95 report indicating any complaints of problems with the back and agreed that this report would be consistent with the Healthline records. Dr. Schlafly (who agreed that Rosenkoetter had told him she had not had any prior back problems before the 8/25/95 fall on the tag) was shown an October 1995 record of Dr. Calvin in which it was written that Rosenkoetter had had an auto accident in 1987, care for last two years, worse last six months, pain in small of back and hip and legs; Dr. Schlafly agreed that this is what the record said, and agreed that if this was true then Rosenkoetter had problems with her low back from 1987 for the next six years, and since the record was an October 1995 record this would indicate that before August of 1995 Rosenkoetter was having problems with her low back; Dr. Schlafly agreed that this would be inconsistent with the history Rosenkoetter had given him. The following testimony then occurred:

Q. In fact, Doctor, you refer to Dr. Calvin and you point to this 10/19/95 report which is his office note, correct?

A. Yes.

Q. And this actually says patient injured back on 10/15/95, correct?

A. Yes.

Q. And then says "and is under Dr. Clark's care", correct?

A. Yes.

Q. Which is the doctor we talked about?

A. Yes.

Q. And that would be different than the date that you had talked about, namely August $5^{\text {th }} of ' 95 , correct?

A. Yes.

Q. And that would indicate that from August 25^{\text {th }}$, '95, up until this reference to injuring her back on 10/15/95, that you're unaware of any treatment that she received for her back, correct, from $8 / 25 to 10 / 15$ ?

A. Right. The treatment in that interval of which I'm aware is the treatment at Healthline directed to the right ankle and right knee.

Q. And you're unaware of any recorded medical records that record - any medical records that record any complaints of pain, ache, discomfort, involving the back or the legs between 8/25/95 and 10/15/95, correct?

A. That's right. I don't have any medical records in that interval on the low back.

Q. You're not aware of any kind, as the doctor calls, injury on 10/15/95, correct?

A. No, I don't know about any 10/15/95 injury.

Q. All you're aware of and all your rating took into account was her history of injuring her back on 8/25/95, correct?

A. Yes. (Schlafly Dp. pp. 38-40)

Dr. Schlafly was shown the October 23, 1995 CT scan of the lumbar spine, and stated that "(P)robably" the findings on the scan, if the scan had been done six months earlier, would have been present; the findings would have been present before 8/25/95. (Schlafly Dp. pg. 41) In regards to the calcified bulging disc seen on the October 23, 1995 CT scan, "I wasn't sure" if it would have been seen prior to 8/25/95, the doctor said. (Schlafly Dp. pg. 42) The doctor was asked would you anticipate that somebody who sustained an acute herniation of a disc could go a month-and-a-half without treatment and/or complaints? "Unlikely", Dr. Schlafly answered. (Schlafly Dp. pg. 43)

Dr. R. Peter Mirkin, M.D. testified by deposition on behalf of the employer/insurer. (Employer/Insurer Exhibit No. 1) A board certified orthopedic surgeon, Dr. Mirkin stated that he examined Rosenkoetter on several occasions and prepared reports. "I reviewed extensive records including records from Dr. Jacob, Dr. Rende, Dr. Calvin, physical therapy notes, records from Healthline", the doctor said. (Mirkin Dp. pg. 6) Dr. Mirkin noted that he also reviewed x-rays the lumbar spine; "I believe there is some preoperative radiology reports in Jacob's records that I reviewed", the doctor stated. (Mirkin Dp. pg. 7) Dr. Mirkin gave his opinion from his review of x-rays and diagnostic studies:

"It was my conclusions this was a lady with very severe degenerative disease in her lumbar spine who underwent a laminectomy. When I first saw her, she really was not having radicular pain. Later on, she was starting to have some recurrent pain, and I recommended that if she had persistent pain that it be reevaluated by MRI or myelogram. (Mirkin Dp. pp. 7-8)

Explaining further, the doctor said:

"I have her x-rays up here on the view finder, and if you look at it, the discs at all levels are markedly decreased in height, there is bone spurs at all levels. There is even a collapsing or degenerative scoliosis where the spine is starting to curve, and that is all a severe wear and tear phenomenon of the spine." (Mirkin Dp. pg. 8)

Dr. Mirkin stated that the findings seen on the radiographic studies would occur over years. Dr. Mirkin testified as to his diagnoses for Rosenkoetter: "It's my opinion this is a lady with severe degenerative spine disease who underwent a decompression procedure by Dr. Jacobs and still suffers from the effects of her degenerative arthritis disease." (Mirkin Dp. pg. 8) Testifying that it was his opinion Rosenkoetter's severe spine disease was not medically causally related to her employment with Integram, Dr. Mirkin explained:

"As we stated before, this is something that occurs over a long period of time. Her initial complaints after her work injury were of knee pain and I believe some ankle pain, and she didn't even talk about back problems. So, you know, I would expect a patient who had an acute injury to have back complaints immediately." (Mirkin Dp. pg. 9)

Commenting on his opinion as to whether Rosenkoetter was capable of working in regards to her back, Dr. Mirkin testified: "Yes, I wrote my last note that I thought she could work with a 30-pound lifting restriction". (Mirkin Dp. pg. 9) Commenting on his opinion of whether or not Rosenkoetter had sustained any permanent partial disability in regards to

her back. Dr. Mirkin stated: "I think she has some permanent partial disability in her back, but none secondary to that incident or incident at work"; "She has very severe degenerative spine disease, and she probably has a permanent partial disability of about 20 percent secondary to that". (Mirkin Dp. pg. 10) ${ }^{[7]}$

On cross examination by the claimant, Dr. Mirkin agreed that the only film studies he ever reviewed were x-rays he had taken, and thus the first films he would have reviewed would have been films taken in 1998, approximately $21 / 2 23 / 4$ years after the injury. Dr. Mirkin stated that the following examination findings seen by Dr. Jacobs on October 30, 1995 could be found in "(P)atients with this degree of spine disease", but agreed that it is possible these findings can be from an aggravation of preexisting degenerative changes - lumbosacral paravertebral muscle spasm, positive straight leg raising on the left at 30 degrees and on the right at 60 degrees, pinprick, hypogeusia in the L4 dermatome, diminished ankle and knee reflex on the left compared to the right, weakness of the great toe and foot extensor strength in the left compared to the right. Dr. Mirkin stated that he had the correct history that Rosenkoetter's back surgery was performed in 1995 and not June of 1997; it was noted that Dr. Mirkin wrote in his April 7, 1998 report - "She has severe degenerative changes, secondary to degenerative arthritis and her previous surgery, in my opinion". (See, Mirkin Dp. pg. 23) The doctor was queried if his opinion would be the same with an injury that had occurred two years earlier (than his 2002 deposition), and Dr. Mirkin responded: "If you had a traumatic injury, like a fracture where some bone was removed, or a severe traumatic injury where the facets were disrupted, sure, but you don't generally get degenerative changes from sprains and strains and things like that." (Mirkin Dp. pg. 24)

Dr. Mirkin stated that he evaluated Rosenkoetter's back, only, and did not assess her for any other possible ailments, such as high blood pressure, a right shoulder injury, a 1998 left tibial plateau fracture and left knee sprain, or bilateral carpal syndrome; I knew of none of these things, the doctor said, I'm looking at her intake sheet and none of those things are checked off. The doctor stated that this intake sheet was dated 2/18/97, and was the only intake sheet he had by Rosenkoetter. Dr. Mirkin agreed that in all of his reports he only refers to an injury in 1995. Agreeing that therefore in all of his opinions where he is talking about whether or not it is work related it's all relating to the injury in 1995, Dr. Mirkin further stated: "When I did these reports, that's the only injury she made me aware of." (Mirkin Dp. pg. 27)

Dr. Mirkin agreed it was his opinion that based on her history, Rosenkoetter had radicular symptoms prior to the surgery by Dr. Jacobs in 1995, the radicular symptoms returned, and to a certain extent have been off and on ever since. Dr. Mirkin agreed that as of April 7, 1998 he felt Rosenkoetter need to be treated by a spine physician; the doctor was queried - you are not disputing that Rosenkoetter needs treatment of the back for her radicular symptoms, it is just a matter of whether or not it is work related. "correct", Dr. Mirkin answered. (Mirkin Dp. pg. 26)

On cross examination by the Second Injury Fund, Dr. Mirkin stated that it was possible to have switching of radicular symptoms with degenerative changes, and explained: "If you have narrowing of the spinal canal from arthritis, you can have pain in either leg or both legs." (Mirkin Dp. pg. 34)

On redirect, Dr. Mirkin was given a hypothetical question in regards to degenerative findings that may or may not be related to the surgical procedure and degenerative findings that would have predated the surgical procedure; Dr. Mirkin was given the following facts - assume that the original injury was on or about 9/15/95, and that prior to the surgical procedure, which I believe occurred on 12/14/95, she underwent a lumbar CT scan that was administered on 10/23/95, further assume that the radiologist's interpretation of that CT scan was that axial images centered through the disc spaces from L2-3 through L5, S were obtained, there were uniformed calcified disc bulging at L2-3, there was disc bulging at L3-4 with a focal area of calcified disc protrusion laterally to the left, hypotrophy in this region as well contributed to the narrowing of the left lateral neuroforamina, there was uniform disc bulging at L4-5 with calcification, facet hypertrophy at that level as well and at all image levels, narrowing was noted at the disc space at L3-4 and L4-5, and no focal herniations of soft disc material were identified; the doctor was asked - assuming those to be accurate conclusions, would that effect his opinion regarding medical causation in any way? Dr. Mirkin answered:

"Certainly that CAT scan report substantiates my opinion that this is a degenerative condition. Those are all degenerative findings. In fact, the radiologist clearly points out there is not an acute disc rupture there. They are all calcified degenerative bulges, protrusions as well as facet hypertrophy, and that's a classic description of an arthritic condition of the back." (Mirkin Dp. pg. 36) (Ruling: Claimant's objections on grounds of, Seven Day Rule and nonresponsive, are overruled. Mirkin Dp. pp. 36 and 37)

The doctor was further queried with the hypothetical facts; he was asked, assuming the same facts to be true and assuming Rosenkoetter did have an injury on or about 9/15/94, would one expect in that period from 9/15/95 through 10/23/95 the development of facet hypertrophy and calcified disc bulging basically from L2-3 all the way down to L5, S1

as a result of the traumatic event. Dr. Mirkin answered: "Absolutely not. These are all changes that take years to evolve." (Mirkin Dp. pg. 37) (Ruling: Claimant's objection on grounds of, Seven Day Rule, is overruled. Mirkin Dp. pg. 37)

On further cross examination by the claimant, Dr. Mirkin stated that he took into consideration Rosenkoetter's subjective complaints when he assigned a 30 -pound lifting restriction. The doctor admitted that he did not ask Rosenkoetter if she could lift without pain or repetitively lift, if she had increased back pain after sitting or standing for a certain period of time, or how long she could walk before increased back pain. Dr. Mirkin further testified:

"She may or may not have those symptoms. I just think that a 265 -pound person can easily do activities where she's lifting approximately 11 or 12 percent of her weight on a regular basis. I don't see anything on her condition that would preclude her from doing that. As I wrote in my report on September 26, '01, I thought she should seek employment where she is not required to bend, stoop, squat or lift. So you are concentrating on the 30 pounds. Certainly the bending, stooping, and squatting are more painful for her than lifting 30 pounds, which is about 12 percent of her body weight." (Mirkin Dp. pg. 39)

Dr. Mirkin agreed, during recross examination by the Second Injury Fund, that the restrictions of the bending, stooping, squatting, those were of Rosenkoetter's physical condition as of the exam in 2001.

Dr. Robert P. Poetz, D.O. testified by deposition on behalf of the employee. (Cl. Exh. H) An osteopathic physician and surgeon, Dr. Poetz testified that the document marked as Deposition H-1 was his June 10, 2002 evaluation report on Mary Rosenkoetter; it was agreed and stipulated to by the parties at Dr. Poetz' deposition that the doctor would testify per his evaluation report. (Ruling: Second Injury Fund's and Employer/Insurer's objection on grounds of Seven Day Rule is overruled. Poetz Dp. pg. 5)

In his June 10, 2002 evaluation report, Dr. Poetz wrote that he saw Rosenkoetter on October 26, 2001 for evaluation of work related injuries occurring while employed with Magna Interior Systems of America as a factory worker for eight years. Rosenkoetter's chief complaints were noted as: constant lower back pain which intensifies with increase activity and prolonged sitting, standing or walking; pain from the lower back that radiates down the right leg and occasionally the left; inside portion of left leg is numb; outside of right ankle is painful and occasionally swells; right knee is painful, and catches and pops with movement; occasionally pulling sensation in the palm of left hand between the 4th and $5^{\text {th }} finger with 5^{\text {th }}$ finger numbness; pain and numbness in both hands and wrists, the left worse than the right; numbness and pain in hands wakes her up at night; very depressed. Dr. Poetz discussed work related injuries relayed by Rosenkoetter, which included: 1. November 23, 1994 - working on a metal pan when she lacerated the palm of her left hand on a sharp edge, and was treated with medicine and hand therapy which included scar management. 2. August 25, 1995 - slipped on a paper tag which caused her to twist her right ankle and knee before falling onto a table, with ongoing occasional pain and swelling at the ankle and knee, and on September 15, 1995 was seen at Healthline and diagnosed with mild right ankle sprain and right knee sprain, and physical therapy was recommended; also reported was that after the incident Rosenkoetter developed lower back, left hip and left leg pain; treatment for the back included radiological studies, and surgery. 3. November 18, 1997 - developed a burning sensation and pain in the lower back while bending and lifting a box at work; treatment was medication and restrictions, and with continuing problems radiological studies were performed including an MRI. Rosenkoetter is currently not employed, Dr. Poetz noted.

Dr. Poetz noted physical examination findings on October 26, 2001 that included: Rosenkoetter is a morbidly obese 56 -year-old female, presents with a depressive facies; she is alert and cooperative, and moves about the examination room in no apparent distress; ambulates with a normal gait. Medications: pain and anti-hypertension. Vital signs: Height 5'4" Weight 279; Blood pressure 176/106. Upper extremities: Phalen's and Tinel's signs are negative bilaterally; grip strength is decreased bilaterally; a 2 cm left volar hand scar between the base of the $4^{\text {th }} and 5^{\text {th }} finger, a 11 / 2 \mathrm{~cm}$ scar at the dorsal firth index finger and a 4 cm right index finger scar; hands are neurovascularly intact wit good capillary refill. Lower extremities: 2+ pre-tibial edema exhibited bilaterally; crepitus at the knees; decreased range of motion at the right ankle; heel and toe walking is performed poorly; feet are neurovascularly intact. Spine: no evidence of kyphosis, lordosis, scoliosis or pelvic list; decreased range of motion at the cervical spine; straight leg raising is positive on the right at 45 degrees in a seated and supine position; a 10 cm vertical lumbar scar. Neuro: cranial nerves are grossly intact; deep tendon reflexes intact; no motor or sensory deficits noted.

Diagnoses made by Dr. Poetz included: 1) 11/23/94 - Laceration palmar aspect left hand with suture repair. 2) 8/25/95 - Right ankle sprain; and right knee sprain. 3) 8/25/95 - Lumbar strains with degenerative disc disease; lumbar spondylosis with myelopathy, severe L3-4, L4-5; displacement disc, lumbar L3-4, L4-5 left and cicatrix of the nerve roots L4 and L5 left; Status post lumbar decompression laminectomy with laser magnification and microdissection L3-4 and L45 left. 4) Lumbar degenerative disc disease and spinal stenosis, L3-4, L4-5, pre-existing. 5) 11/18/97 - Lumbar strain and disc protrusion L5-S1 with exacerbation of pre-existing lumbar condition. 6) Hypertension, pre-existing. 7)

Cardiomegaly, pre-existing. 8) Chronic obstructive pulmonary disease, pre-existing. 9) Tendonitis right elbow, 1985. 10) Concussion, 1985. 11) Cervical strain, 1985. 12) Right shoulder sprain, 1997. 13) Left tibial plateau fracture and left knee sprain, 1998.

Dr. Poetz discussed his recommendations which included weight loss, check blood sugar to evaluate for diabetes and avoiding heavy lifting and strenuous activity.

Dr. Poetz wrote that as a result of his evaluation, which included a review of medical records, it was his opinion that the injuries which occurred on November 23, 1994, August 25, 1995 and November 18, 1997 are a substantial and contributing factor to the following disabilities:

1. 5 % permanent partial disability to the upper left extremity as measured at the left hand resultant from the November 23, 1994 work related injury.
2. 15 % permanent partial disability to the lower right extremity as measured at the right ankle directly resultant from the August 25, 1995 work related injury.
3. 15 % permanent partial disability to the lower right extremity as measured at the right knee directly resultant from the August 25, 1995 work related injury.
4. 10 % permanent partial disability to the body as a whole as measured at the lumbar spine, pre-existing.
5. 30 % permanent partial disability to the body as a whole as measured at the lumbar spine directly resultant from the August 25, 1995 work related injury.
6. 15 % permanent partial disability to the body s a whole as measured at the lumbar spine directly resultant from the November 18, 1997 work related injury.
7. 10 % permanent partial disability to the body as a whole due to hypertension, pre-existing.
8. 10 % permanent partial disability to the body as a whole due to cardiomegaly, pre-existing.
9. 20 % permanent partial disability to the body as a whole due to chronic obstructive pulmonary disease, pre-existing.
10. 10 % permanent partial disability to the upper right extremity as measured at the right elbow, 1985.
11. 10 % permanent partial disability to the body as a whole as measured at the head due to concussion, 1985.
12. 10 % permanent partial disability to the body as a whole as measured at the cervical spine, 1985.
13. 15 % permanent partial disability to the upper right extremity as measured at the right shoulder, 1997.

Dr. Poetz further wrote in his evaluation report:

The combination of the present and prior disabilities results in a total which exceeds the simple sum by 20 %.

On cross examination by the employer/insurer, Dr. Poetz testified that in arriving at my opinions regarding the nature and extent of Rosenkoetter's permanent partial disability I relied in part on the accuracy of Rosenkoetter's relayed history, and "I relied upon my examination, my medical records, my experience, and that's about it". (Poetz Dp. pg. 17) Dr. Poetz agreed that the ratings of disabilities represented all of the permanency he found in Rosenkoetter as of the date of his exam on 10/26/01. Dr. Poetz stated that he did not have any history as to whether or not Rosenkoetter was performing at optimum performance level or whether she was missing any work. The doctor was queried - possibly by history provided to him but according to his conclusions, wasn't it true that Rosenkoetter was able to work with sufficient force and be able to perform her task with sufficient frequency and duration that over that period of time, from the time of her last injury up till the time she developed carpal tunnel her repetitive activities actually caused her injury. "Correct", Dr. Poetz answered. (Poetz Dp. pg. 27)

During cross examination by the employer/insurer, Dr. Poetz agreed that with Rosenkoetter's first accident of a laceration to her left hand, there was no indication of any neurovascular involvement. "There is indication in my report that there was tendon involvement", the doctor said. (Poetz Dp. pg. 38) The doctor was asked if he found any flexor tendonitis as of the date of his exam. "Just the scar", the doctor responded. (Poetz Dp. pg. 39) Dr. Poetz agreed that, as a result of the laceration, there was no indication of decreased range of motion of any of the fingers, no numbness or tingling, and no atrophy found in the hand. The doctor agreed that he did not place any restrictions on Rosenkoetter's ability to use the hand as a result of the laceration.

With respect to the second back injury, an injury to the low back on 11/18/97 and his assessment of 15\% disability as a result of that accident, Dr. Poetz testified about knowing of Dr. Calvin's 9/16/97 record in which it was mentioned that Rosenkoetter reported that on 9/14/97 she was lifting heavy pots at a family reunion and had an increase in her back complaints: "Yeah, I think I knew about that, but that was considered to be insignificant by her, so it wasn't listed". (Poetz Dp. pg. 56)

During cross examination, Dr. Poetz agreed that at the time of his exam, Rosenkoetter was five foot five and 279 pounds; the doctor agreed that he had characterized Rosenkoetter as morbidly obese. Agreeing that morbid obesity adversely affects Rosenkoetter's back, Dr. Poetz testified: "Well, it makes the back work harder". (Poetz Dp. pg. 66) It was noted that on examining Rosenkoetter's legs, the doctor had found two plus pretibial edema bilaterally at the lower extremities; Dr. Poetz was asked if this was from obesity. Answering "No", Dr. Poetz further stated his opinion as to what the edema was from: "Well, I guess cardiovascular disease, renal disease, lymphodema or a combination of all the above plus obesity." (Poetz Dp. pg. 66)

Dr. Poetz agreed, during cross examination, that Rosenkoetter did not provide him with a history of injury to the left knee. When queried, wasn't it correct that he found crepitus in the knee bilaterally, Dr Poetz answered - "Yes". (Poetz Dp. pg. 67) The doctor further agreed that there was no indication that one knee was worse than the other on exam. No atrophy of the lower extremities was found and there was normal range of motion at the level of the knees, the doctor agreed. Dr. Poetz was asked - on your exam of the right knee what is it that you found that was different than your exam of the left knee. "None", the doctor answered. (Poetz Dp. pg. 68)

Concerning the 8/25/95 injury where Rosenkoetter slipped on a paper tag and injured herself, Dr. Poetz agreed that Rosenkoetter's initial treatment was at Healthline, and at that time she had complaints about the right knee and ankle and x-rays were taken of the right knee and ankle. The doctor agreed that the first treatment was on 9/15/95; Dr. Poetz stated that in his review of the initial Healthline reports he did not find any history or complaint of injury to the low back. Dr. Poetz was asked how long after the incident before Rosenkoetter developed low back pain. "I don't know", Dr. Poetz answered. (Poetz Dp. pg. 69) The doctor was questioned - assuming it was Rosenkoetter's signature on a Report of Injury dated 10/7/95, what were the injuries noted by Rosenkoetter on the form, and Dr. Poetz indicated "right ankle and ankle". Agreeing that there was no reference to the back as of 10/7/95, Dr. Poetz testified - "No. It says, sprained right ankle and ankle". (Poetz Dp. pg. 7) The doctor was asked his opinion as to the mechanism in this case of injury to the back for the 1995 problem Rosenkoetter had with her back. Dr. Poetz answered:

"Well, I think that she had indicated in the history there, that she developed this knee and ankle twisting, she continued to have an ankle and knee pain, and eventually after the incident, she developed lower back pain, left hip pain and leg pain.

"And she said she felt that it was related.

"I think that she indicated that she felt that it, it came as a result of it, it was part of the, the ongoing complaint of pain in the knee and the ankle." (Poetz Dp. pg 74)

Dr. Poetz agreed that Rosenkoetter did not provide him any history of additional trauma or repetitive activities that caused her to develop pain with her back. The doctor was queried if he had been provided with any history of Rosenkoetter doing some work painting floors in a stooped position and developing pain complaints in the back as of 10/15/95. "Not to my knowledge", the doctor answered. (Poetz Dp. pg. 75) The doctor agreed that when Rosenkoetter eventually started undergoing diagnostic studies for the back it was through x-rays of the lumbar spine which were done about a month and a half after the incident where she slipped on a tag. Dr. Poetz agreed that the following findings of the radiographic studies were pre-existing conditions to 1995: anterior and posterior osteophytes at L2-3, L3-4, and L4-5; some disc space narrowing, most severe at L5-S1; narrowing of the apaphyseal joints with subcondryl sclerosis; facet hypertrophy and calcified bulging discs at all levels resulting in narrowing of the spinal canal; calcified focal area of disc protrusion and/or osteophyte formation with left lateral position at L3-4; bilateral, lateral recessed narrowing produced by osteophytes at L4-5; and proximal foraminal stenosis that was produced by osteophytes. Dr. Poetz noted that the following findings on radiographic studies may or may not have been pre-existing: the marked narrowing of the left neuroforamina as a result of calcified focal area of disc protrusion. Dr. Poetz stated that the spondylosis (dysfunction of the spinal canal) found when Rosenkoetter was operated on was in part a degenerative condition that occurs over time or a pre-existing condition. Explaining other causes of the spondylosis, Dr. Poetz testified: "Multiple injuries or recent injury to exacerbate it". Poetz Dp. pg. 79) The doctor stated that the stenosis at L3 L4-5, and left lateral recessed stenosis at 34 and L4-5 "would all be preexisting, but the degree of preexisting and the degree of exacerbation is indeterminable". (Poetz Dp. pg 79) Dr. Poetz agreed that in going through this mixed bag of conditions, in trying to portion it out, he thought that overall Rosenkoetter had 40 percent disability and 10 % of that was due to the preexisting degenerative conditions and 30 % to the incident with the tag.

Dr. Poetz was queried, during cross examination, if had reviewed any pulmonary function studies on Rosenkoetter, and the doctor answered - "Not to my knowledge, unless it was within the medical history that I reviewed."

(Poetz Dp. pg. 81) Other than a stethoscope exam where I heard rales, I did not do any other examination of Rosenkoetter's respiratory system, the doctor said. Dr. Poetz stated that he did not know what caused Rosenkoetter's obstructive pulmonary disease.

On redirect examination, Dr. Poetz stated that there was nothing he had been asked in the deposition that would change his opinion as to what he had stated in his report.

Date: $\qquad Made by: \qquad$

LESLIE E. H. BROWN

Administrative Law Judge

Division of Workers' Compensation

A true copy: Attest:

Patricia Secrest

Director

Division of Workers' Compensation

Issued by THE LABOR AND INDUSTRIAL RELATIONS COMMISSION

FINAL AWARD ALLOWING COMPENSATION

(Affirming Award and Decision of Administrative Law Judge)

Injury No.: 97-483041

Employee: Mary Ann Rosenketter

Employer: | Integram St. Louis Section |

Additional Party: Treasurer of Missouri as Custodian

of Second Injury Fund

Date of Accident: November 18-19, 1997

Place and County of Accident: Franklin County, Missouri

The above-entitled workers' compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review as provided by section 287.480 RSMo. Having reviewed the evidence and considered the whole record, the Commission finds that the award of the administrative law judge is supported by competent and substantial evidence and was made in accordance with the Missouri Workers' Compensation Act. Pursuant to section 286.090 RSMo, the Commission affirms the award and decision of the administrative law judge dated May 13, 2005. The award and decision of Administrative Law Judge Leslie E. H. Brown, issued May 13, 2005, is attached and incorporated by this reference.

The Commission further approves and affirms the administrative law judge's allowance of attorney's fee herein as being fair and reasonable.

Any past due compensation shall bear interest as provided by law.

Given at Jefferson City, State of Missouri, this 21st day of March 2006.

Hearing Date: $\quad 5 / 1 / 03,7 / 19 / 04$ and 7/20/04 (finally submitted 10/12/04) Checked by: LEHB/bfb for df

1. Are any benefits awarded herein? Yes
2. Was the injury or occupational disease compensable under Chapter 287? Yes
3. Was there an accident or incident of occupational disease under the Law?Yes
4. Date of accident or onset of occupational disease: November 18/19, 1997
5. State location where accident occurred or occupational disease was contracted: Franklin County, Missouri
6. Was above employee in employ of above employer at time of alleged accident or occupational disease? Yes
7. Did employer receive proper notice? Yes
8. Did accident or occupational disease arise out of and in the course of the employment? Yes
9. Was claim for compensation filed within time required by Law? Yes
10. Was employer insured by above insurer? Yes
11. Describe work employee was doing and how accident occurred or occupational disease contracted: Employee bent over and was putting a large seat in box
12. Did accident or occupational disease cause death? No Date of death? ---
13. Part(s) of body injured by accident or occupational disease: low back
14. Nature and extent of any permanent disability: 7 %
15. Compensation paid to-date for temporary disability: $\ 28.80
16. Value necessary medical aid paid to date by employer/insurer? $\ 0.00

1. Value necessary medical aid not furnished by employer/insurer? $\ 0.00
2. Employee's average weekly wages: $\ 596.40
3. Weekly compensation rate: $\$ 397.60 / \ 278.42
4. Method wages computation: by agreement of the parties

1. Amount of compensation payable:

Unpaid medical expenses:

weeks of temporary total disability (or temporary partial disability)

7 % body as a whole permanent partial disability from Employer, or . . . . . . . . . . \$7,795.76

weeks of disfigurement from Employer

Permanent total disability benefits from Employer beginning, for Claimant's lifetime

1. Second Injury Fund liability: Yes No X Open

TOTAL:

$\ 7,795.76

1. Future requirements awarded: None

Said payments to begin as of the date of this Award and to be payable and be subject to modification and review as provided by law.

The compensation awarded to the claimant shall be subject to a lien in the amount of 25 % of all payments hereunder in favor of the following attorney for necessary legal services rendered to the claimant:

Ray A. Gerritzen, Attorney for Claimant

Employee: Mary Rosenkoetter

Injury No: 97-483041

Before the

DIVISION OF WORKERS'

COMPENSATION

Department of Labor and Industrial Relations of Missouri

This is a hearing setting for five cases involving the claimant, Mary Rosenkoetter, Injury Numbers 94-168476, 95-129017, 97-483041, 98-175851, and 99-123209. In all five cases, the claimant, Mary Rosenkoetter appeared on her own behalf, and through counsel, Attorney Ray Gerritzen. In all five cases, the employer/insurer appeared by and through counsel, Attorney Tim Tierney. In four cases (Injury Numbers 95-129017, 97-483041, 98-175851, and 99-123209), the Second Injury Fund appeared by and through Assistant Attorney General M. Jennifer Sommers.

The parties entered into certain stipulations, and agreements as to the complex issues to be presented in these hearings. Memorandums of Law were filed by the parties.

On or about November 19, 1997: a. the claimant while in the employment of Integram St. Louis Section sustained an injury by accident arising out of and in the course of her employment occurring in Franklin County, Missouri; b. the employer and employee were operating under and subject to the provisions of the Missouri Workers’ Compensation Law; c. the employer’s liability was insured by CNA Insurance Company/RSKCO; d. the employee’s average weekly wage was being $\ 397.60 over $\ 278.42. e. The employer had notice of the injury. f. A Claim for Compensation was filed within the time prescribed by law. g. Temporary total disability benefits was paid in the total amount of $\ 28.80, which represents approximately one day of temporary total disability benefits. h. No medical aid wad paid.

1. Medical causation
2. Liability of past medical expenses
3. Future medical care
4. Nature and extent of permanent partial disability
5. Liability of the Second Injury Fund

No. A: Deposition transcript of Bruce Schlafly, M.D., taken July 9, 2002 on behalf of the claimant, with attachments of: Exhibit A-1, the curriculum vitae of Bruce Schlafly, M.D.; A-2, the March 1, 2001 report of Dr. Bruce Schlafly, M.D. (8 pages); A-3, November 12, 2001 report of Bruce Schlafly, M.D. (1 page); A-4, four photographs taken by Dr. Bruce Schlafly of another patient, not Mary Ann Rosenkoetter, who had persistent problems following prior endoscopes carpal tunnel release and required repeat carpal tunnel release using the standard technique, Exhibit A-3 has the description; A-5, the medical literature provided by Bruce Schlafly, M.D. titled, quote, The Results of Revision Carpal Tunnel Release Following Previous Open Versus Endoscopes Surgery". A-6, the medical literature by Dr. Bruce Schlafly entitled "Persistent or Recurrent Carpal Tunnel Syndrome Following Prior Endoscopes Carpal Tunnel Release"; A-7, operative report of the December 7, 2001 left carpal tunnel release performed by Dr. Bruce Schlafly at St. Anthony’s Medical Center; A-8 is the December 12, 2001 report of Dr. Bruce Schlafly (1 page); A-9, the May 6, 2002 report of Dr. Bruce Schlafly (2 pages); A-10, the operative report of the March 4, 2002 right carpal tunnel release performed by Bruce Schlafly, M.D., at St. Anthony’s Medical Center; A-11, the statement of services of Hand Surgery Associates, P.C./Bruce Schlafly, M.D., in the amount of $\ 3,120.00 for services rendered November 12, 2001 through March 8, 2002; A-12, numerous letters addressed to Bruce Schlafly, M.D., and deposition notices of Dr. Bruce Schlafly relative to his carpal tunnel syndrome treatments. (Admitted subject to the objections therein.) (Ruling: Employer/Insurer’s and Second Injury Fund’s objections to Exhibit A-4 on grounds of, inadequate foundation has been laid, is overruled.) No. B: Certified medical records of Calvin Medical Center No. C: Certified medical records of Hand Therapy Network, certified March 15, 2001 (12 pages) No. D: Certified medical records of HealthLine Corporate Health Services Metro St. Louis certified October 12, 1999 (72 pages) No. E: Certified medical records of Karl A. Jacob, M.D. certified October 9, 1999 (43 pages) No. F: Medical records of Dr. John Kef alas, M.D. certified October 7, 1999

No. G: Certified medical records of Missouri Baptist Medical Center certified January 19, 2000 (219 pages)

No. H: Deposition transcript of Dr. Poetz taken on behalf of the employee on April 28, 2003 (with attachment H-1, the doctor's June 10, 2002 report, 10 pages) [Admitted into evidence subject to the objections therein)

No. I: Certified medical records of St. John's Mercy Hospital in Washington, Missouri, certified May 4, 2000 (14 pages)

No. J: Certified medical records of St. John's Mercy Hospital in Washington, Missouri certified November 17, 1999 (8 pages)

No. K: Certified medical records of St. John's Mercy Hospital, Washington, Missouri certified July 16, 1997 (28 pages)

No. L: Certified medical records of Tesson Heights Orthopaedic \& Arthroscopic Associates certified November 10, 1999 (90 pages)

No. M: Medical bill of Pathology Associates, P.C., for services rendered December 7, 2001 and March 4, 2002 in the amount of $\ 41.00

No. M-1: Collection letter of Diversified Collection Services showing that $\ 27.00 of Exhibit M was turned over to collection

No. N: Medical bill of South County Anesthesia for services rendered December 7, 2001 in the amount of $\ 480.00

No. N-1: Medical bill of South County Anesthesia for services rendered on March 4, 2002 (the second surgery performed by Dr. Schlafly) in the amount of $\ 420.00

No. O: Medical bill of South County Radiologists, Inc. in the amount of $\ 20.00

No. P: Medical bill of St. Anthony's Medical Center for services rendered on December 7, 2001 in the amount of \$2,351.97

No. P-1: Surgical bill

No. Q: Prescription receipt of Heartland Discount Pharmacy in the amount of $\ 5.86 for Cephalexin, 500 milligrams prescribed by Bruce Schlafly, M.D.

No. R and R-1: Deposition transcript of Dr. John Crane, M.D. taken on April 8, 2004, and an August 18, 2003 report by Dr. Crane (Limited admission for these exhibits, only as to the issue of future medical care)

No. S: March 4, 2002 medical bill of St. Anthony's Medical Center, \$2,421.74.

No. 1: Deposition transcript of Dr. R. Peter Mirkin, M.D. taken on behalf of the employer/insurer on 12/13/02 (Admitted subject to the objections therein)

No. 2: Deposition transcript of R. Evan Crandall, M.D. taken on behalf of employer/insurer on December 11, 2002 (Admitted subject to objections therein)

No. 3: Deposition transcript of Dr. Wayne Stallings, M.D. taken on behalf of the employer/insurer on 12-4-02 (Admitted subject to the objections therein)

No. 4: Certified records of Dr. George O. Sertl, M.D.

No. 5: Records of Dr. Clark, D.C.

No. 6: Correspondence between the law offices of Gerritzen \& Gerritzen and Evans \& Dixon pertaining to the issue as to whether surgery had been authorized and when it had been authorized (a. November 20, 2001 letter from Paul Keeven to Mr. Gerritzen; b. November 16, 2001 letter by Mr. Gerritzen to Paul Keeven of Evans \& Dixon; c. October 15, 2001 letter from Mr. Gerritzen to Paul Keeven of Evans \& Dixon; d. October 5, 2001 letter from Paul Keeven to Mr. Gerritzen; e. April 23, 2001 letter of Michael Gerritzen to Paul Keeven)

No. 7: First Workers' Compensation Claimant's Report dated 10-7-95, signed by Miss Rosenkoetter

No. 8: Deposition transcript of Dr. Wayne Stallings, M.D. taken on behalf of the employer/insurer on 4-28-04 (Admitted subject to the objections therein)

No exhibits

The claimant, Rosenkoetter, (who was found to be a basically credible witness though easily confused on historical facts at times), testified that on November 18, 1997 while working at Integram she took one of the larger passenger seats for a minivan to place it in a box, and bent over to put it in and got a real sharp pain in her right lower back. The pain in my low back was in the same area as where I had had the surgery in December 1995, Rosenkoetter stated, and agreed that some time after this, but not that night, the pain went down her leg. After the November 1997 incident I stood there for a while and when it eased down a little bit, I went and told the foreman that I'd hurt my back bending over in the box, Rosenkoetter testified. The foreman called the nurse and she brought some Aleve pills and told me to take them, and I must have been allergic to them, I had a reaction because I couldn't breathe very well, she said. And then the next day I went to see Dr. Calvin and I had a knot come up in my hip and he gave me muscle relaxers and some pain medicine, and he has a therapy machine in his office and I got therapy there, the claimant stated. She was asked how long did she get therapy, and Rosenkoetter responded - I was off work for about a week, I think. When I went back to work after about a week, I just had the pain all the time, the claimant stated, it was just miserable because my back hurt and the more places that I went to do the job, then it was just hard. I was not able to do the same amount of work like I used to, she said.

Giving an example, Rosenkoetter testified that the fork truck drivers would bring the seats in big boxes and you'd have to bend over and get an armful and put them on the bins for the air bag blower, and that's what was really hard because of the bending and lifting the bunch of seat covers, so I always tried to trade that off with anybody that I could get to trade with.

On cross examination by the employer/insurer, Rosenkoetter agreed that she has had two injuries to her back. I don't remember the month of the first injury, September or June, she said, and it was in 1995. Rosenkoetter stated that from the first date of injury to her back up to 11-18-97 she did not recall having any other injuries to her back. At the time of the second back injury I was working full duty without restrictions, as far as I know, Rosenkoetter said. For this second accident on 11-18-97 Integram might have sent me Dr. Rende who was supposed to be a back doctor, Rosenkoetter said. The claimant was asked if she had treated for a relatively short period of time for this second 11-18-97 injury. When I hurt my back at work, Rosenkoetter answered, the next day I went to Dr. Calvin, and I think I was seen by someone else, and I had a knot right across from my spine, and they took me off work for a week and gave me muscle relaxers to see if that would help it. The claimant was asked if she had been seen by Dr. Calvin prior to 11-18-97 for problems with her back, such as six months preceding, and the claimant answered - I go to Dr. Calvin for most everything. I don't remember if I went to Dr. Calvin for complaints or problems with my back in the six months preceding the 11-18-97 incident, the claimant said. I could have but I don't remember going to Dr. Calvin on 5-29-97 for complaints of strain in the back and neck, and severe muscle spasm after lifting liquid soap, Rosenkoetter said, sometimes I turn just right or if I'd pick up a basket of clothes or anything then I strain my back. It was noted that Dr. Calvin's record included a 9-16-97 entry reflecting that Rosenkoetter had advised him that she had strained her back while lifting heavy pots at a family reunion and that she had been diagnosed with acute lumbar sacral strain and severe muscle sprain; the claimant responded - If that's what it says. The claimant was asked if Dr. Calvin in September, 1997 had referred her to Dr. Jacob. I'd already been going to Dr. Jacob, Rosenkoetter answered, I don't know how many times I saw Dr. Jacob after the surgery for the 1995 injury. I had another MRI done and I had other nerve tests done after that because the top of my arm is numb, and the inside of my left leg is numb on certain parts; that's from 1995, it's been that way ever since I come out of surgery, the claimant said. She agreed that this would have been present at the time Dr. Poetz examined her, but stated that she did not know if she would have expressed these complaints and problems to Dr. Poetz; if he would have asked me, she said.

Medical records in evidence revealed:

A. Rosenkoetter was treated at Healthline (Cl's. D) beginning on 11/19/97; it was noted that Rosenkoetter reported that the night before (entry noted a date of injury of 11/18/97) at about 11:35 p.m. at her work in the foam division of Integram she sustained a back injury when she leaned over to retrieve arrange some parts in a box and when she got back up she felt back pain and the pain is going down into her right leg; further written was - Rosenkoetter reported that she had previous back injury, apparently nonoccupational, and that the back was stabilized with some stuff in the back, so I am presuming it might be metal such as Steffe plates or spinal fusion, however I do not have the details of this operative procedure; objective findings on 11/19/97 included essentially normal posture, fairly overweight, able to forward flex fingertips coming to about the knee of just below the knee level bilaterally, mild tenderness in the lower lumbar spine, no paraspinal muscle spasm appreciated especially given her body habitus, reflexes in the knees as well as the ankles are hypoactive but present bilaterally, straight leg raising is negative to almost 80 degrees bilaterally seated, range of motion in the hips, knees and ankles appear essentially within normal limits; diagnosis was - Low back pain; work restrictions were placed of maximum lifting of 15 pounds, occasional stooping, crouching and crawling; it was written that the injury was consistent with work activities or alleged incident. A 12/01/97 Healthline treatment entry included Rosenkoetter reports she is feeling a little bit better, that she felt well after the Thanksgiving weekend and was off a few days, however upon return to work she has redeveloped some of her back pain, denies any paresthesia or radicular symptoms; objective findings included - minimal if any tenderness in the lower lumbar spine, straight leg raising to 90 degrees seated bilaterally; the diagnosis was - Low back pain resolving; Ibuprofen and Flexeril was continued; Rosenkoetter was returned to full duty work, no restrictions.

B. Records described as those of Dr. Clark, D.C. (Emp./Ins. 5) were mostly illegible, but indicated that in about 1994 Rosenkoetter reported a chief complaint of - auto accident in 1987, worse last 6 months with pain in the small of back and hip and legs.

The record included treatment entries in October 1995 for low back complaints. A 10-15-95 treatment note included: "Pat(ient) working today painting floors in flexed or stooped position. Sat down 2-3 hours ago \& got pain - left low back and hip and leg. Constant since then to left ankle."; the 10/15/95 further included - "Off work Bed". A 10/18 entry included that Rosenkoetter had not gone to work; no leg cramping, stiff and taut at L4-5; weight bearing causes ?????.

The next entry of 10/19/95 entry, apparently written by Dr. Glen Calvin, D.O. stated that Rosenkoetter presented that day with severe pain in the lumbar spine running down her left leg, and that they would agreed that her disability began on 10-15-95. She has the potential for having a ruptured disk in the lumbar spine, it was written. In the handwritten entry dated 10/19/95, it was written that Rosenkoetter weighed 215 pounds and had a blood pressure reading of 148/102; also written was that Rosenkoetter had injured her back on 10-15-95 and was under Dr. Clark's care; it was written that Rosenkoetter needed a work disability form from her primary doctor as work would not accept Dr. Clark's.

The record contained a 10/23/95 report of x-rays and a CT scan of the lumbar spine lumbar performed at St. John's Mercy

Hospital. A 10/23/95 radiology report reflected that the studies had been ordered by Dr. Calvin, and the report noted a history of rule out disc; has had low back pain radiating to the left leg for approximately 2 weeks. Plain film findings were: lumbar vertebral bodies are well aligned; anterior and posterior osteophytes noted at L2-3, L3-4, and L4-5; disc space narrowing, most severe at L5S1; narrowing of the apophyseal joints, with subchondral sclerosis. CT scan through the disc spaces from L2-3 through L5-S1 resulted in the following findings:

There is uniform calcified disc bulging at L2-3. There is disc bulging noted at L3-4, with a focal area of calcified disc protrusion laterally to the left. Facet hypertrophy in this region as well contributes to narrowing of the left lateral neural foramina. There is uniform disc bulging at L4-5, with calcification. There is facet hypertrophy at this level as well, and at all imaged levels. Air noted within the disc space at L3-4 and L4-5. No focal herniations of soft disc material is identified. Recommend correlation of these findings with tomogram of the spine, to determine exact location before surgical intervention. For labeling purposes, a short ribbed $12^{\text {th }}$ thoracic vertebral body and sacralized 5th lumbar vertebral body are noted.

CONCLUSION: 1. Facet hypertrophy and calcified bulging discs noted all levels as described above, resulting in narrowing of the spinal canal. There is a calcified focal area of disc protrusion and/or osteophyte formation within the left lateral position at L3-4. This results in marked narrowing of the left nerual foramina. (sic)

The last treatment note of 10/26/95, handwritten, in Dr. Calvin's record indicated - disc lumbar spine, and pain in left leg continues.

C. Medical records of Karl A. Jacob, M.D. (Cl. Exh. E) included a 12/14/95 operative report which reflected that on that date, Dr. Karl Jacob performed the following operation on Rosenkoetter:

Lumbar decompression laminectomy with laser magnification and microdissection L3-4, L4-5 left for posterior decompression of the dura and cauda equina by undercutting of the lamina and the spinous process space of L3, L4 and L5, lateral recessed decompression by resection of the medial $1 / 2$ of the facet joints of L3-4 and L4-5 and the medical one half of the pedicle base of L4 and L5, L4 and L5 nerve root foraminotomies, partial corpectomy. Posterior lateral caudal margin of the vertebral bodies of L3 and L4 and L5, microdissection and laser lysis of vascular adhesions of the anterior and lateral wall of the vertebral canal and L4 and L5 nerve root. Disk removal L3-4 and L4-5 and posterior interspinous stabilization L3, L4 and L5.

The post-operative diagnosis was: Lumbar spondylosis with myelopathy, severe, L3-4 and L4-5. Spinal stenosis, L3-4 and L4-5. Left lateral recessed stenosis, L3-4, L4-5. Displacement disk, lumbar L3-4, L4-5 left. Cicatrix of the nerve roots L4 and L5 left. Dr. Jacob wrote in a 5/6/96 entry the following:

The patient is discharged from follow-up as far as her lumbar spine is concerned. She is to do conditioning for approximately one month after which she can return to work with a 25 pound limit weight lifting restriction. She is to do no lifting that involves bending over at the waist. She should continue a weight loss program since I've told the patient and her husband who accompanied her to the examining room that this is vital to maintenance of her back over a long period of time. If she has any further difficulty in the future, we would be happy to see her again. Otherwise, she is discharged from current follow-up.

Dr. Jacob's record included additional treatment/examination reports beginning with a 06/18/97 re-examination report in which the doctor wrote:

This is a re-examination of this 51-year-old patient of Dr. Glen Calvin who has had right lower extremity pain progressive and involving the area of the distal thigh and the knee, as well as below the knee. A month and a half ago she saw Dr. Rende regarding the right knee. An MRI was negative and the orthopedist said that he thought the pain was related to the patient's back and referred her here.

The patient has had a rather precipitous weight gain since her last surgery for left-sided radicular pain which has now cleared. She has pain in the back of the right thigh and leg distally into the foot and ankle. This pain increases with walking. It does not increase with coughing, sneezing, bending or lifting. She has no bowel or bladder symptoms.

It was noted that Rosenkoetter had a family history of her mother being a diabetic. Examination findings on 6/18/97 included: right upper extremity motor, sensory and DTR exams are grossly normal; on the left, weakness of abduction and adduction of the fifth finger, numbness in the ulnar distribution and weakness of opposition of the thumb on the left greater than the right; chest, heart, lung and abdominal exams are grossly within normal limits; low back - lumbosacral paravertebral muscle spasm, right sciatic notch tenderness positive straight leg raising on the right in the sitting position at about 30 degrees, and negative straight leg raising on the left; left lower extremity motor, sensory and DTR exams are normal; right lower extremity knee reflex is hypoactive; ankle reflex fatigues; some weakness of dorsiflexion of the right foot and great toe and weakness of the quadriceps on the right compared to the

left; Romberg, gait and station is difficult to evaluate because of the patient's weight, however she does a reasonable job of walking heel-to-toe. Dr. Jacob's written impression on 6/18/97 was: 1. Lumbar spondylosis with myelopathy; 2. Rule out displacement disc, lumbar, L3-4, right; and 3. Morbid obesity. An MRI of the spine was scheduled, and Rosenkoetter was to return for follow-up. The next examination report in Dr. Jacob's record was dated 04/01/98, and the doctor wrote that Rosenkoetter was a patient of Dr. Calvin who had reinjured her back at work three months ago bending over putting cushions in a box and heard a popping of her back and pain radiating to the right lower extremity. The pain became progressively worse in spite of conservative management, Dr. Jacob wrote, she can no longer work at her regular employment because of the pain. Dr. Jacob reported similar examination findings, and the diagnoses remained the same as on 6/18/97; there were no written treatment recommendations. The next and last document in Dr. Jacob's record was a 5/24/99 MRI report concerning the lumbar spine; the history noted in the MRI report was: "Lumbar surgery 3 years ago. Recent falls at work with low back pain and left lower extremity radicular pain." The written impression in the 5/24/99 MRI report was: a. Transitional lumbosacral segment which has been referred to as transitional $1^{\text {st }}$ sacral segment (appears to be sacralized bilaterally, there appears to be a rudimentary nonfunctional disk space cauded to the disk space); b Postsurgical changes on the left at L3-4 and L4-5; and c. Severe degenerative disk disease at L3-4, L4-5 and L5-S1. Disk protrusion lateralizes to the right within the canal at L5-S1; Abnormality extends laterally in the canal into the foramen on the left at L4-5 as discussed above; There is some encroachment left greater than right at L3-4.

D. Records of Dr. Glen D. Calvin, D.O. of Calvin Medical Center (Clt's. B) reflected treatment of Rosenkoetter for various ailments (i.e. cough, congestion, pharyngitis, otitis) during the period of March of 1996 through March of 1999. The following are examples of treatment entries. 2/10/97 - acute viral syndrome with secondary problems, symptoms are headaches, eye pain, cervical spine pain, back pain, sneezing, coughing; treatment included Ultram. 5/5/97 - complaints of pulled muscle in left side mid-back for 24 hours after lifting on carpeting; typed entry included that exam revealed severe spasm of the TS and neurological was essentially neg, and was started on Anaprox and Ultram for pain, and therapy. 5/9/97 - continued back pain; written was - "...she had surgery from Dr. Jacobs approx 2 years ago and she was told that there would be a possibility that she would have to have the other side operated on and she states that it has come to the pt. where she thinks that she needs to go back to see him because of the discomfort in the LS and (therapy) is not helping that much and also she is having a lot of family diff. And we will put her on Paxil" (sic); the diagnosis was - LS strain and Sit. Depression. 5/15/97 - treated for viral syndrome with ear infection, and given a slip for work. 5/29/97 - lifted on 5/27/97 two 15-lbs of liquid soap and strained upper back and neck and has severe muscle spasm on exam with cervical spine strain and upper back strain, physical therapy was given and medication of Ultram, and given slip to go back to work the next day. 6/16/97 - complaints of head and chest congestion, "will continue her on antibiotic and Claritin and we will give her breathing treatment today of Preventil and RTW on 6/23/98-She states that she is so run down that she cannot return to work". 6/30/97 - complaints of continued sinus pressure and drainage for 24 hours which came on after working in hay field all day, treatment was continued Claritin and repeat round of antibiotics and RTW that evening if feeling fine. 9/16/97 - "Acute LS strain with muscle spasm and having problems with lifting and had stabilization rods put in her back and now she is lifting again and having severe pain"; the handwritten 9/16/97 entry noted - mid and low back pain for 2 days, states strained while lifting heavy pots at family reunion on 9/14/97. 9/19/97 - treating her all week with an acute LS strain with previous surgery and back injuries, she is seeing Dr. Jacobs, we have been treating since $9 / 16 and allow her to RTW on 9 / 22$ and ask if all possible that she do no heavy lifting but we will let her have a trial of work; "Some improvement, but DX is reoccurrence of an acute LS strain with symptoms of ruptured disc in the LS".

The next entry in Dr. Calvin's record after 9/19/97 was an 11/20/97 entry in which the following was written: "Seen with $\mathrm{c} / \mathrm{o}$ of LS pain and goes down into the rt. leg. States hurt this while bending and lifting a box while at work". Examination findings were: some LS pain radiating into the rt. lower extremity, palpation of LS area reveals a fairly moderate to large sized lipoma which produces more pain and especially into the rt. lower extremity; therapy was started and referral to Dr. Rao for possible excision of lipoma of the rt. LS area. 12/4/97 - complaints of bad pain in the lower rt. present for some time, is under the care of Dr. Jacobs for this who is thinking about surgery apparently on the back, here today due to the unrelenting discomfort, would like to put her on Ultram until she can get in to see Dr. Jacobs; DX - probable ruptured disc of the LS. 1/6/98 - here with acute pyeloneuphritis, needs slip for work and to return in near future; no other significant findings. 1/9/98 - no show for appt. 1/27/98 - complaints of vomiting, fever, cough, body aches, ear pain, sore throat; referred to Dr. Chen due to chronic nature of the positive findings; DX was - 1. acute otitis media, 2. acute pharyngitis, and 3. bronchitis. 1/30/98 - doing much better however still has resolving cough; DX resolving bronchitis and otitis. 2/10/98 - complaints of vertigo, chills, fever and ear pain for last 2 days; has been putting up with these symptoms now since Jan 23, started on Lorbid and referred to an ENT specialist.

After 2/10/98, the next entry was dated 4/9/98, and included - "Here today with an acute anxiety episode with chronic problems with carpal tunnel, chronic degenerative back disease, possible ruptured disc", has some previous stabilization surgeries; "We recommend that she have further work up if her workman's comp. will approve of it"; she will be placed on BuSpar for mild anxiety; no other significant findings. 5/19/98 - treated for diagnosis of fungal infection of the right foot; 5/28/98 - advised to stay off feet; 6/9/98 referred to pediatrist and kept off work until then. The next entry of 6/16/98 indicated - treated for DX of Acute pharyngitis, and Sinusitis.

E. Medical records of Dr. John Kefalas, M.D. (Cl's F) concerned the treatment of Rosenkoetter from 2/26/98 - 5/5/99. The 2/26/98 entry reflected the chief complaint as - right knee injury. It was written that Rosenkoetter relayed that while at home she had fallen sustaining a twisting injury to the right knee. The diagnosis after x-ray and physical examination was - Acute right knee injury with probable patellofemoral subluxation possible, and Quadriceps tendon injury and possible meniscal injury. Rosenkoetter was placed in a neoprene sleeve, was taken off work, and was to return in 2 weeks. The next entry of 3/12/98 included that

Rosenkoetter relayed her knee symptoms were slightly improved, and that she had re-injured her right long finger recently at home. The plan was to observe the right long finger with instructions for digital motion, and for the knee continued use of the neoprene sleeve, quad and hamstring strengthening exercises, and return in 5 weeks; it was written that Rosenkoetter could return to regular duty at work as of $3 / 23 / 98$.

Expert medical opinions were offered in this case. Dr. Bruce Schlafly, who evaluated the claimant on her own behalf, stated the following about the November 1997 injury: Strained her back while working in November, 1997 as a result of bending over to put a seat in a box and felt pain in her low back on the right side of spine; Dr. Jacob had an MRI of the lumbar spine performed on 5/24/99 which showed some post-op changes with severe degenerative disc disease at L3-4, L4-5, and L5-S1 as well as right-sided disc protrusion at L5-S1; no surgery was performed; Rosenkoetter continues to experience pain from the injury at the right side of the lower lumbar spine with some intermittent right leg pain. Dr. Schlafly opined:

Mrs. Rosenkoetter slipped and fell at work on or about 8/25/95, injuring her low back. This work injury is the substantial factor in the cause of her low back condition that necessitated Dr. Jacob's surgical treatment. In my opinion, Mrs. Rosenkoetter has a 42.5 percent permanent partial disability of the body as a whole referable to the low back as a result of this injury, which necessitated Dr. Jacob's surgical treatment. She has an additional 7.5 percent permanent partial disability of the body as a whole referable to the low back on the basis of the work injury of 11/97 that resulted in strain with right lower extremity symptoms.

On cross examination, Dr. Schlafly (who agreed that Rosenkoetter had told him she had not had any prior back problems before the 8/25/95 fall on the tag) was shown the October 1995 record of Dr. Calvin in which it was written that Rosenkoetter had had an auto accident in 1987, care for last two years, worse last six months, pain in small of back and hip and legs; Dr. Schlafly agreed that if this was true then Rosenkoetter had problems with her low back from 1987 for the next six years; Dr. Schlafly agreed that this would be inconsistent with the history Rosenkoetter had given him; Dr. Schlafly admitted that he did not know about a 10/15/95 injury. It was noted that Dr. Calvin's 9/16/97 record reflected that Rosenkoetter had strained her back while lifting heavy pots at a family reunion on 9/14/97 and was having problems with her back, and was seeing Dr. Jacobs and the diagnosis was recurrence of an acute lumbar strain with symptoms of ruptured disc; Dr. Schlafly stated that he was aware of this entry, and that he had taken into account this 9/14/97 incidence. I did not assess any permanency for the 9/14/97 incident, Dr. Schlafly said, and explained "I was not aware that Dr. Jacobs, her treating neurosurgeon, attributed anything to it". (Schlafly Dp. pg. 51) Dr. Schlafly stated that he did not mention the 9/14/97 incident in his report, and noted that he did not recall that a disc herniation was confirmed by any testing by Dr. Calvin at that time. Dr. Schlafly stated that if Dr. Calvin's report was correct, that Rosenkoetter had a 9/14/97 incident and continued to have low back pain, muscle spasm, and a recurrence of symptoms of a ruptured disc in her lumbar spine, then that would change his opinion. Explaining how it would change his opinion, Dr. Schlafly testified: "Well, it would suggest that that was, in fact, a major incident of trauma that perhaps exceeded the incident of trauma at work in November 1997." (Schlafly Dp. pg. 52) "Right now I don't recall discussing that with her, so I may not have", Dr. Schlafly admitted. (Schlafly Dp. pg. 52) The doctor admitted that he might attribute the 71 / 2 % permanent partial disability he had assessed to the November 1997 incident, or a large portion of it, to the $9 / 14 / 97$ incident.

Dr. Mirkin stated that he evaluated the claimant on behalf of the employer/insurer. (Emp./Ins. 1). The evidence indicates that Dr. Mirkin saw Rosenkoetter on several occasions during the period of March of 1998 through July of 2002. During cross examination by the claimant, Dr. Mirkin stated that he evaluated Rosenkoetter's back, only, and did not assess her for any other possible ailments, such as high blood pressure, a right shoulder injury, a 1998 left tibial plateau fracture and left knee sprain, or bilateral carpal syndrome; I knew of none of these things, the doctor said, I'm looking at her intake sheet and none of those things are checked off. The doctor stated that this intake sheet was dated 2/18/97, and was the only intake sheet he had by Rosenkoetter. Dr. Mirkin agreed that in all of his reports he only refers to an injury in 1995. Agreeing that therefore in all of his opinions where he is talking about whether or not it is work related it's all relating to the injury in 1995, Dr. Mirkin further stated: "When I did these reports, that's the only injury she made me aware of." (Mirkin Dp. pg. 27)

Dr. Poetz evaluated the claimant on the claimant's behalf ( $\mathrm{Cl}^{\prime} \mathrm{s}$. H), and testified about work related injuries as relayed by Rosenkoetter, which included: 1. August 25, 1995 - slipped on a paper tag which caused her to twist her right ankle and knee before falling onto a table, with ongoing occasional pain and swelling at the ankle and knee, and on September 15, 1995 was seen at Healthline and diagnosed with mild right ankle sprain and right knee sprain, and physical therapy was recommended; also reported was that after the incident Rosenkoetter developed lower back, left hip and left leg pain; treatment for the back included radiological studies, and surgery. 2. November 18, 1997 - developed a burning sensation and pain in the lower back while bending and lifting a box at work; treatment was medication and restrictions, and with continuing problems radiological studies were performed including an MRI. Diagnoses made by Dr. Poetz included: 1) 8/25/95 - Lumbar strains with degenerative disc disease; lumbar spondylosis with myelopathy, severe L3-4, L4-5; displacement disc, lumbar L3-4, L4-5 left and cicatrix of the nerve roots L4 and L5 left; Status post lumbar decompression laminectomy with laser magnification and microdissection L3-4 and L4-5 left; 2) Lumbar degenerative disc disease and spinal stenosis, L3-4, L4-5, pre-existing; 3) 11/18/97 - Lumbar strain and disc protrusion L5-S1 with exacerbation of pre-existing lumbar condition. Dr. Poetz testified about knowing of Dr. Calvin's 9/16/97 record in which it was mentioned that Rosenkoetter reported that on 9/14/97 she was lifting heavy pots at a family reunion and had an increase in her back complaints: "Yeah, I think I knew about that, but that was considered to be insignificant by her, so it wasn't listed". (Poetz Dp. pg. 56) During cross examination, Dr. Poetz agreed that at the time of his exam, Rosenkoetter was five foot five and 279 pounds; the doctor agreed

that he had characterized Rosenkoetter as morbidly obese. Agreeing that morbid obesity adversely affects Rosenkoetter's back, Dr. Poetz testified: "Well, it makes the back work harder". (Poetz Dp. pg. 66) Dr. Poetz agreed that Rosenkoetter did not provide him any history of additional trauma or repetitive activities that caused her to develop pain with her back. The doctor was queried if he had been provided with any history of Rosenkoetter doing some work painting floors in a stooped position and developing pain complaints in the back as of 10/15/95. "Not to my knowledge", the doctor answered. (Poetz Dp. pg. 75)

Under Missouri law, the employee carries the burden of proving all essential elements of the claim, including causation. Lawrence v. Joplin R. VII School District, 834 S.W.2d 789 (Mo. 1992). The employee must establish a causal connection between the accident and the claimed injuries. Fischer v. Archdioceses of St. Louis, 791 S.W.2d 195 (Mo.App. 1990).

A claimant must show not only causation between the accident and the injury but also that a disability resulted and the extent of such disability. Smith v. National Lead Co., 228 S.W.2d 407, 412(4) (Mo.App.1955). While proof of cause of injury is sufficiently made on reasonable probability (Smith v. Terminal Transfer Company, 372 S.W.2d 659, 664(7) (Mo.App.1963)), proof of permanency of injury requires reasonable certainty. Davis v. Brezner, 380 S.W.2d 523, 588(69) (Mo.App.1964). Whatever may be the quantum of proof the law imposes on a given issue in a compensation case, however, such proof is made only by competent substantial evidence and may not rest on surmise or speculation. Griggs v. A. B. Chance Co., 503 S.W.2d 697, 703 (Mo.App. 1973).

"For an injury to be compensable the evidence must establish a causal connection between the accident and the injury. The testimony of a claimant or other lay witness can constitute substantial evidence of the nature, cause and extent of the disability when the facts fall within the realm of lay understanding.

"An injury may be of such a nature [however] that expert opinion is essential to show that it was caused by the accident to which it is ascribed." (Citations omitted) Griggs, 503 S.W.2d at 704.

"...an injury may be of such a nature that expert opinion is essential to show that it was caused by the accident to which it is ascribed. When the condition presented is a sophisticated injury that requires surgical intervention or other highly scientific techniques for diagnosis, and particularly where there is a serious question of pre-existing disability and its extent, the proof of causation is not within the realm of lay understanding..." Knipp v. Nordyne, Inc. 969 S.W.2d 236, 240 (Mo.App. 1998)

"Medical causation not within common knowledge or experience, must be established by scientific or medical evidence showing the cause and effect relationship between the complained of condition and the asserted cause." Selby v. Trans World Airlines, Inc., 831 S.W.2d 221, 222 (Mo.App. 1992).

"A medical expert's opinion must have in support of it reasons and facts supported by competent evidence which will give the opinion sufficient probative force to be substantial evidence." (citations omitted) Pippin v. St. Joe Minerals Corp., 799 S.W.2d 898, 904 (Mo.App. 1990)

In this case, it was agreed and stipulated to by the parties that on or about November 19, 1997, the claimant while in the employment of Integram St. Louis Section sustained an injury by accident arising out of and in the course of her employment. It is found that the evidence reveals that the claimant's low back is the area of injury from the November 1997 work event. The medical evidence further reveals, though, that the claimant has had multiple injuries to her low back from various causes prior to and subsequent to the November 19, 1997 work incident as well as extensive testing by doctors in determining the diagnosis of back problems for the claimant, thus the nature and causal connection of a back injury with the November 19, 1997 work event is found to be a sophisticated matter and the proof of causation of the back injury as a result of the November 19, 1997 work related event is not within the realm of lay understanding and medical expert opinion is necessary.

It is found, considering the expert medical opinions, that by Dr. Mirkin's admission that the only injury he was aware of was a 1995 back injury, Dr. Mirkin does not offer a competent opinion in the medical causation issue in the 1997 case. It is found that both Dr. Schlafly and Dr. Poetz offered opinions that were probative on diagnosis and causation of the injury caused by the November 19, 1997 work related event, though both made admissions or acknowledgements of medical evidence that were against their stated opinions. Dr. Schlafly, who diagnosed low back strain with right lower extremity symptoms and noted in his assessment of permanent disability that Rosenkoetter had intermittent right leg pain, stated that he gave little significance to Rosenkoettter's 9/14/97 low back injury as it appeared that Dr. Jacob had give little importance to the 9/14/97 back injury; Dr. Jacob, it is found, on

4/1/98 (subsequent to both the 9/14/97 and 11/19/97 injuries), gave the same diagnosis as he had on 6/18/97. However, based on Dr. Calvin's record (which reflects on 9/16/97 a diagnosis of acute lumbar spine strain after lifting heavy pots at family reunion two days earlier), notes on 9/19/97 a reoccurrence of an acute lumbar spine strain with symptoms of ruptured disc in the lumbar spine; Dr. Schlafly admits that this would indicate that 9/14/97 was a major incident that perhaps exceeded the incident of trauma at work in November 1997. Dr. Poetz, who diagnosed lumbar strain and disc protrusion L5-S1 with exacerbation of pre-existing lumbar condition, stated that he was aware of the 9/14/97 injury but did not list it as he relied on Rosenkoetter's opinion that this injury was insignificant. It is found that the substantial weight of the medical evidence does not support the portion of Dr. Poetz' diagnosis for the 11/19/97 injury of a disc protrusion at L5-S1; in addition to Dr. Calvin's record which states in an 11/20/97 entry - complaints of lumbar pain that goes down into the right leg, and in a 12/4/97 entry a diagnosis of - probable ruptured disc of the lumbar spine, there was the following evidence: a. radiographic studies indicated severe degenerative problems at L5-S1 on 10/23/95; b. Dr. Jacob noted Rosenkoetter's complaints of right thigh and lower leg pain on 6/18/97; c. in a 5/24/99 MRI report findings included disc protrusion to the right within the canal L5-S1; d. Healthline records of treatment for the November 19, 1997 work related injury included an 11/19/97 entry which noted a diagnosis of - low back pain, and a 12/07/97 entry noted - low back pain resolving, denies any paresthesia or radicular symptoms . It is found that the substantial weight of the competent medical evidence, giving some weight to both Dr. Schlafly's and Dr. Poetz' opinions, establishes that as a result of the November 19, 1997 work related accident the claimant sustained a back injury of - a low back strain, and an exacerbation of pre-existing lumbar condition and intermittent right leg pain.

It has been determined in this Award that the substantial weight of the competent medical evidence, giving some weight to both Dr. Schlafly's and Dr. Poetz' opinions, establishes that as a result of the November 19, 1997 work related accident the claimant sustained a back injury of a low back strain, and an exacerbation of pre-existing lumbar condition and intermittent right leg pain.

The claimant testified that when she went back to work after about a week subsequent to the November 1997 work related back injury, she just had the pain all the time. It was just miserable because my back hurt and the more places that I went to do the job, then it was just hard, the claimant said. I was not able to do the same amount of work like I used to, she said. Giving an example, Rosenkoetter testified that the fork truck drivers would bring the seats in big boxes and you'd have to bend over and get an armful and put them on the bins for the air bag blower, and that's what was really hard because of the bending and lifting the bunch of seat covers, so I always tried to trade that off with anybody that I could get to trade with.

On the issue of any permanent partial disability as a result of the November 19, 1997 work related low back injury, it is found, some weight is given to the claimant's testimony (it is found that the claimant was forgetful of some other incidents of injuries and exacerbations to her low back before and after the November 1997 work injury with continuing problems, as reflected in the medical records), and some weight is given to Dr. Schlafly's and Dr. Poetz' opinions (it was found that both Dr. Schlafly and Dr. Poetz offered opinions that were probative, though both made admissions or acknowledgements that were against their stated opinions, additionally a portion of Dr. Poetz' diagnosis for the work related injury was not supported by the medical evidence). Dr. Schlafly admitted that he might attribute the 71 / 2 % permanent partial disability he had assessed to the November 1997 incident, or a large portion of it, to the 9/14/97 incident. Dr. Poetz assessed a total of 40 % permanent partial disability to the body as a whole as measured at the lumbar spine, pre-existing, and assessed 15 % permanent partial disability to the body as a whole as measured at the lumbar spine directly resultant from the November 18, 1997 work related injury. It is found that there is substantial and competent evidence to support an award for permanent partial disability as a result of the November 19, 1997 work related low back injury of 7 % permanent partial disability. This would be: $7 \% \times 400 weeks =28 weeks; 28 weeks \times \$ 278.42 / week =\ 7795.76.

It has been determined in this Award that as a result of the November 19, 1997 work related accident the claimant sustained a back injury of a low back strain, and an exacerbation of pre-existing lumbar condition and intermittent right leg pain.

The parameters of Second Injury Fund liability in permanent partial disability cases is set forth in Section 287.220.1 RSMo 1993, which states in pertinent part:

All cases of permanent disability where there has been previous disability shall be compensated as herein provided. Compensation shall be computed on the basis of the average earnings at the time of the last injury. If any employee who has a preexisting permanent partial disability whether from compensable injury or otherwise, of such seriousness as to constitute a hindrance or obstacle to employment or to obtaining reemployment if the employee becomes unemployed, and the preexisting permanent partial disability, if a body as a whole injury, equals a minimum of fifty weeks of compensation or, if a major extremity injury only, equals a minimum of fifteen percent permanent partial disability, according to the medical standards that are used in determining such compensation, receives a subsequent compensable injury resulting in additional permanent partial disability so that the degree or percentage of disability, in an amount equal to a minimum of fifty weeks compensation, if a body as a whole injury or, if a major extremity injury only, equals a minimum of fifteen

percent permanent partial disability..... (Emphasis added)

In this case, the percentage of permanent partial disability for the subsequent compensable injury, the 1997 work related injury as a result of the claimant lifting a large passenger seta and placing it in a box, was found to be 7 % permanent partial disability. This is below the threshold set for consideration of any Second Injury Fund liability, and thus Second Injury Fund liability is denied.

It has been determined in this Award that the substantial weight of the competent medical evidence establishes that as a result of the November 19, 1997 work related accident, the claimant sustained a back injury of a low back strain, and an exacerbation of pre-existing lumbar condition and intermittent right leg pain. The claimant testified about submitting a number of medical bills into evidence concerning carpal tunnel surgery and for the other treatment she had received which no one has paid. It was agreed and stipulated to by the claimant and the employer/insurer that bills in issue were entered in Claimant's Exhibit No. A marked as A-11, and entered into evidence marked as Claimant's Exhibit Nos. M, M-1, N, N-1, O P and Q. The evidence also includes a bill for medical services marked as Claimant's Exhibit S. Considering the bills in evidence, it is found that none of them reflect charges for treatment of the back as a result of the November 19, 1997 work related incident. Consequently, it is found that there is an insufficient factual basis upon which to award compensation for past medical expenses. See, generally, Martin v. MidAmerica, 769 S.W.2d 105, 111-112 (Mo. banc 1989).

Rosenkoetter testified that after the November 18, 1997 back injury at Integram she had pain in her low back in the same area as where she had had surgery in December 1995, and agreed that some time after the November 18, 1997 injury, but not that night, the pain went down her right leg. For the November 1997 back injury I went to see Dr. Calvin and I had a knot come up in my hip and he gave me muscle relaxers and some pain medicine, and he has a therapy machine in his office and I got therapy there, the claimant stated. She was asked how long did she get therapy, and Rosenkoetter responded - I was off work for about a week, I think. When I went back to work after about a week, I just had the pain all the time, the claimant said, it was just miserable because my back hurt and the more places that I went to do the job, it was just hard. I was not able to do the same amount of work like I used to, she said, and it was really hard because of the bending and lifting, so I always tried to trade that off with anybody that I could get to trade with.

I have constant pain all the way down my leg to my heel still today, the claimant said. I'm going to therapy now because I can't hardly get around; my legs just don't work as well. I fell going up my steps, two steps, that I have gone up them a thousand times before; I broke my tibia in my left leg because I thought my foot was up high enough for the step, she said. Also I stepped over a little fence, maybe nine inches tall, and I fell again; I have come out of the barn and when I stepped on the step then my ankle just turned, Rosenkoetter testified. I just think my legs are up high enough, but they aren't, the claimant stated. I have slipped in a hole in the yard and fell, Rosenkoetter stated, and my last thing last week I fell and hurt my arm, all I was doing was walking on the driveway, but my right leg wouldn't come when I was stepping and I just went face down. I attribute these falls at home to my back and my legs, they just don't work right, she said. The claimant was asked if this came from the 1995 back injury, the 1997 back injury with the bench seat, or both. The 1995, she answered. When asked if they got worse in 1997, Rosenkoetter responded - They just seem to be getting worser all the time; the pain never goes away. Since November 18, 1997, every so often my ankle will start aching, I'll be limping around for a while, then it'll get better, the claimant said. It hurts me to walk if I walk a ways, she stated, and sometimes it aches at night; when it gets cold, it hurts. The pain is about a five or a six out of ten, she said. Concerning how far she can walk before the ankle starts swelling up, Rosenkoetter stated that as soon as she gets on her feet it starts swelling.

The claimant testified about the treatment she is getting now. I've been going to Dr. Calvin, Rosenkoetter said, and I go to the therapy at BJC in Union, Missouri twice a week now because of the pain in my right back. When I go Thursday they're supposed to fit me for a cane, she said. This is the second week that I have been going to the BJC Health Care, going twice a week, the claimant stated. I'm getting the cane so when I'm walking it'll help me sturdy myself, maybe keep me from falling, she said. Medicare is paying for this, the claimant stated.

Considering the medical evidence and opinions, the Healthline record reflected treatment for the November 19, 1997 work related back injury; in the last treatment note of 12/01/97, the diagnosis was - Low back pain resolving, Ibuprofen and Flexeril was continued, and Rosenkoetter was returned to full duty work, no restrictions.

The records of Dr. Karl A. Jacob, M.D. (Cl. Exh. E) began with a 10/30/95 initial office exam report; the doctor treated Rosenkoetter for her 1995 low back injury, including surgery on 12/14/95. Dr. Jacob wrote in a 5/6/96 entry that Rosenkoetter was discharged after the 1995 back surgery. The doctor further wrote:

The patient is discharged from follow-up as far as her lumbar spine is concerned. She is to do conditioning for approximately one month after which she can return to work with a 25 pound limit weight lifting restriction. She is to do no lifting that involves bending over at the waist. She should continue a weight loss program since I've told the patient and

her husband who accompanied her to the examining room that this is vital to maintenance of her back over a long period of time. If she has any further difficulty in the future, we would be happy to see her again. Otherwise, she is discharged from current follow-up.

In a 06/18/97 re-examination report, Dr. Jacob wrote:

This is a re-examination of this 51-year-old patient of Dr. Glen Calvin who has had right lower extremity pain progressive and involving the area of the distal thigh and the knee, as well as below the knee. A month and a half ago she saw Dr. Rende regarding the right knee. An MRI was negative and the orthopedist said that he thought the pain was related to the patient's back and referred her here.

The patient has had a rather precipitous weight gain since her last surgery for left-sided radicular pain which has now cleared. She has pain in the back of the right thigh and leg distally into the foot and ankle. This pain increases with walking. It does not increase with coughing, sneezing, bending or lifting. She has no bowel or bladder symptoms.

Examination findings on 6/18/97 included: low back - lumbosacral paravertebral muscle spasm, right sciatic notch tenderness positive straight leg raising on the right in the sitting position at about 30 degrees, and negative straight leg raising on the left; left lower extremity motor, sensory and DTR exams are normal; right lower extremity knee reflex is hypoactive; ankle reflex fatigues; some weakness of dorsiflexion of the right foot and great toe and weakness of the quadriceps on the right compared to the left; Romberg, gait and station is difficult to evaluate because of the patient's weight, however she does a reasonable job of walking heel-to-toe. Dr. Jacob's written impression on 6/18/97 was: 1. Lumbar spondylosis with myelopathy; 2. Rule out displacement disc, lumbar, L3-4, right; and 3. Morbid obesity. An MRI of the spine was scheduled, and Rosenkoetter was to return for follow-up. Dr. Jacob's record next reflected treatment of Rosenkoetter after 6/18/97 on 04/01/98. In the 04/01/98 entry, Dr. Jacobs noted that Rosenkoetter had reinjured her back at work about three months earlier bending over putting cushions in a box and heard a popping of her back and pain radiating to the right lower extremity; Dr. Jacob reported similar examination findings and the diagnoses remained the same as on 6/18/97; there were no treatment recommendations written.

Records of Dr. Calvin, D.O. of Calvin Medical Center (Claimant's Exh. No. B) reflected treatment of Rosenkoetter for various ailments (i.e. cough, congestion, pharyngitis, otitis) during the period of March of 1996 through March of 1999. A 9/16/97 entry included: "Acute LS strain with muscle spasm and having problems with lifting and had stabilization rods put in her back and now she is lifting again and having severe pain"; a handwritten 9/16/97 entry noted - mid and low back pain for 2 days, states strained while lifting heavy pots at family reunion on 9/14/97. 9/19/97 - treating her all week with an acute LS strain with previous surgery and back injuries, she is seeing Dr. Jacobs, we have been treating since 9/16 and allow her to RTW on 9/22 and ask if all possible that she do no heavy lifting but we will let her have a trial of work; "Some improvement, but DX is reoccurrence of an acute LS strain with symptoms of ruptured disc in the LS". The next entry in Dr. Calvin's record was dated 11/20/97 and written was: "Seen with c/o of LS pain and goes down into the rt. leg. States hurt this while bending and lifting a box while at work". Examination findings were: some LS pain radiating into the rt. lower extremity, palpation of LS area reveals a fairly moderate to large sized lipoma which produces more pain and especially into the rt. lower extremity; therapy was started and referral to Dr. Rao for possible excision of lipoma of the rt. LS area. 12/4/97 - complaints of bad pain in the lower rt. present for some time, is under the care of Dr. Jacobs for this who is thinking about surgery apparently on the back, here today due to the unrelenting discomfort, would like to put her on Ultram until she can get in to see Dr. Jacobs; DX - probable ruptured disc of the LS. 1/6/98 - here with acute pyeloneuphritis, needs slip for work and to return in near future; no other significant findings. 1/9/98 - no show for appt. 1/27/98 - complaints of vomiting, fever, cough, body aches, ear pain, sore throat; referred to Dr. Chen due to chronic nature of the positive findings; DX was - 1. acute otitis media, 2. acute pharyngitis, and 3. bronchitis. 1/30/98 - doing much better however still has resolving cough; DX - resolving bronchitis and otitis. 2/10/98 - complaints of vertigo, chills, fever and ear pain for last 2 days; has been putting up with these symptoms now since Jan 23, started on Lorbid and referred to an ENT specialist. The next entry was dated 4/9/98, and included - "Here today with an acute anxiety episode with chronic problems with carpal tunnel, chronic degenerative back disease, possible ruptured disc", has some previous stabilization surgeries; "We recommend that she have further work up if her workman's comp. will approve of it"; she will be placed on BuSpar for mild anxiety; no other significant findings. 5/19/98 - treated for diagnosis of fungal infection of the right foot; 5/28/98 - advised to stay off feet; 6/9/98 referred to pediatrist and kept off work until then. The next entry of 6/16/98 indicated - treated for DX of Acute pharyngitis, and Sinusitis. Dr. Calvin's record reflected treatment of Rosenkoetter for unrelated matters on 9/1/98, 11/24/98, 12/8/98 and 12/18/98. The next entry of 1/6/99 included in the handwritten section - "c/o of left hip pain. No known injury. X-6 months."; the typed 1/6/99 entry stated that Rosenkoetter presented with low back pain radiating into the left hip, x-rays showed degenerative disease in the hip socket, it was written that she "has severe osteoarthritis, scoliosis of the spine" and she has had previous surgery in the past; the plan was evaluation by an orthopedist. January 1999 entries (2) concerned treatment for Chronic bronchitis and for Acute viral gastritis. 2/2/99 - complaints of lower back pain for one day, noticed after picking up laundry basket; the typed 2/2/99 entry noted complaints of left lower back pain, physical exam reveals spasm in LS area more on the left than right and no neurological deficits; therapy was to be started, and Rosenkoetter was to be returned back to work that evening; the DX was - LS strain. The final entries of 3/3/99 and 3/9/99 concerned treatment for symptoms of bronchitis and pharyngitis.

Dr. Schlafly (Cl's. A) evaluated the claimant on the claimant's behalf and filed a report dated March 1, 2001 which included his opinions about the November 19, 1997 work related low back injury. In the Analysis Section of his March 1, 2001 report, Dr.

Schlafly noted that Rosenkoetter had injured her low back in 1995 and had had surgical treatment by Dr. Jacob; Dr. Schlafly assessed permanent partial disability for the 1995 low back injury. Dr. Schlafly further wrote in his report:

She has an additional 7.5 percent permanent partial disability of the body as a whole referable to the low back on the basis of the work injury of 11/97 that resulted in strain with right lower extremity symptoms. The MRI scan that was then performed on 5/24/99 suggested a disc problem to the right side at L5-S1, and Mrs. Rosenkoetter should return to the care of Dr. Jacob for further evaluation and treatment as necessary of her low back. It is possible that further surgery may be required. As a result of her low back condition, she cannot engage in work that requires her to lift more than 20 lbs., or to perform activities such as bending, stooping, twisting, or squatting.

On cross examination, it was noted that in Dr. Calvin's 9/16/97 record was that Rosenkoetter had strained her back while lifting heavy pots at a family reunion on 9/14/97 and was having problems with her back and was seeing Dr. Jacobs, and the diagnosis was recurrence of an acute lumbar strain with symptoms of ruptured disc; Dr. Schlafly stated that he was aware of this entry, and that he had taken into account this 9/14/97 incidence. Dr. Schlafly stated that he did not mention the 9/14/97 incident in his report, and noted that he did not recall that a disc herniation was confirmed by any testing by Dr. Calvin at that time. "I was not aware that Dr. Jacobs, her treating neurosurgeon, attributed anything to it", Dr. Schlafly testified. (Schlafly Dp. pg. 51) Dr. Schlafly stated that if Dr. Calvin's report was correct, that Rosenkoetter had a 9/14/97 incident and continued to have low back pain, muscle spasm, and a recurrence of symptoms of a ruptured disc in her lumbar spine, then that would change his opinion. Explaining how it would change his opinion, Dr. Schlafly testified: "Well, it would suggest that that was, in fact, a major incident of trauma that perhaps exceeded the incident of trauma at work in November 1997." (Schlafly Dp. pg. 52) "Right now I don't recall discussing that with her, so I may not have", Dr. Schlafly admitted. (Schlafly Dp. pg. 52) The doctor stated that he might attribute the 71 / 2 % permanent partial disability he had assessed to the November 1997 incident, or a large portion of it, to the 9/14/97 incident.

Dr. R. Peter Mirkin, M.D., a board certified orthopedic surgeon, Dr. Mirkin stated that he examined Rosenkoetter on several occasions - March 20, 1998, April 7, 1998, September 26, 2001 and July 17, 2002. (Emp/Ins 1) "I reviewed extensive records including records from Dr. Jacob, Dr. Rende, Dr. Calvin, physical therapy notes, records from Healthline", the doctor said. (Mirkin Dp. pg. 6) Dr. Mirkin noted that he also reviewed x-rays of the lumbar spine; "I believe there is some preoperative radiology reports in Jacob's records that I reviewed", the doctor stated. (Mirkin Dp. pg. 7) Dr. Mirkin gave his opinion from his review of xrays and diagnostic studies:

"It was my conclusions this was a lady with very severe degenerative disease in her lumbar spine who underwent a laminectomy. When I first saw her, she really was not having radicular pain. Later on, she was starting to have some recurrent pain, and I recommended that if she had persistent pain that it be reevaluated by MRI or myelogram. (Mirkin Dp. pp. 7-8)

Dr. Mirkin testified as to his diagnoses for Rosenkoetter: "It's my opinion this is a lady with severe degenerative spine disease who underwent a decompression procedure by Dr. Jacobs and still suffers from the effects of her degenerative arthritis disease." (Mirkin Dp. pg. 8) Dr. Mirkin agreed, during cross examination, that as of April 7, 1998 he felt Rosenkoetter needed to be treated by a spine physician; the doctor was queried - you are not disputing that Rosenkoetter needs treatment of the back for her radicular symptoms, it is just a matter of whether or not it is work related. "Correct", Dr. Mirkin answered. (Mirkin Dp. pg. 26) On cross examination by the claimant, it was noted that Dr. Mirkin wrote in his April 7, 1998 report - "She has severe degenerative changes, secondary to degenerative arthritis and her previous surgery, in my opinion". (See, Mirkin Dp. pg. 23) The doctor was queried if his opinion would be the same with an injury that had occurred about two years earlier, and Dr. Mirkin responded:

"If you had a traumatic injury, like a fracture where some bone was removed, or a severe traumatic injury where the facets were disrupted, sure, but you don't generally get degenerative changes from sprains and strains and things like that." (Mirkin Dp. pg. 24)

Dr. Mirkin agreed that in all of his reports he only refers to an injury in 1995. Dr. Mirkin further stated: "When I did these reports, that's the only injury she made me aware of." (Mirkin Dp. pg. 27)

Dr. Robert P. Poetz, D.O. (Cl. Exh. H), an osteopathic physician and surgeon, Dr. evaluated Rosenkoetter on her own behalf on October 26, 2001 and prepared an evaluation report dated June 10, 2002. In his June 10, 2002 evaluation report, Dr. Poetz wrote that he saw Rosenkoetter on October 26, 2001 Dr. Poetz evaluated Rosenkoetter for five alleged work related injuries to various parts of her body; the doctor gave his opinions as to diagnoses for all of the injuries, and in regards to the back his diagnoses included: 1) 8/25/95 - Lumbar strains with degenerative disc disease; lumbar spondylosis with myelopathy, severe L3-4, L4-5; displacement disc, lumbar L3-4, L4-5 left and cicatrix of the nerve roots L4 and L5 left; Status post lumbar decompression laminectomy with laser magnification and microdissection L3-4 and L4-5 left. 2) Lumbar degenerative disc disease and spinal stenosis, L3-4, L4-5, pre-existing. 3) 11/18/97 - Lumbar strain and disc protrusion L5-S1 with exacerbation of pre-existing lumbar condition. Dr. Poetz wrote in the Prognosis section of his evaluation report the following: "The prognosis is guarded due to the length of time elapsed since the injuries and the continuance of pain in all areas of symptomatology." Dr. Poetz' recommendations were: 1. Weight loss; 2. Non-steroidal anti-inflammatory medication; 3. SSRI for treatment of depression; 4. Check blood sugar to evaluate for diabetes; 5. Warm moist packs and range of motion exercises; 6. Avoid heavy lifting and strenuous activity; 7. Avoid

The above-entitled workers' compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review as provided by section 287.480 RSMo. We have heard the oral arguments of the parties. We have reviewed the evidence and considered the whole record and we find that the award of the administrative law judge is supported by competent and substantial evidence and was made in accordance with the Missouri Workers' Compensation Act, except as modified herein. Pursuant to section 286.090 RSMo, we issue this final award and decision modifying the May 13, 2005, award and decision of the administrative law judge. We adopt the findings, conclusions, decision, and award of the administrative law judge to the extent that they are not inconsistent with the findings, conclusions, decision, and modifications set forth below.

