Based on a comprehensive review of the evidence, including Claimant's testimony, the expert medical opinions and deposition, the vocational opinion and deposition, and the medical records, as well as my personal observations of Claimant at hearing, I find:
1) Claimant is a 43-year-old, currently unemployed individual, who last worked for The Boeing Company (Employer) as an engineer until she left that employment in 2005.
2) Claimant graduated from SIU-Carbondale with a BS in Electrical Engineering in 1989. She testified that she is currently trying to complete her Master's Degree in Systems Engineering through an on-line course offered by the University of MissouriRolla. She is taking one class at a time, but is finding it difficult to complete the work because of her memory and concentration problems.
3) Following graduation from SIU-Carbondale, Claimant first worked for The Boeing Company in Washington from 1989 to 1993 in retrofit engineering.
4) In 1992, Claimant was first diagnosed with Multiple Sclerosis (MS). She was noticing numbness in her fingers and toes, and a ringing in her ear. Claimant testified that initially the doctors just watched her condition, but did not provide any significant treatment. She said that her MS had no effect on her work in Washington and she was not using any assistive devices during this time.
5) Claimant left The Boeing Company in 1993 and took a job with American Airlines in Texas, where she worked as an avionics engineer. Claimant testified that the heat in Texas intensified her MS symptoms. She developed tunnel vision and a lack of bladder control. She experienced weakness, a lack of energy and a "bad attitude." Still, despite these problems, Claimant testified that she was not using any assistive devices, like a cane, to get around. Claimant ultimately left the job in Texas because of the problems she was having related to the heat.
6) After leaving American Airlines, Claimant worked as a contract engineer for Aerotech for about six months, and then she began full-time employment with The Boeing
Company in St. Louis in 1999. Claimant testified that her work for Employer was basically performed at a desk in front of a computer. She said the heaviest thing she had to lift was a ream of paper.
7) Medical treatment records from Dr. Sherry Ma (Exhibit H) document the treatment Claimant received from her for her MS starting on July 17, 2001. In that first report, Dr. Ma notes that Claimant was first diagnosed with MS in 1992, when her symptoms of tingling and numbness in all four limbs surfaced. An MRI of the brain in 1992 showed demyelinating process. According to the report, her first MS exacerbation occurred when she was in Texas due to the hot summer weather. Claimant lost her peripheral vision, had poor balance, gait disturbance, vertigo and dizziness, and required treatment with prednisone. The report notes that she had several such exacerbations up until 1997, when she started Avonex immunomodulation therapy. Because of that treatment, Claimant had no MS exacerbations from 1997 until the time of the July 17, 2001 report. At the time of this examination, Claimant continued to complain of some tingling and numbness, some muscle spasm, tightness of the muscles especially in the lower extremities, fatigability, urinary incontinence and loss of sexual function. Her memory was fine and she was not using any assistive device for walking. Dr. Ma diagnosed MS still in relapsing-remitting stage, which was probably in remission at the time of this examination. She diagnosed a neurogenic bladder, which is common for MS patients, but no profound cortical atrophy on MRI findings. Her EDSS score was about a 4, which was described as a rather mild stage. She was continued on her once-a-week Avonex injection and given Detrol for her bladder condition. At her follow-up appointment on September 10, 2001, Claimant's condition was about the same. However, by July 15, 2002, Claimant reported that she felt she had a "memory block" word retrieving difficulty, and her bladder control has been getting gradually worse. Claimant was trying different compensating strategies for her memory problem and was doing well in her job. Dr. Ma diagnosed MS with gradual deterioration of her memory. She suspected Claimant was suffering from volume loss or brain atrophy due to the MS. She recommended a new MRI and perhaps a change in her medication.
8) When Claimant was next examined by Dr. Ma (Exhibit H) on August 13, 2002, she reported that the new MRI showed some decreased overall volume of the parenchyma and slight enlargement of the ventricles, but no new MS lesions. Dr. Ma suggested that the parenchymal atrophy could be related to the memory problems. She decided to keep Claimant on the same immunomodulation therapy. By September 25, 2002, Claimant was reporting forgetfulness, poor concentration, difficulty finishing work tasks and difficulty with daily activities. Dr. Ma recommended neuropsychological testing.
