On September 28, 2007, employee injured her back at work while picking up a wooden pallet. Employee was diagnosed with a lumbosacral strain and abdominal wall strain.
Employee was off work for approximately one month following the work injury. Employee returned to work following her release from treatment, but continued to have severe pain in her back and had trouble performing her work duties. Employee was forced to miss multiple days of work due to her ongoing back pain. On the advice of her treating health care professional, Dr. Rakestraw, employee left her job with employer on June 26, 2008. Employee has not worked since that date.
Following her work separation, employee had an MRI of her lumbar spine. The MRI obtained on July 2, 2008, revealed mild degenerative bulging, a posterior annular margin tear at L4-5, and mild facet joint hypertrophy at L3-4, L4-5, and L5-S1.
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[^0]: ${ }^{1}$ Statutory references are to the Revised Statutes of Missouri 2007 unless otherwise indicated.
Employee received two epidural steroid injections to her lower back, but they did not help relieve her pain. Employee stated that she still experiences sharp pains in her lower back and "[m]ost of the time [her] legs go numb." Employee currently uses a prescribed cane to walk. Employee did not have any problems with her back prior to the September 28, 2007, injury. Employee is currently taking Skelaxin, Carisoprodol, and Tramadol for her back pain. She has gained approximately 145 pounds since the primary injury. She believes that she has gained this weight because she cannot walk or sit for extended periods of time.
At the time of the primary injury employee suffered from significant preexisting psychological disability. Employee's preexisting psychological disability stems from being raised in a dysfunctional family environment, subsequently experiencing significant marital problems with her first two husbands, and losing custody of her children. Employee testified that she began having suicidal thoughts in 2000 or 2001 after she lost custody of her children.
Employee also suffered from preexisting bilateral carpal tunnel syndrome. She had a surgical release for her right wrist, but not for her left wrist. Employee testified that her hands continue to give her difficulty, particularly in cold weather. She indicated that her hands "freeze up."
Employee testified that the primary injury to her back caused a lot of marital problems with her third husband. They are now divorced. Employee stated that her back injury prevented her from cooking, completing chores outside, and "ruined [her] marriage sexually." Employee stated that she is unable to do things for herself due to her lower back pain. Employee experiences crying spells on and off every day. She did not experience these crying spells prior to the primary injury. Employee has been hospitalized three or four times since the primary injury due to suicidal thoughts. Employee testified that her suicidal thoughts stem from her hatred of having to rely on other people to do things for her.
Employee testified that all of the medical treatment she received from St. John's Hospital and the various doctors to treat her lumbar spine was the product of the primary injury on September 28, 2007. Employee further stated that the medical bills identified in employee's Exhibit EEE were the result of those visits. The medical bills related to employee's lower back treatment from St. John's Hospital amount to $\ 7,501.00.
On April 1, 2009, employee saw Dr. Bennoch for the purpose of an independent medical evaluation. Dr. Bennoch opined in his report that as a result of the primary injury employee needed further treatment for her back, including a neurosurgical evaluation and aggressive pain management. Because Dr. Bennoch believed employee needed further treatment, he did not provide a disability rating for her low back at that time. Dr. Bennoch did, however, provide ratings for employee's other disabilities. Dr. Bennoch opined that employee had a total of 20 % impairment of the body as a whole attributable to severe depression, of which 15 % he apportioned to preexisting depression, and 5 % he apportioned to worsening depression secondary to the work-related back injury. Dr. Bennoch also assigned 20\% impairment to the right upper extremity rated at the right wrist and hand, and 10\% impairment to the left upper extremity rated at the left wrist and hand due to preexisting bilateral carpal tunnel syndrome.
In addition to Dr. Bennoch's opinion regarding the degree of impairment resulting from the preexisting bilateral carpal tunnel syndrome, Dr. Mutchler, a treating physician, provided a rating. Dr. Mutchler opined that employee suffered a permanent partial impairment of 13 % of the whole person as a result of her right upper extremity injury.
On November 19, 2009, employer sent employee to Dr. Olive. Dr. Olive initially concluded that employee's back pain was unrelated to the work injury. However, upon further consideration, Dr. Olive opined that the work injury was indeed related and causing the back pain.