The administrative law judge concluded that employee suffered injury in the form of an aggravation of her preexisting personality disorder due to harassment at work. The administrative law judge awarded permanent partial disability of 4 % of the body as a whole referable to the psychiatric condition. We find credible the opinion of Dr. Poetz that employee suffered a 15\% permanent partial disability. Dr. Poetz's opinion is more consistent with employee's description of the impact of the aggravation on her ability to function and the description of employee's mental state appearing in various medical records, including the records of Dr. Calvin and Dr. Oliver.

Dr. Crane believes it is likely that employee will need future medical care including anti-depressants and psychotherapy. We find Dr. Crane's opinion persuasive. Therefore, we modify the award of the administrative law judge to provide that employer shall provide to employee future medical care reasonable and necessary to cure and relieve her of the effects of her aggravated psychological condition.

Because we have determined that employee suffered a 15\% permanent partial disability to the body as a whole, employee meets the threshold for consideration of Second Injury Fund liability. Employee urges that that the "Second Injury Fund should be liable for very substantial permanent partial disability as a result of the combination of the substantial previous disabilities and the depression, which all the competent evidence demonstrates." Unfortunately, the employee did not develop her argument for Second Injury Fund liability in her brief. We will not ferret out the evidence and develop an argument for employee or we risk becoming her advocate. We award no liability against the Second Injury Fund.

The Commission further approves and affirms the administrative law judge's allowance of attorney's fee herein as being fair and reasonable.

Any past due compensation shall bear interest as provided by law. The award and decision of Administrative Law Judge Leslie E. H. Brown, issued May 13, 2005, is attached and incorporated by this reference except to the extent modified herein.

Given at Jefferson City, State of Missouri, this 21st day of March 2006. LABOR AND INDUSTRIAL RELATIONS COMMISSION NOT SITTING William F. Ringer, Chairman

Alice A. Bartlett, Member

Attest:

Secretary

Employee: Mary Rosenkoetter

Invoice No. 98-175851

Employer: Integram St. Louis Section

Address: 9511 W. 1st Street, New York 11, N.Y. 10017

Address: 9511 W. 2nd Street, New York 11, N.Y. 10017

Address: 9511 W. 3rd Street, New York 11, N.Y. 10018

Address: 9511 W. 4th Street, New York 11, N.Y. 10018

Address: 9511 W. 5th Street, New York 11, N.Y. 10019

Address: 9511 W. 6th Street, New York 11, N.Y. 10019

Address: 9511 W. 7th Street, New York 11, N.Y. 10019

Address: 9511 W. 8th Street, New York 11, N.Y. 10019

Address: 9511 W. 9th Street, New York 11, N.Y. 10019

Address: 9511 W. 10th Street, New York 11, N.Y. 10020

1. Are any benefits awarded herein? Yes
2. Was the injury or occupational disease compensable under Chapter 287? Yes
3. Was there an accident or incident of occupational disease under the Law? Yes
4. Date of accident or onset of occupational disease: February 19, 1998
5. State location where accident occurred or occupational disease was contracted: Franklin County, MO
6. Was above employee in employ of above employer at time of alleged accident or occupational disease? Yes
7. Did employer receive proper notice? Yes
8. Did accident or occupational disease arise out of and in the course of the employment? Yes
9. Was claim for compensation filed within time required by Law? Yes
10. Was employer insured by above insurer? Yes
11. Describe work employee was doing and how accident occurred or occupational disease contracted: Factory work.
12. Did accident or occupational disease cause death? No Date of death? ---
13. Part(s) of body injured by accident or occupational disease: Mental injury (Body as a whole)
14. Nature and extent of any permanent disability: 4 % of body as a whole
15. Compensation paid to-date for temporary disability: $\ 0.00
16. Value necessary medical aid paid to date by employer/insurer? $\ 0.00
17. Value necessary medical aid not furnished by employer/insurer? $\ 0.00
18. Employee's average weekly wages: $\ 596.40
19. Weekly compensation rate: $\$ 397.60 / \ 278.42

1. Amount of compensation payable:

Unpaid medical expenses: ---

--- weeks of temporary total disability (or temporary partial disability)

4 % body as a whole permanent partial disability from Employer, or................\$4,454.72

--- weeks of disfigurement from Employer

1. Second Injury Fund liability: No

TOTAL: $\quad \ 4,454.72

1. Future requirements awarded: None

Said payments to begin as of date of this Award and to be payable and be subject to modification and review as provided by law.

The compensation awarded to the claimant shall be subject to a lien in the amount of 25 % of all payments hereunder in favor of the following attorney for necessary legal services rendered to the claimant:

Ray Gerritzen, Attorney for Claimant

Employee: Mary Rosenkoetter

Injury No: 98-175851

Before the

DIVISION OF WORKERS'

COMPENSATION

Department of Labor and Industrial Relations of Missouri

Jefferson City, Missouri

Dependents:

Employer: Integram St. Louis Section

Add. Party: State Treasurer, as Custodian of the Second Injury Fund

Insurer: CNA Insurance Company/RSKCo

Checked by: LEHB:df

This is a hearing setting for five cases involving the claimant, Mary Rosenkoetter, Injury Numbers 94-168476, 95129017, 97-483041, 98-175851, and 99-123209. In all five cases, the claimant, Mary Rosenkoetter appeared on her own behalf, and through counsel, Attorney Ray Gerritzen. In all five cases, the employer/insurer appeared by and through counsel, Attorney Tim Tierney. In four cases (Injury Numbers 95-129017, 97-483041, 98-175851, and 99123209), the Second Injury Fund appeared by and through Assistant Attorney General M. Jennifer Sommers.

The parties entered into certain stipulations, and agreements as to the complex issues to be presented in these hearings.

Memorandums of Law were filed by the parties.

On or about February 19, 1998: a. the claimant while in the employment of Magna Interior Systems sustained an injury by accident arising out of and in the course of her employment occurring in Franklin County, Missouri; b. the employer and employee were operating under and subject to the provisions of the Missouri Workers' Compensation Law; c. the employer's liability was insured by CNA Insurance Company slash RSKCo.; d. the employee's average weekly wage $\ 596.40, the rate being $\ 397.60 over $\ 278.42

e. Employer had notice of the injury. f. A Claim filed within the time prescribed by law. g. No temporary total disability benefits were paid. h. No medical aid was provided.

1. Medical causation
2. Liability of past medical expenses
3. Future medical care
4. Nature and extent of permanent partial disability
5. Liability of the Second Injury Fund

No. A: Deposition transcript of Bruce Schlafly, M.D., taken July 9, 2002 on behalf of the claimant, with attachments of: Exhibit A-1, the curriculum vitae of Bruce Schlafly, M.D.; A-2, the March 1, 2001 report of Dr. Bruce Schlafly, M.D. (8 pages); A-3, November 12, 2001 report of Bruce Schlafly, M.D. (1 page); A-4, four photographs taken by Dr. Bruce Schlafly of another patient, not Mary Ann Rosenkoetter, who had persistent problems following prior endoscopes carpal tunnel release and required repeat carpal tunnel release using the standard technique, Exhibit A-3 has the description; A5, the medical literature provided by Bruce Schlafly, M.D. titled, quote, The Results of Revision Carpal Tunnel Release Following Previous Open Versus Endoscopes Surgery". A-6, the medical literature by Dr. Bruce Schlafly entitled "Persistent or Recurrent Carpal Tunnel Syndrome Following Prior Endoscopes Carpal Tunnel Release"; A-7, operative report of the December 7, 2001 left carpal tunnel release performed by Dr. Bruce Schlafly at St. Anthony's Medical Center; A-8 is the December 12, 2001 report of Dr. Bruce Schlafly (1 page); A-9, the May 6, 2002 report of Dr. Bruce Schlafly (2 pages); A-10, the operative report of the March 4, 2002 right carpal tunnel release performed by Bruce Schlafly, M.D., at St. Anthony's Medical Center; A-11, the statement of services of Hand Surgery Associates, P.C./Bruce Schlafly, M.D., in the amount of $\ 3,120.00 for services rendered November 12, 2001 through March 8, 2002; A-12, numerous letters addressed to Bruce Schlafly, M.D., and deposition notices of Dr. Bruce Schlafly relative to his carpal tunnel syndrome treatments. (Admitted subject to the objections therein.) (Ruling: Employer/Insurer's and Second Injury Fund's objections to Exhibit A-4 on grounds of, inadequate foundation has been laid, is overruled.)

No. B: Certified medical records of Calvin Medical Center

No. C: Certified medical records of Hand Therapy Network, certified March 15, 2001 (12 pages)

No. D: Certified medical records of HealthLine Corporate Health Services Metro St. Louis certified October 12, 1999 (72 pages)

No. E: Certified medical records of Karl A. Jacob, M.D. certified October 9, 1999 (43 pages)

No. F: Medical records of Dr. John Kef alas, M.D. certified October 7, 1999

The claimant talked about working two jobs in the early 1990's: working at East Central for a year as a school custodian in about 1993 or 1994 while working at Integram; and working as a clerk giving out blueprints and inspected machine parts and gave out machine parts out of the storeroom at Bull Moose Tube for about fourteen months. I first went to work for Integram in 1991, I think, the claimant said, and I went to work in maintenance which entailed cleaning all the bathrooms on the production side, sweeping floors, polishing the floors or cleaning them, and then just all around maintenance work.

In 1998 while working at Integram I claimed I had depression due to harassment, Rosenkoetter testified. I had my elbows and that hurt really bad, and I went to the HealthLine and they said I had tendonitis. And just luckily the next time I went there was a different doctor came in there to work and he was looking at my arms and he asked me what was wrong with me and I told him, and he gave me medicine for depression, the claimant testified.

Rosenkoetter testified about the harassment at work: there was people at work if I set my soda or anything on the table, they would go and they would poke a hole in my soda so it would run all over my seat, Kent was one of the guy's name who did this, I don't remember his last name; there was just a bunch of them that was real good friends with the foreman and he would let them get away with that stuff; the foreman wouldn't do nothing to them. I'd be standing on the platform in front of the molds and I didn't like it there anyway, and there was holes, there was grates, and I was always afraid that maybe the carousel would crash or something, and they got them big molds on them, the claimant stated, and they would take a big wrench and they would sneak over there and hit the bottom of the grate, and I would think it was falling. And they would do that all the time because they knew I was upset anyway, she said. And I couldn't leave my food set on the table because I didn't know if they would put stuff in it, the claimant stated. They poked holes in my soda can, and they would spit their chewing tobacco in a soda can, and it would have the top off it, and they would put it on the overhead, and they'd know by the hours when I would be back at the dump, and that soda can would fall on you with all that spit in it, and then you'd have to clean it off the seats, and off of you, and they done that several times, Rosenkoetter testified, and it didn't do no good to tell anybody because they wouldn't do nothing about it. And when I was on the re-work, she testified, they would go and turn things on the valves and the molds, they put a whole bunch of molds release and it would leave holes in the bun parts, and I would have to fix all of them. And sometimes, the claimant testified, there be in an hour that I was on re-work and there would be two or three boxes of bad parts in the boxes, and I'd call the foreman, he'd come over and say - Well, I don't understand that, there must be something going on; the foreman would check this and check that, and say - Well, just go on to your next station. The foreman knew about this stuff and did nothing to change it, the claimant agreed. My one friend, Nick (they used to call him Turkey Man there all the time), he came and he told me what they were doing, that they were doing it on purpose; and they asked him to do it and he said no, he wouldn't do it because he was my friend, Rosenkoetter stated. I didn't see them doing it to anybody else, the claimant stated, they once took a girl's purse and put it overhead and she couldn't get it until it dropped. This started with me just before I went to that HealthLine doctor about my hands, the claimant said. They would speed up the lines on the air bags, they would take and pile up parts so that the line would rush by real fast; and there was about maybe six to eight seat covers that you'd have to blow the plastic off and put them on that line, and they would take them from behind the stop on the machine and then the line would go real fast when they took that last one off, and it would go up, and it would all been empty. And it took me so long to blow each one to get it filled back up again, so I was blowing one and running around putting it up there so that it wouldn't shut down the carousel until I got caught up, she said. This happened until they fired me from work, Rosenkoetter said. I was fired in 1999, I think it was, the claimant stated.

The company never did anything to stop this, Rosenkoetter said. When I complained to the foreman, he'd say he'd talk to them. But it did not stop any, she said. All of these things affected me, Rosenkoetter said, it got my nerves really bad, I started crying all the time at work. Agreeing that the foreman saw her crying at work, Rosenkoetter testified The foreman had this one girl who was his friend, Dawn, and we were back there and cutting and putting the leather covers on, and she'd go talk to fork truck drivers and mess around, wasn't there to do her job, and you'd have to take up the slack for her. So I got so aggravated I went and told the foreman, and he come over there and took her in the office for about four hours, she sat in there and talked to him and I had to do her work and my work, the claimant said.

Explaining how all of these things she had described affected her work or her ability to work, Rosenkoetter stated that she got really upset about all the bad parts. I just didn't have time to fix them, she said, so that makes it look bad on you, because you got two or three boxes with bad parts sitting there that you can't fix. And then they wasn't even entered into the computer because you don't have time to do all of that, she stated. The parts were foam buns, which is the cushion that goes underneath the leather covers. Explaining what was defective about them, the claimant stated that they would put too much mold release and it just eats the foam and it makes holes in it; the guy that was inspecting them, they had strips on them and you tore off the top part and it was like a Velcro left, he would rip it all off, then I'd have to glue them all back on. Pat Brown was one of the guys, she said, he told me he was ripping off this section of these foam buns because it was too tight and it just came off. This was done just to me, the claimant said. The foreman did not say

anything about this, Rosenkoetter stated, he put them all in a box and pushed them to the back, and they would fix them back there.

I was first treated for depression by Dr. Bonney, the claimant said, he was not a regular doctor at HealthLine, but he was filling in that day, and he gave me some medicine that would help me, I forget what the name of it was. When asked what year this was, Rosenkoetter responded - I had gone to HealthLine because of my arms, they were hurting me all the time, tendonitis in my elbows. Before going to Dr. Crane in May of 2003 I had not been to any psychiatrist for depression at all, Rosenkoetter stated. The company sent me to Dr. Stillings, I think, the claimant said, and other than that I don't recall going to any other psychiatrists in my life, she said.

The claimant testified about continuing problems as a result of the harassment at work. It's still with me, she said, everything they done to me all these years, when I slipped on the tag, then after they sent me to Tesson Ferry to a back doctor down there, when I went in there he done x-rays and he come in there and he told me - you didn't have your back operated on, your back wasn't operated on, Dr. Jacobs didn't do anything to your back. The claimant agreed that when she went to be examined she had a surgical scar on her back where Dr. Jacobs had cut on her back and removed the disc. The surgical scar is more than an inch long and is visible now, and was there when I went to this doctor who told me I didn't have any surgery on my back, and this doctor had looked at my back, the claimant said. Well, after that then they sent me back down there, and they did do an MRI of my knee and said there wasn't nothing wrong with it, she said. The doctor took x-rays of my back, and on the x-rays I had a pinched nerve on the right side of my back; I left, I called back and then when I called back there was no pinched nerve, Rosenkoetter testified.

Rosenkoetter testified about the treatment she has received for depression. Just the medicine that one doctor gave me, she said. Rosenkoetter agreed that she was also treated by Dr. Crane right after the last hearing setting in this case in May 2003, that she had gone the next day; Rosenkoetter agreed that she had testified at the last hearing setting that she was so upset that day she didn't feel she could testify. Except for the one time with the HealthLine doctor, this was the first treatment I had had for depression, when I started with Dr. Crane after the last hearing setting, she said. When I first started going to Dr. Crane it was once a month. The reason I went because I couldn't control my anger anymore, Rosenkoetter said. She agreed that she had a lot of crying spells, and agreed that she missed two appointments at her attorney's office to prepare for the trial. I got so bad that I can't stand to go in the elevators, I can't stand to go twenty-five floors up, all the people, and I got so I wouldn't leave my house; I wouldn't go out of the bedroom, and I just slept all the time; I can't stand the people, too many people, and it felt like the buildings were going to fall on me, the claimant testified. Agreeing that she had refused to come to her attorney's office because it was downtown, Rosenkoetter stated - I just told Mr. Gerritzen I couldn't come up there, I just couldn't do it, and he said I could come to his house. And I had to get my husband off of work because I had a car accident in about 1985 and had a real bad concussion and I can't remember, and it messed up a nerve in the back of my head and I couldn't smell and couldn't taste real good; I get lost and I was losing track of time and I would lose hours, I wouldn't know what I did or where I was at; I was lost and I was in Illinois once and I couldn't get home, and I got lost once in St. Charles. I just decided to stay home, the claimant said. Rosenkoetter was queried if she felt her inability with going in the big buildings and being with people was due to what happened to her in 1985 or was it due to what happened at Integram, or due to both. Just all the aggravation at Integram, the claimant answered, all the stuff that they done to me and put me down because of my back, and I worked what I could work, when I could work, and it just wasn't never enough.

I was fired by Integram in 1999, the claimant stated, and the reason they gave was because I was off when I hurt my leg. They changed the contract and they said the insurance papers -- when I hurt my knee, I went on sick leave and I went and got my papers to fill out; it's after I fell and went to the hospital and the doctor said I shouldn't work. So I went to the bone specialist, and I got my insurance papers and I didn't know how to fill them out because they were different, and I called the H.R. and Mary Jo said she would help me fill them out, and she told me what to put down. I had called them and I asked them in H.R. at Integram if there's anything else that I had to do, and she said no, that's all I have to do, the claimant testified. They said they fired me because I didn't come in and fill out new papers; that's why we went, the union man and me, before the arbitration board. It was whoever's the boss down there at Integram, the general foreman, I guess, who said I didn't fill out the papers right, the claimant stated, because they said I was fired because I didn't do my paperwork right. But they already had the doctor's papers there in front of them and then when we went to the arbitration I had my phone bills and everything, and they had three or six women from the H. R. Department sit there and lie, it didn't make any difference what I said, and my union worker denied me the right to have counsel, said he was going to represent me, so I didn't even get to have a lawyer there, Rosenkoetter testified. This was right after they fired me and then went through three steps, and the fourth step was to go before the arbitrator. They denied my unemployment, and I went to the hearing for unemployment and their woman said that was absurd that I would quit my job at fifteen something an hour, and she gave me my unemployment, the woman from Jeff City, the claimant stated.

During cross examination by the employer/insurer, the claimant was asked to what did she attribute her psychiatric problems. I'd been having problems at work with harassment, the claimant answered. When I went to the doctor about my arms, there was another doctor there and not the regular doctor, and he asked me what was wrong, and I told him I'd been having problems at work, and he put it on the paper, the claimant stated, he give me some medicine that would help me. She was asked when did the harassment start. I don't recall, Rosenkoetter answered, all I know is I had problems with them at work and that day was really bothering me, and the doctor asked me what was wrong and I told him. I'd had problems after I went back to work, not being able to do what I was supposed to do, worried about my job, the claimant stated. And all that stuff started with them guys at work; you could never get nothing done; even if you told the foreman, he wouldn't do nothing about it, he'd say - I'll talk to them, and it got worse and worse and worse, the claimant stated. Rosenkoetter agreed that it was sometime after she went back to work after the surgery for the back injury that the harassment started. It was sometime around the end of 1996 or beginning of 1997 that I returned to work, the claimant agreed. Dean Nordman was the supervisor I talked to who did nothing about it, the claimant stated. The harassment occurred on between ten and twenty occasions, Rosenkoetter said. She agreed that during that period after she returned to work, in addition to the harassment, one of the things she was concerned about was her ability to perform her job duties and actually keep her job. The claimant agreed that she believed Dean Nordman played a role in this harassment. The claimant explained that though she believed that along with the other employees Nordman played a role in the harassment that she underwent, but nevertheless when she thought it was a problem she went to Dean Nordman to report it because he was her supervisor. Rosenkoetter stated that she did not file a grievance about the harassment because she didn't know you could do that. I didn't know if there was a hotline at work, the claimant said, I never worked in a place where they had a union. Rosenkoetter stated that she knew there was a human resources department at Integram, and that she trusted them until she lost her job. I did not go to H. R. and tell them I was being harassed because I thought you went there to fill out papers, like medical papers, and insurance papers, and stuff like that; I never thought they would deal with harassment or anything, she said.

Rosenkoetter stated, during cross examination, that she was already was stressed out before her termination; the termination did not make my stress worse, it made me hate you and the company you represent, she testified. Rosenkoetter agreed that her termination and the grievance proceeding was all about insurance paperwork, it wasn't about making bad parts or not doing her job right. No one from the company that I know of ever wrote me up because I made too many bad parts, the claimant said. No one from the company ever came to me on the re-work line and said as a result of my not keeping up with the re-work, we're going to write you up, Rosenkoetter stated.

During cross examination, Rosenkoetter testified about other experiences in her life. She stated that she had been physically assaulted once by her husband's brother on or about 6/6/95, who had jerked a chain out of her hand and hurt her arm. She stated that she went to St. John's Hospital, and they said it was just strained, it was all right. The claimant agreed that her memory was refreshed by the St. John's record which reflected that her brother-in-law just went berserk, grabbed her arm and twisted it and tried to punch her, and she blocked that punch with her right arm. The claimant stated that she thought her brother-in-law had hit her husband with a shovel. Rosenkoetter agreed that they had to take her brother-in-law to court to resolve the issue, and the brother in law got the road and they didn't. What we did about access to our home was made a road, she said. This brother-in-law still lives next to me, she said. Describing the relationship now, Rosenkoetter testified - He talks to me, I talk to him; I give him stuff out of my garden, my husband's over there quite often; he just shut the road off, that's all, so you live with it and go on. I don't think I continue to have problems with my right arm after the assault, she said. The claimant was queried if she knew why the records of Dr. Bedor for 1997 would reflect that he thought she had a rotator cuff tear in that arm. I got a test from our regular man, and he said they done a test in there put medicine in there and took x-rays, and I didn't have a rotator cuff tear, she stated. I didn't know what was causing my right shoulder problems at that point in time, that's why I went to find out; I thought I had a rotator cuff tear, and I didn't, she stated. The claimant was queried if there were any other times that she had been physically assaulted, and she answered that her ex-husband, who she was married to for twenty-five years, used to push her around a little bit off and on. Rosenkoetter agreed that her ex-husband also tried to abuse her emotionally off and on throughout the twenty-five years. He went to the hospital and got help, she stated, he had a medical problem. Rosenkoetter agreed that she had children with her ex-husband, and that her children witnessed some of that emotional and physical abuse. This s why I got divorced, Rosenkoetter explained, and stated that it was a friendly divorce. We visit each other; he comes to my house, he's remarried and I go to their house, she said. Rosenkoetter agreed that she had attempted to take custody of a grandchild, and explained that it was because the child had a drug addict for a father; it wasn't because of my daughter, but I had to put both names on there (my daughter's name and her boyfriend's name) or I couldn't get her. The mom brought the baby to me and I had the child for maybe six or seven months, Rosenkoetter said. I don't know what year it was and I don't know when she went back; I gave her back because her mom got her own apartment, got on HUD, and had money to take care of her.

Rosenkoetter agreed, during cross examination, that over the years she has had some problems with pneumonia

and ear infections and sinus problems, and missed time from work as a result of the problems with bronchitis, including in 1997 and 1998. I believe that it is because of the mold release that I smelled every year for year after year at Integram, she said.

During cross examination by the employer/insurer, the claimant agreed that besides seeing Dr. Stillings one time in 1998, the first time she received any psychiatric treatment was through Dr. Crane's office in 2003. The claimant was asked if she had ever attempted to get treatment through her group health insurance. I didn't think it was bothering me that bad; I didn't want to go to a psychiatrist, she answered. Rosenkoetter agreed that when she thought it was bothering her so bad that she had to go see a psychiatrist was when she went to Dr. Crane. It was noted that this would have been several years after she left the employ of Integram, and Rosenkoetter responded - It kept on and kept on and kept on. My health situation, it eats me up, she said, do you know what it's like to not be able to do anything or fall over everything and get hurt, like my arm, and broke my leg. You don't know what it's like, she indicated; not being able to enjoy my bike no more or ride my motorcycle or go in the field with my husband, he has to do all that work "hisself" now. I can't even plant my frigging flower garden; I try to weed-eat, I bought the lightest weed-eater they had which they said weighed less than five pounds, and I couldn't even do it more than five minutes. That's why I went to Dr. Crane, the claimant stated, because I knew I needed to go someplace and I looked in the phone book and I found Dr. Crane's name and I went to him. It's just been building up and building up and all these years and all these accidents and got so I wouldn't go out of my bedroom, I would stay in there for days, the claimant stated. I didn't want my kids to come, I didn't want to see my grandkids, I didn't want to see nobody, she stated. And every time I got hurt it brings it all back again, the claimant testified, and every time I had to go to these stupid hearings and all these years been going on and going on, it eats at me. Now I have to get surgery on my other hip, and I got to face that, too. You know what it's like getting out of bed for five seconds, not even long enough to go to the bathroom, and you got to go back and lay down because you can't set up, the claimant stated. I want to kill myself, if I could have got a gun, I would have, she said. I go to bed every night crying because my legs and my back hurt so bad; can't go any place around people and enjoy yourself because you're miserable; you can't even sit in a frigging chair, the claimant said. Rosenkoetter agreed that every time she has an injury to her body, it dredges this all back up and makes it worse.

The claimant agreed that she was involved in a motor vehicle accident in October, 2003. My daughter suggested that she and I go down to visit my other daughter and on the way back I was driving, and there was a road on the right side and a man was coming the other way, and he decided he was going to turn and he was drunk, no insurance, two babies in the car and his wife; I didn't have time to stop, and I tried to miss him but it didn't work, Rosenkoetter said. The people in the other car, and my daughter and myself were injured in the accident, she said, no one was killed in the accident. Explaining about her injuries, Rosenkoetter stated that the air bag went off and she was going sideways and it hit her shoulder, and her hand hit something and broke a bone in her left hand, and her knee hit something on the door somehow. I wasn't casted, Rosenkoetter stated.

Joe Laffleur testified on behalf of the employer/insurer, and stated that he is a human resource manager at Integram St. Louis Seating, having been in that position for eight and a half ( $81 / 2$ ) years; Laffleur stated that he started with Integram in 1996. Agreeing that the company has a hotline, Laffleur explained - We are owned by Magna International out of Toronto, and they have a phone number that employees can call if they can't get their issues resolved at the plant and it can be anonymous. The hotline has been in effect at least twenty-five to thirty years, he stated. Employees are made aware of the hotline by us telling them in the orientation that it's available to them, Laffleur said, plus we also have posters in the plant which talks about what the purpose of the hotline is, what the phone number is to call, and plus periodically we'll have representatives come down from Toronto and do a presentation in one of our monthly employee meetings. He agreed that as part of the company's benefits package for the employees, they have an EAP (Employee Assistance Program) program, and stated that this has been in effect since the plant opened in 1989. The services available through the EAP are that the employees can contact the EAP if they have financial issues, chemical dependency issues, emotional issues either for them or for anyone living in their household, Laffleur said. Agreeing that H.R. took an active role in making the employees aware of the EAP program, Laffleur stated that they have posters out in the plant that talks about it, everybody in H.R. has business cards from the EAP, plus periodically they'll have someone come in and do a presentation.

In my years in the H.R. department, Miss Rosenkoetter never came to me and advised me that she was being harassed on the line, Laffleur stated. Laffleur stated that he was present at the grievance of Rosenkoetter but not at the grievance proceedings, as Rosenkoetter would have done that through her union representative. He agreed that as H.R. director for Integram he participates in grievances on a regular basis, and becomes aware of each grievance procedure. My role with the grievance procedures is that I pretty much handle the whole procedure, Laffleur stated. It's actually a four-step grievance procedure, and if that doesn't solve the grievance, then it goes to arbitration; I'm involved in all four steps plus at the arbitration level. And I actually conduct the meetings and I write the grievance, Laffleur testified. He

agreed that in conducting the meetings he represents the company's interest, and in an effort to address his side of the argument, he becomes aware of the grievance allegations. Agreeing that he was aware of the allegations in the case involving Rosenkoetter, Laffleur stated that the allegations were that she did not terminate her seniority.

On cross examination by the claimant, Laffleur stated that Dean Nordman does not still work for Integram; I haven't talked to Dean in five years, so, no, I do not know where he is. Laffleur agreed that as human resources manager, he hires and fires people.

On redirect examination, Laffleur testified about the basis of his terminating Rosenkoetter in 1999. She terminated her seniority in accordance with the labor agreement because she failed to return from her leave of absence, Laffleur said, and agreed that the employer made no proactive attempt to terminate her. To my knowledge, Rosenkoetter was never written up for poor performance, and never written up for problems with quality or quantity of her work, Laffleur said. To my knowledge, in the grievance procedure, ability to perform her job duties was not an issue, he said.

On further cross examination, Laffleur agreed that he had brought Rosenkoetter's personnel file with him to the hearing. He agreed that the file included write-ups of Rosenkoetter, and stated that there were all on attendance. It was noted that included in the personnel file was that it was maintained by Laffleur and found by the appeal judge that the claimant left work on 3-19-99 without good cause. The original judge agreed with us, yes, Laffleur responded. Laffleur agreed that he wrote the termination letter, and that it was based upon Rosenkoetter not returning to work on 3-19-99. Laffleur was queried if he had looked in the file for whether or not Rosenkoetter had complained to Dean Nordman about being harassed at work. I didn't see it in there, but I wasn't looking for that, Laffleur answered. Laffleur agreed that if someone has poor performance, it is possible for them to be disciplined at Integram, and if there's a discipline for poor performance it is it put in their personnel file. Rosenkoetter did not have any discipline forms in her file for poor performance, Laffleur said.

Treatment records in evidence at or near the time of the claimant's allegations of harassment at work in 1997 and 1998 beginning subsequent to back surgery on 12/14/95 included the following. The records of Dr. Glen D. Calvin, D.O. (Cl's B), the claimant's personal doctor, reflected treatment of Rosenkoetter during the period of March of 1996 through March of 1999. The following are examples of treatment entries. 2/10/97 - acute viral syndrome with secondary problems, symptoms are headaches, eye pain, cervical spine pain, back pain, sneezing, coughing; treatment included Ultram. 2/24/97 - complaints of severe headache and cough, patient states she is not able to work at this time; diagnosis was bronchial pneumonia or pulmonary vascular congestion, and Rosenkoetter was sent to Missouri Baptist Hospital under Dr. Shen's care. 2/28/97 - Rosenkoetter was seen for follow-up on Proventil inhaler. 3/3/97 combination of congestive heart failure, bronchitis, pneumonia and difficulty breathing, return to see Dr. Shen ASAP. 4/3/97 - seems to have an exacerbation of her right shoulder, I think she has a torn tendon of her right shoulder but she refuses to have an MRI, sending her to Dr. Stetson for work up, here with severe shoulder pain and severe degenerative arthritis in shoulder. 5/5/97 - complaints of pulled muscle in left side mid-back for 24 hours after lifting on carpeting; typed entry included that exam revealed severe spasm of the TS and neurological was essentially neg, and was started on Anaprox and Ultram for pain, and therapy. In a 5/9/97 entry, depression was mentioned for the first time, the entry included: continued back pain; written was - "..she had surgery from Dr. Jacobs approx 2 years ago and she was told that there would be a possibility that she would have to have the other side operated on and she states that it has come to the pt. where she thinks that she needs to go back to see him because of the discomfort in the LS and (therapy) is not helping that much and also she is having a lot of family diff. And we will put her on Paxil" (sic); the diagnosis was - LS strain and Sit. Depression. Dr. Calvin's record continued with treatment entries in June 1997 through February 1998 for complaints of continued events of sinus pressure and low back pain for which the claimant was taken off work at times. In a 4/9/98 entry it was noted: "Here today with an acute anxiety episode with chronic problems with carpal tunnel, chronic degenerative back disease, possible ruptured disc", has some previous stabilization surgeries; "We recommend that she have further work up if her workman's comp. will approve of it"; she will be placed on BuSpar for mild anxiety; no other significant findings. Dr. Calvin's record continued through 3/9/99 reflecting treatment for left knee injury, low back pain, chronic bronchitis for which the claimant was at times taken off work; there was no more mention of anxiety or depression problems in these last entries. Healthline treatment records (Cl's. D) began with March 1994 notes; the first mention of depression were in the records of treatment for complaints of pain in the wrists and hands which began with an 11/3/97 entry. A 2/19/98 entry by a Dr. David Olinger, M.D. included: complaints of bilateral UE pain for about 6 months, treated with ibuprofen but is getting worse, complaints of numbness in the left index finger and thumb; written objective findings were - "Vague history. The patient appears very depressed and is crying when asked if she is depressed. UE reveals various scratches from working outside at home; the diagnosis was - Complaints of bilateral UE pain, Depression; treatment included - EMG, NCT's and antidepressants; Rosenkoetter was placed on work restrictions of no pushing or pulling with arm for one week greater than 35 pounds; follow-up in one week recommended. In a 2/19/98 Medical Authorization form, Dr. Oliver wrote in the Diagnosis Section of the form: "Subjective complaint of bilat.

Upper extremity pain for 6 mos. Depression which is partly, if not entirely work related. Rec. (treatment with) antidepressant". In the next entry of 3/23/98 by a Dr. Anver Taylor, M.D., written was: Rosenkoetter relayed that she was scheduled to see Dr. Phillips for an EMG and nerve conduction tests the next day, and subsequently to see Dr. Crandall, and these appointments were set by her work place; continued complaints of pain in both hands, wrists, shoulder, and elbows, denies any pain in the neck; states is doing regular work at this time; the diagnosis was Paresthesia to both hands, It is questioned whether or not the patient has any depression from this particular incident, episode, or current complaints; it was written that Rosenkoetter would see Dr. Crandall for UE complaints; she was placed on full duty work status. In a 3/23/98 Certificate of Fitness/Exam form, Dr. Taylor wrote in the Diagnosis Section of the form: "1. Paresthesia both hands, 2. No work related depression."

The section in Missouri Workers' Compensation Law pertaining to compensation for mental injury was amended in 1992, and the requirements are set forth in Section 287.120.8 RSMo. 1992:

Mental injury resulting from work related stress does not arise out of and in the course of the employment, unless it is demonstrated that the stress is work related and was extraordinary and unusual. The amount of work stress shall be measured by objective standards and actual events.

The determination of compensability of a mental injury using Section 287.120.8 RSMo 1992 was done in Tangblade v. Lear Corp., 58 S.W.3d 662, 666 -667 (Mo.App. W.D.,2001), in which the Court noted:

"Pursuant to § 287.120.1, an employee is entitled to workers' compensation benefits for personal injury or death 'by accident arising out of and in the course of his employment[.]' ' 'Arising out of' means that a causal connection exists between the employee's duties and the injury. 'In the course of employment' refers to the time, place and circumstances of the injury." Cruzan v. City of Paris, 922 S.W.2d 473, 475 (Mo.App.1996) (quoting Stockman v. J.C. Indus., 854 S.W.2d 24, 26 (Mo.App.1993)). As such, proof of the causal connection is what establishes that the condition for which compensation is sought arose out of employment. Duncan, 897 S.W.2d at 114 (citation omitted). Hence, to be entitled to workers' compensation benefits, the employee has the burden of proving, inter alia, that his or her injury was caused by a work-related accident. Id.; Goleman v. MCI Transporters, 844 S.W.2d 463, 465 (Mo.App.1992) (citation omitted).

A mental injury is compensable under the Workers' Compensation Law. Rooks v. Trans World Airlines, Inc., 887 S.W.2d 671, 673 (Mo.App.1994) (citing 667 Tibbs v. Rowe Furniture Corp., 691 S.W.2d 410, 412 (Mo.App.1985)). With respect to establishing the requisite causal connection for a claimed "mental injury," § 287.120.8 provides:

Mental injury resulting from work related stress does not arise out of and in the course of employment, unless it is demonstrated that the stress is work related and was extraordinary and unusual. The amount of work stress shall be measured by objective standards and actual events.

Thus, to be entitled to benefits for her claimed mental injury of major depressive disorder, the respondent was required to prove that her condition was caused by work-related stress, which was extraordinary and unusual in nature, as measured by objective standards and actual events. Id.; Williams, 996 S.W.2d at 628.

[12] An injury will be deemed to have arisen out of and in the course of employment only if:

(a) It is reasonably apparent, upon consideration of all the circumstances, that the employment is a substantial factor in causing the injury; and

(b) It can be seen to have followed as a natural incident of the work; and

(c) It can be fairly traced to the employment as a proximate cause; and

(d) It does not come from a hazard or risk unrelated to the employment to which workers would have been equally exposed outside of and unrelated to the employment in normal nonemployment life[.]

§ 287.020.3(2). Accordingly, a mental injury is not compensable, unless it can be shown that the alleged workrelated stress was a substantial factor in causing the injury. Bloss v. Plastic Enters.,32 S.W.3d 666, 672 (Mo.App.2000)."

Thus, to be compensable, a mental injury must be from work-related stress which was extraordinary and unusual in nature as measured by objective standards and actual events and the work-related stress was a substantial factor in causing the injury.

Considering the evidence in this case, it is found that there is no corroborating evidence of the claimant's allegations of being harassed at work by co-employees; in fact, medical evidence offered by the claimant, a Healthline 5/9/97 entry, noted Rosenkoetter's continued complaints of low back pain, therapy is not helping that much, and also she is having a lot of family difficulty, with the diagnosis being - LS strain and Situational Depression. Additionally, there is a

challenge presented by employer/insurer to the claimant's allegations of suffering harassment at work, that challenge being the testimony of Joe Laffleur who stated that he has been a human resource manager at Integram St. Louis Seating and has been with the company since 1996, and further testified in his years in the H.R. department, Rosenkoetter never came to him and advised him that she was being harassed on the line. Notwithstanding, it was agreed and stipulated to by the parties that the claimant suffered an injury by accident arising out of and in the course of her employment on or about February 19, 1998, though medical causation was put in issue[10]; again the injury alleged by the claimant is a mental injury. Thus, further consideration will be made on whether or not the claimant experienced any other actual work related events in the time period in issue that would be considered extraordinary and unusual that produced a compensable mental injury.

In Carnal v. Pride Cleaners, 138 S.W.3d 155, 158 (Mo.App. W.D.,2004) it was noted: "Specifically, the claimant must establish that the work related stress was extraordinary and unusual, as compared to 'the stress encountered by employees having similar positions, regardless of employer, with a focus on evidence of the stress encountered by similarly situated employees for the same employer.'". Considering the evidence in this case during the time period subsequent to the 12/14/95 low back surgery (See, Dr. Jacob's records - Cl's. E) and during 1997-1998, firstly Dr. Jacob's records indicated the following in the 5/6/96 entry:

The patient is discharged from follow-up as far as her lumbar spine is concerned. She is to do conditioning for approximately one month after which she can return to work with a 25 pound limit weight lifting restriction. She is to do no lifting that involves bending over at the waist.

The claimant gave uncontradicted testimony that subsequent to her release from treatment on 5/6/96 from back surgery, she returned back to her regular duties which involved lifting (i.e. a 3-person seat for a minivan) and bending. Rosenkoetter testified that when she went back to work after the surgery, it was hard on her back. I went home the first night that I went back, she said. It's hard on my back to lift the stuff and just to be able to walk from station to station and get back in the routine of anything, she stated, this along with bending was hard. It just made me real sore to start back after not being able to do anything for so long, the claimant testified, and the bending over the re-work table would hurt my back, and I couldn't do the lifting; I'd go home every night and couldn't hardly stand it from the lifting the heavy seats and stuff, and bending over the boxes. And then I'd have so long a time to get from one station to the other and to be on time, Rosenkoetter testified. Walking was from the inspection table to re-work, which wasn't but about five feet, but then you had to go from there all the way into the back, which was maybe sixty, seventy feet, she said, and it was all on level concrete which wasn't real good either. Rosenkoetter stated that from the time she went back to work in November of 1996 there was a difference in her ability to work at Integram, she slowed down a lot. I just didn't do as many parts as I used to; I wouldn't help other people, I just couldn't do that no more, Rosenkoetter said. In a 04/01/98 report, Dr. Jacobs wrote that Rosenkoetter was a patient of Dr. Calvin as she had reinjured her back at work three months ago bending over putting cushions in a box and heard a popping of her back and pain radiating to the right lower extremity. There was evidence that there were similarly situated employees performing these duties, but no evidence presented that the other similarly situated employees performing these work duties were doing so with the restrictions Rosenkoetter had had placed on her. It is found that the evidence establishes that the requirement that Rosenkoetter perform the same work duties as similarly situated employees even though she had restrictions placed by Dr. Jacobs resulted in extraordinary and unusual stress on her.

The next consideration, in light of the immediately above finding, is whether or not this work related stress caused a mental injury. There is medical opinion in the evidence of mental problems for the claimant, however there are different opinions among the doctors as to the diagnosis of the condition(s). The evidence reveals that the claimant was evaluated by multiple doctors, including psychiatrists, and testing was performed to aid in the diagnosis. Thus, medical opinion on the diagnosis and cause is found to be required in this case.

A claimant must show not only causation between the accident and the injury but also that a disability resulted and the extent of such disability. Smith v. National Lead Co., 228 S.W.2d 407, 412(4) (Mo.App.1955). While proof of cause of injury is sufficiently made on reasonable probability (Smith v. Terminal Transfer Company, 372 S.W.2d 659, 664(7) (Mo.App.1963)), proof of permanency of injury requires reasonable certainty. Davis v. Brezner, 380 S.W.2d 523, 588(6-- 9) (Mo.App.1964). Whatever may be the quantum of proof the law imposes on a given issue in a compensation case, however, such proof is made only by competent substantial evidence and may not rest on surmise or speculation. Griggs v. A. B. Chance Co., 503 S.W.2d 697, 703 (Mo.App. 1973).

"For an injury to be compensable the evidence must establish a causal connection between the accident and

the injury. The testimony of a claimant or other lay witness can constitute substantial evidence of the nature, cause and extent of the disability when the facts fall within the realm of lay understanding.

"An injury may be of such a nature [however] that expert opinion is essential to show that it was caused by the accident to which it is ascribed." (Citations omitted) Griggs, 503 S.W.2d at 704.

"...an injury may be of such a nature that expert opinion is essential to show that it was caused by the accident to which it is ascribed. When the condition presented is a sophisticated injury that requires surgical intervention or other highly scientific techniques for diagnosis, and particularly where there is a serious question of pre-existing disability and its extent, the proof of causation is not within the realm of lay understanding..." Knipp v. Nordyne, Inc. 969 S.W.2d 236, 240 (Mo.App. 1998)

"Medical causation not within common knowledge or experience, must be established by scientific or medical evidence showing the cause and effect relationship between the complained of condition and the asserted cause." Selby v. Trans World Airlines, Inc., 831 S.W.2d 221, 222 (Mo.App. 1992).

"A medical expert's opinion must have in support of it reasons and facts supported by competent evidence which will give the opinion sufficient probative force to be substantial evidence." (citations omitted) Pippin v. St. Joe Minerals Corp., 799 S.W.2d 898, 904 (Mo.App. 1990)

Two doctors, in the treatment records, offered opinions on a diagnosis concerning Rosenkoetter's mental state, but expressed opposite reasons for their diagnosis: a.) Dr. Calvin, D.O. in a 5/9/97 entry, noted Rosenkoetter was having a lot of family difficulty and diagnosed Situational Depression, and in a 4/9/98 entry Dr. Calvin noted that Rosenkoetter was there that date with an acute anxiety episode and she would be placed on BuSpar for mild anxiety. b.) In the Healthline record, a 2/19/98 entry by a Dr. Oliver, M.D. included - Vague history. The patient appears very depressed and is crying when asked if she is depressed; the diagnosis included - Depression, and the treatment included - antidepressants; Dr. Oliver wrote in a 2/19/98 Medical Authorization form - "Depression which is partly, if not entirely work related. Rec. (treatment with) antidepressant". In the next entry in the Healthline record of 3/23/98 by a Dr. Anver Taylor, M.D., this doctor's diagnosis included - "It is questioned whether or not the patient has any depression from this particular incident, episode, or current complaints"; in a 3/23/98 Certificate of Fitness/Exam form, Dr. Taylor included in the Diagnosis Section of the form - "No work related depression.". The claimant offered the expert opinion of Dr. Poetz, D.O. who evaluated Rosenkoetter on Rosenkoetter's own behalf on or about June 2002, and discussed a February 19, 1998 work related injury as relayed by Rosenkoetter, noting: a. developed depression as the result of stress and harassment at work; Rosenkoetter claims in 1997 her boss and coworkers were taunting her by deliberately sending her defective parts so that she would have to repair them and they altered the speed of the line to the point that she was unable to keep up and they tampered with her food; and b. when seen on February 19, 1998 for complaints of bilateral upper extremity pain it was noted that Rosenkoetter appeared depressed and was diagnosed with depression. The diagnosis made by Dr. Poetz was: 2/19/98 - Depression secondary to work related stress and harassment. During cross examination, Dr. Poetz agreed that the only history in his report that would have caused the condition he had diagnosed was stress and harassment at the work place. The doctor was queried - you didn't have any history of there being marital problems or family problems or problems outside of work that could have caused or contributed to Rosenkoetter's permanent disability as a result of a psychiatric condition. "Not to my knowledge", Dr. Poetz answered. (Poetz Dp. pg. 41) Dr. Poetz was further queried - so you don't know if the stress was put upon her at the work place was different than the subjective levels of stress that would have been imposed upon other folks at that place of employment. "I don't know", the doctor answered. (Poetz Dp. pg. 42) I'm sure I made inquiries as to whether there were any stressors in her life outside of work, the doctor said. Dr. Poetz responded - "I don't recall"- when queried if he know how long Rosenkoetter had been married, how many times she had been married, if she was ever physically abused or emotionally abused, if her kids were ever emotionally abused. (See Poetz Dp. pp. 47-48) Dr. Poetz stated that he was familiar with the DSMIV, and agreed that it listed psychosocial stressors; the doctor agreed that psychosocial stressors can cause depression. Dr. Poetz agreed that marital discord was on the DSMIV list of psychosocial stressors as well as family discord, physical and emotional abuse. The doctor stated that in his evaluation of Rosenkoetter's mental status he did not need to do a Beck Depression Scale and did not do the MMPI. Dr. Crane, a board certified psychiatrist, offered opinion of a diagnosis of Rosenkoetter's condition as a result of his treating her when she came in on her own behalf on May 2, 2003. Dr. Crane

testified: "Well Mrs. Rosenkoetter came to see me initially in May of '03, May 2 of '03. She was quite depressed at that time; and actually in looking at my records, I'm not sure whether she came on her own behalf. I think she did." (Crane Dp. pg. 7) I conducted a mental status evaluation of Rosenkoetter, Dr. Crane said, I did not do any other psychological testing. I also reviewed medical records, the doctor said. Dr. Crane noted the following:

\#1. Mrs. Rosenkoetter's current Axis I diagnosis is Major Depressive Disorder, severe, chronic, improving with the use of antidepressant medications. On Axis II she presents some symptoms of dependent personality. Axis III would include diabetes mellitus, essential hypertension, chronic cardiovascular disease, severe generalized osteoarthritis, particularly in the low back, and status post bilateral Carpal Tunnel Syndrome. Axis IV is an assessment of the patient's current stress, which would be interpreted to be quite high because of her physical condition, employment condition, and financial condition. Axis V - Current GAF (Global Assessment of Functions) on a scale of 0-100, where 100 is "normal", is assessed at approximately 60. Patient's highest GAF within the past year is assessed as her current 60.

\#4. ......This lady has presented as angry, hostile, and irritable during some of her evaluations and in particular during her psychiatric evaluation with Dr. Stillings. These symptoms were interpreted as being due to severe Personality Disorder, a suggestion with which I disagree, and I believe they were primarily related to her Mood Disorder, although when severely dependent persons are confronted with this type of situation they frequently do become even more upset and angry.

Dr. Crane agreed that on the date of his evaluation his diagnosis was depression, and that his Axis II diagnosis was symptoms of dependent personality. "I believe that she presented symptoms in the past that were consistent with (the) diagnosis (of dependent personality)". (Crane Dp. pg. 29) The doctor was queried if it wasn't correct that depression is something that once a person has it they are more prone to relapse or recurrence. Dr. Crane answered: "Generally speaking, yes. That's correct." (Crane Dp. pg. 62) On examination by the claimant, it was noted that Dr. Crane had mentioned in his report something about future medical care, and the doctor was asked what if any future psychiatric care was Rosenkoetter going to require. Dr. Crane responded: "This lady is likely to require long-term anti-depressants, treatment, and possibly some psychotherapy along the line depending on things that happen in the future, things that may happen in the future." (Crane Dp. pg. 57) (Ruling: Employer/Insurer's and/or Second Injury Fund's objections on grounds of Seven Day Rule are overruled. Crane Dp. pp. 57 and 58) Dr. Crane wrote in his August 18, 2003 report (Cl. Exh. R-1) the following:

Mrs. Rosenkoetter is an obese woman who appears essentially her stated age. She was generally cooperative with the examiner, although when seen initially she was irritable and angry and tended to be somewhat oppositional in answering questions. She initially expressed a "what's the use?" attitude and clearly felt that this evaluation would be no different from previous examinations that she has had over the last nine years. Initially she was tearful, her cadence of speech was somewhat childlike and her thought processes appeared to be slowed. With treatment this has improved and her affect is considerably brighter. She is not tearful during follow up evaluations.........

Notably, during the several sessions with this lady, she has become increasingly cooperative and friendly and this appears to have been a result of simply listening to her.

Dr. Stillings evaluated Rosenkoetter on behalf of the employer in or about August of 2002 (Emp./Ins. 3) The doctor discussed what he thought were the salient features of Rosenkoetter's history:

"Miss Rosenkoetter had a 25-year marriage, and divorcing in 1987 because she was emotionally and physically abused by her first husband. And I think this was a psychologically difficult, and somewhat damaging marriage for her, and it still - she still had scars from that.

I think it's important to note that she was a somewhat vague historian, and somewhat reluctant to talk about her personal psychiatric history, to the extent that she would like to attribute all of her current emotional features and emotional state to the various work-related injuries that are listed in the front of my report.

I think it's also very important to note that Miss Rosenkoetter has never sought any kind of mental health care during her lifetime in a work-related fashion, or otherwise.

She did report that her nerves were bad quote, 'My nerves was bad,' unquote, per Miss Rosenkoetter. (Dr. Stillings agreed that she was describing a mental state rather than a physical condition)

And she had taken some medications through HealthLine sometime in the past, that she thought were beneficial on calming her.

And she attributed her nervousness, correctly or incorrectly, to being harassed at work. It's noteworthy Miss

Rosenkoetter has not worked at Integram, where she worked for about eight years, she has not worked there in greater than three years, and she has not been harassed, in her own perception, in greater than three years.

She also said that her nerves were, quote, 'bad,' unquote, due to back pain, and, quote, 'because they are,' unquote.

And she notes that she was somewhat unhappy, or sad, if you will, because she did not have an independent income, and did not have as much money to spend on her children and grandchildren.

When I saw her she was not taking any type of nerve, or psychotrophic medication, and she described her life at home with her husband as somewhat quiet and docile. She spends a lot of time in her room. Really seems to be somewhat withdrawn.

She and her husband live on a 180-acre farm.

And she has a general distrust of people, even family members, and part of this is related to being assaulted by her brother-in-law in 1995." (Stillings Dp. pp. 8-10)

Dr. Stillings testified about his diagnosis after evaluation of Rosenkoetter:

"On axis one, which is reserved for primary psychiatric problems and disorders, she has no primary psychiatric disorder. Axis two, which is reserved for personality disorders, and developmental disorders, Miss Rosenkoetter is diagnosed with personality disorder not otherwise specified, with pronounced schizoid features, as well as depressive, paranoid, and somatoform.

"Axis III is reserved for medical conditions, and in Miss Rosenkoetter's case, she has morbid obesity, hypertension, and congestive heart failure.

Axis IV is reserved for psychosocial stressors, and her stressors are being unemployed in a solitary existence.

Axis V is global assessment of functioning, or GAF, if you will, as an acronym. And her GAF is 55, which means that she is occupationally able to function, but she has some moderate psychiatric symptoms, such as a flat affect, or a sad affect." (Stillings Dp. pg. 15, 16)

Dr. Stillings agreed that the work-related component, what work may or may not have caused from a psychiatric standpoint, is revealed in Axis I. The doctor was asked if the Axis II diagnoses were a result of a work-related injury or something that made up her personality. Dr. Stillings answered: "Yes, it would not be occupationally related by definition. This would be a combination of her genetic constitution, and also, her early life experiences. Personality disorders, by definition, are present and fixed, and enduring by late adolescence, or early adulthood." (Stillings Dp. pp. 15-16) The doctor agreed that the personality disorder, which is Axis II, is pre-existing, the doctor agreed that Axis III is also preexisting. Dr. Stillings agreed that Axis V, the GAF, took into account everything, Axis I through IV. With respect to her GAF score of 55, the doctor stated: "..this would mean that she probably doesn't function as well as the average person occupationally, or socially. But it doesn't preclude her from working. She is still occupationally functional.". (Stillings Dp.pg. 17)

Dr. Stillings testified as to his opinions in regards to Rosenkoetter. a. Whether or not Rosenkoetter's employment at Integram produced any type of psychological diagnosis: "Her employment at Integram did not cause her any type of psychiatric problem, or diagnosis". (Stillings Dp. pg. 18) b. Whether or not Rosenkoetter's employment at Integram produced any permanent partial disability: "As a result of her work-related aggravation of her pre-existing and coexisting personality disorder, Miss Rosenkoetter has a two to three percent permanent partial psychiatric disability." (Stillings Dp. Pg. 18) It was noted that Dr. Stillings had not provided in his evaluation report of 8/14/02 a rating of disability for any preexisting psychiatric disability which may have existed; the doctor testified, without objection -"My opinion is that Miss Rosenkoetter has a 10 percent permanent partial psychiatric disability as a result of the pre-existing personality disorder." (Stillings Dp. pg. 20)

Dr. Stillingstestified a second time (Emp./Ins. Exh 8), and noted that since his first deposition he had been forwarded and had reviewed a copy of Dr. Crane's records from 5/2/03 through 9/29/03. The doctor was asked, after having reviewed Dr. Crane's record did he deem it necessary to reevaluate Rosenkoetter. "No", Dr. Stillings answered. (Stillings 4/28/04 Dp. pg. 6) The records of Dr. Crane did not affect my opinions as previously set forth in my previous deposition testimony, Dr. Stillings said. The doctor was asked the significance he had attached to the records of Dr. Crane, and Dr. Stillings answered: "Well, I think the significance is very simple. She improved some with his psychiatric administrations." (Stillings 4/28/04 Dp. pg. 6) Dr. Stillings explained:

"Well, when I saw her GAF or global assessment of functioning was 55, Dr. Crane near the end of treatment or at some point during treatment had assigned her a GAF of 60 . So really she's gone from moderate symptoms to slightly moderate symptoms. If you assigned her a 61, then she would have minimal symptoms. So she's real close to falling into another

category of a much better prognosis and just a better outcome for her." (Stillings 4/28/04 Dp. pg. 8-9)

Dr. Stillings testified: "The continuing diagnoses are on axis - nothing on axis one. Axis two, personality disorder, not otherwise specified with schizoid features, depressive features, paranoid and somatoform features." (Stillings Dp. pg. 7) Dr. Stillings was asked to testify as to his opinion of whether or not Rosenkoetter suffered from a diagnosis of major depressive disorder:

"I do not feel she qualifies for the diagnosis of major depressive disorder based on application of the DSM-IV criteria. And this is based - now, those are subjective criteria. On an objective basis, her diagnostic testing on the MMPI does not support that diagnosis either." (Stillings 4/28/04 Dp. pg. 7)

The doctor further explained why Rosenkoetter's condition did not support the diagnosis of major depressive disorder:

"Her code type is an 82/28 and those code types are generally found in people who are schizoid, have personality disorders, have some quasi-psychotic symptoms. It indicates she has emotional distress but not particularly depressive in nature." (Stillings 4/28/04 Dp. pp. 7-8)

Dr. Stillings was asked to explain the difference between a personality disorder, as he had diagnosed, versus a depressive or mood disorder as diagnosed by Dr. Crane:

"Yeah, personality disorders are really an expression of an individual's features or characteristics of their personality, whether they're, for instance, shy or gregarious or outgoing or if they have some paranoid features. So you really are looking at sort of the mixture of their features of their particular makeup as a human being. A mood disorder is a very specific highly defined psychiatric disorder where the essential feature is, of course, a low mood." (Stillings 4/28/04 Dp. pg. 8)

Considering the medical opinions, it is found that the substantial weight of evidence supports and establishes the diagnosis made by Dr. Crane as to Axis I of depression. It is found that Dr. Poetz' opinions are not probative on the issues in that the doctor states his opinion is based on a history of stress as a result of harassment by co-employees at the work place; it has been determined in this Award that the substantial weight of the competent evidence does not establish such work events. It is further found that notwithstanding the diagnosis of depression, the substantial weight of the medical evidence does not establish a causal connection of this diagnosis and the claimant's work or work events on or about February 19, 1998; it is found that there is no competent expert medical opinion stating that the claimant's work or work events on or about February 19, 1998 caused the diagnosis of depression. It is found that both Dr. Crane and Dr. Stillings found a diagnosis on Axis II of a personality disorder (Dr. Crane - dependent personality, and Dr. Stillings "personality disorder not otherwise specified, with pronounced schizoid features, as well as depressive, paranoid, and somatoform"). Dr. Stillings opined that Rosenkoetter's employment at Integram did not cause her any type of psychiatric diagnosis, but that Rosenkoetter's employment at Integram resulted in a work-related aggravation of her pre-existing and coexisting personality disorder, and Dr. Stillings assessed a percentage of permanent partial psychiatric disability.

The Court in Tangblade noted the following:

"The appellants would have us read Duncan as holding that if an employee previously suffered from the mental condition for which he or she is now claiming benefits, the alleged work-related stress could never be found under any circumstances to be a substantial factor in causing the condition, such that it would not be compensable. The appellants misread Duncan. In reading Duncan, it is clear that the court, in reaching its holding, relied on the fact that the Commission had before it substantial and competent evidence that the onset of the employee's complained-of mental condition was inevitable and, thus, was not caused by work-related stress. It did not hold that, as a matter of law, there are no possible circumstances under which it could ever be found that work-related stress is a substantial factor in causing a mental condition, where the employee is predisposed to such a condition or had previously been diagnosed as having the condition. While it is true that a wholly idiopathic injury or condition that was merely precipitated by a work-related accident is not compensable, Alexander v. D.L. Sitton Motor Lines, 851 S.W.2d 525, 528-29 (Mo. banc 1993), if it can be shown than the alleged work stress was a substantial factor in causing the onset of a condition or aggravating an existing condition, it is compensable. Bloss, 32 S.W.3d at 672; Anderson v. Noel T. Adams Ambulance Dist., 931 S.W.2d 850, 854 (Mo.App.1996)." Id. at 668.

It is found that there is competent medical evidence establishing a medical causal connection of an aggravation of the claimant's pre-existing personality disorder to extraordinary and unusual work related events on or about February 19,

The claimant alleges work related mental injury on or about February 19, 1998. Rosenkoetter testified about submitting a number of medical bills into evidence concerning carpal tunnel surgery and for the other treatment she had received which no one has paid. It was agreed and stipulated to by the claimant and the employer/insurer that bills in issue were entered in Claimant's Exhibit No. A marked as A-11, and entered into evidence marked as Claimant's Exhibit Nos. M, M-1, N, N-1, O P and Q. The evidence also includes a bill for medical services marked as Claimant's Exhibit S. It has been determined in this Award that the claimant suffered the mental injury of an aggravation of a pre-existing personality disorder as a result of work related stress on or about February 19, 1998. Considering the bills in evidence, it is found that none of them reflect charges for treatment of a mental injury/personality disorder. Consequently, it is found that there is an insufficient basis upon which to award compensation for past medical expenses. See, generally, Martin v. Mid-America, 769 S.W.2d 105, 111-112 (Mo. banc 1989).

It has been determined in this Award that the claimant suffered the mental injury of an aggravation of a preexisting personality disorder as a result of work related stress on or about February 19, 1998.

The Workers' Compensation Act does not require that there be evidence of the specific medical treatment or procedures that will be necessary in the future as that may put an impossible and unrealistic burden upon the employee; but future medical care must flow from the injuries causally related to the compensable accident before the employer is to be held responsible. See, generally, Sifferman v. Sears, Roebuck and Co., 906 S.W.2d 823, 828 (Mo.App. S.D. 1995).

Dr. Stillings testified that in regard to the work-related aggravation of her pre-existing personality disorders diagnosed in Axis II - "And that set, she doesn't need treatment either." (Stillings Dp. pg. 19) It was noted that Dr. Crane had mentioned in his report something about future psychiatric medical care, and the doctor testified: "This lady is likely to require long-term anti-depressants, treatment, and possibly some psychotherapy along the line depending on things that happen in the future, things that may happen in the future."

Considering the evidence, it is found that there is no medical opinion of a need for future psychiatric care as a result of the compensable injury of an aggravation of pre-existing personality disorders suffered by Rosenkoetter on or about February 19, 1998. Consequently, future psychiatric medical care is denied.

It has been determined in this Award that the claimant suffered the mental injury of an aggravation of a preexisting personality disorder as a result of work related stress on or about February 19, 1998. Testifying as to continuing problems as a result of her perception of the work stress, Rosenkoetter stated - It's still with me, everything they done to me all theses years. Dr. Stillings offered the competent opinion on whether or not this injury resulted in any permanent disability. The doctor testified: "As a result of her work-related aggravation of her pre-existing and coexisting personality disorder, Miss Rosenkoetter has a two to three percent permanent partial psychiatric disability."

Considering the competent evidence, it is found that it supports an award of 4 % permanent partial disability as a result of the February 19, 1998 work related injury. This would be: 400 weeks $\times 4 \%=16 weeks; 16 weeks \times \$ 278.42= \ 4454.72.

The parameters of Second Injury Fund liability in permanent partial disability cases is set forth in Section 287.220.1 RSMo 1993, which states in pertinent part:

All cases of permanent disability where there has been previous disability shall be compensated as herein provided. Compensation shall be computed on the basis of the average earnings at the time of the last injury. If

any employee who has a preexisting permanent partial disability whether from compensable injury or otherwise, of such seriousness as to constitute a hindrance or obstacle to employment or to obtaining reemployment if the employee becomes unemployed, and the preexisting permanent partial disability, if a body as a whole injury, equals a minimum of fifty weeks of compensation or, if a major extremity injury only, equals a minimum of fifteen percent permanent partial disability, according to the medical standards that are used in determining such compensation, receives a subsequent compensable injury resulting in additional permanent partial disability so that the degree or percentage of disability, in an amount equal to a minimum of fifty weeks compensation, if a body as a whole injury or, if a major extremity injury only, equals a minimum of fifteen percent permanent partial disability..... (Emphasis added)

In this case, the percentage of permanent partial disability for the subsequent compensable injury, the 1998 work related injury of an aggravation of a pre-existing personality disorder as a result of work related stress, was found to be 4 % permanent partial disability. This is below the threshold set for consideration of any Second Injury Fund liability, and thus Second Injury Fund liability is denied.

Date: $\qquad Made by: \qquad$

LESLIE E. H. BROWN

Administrative Law Judge

Division of Workers' Compensation

A true copy: ATTEST:

Patricia Secrest

Director

Division of Workers' Compensation

Mary Ann Rosenkoetter, the claimant, testified that she was born on June 30, 1945. My highest education is eleven and a half years schooling and thirty-eight hours of college, she said, I was about two months to graduate. I never graduated from high school, the claimant said. A college I went to was Jeffco for a while, Rosenkoetter said, and I took different classes for blueprint reading and math and machine and welding. I also went to East Central in Union, Missouri where I took horticulture; and I can't recall what else I took there, the claimant stated. I did not get a degree from either one of the colleges, she said. The longest time I would have gone to East Central was a couple semesters, I think, Rosenkoetter stated.

I first went to work when I was eighteen, I think, the claimant testified. As far as I can recall I worked in a factory where you made beer signs and advertisement signs, she said. I have done factory work, school custodian, and storeroom clerk all of my life, the claimant stated. I worked at East Central for a year as a school custodian, and I think it was in about 1993 or 1994, while I was working at Integram. I don't remember how many years I did factory work, the claimant said, it's been several years. As a storeroom clerk; I read the blueprints and inspected machine parts and gave out parts out of the storeroom; this was at Bull Moose Tube where I worked about fourteen months, Rosenkoetter stated. I first went to work for Integram in 1991, I think, the claimant said, and I went to work in maintenance which entailed cleaning all the bathrooms on the production side, sweeping floors, polishing the floors or cleaning them, and then just all around maintenance work.

In 1998 while working at Integram I claimed I had depression due to harassment, Rosenkoetter stated. I had my elbows and that hurt really bad, and I went to the HealthLine and they said I had tendonitis. And just luckily the next time I went there was a different doctor came in there to work and he was looking at my arms and he asked me what was wrong with me and I told him, and he gave me medicine for depression, the claimant testified. And there was people at work if I set my soda or anything on the table, they would go and they would poke a hole in my soda so it would run all over my seat, she said. Kent was one of the guy's name who did this, I don't remember his last name, she said, there was just a bunch of them that was real good friends with the foreman and he would let them get away with that stuff; the foreman wouldn't do nothing to them, Rosenkoetter testified. I'd be standing on the platform in front of the molds and I didn't like it there anyway, and there was holes, there was grates, and I was always afraid that maybe the carousel would crash or something, and they got them big molds on them, the claimant stated, and they would take a big wrench and they would sneak over there and hit the bottom of the grate, and I would think it was falling. And they would do that all the time because they knew I was upset anyway, she said. And I couldn't leave my food set on the table because I didn't know if they would put stuff in it, the claimant stated. It was never the same, when I went back in there for break time, and they poked holes in my soda, and they would spit their chewing tobacco in a soda can, and it would have the top off it, and they would put it on the overhead, and they'd know by the hours when I would be back at the dump, and that soda can would fall on you with all that spit in it, and then you'd have to clean it off the seats, and off of you, and they done that several times, Rosenkoetter testified, and it didn't do no good to tell anybody because they wouldn't do nothing about it. And when I was on the re-work, she testified, they would go and turn things on the valves and the molds, they put a whole bunch of molds release and it would leave holes in the bun parts, and I would have to fix all of them. And sometimes there be in an hour that I was on re-work and there would be two or three boxes of bad parts in the boxes, and I'd call the foreman, he'd come over and say - Well, I don't understand that,

there must be something going on; the foreman would check this and check that, and say - Well, just go on to your next station. So, the claimant agreed, the foreman knew about this stuff and did nothing to change it. My one friend, Nicks (they used to call him Turkey Man there all the time), he came and he told me what they were doing, that they were doing it on purpose; and they asked him to do it and he said no, he wouldn't do it because he was my friend, Rosenkoetter stated. The claimant was queried - So it was different for you than anybody else? I didn't see them doing it to anybody else, the claimant answered, they once took a girl's purse and put it overhead and she couldn't get it until it dropped. This started with me just before I went to that HealthLine doctor about my hands, the claimant said. They would speed up the lines on the air bags, they would take and pile up parts so that the line would rush by real fast; and there was about maybe six to eight seat covers that you'd have to blow the plastic off and put them on that line, and they would take them from behind the stop on the machine and then the line would go real fast when they took that last one off, and it would go up, and it would all been empty. And it took me so long to blow each one to get it filled back up again, so I was blowing one and running around putting it up there so that it wouldn't shut down the carousel until I got caught up, she said. This happened until they fired me from work, Rosenkoetter said. I was fired in 1999, I think it was, the claimant stated.

The company never did anything to stop this, Rosenkoetter said. When I complained to the foreman, he'd say he'd talk to them. But it did not stop any, she said, they still hit the platform with the wrench, they still every time I got over there, they'd say I dumped over their soda, and that was a lie, I never touched nobody's stuff, the claimant testified. All of these things affected me, Rosenkoetter said, it got my nerves really bad, I started crying all the time at work. Agreeing that the foreman saw her crying at work, Rosenkoetter testified - The foreman had this one girl who was his friend, Dawn, and we were back there and cutting and putting the leather covers on, and she'd go talk to fork truck drivers and mess around, wasn't there to do her job, and you'd have to take up the slack for her. So I got so aggravated I went and told the foreman, and he come over there and took her in the office for about four hours, she sat in there and talked to him and I had to do her work and my work, the claimant said.

I was first treated for depression by Dr. Bonney, the claimant said, he was not a regular doctor at HealthLine, but he was filling in that day, and he gave me some medicine that would help me, I forget what the name of it was. I don't know what kind of doctor Dr. Bonney was, she said, I don't know if he was a psychiatrist. When asked what year this was, Rosenkoetter responded - I had gone to HealthLine because of my arms, they were hurting me all the time, tendonitis in my elbows. Rosenkoetter was asked, before Dr. Crane, had she been to any psychiatrist for depression at all. No, she answered. The company sent me to Dr. Stillings, I think, the claimant said, and other than that I don't recall going to any other psychiatrists in my life, she said.

Explaining how all of these things she had described affected her work or her ability to work, Rosenkoetter stated that she got really upset about all the bad parts. I just didn't have time to fix them, she said, so that makes it look bad on you, because you got two or three boxes with bad parts sitting there that you can't fix. And then they wasn't even entered into the computer because you don't have time to do all of that, she stated. The parts were foam buns, which is the cushion that goes underneath the leather covers. Explaining what was defective about them, the claimant stated that they would put too much mold release and it just eats the foam and it makes holes in it; the guy that was inspecting them, they had strips on them and you tore off the top part and it was like a Velcro left, he would rip it all off, then I'd have to glue them all back on. Pat Brown was one of the guys, she said, he told me he was ripping off this section of these foam buns because it was too tight and it just came off. This was done just to me, the claimant said. The foreman did not say anything about this, Rosenkoetter stated, he put them all in a box and pushed them to the back, and they would fix them back there.

The claimant testified about continuing problems as a result of the harassment at work. It's still with me, she said, everything they done to me all these years, when I slipped on the tag, then after they sent me to Lesson Ferry to a back doctor down there, when I went in there he done x-rays and he come in there and he told me - you didn't have your back operated on, your back wasn't operated on, Dr. Jacobs didn't do anything to your back. The claimant agreed that when she went to be examined she had a surgical scar on her back where Dr. Jacobs had cut on her back and removed the disc. The surgical scar is more than an inch long and is visible now, and was there when I went to this doctor who told me I didn't have any surgery on my back, and this doctor had looked at my back, the claimant said. Well, after that then they sent me back down there, and they did do an MRI of my knee and said there wasn't nothing wrong with it, she said. The doctor took x-rays of my back, and on the x-rays I had a pinched nerve on the right side of my back, I left, I called back and then when I called back there was no pinched nerve, Rosenkoetter testified.

Rosenkoetter testified about the treatment she has received for depression. Just the medicine that one doctor gave me, she said. Rosenkoetter agreed that she was also treated by Dr. Crane right after the last hearing setting in this case, that she had gone the next day; Rosenkoetter agreed that she had testified at the last hearing setting that she was so upset that day she didn't feel she could testify. Except for the one time with the HealthLine doctor, this was the first treatment I had had for depression, when I started with Dr. Crane after the last hearing setting, she said. I don't know how often I have seen Dr. Crane since then, which was May of last year, the claimant said, when I first started going to

him it was once a month. The reason I went because I couldn't control my anger anymore, Rosenkoetter said. She agreed that she had a lot of crying spells, and agreed that she missed two appointments at her attorney's office to prepare for the trial. I got so bad that I can't stand to go in the elevators, I can't stand to go twenty-five floors up, all the people, and I got so I wouldn't leave my house; I wouldn't go out of the bedroom, and I just slept all the time; I can't stand the people, too many people, and it felt like the buildings were going to fall on me, the claimant testified. Agreeing that she had refused to come to her attorney's office because it was downtown, Rosenkoetter stated - I just told Mr. Gerritzen I couldn't come up there, I just couldn't do it, and he said I could come to his house. And I had to get my husband off of work because I had a car accident in about 1985 and had a real bad concussion and I can't remember, and it messed up a nerve in the back of my head and I couldn't smell and couldn't taste real good; I get lost and I was losing track of time and I would lose hours, I wouldn't know what I did or where I was at; I was lost and I was in Illinois once and I couldn't get home, and I got lost once in St. Charles. I just decided to stay home, the claimant said.

Rosenkoetter stated that she went to work for Integram in about 1991 and agreed that she got back and forth to work. She was queried if she felt her inability with going in the big buildings and being with people was due to what happened to her in 1985 or was it due to what happened at Integram, or due to both. Just all the aggravation at Integram, the claimant answered, all the stuff that they done to me and put me down because of my back, and I worked what I could work, when I could work, and it just wasn't never enough.

I last saw Dr. Crane last week, the claimant said. The treatment Dr. Crane gives me is that he listens to me for one, Rosenkoetter stated. When I went to that Dr. Stallings, I had to fill out this big long paper, a hundred and some questions, and there was a bunch at the end that I couldn't answer yes or no because it wasn't pertaining to me, and when I turned them in, he said - No, you got to fill them all out or else it's going to be incomplete. So I just went through and marked anything because I didn't know what else to do; then when I went in to talk to him he asked me what my problem was, I tried to tell him that it was the stuff at work, and all he said was - We can't talk about that. We couldn't talk about nothing that they done to other people, the claimant stated, and it was all my ex-husband. My ex-husband and I are friends, she said, they come to my house, I go to their house, we eat dinner together and everything. It's not my exhusband, Rosenkoetter stated, but he didn't want to hear it, he didn't want to hear nothing. And Dr. Crane, he'll listen to me, he doesn't put me off, she said, he gives me the medicine that helps me, unless I get real upset like today, could live a halfway normal life. I took my weed-eater and I beat it up, that's how bad my nerves got, that's why I went to the doctor. I just bought it brand new, and I could not use it for five minutes and my back was hurting so bad I couldn't use it, Rosenkoetter testified. Then I went and made an appointment with Dr. Crane and I started going to him; brand new weed-eater, I just beat it all to pieces; that's why I started going to see Dr. Crane, the claimant testified. She agreed that she was talking about May of last year, 2003. I go to Dr. Crane regularly, once a month or six weeks, sometimes I'll make it two months, Rosenkoetter said. The medicines I am on now are Prozac, two a day; I was given Coreg by my heart doctor since I can't get out and exercise and walk and I got four blockages in my heart, and I take four of them a day; I take Glipizide twice a day; and I got diabetes now, too, because I'm not active enough and I take Metformin; and I take Cardizem for my high blood pressure which I developed after I had the surgery in 1995; and I take a Bayer aspirin every day; and Celebrex; and the rest is just over-the-counter stuff, I have to take the fish oil, two of them a day, and the vitamin and Folic acid and potassium; I take a water pill, it's from the heart doctor, the claimant testified.

Rosenkoetter testified about prior injuries prior to the development of depression in 1998. The claimant stated that in 1985 she was in a motor vehicle accident. I had a small car, an Omni, she stated, and a lady came up on the right side, and she clipped the front of the car and threw me into the median, and I wound up hitting my head pretty hard on the Mirror and broke it and caused me to have a concussion and messed up a nerve in the back of my neck, and there was a bone out of place in the side of my head. I went to a doctor for about seventeen months; I couldn't drive, I would lose track of time, I get lost, I'd be sitting at home and I'd just lose three or four hours, she stated, and I couldn't stand to smell white bread, I couldn't see the trees going by or I had to wear sunglasses. Problems that have continued are with direction, the claimant said, getting turned around and getting lost sometimes. I just don't go far from home and usually my husband takes me if I have to; this is because I get turned around sometimes, but not all the time. Concerning my memory, Rosenkoetter said, as far as everyday things, it's all right. I've never been any good at dates, she said, I can remember what happened, but I can't for, say, remember every day. When queried if she was confident all the history she gave on direct exam was accurate, Rosenkoetter responded - I tried the best I can remember. The claimant was queried, if some of the medical records showed a slightly different history as opposed to what she testified to on direct examination, would she dispute what's in the medical records? I don't know; I done the best I could to remember all the dates; I'm just not good at dates, the claimant answered.

On November 23, 1994 I suffered injury to my left hand and ring finger, Rosenkoetter testified, at that time I had gone from the maintenance to production, and they made seats for Chrysler cars and minivans. I was working on a Saturday, overtime; in the dump area which is where all the seats come from the overhead down in the bin, then you take

the parts out of there and you pack them in the boxes, the claimant testified. And I had two seats come down, front seats, cushions, and I grabbed both of them and I went to turn around to put them in the box and it hit the edge of the box, the one cushion in my left hand, and it started to fall to the floor and I started to grab it, and when I did, it has a metal pan on the bottom and my hand went in the middle of that circle in the middle of the pan, and when it did that it just sliced right down my hand, between my little finger and my ring finger, the claimant said, it went down my hand quite a ways, about an inch. I was bleeding pretty bad and by the time I got to the front and got somebody to help me, the claimant stated, they took me in the nurse's office and they kept looking at it, and the general foreman, George, came over there and he looked at it, and every time they'd take the towels off it would just pump blood out of it. They couldn't decide whether I needed to go to the hospital or not, but I kept bleeding so bad they had to call the nurse, and finally after she came and looked at it, well, then they decided I needed to go to the hospital; so someone from Integram drove me to the hospital where they sewed it up, Rosenkoetter said. I went back to work, and as far as I recall, I was there the next day, Rosenkoetter stated. Continuing problems are that I have numbness on the inside of my little finger, the claimant said, and whenever I drive or use a broom, or anything that goes across my hand there, it really hurts it; it aches in the winter; I can't bend my little finger on my left hand out like the other one, I can't close it all the way like my other hand; I can't pick up a heavy skillet or anything like I used to be able to because the strength just isn't there anymore, I just can't grip as well anything with the left hand. Rosenkoetter displayed her left hand, and it was noted that there was a line scar that went about an inch into the hand between the ring and little finger. It was further noted that the claimant was unable to touch the little finger to the hand by about a fourth of an inch.

On September 15, 1995, that night I was working in Cut and Sew, Rosenkoetter testified, and we have to take leather covers and put them on the foam, and it was always hurry up, hurry up, hurry up, and some tags got dropped on the floor, and I was coming around the table and I stepped on one, and it's real slick on one side, and I slipped and fell towards the table, trying to grab it, I fell to the concrete floor, and especially on my right knee and my foot was kind of turned under me and it hurt my right ankle and jarred my back, the claimant stated. At that time, my ankle was really hurting, my back was throbbing, and I started limping. I finally found the foreman and told him what happened, she stated, and he said to try some ice on my ankle and my knee, and didn't say nothing about my back. I had never had any problems with my right knee, right ankle or my back prior to slipping on this tag in 1995, the claimant said. I did not lose any time from work, she said. I kept getting pain down the back of my right leg and my knee, and I was limping for two weeks before I could get them to finally decide to send me to a doctor. My employer sent me to HealthLine where they wrapped my knee; they didn't take any x-rays or nothing, said it was just sprained and to put ice on my back, and that was it, Rosenkoetter stated. I returned to HealthLine because I still had the pain, and my husband went with me that day, and the doctor said my knee was fine, and I asked for a second opinion on my back and the doctor got mad and said I refused to be seen and took my papers out to the front desk. I said I'm not leaving because I didn't refuse to be seen, and she says if you can act like a patient then come back in here, the claimant testified, so I went back in the office and she wouldn't let my husband go back in there and she said I didn't need a second opinion on my back. The HealthLine doctor never did anything about my back, right knee, and right ankle, the claimant said, and this ended the company's tendered treatment. Rosenkoetter stated that she did not recall HealthLine asking her to come back for anything else, or recall the company sending her somewhere else; she went to the doctor on her own and had the surgery, she said.

My back just kept hurting so bad that I couldn't stand the pain no more, and one night I sat down on the toilet and I couldn't get up, it was that bad, she said, this was about a month after it had happened. My husband carried me to the chiropractor, Dr. Clark, who put some heat and therapy on my back and told me to go home and try to relax, the claimant said. I was back the next day for another treatment, and the next day, Rosenkoetter stated, because I could hardly walk because the pain in my back was really bad and at that time it was going down the back of both of my legs all the way to my heel. I saw Dr. Clark about three times, I think, the claimant said, and then I went to Dr. Calvin, my regular doctor, and he set me up an appointment with Dr. Jacobs, a neurologist. Dr. Jacobs took x-rays, and I had to go to the hospital for some nerve tests, MRI, Rosenkoetter said, and then the doctor wanted to do surgery right away. Surgery was ultimately done on my back by Dr. Jacobs in about November 1995, about a month after I first went to Dr. Jacobs, the claimant said. The surgery was done on my low back on the left side of my spine; Dr. Jacobs took out a disc and put a stabilizer in my back and fused some bones, I think, together, the claimant stated. The affect the surgery had on me, the claimant said, is that my legs don't work right; there is a piece of bone that came off of my spine and runs into the nerve of my leg and that's what is the constant pain all the time. After the surgery I was in bed for a month, the claimant said, I could get up to go to the bathroom, but I couldn't stand to be up any longer than just a few minutes. And then I got a little bit stronger where I could go to the kitchen and come back, and I got so I could sit up and eat at the table for a few minutes, and every little bit, you know, got a little better and a little better where I could walk a little more, Rosenkoetter said.

The claimant testified about ongoing problems with her back and leg. I have constant pain all the time in the low

back in the same area where it originally started when I had the slip on the tag, she said. Sometimes the pain is pretty bad, Rosenkoetter stated, it keeps me from sleeping, and I live on pain pills all the time. With walking, the claimant said, I can make it maybe fifty, sixty feet, but I can't sweep the floor unless I stop three or four times and then come back to it, and mopping is very hard. I am not able to do any activities without repercussions from it; if I do too much then I'm in bed for a couple days for it to get better again, unless I'm going for therapy on my back, she said.

From the time of the 1995 work accident up to the time of surgery I was back at work some days, Rosenkoetter said. I would take off my vacation days; I even got in trouble for taking off days because I just couldn't do it, I done what I could do; I took off TPT days where they had people work for you; I took vacation days and everything I could take off to keep from having to work, the claimant stated. I have no idea how many days I was off work before the surgery, she said.

I was never able to work like I could work before the accident when I slipped on the tag, Rosenkoetter testified. Before I slipped on the tag there'd be weeks that I would work more overtime hours than my regular hours; and I was always going in early on the second shift; and I couldn't do that afterwards, she said.

After the surgery, I was off work close to fourteen months, I think, the claimant said, when I went back to work it would have been close to Christmas of 1996. When I went back to work it was hard on my back, Rosenkoetter stated, I went home the first night that I went back. It's hard on my back to lift the stuff and just to be able to walk from station to station and get back in the routine of anything, she said, this along with bending was hard. It was just made me real sore to start back after not being able to do anything for so long, the claimant said, and the bending over the re-work table would hurt my back, and I couldn't do the lifting; I'd go home every night and couldn't hardly stand it from the lifting the heavy seats and stuff, and bending over the boxes. And then I'd have so long a time to get from one station to the other and to be on time, Rosenkoetter said. Walking was from the inspection table to re-work, which wasn't but about five feet, but then you had to go from there all the way into the back, which was maybe sixty, seventy feet, she said, and it was all on level concrete which wasn't real good either.

My knee and ankle had quit hurting for a while after I had my back surgery, the claimant said, but every once in a while my right ankle flares up. It swells, and in here it's swollen all the time, she said, it's swollen today.

From the time I went back to work in November of 1996 until the accident of November 18, 1997 with the bench seat, the claimant said, the difference in my ability to work at Integram was that it slowed down a lot. I just didn't do as many parts as I used to; I wouldn't help other people, I just couldn't do that no more, Rosenkoetter said.

I also lost a business interest because of the 1995 accident at Integram, the claimant said. I had several mobile homes; some of them were located in trailer parks and three were on pieces of ground in Union, she said. The times that I worked both jobs, the sixteen hours a day, was to pay for these so that I would have something to retire with, and I made all the payments myself and I done all the repairs myself, she said. After I slipped on the tag I had to sell them all because I couldn't do the repairs or keep them up anymore, Rosenkoetter said, I used to be able to tear them down and set them up myself and I couldn't do any of that anymore after the 1995 accident to my back. Also before the 1995 accident at Integram where I slipped on the tag, I had my own motorcycle, and I rode it all the time, Rosenkoetter testified. And when I got married, my husband lives on a farm, and I would go with him all day and helped cut wood, I had my own saw; helped him plow the fields, cut the hay, put the hay up, all those things. I can't do none of that anymore, the claimant said. I have always been an active person, I have always been independent, Rosenkoetter stated, I always depended on myself to make my living and to do the things I needed done, I never had to go and ask anybody. But after I got hurt, I sold my bike; it had sat in the shed for two years. I just couldn't do that stuff anymore, she said. My chainsaws, I sold them, the claimant said.

On November 18, 1997 at Integram I had one of the larger seats which I think seats three people, and I took it to the box and bent over to put it in, and I got a real sharp pain in my right lower back, Rosenkoetter testified. It was the bottom seat, and I guess they're maybe as long as about two to two and a half feet wide, she said, and I think we made all the seats for the minivans. The pain in my low back was in the same area as where I had had the surgery, Rosenkoetter said. Agreeing that some time after this, but not that night, the pain went down her leg. After the November 1997 incident I stood there for a while and when it eased down a little bit, I went and told the foreman that I'd hurt my back bending over in the box, Rosenkoetter testified. The foreman called the nurse and she brought some Aleve pills and told me to take them, and I must have been allergic to them, I had a reaction because I couldn't breathe very well, she said. And then the next day I went to see Dr. Calvin and I had a knot come up in my hip and he gave me muscle relaxers, some pain medicine, and therapy his office, the claimant stated. She was asked how long did she get therapy, and Rosenkoetter responded - I was off work for about a week, I think. When I went back to work after about a

week, I just had the pain all the time, the claimant said, it was just miserable because my back hurt and the more places that I went to do the job, then it was just hard. I was not able to do the same amount of work like I used to, she said. Giving an example, Rosenkoetter testified that the fork truck drivers would bring the seats in big boxes and you'd have to bend over and get an armful and put them on the bins for the air bag blower, and that's what was really hard because of the bending and lifting the bunch of seat covers, so I always tried to trade that off with anybody that I could get to trade with.