9) Claimant saw Dr. Laura Nieder, Ph.D. (Exhibit I) on November 15, 2002 for a neuropsychological evaluation. Claimant reported tingling in her fingers and toes, ringing in her ears, difficulty with balance, use of a cane at times, and poor recent memory, although she denied that the memory problems interfered with her work, since she wrote everything down in a notebook. Overall, Dr. Nieder found that Claimant had a mild neurocognitive abnormality with primary deficits in higher level
cognitive skills. Claimant exhibited relative weakness in the organization of new information and marginal performance on measures of divergent reasoning. After the neuropsychological evaluation, Claimant continued to follow up with Dr. Ma (Exhibit H) on December 12, 2002, March 7, 2003 and July 24, 2003. At each visit her MS condition was described as fairly stable. By the time of that last visit, Claimant was even walking without a cane, even though she was unsteady. She was still having problems with her bladder function and a urologic consult was discussed.
10) Prior to her first injury at work in 2003, Claimant testified that she used a cane occasionally. She had a restriction to avoid climbing ladders, and she was unable to drive at night. She had noticed some memory problems, but she was able to work and she received good reviews from her supervisor. When she had trouble walking, she would use a three-footed cane. She said that she mostly used the cane going to and from her car each day.
11) On October 29, 2003, Claimant was on the elevator going between the second and third floors. When the elevator doors opened, the elevator was lower than the building floor, causing her to stumble forward and jerk herself when she tried to exit the elevator. She did not fall to the floor. She testified that she "jerked" her right knee and ankle. She said that Abbott Ambulance arrived and took her to the medical dispensary. She received some physical therapy for the right knee, which improved her symptoms.
12) Medical treatment reports from Abbott Ambulance, Inc. (Exhibit 2) confirm her history of injury on this date and her complaints of right knee and right ankle pain. The medical treatment records from the Boeing medical dispensary (Exhibit A) document her visit at that facility on October 29, 2003 after having tripped while coming off the elevator. X-rays of the right ankle and right knee were negative. She was diagnosed with a sprained right ankle and a strained right knee. She did not want any medication. When she followed up on November 4, 2003, she reported that her right ankle was fine, but her right knee was still painful. She was given some exercises to perform, but otherwise returned back to full-duty work. By November 11, 2003, Claimant was still complaining of right ankle and knee pain, and she was also walking with a limp. The doctor prescribed a course of physical therapy for her complaints. Claimant then began a course of physical therapy at HealthSouth (Exhibit A) for her right knee and right ankle on November 12, 2003. The last note from this round of physical therapy indicates that Claimant never attended her therapy appointment on November 20, 2003, because she was in the emergency room at the hospital after a fall that injured her left leg and ankle.
13) Claimant saw Dr. Sherry Ma (Exhibit H) on November 13, 2003 for her regular MS evaluation. She was doing well with Detrol LA for her bladder problems. She denied any new symptoms from the MS. She still complained of poor memory, poor organization and concentration issues, but her balance and problems with paresthesias were about the same. She was given a trial of Adderall to see if that helped her concentration issues. By March 18, 2004, Claimant reported that the Adderall did not help her concentration, and her biggest problem was her bladder control. She was
given a trial of a new medication for her bladder issues. Dr. Sherry Ma (Exhibit 3) issued a letter dated April 13, 2004 in which she explained Claimant's need for a wheeled walker with a seat because of progressive problems with her ability to ambulate. The letter notes that she can only walk a short distance and then she has to sit down.
14) Medical records from Abbott Ambulance, Inc. (Exhibit 2) confirm that on January 8, 2004, Claimant had an MS exacerbation resulting in her legs getting numb and not cooperating. Claimant sat down to rest, but did not want to go to the hospital.
15) The next note from the Boeing medical dispensary (Exhibit A) is dated March 30, 2004. Claimant reported that her right ankle got better, but her right knee keeps hurting and is getting worse. She reported pain with climbing stairs and inclines, as well as with knee extension. She also reported that sometimes the knee will give out and will not support her weight. The report contains a statement from her that her MS may be worsening. She was also using a cane at the time of this examination for support while walking. Another course of physical therapy was prescribed for the right knee, which started on April 2, 2004 and continued through April 14, 2004. She is described in the records as having a shuffling gait, in addition to comments that she fatigues easily. When she met again with the doctor on April 16, 2004, she reported that the knee feels more stable, but the pain in the knee has not improved. Her knee was still locking up with walking. Therefore, the doctor recommended an MRI of the right knee to further evaluate her condition.
