Based on the testimony of Charles Jones ("employee") and the medical records and reports admitted, I find as follows:
At the time of the hearing, the employee was 40 years old and had worked for SEMO Electric Cooperative ("employer") out of Sikeston, Missouri, since the time he had been hired in October 2004. Other than working in the State of Mississippi for the employer after Hurricane Katrina, the employee had performed all of his prior work for the employer in Missouri except for a small amount of work on lines at the tip of Kentucky. Although he left school in the ninth grade, the employee eventually obtained his GED. His only other education involved a three day course in working on office equipment. Following his departure from school, the employee worked as a hod carrier until the age 15. After he did odd jobs for a couple of years, the employee entered the military at age 17. While in the Navy from October of 1986 to May of 1988, the employee was trained on firefighting. Once he left the military, he performed a number
of different jobs in construction and in factories. His next employment involved heavy manual labor while working with office equipment, which he performed for about five years. In 1997, the employee began his career in the electrical field for Midwest Power Lines. In the beginning, the employee simply ran a shovel. He was later able to work himself up to being a lineman and eventually a working foreman. During the time he worked for the employer and up to the time of his accident on September 12, 2005, the employee worked as a lineman on both underground and overhead electrical lines.
Prior to his work accident of September 12, 2005, the employee had received medical treatment for his right wrist, low back, and right knee (Employee Exhibit A, Deposition Exhibit 2). During the seventh grade, the employee fell and fractured his wrist which was placed in a cast for six weeks. Although he had previously noted occasional stiffness with cold and rainy weather, the employee testified at the hearing that he really was not having any problems with his wrist. In 1989, the employee fell off of the top of a machine. Although he had a mild bulge or herniation, the employee treated conservatively with just physical therapy. His main current complaint with his back is soreness and tenderness during cold weather. In April 2004, the employee injured his right knee. Dr. Patrick Knight performed a partial medial menisectomy, partial lateral menisectomy, limited synovectomy, and right knee arthroscopy on June 7, 2004 (Employee Exhibit L, Pages 2-4 \& 8-9). The employee continued to perform his job for the employer but did have aching in his knee during cold weather.
On September 12, 2005, the employee was working for the employer in Mississippi following Hurricane Katrina. The employee's primary job in Mississippi was to restore power to houses. While attempting to hook the power line back to the house, the employee picked up the cut wire and it went through his glove and into the side of his left index finger. After he cleaned his finger, the employee returned to working. At the end of the day, the employee reported the incident to his supervisor, Marty Vineyard. On the next day, the employee was unable to bend his finger, and it was very swollen. A coworker took the employee to a medical tent in a parking lot for treatment. A doctor performed surgery by placing a drain into his finger to relieve the swelling. The employee stayed in Mississippi for a few more days and then rode back to Missouri with the other workers. Upon his return to Missouri the employee was referred to a hand specialist, Dr. Thomas Tobin.
Dr. Tobin first saw the employee on September 20, 2005 and performed an exploration of the left hand wound and irrigation and drainage of the left index finger flexor tendon sheath on the very next day (Employee Exhibit D, Page $3 \& 30$ ). Following the surgery, the employee initially showed improvement and was referred to physical therapy at Saint Francis Center for Health and Rehabilitation beginning September 28, 2005 (Employee Exhibit E, Page 20). On October 20, 2005, Dr. Tobin noted that the employee's pain and swelling persists and that he saw visible vasal motor changes in terms of sweating to the index finger and part of the palm. Additionally, Dr. Tobin "saw some change in the color during the time that he was here in the office from a dark bluish red to a much, much lighter color and then went back down to the dark blue again" (Employee Exhibit D, Page 14). At his next visit, Dr. Tobin opined that "we definitely have a sympathetic mediate component here and it could be call RSD". As a result, Dr. Tobin noted on October 25, 2005 that he planned to continue the active motion and not do
the dystrophile and stellate ganglion blocks, but eventually referred him to Dr. Chaudhari for stellate ganglion blocks on November 8, 2005 (Employee Exhibit D, Page 17 \& 20).