I have constant pain all the way down my leg to my heel still today, the claimant said. I'm going to therapy now because I can't hardly get around; my legs just don't work as well, and I fell going up my steps, two steps, that I have gone up them a thousand times before. I fell, broke my tibia in my left leg because I thought my foot was up high enough for the step, she said, also I stepped over a little fence, maybe nine inches tall, and I fell again. I have come out of the barn and when I stepped on the step then my ankle just turned; I just think my legs are up high enough, but they aren't, the claimant stated. I have slipped in a hole in the yard and fell, Rosenkoetter stated, and my last thing last week I fell and hurt my arm, all I was doing was walking on the driveway, but my right leg wouldn't come when I was stepping and I just went face down. I attribute these falls at home to my back and my legs, they just don't work right, she said. The claimant was asked if this came from the 1995 accident on the tag, the 1997 accident with the bench seat, or both. The 1995, she answered. When asked if they got worse in 1997, Rosenkoetter responded - They just seem to be getting worser all the time; the pain never goes away. The claimant testified that treatment she is getting now is from Dr. Calvin, and that this is the second week she is going to the therapy twice a week now because of the pain in her right back, and when she next goes they are supposed to fit her for a cane. Rosenkoetter was asked how long had her right ankle been swelling up all the time. I was on the work station on the dump, and we packed the parts in boxes, and I was packing a bench part in the box and when I bent over I had a bad pain in my right lower back, and it's been swollen ever since then, she answered, and agreed that she was talking about the accident on November 18, 1997. The only time it's not swollen is when I first get out of bed in the morning, she said. Since November 18, 1997, every so often my ankle will start aching, I'll be limping around for a while, then it'll get better, the claimant said. It hurts me to walk if I walk a ways, she stated, and sometimes it aches at night; when it gets cold, it hurts. The pain is about a five or a six out of ten, she said. Concerning how far she can walk before the ankle starts swelling up, Rosenkoetter stated that as soon as she gets on her feet it starts swelling.

I was fired by Integram in 1999, the claimant stated, and the reason they gave was because I was off when I hurt my leg; and they changed the contract and they said the insurance papers -- when I hurt my knee, I went on sick leave and I went and got my papers to fill out; it's after I fell and went to the hospital and the doctor said I shouldn't work. So I went to the bone specialist, and I got my insurance papers and I didn't know how to fill them out because they were different, and I called the H.R. and Mary Jo said she would help me fill them out, and she told me what to put down. And I went to the doctor, the bone specialist, Dr. Kef alas, and I had an immobilizer on my knee and a gel cast on my ankle and I was on crutches; and I think that was on a Wednesday, and Thursday I had called work, I had all my phone bills because it was long distance, and I had called them on a Friday and I asked them in H.R. at Integram if there's anything else that I had to do, and she said no, that's all I have to do, the claimant testified. On the Thursday the doctor had faxed my medical papers from his office to work; they had them, but she lied to me, she said there was nothing else to do and that wasn't true, the claimant said. They said they fired me because I didn't come in and fill out new papers; that's why we went, the union man and me, before the arbitration board. It was whoever's the boss down there at Integram, the general foreman, I guess, who said I didn't fill out the papers right, the claimant stated, because they said I was fired because I didn't do my paperwork right. But they already had the doctor's papers there in front of them and then when we went to the arbitration I had my phone bills and everything, and they had three or six women from the H. R. Department sit there and lie, it didn't make any difference what I said, and my union worker denied me the right to have counsel, said he was going to represent me, so I didn't even get to have a lawyer there, Rosenkoetter testified. This was right after they fired me and then went through three steps, and the fourth step was to go before the arbitrator. They denied my unemployment, and I went to the hearing for unemployment and their woman said that was absurd that I would quit my job at fifteen something an hour, and she gave me my unemployment, the woman from Jeff City, the claimant stated.

Rosenkoetter stated that she has tried to work since leaving Integram. I tried to find a job, and I filled out applications and applications, and nobody would hire me, she said. Wal-Mart said I had to bend over and pick up a dime off the floor, I couldn't do that, my back wouldn't let me bend over that far, the claimant said. I filled out applications for wherever I had education to do -- machine shops and different places like that; but as soon as they find out you had a back problem they don't want nothing to do with you, Rosenkoetter stated. She was asked if she believed she is able to work now anywhere. No, Rosenkoetter answered, and explained that it was just all the injuries to her body. I just can't do it, she said, I wish I could.

The claimant testified about her daily routine now. I try to do my dishes in the morning, and get my husband off to work, and make his lunch, she said, and try to sweep the floor, that takes me a while because I quit and go back, and sometimes l'll sit on the porch, or sometimes I watch TV for a while. I can't sit very long, can't stand very long, the claimant stated, I sit for maybe about forty-five minutes or so, then I got to get up and walk around. With standing it's really hard for me to bend over the sink to do the dishes, Rosenkoetter said, l'll stand for a while, depends on what I'm doing. I think the longest I can stand is about an hour or so, I guess, she said. I can't walk very far, the claimant said, l'd walk from the house to the barn and turn the water faucet on for the cows but last time I went out there, I fell, this was last week. I fell because of my leg, Rosenkoetter stated, I had bad pains in my right hip and lower back for the last month and a half, and when I went to step it was just real bad pain, I couldn't bring my foot up and I just fell face down in the gravel. But I got a bone on the left side that catches on my hip bone, and I can feel it, I can feel it rubbing, the claimant said.

Rosenkoetter agreed that she had submitted a number of medical bills in the case for the carpal tunnel surgery and for the other treatment she had received, and that she was asking for an award of compensation for those bills. No one has paid these bills of Dr. Schlafly's and of St. Anthony's, she said. It was agreed and stipulated to by the claimant and the employer/insurer that bills in issue were entered in Claimant's Exhibit No. A marked as A-11, and entered into evidence marked as Claimant's Exhibit Nos. M, M-1, N, N-1, O P and Q.

On cross examination by the employer/insurer, Rosenkoetter agreed that the first time her case was set for hearing, exhibits were entered into evidence on the record and then on that date she had indicated that she didn't feel like she was able to testify. My nerves was really bad that day, she said. The claimant was asked if she had felt competent to testify on direct examination the day before. I got nervous, but the medicine the doctor gives me helps me, Rosenkoetter answered. I'm not real good today, she stated, but I feel I am competent to testify today.

During cross examination, the claimant agreed that her first injury was the cut to her left hand in 1994. When asked if she remembered the date of this injury, Rosenkoetter responded - I know it was around Thanksgiving because I cut this hand [indicating] on Thanksgiving and it was wrapped up as well as on this finger, and on Christmas I couldn't make pies or nothing for everybody because it was cut, she said. My employer sent me to HealthLine for treatment for this injury, and the treatment was paid for by my employer or my insurance; I don't know, she said. The claimant was queried if HealthLine had initially discharged her from their care on approximately January 4, 1995. I don't know what date it was, she answered. I don't think I was ever off of work for this injury, the claimant said. She said that she did not recall but would not dispute the records of HealthLine which indicated that as of January 4, 1995 they felt she could work without restrictions. When asked if January 4, 1995 was the last time she received treatment, Rosenkoetter responded - I don't know; I have no idea; I can't remember the dates; it's like I can remember people, I can't remember their names, a lot of them. She stated that she guessed it was correct that once she got off the re-work status at Integram she continued to work her regular duties at Integram, and stated that she imagined it was correct that she then continued to work without restriction and without lost time. The problem of having a hard time closing my fingers, as I testified to earlier, has been a problem since I got my hand cut, the claimant said. When queried if it was correct it had been a problem since approximately November of 1994 up through today, Rosenkoetter responded - It got worse when I got the carpal tunnel. She agreed that the inability to close her fingers all the way to make a fist with that hand is something she has had on a daily basis from the time of the laceration up until today.

Rosenkoetter agreed, during cross examination by the employer/insurer, that she has had two injuries to her back. I don't remember the month of the first injury, September or June, she said, and it was in 1995. She agreed that she had testified earlier this first injury was as a result of stepping on a tag and slipping. Indicating that she had continued working and finished her shift that day, Rosenkoetter stated - When I fell it was almost time for the shift to be over. Agreeing that she had returned to work at Integram the next day, the claimant said that she had to. It was noted that Rosenkoetter had testified that she had requested treatment but it took them a while to get her to a treating doctor. They said to put ice on it, she responded. When queried that she continued to work at Integram up until the time she was first seen by a treating doctor, Rosenkoetter responded - As far as I know, I don't know if I had any days to take off or not. The first treatment was about ten days after the tag incident, the claimant said. She was queried if she had attempted to go to a doctor on her own during those first ten days. We were told to go to the foreman and the foreman would set up an appointment for me to go to HealthLine, because with an injury at work you had to go to the workmen's comp doctor, the claimant answered. The claimant was queried, you waited ten days to get treatment? I kept telling the foreman - it's hurting, and he said he'd get me an appointment, and after ten days then he finally got me an appointment, she answered.

During cross examination, Rosenkoetter was questioned about the first back injury stipulated to by the parties as to have occurred on September 15, 1995. The claimant was referred to Employer/Insurer's Exhibit No. 7 (first workers'

compensation claimant's report dated 10-7-95); Rosenkoetter stated that it looked like her signature at the bottom of this form. It was noted that Exhibit No. 7 reflected that Rosenkoetter had hurt herself on 8-25-95. I don't know if I filled that out the night I got hurt or I filled it out after, I don't remember, the claimant answered, all I know is I went in the office after I found the foreman and I told him, and he filled out a paper. It was September 15th that I got wrote down, the claimant stated, I think that's the date that I hurt my back. Rosenkoetter stated that as far as she could recall, between the time she did hurt herself - be it June, August, or September - in the time she first received treatment she continued to work at Integram. When queried, wasn't it correct that the first place she received treatment was Healthline, the claimant responded - First treatment I got was putting ice on it; that's what the foreman told me to do. She agreed that the first hospital, emergency room, or clinic, or doctor that she was seen by was at Healthline. Agreeing that from the time of the injury up until the time she went to Healthline she continued to work at Integram doing her regular duties without restrictions. I had to, I didn't have no days off, Rosenkoetter answered. She agreed that when she went to Healthline the doctor took a history from her and asked her what body parts were hurt. From the time I got hurt until ten days later when I went to that doctor, yes, I had problems with my back, the claimant said. When the doctor asked what body parts I had hurt I told her - my ankle, my knee, and my back, the claimant stated. When queried, so if the only history in those medical records is that you injured your ankle and your knee that would be inconsistent with your recollection, Rosenkoetter responded - The doctor told me there wasn't nothing wrong with my back. Concerning the "first workers' compensation claimant's report" dated 10-7-95, Rosenkoetter agreed that she had signed it, but further stated - I don't remember filling it out. She admitted that at the time she signed and dated this report it was filled out. I don't recall if I had an opportunity to review the report before I signed and dated it, she said. It was noted that the 10-7-95 report specifically made inquiry as to what were her injuries; at the hearing, the claimant noted that it stated "right ankle and ankle", and admitted that she did not see on the report any reference to an injury to the back. After HealthLine the next place I received treatment for my back was when they sent me to Dr. Clark, the claimant said, and for three days he got me to where I could walk again, then I went to Dr. Calvin. From that time where I slipped on the tag in June or August or September up until the time I went to Dr. Clark, I did not have any new injuries to my back, Rosenkoetter said.

The claimant was queried during cross examination if she had ever worked painting floors at Integram. Not that I can recall; she answered, the only painting they done was to paint a yellow line on the -- when they were off for model to change over, and I don't even remember if I even done that or not. Rosenkoetter said that she did not recall if she would have been painting at Integram on October 14 and 15, 1995; she agreed that October 14 and 15, 1995 was a weekend, and assuming that to be the case, she would not have been working at Integram. Rosenkoetter agreed that Dr. Clark was a doctor that she picked on her own, and she stated that she supposed Dr. Clark took a history from her as to how she had injured herself when she went to him on October 15, 1995. I told him I sat on the toilet and I couldn't get up, Rosenkoetter stated. The claimant was queried if it would be consistent with her recollection if Dr. Clark's record of 10-15-95 reflected that she relayed that she had been painting floors in a flexed stooped position and after sitting down two to three hours ago she had an onset of pain in the left low back, hip, and leg. I don't know where he got the painting floors at, Rosenkoetter responded. I know what I told the doctor, I don't know what he wrote down, she said. The claimant agreed that Dr. Calvin was a doctor she had picked on her own, the company did not send her to Dr. Calvin. Dr. Calvin is my main doctor, Rosenkoetter said. The history I told Dr. Calvin as to how I had hurt my back, Rosenkoetter stated, was that I just sat down and I couldn't get up. The claimant stated that it was at Leslie Depot, a bar and eating place where they have live music on the weekends, where she had attempted to use the restroom and was unable to get up. No one had talked to me about a need for surgery on my back until I went to Dr. Calvin, the claimant said. Rosenkoetter was questioned about physical therapy records indicating that she missed the first physical therapy session on 10-17-95 for her knee because of an injury to her back sustained over the weekend. I wasn't in no accident since I hurt my back until I sat on the frigging commode and couldn't get up; there was no accident in between there, I just sit down and I couldn't get up, Rosenkoetter responded.

The claimant stated that as far as she knew, she had have never been to Dr. Clark prior to the 10-15-95 injury to her back. She was queried if it would be inconsistent with her recollection if Dr. Clark's records from 1994 indicated that she had been involved in a motor vehicle accident and that she had pain in the small of her back, and hip, and legs that was worse in the last six months. I only been in two car accidents, the claimant responded.

Rosenkoetter stated, during cross examination, on 11-18-97 she hurt her right back when she put the bench seat in the box, and that from the first date of injury to her back up to 11-18-97 she did not recall having any other injuries to her back. At the time of the second back injury I was working full duty without restrictions, as far as I know, Rosenkoetter said. The claimant was asked if she had been seen by Dr. Calvin prior to 11-18-97 for problems with her back, such as six months preceding, and the claimant answered - I go to Dr. Calvin for most everything. I don't remember if I went to Dr. Calvin for complaints or problems with my back in the six months preceding the 11-18-97 incident, the claimant said. I could have but I don't remember going to Dr. Calvin on 5-29-97 for complaints of strain in the upper back and neck, and severe muscle spasm after lifting liquid soap, Rosenkoetter said, sometimes I turn just right or if I'd pick up a basket of

clothes or anything then I strain my back. It was noted that Dr. Calvin's record included a 9-16-97 entry reflecting that Rosenkoetter had advised him that she had strained her back while lifting heavy pots at a family reunion and that she had been diagnosed with acute lumbar sacral strain and severe muscle sprain; the claimant responded - If that's what it says.

During cross examination by the employer/insurer, the claimant was questioned about her Claim for Compensation pertained to her psychiatric condition; she was asked to what did she attribute her psychiatric problems. I'd been having problems at work with harassment, the claimant answered. When I went to the doctor about my arms, there was another doctor there and not the regular doctor, and he asked me what was wrong, and I told him I'd been having problems at work, and he put it on the paper, the claimant stated, he give me some medicine that would help me. As far as I can recall, that was the first time I ever had a discussion with a physician about any psychiatric issues and the first time any physician prescribed me any medications for any psychiatric issues, Rosenkoetter said. She was asked when did the harassment start. I don't recall, Rosenkoetter answered, all I know is I had problems with them at work and that day was really bothering me, and the doctor asked me what was wrong and I told him. I'd had problems after I went back to work, not being able to do what I was supposed to do, worried about my job, the claimant stated. And all that stuff started with them guys at work; you could never get nothing done; even if you told the foreman, he wouldn't do nothing about it, he'd say - I'll talk to them, and it got worse and worse and worse, the claimant stated. Rosenkoetter agreed that it was sometime after she went back to work after the surgery for the back injury that the harassment started. It was sometime around the end of 1996 or beginning of 1997 that I returned to work, the claimant agreed. Dean Nordman was the supervisor I talked to who did nothing about it, the claimant stated. The harassment occurred on between ten and twenty occasions, Rosenkoetter said. They would hit the platform that I stand on; when I was spraying the molds or putting the covers on the molds, then they would come from around with the big wrench, and when I wasn't looking they would hit up on that and I would think it was falling, she said. They would do things all the time and they'd stand there and laugh because they knew it scared me, she said, and they wouldn't stop, every chance they got. It just upset me that they did it; I asked them to quit, and the more you asked them, the worse it would get, Rosenkoetter said. She agreed that during that period after she returned to work, in addition to the harassment, one of the things she was concerned about was her ability to perform her job duties and actually keep her job. The claimant agreed that she believed Dean Nordman played a role in this harassment. He never done anything about it, she said. When asked if Nordman had promoted it at all, Rosenkoetter responded - I believe he was in on some of it. The claimant explained that though she believed that along with the other employees Nordman played a role in the harassment that she underwent, but nevertheless when she thought it was a problem she went to Dean Nordman to report it because he was her supervisor. Rosenkoetter stated that she did not file a grievance about the harassment because she didn't know you could do that. I didn't know if there was a hotline at work, the claimant said, I never worked in a place where they had a union. Rosenkoetter stated that she knew there was a human resources department at Integram, and that she trusted them until she lost her job. I did not go to H. R. and tell them I was being harassed because I thought you went there to fill out papers, like medical papers, and insurance papers, and stuff like that; I never thought they would deal with harassment or anything, she said.

Rosenkoetter stated, during cross examination, that she already was stressed out before her termination; the termination did not make my stress worse, it made me hate you and the company you represent. Rosenkoetter agreed that her termination and the grievance proceeding was all about insurance paperwork, it wasn't about making bad parts or not doing her job right. No one from the company that I know of ever wrote me up because I made too many bad parts, the claimant said. No one from the company ever came to me on the re-work line and said as a result of my not keeping up with the re-work, we're going to write you up, Rosenkoetter stated, they did come back and tell us if people was going to chew, then they had to have a bottle with a lid on it and keep the lid on it.

Rosenkoetter agreed, during cross examination, that she had been physically assaulted once. My husband's brother jerked a chain out of my hand and hurt my arm, she said. She agreed that this happened on about 6/6/95. I went to St. John's Hospital, the claimant said, and they said it was just strained, it was all right. The claimant agreed that a history of what had occurred was taken from her at the hospital. When asked if her brother-in-law had tried to punch her on that date, Rosenkoetter responded - I think he tried to punch my husband or hit him with a shovel, or might have tried to take a swing at me, but he didn't hit me. The claimant agreed that her memory was refreshed by the St. John's record which reflected that her brother-in-law just went berserk, grabbed her arm and twisted it and tried to punch her, and she blocked that punch with her right arm. He grabbed a chain that I had in my hand and brought it around a post and it twisted my hand, she explained. Explaining what caused her brother-in-law to go berserk, Rosenkoetter testified that he lived in the farmhouse and his dad had given him six and a half acres to build a house. He wouldn't work on the house so we kicked him out; he had to pay rent or move; and then when we told him that dad wanted him to pay rent, he got mad and he moved out, and then put chains around the gate to keep us from going to our house; and we went up there and told him that we had to get in, we had no other way to get to the house, there was no other roads, and my husband said - Well, we'll just put chains on it and you won't get out; and that's when he just went crazy, the claimant testified.

She was asked if her brother-in-law had hit her husband with a shovel. I think he did, the claimant answered.

Rosenkoetter agreed that they had to take her brother-in-law to court to resolve this issue. We just went to the court and we told them our side, he told them his side, and they gave the road to him because it wasn't specified on the deed about the road and the easement, and he got the road and we didn't, the claimant said. What we did about access to our home was made a road, she said. This brother-in-law still lives next to me, she said. Describing the relationship now, Rosenkoetter testified - He talks to me, I talk to him; I give him stuff out of my garden, my husband's over there quite often; he just shut the road off, that's all, so you live with it and go on. I don't think I continue to have problems with my right arm after the assault, she said. The claimant was queried if she knew why the records of Dr. Bedor for 1997 would reflect that he thought she had a rotator cuff tear in that arm. I got a test from our regular man, and he said they done a test in there put medicine in there and took x-rays, and I didn't have a rotator cuff tear, she stated. I didn't know what was causing my right shoulder problems at that point in time, that's why I went to find out; I thought I had a rotator cuff tear, and I didn't, she stated. Rosenkoetter stated that she did not remember if she missed time from work as a result of the problems with her right shoulder. I do not recall my shoulder affecting my ability to do my job duties, the claimant said. Rosenkoetter agreed that the police were involved in the altercation involving her brother-in-law, and charges were filed, but she didn't think charges were filed against her or her husband. The claimant was asked if there were any other times that she had been physically assaulted. Well, my ex-husband used to push me around a little bit off and on, she answered. I was married to my ex-husband for twenty-five years, she said. Rosenkoetter agreed that her ex-husband also tried to abuse her emotionally off and on throughout the twenty-five years. He went to the hospital and got help, she stated, he had a medical problem. Rosenkoetter agreed that she had children with her ex-husband, and that her children witnessed some of that emotional and physical abuse. Agreeing that her children were subject to that emotional or physical abuse, Rosenkoetter explained that that was why she got a divorce. It was a friendly divorce, she said, we visit each other; he comes to my house, he's remarried and I go to their house. I have not had any other family issues that caused me stress or added to my depression, the claimant said. She agreed that she had attempted to take custody of a grandchild, and explained that it was because the child had a drug addict for a father. The mom brought the baby to me, and he wouldn't buy her diapers, and she had no place to keep the baby clean, and she asked me if I would take her and I said yes. I had the child for maybe six or seven months, Rosenkoetter said. I don't know what year it was and I don't know when she went back; I gave her back because her mom got her own apartment, got on HUD, and had money to take care of her; it wasn't because of my daughter, but I had to put both names on there (my daughter's name and her boyfriend's name), or I couldn't get her.

Rosenkoetter agreed, during cross examination, that over the years she has had some problems with pneumonia and ear infections and sinus problems. I believe that it is because of the mold release that I smelled every year for year after year, she said. The claimant agreed that she missed time from work as a result of the problems with bronchitis. It was noted that she missed time from work in 1997 and 1998 because of problems with bronchitis and the breathing, and Rosenkoetter responded - You know, now I very seldom get bronchitis or get sick.

During cross examination by the employer/insurer, the claimant agreed that besides seeing Dr. Stillings one time in 1998, the first time she received any psychiatric treatment was through Dr. Crane's office in 2004. Rosenkoetter stated that she did not know if her employer had an employee assistance program (EAP). The claimant was asked if she had ever attempted to get treatment through her group health insurance. I didn't think it was bothering me that bad; I didn't want to go to a psychiatrist, she answered. Rosenkoetter agreed that when she thought it was bothering her so bad that she had to go see a psychiatrist was when she went to Dr. Crane. It was noted that this would have been several years after she left the employ of Integram, and Rosenkoetter responded - It kept on and kept on and kept on. My health situation, it eats me up, she said, do you know what it's like to not be able to do anything or fall over everything and get hurt, like my arm, and broke my leg. You don't know what it's like, she indicated; not being able to enjoy my bike no more or ride my motorcycle or go in the field with my husband, he has to do all that work "hisself" now. I can't even plant my frigging flower garden; I try to weed-eat, I bought the lightest weed-eater they had which they said weighed less than five pounds, and I couldn't even do it more than five minutes. That's why I went to Dr. Crane, the claimant stated, because I knew I needed to go someplace and I looked in the phone book and I found Dr. Crane's name and I went to him. It's just been building up and building up and all these years and all these accidents and got so I wouldn't go out of my bedroom, I would stay in there for days, the claimant stated. I didn't want my kids to come, I didn't want to see my grandkids, I didn't want to see nobody, she stated. And every time I got hurt it brings it all back again, the claimant testified, and every time I had to go to these stupid hearings and all these years been going on and going on, it eats at me. Now I have to get surgery on my other hip, and I got to face that, too. You know what it's like getting out of bed for five seconds, not even long enough to go to the bathroom, and you got to go back and lay down because you can't set up, the claimant stated. I want to kill myself, if I could have got a gun, I would have, she said. I go to bed every night crying because my legs and my back hurt so bad; can't go any place around people and enjoy yourself because you're miserable; you can't even sit in a frigging chair, the claimant said. Rosenkoetter agreed that every time she has an injury to her body, it dredges this all back up and makes it worse.

The claimant agreed that she was involved in a motor vehicle accident in October, 2003. My daughter suggested that she and I go down to visit my other daughter and we went down there, and I rested while I was there, and we spent the day and had dinner. We started back home, and I was driving on Highway A, and there was a road on the right side and the man was coming the other way, and he decided he was going to turn and he was drunk, no insurance, two babies in the car and his wife; I didn't have time to stop, and I tried to miss him but it didn't work, Rosenkoetter said. The people in the other car, and my daughter and myself were injured in the accident, she said, no one was killed in the accident. Explaining about her injuries, Rosenkoetter stated that the air bag went off and she was going sideways and it hit her shoulder, and her hand hit something and broke a bone in her left hand, and her knee hit something on the door somehow. I wasn't casted, Rosenkoetter stated, it seems like my bones don't break across but rather they break down, and they put five, I don't know what you call it, it had a metal piece on the bottom and you wrapped it there; I had to wear that for a month. I did not have any problems with my neck or anything else as a result of this injury, she said.

Rosenkoetter agreed that she was sent to Dr. Poetz on her own behalf. I don't recall but I think I did talk to Dr. Poetz about my psychiatric condition, she said, we went over a whole lot of stuff the day I was there.

The claimant was queried during cross examination if it wasn't correct that she didn't quit working at Integram because of the problems with her hands, she quit working because of the paperwork mess. I had to quit anyway, the claimant answered, my health just keep getting worse. It didn't get better. And Dr. Schlafly said these two fingers still go numb, and I might have to get my elbow done.

Rosenkoetter agreed on cross examination that the problem that came up that led to the whole paperwork mess and that eventually led to her termination was an injury that she had to her left leg that occurred at her home. I had several injuries happen at my house, my legs wouldn't work right; I wasn't never sure if my foot was high enough or if I was stepping right, it just didn't work right, the claimant stated. The first time I fell on some steps I broke my tibia, she said. When I fell on 3-17-99, I didn't fall because I was dizzy or disoriented, I fell because of the problems with my legs that I know was due to my back, the claimant stated. I told Dr. Jacob, the one who did the surgery, that my legs just didn't work right, and he said there's nothing more that he could do for me, the claimant stated. I went to my bone doctor, Dr. Kef alas, for treatment when I fell at home on 3-15-99, she said.

The claimant was queried if it would be inconsistent with her memory of how she was injured if Dr. Kefalas' notes of 3-17-99 indicated that she became dizzy at home and fell. When I came out of the barn I thought my foot was on the step, but it wasn't, and I stepped in a hole and the ground was uneven and I went down, the claimant responded. It was noted that Rosenkoetter had said that she fell on the steps. The first time I got hurt after the surgery I was going up the steps and my foot caught on the steps because it wasn't up high enough and I fell and I broke my tibia bone, the claimant answered, and then I come out of the barn and I thought my foot was on the step but it wasn't, it went sideways, and I fell, and fell in the hole in the yard. I don't know if the fall into the hole in the yard was on 3-15-99, the claimant said. Dr. Kafalas took me off work for the 3-15-99 injury, the claimant said, I had a mobilizer on my knee, I was on crutches, and I had a metal-with-gel-cast on the inside of my ankle. The claimant was asked if it sounded accurate that as reflected in the doctor's record he kept her off work through 4-7-99; and she answered that she did not remember the date, but she thought it was in sometime in April. Rosenkoetter denied that at that time she attempted to return to work. When the doctor or the hospital man said I couldn't work, I called work and said I couldn't work that I had to go to my doctor the next day. I called work and I asked for insurance papers; when I was off when I broke my leg before, they got a new contract, and I didn't have a new book, I didn't know what the new rules was because nobody said anything, she said. And when I called the human resource and asked the gal for my papers, she faxed them to me, and I looked and they were different and I didn't know how to fill them out. So I called back and I asked her how to fill them out, and she told me; I put down what she told me, and then I went to my doctor and I showed him the papers. The doctor looked at my knee and stuff and x-rays and said that I should not work on it, to stay on the crutches, and that's what I did. The claimant was queried, wasn't it correct that at some point she got off the crutches, the air cast and off the gel cast, and Dr. Kef alas was done treating her for this injury. When they said I was supposed to be back at work, I was on crutches, I had that on my ankle, and I had it on my knee; there was no way that I could come in there and work, the claimant responded. Rosenkoetter then again denied that at some point she attempted to return to work at Integram. She was asked if she had filed a grievance. I went to the union, she answered. She agreed that she basically went to the union saying that they had unfairly taken her job away, and that she should be able to continue working at Integram, that she filed a grievance saying she should be working at Integram. Rosenkoetter stated that she went through, she thought, four different levels of the grievance proceeding, the most you could go through. I don't think I was even at the three meetings, she said. The claimant was asked if it upset her that she wasn't successful in her grievance proceeding. What upset me, she answered, was that they frigging sat there and lied; no matter what I told them, no matter the bills I showed them, they sat there and lied and he took it. And you know what upsets me is that those people can make

bombs, they can layoff, they can sneak out of work and everything, and nothing happens to them, only three days suspension, Rosenkoetter stated. Not having a lawyer present that upset me, too, she said. Rosenkoetter agreed that after she was terminated from Integram she applied for unemployment benefits. I did not receive those benefits right away, she said, Integram said that I didn't deserve them, I was fired. Rosenkoetter stated that she did not have much choice when receiving those benefits on a weekly basis in filling out a statement alleging that she was ready, willing, and able to work. I had to get a job because I knew that wouldn't last very long, she stated, I was out there every day trying to find a job, but then when you put down you had surgery and this and that, they don't want nothing to do with you. You can't lift; they don't want you in the machine shop if you can't lift stuff, she stated.

It was noted during cross examination by the employer/insurer that the claimant had testified that as a result of all these conditions she had been inhibited in her ability to engage in activities around the farm, and Rosenkoetter was asked how long had she had that limitation. Ever since I fell on the tag, the claimant answered. Rosenkoetter was queried if she would question the accuracy of Dr. Sertl's record which contained a history that she had injured her left leg riding a tractor in September of 1998. I would try to do stuff; I didn't have as much wrong with me then; it was just all the stuff just piles up; I still try to do stuff, it just don't work, the claimant said.

On cross examination by the Second Injury Fund, Rosenkoetter stated that after recovering from her broken tibia injury that occurred in the Summer of 1998, she was working full job duties on her regular scheduled hours up to the time she hurt her right knee and she was fired from Integram. My regularly scheduled hours were to start at eleven p.m. and I think we got off at seven-ten. The time I worked at Integram my job title was Foam Production, the claimant said, and agreed that there were other people who worked with her who did the same jobs she did. Agreeing that there were other shifts at Integram besides the one she worked, Rosenkoetter stated that there might have been three shifts including a day shift, and she worked on evening shift one time. I imagine there was somebody else doing that same foam production job that I was doing on those other two shifts, the claimant said. I started in foam production in 1991, I don't remember the month, the claimant said, and worked there until I left Integram. During this time period I was doing the same job duties throughout the whole time, she said. Discussing this job in more detail, Rosenkoetter agreed that she worked with the foam seats that went in minivans. The bench seats were quite long; I have no idea what they would weigh, I really don't, she said. I also lifted all the cushions backs or the cushion part; there was child seat cushions, and the cut and sew was the foam buns with other covers on them and heaters in them. The cushions had a metal pan on them, so they might have been the heaviest, I really don't know, the claimant stated. The whole work-day was spent on my feet, she said. Rosenkoetter stated that she was doing bending with just about every position there, and explained that they rotated to different stations. I don't think I ever had to do any squatting or kneeling in doing my job duties, the claimant said, not unless you dropped something. Rosenkoetter denied that during the last six months that she was physically working at Integram she was doing the same job duties that she had been doing since she'd been in foam production beginning in 1991. I wouldn't help nobody anymore, and I was lucky to get my job done, she stated. I would trade off because lifting covers was really hard on me because you'd have to lift like ten or so at a time, and then you had to bend over in the boxes and lift the heavy lids off the boxes; it was really hard on my back, the claimant testified.

During cross examination by the Second Injury Fund, Rosenkoetter agreed, that at the time that she was terminated from Integram she was on sick leave for her leg. The doctor kept me off work for a period of time for my leg at that time, the claimant agreed, and this was about April of 1999. It was my intention to return to my job at Integram after I recovered from this leg injury, the claimant said. The claimant was queried if it was correct that one of the reasons she filed a grievance at the time Integram let her go in April of '99 was because she had planned and wanted to return to her job at Integram. No, Rosenkoetter answered, I filed a grievance because the lady in the H.R. lied, she said I didn't have to fill out anymore papers, and that's why I lost my job. The claimant agreed that when she filed the grievance she was trying to get her job back.

Since I left Integram in 1999, the claimant stated, the condition of my low back has gotten worse. The claimant was also queried, since you left Integram had the condition of her right ankle had gotten better, gotten worse, or stayed about the same? When I hurt my right ankle, after I did what the doctor told me, it got better, Rosenkoetter answered, it just gives me trouble every once in a while, it gets real sore, it swells, it stays swollen all the time. When I left Integram in April of 1999 my right ankle was pretty messed up because I had to wear a gel cast on it for like six weeks, but the problem I have now is that walking sometimes will irritate it or it just swells all the time. Rosenkoetter agreed that the condition of her hands got better after the carpal tunnel surgery. The symptoms I still have in my hands now from the carpal tunnel is that every once in a while my hands will cramp up; I can't sew anymore, I used to hand quilt and I can't do that anymore, I can't hold the needle; it's just like charley horses in my hands, the claimant testified. The claimant was asked if her depression had gotten better, gotten worse, or stayed about the same since April of 1999. Gotten worse, she answered. Rosenkoetter stated that she still has problems in her right hip. Right now I'm going for therapy, she said, they're going to fit me for a cane Thursday so it will help steady me when I'm walking. When asked if she had had

problems with her right hip in April of 1999, the claimant answered - I've had problems with it off and on since I hurt it in 1997 when I bent over in that box. She agreed that this was her second back injury. The condition of my right hip has gotten worse since I left Integram in 1999, the claimant said, my doctor suggested that I find another neurosurgeon because mine retired, he's looking for one for me now.

On redirect examination, the claimant testified that prior to slipping on the tag at Integram she worked overtime at one time every day, and then sometimes once or twice a week. In the year before I slipped on the tag I worked two jobs, I worked sixteen hours a day, Rosenkoetter said. Agreeing that her life changed as a result of slipping on the tag at work, the claimant stated that she doesn't have a life no more. I had to sell my mobile homes and that was something I enjoyed, that was going to be my old age retirement.

On further cross examination, the claimant agreed that when she had the first injury to her back in 1995 that slowed her down at work; she agreed that also as a result of this she couldn't work as much overtime. Rosenkoetter was queried about Dr. Bedor's records which indicated on 5-28-98 that she was working ten to twelve hour days, six to seven days a week. My back was bad in May of 1998, she said, but if they said for you to work, you worked.

Joe Laffleur testified on behalf of the employer/insurer. I'm a human resource manager at Integram St. Louis Seating, and have been in that position for eight and a half years, Laffleur said. He agreed that in his position he deals with the union, UAW, at Integram, and stated that the union has been involved with this particular Integram plant since July of 1995. If one is to be employed at Integram as an assembly worker, they are required to be a member of that union, Laffleur stated. As the H.R. manager I am familiar with the company handbook which has been in existence since 1989, he said. Explaining how employees are made aware of this handbook, Laffleur stated that employees are given a copy of it when they're hired; when the union came in, the contract took the place of the handbook for the hourly employees; but prior to the union coming in, we had the handbook and it pertained to all the employees. Agreeing that the company has a hotline, Laffleur explained - We are owned by Magna International out of Toronto, and they have a phone number that employees can call if they can't get their issues resolved at the plant and it can be anonymous. The hotline has been in effect at least twenty-five to thirty years, he stated. Employees are made aware of the hotline by us telling them in the orientation that it's available to them, Laffleur said, plus we also have posters in the plant which talks about what the purpose of the hotline is, what the phone number is to call, and plus periodically we'll have representatives come down from Toronto and do a presentation in one of our monthly employee meetings. The posters are in the H.R. department where we do the orientation, plus they're out in the plant in several locations, Laffleur said. He agreed that as part of the company's benefits package for the employees, they have an EAP (Employee Assistance Program) program, and stated that this has been in effect since the plant opened in 1989. The services available through the EAP are that the employees can contact the EAP if they have financial issues, chemical dependency issues, emotional issues either for them or for anyone living in their household, Laffleur said. Agreeing that H.R. took an active role in making the employees aware of the EAP program, Laffleur stated that they have posters out in the plant that talks about it, everybody in H.R. has business cards from the EAP, plus periodically they'll have someone come in and do a presentation. He agreed that this is something that is in the handbook.

In my years in the H.R. department, Miss Rosenkoetter never came to me and advised me that she was being harassed on the line, Laffleur stated. It was noted that the claimant had made reference a few times during her testimony to an employee making a bomb in the plant, and Laffleur was asked if he was familiar with such an incident or allegation. Not about a bomb, but I think I know what she was talking about because she mentioned the employee, yes, he answered. Laffleur stated that he was familiar with the employee Rosenkoetter had mentioned, and it was Pat Brown. Pat Brown is not a union representative, he is just an ordinary union employee, Laffleur said. To my recollection, what occurred with Mr. Brown is that he had gotten a plastic bottle and put some dry ice in it and then thrown it, not towards any employees, but just in the foam department; nothing happened with Rosenkoetter, Laffleur testified. He agreed that it did not explode and no one was injured. Agreeing that there was a consequence to this action, Laffleur stated that the company gave pat Brown a three days off for horseplay. Laffleur stated that he was present at the grievance of Rosenkoetter but not at the grievance proceedings, as Rosenkoetter would have done that through her union representative. He agreed that as H.R. director for Integram he participates in grievances on a regular basis, and becomes aware of each grievance procedure. My role with the grievance procedures is that I pretty much handle the whole procedure, Laffleur stated. It's actually a four-step grievance procedure, and if that doesn't solve the grievance, then it goes to arbitration; I'm involved in all four steps plus at the arbitration level. And I actually conduct the meetings and I write the grievance, Laffleur testified. He agreed that in conducting the meetings he represents the company's interest, and in an effort to address his side of the argument, he becomes aware of the grievance allegations. Agreeing that he was aware of the allegations in the case involving Rosenkoetter, Laffleur stated that the allegations were that she did not terminate her seniority.

On cross examination by the claimant, Laffleur stated that he started at Integram in January of 1996. He agreed that, therefore, he is totally unaware of any orientation Rosenkoetter would have had when she went to work at Integram. Laffleur stated that he was aware that Rosenkoetter did have an orientation based on the company's records.

Dean Nordman does not still work for Integram, Laffleur stated, I haven't talked to Dean in five years, so, no, I do not know where he is.

Laffleur agreed that Integram keeps the records of pre-employment physicals, and that he had a record of Rosenkoetter's pre-employment physical. I have never looked at it, Laffleur said. I did not review Rosenkoetter's deposition, he said.

There are six hundred and fifty employees in the plant right now, Laffleur stated. He agreed that as human resources manager, he hires and fires people.

On redirect examination, Laffleur testified about the basis of his terminating Rosenkoetter in 1999. She terminated her seniority in accordance with the labor agreement because she failed to return from her leave of absence, Laffleur said, and agreed that the employer made no proactive attempt to terminate her. To my knowledge, Rosenkoetter was never written up for poor performance, and never written up for problems with quality or quantity of her work, Laffleur said. To my knowledge, in the grievance procedure, ability to perform her job duties was not an issue, he said.

On further cross examination by the claimant, Laffleur agreed that he had brought Rosenkoetter's personnel file with him to the hearing. He agreed that the file included write-ups of Rosenkoetter, and stated that there were all on attendance. He was queried if he had looked in the file for whether or not Rosenkoetter had complained to Dean Nordman about being harassed at work. I didn't see it in there, but I wasn't looking for that, Laffleur answered. Laffleur stated that in the personnel file he had attendance discipline records but not the attendance records. I have no idea what the attendance records were for the six months prior to September 15, 1995, he said, we don't have those records prior to 1995. I never had the attendance records for six months prior to 1995; they were made at the time, I'm sure; I wasn't here, Laffleur testified. In explaining about how far back the company's attendance records went, Laffleur testified - We put in a new attendance system back, I believe, in the year 1997 or 1998, that's as far back as it goes. Laffleur stated that the company did have the pre-employment physical records, but he believed it was back at the plant; they're kept in a medical file, if you're talking about the exam Rosenkoetter had when she got hired, that would be a separate file, that would be a medical file. It was noted that included in the personnel file was that it was maintained by Laffleur and found by the appeal judge that the claimant left work on 3-19-99 without good cause. The original judge agreed with us, yes, Laffleur responded. Laffleur agreed that he wrote the termination letter, and that it was based upon Rosenkoetter not returning to work on 3-19-99. He stated that at that time he knew that Rosenkoetter's doctor had given her an off-work slip. Laffleur agreed that it was just a question of a leave request form not being filled out and sent in. Laffleur agreed that the personnel file included: a. that Rosenkoetter had missed eighteen days from work, 10-22-98 to 1-25-99, adding that it was a chronic attendance letter which is part of the labor agreement; b. that on 1-6-99 Dr. Calvin wrote him a note that Rosenkoetter has severe degenerative disc disease; c. that on February 13, 1998 the company wrote Rosenkoetter a letter that she was the most frequently absent from work in November 1997, December 1997, and January 1998; d. that shortly after the bench case of November 18, 1997, on 11-20-97, there is a note from Dr. Calvin saying Rosenkoetter has somatic dysfunction of her lower back; e. a 7-21-97 note the Rosenkoetter has chronic degenerative disease of the right ankle. Laffleur agreed that he knew about all these conditions Rosenkoetter had when he decided she didn't conform to the filling out the form properly (reporting on March 19, 1999) even though he knew she had been taken off work by her doctor.

On cross examination by the Second Injury Fund, Laffleur agreed that if someone has poor performance, it is possible for them to be disciplined at Integram, and if there's a discipline for poor performance it is it put in their personnel file. Rosenkoetter did not have any discipline forms in her file for poor performance, Laffleur said.

On further direct examination, Laffleur stated that the slips he had been asked about that were in Rosenkoetter's personnel file, he got them either from the supervisor -- the employee gives them to the supervisor and the supervisor gives them to us in H.R. Agreeing that somehow the employee directs the routing of these to the file, Laffleur added that the employee brings the note in. He agreed that it appeared Rosenkoetter was aware of the need to bring those forms in.

Medical records in evidence included the following:

1.Certified medical records of HealthLine Corporate Health Services Metro St. Louis (Claimant's Exh. D) indicated a majority of the treatment as employer (Integram) authorized treatment; the record concerned the treatment

of Rosenkoetter for various complaints and injuries from March of 1994 through October of 1999.

The first entry of 3/18/94 indicated that Rosenkoetter presented for evaluation of her right wrist, with a history that the wrist had been bruised on two separate occasions in the past week; she was evaluated at the emergency room and x-rays were taken which were negative; the diagnosis was - wrist contusion and hematoma; it was written that Rosenkoetter was returned to regular duties, and that the company had flexible wrist supports which was recommended Rosenkoetter obtain and use. The next and subsequent entries included the following.

12/01/94 - treatment for an 11/23/94 laceration injury to Rosenkoetter's left palm as a result of cutting her hand on the sharp edge of a pan while working; exam findings included that the wound was quite deep, tenderness to palpation about the area, decreased grip secondary to pain, some numbness over the radial aspect of the left little finger near the area of the wound; some sutures were removed and others left in; Rosenkoetter was placed on restricted duty. 12/6/94 treatment for re-opening of wound subsequent to another doctor removing the sutures; Rosenkoetter was restricted to no use of the left hand. 12/16/94 - follow-up treatment to the laceration injury, and it was noted that she complained of pain to the left wrist which occurred with the injury; written in the entry was - "I told her that she never mentioned this wrist pain to myself throughout all of her visits here and when discussed with Carolyn, Carolyn states this has also never been mentioned to her. Because of the time frame from her first visit here to the current complaints of wrist pain, which is approximately 16 days, this injury to the left wrist has been rejected by her employer"; the diagnosis remained laceration left palm healing; Rosenkoetter was continued on restricted duty of use of left hand as tolerated. 1/4/95 -follow-up appointment for the laceration injury, it was noted that Rosenkoetter had been off work for sometime as she had recently lacerated a tendon which was non-occupational of the right hand; exam findings were improvement with the laceration but still some tenderness about the area of the wound and pain with forced abduction of the thumb and index finger; the diagnosis remained - laceration left palm healing, and Rosenkoetter was discharged from the clinic, full duty status. 9/15/95 (the next entry in the record) - complaints of pain to the left palm in the area of the previous laceration which was at the radial aspect of the base of the left little finger, and complaints of numbness along the radial aspect of the little finger with some pain along the scar area extending to the palm; the assessment after examination was - 1. Pain left palm status post laceration which is old, and 2. Flexor tendonitis left hand which is new; the plan was for hand therapy with scar management; Rosenkoetter was returned to full duty; it was indicated that this injury was consistent with the 11/23/94 incident. 10/6/95 - Rosenkoetter presented with complaints that her little finger drew up and the pain was unbearable; objective findings were - no swelling to the area of the healed laceration, no excessive scar tissue present, skin appears to move easily as if there is no adherence of the underlying tendons, excellent resisted flexion, full extension; it was noted that Rosenkoetter said she could not find anything wrong with her hand; the diagnosis was - pain left palm, no change; therapy for scar massage was ordered; written was a question as to whether injury was consistent with alleged 11/23/94 incident as the doctor wrote that she could really never find anything wrong with the hand other than Rosenkoetter's subjective complaints; Rosenkoetter was continued on full duty work status.

9/15/95 - Rosenkoetter was seen for complaints of pain and intermittent swelling in the right ankle and right knee as a result of twisting and slipping on a piece of paper at work on 8/25/95; an x-ray report, dated 9/15/95 and indicating a date of injury of 8/25/95, indicated exams of the right knee and the right ankle, and results for both were - negative/no bone or joint abnormality evident; the diagnosis after examination was - Mild sprain right ankle, and Strain right knee; treatment was a Futuro wrap for the ankle and Genu-Medi for the knee and also ice, heat and medication; it was indicated that the injury was consistent with Rosenkoetter's work activities or the alleged incident; she was released to full duty. 9/25/95 - follow-up of sprain to the right ankle and strain to the right knee; it was written - "Although, her injury seemed mild on her last visit here she complains of continued pain and states she is not improved. She requests to only work 40 hours a week 8 hours a day. I told her that we would consider other restrictions instead and she was very unhappy with this."; diagnosis after examination was - Sprain right ankle, and Strain right knee; physical therapy was ordered; ordered was light duty work of seated duty for half a shift and self-paced walking; it was noted that the injury was consistent with work activities of the alleged 8/25/95 incident. 10/6/95 - follow-up of an injury to the right knee and right ankle; included in the entry was - "Upon my entrance to the room I asked the patient if she had improved and how she was feeling. She did not respond for several minutes. I asked her again how she was doing and she states I want to see a Specialist. I told her I did not think that was necessary at this time as she had yet to attend any of the therapy sessions that were ordered for her and that were apparently set up."; the entry indicated further friction, but eventual examination did occur, and the assessment was - Sprain right ankle - improved, and Strain right knee - improved; it was written that six visits of therapy was set up for Rosenkoetter, and medication was to be continued; light duty recommendation was continued.

11/3/97 - Rosenkoetter presents with complaints that for the past month or two she has developed pain in both of her wrists and forearms, sometimes it is hard to close her hands, and she is beginning to lose strength; objective findings included - Phalen's is negative bilaterally, Tinel's is negative at the median and ulnar nerves, mild tenderness over both

epicondyles; the diagnosis was - Tendonitis both wrists; Ibuprofen and home exercises were prescribed; it was indicated that the injury was consistent with work activities or the alleged incident (the date of injury was noted as 11/3/97); Rosenkoetter was returned to regular duty. The record indicated that Rosenkoetter missed scheduled appointments of 11/17/97, 11/26/97, 3/10/98 and 3/17/98. 11/19/97 - Rosenkoetter indicated that she had had improvement in the function of her hands, especially the left one; exam findings included negative Phalen's, and negative Tinel's at median and ulnar nerves at the wrist; the diagnosis was - Paresthesia both hands, resolving; mediation was continued, and she was maintained at regular work. 12/1/97 - Rosenkoetter reported that she was feeling relatively well over the long weekend, went back to work early this morning on a four hour shift and now her hands hurt; other complaints are that the left hand and little and ring finger go to sleep during her sleep, she awakes and changes positions and the numbness disappears from the two fingers; objective findings were - neurovascular status is intact in both hands, good grip, excellent range of motion in the C-spine shoulder wrist and elbow, Tinel's and Phalen's negative; the diagnosis was Wrist sprain bilateral; it was noted that the injury was consistent with Rosenkoetter's work activities; she was returned to regular work. 2/19/98 - complaints of bilateral UE pain for about 6 months, treated with ibuprofen but is getting worse, complaints of numbness in the left index finger and thumb; written objective findings were - "Vague history. The patient appears very depressed and is crying when asked if she is depressed. UE reveals various scratches from working outside at home. Diffuse muscle tenderness in both arms, from shoulder to hands. Joints reveal no swelling and full ROM."; the diagnosis was - Complaints of bilateral UE pain, Depression; treatment included - EMG, NCT's and antidepressants; Rosenkoetter was placed on work restrictions of no pushing or pulling with arm for one week greater than 35 pounds; follow-up in one week recommended. In a 2/19/98 Medical Authorization form, Dr. Oliver wrote in the Diagnosis section of the form: "Subjective complaint of bilat. Upper extremity pain for 6 mos. Depression which is partly, if not entirely work related. Rec. (treatment with) antidepressant". 3/23/98 - Rosenkoetter relayed that she was scheduled to see Dr. Phillips for an EMG and nerve conduction tests the next day, and subsequently to see Dr. Crandall, and these appointments were set by her work place; continued complaints of pain in both hands, wrists, shoulder, and elbows, denies any pain in the neck; states is doing regular work at this time; objective findings included - Tinel's is equivocal bilaterally and Phalen's is equivocal bilaterally, no tenderness over the medial or lateral epicondyle; the diagnosis was Paresthesia to both hands, It is questioned whether or not the patient has any depression from this particular incident, episode, or current complaints; it was written that Rosenkoetter would see Dr. Crandall for UE complaints; she was placed on full duty work status. In a 3/23/98 Certificate of Fitness/Exam form, the examining doctor, Dr. Anver Taylor, M.D. wrote in the Diagnosis Section of the form: "1. Paresthesia both hands, 2. No work related depression."

1. Medical records of St. John's Mercy Hospital, Washington, Missouri (Claimant's Exh. J). The record included treatment of Rosenkoetter in the emergency room on 06/06/95 for complaints of an alleged assault with hand and arm injury. The written history of injury was:

49-year-old female with history that allegedly she was assaulted by her brother-in-law, I believe. She says that the brother-in-law just "went berserk," grabbed her arm, twisted it. Also tried to punch and she blocked the punch with her right hand. The patient says that due to the twisting action, she has pain across her entire arm, mainly in the shoulder area and across the upper forearm and humerus. Says that there was no direct trauma to any of these areas.

Physical exam findings on 06/06/95 included: some minimal soft tissue swelling across the dorsum of her right hand, no obvious bony deformity, no ecchymotic change, some soft tissue swelling noted, rest of evaluation within normal limits, neurovascular to the arm was intact, chest was unremarkable. Report of an x-ray taken on 6/6/95 noted the following: right hand - negative for fracture or bone destruction. The assessment on 6/6/95 was - Soft tissue hand and arm injury; negative for fracture. The After Care Instruction sheet dated 6/6/95 indicated that treatment was - wear sling on right arm for 5-7 days; ice to shoulder, elbow and hand for 2 days, Darvocet, off work for that day, and see Dr. Refalus as needed. A radiology report dated 6/15/95 noted a history of - rule out abnormality of pain, and also noted the following findings: right shoulder - negative; right clavicle - negative; and cervical spine - 1. Marked scoliosis and straightening usually indicative of neck muscle spasm, and 2. Inability to adequately visualize C1 and C2 because of the marked scoliosis (it was also noted in the discussion section that "[T[he patient refused and could not straighten her neck from this position).

1. Records described as those of Dr. Clark, D.C. (Emp./Ins. 5) were mostly illegible, but indicated that in about 1994 Rosenkoetter reported a chief complaint of - auto accident in 1987, worse last 6 months with pain in the small of back and hip and legs.

The record included treatment entries in October 1995 for low back complaints. A 10-15-95 treatment note included: "Pat(ient) working today painting floors in flexed or stooped position. Sat down 2-3 hours ago \& got pain - left low back and hip and leg. Constant since then to left ankle."; the 10/15/95 further included - "Off work Bed". The next entry of 10/16 included that Rosenkoetter was somewhat better that morning - range of motion and stability had increased, less spasm, L4-5 interspace tender and taut. The 10/17 entry included that Rosenkoetter was feeling better, had mild to

moderate ache in left leg without cramping or spasm, ?continued left leg numbness?; it was noted that Rosenkoetter had worked that day. The 10/18 entry included that Rosenkoetter had not gone to work; no leg cramping, stiff and taut at L45; weight bearing causes ?????.

The next entry of 10/19/95 entry, apparently written by Dr. Glen Calvin, D.O. stated that Rosenkoetter presented that day with severe pain in the lumbar spine running down her left leg, and that they would agreed that her disability began on 10-15-95. She has the potential for having a ruptured disk in the lumbar spine, it was written. In the handwritten entry dated 10/19/95, it was written that Rosenkoetter weighed 215 pounds and had a blood pressure reading of 148/102; also written was that Rosenkoetter had injured her back on 10-15-95 and was under Dr. Clark's care; it was written that Rosenkoetter needed a work disability form from her primary doctor as work would not accept Dr. Clark's. The 10/23/95 report of x-rays and a CT scan of the lumbar spine lumbar performed at St. John's Mercy Hospital. A last treatment note of 10/26/95, handwritten, apparently in Dr. Calvin's record indicated - disc lumbar spine, and pain in left leg continues.

1. Medical records of Karl A. Jacob, M.D. (Cl. Exh. E) began with a 10/30/95 initial office exam report, and indicated that the doctor treated the claimant for back complaints. A 12/14/95 operative report reflected that on that date, Dr. Karl Jacob performed the following operation on Rosenkoetter:

Lumbar decompression laminectomy with laser magnification and microdissection L3-4, L4-5 left for posterior decompression of the dura and cauda equina by undercutting of the lamina and the spinous process space of L3, L4 and L5, lateral recessed decompression by resection of the medial $1 / 2$ of the facet joints of L3-4 and L4-5 and the medical one half of the pedicle base of L4 and L5, L4 and L5 nerve root foraminotomies, partial corpectomy. Posterior lateral caudal margin of the vertebral bodies of L3 and L4 and L5, microdissection and laser lysis of vascular adhesions of the anterior and lateral wall of the vertebral canal and L4 and L5 nerve root. Disk removal L3-4 and L4-5 and posterior interspinous stabilization L3, L4 and L5.

The post-operative diagnosis was: Lumbar spondylosis with myelopathy, severe, L3-4 and L4-5. Spinal stenosis, L3-4 and L4-5. Left lateral recessed stenosis, L3-4, L4-5. Displacement disk, lumbar L3-4, L4-5 left. Cicatrix of the nerve roots L4 and L5 left.

A 1/17/96 follow-up entry reflected that Rosenkoetter was one month post left lumbar decompression laminectomy at L3-4 and L4-5 with posterior interspinous stabilization. It was noted that Rosenkoetter's leg pain had totally cleared. Medication was prescribed; it was written that Rosenkoetter was to return in one month and hopefully at that time she has lost enough weight that knee-shoulder flexion exercises could be started. A 2/26/96 entry included that despite all admonitions Rosenkoetter continued to gain weight rather than lose it. She is carrying too much weight for her back to tolerate it on a permanent basis, Dr. Jacob wrote, and further wrote that because of her weight she could not do the strengthening exercises.

In a 3/18/96 follow-up entry, it was written that Rosenkoetter seemed to be continuing to gain weight, and that she had complaints of discomfort in both lower extremities even when she walked just to go to the end of the driveway. It was further noted that Rosenkoetter was complaining about some sensory loss in the dorsum of the left forearm in the distribution of the cutaneous branch of the radial nerve since she awoke from surgery, numbness in this area was confirmed by pinprick, the doctor wrote. A radial never conduction test was scheduled. Dr. Jacob wrote in the 5/6/96 follow up entry that the radial nerve conduction time bilaterally was excellent and no problems. It was noted that Rosenkoetter still had numbness on the dorsum of the left forearm, but it was improving with time. Dr. Jacob finally wrote in the 5/6/96 entry the following:

The patient is discharged from follow-up as far as her lumbar spine is concerned. She is to do conditioning for approximately one month after which she can return to work with a 25 pound limit weight lifting restriction. She is to do no lifting that involves bending over at the waist. She should continue a weight loss program since I've told the patient and her husband who accompanied her to the examining room that this is vital to maintenance of her back over a long period of time. If she has any further difficulty in the future, we would be happy to see her again. Otherwise, she is discharged from current follow-up.

Dr. Jacob's record included additional treatment/examination reports beginning with a 06/18/97 re-examination report in which the doctor wrote:

This is a re-examination of this 51-year-old patient of Dr. Glen Calvin who has had right lower extremity pain progressive and involving the area of the distal thigh and the knee, as well as below the knee. A month and a half ago she saw Dr. Rende regarding the right knee. An MRI was negative and the orthopedist said that he thought the pain was related to the patient's back and referred her here.

The patient has had a rather precipitous weight gain since her last surgery for left-sided radicular pain which has now cleared. She has pain in the back of the right thigh and leg distally into the foot and ankle. This pain increases with walking. It does not increase with coughing, sneezing, bending or lifting. She has no bowel or bladder symptoms.

It was noted that Rosenkoetter had a family history of her mother being a diabetic. Dr. Jacob's written impression on 6/18/97 was: 1. Lumbar spondylosis with myelopathy; 2. Rule out displacement disc, lumbar, L3-4, right; and 3. Morbid obesity. An MRI of the spine was scheduled, and Rosenkoetter was to return for follow-up.

The next examination report in the record was dated 04/01/98, and Dr. Jacobs wrote that Rosenkoetter was a patient of Dr. Calvin as she had reinjured her back at work three months ago bending over putting cushions in a box and heard a popping of her back and pain radiating to the right lower extremity. The pain became progressively worse in spite of conservative management, Dr. Jacob wrote, she can no longer work at her regular employment because of the pain. Dr. Jacob reported similar examination findings, and the diagnoses remained the same as on 6/18/97. There were no written treatment recommendations.

The next and last document in Dr. Jacob's record was a 5/24/99 report of an MRI of the lumbar spine. The history noted in the report was: "Lumbar surgery 3 years ago. Recent falls at work with low back pain and left lower extremity radicular pain." The written impression was:

1. Transitional lumbosacral segment which has been referred to as transitional $1^{\text {st }}$ sacral segment (appears to be sacralized bilaterally, there appears to be a rudimentary nonfunctional disk space cauded to the disk space);
2. Postsurgical changes on the left at L3-4 and L4-5; and
3. Severe degenerative disk disease at L3-4, L4-5 an L5-S1. Disk protrusion latralizes to the right within the canal at L5-S1. Abnormality extends laterally in the canal into the foramen on the left at L4-5 as discussed above. There is some encroachment left greater than right at L3-4.
4. Records of Dr. Glen D. Calvin, D.O. of Calvin Medical Center (Claimant's Exh. No. B) reflected treatment of Rosenkoetter for various ailments (i.e. cough, congestion, pharyngitis, otitis) during the period of March of 1996 through March of 1999. The following are examples of treatment entries. 2/10/97 - acute viral syndrome with secondary problems, symptoms are headaches, eye pain, cervical spine pain, back pain, sneezing, coughing; treatment included Ultram. 2/24/97 - complaints of severe headache and cough, patient states she is not able to work at this time; diagnosis was bronchial pneumonia or pulmonary vascular congestion, and Rosenkoetter was sent to Missouri Baptist Hospital under Dr. Shen's care. 2/28/97 - Rosenkoetter was seen for follow-up on Proventil inhaler. 3/3/97 combination of congestive heart failure, bronchitis, pneumonia and difficulty breathing, return to see Dr. Shen ASAP. 4/3/97 - seems to have an exacerbation of her right shoulder, I think she has a torn tendon of her right shoulder but she refuses to have an MRI, sending her to Dr. Stetson for work up, here with severe shoulder pain and severe degenerative arthritis in shoulder. 5/5/97 - complaints of pulled muscle in left side mid-back for 24 hours after lifting on carpeting; typed entry included that exam revealed severe spasm of the TS and neurological was essentially neg, and was started on Anaprox and Ultram for pain, and therapy. 5/9/97 - continued back pain; written was - "..she had surgery from Dr. Jacobs approx 2 years ago and she was told that there would be a possibility that she would have to have the other side operated on and she states that it has come to the pt. where she thinks that she needs to go back to see him because of the discomfort in the LS and (therapy) is not helping that much and also she is having a lot of family diff. And we will put her on Paxil" (sic); the diagnosis was - LS strain and Sit. Depression. 5/15/97 - treated for viral syndrome with ear infection, and given a slip for work. 5/29/97 - lifted on 5/27/97 two 15-lbs of liquid soap and strained upper back and neck and has severe muscle spasm on exam with cervical spine strain and upper back strain, physical therapy was given and medication of Ultram, and given slip to go back to work the next day. 6/16/97 - complaints of head and chest congestion, "will continue her on antibiotic and Claritin and we will give her breathing treatment today of Preventil and RTW on 6/23/98-She states that she is so run down that she cannot return to work". 6/30/97 complaints of continued sinus pressure and drainage for 24 hours which came on after working in hay field all day, treatment was continued Claritin and repeat round of antibiotics and RTW that evening if feeling fine. 9/16/97 - "Acute LS strain with muscle spasm and having problems with lifting and had stabilization rods put in her back and now she is lifting again and having severe pain"; handwritten 9/16/97 entry noted - mid and low back pain for 2 days, states strained while lifting heavy pots at family reunion on 9/14/97. 9/19/97 - treating her all week with an acute LS strain with previous surgery and back injuries, she is seeing Dr. Jacobs, we have been treating since 9/16 and allow her to RTW on 9/22 and ask if all possible that she do no heavy lifting but we will let her have a trail of work; "Some improvement, but DX is reoccurrence of an acute LS strain with symptoms of ruptured disc in the LS".

The next entry in Dr. Calvin's record after 9/19/97 was an 11/20/97 entry in which the following was written: "Seen with c/o of LS pain and goes down into the rt. leg. States hurt this while bending and lifting a box while at work". Examination findings were: some LS pain radiating into the rt. lower extremity, palpation of LS area reveals a fairly moderate to large sized lipoma which produces more pain and especially into the rt. lower extremity; therapy was started and referral to Dr. Rao for possible excision of lipoma of the rt. LS area. 12/4/97 - complaints of bad pain in the lower rt. present for some time, is under the care of Dr. Jacobs for this who is thinking about surgery apparently on the back, here today due to the unrelenting discomfort, would like to put her on Ultram until she can get in to see Dr. Jacobs; DX probable ruptured disc of the LS. 1/6/98 - here with acute pyeloneuphritis, needs slip for work and to return in near future; no other significant findings. 1/9/98 - no show for appt. 1/27/98 - complaints of vomiting, fever, cough, body aches, ear pain, sore throat; referred to Dr. Chen due to chronic nature of the positive findings; DX was - 1. acute otitis media, 2. acute pharyngitis, and 3. bronchitis. 1/30/98 - doing much better however still has resolving cough; DX resolving bronchitis and otitis. 2/10/98 - complaints of vertigo, chills, fever and ear pain for last 2 days; has been putting up with these symptoms now since Jan 23, started on Lorbid and referred to an ENT specialist.

After 2/10/98, the next entry was dated 4/9/98, and included - "Here today with an acute anxiety episode with chronic problems with carpal tunnel, chronic degenerative back disease, possible ruptured disc", has some previous stabilization surgeries; "We recommend that she have further work up if her workman's comp. will approve of it"; she will be placed on BuSpar for mild anxiety; no other significant findings. 5/19/98 - treated for diagnosis of fungal infection of the right foot; 5/28/98 - advised to stay off feet; 6/9/98 referred to pediatrist and kept off work until then. The next entry of 6/16/98 indicated - treated for DX of Acute pharyngitis, and Sinusitis.

9/1/98 - complaints of pain and edema in left knee for 1 day; this is a re-injury 6/98 with Dr. Kef alas; patient noticed symptoms after pushing in brake on a tractor; the typed 9/1/98 entry included that this was a reinjury from a fracture, that she had a knee brace in place for patella support, x-rays were negative, and the diagnosis was - contusion of the left knee. The claimant was treated for Bronchitis on 11/24/98 and 12/8/98, and for Sinusitis and Resolving bronchitis on 12/18/98.

The next entry of 1/6/99 included in the handwritten section - "c/o of left hip pain. No known injury. X-6 months."; the typed 1/6/99 entry stated that Rosenkoetter presented with low back pain radiating into the left hip, x-rays showed degenerative disease in the hip socket, it was written that she "has severe osteoarthritis, scoliosis of the spine" and she has had previous surgery in the past; the plan was evaluation by an orthopedist. January 1999 entries (2) concerned treatment for Chronic bronchitis and for Acute viral gastritis. 2/2/99 - complaints of lower back pain for one day, noticed after picking up laundry basket; the typed 2/2/99 entry noted - complaints of left lower back pain, physical exam reveals spasm in LS area more on the left than right and no neurological deficits; therapy was to be started, and Rosenkoetter was to be returned back to work that evening; the DX was - LS strain. The final entries of 3/3/99 and 3/9/99 concerned treatment for symptoms of bronchitis and pharyngitis.

6.Medical records of Dr. John Kef alas, M.D. (Claimant's Exh. No. F) concerned the treatment of Rosenkoetter from 2/26/98 - 5/5/99. The 2/26/98 entry reflected the chief complaint as - right knee injury. It was written that Rosenkoetter relayed that while at home she had fallen sustaining a twisting injury to the right knee. The diagnosis after x-ray and physical examination was - Acute right knee injury with probable patellofemoral subluxation possible, and Quadriceps tendon injury and possible meniscal injury. Rosenkoetter was placed in a neoprene sleeve, was taken off work, and was to return in 2 weeks. The next entry of 3/12/98 included that Rosenkoetter relayed her knee symptoms were slightly improved, and that she had re-injured her right long finger recently at home. The plan was to observe the right long finger with instructions for digital motion, and for the knee continued use of the neoprene sleeve, quad and hamstring strengthening exercises, and return in 5 weeks; it was written that Rosenkoetter could return to regular duty at work as of $3 / 23 / 98$.

The next entry of 6/17/98 noted that Rosenkoetter reported that on 6/16/98 she had missed a step and fell on her wood porch at her home, landing directly on the anterior aspect of the left knee. It was noted that radiographs from her emergency room visit the day before showed a question of a possible proximal left tibial plateau fracture; the diagnosis was left tibial plateau fracture, and the plan was a continuation of non-weight bearing with a walker, starting therapy for this, a knee immobilazer, return in 2 weeks, and no work. In the next entry of 7/1/98, examination findings were: left knee is minimally tender over the proximal tibia, no effusion, nontender anteriorly over the patella, tender over the medial joint line, neurologic function is unchanged (the distal neurovascular function is normal). It was written that repeat radiographs failed to reveal any obvious tibial plateau fractures. The plan was to continue weight bearing as tolerated, a neoprene sleeve, and follow up in 3 weeks. In the next entry of 7/22/98, it was written that Rosenkoetter relayed her symptoms were slowly improving; the plan was for weight bearing as tolerated, weaning herself from the walker, continue using the knee splint, physical therapy for range of motion and strengthening, no work, and return in 4 weeks. In the

8/19/98 entry it was written that Rosenkoetter still noted achiness in the knee. Exam findings were - no effusion, full extension and flexion to 90 degrees, collateral ligament are stable, and tender over the patellofemoral joint and medial pes bursa. The plan was continuing strengthening on her own, Motrin, a new Ace bandage was applied, follow-up in 6 weeks, and Rosenkoetter was returned to regular duty at work on 8/20/98. A 12/4/98 entry stated that per patient's disability form she was now seeing Dr. G. Sort at Orthopedic Associates.

The next entry of 3/17/99 noted Rosenkoetter relayed that on 3/15/99 while at home she sustained an injury to the left knee, ankle and foot after she fell after becoming dizzy. Further written was: "She states she twisted her left ankle and knee. Denies back pain or any other musculoskeletal complaints. She states the dizziness has improved.". It was noted that radiographs of the left knee, the left ankle and the left foot showed no obvious fractures. The impression was: 1. Left knee contusion, 2. Left ankle sprain, and 3. Left foot sprain. The treatment plan was the application of an aircast and a knee immobilizer, Celebrex was prescribed, no work, and follow-up in 2 weeks. The 4/7/99 entry included that Rosenkoetter relayed she had removed the knee immobilizer as her left knee had improved; she was still using the aircast on the left and still noted left heel and ankle pain. After examination, the treatment plan was to continue with Aircast, if symptoms in the heel persisted then repeat radiographs of calcaneus, follow up in 4 weeks, new prescription of Celebrex, and return to regular duty at work on 4/7/99. The 5/5/99 entry, the last entry, indicated that Rosenkoetter missed the appointment.

1. Medical records of St. John's Mercy Hospital in Washington, Missouri (Cl's Exh. I) consisted of physical therapy progress notes upon referral of Rosenkoetter by various doctors beginning in June 1997. A 6/16/97 Initial Evaluation sheet reflected that Rosenkoetter had been referred by Dr. Bassman for rotator cuff tendonits. It was written that Rosenkoetter reported "she has (R) shoulder pain for the past several years. Initially she reports her shoulder getting pulled when she was holding a chain and a relative pulling the other end suddenly. She states that she has been to an MD several times for this, however her focus had been on her back surgery.". It was noted that Rosenkoetter was working full time in a factory making seats for mini vans, and this involved lifting, pushing, pulling and holding a spray gun which she is able to use 2 hands for. It was noted that Rosenkoetter reported no numbness or tingling in the upper extremities. Assessment was chronic right shoulder tenderness and rotator cuff tendonitis, and physical therapy treatment was for 6 weeks centering on the right shoulder.

The record reflected that Rosenkoetter was referred by Dr. Kefalas in July 1998 with a diagnosis of status post left proximal tibia fracture. Written was that Rosenkoetter relayed she had fallen on June 16, 1998 and sustained a proximal tibia fracture. It was noted that Rosenkoetter had been in a knee immobilizer for about 5-6 weeks, and was now full weight bearing within the last 24 hours; it was noted that Rosenkoetter worked at Integram but was currently off due to this injury.

1. Medical records of Dr. George O. Sort, M.D. of Orthopedic Associates, Inc. (Emp./Ins. 4) began with a September 3, 1998 evaluation report by Dr. Sort to Dr. Calvin after referral of Rosenkoetter for evaluation of pain in the left knee. Dr. Sort wrote about the history relayed by Rosenkoetter, which included the following:

...about two months earlier she had broken her leg, and had pointed to the proximal tibia area. She apparently fractured this when she stepped off of a step at her daughter's and hurt her leg. She was treated with crutches and a cylinder extension splint. She said that the leg healed and she was doing pretty good until just a couple of days ago when she was riding on the tractor and she pushed in on the brake and she felt something pop in her left knee and since then has had a lot of pain in the knee, not in the area where she had the prior broken leg. She points to the medial side of the joint where she is noting the pain at this time.

It was noted that Rosenkoetter was working at that time. After examination and x-rays, Dr. Sertl's diagnosis was: 1. Left knee pain; 2. Tear of medial meniscus; 3. Degenerative arthritis; 4. Prior fracture of proximal tibia; and 5. Exogenous obesity. An MRI of the left knee was recommended. Dr. Sort wrote that Rosenkoetter was unable to return to regular work

The record indicated that Rosenkoetter was seen on follow-up on 9/17/98 and reported that since last seen she had hurt her knee again when she bumped against something. Dr. Sort wrote that the MRI showed some evidence of increased intensity in the posterior horn of the medial meniscus, but there was no evidence of a tear. Exam findings included: tenderness about the knee; no effusion and no ligamentous instability; no real localized area of pain is noted anymore at this time. The diagnosis was: Left knee pain; Sprain of left knee; and Degeneration of medial meniscus. Rosenkoetter was continued at "unable to return to regular work" status, and was to return in 2 weeks. In the final treatment entry of 10/01/98, it was written that Rosenkoetter reported that she thought she was improving with therapy. After examination, the diagnosis was: Left knee pain, resolving; Sprain of knee; and Degeneration of medial meniscus

status post fracture proximal tibia. Dr. Sort wrote that physical therapy would be continued for an additional two weeks, Rosenkoetter would then be re-evaluated, and if all had gone well she would be allowed to return to work at that time.

Dr. Wayne Stillings, M.D. testified by deposition on behalf of the employer/insurer (Emp./Ins. Exh. 3). A board certified psychiatrist, Dr. Stillings stated that the components of his evaluation consist of: the claimant's age, marital status, "a lifetime psychosocial history from birth until the present", educational and work backgrounds, her past medical history, her present complaints; a review of the medical records; and testing. Stillings Dp. pg. 7) At his deposition, Dr. Stillings' evaluation report of August 14, 2002 was marked as Employer's Exhibit B, and was admitted into evidence without objection and on the stipulation that the doctor would testify in accordance with his report; Dr. Stillings noted in his report dates of injuries for the claimant for his August 14, 2002 psychiatric independent medical evaluation of - 11/23/94, 9/15/95, 11/18/97, 2/19/98, and 3/14/99.

Dr. Stillings discussed what he thought were the salient features of Rosenkoetter's history:

"Miss Rosenkoetter had a 25-year marriage, and divorcing in 1987 because she was emotionally and physically abused by her first husband. And I think this was a psychologically difficult, and somewhat damaging marriage for her, and it still - she still had scars from that.

I think it's important to note that she was a somewhat vague historian, and somewhat reluctant to talk about her personal psychiatric history, to the extent that she would like to attribute all of her current emotional features and emotional state to the various work-related injuries that are listed in the front of my report.

I think it's also very important to note that Miss Rosenkoetter has never sought any kind of mental health care during her lifetime in a work-related fashion, or otherwise.

She did report that her nerves were bad quote, 'My nerves was bad,' unquote, per Miss Rosenkoetter. (Dr. Stillings agreed that she was describing a mental state rather than a physical condition)

And she had taken some medications through HealthLine sometime in the past, that she thought were beneficial on calming her.

And she attributed her nervousness, correctly or incorrectly, to being harassed at work. It's noteworthy Miss Rosenkoetter has not worked at Integram, where she worked for about eight years, she has not worked there in greater than three years, and she has not been harassed, in her own perception, in greater than three years.

She also said that her nerves were, quote, 'bad,' unquote, due to back pain, and, quote, 'because they are,' unquote.

And she notes that she was somewhat unhappy, or sad, if you will, because she did not have an independent income, and did not have as much money to spend on her children and grandchildren.

When I saw her she was not taking any type of nerve, or psychotrophic medication, and she described her life at home with her husband as somewhat quiet and docile. She spends a lot of time in her room. Really seems to be somewhat withdrawn.

She and her husband live on a 180-acre farm.

And she has a general distrust of people, even family members, and part of this is related to being assaulted by her brother-in-law in 1995." (Stillings Dp. pp. 8-10)

Dr. Stillings discussed what Rosenkoetter's mental status examination revealed:

"Miss Rosenkoetter was an alert, somewhat rude, passively uncooperative, non-communicated, obese, casuallyattired white female.

She avoided talking about psychosocial stressors in her life, other than her perception of work-related situations.

She attempted to attribute all of her problems to her employment with Integram. She answered many questions by stating, quote, 'I don't know,' closed quote, making no effort to respond. Her speech was sparse.

She displayed psychological distress in the form of crying, and physiologic re-activity in the form of flushing and agitation when discussing the emotional abuse she suffered in her first marriage.

She was disinterested in the evaluation, and had very little eye contact with the examiner. Initially, her affect was matter of fact, but later became somewhat dramatic and labile.

In general, her affect was cold and detached. No psychological distress nor physiologic re-activity was manifest in regard to the work incidents known as sequelae, at Integram.

Her mood was variable. At times was angry and assailed the quote, 'workers' compensation doctors,' closed quote. At other times she appeared sad.

She denied hallucinations, delusions, obsessions, compulsions, phobias, suicidal and homicidal ideation.

She was fully oriented to time, place and person. Recent and remote memory functions were in tact.

Cognitively, she functions in the normal range. Verbal comprehension was fair at best. Concentration was fair. Intellectual functioning was in the normal range. Insight and judgment are questionable." (Stillings Dp. pp. 11-12) (Ruling: Claimant's objection on grounds of repetitious is overruled. Stillings Dp. pp. 10-11,15)

Dr. Stillings discussed the results of the testing he had performed on Rosenkoetter:

"The revised Oswestry reveals that this individual reported low back pain in the cripple region, which is inconsistent with her medical status, in that she's not crippled.

The 15 -items test results are that this individual's fairly claiming that her pain levels are impairing her concentration and memory functions.

MMPI test results are as follows: The overall profile should be approached with caution, and may reflect distortion due to confusion, and delusional thinking, or an attempt to over-report subjective symptoms. Assuming the latter is not true, the overall profile is consistent with schizoid personality disorder, with depression as a central feature.

She may express her sadness and open tearfulness. She's likely to have a retarded stream of thought. And 70 percent of individuals with this profile are judged to be psychotic, which is supported by the elevations on the 8-6 scale. That's a specific psychotic scale on the MMPI.

The expression of psychological conflict to somatic or physical channels is encountered very frequently among individuals generating this profile.

She's likely to view her problems and her disorder as being physically ill, and she's likely to be defensive about admitting any psychiatric component.

She's also likely to avoid close interpersonal relationships, which is a cardinal characteristic of individuals with this profile.

She will strive to keep people at a distance, and involvement of any intimate sort with others as threatening, yet 70 percent of the individual with this profile are married.

This individual will view others with mistrust, and their motivations will be questioned. She has conflict about emotional dependency, and pressure with a general irritable manner or tone. Others will describe her as tense, high strung, anxious, and jumpy.

She is prone to obsessional thinking and repeated ruminative pre-occupation. Her thinking is unoriginal, and problem solving is stereotypic, rather than flexible.

She's likely to be quite forgetful, and under-assertive. She reports conflict of authority figures, and has chronic longstanding social and self-alienation.

She has a paranoid flair to her personality, and is likely to blame others in external situations for her personal problems, and short-comings in life.

She's likely to feel that she has been misunderstood, and has gotten a raw deal from life. She views the world as a threatening place. Feels that others have unfairly blamed, or punished her, and may even have delusions of persecution. She reports family problems and is somewhat compulsive. She has somatoform features to her personality, as understood by elevations on HY4, SC3, TSX and GRPS. The depression subtle scale is normal." (Stillings Dp. pp. 12-15)

The doctor agreed, during cross examination by the claimant, that he interprets his own MMPIs.

Dr. Stillings testified about his diagnosis after evaluation of Rosenkoetter:

"On axis one, which is reserved for primary psychiatric problems and disorders, she has no primary psychiatric disorder. Axis two, which is reserved for personality disorders, and developmental disorders, Miss Rosenkoetter is diagnosed with personality disorder not otherwise specified, with pronounced schizoid features, as well as depressive, paranoid, and somatoform.

"Axis III is reserved for medical conditions, and in Miss Rosenkoetter's case, she has morbid obesity, hypertension, and congestive heart failure.

Axis IV is reserved for psychosocial stressors, and her stressors are being unemployed in a solitary existence.

Axis V is global assessment of functioning, or GAF, if you will, as an acronym. And her GAF is 55, which means that she is occupationally able to function, but she has some moderate psychiatric symptoms, such as a flat affect, or a sad affect." (Stillings Dp. pg. 15, 16)

Dr. Stillings agreed that the work-related component, what work may or may not have caused from a psychiatric standpoint, is revealed in Axis I. The doctor was asked if the Axis II diagnoses were a result of a work-related injury or something that made up her personality. Dr. Stillings answered: "Yes, it would not be occupationally related by definition.

This would be a combination of her genetic constitution, and also, her early life experiences. Personality disorders, by definition, are present and fixed, and enduring by late adolescence, or early adulthood." (Stillings Dp. pp. 15-16) The doctor agreed that the personality disorder, which is Axis II, is pre-exiting, the doctor agreed that Axis III is also preexisting. Dr. Stillings agreed that Axis V, the GAF, took into account everything, Axis I through IV. With respect to her GAF score of 55, the doctor stated: "..this would mean that she probably doesn't function as well as the average person occupationally, or socially. But it doesn't preclude her from working. She is still occupationally functional.". (Stillings Dp. pg. 17)

Dr. Stillings testified as to his opinions in regards to Rosenkoetter. a. Whether or not Rosenkoetter's employment at Integram produced any type of psychological diagnosis: "Her employment at Integram did not cause her any type of psychiatric problem, or diagnosis". (Stillings Dp. pg. 18) b. Whether or not Rosenkoetter's employment at Integram produced any permanent partial disability: "As a result of her work-related aggravation of her pre-existing and coexisting personality disorder, Miss Rosenkoetter has a two to three percent permanent partial psychiatric disability." (Stillings Dp. Pg. 18) It was noted that Dr. Stillings had not provided in his evaluation report of 8/14/02 a rating of disability for any preexisting psychiatric disability which may have existed; the doctor testified, without objection -"My opinion is that Miss Rosenkoetter has a 10 percent permanent partial psychiatric disability as a result of the pre-existing personality disorder." (Stillings Dp. pg. 20) c. With respect to the Rosenkoetter's claim of mental stress as a result of her employment at Integram and whether or not she is in need of any further psychiatric treatment - "She is not in need of any treatment related to her employment with Integram." (Stillings Dp. pg. 19) With regard to the work-related aggravation of her preexisting personality disorders - "And that set, she doesn't need treatment either." (Stillings Dp. pg. 19) d. Whether or not Rosenkoetter's employment at Integram left her in any way unable to work - "Her employment at Integram did not impair her from an occupational standpoint. In other words, she's just as able to work now as when she was at Integram, or before she worked at Integram." (Stillings Dp. pg. 20) The doctor agreed that at least as of the date when he saw Rosenkoetter, which was in August of 2002, she was capable of working in the open labor market.

Dr. Stillings testified a second time by deposition on April 28, 2004. (Emp./Ins. Exh 8) Since my first deposition in this case, Dr. Stillings stated, I was forwarded and reviewed a copy of Dr. Crane's records from 5/2/03 through 9/29/03. The doctor was asked, after having reviewed Dr. Crane's record did he deem it necessary to reevaluate Rosenkoetter. "No", Dr. Stillings answered. (Stillings 4/28/04 Dp. pg. 6) The records of Dr. Crane did not affect my opinions as previously set forth in my previous deposition testimony, Dr. Stillings said. The doctor was asked the significance he had attached to the records of Dr. Crane, and Dr. Stillings answered: "Well, I think the significance is very simple. She improved some with his psychiatric administrations." (Stillings 4/28/04 Dp. pg. 6) Dr. Stillings explained the basis upon which he felt Rosenkoetter had improved with treatment by Dr. Crane:

"Well, when I saw her GAF or global assessment of functioning was 55, Dr. Crane near the end of treatment or at some point during treatment had assigned her a GAF of 60 . So really she's gone from moderate symptoms to slightly moderate symptoms. If you assigned her a 61, then she would have minimal symptoms. So she's real close to falling into another category of a much better prognosis and just a better outcome for her." (Stillings 4/28/04 Dp. pg. 8-9)

Testifying as to his continuing diagnoses, Dr. Stillings stated: "The continuing diagnoses are on axis - nothing on axis one. Axis two, personality disorder, not otherwise specified with schizoid features, depressive features, paranoid and somatoform features." (Stillings Dp. pg. 7) Dr. Stillings was asked to testify as to his opinion of whether or not Rosenkoetter suffered from a diagnosis of major depressive disorder:

"I do not feel she qualifies for the diagnosis of major depressive disorder based on application of the DSM-IV criteria. And this is based - now, those are subjective criteria. On an objective basis, her diagnostic testing on the MMPI does not support that diagnosis either." (Stillings 4/28/04 Dp. pg. 7)

The doctor further explained why Rosenkoetter's condition did not support the diagnosis of major depressive disorder:

"Her code type is an 82/28 and those code types are generally found in people who are schizoid, have personality disorders, have some quasi-psychotic symptoms. It indicates she has emotional distress but not particularly depressive in nature." (Stillings 4/28/04 Dp. pp. 7-8)

Dr. Stillings was asked to explain the difference between a personality disorder, as he had diagnosed, versus a depressive or mood disorder as diagnosed by Dr. Crane:

"Yeah, personality disorders are really an expression of an individual's features or characteristics of their personality, whether they're, for instance, shy or gregarious or outgoing or if they have some paranoid features. So you really are looking at sort of the mixture of their features of their particular makeup as a human being. A mood disorder is a very

specific highly defined psychiatric disorder where the essential feature is, of course, a low mood." (Stillings 4/28/04 Dp. pg. 8)

Dr. Stillings stated that after reviewing the records of Dr. Crane his opinions regarding the nature and extent of Rosenkoetter's permanent partial disability did not change in any way. My opinions regarding Rosenkoetter's ability to work did not change, the doctor said. Dr. Stillings was asked his opinion as to whether his opinion of 2-3\% permanent partial disability from a psychiatric standpoint he had assigned as a result of Rosenkoetter's work injuries would preclude her from working or finding employment in the open labor market. "My opinion is that it would not", Dr. Stillings answered. (Stillings 4/28/04 Dp. pg. 9)

John B. Crane, M.D. testified by deposition (Cl. Exh. R[11]) and stated that he is a board certified psychiatrist, and recently became a distinguished fellow of the American Psychiatric Association. Dr. Crane testified: "Well Mrs. Rosenkoetter came to see me initially in May of '03, May 2 of '03. She was quite depressed at that time; and actually in looking at my records, I'm not sure whether she came on her own behalf. I think she did." (Crane Dp. pg. 7) I conducted a mental status evaluation of Rosenkoetter, Dr. Crane said, I did not do any other psychological testing. I also reviewed medical records, the doctor said. Commenting on how many times he saw Rosenkoetter, Dr. Crane testified - "Between that first visit and August 18 of '03 - let's see, one, two, three, four - four visits." (Crane Dp. pg 9)

Dr. Crane agreed that on the date of his evaluation his diagnosis was depression and he provided Rosenkoetter with some medications. The doctor agreed that his Axis II diagnosis was symptoms of dependent personality. When queried wasn't it true that he was still continuing to treat Rosenkoetter, Dr. Crane answered - "That's correct". (Crane Dp. pg. 60) The doctor was queried if he was continuing to treat Rosenkoetter under the impression that he could make her better. "One hopes so", Dr. Crane answered. (Crane Dp. p. 60) The doctor was queried if it wasn't correct that depression is something that once a person has it they are more prone to relapse or recurrence. Dr. Crane answered: "Generally speaking, yes. That's correct." (Crane Dp. pg. 62)

On examination by the claimant, it was noted that Dr. Crane had mentioned in his report something about future medical care, and the doctor was asked what if any future psychiatric care was Rosenkoetter going to require. Dr. Crane responded: "This lady is likely to require long-term anti-depressants, treatment, and possibly some psychotherapy along the line depending on things that happen in the future, things that may happen in the future." (Crane Dp. pg. 57) (Ruling: Employer/Insurer's and/or Second Injury Fund's objections on grounds of Seven Day Rule are overruled. Crane Dp. pp. 57 and 58) Dr. Crane explained "the definition of psycho therapy is talking therapy, and it is aimed at helping a patient deal with stresses that may bear upon their mental status." (Crane Dp. pg. 58)

In his August 18, 2003 report (Cl. Exh. R-1), Dr. Crane included the following:

Mrs. Rosenkoetter is an obese woman who appears essentially her stated age. She was generally cooperative with the examiner, although when seen initially she was irritable and angry and tended to be somewhat oppositional in answering questions. She initially expressed a "what's the use?" attitude and clearly felt that this evaluation would be no different from previous examinations that she has had over the last nine years. Initially she was tearful, her cadence of speech was somewhat childlike and her thought processes appeared to be slowed. With treatment this has improved and her affect is considerably brighter. She is not tearful during follow up evaluations.........

