Julia Hines v. Laclede Gas Company

(Affirming Award and Decision of Administrative Law Judge)

Injury No.: 04-008692

Employee: Julia Hines

Employer: Laclede Gas Company

Insurer: Self-Insured

Date of Accident: January 15, 2004

Place and County of Accident: St. Louis, 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 November 21, 2006. The award and decision of Administrative Law Judge Suzette Carlisle, issued November 21, 2006, 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 $20^{\text {th }}$ day of July 2007.

LABOR AND INDUSTRIAL RELATIONS COMMISSION

William F. Ringer, Chairman

Alice A. Bartlett, Member

John J. Hickey, Member

Attest:

Secretary

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: January 15, 2004
5. State location where accident occurred or occupational disease was contracted: St. Louis, 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:

Claimant's repetitive data entry work as a Customer Service Representative resulted in bilateral carpal tunnel syndrome. 12. Did accident or occupational disease cause death? No 13. Part(s) of body injured by accident or occupational disease: bilateral hands 14. Nature and extent of any permanent disability: 17.5 % of each wrist, and 12.5 % load 15. Compensation paid to-date for temporary disability: -0 - 16. Value necessary medical aid paid to date by employer/insurer? -0 -

Employee: Julia Hines Injury No.: 04-008692 17. Value of necessary medical aid alleged, but not furnished by employer/insurer? \9,800.00 18. Employee's average weekly wages: \ 885.58 19. Weekly compensation rate: $\$ 590.39 / \ 347.05 20. Method wages computation: Stipulation

1. Amount of compensation payable:

Unpaid medical expenses: $\ 8,028.95

Said payments to begin 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 22.5 % of all payments hereunder in favor of the following attorney for necessary legal services rendered to the claimant:

Michael C. Goldberg

Injury No.: 04-008692 Before the Division of Workers' Compensation Department of Labor and Industrial Relations of Missouri Jefferson City, Missouri Checked by: SC:tr

A hearing for a final award was held on August 9, 2006, in the Missouri Division of Workers’ Compensation St. Louis office at the request of Julia Hines ("Claimant") pursuant to §287.450. Attorney Michael C. Goldberg represented Claimant. Attorney Mark M. Anson represented Laclede Gas Company ("Employer"), which is self-insured. The Second Injury Fund was not a party to the proceeding. The record remained open until the submission of Employer’s Exhibit 4 on September 8, 2006. Venue is proper and jurisdiction properly lies with the Missouri Division of Workers’ Compensation.

1. Employer and Claimant were operating under the provisions of the Missouri Workers’ Compensation law at the time of the alleged injury.
2. Employer’s liability was fully self-insured on the alleged date of injury.
3. Employer had notice of the injury and a Claim for Compensation was filed within the time prescribed by law.
4. Claimant’s average weekly wage is $\ 885.58 and the rates for temporary total disability (TTD) and permanent partial disability (PPD) are $\ 590.39 and $\ 347.05 respectively.
5. If Claimant testified a second time she would have said Dr. Farley and SSM DePaul Hospital only provided treatment for carpal tunnel syndrome (CTS).

The issues to be decided at the hearing are:

Only evidence supporting this award is summarized below. Any objections not expressly ruled on are overruled. Claimant offered Exhibits A through D, which were admitted into evidence without objection. Employer offered Exhibits 1 through 4, which were admitted into evidence without objection.

Based upon competent and substantial evidence presented at hearing, I find the following facts:

1. Claimant is 36 years old and has worked for Employer nine years as a Customer Service Representative (CSR). Claimant worked at her desk at least $71 / 2$ hours per day with a 45 -minute lunch and two 15 -minute breaks. Claimant worked considerable overtime between December and February. Claimant also worked for Employer on the Disputed Jobbing Desk (DJD) until she returned to work after carpal tunnel surgery.
2. Claimant is one of sixty CSRs working in individuals cubicles. Each CSR is expected to handle 90 to 100 telephone calls per day and assist customers. Length of calls vary from 2 to 8 minutes, depending on the call. Each CSR is equipped with a computer, mouse, keyboard, headset and telephone. More than half the computer time was spent documenting calls. Each call required entering the customer’s address into the computer. The mouse was used to change screens. While talking to customers, Claimant provided information and updated customer accounts.
3. When a call was completed another call was sent to Claimant unless the computer was in "after call" mode; permitting time to wrap up the previous phone call. In-coming calls were held in a queue. Wrap up included computer entries, typing a memo to a foreman or writing a work order. When completed, Claimant pressed the "ready" button and another call was received. Claimant cannot stay in the "after call" mode longer than needed because supervisors have access to screens and know who is taking a call. They also walk around and remind CSRs that calls are waiting.
4. Claimant typed abbreviations for commonly used terms, i.e. "TONN" for "turn on" and "TOFF" for "turn off," services, filled in boxes and typed memos. Abbreviations and the narratives vary depending on the customer needs. No single key allowed information to be retrieved. Claimant did not type everything discussed with a customer.
5. Claimant worked in a fast paced environment assisting customers and inputting data. The workload varied depending upon the season. Claimant worked at her desk unless meeting with her supervisor, working the DJD, or taking a break. She often performed CSR and DJD duties during a single shift.
6. Claimant received requests to review billing errors on the DJD. She reviewed work orders, decided billing accuracy, discussed payment arrangements, updated customers and the computer. Hundreds of documents, located on another floor, were reviewed by Claimant during slow periods and when co-workers were absent. Claimant held documents in her left hand and flipped through them with the right.
7. Employer selected Claimant to work DJD because she successfully met telephone expectations in a timely manner. Claimant voluntarily stopped working DJD because she was tired of working between two positions.
8. On January 15, 2004, Claimant trained a co-worker while answering calls, and noticed swelling in her right hand. Claimant sought treatment from her physician, Dr. Bernhart, with complaints of bilateral swelling of her arms and wrists, worse on the right. Claimant denied having hormone, diabetes, or thyroid conditions. A nerve conduction study revealed bi-lateral CTS. Claimant completed a report of injury because she believed the condition to be work related.
9. Dr. Ollinger examined Claimant at Employer’s request on February 25, 2004. Claimant complained of right hand and arm pain, swelling to the shoulder and bilateral sore shoulders. A Positive Phalen’s and Tinel’s sign were found bilaterally over the carpal tunnels. Dr. Ollinger diagnosed obesity due to a body mass index (BMI) of 31(based on BMI of 30 being obese), and bilateral CTS. He opined obesity caused the CTS.
10. Alternatively, Dr. Ollinger opined the CTS was idiopathic because Claimant’s work lacked significant repetition, force, awkward posture, contact stress, vibration, or duration for work to be a substantial factor (Ex 1, Dep Ex-B).
11. Dr. Ollinger relied on Employer’s Job Analysis, Claimant’s work history, and the following articles on keystroke analysis by a) the American National Standards Institute (ANSI), b) Kilbom, c) Threshold Limit Value for Hand Activity, and d)

Mathiowetz. Dr. Ollinger applied the analysis used in those articles to reach a conclusion based on a reasonable degree of medical certainty. He did not know the authors and their results have not been validated scientifically. Nor have they been adopted by any governmental, medical or ergonomic agency (Ex 1-62- 64, 67, 72).