16) The MRI of the right knee was taken at HealthSouth Diagnostic Center of North County (Exhibit B) on April 20, 2004. The impression was inferolateral Hoffa's fat pad synovitis, with normal meniscal contours, normal ligaments and tendons, and normal patella femoral articulation.
17) Following the MRI, she was continued in physical therapy, and again saw the doctor on June 4, 2004. Her right ankle was fine, but her right knee was painful, more swollen, and locking up and giving out, causing her to fall. She reported having a walker due to her MS, which was really helping her keep her balance. Because of these complaints, she was referred to an orthopedist for further evaluation.
18) Claimant was examined by Dr. Gary Schmidt (Exhibit C) on June 30, 2004. She reported a consistent history of her injury at work and of continued anterior knee pain. She denied locking or snapping, but reported two episodes of feeling unstable while walking. She walked with somewhat of a limp. Physical examination revealed tenderness in the infrapatellar region of the fat pad and mild knee effusion. Dr. Schmidt recommended a course of physical therapy and anti-inflammatory medication. Claimant continued her physical therapy at HealthSouth (Exhibit A) and saw Dr. Schmidt (Exhibit C) again on August 26, 2004. Claimant reported some improvement with the physical therapy, with less pain and tenderness. She was walking with a quad cane. She had full range of motion, but some vastus medialis atrophy. Dr. Schmidt diagnosed insertional patellar tendinitis. He prescribed a knee brace, continued physical therapy and continued full-duty work without restriction.
The final physical therapy note in the file is dated October 29, 2003, in which Claimant was still complaining of right knee pain.
19) Claimant returned to see Dr. Sherry Ma (Exhibit H) on January 31, 2005. The note indicates she was seen "urgently with worsening of her symptoms." She had missed several dosages of Avonex and was under a lot of stress at work. Claimant was complaining of increased forgetfulness and disorganization, difficulty with work, increased fatigue and loss of balance. She was walking with a cane for assistance. Her EDSS score was about 5. A repeat brain MRI was recommended.
20) Claimant then saw Dr. Mark Miller (Exhibit D) for her right knee pain on February 2, 2005. Claimant described a consistent history of injury and of continued pain with walking or kneeling. She described three separate instability episodes where she had actually fallen. After his physical examination, Dr. Miller diagnosed meniscus tear versus fat pad syndrome. With her history of a twisting injury and her continued pain and instability complaints, he suggested that she may have an injury to an anterior horn of the medial meniscus, which often does not show up on an MRI. Since she had failed conservative management of her symptoms, he recommended a diagnostic arthroscopy, or a Synvisc or cortisone injection for the right knee. The report indicates Claimant wished to proceed with the surgery.
21) Claimant testified that Dr. Miller recommended surgery, but she did not want it because Dr. Miller could not provide her a definite enough opinion that the surgery would help her knee condition. Claimant testified that she wanted a second opinion on the need for that surgery, but she never got one.
22) Following her 2003 right knee injury, Claimant testified that she was not as mobile, and she did not leave her desk as much. She said that she began using a cane all day, every day after the 2003 right knee accident. She did not do many activities outside of her house, and she used motorized carts in the grocery store. She was using a cane more often. However, she testified that she did not believe her MS had changed very much during this time, but she did have some memory loss and concentration problems.
23) On February 7, 2005, Claimant testified that she was once again riding an elevator between the second and third floors. This time, the elevator stopped higher than the building floor, causing her to stumble forward and jerk herself. She testified that she "jerked" her left knee. Again, she did not fall. She said that Abbott Ambulance arrived and took her to the medical dispensary. She saw Dr. Kramer, who drained her left knee and gave her a cortisone injection.
24) The first medical report following this accident was from Abbott EMS (Exhibits E and 2) dated February 7, 2005. It contains a consistent history of her tripping, but not falling, when the elevator had not stopped level with the floor. The report indicates that she twisted her left foot. It further noted that she was walking out the front door of the building to meet them as they arrived. She was not using her cane at the time of her fall. She was transported to Boeing medical for further evaluation.