Dr. Chaudhari evaluated the employee on November 15, 2008 and opined that the employee has complex regional pain syndrome (CRPS) Type I, also known as reflex sympathetic dystrophy (RSD), in his left hand and forearm. Further, Dr. Chaudhari noted that the puncture wound followed by local sepsis was perhaps the triggering event (Employee Exhibit H, Pages 24). Following a series of nerve blocks and medication, Dr. Chaudhari opined that the employee could resume work and should notify him if he has a recurrence of pain (Employee Exhibit H, Page 11). The employee also concluded his initial round of physical therapy on December 20, 2005 (Employee Exhibit E). On January 31, 2006, Dr. Chaudhari noted that the employee was now having thickening in the flexor tendon and fibrous sheath in the left index finger and having panic attacks (Employee Exhibit H, Pages 12-13). Over the next few months, the employee's RSD symptoms returned with stabbing pain in the C7 dermatomal distribution of the left arm reaching up to the neck (Employee Exhibit H, Pages 15-17). The employee was then referred to Dr. Susan Mackinnon for treatment.
Following her examination of the employee on May 6, 2006, Dr. Susan Mackinnon performed a release of the left carpal tunnel, a release of the left median nerve and proximal forearm with step-lengthening tenotomy of the pronator teres tendon, and a release of the left radial sensory nerve and forearm with tenotomy of the brachioradialis tendon on June 26, 2006 (Employee Exhibit K, Pages 2-5). On July 5, 2006, the employee returned to Dr. Chaudhari with continued RSD complaints including swelling and edema in the left arm with tingling paresthesia in the lateral $31 / 2$ fingers of the left hand (Employee Exhibit I, Pages 2-3). On July 14, 2006, Dr. Mackinnon noted that the employee had not improved after surgery and recommended that the employee receive either a median nerve stimulator or a cervical dorsal column stimulator (Employee Exhibit K, Page 8). At that same time, the employee began his second round of physical therapy at Saint Francis Center for Health and Rehabilitation (Employee Exhibit F). Following his surgery with Dr. Mackinnon, the employee was evaluated by Washington University Pain Management Center who recommended a cervical MRI among other things (Employee Exhibit P).
Eventually, the employee returned to treatment with Dr. Chaudhari with complaints in his left upper extremity running up to the left side of his neck (Employee Exhibit I, Pages 6-12). Dr. Chaudhari administered medication and nerve blocks which eventually led to the employee believing that he was on the right track to recovery and that he would be able to go back to work as of October 31, 2006 (Employee Exhibit I, Page 13-14). The employee continued to treat with Dr. Chaudhari over the next several months and was referred to Dr. Terry Cleaver since he performed radiofrequency stellate ganglion block neurolysis. The first one was performed on February 14, 2007 (Employee Exhibit G, Pages 1-2). The employee responded to the treatment and even returned to work for a short time. As a result, Dr. Chaudhari placed the employee at maximum medical improvement on May 3, 2007 (Employee Exhibit I, Pages 23-24).
On June 28, 2007, the employee returned to Dr. Chaudhari with returned pain complaints in his left upper extremity (Employee Exhibit J, Pages 1-2). The employee then received another
radiofrequency stellate ganglion block neurolysis from Dr. Cleaver on July 25, 2007 (Employee Exhibit G, Pages 3-4). A week later, the employee returned to Dr. Chaudhari with headaches and twitching of the eyelids following the radiofrequency blocks (Employee Exhibit G, Pages 3-4). The employee's pain management was then switched to Dr. Annamaria Guidos who is also in Dr. Cleaver's office. Following Dr. Guidos' recommendation of an MRI, the employee had a MRI of his left shoulder which indicated markedly severe supraspinatus tendinopathy with bursal sided fraying (Employee Exhibit L, Pages 10-11). As a result, Dr. Schafer referred the employee to physical therapy and gave him Naprosyn (Employee Exhibit L, Page 7). On December 12, 2007, Dr. Cleaver performed a percutaneous implantation of single octapolar spinal cord stimulator electrode array under fluoroscopic guidance (Employee Exhibit N, Pages 8-9). Since the employee received a benefit from the temporary placement, Dr. Cleaver and Dr. Vaught decided to make the stimulator permanent.