1. Dr. Ollinger acknowledged no minimum number of keystrokes was known to cause CTS. However, he believed a 'gray zone' could be established, and a reasonableness standard applied (Ex 1-77). Insurer denied treatment based on Dr. Ollinger's report, and Claimant pursued treatment on her own.
2. Gary W. Farley, D.O., performed bilateral endoscopic carpal tunnel releases on April 5, 2004 and May 10, 2004. Claimant missed time from work after each surgery. The medical treatment was paid through her group health insurance. Claimant was off work from April 5, 2004 to June 20, 2004, following the surgeries and received a course of physical therapy. Dr. Farley opined the CTS was directly related to Claimant's work, based on the job description and history provided by Claimant. He concluded the work to be the most substantial factor contributing to her complaints (Ex B, EE 4).
3. Bruce Schlafly, M.D., a board certified hand surgeon, examined Claimant at her attorney's request for an Independent Medical Examination, and opined Claimant's repetitive work with her hands was the substantial factor in causing bilateral CTS and the need for treatment, and rated her as having 25 % PPD for each wrist plus a loading factor (Ex B, Ex 2). Dr. Schlafly explained data entry typing required movement back and forth of the flexor tendons through the wrist to the fingers, causing friction and nerve symptoms that can create CTS. He opined use of the mouse had a similar impact.
4. Dr. Schlafly did not endorse Dr. Ollinger's obesity theory, nor did he consider Claimant obese at 156 pounds when he examined her in June 2005 (Ex B -25). Dr. Schlafly was not aware of a scientific minimum number of keystrokes required to develop CTS (Ex B-21).
5. Dr. Schlafly reviewed medical expenses for services provided by Dr. Farley and SSM DePaul Hospital, and found them to fair, reasonable and necessary for CTS treatment. (Ex B-2).
6. Claimant disagreed with the Job Analysis statement that typing was not a constant job function (Ex 1-ER-2). She denied breaks between calls lasting more than two minutes or multiple breaks. Claimant did not consult binders for information. The job description did not include her responsibilities on the DJD. Claimant testified she typed constantly but did not know how many keystrokes were made per call.
7. The "Total Aux/Other" column on Claimant's Daily Report, included lunch breaks, supervisor discussions and DJD duties. The "Total Time Staffed" column represented 500 minutes of phone time during an 8 -hour shift. Fewer calls were caused by slow periods or other job activities. However, Claimant did not sit idle.
8. Victor J. Zuccarello, Vice President of Bio-Ergonomics, Inc., authored the CSR job analysis of physical demands for Employer, date unknown. He testified by deposition that he did not recall the number of workers measured, their gender, or whether Claimant was included. He observed more than one worker for at least two hours. The results were based on observation and supervisor input. Keystrokes per call were based on observation, and work samples of a 'typical representative' for one week. Mr. Zuccarello was not certain if the samples were from one person or more than one (Dep 4-13, 14).
9. No underlying data for Mr. Zuccarello's analysis was available. On cross-examination he conceded Claimant's fingers and hands performed an essential job function, but he did not include them in the job analysis. He intended to say CSRs took breaks. He did not intend to say typing was not a constant function for CSRs. During cross-examination, he was not surprised to learn Claimant had back to back calls on some days.
10. After treatment, Claimant denied any numbness, tingling or pain from CTS. Occasionally, her fingers cramp with overuse, requiring her to "wiggle" her fingers to loosen them.

After careful consideration of the entire record, based upon the above testimony, the competent and substantial evidence presented, and the applicable law of the State of Missouri, I find the following:

§287.020.2 defines "accident" as an unexpected or unforeseen identifiable event or series of events happening suddenly and violently, with or without human fault, and producing at the time objective symptoms of an injury.

Claimant reported sudden swelling of her right hand and arm on January 15, 2004. However, no violent event occurred. Although Drs. Caciola and Schlafly described Claimant's initial complaints as 'atypical,' Drs. Farley, Ollinger and Schlafly diagnosed CTS through tests and physical examination. Given Claimant's work activity, I do not find that she

sustained an accident.

1. Claimant sustained bilateral CTS, an occupational disease, which arose out of and in the course of her employment, and was medically causally related to Claimant's employment.

In order to support a finding of occupational disease, employee must provide substantial and competent evidence that [she] has contracted an occupationally induced disease rather than an ordinary disease of life. Hayes v. Hudson Foods, Inc., 818 S.W.2d 296, 299-300 (Mo. App. 1991) (overruled by Hampton v. Big Boy Steel Erection 121 S.W.3d 220 (Mo 2003) on other grounds). The inquiry involves two considerations: (1) whether there was an exposure to the disease which was greater than or different from that which affects the public generally, and (2) whether there was a recognizable link between the disease and some distinctive feature of the employee's job which is common to all jobs of that sort. Polavarapu v. General Motors Corp., 897 S.W.2d 63, 65 (Mo. App. E.D. 1995); Dawson v. Associated Electric, 885 S.W.2d 712, 716 (Mo. App. W.D. 1994) (overruled by Hampton on other grounds); Hayes, 818 S.W.2d at 300; Sellers v. Trans World Airlines, Inc., 752 S.W.2d 413, 415 (Mo. App. 1988) (overruled by Hampton on other grounds); Jackson v. Risby Pallet and Lumber Co., 736 S.W.2d 575, 578 (Mo. App. 1987).