25) Claimant was next examined at the Boeing medical dispensary (Exhibit F) on that same date, February 7, 2005, with complaints primarily of left ankle and knee discomfort, but also a feeling that her right foot was swelling. X-rays of the left foot, ankle and knee, and the right foot were all negative. She was diagnosed with a left knee strain, left ankle/foot strain and a right foot strain. When she followed up on February 11, 2005, Claimant reported that she felt she was doing better. Her left foot was a little swollen, "but it usually is to some degree." She also reported a little soreness in the left knee. The doctor found that her right and left ankles were painfree, and her knee was not painful to move or walk, only tender to touch. She was back to a normal gait with her cane. The doctor diagnosed an improving left knee strain and discharged her from care.
26) Claimant had the MRI of the brain (Exhibit H) with and without contrast on February 9, 2005. She next saw Dr. Ma on February 23, 2005. Dr. Ma read the MRI as showing no active lesion, but a progression of brain atrophy and ventricular dilatation. She assessed Claimant as having MS, relapsing and remitting type, with cognitive impairment.
27) Additional records from Abbott Ambulance, Inc. (Exhibit 2) document service calls on February 15, 2005 for bilateral knee pain caused by walking a distance to get to her car, and on March 8, 2005 for knee pain and tingling after walking around and gathering a bunch of signatures on paperwork at work.
28) Claimant came under the care of Dr. Robert Kramer (Exhibit 1) for her knees on March 10, 2005. His report contains a consistent history of the injury at work in 2003 as well as four other subsequent falls she attributed to the weakness in her legs from the MS. He diagnosed her with right knee pain based on her physical examination and his review of the records. He opined that her MS was the cause of the weakness and instability in her legs. He would not recommend surgery related to the October 2003 injury and thought she was at maximum medical improvement for that right knee injury.
29) Apparently, because of continued left knee problems, Claimant had an MRI of the left knee taken at Metro Imaging (Exhibit G) on March 31, 2005. The MRI revealed minimal joint effusion and subtle osseous deformity involving the medial femoral condyle which could represent an osteochondral injury or osteochondritis dissecans, but no meniscal or ligamentous tears identified.
30) She had a similar evaluation with Dr. Kramer (Exhibit 1) on April 21, 2005 regarding her left knee. He diagnosed a left knee strain. Dr. Kramer felt she would benefit from a left knee aspiration and cortisone injection. He performed the cortisone injection on April 26, 2005. He then apparently released her from care on May 17, 2005.
31) Employer paid medical benefits totaling $\ 2,738.22, but paid no temporary total disability (TTD) benefits in this case.
32) Claimant continued to work after the 2005 injury, but she rarely got up from her desk. She said that she had a really bad attitude. She said that her knees would give out on her at times, and they were painful and unstable. She testified that she did not end up working that long, because she was in pain mentally and physically. She also noted that her MS cognitive symptoms were making it difficult to do her job.
33) When Claimant was next examined by Dr. Sherry Ma (Exhibit H) on April 7, 2005, she was unchanged from the prior visit. She had applied for short-term disability and the company was asking for a letter regarding her work restrictions and medical limitations. Dr. Ma noted that Claimant had had a cognitive decline, ambulation issues and an inability to function at her baseline level. On April 28, 2005, Claimant reported that she was not doing well and she was taking sick leave from work. She was using a cane to walk. Her disability had not been approved. Dr. Ma diagnosed MS, cognitive impairment due to MS and spastic gait due to MS.
34) Claimant's last visit with Dr. Ma (Exhibit H) occurred on June 9, 2005. Claimant requested paperwork for long-term disability. She reported that she has less stamina and her depth perception was worse since her last visit. Her memory was also not as good and she had increased numbness and tingling in both hands. However, her bladder function was the same and she was still using a cane. In addition to cognitive impairment and spastic gait due to her MS, Dr. Ma also diagnosed decreased stamina and depression, for which she prescribed some medication for Claimant.