On January 8, 2008, Dr. Vaught performed placement of a cervical dorsal column stimulator resume TL4 electrode paddle with rechargeable battery in the employee (Employee Exhibit M, Pages 22-23). Although the employee responded well to the stimulator, it malfunctioned and increased his pain (Employee Exhibit N, Pages 15-16). Dr. Vaught removed the broken dorsal column stimulator lead extension and placed two new extensions through two separate incisions and performed an intraoperative programming of the dorsal column stimulator on January 18, 2008 (Employee Exhibit M, Pages 25-26). After a few weeks, the stimulator malfunctioned again and Dr. Vaught noted that the employee will likely need an additional surgery (Employee Exhibit N, Pages 20-22). On February 19, 2008, Dr. Vaught removed a fractured 60 centimeter extension and damaged 20 centimeter lead extension and replaced them with new 60 centimeter and 40 centimeter lead extensions (Employee Exhibit M, Pages 29-30). Following this surgery, the employee noted that the stimulator was doing exceptionally well and he was able to decrease the amount of oral pain medication that he was taking. Approximately one week later, the employee had a coughing spell, felt a twinge in his arms, and had a return of his RSD symptoms in both arms. On March 12, 2008, Dr. Vaught indicated that a new surgery was needed to repair the stimulator failure (Employee Exhibit N, Pages 25-27). Dr. Vaught performed a revision of malfunctioning and fractured dorsal column stimulator lead extension on March 20, 2008 (Employee Exhibit M, Pages 31-32).
Dr. Vaught placed the employee at maximum medical improvement from a neurological standpoint on April 28, 2008 and noted that the employee no longer had CRPS symptoms but still had pain and muscle spasms. After recommending follow up care with Dr. Cleaver for narcotic medication management, Dr. Vaught discharged the employee to work on a light duty basis with a maximum lifting of 15 pounds with no overhead work and no highly repetitive bending, stooping or twisting (Employee Exhibit N, Pages 30-32). The employee followed up with Dr. Cleaver on May 19, 2008 with continued complaints of muscle spasms although he had pain relief from the stimulator. At that time, Dr. Cleaver noted that "the patient also has had some difficulty maintaining employment with release with limitations which is causing him some anxiety and depression type symptoms" and diagnosed him with CRPS favorably responsive to spinal cord stimulation, residual paraspinous muscle spasm, and underlying anxiety depression likely. Dr. Cleaver placed the employee at maximum medical improvement in regard to further intervention for his CRPS, but opined that the employee will require ongoing medical
management utilizing medications, potential intermittent injections for muscle spasms, and limitations of his physical activity secondary to utilizing the therapy and its inability to be utilized 24 hours a day (Employee Exhibit O, Pages 1-2). Later that day, Dr. Guidos examined the employee for an independent medical examination. Dr. Guidos noted that the employee had restrictions and would need future medical treatment and opined that the employee had an impairment rating of 25 % at the level of the shoulder (Employee Exhibit O, Pages 3-5). At her deposition on June 12, 2009, Dr. Guidos testified that her specialty was physical medicine and rehabilitation but she was not board certified (Employer-Insurer Exhibit 1, Deposition Pages 8 \& 19). Further, she noted that her opinion was not changed despite the employee's follow-up treatment from Dr. Jarvis and Dr. Cleaver (Employer-Insurer Exhibit 1, Deposition Page 17).
On May 4, 2009, the employee returned to Dr. Cleaver with continuing complaints of worsening neck, shoulder, and bilateral upper extremity pain. The employee reported increased sweating and redness in his hands. Dr. Cleaver noted that the CRPS was no longer adequately responding to neuromodulation and current medical regimen. As a result, Dr. Cleaver reprogrammed the spinal cord stimulator, gave the employee the power to control the rate of the stimulator, and added Oxycodone to his medication (Employee Exhibit N, Pages 6-7).