Notably, during the several sessions with this lady, she has become increasingly cooperative and friendly and this appears to have been a result of simply listening to her.

Dr. Crane noted that he was addressing specific questions presented to him, and included the following in his answers:

\#1. Mrs. Rosenkoetter's current Axis I diagnosis is Major Depressive Disorder, severe, chronic, improving with the use of antidepressant medications. On Axis II she presents some symptoms of dependent personality. Axis III would include diabetes mellitus, essential hypertension, chronic cardiovascular disease, severe generalized osteoarthritis, particularly in the low back, and status post bilateral Carpal Tunnel Syndrome. Axis IV is an assessment of the patient's current stress, which would be interpreted to be quite high because of her physical condition, employment condition, and financial condition. Axis V - Current GAF (Global Assessment of Functions) on a scale of 0-100, where 100 is "normal", is assessed at approximately 60. Patient's highest GAF within the past year is assessed as her current 60.

\#4. ......This lady has presented as angry, hostile, and irritable during some of her evaluations and in

particular during her psychiatric evaluation with Dr. Stillings. These symptoms were interpreted as being due to severe Personality Disorder, a suggestion with which I disagree, and I believe they were primarily related to her Mood Disorder, although when severely dependent persons are confronted with this type of situation they frequently do become even more upset and angry.

Dr. Poetz evaluated Rosenkoetter on Rosenkoetter's own behalf (Cl's. H), and discussed in his June 10, 2002 evaluation report the work related injuries relayed by Rosenkoetter which included: February 19, 1998 - developed depression as the result of stress and harassment at work; Rosenkoetter claims in 1997 her boss and coworkers were taunting her by deliberately sending her defective parts so that she would have to repair them and they altered the speed of the line to the point that she was unable to keep up and they tampered with her food; when seen on February 19, 1998 for complaints of bilateral upper extremity pain it was noted that Rosenkoetter appeared depressed and was diagnosed with depression, Rosenkoetter denies further care of psychiatric evaluation. Diagnosis made by Dr. Poetz was: 2/19/98 Depression secondary to work related stress and harassment. Dr. Poetz opined that Rosenkoetter had 15\% permanent partial disability to the body as a whole due to depression directly resultant from the February 19, 1998 work related injury. During cross examination by the employer/insurer, Dr. Poetz agreed that the only history in his report that would have caused the condition he had diagnosed was stress and harassment at the work place. The doctor was queried you didn't have any history of there being marital problems or family problems or problems outside of work that could have caused or contributed to Rosenkoetter's permanent disability as a result of a psychiatric condition. "Not to my knowledge", Dr. Poetz answered. (Poetz Dp. pg. 41) It was noted that the specific history in his report was that depression as a result of stress and harassment at work; approximately 1997, the patient claims that her boss and coworkers were taunting her, deliberately sending her defective parts so that she would have to repair them, they altered the speed of the line to the point she was unable to keep up and they tampered with her food. Dr. Poetz admitted that he did not know how often these things occurred. The doctor was questioned, you indicated that they altered the speed of the line and did he know if the line had multiple people working on it, and Dr. Poetz responded - "I don't know if her specific station was able to be adjusted. I don't know that." (Poetz Dp. pg. 42) When further queried - so you don't know if the stress was put upon her at the work place was different than the subjective levels of stress that would have been imposed upon other folks at that place of employment. "I don't know", the doctor answered. (Poetz Dp. pg. 42) Dr. Poetz agreed that at the time he saw Rosenkoetter she was not on any medication for depression. I did recommend additional treatment as a result of her diagnosis of depression, the doctor said, SSRV, "selective seratonin inhibitors", an antidepressant medication. (Poetz Dp pg. 43) I did not prescribe this for her when I saw her, Dr. Poetz said. Depression is caused by "altercation of seratonin secretion by the brain as a result of certain stressful stimuli", Dr. Poetz explained. (Poetz Dp. pg. 44) Persons with a family history of depression are more susceptible to having their seratonin altered by means of eternal stressful stimuli, the doctor said. I don't know if Rosenkoetter has a family history of depression, Dr. Poetz stated. The doctor agreed that marital difficulties could be an external stressful stimulus for seratonin altercation if the patient feels it is the reason for their depression. Dr. Poetz agreed that he asked Rosenkoetter what were the causes or stimulus for her depression, and she said - work. I'm sure I made inquiries as to whether there were any stressors in her life outside of work, the doctor said. "I can tell you that after 40 years of experience of trying to determine how and why patients are depressed, that I am skillful at asking the right number of questions until I'm satisfied to the answer that I receive is significant for that patient's response", Dr. Poetz said. (Poetz Dp. pg. 46) Dr. Poetz responded - "I don't recall"when queried if he know how long Rosenkoetter had been married, how many times she had been married, if she was ever physically abused or emotionally abused, if her kids were ever emotionally abused. (See Poetz Dp. pp. 47-48) Dr. Poetz stated that he was familiar with the DSMIV, and agreed that it listed psychosocial stressors; the doctor agreed that psychosocial stressors can cause depression. Dr. Poetz agreed that marital discord was on the DSMIV list of psychosocial stressors as well as family discord, physical and emotional abuse. The doctor was queried about his evaluation of Rosenkoetter's mental status; Dr. Poetz stated that he did not need to do a Beck Depression Scale and did not do the MMPI. "I spent an hour with the lady and I make determinations when I, the depressive faces that she showed, by the things that she told me, and not only did I make a diagnosis based on an hour of studying the patient, but I also made recommendations as to her management of her depression", Dr. Poetz testified. (Poetz Dp. pg. 52)

Dr. Schlafly, who also evaluated Rosenkoetter on Rosenkoetter's own behalf, wrote that he would defer to a psychiatrist as to the extent of any psychiatric disability from work related depression.

Employee: Mary Rosenkoetter

Imjury No. 98-175851

Employer: Integram St. Louis Section

1. Are any benefits awarded herein? Yes
2. Was the injury or occupational disease compensable under Chapter 287? Yes
3. Was there an accident or incident of occupational disease under the Law? Yes
4. Date of accident or onset of occupational disease: February 19, 1998
5. State location where accident occurred or occupational disease was contracted: Franklin County, MO
6. Was above employee in employ of above employer at time of alleged accident or occupational disease? Yes
7. Did employer receive proper notice? Yes
8. Did accident or occupational disease arise out of and in the course of the employment? Yes
9. Was claim for compensation filed within time required by Law? Yes
10. Was employer insured by above insurer? Yes
11. Describe work employee was doing and how accident occurred or occupational disease contracted: Factory work.
12. Did accident or occupational disease cause death? No Date of death? ---
13. Part(s) of body injured by accident or occupational disease: Mental injury (Body as a whole)
14. Nature and extent of any permanent disability: 4 % of body as a whole
15. Compensation paid to-date for temporary disability: $\ 0.00
16. Value necessary medical aid paid to date by employer/insurer? $\ 0.00
17. Value necessary medical aid not furnished by employer/insurer? $\ 0.00
18. Employee's average weekly wages: $\ 596.40
19. Weekly compensation rate: $\$ 397.60 / \ 278.42
20. Method wages computation: By agreement of the parties

1. Amount of compensation payable:

Unpaid medical expenses: --- --- weeks of temporary total disability (or temporary partial disability) 4 % body as a whole permanent partial disability from Employer, or 4,454.72 --- weeks of disfigurement from Employer

1. Second Injury Fund liability: No

TOTAL: $\quad \ 4,454.72

1. Future requirements awarded: None

Said payments to begin as of date of this Award and to be payable and be subject to modification and review as provided by law.

The compensation awarded to the claimant shall be subject to a lien in the amount of 25 % of all payments hereunder in favor of the following attorney for necessary legal services rendered to the claimant:

Ray Gerritzen, Attorney for Claimant

Employee: Mary Rosenkoetter

Injury No: 98-175851

Before the

DIVISION OF WORKERS'

COMPENSATION

Department of Labor and Industrial Relations of Missouri

Jefferson City, Missouri

Dependents:

Employer: | Integram St. Louis Section |

Insurer: CNA Insurance Company/RSKCo

Checked by: LEHB:df

This is a hearing setting for five cases involving the claimant, Mary Rosenkoetter, Injury Numbers 94-168476, 95129017, 97-483041, 98-175851, and 99-123209. In all five cases, the claimant, Mary Rosenkoetter appeared on her own behalf, and through counsel, Attorney Ray Gerritzen. In all five cases, the employer/insurer appeared by and through counsel, Attorney Tim Tierney. In four cases (Injury Numbers 95-129017, 97-483041, 98-175851, and 99123209), the Second Injury Fund appeared by and through Assistant Attorney General M. Jennifer Sommers.

The parties entered into certain stipulations, and agreements as to the complex issues to be presented in these hearings.

Memorandums of Law were filed by the parties.

On or about February 19, 1998: a. the claimant while in the employment of Magna Interior Systems sustained an injury by accident arising out of and in the course of her employment occurring in Franklin County, Missouri; b. the employer and employee were operating under and subject to the provisions of the Missouri Workers' Compensation Law; c. the employer's liability was insured by CNA Insurance Company slash RSKCo.; d. the employee's average weekly wage $\ 596.40, the rate being $\ 397.60 over $\ 278.42

e. Employer had notice of the injury. f. A Claim filed within the time prescribed by law. g. No temporary total disability benefits were paid. h. No medical aid was provided.

1. Medical causation
2. Liability of past medical expenses
3. Future medical care
4. Nature and extent of permanent partial disability
5. Liability of the Second Injury Fund

No. A: Deposition transcript of Bruce Schlafly, M.D., taken July 9, 2002 on behalf of the claimant, with attachments of: Exhibit A-1, the curriculum vitae of Bruce Schlafly, M.D.; A-2, the March 1, 2001 report of Dr. Bruce Schlafly, M.D. (8 pages); A-3, November 12, 2001 report of Bruce Schlafly, M.D. (1 page); A-4, four photographs taken by Dr. Bruce Schlafly of another patient, not Mary Ann Rosenkoetter, who had persistent problems following prior endoscopes carpal tunnel release and required repeat carpal tunnel release using the standard technique, Exhibit A-3 has the description; A5, the medical literature provided by Bruce Schlafly, M.D. titled, quote, The Results of Revision Carpal Tunnel Release Following Previous Open Versus Endoscopes Surgery". A-6, the medical literature by Dr. Bruce Schlafly entitled "Persistent or Recurrent Carpal Tunnel Syndrome Following Prior Endoscopes Carpal Tunnel Release"; A-7, operative report of the December 7, 2001 left carpal tunnel release performed by Dr. Bruce Schlafly at St. Anthony's Medical Center; A-8 is the December 12, 2001 report of Dr. Bruce Schlafly (1 page); A-9, the May 6, 2002 report of Dr. Bruce Schlafly (2 pages); A-10, the operative report of the March 4, 2002 right carpal tunnel release performed by Bruce Schlafly, M.D., at St. Anthony's Medical Center; A-11, the statement of services of Hand Surgery Associates, P.C./Bruce Schlafly, M.D., in the amount of $\ 3,120.00 for services rendered November 12, 2001 through March 8, 2002; A-12, numerous letters addressed to Bruce Schlafly, M.D., and deposition notices of Dr. Bruce Schlafly relative to his carpal tunnel syndrome treatments. (Admitted subject to the objections therein.) (Ruling: Employer/Insurer's and Second Injury Fund's objections to Exhibit A-4 on grounds of, inadequate foundation has been laid, is overruled.)

No. B: Certified medical records of Calvin Medical Center

No. C: Certified medical records of Hand Therapy Network, certified March 15, 2001 (12 pages)

No. D: Certified medical records of HealthLine Corporate Health Services Metro St. Louis certified October 12, 1999 (72 pages)

No. E: Certified medical records of Karl A. Jacob, M.D. certified October 9, 1999 (43 pages)

No. F: Medical records of Dr. John Kef alas, M.D. certified October 7, 1999

No. G: Certified medical records of Missouri Baptist Medical Center certified January 19, 2000 (219 pages)

No. H: Deposition transcript of Dr. Poetz taken on behalf of the employee on April 28, 2003 (with attachment H-1, the doctor's June 10, 2002 report, 10 pages) [Admitted into evidence subject to the objections therein)

No. I: Certified medical records of St. John's Mercy Hospital in Washington, Missouri, certified May 4, 2000 (14 pages)

No. J: Certified medical records of St. John's Mercy Hospital in Washington, Missouri certified November 17, 1999 (8 pages)

No. K: Certified medical records of St. John's Mercy Hospital, Washington, Missouri certified July 16, 1997 (28 pages)

No. L: Certified medical records of Lesson Heights Orthopaedic \& Arthroscopic Associates certified November 10, 1999 ( 90 pages)

No. M: Medical bill of Pathology Associates, P.C., for services rendered December 7, 2001 and March 4, 2002 in the amount of $\ 41.00

No. M-1: Collection letter of Diversified Collection Services showing that $\ 27.00 of Exhibit M was turned over to collection

No. N: Medical bill of South County Anesthesia for services rendered December 7, 2001 in the amount of $\ 480.00

No. N-1: Medical bill of South County Anesthesia for services rendered on March 4, 2002 (the second surgery performed by Dr. Schlafly) in the amount of $\ 420.00

No. O: Medical bill of South County Radiologists, Inc. in the amount of $\ 20.00

No. P: Medical bill of St. Anthony's Medical Center for services rendered on December 7, 2001 in the amount of $\ 2,351.97

No. P-1: Surgical bill

No. Q: Prescription receipt of Heartland Discount Pharmacy in the amount of $\ 5.86 for Cephalexin, 500 milligrams prescribed by Bruce Schlafly, M.D.

No. R and R-1: Deposition transcript of Dr. John Crane, M.D. taken on April 8, 2004, and an August 18, 2003 report by Dr. Crane (Limited admission for these exhibits, only as to the issue of future medical care)

No. S: March 4, 2002 medical bill of St. Anthony's Medical Center, \$2,421.74

No. 1: Deposition transcript of Dr. R. Peter Mirkin, M.D. taken on behalf of the employer/insurer on 12/13/02 (Admitted subject to the objections therein)

No. 2: Deposition transcript of R. Evan Crandall, M.D. taken on behalf of employer/insurer on December 11, 2002 (Admitted subject to objections therein)

No. 3: Deposition transcript of Dr. Wayne Stallings, M.D. taken on behalf of the employer/insurer on 12-4-02 (Admitted subject to the objections therein)

No. 4: Certified records of Dr. George O. Sort, M.D.

No. 5: Records of Dr. Clark, D.C.

No. 6: Correspondence between the law offices of Gerritzen \& Gerritzen and Evans \& Dixon pertaining to the issue as to whether surgery had been authorized and when it had been authorized (a. November 20, 2001 letter from Paul Keeven to Mr. Gerritzen; b. November 16, 2001 letter by Mr. Gerritzen to Paul Keeven of Evans \& Dixon; c. October 15, 2001 letter from Mr. Gerritzen to Paul Keeven of Evans \& Dixon; d. October 5, 2001 letter from Paul Keeven to Mr. Gerritzen; e. April 23, 2001 letter of Michael Gerritzen to Paul Keevenn)

No. 7: First Workers' Compensation Claimant's Report dated 10-7-95, signed by Miss Rosenkoetter

No. 8: Deposition transcript of Dr. Wayne Stallings, M.D. taken on behalf of the employer/insurer on 4-28-04 (Admitted subject to the objections therein)

No exhibits.

The claimant, Mary Ann Rosenkoetter, (who was found to be a basically credible witness though confused on historical facts and dates at times), testified that her highest education was eleven and half years of high school, with thirty-eight hours of college. I never graduated from high school, the claimant said. I first went to work when I was eighteen, Rosenkoetter stated, and I have done factory work, school custodian and storeroom clerk work all of my life. The claimant talked about working two jobs in the early 1990's: working at East Central for a year as a school custodian in about 1993 or 1994 while working at Integram; and working as a clerk giving out blueprints and inspected machine parts and gave out machine parts out of the storeroom at Bull Moose Tube for about fourteen months. I first went to work for Integram in 1991, I think, the claimant said, and I went to work in maintenance which entailed cleaning all the bathrooms on the production side, sweeping floors, polishing the floors or cleaning them, and then just all around maintenance work.

In 1998 while working at Integram I claimed I had depression due to harassment, Rosenkoetter testified. I had my elbows and that hurt really bad, and I went to the HealthLine and they said I had tendonitis. And just luckily the next time I went there was a different doctor came in there to work and he was looking at my arms and he asked me what was wrong with me and I told him, and he gave me medicine for depression, the claimant testified.

Rosenkoetter testified about the harassment at work: there was people at work if I set my soda or anything on the table, they would go and they would poke a hole in my soda so it would run all over my seat, Kent was one of the guy's

name who did this, I don't remember his last name; there was just a bunch of them that was real good friends with the foreman and he would let them get away with that stuff; the foreman wouldn't do nothing to them. I'd be standing on the platform in front of the molds and I didn't like it there anyway, and there was holes, there was grates, and I was always afraid that maybe the carousel would crash or something, and they got them big molds on them, the claimant stated, and they would take a big wrench and they would sneak over there and hit the bottom of the grate, and I would think it was falling. And they would do that all the time because they knew I was upset anyway, she said. And I couldn't leave my food set on the table because I didn't know if they would put stuff in it, the claimant stated. They poked holes in my soda can, and they would spit their chewing tobacco in a soda can, and it would have the top off it, and they would put it on the overhead, and they'd know by the hours when I would be back at the dump, and that soda can would fall on you with all that spit in it, and then you'd have to clean it off the seats, and off of you, and they done that several times, Rosenkoetter testified, and it didn't do no good to tell anybody because they wouldn't do nothing about it. And when I was on the re-work, she testified, they would go and turn things on the valves and the molds, they put a whole bunch of molds release and it would leave holes in the bun parts, and I would have to fix all of them. And sometimes, the claimant testified, there be in an hour that I was on re-work and there would be two or three boxes of bad parts in the boxes, and I'd call the foreman, he'd come over and say - Well, I don't understand that, there must be something going on; the foreman would check this and check that, and say - Well, just go on to your next station. The foreman knew about this stuff and did nothing to change it, the claimant agreed. My one friend, Nick (they used to call him Turkey Man there all the time), he came and he told me what they were doing, that they were doing it on purpose; and they asked him to do it and he said no, he wouldn't do it because he was my friend, Rosenkoetter stated. I didn't see them doing it to anybody else, the claimant stated, they once took a girl's purse and put it overhead and she couldn't get it until it dropped. This started with me just before I went to that HealthLine doctor about my hands, the claimant said. They would speed up the lines on the air bags, they would take and pile up parts so that the line would rush by real fast; and there was about maybe six to eight seat covers that you'd have to blow the plastic off and put them on that line, and they would take them from behind the stop on the machine and then the line would go real fast when they took that last one off, and it would go up, and it would all been empty. And it took me so long to blow each one to get it filled back up again, so I was blowing one and running around putting it up there so that it wouldn't shut down the carousel until I got caught up, she said. This happened until they fired me from work, Rosenkoetter said. I was fired in 1999, I think it was, the claimant stated.

The company never did anything to stop this, Rosenkoetter said. When I complained to the foreman, he'd say he'd talk to them. But it did not stop any, she said. All of these things affected me, Rosenkoetter said, it got my nerves really bad, I started crying all the time at work. Agreeing that the foreman saw her crying at work, Rosenkoetter testified The foreman had this one girl who was his friend, Dawn, and we were back there and cutting and putting the leather covers on, and she'd go talk to fork truck drivers and mess around, wasn't there to do her job, and you'd have to take up the slack for her. So I got so aggravated I went and told the foreman, and he come over there and took her in the office for about four hours, she sat in there and talked to him and I had to do her work and my work, the claimant said.

Explaining how all of these things she had described affected her work or her ability to work, Rosenkoetter stated that she got really upset about all the bad parts. I just didn't have time to fix them, she said, so that makes it look bad on you, because you got two or three boxes with bad parts sitting there that you can't fix. And then they wasn't even entered into the computer because you don't have time to do all of that, she stated. The parts were foam buns, which is the cushion that goes underneath the leather covers. Explaining what was defective about them, the claimant stated that they would put too much mold release and it just eats the foam and it makes holes in it; the guy that was inspecting them, they had strips on them and you tore off the top part and it was like a Velcro left, he would rip it all off, then I'd have to glue them all back on. Pat Brown was one of the guys, she said, he told me he was ripping off this section of these foam buns because it was too tight and it just came off. This was done just to me, the claimant said. The foreman did not say anything about this, Rosenkoetter stated, he put them all in a box and pushed them to the back, and they would fix them back there.

I was first treated for depression by Dr. Bonney, the claimant said, he was not a regular doctor at HealthLine, but he was filling in that day, and he gave me some medicine that would help me, I forget what the name of it was. When asked what year this was, Rosenkoetter responded - I had gone to HealthLine because of my arms, they were hurting me all the time, tendonitis in my elbows. Before going to Dr. Crane in May of 2003 I had not been to any psychiatrist for depression at all, Rosenkoetter stated. The company sent me to Dr. Stillings, I think, the claimant said, and other than that I don't recall going to any other psychiatrists in my life, she said.

The claimant testified about continuing problems as a result of the harassment at work. It's still with me, she said, everything they done to me all these years, when I slipped on the tag, then after they sent me to Tesson Ferry to a back doctor down there, when I went in there he done x-rays and he come in there and he told me - you didn't have your back operated on, your back wasn't operated on, Dr. Jacobs didn't do anything to your back. The claimant agreed that when

she went to be examined she had a surgical scar on her back where Dr. Jacobs had cut on her back and removed the disc. The surgical scar is more than an inch long and is visible now, and was there when I went to this doctor who told me I didn't have any surgery on my back, and this doctor had looked at my back, the claimant said. Well, after that then they sent me back down there, and they did do an MRI of my knee and said there wasn't nothing wrong with it, she said. The doctor took x-rays of my back, and on the x-rays I had a pinched nerve on the right side of my back; I left, I called back and then when I called back there was no pinched nerve, Rosenkoetter testified.

Rosenkoetter testified about the treatment she has received for depression. Just the medicine that one doctor gave me, she said. Rosenkoetter agreed that she was also treated by Dr. Crane right after the last hearing setting in this case in May 2003, that she had gone the next day; Rosenkoetter agreed that she had testified at the last hearing setting that she was so upset that day she didn't feel she could testify. Except for the one time with the HealthLine doctor, this was the first treatment I had had for depression, when I started with Dr. Crane after the last hearing setting, she said. When I first started going to Dr. Crane it was once a month. The reason I went because I couldn't control my anger anymore, Rosenkoetter said. She agreed that she had a lot of crying spells, and agreed that she missed two appointments at her attorney's office to prepare for the trial. I got so bad that I can't stand to go in the elevators, I can't stand to go twenty-five floors up, all the people, and I got so I wouldn't leave my house; I wouldn't go out of the bedroom, and I just slept all the time; I can't stand the people, too many people, and it felt like the buildings were going to fall on me, the claimant testified. Agreeing that she had refused to come to her attorney's office because it was downtown, Rosenkoetter stated - I just told Mr. Gerritzen I couldn't come up there, I just couldn't do it, and he said I could come to his house. And I had to get my husband off of work because I had a car accident in about 1985 and had a real bad concussion and I can't remember, and it messed up a nerve in the back of my head and I couldn't smell and couldn't taste real good; I get lost and I was losing track of time and I would lose hours, I wouldn't know what I did or where I was at; I was lost and I was in Illinois once and I couldn't get home, and I got lost once in St. Charles. I just decided to stay home, the claimant said. Rosenkoetter was queried if she felt her inability with going in the big buildings and being with people was due to what happened to her in 1985 or was it due to what happened at Integram, or due to both. Just all the aggravation at Integram, the claimant answered, all the stuff that they done to me and put me down because of my back, and I worked what I could work, when I could work, and it just wasn't never enough.

I was fired by Integram in 1999, the claimant stated, and the reason they gave was because I was off when I hurt my leg. They changed the contract and they said the insurance papers -- when I hurt my knee, I went on sick leave and I went and got my papers to fill out; it's after I fell and went to the hospital and the doctor said I shouldn't work. So I went to the bone specialist, and I got my insurance papers and I didn't know how to fill them out because they were different, and I called the H.R. and Mary Jo said she would help me fill them out, and she told me what to put down. I had called them and I asked them in H.R. at Integram if there's anything else that I had to do, and she said no, that's all I have to do, the claimant testified. They said they fired me because I didn't come in and fill out new papers; that's why we went, the union man and me, before the arbitration board. It was whoever's the boss down there at Integram, the general foreman, I guess, who said I didn't fill out the papers right, the claimant stated, because they said I was fired because I didn't do my paperwork right. But they already had the doctor's papers there in front of them and then when we went to the arbitration I had my phone bills and everything, and they had three or six women from the H. R. Department sit there and lie, it didn't make any difference what I said, and my union worker denied me the right to have counsel, said he was going to represent me, so I didn't even get to have a lawyer there, Rosenkoetter testified. This was right after they fired me and then went through three steps, and the fourth step was to go before the arbitrator. They denied my unemployment, and I went to the hearing for unemployment and their woman said that was absurd that I would quit my job at fifteen something an hour, and she gave me my unemployment, the woman from Jeff City, the claimant stated.

During cross examination by the employer/insurer, the claimant was asked to what did she attribute her psychiatric problems. I'd been having problems at work with harassment, the claimant answered. When I went to the doctor about my arms, there was another doctor there and not the regular doctor, and he asked me what was wrong, and I told him I'd been having problems at work, and he put it on the paper, the claimant stated, he give me some medicine that would help me. She was asked when did the harassment start. I don't recall, Rosenkoetter answered, all I know is I had problems with them at work and that day was really bothering me, and the doctor asked me what was wrong and I told him. I'd had problems after I went back to work, not being able to do what I was supposed to do, worried about my job, the claimant stated. And all that stuff started with them guys at work; you could never get nothing done; even if you told the foreman, he wouldn't do nothing about it, he'd say - I'll talk to them, and it got worse and worse and worse, the claimant stated. Rosenkoetter agreed that it was sometime after she went back to work after the surgery for the back injury that the harassment started. It was sometime around the end of 1996 or beginning of 1997 that I returned to work, the claimant agreed. Dean Nordman was the supervisor I talked to who did nothing about it, the claimant stated. The harassment occurred on between ten and twenty occasions, Rosenkoetter said. She agreed that during that period after she returned to work, in addition to the harassment, one of the things she was concerned about was her ability to perform her job

duties and actually keep her job. The claimant agreed that she believed Dean Nordman played a role in this harassment. The claimant explained that though she believed that along with the other employees Nordman played a role in the harassment that she underwent, but nevertheless when she thought it was a problem she went to Dean Nordman to report it because he was her supervisor. Rosenkoetter stated that she did not file a grievance about the harassment because she didn't know you could do that. I didn't know if there was a hotline at work, the claimant said, I never worked in a place where they had a union. Rosenkoetter stated that she knew there was a human resources department at Integram, and that she trusted them until she lost her job. I did not go to H. R. and tell them I was being harassed because I thought you went there to fill out papers, like medical papers, and insurance papers, and stuff like that; I never thought they would deal with harassment or anything, she said.

Rosenkoetter stated, during cross examination, that she was already was stressed out before her termination; the termination did not make my stress worse, it made me hate you and the company you represent, she testified. Rosenkoetter agreed that her termination and the grievance proceeding was all about insurance paperwork, it wasn't about making bad parts or not doing her job right. No one from the company that I know of ever wrote me up because I made too many bad parts, the claimant said. No one from the company ever came to me on the re-work line and said as a result of my not keeping up with the re-work, we're going to write you up, Rosenkoetter stated.

During cross examination, Rosenkoetter testified about other experiences in her life. She stated that she had been physically assaulted once by her husband's brother on or about 6/6/95, who had jerked a chain out of her hand and hurt her arm. She stated that she went to St. John's Hospital, and they said it was just strained, it was all right. The claimant agreed that her memory was refreshed by the St. John's record which reflected that her brother-in-law just went berserk, grabbed her arm and twisted it and tried to punch her, and she blocked that punch with her right arm. The claimant stated that she thought her brother-in-law had hit her husband with a shovel. Rosenkoetter agreed that they had to take her brother-in-law to court to resolve the issue, and the brother in law got the road and they didn't. What we did about access to our home was made a road, she said. This brother-in-law still lives next to me, she said. Describing the relationship now, Rosenkoetter testified - He talks to me, I talk to him; I give him stuff out of my garden, my husband's over there quite often; he just shut the road off, that's all, so you live with it and go on. I don't think I continue to have problems with my right arm after the assault, she said. The claimant was queried if she knew why the records of Dr. Bedor for 1997 would reflect that he thought she had a rotator cuff tear in that arm. I got a test from our regular man, and he said they done a test in there put medicine in there and took x-rays, and I didn't have a rotator cuff tear, she stated. I didn't know what was causing my right shoulder problems at that point in time, that's why I went to find out; I thought I had a rotator cuff tear, and I didn't, she stated. The claimant was queried if there were any other times that she had been physically assaulted, and she answered that her ex-husband, who she was married to for twenty-five years, used to push her around a little bit off and on. Rosenkoetter agreed that her ex-husband also tried to abuse her emotionally off and on throughout the twenty-five years. He went to the hospital and got help, she stated, he had a medical problem. Rosenkoetter agreed that she had children with her ex-husband, and that her children witnessed some of that emotional and physical abuse. This s why I got divorced, Rosenkoetter explained, and stated that it was a friendly divorce. We visit each other; he comes to my house, he's remarried and I go to their house, she said. Rosenkoetter agreed that she had attempted to take custody of a grandchild, and explained that it was because the child had a drug addict for a father; it wasn't because of my daughter, but I had to put both names on there (my daughter's name and her boyfriend's name) or I couldn't get her. The mom brought the baby to me and I had the child for maybe six or seven months, Rosenkoetter said. I don't know what year it was and I don't know when she went back; I gave her back because her mom got her own apartment, got on HUD, and had money to take care of her.

Rosenkoetter agreed, during cross examination, that over the years she has had some problems with pneumonia and ear infections and sinus problems, and missed time from work as a result of the problems with bronchitis, including in 1997 and 1998. I believe that it is because of the mold release that I smelled every year for year after year at Integram, she said.

During cross examination by the employer/insurer, the claimant agreed that besides seeing Dr. Stillings one time in 1998, the first time she received any psychiatric treatment was through Dr. Crane's office in 2003. The claimant was asked if she had ever attempted to get treatment through her group health insurance. I didn't think it was bothering me that bad; I didn't want to go to a psychiatrist, she answered. Rosenkoetter agreed that when she thought it was bothering her so bad that she had to go see a psychiatrist was when she went to Dr. Crane. It was noted that this would have been several years after she left the employ of Integram, and Rosenkoetter responded - It kept on and kept on and kept on. My health situation, it eats me up, she said, do you know what it's like to not be able to do anything or fall over everything and get hurt, like my arm, and broke my leg. You don't know what it's like, she indicated; not being able to enjoy my bike no more or ride my motorcycle or go in the field with my husband, he has to do all that work "hisself" now. I can't even plant my frigging flower garden; I try to weed-eat, I bought the lightest weed-eater they had which they said

weighed less than five pounds, and I couldn't even do it more than five minutes. That's why I went to Dr. Crane, the claimant stated, because I knew I needed to go someplace and I looked in the phone book and I found Dr. Crane's name and I went to him. It's just been building up and building up and all these years and all these accidents and got so I wouldn't go out of my bedroom, I would stay in there for days, the claimant stated. I didn't want my kids to come, I didn't want to see my grandkids, I didn't want to see nobody, she stated. And every time I got hurt it brings it all back again, the claimant testified, and every time I had to go to these stupid hearings and all these years been going on and going on, it eats at me. Now I have to get surgery on my other hip, and I got to face that, too. You know what it's like getting out of bed for five seconds, not even long enough to go to the bathroom, and you got to go back and lay down because you can't set up, the claimant stated. I want to kill myself, if I could have got a gun, I would have, she said. I go to bed every night crying because my legs and my back hurt so bad; can't go any place around people and enjoy yourself because you're miserable; you can't even sit in a frigging chair, the claimant said. Rosenkoetter agreed that every time she has an injury to her body, it dredges this all back up and makes it worse.

The claimant agreed that she was involved in a motor vehicle accident in October, 2003. My daughter suggested that she and I go down to visit my other daughter and on the way back I was driving, and there was a road on the right side and a man was coming the other way, and he decided he was going to turn and he was drunk, no insurance, two babies in the car and his wife; I didn't have time to stop, and I tried to miss him but it didn't work, Rosenkoetter said. The people in the other car, and my daughter and myself were injured in the accident, she said, no one was killed in the accident. Explaining about her injuries, Rosenkoetter stated that the air bag went off and she was going sideways and it hit her shoulder, and her hand hit something and broke a bone in her left hand, and her knee hit something on the door somehow. I wasn't casted, Rosenkoetter stated.

Joe Laffleur testified on behalf of the employer/insurer, and stated that he is a human resource manager at Integram St. Louis Seating, having been in that position for eight and a half ( $81 / 2$ ) years; Laffleur stated that he started with Integram in 1996. Agreeing that the company has a hotline, Laffleur explained - We are owned by Magna International out of Toronto, and they have a phone number that employees can call if they can't get their issues resolved at the plant and it can be anonymous. The hotline has been in effect at least twenty-five to thirty years, he stated. Employees are made aware of the hotline by us telling them in the orientation that it's available to them, Laffleur said, plus we also have posters in the plant which talks about what the purpose of the hotline is, what the phone number is to call, and plus periodically we'll have representatives come down from Toronto and do a presentation in one of our monthly employee meetings. He agreed that as part of the company's benefits package for the employees, they have an EAP (Employee Assistance Program) program, and stated that this has been in effect since the plant opened in 1989. The services available through the EAP are that the employees can contact the EAP if they have financial issues, chemical dependency issues, emotional issues either for them or for anyone living in their household, Laffleur said. Agreeing that H.R. took an active role in making the employees aware of the EAP program, Laffleur stated that they have posters out in the plant that talks about it, everybody in H.R. has business cards from the EAP, plus periodically they'll have someone come in and do a presentation.

In my years in the H.R. department, Miss Rosenkoetter never came to me and advised me that she was being harassed on the line, Laffleur stated. Laffleur stated that he was present at the grievance of Rosenkoetter but not at the grievance proceedings, as Rosenkoetter would have done that through her union representative. He agreed that as H.R. director for Integram he participates in grievances on a regular basis, and becomes aware of each grievance procedure. My role with the grievance procedures is that I pretty much handle the whole procedure, Laffleur stated. It's actually a four-step grievance procedure, and if that doesn't solve the grievance, then it goes to arbitration; I'm involved in all four steps plus at the arbitration level. And I actually conduct the meetings and I write the grievance, Laffleur testified. He agreed that in conducting the meetings he represents the company's interest, and in an effort to address his side of the argument, he becomes aware of the grievance allegations. Agreeing that he was aware of the allegations in the case involving Rosenkoetter, Laffleur stated that the allegations were that she did not terminate her seniority.

On cross examination by the claimant, Laffleur stated that Dean Nordman does not still work for Integram; I haven't talked to Dean in five years, so, no, I do not know where he is. Laffleur agreed that as human resources manager, he hires and fires people.

On redirect examination, Laffleur testified about the basis of his terminating Rosenkoetter in 1999. She terminated her seniority in accordance with the labor agreement because she failed to return from her leave of absence, Laffleur said, and agreed that the employer made no proactive attempt to terminate her. To my knowledge, Rosenkoetter was never written up for poor performance, and never written up for problems with quality or quantity of her work, Laffleur said. To my knowledge, in the grievance procedure, ability to perform her job duties was not an issue, he said.

On further cross examination, Laffleur agreed that he had brought Rosenkoetter's personnel file with him to the hearing. He agreed that the file included write-ups of Rosenkoetter, and stated that there were all on attendance. It was noted that included in the personnel file was that it was maintained by Laffleur and found by the appeal judge that the claimant left work on 3-19-99 without good cause. The original judge agreed with us, yes, Laffleur responded. Laffleur agreed that he wrote the termination letter, and that it was based upon Rosenkoetter not returning to work on 3-19-99. Laffleur was queried if he had looked in the file for whether or not Rosenkoetter had complained to Dean Nordman about being harassed at work. I didn't see it in there, but I wasn't looking for that, Laffleur answered. Laffleur agreed that if someone has poor performance, it is possible for them to be disciplined at Integram, and if there's a discipline for poor performance it is it put in their personnel file. Rosenkoetter did not have any discipline forms in her file for poor performance, Laffleur said.

Treatment records in evidence at or near the time of the claimant's allegations of harassment at work in 1997 and 1998 beginning subsequent to back surgery on 12/14/95 included the following. The records of Dr. Glen D. Calvin, D.O. (Cl's B), the claimant's personal doctor, reflected treatment of Rosenkoetter during the period of March of 1996 through March of 1999. The following are examples of treatment entries. 2/10/97 - acute viral syndrome with secondary problems, symptoms are headaches, eye pain, cervical spine pain, back pain, sneezing, coughing; treatment included Ultram. 2/24/97 - complaints of severe headache and cough, patient states she is not able to work at this time; diagnosis was bronchial pneumonia or pulmonary vascular congestion, and Rosenkoetter was sent to Missouri Baptist Hospital under Dr. Shen's care. 2/28/97 - Rosenkoetter was seen for follow-up on Proventil inhaler. 3/3/97 combination of congestive heart failure, bronchitis, pneumonia and difficulty breathing, return to see Dr. Shen ASAP. 4/3/97 - seems to have an exacerbation of her right shoulder, I think she has a torn tendon of her right shoulder but she refuses to have an MRI, sending her to Dr. Stetson for work up, here with severe shoulder pain and severe degenerative arthritis in shoulder. 5/5/97 - complaints of pulled muscle in left side mid-back for 24 hours after lifting on carpeting; typed entry included that exam revealed severe spasm of the TS and neurological was essentially neg, and was started on Anaprox and Ultram for pain, and therapy. In a 5/9/97 entry, depression was mentioned for the first time, the entry included: continued back pain; written was - "...she had surgery from Dr. Jacobs approx 2 years ago and she was told that there would be a possibility that she would have to have the other side operated on and she states that it has come to the pt. where she thinks that she needs to go back to see him because of the discomfort in the LS and (therapy) is not helping that much and also she is having a lot of family diff. And we will put her on Paxil" (sic); the diagnosis was - LS strain and Sit. Depression. Dr. Calvin's record continued with treatment entries in June 1997 through February 1998 for complaints of continued events of sinus pressure and low back pain for which the claimant was taken off work at times. In a 4/9/98 entry it was noted: "Here today with an acute anxiety episode with chronic problems with carpal tunnel, chronic degenerative back disease, possible ruptured disc", has some previous stabilization surgeries; "We recommend that she have further work up if her workman's comp. will approve of it"; she will be placed on BuSpar for mild anxiety; no other significant findings. Dr. Calvin's record continued through 3/9/99 reflecting treatment for left knee injury, low back pain, chronic bronchitis for which the claimant was at times taken off work; there was no more mention of anxiety or depression problems in these last entries. Healthline treatment records (Cl's. D) began with March 1994 notes; the first mention of depression were in the records of treatment for complaints of pain in the wrists and hands which began with an 11/3/97 entry. A 2/19/98 entry by a Dr. David Olinger, M.D. included: complaints of bilateral UE pain for about 6 months, treated with ibuprofen but is getting worse, complaints of numbness in the left index finger and thumb; written objective findings were - "Vague history. The patient appears very depressed and is crying when asked if she is depressed. UE reveals various scratches from working outside at home; the diagnosis was - Complaints of bilateral UE pain, Depression; treatment included - EMG, NCT's and antidepressants; Rosenkoetter was placed on work restrictions of no pushing or pulling with arm for one week greater than 35 pounds; follow-up in one week recommended. In a 2/19/98 Medical Authorization form, Dr. Oliver wrote in the Diagnosis Section of the form: "Subjective complaint of bilat. Upper extremity pain for 6 mos. Depression which is partly, if not entirely work related. Rec. (treatment with) antidepressant". In the next entry of 3/23/98 by a Dr. Anver Taylor, M.D., written was: Rosenkoetter relayed that she was scheduled to see Dr. Phillips for an EMG and nerve conduction tests the next day, and subsequently to see Dr. Crandall, and these appointments were set by her work place; continued complaints of pain in both hands, wrists, shoulder, and elbows, denies any pain in the neck; states is doing regular work at this time; the diagnosis was Paresthesia to both hands, It is questioned whether or not the patient has any depression from this particular incident, episode, or current complaints; it was written that Rosenkoetter would see Dr. Crandall for UE complaints; she was placed on full duty work status. In a 3/23/98 Certificate of Fitness/Exam form, Dr. Taylor wrote in the Diagnosis Section of the form: "1. Paresthesia both hands, 2. No work related depression."

The section in Missouri Workers' Compensation Law pertaining to compensation for mental injury was amended in 1992, and the requirements are set forth in Section 287.120.8 RSMo. 1992:

Mental injury resulting from work related stress does not arise out of and in the course of the employment, unless it is

demonstrated that the stress is work related and was extraordinary and unusual. The amount of work stress shall be measured by objective standards and actual events.

The determination of compensability of a mental injury using Section 287.120.8 RSMo 1992 was done in Tangblade v. Lear Corp., 58 S.W.3d 662, 666 -667 (Mo.App. W.D.,2001), in which the Court noted:

"Pursuant to § 287.120.1, an employee is entitled to workers' compensation benefits for personal injury or death 'by accident arising out of and in the course of his employment[.]' ' 'Arising out of' means that a causal connection exists between the employee's duties and the injury. 'In the course of employment' refers to the time, place and circumstances of the injury." Cruzan v. City of Paris, 922 S.W.2d 473, 475 (Mo.App.1996) (quoting Stockman v. J.C. Indus., 854 S.W.2d 24, 26 (Mo.App.1993)). As such, proof of the causal connection is what establishes that the condition for which compensation is sought arose out of employment. Duncan, 897 S.W.2d at 114 (citation omitted). Hence, to be entitled to workers' compensation benefits, the employee has the burden of proving, inter alia, that his or her injury was caused by a work-related accident. Id.; Goleman v. MCI Transporters, 844 S.W.2d 463, 465 (Mo.App.1992) (citation omitted).

A mental injury is compensable under the Workers' Compensation Law. Rooks v. Trans World Airlines, Inc., 887 S.W.2d 671, 673 (Mo.App.1994) (citing 667 Tibbs v. Rowe Furniture Corp., 691 S.W.2d 410, 412 (Mo.App.1985)). With respect to establishing the requisite causal connection for a claimed "mental injury," § 287.120.8 provides:

Mental injury resulting from work related stress does not arise out of and in the course of employment, unless it is demonstrated that the stress is work related and was extraordinary and unusual. The amount of work stress shall be measured by objective standards and actual events.

Thus, to be entitled to benefits for her claimed mental injury of major depressive disorder, the respondent was required to prove that her condition was caused by work-related stress, which was extraordinary and unusual in nature, as measured by objective standards and actual events. Id.; Williams, 996 S.W.2d at 628.

[12] An injury will be deemed to have arisen out of and in the course of employment only if:

(a) It is reasonably apparent, upon consideration of all the circumstances, that the employment is a substantial factor in causing the injury; and

(b) It can be seen to have followed as a natural incident of the work; and

(c) It can be fairly traced to the employment as a proximate cause; and

(d) It does not come from a hazard or risk unrelated to the employment to which workers would have been equally exposed outside of and unrelated to the employment in normal nonemployment life[.]

§ 287.020.3(2). Accordingly, a mental injury is not compensable, unless it can be shown that the alleged workrelated stress was a substantial factor in causing the injury. Bloss v. Plastic Enters.,32 S.W.3d 666, 672 (Mo.App.2000)."

Thus, to be compensable, a mental injury must be from work-related stress which was extraordinary and unusual in nature as measured by objective standards and actual events and the work-related stress was a substantial factor in causing the injury.

Considering the evidence in this case, it is found that there is no corroborating evidence of the claimant's allegations of being harassed at work by co-employees; in fact, medical evidence offered by the claimant, a Healthline 5/9/97 entry, noted Rosenkoetter's continued complaints of low back pain, therapy is not helping that much, and also she is having a lot of family difficulty, with the diagnosis being - LS strain and Situational Depression. Additionally, there is a challenge presented by employer/insurer to the claimant's allegations of suffering harassment at work, that challenge being the testimony of Joe Laffleur who stated that he has been a human resource manager at Integram St. Louis Seating and has been with the company since 1996, and further testified in his years in the H.R. department, Rosenkoetter never came to him and advised him that she was being harassed on the line. Notwithstanding, it was agreed and stipulated to by the parties that the claimant suffered an injury by accident arising out of and in the course of her employment on or about February 19, 1998, though medical causation was put in issue ${ }^{[13]}$; again the injury alleged by the claimant is a mental injury. Thus, further consideration will be made on whether or not the claimant experienced any other actual work related events in the time period in issue that would be considered extraordinary and unusual that produced a compensable mental injury.

In Carnal v. Pride Cleaners, 138 S.W.3d 155, 158 (Mo.App. W.D.,2004) it was noted: "Specifically, the claimant must establish that the work related stress was extraordinary and unusual, as compared to 'the stress encountered by employees having similar positions, regardless of employer, with a focus on evidence of the stress encountered by similarly situated employees for the same employer.'". Considering the evidence in this case during the time period

subsequent to the 12/14/95 low back surgery (See, Dr. Jacob's records - Cl's. E) and during 1997-1998, firstly Dr. Jacob's records indicated the following in the 5/6/96 entry:

The patient is discharged from follow-up as far as her lumbar spine is concerned. She is to do conditioning for approximately one month after which she can return to work with a 25 pound limit weight lifting restriction. She is to do no lifting that involves bending over at the waist.

The claimant gave uncontradicted testimony that subsequent to her release from treatment on 5/6/96 from back surgery, she returned back to her regular duties which involved lifting (i.e. a 3-person seat for a minivan) and bending. Rosenkoetter testified that when she went back to work after the surgery, it was hard on her back. I went home the first night that I went back, she said. It's hard on my back to lift the stuff and just to be able to walk from station to station and get back in the routine of anything, she stated, this along with bending was hard. It just made me real sore to start back after not being able to do anything for so long, the claimant testified, and the bending over the re-work table would hurt my back, and I couldn't do the lifting; I'd go home every night and couldn't hardly stand it from the lifting the heavy seats and stuff, and bending over the boxes. And then I'd have so long a time to get from one station to the other and to be on time, Rosenkoetter testified. Walking was from the inspection table to re-work, which wasn't but about five feet, but then you had to go from there all the way into the back, which was maybe sixty, seventy feet, she said, and it was all on level concrete which wasn't real good either. Rosenkoetter stated that from the time she went back to work in November of 1996 there was a difference in her ability to work at Integram, she slowed down a lot. I just didn't do as many parts as I used to; I wouldn't help other people, I just couldn't do that no more, Rosenkoetter said. In a 04/01/98 report, Dr. Jacobs wrote that Rosenkoetter was a patient of Dr. Calvin as she had reinjured her back at work three months ago bending over putting cushions in a box and heard a popping of her back and pain radiating to the right lower extremity. There was evidence that there were similarly situated employees performing these duties, but no evidence presented that the other similarly situated employees performing these work duties were doing so with the restrictions Rosenkoetter had had placed on her. It is found that the evidence establishes that the requirement that Rosenkoetter perform the same work duties as similarly situated employees even though she had restrictions placed by Dr. Jacobs resulted in extraordinary and unusual stress on her.

The next consideration, in light of the immediately above finding, is whether or not this work related stress caused a mental injury. There is medical opinion in the evidence of mental problems for the claimant, however there are different opinions among the doctors as to the diagnosis of the condition(s). The evidence reveals that the claimant was evaluated by multiple doctors, including psychiatrists, and testing was performed to aid in the diagnosis. Thus, medical opinion on the diagnosis and cause is found to be required in this case.

A claimant must show not only causation between the accident and the injury but also that a disability resulted and the extent of such disability. Smith v. National Lead Co., 228 S.W.2d 407, 412(4) (Mo.App.1955). While proof of cause of injury is sufficiently made on reasonable probability (Smith v. Terminal Transfer Company, 372 S.W.2d 659, 664(7) (Mo.App.1963)), proof of permanency of injury requires reasonable certainty. Davis v. Brezner, 380 S.W.2d 523, 588(6-- 9) (Mo.App.1964). Whatever may be the quantum of proof the law imposes on a given issue in a compensation case, however, such proof is made only by competent substantial evidence and may not rest on surmise or speculation. Griggs v. A. B. Chance Co., 503 S.W.2d 697, 703 (Mo.App. 1973).

"For an injury to be compensable the evidence must establish a causal connection between the accident and the injury. The testimony of a claimant or other lay witness can constitute substantial evidence of the nature, cause and extent of the disability when the facts fall within the realm of lay understanding.

"An injury may be of such a nature [however] that expert opinion is essential to show that it was caused by the accident to which it is ascribed." (Citations omitted) Griggs, 503 S.W.2d at 704.

"...an injury may be of such a nature that expert opinion is essential to show that it was caused by the accident to which it is ascribed. When the condition presented is a sophisticated injury that requires surgical intervention or other highly scientific techniques for diagnosis, and particularly where there is a serious question of pre-existing disability and its extent, the proof of causation is not within the realm of lay understanding..." Knipp v. Nordyne, Inc. 969 S.W.2d 236, 240 (Mo.App. 1998)

"Medical causation not within common knowledge or experience, must be established by scientific or medical evidence showing the cause and effect relationship between the complained of condition and the asserted cause." Selby v. Trans World Airlines, Inc., 831 S.W.2d 221, 222 (Mo.App. 1992).

"A medical expert's opinion must have in support of it reasons and facts supported by competent evidence which will give the opinion sufficient probative force to be substantial evidence." (citations omitted) Pippin v. St. Joe Minerals Corp., 799 S.W.2d 898, 904 (Mo.App. 1990)

Two doctors, in the treatment records, offered opinions on a diagnosis concerning Rosenkoetter's mental state, but expressed opposite reasons for their diagnosis: a.) Dr. Calvin, D.O. in a 5/9/97 entry, noted Rosenkoetter was having a lot of family difficulty and diagnosed Situational Depression, and in a 4/9/98 entry Dr. Calvin noted that Rosenkoetter was there that date with an acute anxiety episode and she would be placed on BuSpar for mild anxiety. b.) In the Healthline record, a 2/19/98 entry by a Dr. Oliver, M.D. included - Vague history. The patient appears very depressed and is crying when asked if she is depressed; the diagnosis included - Depression, and the treatment included - antidepressants; Dr. Oliver wrote in a 2/19/98 Medical Authorization form - "Depression which is partly, if not entirely work related. Rec. (treatment with) antidepressant". In the next entry in the Healthline record of 3/23/98 by a Dr. Anver Taylor, M.D., this doctor's diagnosis included - "It is questioned whether or not the patient has any depression from this particular incident, episode, or current complaints"; in a 3/23/98 Certificate of Fitness/Exam form, Dr. Taylor included in the Diagnosis Section of the form - "No work related depression.". The claimant offered the expert opinion of Dr. Poetz, D.O. who evaluated Rosenkoetter on Rosenkoetter's own behalf on or about June 2002, and discussed a February 19, 1998 work related injury as relayed by Rosenkoetter, noting: a. developed depression as the result of stress and harassment at work; Rosenkoetter claims in 1997 her boss and coworkers were taunting her by deliberately sending her defective parts so that she would have to repair them and they altered the speed of the line to the point that she was unable to keep up and they tampered with her food; and b. when seen on February 19, 1998 for complaints of bilateral upper extremity pain it was noted that Rosenkoetter appeared depressed and was diagnosed with depression. The diagnosis made by Dr. Poetz was: 2/19/98 - Depression secondary to work related stress and harassment. During cross examination, Dr. Poetz agreed that the only history in his report that would have caused the condition he had diagnosed was stress and harassment at the work place. The doctor was queried - you didn't have any history of there being marital problems or family problems or problems outside of work that could have caused or contributed to Rosenkoetter's permanent disability as a result of a psychiatric condition. "Not to my knowledge", Dr. Poetz answered. (Poetz Dp. pg. 41) Dr. Poetz was further queried - so you don't know if the stress was put upon her at the work place was different than the subjective levels of stress that would have been imposed upon other folks at that place of employment. "I don't know", the doctor answered. (Poetz Dp. pg. 42) I'm sure I made inquiries as to whether there were any stressors in her life outside of work, the doctor said. Dr. Poetz responded - "I don't recall"- when queried if he know how long Rosenkoetter had been married, how many times she had been married, if she was ever physically abused or emotionally abused, if her kids were ever emotionally abused. (See Poetz Dp. pp. 47-48) Dr. Poetz stated that he was familiar with the DSMIV, and agreed that it listed psychosocial stressors; the doctor agreed that psychosocial stressors can cause depression. Dr. Poetz agreed that marital discord was on the DSMIV list of psychosocial stressors as well as family discord, physical and emotional abuse. The doctor stated that in his evaluation of Rosenkoetter's mental status he did not need to do a Beck Depression Scale and did not do the MMPI. Dr. Crane, a board certified psychiatrist, offered opinion of a diagnosis of Rosenkoetter's condition as a result of his treating her when she came in on her own behalf on May 2, 2003. Dr. Crane testified: "Well Mrs. Rosenkoetter came to see me initially in May of '03, May 2 of '03. She was quite depressed at that time; and actually in looking at my records, I'm not sure whether she came on her own behalf. I think she did." (Crane Dp. pg. 7) I conducted a mental status evaluation of Rosenkoetter, Dr. Crane said, I did not do any other psychological testing. I also reviewed medical records, the doctor said. Dr. Crane noted the following:

\#1. Mrs. Rosenkoetter's current Axis I diagnosis is Major Depressive Disorder, severe, chronic, improving with the use of antidepressant medications. On Axis II she presents some symptoms of dependent personality. Axis III would include diabetes mellitus, essential hypertension, chronic cardiovascular disease, severe generalized osteoarthritis, particularly in the low back, and status post bilateral Carpal Tunnel Syndrome. Axis IV is an assessment of the patient's current stress, which would be interpreted to be quite high because of her physical condition, employment condition, and financial condition. Axis V - Current GAF (Global Assessment of Functions) on a scale of 0-100, where 100 is "normal", is assessed at approximately 60. Patient's highest GAF within the past year is assessed as her current 60.

\#4. ......This lady has presented as angry, hostile, and irritable during some of her evaluations and in particular during her psychiatric evaluation with Dr. Stillings. These symptoms were interpreted as being due to severe Personality Disorder, a suggestion with which I disagree, and I believe they were primarily related to her Mood Disorder, although when severely dependent persons are confronted with this type of situation they frequently do become even more upset and angry.

Dr. Crane agreed that on the date of his evaluation his diagnosis was depression, and that his Axis II diagnosis was symptoms of dependent personality. "I believe that she presented symptoms in the past that were consistent with (the) diagnosis (of dependent personality)". (Crane Dp. pg. 29) The doctor was queried if it wasn't correct that depression is something that once a person has it they are more prone to relapse or recurrence. Dr. Crane answered: "Generally speaking, yes. That's correct." (Crane Dp. pg. 62) On examination by the claimant, it was noted that Dr. Crane had mentioned in his report something about future medical care, and the doctor was asked what if any future psychiatric care was Rosenkoetter going to require. Dr. Crane responded: "This lady is likely to require long-term anti-depressants, treatment, and possibly some psychotherapy along the line depending on things that happen in the future, things that may happen in the future." (Crane Dp. pg. 57) (Ruling: Employer/Insurer's and/or Second Injury Fund's objections on grounds of Seven Day Rule are overruled. Crane Dp. pp. 57 and 58) Dr. Crane wrote in his August 18, 2003 report (Cl. Exh. R-1) the following:

Mrs. Rosenkoetter is an obese woman who appears essentially her stated age. She was generally cooperative with the examiner, although when seen initially she was irritable and angry and tended to be somewhat oppositional in answering questions. She initially expressed a "what's the use?" attitude and clearly felt that this evaluation would be no different from previous examinations that she has had over the last nine years. Initially she was tearful, her cadence of speech was somewhat childlike and her thought processes appeared to be slowed. With treatment this has improved and her affect is considerably brighter. She is not tearful during follow up evaluations.........

Notably, during the several sessions with this lady, she has become increasingly cooperative and friendly and this appears to have been a result of simply listening to her.

Dr. Stillings evaluated Rosenkoetter on behalf of the employer in or about August of 2002 (Emp./Ins. 3) The doctor discussed what he thought were the salient features of Rosenkoetter's history:

"Miss Rosenkoetter had a 25-year marriage, and divorcing in 1987 because she was emotionally and physically abused by her first husband. And I think this was a psychologically difficult, and somewhat damaging marriage for her, and it still - she still had scars from that.

I think it's important to note that she was a somewhat vague historian, and somewhat reluctant to talk about her personal psychiatric history, to the extent that she would like to attribute all of her current emotional features and emotional state to the various work-related injuries that are listed in the front of my report.

I think it's also very important to note that Miss Rosenkoetter has never sought any kind of mental health care during her lifetime in a work-related fashion, or otherwise.

She did report that her nerves were bad quote, 'My nerves was bad,' unquote, per Miss Rosenkoetter. (Dr. Stillings agreed that she was describing a mental state rather than a physical condition)

And she had taken some medications through HealthLine sometime in the past, that she thought were beneficial on calming her.

And she attributed her nervousness, correctly or incorrectly, to being harassed at work. It's noteworthy Miss Rosenkoetter has not worked at Integram, where she worked for about eight years, she has not worked there in greater than three years, and she has not been harassed, in her own perception, in greater than three years.

She also said that her nerves were, quote, 'bad,' unquote, due to back pain, and, quote, 'because they are,' unquote.

And she notes that she was somewhat unhappy, or sad, if you will, because she did not have an independent income, and did not have as much money to spend on her children and grandchildren.

When I saw her she was not taking any type of nerve, or psychotrophic medication, and she described her life at home with her husband as somewhat quiet and docile. She spends a lot of time in her room. Really seems to be somewhat withdrawn.

She and her husband live on a 180-acre farm.

And she has a general distrust of people, even family members, and part of this is related to being assaulted by her brother-in-law in 1995." (Stillings Dp. pp. 8-10)

Dr. Stillings testified about his diagnosis after evaluation of Rosenkoetter:

"On axis one, which is reserved for primary psychiatric problems and disorders, she has no primary psychiatric disorder. Axis two, which is reserved for personality disorders, and developmental disorders, Miss Rosenkoetter is diagnosed with personality disorder not otherwise specified, with pronounced schizoid features, as well as depressive, paranoid, and somatoform.

"Axis III is reserved for medical conditions, and in Miss Rosenkoetter's case, she has morbid obesity, hypertension, and congestive heart failure.

Axis IV is reserved for psychosocial stressors, and her stressors are being unemployed in a solitary existence.

Axis V is global assessment of functioning, or GAF, if you will, as an acronym. And her GAF is 55, which means that she is occupationally able to function, but she has some moderate psychiatric symptoms, such as a flat affect, or a sad affect." (Stillings Dp. pg. 15, 16)

Dr. Stillings agreed that the work-related component, what work may or may not have caused from a psychiatric standpoint, is revealed in Axis I. The doctor was asked if the Axis II diagnoses were a result of a work-related injury or something that made up her personality. Dr. Stillings answered: "Yes, it would not be occupationally related by definition. This would be a combination of her genetic constitution, and also, her early life experiences. Personality disorders, by definition, are present and fixed, and enduring by late adolescence, or early adulthood." (Stillings Dp. pp. 15-16) The doctor agreed that the personality disorder, which is Axis II, is pre-existing, the doctor agreed that Axis III is also preexisting. Dr. Stillings agreed that Axis V, the GAF, took into account everything, Axis I through IV. With respect to her GAF score of 55, the doctor stated: "..this would mean that she probably doesn't function as well as the average person occupationally, or socially. But it doesn't preclude her from working. She is still occupationally functional.". (Stillings Dp.pg. 17)

Dr. Stillings testified as to his opinions in regards to Rosenkoetter. a. Whether or not Rosenkoetter's employment at Integram produced any type of psychological diagnosis: "Her employment at Integram did not cause her any type of psychiatric problem, or diagnosis". (Stillings Dp. pg. 18) b. Whether or not Rosenkoetter's employment at Integram produced any permanent partial disability: "As a result of her work-related aggravation of her pre-existing and coexisting personality disorder, Miss Rosenkoetter has a two to three percent permanent partial psychiatric disability." (Stillings Dp. Pg. 18) It was noted that Dr. Stillings had not provided in his evaluation report of 8/14/02 a rating of disability for any preexisting psychiatric disability which may have existed; the doctor testified, without objection -"My opinion is that Miss Rosenkoetter has a 10 percent permanent partial psychiatric disability as a result of the pre-existing personality disorder." (Stillings Dp. pg. 20)

Dr. Stillingstestified a second time (Emp./Ins. Exh 8), and noted that since his first deposition he had been forwarded and had reviewed a copy of Dr. Crane's records from 5/2/03 through 9/29/03. The doctor was asked, after having reviewed Dr. Crane's record did he deem it necessary to reevaluate Rosenkoetter. "No", Dr. Stillings answered. (Stillings 4/28/04 Dp. pg. 6) The records of Dr. Crane did not affect my opinions as previously set forth in my previous deposition testimony, Dr. Stillings said. The doctor was asked the significance he had attached to the records of Dr. Crane, and Dr. Stillings answered: "Well, I think the significance is very simple. She improved some with his psychiatric administrations." (Stillings 4/28/04 Dp. pg. 6) Dr. Stillings explained:

"Well, when I saw her GAF or global assessment of functioning was 55, Dr. Crane near the end of treatment or at some point during treatment had assigned her a GAF of 60 . So really she's gone from moderate symptoms to slightly moderate symptoms. If you assigned her a 61, then she would have minimal symptoms. So she's real close to falling into another category of a much better prognosis and just a better outcome for her." (Stillings 4/28/04 Dp. pg. 8-9)

Dr. Stillings testified: "The continuing diagnoses are on axis - nothing on axis one. Axis two, personality disorder, not otherwise specified with schizoid features, depressive features, paranoid and somatoform features." (Stillings Dp. pg. 7) Dr. Stillings was asked to testify as to his opinion of whether or not Rosenkoetter suffered from a diagnosis of major depressive disorder:

"I do not feel she qualifies for the diagnosis of major depressive disorder based on application of the DSM-IV criteria. And this is based - now, those are subjective criteria. On an objective basis, her diagnostic testing on the MMPI does not support that diagnosis either." (Stillings 4/28/04 Dp. pg. 7)

The doctor further explained why Rosenkoetter's condition did not support the diagnosis of major depressive disorder:

"Her code type is an 82/28 and those code types are generally found in people who are schizoid, have

personality disorders, have some quasi-psychotic symptoms. It indicates she has emotional distress but not particularly depressive in nature." (Stillings 4/28/04 Dp. pp. 7-8)

Dr. Stillings was asked to explain the difference between a personality disorder, as he had diagnosed, versus a depressive or mood disorder as diagnosed by Dr. Crane:

"Yeah, personality disorders are really an expression of an individual's features or characteristics of their personality, whether they're, for instance, shy or gregarious or outgoing or if they have some paranoid features. So you really are looking at sort of the mixture of their features of their particular makeup as a human being. A mood disorder is a very specific highly defined psychiatric disorder where the essential feature is, of course, a low mood." (Stillings 4/28/04 Dp. pg. 8)

Considering the medical opinions, it is found that the substantial weight of evidence supports and establishes the diagnosis made by Dr. Crane as to Axis I of depression. It is found that Dr. Poetz' opinions are not probative on the issues in that the doctor states his opinion is based on a history of stress as a result of harassment by co-employees at the work place; it has been determined in this Award that the substantial weight of the competent evidence does not establish such work events. It is further found that notwithstanding the diagnosis of depression, the substantial weight of the medical evidence does not establish a causal connection of this diagnosis and the claimant's work or work events on or about February 19, 1998; it is found that there is no competent expert medical opinion stating that the claimant's work or work events on or about February 19, 1998 caused the diagnosis of depression. It is found that both Dr. Crane and Dr. Stillings found a diagnosis on Axis II of a personality disorder (Dr. Crane - dependent personality, and Dr. Stillings "personality disorder not otherwise specified, with pronounced schizoid features, as well as depressive, paranoid, and somatoform"). Dr. Stillings opined that Rosenkoetter's employment at Integram did not cause her any type of psychiatric diagnosis, but that Rosenkoetter's employment at Integram resulted in a work-related aggravation of her pre-existing and coexisting personality disorder, and Dr. Stillings assessed a percentage of permanent partial psychiatric disability.

The Court in Tangblade noted the following:

"The appellants would have us read Duncan as holding that if an employee previously suffered from the mental condition for which he or she is now claiming benefits, the alleged work-related stress could never be found under any circumstances to be a substantial factor in causing the condition, such that it would not be compensable. The appellants misread Duncan. In reading Duncan, it is clear that the court, in reaching its holding, relied on the fact that the Commission had before it substantial and competent evidence that the onset of the employee's complained-of mental condition was inevitable and, thus, was not caused by work-related stress. It did not hold that, as a matter of law, there are no possible circumstances under which it could ever be found that work-related stress is a substantial factor in causing a mental condition, where the employee is predisposed to such a condition or had previously been diagnosed as having the condition. While it is true that a wholly idiopathic injury or condition that was merely precipitated by a work-related accident is not compensable, Alexander v. D.L. Sitton Motor Lines, 851 S.W.2d 525, 528-29 (Mo. banc 1993), if it can be shown than the alleged work stress was a substantial factor in causing the onset of a condition or aggravating an existing condition, it is compensable. Bloss, 32 S.W.3d at 672; Anderson v. Noel T. Adams Ambulance Dist., 931 S.W.2d 850, 854 (Mo.App.1996)." Id. at 668.

It is found that there is competent medical evidence establishing a medical causal connection of an aggravation of the claimant's pre-existing personality disorder to extraordinary and unusual work related events on or about February 19, 1998.

The claimant alleges work related mental injury on or about February 19, 1998. Rosenkoetter testified about submitting a number of medical bills into evidence concerning carpal tunnel surgery and for the other treatment she had received which no one has paid. It was agreed and stipulated to by the claimant and the employer/insurer that bills in issue were entered in Claimant's Exhibit No. A marked as A-11, and entered into evidence marked as Claimant's Exhibit Nos. M, M-1, N, N-1, O P and Q. The evidence also includes a bill for medical services marked as Claimant's Exhibit S. It has been determined in this Award that the claimant suffered the mental injury of an aggravation of a pre-existing personality disorder as a result of work related stress on or about February 19, 1998. Considering the bills in evidence, it

is found that none of them reflect charges for treatment of a mental injury/personality disorder. Consequently, it is found that there is an insufficient basis upon which to award compensation for past medical expenses. See, generally, Martin v. Mid-America, 769 S.W.2d 105, 111-112 (Mo. banc 1989).

It has been determined in this Award that the claimant suffered the mental injury of an aggravation of a preexisting personality disorder as a result of work related stress on or about February 19, 1998.

The Workers' Compensation Act does not require that there be evidence of the specific medical treatment or procedures that will be necessary in the future as that may put an impossible and unrealistic burden upon the employee; but future medical care must flow from the injuries causally related to the compensable accident before the employer is to be held responsible. See, generally, Sifferman v. Sears, Roebuck and Co., 906 S.W.2d 823, 828 (Mo.App. S.D. 1995).

Dr. Stillings testified that in regard to the work-related aggravation of her pre-existing personality disorders diagnosed in Axis II - "And that set, she doesn't need treatment either." (Stillings Dp. pg. 19) It was noted that Dr. Crane had mentioned in his report something about future psychiatric medical care, and the doctor testified: "This lady is likely to require long-term anti-depressants, treatment, and possibly some psychotherapy along the line depending on things that happen in the future, things that may happen in the future."

Considering the evidence, it is found that there is no medical opinion of a need for future psychiatric care as a result of the compensable injury of an aggravation of pre-existing personality disorders suffered by Rosenkoetter on or about February 19, 1998. Consequently, future psychiatric medical care is denied.

It has been determined in this Award that the claimant suffered the mental injury of an aggravation of a preexisting personality disorder as a result of work related stress on or about February 19, 1998. Testifying as to continuing problems as a result of her perception of the work stress, Rosenkoetter stated - It's still with me, everything they done to me all theses years. Dr. Stillings offered the competent opinion on whether or not this injury resulted in any permanent disability. The doctor testified: "As a result of her work-related aggravation of her pre-existing and coexisting personality disorder, Miss Rosenkoetter has a two to three percent permanent partial psychiatric disability."

Considering the competent evidence, it is found that it supports an award of 4 % permanent partial disability as a result of the February 19, 1998 work related injury. This would be: 400 weeks $\times 4 \%=16 weeks; 16 weeks \times \$ 278.42= \ 4454.72.

The parameters of Second Injury Fund liability in permanent partial disability cases is set forth in Section 287.220.1 RSMo 1993, which states in pertinent part:

All cases of permanent disability where there has been previous disability shall be compensated as herein provided. Compensation shall be computed on the basis of the average earnings at the time of the last injury. If any employee who has a preexisting permanent partial disability whether from compensable injury or otherwise, of such seriousness as to constitute a hindrance or obstacle to employment or to obtaining reemployment if the employee becomes unemployed, and the preexisting permanent partial disability, if a body as a whole injury, equals a minimum of fifty weeks of compensation or, if a major extremity injury only, equals a minimum of fifteen percent permanent partial disability, according to the medical standards that are used in determining such compensation, receives a subsequent compensable injury resulting in additional permanent partial disability so that the degree or percentage of disability, in an amount equal to a minimum of fifty weeks compensation, if a body as a whole injury or, if a major extremity injury only, equals a minimum of fifteen percent permanent partial disability..... (Emphasis added)

In this case, the percentage of permanent partial disability for the subsequent compensable injury, the 1998 work related injury of an aggravation of a pre-existing personality disorder as a result of work related stress, was found to be 4 % permanent partial disability. This is below the threshold set for consideration of any Second Injury Fund liability, and thus Second Injury Fund liability is denied.

A true copy: ATTEST:

Mary Ann Rosenkoetter, the claimant, testified that she was born on June 30, 1945. My highest education is eleven and a half years schooling and thirty-eight hours of college, she said, I was about two months to graduate. I never graduated from high school, the claimant said. A college I went to was Jeffco for a while, Rosenkoetter said, and I took different classes for blueprint reading and math and machine and welding. I also went to East Central in Union, Missouri where I took horticulture; and I can't recall what else I took there, the claimant stated. I did not get a degree from either one of the colleges, she said. The longest time I would have gone to East Central was a couple semesters, I think, Rosenkoetter stated.

I first went to work when I was eighteen, I think, the claimant testified. As far as I can recall I worked in a factory where you made beer signs and advertisement signs, she said. I have done factory work, school custodian, and storeroom clerk all of my life, the claimant stated. I worked at East Central for a year as a school custodian, and I think it was in about 1993 or 1994, while I was working at Integram. I don't remember how many years I did factory work, the claimant said, it's been several years. As a storeroom clerk; I read the blueprints and inspected machine parts and gave out parts out of the storeroom; this was at Bull Moose Tube where I worked about fourteen months, Rosenkoetter stated. I first went to work for Integram in 1991, I think, the claimant said, and I went to work in maintenance which entailed cleaning all the bathrooms on the production side, sweeping floors, polishing the floors or cleaning them, and then just all around maintenance work.

In 1998 while working at Integram I claimed I had depression due to harassment, Rosenkoetter stated. I had my elbows and that hurt really bad, and I went to the HealthLine and they said I had tendonitis. And just luckily the next time I went there was a different doctor came in there to work and he was looking at my arms and he asked me what was wrong with me and I told him, and he gave me medicine for depression, the claimant testified. And there was people at work if I set my soda or anything on the table, they would go and they would poke a hole in my soda so it would run all over my seat, she said. Kent was one of the guy's name who did this, I don't remember his last name, she said, there was just a bunch of them that was real good friends with the foreman and he would let them get away with that stuff; the foreman wouldn't do nothing to them, Rosenkoetter testified. I'd be standing on the platform in front of the molds and I didn't like it there anyway, and there was holes, there was grates, and I was always afraid that maybe the carousel would crash or something, and they got them big molds on them, the claimant stated, and they would take a big wrench and they would sneak over there and hit the bottom of the grate, and I would think it was falling. And they would do that all the time because they knew I was upset anyway, she said. And I couldn't leave my food set on the table because I didn't know if they would put stuff in it, the claimant stated. It was never the same, when I went back in there for break time, and they poked holes in my soda, and they would spit their chewing tobacco in a soda can, and it would have the top off it, and they would put it on the overhead, and they'd know by the hours when I would be back at the dump, and that soda can would fall on you with all that spit in it, and then you'd have to clean it off the seats, and off of you, and they done that several times, Rosenkoetter testified, and it didn't do no good to tell anybody because they wouldn't do nothing about it. And when I was on the re-work, she testified, they would go and turn things on the valves and the molds, they put a whole bunch of molds release and it would leave holes in the bun parts, and I would have to fix all of them. And sometimes there be in an hour that I was on re-work and there would be two or three boxes of bad parts in the boxes, and I'd call the foreman, he'd come over and say - Well, I don't understand that, there must be something going on; the foreman would check this and check that, and say - Well, just go on to your next station. So, the claimant agreed, the foreman knew about this stuff and did nothing to change it. My one friend, Nicks (they used to call him Turkey Man there all the time), he came and he told me what they were doing, that they were doing it on purpose; and they asked him to do it and he said no, he wouldn't do it because he was my friend, Rosenkoetter stated. The claimant was queried - So it was different for you than anybody else? I didn't see them doing it to anybody else, the claimant answered, they once took a girl's purse and put it overhead and she couldn't get it until it dropped. This started with me just before I went to that HealthLine doctor about my hands, the claimant said. They would speed up the lines on the air bags, they would take and pile up parts so that the line would rush by real fast; and there was about maybe six to eight seat covers that you'd have to blow the plastic off and put them on that line, and they would take them from behind the stop on the machine and then the line would go real fast when they took that last one off, and it would go up, and it would all been empty. And it took me so long to blow each one to get it filled back up again, so I was blowing one and running around putting it up there so that it wouldn't shut down the carousel until I got caught up, she said. This happened until they fired me from work, Rosenkoetter said. I was fired in 1999, I think it was, the claimant stated.

The company never did anything to stop this, Rosenkoetter said. When I complained to the foreman, he'd say

he'd talk to them. But it did not stop any, she said, they still hit the platform with the wrench, they still every time I got over there, they'd say I dumped over their soda, and that was a lie, I never touched nobody's stuff, the claimant testified. All of these things affected me, Rosenkoetter said, it got my nerves really bad, I started crying all the time at work. Agreeing that the foreman saw her crying at work, Rosenkoetter testified - The foreman had this one girl who was his friend, Dawn, and we were back there and cutting and putting the leather covers on, and she'd go talk to fork truck drivers and mess around, wasn't there to do her job, and you'd have to take up the slack for her. So I got so aggravated I went and told the foreman, and he come over there and took her in the office for about four hours, she sat in there and talked to him and I had to do her work and my work, the claimant said.

I was first treated for depression by Dr. Bonney, the claimant said, he was not a regular doctor at HealthLine, but he was filling in that day, and he gave me some medicine that would help me, I forget what the name of it was. I don't know what kind of doctor Dr. Bonney was, she said, I don't know if he was a psychiatrist. When asked what year this was, Rosenkoetter responded - I had gone to HealthLine because of my arms, they were hurting me all the time, tendonitis in my elbows. Rosenkoetter was asked, before Dr. Crane, had she been to any psychiatrist for depression at all. No, she answered. The company sent me to Dr. Stillings, I think, the claimant said, and other than that I don't recall going to any other psychiatrists in my life, she said.

Explaining how all of these things she had described affected her work or her ability to work, Rosenkoetter stated that she got really upset about all the bad parts. I just didn't have time to fix them, she said, so that makes it look bad on you, because you got two or three boxes with bad parts sitting there that you can't fix. And then they wasn't even entered into the computer because you don't have time to do all of that, she stated. The parts were foam buns, which is the cushion that goes underneath the leather covers. Explaining what was defective about them, the claimant stated that they would put too much mold release and it just eats the foam and it makes holes in it; the guy that was inspecting them, they had strips on them and you tore off the top part and it was like a Velcro left, he would rip it all off, then I'd have to glue them all back on. Pat Brown was one of the guys, she said, he told me he was ripping off this section of these foam buns because it was too tight and it just came off. This was done just to me, the claimant said. The foreman did not say anything about this, Rosenkoetter stated, he put them all in a box and pushed them to the back, and they would fix them back there.

The claimant testified about continuing problems as a result of the harassment at work. It's still with me, she said, everything they done to me all these years, when I slipped on the tag, then after they sent me to Lesson Ferry to a back doctor down there, when I went in there he done x-rays and he come in there and he told me - you didn't have your back operated on, your back wasn't operated on, Dr. Jacobs didn't do anything to your back. The claimant agreed that when she went to be examined she had a surgical scar on her back where Dr. Jacobs had cut on her back and removed the disc. The surgical scar is more than an inch long and is visible now, and was there when I went to this doctor who told me I didn't have any surgery on my back, and this doctor had looked at my back, the claimant said. Well, after that then they sent me back down there, and they did do an MRI of my knee and said there wasn't nothing wrong with it, she said. The doctor took x-rays of my back, and on the x-rays I had a pinched nerve on the right side of my back, I left, I called back and then when I called back there was no pinched nerve, Rosenkoetter testified.

Rosenkoetter testified about the treatment she has received for depression. Just the medicine that one doctor gave me, she said. Rosenkoetter agreed that she was also treated by Dr. Crane right after the last hearing setting in this case, that she had gone the next day; Rosenkoetter agreed that she had testified at the last hearing setting that she was so upset that day she didn't feel she could testify. Except for the one time with the HealthLine doctor, this was the first treatment I had had for depression, when I started with Dr. Crane after the last hearing setting, she said. I don't know how often I have seen Dr. Crane since then, which was May of last year, the claimant said, when I first started going to him it was once a month. The reason I went because I couldn't control my anger anymore, Rosenkoetter said. She agreed that she had a lot of crying spells, and agreed that she missed two appointments at her attorney's office to prepare for the trial. I got so bad that I can't stand to go in the elevators, I can't stand to go twenty-five floors up, all the people, and I got so I wouldn't leave my house; I wouldn't go out of the bedroom, and I just slept all the time; I can't stand the people, too many people, and it felt like the buildings were going to fall on me, the claimant testified. Agreeing that she had refused to come to her attorney's office because it was downtown, Rosenkoetter stated - I just told Mr. Gerritzen I couldn't come up there, I just couldn't do it, and he said I could come to his house. And I had to get my husband off of work because I had a car accident in about 1985 and had a real bad concussion and I can't remember, and it messed up a nerve in the back of my head and I couldn't smell and couldn't taste real good; I get lost and I was losing track of time and I would lose hours, I wouldn't know what I did or where I was at; I was lost and I was in Illinois once and I couldn't get home, and I got lost once in St. Charles. I just decided to stay home, the claimant said.

Rosenkoetter stated that she went to work for Integram in about 1991 and agreed that she got back and forth to

work. She was queried if she felt her inability with going in the big buildings and being with people was due to what happened to her in 1985 or was it due to what happened at Integram, or due to both. Just all the aggravation at Integram, the claimant answered, all the stuff that they done to me and put me down because of my back, and I worked what I could work, when I could work, and it just wasn't never enough.

I last saw Dr. Crane last week, the claimant said. The treatment Dr. Crane gives me is that he listens to me for one, Rosenkoetter stated. When I went to that Dr. Stallings, I had to fill out this big long paper, a hundred and some questions, and there was a bunch at the end that I couldn't answer yes or no because it wasn't pertaining to me, and when I turned them in, he said - No, you got to fill them all out or else it's going to be incomplete. So I just went through and marked anything because I didn't know what else to do; then when I went in to talk to him he asked me what my problem was, I tried to tell him that it was the stuff at work, and all he said was - We can't talk about that. We couldn't talk about nothing that they done to other people, the claimant stated, and it was all my ex-husband. My ex-husband and I are friends, she said, they come to my house, I go to their house, we eat dinner together and everything. It's not my exhusband, Rosenkoetter stated, but he didn't want to hear it, he didn't want to hear nothing. And Dr. Crane, he'll listen to me, he doesn't put me off, she said, he gives me the medicine that helps me, unless I get real upset like today, could live a halfway normal life. I took my weed-eater and I beat it up, that's how bad my nerves got, that's why I went to the doctor. I just bought it brand new, and I could not use it for five minutes and my back was hurting so bad I couldn't use it, Rosenkoetter testified. Then I went and made an appointment with Dr. Crane and I started going to him; brand new weed-eater, I just beat it all to pieces; that's why I started going to see Dr. Crane, the claimant testified. She agreed that she was talking about May of last year, 2003. I go to Dr. Crane regularly, once a month or six weeks, sometimes I'll make it two months, Rosenkoetter said. The medicines I am on now are Prozac, two a day; I was given Coreg by my heart doctor since I can't get out and exercise and walk and I got four blockages in my heart, and I take four of them a day; I take Glipizide twice a day; and I got diabetes now, too, because I'm not active enough and I take Metformin; and I take Cardizem for my high blood pressure which I developed after I had the surgery in 1995; and I take a Bayer aspirin every day; and Celebrex; and the rest is just over-the-counter stuff, I have to take the fish oil, two of them a day, and the vitamin and Folic acid and potassium; I take a water pill, it's from the heart doctor, the claimant testified.

Rosenkoetter testified about prior injuries prior to the development of depression in 1998. The claimant stated that in 1985 she was in a motor vehicle accident. I had a small car, an Omni, she stated, and a lady came up on the right side, and she clipped the front of the car and threw me into the median, and I wound up hitting my head pretty hard on the Mirror and broke it and caused me to have a concussion and messed up a nerve in the back of my neck, and there was a bone out of place in the side of my head. I went to a doctor for about seventeen months; I couldn't drive, I would lose track of time, I get lost, I'd be sitting at home and I'd just lose three or four hours, she stated, and I couldn't stand to smell white bread, I couldn't see the trees going by or I had to wear sunglasses. Problems that have continued are with direction, the claimant said, getting turned around and getting lost sometimes. I just don't go far from home and usually my husband takes me if I have to; this is because I get turned around sometimes, but not all the time. Concerning my memory, Rosenkoetter said, as far as everyday things, it's all right. I've never been any good at dates, she said, I can remember what happened, but I can't for, say, remember every day. When queried if she was confident all the history she gave on direct exam was accurate, Rosenkoetter responded - I tried the best I can remember. The claimant was queried, if some of the medical records showed a slightly different history as opposed to what she testified to on direct examination, would she dispute what's in the medical records? I don't know; I done the best I could to remember all the dates; I'm just not good at dates, the claimant answered.

On November 23, 1994 I suffered injury to my left hand and ring finger, Rosenkoetter testified, at that time I had gone from the maintenance to production, and they made seats for Chrysler cars and minivans. I was working on a Saturday, overtime; in the dump area which is where all the seats come from the overhead down in the bin, then you take the parts out of there and you pack them in the boxes, the claimant testified. And I had two seats come down, front seats, cushions, and I grabbed both of them and I went to turn around to put them in the box and it hit the edge of the box, the one cushion in my left hand, and it started to fall to the floor and I started to grab it, and when I did, it has a metal pan on the bottom and my hand went in the middle of that circle in the middle of the pan, and when it did that it just sliced right down my hand, between my little finger and my ring finger, the claimant said, it went down my hand quite a ways, about an inch. I was bleeding pretty bad and by the time I got to the front and got somebody to help me, the claimant stated, they took me in the nurse's office and they kept looking at it, and the general foreman, George, came over there and he looked at it, and every time they'd take the towels off it would just pump blood out of it. They couldn't decide whether I needed to go to the hospital or not, but I kept bleeding so bad they had to call the nurse, and finally after she came and looked at it, well, then they decided I needed to go to the hospital; so someone from Integram drove me to the hospital where they sewed it up, Rosenkoetter said. I went back to work, and as far as I recall, I was there the next day, Rosenkoetter stated. Continuing problems are that I have numbness on the inside of my little finger, the claimant said, and whenever I drive or use a broom, or anything that goes across my hand there, it really hurts it; it aches

in the winter; I can't bend my little finger on my left hand out like the other one, I can't close it all the way like my other hand; I can't pick up a heavy skillet or anything like I used to be able to because the strength just isn't there anymore, I just can't grip as well anything with the left hand. Rosenkoetter displayed her left hand, and it was noted that there was a line scar that went about an inch into the hand between the ring and little finger. It was further noted that the claimant was unable to touch the little finger to the hand by about a fourth of an inch.

On September 15, 1995, that night I was working in Cut and Sew, Rosenkoetter testified, and we have to take leather covers and put them on the foam, and it was always hurry up, hurry up, hurry up, and some tags got dropped on the floor, and I was coming around the table and I stepped on one, and it's real slick on one side, and I slipped and fell towards the table, trying to grab it, I fell to the concrete floor, and especially on my right knee and my foot was kind of turned under me and it hurt my right ankle and jarred my back, the claimant stated. At that time, my ankle was really hurting, my back was throbbing, and I started limping. I finally found the foreman and told him what happened, she stated, and he said to try some ice on my ankle and my knee, and didn't say nothing about my back. I had never had any problems with my right knee, right ankle or my back prior to slipping on this tag in 1995, the claimant said. I did not lose any time from work, she said. I kept getting pain down the back of my right leg and my knee, and I was limping for two weeks before I could get them to finally decide to send me to a doctor. My employer sent me to HealthLine where they wrapped my knee; they didn't take any x-rays or nothing, said it was just sprained and to put ice on my back, and that was it, Rosenkoetter stated. I returned to HealthLine because I still had the pain, and my husband went with me that day, and the doctor said my knee was fine, and I asked for a second opinion on my back and the doctor got mad and said I refused to be seen and took my papers out to the front desk. I said I'm not leaving because I didn't refuse to be seen, and she says if you can act like a patient then come back in here, the claimant testified, so I went back in the office and she wouldn't let my husband go back in there and she said I didn't need a second opinion on my back. The HealthLine doctor never did anything about my back, right knee, and right ankle, the claimant said, and this ended the company's tendered treatment. Rosenkoetter stated that she did not recall HealthLine asking her to come back for anything else, or recall the company sending her somewhere else; she went to the doctor on her own and had the surgery, she said.