35) Claimant then began a course of treatment with Dr. Ksenija Kos (Exhibit K) on June 29, 2005 for her MS. The report contains a history of her complaints and treatment for the MS up to that point. Claimant reported "constant fatigue and cognitive decline." The report indicates, "This is the reason why she recently stopped working." Although there was a discussion of a car accident in 1999, there was no mention of the two work injuries from 2003 and 2005. Dr. Kos diagnosed MS that appears to be stable, but may be slowly progressive or secondary progressive. He recommended a course of care to try to deal with her continued symptoms.
36) Dr. Kristen Sands, Ph.D. (Exhibit J) met with Claimant for a follow-up neuropsychological evaluation at the request of Dr. Kos on October 11, 2005. Claimant reported that her memory loss had increased substantially and her boss was noticing problems with memory and repeating herself. Claimant had been off work since April 2005. She complained of decreased speech articulation, poor handwriting and diminished spelling skills. She was using a walker more often, whereas she had been using a cane from time to time. Claimant's husband reported that her short-term memory loss has become a significant problem, and she was also having communication difficulties. In comparing her recent test results with those from her prior evaluation on November 15, 2002, Dr. Sands found that Claimant "exhibits significant neurocognitive deterioration affecting speed of information processing, cognitive flexibility, mathematical efficiency, multimodal memory, word retrieval skills, spatial abilities, and higher abstract reasoning and problem solving." She characterized the deterioration in her overall mental status compared to the previous exam, as "fairly widespread." She classified Claimant, now, as having moderate
impairment and she also found that Claimant was no longer asymptomatic for psychological stress as a result of her condition. Dr. Sands recommended that Claimant maintain cognitive activity and productivity to the extent she is able. She recommended that Claimant pursue a position with part-time job functions already known to her, such as in mathematics. Dr. Sands wrote, "Based on her current cognitive profile, she should qualify for disability from her job as an electrical engineer."
37) Claimant was then examined by Dr. William Logan at the St. John's Mercy Medical Center Emergency Room (Exhibit K) on March 4, 2006. She went to the emergency room with complaints of progressive weakness in her legs. Claimant explained that in recent years she had a decline in her gait, resulting in falls on occasion, as well as moving from a cane to a walker for standard activity. She reported increased problems with memory and concentration over the past year. Further testing was ordered to try to determine the reason for her decline over the last few weeks. Dr. Reddy's notes from March 5, 2006 at the hospital, show that in addition to the increased lower extremity weakness and unsteady gait, Claimant was also reporting increased blood sugar levels, recurrent urinary tract infections, and that she has been prone to falls even though she is using a walker at home.
38) Claimant treated with Dr. Nabil Ahmad (Exhibit L) for her low back pain from August 31, 2007 through June 4, 2008, based on the records admitted into evidence in this case. Dr. Ahmad found, as of August 31, 2007, that her low back pain and bilateral sacroiliac joint pain has become so limiting that she has problems standing and walking. There was no description of any discreet injuries contained in his reports. Dr. Ahmad attributed her gradually worsened low back pain to her MS that was adversely affecting her gait. He recommended a course of facet joint injections to try to relieve her low back complaints. He performed bilateral L4-5 and L5-S1 facet joint injections under fluoroscopy on May 12, 2008. By June 4, 2008, Claimant reported some easing of her pain with the injections. Based on her ambulation because of the MS, he recommended a course of continued treatment to try to alleviate her complaints.
39) The final note from Dr. Kos (Exhibit K) is dated December 8, 2008. Since her prior visit on July 23, 2007, Claimant described a worsening of her gait and falling frequently. She continued to use a walker, complained of short-term memory problems, and also now had low back pain. Claimant was described as a high fall risk because she was very unsteady and walked with a walker. Dr. Kos noted that Claimant seemed to be doing worse with her MS symptoms compared to her last evaluation.
40) Claimant was sent by her attorney for an examination with Dr. Raymond Cohen (Exhibit M). According to Dr. Cohen's report dated September 26, 2006, Claimant provided a consistent history of the injuries at work in 2003 and 2005, but she also apparently reported that "she could walk fairly well between the two primary workrelated injuries, although her gait became wider based after the injury on or about 2-705." She also apparently stated, "that now she uses a cane if she only has to go a short
distance." Otherwise, she uses a motorized cart in a store or a Rololator. She reported low back pain that began in 2005, and noted that she walked differently since injuring her knees. She noted that she wears knee braces to help her walk. Claimant reported her prior diagnosis of MS, and restrictions on balance and working in heat that caused her problems. She admitted that the MS made her gait uncoordinated and she also had bladder issues. She also reported prior problems with memory and fatigue related to the MS.
