The claimant testified that she held many positions with this employer involving repetitive use of her upper-extremities full-time. Training records contained in the personnel file reveal: "clipping wires, end cap assembly, clip assembly, packing/labeling, trimming, bracket assembly and Injection Molding." See Exhibit 4. The claimant testified that some of her earlier jobs also required lifting up to sixty-pounds several times an hour. See claimant deposition, page, 24 .
On June 18, 2014, Dr. Verdine examined the claimant for visible and palpable triggering of her right ring finger as well as a right volar wrist mass 1 centimeter in side over the radial carpal interval. See Exhibit B. He diagnosed bilateral carpal tunnel syndrome and explored treatment options for ring finger trigger digit, carpal tunnel syndrome, and volar wrist ganglion. Dr. Verdine reported that the claimant,
"...presented with a 5 year history of bilateral hand pain, numbness. Reports it has worsened recently. She did suffer a fall last year, with difficulties with
Issued by DIVISION OF WORKERS' COMPENSATION
Linda M. Miller
Injury No.: 16-024233
shoulder and neck pain afterwards. She did undergo R rotator cuff surgery last April. She additionally reports knots and a month locking of the R ring finger. Positive for night waking. Has tried splinting with minimal relief. She has been previously evaluated with MRI of her neck as well as epidural steroid injections. She does have a left-sided disc issue, which did not significantly improve with injection. Has been taking Gabapentin for 6 months with relief. Past Medical History Diagnoses: Seizure disorder, Fatigue, Arthritis, Joint pain, SOB (Shortness of breath), Irregular heartbeat, Numbness and tingling, Environmental Allergies." See Exhibit B, Attachment B.
The claimant did not opt to pursue operative intervention for these conditions in 2014. Specifically, the claimant declined surgical procedures to remedy her carpal tunnel syndrome and trigger finger in her right ring finger. The claimant continued to work full time with accommodations for other health conditions in 2014 and 2015. The claimant described the work as "menial." See claimant deposition, pages 37, 38. When asked to elaborate, the claimant cited dusting, cutting little pieces of labels, collating and stapling 1500 copies of a five-page document. The claimant testified that during this time, longstanding bilateral upper extremity complaints began to flare up. She testified that she informed Mike Hall (safetyman) of increasing symptoms in her hands, including them cramping, falling asleep and hardening. See Exhibit 6, pages 38-43. The "Report of Injury" contained within the Division certified records notes, "Associate informed me on 1/21/16 that she is having carpal tunnel related symptoms, no specific time or date associated with injury." The Report of Injury also notes an occupation job title of "DL Tech 3" and states the claimant's employment status to be "DS Disabled." See Exhibit 1. The claimant testified that she learned on January 22, 2016, that this employer no longer had a job available for her and could not accommodate her restrictions. The claimant has not been employed since that date.
On January 27, 2016, the claimant went to Dr. Enkvetchakul who took a medical history that she had numbness and tingling in both of her hands for several years, and that the symptoms had been waking her up and disrupting her sleep for over a year. Dr. Enkvetchakul diagnosed "1. Right carpal tunnel syndrome. 2. Left hand numbness and tingling likely carpal tunnel syndrome as well. 3. Left thumb CMC arthritis 4. Right hand Dupuytren's contracture, very early." Dr. Enkvetchakul did not believe the CMC arthritis or Dupuytren's to be work related. Dr. Enkvetchakul understood that the claimant was no longer working on that date. Dr. Enkvetchakul commented that he would not place any further restrictions on the claimant with regard to her bilateral hand activities. On February 17, 2016, Dr. Enkvetchakul opined, "Based on the information available, it is my opinion that Ms. Miller's carpal tunnel syndrome (median neuropathy at the wrist) is related to her 27 years of work at Henniges Automotive." See Exhibit 7. On February 11, 2016, bilateral consultative electrical diagnostic studies revealed:
"In the left hand the ring finger is the most severely involved. She reports left thumb pain." Upon physical examination, palpable radial pulses were noted and Dr. Daniel Phillips felt she had bilateral positive Tinel's and Phalen's signs at the carpal tunnels and noted tenderness over the left CMC joint. He noted weakness in her right thenar group. EMG demonstrates chronic right thenar group denervation. Impressions included, "...rather severe chronic sensory motor median neuropathy across the left carpal tunnel. There is mild, predominantly
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demyelinate ulnar neuropathy across the left elbow... There is severe chronic sensorimotor median neuropathy across the right carpal tunnel. There is mild demyelinate ulnar neuropathy across the elbow... The study is not impressive for active cervical radiculopathy or brachial plexopathy. The right spinal accessory responses (sic) normal." See Exhibit 7.