My back just kept hurting so bad that I couldn't stand the pain no more, and one night I sat down on the toilet and I couldn't get up, it was that bad, she said, this was about a month after it had happened. My husband carried me to the chiropractor, Dr. Clark, who put some heat and therapy on my back and told me to go home and try to relax, the claimant said. I was back the next day for another treatment, and the next day, Rosenkoetter stated, because I could hardly walk because the pain in my back was really bad and at that time it was going down the back of both of my legs all the way to my heel. I saw Dr. Clark about three times, I think, the claimant said, and then I went to Dr. Calvin, my regular doctor, and he set me up an appointment with Dr. Jacobs, a neurologist. Dr. Jacobs took x-rays, and I had to go to the hospital for some nerve tests, MRI, Rosenkoetter said, and then the doctor wanted to do surgery right away. Surgery was ultimately done on my back by Dr. Jacobs in about November 1995, about a month after I first went to Dr. Jacobs, the claimant said. The surgery was done on my low back on the left side of my spine; Dr. Jacobs took out a disc and put a stabilizer in my back and fused some bones, I think, together, the claimant stated. The affect the surgery had on me, the claimant said, is that my legs don't work right; there is a piece of bone that came off of my spine and runs into the nerve of my leg and that's what is the constant pain all the time. After the surgery I was in bed for a month, the claimant said, I could get up to go to the bathroom, but I couldn't stand to be up any longer than just a few minutes. And then I got a little bit stronger where I could go to the kitchen and come back, and I got so I could sit up and eat at the table for a few minutes, and every little bit, you know, got a little better and a little better where I could walk a little more, Rosenkoetter said.

The claimant testified about ongoing problems with her back and leg. I have constant pain all the time in the low back in the same area where it originally started when I had the slip on the tag, she said. Sometimes the pain is pretty bad, Rosenkoetter stated, it keeps me from sleeping, and I live on pain pills all the time. With walking, the claimant said, I can make it maybe fifty, sixty feet, but I can't sweep the floor unless I stop three or four times and then come back to it, and mopping is very hard. I am not able to do any activities without repercussions from it; if I do too much then I'm in bed for a couple days for it to get better again, unless I'm going for therapy on my back, she said.

From the time of the 1995 work accident up to the time of surgery I was back at work some days, Rosenkoetter said. I would take off my vacation days; I even got in trouble for taking off days because I just couldn't do it, I done what I could do; I took off TPT days where they had people work for you; I took vacation days and everything I could take off to keep from having to work, the claimant stated. I have no idea how many days I was off work before the surgery, she said.

I was never able to work like I could work before the accident when I slipped on the tag, Rosenkoetter testified.

Before I slipped on the tag there'd be weeks that I would work more overtime hours than my regular hours; and I was always going in early on the second shift; and I couldn't do that afterwards, she said.

After the surgery, I was off work close to fourteen months, I think, the claimant said, when I went back to work it would have been close to Christmas of 1996. When I went back to work it was hard on my back, Rosenkoetter stated, I went home the first night that I went back. It's hard on my back to lift the stuff and just to be able to walk from station to station and get back in the routine of anything, she said, this along with bending was hard. It was just made me real sore to start back after not being able to do anything for so long, the claimant said, and the bending over the re-work table would hurt my back, and I couldn't do the lifting; I'd go home every night and couldn't hardly stand it from the lifting the heavy seats and stuff, and bending over the boxes. And then I'd have so long a time to get from one station to the other and to be on time, Rosenkoetter said. Walking was from the inspection table to re-work, which wasn't but about five feet, but then you had to go from there all the way into the back, which was maybe sixty, seventy feet, she said, and it was all on level concrete which wasn't real good either.

My knee and ankle had quit hurting for a while after I had my back surgery, the claimant said, but every once in a while my right ankle flares up. It swells, and in here it's swollen all the time, she said, it's swollen today.

From the time I went back to work in November of 1996 until the accident of November 18, 1997 with the bench seat, the claimant said, the difference in my ability to work at Integram was that it slowed down a lot. I just didn't do as many parts as I used to; I wouldn't help other people, I just couldn't do that no more, Rosenkoetter said.

I also lost a business interest because of the 1995 accident at Integram, the claimant said. I had several mobile homes; some of them were located in trailer parks and three were on pieces of ground in Union, she said. The times that I worked both jobs, the sixteen hours a day, was to pay for these so that I would have something to retire with, and I made all the payments myself and I done all the repairs myself, she said. After I slipped on the tag I had to sell them all because I couldn't do the repairs or keep them up anymore, Rosenkoetter said, I used to be able to tear them down and set them up myself and I couldn't do any of that anymore after the 1995 accident to my back. Also before the 1995 accident at Integram where I slipped on the tag, I had my own motorcycle, and I rode it all the time, Rosenkoetter testified. And when I got married, my husband lives on a farm, and I would go with him all day and helped cut wood, I had my own saw; helped him plow the fields, cut the hay, put the hay up, all those things. I can't do none of that anymore, the claimant said. I have always been an active person, I have always been independent, Rosenkoetter stated, I always depended on myself to make my living and to do the things I needed done, I never had to go and ask anybody. But after I got hurt, I sold my bike; it had sat in the shed for two years. I just couldn't do that stuff anymore, she said. My chainsaws, I sold them, the claimant said.

On November 18, 1997 at Integram I had one of the larger seats which I think seats three people, and I took it to the box and bent over to put it in, and I got a real sharp pain in my right lower back, Rosenkoetter testified. It was the bottom seat, and I guess they're maybe as long as about two to two and a half feet wide, she said, and I think we made all the seats for the minivans. The pain in my low back was in the same area as where I had had the surgery, Rosenkoetter said. Agreeing that some time after this, but not that night, the pain went down her leg. After the November 1997 incident I stood there for a while and when it eased down a little bit, I went and told the foreman that I'd hurt my back bending over in the box, Rosenkoetter testified. The foreman called the nurse and she brought some Aleve pills and told me to take them, and I must have been allergic to them, I had a reaction because I couldn't breathe very well, she said. And then the next day I went to see Dr. Calvin and I had a knot come up in my hip and he gave me muscle relaxers, some pain medicine, and therapy his office, the claimant stated. She was asked how long did she get therapy, and Rosenkoetter responded - I was off work for about a week, I think. When I went back to work after about a week, I just had the pain all the time, the claimant said, it was just miserable because my back hurt and the more places that I went to do the job, then it was just hard. I was not able to do the same amount of work like I used to, she said. Giving an example, Rosenkoetter testified that the fork truck drivers would bring the seats in big boxes and you'd have to bend over and get an armful and put them on the bins for the air bag blower, and that's what was really hard because of the bending and lifting the bunch of seat covers, so I always tried to trade that off with anybody that I could get to trade with.

I have constant pain all the way down my leg to my heel still today, the claimant said. I'm going to therapy now because I can't hardly get around; my legs just don't work as well, and I fell going up my steps, two steps, that I have gone up them a thousand times before. I fell, broke my tibia in my left leg because I thought my foot was up high enough for the step, she said, also I stepped over a little fence, maybe nine inches tall, and I fell again. I have come out of the barn and when I stepped on the step then my ankle just turned; I just think my legs are up high enough, but they aren't, the claimant stated. I have slipped in a hole in the yard and fell, Rosenkoetter stated, and my last thing last week I fell

and hurt my arm, all I was doing was walking on the driveway, but my right leg wouldn't come when I was stepping and I just went face down. I attribute these falls at home to my back and my legs, they just don't work right, she said. The claimant was asked if this came from the 1995 accident on the tag, the 1997 accident with the bench seat, or both. The 1995, she answered. When asked if they got worse in 1997, Rosenkoetter responded - They just seem to be getting worser all the time; the pain never goes away. The claimant testified that treatment she is getting now is from Dr. Calvin, and that this is the second week she is going to the therapy twice a week now because of the pain in her right back, and when she next goes they are supposed to fit her for a cane. Rosenkoetter was asked how long had her right ankle been swelling up all the time. I was on the work station on the dump, and we packed the parts in boxes, and I was packing a bench part in the box and when I bent over I had a bad pain in my right lower back, and it's been swollen ever since then, she answered, and agreed that she was talking about the accident on November 18, 1997. The only time it's not swollen is when I first get out of bed in the morning, she said. Since November 18, 1997, every so often my ankle will start aching, I'll be limping around for a while, then it'll get better, the claimant said. It hurts me to walk if I walk a ways, she stated, and sometimes it aches at night; when it gets cold, it hurts. The pain is about a five or a six out of ten, she said. Concerning how far she can walk before the ankle starts swelling up, Rosenkoetter stated that as soon as she gets on her feet it starts swelling.

I was fired by Integram in 1999, the claimant stated, and the reason they gave was because I was off when I hurt my leg; and they changed the contract and they said the insurance papers -- when I hurt my knee, I went on sick leave and I went and got my papers to fill out; it's after I fell and went to the hospital and the doctor said I shouldn't work. So I went to the bone specialist, and I got my insurance papers and I didn't know how to fill them out because they were different, and I called the H.R. and Mary Jo said she would help me fill them out, and she told me what to put down. And I went to the doctor, the bone specialist, Dr. Kef alas, and I had an immobilizer on my knee and a gel cast on my ankle and I was on crutches; and I think that was on a Wednesday, and Thursday I had called work, I had all my phone bills because it was long distance, and I had called them on a Friday and I asked them in H.R. at Integram if there's anything else that I had to do, and she said no, that's all I have to do, the claimant testified. On the Thursday the doctor had faxed my medical papers from his office to work; they had them, but she lied to me, she said there was nothing else to do and that wasn't true, the claimant said. They said they fired me because I didn't come in and fill out new papers; that's why we went, the union man and me, before the arbitration board. It was whoever's the boss down there at Integram, the general foreman, I guess, who said I didn't fill out the papers right, the claimant stated, because they said I was fired because I didn't do my paperwork right. But they already had the doctor's papers there in front of them and then when we went to the arbitration I had my phone bills and everything, and they had three or six women from the H. R. Department sit there and lie, it didn't make any difference what I said, and my union worker denied me the right to have counsel, said he was going to represent me, so I didn't even get to have a lawyer there, Rosenkoetter testified. This was right after they fired me and then went through three steps, and the fourth step was to go before the arbitrator. They denied my unemployment, and I went to the hearing for unemployment and their woman said that was absurd that I would quit my job at fifteen something an hour, and she gave me my unemployment, the woman from Jeff City, the claimant stated.

Rosenkoetter stated that she has tried to work since leaving Integram. I tried to find a job, and I filled out applications and applications, and nobody would hire me, she said. Wal-Mart said I had to bend over and pick up a dime off the floor, I couldn't do that, my back wouldn't let me bend over that far, the claimant said. I filled out applications for wherever I had education to do -- machine shops and different places like that; but as soon as they find out you had a back problem they don't want nothing to do with you, Rosenkoetter stated. She was asked if she believed she is able to work now anywhere. No, Rosenkoetter answered, and explained that it was just all the injuries to her body. I just can't do it, she said, I wish I could.

The claimant testified about her daily routine now. I try to do my dishes in the morning, and get my husband off to work, and make his lunch, she said, and try to sweep the floor, that takes me a while because I quit and go back, and sometimes I'll sit on the porch, or sometimes I watch TV for a while. I can't sit very long, can't stand very long, the claimant stated, I sit for maybe about forty-five minutes or so, then I got to get up and walk around. With standing it's really hard for me to bend over the sink to do the dishes, Rosenkoetter said, I'll stand for a while, depends on what I'm doing. I think the longest I can stand is about an hour or so, I guess, she said. I can't walk very far, the claimant said, I'd walk from the house to the barn and turn the water faucet on for the cows but last time I went out there, I fell, this was last week. I fell because of my leg, Rosenkoetter stated, I had bad pains in my right hip and lower back for the last month and a half, and when I went to step it was just real bad pain, I couldn't bring my foot up and I just fell face down in the gravel. But I got a bone on the left side that catches on my hip bone, and I can feel it, I can feel it rubbing, the claimant said.

Rosenkoetter agreed that she had submitted a number of medical bills in the case for the carpal tunnel surgery

and for the other treatment she had received, and that she was asking for an award of compensation for those bills. No one has paid these bills of Dr. Schlafly's and of St. Anthony's, she said. It was agreed and stipulated to by the claimant and the employer/insurer that bills in issue were entered in Claimant's Exhibit No. A marked as A-11, and entered into evidence marked as Claimant's Exhibit Nos. M, M-1, N, N-1, O P and Q.

On cross examination by the employer/insurer, Rosenkoetter agreed that the first time her case was set for hearing, exhibits were entered into evidence on the record and then on that date she had indicated that she didn't feel like she was able to testify. My nerves was really bad that day, she said. The claimant was asked if she had felt competent to testify on direct examination the day before. I got nervous, but the medicine the doctor gives me helps me, Rosenkoetter answered. I'm not real good today, she stated, but I feel I am competent to testify today.

During cross examination, the claimant agreed that her first injury was the cut to her left hand in 1994. When asked if she remembered the date of this injury, Rosenkoetter responded - I know it was around Thanksgiving because I cut this hand [indicating] on Thanksgiving and it was wrapped up as well as on this finger, and on Christmas I couldn't make pies or nothing for everybody because it was cut, she said. My employer sent me to HealthLine for treatment for this injury, and the treatment was paid for by my employer or my insurance; I don't know, she said. The claimant was queried if HealthLine had initially discharged her from their care on approximately January 4, 1995. I don't know what date it was, she answered. I don't think I was ever off of work for this injury, the claimant said. She said that she did not recall but would not dispute the records of HealthLine which indicated that as of January 4, 1995 they felt she could work without restrictions. When asked if January 4, 1995 was the last time she received treatment, Rosenkoetter responded - I don't know; I have no idea; I can't remember the dates; it's like I can remember people, I can't remember their names, a lot of them. She stated that she guessed it was correct that once she got off the re-work status at Integram she continued to work her regular duties at Integram, and stated that she imagined it was correct that she then continued to work without restriction and without lost time. The problem of having a hard time closing my fingers, as I testified to earlier, has been a problem since I got my hand cut, the claimant said. When queried if it was correct it had been a problem since approximately November of 1994 up through today, Rosenkoetter responded - It got worse when I got the carpal tunnel. She agreed that the inability to close her fingers all the way to make a fist with that hand is something she has had on a daily basis from the time of the laceration up until today.

Rosenkoetter agreed, during cross examination by the employer/insurer, that she has had two injuries to her back. I don't remember the month of the first injury, September or June, she said, and it was in 1995. She agreed that she had testified earlier this first injury was as a result of stepping on a tag and slipping. Indicating that she had continued working and finished her shift that day, Rosenkoetter stated - When I fell it was almost time for the shift to be over. Agreeing that she had returned to work at Integram the next day, the claimant said that she had to. It was noted that Rosenkoetter had testified that she had requested treatment but it took them a while to get her to a treating doctor. They said to put ice on it, she responded. When queried that she continued to work at Integram up until the time she was first seen by a treating doctor, Rosenkoetter responded - As far as I know, I don't know if I had any days to take off or not. The first treatment was about ten days after the tag incident, the claimant said. She was queried if she had attempted to go to a doctor on her own during those first ten days. We were told to go to the foreman and the foreman would set up an appointment for me to go to HealthLine, because with an injury at work you had to go to the workmen's comp doctor, the claimant answered. The claimant was queried, you waited ten days to get treatment? I kept telling the foreman - it's hurting, and he said he'd get me an appointment, and after ten days then he finally got me an appointment, she answered.

During cross examination, Rosenkoetter was questioned about the first back injury stipulated to by the parties as to have occurred on September 15, 1995. The claimant was referred to Employer/Insurer's Exhibit No. 7 (first workers' compensation claimant's report dated 10-7-95); Rosenkoetter stated that it looked like her signature at the bottom of this form. It was noted that Exhibit No. 7 reflected that Rosenkoetter had hurt herself on 8-25-95. I don't know if I filled that out the night I got hurt or I filled it out after, I don't remember, the claimant answered, all I know is I went in the office after I found the foreman and I told him, and he filled out a paper. It was September 15th that I got wrote down, the claimant stated, I think that's the date that I hurt my back. Rosenkoetter stated that as far as she could recall, between the time she did hurt herself - be it June, August, or September - in the time she first received treatment she continued to work at Integram. When queried, wasn't it correct that the first place she received treatment was Healthline, the claimant responded - First treatment I got was putting ice on it; that's what the foreman told me to do. She agreed that the first hospital, emergency room, or clinic, or doctor that she was seen by was at Healthline. Agreeing that from the time of the injury up until the time she went to Healthline she continued to work at Integram doing her regular duties without restrictions. I had to, I didn't have no days off, Rosenkoetter answered. She agreed that when she went to Healthline the doctor took a history from her and asked her what body parts were hurt. From the time I got hurt until ten days later when I went to that doctor, yes, I had problems with my back, the claimant said. When the doctor asked what body parts I had

hurt I told her - my ankle, my knee, and my back, the claimant stated. When queried, so if the only history in those medical records is that you injured your ankle and your knee that would be inconsistent with your recollection, Rosenkoetter responded - The doctor told me there wasn't nothing wrong with my back. Concerning the "first workers' compensation claimant's report" dated 10-7-95, Rosenkoetter agreed that she had signed it, but further stated - I don't remember filling it out. She admitted that at the time she signed and dated this report it was filled out. I don't recall if I had an opportunity to review the report before I signed and dated it, she said. It was noted that the 10-7-95 report specifically made inquiry as to what were her injuries; at the hearing, the claimant noted that it stated "right ankle and ankle", and admitted that she did not see on the report any reference to an injury to the back. After HealthLine the next place I received treatment for my back was when they sent me to Dr. Clark, the claimant said, and for three days he got me to where I could walk again, then I went to Dr. Calvin. From that time where I slipped on the tag in June or August or September up until the time I went to Dr. Clark, I did not have any new injuries to my back, Rosenkoetter said.

The claimant was queried during cross examination if she had ever worked painting floors at Integram. Not that I can recall; she answered, the only painting they done was to paint a yellow line on the -- when they were off for model to change over, and I don't even remember if I even done that or not. Rosenkoetter said that she did not recall if she would have been painting at Integram on October 14 and 15, 1995; she agreed that October 14 and 15, 1995 was a weekend, and assuming that to be the case, she would not have been working at Integram. Rosenkoetter agreed that Dr. Clark was a doctor that she picked on her own, and she stated that she supposed Dr. Clark took a history from her as to how she had injured herself when she went to him on October 15, 1995. I told him I sat on the toilet and I couldn't get up, Rosenkoetter stated. The claimant was queried if it would be consistent with her recollection if Dr. Clark's record of 10-15-95 reflected that she relayed that she had been painting floors in a flexed stooped position and after sitting down two to three hours ago she had an onset of pain in the left low back, hip, and leg. I don't know where he got the painting floors at, Rosenkoetter responded. I know what I told the doctor, I don't know what he wrote down, she said. The claimant agreed that Dr. Calvin was a doctor she had picked on her own, the company did not send her to Dr. Calvin. Dr. Calvin is my main doctor, Rosenkoetter said. The history I told Dr. Calvin as to how I had hurt my back, Rosenkoetter stated, was that I just sat down and I couldn't get up. The claimant stated that it was at Leslie Depot, a bar and eating place where they have live music on the weekends, where she had attempted to use the restroom and was unable to get up. No one had talked to me about a need for surgery on my back until I went to Dr. Calvin, the claimant said. Rosenkoetter was questioned about physical therapy records indicating that she missed the first physical therapy session on 10-17-95 for her knee because of an injury to her back sustained over the weekend. I wasn't in no accident since I hurt my back until I sat on the frigging commode and couldn't get up; there was no accident in between there, I just sit down and I couldn't get up, Rosenkoetter responded.

The claimant stated that as far as she knew, she had have never been to Dr. Clark prior to the 10-15-95 injury to her back. She was queried if it would be inconsistent with her recollection if Dr. Clark's records from 1994 indicated that she had been involved in a motor vehicle accident and that she had pain in the small of her back, and hip, and legs that was worse in the last six months. I only been in two car accidents, the claimant responded.

Rosenkoetter stated, during cross examination, on 11-18-97 she hurt her right back when she put the bench seat in the box, and that from the first date of injury to her back up to 11-18-97 she did not recall having any other injuries to her back. At the time of the second back injury I was working full duty without restrictions, as far as I know, Rosenkoetter said. The claimant was asked if she had been seen by Dr. Calvin prior to 11-18-97 for problems with her back, such as six months preceding, and the claimant answered - I go to Dr. Calvin for most everything. I don't remember if I went to Dr. Calvin for complaints or problems with my back in the six months preceding the 11-18-97 incident, the claimant said. I could have but I don't remember going to Dr. Calvin on 5-29-97 for complaints of strain in the upper back and neck, and severe muscle spasm after lifting liquid soap, Rosenkoetter said, sometimes I turn just right or if I'd pick up a basket of clothes or anything then I strain my back. It was noted that Dr. Calvin's record included a 9-16-97 entry reflecting that Rosenkoetter had advised him that she had strained her back while lifting heavy pots at a family reunion and that she had been diagnosed with acute lumbar sacral strain and severe muscle sprain; the claimant responded - If that's what it says.

During cross examination by the employer/insurer, the claimant was questioned about her Claim for Compensation pertained to her psychiatric condition; she was asked to what did she attribute her psychiatric problems. I'd been having problems at work with harassment, the claimant answered. When I went to the doctor about my arms, there was another doctor there and not the regular doctor, and he asked me what was wrong, and I told him I'd been having problems at work, and he put it on the paper, the claimant stated, he give me some medicine that would help me. As far as I can recall, that was the first time I ever had a discussion with a physician about any psychiatric issues and the first time any physician prescribed me any medications for any psychiatric issues, Rosenkoetter said. She was asked when did the harassment start. I don't recall, Rosenkoetter answered, all I know is I had problems with them at work and that day was

really bothering me, and the doctor asked me what was wrong and I told him. I'd had problems after I went back to work, not being able to do what I was supposed to do, worried about my job, the claimant stated. And all that stuff started with them guys at work; you could never get nothing done; even if you told the foreman, he wouldn't do nothing about it, he'd say - l'll talk to them, and it got worse and worse and worse, the claimant stated. Rosenkoetter agreed that it was sometime after she went back to work after the surgery for the back injury that the harassment started. It was sometime around the end of 1996 or beginning of 1997 that I returned to work, the claimant agreed. Dean Nordman was the supervisor I talked to who did nothing about it, the claimant stated. The harassment occurred on between ten and twenty occasions, Rosenkoetter said. They would hit the platform that I stand on; when I was spraying the molds or putting the covers on the molds, then they would come from around with the big wrench, and when I wasn't looking they would hit up on that and I would think it was falling, she said. They would do things all the time and they'd stand there and laugh because they knew it scared me, she said, and they wouldn't stop, every chance they got. It just upset me that they did it; I asked them to quit, and the more you asked them, the worse it would get, Rosenkoetter said. She agreed that during that period after she returned to work, in addition to the harassment, one of the things she was concerned about was her ability to perform her job duties and actually keep her job. The claimant agreed that she believed Dean Nordman played a role in this harassment. He never done anything about it, she said. When asked if Nordman had promoted it at all, Rosenkoetter responded - I believe he was in on some of it. The claimant explained that though she believed that along with the other employees Nordman played a role in the harassment that she underwent, but nevertheless when she thought it was a problem she went to Dean Nordman to report it because he was her supervisor. Rosenkoetter stated that she did not file a grievance about the harassment because she didn't know you could do that. I didn't know if there was a hotline at work, the claimant said, I never worked in a place where they had a union. Rosenkoetter stated that she knew there was a human resources department at Integram, and that she trusted them until she lost her job. I did not go to H. R. and tell them I was being harassed because I thought you went there to fill out papers, like medical papers, and insurance papers, and stuff like that; I never thought they would deal with harassment or anything, she said.

Rosenkoetter stated, during cross examination, that she already was stressed out before her termination; the termination did not make my stress worse, it made me hate you and the company you represent. Rosenkoetter agreed that her termination and the grievance proceeding was all about insurance paperwork, it wasn't about making bad parts or not doing her job right. No one from the company that I know of ever wrote me up because I made too many bad parts, the claimant said. No one from the company ever came to me on the re-work line and said as a result of my not keeping up with the re-work, we're going to write you up, Rosenkoetter stated, they did come back and tell us if people was going to chew, then they had to have a bottle with a lid on it and keep the lid on it.

Rosenkoetter agreed, during cross examination, that she had been physically assaulted once. My husband's brother jerked a chain out of my hand and hurt my arm, she said. She agreed that this happened on about 6/6/95. I went to St. John's Hospital, the claimant said, and they said it was just strained, it was all right. The claimant agreed that a history of what had occurred was taken from her at the hospital. When asked if her brother-in-law had tried to punch her on that date, Rosenkoetter responded - I think he tried to punch my husband or hit him with a shovel, or might have tried to take a swing at me, but he didn't hit me. The claimant agreed that her memory was refreshed by the St. John's record which reflected that her brother-in-law just went berserk, grabbed her arm and twisted it and tried to punch her, and she blocked that punch with her right arm. He grabbed a chain that I had in my hand and brought it around a post and it twisted my hand, she explained. Explaining what caused her brother-in-law to go berserk, Rosenkoetter testified that he lived in the farmhouse and his dad had given him six and a half acres to build a house. He wouldn't work on the house so we kicked him out; he had to pay rent or move; and then when we told him that dad wanted him to pay rent, he got mad and he moved out, and then put chains around the gate to keep us from going to our house; and we went up there and told him that we had to get in, we had no other way to get to the house, there was no other roads, and my husband said - Well, we'll just put chains on it and you won't get out; and that's when he just went crazy, the claimant testified. She was asked if her brother-in-law had hit her husband with a shovel. I think he did, the claimant answered.

Rosenkoetter agreed that they had to take her brother-in-law to court to resolve this issue. We just went to the court and we told them our side, he told them his side, and they gave the road to him because it wasn't specified on the deed about the road and the easement, and he got the road and we didn't, the claimant said. What we did about access to our home was made a road, she said. This brother-in-law still lives next to me, she said. Describing the relationship now, Rosenkoetter testified - He talks to me, I talk to him; I give him stuff out of my garden, my husband's over there quite often; he just shut the road off, that's all, so you live with it and go on. I don't think I continue to have problems with my right arm after the assault, she said. The claimant was queried if she knew why the records of Dr. Bedor for 1997 would reflect that he thought she had a rotator cuff tear in that arm. I got a test from our regular man, and he said they done a test in there put medicine in there and took x-rays, and I didn't have a rotator cuff tear, she stated. I didn't know what was causing my right shoulder problems at that point in time, that's why I went to find out; I thought I had a rotator cuff tear, and I didn't, she stated. Rosenkoetter stated that she did not remember if she missed time from work as a result of the problems with her right shoulder. I do not recall my shoulder affecting my ability to do my job duties, the claimant

said. Rosenkoetter agreed that the police were involved in the altercation involving her brother-in-law, and charges were filed, but she didn't think charges were filed against her or her husband. The claimant was asked if there were any other times that she had been physically assaulted. Well, my ex-husband used to push me around a little bit off and on, she answered. I was married to my ex-husband for twenty-five years, she said. Rosenkoetter agreed that her ex-husband also tried to abuse her emotionally off and on throughout the twenty-five years. He went to the hospital and got help, she stated, he had a medical problem. Rosenkoetter agreed that she had children with her ex-husband, and that her children witnessed some of that emotional and physical abuse. Agreeing that her children were subject to that emotional or physical abuse, Rosenkoetter explained that that was why she got a divorce. It was a friendly divorce, she said, we visit each other; he comes to my house, he's remarried and I go to their house. I have not had any other family issues that caused me stress or added to my depression, the claimant said. She agreed that she had attempted to take custody of a grandchild, and explained that it was because the child had a drug addict for a father. The mom brought the baby to me, and he wouldn't buy her diapers, and she had no place to keep the baby clean, and she asked me if I would take her and I said yes. I had the child for maybe six or seven months, Rosenkoetter said. I don't know what year it was and I don't know when she went back; I gave her back because her mom got her own apartment, got on HUD, and had money to take care of her; it wasn't because of my daughter, but I had to put both names on there (my daughter's name and her boyfriend's name), or I couldn't get her.

Rosenkoetter agreed, during cross examination, that over the years she has had some problems with pneumonia and ear infections and sinus problems. I believe that it is because of the mold release that I smelled every year for year after year, she said. The claimant agreed that she missed time from work as a result of the problems with bronchitis. It was noted that she missed time from work in 1997 and 1998 because of problems with bronchitis and the breathing, and Rosenkoetter responded - You know, now I very seldom get bronchitis or get sick.

During cross examination by the employer/insurer, the claimant agreed that besides seeing Dr. Stillings one time in 1998, the first time she received any psychiatric treatment was through Dr. Crane's office in 2004. Rosenkoetter stated that she did not know if her employer had an employee assistance program (EAP). The claimant was asked if she had ever attempted to get treatment through her group health insurance. I didn't think it was bothering me that bad; I didn't want to go to a psychiatrist, she answered. Rosenkoetter agreed that when she thought it was bothering her so bad that she had to go see a psychiatrist was when she went to Dr. Crane. It was noted that this would have been several years after she left the employ of Integram, and Rosenkoetter responded - It kept on and kept on and kept on. My health situation, it eats me up, she said, do you know what it's like to not be able to do anything or fall over everything and get hurt, like my arm, and broke my leg. You don't know what it's like, she indicated; not being able to enjoy my bike no more or ride my motorcycle or go in the field with my husband, he has to do all that work "hisself" now. I can't even plant my frigging flower garden; I try to weed-eat, I bought the lightest weed-eater they had which they said weighed less than five pounds, and I couldn't even do it more than five minutes. That's why I went to Dr. Crane, the claimant stated, because I knew I needed to go someplace and I looked in the phone book and I found Dr. Crane's name and I went to him. It's just been building up and building up and all these years and all these accidents and got so I wouldn't go out of my bedroom, I would stay in there for days, the claimant stated. I didn't want my kids to come, I didn't want to see my grandkids, I didn't want to see nobody, she stated. And every time I got hurt it brings it all back again, the claimant testified, and every time I had to go to these stupid hearings and all these years been going on and going on, it eats at me. Now I have to get surgery on my other hip, and I got to face that, too. You know what it's like getting out of bed for five seconds, not even long enough to go to the bathroom, and you got to go back and lay down because you can't set up, the claimant stated. I want to kill myself, if I could have got a gun, I would have, she said. I go to bed every night crying because my legs and my back hurt so bad; can't go any place around people and enjoy yourself because you're miserable; you can't even sit in a frigging chair, the claimant said. Rosenkoetter agreed that every time she has an injury to her body, it dredges this all back up and makes it worse.

The claimant agreed that she was involved in a motor vehicle accident in October, 2003. My daughter suggested that she and I go down to visit my other daughter and we went down there, and I rested while I was there, and we spent the day and had dinner. We started back home, and I was driving on Highway A, and there was a road on the right side and the man was coming the other way, and he decided he was going to turn and he was drunk, no insurance, two babies in the car and his wife; I didn't have time to stop, and I tried to miss him but it didn't work, Rosenkoetter said. The people in the other car, and my daughter and myself were injured in the accident, she said, no one was killed in the accident. Explaining about her injuries, Rosenkoetter stated that the air bag went off and she was going sideways and it hit her shoulder, and her hand hit something and broke a bone in her left hand, and her knee hit something on the door somehow. I wasn't casted, Rosenkoetter stated, it seems like my bones don't break across but rather they break down, and they put five, I don't know what you call it, it had a metal piece on the bottom and you wrapped it there; I had to wear that for a month. I did not have any problems with my neck or anything else as a result of this injury, she said.

Rosenkoetter agreed that she was sent to Dr. Poetz on her own behalf. I don't recall but I think I did talk to Dr. Poetz about my psychiatric condition, she said, we went over a whole lot of stuff the day I was there.

The claimant was queried during cross examination if it wasn't correct that she didn't quit working at Integram because of the problems with her hands, she quit working because of the paperwork mess. I had to quit anyway, the claimant answered, my health just keep getting worse. It didn't get better. And Dr. Schlafly said these two fingers still go numb, and I might have to get my elbow done.

Rosenkoetter agreed on cross examination that the problem that came up that led to the whole paperwork mess and that eventually led to her termination was an injury that she had to her left leg that occurred at her home. I had several injuries happen at my house, my legs wouldn't work right; I wasn't never sure if my foot was high enough or if I was stepping right, it just didn't work right, the claimant stated. The first time I fell on some steps I broke my tibia, she said. When I fell on 3-17-99, I didn't fall because I was dizzy or disoriented, I fell because of the problems with my legs that I know was due to my back, the claimant stated. I told Dr. Jacob, the one who did the surgery, that my legs just didn't work right, and he said there's nothing more that he could do for me, the claimant stated. I went to my bone doctor, Dr. Kef alas, for treatment when I fell at home on 3-15-99, she said.

The claimant was queried if it would be inconsistent with her memory of how she was injured if Dr. Kefalas' notes of 3-17-99 indicated that she became dizzy at home and fell. When I came out of the barn I thought my foot was on the step, but it wasn't, and I stepped in a hole and the ground was uneven and I went down, the claimant responded. It was noted that Rosenkoetter had said that she fell on the steps. The first time I got hurt after the surgery I was going up the steps and my foot caught on the steps because it wasn't up high enough and I fell and I broke my tibia bone, the claimant answered, and then I come out of the barn and I thought my foot was on the step but it wasn't, it went sideways, and I fell, and fell in the hole in the yard. I don't know if the fall into the hole in the yard was on 3-15-99, the claimant said. Dr. Kafalas took me off work for the 3-15-99 injury, the claimant said, I had a mobilizer on my knee, I was on crutches, and I had a metal-with-gel-cast on the inside of my ankle. The claimant was asked if it sounded accurate that as reflected in the doctor's record he kept her off work through 4-7-99; and she answered that she did not remember the date, but she thought it was in sometime in April. Rosenkoetter denied that at that time she attempted to return to work. When the doctor or the hospital man said I couldn't work, I called work and said I couldn't work that I had to go to my doctor the next day. I called work and I asked for insurance papers; when I was off when I broke my leg before, they got a new contract, and I didn't have a new book, I didn't know what the new rules was because nobody said anything, she said. And when I called the human resource and asked the gal for my papers, she faxed them to me, and I looked and they were different and I didn't know how to fill them out. So I called back and I asked her how to fill them out, and she told me; I put down what she told me, and then I went to my doctor and I showed him the papers. The doctor looked at my knee and stuff and x-rays and said that I should not work on it, to stay on the crutches, and that's what I did. The claimant was queried, wasn't it correct that at some point she got off the crutches, the air cast and off the gel cast, and Dr. Kef alas was done treating her for this injury. When they said I was supposed to be back at work, I was on crutches, I had that on my ankle, and I had it on my knee; there was no way that I could come in there and work, the claimant responded. Rosenkoetter then again denied that at some point she attempted to return to work at Integram. She was asked if she had filed a grievance. I went to the union, she answered. She agreed that she basically went to the union saying that they had unfairly taken her job away, and that she should be able to continue working at Integram, that she filed a grievance saying she should be working at Integram. Rosenkoetter stated that she went through, she thought, four different levels of the grievance proceeding, the most you could go through. I don't think I was even at the three meetings, she said. The claimant was asked if it upset her that she wasn't successful in her grievance proceeding. What upset me, she answered, was that they frigging sat there and lied; no matter what I told them, no matter the bills I showed them, they sat there and lied and he took it. And you know what upsets me is that those people can make bombs, they can layoff, they can sneak out of work and everything, and nothing happens to them, only three days suspension, Rosenkoetter stated. Not having a lawyer present that upset me, too, she said. Rosenkoetter agreed that after she was terminated from Integram she applied for unemployment benefits. I did not receive those benefits right away, she said, Integram said that I didn't deserve them, I was fired. Rosenkoetter stated that she did not have much choice when receiving those benefits on a weekly basis in filling out a statement alleging that she was ready, willing, and able to work. I had to get a job because I knew that wouldn't last very long, she stated, I was out there every day trying to find a job, but then when you put down you had surgery and this and that, they don't want nothing to do with you. You can't lift; they don't want you in the machine shop if you can't lift stuff, she stated.

It was noted during cross examination by the employer/insurer that the claimant had testified that as a result of all these conditions she had been inhibited in her ability to engage in activities around the farm, and Rosenkoetter was asked how long had she had that limitation. Ever since I fell on the tag, the claimant answered. Rosenkoetter was queried if she would question the accuracy of Dr. Sertl's record which contained a history that she had injured her left leg

riding a tractor in September of 1998. I would try to do stuff; I didn't have as much wrong with me then; it was just all the stuff just piles up; I still try to do stuff, it just don't work, the claimant said.

On cross examination by the Second Injury Fund, Rosenkoetter stated that after recovering from her broken tibia injury that occurred in the Summer of 1998, she was working full job duties on her regular scheduled hours up to the time she hurt her right knee and she was fired from Integram. My regularly scheduled hours were to start at eleven p.m. and I think we got off at seven-ten. The time I worked at Integram my job title was Foam Production, the claimant said, and agreed that there were other people who worked with her who did the same jobs she did. Agreeing that there were other shifts at Integram besides the one she worked, Rosenkoetter stated that there might have been three shifts including a day shift, and she worked on evening shift one time. I imagine there was somebody else doing that same foam production job that I was doing on those other two shifts, the claimant said. I started in foam production in 1991, I don't remember the month, the claimant said, and worked there until I left Integram. During this time period I was doing the same job duties throughout the whole time, she said. Discussing this job in more detail, Rosenkoetter agreed that she worked with the foam seats that went in minivans. The bench seats were quite long; I have no idea what they would weigh, I really don't, she said. I also lifted all the cushions backs or the cushion part; there was child seat cushions, and the cut and sew was the foam buns with other covers on them and heaters in them. The cushions had a metal pan on them, so they might have been the heaviest, I really don't know, the claimant stated. The whole work-day was spent on my feet, she said. Rosenkoetter stated that she was doing bending with just about every position there, and explained that they rotated to different stations. I don't think I ever had to do any squatting or kneeling in doing my job duties, the claimant said, not unless you dropped something. Rosenkoetter denied that during the last six months that she was physically working at Integram she was doing the same job duties that she had been doing since she'd been in foam production beginning in 1991. I wouldn't help nobody anymore, and I was lucky to get my job done, she stated. I would trade off because lifting covers was really hard on me because you'd have to lift like ten or so at a time, and then you had to bend over in the boxes and lift the heavy lids off the boxes; it was really hard on my back, the claimant testified.

During cross examination by the Second Injury Fund, Rosenkoetter agreed, that at the time that she was terminated from Integram she was on sick leave for her leg. The doctor kept me off work for a period of time for my leg at that time, the claimant agreed, and this was about April of 1999. It was my intention to return to my job at Integram after I recovered from this leg injury, the claimant said. The claimant was queried if it was correct that one of the reasons she filed a grievance at the time Integram let her go in April of '99 was because she had planned and wanted to return to her job at Integram. No, Rosenkoetter answered, I filed a grievance because the lady in the H.R. lied, she said I didn't have to fill out anymore papers, and that's why I lost my job. The claimant agreed that when she filed the grievance she was trying to get her job back.

Since I left Integram in 1999, the claimant stated, the condition of my low back has gotten worse. The claimant was also queried, since you left Integram had the condition of her right ankle had gotten better, gotten worse, or stayed about the same? When I hurt my right ankle, after I did what the doctor told me, it got better, Rosenkoetter answered, it just gives me trouble every once in a while, it gets real sore, it swells, it stays swollen all the time. When I left Integram in April of 1999 my right ankle was pretty messed up because I had to wear a gel cast on it for like six weeks, but the problem I have now is that walking sometimes will irritate it or it just swells all the time. Rosenkoetter agreed that the condition of her hands got better after the carpal tunnel surgery. The symptoms I still have in my hands now from the carpal tunnel is that every once in a while my hands will cramp up; I can't sew anymore, I used to hand quilt and I can't do that anymore, I can't hold the needle; it's just like charley horses in my hands, the claimant testified. The claimant was asked if her depression had gotten better, gotten worse, or stayed about the same since April of 1999. Gotten worse, she answered. Rosenkoetter stated that she still has problems in her right hip. Right now I'm going for therapy, she said, they're going to fit me for a cane Thursday so it will help steady me when I'm walking. When asked if she had had problems with her right hip in April of 1999, the claimant answered - l've had problems with it off and on since I hurt it in 1997 when I bent over in that box. She agreed that this was her second back injury. The condition of my right hip has gotten worse since I left Integram in 1999, the claimant said, my doctor suggested that I find another neurosurgeon because mine retired, he's looking for one for me now.

On redirect examination, the claimant testified that prior to slipping on the tag at Integram she worked overtime at one time every day, and then sometimes once or twice a week. In the year before I slipped on the tag I worked two jobs, I worked sixteen hours a day, Rosenkoetter said. Agreeing that her life changed as a result of slipping on the tag at work, the claimant stated that she doesn't have a life no more. I had to sell my mobile homes and that was something I enjoyed, that was going to be my old age retirement.

On further cross examination, the claimant agreed that when she had the first injury to her back in 1995 that slowed her down at work; she agreed that also as a result of this she couldn't work as much overtime. Rosenkoetter was

queried about Dr. Bedor's records which indicated on 5-28-98 that she was working ten to twelve hour days, six to seven days a week. My back was bad in May of 1998, she said, but if they said for you to work, you worked.

Joe Laffleur testified on behalf of the employer/insurer. I'm a human resource manager at Integram St. Louis Seating, and have been in that position for eight and a half years, Laffleur said. He agreed that in his position he deals with the union, UAW, at Integram, and stated that the union has been involved with this particular Integram plant since July of 1995. If one is to be employed at Integram as an assembly worker, they are required to be a member of that union, Laffleur stated. As the H.R. manager I am familiar with the company handbook which has been in existence since 1989, he said. Explaining how employees are made aware of this handbook, Laffleur stated that employees are given a copy of it when they're hired; when the union came in, the contract took the place of the handbook for the hourly employees; but prior to the union coming in, we had the handbook and it pertained to all the employees. Agreeing that the company has a hotline, Laffleur explained - We are owned by Magna International out of Toronto, and they have a phone number that employees can call if they can't get their issues resolved at the plant and it can be anonymous. The hotline has been in effect at least twenty-five to thirty years, he stated. Employees are made aware of the hotline by us telling them in the orientation that it's available to them, Laffleur said, plus we also have posters in the plant which talks about what the purpose of the hotline is, what the phone number is to call, and plus periodically we'll have representatives come down from Toronto and do a presentation in one of our monthly employee meetings. The posters are in the H.R. department where we do the orientation, plus they're out in the plant in several locations, Laffleur said. He agreed that as part of the company's benefits package for the employees, they have an EAP (Employee Assistance Program) program, and stated that this has been in effect since the plant opened in 1989. The services available through the EAP are that the employees can contact the EAP if they have financial issues, chemical dependency issues, emotional issues either for them or for anyone living in their household, Laffleur said. Agreeing that H.R. took an active role in making the employees aware of the EAP program, Laffleur stated that they have posters out in the plant that talks about it, everybody in H.R. has business cards from the EAP, plus periodically they'll have someone come in and do a presentation. He agreed that this is something that is in the handbook.

In my years in the H.R. department, Miss Rosenkoetter never came to me and advised me that she was being harassed on the line, Laffleur stated. It was noted that the claimant had made reference a few times during her testimony to an employee making a bomb in the plant, and Laffleur was asked if he was familiar with such an incident or allegation. Not about a bomb, but I think I know what she was talking about because she mentioned the employee, yes, he answered. Laffleur stated that he was familiar with the employee Rosenkoetter had mentioned, and it was Pat Brown. Pat Brown is not a union representative, he is just an ordinary union employee, Laffleur said. To my recollection, what occurred with Mr. Brown is that he had gotten a plastic bottle and put some dry ice in it and then thrown it, not towards any employees, but just in the foam department; nothing happened with Rosenkoetter, Laffleur testified. He agreed that it did not explode and no one was injured. Agreeing that there was a consequence to this action, Laffleur stated that the company gave pat Brown a three days off for horseplay. Laffleur stated that he was present at the grievance of Rosenkoetter but not at the grievance proceedings, as Rosenkoetter would have done that through her union representative. He agreed that as H.R. director for Integram he participates in grievances on a regular basis, and becomes aware of each grievance procedure. My role with the grievance procedures is that I pretty much handle the whole procedure, Laffleur stated. It's actually a four-step grievance procedure, and if that doesn't solve the grievance, then it goes to arbitration; I'm involved in all four steps plus at the arbitration level. And I actually conduct the meetings and I write the grievance, Laffleur testified. He agreed that in conducting the meetings he represents the company's interest, and in an effort to address his side of the argument, he becomes aware of the grievance allegations. Agreeing that he was aware of the allegations in the case involving Rosenkoetter, Laffleur stated that the allegations were that she did not terminate her seniority.

On cross examination by the claimant, Laffleur stated that he started at Integram in January of 1996. He agreed that, therefore, he is totally unaware of any orientation Rosenkoetter would have had when she went to work at Integram. Laffleur stated that he was aware that Rosenkoetter did have an orientation based on the company's records.

Dean Nordman does not still work for Integram, Laffleur stated, I haven't talked to Dean in five years, so, no, I do not know where he is.

Laffleur agreed that Integram keeps the records of pre-employment physicals, and that he had a record of Rosenkoetter's pre-employment physical. I have never looked at it, Laffleur said. I did not review Rosenkoetter's deposition, he said.

There are six hundred and fifty employees in the plant right now, Laffleur stated. He agreed that as human resources manager, he hires and fires people.

On redirect examination, Laffleur testified about the basis of his terminating Rosenkoetter in 1999. She terminated her seniority in accordance with the labor agreement because she failed to return from her leave of absence, Laffleur said, and agreed that the employer made no proactive attempt to terminate her. To my knowledge, Rosenkoetter was never written up for poor performance, and never written up for problems with quality or quantity of her work, Laffleur said. To my knowledge, in the grievance procedure, ability to perform her job duties was not an issue, he said.

On further cross examination by the claimant, Laffleur agreed that he had brought Rosenkoetter's personnel file with him to the hearing. He agreed that the file included write-ups of Rosenkoetter, and stated that there were all on attendance. He was queried if he had looked in the file for whether or not Rosenkoetter had complained to Dean Nordman about being harassed at work. I didn't see it in there, but I wasn't looking for that, Laffleur answered. Laffleur stated that in the personnel file he had attendance discipline records but not the attendance records. I have no idea what the attendance records were for the six months prior to September 15, 1995, he said, we don't have those records prior to 1995. I never had the attendance records for six months prior to 1995; they were made at the time, I'm sure; I wasn't here, Laffleur testified. In explaining about how far back the company's attendance records went, Laffleur testified - We put in a new attendance system back, I believe, in the year 1997 or 1998, that's as far back as it goes. Laffleur stated that the company did have the pre-employment physical records, but he believed it was back at the plant; they're kept in a medical file, if you're talking about the exam Rosenkoetter had when she got hired, that would be a separate file, that would be a medical file. It was noted that included in the personnel file was that it was maintained by Laffleur and found by the appeal judge that the claimant left work on 3-19-99 without good cause. The original judge agreed with us, yes, Laffleur responded. Laffleur agreed that he wrote the termination letter, and that it was based upon Rosenkoetter not returning to work on 3-19-99. He stated that at that time he knew that Rosenkoetter's doctor had given her an off-work slip. Laffleur agreed that it was just a question of a leave request form not being filled out and sent in. Laffleur agreed that the personnel file included: a. that Rosenkoetter had missed eighteen days from work, 10-22-98 to 1-25-99, adding that it was a chronic attendance letter which is part of the labor agreement; b. that on 1-6-99 Dr. Calvin wrote him a note that Rosenkoetter has severe degenerative disc disease; c. that on February 13, 1998 the company wrote Rosenkoetter a letter that she was the most frequently absent from work in November 1997, December 1997, and January 1998; d. that shortly after the bench case of November 18, 1997, on 11-20-97, there is a note from Dr. Calvin saying Rosenkoetter has somatic dysfunction of her lower back; e. a 7-21-97 note the Rosenkoetter has chronic degenerative disease of the right ankle. Laffleur agreed that he knew about all these conditions Rosenkoetter had when he decided she didn't conform to the filling out the form properly (reporting on March 19, 1999) even though he knew she had been taken off work by her doctor.

On cross examination by the Second Injury Fund, Laffleur agreed that if someone has poor performance, it is possible for them to be disciplined at Integram, and if there's a discipline for poor performance it is it put in their personnel file. Rosenkoetter did not have any discipline forms in her file for poor performance, Laffleur said.

On further direct examination, Laffleur stated that the slips he had been asked about that were in Rosenkoetter's personnel file, he got them either from the supervisor -- the employee gives them to the supervisor and the supervisor gives them to us in H.R. Agreeing that somehow the employee directs the routing of these to the file, Laffleur added that the employee brings the note in. He agreed that it appeared Rosenkoetter was aware of the need to bring those forms in.

Medical records in evidence included the following:

1.Certified medical records of HealthLine Corporate Health Services Metro St. Louis (Claimant's Exh. D) indicated a majority of the treatment as employer (Integram) authorized treatment; the record concerned the treatment of Rosenkoetter for various complaints and injuries from March of 1994 through October of 1999.

The first entry of 3/18/94 indicated that Rosenkoetter presented for evaluation of her right wrist, with a history that the wrist had been bruised on two separate occasions in the past week; she was evaluated at the emergency room and x-rays were taken which were negative; the diagnosis was - wrist contusion and hematoma; it was written that Rosenkoetter was returned to regular duties, and that the company had flexible wrist supports which was recommended Rosenkoetter obtain and use. The next and subsequent entries included the following.

12/01/94 - treatment for an 11/23/94 laceration injury to Rosenkoetter's left palm as a result of cutting her hand on the sharp edge of a pan while working; exam findings included that the wound was quite deep, tenderness to palpation about the area, decreased grip secondary to pain, some numbness over the radial aspect of the left little finger near the area of the wound; some sutures were removed and others left in; Rosenkoetter was placed on restricted duty. 12/6/94 treatment for re-opening of wound subsequent to another doctor removing the sutures; Rosenkoetter was restricted to no

use of the left hand. 12/16/94 - follow-up treatment to the laceration injury, and it was noted that she complained of pain to the left wrist which occurred with the injury; written in the entry was - "I told her that she never mentioned this wrist pain to myself throughout all of her visits here and when discussed with Carolyn, Carolyn states this has also never been mentioned to her. Because of the time frame from her first visit here to the current complaints of wrist pain, which is approximately 16 days, this injury to the left wrist has been rejected by her employer"; the diagnosis remained laceration left palm healing; Rosenkoetter was continued on restricted duty of use of left hand as tolerated. 1/4/95 -follow-up appointment for the laceration injury, it was noted that Rosenkoetter had been off work for sometime as she had recently lacerated a tendon which was non-occupational of the right hand; exam findings were improvement with the laceration but still some tenderness about the area of the wound and pain with forced abduction of the thumb and index finger; the diagnosis remained - laceration left palm healing, and Rosenkoetter was discharged from the clinic, full duty status. 9/15/95 (the next entry in the record) - complaints of pain to the left palm in the area of the previous laceration which was at the radial aspect of the base of the left little finger, and complaints of numbness along the radial aspect of the little finger with some pain along the scar area extending to the palm; the assessment after examination was - 1. Pain left palm status post laceration which is old, and 2. Flexor tendonitis left hand which is new; the plan was for hand therapy with scar management; Rosenkoetter was returned to full duty; it was indicated that this injury was consistent with the 11/23/94 incident. 10/6/95 - Rosenkoetter presented with complaints that her little finger drew up and the pain was unbearable; objective findings were - no swelling to the area of the healed laceration, no excessive scar tissue present, skin appears to move easily as if there is no adherence of the underlying tendons, excellent resisted flexion, full extension; it was noted that Rosenkoetter said she could not find anything wrong with her hand; the diagnosis was - pain left palm, no change; therapy for scar massage was ordered; written was a question as to whether injury was consistent with alleged 11/23/94 incident as the doctor wrote that she could really never find anything wrong with the hand other than Rosenkoetter's subjective complaints; Rosenkoetter was continued on full duty work status.

9/15/95 - Rosenkoetter was seen for complaints of pain and intermittent swelling in the right ankle and right knee as a result of twisting and slipping on a piece of paper at work on 8/25/95; an x-ray report, dated 9/15/95 and indicating a date of injury of 8/25/95, indicated exams of the right knee and the right ankle, and results for both were - negative/no bone or joint abnormality evident; the diagnosis after examination was - Mild sprain right ankle, and Strain right knee; treatment was a Futuro wrap for the ankle and Genu-Medi for the knee and also ice, heat and medication; it was indicated that the injury was consistent with Rosenkoetter's work activities or the alleged incident; she was released to full duty. 9/25/95 - follow-up of sprain to the right ankle and strain to the right knee; it was written - "Although, her injury seemed mild on her last visit here she complains of continued pain and states she is not improved. She requests to only work 40 hours a week 8 hours a day. I told her that we would consider other restrictions instead and she was very unhappy with this."; diagnosis after examination was - Sprain right ankle, and Strain right knee; physical therapy was ordered; ordered was light duty work of seated duty for half a shift and self-paced walking; it was noted that the injury was consistent with work activities of the alleged 8/25/95 incident. 10/6/95 - follow-up of an injury to the right knee and right ankle; included in the entry was - "Upon my entrance to the room I asked the patient if she had improved and how she was feeling. She did not respond for several minutes. I asked her again how she was doing and she states I want to see a Specialist. I told her I did not think that was necessary at this time as she had yet to attend any of the therapy sessions that were ordered for her and that were apparently set up."; the entry indicated further friction, but eventual examination did occur, and the assessment was - Sprain right ankle - improved, and Strain right knee - improved; it was written that six visits of therapy was set up for Rosenkoetter, and medication was to be continued; light duty recommendation was continued.

11/3/97 - Rosenkoetter presents with complaints that for the past month or two she has developed pain in both of her wrists and forearms, sometimes it is hard to close her hands, and she is beginning to lose strength; objective findings included - Phalen's is negative bilaterally, Tinel's is negative at the median and ulnar nerves, mild tenderness over both epicondyles; the diagnosis was - Tendonitis both wrists; Ibuprofen and home exercises were prescribed; it was indicated that the injury was consistent with work activities or the alleged incident (the date of injury was noted as 11/3/97); Rosenkoetter was returned to regular duty. The record indicated that Rosenkoetter missed scheduled appointments of 11/17/97, 11/26/97, 3/10/98 and 3/17/98. 11/19/97 - Rosenkoetter indicated that she had had improvement in the function of her hands, especially the left one; exam findings included negative Phalen's, and negative Tinel's at median and ulnar nerves at the wrist; the diagnosis was - Paresthesia both hands, resolving; mediation was continued, and she was maintained at regular work. 12/1/97 - Rosenkoetter reported that she was feeling relatively well over the long weekend, went back to work early this morning on a four hour shift and now her hands hurt; other complaints are that the left hand and little and ring finger go to sleep during her sleep, she awakes and changes positions and the numbness disappears from the two fingers; objective findings were - neurovascular status is intact in both hands, good grip, excellent range of motion in the C-spine shoulder wrist and elbow, Tinel's and Phalen's negative; the diagnosis was Wrist sprain bilateral; it was noted that the injury was consistent with Rosenkoetter's work activities; she was returned to regular work. 2/19/98 - complaints of bilateral UE pain for about 6 months, treated with ibuprofen but is getting worse,

complaints of numbness in the left index finger and thumb; written objective findings were - "Vague history. The patient appears very depressed and is crying when asked if she is depressed. UE reveals various scratches from working outside at home. Diffuse muscle tenderness in both arms, from shoulder to hands. Joints reveal no swelling and full ROM."; the diagnosis was - Complaints of bilateral UE pain, Depression; treatment included - EMG, NCT's and antidepressants; Rosenkoetter was placed on work restrictions of no pushing or pulling with arm for one week greater than 35 pounds; follow-up in one week recommended. In a 2/19/98 Medical Authorization form, Dr. Oliver wrote in the Diagnosis section of the form: "Subjective complaint of bilat. Upper extremity pain for 6 mos. Depression which is partly, if not entirely work related. Rec. (treatment with) antidepressant". 3/23/98 - Rosenkoetter relayed that she was scheduled to see Dr. Phillips for an EMG and nerve conduction tests the next day, and subsequently to see Dr. Crandall, and these appointments were set by her work place; continued complaints of pain in both hands, wrists, shoulder, and elbows, denies any pain in the neck; states is doing regular work at this time; objective findings included - Tinel's is equivocal bilaterally and Phalen's is equivocal bilaterally, no tenderness over the medial or lateral epicondyle; the diagnosis was Paresthesia to both hands, It is questioned whether or not the patient has any depression from this particular incident, episode, or current complaints; it was written that Rosenkoetter would see Dr. Crandall for UE complaints; she was placed on full duty work status. In a 3/23/98 Certificate of Fitness/Exam form, the examining doctor, Dr. Anver Taylor, M.D. wrote in the Diagnosis Section of the form: "1. Paresthesia both hands, 2. No work related depression."

1. Medical records of St. John's Mercy Hospital, Washington, Missouri (Claimant's Exh. J). The record included treatment of Rosenkoetter in the emergency room on 06/06/95 for complaints of an alleged assault with hand and arm injury. The written history of injury was:

49-year-old female with history that allegedly she was assaulted by her brother-in-law, I believe. She says that the brother-in-law just "went berserk," grabbed her arm, twisted it. Also tried to punch and she blocked the punch with her right hand. The patient says that due to the twisting action, she has pain across her entire arm, mainly in the shoulder area and across the upper forearm and humerus. Says that there was no direct trauma to any of these areas.

Physical exam findings on 06/06/95 included: some minimal soft tissue swelling across the dorsum of her right hand, no obvious bony deformity, no ecchymotic change, some soft tissue swelling noted, rest of evaluation within normal limits, neurovascular to the arm was intact, chest was unremarkable. Report of an x-ray taken on 6/6/95 noted the following: right hand - negative for fracture or bone destruction. The assessment on 6/6/95 was - Soft tissue hand and arm injury; negative for fracture. The After Care Instruction sheet dated 6/6/95 indicated that treatment was - wear sling on right arm for 5-7 days; ice to shoulder, elbow and hand for 2 days, Darvocet, off work for that day, and see Dr. Refalus as needed. A radiology report dated 6/15/95 noted a history of - rule out abnormality of pain, and also noted the following findings: right shoulder - negative; right clavicle - negative; and cervical spine - 1. Marked scoliosis and straightening usually indicative of neck muscle spasm, and 2. Inability to adequately visualize C 1 and C 2 because of the marked scoliosis (it was also noted in the discussion section that "[T]he patient refused and could not straighten her neck from this position).

1. Records described as those of Dr. Clark, D.C. (Emp./Ins. 5) were mostly illegible, but indicated that in about 1994 Rosenkoetter reported a chief complaint of - auto accident in 1987, worse last 6 months with pain in the small of back and hip and legs.

The record included treatment entries in October 1995 for low back complaints. A 10-15-95 treatment note included: "Pat(ient) working today painting floors in flexed or stooped position. Sat down 2-3 hours ago \& got pain - left low back and hip and leg. Constant since then to left ankle."; the 10/15/95 further included - "Off work Bed". The next entry of 10/16 included that Rosenkoetter was somewhat better that morning - range of motion and stability had increased, less spasm, L4-5 interspace tender and taut. The 10/17 entry included that Rosenkoetter was feeling better, had mild to moderate ache in left leg without cramping or spasm, ?continued left leg numbness?; it was noted that Rosenkoetter had worked that day. The 10/18 entry included that Rosenkoetter had not gone to work; no leg cramping, stiff and taut at L45; weight bearing causes ?????.

The next entry of 10/19/95 entry, apparently written by Dr. Glen Calvin, D.O. stated that Rosenkoetter presented that day with severe pain in the lumbar spine running down her left leg, and that they would agreed that her disability began on 10-15-95. She has the potential for having a ruptured disk in the lumbar spine, it was written. In the handwritten entry dated 10/19/95, it was written that Rosenkoetter weighed 215 pounds and had a blood pressure reading of 148/102; also written was that Rosenkoetter had injured her back on 10-15-95 and was under Dr. Clark's care; it was written that Rosenkoetter needed a work disability form from her primary doctor as work would not accept Dr. Clark's. The 10/23/95 report of x-rays and a CT scan of the lumbar spine lumbar performed at St. John's Mercy Hospital. A last treatment note of 10/26/95, handwritten, apparently in Dr. Calvin's record indicated - disc lumbar spine, and pain in left leg continues.

1. Medical records of Karl A. Jacob, M.D. (Cl. Exh. E) began with a 10/30/95 initial office exam report, and indicated that the doctor treated the claimant for back complaints. A 12/14/95 operative report reflected that on that date, Dr. Karl Jacob performed the following operation on Rosenkoetter:

Lumbar decompression laminectomy with laser magnification and microdissection L3-4, L4-5 left for posterior decompression of the dura and cauda equina by undercutting of the lamina and the spinous process space of L3, L4 and L5, lateral recessed decompression by resection of the medial $1 / 2$ of the facet joints of L3-4 and L4-5 and the medical one half of the pedicle base of L4 and L5, L4 and L5 nerve root foraminotomies, partial corpectomy. Posterior lateral caudal margin of the vertebral bodies of L3 and L4 and L5, microdissection and laser lysis of vascular adhesions of the anterior and lateral wall of the vertebral canal and L4 and L5 nerve root. Disk removal L3-4 and L4-5 and posterior interspinous stabilization L3, L4 and L5.

The post-operative diagnosis was: Lumbar spondylosis with myelopathy, severe, L3-4 and L4-5. Spinal stenosis, L3-4 and L4-5. Left lateral recessed stenosis, L3-4, L4-5. Displacement disk, lumbar L3-4, L4-5 left. Cicatrix of the nerve roots L4 and L5 left.

A 1/17/96 follow-up entry reflected that Rosenkoetter was one month post left lumbar decompression laminectomy at L3-4 and L4-5 with posterior interspinous stabilization. It was noted that Rosenkoetter's leg pain had totally cleared. Medication was prescribed; it was written that Rosenkoetter was to return in one month and hopefully at that time she has lost enough weight that knee-shoulder flexion exercises could be started. A 2/26/96 entry included that despite all admonitions Rosenkoetter continued to gain weight rather than lose it. She is carrying too much weight for her back to tolerate it on a permanent basis, Dr. Jacob wrote, and further wrote that because of her weight she could not do the strengthening exercises.

In a 3/18/96 follow-up entry, it was written that Rosenkoetter seemed to be continuing to gain weight, and that she had complaints of discomfort in both lower extremities even when she walked just to go to the end of the driveway. It was further noted that Rosenkoetter was complaining about some sensory loss in the dorsum of the left forearm in the distribution of the cutaneous branch of the radial nerve since she awoke from surgery, numbness in this area was confirmed by pinprick, the doctor wrote. A radial never conduction test was scheduled. Dr. Jacob wrote in the 5/6/96 follow up entry that the radial nerve conduction time bilaterally was excellent and no problems. It was noted that Rosenkoetter still had numbness on the dorsum of the left forearm, but it was improving with time. Dr. Jacob finally wrote in the 5/6/96 entry the following:

The patient is discharged from follow-up as far as her lumbar spine is concerned. She is to do conditioning for approximately one month after which she can return to work with a 25 pound limit weight lifting restriction. She is to do no lifting that involves bending over at the waist. She should continue a weight loss program since I've told the patient and her husband who accompanied her to the examining room that this is vital to maintenance of her back over a long period of time. If she has any further difficulty in the future, we would be happy to see her again. Otherwise, she is discharged from current follow-up.

Dr. Jacob's record included additional treatment/examination reports beginning with a 06/18/97 re-examination report in which the doctor wrote:

This is a re-examination of this 51-year-old patient of Dr. Glen Calvin who has had right lower extremity pain progressive and involving the area of the distal thigh and the knee, as well as below the knee. A month and a half ago she saw Dr. Rende regarding the right knee. An MRI was negative and the orthopedist said that he thought the pain was related to the patient's back and referred her here.

The patient has had a rather precipitous weight gain since her last surgery for left-sided radicular pain which has now cleared. She has pain in the back of the right thigh and leg distally into the foot and ankle. This pain increases with walking. It does not increase with coughing, sneezing, bending or lifting. She has no bowel or bladder symptoms.

It was noted that Rosenkoetter had a family history of her mother being a diabetic. Dr. Jacob's written impression on 6/18/97 was: 1. Lumbar spondylosis with myelopathy; 2. Rule out displacement disc, lumbar, L3-4, right; and 3. Morbid obesity. An MRI of the spine was scheduled, and Rosenkoetter was to return for follow-up.

The next examination report in the record was dated 04/01/98, and Dr. Jacobs wrote that Rosenkoetter was a patient of Dr. Calvin as she had reinjured her back at work three months ago bending over putting cushions in a box and heard a popping of her back and pain radiating to the right lower extremity. The pain became progressively worse in

spite of conservative management, Dr. Jacob wrote, she can no longer work at her regular employment because of the pain. Dr. Jacob reported similar examination findings, and the diagnoses remained the same as on 6/18/97. There were no written treatment recommendations.

The next and last document in Dr. Jacob's record was a 5/24/99 report of an MRI of the lumbar spine. The history noted in the report was: "Lumbar surgery 3 years ago. Recent falls at work with low back pain and left lower extremity radicular pain." The written impression was:

1. Transitional lumbosacral segment which has been referred to as transitional $1^{\text {st }}$ sacral segment (appears to be sacralized bilaterally, there appears to be a rudimentary nonfunctional disk space cauded to the disk space);
2. Postsurgical changes on the left at L3-4 and L4-5; and
3. Severe degenerative disk disease at L3-4, L4-5 an L5-S1. Disk protrusion latralizes to the right within the canal at L5-S1. Abnormality extends laterally in the canal into the foramen on the left at L4-5 as discussed above. There is some encroachment left greater than right at L3-4.
4. Records of Dr. Glen D. Calvin, D.O. of Calvin Medical Center (Claimant's Exh. No. B) reflected treatment of Rosenkoetter for various ailments (i.e. cough, congestion, pharyngitis, otitis) during the period of March of 1996 through March of 1999. The following are examples of treatment entries. 2/10/97 - acute viral syndrome with secondary problems, symptoms are headaches, eye pain, cervical spine pain, back pain, sneezing, coughing; treatment included Ultram. 2/24/97 - complaints of severe headache and cough, patient states she is not able to work at this time; diagnosis was bronchial pneumonia or pulmonary vascular congestion, and Rosenkoetter was sent to Missouri Baptist Hospital under Dr. Shen's care. 2/28/97 - Rosenkoetter was seen for follow-up on Proventil inhaler. 3/3/97 combination of congestive heart failure, bronchitis, pneumonia and difficulty breathing, return to see Dr. Shen ASAP. 4/3/97 - seems to have an exacerbation of her right shoulder, I think she has a torn tendon of her right shoulder but she refuses to have an MRI, sending her to Dr. Stetson for work up, here with severe shoulder pain and severe degenerative arthritis in shoulder. 5/5/97 - complaints of pulled muscle in left side mid-back for 24 hours after lifting on carpeting; typed entry included that exam revealed severe spasm of the TS and neurological was essentially neg, and was started on Anaprox and Ultram for pain, and therapy. 5/9/97 - continued back pain; written was - "..she had surgery from Dr. Jacobs approx 2 years ago and she was told that there would be a possibility that she would have to have the other side operated on and she states that it has come to the pt. where she thinks that she needs to go back to see him because of the discomfort in the LS and (therapy) is not helping that much and also she is having a lot of family diff. And we will put her on Paxil" (sic); the diagnosis was - LS strain and Sit. Depression. 5/15/97 - treated for viral syndrome with ear infection, and given a slip for work. 5/29/97 - lifted on 5/27/97 two 15-lbs of liquid soap and strained upper back and neck and has severe muscle spasm on exam with cervical spine strain and upper back strain, physical therapy was given and medication of Ultram, and given slip to go back to work the next day. 6/16/97 - complaints of head and chest congestion, "will continue her on antibiotic and Claritin and we will give her breathing treatment today of Preventil and RTW on 6/23/98-She states that she is so run down that she cannot return to work". 6/30/97 complaints of continued sinus pressure and drainage for 24 hours which came on after working in hay field all day, treatment was continued Claritin and repeat round of antibiotics and RTW that evening if feeling fine. 9/16/97 - "Acute LS strain with muscle spasm and having problems with lifting and had stabilization rods put in her back and now she is lifting again and having severe pain"; handwritten 9/16/97 entry noted - mid and low back pain for 2 days, states strained while lifting heavy pots at family reunion on 9/14/97. 9/19/97 - treating her all week with an acute LS strain with previous surgery and back injuries, she is seeing Dr. Jacobs, we have been treating since 9/16 and allow her to RTW on 9/22 and ask if all possible that she do no heavy lifting but we will let her have a trail of work; "Some improvement, but DX is reoccurrence of an acute LS strain with symptoms of ruptured disc in the LS".

The next entry in Dr. Calvin's record after 9/19/97 was an 11/20/97 entry in which the following was written: "Seen with c/o of LS pain and goes down into the rt. leg. States hurt this while bending and lifting a box while at work". Examination findings were: some LS pain radiating into the rt. lower extremity, palpation of LS area reveals a fairly moderate to large sized lipoma which produces more pain and especially into the rt. lower extremity; therapy was started and referral to Dr. Rao for possible excision of lipoma of the rt. LS area. 12/4/97 - complaints of bad pain in the lower rt. present for some time, is under the care of Dr. Jacobs for this who is thinking about surgery apparently on the back, here today due to the unrelenting discomfort, would like to put her on Ultram until she can get in to see Dr. Jacobs; DX probable ruptured disc of the LS. 1/6/98 - here with acute pyeloneuphritis, needs slip for work and to return in near future; no other significant findings. 1/9/98 - no show for appt. 1/27/98 - complaints of vomiting, fever, cough, body aches, ear pain, sore throat; referred to Dr. Chen due to chronic nature of the positive findings; DX was - 1. acute otitis media, 2. acute pharyngitis, and 3. bronchitis. 1/30/98 - doing much better however still has resolving cough; DX resolving bronchitis and otitis. 2/10/98 - complaints of vertigo, chills, fever and ear pain for last 2 days; has been putting up with these symptoms now since Jan 23, started on Lorbid and referred to an ENT specialist.

After 2/10/98, the next entry was dated 4/9/98, and included - "Here today with an acute anxiety episode with chronic problems with carpal tunnel, chronic degenerative back disease, possible ruptured disc", has some previous stabilization surgeries; "We recommend that she have further work up if her workman's comp. will approve of it"; she will be placed on BuSpar for mild anxiety; no other significant findings. 5/19/98 - treated for diagnosis of fungal infection of the right foot; 5/28/98 - advised to stay off feet; 6/9/98 referred to pediatrist and kept off work until then. The next entry of 6/16/98 indicated - treated for DX of Acute pharyngitis, and Sinusitis.

9/1/98 - complaints of pain and edema in left knee for 1 day; this is a re-injury 6/98 with Dr. Kef alas; patient noticed symptoms after pushing in brake on a tractor; the typed $9 / 1 / 98$ entry included that this was a reinjury from a fracture, that she had a knee brace in place for patella support, x-rays were negative, and the diagnosis was - contusion of the left knee. The claimant was treated for Bronchitis on 11/24/98 and 12/8/98, and for Sinusitis and Resolving bronchitis on 12/18/98.

The next entry of 1/6/99 included in the handwritten section - "c/o of left hip pain. No known injury. X-6 months."; the typed 1/6/99 entry stated that Rosenkoetter presented with low back pain radiating into the left hip, x-rays showed degenerative disease in the hip socket, it was written that she "has severe osteoarthritis, scoliosis of the spine" and she has had previous surgery in the past; the plan was evaluation by an orthopedist. January 1999 entries (2) concerned treatment for Chronic bronchitis and for Acute viral gastritis. 2/2/99 - complaints of lower back pain for one day, noticed after picking up laundry basket; the typed 2/2/99 entry noted - complaints of left lower back pain, physical exam reveals spasm in LS area more on the left than right and no neurological deficits; therapy was to be started, and Rosenkoetter was to be returned back to work that evening; the DX was - LS strain. The final entries of 3/3/99 and 3/9/99 concerned treatment for symptoms of bronchitis and pharyngitis.

6.Medical records of Dr. John Kef alas, M.D. (Claimant's Exh. No. F) concerned the treatment of Rosenkoetter from 2/26/98 - 5/5/99. The 2/26/98 entry reflected the chief complaint as - right knee injury. It was written that Rosenkoetter relayed that while at home she had fallen sustaining a twisting injury to the right knee. The diagnosis after x-ray and physical examination was - Acute right knee injury with probable patellofemoral subluxation possible, and Quadriceps tendon injury and possible meniscal injury. Rosenkoetter was placed in a neoprene sleeve, was taken off work, and was to return in 2 weeks. The next entry of 3/12/98 included that Rosenkoetter relayed her knee symptoms were slightly improved, and that she had re-injured her right long finger recently at home. The plan was to observe the right long finger with instructions for digital motion, and for the knee continued use of the neoprene sleeve, quad and hamstring strengthening exercises, and return in 5 weeks; it was written that Rosenkoetter could return to regular duty at work as of $3 / 23 / 98$.

The next entry of 6/17/98 noted that Rosenkoetter reported that on 6/16/98 she had missed a step and fell on her wood porch at her home, landing directly on the anterior aspect of the left knee. It was noted that radiographs from her emergency room visit the day before showed a question of a possible proximal left tibial plateau fracture; the diagnosis was left tibial plateau fracture, and the plan was a continuation of non-weight bearing with a walker, starting therapy for this, a knee immobilazer, return in 2 weeks, and no work. In the next entry of 7/1/98, examination findings were: left knee is minimally tender over the proximal tibia, no effusion, nontender anteriorly over the patella, tender over the medial joint line, neurologic function is unchanged (the distal neurovascular function is normal). It was written that repeat radiographs failed to reveal any obvious tibial plateau fractures. The plan was to continue weight bearing as tolerated, a neoprene sleeve, and follow up in 3 weeks. In the next entry of 7/22/98, it was written that Rosenkoetter relayed her symptoms were slowly improving; the plan was for weight bearing as tolerated, weaning herself from the walker, continue using the knee splint, physical therapy for range of motion and strengthening, no work, and return in 4 weeks. In the 8/19/98 entry it was written that Rosenkoetter still noted achiness in the knee. Exam findings were - no effusion, full extension and flexion to 90 degrees, collateral ligament are stable, and tender over the patellofemoral joint and medial pes bursa. The plan was continuing strengthening on her own, Motrin, a new Ace bandage was applied, follow-up in 6 weeks, and Rosenkoetter was returned to regular duty at work on 8/20/98. A 12/4/98 entry stated that per patient's disability form she was now seeing Dr. G. Sort at Orthopedic Associates.

The next entry of 3/17/99 noted Rosenkoetter relayed that on 3/15/99 while at home she sustained an injury to the left knee, ankle and foot after she fell after becoming dizzy. Further written was: "She states she twisted her left ankle and knee. Denies back pain or any other musculoskeletal complaints. She states the dizziness has improved.". It was noted that radiographs of the left knee, the left ankle and the left foot showed no obvious fractures. The impression was: 1. Left knee contusion, 2. Left ankle sprain, and 3. Left foot sprain. The treatment plan was the application of an aircast and a knee immobilizer, Celebrex was prescribed, no work, and follow-up in 2 weeks. The 4/7/99 entry included that Rosenkoetter relayed she had removed the knee immobilizer as her left knee had improved; she was still using the

aircast on the left and still noted left heel and ankle pain. After examination, the treatment plan was to continue with Aircast, if symptoms in the heel persisted then repeat radiographs of calcaneus, follow up in 4 weeks, new prescription of Celebrex, and return to regular duty at work on 4/7/99. The 5/5/99 entry, the last entry, indicated that Rosenkoetter missed the appointment.

1. Medical records of St. John's Mercy Hospital in Washington, Missouri (Cl's Exh. I) consisted of physical therapy progress notes upon referral of Rosenkoetter by various doctors beginning in June 1997. A 6/16/97 Initial Evaluation sheet reflected that Rosenkoetter had been referred by Dr. Bassman for rotator cuff tendonits. It was written that Rosenkoetter reported "she has (R) shoulder pain for the past several years. Initially she reports her shoulder getting pulled when she was holding a chain and a relative pulling the other end suddenly. She states that she has been to an MD several times for this, however her focus had been on her back surgery.". It was noted that Rosenkoetter was working full time in a factory making seats for mini vans, and this involved lifting, pushing, pulling and holding a spray gun which she is able to use 2 hands for. It was noted that Rosenkoetter reported no numbness or tingling in the upper extremities. Assessment was chronic right shoulder tenderness and rotator cuff tendonitis, and physical therapy treatment was for 6 weeks centering on the right shoulder.

The record reflected that Rosenkoetter was referred by Dr. Kefalas in July 1998 with a diagnosis of status post left proximal tibia fracture. Written was that Rosenkoetter relayed she had fallen on June 16, 1998 and sustained a proximal tibia fracture. It was noted that Rosenkoetter had been in a knee immobilizer for about 5-6 weeks, and was now full weight bearing within the last 24 hours; it was noted that Rosenkoetter worked at Integram but was currently off due to this injury.

1. Medical records of Dr. George O. Sort, M.D. of Orthopedic Associates, Inc. (Emp./Ins. 4) began with a September 3, 1998 evaluation report by Dr. Sort to Dr. Calvin after referral of Rosenkoetter for evaluation of pain in the left knee. Dr. Sort wrote about the history relayed by Rosenkoetter, which included the following:

...about two months earlier she had broken her leg, and had pointed to the proximal tibia area. She apparently fractured this when she stepped off of a step at her daughter's and hurt her leg. She was treated with crutches and a cylinder extension splint. She said that the leg healed and she was doing pretty good until just a couple of days ago when she was riding on the tractor and she pushed in on the brake and she felt something pop in her left knee and since then has had a lot of pain in the knee, not in the area where she had the prior broken leg. She points to the medial side of the joint where she is noting the pain at this time.

It was noted that Rosenkoetter was working at that time. After examination and x-rays, Dr. Sertl's diagnosis was: 1. Left knee pain; 2. Tear of medial meniscus; 3. Degenerative arthritis; 4. Prior fracture of proximal tibia; and 5. Exogenous obesity. An MRI of the left knee was recommended. Dr. Sort wrote that Rosenkoetter was unable to return to regular work

The record indicated that Rosenkoetter was seen on follow-up on 9/17/98 and reported that since last seen she had hurt her knee again when she bumped against something. Dr. Sort wrote that the MRI showed some evidence of increased intensity in the posterior horn of the medial meniscus, but there was no evidence of a tear. Exam findings included: tenderness about the knee; no effusion and no ligamentous instability; no real localized area of pain is noted anymore at this time. The diagnosis was: Left knee pain; Sprain of left knee; and Degeneration of medial meniscus. Rosenkoetter was continued at "unable to return to regular work" status, and was to return in 2 weeks. In the final treatment entry of 10/01/98, it was written that Rosenkoetter reported that she thought she was improving with therapy. After examination, the diagnosis was: Left knee pain, resolving; Sprain of knee; and Degeneration of medial meniscus status post fracture proximal tibia. Dr. Sort wrote that physical therapy would be continued for an additional two weeks, Rosenkoetter would then be re-evaluated, and if all had gone well she would be allowed to return to work at that time.

Dr. Wayne Stillings, M.D. testified by deposition on behalf of the employer/insurer (Emp./Ins. Exh. 3). A board certified psychiatrist, Dr. Stillings stated that the components of his evaluation consist of: the claimant's age, marital status, "a lifetime psychosocial history from birth until the present", educational and work backgrounds, her past medical history, her present complaints; a review of the medical records; and testing. Stillings Dp. pg. 7) At his deposition, Dr. Stillings' evaluation report of August 14, 2002 was marked as Employer's Exhibit B, and was admitted into evidence without objection and on the stipulation that the doctor would testify in accordance with his report; Dr. Stillings noted in his report dates of injuries for the claimant for his August 14, 2002 psychiatric independent medical evaluation of - 11/23/94, 9/15/95, 11/18/97, 2/19/98, and 3/14/99.

Dr. Stillings discussed what he thought were the salient features of Rosenkoetter's history:

"Miss Rosenkoetter had a 25-year marriage, and divorcing in 1987 because she was emotionally and physically abused by her first husband. And I think this was a psychologically difficult, and somewhat damaging marriage for her, and it still - she still had scars from that.

I think it's important to note that she was a somewhat vague historian, and somewhat reluctant to talk about her personal psychiatric history, to the extent that she would like to attribute all of her current emotional features and emotional state to the various work-related injuries that are listed in the front of my report.

I think it's also very important to note that Miss Rosenkoetter has never sought any kind of mental health care during her lifetime in a work-related fashion, or otherwise.

She did report that her nerves were bad quote, 'My nerves was bad,' unquote, per Miss Rosenkoetter. (Dr. Stillings agreed that she was describing a mental state rather than a physical condition)

And she had taken some medications through HealthLine sometime in the past, that she thought were beneficial on calming her.

And she attributed her nervousness, correctly or incorrectly, to being harassed at work. It's noteworthy Miss Rosenkoetter has not worked at Integram, where she worked for about eight years, she has not worked there in greater than three years, and she has not been harassed, in her own perception, in greater than three years.

She also said that her nerves were, quote, 'bad,' unquote, due to back pain, and, quote, 'because they are,' unquote.

And she notes that she was somewhat unhappy, or sad, if you will, because she did not have an independent income, and did not have as much money to spend on her children and grandchildren.

When I saw her she was not taking any type of nerve, or psychotrophic medication, and she described her life at home with her husband as somewhat quiet and docile. She spends a lot of time in her room. Really seems to be somewhat withdrawn.

She and her husband live on a 180-acre farm.

And she has a general distrust of people, even family members, and part of this is related to being assaulted by her brother-in-law in 1995." (Stillings Dp. pp. 8-10)

Dr. Stillings discussed what Rosenkoetter's mental status examination revealed:

"Miss Rosenkoetter was an alert, somewhat rude, passively uncooperative, non-communicated, obese, casuallyattired white female.

She avoided talking about psychosocial stressors in her life, other than her perception of work-related situations.

She attempted to attribute all of her problems to her employment with Integram. She answered many questions by stating, quote, 'I don't know,' closed quote, making no effort to respond. Her speech was sparse.

She displayed psychological distress in the form of crying, and physiologic re-activity in the form of flushing and agitation when discussing the emotional abuse she suffered in her first marriage.

She was disinterested in the evaluation, and had very little eye contact with the examiner. Initially, her affect was matter of fact, but later became somewhat dramatic and labile.

In general, her affect was cold and detached. No psychological distress nor physiologic re-activity was manifest in regard to the work incidents known as sequelae, at Integram.

Her mood was variable. At times was angry and assailed the quote, 'workers' compensation doctors,' closed quote. At other times she appeared sad.

She denied hallucinations, delusions, obsessions, compulsions, phobias, suicidal and homicidal ideation.

She was fully oriented to time, place and person. Recent and remote memory functions were in tact.

Cognitively, she functions in the normal range. Verbal comprehension was fair at best. Concentration was fair. Intellectual functioning was in the normal range. Insight and judgment are questionable." (Stillings Dp. pp. 11-12) (Ruling: Claimant's objection on grounds of repetitious is overruled. Stillings Dp. pp. 10-11,15)

Dr. Stillings discussed the results of the testing he had performed on Rosenkoetter:

"The revised Oswestry reveals that this individual reported low back pain in the cripple region, which is inconsistent with her medical status, in that she's not crippled.

The 15 -items test results are that this individual's fairly claiming that her pain levels are impairing her concentration and memory functions.

MMPI test results are as follows: The overall profile should be approached with caution, and may reflect distortion due to confusion, and delusional thinking, or an attempt to over-report subjective symptoms. Assuming the latter is not true, the overall profile is consistent with schizoid personality disorder, with depression as a

central feature.

She may express her sadness and open tearfulness. She's likely to have a retarded stream of thought. And 70 percent of individuals with this profile are judged to be psychotic, which is supported by the elevations on the 8-6 scale. That's a specific psychotic scale on the MMPI.

The expression of psychological conflict to somatic or physical channels is encountered very frequently among individuals generating this profile.

She's likely to view her problems and her disorder as being physically ill, and she's likely to be defensive about admitting any psychiatric component.

She's also likely to avoid close interpersonal relationships, which is a cardinal characteristic of individuals with this profile.

She will strive to keep people at a distance, and involvement of any intimate sort with others as threatening, yet 70 percent of the individual with this profile are married.

This individual will view others with mistrust, and their motivations will be questioned. She has conflict about emotional dependency, and pressure with a general irritable manner or tone. Others will describe her as tense, high strung, anxious, and jumpy.

She is prone to obsessional thinking and repeated ruminative pre-occupation. Her thinking is unoriginal, and problem solving is stereotypic, rather than flexible.

She's likely to be quite forgetful, and under-assertive. She reports conflict of authority figures, and has chronic longstanding social and self-alienation.

She has a paranoid flair to her personality, and is likely to blame others in external situations for her personal problems, and short-comings in life.

She's likely to feel that she has been misunderstood, and has gotten a raw deal from life. She views the world as a threatening place. Feels that others have unfairly blamed, or punished her, and may even have delusions of persecution. She reports family problems and is somewhat compulsive. She has somatoform features to her personality, as understood by elevations on HY4, SC3, TSX and GRPS. The depression subtle scale is normal." (Stillings Dp. pp. 12-15)

The doctor agreed, during cross examination by the claimant, that he interprets his own MMPIs.

Dr. Stillings testified about his diagnosis after evaluation of Rosenkoetter:

"On axis one, which is reserved for primary psychiatric problems and disorders, she has no primary psychiatric disorder. Axis two, which is reserved for personality disorders, and developmental disorders, Miss Rosenkoetter is diagnosed with personality disorder not otherwise specified, with pronounced schizoid features, as well as depressive, paranoid, and somatoform.

"Axis III is reserved for medical conditions, and in Miss Rosenkoetter's case, she has morbid obesity, hypertension, and congestive heart failure.

Axis IV is reserved for psychosocial stressors, and her stressors are being unemployed in a solitary existence.

Axis V is global assessment of functioning, or GAF, if you will, as an acronym. And her GAF is 55, which means that she is occupationally able to function, but she has some moderate psychiatric symptoms, such as a flat affect, or a sad affect." (Stillings Dp. pg. 15, 16)

Dr. Stillings agreed that the work-related component, what work may or may not have caused from a psychiatric standpoint, is revealed in Axis I. The doctor was asked if the Axis II diagnoses were a result of a work-related injury or something that made up her personality. Dr. Stillings answered: "Yes, it would not be occupationally related by definition. This would be a combination of her genetic constitution, and also, her early life experiences. Personality disorders, by definition, are present and fixed, and enduring by late adolescence, or early adulthood." (Stillings Dp. pp. 15-16) The doctor agreed that the personality disorder, which is Axis II, is pre-exiting, the doctor agreed that Axis III is also preexisting. Dr. Stillings agreed that Axis V, the GAF, took into account everything, Axis I through IV. With respect to her GAF score of 55, the doctor stated: "..this would mean that she probably doesn't function as well as the average person occupationally, or socially. But it doesn't preclude her from working. She is still occupationally functional.". (Stillings Dp.pg. 17)

Dr. Stillings testified as to his opinions in regards to Rosenkoetter. a. Whether or not Rosenkoetter's employment at Integram produced any type of psychological diagnosis: "Her employment at Integram did not cause her any type of psychiatric problem, or diagnosis". (Stillings Dp. pg. 18) b. Whether or not Rosenkoetter's employment at Integram produced any permanent partial disability: "As a result of her work-related aggravation of her pre-existing and coexisting personality disorder, Miss Rosenkoetter has a two to three percent permanent partial psychiatric disability." (Stillings Dp.