41) Dr. Cohen reviewed the medical treatment records and performed a physical examination. He diagnosed fat pad syndrome (Hoffa's fat pad disease) of the right knee related to the October 29, 2003 injury, a left knee osteochondral injury related to the February 7, 2005 accident, and pre-existing severe multiple sclerosis with chronic fatigue, cognitive dysfunction, incoordination and neurogenic bladder. Dr. Cohen opined that she needed further treatment on her knees because of the symptoms she continued to have. He recommended that she be seen by an orthopedic surgeon for consideration of a diagnostic and therapeutic arthroscopy of each knee. However, assuming that she had no further treatment, Dr. Cohen opined that Claimant had 25\% permanent partial disability of the right knee due to the October 29, 2003 accident and 15 % permanent partial disability of the left knee due to the February 7, 2005 accident. He rated a 40 % permanent partial disability of the body as a whole referable to the pre-existing MS. He further opined that the disabilities combined to create an overall disability greater than their simple sum, and that the combination of the disabilities rendered Claimant permanently and totally disabled.
42) The deposition of Dr. Raymond Cohen was taken by Claimant on November 4, 2008 to make his opinions in this case admissible at trial (Exhibit M). Dr. Cohen is a board certified osteopathic neurologist. He examined Claimant on one occasion, September 26, 2006, at the request of Claimant's attorney, and he provided no medical treatment to Claimant. Dr. Cohen testified consistent with his opinions contained in his report and described above. In characterizing the severity of Claimant's MS condition prior to the knee injuries, Dr. Cohen responded that it was "fairly severe" and progressive from 1992 up until the time he saw her. He explained that the fact she had a neurogenic bladder that required medications, was a bad sign of MS. Dr. Cohen explained some of the more pertinent findings on his physical examination of Claimant. He pointed to the hyperactive reflexes in the arms and legs, the clonus in the legs (the foot keeps shaking when pushed up toward the knee) and the borderline Babinski's test as signs of central nervous system pathology related to the MS. On the right knee exam, she had mild effusion, tenderness to palpation, crepitus, a mild loss of range of motion and mild weakness. On the left knee exam, she had mild effusion, discomfort with palpation and a very mild loss of range of motion, but no weakness, crepitus, or instability.
43) On cross-examination, Dr. Cohen was asked about his understanding of Claimant's problems with her gait or walking before the knee injuries. Dr. Cohen testified that he remembered only one note prior to her knee injuries that discussed a problem with tandem walking, but other than that he did not find a lot of evidence of any progressive problems with her gait prior to the knee injuries. However, now, after the
knee injuries, she definitely had difficulties with walking. Dr. Cohen believed her only prior problems with walking had to do with strength or walking fast, but he did not believe she had problems with stability prior to the knee injuries.
44) Mr. James England, Jr. (Exhibit N) met Claimant for a vocational rehabilitation evaluation on May 29, 2007 at the request of her attorney. He interviewed Claimant and also reviewed her medical treatment records. Claimant admitted, in Mr. England's report, that her MS has become progressively worse over the years. She admitted that even before the knee injuries, she could not walk straight and had poor balance. Claimant told Mr. England she is most limited by her confusion and memory loss, followed by the severe pain in her knees and back, and then poor upper extremity coordination. She described continued problems with being on her feet for more than seven minutes at a time, and she must use a walker to go more than very short distances. She cannot bend, lift or carry more than a gallon of liquid, sit more than an hour, or drive more than a 3-4 mile radius. She described poor grip. She drops things, cannot write as long now, and cannot keyboard more than briefly before missing the keys. Mr. England agreed that the neuropsychological testing showed her condition was worsening instead of improving. Mr. England ultimately concluded that considering the combination of her physical limitations and those of a neurocognitive nature, he did believe a normal employer in the course of business would hire her, and, therefore, he did not believe she was competitively employable. He opined that she was totally disabled from a vocational standpoint.