Claimant must also establish, generally through expert testimony, the probability that the claimed occupational disease was caused by conditions in the work place. Selby v. Trans World Airlines, Inc., 831 S.W.2d 221, 223 (Mo. App. W.D. 1992) (overruled by Hampton on other grounds); Brundige v. Boehringer Ingelheim, 812 S.W.2d 200, 202 (Mo. App. 1991). Claimant must prove "a direct causal connection between the conditions under which the work is performed and the occupational disease." Webber v. Chrysler Corp., 826 S.W.2d 51, 54 (Mo. App. 1992) (overruled by Hampton on other grounds); Sellers, 752 S.W.2d at 416; Estes v. Noranda Aluminum, Inc., 574 S.W.2d 34, 38 (Mo. App. 1978).

Medical causation, not within the 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." Brundige v. Boehringer Ingelheim, 812 S.W.2d 200, 202 (Mo.App.1991) (overruled by Hampton on other grounds). McGrath v. Satellite Sprinkler Systems, Inc. 877 S.W.2d 704, 708 (Mo.App. E.D. 1994) (overruled by Hampton on other grounds). The ultimate importance of the expert testimony is to be determined from the testimony as a whole and less than direct statements of reasonable medical certainty will be sufficient. Choate v. Lily Tulip, Inc., 809 S.W.2d 102, 105 (Mo.App.1991) (overruled by Hampton on other grounds). The commission may not substitute an administrative law judge's personal opinion on the question of medical causation...for the uncontradicted testimony of a qualified medical expert. Wright v. Sports Associated, Inc. 887 S.W.2d 596, 600 (Mo.1994) (overruled by Hampton on other grounds).

Where there are conflicting medical opinions, the fact finder may reject all or part of one party's expert testimony which it does not consider credible and accept as true the contrary testimony given by the other litigant's expert. George v. Shop 'N Save Warehouse Foods, Inc., 855 S.W.2d 460, 462 (Mo. App. E.D. 1993) (overruled by Hampton on other grounds); Webber, 826 S.W.2d at 54 (overruled by Hampton on other grounds); Hutchinson v. Tri-State Motor Transit Co., 721 S.W.2d 158, 163 (Mo. App. 1986) (overruled by Hampton on other grounds).

I find Dr. Farley and Dr. Schlafly's causation opinions more credible than Dr. Ollinger's. Dr. Ollinger concluded the CTS was due to Claimant's body mass index (BMI) of 31. A BMI of 30 is considered obese. I do not find Dr. Ollinger's obesity opinion persuasive. Claimant stood 5'3" tall and weighed 175 pounds when examined by Dr. Ollinger on February 25, 2004 and he conceded Claimant would not be obese if she were 25 pounds lighter. Claimant was 19 pounds lighter when Dr. Schlafly examined her June 7, 2005, and he did not find her to be obese. Dr. Schlafly found it difficult to define obesity or connect it to the development of CTS. Although some studies have connected obesity to CTS, I do not find Claimant's weight to be a substantial factor in the development of CTS.

Dr. Ollinger's reliance on four literary keystroke articles is not credible. He admitted the articles have not been validated by the scientific or medical community and he was unaware the ANSI standard Z365 article was withdrawn in 2003 (Ex 1-68, 89).

Dr. Ollinger also relied on Employer's incomplete job analysis. Mr. Zuccarello, vice president of Bio-Ergonomics, Inc., holds a Bachelor of Science degree in occupational therapy. He authored Employer's CSR job analysis. Mr. Zuccarello admitted on cross-examination that Claimant's hand/finger activity was an essential job function, but he did not include it in the job analysis. No keystroke analysis was performed for CSRs. The job analysis was based on observation of an unknown number of CSRs for several hours. Overtime work was not considered although Claimant worked considerable overtime in

winter months. Mr. Zuccarello admitted he was not surprised to learn, after cross examination, that Claimant averaged seven seconds of down time between calls some days (Ex 4-41). Claimant's DJD duties were not included in the job analysis. Dr. Ollinger did not ask Claimant to compare Employer's job description to her job duties.