Pg. 18) It was noted that Dr. Stillings had not provided in his evaluation report of 8/14/02 a rating of disability for any preexisting psychiatric disability which may have existed; the doctor testified, without objection -"My opinion is that Miss Rosenkoetter has a 10 percent permanent partial psychiatric disability as a result of the pre-existing personality disorder." (Stillings Dp. pg. 20) c, With respect to the Rosenkoetter's claim of mental stress as a result of her employment at Integram and whether or not she is in need of any further psychiatric treatment - "She is not in need of any treatment related to her employment with Integram." (Stillings Dp. pg. 19) With regard to the work-related aggravation of her preexisting personality disorders - "And that set, she doesn't need treatment either." (Stillings Dp. pg. 19) d, Whether or not Rosenkoetter's employment at Integram left her in any way unable to work - "Her employment at Integram did not impair her from an occupational standpoint. In other words, she's just as able to work now as when she was at Integram, or before she worked at Integram." (Stillings Dp. pg. 20) The doctor agreed that at least as of the date when he saw Rosenkoetter, which was in August of 2002, she was capable of working in the open labor market.

Dr. Stillings testified a second time by deposition on April 28, 2004. (Emp./Ins. Exh 8) Since my first deposition in this case, Dr. Stillings stated, I was forwarded and reviewed a copy of Dr. Crane's records from 5/2/03 through 9/29/03. The doctor was asked, after having reviewed Dr. Crane's record did he deem it necessary to reevaluate Rosenkoetter. "No", Dr. Stillings answered. (Stillings 4/28/04 Dp. pg. 6) The records of Dr. Crane did not affect my opinions as previously set forth in my previous deposition testimony, Dr. Stillings said. The doctor was asked the significance he had attached to the records of Dr. Crane, and Dr. Stillings answered: "Well, I think the significance is very simple. She improved some with his psychiatric administrations." (Stillings 4/28/04 Dp. pg. 6) Dr. Stillings explained the basis upon which he felt Rosenkoetter had improved with treatment by Dr. Crane:

"Well, when I saw her GAF or global assessment of functioning was 55, Dr. Crane near the end of treatment or at some point during treatment had assigned her a GAF of 60 . So really she's gone from moderate symptoms to slightly moderate symptoms. If you assigned her a 61, then she would have minimal symptoms. So she's real close to falling into another category of a much better prognosis and just a better outcome for her." (Stillings 4/28/04 Dp. pg. 8-9)

Testifying as to his continuing diagnoses, Dr. Stillings stated: "The continuing diagnoses are on axis - nothing on axis one. Axis two, personality disorder, not otherwise specified with schizoid features, depressive features, paranoid and somatoform features." (Stillings Dp. pg. 7) Dr. Stillings was asked to testify as to his opinion of whether or not Rosenkoetter suffered from a diagnosis of major depressive disorder:

"I do not feel she qualifies for the diagnosis of major depressive disorder based on application of the DSM-IV criteria. And this is based - now, those are subjective criteria. On an objective basis, her diagnostic testing on the MMPI does not support that diagnosis either." (Stillings 4/28/04 Dp. pg. 7)

The doctor further explained why Rosenkoetter's condition did not support the diagnosis of major depressive disorder:

"Her code type is an 82/28 and those code types are generally found in people who are schizoid, have personality disorders, have some quasi-psychotic symptoms. It indicates she has emotional distress but not particularly depressive in nature." (Stillings 4/28/04 Dp. pp. 7-8)

Dr. Stillings was asked to explain the difference between a personality disorder, as he had diagnosed, versus a depressive or mood disorder as diagnosed by Dr. Crane:

"Yeah, personality disorders are really an expression of an individual's features or characteristics of their personality, whether they're, for instance, shy or gregarious or outgoing or if they have some paranoid features. So you really are looking at sort of the mixture of their features of their particular makeup as a human being. A mood disorder is a very specific highly defined psychiatric disorder where the essential feature is, of course, a low mood." (Stillings 4/28/04 Dp. pg. 8)

Dr. Stillings stated that after reviewing the records of Dr. Crane his opinions regarding the nature and extent of Rosenkoetter's permanent partial disability did not change in any way. My opinions regarding Rosenkoetter's ability to work did not change, the doctor said. Dr. Stillings was asked his opinion as to whether his opinion of 2-3\% permanent partial disability from a psychiatric standpoint he had assigned as a result of Rosenkoetter's work injuries would preclude her from working or finding employment in the open labor market. "My opinion is that it would not", Dr. Stillings answered. (Stillings 4/28/04 Dp. pg. 9)

John B. Crane, M.D. testified by deposition (Cl. Exh. R[14]) and stated that he is a board certified psychiatrist, and recently became a distinguished fellow of the American Psychiatric Association. Dr. Crane testified: "Well Mrs.

Rosenkoetter came to see me initially in May of '03, May 2 of '03. She was quite depressed at that time; and actually in looking at my records, I'm not sure whether she came on her own behalf. I think she did." (Crane Dp. pg. 7) I conducted a mental status evaluation of Rosenkoetter, Dr. Crane said, I did not do any other psychological testing. I also reviewed medical records, the doctor said. Commenting on how many times he saw Rosenkoetter, Dr. Crane testified - "Between that first visit and August 18 of '03 - let's see, one, two, three, four - four visits." (Crane Dp. pg 9)

Dr. Crane agreed that on the date of his evaluation his diagnosis was depression and he provided Rosenkoetter with some medications. The doctor agreed that his Axis II diagnosis was symptoms of dependent personality. When queried wasn't it true that he was still continuing to treat Rosenkoetter, Dr. Crane answered - "That's correct". (Crane Dp. pg. 60) The doctor was queried if he was continuing to treat Rosenkoetter under the impression that he could make her better. "One hopes so", Dr. Crane answered. (Crane Dp. p. 60) The doctor was queried if it wasn't correct that depression is something that once a person has it they are more prone to relapse or recurrence. Dr. Crane answered: "Generally speaking, yes. That's correct." (Crane Dp. pg. 62)

On examination by the claimant, it was noted that Dr. Crane had mentioned in his report something about future medical care, and the doctor was asked what if any future psychiatric care was Rosenkoetter going to require. Dr. Crane responded: "This lady is likely to require long-term anti-depressants, treatment, and possibly some psychotherapy along the line depending on things that happen in the future, things that may happen in the future." (Crane Dp. pg. 57) (Ruling: Employer/Insurer's and/or Second Injury Fund's objections on grounds of Seven Day Rule are overruled. Crane Dp. pp. 57 and 58) Dr. Crane explained "the definition of psycho therapy is talking therapy, and it is aimed at helping a patient deal with stresses that may bear upon their mental status." (Crane Dp. pg. 58)

In his August 18, 2003 report (Cl. Exh. R-1), Dr. Crane included the following:

Mrs. Rosenkoetter is an obese woman who appears essentially her stated age. She was generally cooperative with the examiner, although when seen initially she was irritable and angry and tended to be somewhat oppositional in answering questions. She initially expressed a "what's the use?" attitude and clearly felt that this evaluation would be no different from previous examinations that she has had over the last nine years. Initially she was tearful, her cadence of speech was somewhat childlike and her thought processes appeared to be slowed. With treatment this has improved and her affect is considerably brighter. She is not tearful during follow up evaluations.........

Notably, during the several sessions with this lady, she has become increasingly cooperative and friendly and this appears to have been a result of simply listening to her.

Dr. Crane noted that he was addressing specific questions presented to him, and included the following in his answers:

\#1. Mrs. Rosenkoetter's current Axis I diagnosis is Major Depressive Disorder, severe, chronic, improving with the use of antidepressant medications. On Axis II she presents some symptoms of dependent personality. Axis III would include diabetes mellitus, essential hypertension, chronic cardiovascular disease, severe generalized osteoarthritis, particularly in the low back, and status post bilateral Carpal Tunnel Syndrome. Axis IV is an assessment of the patient's current stress, which would be interpreted to be quite high because of her physical condition, employment condition, and financial condition. Axis V - Current GAF (Global Assessment of Functions) on a scale of 0-100, where 100 is "normal", is assessed at approximately 60. Patient's highest GAF within the past year is assessed as her current 60.

\#4. ......This lady has presented as angry, hostile, and irritable during some of her evaluations and in particular during her psychiatric evaluation with Dr. Stillings. These symptoms were interpreted as being due to severe Personality Disorder, a suggestion with which I disagree, and I believe they were primarily related to her Mood Disorder, although when severely dependent persons are confronted with this type of situation they frequently do become even more upset and angry.

Dr. Poetz evaluated Rosenkoetter on Rosenkoetter's own behalf (Cl's. H), and discussed in his June 10, 2002 evaluation report the work related injuries relayed by Rosenkoetter which included: February 19, 1998 - developed depression as the result of stress and harassment at work; Rosenkoetter claims in 1997 her boss and coworkers were taunting her by deliberately sending her defective parts so that she would have to repair them and they altered the speed of the line to the point that she was unable to keep up and they tampered with her food; when seen on February 19, 1998 for complaints of bilateral upper extremity pain it was noted that Rosenkoetter appeared depressed and was diagnosed with depression, Rosenkoetter denies further care of psychiatric evaluation. Diagnosis made by Dr. Poetz was: 2/19/98 -

Depression secondary to work related stress and harassment. Dr. Poetz opined that Rosenkoetter had 15\% permanent partial disability to the body as a whole due to depression directly resultant from the February 19, 1998 work related injury. During cross examination by the employer/insurer, Dr. Poetz agreed that the only history in his report that would have caused the condition he had diagnosed was stress and harassment at the work place. The doctor was queried you didn't have any history of there being marital problems or family problems or problems outside of work that could have caused or contributed to Rosenkoetter's permanent disability as a result of a psychiatric condition. "Not to my knowledge", Dr. Poetz answered. (Poetz Dp. pg. 41) It was noted that the specific history in his report was that depression as a result of stress and harassment at work; approximately 1997, the patient claims that her boss and coworkers were taunting her, deliberately sending her defective parts so that she would have to repair them, they altered the speed of the line to the point she was unable to keep up and they tampered with her food. Dr. Poetz admitted that he did not know how often these things occurred. The doctor was questioned, you indicated that they altered the speed of the line and did he know if the line had multiple people working on it, and Dr. Poetz responded - "I don't know if her specific station was able to be adjusted. I don't know that." (Poetz Dp. pg. 42) When further queried - so you don't know if the stress was put upon her at the work place was different than the subjective levels of stress that would have been imposed upon other folks at that place of employment. "I don't know", the doctor answered. (Poetz Dp. pg. 42) Dr. Poetz agreed that at the time he saw Rosenkoetter she was not on any medication for depression. I did recommend additional treatment as a result of her diagnosis of depression, the doctor said, SSRV, "selective seratonin inhibitors", an antidepressant medication. (Poetz Dp pg. 43) I did not prescribe this for her when I saw her, Dr. Poetz said. Depression is caused by "altercation of seratonin secretion by the brain as a result of certain stressful stimuli", Dr. Poetz explained. (Poetz Dp. pg. 44) Persons with a family history of depression are more susceptible to having their seratonin altered by means of eternal stressful stimuli, the doctor said. I don't know if Rosenkoetter has a family history of depression, Dr. Poetz stated. The doctor agreed that marital difficulties could be an external stressful stimulus for seratonin altercation if the patient feels it is the reason for their depression. Dr. Poetz agreed that he asked Rosenkoetter what were the causes or stimulus for her depression, and she said - work. I'm sure I made inquiries as to whether there were any stressors in her life outside of work, the doctor said. "I can tell you that after 40 years of experience of trying to determine how and why patients are depressed, that I am skillful at asking the right number of questions until I'm satisfied to the answer that I receive is significant for that patient's response", Dr. Poetz said. (Poetz Dp. pg. 46) Dr. Poetz responded - "I don't recall"when queried if he know how long Rosenkoetter had been married, how many times she had been married, if she was ever physically abused or emotionally abused, if her kids were ever emotionally abused. (See Poetz Dp. pp. 47-48) Dr. Poetz stated that he was familiar with the DSMIV, and agreed that it listed psychosocial stressors; the doctor agreed that psychosocial stressors can cause depression. Dr. Poetz agreed that marital discord was on the DSMIV list of psychosocial stressors as well as family discord, physical and emotional abuse. The doctor was queried about his evaluation of Rosenkoetter's mental status; Dr. Poetz stated that he did not need to do a Beck Depression Scale and did not do the MMPI. "I spent an hour with the lady and I make determinations when I, the depressive faces that she showed, by the things that she told me, and not only did I make a diagnosis based on an hour of studying the patient, but I also made recommendations as to her management of her depression", Dr. Poetz testified. (Poetz Dp. pg. 52)

Dr. Schlafly, who also evaluated Rosenkoetter on Rosenkoetter's own behalf, wrote that he would defer to a psychiatrist as to the extent of any psychiatric disability from work related depression.

Issued by THE LABOR AND INDUSTRIAL RELATIONS COMMISSION

Injury No.: 99-123209

Employee: Mary Ann Rosenketter

Employer: | Integram St. Louis Section |

Additional Party: Treasurer of Missouri as Custodian

of Second Injury Fund

Date of Accident: March 14, 1999

The above-entitled workers' compensation case is submitted to the Labor and Industrial Relations Commission (Commission) for review as provided by section 287.480 RSMo. Having reviewed the evidence and considered the whole record, the Commission finds that the award of the administrative law judge is supported by competent and substantial evidence and was made in accordance with the Missouri Workers' Compensation Act. Pursuant to section 286.090 RSMo, the Commission affirms the award and decision of the administrative law judge dated May 13, 2005. The award and decision of Administrative Law Judge Leslie E. H. Brown, issued May 13, 2005, is attached and incorporated by this reference.

The Commission further approves and affirms the administrative law judge's allowance of attorney's fee herein as being fair and reasonable.

Any past due compensation shall bear interest as provided by law.

Given at Jefferson City, State of Missouri, this $\underline{21^{\text {st }}}$ day of March 2006.

LABOR AND INDUSTRIAL RELATIONS COMMISSION

NOT SITTING

William F. Ringer, Chairman

Alice A. Bartlett, Member

John J. Hickey, Member

Attest:

Secretary

Employee: Mary Rosenkoetter

Injury No. 99-123209

Dependents: ---

Employer: Integram St. Louis Section

Additional Party:----

Insurer: CNA Insurance Company/RSKO

DIVISION OF WORKERS' COMPENSATION

Department of Labor and Industrial

Relations of Missouri

Jefferson City, Missouri

Hearing Date: $\quad 5 / 1 / 03,7 / 19 / 04$ and 7/20/04 (finally submitted 10/12/04) Checked by: LEHB/bfb for df

1. Are any benefits awarded herein? Yes
2. Was the injury or occupational disease compensable under Chapter 287? Yes
3. Was there an accident or incident of occupational disease under the Law?Yes
4. Date of accident or onset of occupational disease: March 14, 1999

1. State location where accident occurred or occupational disease was contracted: Franklin County, Missouri
2. Was above employee in employ of above employer at time of alleged accident or occupational disease? Yes
3. Did employer receive proper notice? Yes
4. Did accident or occupational disease arise out of and in the course of the employment? Yes
5. Was claim for compensation filed within time required by Law? Yes
6. Was employer insured by above insurer? Yes
7. Describe work employee was doing and how accident occurred or occupational disease contracted: Repetitive factory work
8. Did accident or occupational disease cause death? No Date of death? ---
9. Part(s) of body injured by accident or occupational disease: left and right wrists/hands
10. Nature and extent of any permanent disability: 17.5 % each wrist; and 15 % load factor
11. Compensation paid to-date for temporary disability: $\ 0.00
12. Value necessary medical aid paid to date by employer/insurer? $\ 140.10
13. Value necessary medical aid not furnished by employer/insurer? $\ 0.00
14. Employee's average weekly wages: ---
15. Weekly compensation rate: $\$ 397.60 / \ 294.73
16. Method wages computation: by agreement of the parties

1. Amount of compensation payable:

Unpaid medical expenses: -----

------ weeks of temporary total disability (or temporary partial disability)

17.5 % of the left and right hands permanent partial disability from Employer, or . \$18,052.21

2 weeksof disfigurementromEmployer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \$ 589.46

Multiplicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \$ 1,353.92

-----Permanent total disability benefits from Employer beginning, for Claimant's lifetime

1. Second Injury Fund liability: Yes X No Open . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The compensation awarded to the claimant shall be subject to a lien in the amount of 25 % of all payments hereunder in favor of the following attorney for necessary legal services rendered to the claimant:

Ray A. Gerritzen, Attorney for Claimant

Employee: Mary Rosenkoetter

Injury No: 99-123209

Before the

DIVISION OF WORKERS'

COMPENSATION

Department of Labor and Industrial Relations of Missouri

Jefferson City, Missouri

Dependents: ---

Employer: Integram St. Louis Section

Additional Party

Insurer: CNA Insurance Company/RSKO

Checked by: LEHB/bfb for df

This is a hearing setting for five cases involving the claimant, Mary Rosenkoetter, Injury Numbers 94-168476, 95-129017, 97483041, 98-175851, and 99-123209. In all five cases, the claimant, Mary Rosenkoetter appeared on her own behalf, and through counsel, Attorney Ray Gerritzen. In all five cases, the employer/insurer appeared by and through counsel, Attorney Tim Tierney. In four cases (Injury Numbers 95-129017, 97-483041, 98-175851, and 99-123209), the Second Injury Fund appeared by and through Assistant Attorney General M. Jennifer Sommers.

The parties entered into certain stipulations, and agreements as to the complex issues to be presented in these hearings. Memorandums of Law were filed by the parties.

Up to the date of March 14, 1999: a. the claimant while in the employment of Magna Interior Systems sustained an injury by occupational disease arising out of and in the course of her employment occurring in Franklin County, Missouri.

b. The employer and employee were operating under and subject to the provisions of the Missouri Workers' Compensation Law. c. The employer's liability was insured by CNA Insurance Company/RSKCo. d. The rate on the date of the occupational disease was $\ 397.60 over $\ 294.73. e. The employer had notice of the injury. f. A Claim for Compensation was filed within the time prescribed by law. g. No temporary total disability benefits have been paid. h. Medical was provided in the total amount of $\ 140.10.

1. Liability of past medical expenses
2. Future medical care
3. Nature and extent of permanent disability - whether partial or total

No. A: Deposition transcript of Bruce Schlafly, M.D., taken July 9, 2002 on behalf of the claimant, with attachments of: Exhibit A-1, the curriculum vitae of Bruce Schlafly, M.D.; A-2, the March 1, 2001 report of Dr. Bruce Schlafly, M.D. (8 pages); A-3, November 12, 2001 report of Bruce Schlafly, M.D. (1 page); A-4, four photographs taken by Dr. Bruce Schlafly of another patient, not Mary Ann Rosenkoetter, who had persistent problems following prior endoscopes carpal tunnel release and required repeat carpal tunnel release using the standard technique, Exhibit A-3 has the description; A-5, the medical literature provided by Bruce Schlafly, M.D. titled, quote, The Results of Revision Carpal Tunnel Release Following Previous Open Versus Endoscopes Surgery". A-6, the medical literature by Dr. Bruce Schlafly entitled "Persistent or Recurrent Carpal Tunnel Syndrome Following Prior Endoscopes Carpal Tunnel Release"; A-7, operative report of the December 7, 2001 left carpal tunnel release performed by Dr. Bruce Schlafly at St. Anthony's Medical Center; A-8 is the December 12, 2001 report of Dr. Bruce Schlafly (1 page); A-9, the May 6, 2002 report of Dr. Bruce Schlafly (2 pages); A-10, the operative report of the March 4, 2002 right carpal tunnel release performed by Bruce Schlafly, M.D., at St. Anthony's Medical Center; A-11, the statement of services of Hand Surgery Associates, P.C./Bruce Schlafly, M.D., in the amount of \$3,120.00 for services rendered November 12, 2001 through March 8, 2002; A-12, numerous letters addressed to Bruce Schlafly, M.D., and deposition notices of Dr. Bruce Schlafly relative to his carpal tunnel syndrome treatments. (Admitted subject to the objections therein.) (Ruling: Employer/Insurer's and Second Injury Fund's objections to Exhibit A-4 on grounds of, inadequate foundation has been laid, is overruled.)

No. B: Certified medical records of Calvin Medical Center

No. C: Certified medical records of Hand Therapy Network, certified March 15, 2001 (12 pages)

No. D: Certified medical records of HealthLine Corporate Health Services Metro St. Louis certified October 12, 1999 (72 pages)

No. E: Certified medical records of Karl A. Jacob, M.D. certified October 9, 1999 (43 pages)

No. F: Medical records of Dr. John Kef alas, M.D. certified October 7, 1999

No. G: Certified medical records of Missouri Baptist Medical Center certified January 19, 2000 (219 pages)

No. H: Deposition transcript of Dr. Poetz taken on behalf of the employee on April 28, 2003 (with attachment H-1, the doctor's June 10, 2002 report, 10 pages) [Admitted into evidence subject to the objections therein)

No. I: Certified medical records of St. John's Mercy Hospital in Washington, Missouri, certified May 4, 2000 (14 pages)

No. J: Certified medical records of St. John's Mercy Hospital in Washington, Missouri certified November 17, 1999 (8 pages)

No. K: Certified medical records of St. John's Mercy Hospital, Washington, Missouri certified July 16, 1997 (28 pages)

No. L: Certified medical records of Lesson Heights Orthopaedic \& Arthroscopic Associates certified November 10, 1999 (90 pages)

No. M: Medical bill of Pathology Associates, P.C., for services rendered December 7, 2001 and March 4, 2002 in the amount of $\ 41.00

No. M-1: Collection letter of Diversified Collection Services showing that $\ 27.00 of Exhibit M was turned over to collection

No. N: Medical bill of South County Anesthesia for services rendered December 7, 2001 in the amount of $\ 480.00

No. N-1: Medical bill of South County Anesthesia for services rendered on March 4, 2002 (the second surgery performed by Dr. Schlafly) in the amount of $\ 420.00

No. O: Medical bill of South County Radiologists, Inc. in the amount of $\ 20.00

No. P: Medical bill of St. Anthony's Medical Center for services rendered on December 7, 2001 in the amount of \$2,351.97

No. P-1: Surgical bill

No. Q: Prescription receipt of Heartland Discount Pharmacy in the amount of $\ 5.86 for Cephalexin, 500 milligrams prescribed by Bruce Schlafly, M.D.

No. R and R-1: Deposition transcript of Dr. John Crane, M.D. taken on April 8, 2004, and an August 18, 2003 report by Dr. Crane (Limited admission for these exhibits, only as to the issue of future medical care)

No. S: March 4, 2002 medical bill of St. Anthony's Medical Center, \$2,421.74

No. 1: Deposition transcript of Dr. R. Peter Mirkin, M.D. taken on behalf of the employer/insurer on 12/13/02 (Admitted subject to the objections therein)

No. 2: Deposition transcript of R. Evan Crandall, M.D. taken on behalf of employer/insurer on December 11, 2002 (Admitted subject to objections therein)

No. 3: Deposition transcript of Dr. Wayne Stallings, M.D. taken on behalf of the employer/insurer on 12-4-02 (Admitted subject to the objections therein)

No. 4: Certified records of Dr. George O. Sort, M.D.

No. 5: Records of Dr. Clark, D.C.

No. 6: Correspondence between the law offices of Gerritzen \& Gerritzen and Evans \& Dixon pertaining to the issue as to whether surgery had been authorized and when it had been authorized (a. November 20, 2001 letter from Paul Keeven to Mr. Gerritzen; b. November 16, 2001 letter by Mr. Gerritzen to Paul Keeven of Evans \& Dixon; c. October 15, 2001 letter from Mr. Gerritzen to Paul Keeven of Evans \& Dixon; d. October 5, 2001 letter from Paul Keeven to Mr. Gerritzen; e. April 23, 2001 letter of Michael Gerritzen to Paul Keevenn)

No. 7: First Workers' Compensation Claimant's Report dated 10-7-95, signed by Miss Rosenkoetter

No. 8: Deposition transcript of Dr. Wayne Stallings, M.D. taken on behalf of the employer/insurer on 4-28-04 (Admitted subject

No exhibits.

There is no dispute that the claimant sustained an occupational disease as a result of her employment with Magna Interior Systems (Integram) up to about March 14, 1999. There is no dispute in the medical opinions that the occupational disease the claimant sustained was bilateral carpal tunnel syndrome: a. Dr. Schlafly stated - Rosenkoetter's work at Integram is the substantial factor in the cause of the bilateral carpal tunnel syndrome and in the need for bilateral carpal tunnel releases; b. Dr. Crandall indicated that Rosenkoetter had sustained carpal tunnel syndrome in the left and right wrist as a result of her employment with Integram; and c. Dr. Poetz noted that his evaluation revealed Rosenkoetter's factory work at Integram from 1991 through 1999 was a substantial factor in the development of moderate bilateral carpal tunnel syndrome. The issue is liability for the bills generated by the treatment of the bilateral carpal tunnel syndrome occupational disease.

Section 287.140 RSMo pertains to the treatment for work related injuries, and states in pertinent part:

1. In addition to all other compensation, the employee shall receive and the employer shall provide such medical, surgical, chiropractic, and hospital treatment, including nursing, custodial, ambulance and medicines, as may reasonably be required after the injury or disability, to cure and relieve from the effects of the injury. If the employee desires, he shall have the right to select his own physician, surgeon, or other such requirement at his own expense.

Mary Rosenkoetter, the claimant, (who was found to be a basically credible witness though easily confused on historical facts at times), testified her wrists and hands bothered her for a while from performing her job duties, but she didn't know what carpal tunnel was. I just thought it was just repetition stuff, just sore, until my friend was talking about what carpal tunnel was, Rosenkoetter said. I went to the foreman and told him that my hands were really hurting, that I would like to have them checked out, and he sent me to HealthLine, the claimant stated. At HealthLine I saw a Dr. Crandall, a hand doctor, and they done nerve tests, the claimant said. The doctor did not give me any treatment, Rosenkoetter stated. She explained that the doctor had said she needed surgery because she had carpal tunnel and it was worse in the left hand than in the right hand. The doctor wanted to do that microscopic surgery in his office and do both of my hands at once, but I wouldn't been able to do anything and I told him I couldn't do that, Rosenkoetter testified. He didn't ask me if I had heart problems or nothing, he just wanted to set me up for the surgery in his office, the claimant said. I told the doctor I wanted a second opinion, she stated. I then went to see Dr. Bruce Schlafly, and Dr. Schlafly operated on both of my wrists separately, the claimant said, I wouldn't get them done at the same time. The surgeries were performed at St. Anthony's Hospital, the claimant stated, and the doctor did the open hand surgery on both wrists. Dr. Schlafly gave me about a month for the one to heal before doing the other surgery, otherwise I wouldn't be able to get dressed or tie my shoes or nothing, she said. Indicating that the surgery helped her hands and wrists, Rosenkoetter stated that the numbness has stopped, and on the inside of the palm of her hand down from her thumb on both hands was really always sore. Sometimes, though, my hands will cramp up, the claimant testified, and as a result I can't sew anymore, I can't hold the needle or anything. I used to make quilts all the time, I can't do that anymore, she said. My hands and wrists prevent me from being able to pick up a full skillet like I used to; I can't open jars, I don't have no strength, it didn't come back in my hands; it's just hard to pick up stuff with your hands, Rosenkoetter stated.

On cross examination by the employer/insurer, Rosenkoetter stated when she reported the problems with her hands to the employer and they sent her to Dr. Crandall for treatment. Dr. Crandall first treated me conservatively with some testing, physical therapy and splints for both hands, Rosenkoetter stated. Dr. Crandall wanted to do laser surgery, Rosenkoetter said. Dr. Crandall gave me the paper on what they did, and that I should have the microscopic surgery and they would do it in their office; I asked him if that wasn't risky, and he said no, it only takes forty-five minutes, he was going to do both my hands at one time, the claimant testified. Rosenkoetter was queried - if Dr. Crandall's file notes of 8-2-01 reflected that he offered her either an open or an endoscopic procedure, would that be inconsistent with her recollection. He gave me a paper that showed me what they did on both, but he recommended the laser surgery because he could do it in his office, and it only took forty-five minutes, and he could do both hands at once and it would be over with, the claimant answered. She stated that she was sure Dr. Crandall discussed both of the procedures with her. After this, Rosenkoetter agreed, I talked to a friend of mine about what the microscopic surgery was, and my son-in-law told me about Dr. Schlafly, that he was a good doctor, so I called him for a second opinion. The claimant stated that she did not recall if Dr. Crandall ever offered to do the endoscopic procedure on separate dates. When asked if she was ever advised by anyone that she was offered the opportunity to undergo the open procedures on separate dates, Rosenkoetter answered - Not until after I went to Dr. Crandall, that's when I went to Dr. Schlafly. After I went to Dr. Schlafly, I do not recall the employer or the insurer ever offering me the opportunity to undergo open carpal tunnel releases on separate dates, the claimant said, Dr. Crandall just

wanted to do it in his office and do the microscopic. The claimant was asked if she recalled being called by Dr. Crandall's office on 11-26-01 at 2:42 p.m. to schedule open procedures. I wouldn't go there because I didn't trust them, the claimant answered, they were company doctors. Dr. Crandall didn't even ask me if I had heart problems or blood pressure or nothing, Rosenkoetter testified, I was scared if I went in and had it done, what if I would have died there. I didn't think that was a good idea having both of my hands done in an office, not even a hospital, an office; it just didn't sound right; I was scared of the surgery in Dr. Crandall's office, the claimant testified. The claimant was queried if she had trusted Dr. Schlafly, if she had wanted him to do the surgery. When I went to Dr. Schlafly, he told me that it was better to do the open hand, and it would be done, and I wouldn't have to get it done again, she answered, I wasn't crazy about the laser and I didn't want both of my hands done as I couldn't even take care of myself. I don't know if Dr. Crandall's office ever contacted me at home by phone on 11-26-01 at 2:42 p.m. to schedule open procedures on my hands, the claimant said. They were upset because I told them I didn't want the laser surgery done; but in the meantime I'd already called Dr. Schlafly and I asked him about what it was and if it was better, and he said yes. After that, the claimant was asked, did Dr. Crandall's office ever offer you the open procedures? If they did, I didn't do it, the claimant answered, and again explained that she didn't like the laser surgery, she didn't want to have both of her hands done at one time, and she didn't like the idea that the doctor didn't ask her her health problems then as most doctors do.

The claimant explained further how she ended up at Dr. Bruce Schlafly's office during cross examination. I was scared about the doctor taking me in the office, Dr. Crandall, and doing that laser surgery, because he didn't ask me about my heart condition or my blood pressure or no medical history, I don't remember him asking me unless I filled it out on paper, he just wanted to do both my hands, the claimant said. And then I'd heard from a friend that the laser surgery wasn't as good, that sometimes you have to go back and have it done again, and I wouldn't be able to dress myself or wipe my own self or take care of myself and I was worried about having the surgery done in his office. And my son-in-law said that he had gone to Dr. Schlafly to have a bone taken out of his arm and plastic put in, and I thought if he could do that, he would be good on my hands. And I wanted another opinion, so I called and got an appointment and I went to him, Rosenkoetter testified. Dr. Crandall had recommended laser surgery, Rosenkoetter said, and he got really mad at me because I wouldn't go ahead and have it done. The claimant agreed that she found Dr. Schlafly through a relative and went to him for a second opinion on her own.

Dr. Bruce Schlafly, M.D. testified on behalf of the claimant. (Clt.'s A) In his November 12, 2001 report, Dr. Schlafly stated:

I recommend the standard technique rather than the endoscopic technique. I enclose medical literature on this subject. I also enclose copies of photographs of another patient who had persistent problems following prior endoscopic carpal tunnel release, and required repeat carpal tunnel release using the standard technique. The photographs show that at surgery, the prior endoscopic carpal tunnel release had not fully released the transverse carpal tunnel ligament. A full release of this ligament is required in order to perform an effective carpal tunnel release.

Dr. Schlafly's record reflected that on 12/07/01 he performed on Rosenkoetter the procedure of a left carpal tunnel release with a pre- and post-operative diagnosis of left carpal tunnel syndrome, and on 03/04/02 he performed on Rosenkoetter the procedure of a right carpal tunnel release with a pre- and post-operative diagnosis of right carpal tunnel syndrome. In his last examination report of May 6, 2002, Dr. Schlafly wrote that Rosenkoetter reported that surgery helped both hands.

The doctor testified about his opinion on the difference between the standard, or open carpal tunnel, release versus endoscopic tunnel release: "In my opinion for carpal tunnel release it's better to visualize both the nerve and all the ligaments and to directly view those objects that you're cutting and the nerve itself and to make sure it's completely decompressed". (Schlafly Dp. pg. 9) Dr. Schlafly agreed that there have been instances where he has redone previous endoscopic surgeries, and noted that he has found during the procedure "(B)ands of ligament or ligament interspaced with scar tissue that are still compressing the median nerve and require release". (Schlafly Dp. pg. 10) Dr. Schlafly noted that an article by the authors from Department of Orthopedics at Brown University - "The Results of Revision Carpal Tunnel Release Following Previously Open Versus Endoscopic Surgery", printed in the reputable and widely read journal called The Journal of Hand Surgery - concluded that their results of their studies showed a higher incidence of incomplete release of the carpal tunnel with endoscopic surgery than with open release. On cross examination by the employer/insurer, it was noted that one of the points of this article was to say when you have to go back and redo the carpal tunnel, they suggest doing open versus endoscopic. "That was one of the points made, yes", Dr. Schlafly responded. (Schlafly Dp. pg. 20) Dr. Schlafly agreed that the article also talks about that you have to consider three possible causes for persistent symptoms, one of which is ulterior motives to remain clinically symptomatic.

Dr. Schlafly identified Deposition Exhibit K as his bill; the doctor agreed that it was his opinion the surgery he had performed on Rosenkoetter was reasonable and necessary to the work-related bilateral carpal tunnel syndrome. The doctor agreed that his was a reasonable charge for the services he had rendered to Rosenkoetter. The doctor agreed that it was his opinion what was indicated for Rosenkoetter was the standard release rather than the endoscopic release; when asked why, Dr. Schlafly's response was - "I don't recommend endoscopic release". (Schlafly Dp. pg. 17)

On cross examination, Dr. Schlafly agreed that he is a hand specialist; "I limit my surgical practice to hand and upper extremity, yes", the doctor said. (Schlafly Dp. pg. 18) Dr. Schlafly agreed that Rosenkoetter was sent to him by her attorney, not a referral from any doctor. The doctor was asked if he had ever done endoscopic procedures, and he answered - "No". (Schlafly Dp.

pg. 19) The following testimony was given by Dr. Schlafly on the question of whether or not endoscopic procedure was up to medical standard:

Q. Do you think it's within the proper standard of medical care to do endoscopic release?

A. I recognize that there two are two schools of thought on them in the medical community. (sic)

Q. Okay. So you would not say endoscopic releases are outside the standard of care, the proper standard of care?

A. Not in and of itself. (Schlafly Dp. pp. 19-20)

Dr. Schlafly agreed that he provided in his November 12, 2001 letter an explanation of his preference for open versus endoscopic procedure as well as the articles in support of his position in response to Attorney Gerritzen's November 8, 2001 letter in which he asked the doctor to explain his preference.

On cross examination by the Second Injury Fund, Dr. Schlafly was questioned - you saw Rosenkoetter at her attorney's request and treated her at her attorney's request? Dr. Schlafly answered: "Well, I think the treatment decision was hers. I initially saw her at her attorney's request, yes." (Schlafly Dp. pg. 70)

Dr. R. Evan Crandall, M.D. testified by deposition on behalf of the employer/insurer. (Emp./Ins. Exh. 2) Board certified in plastic surgery, with a subspecialty and certified in hand surgery, Dr. Crandall stated that he saw Rosenkoetter at the request of the employer/insurer. I initially saw her in 1998, the doctor said. "I thought that her, she would be best served with a conservative treatment program, since her nerve conduction studies were border line", the doctor said. (Crandall Dp. pg. 7) Agreeing that at a later date his opinion changed, Dr. Crandall testified:

"I saw her on the 6-19-01 and 8-23-01. It obviously had been several years since she had been treated conservatively and we had found that with a new study that her condition had worsened, despite the fact she had not been working. And because of this worsening of the numbness, I thought she was a candidate for surgery and stated so in my report of 8-2301." (Crandall Dp. pg. 7) (Ruling: Claimant's objection on grounds of - think this is what we stipulated and agreed he would testify to - is overruled. Crandall Dp. pg. 7)

Dr. Crandall agreed that he recommended surgery at that time, and that the surgery was authorized through the employer and insurer. I did not perform these surgeries, the doctor said.

During cross examination, Dr. Crandall denied that the only surgery he offered Rosenkoetter was endoscopic. Testifying as to where in his record he offered open surgery, Dr. Crandall testified: "On 8-2(3)-01[16]. I said it can be done open technique or the endoscopic technique, one hand being done at a time or both hands can be done at the same time". (Crandall Dp. pg. 14) Dr. Crandall admitted that he probably did recommend one technique over the other. The doctor further testified: "I think both are great procedures and they work, results are really good either way. And we just tell them what's available and then let them choose. And they usually know, because they have lots of friends at work that may have had it done." (Crandall Dp. pg. 14) Dr. Crandall stated it was correct that he did not have the same understanding as Rosenkoetter if she understood that he had said he would only do the endoscopic on her. "I wouldn't refuse a person to do it another way", Dr. Crandall stated. (Crandall Dp. pg. 15)

Dr. Crandall was asked, during cross examination by the claimant, if he knew of any patient that he had performed endoscopic procedure on and Dr Bruce Schlafly had to correct or further treat with open decompression. Dr. Crandall responded: "I'm aware that some patients have been re-operated on by Dr. Schlafly that I've done. Specific patient's name, I do not recall. I know our revision rate is less than one half percent, which is better than the national average, but that is fine." (Crandall Dp. pp. 1617) (Ruling: Employer/Insurer's and Second Injury Fund's objections on grounds of speculation and irrelevant are overruled. Crandall Dp. pg. 16) Dr. Crandall was shown four photographs (marked Dp. Exh A) and asked if he had ever seen them before; the doctor further testified: "I have seen that, yes. I have seen that before. Dr. Schlafly......likes to preach all the time against endoscopic techniques." (Crandall Dp. pg. 19) (Ruling: Employer/Insurer's and Second Injury Fund's objections are overruled. Crandall Dp. pg. 18 and 19) Explaining where he had seen the photographs before, Dr. Crandall stated that it was "(I)n Dr. Schlafly's report, he does it all the time". (Crandall Dp. pg. 19) When queried - are you aware of the fact that the patient depicted in the photographs is somebody you did endoscopic surgery on - Dr. Crandall responded: "No. That's actually, that's been challenged before and it's never been proven that that is a patient here in Missouri. That looks like a picture out of a textbook to me." (Crandall Dp. pg. 19) The doctor was asked if he was familiar with an article - "The Results of Revision Carpal Tunnel Release Following Previous Open Versus Endoscopic Surgery" by Hulsizer, Staebler, Arnold-Peter Weiss, Edward Akelman, copyrighted 1998, the American Society for Surgery of the Hand. Dr. Crandall answered: "Yes. I think this is the author that came in and testified to one of Dr. Schlafly's malpractice trials, Dr. Weiss." (Crandall Dp. pg. 21) Dr. Crandall acknowledged that Dr. Schlafly was not found guilty of malpractice. Dr. Crandall agreed that he was familiar with the article - "Persistent Recurrent Carpal Tunnel Syndrome Following Prior Endoscopic Carpal Tunnel Release" by Forman, Watson, Caulfield, Shenko, Caputo, Ashmead, copyrighted in 1998, American Society for Surgery of the Hand. Dr. Crandall stated that he disagreed with both of these articles. "They are substantially flat and I demonstrated that before in previous depositions" Dr. Crandall stated. (Crandall Dp. pg. 23)

On redirect examination, Dr. Crandall agreed that in the first article, "The Results of Revision Carpal Tunnel Release Following Previous Open Versus Endoscopic Surgery", it would be fair to say that one of the conclusions of the article is that workers' compensation patients in general have statistically significant worse results biett endoscopic or open surgical procedures. "That's usually a common finding in almost every study done -" (Crandall Dp. pg. 25) The doctor was queried about when they started doing endoscopic procedures, and Dr. Crandall answered: "1988 in Japan and it became popular in the United States in 1991. Started at that time, done over 6000 endoscopic carpal tunnel release with a revision rate of less than a half percent." (Crandall Dp.pg. 26)

Dr. Crandall was referred to correspondence with a letterhead of Gerritzen and Gerritzen, dated November 16, 2001 ${ }^{[17]}$ to the employer/insurer attorney, and it was noted that it said - "Dear Mr. Keeven, on Friday, November 16, 2001, at 2:42 p.m. Maryann Rosenkoetter called my office and stated that she had just received a call from Dr. Crandall's office direct to schedule her for open surgery on the carpal tunnel syndrome that she had.". Dr. Crandall was asked if this would be consistent with his notes, and the doctor responded: "I have been made aware of documents, legal documents, well, gone over the documents staff keep for contacting patients. The patient was originally requested open. It was offered to her and that she declined to do surgery with us." (Crandall Dp. pg. 28) The doctor was queried - so isn't it correct that you not only offered, but you even attempted to schedule the procedures? Dr. Crandall answered: "Yes. It was offered to her to schedule them." (Crandall Dp. pg. 28)

It is found, considering the evidence, that the claimant admits that her employer authorized treatment for the occupational disease of bilateral carpal tunnel with Dr. Crandall who did the initial conservative treatment. Rosenkoetter further admits that she learned of Dr. Schlafly through her son-in-law and she called Dr. Schlafly and went to this doctor for a second opinion on her own, and proceeded with treatment by Dr. Schlafly. Dr. Schlafly himself testified: "Well, I think the treatment decision was (Rosenkoetter's). I initially saw her at her attorney's request, yes." There is evidence in the case (i.e. a November 16, 2001 letter from the claimant's attorney) which establishes that the authorized treating doctor's, Dr. Crandall's, office had contacted the claimant to provide the claimant's preferred method of surgical treatment; it is found that at no time did the employer refuse to provide treatment for the occupational disease.

In Gonzales v. Johnston Foil Mfg. Co,. 305 S.W.2d 45, *53 (Mo.App.1957) where it was held that the Commission properly refused to allow the claimant the medical expenses she sustained in connection with doctors she selected on her own account, the Court stated the following:

"We ruled in the case of Sams v. Hayes Adhesive Co., Mo.App., 260 S.W.2d 815, loc. cit. 820, that the question relating to the claim for medical benefits is one of fact for the Commission. We also pointed out that the Commission's finding in this regard is to be reviewed in the same manner as any other issue of fact and that the burden of proof and persuasion was upon the claimant.

A review of the evidence on this point discloses that the Commission did not err in refusing to allow the employee the medical expenses she sustained in connection with the doctors she selected on her own account. The record shows that immediately after the accident the employee was sent by the employer to Dr. Reuben Smith who treated the employee for some time. Thereafter, the employee sought medical treatment and advice from Dr. Robert O'Brien on her own account and she was sent to Doctors Mueller, Wennerman and Gitt by her attorneys. At no time was there any refusal on the part of the employer or insurer to furnish additional medical treatment. She visited the doctors of her own choice without consulting the employer or insurer or securing their permission. Under a similar state of facts, we ruled in the case of Kopolow v. Zavodnik, Mo.App., 177 S.W.2d 647, loc. cit. 654, and in Sams v. Hayes Adhesive Co., supra, that there was an election by the employee to select her own physicians at her own expense. This contention is ruled against the employee."

The claimant in this case, though, goes further and puts into issue the reasonableness or the potential endangerment of her health by Dr. Crandall's proposed treatment. Section 287.140, which deals with medical treatment under Missouri Workers' Compensation Law, states in subsection 2:

If it be shown to the division or the commission that the requirements are being furnished in such manner that there is reasonable ground for believing that the life, health, or recovery of the employee is endangered thereby, the division or the commission may order a change in the physician, surgeon, hospital or other requirement.

Rosenkoetter testified that Dr. Crandall wanted to do endoscopic surgery in his office and do both of her hands at once, and that she then wouldn't have been able to do anything.

Dr. Crandall didn't even ask me if I had heart problems or blood pressure or nothing, Rosenkoetter testified, I was scared if I went in and had it done, what if I would have died there. I didn't think that was a good idea having both of my hands done in an office, not even a hospital, an office; it just didn't sound right; I was scared of the surgery in Dr. Crandall's office, the claimant testified. I then went to see Dr. Bruce Schlafly, and Dr. Schlafly operated on my wrists separately, and the surgeries were performed at St. Anthony's Hospital, the claimant stated. When the 11/26/01, 2:42 p.m. call from Dr. Crandall's office to schedule open procedures was mentioned, Rosenkoetter responded - I wouldn't go there because I didn't trust them, they were company doctors. Rosenkoetter testified that she had heard from friends/family that Dr Schlafly was a good doctor. When I went to Dr. Schlafly, he told me that it

was better to do the open hand, and it would be done, and I wouldn't have to get it done again, the claimant said, I wasn't crazy about the laser and I didn't want both of my hands done as I couldn't even take care of myself. The claimant introduced expert opinion from Dr. Schlafly who testified it was his opinion that for carpal tunnel release it was better to do the open procedure because "it's better to visualize both the nerve and all the ligaments and to directly view those objects that you're cutting and the nerve itself and to make sure it's completely decompressed". Dr. Schlafly noted an article which concluded that there was a higher incidence of incomplete release of the carpal tunnel with endoscopic surgery than with open release; the doctor agreed, during cross examination, that one of the points in this article was that when you have to go back and redo the carpal tunnel they suggested doing open versus endoscopic. Dr. Schlafly admitted, during cross examination, that endoscopic release was within the proper standard of medical care. Dr. Crandall admitted that he probably recommend one technique over the other, but also testified: "On 8-2(3)-01. I said it can be done open technique or the endoscopic technique, one hand being done at a time or both hands can be done at the same time". Dr. Crandall testified during cross examination by the claimant: "I'm aware that some patients have been re-operated on by Dr. Schlafly that I've done. Specific patient's name, I do not recall. I know our revision rate is less than one half percent, which is better than the national average, but that is fine." Dr. Crandall testified about when endoscopic procedure started: : "1988 in Japan and it became popular in the United States in 1991. Started at that time, done over 6000 endoscopic carpal tunnel release with a revision rate of less than a half percent."

In Stawizynski v. J.S. Alberici Const. Co., 936 S.W.2d 159, (Mo.App. E.D. 1996) the question of - reasonable grounds to believe claimant's health or recovery was endangered by the authorized treating doctor - was the issue. The following is from Stawizynski:

"In July 1991 claimant told his treating physician, Dr. Hulsey, of his recurring nightmares. Dr. Hulsey recommended claimant receive a psychiatric evaluation by Dr. Wayne Stillings. The employer agreed. At the suggestion of his attorney, claimant saw another psychiatrist--Dr. Edwin Wolfgram--before seeing Dr. Stillings. After examining claimant, Dr. Wolfgram diagnosed him as suffering from somatoform pain disorder and major depression. Dr. Wolfgram concluded claimant was totally and permanently disabled.

Claimant then went to Dr. Stillings, a doctor retained by the employer and its insurance company. Dr. Stillings concluded claimant was not totally and permanently disabled and planned a course of therapy designed to get claimant back to work. He did admit, however, some form of psychiatric intervention was necessary to help claimant. Claimant would later complain to the administrative law judge (ALJ) of his lack of rapport with Dr. Stillings, describing how the doctor did not allow him to fully answer questions and how he made it appear as though he thought claimant was exaggerating his injuries. Dr. Stillings suggested claimant see Paul Kling, a psychologist, but claimant refused to see Kling and instead continued treatment with Dr. Wolfgram.

"In its second point on appeal, employer argues the Commission erred in requiring it to pay Dr. Wolfgram's bill. Employer argues the employer is entitled to select the treating physician under Missouri law. According to the statute, the employee may select his own physician, but he does so at his own expense:

1. In addition to all other compensation, the employee shall receive and the employer shall provide such medical ... as may reasonably be required after the injury or disability, to cure and relieve from the effects of the injury. If the employee desires, he shall have the right to select his own physician, surgeon, or other such requirement at his own expense.

§ 287.140(1) RSMo. In response, claimant argues the employee is entitled to select his own physician at the employer's expense where the treatment suggested by the employer endangers the employee's health or recovery. In support of his argument claimant points to $\S 287.140(2)$ :

1. If it be shown to the division or the commission that the requirements are being furnished in such manner that there is reasonable ground for believing that the life, health, or recovery of the employee is endangered thereby, the division or the commission may order a change in the physician, surgeon or other requirement.

§ 287.140(2) RSMo.

When the Commission ordered employer to pay for Dr. Wolfgram's psychiatric expenses, the only way it could was if it found reasonable grounds for believing the health or recovery of the employee was endangered by treatment with Dr. Stillings. A legitimate inference from the decision is that the Commission found such grounds. The issue before this court, then, is whether there is substantial and competent evidence to support the Commission's decision that reasonable grounds existed to believe the health or recovery of claimant was endangered by Dr. Stillings' method of treatment. Herring v. Yellow Freight System, Inc., 914 S.W.2d 816 (Mo.App. W.D.1996). We do not believe such evidence exists.

Dr. Stillings testified his method of treatment would not be harmful to claimant's health, life or recovery. In fact, the method of treatment he proposed was intended to help claimant recover. The ALJ, in his original award, noted the method of treatment proposed by Dr. Stillings was not unreasonable and did not endanger claimant's health, life or recovery. In

excluding Dr. Stillings as a possible treating physician, the ALJ noted the lack of rapport between the claimant and the doctor. In reversing the ALJ, the Commission specifically noted Dr. Stillings could not be excluded as a treating physician simply because a lack of rapport existed between the doctor and claimant. When the Commission remanded the case to the ALJ, the issue of whether Dr. Stillings was an appropriate treating mental health provider was not at issue. As a result claimant was entitled to continue to treat with Dr. Wolfgram, but he did so at his own expense. § 287.140(1) RSMo. Therefore, the Commission later erred when it ordered employer to pay Dr. Wolfgram's medical bills." Stawizynski, at 161 and 164 .

In this case, firstly, there is no evidence that a request was made to the Division or Commission for a change in physician from Dr. Crandall on grounds of endangerment, and no evidence of such an order being entered by the Division or Commission. Nevertheless, Dr. Crandall testified to offering to the claimant both methods of surgical treatment, treatment which the evidence indicates are both accepted methods of treatment with no evidence presented that either method was harmful; Dr. Schlafly admitted that the procedure in issue, endoscopic release, was within the proper standard of medical care. The claimant notes that the open release procedure performed by Dr. Schlafly was performed at a hospital; there is no evidence of whether or not the open release procedure proposed by Dr. Crandall would have been performed in his office or at a hospital, or if there is an accepted method(s) for place of performing open release procedures. The claimant further stated that her preference for Dr. Schlafly and his proposed procedure was that Dr. Crandall didn't ask her if she had heart problems or blood pressure or anything, and she was scared of the procedure being performed in an office, what if she would have died there; the evidence reveals that the open procedures performed by Dr. Schlafly were performed at St. Anthony's Medical Center and bills from St. Anthony's Medical Center were submitted into evidence which reflected such services as - a) basic metabolic panel, b) hemogram w/auto diff charge, and c) basic metabolic panel, eletrocardiogram. However, other than the 12/07/2001 and the 03/04/2002 operative notes, the St. Anthony's Medical Center record was not submitted into evidence, thus making a determination as to nature and possibly the reason for these listed services purely speculative, and thus further making it speculative to determine whether or not such services were the norm for the surgical procedure of an open release, or a special requirement due to this claimant's physical condition ${ }^{[18]}$.

It is found that the substantial and competent evidence establishes that the claimant elected to seek treatment on her own from Dr. Schlafly for her occupational disease of bilateral carpal tunnel syndrome; it is further found that the substantial and competent evidence establishes that the method of treatment proposed by the authorized treating doctor, Dr. Crandall, was not unreasonable and did not endanger claimant's health, life or recovery. Consequently, liability for bills generated from Dr. Schlafly's treatment of the occupational disease of bilateral carpal tunnel syndrome is found to be with the claimant.

Rosenkoetter, the claimant, testified that surgery for her bilateral carpal tunnel syndrome was performed by Dr. Schlafly; the surgery for each hand was performed on a different days, she said. Operative reports in evidence reflected that Dr. Schlafly performed left carpal tunnel release on 12/07/01 and right carpal tunnel release on 03/04/02. The claimant noted that after the surgeries, two fingers still get numb and it goes down to my elbow; the doctor said I would eventually have to have my elbow done, she stated. Dr. Schlafly wrote in his May 6, 2002 report the following: "I do not have any further treatment to recommend for her hands." The doctor further opined as to the amount of percent permanent partial disability of each hand from the work-related bilateral carpal tunnel syndrome/releases, and made work restrictions recommendations. Dr. Schlafly agreed, during cross examination, that Rosenkoetter reached maximum medical improvement for the carpal tunnel syndrome releases on May 6, 2002. Dr. Crandall saw Rosenkoetter on 7/25/02, subsequent to her surgeries, and testified that at the time of the 7/25/02 appointment he found Rosenkoetter to be of maximum medical improvement. Dr. Crandall further stated: "I did reach an opinion and it was that she had completed her treatment program. She was not in need of any further surgery or therapy." (Crandall Dp. pg. 9) Dr. Poetz stated his opinion after evaluating Rosenkoetter that bilateral carpal tunnel release was indicated if symptoms persisted; Dr. Poetz, however, evaluated Rosenkoetter on October 26, 2001, prior to either of the surgical procedures performed by Dr. Schlafly, and testified at his April 28, 2003 deposition that as of the date of his deposition he was not aware that Rosenkoetter had had carpal tunnel releases nor did he know the result of those releases.

Considering the evidence it is found that there is no competent medical opinion supporting the claimant's allegation of a need for further medical treatment as a result of the occupational disease sustained as a result of her employment with Magna Interior Systems (Integram) up to March 14, 1999, the substantial weight of the evidence establishing that the occupational disease is bilateral carpal tunnel syndrome. Consequently, future medical care is denied.

The claimant testified about ongoing problems as a result of her occupational disease of bilateral carpal tunnel syndrome. Rosenkoetter indicated that the surgery helped her hands and wrists. The numbness has stopped, she said, as well as on the inside of the palm of my hand down from my thumb on both hands, it was really always sore. Sometimes, though, my hands will cramp up, the claimant testified, and as a result I can't sew anymore, I can't hold the needle or anything. I used to make quilts all the time, I can't do that anymore, she said. My hands and wrists prevented me from being able to pick up a full skillet like I used to; I can't open jars, I don't have no strength, it didn't come back in my hands; it's just hard to pick up stuff with your hands, Rosenkoetter

stated. During cross examination, Rosenkoetter noted that two fingers still go numb.

Reviewing the medical opinions, Dr. Schlafly, the doctor who performed the bilateral carpal tunnel open releases, initially evaluated the claimant on March 1, 2001 for right and left hand carpal tunnel symptoms, and also performed an evaluation as to other various injuries and conditions of the claimant; Dr. Schafly wrote about his opinion of permanent partial disability as to the various injuries and conditions, noting the following as to Rosenkoetter's right and left hands:

With regard to the tender scar from the work related laceration in the left hand dating back to 11/94, my opinion is that this has produced a 25 percent permanent partial disability of the left small finger ( 22 week level), as well as an additional 7.5 percent permanent partial disability of the left hand. This is in addition to the disability in the left hand from the left carpal tunnel syndrome....

Subsequent to the surgical procedures, Dr. Schlafly opined on May 6, 2002:

I do not have any further treatment to recommend for her hands. My opinion is that she has 25 percent permanent partial disability of each hand measured at the level of the wrist joint from the work-related bilateral carpal tunnel syndrome/releases.....Since she has disability in both hands, a condition of multiplicity exists which should be compensated by a loading factor applied to the permanent partial disability ratings. She should try to avoid work that requires heavy, repetitive gripping, pushing, and pulling with her hands, or use of vibrating tools.

Dr. Crandall, who had performed conservative treatment for the claimant's bilateral carpal tunnel syndrome condition, again evaluated Rosenkoetter subsequent to her surgeries with Dr. Schlafly. Agreeing that he had an opinion as to whether Rosenkoetter had sustained any permanent partial disability to the left or right wrist as a result of her employment with Integram, Dr. Crandall testified: "I thought she had a permanent partial impairment of 10 percent of each upper extremity at the level secondary to her carpal tunnel syndrome..." (Crandall Dp. pg. 8) The doctor agreed that he also had an opinion at that time as to whether Rosenkoetter was capable of working with or without restrictions, and testified: "She was capable of working with her upper extremities without restriction." (Crandall Dp. pg. 9) Dr. Peter Mirkin evaluated the claimant on several occasions and offered opinions on permanent partial disability, but noted that he evaluated Rosenkoetter in regards to a 1995 back injury, only; Dr. Mirkin stated that he evaluated Rosenkoetter's back, only, and did not assess her for any other possible ailments, such as high blood pressure, a right shoulder injury, a 1998 left tibial plateau fracture and left knee sprain, or bilateral carpal syndrome; I knew of none of these things, the doctor said. Dr. Poetz assessed permanent partial disability for symptoms he felt were directly from the 1991 1999 work related injury of occupational disease, but Dr. Poetz evaluated Rosenkoetter prior to her surgical procedures for bilateral carpal tunnel syndrome. When queried if it would be possible his opinion that Rosenkoetter was permanently and totally disabled would be changed if she had had received surgical care for the bilateral carpal tunnel syndrome after he saw her, Dr. Poetz responded - "...we're not talking about the same patient. I would have to reassess this other patient you're talking about." (Poetz Dp. pg. 29) Dr. Poetz agreed that up to the date of his deposition he was not aware Rosenkoetter had had carpal tunnel releases, and when queried wasn't it correct that he did not know the result of the releases, the doctor responded - "Correct". (Poetz Dp. pg. 35) The doctor was asked if he had an opinion as to whether Rosenkoetter was permanently and totally disabled prior to the development of the carpal tunnel complaints. "I don't think I gave a determination regarding that in my report", Dr. Poetz answered. (Poetz Dp. pg. 37) The doctor further stated that he was not able to give a determination regarding this at that time.

It is found that all of the medical expert opinions assess permanent partial disability for the claimant as a result of her work related March 1999 occupational disease of bilateral carpal tunnel syndrome; there is no medical expert opinion that the claimant is permanently and totally disabled as a result of the March 1999 occupational disease. It is found that Dr. Poetz' opinion is not probative on the question of permanent partial disability as a result of the March 1999 occupational disease in that the doctor's opinion is based on less than all of the facts in the case. The opinions of Dr. Schlafly and Dr. Crandall are found to be competent on the issue, and considering these doctors' opinions, the claimant's testimony, as well as the remainder of the competent evidence, it is found that the substantial weight of the competent evidence supports an award of 17.5 % permanent partial disability of each hand at the wrist. This would be: 175 weeks x $17.5 \%=30.625 weeks; 30.625 weeks x 2 hands =61.25 weeks; 61.25 weeks x \$ 294.73 / week =\ 18,052.21.

In Eagle v. City of St. James, 669 S.W.2d 36, 43 (Mo. App. 1984) the Court held that the language of Section 287.190.3 RSMo "For permanent injuries other than those specified in the schedule of losses..." - allowed a special or additional allowance for cumulative disabilities resulting from a multiplicity of injuries. In this case, Dr. Schlafly specifically noted that a load factor should be added "(S)ince she has disability in both hands, a condition of multiplicity exists which should be compensated". Considering the evidence, it is found that there is substantial and competent evidence establishing a synergistic effect due to injuries to both upper extremities as a result of the March 14, 1999 occupational disease. The claimant is entitled to additional compensation as follows: 30.625 weeks x 15 % load $=4.59375 weeks; 4.59375 weeks x \$ 294.73=\ 1353.92.

It should be noted that Dr. Schlafly in his May 6, 2002 report (at the doctor's deposition, it was agreed and stipulated to that Dr. Schlafly would testify in accordance with his reports, See Schlafly Dp. pp. 4-8) wrote: "She has good range of motion in the hands with a pair of 1.75 inch longitudinal scars in each palm from the carpal tunnel releases". It is found that there is competent evidence establishing an award for disfigurement. See, Section 287.190.4 RSMo. It is found that the competent evidence supports as award

of 1 week of disfugurement for each of the claimant's hands. This would be: 2 weeks $x \$ 294.73=\ 589.46.

Missouri workers' compensation law provides that when permanent partial disability has been assessed against an employer, and there is evidence of preexisting disability such that the combination results in permanent partial disability above the simple sum or results in permanent total disability, then there is Second Injury Fund liability; there are threshold requirements in the situation of permanent partial disability liability. See Section 287.220 RSMo 1993.

In this case, it has been found that the claimant sustained permanent partial disability as a result of the March 1999 occupational disease herein. The claimant further testified about injuries and conditions she had prior to the March 1999 occupational disease and continuing problems and limitations from them; the claimant is alleging that she is permanently and totally disabled. There are medical expert opinions of permanent disability as a result of some of Rosenkoetter's preexisting injuries and conditions.

Considering the expert medical opinions in regards to permanent total disability,

Dr. Schlafly in his initial evaluation report of March 1, 2001 assessed permanent partial disability for various injuries and conditions of the claimant, including for the left and right hands, and Dr. Schafly further wrote:

Given the problems with her hands, she is not fit for work that requires heavy, repetitive gripping, pushing, and pulling with her hands, or use of vibrating tools.

Mrs. Rosenkoetter may be permanently totally disabled. A vocational rehabilitation counselor who is expert in the current labor market could be consulted to determine if there is work available that she could perform, given the problems described in this report. She has a combination of disabilities that creates a synergistic effect between the disability of her low back and the disabilities of her hands, giving a combined effect greater than the simple sum of the components. These disabilities create an obstacle or hindrance to employment. (emphasis added)

Subsequent to the surgical procedures, in his final report of May 6, 2002, Dr. Schlafly discussed permanent disability as a result of the bilateral carpal tunnel syndrome occupational disease with surgery, and assigned work restrictions; the doctor wrote:

My opinion is that she has 25 percent permanent partial disability of each hand measured at the level of the wrist joint from the work-related bilateral carpal tunnel syndrome/releases.....Since she has disability in both hands, a condition of multiplicity exists which should be compensated by a loading factor applied to the permanent partial disability ratings. She should try to avoid work that requires heavy, repetitive gripping, pushing, and pulling with her hands, or use of vibrating tools.

In his May 6, 2002 report, Dr. Schlafly requested that one refer to his earlier reports, and wrote - "She is not working. She has a variety of physical problems, as discussed in my prior report.". No other comment or opinion on permanent partial or permanent total disability was given by Dr. Schlafly in his May 6, 2002 report. Dr. Poetz assessed permanent partial disability for various preexisting injuries and conditions the claimant had as well as for the 1999 occupational disease; the doctor further wrote:

It is also my opinion that Ms. Rosenkoetter is Permanently and Totally Disabled as a result of the November 23, 1994, August 1995, November 19, 1997, February 19, 1998, and 1991 though 1999 work related injuries combined with her preexisting conditions. She is and will be permanently and totally unemployable in the open labor market.

Dr. Poetz, however, evaluated Rosenkoetter prior to her surgical procedures for bilateral carpal tunnel syndrome. When queried if it would be possible his opinion that Rosenkoetter was permanently and totally disabled would be changed if she had had received surgical care for the bilateral carpal tunnel syndrome after he saw her, Dr. Poetz responded - "...we're not talking about the same patient. I would have to reassess this other patient you're talking about." Dr. Poetz agreed that up to the date of his deposition he was not aware Rosenkoetter had had carpal tunnel releases, and when queried wasn't it correct that he did not know the result of the releases, the doctor responded - "Correct". Dr. Poetz admitted that he did not have for review the deposition of Dr. Schlafly which had been taken on July 9, 2002 (a month after Dr. Poetz' June 10, 2002 report), nor did he have the attachments to Dr. Schlafly's deposition transcript, or the medical records of Dr. Schlafly. Dr. Poetz was asked if he had an opinion as to whether Rosenkoetter was permanently and totally disabled prior to the development of the carpal tunnel complaints. "I don't think I gave a determination regarding that in my report", Dr. Poetz answered. (Poetz Dp. pg. 37) The doctor further stated that he was not able to give a determination regarding this at that time. Dr. Crandall who provided the authorized initial conservative treatment for the claimant's bilateral carpal tunnel syndrome and evaluated the claimant subsequent to the bilateral carpal tunnel release surgeries in regards to any permanent disability, testified: "I thought she had a permanent partial impairment of 10 percent of each upper extremity at the level secondary to her carpal tunnel syndrome..." (Crandall Dp. pg. 8) The doctor agreed that he also had an opinion at that time as to whether Rosenkoetter was capable of working with or without restrictions, and testified: "She was capable of working with her upper extremities without restriction." (Crandall Dp. pg. 9)

Other expert medical opinion on the disability of the claimant was in evidence. Dr. Mirkin evaluated that claimant's back on

several occasions on behalf of the employer/insurer; which included review of medical records. Dr. Mirkin admitted that his opinions were in regards to a 1995 back injury, nevertheless the doctor evaluated the claimant the last time on July 17, 2002, and gave opinions at that time which included whether or not Rosenkoetter was capable of working in regards to her back. Dr. Mirkin testified: "Yes, I wrote my last note that I thought she could work with a 30-pound lifting restriction". (Mirkin Dp. pg. 9) Commenting on his opinion of whether or not Rosenkoetter had sustained any permanent partial disability in regards to her back. Dr. Mirkin stated: "I think she has some permanent partial disability in her back, but none secondary to that incident or incident at work"; "She has very severe degenerative spine disease, and she probably has a permanent partial disability of about 20 percent secondary to that". (Mirkin Dp. pg. 10) Dr. Stillings, a board certified psychiatrist, performed a psychiatric independent medical evaluation of Rosenkoetter on August 14, 2002 on behalf of the employer/insurer. Dr. Stillings testified that with respect to Rosenkoetter's GAF score of 55 at that time, "..this would mean that she probably doesn't function as well as the average person occupationally, or socially. But it doesn't preclude her from working. She is still occupationally functional.". (Stillings Dp. pg. 17) Dr. Crane offered opinions in this case, but this doctor's opinions were admitted on a limited basis as to the issue of future medical care, only.

"While proof of cause of injury is sufficiently made on reasonable probability (Smith v. Terminal Transfer Company, 372 S.W.2d 659, 664(7) (Mo.App.1963)), proof of permanency of injury requires reasonable certainty. Davis v. Brezner, 380 S.W.2d 523, 588(6-- 9) (Mo.App.1964). Whatever may be the quantum of proof the law imposes on a given issue in a compensation case, however, such proof is made only by competent substantial evidence and may not rest on surmise or speculation." Griggs v. A. B. Chance Co., 503 S.W.2d 697, 703 (Mo.App. 1973).

It is found, considering the medical opinions, that there is no competent medical opinion that the claimant is permanently and total disabled, either from disability as a result of the last work related injury or from a combination of pre-existing disabilities with the compensable injury herein.

The test for determining permanent total disability is stated in Karoutzos v. Treasurer of State, 55 S.W.3d 493, 498 499 (Mo.App. W.D.,2001):

"Total disability is defined as the inability to return to any employment and not merely the employment in which the employee was engaged at the time of the accident. § 287.020.7. 'The test for permanent total disability is the worker's ability to compete in the open labor market in that it measures the worker's potential for returning to employment.' Reese, 5 S.W.3d at 526. 'The critical question then becomes whether any employer in the usual course of employment would reasonably be expected to hire this employee in his or her present physical condition.' Id."

In light of the test for permanent total disability, the following evidence and testimony will be considered. The claimant testified that in 1999 from using her hands and wrists at work at Integram she got carpal tunnel. Back then we didn't have the pan machine, and the cushions had to have metal pans put on them, and you lay them on the table and you put the pan in the bottom, and the seat covers had clips that had to go on the side of the pans, you push down with one hand and then roll the clips over with your other hand on both sides and on the front, she stated. During cross examination, Rosenkoetter agreed when she developed problems with numbness and tingling in her hands during her employment with Integram the employer sent her to Dr. Crandall for treatment. Dr. Crandall first treated me conservatively with some testing, physical therapy and splints for both hands, Rosenkoetter stated. When queried if she continued to treat conservatively with Dr. Crandall beyond the time that she last worked at Integram, she answered - I don't know how long it was. I last worked at Integram on March 15, 1999, the claimant said. She was asked - at the time you left Integram did anybody recommend that you have surgery on your hands? Dr. Crandall wanted to do the laser surgery, Rosenkoetter answered, but admitted that she did not know if this was after she left Integram or during her employment with Integram. Dr. Crandall testified (Emp./Ins. Exh. 2) that he initially saw Rosenkoetter in 1998 at the employer/insurer's request, and stated that after examination and a nerve conduction study which demonstrated borderline carpal tunnel syndrome at early stage, "I thought that her, she would be best served with a conservative treatment program, since her nerve conduction studies were border line". (Crandall Dp. pg. 7) Dr. Crandall testified:

"I saw her on the 6-19-01 and 8-23-01. It obviously had been several years since she had been treated conservatively and we had found that with a new study that her condition had worsened, despite the fact she had not been working. And because of this worsening of the numbness, I thought she was a candidate for surgery and stated so in my report of 8-2301."

The evidence reveals that Dr. Schlafly performed the bilateral carpal tunnel release procedures, first on 12/07/01 the procedure of a left carpal tunnel release and on 03/04/02 the procedure of a right carpal tunnel release. The claimant testified that it took a while for her hands to get better from the carpal tunnel release procedures, but the procedures helped her hands get better. I still haven't got no strength like I used to have, Rosenkoetter stated. The claimant agreed, during cross examination, that her hands continued to get better as time went on, that her hands were better six months to a year after the surgery than they were two months after the surgery.

I was fired by Integram in 1999, the claimant testified, and the reason they gave was because I was off when I hurt my leg; and they changed the contract and they said the insurance papers -- when I hurt my knee, I went on sick leave and I went and got

my papers to fill out; it's after I fell and went to the hospital and the doctor said I shouldn't work. So I got my insurance papers and I didn't know how to fill them out because they were different, and I called the H.R. and Mary Jo said she would help me fill them out, and she told me what to put down. They said they fired me because I didn't come in and fill out new papers; that's why we went, the union man and me, before the arbitration board. It was whoever's the boss down there at Integram, the general foreman, I guess, who said I didn't fill out the papers right, the claimant stated, because they said I was fired because I didn't do my paperwork right. When we went to the arbitration I had my phone bills and everything, and they had three or six women from the H. R. Department sit there and lie, it didn't make any difference what I said, and my union worker denied me the right to have counsel, said he was going to represent me, so I didn't even get to have a lawyer there, Rosenkoetter testified. This was right after they fired me and then went through three steps, and the fourth step was to go before the arbitrator. They denied my unemployment, and I went to the hearing for unemployment and their woman said that was absurd that I would quit my job at fifteen something an hour, and she gave me my unemployment, the woman from Jeff City, the claimant stated. The claimant was queried during cross examination if it wasn't correct that she didn't quit working at Integram because of the problems with her hands, she quit working because of the insurance paperwork mess. I had to quit anyway, the claimant answered, my health just keeps getting worse. It didn't get better. And Dr. Schlafly said these two fingers still go numb, and I might have to get my elbow done, she stated.

Rosenkoetter agreed on cross examination that the problem that came up that led to the whole paperwork mess and that eventually led to her termination was an injury that she had to her left leg which occurred at her home on 3/17/99. I had several injuries happen at my house, my legs wouldn't work right; I wasn't never sure if my foot was high enough or if I was stepping right, it just didn't work right, the claimant stated. When I fell on 3-17-99, I didn't fall because I was dizzy or disoriented, I fell because of the problems with my legs that I know was due to my back, the claimant stated. I told Dr. Jacob, the one who did the surgery, that my legs just didn't work right, and he said there's nothing more that he could do for me, the claimant stated. I went to my bone doctor, Dr. Kefalas, for treatment when I fell at home on 3-15-99, she said. The claimant was queried if it would be inconsistent with her memory of how she was injured if Dr. Kefalas' notes of 3-17-99 indicated that she became dizzy at home and fell. When I came out of the barn I thought my foot was on the step, but it wasn't, and I stepped in a hole and the ground was uneven and I went down, the claimant responded. It was noted that Rosenkoetter had said that she fell on the steps. The first time I got hurt after the surgery I was going up the steps and my foot caught on the steps because it wasn't up high enough and I fell and I broke my tibia bone, the claimant answered, and then I come out of the barn and I thought my foot was on the step but it wasn't, it went sideways, and I fell, and fell in the hole in the yard. I don't know if the fall into the hole in the yard was on 3-15-99, the claimant said. Dr. Kafalas took me off work for the 3-15-99 injury, the claimant said. The claimant was asked if it sounded accurate that as reflected in the doctor's record he kept her off work through 4-7-99; and she answered that she did not remember the date, but she thought it was in sometime in April. Rosenkoetter stated that it was at this time that she had called work and asked for insurance papers. The claimant was queried, wasn't it correct that at some point she got off the crutches, the air cast and off the gel cast, and Dr. Kefalas was done treating her for this injury. When they said I was supposed to be back at work, I was on crutches, I had that on my ankle, and I had it on my knee; there was no way that I could come in there and work, the claimant responded. Rosenkoetter denied that at some point she attempted to return to work at Integram. She was asked if she had filed a grievance. I went to the union, she answered. She agreed that she basically went to the union saying that they had unfairly taken her job away, and that she should be able to continue working at Integram, that she filed a grievance saying she should be working at Integram. Rosenkoetter stated that she went through, she thought, four different levels of the grievance proceeding, the most you could go through. I don't think I was even at the three meetings, she said. The claimant was asked if it upset her that she wasn't successful in her grievance proceeding. What upset me, she answered, was that they frigging sat there and lied; no matter what I told them, no matter the bills I showed them, they sat there and lied and he took it. And you know what upsets me is that those people can make bombs, they can layoff, they can sneak out of work and everything, and nothing happens to them, only three days suspension, Rosenkoetter stated. Not having a lawyer present that upset me, too, she said. Rosenkoetter agreed that after she was terminated from Integram she applied for unemployment benefits. I did not receive those benefits right away, she said, Integram said that I didn't deserve them, I was fired. Rosenkoetter stated that she did not have much choice when receiving those benefits on a weekly basis in filling out a statement alleging that she was ready, willing, and able to work. I had to get a job because I knew that wouldn't last very long, she stated, I was out there every day trying to find a job, but then when you put down you had surgery and this and that, they don't want nothing to do with you. You can't lift; they don't want you in the machine shop if you can't lift stuff, she stated.

Rosenkoetter stated that she has tried to work since leaving Integram. I tried to find a job, and I filled out applications and applications, and nobody would hire me, she said. Wal-Mart said I had to bend over and pick up a dime off the floor, I couldn't do that, my back wouldn't let me bend over that far, the claimant said. I filled out applications for wherever I had education to do -machine shops and different places like that; but as soon as they find out you had a back problem they don't want nothing to do with you, Rosenkoetter stated. She was asked if she believed she is able to work now anywhere. No, Rosenkoetter answered, and explained that it was just all the injuries to her body. I just can't do it, she said, I wish I could.

It was noted, during cross examination, that the claimant had testified that as a result of all of her conditions she had been inhibited in her ability to engage in activities around the farm, and Rosenkoetter was asked how long had she had that limitation. Ever since I fell on the tag (in 1995), the claimant answered. Rosenkoetter was queried if she would question the accuracy of Dr. Sertl's record which contained a history that she had injured her left leg riding a tractor in September of 1998. I would try to do stuff; I didn't have as much wrong with me then; it was just all the stuff just piles up; I still try to do stuff, it just don't work, the claimant said.

On cross examination by the Second Injury Fund, Rosenkoetter stated that after recovering from her broken tibia injury that occurred in the Summer of 1998, she was working full job duties on her regular scheduled hours up to the time she hurt her right knee and she was fired from Integram. My regularly scheduled hours were to start at eleven p.m. and I think we got off at seventeen, she said. The time I worked at Integram my job title was Foam Production, the claimant stated. I started in foam production in 1991, I don't remember the month, the claimant said, and worked there until I left Integram. During this time period I was doing the same job duties throughout the whole time, she said. Discussing this job in more detail, Rosenkoetter agreed that she worked with the foam seats that went in minivans. The bench seats were quite long; I have no idea what they would weigh, she said. I also lifted all the cushion backs or the cushion part; there was child seat cushions, and the cut and sew was the foam buns with other covers on them and heaters in them. The cushions had a metal pan on them, so they might have been the heaviest, I really don't know, the claimant stated. The whole work-day was spent on my feet, she said. Rosenkoetter stated that she was doing bending with just about every position there, and explained that they rotated to different stations. I don't think I ever had to do any squatting or kneeling in doing my job duties, the claimant said, not unless you dropped something. Rosenkoetter denied that during the last six months that she was physically working at Integram she was doing the same job duties that she had been doing since she'd been in foam production beginning in 1991. I wouldn't help nobody anymore, and I was lucky to get my job done, she stated. I would trade off because lifting covers was really hard on me because you'd have to lift like ten or so at a time, and then you had to bend over in the boxes and lift the heavy lids off the boxes; it was really hard on my back, the claimant testified. After I hurt my back in 1995 when I fell on the tag I was never able to work the same as before then, the claimant stated. It wasn't only work, she said, it was my activities at home and just the things I enjoyed doing, couldn't do no more.

Rosenkoetter agreed, during cross examination by the Second Injury Fund, that at the time that she was terminated from Integram she was on sick leave for her leg, and agreed that this was about April of 1999. It was my intention to return to my job at Integram after I recovered from this leg injury, the claimant said. The claimant was queried if it was correct that one of the reasons she filed a grievance at the time Integram let her go in April of '99 was because she had planned and wanted to return to her job at Integram. No, Rosenkoetter answered, I filed a grievance because the lady in the H.R. lied, she said I didn't have to fill out anymore papers, and that's why I lost my job. The claimant agreed that when she filed the grievance she was trying to get her job back.

On further cross examination, the claimant was queried, in light of her testimony that because of what happened at Integram she has been unable to work, if at the time in 1999 when she was terminated by Integram and she went through the four grievance proceedings and said to the arbitrator - give me my job back, I could do the job - was that all a misrepresentation. At that time I thought I could, and I would have tried, the claimant responded.

Since I left Integram in 1999, the claimant stated, the condition of my low back has gotten worse. The claimant was also queried, since you left Integram had the condition of her right ankle had gotten better, gotten worse, or stayed about the same? When I hurt my right ankle, after I did what the doctor told me, it got better, Rosenkoetter answered, it just gives me trouble every once in a while, it gets real sore, it swells, it stays swollen all the time. When I left Integram in April of 1999 my right ankle was pretty messed up because I had to wear a gel cast on it for like six weeks, but the problem I have now is that walking sometimes will irritate it or it just swells all the time. Rosenkoetter agreed that the condition of her hands got better after the carpal tunnel surgery. The symptoms I still have in my hands now from the carpal tunnel is that every once in a while my hands will cramp up; I can't sew anymore, I used to hand quilt and I can't do that anymore, I can't hold the needle; it's just like charley horses in my hands, the claimant testified. The claimant was asked if her depression had gotten better, gotten worse, or stayed about the same since April of 1999. Gotten worse, she answered. Rosenkoetter stated that she still has problems in her right hip. Right now I'm going for therapy, she said, they're going to fit me for a cane Thursday so it will help steady me when I'm walking. When asked if she had had problems with her right hip in April of 1999, the claimant answered - I've had problems with it off and on since I hurt it in 1997 when I bent over in that box, and agreed that this was her second back injury. The condition of my right hip has gotten worse since I left Integram in 1999, the claimant said, my doctor suggested that I find another neurosurgeon because mine retired, he's looking for one for me now.

The claimant agreed that she was involved in a motor vehicle accident in October, 2003. The people in the other car, and my daughter and myself were injured in the accident, she said, no one was killed in the accident. Explaining about her injuries, Rosenkoetter stated that the air bag went off and she was going sideways and it hit her shoulder, and her hand hit something and broke a bone in her left hand, and her knee hit something on the door somehow. I wasn't casted, Rosenkoetter stated, it seems like my bones don't break across but rather they break down, and they put five, I don't know what you call it, it had a metal piece on the bottom and you wrapped it there; I had to wear that for a month. I did not have any problems with my neck or anything else as a result of this injury, she said.

On redirect examination, Rosenkoetter was asked what was the major factor she felt was the reason she is unable to work now. I just had to accept it that my body wouldn't do it no more, Rosenkoetter answered. It's a combination of everything that's happened to me, she said, but more it's my back. The bending, I can't even bend over the table to make dumplings anymore for my family, or make pies, or stand at the kitchen sink at one time and finish up my dishes when the kids come, you're just bent over and that's it, the claimant stated. The claimant was asked, in regards to unemployment, was she, in her judgment, physically able to go back to work at Integram when they fired her or was she not able to go back to work. I went back to work because I had no choice,

Rosenkoetter answered, I had kids to take care of, I had bills, and I like my job. The claimant was asked if she believed she was unable to work now and had been unable to work since 1999 because of what happened at Integram. I honestly don't think I can work because of what happened at Integram; my back, it started the whole thing, she said. And I think my weight problems is because of my back and my nerves and I can't get out and exercise, and now I've got diabetes because of it, Rosenkoetter added. Since 1995 when I hurt my back I have gained about forty-five pounds, she said.

The claimant agreed, during further cross examination that when she had the first injury to her back in 1995 that slowed her down at work; she agreed that also as a result of this she couldn't work as much overtime. Rosenkoetter was queried about Dr. Bedor's records which indicated on 5-28-98 that she was working ten to twelve hour days, six to seven days a week. My back was bad in May of 1998, she said, but if they said for you to work, you worked.

John Laffleur testified on behalf of the employer/insurer and stated that he is a human resource manager at Integram St. Louis Seating, and has been in that position for eight and a half years. Laffleur agreed that as H.R. director for Integram he participates in grievances on a regular basis, and becomes aware of each grievance procedure. My role with the grievance procedures is that I pretty much handle the whole procedure, Laffleur stated. It's actually a four-step grievance procedure, and if that doesn't solve the grievance, then it goes to arbitration; I'm involved in all four steps plus at the arbitration level. And I actually conduct the meetings and I write the grievance, Laffleur testified. He agreed that in conducting the meetings he represents the company's interest, and in an effort to address his side of the argument, he becomes aware of the grievance allegations. Laffleur stated that he was present at the grievance of Rosenkoetter but not at the grievance proceedings, as Rosenkoetter would have done that through her union representative. Agreeing that he was aware of the allegations in the case involving Rosenkoetter, Laffleur stated that the allegations were that she did not terminate her seniority.

On redirect examination, Laffleur testified about the basis of his terminating Rosenkoetter in 1999. She terminated her seniority in accordance with the labor agreement because she failed to return from her leave of absence, Laffleur said, and agreed that the employer made no proactive attempt to terminate her. To my knowledge, Rosenkoetter was never written up for poor performance, and never written up for problems with quality or quantity of her work, Laffleur said. To my knowledge, in the grievance procedure, ability to perform her job duties was not an issue, he said.

Considering this evidence, it is found that it does not indicate that the claimant was terminated from her employment by her employer as a result of her physical ability to do the work, but rather due to her absence from work and a failure to return to work following an injury sustained at her home; the evidence reveals that in her present physical condition at the time of the injury sustained at home, Integram was employing Roenkoetter and there is no evidence that the employer was questioning the quality of or her ability to perform her work. It is found that the evidence reveals that subsequent to Rosenkoetter's employment at Integram which ended in March or April of 1999, her physical problems worsened due to her physical condition or due to subsequent injuries. [See, generally, Lawrence v. Joplin R-VIII School Dist., 834 S.W.2d 789, 793 (Mo.App. S.D. 1992) in which it was noted that an ALJ is to consider the degree of employee's disability that is attributable to all injuries or conditions existing at the time the last injury is sustained, liability against the Second Injury Fund cannot be imposed for a worsening of a pre-existing disability occurring after the last injury was sustained when the worsening was not caused by the last injury\}

It is found that the substantial weight of the competent medical opinions do not establish that the claimant is permanently and totally disabled due to her last work related injury or due to a combination of her last work related injury combined with her prior injuries, and it is found that the weight of the competent evidence does not establish that a reasonable employer would not have employed the claimant in her present physical state at the time of her termination for failure to return to work. Consequently, permanent total disability liability cannot be found.

There remains a question of Second Injury Fund liability for permanent partial disability. The parameters of Second Injury Fund liability in permanent partial disability cases is set forth in Section 287.220.1 RSMo 1993, which states in pertinent part:

All cases of permanent disability where there has been previous disability shall be compensated as herein provided. Compensation shall be computed on the basis of the average earnings at the time of the last injury. If any employee who has a preexisting permanent partial disability whether from compensable injury or otherwise, of such seriousness as to constitute a hindrance or obstacle to employment or to obtaining reemployment if the employee becomes unemployed, and the preexisting permanent partial disability, if a body as a whole injury, equals a minimum of fifty weeks of compensation or, if a major extremity injury only, equals a minimum of fifteen percent permanent partial disability, according to the medical standards that are used in determining such compensation, receives a subsequent compensable injury resulting in additional permanent partial disability so that the degree or percentage of disability, in an amount equal to a minimum of fifty weeks compensation, if a body as a whole injury or, if a major extremity injury only, equals a minimum of fifteen percent permanent partial disability $\qquad$ (Emphasis added)

In this case, the percentage of permanent partial disability for the subsequent compensable injury, the 1999 occupational disease of bilateral carpal tunnel syndrome, was found to be 17.5 % permanent partial disability of each hand at the wrist. It has been determined by the ALJ the claimant has sustained permanent partial disability, preexisting, to the lumbar spine that meets the threshold parameters of Section 287.220; it has been determined that the claimant has a total of 16 % permanent partial disability to

the low back, preexisting.

In the Analysis Section of his March 1, 2001 report, Dr. Schlafly included the following:

Mrs. Rosenkoetter.......has a combination of disabilities that creates a synergistic effect between the disability of her low back and the disabilities of her hands, giving a combined effect greater than the simple sum of the components. These disabilities create an obstacle or hindrance to employment.

Dr. Poetz also noted n his evaluation report: "The combination of the present and prior disabilities results in a total which exceeds the simple sum by 20 %. "

It is found that the substantial competent evidence establishes the following Second Injury Fund liability: [( 17.5 % x 175 weeks $= 30.625 weeks) x 2=61.25$ weeks; 61.25 weeks +(16 % x 400 weeks $=64 weeks )=125.25$ weeks; 125.25 weeks x 20 % load $= 25.05 weeks; 25.05 weeks x \$ 294.73=\ 7382.99.

Mary Ann Rosenkoetter, the claimant, testified that she was born on June 30, 1945. My highest education is eleven and a half years schooling and thirty-eight hours of college, she said, I was about two months to graduate. I never graduated from high school, the claimant said. A college I went to was Jeffco for a while, Rosenkoetter said, and I took different classes for blueprint reading and math and machine and welding. I also went to East Central in Union, Missouri where I took horticulture; and I can't recall what else I took there, the claimant stated. I did not get a degree from either one of the colleges, she said. The longest time I would have gone to East Central was a couple semesters, I think, Rosenkoetter stated.