45) The deposition of Mr. James England, Jr. (Exhibit N) was taken by Claimant on January 29, 2009 to make his opinions in this case admissible at trial. Mr. England is a certified vocational rehabilitation counselor. Mr. England testified consistent with the opinions contained in his report. He essentially concluded that Claimant was unemployable in the open labor market due to the combination of her physical and neurocognitive impairments and restrictions. When pressed on cross-examination, Mr. England agreed that Claimant's cognitive condition, attributable to her MS, has deteriorated since 2005. He agreed that Claimant's limitations from the MS, from a cognitive standpoint, would preclude even sedentary work for her, and those MS limitations would also preclude physical work that exceeded the sedentary demand level. Therefore, Mr. England agreed that if you looked just at the limitations from the MS, excluding the two knee injuries, she would still not be employable.
46) Claimant was seen by Dr. Robert Kramer (Exhibit 1) for an independent medical examination at Employer's request on March 31, 2009. Dr. Kramer is a board certified orthopedic surgeon. Since his initial examinations of her on March 10, 2005 and April 21, 2005, according to his report, Claimant told him that her MS has progressed resulting in frequent falls or sliding out of chairs due to the weakness in her legs. She noted crawling on her knees a lot to get around. She reported being on Social Security because of her MS. Claimant described muscle spasms that lock her knees out straight, and discomfort, achiness and soreness in the knees. She walked with a spastic, slow, steady, wide-based gait using a walker. His physical examination revealed full range of motion, with no effusion, no instability, and only some tenderness and thickening over the anterior tibial tubercle in each knee. Dr.
Kramer diagnosed bilateral anterior knee pain and bilateral lower extremity weakness, secondary to MS. He opined that Claimant had no residual injuries to her right and left knees from these accidents. He opined that the current condition of her knees was attributable to her subsequent falls, and that her gait abnormality and instability was secondary to her MS. Dr. Kramer did not believe she needed any further orthopedic treatment for either knee. He further opined that she had no permanent partial disability in either knee attributable to these accidents at work.
47) In terms of her current complaints and ability to function, Claimant testified that it is very difficult to exercise because of the pain in her knees. She said that sometimes her knees give out and sometimes they lock up on her. She estimated that she spends 98 % of her time in a wheelchair now, and, in fact, she appeared for trial and testified from her wheelchair. She noted that she needs assistance getting out of bed in the morning because of problems with falling. Claimant takes 14 medications in the morning every day. She said that more recently she developed a blood clot from being in the wheelchair so much.
48) On cross-examination from Employer, Claimant confirmed the progression of her use of assistive devices for walking. She started out using a cane, then went to a quad cane around the time of her fall in 2003, a rolling walker in 2004, and then a wheelchair after 2005, perhaps in 2007 sometime. Claimant admitted that before 2003 she did collapse because of a loss of strength. She admitted that she also suffered from a lack of motor coordination both before and after 2003. She explained that she would try to move her foot, but could not, or she would try to get up out of a chair, but could not. Claimant admitted that she is not under any active treatment for her knees. She further admitted that she was told prior to 2003 that she had arthritis in the knees. Prior to 2003, she also admitted that she had problems with depth perception and carrying things overhead. Prior to 2003, she was wobbly while trying to walk a straight line and she was prohibited from driving Boeing company vehicles. Finally, she admitted that her MS has gotten worse since October 2003 because she is now in a wheelchair.
49) On cross-examination from the Second Injury Fund, Claimant agreed that Dr. Miller's report indicates she did not have significant lower extremity problems related to her MS, but nonetheless, she had fallen twice, because of lack of strength and fatigue, even though she was using a cane. Although Dr. Ma's records indicate she was seen urgently on January 31, 2005 because of a worsening of her MS symptoms, Claimant testified that she did not remember any such urgent visit. She admitted that in 2007, her MS was preventing her from getting out of bed in the morning.
50) Claimant testified that she did not believe she could return to work, even if her knees were not injured in the falls, because of the extent of the MS symptoms she is experiencing. She admitted that she missed no work because of her MS prior to the 2003 accident. While she was having memory problems in 2002, she was not having any problems with work. However, she admitted her memory problems increased in 2005.