The record contains no evidence that Claimant's CSR Daily Report production was considered in Dr. Ollinger's causation opinion. Dr. Ollinger reviewed no medical records after January 30, 2004 (Ex1-48). Dr. Ollinger's opinion that Claimant's CTS may be idiopathic is not credible. Claimant had no known risk factors for CTS.

Claimant testified credibly regarding her job duties. Her testimony was consistent with medical history and findings. Dr. Farley found the CTS 'directly related to Claimant's job', and 'the most substantial factor' for her complaints. Dr. Schlafly, a board certified hand surgeon, explained that data entry requires a back and forth movement of the flexor tendons through the wrist to the fingers. Friction can cause tendinitis of the flexor tendons and thickening of the synovium around the tendons and nerve. If the condition continues, nerve symptoms can develop in the form of CTS. Dr. Schlafly opined use of the mouse had a similar impact. Based upon his examination, review of Employer's job description with Claimant, and Dr. Farley's medical records, Dr. Schlafly concluded Claimant's repetitive work with her hands was the substantial factor in causing bilateral CTS and the need for surgery (Ex B-8-9, 16-17). He found his opinion to be consistent with Dr. Farley's opinion. I find Dr. Schlafly's opinion credible.

I find Claimant's typing was constant and fast paced. Claimant's CSR Daily Report corroborated her testimony (Exhibit 3). Production for eleven months showed numerous days when Claimant averaged 90 to 100 calls with little or no downtime between calls. Downtime was defined as the time when Claimant completed after call work, and was waiting for another call. For example, on February 14, 2003, Claimant's total downtime for the day was 33 minutes and thirty-seven seconds. This resulted in an average of 7.4 seconds between calls (Ex 1-41). The finding contradicted Dr. Ollinger's opinion that Claimant had sufficient rest cycles for tissue to heal (Ex 1-43).

Claimant may not type continuously all day, but evidence showed she types a good part of the day and her work is hand intensive. I find Claimant's exposure to CTS was greater than that of the general public. I find a recognizable link between CTS and Claimant's data entry work. I find that Claimant has met her burden to show the probability the CTS was caused by conditions in the work place.

The statute provides:

$\S 287.020 .3$ (2) provides that an injury arises out of and in the course of the 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."

I find Claimant's CTS arose out of and in the course of her employment with Employer. Dr. Schlafly and Dr. Farley opined repetitive typing caused Claimant to develop CTS. There is no dispute Claimant is expected to answer 90 to 100 calls per day and each call requires data entry. Both Dr. Ollinger and Dr. Schlafly acknowledge there is no minimum number of keystrokes required to develop CTS and each case is reviewed individually.

Even if obesity was a factor, the law does not prevent work from being a contributing factor also. Case law has held that "... such conditions need not be the sole cause of the occupational disease, so long as they are a major contributing factor to the disease. Hayes, 818 S.W.2d at 299; Sheehan v. Springfield Seed \& Floral, 733 S.W.2d 795, 797-8 (Mo. App. 1987). Dr. Schlafly did not find Claimant's weight to be a substantial factor in developing CTS. I do not find Claimant's weight to be a substantial factor in the development of CTS. There is no evidence of diabetes, thyroid or hormonal conditions that may have contributed to the development of CTS. I do not find the CTS was idiopathic, but I do find competent and substantial evidence the CTS arose out of and in the course of Claimant's data entry duties with Employer, and are medically causally related to her employment.

At hearing, Claimant requested \ 9,800.00 in medical expenses. Section 287.140.3, RSMo (2000) requires a showing that compensable medical charges be "fair and reasonable for similar treatment of other similarly injured persons..." Case law has held "...when ...testimony accompanies the bills, which the employee identifies as being related to and the product of her injury, and when the bills relate to the professional services rendered as shown by the medical records in evidence, a sufficient factual basis exists for the commission to award compensation." Martin v. Mid-America Farm Lines, Inc. 769 S.W.2d 105 (Mo.1989).