Dr. Lennard saw employee on May 6, 2010, for the purpose of an independent medical evaluation. Dr. Lennard diagnosed major depression and lumbar strain. Dr. Lennard opined that employee had reached maximum medical improvement following the work injury and assigned a rating of 10 % permanent partial disability of the body as a whole attributable to her lumbar spine, of which he attributed 5 % to the work injury and 5 % to non-work-related degenerative changes. Dr. Lennard opined that employee needed further treatment for her depression.
Dr. Bennoch examined employee for a second time on August 18, 2010. Dr. Bennoch diagnosed a traumatic low back injury, which resulted in an L5-S1 nerve impingement. Dr. Bennoch opined in his report that if employee receives no further therapy, she is at maximum medical improvement. He opined that the primary injury of September 28, 2007, was the prevailing factor in causing 40 % impairment to the body as a whole referable to the lumbar spine. With respect to employee's psychological disability, Dr. Bennoch referred to his opinions listed in his April 2009 report (listed above).
Dr. Bennoch opined that the combination of employee's impairments creates a substantially greater impairment than the total of each separate injury/illness and a loading factor should be added. Dr. Bennoch went on to state that in his opinion, employee was temporarily totally disabled from the time of the injury up until the time of the August 18, 2010, exam. Finally, Dr. Bennoch opined that employee is permanently and totally disabled secondary to the primary injury alone.
Dr. Franks, a clinical psychologist, saw employee on two separate occasions and issued reports after each visit. Dr. Franks first saw employee on June 5, 2009. He diagnosed employee with major depressive disorder, which had significantly deteriorated since the September 28, 2007, work injury. After his initial evaluation, Dr. Franks assigned a 20\% impairment rating for employee's psychological disability, "with 10\% attributable to her injury and 10 % attributable to preexisting factors."
Dr. Franks saw employee again on November 29, 2010. At the second exam, Dr. Franks noted that employee was highly agitated, tearful, and emotional. Dr. Franks altered his initial ratings slightly and opined that employee had a total psychological impairment of 25 %, with 15 % caused by the work injury and 10 % preexisting. Dr. Franks testified that the prevailing factor in causing employee to initially develop depression and personality disorder preexisted the work injury, but that the work injury was the prevailing factor in causing those conditions to deteriorate. Dr. Franks testified that employee's three
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psychologically-related hospitalizations in 2008 were necessary to cure and relieve the effects of the work injury. However, Dr. Franks conceded that employee's preexisting psychological disability contributed to those hospitalizations as well.
The medical records and corresponding medical bills submitted by employee reflect that she incurred medical expenses of $14,923.05 as a result of her psychiatric hospitalization with Jefferson Memorial Hospital, and $11,229.05 as a result of her two psychiatric hospitalizations with Poplar Bluff Regional Medical Center.
Dr. Franks did not feel that employee was permanently totally disabled purely from a psychological perspective, but admitted that he would not expect an employer to hire and retain someone who has crying spells on a daily basis.
Another psychologist, Dr. Halfaker, reviewed employee's records, met with employee, and provided a comprehensive psychological assessment of employee's condition. Dr. Halfaker testified that the major area of disagreement between him and Dr. Franks relates to the influence of the September 28, 2007, work injury on employee's psychological condition. Dr. Halfaker disagrees with Dr. Franks' assessment that employee's major depressive disorder was worsened by the work injury. Dr. Halfaker believes it is not so much that the work injury worsens employee's depression, but that her psychological problems (major depression disorder and borderline personality disorder) interfere with her medical condition. Dr. Halfaker believes that her preexisting psychological condition worsens her ability to recover from and deal with her low back injury. Dr. Halfaker did not feel that employee's psychological condition was materially different from before the work accident. Dr. Halfaker agreed that employee does have some chronic pain, but her psychological factors predispose her to over-reporting or magnifying her symptoms.
Dr. Halfaker provided the following in his report:
> In this case, it is thought to be obvious that there is significant preexisting psychological disability associated with her history of depression, anxiety, and personality disorder. Most, if not all, of that psychological disability appears to carry forward into the post 9/28/2007 injury period and interferes with her ability to recover from that injury. As such, I would apportion very little to no permanent partial disability of the person as a whole as arising from the 9/28/2007 injury in isolation. It continues to be my opinion that whatever degree of psychological