I first went to work when I was eighteen, I think, the claimant testified. As far as I can recall I worked in a factory where you made beer signs and advertisement signs, she said. I have done factory work, school custodian, and storeroom clerk all of my life, the claimant stated. I worked at East Central for a year as a school custodian, and I think it was in about 1993 or 1994, while I was working at Integram. I don't remember how many years I did factory work, the claimant said, it's been several years. As a storeroom clerk; I read the blueprints and inspected machine parts and gave out parts out of the storeroom; this was at Bull Moose Tube where I worked about fourteen months, Rosenkoetter stated. I first went to work for Integram in 1991, I think, the claimant said, and I went to work in maintenance which entailed cleaning all the bathrooms on the production side, sweeping floors, polishing the floors or cleaning them, and then just all around maintenance work.

In 1999 from using my hands and wrists at work at Integram I got carpal tunnel, the claimant testified. Back then we didn't have the pan machine, and the cushions had to have metal pans put on them, and you lay them on the table and you put the pan in the bottom, and the seat covers had clips that had to go on the side of the pans, you push down with one hand and then roll the clips over with your other hand on both sides and on the front, she stated. To do this, I'd push down with my left hand on the pan and then I'd take my right hand and thumb and roll the clip over onto the pan; I did this when I went into production, when I first started there I was in maintenance for about a year or so, the claimant stated. The claimant agreed that she used her hands and wrists in maintenance, stating - I was always sweeping, mopping, cleaning, and running the scrubber. I used my hands and wrists mostly on the pans -- pushing down on the metal pans and rolling the clips over, and then on the front of the cushion you had a long plastic thing and you had to get a hold and roll it over onto the metal pan. It was an hour a night when they started the rotation, and in that hour I might put on maybe a box and a half to two boxes of pans, maybe forty or fifty in a box; I did quite a few, I don't remember the exact, I never did count. I did this every night up until they got the pan machine, the claimant said, I think it was more than a year when they got the pan machine. My wrists and hands bothered me for a while, but I didn't know what it was because I didn't know what carpal tunnel was; I just thought it was just repetition stuff, just sore, until my friend was talking about what carpal tunnel was, Rosenkoetter said. And I went to the foreman and told him that my hands were really hurting, I would like to have them checked out, and he sent me to HealthLine again.

At HealthLine I saw a Dr. Crandall, a hand doctor, and they done nerve tests. The doctor did not give me any treatment, the claimant said. She explained that the doctor had said she needed surgery because she had carpal tunnel and it was worse in the left hand than in the right hand. The doctor wanted to do that microscopic surgery in his office and do both of my hands at once, but I wouldn't been able to do anything and I told him I couldn't do that, Rosenkoetter testified. He didn't ask me if I had heart problems or nothing, he just wanted to set me up for the surgery in his office, the claimant said. I told the doctor I wanted a second opinion, she stated. I then went to see Dr. Bruce Schlafly, and Dr. Schlafly operated on both of my wrists separately, the claimant said, I wouldn't get them done at the same time. The surgeries were performed at St. Anthony's Hospital, the claimant stated, and the doctor did the open hand surgery on both wrists. Dr. Schlafly gave me about a month for the one to heal before doing the other surgery, otherwise I wouldn't be able to get dressed or tie my shoes or nothing, she said. Indicating that the surgery helped her hands and wrists, Rosenkoetter stated that the numbness has stopped, and on the inside of the palm of her hand down from her thumb on both hands was really always sore. Sometimes, though, my hands will cramp up, the claimant testified, and as a result I

can't sew anymore, I can't hold the needle or anything. I used to make quilts all the time, I can't do that anymore, she said. At work my hands and wrists prevents me from being able to pick up a full skillet like I used to; I can't open jars, I don't have no strength, it didn't come back in my hands; it's just hard to pick up stuff with your hands, Rosenkoetter stated.

During cross examination by the employer/insurer, Rosenkoetter agreed that at some point during her employment with Integram she developed problems with numbness and tingling in her hands. After I found out what it was or might be I reported this to the employer and they sent me to Dr. Crandall for treatment, the claimant said. Dr. Crandall first treated me conservatively with some testing, physical therapy and splints for both hands, Rosenkoetter stated. When queried if she continued to treat conservatively with Dr. Crandall beyond the time that she last worked at Integram, she answered - I don't know how long it was. I last worked at Integram on March 15, 1999, the claimant said. She was asked - at the time you left Integram did anybody recommend that you have surgery on your hands? Dr. Crandall wanted to do the laser surgery, Rosenkoetter answered. She admitted that she did not know if this was after she left Integram or during her employment with Integram. The claimant was asked if it sounded accurate if Dr. Crandall's records indicated that it was sometime in the Summer of 2001 that he first discussed surgery with her. I'm not for sure; I don't remember, she claimant answered, all I know is I went to him and I had nerve tests done and he said I had carpal tunnel, and it was worse in the left hand than in the right hand, that I should think about it. Dr. Crandall gave me the paper on what they did, and that I should have the microscopic surgery and they would do it in their office; I asked him if that wasn't risky, and he said no, it only takes forty-five minutes, he was going to do both my hands at one time, the claimant testified. Rosenkoetter was queried - if Dr. Crandall's file notes of 8-2-01 reflected that he offered her either an open or an endoscopic procedure, would that be inconsistent with her recollection. He gave me a paper that showed me what they did on both, but he recommended the laser surgery because he could do it in his office, and it only took forty-five minutes, and he could do both hands at once and it would be over with, the claimant answered. She stated that she was sure Dr. Crandall discussed both of the procedures with her. After this, Rosenkoetter agreed, I talked to a friend of mine about what the microscopic surgery was, and my son-in-law told me about Dr. Schlafly, that he was a good doctor, so I called him for a second opinion. The claimant stated that she did not recall if Dr. Crandall ever offered to do the endoscopic procedure on separate dates. When asked if she was ever advised by anyone that she was offered the opportunity to undergo the open procedures on separate dates, Rosenkoetter answered - Not until after I went to Dr. Crandall, that's when I went to Dr. Schlafly. After I went to Dr. Schlafly, I do not recall the employer or the insurer ever offering me the opportunity to undergo open carpal tunnel releases on separate dates, the claimant said, Dr. Crandall just wanted to do it in his office and do the microscopic. The claimant was asked if she recalled being called by Dr. Crandall's office on 11-26-01 at 2:42 p.m. to schedule open procedures. I wouldn't go there because I didn't trust them, the claimant answered, they were company doctors. Dr. Crandall didn't even ask me if I had heart problems or blood pressure or nothing, Rosenkoetter testified, I was scared if I went in and had it done, what if I would have died there. I didn't think that was a good idea having both of my hands done in an office, not even a hospital, an office; it just didn't sound right; I was scared of the surgery in Dr. Crandall's office, the claimant testified. The claimant was queried if she had trusted Dr. Schlafly, if she had wanted him to do the surgery. When I went to Dr. Schlafly, he told me that it was better to do the open hand, and it would be done, and I wouldn't have to get it done again, she answered, I wasn't crazy about the laser and I didn't want both of my hands done as I couldn't even take care of myself. I don't know if Dr. Crandall's office ever contacted me at home by phone on 11-26-01 at 2:42 p.m. to schedule open procedures on my hands, the claimant said. They were upset because I told them I didn't want the laser surgery done; but in the meantime I'd already called Dr. Schlafly and I asked him about what it was and if it was better, and he said yes. After that, the claimant was asked, did Dr. Crandall's office ever offer you the open procedures? If they did, I didn't do it, the claimant answered, and again explained that she didn't like the laser surgery, she didn't want to have both of her hands done at one time, and she didn't like the idea that the doctor didn't ask her her health problems then as most doctors do.

The procedures helped my hands get better, Rosenkoetter stated during cross examination. It took a while for my hands to get better, she said, I still haven't got no strength like I used to have. The claimant agreed that her hands continued to get better as time went on; her hands were better six months to a year after the surgery than they were two months after the surgery.

The claimant explained further how she ended up at Dr. Bruce Schlafly's office during cross examination. I was scared about the doctor taking me in the office, Dr. Crandall, and doing that laser surgery, because he didn't ask me about my heart condition or my blood pressure or no medical history, I don't remember him asking me unless I filled it out on paper, he just wanted to do both my hands, the claimant said. And then I'd heard from a friend that the laser surgery wasn't as good, that sometimes you have to go back and have it done again, and I wouldn't be able to dress myself or wipe my own self or take care of myself and I was worried about having the surgery done in his office. And my son-in-law said that he had gone to Dr. Schlafly to have a bone taken out of his arm and plastic put in, and I thought if he could do that, he would be good on my hands. And I wanted another opinion, so I called and got an appointment and I went to him, Rosenkoetter testified. Dr. Crandall had recommended laser surgery, Rosenkoetter said, and he got really mad at me because I wouldn't go ahead and have it done. The claimant agreed that she found Dr. Schlafly through a relative and went to him for a second opinion on her own.

The claimant was queried during cross examination if it wasn't correct that she didn't quit working at Integram because of the problems with her hands, she quit working because of the paperwork mess. I had to quit anyway, the claimant answered, my health just keep getting worse. It didn't get better. And Dr. Schlafly said these two fingers still go numb, and I might have to get my elbow done.

Testifying about prior injuries during direct examination, Rosenkoetter stated that on November 23, 1994 she suffered injury

to her left hand and ring finger. The claimant stated that at that time she had gone from the maintenance to production, and they made seats for Chrysler cars and minivans. I was working on a Saturday, overtime; I was working at the dump area - that's where all the seats come from the overhead down in the bin, then you take the parts out of there and you pack them in the boxes, the claimant testified. And I had two seats come down, front seats, cushions, and I grabbed both of them and I went to turn around to put them in the box and it hit the edge of the box, the one cushion in my left hand, and it started to fall to the floor and I started to grab it, and when I did, it has a metal pan on the bottom and my hand went in the middle of that circle in the middle of the pan, and when it did that it just sliced right down my hand, between my little finger and my ring finger, the claimant said, it went down my hand quite a ways, about an inch. They couldn't decide whether I needed to go to the hospital or not, but I kept bleeding so bad they had to call the nurse, and finally after she came and looked at it, well, then they decided I needed to go to the hospital; so someone from Integram drove me to the hospital where they sewed it up with three stitches, Rosenkoetter said. The stitches were from the inside of my finger down about an inch down my hand, she said. I went back to work, and as far as I recall, I was there the next day, Rosenkoetter said.

Continuing problems are that I have numbness on the inside of my little finger, the claimant said. Whenever anything that goes across my hand there, it really hurts it; it aches in the winter; I can't bend my little finger on my left hand out like the other one, I can't close it all the way like my other hand, Rosenkoetter testified. I can't pick up a heavy skillet or anything like I used to be able to because the strength just isn't there anymore, the claimant said, and I just can't grip as well anything with the left hand. Rosenkoetter displayed her left hand, and it was noted that there was a line scar that went about an inch into the hand between the ring and little finger. It was further noted that the claimant was unable to touch the little finger to the hand by about a fourth of an inch.

Concerning a September 15, 1995 accident at Integram, the claimant testified, that night I was working in Cut and Sew. We have to take leather covers and put them on the foam, and it was always hurry up, hurry up, hurry up, and some tags got dropped on the floor, and I was coming around the table and I stepped on one, and it's real slick on one side, and I slipped and fell towards the table, trying to grab it, I fell to the concrete floor, and especially on my right knee and my foot was kind of turned under me and it hurt my right ankle and jarred my back, the claimant stated. My employer sent me to HealthLine where they wrapped my knee, Rosenkoetter stated. I returned to HealthLine because I still had the pain, she said, my knee was fine and I asked for a second opinion on my back. I went to the doctor on my own and had surgery on my back, she said. I went to Dr. Calvin, my regular doctor, and he set me up an appointment with Dr. Jacobs, a neurologist, Rosenkoetter said.

Dr. Jacobs took x-rays, and I had to go to the hospital for some nerve tests, MRI, Rosenkoetter said, and then the doctor wanted to do surgery right away. Surgery was ultimately done on my back, the claimant said, about a month after I first went to Dr. Jacobs. The surgery was done by Dr. Jacobs at Missouri Baptist in about November of 1995, she said, and it was done on my low back on the left side of my spine. Dr. Jacobs took out a disc and put a stabilizer in my back and fused some bones, I think, together, the claimant said. The affect the surgery had on me, the claimant said, is that my legs don't work right; there is a piece of bone that came off of my spine and runs into the nerve of my leg and that's what is the constant pain all the time. After the surgery I was in bed for a month, the claimant said, I could get up to go to the bathroom, but I couldn't stand to be up any longer than just a few minutes. And then I got a little bit stronger where I could go to the kitchen and come back, and I got so I could sit up and eat at the table for a few minutes, and every little bit, you know, got a little better and a little better where I could walk a little more, Rosenkoetter said.

The claimant testified about ongoing problems with her back and leg. I have constant pain all the time in the low back in the same area where it originally started when I had the slip on the tag, she said. Sometimes the pain is pretty bad, Rosenkoetter stated, it keeps me from sleeping, and I live on pain pills all the time. With walking, the claimant said, I can make it maybe fifty, sixty feet, but I can't sweep the floor unless I stop three or four times and then come back to it, and mopping is very hard. I am not able to do any activities without repercussions from it; the pain is -- if I do too much then I'm in bed for a couple days for it to get better again, unless I'm going for therapy on my back, she said.

I was never able to work like I could work before the accident when I slipped on the tag (and had back injury and surgery), Rosenkoetter testified. Before I slipped on the tag there'd be weeks that I would work more overtime hours than my regular hours; and I was always going in early on the second shift; and I couldn't do that afterwards, she said.

After the surgery, I was off work close to fourteen months, I think, the claimant said, when I went back to work it would have been close to Christmas of 1996. When I went back to work it was hard on my back, Rosenkoetter stated, I went home the first night that I went back. It's hard on my back to lift the stuff and just to be able to walk from station to station and get back in the routine of anything, she said, this along with bending was hard. It was just made me real sore to start back after not being able to do anything for so long, the claimant said, and the bending over the re-work table would hurt my back, and I couldn't do the lifting; I'd go home every night and couldn't hardly stand it from the lifting the heavy seats and stuff, and bending over the boxes. And then I'd have so long a time to get from one station to the other and to be on time, Rosenkoetter said. Walking was from the inspection table to re-work, which wasn't but about five feet, but then you had to go from there all the way into the back, which was maybe sixty, seventy feet, she said, and it was all on level concrete which wasn't real good either.

My knee and ankle had quit hurting for a while after I had my back surgery, the claimant said, but every once in a while my

right ankle flares up. It swells, and in here it's swollen all the time, she said, it's swollen today. The only time it's not swollen is when I first get out of bed in the morning, she said. Since November 18, 1997, every so often my ankle will start aching, I'll be limping around for a while, then it'll get better, the claimant said. It hurts me to walk if I walk a ways, she stated, and sometimes it aches at night; when it gets cold, it hurts. The pain is about a five or a six out of ten, she said. Concerning how far she can walk before the ankle starts swelling up, Rosenkoetter stated that as soon as she gets on her feet it starts swelling.

From the time I went back to work in November of 1996 until the accident of November 18, 1997 with the bench seat, the claimant said, the difference in my ability to work at Integram was that it slowed down a lot. I just didn't do as many parts as I used to; I wouldn't help other people, I just couldn't do that no more, Rosenkoetter said.

I also lost a business interest because of the 1995 accident at Integram, the claimant said. I had several mobile homes; some of them were located in trailer parks and three were on pieces of ground in Union, she said. The times that I worked both jobs, the sixteen hours a day, was to pay for these so that I would have something to retire with, and I made all the payments myself and I done all the repairs myself, she said. After I slipped on the tag I had to sell them all because I couldn't do the repairs or keep them up anymore, Rosenkoetter said, I used to be able to tear them down and set them up myself and I couldn't do any of that anymore after the 1995 accident to my back.

Also before the 1995 accident at Integram where I slipped on the tag, I had my own motorcycle, and I rode it all the time, Rosenkoetter testified. And when I got married, my husband lives on a farm, and I would go with him all day and helped cut wood, I had my own saw; helped him plow the fields, cut the hay, put the hay up, all those things. I can't do none of that anymore, the claimant said. I have always been an active person, I have always been independent, Rosenkoetter stated, I always depended on myself to make my living and to do the things I needed done, I never had to go and ask anybody. But after I got hurt, I sold my bike; it had sat in the shed for two years. I just couldn't do that stuff anymore, she said. My chainsaws, I sold them, the claimant said.

On November 18, 1997 at Integram I had one of the larger seats, and I took it to the box and bent over to put it in, and I got a real sharp pain in my right lower back, Rosenkoetter testified. The size of these seats, I think they seated three, the claimant said, it was the bottom seat, and I guess they're maybe as long as about two to two and a half feet wide. I think we made all the seats for the minivans, she said. The pain in my low back was in the same area as where I had had the surgery, Rosenkoetter said. Agreeing that some time after this, but not that night, the pain went down her leg.

I have constant pain all the way down my leg to my heel still today, the claimant said. I'm going to therapy now because I can't hardly get around; my legs just don't work as well, and I fell going up my steps, two steps, that I have gone up them a thousand times before. I fell, broke my tibia in my left leg because I thought my foot was up high enough for the step, she said, also I stepped over a little fence, maybe nine inches tall, and I fell again. I have come out of the barn and when I stepped on the step then my ankle just turned; I just think my legs are up high enough, but they aren't, the claimant stated. I have slipped in a hole in the yard and fell, Rosenkoetter stated, and my last thing last week I fell and hurt my arm, all I was doing was walking on the driveway, but my right leg wouldn't come when I was stepping and I just went face down. I attribute these falls at home to my back and my legs, they just don't work right, she said. The claimant was asked if this came from the 1995 accident on the tag, the 1997 accident with the bench seat, or both. The 1995, she answered. When asked if they got worse in 1997, Rosenkoetter responded They just seem to be getting worser all the time; the pain never goes away.

The claimant testified about the treatment she is getting now. I've been going to Dr. Calvin, Rosenkoetter said, and I go to the therapy at BJC in Union, Missouri twice a week now because of the pain in my right back. When I go Thursday they're supposed to fit me for a cane, she said. This is the second week that I have been going to the BJC Health Care, going twice a week, the claimant stated. I'm getting the cane so when I'm walking it'll help me sturdy myself, maybe keep me from falling, she said. Medicare is paying for this, the claimant stated.

After the November 1997 incident I went to see Dr. Calvin and I had a knot come up in my hip and he gave me muscle relaxers and some pain medicine, and he has a therapy machine in his office and I got therapy there, the claimant stated. She was asked how long did she get therapy, and Rosenkoetter responded - I was off work for about a week, I think.

When I went back to work after about a week, I just had the pain all the time, the claimant said, it was just miserable because my back hurt and the more places that I went to do the job, then it was just hard. I was not able to do the same amount of work like I used to, she said. Giving an example, Rosenkoetter testified that the fork truck drivers would bring the seats in big boxes and you'd have to bend over and get an armful and put them on the bins for the air bag blower, and that's what was really hard because of the bending and lifting the bunch of seat covers, so I always tried to trade that off with anybody that I could get to trade with.

Testifying about what she can no longer do as a result of the 1997 work accident involving the bench seat, Rosenkoetter testified that it is just about the same things that she couldn't do before, when she hurt her back originally in 1995. I can't sweep and mop like I used to; I can't go work in the fields; I can't ride my bike; it's just pain all the time, she said.

In 1998 while working at Integram I claimed I had depression due to harassment, Rosenkoetter stated. I had my elbows and that hurt really bad, and I went to the HealthLine and they said I had tendonitis. And just luckily the next time I went there was a different doctor came in there to work and he was looking at my arms and he asked me what was wrong with me and I told him, and he gave me medicine for depression, the claimant testified. Rosenkoetter testified about episodes of harassment she experienced from co-workers, such as: if I set my soda or anything on the table, people at work would go and they would poke a hole in my soda so it would run all over my seat; I'd be standing on the platform in front of the molds and I didn't like it there anyway, and there was holes, there was grates, and I was always afraid that maybe the carousel would crash or something, and they got them big molds on them, and they would take a big wrench and they would sneak over there and hit the bottom of the grate, and I would think it was falling; they would spit their chewing tobacco in a soda can, and it would have the top off it, and they would put it on the overhead, and they'd know by the hours when I would be back at the dump, and that soda can would fall on you with all that spit in it, and then you'd have to clean it off the seats, and off of you, and they done that several times.

This started with me just before I went to that HealthLine doctor about my hands, the claimant said. They would speed up the lines on the air bags, they would take and pile up parts so that the line would rush by real fast; and there was about maybe six to eight seat covers that you'd have to blow the plastic off and put them on that line, and they would take them from behind the stop on the machine and then the line would go real fast when they took that last one off, and it would go up, and it would all been empty. And it took me so long to blow each one to get it filled back up again, so I was blowing one and running around putting it up there so that it wouldn't shut down the carousel until I got caught up, she said. This happened until they fired me from work, Rosenkoetter said. I was fired in 1999, I think it was, the claimant stated. The company never did anything to stop this, Rosenkoetter said. When I complained to the foreman, he'd say he'd talk to them. But it did not stop any, she said.

I was first treated for depression by Dr. Bonney, the claimant said, he was not a regular doctor at HealthLine, but he was filling in that day, and he gave me some medicine that would help me, I forget what the name of it was. I don't know what kind of doctor Dr. Bonney was, she said, I don't know if he was a psychiatrist. When asked what year this was, Rosenkoetter responded - I had gone to HealthLine because of my arms, they were hurting me all the time, tendonitis in my elbows. Rosenkoetter was asked, before Dr. Crane, had she been to any psychiatrist for depression at all. No, she answered. The company sent me to Dr. Stillings, I think, the claimant said, and other than that I don't recall going to any other psychiatrists in my life, she said.

Explaining how all of these things she had described affected her work or her ability to work, Rosenkoetter stated that she got really upset about all the bad parts. I just didn't have time to fix them, she said, so that makes it look bad on you, because you got two or three boxes with bad parts sitting there that you can't fix. And then they wasn't even entered into the computer because you don't have time to do all of that, she stated. The parts were foam buns, which is the cushion that goes underneath the leather covers. Explaining what was defective about them, the claimant stated that they would put too much mold release and it just eats the foam and it makes holes in it; the guy that was inspecting them, they had strips on them and you tore off the top part and it was like a Velcro left, he would rip it all off, then I'd have to glue them all back on. This was done just to me, the claimant said. The foreman did not say anything about this, Rosenkoetter stated, he put them all in a box and pushed them to the back, and they would fix them back there.

The claimant testified about continuing problems as a result of the harassment at work. It's still with me, she said, everything they done to me all these years, when I slipped on the tag, then after they sent me to Tesson Ferry to a back doctor down there, when I went in there he done x-rays and he come in there and he told me - you didn't have your back operated on, your back wasn't operated on, Dr. Jacobs didn't do anything to your back. The claimant agreed that when she went to be examined she had a surgical scar on her back where Dr. Jacobs had cut on her back and removed the disc. The surgical scar is more than an inch long and is visible now, and was there when I went to this doctor who told me I didn't have any surgery on my back, and this doctor had looked at my back, the claimant said. Well, after that then they sent me back down there, and they did do an MRI of my knee and said there wasn't nothing wrong with it, she said. The doctor took x-rays of my back, and on the x-rays I had a pinched nerve on the right side of my back, I left, I called back and then when I called back there was no pinched nerve, Rosenkoetter testified.

Rosenkoetter testified about the treatment she has received for depression. Just the medicine that one doctor gave me, she said. Rosenkoetter agreed that she was also treated by Dr. Crane right after the last hearing setting in this case in May 2003, that she had gone the next day; Rosenkoetter agreed that she had testified at the last hearing setting that she was so upset that day she didn't feel she could testify. Except for the one time with the HealthLine doctor, this was the first treatment I had had for depression, when I started with Dr. Crane after the last hearing setting, she said. I don't know how often I have seen Dr. Crane since then, which was May of last year, the claimant said, when I first started going to him it was once a month. The reason I went because I couldn't control my anger anymore, Rosenkoetter said. She agreed that she had a lot of crying spells, and agreed that she missed two appointments at her attorney's office to prepare for the trial. I got so bad that I can't stand to go in the elevators, I can't stand to go twenty-five floors up, all the people, and I got so I wouldn't leave my house; I wouldn't go out of the bedroom, and I just slept all the time; I can't stand the people, too many people, and it felt like the buildings were going to fall on me, the claimant testified. Agreeing that she had refused to come to her attorney's office because it was downtown, Rosenkoetter stated - I just told Mr. Gerritzen I couldn't come up there, I just couldn't do it, and he said I could come to his house. And I had to get my husband off of work because I had a car accident in about 1985 and had a real bad concussion and I can't remember, and it messed up a nerve in the back of my head and I couldn't smell and couldn't taste real good; I get lost and I was losing track of time and I would lose hours, I wouldn't know what I did or where I was at; I was lost and I was in Illinois once and I couldn't get home, and I got lost once in St. Charles. I just decided to stay home, the claimant said.

Rosenkoetter was queried if she felt her inability with going in the big buildings and being with people was due to what happened to her in 1985 or was it due to what happened at Integram, or due to both. Just all the aggravation at Integram, the claimant answered, all the stuff that they done to me and put me down because of my back, and I worked what I could work, when I could work, and it just wasn't never enough.

I last saw Dr. Crane last week, the claimant testified. The treatment Dr. Crane gives me is that he listens to me for one, Rosenkoetter stated. When I went to that Dr. Stillings, I had to fill out this big long paper, a hundred and some questions, and there was a bunch at the end that I couldn't answer yes or no because it wasn't pertaining to me, and when I turned them in, he said - No, you got to fill them all out or else it's going to be incomplete. So I just went through and marked anything because I didn't know what else to do; then when I went in to talk to him he asked me what my problem was, I tried to tell him that it was the stuff at work, and all he said was - We can't talk about that. We couldn't talk about nothing that they done to other people, the claimant stated, and it was all my ex-husband. My ex-husband and I are friends, she said, they come to my house, I go to their house, we eat dinner together and everything. It's not my ex-husband, Rosenkoetter stated, but he didn't want to hear it, he didn't want to hear nothing. And Dr. Crane, he'll listen to me, he doesn't put me off, she said, he gives me the medicine that helps me, unless I get real upset like today, could live a halfway normal life. I took my weed-eater and I beat it up, that's how bad my nerves got, that's why I went to the doctor. I just bought it brand new, and I could not use it for five minutes and my back was hurting so bad I couldn't use it, Rosenkoetter testified. Then I went and made an appointment with Dr. Crane and I started going to him; brand new weed-eater, I just beat it all to pieces; that's why I started going to see Dr. Crane, the claimant testified. She agreed that she was talking about May of last year, 2003. I go to Dr. Crane regularly, once a month or six weeks, sometimes I'll make it two months, Rosenkoetter said. The medicines I am on now are Prozac, two a day; I was given Coreg by my heart doctor since I can't get out and exercise and walk and I got four blockages in my heart, and I take four of them a day; I take Glipizide twice a day; and I got diabetes now, too, because I'm not active enough and I take Metformin; and I take Cardizem for my high blood pressure which I developed after I had the surgery in 1995; and I take a Bayer aspirin every day; and Celebrex; and the rest is just over-the-counter stuff, I have to take the fish oil, two of them a day, and the vitamin and Folic acid and potassium; I take a water pill, it's from the heart doctor, the claimant testified.

I was fired by Integram in 1999, the claimant stated, and the reason they gave was because I was off when I hurt my leg; and they changed the contract and they said the insurance papers -- when I hurt my knee, I went on sick leave and I went and got my papers to fill out; it's after I fell and went to the hospital and the doctor said I shouldn't work. So I went to the bone specialist, and I got my insurance papers and I didn't know how to fill them out because they were different, and I called the H.R. and Mary Jo said she would help me fill them out, and she told me what to put down. And I went to the doctor, the bone specialist, Dr. Kef alas, and I had an immobilizer on my knee and a gel cast on my ankle and I was on crutches; and I think that was on a Wednesday, and Thursday I had called work, I had all my phone bills because it was long distance, and I had called them on a Friday and I asked them in H.R. at Integram if there's anything else that I had to do, and she said no, that's all I have to do, the claimant testified. On the Thursday the doctor had faxed my medical papers from his office to work; they had them, but she lied to me, she said there was nothing else to do and that wasn't true, the claimant said. They said they fired me because I didn't come in and fill out new papers; that's why we went, the union man and me, before the arbitration board. It was whoever's the boss down there at Integram, the general foreman, I guess, who said I didn't fill out the papers right, the claimant stated, because they said I was fired because I didn't do my paperwork right. But they already had the doctor's papers there in front of them and then when we went to the arbitration I had my phone bills and everything, and they had three or six women from the H. R. Department sit there and lie, it didn't make any difference what I said, and my union worker denied me the right to have counsel, said he was going to represent me, so I didn't even get to have a lawyer there, Rosenkoetter testified. This was right after they fired me and then went through three steps, and the fourth step was to go before the arbitrator. They denied my unemployment, and I went to the hearing for unemployment and their woman said that was absurd that I would quit my job at fifteen something an hour, and she gave me my unemployment, the woman from Jeff City, the claimant stated.

Rosenkoetter stated that she has tried to work since leaving Integram. I tried to find a job, and I filled out applications and applications, and nobody would hire me, she said. Wal-Mart said I had to bend over and pick up a dime off the floor, I couldn't do that, my back wouldn't let me bend over that far, the claimant said. I filled out applications for wherever I had education to do -machine shops and different places like that; but as soon as they find out you had a back problem they don't want nothing to do with you, Rosenkoetter stated. She was asked if she believed she is able to work now anywhere. No, Rosenkoetter answered, and explained that it was just all the injuries to her body. I just can't do it, she said, I wish I could.

The claimant testified about her daily routine now. I try to do my dishes in the morning, and get my husband off to work, and make his lunch, she said, and try to sweep the floor, that takes me a while because I quit and go back, and sometimes I'll sit on the porch, or sometimes I watch TV for a while. I can't sit very long, can't stand very long, the claimant stated, I sit for maybe about forty-five minutes or so, then I got to get up and walk around. With standing it's really hard for me to bend over the sink to do the dishes, Rosenkoetter said, I'll stand for a while, depends on what I'm doing. I think the longest I can stand is about an hour or so, I guess, she said. I can't walk very far, the claimant said, I'd walk from the house to the barn and turn the water faucet on for the cows but last time I went out there, I fell, this was last week. I fell because of my leg, Rosenkoetter stated, I had bad pains in my right hip and lower back for the last month and a half, and when I went to step it was just real bad pain, I couldn't bring my foot up and I just fell face down in the gravel. But I got a bone on the left side that catches on my hip bone, and I can feel it, I can

feel it rubbing, the claimant said.

Rosenkoetter agreed that she had submitted a number of medical bills in the case for the carpal tunnel surgery and for the other treatment she had received, and that she was asking for an award of compensation for those bills. No one has paid these bills of Dr. Schlafly's and of St. Anthony's, she said. It was agreed and stipulated to by the claimant and the employer/insurer that bills in issue were entered in Claimant's Exhibit No. A marked as A-11, and entered into evidence marked as Claimant's Exhibit Nos. M, M-1, N, N-1, O P and Q.

On cross examination by the employer/insurer, Rosenkoetter was asked about her 1985 motor vehicle accident. I had a small car, an Omni, she stated, and a lady came up on the right side, and she clipped the front of the car and threw me into the median, and I wound up hitting my head pretty hard on the mirror and broke it and caused me to have a concussion and messed up a nerve in the back of my neck, and there was a bone out of place in the side of my head. I went to a doctor for about seventeen months; I couldn't drive, I would lose track of time, I get lost, I'd be sitting at home and I'd just lose three or four hours, she stated, and I couldn't stand to smell white bread, I couldn't see the trees going by or I had to wear sunglasses. Problems that have continued are with direction, the claimant said, getting turned around and getting lost sometimes. I just don't go far from home and usually my husband takes me if I have to; this is because I get turned around sometimes, but not all the time. Concerning my memory, Rosenkoetter said, as far as everyday things, it's all right. I've never been any good at dates, she said, I can remember what happened, but I can't for, say, remember every day. When queried if she was confident all the history she gave on direct exam was accurate, Rosenkoetter responded - I tried the best I can remember. The claimant was queried, if some of the medical records showed a slightly different history as opposed to what she testified to on direct examination, would she dispute what's in the medical records? I don't know; I done the best I could to remember all the dates; I'm just not good at dates, the claimant answered.

During cross examination, Rosenkoetter agreed that she had had two back injuries, the first one in 1995. The claimant stated that as far as she knew, she had have never been to Dr. Clark prior to the 10-15-95 injury to her back. She was queried if it would be inconsistent with her recollection if Dr. Clark's records from 1994 indicated that she had been involved in a motor vehicle accident and that she had pain in the small of her back, and hip, and legs that was worse in the last six months. I only been in two car accidents, the claimant responded. Rosenkoetter agreed that Dr. Jacob is the physician who operated on her back. Dr. Calvin sent me to Dr. Jacob, the claimant said. I don't know if Healthline had discharged me from their care prior to my seeing Dr. Jacob, Rosenkoetter stated. She was queried if, prior to her seeing Dr. Jacob, had anyone at Integram ever said to her that they were done with treating her, that they were not going to treat her legs or back anymore. I don't recall that, the claimant answered. Dr. Jacob's bills were paid through my group insurance, Rosenkoetter said. The claimant agreed that she was off for some time after this back surgery, and when asked if she believed upon her return to work in June of 1996 did she feel she was able to return to work, the claimant responded - I didn't have no choice. Rosenkoetter stated that on 11-18-97 she hurt her right back when she put the bench seat in the box, and that from the first date of injury to her back up to 11-18-97 she did not recall having any other injuries to her back. At the time of the second back injury I was working full duty without restrictions, as far as I know, Rosenkoetter said. For this second accident on 11-18-97 Integram might have sent me to Dr. Rende who was supposed to be a back doctor, Rosenkoetter said. The claimant was asked if she had treated for a relatively short period of time for this second 11-18-97 injury. When I hurt my back at work, Rosenkoetter answered, the next day I went to Dr. Calvin, and I think I was seen by someone else, and I had a knot right across from my spine, and they took me off work for a week and gave me muscle relaxers to see if that would help it. The claimant was asked if she had been seen by Dr. Calvin prior to 11-18-97 for problems with her back, such as six months preceding, and the claimant answered - I go to Dr. Calvin for most everything. I don't remember if I went to Dr. Calvin for complaints or problems with my back in the six months preceding the 11-18-97 incident, the claimant said. I could have but I don't remember going to Dr. Calvin on 5-29-97 for complaints of strain in the upper back and neck, and severe muscle spasm after lifting liquid soap, Rosenkoetter said, sometimes I turn just right or if I'd pick up a basket of clothes or anything then I strain my back. It was noted that Dr. Calvin's record included a 9-16-97 entry reflecting that Rosenkoetter had advised him that she had strained her back while lifting heavy pots at a family reunion and that she had been diagnosed with acute lumbar sacral strain and severe muscle sprain; the claimant responded - If that's what it says. The claimant was asked if Dr. Calvin in September, 1997 had referred her to Dr. Jacob. I'd already been going to Dr. Jacob, Rosenkoetter answered, I don't know how many times I saw Dr. Jacob after the surgery for the 1995 injury. I had another MRI done and I had other nerve tests done after that because the top of my arm is numb, and the inside of my left leg is numb on certain parts; that's from 1995, it's been that way ever since I come out of surgery, the claimant said.

During cross examination by the employer/insurer, it was noted that Rosenkoetter's fourth Claim for Compensation pertained to her psychiatric condition, and the claimant was asked to what did she attribute her psychiatric problems. I'd been having problems at work with harassment, the claimant answered. She was asked when did the harassment start. I don't recall, Rosenkoetter answered, all I know is I had problems with them at work and that day was really bothering me, and the doctor asked me what was wrong and I told him. I'd had problems after I went back to work, not being able to do what I was supposed to do, worried about my job, the claimant stated. Rosenkoetter agreed that it was sometime after she went back to work after the surgery for the back injury that the harassment started.

Rosenkoetter stated, during cross examination, that she was already was stressed out before her termination; the termination did not make my stress worse, it made me hate you and the company you represent. Rosenkoetter agreed that her termination and the grievance proceeding was all about insurance paperwork, it wasn't about making bad parts or not doing her job right. No one

from the company that I know of ever wrote me up because I made too many bad parts, the claimant said. No one from the company ever came to me on the re-work line and said as a result of my not keeping up with the re-work, we're going to write you up, Rosenkoetter stated, they did come back and tell us if people was going to chew, then they had to have a bottle with a lid on it and keep the lid on it.

Rosenkoetter agreed, during cross examination, that she had been physically assaulted once. My husband's brother jerked a chain out of my hand and hurt my arm, she said. She agreed that this happened on about 6/6/95. I went to St. John's Hospital, the claimant said, and they said it was just strained, it was all right. The claimant agreed that a history of what had occurred was taken from her at the hospital. When asked if her brother-in-law had tried to punch her on that date, Rosenkoetter responded - I think he tried to punch my husband or hit him with a shovel, or might have tried to take a swing at me, but he didn't hit me. The claimant agreed that her memory was refreshed by the St. John's record which reflected that her brother-in-law just went berserk, grabbed her arm and twisted it and tried to punch her, and she blocked that punch with her right arm. He grabbed a chain that I had in my hand and brought it around a post and it twisted my hand, she explained. Explaining what caused her brother-in-law to go berserk, Rosenkoetter testified that he lived in the farmhouse and his dad had given him six and a half acres to build a house. He wouldn't work on the house so we kicked him out; he had to pay rent or move; and then when we told him that dad wanted him to pay rent, he got mad and he moved out, and then put chains around the gate to keep us from going to our house; and we went up there and told him that we had to get in, we had no other way to get to the house, there was no other roads, and my husband said - Well, we'll just put chains on it and you won't get out; and that's when he just went crazy, the claimant testified. She was asked if her brother-in-law had hit her husband with a shovel. I think he did, the claimant answered. Rosenkoetter agreed that they had to take her brother-in-law to court to resolve this issue. We just went to the court and we told them our side, he told them his side, and they gave the road to him because it wasn't specified on the deed about the road and the easement, and he got the road and we didn't, the claimant said. What we did about access to our home was made a road, she said. This brother-in-law still lives next to me, she said. Describing the relationship now, Rosenkoetter testified - He talks to me, I talk to him; I give him stuff out of my garden, my husband's over there quite often; he just shut the road off, that's all, so you live with it and go on. I don't think I continue to have problems with my right arm after the assault, she said. The claimant was queried if she knew why the records of Dr. Bedor for 1997 would reflect that he thought she had a rotator cuff tear in that arm. I got a test from our regular man, and he said they done a test in there put medicine in there and took x-rays, and I didn't have a rotator cuff tear, she stated. I didn't know what was causing my right shoulder problems at that point in time, that's why I went to find out; I thought I had a rotator cuff tear, and I didn't, she stated. Rosenkoetter stated that she did not remember if she missed time from work as a result of the problems with her right shoulder. I do not recall my shoulder affecting my ability to do my job duties, the claimant said. Rosenkoetter agreed that the police were involved in the altercation involving her brother-in-law, and charges were filed, but she didn't think charges were filed against her or her husband. The claimant was asked if there were any other times that she had been physically assaulted. Well, my ex-husband used to push me around a little bit off and on, she answered. I was married to my ex-husband for twenty-five years, she said. Rosenkoetter agreed that her ex-husband also tried to abuse her emotionally off and on throughout the twenty-five years. He went to the hospital and got help, she stated, he had a medical problem. Rosenkoetter agreed that she had children with her exhusband, and that her children witnessed some of that emotional and physical abuse. Agreeing that her children were subject to that emotional or physical abuse, Rosenkoetter explained that that was why she got a divorce. It was a friendly divorce, she said, we visit each other; he comes to my house, he's remarried and I go to their house. I have not had any other family issues that caused me stress or added to my depression, the claimant said. She agreed that she had attempted to take custody of a grandchild, and explained that it was because the child had a drug addict for a father. The mom brought the baby to me, and he wouldn't buy her diapers, and she had no place to keep the baby clean, and she asked me if I would take her and I said yes. I had the child for maybe six or seven months, Rosenkoetter said. I don't know what year it was and I don't know when she went back; I gave her back because her mom got her own apartment, got on HUD, and had money to take care of her; it wasn't because of my daughter, but I had to put both names on there (my daughter's name and her boyfriend's name), or I couldn't get her.

Rosenkoetter agreed, during cross examination, that over the years she has had some problems with pneumonia and ear infections and sinus problems. I believe that it is because of the mold release that I smelled every year for year after year, she said. The claimant agreed that she missed time from work as a result of the problems with bronchitis. It was noted that she missed time from work in 1997 and 1998 because of problems with bronchitis and the breathing, and Rosenkoetter responded - You know, now I very seldom get bronchitis or get sick.

During cross examination by the employer/insurer, the claimant agreed that besides seeing Dr. Stillings one time in 1998, the first time she received any psychiatric treatment was through Dr. Crane's office in 200(3). The claimant was asked if she had ever attempted to get treatment through her group health insurance. I didn't think it was bothering me that bad; I didn't want to go to a psychiatrist, she answered. Rosenkoetter agreed that when she thought it was bothering her so bad that she had to go see a psychiatrist was when she went to Dr. Crane. It was noted that this would have been several years after she left the employ of Integram, and Rosenkoetter responded - It kept on and kept on and kept on. My health situation, it eats me up, she said, do you know what it's like to not be able to do anything or fall over everything and get hurt, like my arm, and broke my leg. You don't know what it's like, she indicated; not being able to enjoy my bike no more or ride my motorcycle or go in the field with my husband, he has to do all that work "hisself" now. I can't even plant my frigging flower garden; I try to weed-eat, I bought the lightest weed-eater they had which they said weighed less than five pounds, and I couldn't even do it more than five minutes. That's why I went to Dr. Crane, the claimant stated, because I knew I needed to go someplace and I looked in the phone book and I found Dr. Crane's name and I went to him. It's just been building up and building up and all these years and all these accidents and

got so I wouldn't go out of my bedroom, I would stay in there for days, the claimant stated. I didn't want my kids to come, I didn't want to see my grandkids, I didn't want to see nobody, she stated. And every time I got hurt it brings it all back again, the claimant testified, and every time I had to go to these stupid hearings and all these years been going on and going on, it eats at me. Now I have to get surgery on my other hip, and I got to face that, too. You know what it's like getting out of bed for five seconds, not even long enough to go to the bathroom, and you got to go back and lay down because you can't set up, the claimant stated. I want to kill myself, if I could have got a gun, I would have, she said. I go to bed every night crying because my legs and my back hurt so bad; can't go any place around people and enjoy yourself because you're miserable; you can't even sit in a frigging chair, the claimant said. Rosenkoetter agreed that every time she has an injury to her body, it dredges this all back up and makes it worse.

The claimant agreed that she was involved in a motor vehicle accident in October, 2003. My daughter suggested that she and I go down to visit my other daughter and we went down there, and I rested while I was there, and we spent the day and had dinner. We started back home, and I was driving on Highway A, and there was a road on the right side and the man was coming the other way, and he decided he was going to turn and he was drunk, no insurance, two babies in the car and his wife; I didn't have time to stop, and I tried to miss him but it didn't work, Rosenkoetter said. The people in the other car, and my daughter and myself were injured in the accident, she said, no one was killed in the accident. Explaining about her injuries, Rosenkoetter stated that the air bag went off and she was going sideways and it hit her shoulder, and her hand hit something and broke a bone in her left hand, and her knee hit something on the door somehow. I wasn't casted, Rosenkoetter stated, it seems like my bones don't break across but rather they break down, and they put five, I don't know what you call it, it had a metal piece on the bottom and you wrapped it there; I had to wear that for a month. I did not have any problems with my neck or anything else as a result of this injury, she said.

Rosenkoetter agreed on cross examination that the problem that came up that led to the whole paperwork mess and that eventually led to her termination was an injury that she had to her left leg that occurred at her home. I had several injuries happen at my house, my legs wouldn't work right; I wasn't never sure if my foot was high enough or if I was stepping right, it just didn't work right, the claimant stated. The first time I fell on some steps I broke my tibia, she said. When I fell on 3-17-99, I didn't fall because I was dizzy or disoriented, I fell because of the problems with my legs that I know was due to my back, the claimant stated. I told Dr. Jacob, the one who did the surgery, that my legs just didn't work right, and he said there's nothing more that he could do for me, the claimant stated. I went to my bone doctor, Dr. Kefalas, for treatment when I fell at home on 3-15-99, she said.

The claimant was queried if it would be inconsistent with her memory of how she was injured if Dr. Kefalas' notes of 3-1799 indicated that she became dizzy at home and fell. When I came out of the barn I thought my foot was on the step, but it wasn't, and I stepped in a hole and the ground was uneven and I went down, the claimant responded. It was noted that Rosenkoetter had said that she fell on the steps. The first time I got hurt after the surgery I was going up the steps and my foot caught on the steps because it wasn't up high enough and I fell and I broke my tibia bone, the claimant answered, and then I come out of the barn and I thought my foot was on the step but it wasn't, it went sideways, and I fell, and fell in the hole in the yard. I don't know if the fall into the hole in the yard was on 3-15-99, the claimant said. Dr. Kafalas took me off work for the 3-15-99 injury, the claimant said, I had a mobilizer on my knee, I was on crutches, and I had a metal-with-gel-cast on the inside of my ankle. The claimant was asked if it sounded accurate that as reflected in the doctor's record he kept her off work through 4-7-99; and she answered that she did not remember the date, but she thought it was in sometime in April. Rosenkoetter denied that at that time she attempted to return to work. When the doctor or the hospital man said I couldn't work, I called work and said I couldn't work that I had to go to my doctor the next day. I called work and I asked for insurance papers; when I was off when I broke my leg before, they got a new contract, and I didn't have a new book, I didn't know what the new rules was because nobody said anything, she said. And when I called the human resource and asked the gal for my papers, she faxed them to me, and I looked and they were different and I didn't know how to fill them out. So I called back and I asked her how to fill them out, and she told me; I put down what she told me, and then I went to my doctor and I showed him the papers. The doctor looked at my knee and stuff and x-rays and said that I should not work on it, to stay on the crutches, and that's what I did. The claimant was queried, wasn't it correct that at some point she got off the crutches, the air cast and off the gel cast, and Dr. Kef alas was done treating her for this injury. When they said I was supposed to be back at work, I was on crutches, I had that on my ankle, and I had it on my knee; there was no way that I could come in there and work, the claimant responded. Rosenkoetter then again denied that at some point she attempted to return to work at Integram. She was asked if she had filed a grievance. I went to the union, she answered. She agreed that she basically went to the union saying that they had unfairly taken her job away, and that she should be able to continue working at Integram, that she filed a grievance saying she should be working at Integram. Rosenkoetter stated that she went through, she thought, four different levels of the grievance proceeding, the most you could go through. I don't think I was even at the three meetings, she said. The claimant was asked if it upset her that she wasn't successful in her grievance proceeding. What upset me, she answered, was that they frigging sat there and lied; no matter what I told them, no matter the bills I showed them, they sat there and lied and he took it. And you know what upsets me is that those people can make bombs, they can layoff, they can sneak out of work and everything, and nothing happens to them, only three days suspension, Rosenkoetter stated. Not having a lawyer present that upset me, too, she said. Rosenkoetter agreed that after she was terminated from Integram she applied for unemployment benefits. I did not receive those benefits right away, she said, Integram said that I didn't deserve them, I was fired. Rosenkoetter stated that she did not have much choice when receiving those benefits on a weekly basis in filling out a statement alleging that she was ready, willing, and able to work. I had to get a job because I knew that wouldn't last very long, she stated, I was out there every day trying to find a job, but then when you put down you had surgery and this and that, they don't want nothing to do with you. You can't lift; they don't want you in the machine shop if you can't lift stuff, she stated.

It was noted during cross examination by the employer/insurer that the claimant had testified that as a result of all these conditions she had been inhibited in her ability to engage in activities around the farm, and Rosenkoetter was asked how long had she had that limitation. Ever since I fell on the tag, the claimant answered. Rosenkoetter was queried if she would question the accuracy of Dr. Sertl's record which contained a history that she had injured her left leg riding a tractor in September of 1998. I would try to do stuff; I didn't have as much wrong with me then; it was just all the stuff just piles up; I still try to do stuff, it just don't work, the claimant said.

On cross examination by the Second Injury Fund, Rosenkoetter stated that after recovering from her broken tibia injury that occurred in the Summer of 1998, she was working full job duties on her regular scheduled hours up to the time she hurt her right knee and she was fired from Integram. My regularly scheduled hours were to start at eleven p.m. and I think we got off at seven ten. The time I worked at Integram my job title was Foam Production, the claimant said, and agreed that there were other people who worked with her who did the same jobs she did. The only time that there was more than one person at a work station doing the same job was at the dump where the cushions would come down and you'd inspect them and then put them in boxes, the claimant said. Agreeing that there were other shifts at Integram besides the one she worked, Rosenkoetter stated that there might have been three shifts including a day shift, and she worked on evening shift one time. I imagine there was somebody else doing that same foam production job that I was doing on those other two shifts, the claimant said. I started in foam production in 1991, I don't remember the month, the claimant said, and worked there until I left Integram. During this time period I was doing the same job duties throughout the whole time, she said. Discussing this job in more detail, Rosenkoetter agreed that she worked with the foam seats that went in minivans. The bench seats were quite long; I have no idea what they would weigh, I really don't, she said. I also lifted all the cushions backs or the cushion part; there was child seat cushions, and the cut and sew was the foam buns with other covers on them and heaters in them. The cushions had a metal pan on them, so they might have been the heaviest, I really don't know, the claimant stated. The whole work-day was spent on my feet, she said. Rosenkoetter stated that she was doing bending with just about every position there, and explained that they rotated to different stations. I don't think I ever had to do any squatting or kneeling in doing my job duties, the claimant said, not unless you dropped something. Rosenkoetter denied that during the last six months that she was physically working at Integram she was doing the same job duties that she had been doing since she'd been in foam production beginning in 1991. I wouldn't help nobody anymore, and I was lucky to get my job done, she stated. I would trade off because lifting covers was really hard on me because you'd have to lift like ten or so at a time, and then you had to bend over in the boxes and lift the heavy lids off the boxes; it was really hard on my back, the claimant testified.

Before I had slipped on that tab and had the surgery I worked a lot of overtime, Rosenkoetter testified, I would usually go in early and sometimes I'd stay over late, and there for a while I made more overtime hours than I did regular hours. I don't remember if I worked any overtime after the slip on the tag on the floor, the claimant said.

Rosenkoetter agreed, during cross examination by the Second Injury Fund, that at the time that she was terminated from Integram she was on sick leave for her leg. The doctor kept me off work for a period of time for my leg at that time, the claimant agreed, and this was about April of 1999. It was my intention to return to my job at Integram after I recovered from this leg injury, the claimant said. The claimant was queried if it was correct that one of the reasons she filed a grievance at the time Integram let her go in April of ' 99 was because she had planned and wanted to return to her job at Integram. No, Rosenkoetter answered, I filed a grievance because the lady in the H.R. lied, she said I didn't have to fill out anymore papers, and that's why I lost my job. The claimant agreed that when she filed the grievance she was trying to get her job back.

Since I left Integram in 1999, the claimant stated, the condition of my low back has gotten worse. The claimant was also queried, since you left Integram had the condition of her right ankle had gotten better, gotten worse, or stayed about the same? When I hurt my right ankle, after I did what the doctor told me, it got better, Rosenkoetter answered, it just gives me trouble every once in a while, it gets real sore, it swells, it stays swollen all the time. When I left Integram in April of 1999 my right ankle was pretty messed up because I had to wear a gel cast on it for like six weeks, but the problem I have now is that walking sometimes will irritate it or it just swells all the time. Rosenkoetter agreed that the condition of her hands got better after the carpal tunnel surgery. The symptoms I still have in my hands now from the carpal tunnel is that every once in a while my hands will cramp up; I can't sew anymore, I used to hand quilt and I can't do that anymore, I can't hold the needle; it's just like charley horses in my hands, the claimant testified. The claimant was asked if her depression had gotten better, gotten worse, or stayed about the same since April of 1999. Gotten worse, she answered. Rosenkoetter stated that she still has problems in her right hip. Right now I'm going for therapy, she said, they're going to fit me for a cane Thursday so it will help steady me when I'm walking. When asked if she had had problems with her right hip in April of 1999, the claimant answered - I've had problems with it off and on since I hurt it in 1997 when I bent over in that box. She agreed that this was her second back injury. The condition of my right hip has gotten worse since I left Integram in 1999, the claimant said, my doctor suggested that I find another neurosurgeon because mine retired, he's looking for one for me now.

On redirect examination, Rosenkoetter was asked what was the major factor she felt was the reason she is unable to work now. I just had to accept it that my body wouldn't do it no more, Rosenkoetter answered. It's a combination of everything that's happened to me, she said, but more it's my back. The bending, I can't even bend over the table to make dumplings anymore for my family, or make pies, or stand at the kitchen sink at one time and finish up my dishes when the kids come, you're just bent over and that's it, the claimant stated. The claimant was asked, in regards to unemployment, was she, in her judgment, physically able to go back to work at Integram when they fired her or was she not able to go back to work. I went back to work because I had no choice,

Rosenkoetter answered, I had kids to take care of, I had bills, and I like my job.

After I hurt my back in 1995 when I fell on the tag I was never able to work the same as before then, the claimant stated. It wasn't only work, she said, it was my activities at home and just the things I enjoyed doing, couldn't do no more.

The claimant was asked, during redirect examination, if she believed she was unable to work now and had been unable to work since 1999 because of what happened at Integram. I honestly don't think I can work because of what happened at Integram; my back, it started the whole thing, she said. And I think my weight problems is because of my back and my nerves and I can't get out and exercise, and now I've got diabetes because of it, Rosenkoetter added. Since 1995 when I hurt my back I have gained about forty-five pounds, she said.

On further cross examination, the claimant was queried, in light of her testimony that because of what happened at Integram she has unable to work, if at the time in 1999 when she was terminated by Integram and she went through the four grievance proceedings and said to the arbitrator - give me my job back, I could do the job - was that all a misrepresentation. At that time I thought I could, and I would have tried, the claimant responded.

The claimant agreed, during further cross examination that when she had the first injury to her back in 1995 that slowed her down at work; she agreed that also as a result of this she couldn't work as much overtime. Rosenkoetter was queried about Dr. Bedor's records which indicated on 5-28-98 that she was working ten to twelve hour days, six to seven days a week. My back was bad in May of 1998, she said, but if they said for you to work, you worked.

On further cross examination by the Second Injury Fund, the claimant was asked if carpal tunnel problems she was having with both wrists, did that get better, get worse, or stay the same between the time she left Integram in 1999 and the time she had the surgery on her wrists in 2001 or 2002. With my hands until I had the surgery with Dr. Schlafly, she answered, it got worse because I went and had the surgery. And these two fingers still get numb and goes down to my elbow because he said I would eventually have to have my elbow done, the claimant further stated.

Joe Laffleur testified on behalf of the employer/insurer. I'm a human resource manager at Integram St. Louis Seating, and have been in that position for eight and a half years, Laffleur said. He agreed that in his position he deals with the union, UAW, at Integram, and stated that the union has been involved with this particular Integram plant since July of 1995.

Laffleur stated that he was present at the grievance of Rosenkoetter but not at the grievance proceedings, as Rosenkoetter would have done that through her union representative. He agreed that as H.R. director for Integram he participates in grievances on a regular basis, and becomes aware of each grievance procedure. My role with the grievance procedures is that I pretty much handle the whole procedure, Laffleur stated. It's actually a four-step grievance procedure, and if that doesn't solve the grievance, then it goes to arbitration; I'm involved in all four steps plus at the arbitration level. And I actually conduct the meetings and I write the grievance, Laffleur testified. He agreed that in conducting the meetings he represents the company's interest, and in an effort to address his side of the argument, he becomes aware of the grievance allegations. Agreeing that he was aware of the allegations in the case involving Rosenkoetter, Laffleur stated that the allegations were that she did not terminate her seniority.

On cross examination by the claimant, Laffleur stated that there are six hundred and fifty employees in the plant right now, Laffleur stated. He agreed that as human resources manager, he hires and fires people.

On redirect examination, Laffleur testified about the basis of his terminating Rosenkoetter in 1999. She terminated her seniority in accordance with the labor agreement because she failed to return from her leave of absence, Laffleur said, and agreed that the employer made no proactive attempt to terminate her. To my knowledge, Rosenkoetter was never written up for poor performance, and never written up for problems with quality or quantity of her work, Laffleur said. To my knowledge, in the grievance procedure, ability to perform her job duties was not an issue, he said.

On further cross examination by the claimant, Laffleur agreed that he had brought Rosenkoetter's personnel file with him to the hearing. He agreed that the file included write-ups of Rosenkoetter, and stated that there were all on attendance. Laffleur stated that in the personnel file he had attendance discipline records but not the attendance records. I have no idea what the attendance records were for the six months prior to September 15, 1995, he said, we don't have those records prior to 1995. I never had the attendance records for six months prior to 1995; they were made at the time, I'm sure; I wasn't here, Laffleur testified. In explaining about how far back the company's attendance records went, Laffleur testified - We put in a new attendance system back, I believe, in the year 1997 or 1998, that's as far back as it goes. Laffleur stated that the company did have the pre-employment physical records, but he believed it was back at the plant; they're kept in a medical file, if you're talking about the exam Rosenkoetter had when she got hired, that would be a separate file, that would be a medical file. It was noted that included in the personnel file was that it was maintained by Laffleur and found by the appeal judge that the claimant left work on 3-19-99 without good cause. The original judge agreed with us, yes, Laffleur responded. Laffleur agreed that he wrote the termination letter, and that it was based upon Rosenkoetter not returning to work on 3-19-99. He stated that at that time he knew that Rosenkoetter's doctor had given her an off-work slip. Laffleur agreed that it was just a question of a leave request form not being filled out and sent in. Laffleur agreed that the personnel file included: a. that Rosenkoetter had missed eighteen days from work, 10-22-98 to 1-

25-99, adding that it was a chronic attendance letter which is part of the labor agreement; b. that on 1-6-99 Dr. Calvin wrote him a note that Rosenkoetter has severe degenerative disc disease; c. that on February 13, 1998 the company wrote Rosenkoetter a letter that she was the most frequently absent from work in November 1997, December 1997, and January 1998; d. that shortly after the bench case of November 18, 1997, on 11-20-97, there is a note from Dr. Calvin saying Rosenkoetter has somatic dysfunction of her lower back; e. a 7-21-97 note the Rosenkoetter has chronic degenerative disease of the right ankle. Laffleur agreed that he knew about all these conditions Rosenkoetter had when he decided she didn't conform to the filling out the form properly (reporting on March 19, 1999) even though he knew she had been taken off work by her doctor.

On cross examination by the Second Injury Fund, Laffleur agreed that if someone has poor performance, it is possible for them to be disciplined at Integram, and if there's a discipline for poor performance it is it put in their personnel file. Rosenkoetter did not have any discipline forms in her file for poor performance, Laffleur said.

On further direct examination, Laffleur stated that the slips he had been asked about that were in Rosenkoetter's personnel file, he got them either from the supervisor -- the employee gives them to the supervisor and the supervisor gives them to us in H.R. Agreeing that somehow the employee directs the routing of these to the file, Laffleur added that the employee brings the note in. He agreed that it appeared Rosenkoetter was aware of the need to bring those forms in.

Medical records in evidence included the following:

1.Certified medical records of HealthLine Corporate Health Services Metro St. Louis (Claimant's Exh. D) indicated a majority of the treatment as employer (Integram) authorized treatment; the record concerned the treatment of Rosenkoetter for various complaints and injuries from March of 1994 through October of 1999.

The first entry of 3/18/94 indicated that Rosenkoetter presented for evaluation of her right wrist, with a history that the wrist had been bruised on two separate occasions in the past week; she was evaluated at the emergency room and x-rays were taken which were negative; the diagnosis was - wrist contusion and hematoma; it was written that Rosenkoetter was returned to regular duties, and that the company had flexible wrist supports which was recommended Rosenkoetter obtain and use. The next and subsequent entries included the following.

12/01/94 - treatment for an 11/23/94 laceration injury to Rosenkoetter's left palm as a result of cutting her hand on the sharp edge of a pan while working; exam findings included that the wound was quite deep, tenderness to palpation about the area, decreased grip secondary to pain, some numbness over the radial aspect of the left little finger near the area of the wound; some sutures were removed and others left in; Rosenkoetter was placed on restricted duty. 12/6/94 - treatment for re-opening of wound subsequent to another doctor removing the sutures; Rosenkoetter was restricted to no use of the left hand. 12/16/94 - follow-up treatment to the laceration injury, and it was noted that she complained of pain to the left wrist which occurred with the injury; written in the entry was - "I told her that she never mentioned this wrist pain to myself throughout all of her visits here and when discussed with Carolyn, Carolyn states this has also never been mentioned to her. Because of the time frame from her first visit here to the current complaints of wrist pain, which is approximately 16 days, this injury to the left wrist has been rejected by her employer"; the diagnosis remained - laceration left palm healing; Rosenkoetter was continued on restricted duty of use of left hand as tolerated. 1/4/95 - follow-up appointment for the laceration injury, it was noted that Rosenkoetter had been off work for sometime as she had recently lacerated a tendon which was non-occupational of the right hand; exam findings were improvement with the laceration but still some tenderness about the area of the wound and pain with forced abduction of the thumb and index finger; the diagnosis remained - laceration left palm healing, and Rosenkoetter was discharged from the clinic, full duty status. 9/15/95 (the next entry in the record) - complaints of pain to the left palm in the area of the previous laceration which was at the radial aspect of the base of the left little finger, and complaints of numbness along the radial aspect of the little finger with some pain along the scar area extending to the palm; the assessment after examination was -1 . Pain left palm status post laceration which is old, and 2. Flexor tendonitis left hand which is new; the plan was for hand therapy with scar management; Rosenkoetter was returned to full duty; it was indicated that this injury was consistent with the 11/23/94 incident. 10/6/95 - Rosenkoetter presented with complaints that her little finger drew up and the pain was unbearable; objective findings were - no swelling to the area of the healed laceration, no excessive scar tissue present, skin appears to move easily as if there is no adherence of the underlying tendons, excellent resisted flexion, full extension; it was noted that Rosenkoetter said she could not find anything wrong with her hand; the diagnosis was - pain left palm, no change; therapy for scar massage was ordered; written was a question as to whether injury was consistent with alleged 11/23/94 incident as the doctor wrote that she could really never find anything wrong with the hand other than Rosenkoetter's subjective complaints; Rosenkoetter was continued on full duty work status.

9/15/95 - Rosenkoetter was seen for complaints of pain and intermittent swelling in the right ankle and right knee as a result of twisting and slipping on a piece of paper at work on 8/25/95; an x-ray report, dated 9/15/95 and indicating a date of injury of 8/25/95, indicated exams of the right knee and the right ankle, and results for both were - negative/no bone or joint abnormality evident; the diagnosis after examination was - Mild sprain right ankle, and Strain right knee; treatment was a Futuro wrap for the ankle and Genu-Medi for the knee and also ice, heat and medication; it was indicated that the injury was consistent with Rosenkoetter's work activities or the alleged incident; she was released to full duty. 9/25/95 - follow-up of sprain to the right ankle and strain to the right knee; it was written - "Although, her injury seemed mild on her last visit here she complains of continued pain and states she is not improved. She requests to only work 40 hours a week 8 hours a day. I told her that we would consider

other restrictions instead and she was very unhappy with this."; diagnosis after examination was - Sprain right ankle, and Strain right knee; physical therapy was ordered; ordered was light duty work of seated duty for half a shift and self-paced walking; it was noted that the injury was consistent with work activities of the alleged $8 / 25 / 95$ incident. 10/6/95 - follow-up of an injury to the right knee and right ankle; included in the entry was - "Upon my entrance to the room I asked the patient if she had improved and how she was feeling. She did not respond for several minutes. I asked her again how she was doing and she states I want to see a Specialist. I told her I did not think that was necessary at this time as she had yet to attend any of the therapy sessions that were ordered for her and that were apparently set up."; the entry indicated further friction, but eventual examination did occur, and the assessment was - Sprain right ankle - improved, and Strain right knee - improved; it was written that six visits of therapy was set up for Rosenkoetter, and medication was to be continued; light duty recommendation was continued.

11/3/97 - Rosenkoetter presents with complaints that for the past month or two she has developed pain in both of her wrists and forearms, sometimes it is hard to close her hands, and she is beginning to lose strength; objective findings included - Phalen's is negative bilaterally, Tinel's is negative at the median and ulnar nerves, mild tenderness over both epicondyles; the diagnosis was Tendonitis both wrists; Ibuprofen and home exercises were prescribed; it was indicated that the injury was consistent with work activities or the alleged incident (the date of injury was noted as 11/3/97); Rosenkoetter was returned to regular duty. The record indicated that Rosenkoetter missed scheduled appointments of 11/17/97, 11/26/97, 3/10/98 and 3/17/98. 11/19/97 - Rosenkoetter indicated that she had had improvement in the function of her hands, especially the left one; exam findings included negative Phalen's, and negative Tinel's at median and ulnar nerves at the wrist; the diagnosis was - Paresthesia both hands, resolving; mediation was continued, and she was maintained at regular work. 12/1/97 - Rosenkoetter reported that she was feeling relatively well over the long weekend, went back to work early this morning on a four hour shift and now her hands hurt; other complaints are that the left hand and little and ring finger go to sleep during her sleep, she awakes and changes positions and the numbness disappears from the two fingers; objective findings were - neurovascular status is intact in both hands, good grip, excellent range of motion in the C-spine shoulder wrist and elbow, Tinel's and Phalen's negative; the diagnosis was - Wrist sprain bilateral; it was noted that the injury was consistent with Rosenkoetter's work activities; she was returned to regular work. 2/19/98 - complaints of bilateral UE pain for about 6 months, treated with ibuprofen but is getting worse, complaints of numbness in the left index finger and thumb; objective findings were - "Vague history. The patient appears very depressed and is crying when asked if she is depressed. UE reveals various scratches from working outside at home. Diffuse muscle tenderness in both arms, from shoulder to hands. Joints reveal no swelling and full ROM."; the diagnosis was - Complaints of bilateral UE pain, Depression; treatment included - EMG, NCT's and antidepressants; Rosenkoetter was placed on work restrictions of no pushing or pulling with arm for one week greater than 35 pounds; follow-up in one week recommended. 3/23/98 - Rosenkoetter relayed that she was scheduled to see Dr. Phillips for an EMG and nerve conduction tests the next day, and subsequently to see Dr. Crandall, and these appointments were set by her work place; continued complaints of pain in both hands, wrists, shoulder, and elbows, denies any pain in the neck; states is doing regular work at this time; objective findings included - Tinel's is equivocal bilaterally and Phalen's is equivocal bilaterally, no tenderness over the medial or lateral epicondyle; the diagnosis was - Paresthesia to both hands, It is questioned whether or not the patient has any depression from this particular incident, episode, or current complaints; it was written that Rosenkoetter would see Dr. Crandall for UE complaints; she was placed on full duty work status.

11/19/97 - Rosenkoetter reports that the night before (entry noted a date of injury of 11/18/97) at about 11:35 p.m. at her work in the foam division of Integram she sustained a back injury when she leaned over to retrieve arrange some parts in a box and when she got back up she felt back pain and the pain is going down into her right leg; further written was Rosenkoetter reported that she had previous back injury, apparently nonoccupational, and that the back was stabilized with some stuff in the back, so I am presuming it might be metal such as Steffe plates or spinal fusion, however I do not have the details of this operative procedure; objective findings included - essentially normal posture, fairly overweight, able to forward flex fingertips coming to about the knee of just below the knee level bilaterally, mild tenderness in the lower lumbar spine, no paraspinal muscle spasm appreciated especially given her body habitus, reflexes in the knees as well as the ankles are hypoactive but present bilaterally, straight leg raising is negative to almost 80 degrees bilaterally seated, range of motion in the hips, knees and ankles appear essentially within normal limits; diagnosis was - Low back pain; work restrictions were placed of maximum lifting of 15 pounds, occasional stooping, crouching and crawling; it was written that the injury was consistent with work activities or alleged incident. 12/01/97 Rosenkoetter reports she is feeling a little bit better, that she felt well after the Thanksgiving weekend and was off a few days, however upon return to work she has redeveloped some of her back pain, denies any paresthesia or radicular symptoms; objective findings included - minimal if any tenderness in the lower lumbar spine, straight leg raising to 90 degrees seated bilaterally; the diagnosis was - Low back pain resolving; Ibuprofen and Flexeril was continued; Rosenkoetter was returned to full duty work, no restrictions.

1. Medical records of St. John's Mercy Hospital, Washington, Missouri (Claimant's Exh. J). A 10/23/95 radiology report reflected that studies had been ordered by Dr. Calvin, and the report noted a history of - rule out disc; has had low back pain radiating to the left leg for approximately 2 weeks. Plain film findings were: lumbar vertebral bodies are well aligned; anterior and posterior osteophytes noted at L2-3, L3-4, and L4-5; disc space narrowing, most severe at L5-S1; narrowing of the apophyseal joints, with subchondral sclerosis. CT scan through the disc spaces from L2-3 through L5-S1 resulted in the following findings:

There is uniform calcified disc bulging at L2-3. There is disc bulging noted at L3-4, with a focal area of calcified disc protrusion laterally to the left. Facet hypertrophy in this region as well contributes to narrowing of the left lateral neural foramina. There is uniform disc bulging at L4-5, with calcification. There is facet hypertrophy at this level as well, and at

all imaged levels. Air noted within the disc space at L3-4 and L4-5. No focal herniations of soft disc material is identified. Recommend correlation of these findings with tomogram of the spine, to determine exact location before surgical intervention. For labeling purposes, a short ribbed $12^{\text {th }}$ thoracic vertebral body and sacralized 5th lumbar vertebral body are noted.

CONCLUSION: 1. Facet hypertrophy and calcified bulging discs noted all levels as described above, resulting in narrowing of the spinal canal. There is a calcified focal area of disc protrusion and/or osteophyte formation within the let lateral position at L3-4. This results in marked narrowing of the left nerual foramina. (No focal herniations of soft disc material is identified). (sic)

1. Records described as those of Dr. Clark, D.C. (Emp./Ins. 5) were mostly illegible, but indicated that in about 1994 Rosenkoetter reported a chief complaint of - auto accident in 1987, worse last 6 months with pain in the small of back and hip and legs.

The record included treatment entries in October 1995 for low back complaints. A 10-15-95 treatment note included: "Pat(ient) working today painting floors in flexed or stooped position. Sat down 2-3 hours ago \& got pain - left low back and hip and leg. Constant since then to left ankle."; the 10/15/95 further included - "Off work Bed". The next entry of 10/16 included that Rosenkoetter was somewhat better that morning - range of motion and stability had increased, less spasm, L4-5 interspace tender and taut. The 10/17 entry included that Rosenkoetter was feeling better, had mild to moderate ache in left leg without cramping or spasm, ?continued left leg numbness?; it was noted that Rosenkoetter had worked that day. The 10/18 entry included that Rosenkoetter had not gone to work; no leg cramping, stiff and taut at L4-5; weight bearing causes ?????

The next entry of 10/19/95 entry, apparently written by Dr. Glen Calvin, D.O. stated that Rosenkoetter presented that day with severe pain in the lumbar spine running down her left leg, and that they would agreed that her disability began on 10-15-95. She has the potential for having a ruptured disk in the lumbar spine, it was written. In the handwritten entry dated 10/19/95, it was written that Rosenkoetter weighed 215 pounds and had a blood pressure reading of 148/102; also written was that Rosenkoetter had injured her back on 10-15-95 and was under Dr. Clark's care; it was written that Rosenkoetter needed a work disability form from her primary doctor as work would not accept Dr. Clark's. The 10/23/95 report of x-rays and a CT scan of the lumbar spine lumbar performed at St. John's Mercy Hospital. A last treatment note of 10/26/95, handwritten, apparently in Dr. Calvin's record indicated - disc lumbar spine, and pain in left leg continues.

1. Medical records of Karl A. Jacob, M.D. (Cl. Exh. E) began with a 10/30/95 initial office exam report; the doctor noted that Rosenkoetter was being seen for an injury that had occurred three weeks earlier when she had slipped at work on a tag that was on the floor, twisted her right ankle and her right knee and had pain immediately, and then developed left low back, hip and leg pain after sitting for a long period of time. Treatment by Dr. Clark, D.C. resulted in some improvement but then the left lower extremity pain reccured, Dr. Jacob wrote, she was seen by Dr. Calvin and was noted to have left low back, hip and leg pain radiating to the foot. Dr. Jacob's examination findings included: somewhat obese; on the left, weakness of abduction and adduction of the fifth finger, numbness in the ulnar distribution and weakness of opposition of the thumb on the left greater than on the right; low back lumbosacral paravertebral muscle spasm, positive straight leg raising on the left at 30 degrees and positive straight leg raising on the right at 60 degrees related to the hamstring; right lower extremity motor, sensory and DTR exam are grossly normal; left lower extremity - extremity pinprick hypalgesia in the L4 dermatome, knee reflex is diminished compared to the right, weakness of great toe and foot extensor. The impression on 10/30/95 was: 1. Lumbar spondylosis with myelopathy; 2. Displacement disc, L3-4, left suspected; 3. Foot drop, left; 4. Ulnar neuropathy, left greater than right; 5. Median neuropathy, left greater than right; 6. Transitional segment, L5-S1. Radiographic studies were performed; it was indicated in a Missouri Baptist Medical Center 11/16/95 Discharge Summary report that a post myelogram CT scan revealed multiple levels of lateral recess stenosis, bulging disc. It was noted that Rosenkoetter was going to consider surgery at a future date.

A 12/14/95 operative report reflected that on that date, Dr. Karl Jacob performed the following operation on Rosenkoetter:

Lumbar decompression laminectomy with laser magnification and microdissection L3-4, L4-5 left for posterior decompression of the dura and cauda equina by undercutting of the lamina and the spinous process space of L3, L4 and L5, lateral recessed decompression by resection of the medial $1 / 2$ of the facet joints of L3-4 and L4-5 and the medical one half of the pedicle base of L4 and L5, L4 and L5 nerve root foraminotomies, partial corpectomy. Posterior lateral caudal margin of the vertebral bodies of L3 and L4 and L5, microdissection and laser lysis of vascular adhesions of the anterior and lateral wall of the vertebral canal and L4 and L5 nerve root. Disk removal L3-4 and L4-5 and posterior interspinous stabilization L3, L4 and L5.

The post-operative diagnosis was: Lumbar spondylosis with myelopathy, severe, L3-4 and L4-5. Spinal stenosis, L3-4 and L4-5. Left lateral recessed stenosis, L3-4, L4-5. Displacement disk, lumbar L3-4, L4-5 left. Cicatrix of the nerve roots L4 and L5 left. A discharge summary indicated that Rosenkoetter was discharged from Missouri Baptist Medical Center on 12/17/95; in the Hospital Course section of the discharge summary, the following was included:

This 50 year old patient of Dr. Glen Calvin and Dr. Jerome Dwyer slipped at work on a tag that was on the floor. She twisted her right ankle, right knee, pain immediately in the left low back, hip and leg after sitting for a long period of time. She was seen by Dr. Clark for chiropractic evaluation. She was followed by Dr. Clark for the two days post injury. She was noted to have left low back, hip and leg pain. Denied bowel and bladder symptoms and was admitted for myelography on $11 / 15 / 95$.

This revealed degenerative changes in addition to bulging disc and more focal protrusion lateralizing to the right within the canal at L2-3, however, she was symptomatic on the left; osteophytes produce lateral recess narrowing on the left at L3-4 and L4-5. She had a transitional segment at L5-S1. The left lower extremity had pin prick hypalgesia in the L4 dermatome. Reflex was diminished on the left as was the ankle reflex. There was weakness of extensors of great toe, foot and extensor strength on the left compared to the right preoperatively. At the time of surgery, there was tremendous lateral recess stenosis at L3-4 and 14-5; total decompression of the nerve roots was carried out through the foramen. All cicatrix and vascular adhesions were removed from the anterior and lateral wall of the canal. Posterior decompression was accomplished by undercutting of the lamina and enlarged the size of the canal and a posterior Tycron interspinous stabilization was carried out at the end of the procedure between L3-4, L4-5.

A 1/17/96 follow-up entry reflected that Rosenkoetter was one month post left lumbar decompression laminectomy at L3-4 and L4-5 with posterior interspinous stabilization. It was noted that Rosenkoetter's leg pain had totally cleared. Medication was prescribed; it was written that Rosenkoetter was to return in one month and hopefully at that time she has lost enough weight that knee-shoulder flexion exercises could be started. A 2/26/96 entry included that despite all admonitions Rosenkoetter continued to gain weight rather than lose it. She is carrying too much weight for her back to tolerate it on a permanent basis, Dr. Jacob wrote, and further wrote that because of her weight she could not do the strengthening exercises.

In a 3/18/96 follow-up entry, it was written that Rosenkoetter seemed to be continuing to gain weight, and that she had complaints of discomfort in both lower extremities even when she walked just to go to the end of the driveway. Exam findings were: no muscle spasm; can flex to about 80 degrees without any radicular pain; a 90 degrees straight leg raising bilaterally in both lower extremities. It was further noted that Rosenkoetter was complaining about some sensory loss in the dorsum of the left forearm in the distribution of the cutaneous branch of the radial nerve since she awoke from surgery, numbness in this area was confirmed by pinprick, the doctor wrote. A radial never conduction test was scheduled. Dr. Jacob wrote in the 5/6/96 follow up entry that the radial nerve conduction time bilaterally was excellent and no problems. It was noted that Rosenkoetter still had numbness on the dorsum of the left forearm, but it was improving with time. Dr. Jacob finally wrote in the 5/6/96 entry the following:

The patient is discharged from follow-up as far as her lumbar spine is concerned. She is to do conditioning for approximately one month after which she can return to work with a 25 pound limit weight lifting restriction. She is to do no lifting that involves bending over at the waist. She should continue a weight loss program since I've told the patient and her husband who accompanied her to the examining room that this is vital to maintenance of her back over a long period of time. If she has any further difficulty in the future, we would be happy to see her again. Otherwise, she is discharged from current follow-up.

Dr. Jacob's record included additional treatment/examination reports beginning with a 06/18/97 re-examination report in which the doctor wrote:

This is a re-examination of this 51-year-old patient of Dr. Glen Calvin who has had right lower extremity pain progressive and involving the area of the distal thigh and the knee, as well as below the knee. A month and a half ago she saw Dr. Rende regarding the right knee. An MRI was negative and the orthopedist said that he thought the pain was related to the patient's back and referred her here.

The patient has had a rather precipitous weight gain since her last surgery for left-sided radicular pain which has now cleared. She has pain in the back of the right thigh and leg distally into the foot and ankle. This pain increases with walking. It does not increase with coughing, sneezing, bending or lifting. She has no bowel or bladder symptoms.

It was noted that Rosenkoetter had a family history of her mother being a diabetic. Examination findings on 6/18/97 included: right upper extremity motor, sensory and DTR exams are grossly normal; on the left, weakness of abduction and adduction of the fifth finger, numbness in the ulnar distribution and weakness of opposition of the thumb on the left greater than the right; chest, heart, lung and abdominal exams are grossly within normal limits; low back - lumbosacral paravertebral muscle spasm, right sciatic notch tenderness positive straight leg raising on the right in the sitting position at about 30 degrees, and negative straight leg raising on the left; left lower extremity motor, sensory and DTR exams are normal; right lower extremity knee reflex is hypoactive; ankle reflex fatigues; some weakness of dorsiflexion of the right foot and great toe and weakness of the quadriceps on the right compared to the left; Romberg, gait and station is difficult to evaluate because of the patient's weight, however she does a reasonable job of walking heel-to-toe. Dr. Jacob's written impression on 6/18/97 was: 1. Lumbar spondylosis with myelopathy; 2. Rule out displacement disc, lumbar, L3-4, right; and 3. Morbid obesity. An MRI of the spine was scheduled, and Rosenkoetter was to return for follow-up.

The next examination report in the record was dated 04/01/98, and Dr. Jacobs wrote that Rosenkoetter was a patient of Dr.

Calvin who had reinjured her back at work three months ago bending over putting cushions in a box and heard a popping of her back and pain radiating to the right lower extremity. The pain became progressively worse in spite of conservative management, Dr. Jacob wrote, she can no longer work at her regular employment because of the pain. Dr. Jacob reported similar examination findings, and the diagnoses remained the same as on 6/18/97. There were no written treatment recommendations.

The next and last document in Dr. Jacob's record was a 5/24/99 report of an MRI of the lumbar spine. The history noted in the report was: "Lumbar surgery 3 years ago. Recent falls at work with low back pain and left lower extremity radicular pain." The written impression was:

1. Transitional lumbosacral segment which has been referred to as transitional $1^{\text {st }}$ sacral segment (appears to be sacralized bilaterally, there appears to be a rudimentary nonfunctional disk space cauded to the disk space);
2. Postsurgical changes on the left at L3-4 and L4-5; and
3. Severe degenerative disk disease at L3-4, L4-5 an L5-S1. Disk protrusion latralizes to the right within the canal at L5-S1. Abnormality extends laterally in the canal into the foramen on the left at L4-5 as discussed above. There is some encroachment left greater than right at L3-4.
4. Records of Dr. Glen D. Calvin, D.O. of Calvin Medical Center (Claimant's Exh. No. B) reflected treatment of Rosenkoetter for various ailments (i.e. cough, congestion, pharyngitis, otitis) during the period of March of 1996 through March of 1999. The following are examples of treatment entries. 2/10/97 - acute viral syndrome with secondary problems, symptoms are headaches, eye pain, cervical spine pain, back pain, sneezing, coughing; treatment included Ultram. 2/24/97 - complaints of severe headache and cough, patient states she is not able to work at this time; diagnosis was bronchial pneumonia or pulmonary vascular congestion, and Rosenkoetter was sent to Missouri Baptist Hospital under Dr. Shen's care. 2/28/97 - Rosenkoetter was seen for follow-up on Proventil inhaler. 3/3/97 - combination of congestive heart failure, bronchitis, pneumonia and difficulty breathing, return to see Dr. Shen ASAP. 4/3/97 - seems to have an exacerbation of her right shoulder, I think she has a torn tendon of her right shoulder but she refuses to have an MRI, sending her to Dr. Stetson for work up, here with severe shoulder pain and severe degenerative arthritis in shoulder. 5/5/97 - complaints of pulled muscle in left side mid-back for 24 hours after lifting on carpeting; typed entry included that exam revealed severe spasm of the TS and neurological was essentially neg, and was started on Anaprox and Ultram for pain, and therapy. 5/9/97 - continued back pain; written was - "..she had surgery from Dr. Jacobs approx 2 years ago and she was told that there would be a possibility that she would have to have the other side operated on and she states that it has come to the pt. where she thinks that she needs to go back to see him because of the discomfort in the LS and (therapy) is not helping that much and also she is having a lot of family diff. And we will put her on Paxil" (sic); the diagnosis was - LS strain and Sit. Depression. 5/15/97 - treated for viral syndrome with ear infection, and given a slip for work. 5/29/97 - lifted on 5/27/97 two 15-lbs of liquid soap and strained upper back and neck and has severe muscle spasm on exam with cervical spine strain and upper back strain, physical therapy was given and medication of Ultram, and given slip to go back to work the next day. 6/16/97 complaints of head and chest congestion, "will continue her on antibiotic and Claritin and we will give her breathing treatment today of Preventil and RTW on 6/23/98-She states that she is so run down that she cannot return to work". 6/30/97 complaints of continued sinus pressure and drainage for 24 hours which came on after working in hay field all day, treatment was continued Claritin and repeat round of antibiotics and RTW that evening if feeling fine. 9/16/97 - "Acute LS strain with muscle spasm and having problems with lifting and had stabilization rods put in her back and now she is lifting again and having severe pain"; handwritten 9/16/97 entry noted - mid and low back pain for 2 days, states strained while lifting heavy pots at family reunion on 9/14/97. 9/19/97 - treating her all week with an acute LS strain with previous surgery and back injuries, she is seeing Dr. Jacobs, we have been treating since $9 / 16 and allow her to RTW on 9 / 22$ and ask if all possible that she do no heavy lifting but we will let her have a trail of work; "Some improvement, but DX is reoccurrence of an acute LS strain with symptoms of ruptured disc in the LS".

The next entry in Dr. Calvin's record after 9/19/97 was an 11/20/97 entry in which the following was written: "Seen with $\mathrm{c} / \mathrm{o}$ of LS pain and goes down into the rt. leg. States hurt this while bending and lifting a box while at work". Examination findings were: some LS pain radiating into the rt. lower extremity, palpation of LS area reveals a fairly moderate to large sized lipoma which produces more pain and especially into the rt. lower extremity; therapy was started and referral to Dr. Rao for possible excision of lipoma of the rt. LS area. 12/4/97 - complaints of bad pain in the lower rt. present for some time, is under the care of Dr. Jacobs for this who is thinking about surgery apparently on the back, here today due to the unrelenting discomfort, would like to put her on Ultram until she can get in to see Dr. Jacobs; DX - probable ruptured disc of the LS. 1/6/98 - here with acute pyeloneuphritis, needs slip for work and to return in near future; no other significant findings. 1/9/98 - no show for appt. 1/27/98 - complaints of vomiting, fever, cough, body aches, ear pain, sore throat; referred to Dr. Chen due to chronic nature of the positive findings; DX was - 1. acute otitis media, 2. acute pharyngitis, and 3. bronchitis. 1/30/98 - doing much better however still has resolving cough; DX resolving bronchitis and otitis. 2/10/98 - complaints of vertigo, chills, fever and ear pain for last 2 days; has been putting up with these symptoms now since Jan 23, started on Lorbid and referred to an ENT specialist.

After 2/10/98, the next entry was dated 4/9/98, and included - "Here today with an acute anxiety episode with chronic problems with carpal tunnel, chronic degenerative back disease, possible ruptured disc", has some previous stabilization surgeries; "We recommend that she have further work up if her workman's comp. will approve of it"; she will be placed on BuSpar for mild anxiety; no other significant findings. 5/19/98 - treated for diagnosis of fungal infection of the right foot; 5/28/98 - advised to stay

off feet; 6/9/98 referred to pediatrist and kept off work until then. The next entry of 6/16/98 indicated - treated for DX of Acute pharyngitis, and Sinusitis.

9/1/98 - complaints of pain and edema in left knee for 1 day; this is a re-injury 6/98 with Dr. Kef alas; patient noticed symptoms after pushing in brake on a tractor; the typed $9 / 1 / 98$ entry included that this was a reinjury from a fracture, that she had a knee brace in place for patella support, x-rays were negative, and the diagnosis was - contusion of the left knee. The claimant was treated for Bronchitis on 11/24/98 and 12/8/98, and for Sinusitis and Resolving bronchitis on 12/18/98.

The next entry of 1/6/99 included in the handwritten section - "c/o of left hip pain. No known injury. X-6 months."; the typed 1/6/99 entry stated that Rosenkoetter presented with low back pain radiating into the left hip, x-rays showed degenerative disease in the hip socket, it was written that she "has severe osteoarthritis, scoliosis of the spine" and she has had previous surgery in the past; the plan was evaluation by an orthopedist. January 1999 entries (2) concerned treatment for Chronic bronchitis and for Acute viral gastritis. 2/2/99 - complaints of lower back pain for one day, noticed after picking up laundry basket; the typed 2/2/99 entry noted - complaints of left lower back pain, physical exam reveals spasm in LS area more on the left than right and no neurological deficits; therapy was to be started, and Rosenkoetter was to be returned back to work that evening; the DX was - LS strain. The final entries of 3/3/99 and 3/9/99 concerned treatment for symptoms of bronchitis and pharyngitis.