The employee was also examined by Dr. Mark Lichtenfeld on two occasions for the purposes of an independent medical examination. As a direct result of the work injury of September 12, 2005, Dr. Lichtenfeld opined on August 17, 2007 that the employee suffered the following permanent partial disability: 45 % of the left thumb MP joint, 85 % of the left index finger MP joint, 45 % of the left long finger MP joint, 40 % of the left ring finger MP joint, 35 % of the left small finger MP joint, a 25 % loading factor for injuries to the left fingers due to the combination of the finger injuries being greater than the simple sum, 40 % of the left wrist, 30 % of the left elbow, and 40 % of the body as a whole due to RSD (CRPS). With regard to his preexisting disabilities, Dr. Lichtenfeld opined that the employee suffered the following permanent partial disability: 30 % of the right wrist; 35 % of the right knee, and 12.5 % of the body as a whole due to the low back. Further, Dr. Lichtenfeld opined that the disabilities combine to form an overall disability greater than the simple sum and that the disabilities create a significant obstacle and/or hindrance to obtaining employment and/or re-employment. Dr. Lichtenfeld also noted that the employee would benefit from additional medical treatment in the form of regular treatment with a pain management specialist, radiofrequency treatment, narcotic pain medication, and/or a peripheral nerve stimulator. Finally, Dr. Lichtenfeld placed the following restrictions on the employee: avoid any type of trauma to his left upper extremity; avoid power and repetitive gripping as well as using any type of gas, electric, or air powered tools with his left upper extremity; avoid using impact and torquing tools with his left upper extremity; avoid lifting more than 5 pounds on a one time basis, avoid all repetitive lifting with his left upper extremity; exert extra caution to avoid injuring his right upper extremity; avoid working around dangerous equipment if possible, and avoid exposure to extreme temperatures (Employee Exhibit A, Deposition Exhibit 2).
Following his next examination on September 19, 2008, Dr. Lichtenfeld reiterated his prior opinions and added a few additional ones. First, Dr. Lichtenfeld opined that the employee also suffered a permanent partial disability of 17.5 % of the body as a whole due to chronic
cervical and thoracic spine spasms. Next, Dr. Lichtenfeld noted that the employee would require battery replacements and ongoing treatment for his dorsal column stimulator for the remainder of his life. With regard to his restrictions, Dr. Lichtenfeld opined that the prior restrictions should apply to both upper extremities, that the employee should avoid working with his arms outstretched and overhead, and that the employee should avoid reaching overhead and should perform no lifting above the shoulder height. Finally, Dr. Lichtenfeld opined that the employee is totally and permanently disabled as he is unable to compete on the open labor market. Dr. Lichtenfeld based his opinion after considering the employee's educational background and vocational history, the employee's pre-existing medical conditions, the employee's injuries caused by his work injury of September 12, 2005, and the employee's need for taking narcotic pain medication for his chronic pain which affects his mental status and ability to function in nearly every type of work environment (Employee Exhibit A, Deposition Exhibit 3). At his deposition, Dr. Lichtenfeld opined that employee's work related accident of September 12, 2005 was the prevailing factor and substantial cause in the development of the employee's diagnoses (Employee Exhibit A, Deposition Page 20). Additionally, Dr. Lichtenfeld testified on crossexamination that the employee was able to return to full duty with no permanent restrictions after each of his pre-existing injuries to his right wrist, back, and right knee (Employee Exhibit A, Deposition Pages 41-45).
The employee was examined by both Dr. Wayne Stillings and Dr Michael Jarvis for the purpose of an independent psychiatric examination. On October 28, 2008, Dr. Wayne Stillings examined the employee and opined that the September 12, 2005 work injury was the prevailing factor in causing the employee's 15 % permanent partial psychiatric disability of the body as a whole due to the mood disorder; 10 % permanent partial psychiatric disability of the body as a whole due to the pain disorder; and 5\% permanent partial psychiatric disability of the body as a whole due to the anxiety disorder. With regard to pre-existing psychiatric disabilities, Dr. Stillings opined that the employee had a dysfunctional family of origin disorder, a parent-child relational problem disorder, and a personality disorder. Consequently, Dr. Stillings noted that the employee is permanently and totally disabled when considering all of his physical and psychiatric disabilities and that the employee is in need of further psychiatric care and maintenance due to his work injury (Employee Exhibit B, Deposition Exhibit 2). At his deposition on April 27, 2009, Dr. Stillings testified that the employee had no prior psychiatric treatment and was not taking any psychiatric medication prior to the work related injury of September 12, 2005 (Employee Exhibit B, Deposition Page 16).