Claimant testified she received medical treatment from Dr. Farley for CTS, but she did not identify the medical bills. Attorneys for Claimant and Employer stipulated if Claimant had appeared at hearing again, she would testify the doctor and hospital bills were incurred exclusively for CTS.

SSM DePaul Hospital records show $\ 8,028.95 in medical services provided to Claimant for carpal tunnel surgeries. However, Dr. Farley's medical charges are not clear. Dr. Farley's total charges are not certain from the bills. Dr. Schlafly testified the medical bills for services provided by Dr. Farley and SSM were fair and reasonable, and the treatment was necessary to cure and relieve Claimant from the effects of CTS. I find Employer is liable for $\ 8,028.95 in past hospital expenses. I do not find Employer liable for any other medical expenses as there is insufficient evidence to determine the amount charged.

Under the Missouri Worker's Compensation Act, "total disability" is defined as the inability to return to any employment_Messex v. Sachs Elec. Co,, 989 S.W.2d 206, 210 (Mo.App. E.D. 1999) (overruled by Hampton on other grounds). The words "inability to return to any employment" means that "the employee is unable to perform the usual duties of the employment under consideration in the manner that such duties are customarily performed by the average person engaged in such employment." Kowalski v. M-G Metals and Sales, Inc,, 631 S.W.2d 919, 922 (Mo.App. S.D. 1982).

Claimant testified she missed work after each surgery from April 5, 2004 to June 20, 2004 and Employer agreed. Dr. Farley released Claimant to work light duty June 21, 2004 (Ex A-8). I find Claimant was unable to return to any employment between April 5, 2004 and June 20, 2004. I find Employer liable for TTD benefits totaling \6,494.29 (11 weeks x \ 590.39 per week).

A permanent partial award is intended to cover claimant's permanent limitations due to a work related injury and any restrictions his limitations may impose on employment opportunities. Phelps v. Jeff Wolk Construction Co., 803 S.W.2d 641,646 (Mo.App. 1991) (overruled by Hampton on other grounds). With respect to the degree of permanent partial disability, a determination of the specific amount of percentage of disability is within the special province of the finder of fact. Banner Iron Works v. Mords, 663 S.W.2d 770, 773 (Mo.App. 1983) (overruled by Hampton on other grounds).

Dr. Ollinger found CTS but did not find it causally related to Claimant's work. Dr. Schlafly rated Claimant 25\% disabled for each wrist due to work related CTS. Claimant has occasional cramping when typing, combing her daughter's hair or washing dishes. She "wiggles" her fingers to loosen them. Numbness, tingling, and swelling have completely resolved. I find Claimant sustained 17.5\% PPD of each wrist for work related CTS.

A multiplicity factor is "a special or additional allowance for cumulative disabilities resulting from a multiplicity of injuries." Eagle v. City of St. James, 669 S.W.2d 36, 42 (Mo.App.1984) (overruled by Hampton on other grounds). The commission has the discretion to include a multiplicity factor in assessing cumulative disabilities but is not required to do so. Chambliss v. Lutheran Medical Center, 822 S.W.2d 926, 932 (Mo.App.1991) (overruled by Hampton on other grounds). Dr. Schlafly opined Claimant's bilateral CTS had a synergistic effect (Ex B-17). I find substantial evidence to support a 12.5 % multiciplicity for bilateral CTS.

Claimant sustained an injury by occupational disease which arose out of and in the course of her work activity. Claimant sustained 17.5\% permanent partial disability of each wrist and 12.5\% for multiciplicity. Employer is responsible for TTD and past medical expenses pursuant to this award. Claimant's attorney is entitled to a lien of 22.5 % of all sums paid or collected pursuant to this award for legal services rendered.

Date: $\qquad Made by: \qquad$

Suzette Carlisle

Administrative Law Judge

Division of Workers' Compensation

A true copy: Attest:

Division of Workers' Compensation