6.Medical records of Dr. John Kef alas, M.D. (Claimant's Exh. No. F) concerned the treatment of Rosenkoetter from 2/26/98 - 5/5/99. The 2/26/98 entry reflected the chief complaint as - right knee injury. It was written that Rosenkoetter relayed that while at home she had fallen sustaining a twisting injury to the right knee. The diagnosis after x-ray and physical examination was - Acute right knee injury with probable patellofemoral subluxation possible, and Quadriceps tendon injury and possible meniscal injury. Rosenkoetter was placed in a neoprene sleeve, was taken off work, and was to return in 2 weeks. The next entry of $3 / 12 / 98$ included that Rosenkoetter relayed her knee symptoms were slightly improved, and that she had re-injured her right long finger recently at home. The plan was to observe the right long finger with instructions for digital motion, and for the knee continued use of the neoprene sleeve, quad and hamstring strengthening exercises, and return in 5 weeks; it was written that Rosenkoetter could return to regular duty at work as of 3/23/98.

The next entry of 6/17/98 noted that Rosenkoetter reported that on 6/16/98 she had missed a step and fell on her wood porch at her home, landing directly on the anterior aspect of the left knee. It was noted that radiographs from her emergency room visit the day before showed a question of a possible proximal left tibial plateau fracture; the diagnosis was left tibial plateau fracture, and the plan was a continuation of non-weight bearing with a walker, starting therapy for this, a knee immobilazer, return in 2 weeks, and no work. In the next entry of 7/1/98, examination findings were: left knee is minimally tender over the proximal tibia, no effusion, nontender anteriorly over the patella, tender over the medial joint line, neurologic function is unchanged (the distal neurovascular function is normal). It was written that repeat radiographs failed to reveal any obvious tibial plateau fractures. The plan was to continue weight bearing as tolerated, a neoprene sleeve, and follow up in 3 weeks. In the next entry of 7/22/98, it was written that Rosenkoetter relayed her symptoms were slowly improving; the plan was for weight bearing as tolerated, weaning herself from the walker, continue using the knee splint, physical therapy for range of motion and strengthening, no work, and return in 4 weeks. In the 8/19/98 entry it was written that Rosenkoetter still noted achiness in the knee. Exam findings were - no effusion, full extension and flexion to 90 degrees, collateral ligament are stable, and tender over the patellofemoral joint and medial pes bursa. The plan was continuing strengthening on her own, Motrin, a new Ace bandage was applied, follow-up in 6 weeks, and Rosenkoetter was returned to regular duty at work on 8/20/98. A 12/4/98 entry stated that per patient's disability form she was now seeing Dr. G. Sort at Orthopedic Associates.

The next entry of 3/17/99 noted Rosenkoetter relayed that on 3/15/99 while at home she sustained an injury to the left knee, ankle and foot after she fell after becoming dizzy. Further written was: "She states she twisted her left ankle and knee. Denies back pain or any other musculoskeletal complaints. She states the dizziness has improved.". The following examination findings were noted on 3/17/99:

Exam today shows her spine is nontender. Shoulders, elbows and wrists had good motion, no pain. Pelvis is stable. Right hip, knee and ankle had good motion, no pain. The left hip is nontender and had good motion. The left knee skin is intact. She is tender over the medial tibial plateau as well as the MCL. Nontender over either medial or lateral joint line. Good quad control. Distal neurovascular function is intact. She is tender over the anterior talofibular ligament of the left ankle. Nontender medially over the deltoid. Nontender over the hindfoot, midfoot or forefoot. She had good digital motion.

It was noted that radiographs of the left knee, the left ankle and the left foot showed no obvious fractures. The impression was: 1. Left knee contusion, 2. Left ankle sprain, and 3. Left foot sprain. The treatment plan was the application of an aircast and a knee immobilizer, Celebrex was prescribed, no work, and follow-up in 2 weeks. The 4/7/99 entry included that Rosenkoetter relayed she had removed the knee immobilizer as her left knee had improved; she was still using the aircast on the left and still noted left heel and ankle pain. Examination findings on 4/7/99 included: ambulating with a slight antalgic gait; spine is nontender to palpation; hips had good motion, no pain; left knee had full extension, lacking about 5 degrees, flexes about 120 degrees; collateral ligaments are stable; still tender over the MCL; still tender over the ATF; also tender with medial and lateral compression of the calcaneus. The treatment plan was to continue with Aircast, if symptoms in the heel persisted then repeat radiographs of calcaneus, follow up in

4 weeks, new prescription of Celebrex, and return to regular duty at work on 4/7/99. The 5/5/99 entry, the last entry, indicated that Rosenkoetter missed the appointment.

1. Medical records of St. John's Mercy Hospital in Washington, Missouri (Cl's Exh. I) consisted of physical therapy progress notes upon referral of Rosenkoetter by various doctors beginning in June 1997. A 6/16/97 Initial Evaluation sheet reflected that Rosenkoetter had been referred by Dr. Bassman for rotator cuff tendonits. It was written that Rosenkoetter reported "she has (R) shoulder pain for the past several years. Initially she reports her shoulder getting pulled when she was holding a chain and a relative pulling the other end suddenly. She states that she has been to an MD several times for this, however her focus had been on her back surgery.". It was noted that Rosenkoetter was working full time in a factory making seats for mini vans, and this involved lifting, pushing, pulling and holding a spray gun which she is able to use 2 hands for. It was noted that Rosenkoetter reported no numbness or tingling in the upper extremities. Assessment was chronic right shoulder tenderness and rotator cuff tendonitis, and physical therapy treatment was for 6 weeks centering on the right shoulder.

The record reflected that Rosenkoetter was referred by Dr. Kefalas in July 1998 with a diagnosis of status post left proximal tibia fracture. Written was that Rosenkoetter relayed she had fallen on June 16, 1998 and sustained a proximal tibia fracture. It was noted that Rosenkoetter had been in a knee immobilizer for about 5-6 weeks, and was now full weight bearing within the last 24 hours; it was noted that Rosenkoetter worked at Integram but was currently off due to this injury.

1. Medical records of Dr. George O. Sort, M.D. of Orthopedic Associates, Inc. (Emp./Ins. 4) began with a September 3, 1998 evaluation report by Dr. Sort to Dr. Calvin after referral of Rosenkoetter for evaluation of pain in the left knee. Dr. Sort wrote about the history relayed by Rosenkoetter, which included the following:

...about two months earlier she had broken her leg, and had pointed to the proximal tibia area. She apparently fractured this when she stepped off of a step at her daughter's and hurt her leg. She was treated with crutches and a cylinder extension splint. She said that the leg healed and she was doing pretty good until just a couple of days ago when she was riding on the tractor and she pushed in on the brake and she felt something pop in her left knee and since then has had a lot of pain in the knee, not in the area where she had the prior broken leg. She points to the medial side of the joint where she is noting the pain at this time.

It was noted that Rosenkoetter was working at that time. After examination and x-rays, Dr. Sertl's diagnosis was: 1. Left knee pain; 2. Tear of medial meniscus; 3. Degenerative arthritis; 4. Prior fracture of proximal tibia; and 5. Exogenous obesity. An MRI of the left knee was recommended. Dr. Sort wrote that Rosenkoetter was unable to return to regular work

The record indicated that Rosenkoetter was seen on follow-up on 9/17/98 and reported that since last seen she had hurt her knee again when she bumped against something. Dr. Sort wrote that the MRI showed some evidence of increased intensity in the posterior horn of the medial meniscus, but there was no evidence of a tear. Exam findings included: tenderness about the knee; no effusion and no ligamentous instability; no real localized area of pain is noted anymore at this time. The diagnosis was: Left knee pain; Sprain of left knee; and Degeneration of medial meniscus. Rosenkoetter was continued at "unable to return to regular work" status, and was to return in 2 weeks. In the final treatment entry of 10/01/98, it was written that Rosenkoetter reported that she thought she was improving with therapy. After examination, the diagnosis was: Left knee pain, resolving; Sprain of knee; and Degeneration of medial meniscus status post fracture proximal tibia. Dr. Sort wrote that physical therapy would be continued for an additional two weeks, Rosenkoetter would then be re-evaluated, and if all had gone well she would be allowed to return to work at that time.

Dr. Bruce Schlafly, M.D. testified by deposition on behalf of the claimant. (Claimant's Exh. A) The doctor identified his treatment reports which had been marked as deposition exhibits, and it was agreed and stipulated to by the parties that Dr. Schlafly would testify per his reports (See Schlafly Dp. pp. 4-8).

Dr. Schlafly's examination/treatment reports, addressed to the claimant's attorney Ray Gerritzen, began with a March 1, 2001 report in which the doctor wrote that he had examined Rosenkoetter on that date and had reviewed very extensive medical records; Dr. Schlafly noted that he did not have at that time the records of Dr. Phillips and Dr. Crandall. Dr. Schlafly wrote that Rosenkoetter had relayed a history of working full-time at Integram for eight years until she lost her job two years ago in March of 1999, and she had been unemployed since then. Dr. Schlafly noted that Rosenkoetter relayed that she had been in good health when she started working for Integram, even riding her motorcycle to work; it was noted that she relayed she had a motor vehicle accident around 1985 which produced a concussion and some type of whiplash injury to her neck. She says she had symptoms related to her head and neck for several years, but they eventually resolved and at this time she has only minimal complaints involving the neck, the doctor wrote, and I saw x-rays of the neck done 6/15/95 which showed only some curvature of the neck suggesting some muscle spasm at that time. The doctor wrote that Rosenkoetter spent her first $11 / 2$ years at Integram performing maintenance work, but then was switched to the production line where they made seats for the Chrysler mini vans. She tells me that the working On the assembly of the seats required a lot of repetitive use of her hands, the doctor wrote.

Dr. Schlafly noted in his March 1, 2001 report injuries Rosenkoetter had suffered: a. A laceration to the left hand in 11/94 at work with wound problems and persistent pain at the scar, and the symptoms were attributed to flexor tendonitis; she relays

continuing pain at the scar with gripping, residual numbness in the left small finger and loss of hyperextension of the left small finger from the location of the laceration. $\underline{b}$. A major injury at work on or about 8/25/95 where she slipped on a slick paper tag on the floor "and fell to the concrete floor, landing on her knees and back and also apparently twisting her right ankle"; the next day she was experiencing considerable low back pain with swelling at the right ankle and she sought medical attention; I see medical records where she was evaluated at the Healthline clinic on 9/15/95 for the injury, where her complaints involving her right ankle and right knee were noted and x-rays were negative, and she was given a diagnosis of mild sprain of her right ankle and strain of the right knee; she says that her back was not properly evaluated at Healthline and she had to obtain on her own treatment from her personal physician, Dr. Calvin, who on 10/19/95 noted that she had severe pain along the lumbar spine with pain radiating into the left leg, and diagnosed a ruptured disc and referred her to Dr. Jacob. Dr. Jacob ordered an MRI scan of he lumbar spine that revealed degenerative change, and then ordered a lumbar myelogram with CT scan which showed changes such as narrowing of the lateral recess on each side at L4-5; her symptoms continued, and Dr. Jacob operated on her on 12/14/95 at which time he found displacement at L3-4 and L4-5 with spinal stenosis at these level; following surgery Rosenkoetter noticed numbness in the dorsum of the left forearm, and electrical studies Dr. Jacob had performed on 5/6/96 were negative. Prior to the 8/25/95 fall at work, she tells me that she had no problems with her low back, Dr. Schlafly wrote. c. Strained her back while working in November, 1997 as a result of bending over to put a seat in a box and felt pain in her low back on the right side of spine; Dr. Jacob had an MRI of the lumbar spine performed on 5/24/99 which showed some post-op changes with severe degenerative disc disease at L3-4, L4-5, and L5-S1 as well as right-sided disc protrusion at L5-S1; no surgery was performed; Rosenkoetter continues to experience pain from the injury at the right side of the lower lumbar spine with some intermittent right leg pain, the doctor wrote. Dr. Schlafly noted that when Rosenkoetter visited the Healthline clinic in 11/97 she had complaints of pain and parasthesia in the hands, and on 2/19/98 she was told to obtain electrical studies on her hands; Healthline noted that she was to see Dr. Phillips and Dr. Crandall for her hands; Rosenkoetter said electrical tests were done and she was advised she has carpal tunnel syndrome worse in the left hand than the right hand; she was treated in nonoperative fashion; she relays she continues to experience numbness and tingling in her hands. d. Healthline clinic in 2/98 noted Rosenkoetter's problem with depression, however I do not have any medical records discussing psychiatric evaluation of her depression, Dr. Schlafly wrote. g. 2/18/97 - examined by Dr. Rende with regard to right knee and ankle complaints, an MRI of the knee was negative and no further treatment was recommended for the right knee and ankle. f. 3/20/98 Dr. Mirkin examined Rosenkoetter for the low back condition. g. Dr. Kefalas, in the summer of 1998, treated her for a possible fracture involving the left proximal tibia after she fell at home; she states injury forced her off work for $11 / 2$ months, but she healed well from the injury. g. 3/15/99 - she again fell at home sustaining contusion and sprains of the left knee and ankle; Dr. Kef alas treated conservatively including Celebrex and released her to return to work on 4/07/99 but by that time she had lost her job.

Examination findings on March 1, 2001 for Rosenkoetter in regards to her upper and lower extremities, her hips and her back were discussed by Dr. Schlafly in his report, and the findings included: "I did not find any Tinel's sign over the median nerve of either wrist and Phalen's test for carpal tunnel syndrome is negative in the right hand, although it is positive in the left hand. In the Analysis Section of his March 1, 2001 report, Dr. Schlafly included the following:

Mrs. Rosenkoetter slipped and fell at work on or about 8/25/95, injuring her low back. This work injury is the substantial factor in the cause of her low back condition that necessitated Dr. Jacob's surgical treatment. In my opinion, Mrs. Rosenkoetter has a 42.5 percent permanent partial disability of the body as a whole referable to the low back as a result of this injury, which necessitated Dr. Jacob's surgical treatment. She has an additional 7.5 percent permanent partial disability of the body as a whole referable to the low back on the basis of the work injury of 11/97 that resulted in strain with right lower extremity symptoms. The MRI scan that was then performed on 5/24/99 suggested a disc problem to the right side at L5-S1, and Mrs. Rosenkoetter should return to the care of Dr. Jacob for further evaluation and treatment as necessary of her low back. It is possible that further surgery may be required. As a result of her low back condition, she cannot engage in work that requires her to lift more than 20 lbs., or to perform activities such as bending, stooping, twisting, or squatting.

My opinion is that Mrs. Rosenkoetter has work related left carpal tunnel syndrome. I cannot make a definite diagnosis of right carpal tunnel syndrome on the basis of my exam today, but she should return to the care of a hand surgeon for further diagnosis and treatment of her hands. She may require carpal tunnel releases. My opinion is that her repetitive work with her hands at Integram is the substantial factor in the cause of her left carpal tunnel syndrome. She probably has tendonitis or right carpal tunnel syndrome from this work....Given the unusual symptoms in the left forearm, previously evaluated by Dr. Jacob, there is an outside chance that she could have a component of cervical radiculopathy, and it would be wise to check her with an MRI scan of the neck, although the physical findings at the level of the neck today are minimal. As of today, I do not find any significant disability resulting from the prior motor vehicle accident and injuries of her head and neck.

My opinion is that she carries a 10 percent permanent partial disability of the right ankle as a result of the right ankle sprain sustained when she fell at work on 8/25/95. I do not find any significant disability of her knees or left ankle, or right index finger. With regard to the tender scar from the work related laceration in the left hand dating back to 11/94, my opinion is that this has produced a 25 percent permanent partial disability of the left small finger ( 22 week level), as well as an additional 7.5 percent permanent partial disability of the left hand. This is in addition to the disability in the left hand from the left carpal tunnel syndrome.

I do not find significant disability involving her shoulders, hips, or elbows, and at this time I cannot confirm any significant

industrial disability related to her eyes, heart, or lungs. I would defer to a psychiatrist as to the extent of any psychiatric disability from work related depression.

Given the problems with her hands, she is not fit for work that requires heavy, repetitive gripping, pushing, and pulling with her hands, or use of vibrating tools.

Mrs. Rosenkoetter may be permanently totally disabled. A vocational rehabilitation counselor who is expert in the current labor market could be consulted to determine if there is work available that she could perform, given the problems described in this report. She has a combination of disabilities that creates a synergistic effect between the disability of her low back and the disabilities of her hands, giving a combined effect greater than the simple sum of the components. These disabilities create an obstacle or hindrance to employment.

In his next examination report of November 12, 2001, Dr. Schlafly noted that he had last seen Rosenkoetter on March 1, 2001. Rosenkoetter's present complaints were noted as - numbness in her hands, worse on the left hand than the right hand, and they wake her up at night. Dr. Schlafly wrote that he had received a copy of Dr. Crandall's and Dr. Philips' records, and Dr. Phillips had performed electrical studies on 7/19/01 that showed bilateral carpal tunnel syndrome, worse in the left hand than the right hand. Dr. Schlafly noted that exam findings on November 12, 2001 were: a positive Tinel's sign over the median nerve of each wrist with a positive Phalen's sign bilaterally. The doctor further wrote in his November 12, 2001 report:

I recommend the standard technique rather than the endoscopic technique. I enclose medical literature on this subject. I also enclose copies of photographs of another patient who had persistent problems following prior endoscopic carpal tunnel release, and required repeat carpal tunnel release using the standard technique. The photographs show that at surgery, the prior endoscopic carpal tunnel release had not fully released the transverse carpal tunnel ligament. A full release of this ligament is required in order to perform an effective carpal tunnel release.

Operative reports were in Dr. Schlafly's record which reflected that on 12/07/01 he performed on Rosenkoetter the procedure of a left carpal tunnel release with a pre- and post-operative diagnosis of left carpal tunnel syndrome, and on 03/04/02 he performed on Rosenkoetter the procedure of a right carpal tunnel release with a pre- and post-operative diagnosis of right carpal tunnel syndrome. In his last examination report of May 6, 2002, Dr. Schlafly wrote that Rosenkoetter reported that surgery helped both hands. It was noted that the healing was more advanced in the left hand than the right hand since the left carpal tunnel release had been done approximately three months prior to the right carpal tunnel release; she has some soreness along the scar in the right, but I think both hands will end up the same with regard to her carpal tunnel syndrome/release, the doctor wrote. Dr. Schlafly further wrote in his May 6, 2002 report the following:

I do not have any further treatment to recommend for her hands. My opinion is that she has 25 percent permanent partial disability of each hand measured at the level of the wrist joint from the work-related bilateral carpal tunnel syndrome/releases. Her work at Integram is the substantial factor in the cause of the bilateral carpal tunnel syndrome and in the need for bilateral carpal tunnel releases. Since she has disability in both hands, a condition of multiplicity exists which should be compensated by a loading factor applied to the permanent partial disability ratings. She should try to avoid work that requires heavy, repetitive gripping, pushing, and pulling with her hands, or use of vibrating tools.

The doctor testified at the deposition about his opinion on the difference between the standard, or open carpal tunnel, release versus endoscopic tunnel release: "In my opinion for carpal tunnel release it's better to visualize both the nerve and all the ligaments and to directly view those objects that you're cutting and the nerve itself and to make sure it's completely decompressed". (Schlafly Dp. pg. 9) Dr. Schlafly agreed that there have been instances where he has redone previous endoscopic surgeries, and noted that he has found during the procedure "(B)ands of ligament or ligament interspaced with scar tissue that are still compressing the median nerve and require release". (Schlafly Dp. pg. 10) Dr. Schlafly noted that an article by the authors from Department of Orthopedics at Brown University - "The Results of Revision Carpal Tunnel Release Following Previously Open Versus Endoscopic Surgery", printed in the reputable and widely read journal called The Journal of Hand Surgery - concluded that their results of their studies showed a higher incidence of incomplete release of the carpal tunnel with endoscopic surgery than with open release. On cross examination by the employer/insurer, it was noted that one of the points of this article was to say when you have to go back and redo the carpal tunnel, they suggest doing open versus endoscopic. "That was one of the points made, yes", Dr. Schlafly responded. (Schlafly Dp. pg. 20) Dr. Schlafly agreed that the article also talks about that you have to consider three possible causes for persistent symptoms, one of which is ulterior motives to remain clinically symptomatic. The testimony continued as follows:

Q. And the third one then goes on in the next paragraph to say that the motive to remain symptomatic and disabled from employment may contribute to a difference in outcome between patients covered by private insurance and those by workers' compensation, correct?

A. Yes, that's correct. What you're reading from the article is accurate, yes.

Q. And those patients not covered by workers' compensation insurance did significantly better than those who were covered following revision surgery. These results are consistent with other reports indicating greater subjective complaints of pain and longer periods of disability before returning to work in workers' compensation patient, correct?

A. That's accurate what you're reading from, yes.

Q. You cited this article. Would you agree with this paragraph as well?

A. I don't know. (Schlafly Dp. pg. 21)

Dr. Schlafly was asked, during direct examination, what, if anything, was there about Rosenkoetter's relayed history of her work from 1991 to 1999 that he attached a causal connection between her work and the bilateral carpal tunnel, and the doctor answered: "She worked at Integram where they make seats for the minivans and she told me that she did production work there that required a lot of repetitive use of her hands for seat assembly"; "My opinion is that such repetitive work with the hands is a cause of carpal tunnel syndrome on an occupational basis". (Schlafly Dp. pg. 15)

Dr. Schlafly identified Deposition Exhibit K as his bill; the doctor agreed that it was his opinion the surgery he had performed on Rosenkoetter was reasonable and necessary to the work-related bilateral carpal tunnel syndrome. The doctor agreed that his was a reasonable charge for the services he had rendered to Rosenkoetter. The doctor agreed that it was his opinion what was indicated for Rosenkoetter was the standard release rather than the endoscopic release; when asked why, Dr. Schlafly's response was - "I don't recommend endoscopic release". (Schlafly Dp. pg. 17)

On cross examination by the employer/insurer, Dr. Schlafly agreed that he is a hand specialist; "I limit my surgical practice to hand and upper extremity, yes", the doctor said. (Schlafly Dp. pg. 18) Dr. Schlafly agreed that Rosenkoetter was sent to him by her attorney, not a referral from any doctor. The doctor was asked if he had ever done endoscopic procedures, and he answered "No". (Schlafly Dp. pg. 19) The following testimony was given by Dr. Schlafly on the question of whether or not endoscopic procedure was up to medical standard:

R. Do you think it's within the proper standard of medical care to do endoscopic release?

B. I recognize that there two are two schools of thought on them in the medical community. (sic)

R. Okay. So you would not say endoscopic releases are outside the standard of care, the proper standard of care?

B. Not in and of itself. (Schlafly Dp. pp. 19-20)

Dr. Schlafly agreed that he provided in his November 12, 2001 letter an explanation of his preference for open versus endoscopic procedure as well as the articles in support of his position in response to Attorney Gerritzen's November 8, 2001 letter in which he asked the doctor to explain his preference.

During cross examination by the employer/insurer, it was noted that another article in

The Journal of Hand Surgery talked about the findings of a study that supported the hypothesis that obesity is a risk factor for carpal tunnel; Dr. Schlafly stated that he had seen this article. It was noted that Rosenkoetter had been described throughout the records as obese to morbidly obese. "I have her at five feet our inches tall, 265 pounds, so yes, she's obese", Dr. Schlafly responded. (Schlafly Dp. pg. 25) Dr. Schlafly stated - "I don't know" - if he would agree that obesity is a risk factor on carpal tunnel. (Schlafly Dp. pg. 26) The doctor was asked, assuming all the facts of Rosenkoetter's history and onset of symptomatology, could he rule out in this particular case that obesity could have been a substantial factor in the development of carpal tunnel in this particular woman, not exclusive of other factors but could have been a substantial factor? Dr. Schlafly answered:

"Well, I'm just saying that there is the obesity hypothesis and I just don't have an opinion on that hypothesis. If you're asking me if I can exclude the hypothesis as relevant in this case, I cannot. I can neither exclude it nor include it." (Schlafly Dp. pg. 27)

Dr. Schlafly agreed that he did not know about rest intervals that Rosenkoetter may have had during her employment over eight or nine years with Integram; as to the frequency or duration during her work, Dr. Schlafly stated - "Other than in a qualitative sense from her description, description of other Integram workers". (Schlafly Dp. pg. 28) Dr. Schlafly further testified:

"Well, it's true, I don't have a quantitative analysis of her job. I have a qualitative assessment. I mean, you say I know nothing about her job, but I know that she worked full time on an assembly line doing production work making parts for minivans, so it's not quite fair to say I know nothing about her job.

"I mean she described work to me that was hand intensive." (Schlafly Dp. pp. 31-32)

When queried if he knew when her symptoms began, Dr. Schlafly answered: "I don't know which month other than the records show that she complained about them to a health care provider, the Healthline Clinic in November 1997". (Schlafly Dp. pg. 28) I am not aware of Rosenkoetter having any complaints of pain, ache, discomfort or numbness in her hands prior to 1997, the doctor said. Dr. Schlafly further noted that the history is confusing with Rosenkoetter's laceration injury and subsequent complaints, that "all those may have been due simply to the laceration, but it's possible there could be an overlap here with early carpal tunnel syndrome, but that's just a possibility. If she had no combination of pain, numbness and tingling in her hands prior to 1997, then I don't think she had carpal tunnel syndrome prior to 1997". (Schlafly Dp. pg. 30) Dr. Schlafly agreed that Rosenkoetter was also on blood pressure medication for hypertension. "I'm not aware of that linkage", the doctor said, when queried if he would agree that

hypertension or medication for it is a risk factor for the development of carpal tunnel syndrome. (Schlafly Dp. pg. 32) Dr. Schlafly testified that to his knowledge neither hypertension or medication for hypertension causes carpal tunnel syndrome.

On cross examination, Dr. Schlafly stated that his review of Healthline's records following the 8/25/95 incident revealed that Healthline did not record complaints referable to the back at that time; the doctor agreed that Healthline recorded complaints with respect to the right ankle and the knee. It was noted that Dr. Schlafly wrote that Rosenkoetter relayed to him that her back was not properly evaluated at Healthline; Dr. Schlafly was shown a workers' compensation report signed by Rosenkoetter on 10/7/95, and Dr. Schlafly agreed that there was nothing on the 10/7/95 report indicating any complaints of problems with the back and agreed that this report would be consistent with the Healthline records. Dr. Schlafly (who agreed that Rosenkoetter had told him she had not had any prior back problems before the 8/25/95 fall on the tag) was shown an October 1995 record of Dr. Calvin in which it was written that Rosenkoetter had had an auto accident in 1987, care for last two years, worse last six months, pain in small of back and hip and legs; Dr. Schlafly agreed that this is what the record said, and agreed that if this was true then Rosenkoetter had problems with her low back from 1987 for the next six years, and since the record was an October 1995 record this would indicate that before August of 1995 Rosenkoetter was having problems with her low back; Dr. Schlafly agreed that this would be inconsistent with the history Rosenkoetter had given him. The following testimony then occurred:

R. In fact, Doctor, you refer to Dr. Calvin and you point to this 10/19/95 report which is his office note, correct?

B. Yes.

R. And this actually says patient injured back on 1015/95, correct?

B. Yes.

R. And then says "and is under Dr. Clark's care", correct?

B. Yes.

R. Which is the doctor we talked about?

B. Yes.

R. And that would be different than the date that you had talked about, namely August $5^{\text {th }} of ' 95 , correct?

B. Yes.

R. And that would indicate that from August 25^{\text {th }}$, '95, up until this reference to injuring her back on 10/15/95, that you're unaware of any treatment that she received for her back, correct, from $8 / 25 to 10 / 15$ ?

B. Right. The treatment in that interval of which I'm aware is the treatment at Healthline directed to the right ankle and right knee.

R. And you're unaware of any recorded medical records that record - any medical records that record any complaints of pain, ache, discomfort, involving the back or the legs between 8/25/95 and 10/15/95, correct?

B. That's right. I don't have any medical records in that interval on the low back.

R. You're not aware of any kind, as the doctor calls, injury on 10/15/95, correct?

B. No, I don't know about any 10/15/95 injury.

R. All you're aware of and all your rating took into account was her history of injuring her back on 8/25/95, correct?

B. Yes. (Schlafly Dp. pp. 38-40)

Dr. Schlafly was shown the October 23, 1995 CT scan of the lumbar spine, and stated that "(P)robably" the findings on the scan, if the scan had been done six months earlier, would have been present; the findings would have been present before 8/25/95. (Schlafly Dp. pg. 41) In regards to the calcified bulging disc seen on the October 23, 1995 CT scan, "I wasn't sure" if it would have been seen prior to 8/25/95, the doctor said. (Schlafly Dp. pg. 42) The doctor was asked - would you anticipate that somebody who sustained an acute herniation of a disc could go a month-and-a-half without treatment and/or complaints? "Unlikely", Dr. Schlafly answered. (Schlafly Dp. pg. 43) It was noted that in Dr. Calvin's 9/16/97 record was that Rosenkoetter had strained her back while lifting heavy pots at a family reunion on 9/14/97 and was having problems with her back, and was seeing Dr. Jacobs and the diagnosis was recurrence of an acute lumbar strain with symptoms of ruptured disc; Dr. Schlafly stated that he was aware of this entry, and that he had taken into account this 9/14/97 incidence. I did not assess any permanency for the 9/14/97 incident, Dr. Schlafly said, and explained "I was not aware that Dr. Jacobs, her treating neurosurgeon, attributed anything to it". (Schlafly Dp. pg. 51) Dr. Schlafly stated that he did not mention the 9/14/97 incident in his report, and noted that he did not recall that a disc herniation was confirmed by any testing by Dr. Calvin at that time. Dr. Schlafly stated that if Dr. Calvin's report was correct, that Rosenkoetter had a 9/14/97 incident and continued to have low back pain, muscle spasm, and a recurrence of symptoms of a ruptured disc in her lumbar spine, then that would change his opinion. Explaining how it would change his opinion, Dr. Schlafly testified: "Well, it would suggest that that was, in fact, a major incident of trauma that perhaps exceeded the incident of trauma at work in November 1997." (Schlafly Dp. pg. 52) "Right now I don't recall discussing that with her, so I may not have", Dr. Schlafly admitted. (Schlafly Dp. pg. 52) The doctor admitted that he might attribute the 71 / 2 % permanent partial disability he had assessed to the November 1997 incident, or a large portion of it, to the 9/14/97 incident.

Dr. Schlafly agreed, during cross examination, that Rosenkoetter reached maximum medical improvement for the carpal tunnel syndrome releases on May 6, 2002. The doctor was queried - if work was what caused the carpal tunnel syndrome, what is it that happened between March 2001 and when he operated on Rosenkoetter in March of 2002 that would have made her condition

worse. "Prolonged nerve compression", the doctor answered. (Schlafly Dp. pg. 66)

On cross examination by the Second Injury Fund, Dr. Schlafly was questioned - you saw Rosenkoetter at her attorney's request and treated her at her attorney's request? Dr. Schlafly answered: "Well, I think the treatment decision was hers. I initially saw her at her attorney's request, yes." (Schlafly Dp. pg. 70)

Dr. R. Evan Crandall, M.D. testified by deposition on behalf of the employer/insurer. (Emp./Ins. Exh. 2) Board certified in plastic surgery, with a subspecialty and certified in hand surgery, Dr. Crandall stated that he saw Rosenkoetter at the request of the employer/insurer. I initially saw her in 1998, the doctor said, and testified about Rosenkoetter's condition at that time: "She had complaints of numbness and pain in her hand. She had medical problems of high blood pressure. She had an examination that was positive for carpal tunnel syndrome. I recommended a nerve conduction study, which was obtained. And it demonstrated border line carpal tunnel syndrome at early stage." (Crandall Dp. pg. 6) "I thought that her, she would be best served with a conservative treatment program, since her nerve conduction studies were border line", the doctor said. (Crandall Dp. pg. 7) Agreeing that at a later date his opinion changed, Dr. Crandall testified:

"I saw her on the 6-19-01 and 8-23-01. It obviously had been several years since she had been treated conservatively and we had found that with a new study that her condition had worsened, despite the fact she had not been working. And because of this worsening of the numbness, I thought she was a candidate for surgery and stated so in my report of 8-2301." (Crandall Dp. pg. 7) (Ruling: Claimant's objection on grounds of - think this is what we stipulated and agreed he would testify to - is overruled. Crandall Dp. pg. 7)

Dr. Crandall agreed that he recommended surgery at that time, and that the surgery was authorized through the employer and insurer. I did not perform these surgeries, the doctor said. Dr. Crandall agreed that he subsequently saw Rosenkoetter on 7/25/02, and at that time found her to be of maximum medical improvement. Dr. Crandall further stated: "I did reach an opinion and it was that she had completed her treatment program. She was not in need of any further surgery or therapy." (Crandall Dp. pg. 9) Agreeing that at that time he had an opinion as to whether Rosenkoetter had sustained any permanent partial disability to the left or right wrist as a result of her employment with Integram, Dr. Crandall testified: "I thought she had a permanent partial impairment of 10 percent of each upper extremity at the level secondary to her carpal tunnel syndrome..." (Crandall Dp. pg. 8) The doctor agreed that he also had an opinion at that time as to whether Rosenkoetter was capable of working with or without restrictions, and testified: "She was capable of working with her upper extremities without restriction." (Crandall Dp. pg. 9)

On cross examination by the claimant, Dr. Crandall was asked - if Rosenkoetter couldn't work because of any other part of her body, contributing to other parts, you are not venturing any opinion regarding that? "No, I have not evaluated that at this point, Dr. Crandall answered. (Crandall Dp. pg. 11)

During cross examination, Dr. Crandall denied that the only surgery he offered Rosenkoetter was endoscopic. Testifying as to where in his record he offered open surgery, Dr. Crandall testified: "On 8-2(3)-01 19. I said it can be done open technique or the endoscopic technique, one hand being done at a time or both hands can be done at the same time". (Crandall Dp. pg. 14) Dr. Crandall admitted that he probably did recommend one technique over the other. The doctor further testified: "I think both are great procedures and they work, results are really good either way. And we just tell them what's available and then let them choose. And they usually know, because they have lots of friends at work that may have had it done." (Crandall Dp. pg. 14) Dr. Crandall stated it was correct that he did not have the same understanding as Rosenkoetter if she understood that he had said he would only do the endoscopic on her. "I wouldn't refuse a person to do it another way", Dr. Crandall stated. (Crandall Dp. pg. 15)

Dr. Crandall was asked, during cross examination by the claimant, if he knew of any patient that he had performed endoscopic procedure on and Dr Bruce Schlafly had to correct or further treat with open decompression. Dr. Crandall responded: "I'm aware that some patients have been re-operated on by Dr. Schlafly that I've done. Specific patient's name, I do not recall. I know our revision rate is less than one half percent, which is better than the national average, but that is fine." (Crandall Dp. pp. 1617) (Ruling: Employer/Insurer's and Second Injury Fund's objections on grounds of speculation and irrelevant are overruled. Crandall Dp. pg. 16) Dr. Crandall was shown four photographs (marked Dp. Exh A) and asked if he had ever seen them before; the doctor further testified: "I have seen that, yes. I have seen that before. Dr. Schlafly --...Dr. Schlafly likes to preach all the time against endoscopic techniques." (Crandall Dp. pg. 19) (Ruling: Employer/Insurer's and Second Injury Fund's objections are overruled. Crandall Dp. pg. 18 and 19) Explaining where he had seen the photographs before, Dr. Crandall stated that it was "(I)n Dr. Schlafly's report, he does it all the time". (Crandall Dp. pg. 19) When queried - are you aware of the fact that the patient depicted in the photographs is somebody you did endoscopic surgery on - Dr. Crandall responded: "No. That's actually, that's been challenged before and it's never been proven that that is a patient here in Missouri. That looks like a picture out of a textbook to me." (Crandall Dp. pg. 19) The doctor was asked if he was familiar with an article - "The Results of Revision Carpal Tunnel Release Following Previous Open Versus Endoscopic Surgery" by Hulsizer, Staebler, Arnold-Peter Weiss, Edward Akelman, copyrighted 1998, the American Society for Surgery of the Hand. Dr. Crandall answered: "Yes. I think this is the author that came in and testified to one of Dr. Schlafly's malpractice trials, Dr. Weiss." (Crandall Dp. pg. 21) Dr. Crandall acknowledged that Dr. Schlafly was not found guilty of malpractice. Dr. Crandall agreed that he was familiar with the article - "Persistent Recurrent Carpal Tunnel Syndrome Following Prior Endoscopic Carpal Tunnel Release" by Forman, Watson, Caulfield, Shenko, Caputo,

Ashmead, copyrighted in 1998, American Society for Surgery of the Hand. Dr. Crandall stated that he disagreed with both of these articles. "They are substantially flat and I demonstrated that before in previous depositions" Dr. Crandall stated. (Crandall Dp. pg. 23)

On redirect examination, Dr. Crandall agreed that in the first article, "The Results of Revision Carpal Tunnel Release Following Previous Open Versus Endoscopic Surgery", it would be fair to say that one of the conclusions of the article is that workers' compensation patients in general have statistically significant worse results biett endoscopic or open surgical procedures. "That's usually a common finding in almost every study done -" (Crandall Dp. pg. 25) The doctor was queried about when they started doing endoscopic procedures, and Dr. Crandall answered: "1988 in Japan and it became popular in the United States in 1991. Started at that time, done over 6000 endoscopic carpal tunnel release with a revision rate of less than a half percent." (Crandall Dp. pg. 26)

Dr. Crandall was referred to correspondence with a letterhead of Gerritzen and Gerritzen, dated November 16, 2001[20], and it was noted that it said - "Dear Mr. Keeven, on Friday, November 16, 2001, at 2:42 p.m. Maryann Rosenkoetter called my office and stated that she had just received a call from Dr. Crandall's office direct to schedule her for open surgery on the carpal tunnel syndrome that she had.". Dr. Crandall was asked if this would be consistent with his notes, and the doctor responded: "I have been made aware of documents, legal documents, well, gone over the documents staff keep for contacting patients. The patient was originally requested open. It was offered to her and that she declined to do surgery with us." (Crandall Dp. pg. 28) The doctor was queried - so isn't it correct that you not only offered, but you even attempted to schedule the procedures? Dr. Crandall answered: "Yes. It was offered to her to schedule them." (Crandall Dp. pg. 28)

Dr. R. Peter Mirkin, M.D. testified by deposition on behalf of the employer/insurer. (Employer/Insurer Exhibit No. 1) A board certified orthopedic surgeon, Dr. Mirkin stated that he examined Rosenkoetter on several occasions and prepared reports. "I reviewed extensive records including records from Dr. Jacob, Dr. Rende, Dr. Calvin, physical therapy notes, records from Healthline", the doctor said. (Mirkin Dp. pg. 6) Dr. Mirkin noted that he also reviewed x-rays the lumbar spine; "I believe there is some preoperative radiology reports in Jacob's records that I reviewed", the doctor stated. (Mirkin Dp. pg. 7) Dr. Mirkin gave his opinion from his review of x-rays and diagnostic studies:

"It was my conclusions this was a lady with very severe degenerative disease in her lumbar spine who underwent a laminectomy. When I first saw her, she really was not having radicular pain. Later on, she was starting to have some recurrent pain, and I recommended that if she had persistent pain that it be reevaluated by MRI or myelogram. (Mirkin Dp. pp. 7-8)

Explaining further, the doctor said:

"I have her x-rays up here on the view finder, and if you look at it, the discs at all levels are markedly decreased in height, there is bone spurs at all levels. There is even a collapsing or degenerative scoliosis where the spine is starting to curve, and that is all a severe wear and tear phenomenon of the spine." (Mirkin Dp. pg. 8)

Dr. Mirkin stated that the findings seen on the radiographic studies would occur over years. Dr. Mirkin testified as to his diagnoses for Rosenkoetter: ""It's my opinion this is a lady with severe degenerative spine disease who underwent a decompression procedure by Dr. Jacobs and still suffers from the effects of her degenerative arthritis disease." (Mirkin Dp. pg. 8) Testifying that it was his opinion Rosenkoetter's severe spine disease was not medically causally related to her employment with Integram, Dr. Mirkin explained:

"As we stated before, this is something that occurs over a long period of time. Her initial complaints after her work injury were of knee pain and I believe some ankle pain, and she didn't even talk about back problems. So, you know, I would expect a patient who had an acute injury to have back complaints immediately." (Mirkin Dp. pg. 9)

Commenting on his opinion as to whether Rosenkoetter was capable of working in regards to her back, Dr. Mirkin testified: "Yes, I wrote my last note that I thought she could work with a 30-pound lifting restriction". (Mirkin Dp. pg. 9) Commenting on his opinion of whether or not Rosenkoetter had sustained any permanent partial disability in regards to her back. Dr. Mirkin stated: "I think she has some permanent partial disability in her back, but none secondary to that incident or incident at work"; "She has very severe degenerative spine disease, and she probably has a permanent partial disability of about 20 percent secondary to that". (Mirkin Dp. pg. 10) ${ }^{[21]}$

On cross examination by the claimant, Dr. Mirkin agreed that the only film studies he ever reviewed were x-rays he had taken, and thus the first films he would have reviewed would have been films taken in 1998, approximately $21 / 2-23 / 4$ years after the injury. Dr. Mirkin stated that the following examination findings seen by Dr. Jacobs on October 30, 1995 could be found in "(P)atients with this degree of spine disease", but agreed that it is possible these findings can be from an aggravation of preexisting degenerative changes - lumbosacral paravertebral muscle spasm, positive straight leg raising on the left at 30 degrees and on the right at 60 degrees, pinprick, hypogeusia in the L4 dermatome, diminished ankle and knee reflex on the left compared to the right,

weakness of the great toe and foot extensor strength in the left compared to the right. Dr. Mirkin stated that he had the correct history that Rosenkoetter's back surgery was performed in 1995 and not June of 1997; it was noted that Dr. Mirkin wrote in his April 7, 1998 report - "She has severe degenerative changes, secondary to degenerative arthritis and her previous surgery, in my opinion". (See, Mirkin Dp. pg. 23) The doctor was queried if his opinion would be the same with an injury that had occurred two years earlier (than his 2002 deposition), and Dr. Mirkin responded:

"If you had a traumatic injury, like a fracture where some bone was removed, or a severe traumatic injury where the facets were disrupted, sure, but you don't generally get degenerative changes from sprains and strains and things like that." (Mirkin Dp. pg. 24)

Dr. Mirkin stated that he evaluated Rosenkoetter's back, only, and did not assess her for any other possible ailments, such as high blood pressure, a right shoulder injury, a 1998 left tibial plateau fracture and left knee sprain, or bilateral carpal syndrome; I knew of none of these things, the doctor said, I'm looking at her intake sheet and none of those things are checked off. The doctor stated that this intake sheet was dated $2 / 18 / 97$, and was the only intake sheet he had by Rosenkoetter. Dr. Mirkin agreed that in all of his reports he only refers to an injury in 1995. Agreeing that therefore in all of his opinions where he is talking about whether or not it is work related it's all relating to the injury in 1995, Dr. Mirkin further stated: "When I did these reports, that's the only injury she made me aware of." (Mirkin Dp. pg. 27)

Dr. Mirkin agreed it was his opinion that based on her history, Rosenkoetter had radicular symptoms prior to the surgery by Dr. Jacobs in 1995, the radicular symptoms returned, and to a certain extent have been off and on ever since. Dr. Mirkin agreed that as of April 7, 1998 he felt Rosenkoetter need to be treated by a spine physician; the doctor was queried - you are not disputing that Rosenkoetter needs treatment of the back for her radicular symptoms, it is just a matter of whether or not it is work related. "correct", Dr. Mirkin answered. (Mirkin Dp. pg. 26)

On cross examination by the Second Injury Fund, Dr. Mirkin stated that it was possible to have switching of radicular symptoms with degenerative changes, and explained: "If you have narrowing of the spinal canal from arthritis, you can have pain in either leg or both legs." (Mirkin Dp. pg. 34)

On redirect, Dr. Mirkin was given a hypothetical question in regards to degenerative findings that may or may not be related to the surgical procedure and degenerative findings that would have predated the surgical procedure; Dr. Mirkin was given the following facts - assume that the original injury was on or about 9/15/95, and that prior to the surgical procedure, which I believe occurred on 12/14/95, she underwent a lumbar CT scan that was administered on 10/23/95, further assume that the radiologist's interpretation of that CT scan was that axial images centered through the disc spaces from L2-3 through L5, S were obtained, there were uniformed calcified disc bulging at L2-3, there was disc bulging at L3-4 with a focal area of calcified disc protrusion laterally to the left, hypotrophy in this region as well contributed to the narrowing of the left lateral neuroforamina, there was uniform disc bulging at L4-5 with calcification, facet hypertrophy at that level as well and at all image levels, narrowing was noted at the disc space at L3-4 and L4-5, and no focal herniations of soft disc material were identified; the doctor was asked - assuming those to be accurate conclusions, would that effect his opinion regarding medical causation in any way? Dr. Mirkin answered:

"Certainly that CAT scan report substantiates my opinion that this is a degenerative condition. Those are all degenerative findings. In fact, the radiologist clearly points out there is not an acute disc rupture there. They are all calcified degenerative bulges, protrusions as well as facet hypertrophy, and that's a classic description of an arthritic condition of the back." (Mirkin Dp. pg. 36) (Ruling: Claimant's objections on grounds of, Seven Day Rule and nonresponsive, are overruled. Mirkin Dp. pp. 36 and 37)

The doctor was further queried with the hypothetical facts; he was asked, assuming the same facts to be true and assuming Rosenkoetter did have an injury on or about 9/15/94, would one expect in that period from 9/15/95 through 10/23/95 the development of facet hypertrophy and calcified disc bulging basically from L2-3 all the way down to L5, S1 as a result of the traumatic event. Dr. Mirkin answered: "Absolutely not. These are all changes that take years to evolve." (Mirkin Dp. pg. 37) (Ruling: Claimant's objection on grounds of, Seven Day Rule, is overruled. Mirkin Dp. pg. 37)

On further cross examination by the claimant, Dr. Mirkin stated that he took into consideration Rosenkoetter's subjective complaints when he assigned a 30-pound lifting restriction. The doctor admitted that he did not ask Rosenkoetter if she could lift without pain or repetitively lift, if she had increased back pain after sitting or standing for a certain period of time, or how long she could walk before increased back pain. Dr. Mirkin further testified:

"She may or may not have those symptoms. I just think that a 265 -pound person can easily do activities where she's lifting approximately 11 or 12 percent of her weight on a regular basis. I don't see anything on her condition that would preclude her from doing that. As I wrote in my report on September 26, '01, I thought she should seek employment where she is not required to bend, stoop, squat or lift. So you are concentrating on the 30 pounds. Certainly the bending, stooping, and squatting are more painful for her than lifting 30 pounds, which is about 12 percent of her body weight." (Mirkin Dp. pg. 39)

Dr. Mirkin agreed, during recross examination by the Second Injury Fund, that the restrictions of the bending, stooping, squatting, those were of Rosenkoetter's physical condition as of the exam in 2001.

Dr. Robert P. Poetz, D.O. testified by deposition on behalf of the employee. (Cl. Exh. H) An osteopathic physician and surgeon, Dr. Poetz testified that the document marked as Deposition H-1 was his June 10, 2002 evaluation report on Mary Rosenkoetter; it was agreed and stipulated to by the parties at Dr. Poetz' deposition that the doctor would testify per his evaluation report. (Ruling: Second Injury Fund's and Employer/Insurer's objection on grounds of Seven Day Rule is overruled. Poetz Dp. pg. 5)

In his June 10, 2002 evaluation report, Dr. Poetz wrote that he saw Rosenkoetter on October 26, 2001 for evaluation of work related injuries occurring while employed with Magna Interior Systems of America as a factory worker for eight years. Rosenkoetter's chief complaints were noted as: constant lower back pain which intensifies with increase activity and prolonged sitting, standing or walking; pain from the lower back that radiates down the right leg and occasionally the left; inside portion of left leg is numb; outside of right ankle is painful and occasionally swells; right knee is painful, and catches and pops with movement; occasionally pulling sensation in the palm of left hand between the 4th and $5^{\text {th }} finger with 5^{\text {th }}$ finger numbness; pain and numbness in both hands and wrists, the left worse than the right; numbness and pain in hands wakes her up at night; very depressed. Dr. Poetz discussed five (5) work related injuries relayed by Rosenkoetter: 1. November 23, 1994 - working on a metal pan when she lacerated the palm of her left hand on a sharp edge, and was treated with medicine and hand therapy which included scar management. 2. August 25, 1995 - slipped on a paper tag which caused her to twist her right ankle and knee before falling onto a table, with ongoing occasional pain and swelling at the ankle and knee, and on September 15, 1995 was seen at Healthline and diagnosed with mild right ankle sprain and right knee sprain, and physical therapy was recommended; also reported was that after the incident Rosenkoetter developed lower back, left hip and left leg pain; treatment for the back included radiological studies, and surgery. 3. November 18, 1997 - developed a burning sensation and pain in the lower back while bending and lifting a box at work; treatment was medication and restrictions, and with continuing problems radiological studies were performed including an MRI. 4. February 19, 1998 - developed depression as the result of stress and harassment at work; Rosenkoetter claims in 1997 her boss and coworkers were taunting her by deliberately sending her defective parts so that she would have to repair them and they altered the speed of the line to the point that she was unable to keep up and they tampered with her food; when seen on February 19, 1998 for complaints of bilateral upper extremity pain it was noted that Rosenkoetter appeared depressed and was diagnosed with depression, Rosenkoetter denies further care of psychiatric evaluation. 5. 1991 to 1999 - Rosenkoetter states that in approximately October of 1997 she developed pain in her wrists and forearms, and on November 3, 1997 was seen at Healthline and was diagnosed with tendonitis, treatment of Ibuprofen provided no relief; on March 17, 1998 was referred to Dr. Crandall, and a nerve conduction study revealed borderline carpal tunnel syndrome on the right and mild on the left; on June 19, 2001 seen again by Dr. Crandall and a new nerve conduction study showed moderate carpal tunnel syndrome, and Rosenkoetter states surgery was recommended. Rosenkoetter is currently not employed, Dr. Poetz noted.

Dr. Poetz noted physical examination findings on October 26, 2001 that included: Rosenkoetter is a morbidly obese 56-year-old female, presents with a depressive facies; she is alert and cooperative, and moves about the examination room in no apparent distress; ambulates with a normal gait. Medications: pain and anti-hypertension. Vital signs: Height 5'4" Weight 279; Blood pressure 176/106. Upper extremities: Phalen's and Tinel's signs are negative bilaterally; grip strength is decreased bilaterally; a 2 cm left volar hand scar between the base of the $4^{\text {th }} and 5^{\text {th }} finger, a 11 / 2 \mathrm{~cm}$ scar at the dorsal firth index finger and a 4 cm right index finger scar; hands are neurovascularly intact wit good capillary refill. Lower extremities: $2+$ pre-tibial edema exhibited bilaterally; crepitus at the knees; decreased range of motion at the right ankle; heel and toe walking is performed poorly; feet are neurovascularly intact. Spine: no evidence of kyphosis, lordosis, scoliosis or pelvic list; decreased range of motion at the cervical spine; straight leg raising is positive on the right at 45 degrees in a seated and supine position; a 10 cm vertical lumbar scar. Neuro: cranial nerves are grossly intact; deep tendon reflexes intact; no motor or sensory deficits noted.

Diagnoses made by Dr. Poetz were: 1) 11/23/94 - Laceration palmar aspect left hand with suture repair. 2) 8/25/95 - Right ankle sprain; and right knee sprain. 3) 8/25/95 - Lumbar strains with degenerative disc disease; lumbar spondylosis with myelopathy, severe L3-4, L4-5; displacement disc, lumbar L3-4, L4-5 left and cicatrix of the nerve roots L4 and L5 left; Status post lumbar decompression laminectomy with laser magnification and microdissection L3-4 and L4-5 left. 4) Lumbar degenerative disc disease and spinal stenosis, L3-4, L4-5, pre-existing. 5) 11/18/97 - Lumbar strain and disc protrusion L5-S1 with exacerbation of pre-existing lumbar condition. 6) 2/19/98 - Depression secondary to work related stress and harassment. 7) 1991 to 1999 - Bilateral carpal tunnel syndrome. 8) Hypertension, pre-existing. 9) Cardiomegaly, pre-existing. 10) Chronic obstructive pulmonary disease, pre-existing. 11) Tendonitis right elbow, 1985. 12) Concussion, 1985. 13) Cervical strain, 1985. 14) Right shoulder sprain, 1997. 15) Left tibial plateau fracture and left knee sprain, 1998.

Dr. Poetz discussed his recommendations which included weight loss, check blood sugar to evaluate for diabetes, avoiding heavy lifting and strenuous activity, and bilateral carpal tunnel release indicated if symptoms persist.

Dr. Poetz wrote that as a result of his evaluation, which included a review of medical records, it was his opinion that the injuries which occurred on November 23, 1994, August 25, 1995, November 18, 1997, February 19, 1998, and 1991 though 1999 are a substantial and contributing factor to the following disabilities:

was his conclusion that surgery may be appropriate. The doctor agreed that Rosenkoetter had removed herself from the work force, and testified as to his opinion on when he would anticipate Rosenkoetter's condition would remain static or improve with time: "I won't know what to anticipate. I would only have to wait and see what happens. Sometimes they get better and sometimes they don't." (Poetz Dp. pg. 29) When queried if it would be possible his opinion that Rosenkoetter was permanently and totally disabled would be changed if she had had received surgical care for the bilateral carpal tunnel syndrome after he saw her, Dr. Poetz responded - "...we're not talking about the same patient. I would have to reassess this other patient you're talking about." (Poetz Dp. pg. 29) Dr. Poetz agreed that up to the date of his deposition he was not aware Rosenkoetter had had carpal tunnel releases, and when queried wasn't it correct that he did not know the result of the releases, the doctor responded - "Correct". (Poetz Dp. pg. 35) The doctor was asked if he had an opinion as to whether Rosenkoetter was permanently and totally disabled prior to the development of the carpal tunnel complaints. "I don't think I gave a determination regarding that in my report", Dr. Poetz answered. (Poetz Dp. pg. 37) The doctor further stated that he was not able to give a determination regarding this at that time.

During cross examination by the employer/insurer, Dr. Poetz agreed that with Rosenkoetter's first accident of a laceration to her left hand, there was no indication of any neurovascular involvement. "There is indication in my report that there was tendon involvement", the doctor said. (Poetz Dp. pg. 38) The doctor was asked if he found any flexor tendonitis as of the date of his exam. "Just the scar", the doctor responded. (Poetz Dp. pg. 39) Dr. Poetz agreed that, as a result of the laceration, there was no indication of decreased range of motion of any of the fingers, no numbness or tingling, and no atrophy found in the hand. The doctor agreed that he did not place any restrictions on Rosenkoetter's ability to use the hand as a result of the laceration. Dr. Poetz stated that he also diagnosed Rosenkoetter with depression and assessed disability as a result. The only history in my report that would have caused such a condition was stress and harassment at the work place, the doctor agreed. The doctor was queried - you didn't have any history of there being marital problems or family problems or problems outside of work that could have caused or contributed to Rosenkoetter's permanent disability as a result of a psychiatric condition. "Not to my knowledge", Dr. Poetz answered. (Poetz Dp. pg. 41) It was noted that the specific history in his report was that depression as a result of stress and harassment at work; approximately 1997, the patient claims that her boss and co-workers were taunting her, deliberately sending her defective parts so that she would have to repair them, they altered the speed of the line to the point she was unable to keep up and they tampered with her food. Dr. Poetz admitted that he did not know how often these things occurred. The doctor was questioned, you indicated that they altered the speed of the line and did he know if the line had multiple people working on it, and Dr. Poetz responded - "I don't know if her specific station was able to be adjusted. I don't know that." (Poetz Dp. pg. 42) When further queried - so you don't know if the stress was put upon her at the work place was different than the subjective levels of stress that would have been imposed upon other folks at that place of employment. "I don't know", the doctor answered. (Poetz Dp. pg. 42) Dr. Poetz agreed that at the time he saw Rosenkoetter she was not on any medication for depression. I did recommend additional treatment as a result of her diagnosis of depression, the doctor said, SSRV, "selective seratonin inhibitors", an antidepressant medication. (Poetz Dp pg. 43) I did not prescribe this for her when I saw her, Dr. Poetz said. Depression is caused by "altercation of seratonin secretion by the brain as a result of certain stressful stimuli", Dr. Poetz explained. (Poetz Dp. pg. 44) Persons with a family history of depression are more susceptible to having their seratonin altered by means of eternal stressful stimuli, the doctor said. I don't know if Rosenkoetter has a family history of depression, Dr. Poetz stated. The doctor agreed that marital difficulties could be an external stressful stimulus for seratonin altercation if the patient feels it is the reason for their depression. Dr. Poetz agreed that he asked Rosenkoetter what were the causes or stimulus for her depression, and she said - work. I'm sure I made inquiries as to whether there were any stressors in her life outside of work, the doctor said. "I can tell you that after 40 years of experience of trying to determine how and why patients are depressed, that I am skillful at asking the right number of questions until I'm satisfied to the answer that I receive is significant for that patient's response", Dr. Poetz said. (Poetz Dp. pg. 46) Dr. Poetz responded - "I don't recall"- when queried if he know how long Rosenkoetter had been married, how many times she had been married, if she was ever physically abused or emotionally abused, if her kids were ever emotionally abused. (See Poetz Dp. pp. 4748) Dr. Poetz stated that he was familiar with the DSMIV, and agreed that it listed psychosocial stressors; the doctor agreed that psychosocial stressors can cause depression. Dr. Poetz agreed that marital discord was on the DSMIV list of psychosocial stressors as well as family discord, physical and emotional abuse. The doctor was queried about his evaluation of Rosenkoetter's mental status; Dr. Poetz stated that he did not need to do a Beck Depression Scale and did not do the MMPI. "I spent an hour with the lady and I make determinations when I, the depressive faces that she showed, by the things that she told me, and not only did I make a diagnosis based on an hour of studying the patient, but I also made recommendations as to her management of her depression", Dr. Poetz testified. (Poetz Dp. pg. 52)

With respect to the second injury, an injury to the low back on 11/18/97 and his assessment of 15 % disability as a result of that accident, Dr. Poetz testified about knowing of Dr. Calvin's 9/16/97 record in which it was mentioned that Rosenkoetter reported that on $9 / 14 / 97$ she was lifting heavy pots at a family reunion and had an increase in her back complaints: "Yeah, I think I knew about that, but that was considered to be insignificant by her, so it wasn't listed". (Poetz Dp. pg. 56)

During cross examination, Dr. Poetz agreed that at the time of his exam, Rosenkoetter was five foot five and 279 pounds; the doctor agreed that he had characterized Rosenkoetter as morbidly obese. The doctor agreed that he is familiar with studies that identified obesity as a risk factor in the development of carpal tunnel syndrome. Dr. Poetz stated his opinion: "Patients who are obese, who are diabetic, who are pregnant, have a higher risk of developing carpal tunnel syndrome if they have excessive and repetitive use of their hands and wrists." (Poetz Dp. pp. 65-66) Dr. Poetz agreed that he had concerns of diabetes in Rosenkoetter, in part because of her weight. Agreeing that morbid obesity adversely affects Rosenkoetter's back, Dr. Poetz testified: "Well, it makes the back work harder". (Poetz Dp. pg. 66) It was noted that on examining Rosenkoetter's legs, the doctor had found two plus pretibial edema

bilaterally at the lower extremities; Dr. Poetz was asked if this was from obesity. Answering "No", Dr. Poetz further stated his opinion as to what the edema was from: "Well, I guess cardiovascular disease, renal disease, lymphodema or a combination of all the above plus obesity." (Poetz Dp. pg. 66)

Dr. Poetz agreed, during cross examination, that Rosenkoetter did not provide him with a history of injury to the left knee. When queried, wasn't it correct that he found crepitus in the knee bilaterally, Dr Poetz answered - "Yes". (Poetz Dp. pg. 67) The doctor further agreed that there was no indication that one knee was worse that the other on exam. No atrophy of the lower extremities was found and there was normal range of motion at the level of the knees, the doctor agreed. Dr. Poetz was asked - on your exam of the right knee what is it that you found that was different than your exam of the left knee. "None", the doctor answered. (Poetz Dp. pg. 68)

Concerning the 8/25/95 injury where Rosenkoetter slipped on a paper tag and injured herself, Dr. Poetz agreed that Rosenkoetter's initial treatment was at Healthline, and at that time she had complaints about the right knee and ankle and x-rays were taken of the right knee and ankle. The doctor agreed that the first treatment was on 9/15/95; Dr. Poetz stated that in his review of the initial Healthline reports he did not find any history or complaint of injury to the low back. Dr. Poetz was asked how long after the incident before Rosenkoetter developed low back pain. "I don't know", Dr. Poetz answered. (Poetz Dp. pg. 69) The doctor was questioned - assuming it was Rosenkoetter's signature on a Report of Injury dated 10/7/95, what were the injuries noted by Rosenkoetter on the form, and Dr. Poetz indicated "right ankle and ankle". Agreeing that there was no reference to the back as of 10/7/95, Dr. Poetz testified - "No. It says, sprained right ankle and ankle". (Poetz Dp. pg. 7) The doctor was asked his opinion as to the mechanism in this case of injury to the back for the 1995 problem Rosenkoetter had with her back. Dr. Poetz answered:

"Well, I think that she had indicated in the history there, that she developed this knee and ankle twisting, she continued to have an ankle and knee pain, and eventually after the incident, she developed lower back pain, left hip pain and leg pain.

"And she said she felt that it was related.

"I think that she indicated that she felt that it, it came as a result of it, it was part of the, the ongoing complaint of pain in the knee and the ankle." (Poetz Dp. pg 74)

Dr. Poetz agreed that Rosenkoetter did not provide him any history of additional trauma or repetitive activities that caused her to develop pain with her back. The doctor was queried if he had been provided with any history of Rosenkoetter doing some work painting floors in a stooped position and developing pain complaints in the back as of 10/15/95. "Not to my knowledge", the doctor answered. (Poetz Dp. pg. 75) The doctor agreed that when Rosenkoetter eventually started undergoing diagnostic studies for the back it was through x-rays of the lumbar spine which were done about a month and a half after the incident where she slipped on a tag. Dr. Poetz agreed that the following findings of the radiographic studies were pre-existing conditions to 1995: anterior and posterior osteophytes at L2-3, L3-4, and L4-5; some disc space narrowing, most severe at L5-S1; narrowing of the apaphyseal joints with subcondryl sclerosis; facet hypertrophy and calcified bulging discs at all levels resulting in narrowing of the spinal canal; calcified focal area of disc protrusion and/or osteophyte formation with left lateral position at L3-4; bilateral, lateral recessed narrowing produced by osteophytes at L4-5; and proximal foraminal stenosis that was produced by osteophytes. Dr. Poetz noted that the following findings on radiographic studies may or may not have been pre-existing: the marked narrowing of the left neuroforamina as a result of calcified focal area of disc protrusion. Dr. Poetz stated that the spondylosis (dysfunction of the spinal canal) found when Rosenkoetter was operated on was in part a degenerative condition that occurs over time or a pre-existing condition. Explaining other causes of the spondylosis, Dr. Poetz testified: "Multiple injuries or recent injury to exacerbate it". Poetz Dp. pg. 79) The doctor stated that the stenosis at L3 L4-5, and left lateral recessed stenosis at 3-4 and L4-5 "would all be preexisting, but the degree of preexisting and the degree of exacerbation is indeterminable". (Poetz Dp. pg 79) Dr. Poetz agreed that in going through this mixed bag of conditions, in trying to portion it out, he thought that overall Rosenkoetter had 40 percent disability and 10 % of that was due to the preexisting degenerative conditions and 30 % to the incident with the tag.

Dr. Poetz was queried, during cross examination, if had reviewed any pulmonary function studies on Rosenkoetter, and the doctor answered - "Not to my knowledge, unless it was within the medical history that I reviewed." (Poetz Dp. pg. 81) Other than a stethoscope exam where I heard rales, I did not do any other examination of Rosenkoetter's respiratory system, the doctor said. Dr. Poetz stated that he did not know what caused Rosenkoetter's obstructive pulmonary disease.

Dr. Poetz stated that he did not recall reviewing any work hardening reports concerning Rosenkoetter. To my knowledge I did not review any vocational reports about Rosenkoetter, the doctor said. Dr. Poetz stated that he did not recall Rosenkoetter's prior work history. I did not do any testing as to Rosenkoetter's IQ, the doctor stated, and I do not know what kind of transferable skills she has.

On cross examination by the Second Injury Fund, Dr. Poetz agreed the medications Rosenkoetter was on as of the date he saw her were pain medication and anti-hypertension medication; she was not on any type of medication for a pulmonary or a cardiac condition. Dr. Poetz stated that he would not defer to a vocational expert as to whether or not any jobs were available to Rosenkoetter within the restrictions he had recommended. Dr. Poetz explained: "Well, because I'm a physician. And I would tell

this patient regardless of what a vocational expert would tell her, I'd tell her what would be appropriate for her longevity and her morbidity." (Poetz Dp pg. 91)

On redirect examination, Dr Poetz was asked - given the history Rosenkoetter has of repetitive use in the factory of the hands and wrists, her weight and diabetes, etc, in his opinion was the repetitive use of the hands at work a substantial factor in the cause of the bilateral carpal tunnel syndrome. "Yes, it is", the doctor answered. (Poetz Dp. pg. 94) Dr. Poetz stated that there was nothing he had been asked in the deposition that would change his opinion as to what he had stated in his report.

Dr. Wayne Stillings, M.D. testified by deposition on behalf of the

employer/insurer (Emp./Ins. Exh. 3). A board certified psychiatrist, Dr. Stillings stated that the components of his evaluation consist of: the claimant's age, marital status, "a lifetime psychosocial history from birth until the present", educational and work backgrounds, her past medical history, her present complaints; a review of the medical records; and testing. Stillings Dp. pg. 7) At his deposition, Dr. Stillings' evaluation report of August 14, 2002 was marked as Employer's Exhibit B, and was admitted into evidence without objection and on the stipulation that the doctor would testify in accordance with his report; Dr. Stillings noted in his report dates of injuries for the claimant for his August 14, 2002 psychiatric independent medical evaluation of - 11/23/94, $9 / 15 / 95,11 / 18 / 97,2 / 19 / 98, and 3 / 14 / 99$.

Dr. Stillings discussed what he thought were the salient features of Rosenkoetter's history:

"Miss Rosenkoetter had a 25-year marriage, and divorcing in 1987 because she was emotionally and physically abused by her first husband. And I think this was a psychologically difficult, and somewhat damaging marriage for her, and it still - she still had scars from that.

I think it's important to note that she was a somewhat vague historian, and somewhat reluctant to talk about her personal psychiatric history, to the extent that she would like to attribute all of her current emotional features and emotional state to the various work-related injuries that are listed in the front of my report.

I think it's also very important to note that Miss Rosenkoetter has never sought any kind of mental health care during her lifetime in a work-related fashion, or otherwise.

She did report that her nerves were bad quote, 'My nerves was bad,' unquote, per Miss Rosenkoetter. (Dr. Stillings agreed that she was describing a mental state rather than a physical condition)

And she had taken some medications through HealthLine sometime in the past, that she thought were beneficial on calming her.

And she attributed her nervousness, correctly or incorrectly, to being harassed at work. It's noteworthy Miss Rosenkoetter has not worked at Integram, where she worked for about eight years, she has not worked there in greater than three years, and she has not been harassed, in her own perception, in greater than three years.

She also said that her nerves were, quote, 'bad,' unquote, due to back pain, and, quote, 'because they are,' unquote.

And she notes that she was somewhat unhappy, or sad, if you will, because she did not have an independent income, and did not have as much money to spend on her children and grandchildren.

When I saw her she was not taking any type of nerve, or psychotrophic medication, and she described her life at home with her husband as somewhat quiet and docile. She spends a lot of time in her room. Really seems to be somewhat withdrawn.

She and her husband live on a 180-acre farm.

And she has a general distrust of people, even family members, and part of this is related to being assaulted by her brother-in-law in 1995." (Stillings Dp. pp. 8-10)

Dr. Stillings discussed what Rosenkoetter's mental status examination revealed:

"Miss Rosenkoetter was an alert, somewhat rude, passively uncooperative, non-communicated, obese, casuallyattired white female.

She avoided talking about psychosocial stressors in her life, other than her perception of work-related situations.

She attempted to attribute all of her problems to her employment with Integram. She answered many questions by stating, quote, 'I don't know,' closed quote, making no effort to respond. Her speech was sparse.

She displayed psychological distress in the form of crying, and physiologic re-activity in the form of flushing and agitation when discussing the emotional abuse she suffered in her first marriage.

She was disinterested in the evaluation, and had very little eye contact with the examiner. Initially, her affect was matter of fact, but later became somewhat dramatic and labile.

In general, her affect was cold and detached. No psychological distress nor physiologic re-activity was manifest in regard to the work incidents known as sequelae, at Integram.

Her mood was variable. At times was angry and assailed the quote, 'workers' compensation doctors,' closed quote. At other times she appeared sad.

She denied hallucinations, delusions, obsessions, compulsions, phobias, suicidal and homicidal ideation.

She was fully oriented to time, place and person. Recent and remote memory functions were in tact.

Cognitively, she functions in the normal range. Verbal comprehension was fair at best. Concentration was fair. Intellectual functioning was in the normal range. Insight and judgment are questionable." (Stillings Dp. pp. 11-12)

(Ruling: Claimant's objection on grounds of repetitious is overruled. Stillings Dp. pp. 10-11,15)

Dr. Stillings discussed the results of the testing he had performed on Rosenkoetter:

"The revised Oswestry reveals that this individual reported low back pain in the cripple region, which is inconsistent with her medical status, in that she's not crippled.

The 15 -items test results are that this individual's fairly claiming that her pain levels are impairing her concentration and memory functions.

MMPI test results are as follows: The overall profile should be approached with caution, and may reflect distortion due to confusion, and delusional thinking, or an attempt to over-report subjective symptoms. Assuming the latter is not true, the overall profile is consistent with schizoid personality disorder, with depression as a central feature.

She may express her sadness and open tearfulness. She's likely to have a retarded stream of thought. And 70 percent of individuals with this profile are judged to be psychotic, which is supported by the elevations on the 8-6 scale. That's a specific psychotic scale on the MMPI.

The expression of psychological conflict to somatic or physical channels is encountered very frequently among individuals generating this profile.

She's likely to view her problems and her disorder as being physically ill, and she's likely to be defensive about admitting any psychiatric component.

She's also likely to avoid close interpersonal relationships, which is a cardinal characteristic of individuals with this profile.

She will strive to keep people at a distance, and involvement of any intimate sort with others as threatening, yet 70 percent of the individual with this profile are married.

This individual will view others with mistrust, and their motivations will be questioned. She has conflict about emotional dependency, and pressure with a general irritable manner or tone. Others will describe her as tense, high strung, anxious, and jumpy.

She is prone to obsessional thinking and repeated ruminative pre-occupation. Her thinking is unoriginal, and problem solving is stereotypic, rather than flexible.

She's likely to be quite forgetful, and under-assertive. She reports conflict of authority figures, and has chronic longstanding social and self-alienation.

She has a paranoid flair to her personality, and is likely to blame others in external situations for her personal problems, and short-comings in life.

She's likely to feel that she has been misunderstood, and has gotten a raw deal from life. She views the world as a threatening place. Feels that others have unfairly blamed, or punished her, and may even have delusions of persecution. She reports family problems and is somewhat compulsive. She has somatoform features to her personality, as understood by elevations on HY4, SC3, TSX and GRPS. The depression subtle scale is normal." (Stillings Dp. pp. 12-15)

The doctor agreed, during cross examination by the claimant, that he interprets his own MMPIs.

Dr. Stillings testified about his diagnosis after evaluation of Rosenkoetter:

"On axis one, which is reserved for primary psychiatric problems and disorders, she has no primary psychiatric disorder. Axis two, which is reserved for personality disorders, and developmental disorders, Miss Rosenkoetter is diagnosed with personality disorder not otherwise specified, with pronounced schizoid features, as well as depressive, paranoid, and somatoform.

"Axis III is reserved for medical conditions, and in Miss Rosenkoetter's case, she has morbid obesity, hypertension, and congestive heart failure.

Axis IV is reserved for psychosocial stressors, and her stressors are being unemployed in a solitary existence.

Axis V is global assessment of functioning, or GAF, if you will, as an acronym. And her GAF is 55, which means that she is occupationally able to function, but she has some moderate psychiatric symptoms, such as a flat affect, or a sad affect." (Stillings Dp. pg. 15, 16)

Dr. Stillings agreed that the work-related component, what work may or may not have caused from a psychiatric standpoint, is revealed in Axis I. The doctor was asked if the Axis II diagnoses were a result of a work-related injury or something that made up her personality. Dr. Stillings answered: "Yes, it would not be occupationally related by definition. This would be a combination of her genetic constitution, and also, her early life experiences. Personality disorders, by definition, are present and fixed, and enduring by late adolescence, or early adulthood." (Stillings Dp. pp. 15-16) The doctor agreed that the personality disorder, which is Axis II, is pre-exiting, the doctor agreed that Axis III is also pre-existing. Dr. Stillings agreed that Axis V, the GAF, took into account everything, Axis I through IV. With respect to her GAF score of 55, the doctor stated: "..this would mean that she probably doesn't function as well as the average person occupationally, or socially. But it doesn't preclude her from working. She is still occupationally functional.". (Stillings Dp. pg. 17)

Dr. Stillings testified as to his opinions in regards to Rosenkoetter. a. Whether or not Rosenkoetter's employment at

Integram produced any type of psychological diagnosis: "Her employment at Integram did not cause her any type of psychiatric problem, or diagnosis". (Stillings Dp. pg. 18) b. Whether or not Rosenkoetter's employment at Integram produced any permanent partial disability: "As a result of her work-related aggravation of her pre-existing and coexisting personality disorder, Miss Rosenkoetter has a two to three percent permanent partial psychiatric disability." (Stillings Dp. Pg. 18) It was noted that Dr. Stillings had not provided in his evaluation report of 8/14/02 a rating of disability for any pre-existing psychiatric disability which may have existed; the doctor testified, without objection -"My opinion is that Miss Rosenkoetter has a 10 percent permanent partial psychiatric disability as a result of the pre-existing personality disorder." (Stillings Dp. pg. 20) c. With respect to the Rosenkoetter's claim of mental stress as a result of her employment at Integram and whether or not she is in need of any further psychiatric treatment - "She is not in need of any treatment related to her employment with Integram." (Stillings Dp. pg. 19) With regard to the work-related aggravation of her pre-existing personality disorders - "And that set, she doesn't need treatment either." (Stillings Dp. pg. 19) d. Whether or not Rosenkoetter's employment at Integram left her in any way unable to work - "Her employment at Integram did not impair her from an occupational standpoint. In other words, she's just as able to work now as when she was at Integram, or before she worked at Integram." (Stillings Dp. pg. 20) The doctor agreed that at least as of the date when he saw Rosenkoetter, which was in August of 2002, she was capable of working in the open labor market.

Dr. Stillings testified a second time by deposition on April 28, 2004. (Emp./Ins. Exh 8) Since my first deposition in this case, Dr. Stillings stated, I was forwarded and reviewed a copy of Dr. Crane's records from 5/2/03 through 9/29/03. The doctor was asked, after having reviewed Dr. Crane's record did he deem it necessary to reevaluate Rosenkoetter. "No", Dr. Stillings answered. (Stillings 4/28/04 Dp. pg. 6) The records of Dr. Crane did not affect my opinions as previously set forth in my previous deposition testimony, Dr. Stillings said. The doctor was asked the significance he had attached to the records of Dr. Crane, and Dr. Stillings answered: "Well, I think the significance is very simple. She improved some with his psychiatric administrations." (Stillings 4/28/04 Dp. pg. 6) Dr. Stillings explained the basis upon which he felt Rosenkoetter had improved with treatment by Dr. Crane:

"Well, when I saw her GAF or global assessment of functioning was 55, Dr. Crane near the end of treatment or at some point during treatment had assigned her a GAF of 60 . So really she's gone from moderate symptoms to slightly moderate symptoms. If you assigned her a 61, then she would have minimal symptoms. So she's real close to falling into another category of a much better prognosis and just a better outcome for her." (Stillings 4/28/04 Dp. pg. 8-9)

Testifying as to his continuing diagnoses, Dr. Stillings stated: "The continuing diagnoses are on axis - nothing on axis one. Axis two, personality disorder, not otherwise specified with schizoid features, depressive features, paranoid and somatoform features." (Stillings Dp. pg. 7) Dr. Stillings was asked to testify as to his opinion of whether or not Rosenkoetter suffered from a diagnosis of major depressive disorder:

"I do not feel she qualifies for the diagnosis of major depressive disorder based on application of the DSM-IV criteria. And this is based - now, those are subjective criteria. On an objective basis, her diagnostic testing on the MMPI does not support that diagnosis either." (Stillings 4/28/04 Dp. pg. 7)

The doctor further explained why Rosenkoetter's condition did not support the diagnosis of major depressive disorder:

"Her code type is an $82 / 28$ and those code types are generally found in people who are schizoid, have personality disorders, have some quasi-psychotic symptoms. It indicates she has emotional distress but not particularly depressive in nature." (Stillings 4/28/04 Dp. pp. 7-8)

Dr. Stillings was asked to explain the difference between a personality disorder, as he had diagnosed, versus a depressive or mood disorder as diagnosed by Dr. Crane:

"Yeah, personality disorders are really an expression of an individual's features or characteristics of their personality, whether they're, for instance, shy or gregarious or outgoing or if they have some paranoid features. So you really are looking at sort of the mixture of their features of their particular makeup as a human being. A mood disorder is a very specific highly defined psychiatric disorder where the essential feature is, of course, a low mood." (Stillings 4/28/04 Dp. pg. 8)

Dr. Stillings stated that after reviewing the records of Dr. Crane his opinions regarding the nature and extent of Rosenkoetter's permanent partial disability did not change in any way. My opinions regarding Rosenkoetter's ability to work did not change, the doctor said. Dr. Stillings was asked his opinion as to whether his opinion of 2-3\% permanent partial disability from a psychiatric standpoint he had assigned as a result of Rosenkoetter's work injuries would preclude her from working or finding employment in the open labor market. "My opinion is that it would not", Dr. Stillings answered. (Stillings 4/28/04 Dp. pg. 9)

John B. Crane, M.D. testified by deposition (Cl. Exh. $\mathrm{R}^{[22]}$ ) and stated that he is a board certified psychiatrist, and recently became a distinguished fellow of the American Psychiatric Association. Dr. Crane testified: "Well Mrs. Rosenkoetter came to see me initially in May of '03, May 2 of '03. She was quite depressed at that time; and actually in looking at my records, I'm not sure whether she came on her own behalf. I think she did." (Crane Dp. pg. 7) I conducted a mental status evaluation of Rosenkoetter, Dr.

Crane said, I did not do any other psychological testing. I also reviewed medical records, the doctor said. Commenting on how many times he saw Rosenkoetter, Dr. Crane testified - "Between that first visit and August 18 of '03 - let's see, one, two, three, four - four visits." (Crane Dp. pg 9)

Dr. Crane agreed that on the date of his evaluation his diagnosis was depression and he provided Rosenkoetter with some medications. The doctor agreed that his Axis II diagnosis was symptoms of dependent personality. When queried wasn't it true that he was still continuing to treat Rosenkoetter, Dr. Crane answered - "That's correct". (Crane Dp. pg. 60) The doctor was queried if he was continuing to treat Rosenkoetter under the impression that he could make her better. "One hopes so", Dr. Crane answered. (Crane Dp. p. 60) The doctor was queried if it wasn't correct that depression is something that once a person has it they are more prone to relapse or recurrence. Dr. Crane answered: "Generally speaking, yes. That's correct." (Crane Dp. pg. 62)

On examination by the claimant, it was noted that Dr. Crane had mentioned in his report something about future medical care, and the doctor was asked what if any future psychiatric care was Rosenkoetter going to require. Dr. Crane responded: "This lady is likely to require long-term anti-depressants, treatment, and possibly some psychotherapy along the line depending on things that happen in the future, things that may happen in the future." (Crane Dp. pg. 57) (Ruling: Employer/Insurer's and/or Second Injury Fund's objections on grounds of Seven Day Rule are overruled. Crane Dp. pp. 57 and 58) Dr. Crane explained "the definition of psycho therapy is talking therapy, and it is aimed at helping a patient deal with stresses that may bear upon their mental status." (Crane Dp. pg. 58)

In his August 18, 2003 report (Cl. Exh. R-1), Dr. Crane included the following:

Mrs. Rosenkoetter is an obese woman who appears essentially her stated age. She was generally cooperative with the examiner, although when seen initially she was irritable and angry and tended to be somewhat oppositional in answering questions. She initially expressed a "what's the use?" attitude and clearly felt that this evaluation would be no different from previous examinations that she has had over the last nine years. Initially she was tearful, her cadence of speech was somewhat childlike and her thought processes appeared to be slowed. With treatment this has improved and her affect is considerably brighter. She is not tearful during follow up evaluations.........

Notably, during the several sessions with this lady, she has become increasingly cooperative and friendly and this appears to have been a result of simply listening to her.

Dr. Crane noted that he was addressing specific questions presented to him, and included the following in his answers:

\#1. Mrs. Rosenkoetter's current Axis I diagnosis is Major Depressive Disorder, severe, chronic, improving with the use of antidepressant medications. On Axis II she presents some symptoms of dependent personality. Axis III would include diabetes mellitus, essential hypertension, chronic cardiovascular disease, severe generalized osteoarthritis, particularly in the low back, and status post bilateral Carpal Tunnel Syndrome. Axis IV is an assessment of the patient's current stress, which would be interpreted to be quite high because of her physical condition, employment condition, and financial condition. Axis V - Current GAF (Global Assessment of Functions) on a scale of 0-100, where 100 is "normal", is assessed at approximately 60 . Patient's highest GAF within the past year is assessed as her current 60.

\#4. ......This lady has presented as angry, hostile, and irritable during some of her evaluations and in particular during her psychiatric evaluation with Dr. Stillings. These symptoms were interpreted as being due to severe Personality Disorder, a suggestion with which I disagree, and I believe they were primarily related to her Mood Disorder, although when severely dependent persons are confronted with this type of situation they frequently do become even more upset and angry.

/s/ PATRICIA "PAT" SECREST

PATRICIA "PAT" SECREST

Director

Division of Workers' Compensation

[1] NOTE: Gerald Kretmar, Attorney at Law and former attorney for the claimant filed an Attorney's lien in this case. Stated on record at the beginning of this hearing was that the Notice of Hearing letter in this case reflected that a copy was sent to Attorney Gerald Kretmar. Attorney Kretmar was not present at the hearing to prosecute his lien and has made no contact to the Division to request a continuance on this matter. It is found that Attorney Gerald Kretmar's lien was not protected during the course of this hearing, and thus is denied.

[2] NOTE: the Division file is showing that Integram was insured by Transportation Insurance Company. Attorney Tim Tierney for Integram: CAN/RSKCo is the correct coverage at the time of the injury.

[3] SUMMARY OF THE EVIDENCE begins on page 13.

[4] NOTE: A Report of Injury form (Form 1) was included in Dr. Mirkin's records; the form - dated 9/27/95 and completed by Angela Straatmann

Human Resource Administrator - included that Rosenkoetter reported that on 9/15/95 she twisted her right ankle when she slipped on a piece of paper while walking around table in cut \& sew area; the form reflected the injury as - mild sprain right ankle, strain right knee; it was noted that the attending physician was Healthline at St. John's Mercy Hospital; and it was noted that Rosenkoetter had returned to work on 9-16-95. (See Cl's. L)

[5] On cross examination, the claimant was queried if she had ever worked painting floors at Integram. Not that I can recall; she answered, the only painting they done was to paint a yellow line on the -- when they were off for model to change over, and I don't even remember if I even done that or not. Rosenkoetter stated that she did not recall if she would have been painting at Integram on October 14 and 15, 1995; she agreed that October 14 and 15, 1995 was a weekend, and assuming that to be the case, she would not have been working at Integram.

[6] Medial treatment records reflect treatment of Rosenkoetter for left knee complaints; i.e. a) in September 1998 - Dx: left knee pain (Emp./Ins. 4); and b) in March 1999 - Dx: left knee contusion (Cla. F).

[7] Claimant's objection on grounds of Seven Day Rule (Mirkin Dp. pg. 10) is overruled in that it is found that the claimant was not prejudiced by this testimony: a. Dr. Mirkin's depo was in December 2002 and the hearing was held in May 2003 and July 2004; b. there is no evidence the claimant made an effort to re-cross exam the doctor on his assessment of permanent partial disability; c. the claimant did not object to the admission of the doctor's deposition testimony at the hearing, only renewing objections made at the time of the deposition; and d. Dr. Mirkin's records [Tesson Heights Orthopaedic \& Arthroscopic Associates records] were offered into evidence by the claimant, Cl's. Exh. No. L.

[8] SUMMARY OF THE EVIDENCE is under separate cover.

[9] SUMMARY OF THE EVIDENCE by separate cover.

[10] It should be noted that in its Memorandum of Law, the employer/insurer indicated that "Accident/occupational disease" were in issue, but this was not presented as an issue at the hearing.

[11] Claimant's Exhibit R and attached report (No. R-1) was admitted on a limited basis as to the issue of future medical care, only.

[12] SUMMARY OF THE EVIDENCE by separate cover.

[13] It should be noted that in its Memorandum of Law, the employer/insurer indicated that "Accident/occupational disease" were in issue, but this was not presented as an issue at the hearing.

[14] Claimant's Exhibit R and attached report (No. R-1) was admitted on a limited basis as to the issue of future medical care, only.

[15] SUMMARY OF THE EVIDENCE begins on page 24.

[16] Dr. Crandall corrected the date from 8-22-01 to 8-23-01 in his deposition. See, Crandall Dp. pg. 14.

[17] See, Employer/Insurer's Exhibit No. 6 for copy of this November 16, 2001 letter.

[18] Additionally, there is a question of whether or not a sufficient factual basis exists to award compensation for these bills without the medical records in evidence for corroboration. See, Martin v. Mid-America Farm Lines, Inc., 769 S.W.2d 105, 111-112 (Mo. banc 1989).

[19] Dr. Crandall corrected the date from 8-22-01 to 8-23-01 in his deposition. See, Crandall Dp. pg. 14.

[20] See. Employer/Insurer's Exhibit No. 6 for copy of this November 16, 2001 letter.

[21] Claimant's objection on grounds of Seven Day Rule (Mirkin Dp. pg. 10) is overruled in that it is found that the claimant was not prejudiced by this testimony: a. Dr. Mirkin's depo was in December 2002 and the hearing was held in May 2003 and July 2004; b. there is no evidence the claimant made an effort to re-cross exam the doctor on his assessment of permanent partial disability; c. the claimant did not object to the admission of the doctor's deposition testimony at the hearing, only renewing objections made at the time of the deposition; and d. Dr. Mirkin's records [Tesson Heights Orthopaedic \& Arthroscopic Associates records] were offered into evidence by the claimant, Cl's. Exh. No. L.

[22] Claimant's Exhibit R and attached report (No. R-1) was admitted on a limited basis as to the issue of future medical care, only.