On May 29, 2009, Dr. Michael Jarvis examined the employee and did not opine as to permanent disability that the employee had, but did mention that he felt the employee's condition would clear once his workers' compensation case is brought to a close. Further, Dr. Jarvis opined that the employee was not disabled from work from a psychiatric point of view (EmployerInsurer Exhibit 2, Deposition Exhibit 2). At his deposition, Dr. Jarvis admitted that he was not offering a vocational rehabilitation opinion as to the employee's ability to work, but just a medical opinion that the employee gets agitated when he has pain (Employee Exhibit 2, Deposition Page 43). After noting that the employee's stressors have continued, Dr. Jarvis testified that the DSM-IV indicates that the adjustment disorder may persist if the stressors or its consequences persist (Employee Exhibit 2, Deposition Page 50).
The employee was also examined by both Mr. Timothy Lalk and Ms. June Blaine for the purpose of a vocational rehabilitation examination. On November 7, 2008, Mr. Timothy Lalk, a vocational rehabilitation specialist, evaluated the employee and noted that he could not recommend any vocational rehabilitation services for the employee. Based on the restrictions recommended by Dr. Vaught and Dr. Guidos, Mr. Lalk opined that the employee would not be able to perform his former employment, but would be able to perform unskilled entry-level positions like unarmed security guard/information clerk, desk clerk at motel or rental store, cashier in a self-service or convenience store, and a variety of customer service representative positions. Based on the employee's symptoms and the opinions of Dr. Lichtenfeld and Dr. Stillings, Mr. Lalk opined that the employee would not be employable in the open labor market (Employee Exhibit C, Deposition Exhibit 2). At his deposition, Mr. Lalk testified that the employee was working full-time with no permanent work restrictions prior to the work related injury of September 12, 2005 (Employee Exhibit C, Deposition Exhibit 2).
On September 23, 2009, Ms. June Blaine, a vocational rehabilitation specialist, evaluated the employee and opined that the employee was employable in the open labor market given his background, education, and work experience while taking under consideration his functional capacities. Based on the opinions of Dr. Vaught, Dr. Guidos, and Dr. Jarvis, Ms. Blaine opined that the employee would be employable in sedentary to light level work demand including a cashier, security, motel/hotel clerk, expediter, rental clerk, order clerk, production clerk, and scheduler clerk. Based on the opinions of Dr. Lichtenfeld and Dr. Stillings, Ms. Blaine noted that the employee would be considered permanently and totally disabled, but chose not to follow those opinions (Employee Exhibit 3, Deposition Exhibit B). At her deposition, Ms. Blaine testified that she assumed that the dorsal column stimulator was quite functional and would control his pain at work (Employee Exhibit 3, Deposition Pages 21-22). On cross-examination, Ms. Blaine testified that the use of narcotic pain medication, anger, attendance problems, depression, gripping difficulty, balance problems, nausea, and sleepiness can negatively affect employability.
At the time of the hearing, the employee testified that he continues to treat with Dr. Cleaver, who is providing him with medications, as well as monitoring of his stimulator. His medications include those for depression, anxiety, pain, muscle relaxation and anti-inflammation. The employee testified that he takes all of these medications everyday, even when he is using his stimulator. The stimulator causes the employee to have muscle spasms between his shoulder blades and into his neck, so he frequently has to stop using the stimulator and increase his medication. On those days when he is not able to use his stimulator, the employee simply takes more medication. The stimulator also negatively affects his ability to drive, take showers, sleep, do laundry, do yard work, and do everyday activities. The employee has not worked since he was terminated by the employer on May 20, 2008, which was the day after he reached maximum medical improvement according to Dr. Cleaver and Dr. Guidos. Since that time, the employee has looked for work but has been unsuccessful. Further, he has been told by potential employers that he is a liability. With regard to disfigurement, the employee had a $31 / 2 inch Z scar at the left index finger and hand, a 3 inch scar in the palm, a 21 / 2 inch scar on the lower forearm, a 51 / 2$ inch scar on the upper forearm, and a darkened spot approximately the size of a quarter on his left
wrist from his injections. Throughout the hearing, the employee swayed back and forth and his hands changed colors from white to purple.