On February 19, 2016, a cervical spine MRI revealed, "1. Degenerative discs are seen at all levels with diffuse disc bulge/protrusion at C6-C7, asymmetric to the left and 2. The cord is of normal size and signal. Marrow signal normal." See Exhibit 7.
On March 21, 2016, Dr. Verdine noted:
She presents with multiple complaints. The first is of right greater than left radial sided hand numbness and tingling. She reports this has been present for many years, and in fact has been previously evaluated by my office for this, though not as a workers compensation claim. She reports nighttime waking, not improved with splinting... She saw occupational medicine on January 27, 2016. In that examination, she was diagnosed with right carpal tunnel syndrome, left hand paresthesia, left thumb CMCC arthritis, and early Dupuytren's contracture of the right hand. She was started on conservative treatments with bilateral wrist splints to be worn at night. She was also referred for repeat nerve conduction studies. It was felt that her thumb and her Dupuytren's were not work related. In addition, she has a secondary workers' compensation claim related to her right upper extremity with an injury that occurred in September of last year, according to the patient. I have no documentation details regarding this, but she reports this involves neck pain and paresthesia which shoots down her arm, as well, distinct and different than her carpal tunnel type symptoms.... Assessment; 1. Carpal tunnel syndrome, right. 2. Carpal tunnel syndrome, left. 3. Intermittent paresthesia of right hand and foot. 4. Dupuytren's contracture of right hand... She does appear to have bilateral carpal tunnel syndrome. These do appear to be work related in nature... I have recommended sequential bilateral carpal tunnel release... Also importantly, she understands that her more proximal symptoms will not be alleviated by carpal tunnel, and that this is a completely separate issue for which I would recommend further neck and shoulder evaluation, neither of which I provide, and unrelated to this claim. See Exhibit 7.
On April 21, 2016, Dr. Verdine performed a right carpal tunnel release and a left carpal tunnel release on June 7, 2016. See Exhibit 7. On August 31, 2016, Dr. Verdine noted that he believed claimant to be at maximum medical improvement and released her from care with no restrictions. See Exhibit 7. On November 28, 2016, Dr. Verdine opined that the claimant suffered a "1% person for right, 1% person for left = 2%" in response to a question requesting a permanent partial impairment rating. See Dr. Verdine deposition, Attachment. He testified that the claimant suffered a permanent partial impairment of "two percent at the level of the right hand, one percent the level of the left hand." See Dr. Verdine deposition, page 18.
The claimant testified that she began receiving SSDI benefits sometime during her
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treatment with Dr. Verdine, in July 2016. The defense terminated temporary total disability benefits on August 4, 2016. See Exhibit F.
The claimant testified that she is now able to lift 20 pounds and that her right arm range of motion was affected by the August 17, 2015, accident. The claimant returned to work for this employer full-time after the August 17, 2015, accident, working in the office, sorting papers, dusting, sweeping, updating information boards, pealing letters and putting them on boards, helping HR with insurance packets, sorting and stapling. The claimant last worked for this employer on January 22, 2016. Her employer had nothing for her to do and her employer let her go. She has not worked anywhere since then. She testified that it would be very hard to work anywhere and she has not sought employment since then. She began receiving SSDI benefits in July 2016.
She testified that she has many issues with her hands. She had bilateral carpal tunnel surgery releases. Her left thumb still bothers her, and her right little finger cramps. She testified that she did not receive temporary total disability benefits from January 23, 2016, through March 21, 2016. She testified that she can hunt and peck to type but has never used Microsoft Word or PowerPoint. She has a computer and can email. She has a smartphone and sometimes emails from the smart phone. She looks at Facebook. She is currently taking Gabapentin for nerve pain, phenytoin for seizures, Advair, Aleve and uses cream for pain. The Gabapentin and Dilantin makes her very tired. They have reduced the amount she takes a little bit. She lies down once a day for 1-2 hours and her bedtime is at 8:30 pm. She testified that her typical day is boring. She gets up between 4:00 am and 6:00 am, has coffee, and eats something simple for breakfast. She does simple laundry. She used to cook a lot before 2013 but she barely cooks anymore. She cannot lift any hams or roasts.
Pre-existing Conditions
In 2011, the claimant sustained a compensable occupational disease injury to her right shoulder and underwent a right shoulder arthroscopy with subacromial decompression and interscalene approach to brachial plexus for postoperative pain control on July 29, 2011. The claimant estimated that she was out of work because of this injury/surgery for two to four weeks. She continued to have issues with her shoulder, and Dr. Howard recommended that she be removed from her Nissan Job and placed in a less physically demanding job for a month after her October 25, 2011, appointment. See Exhibit 7. On November 22, 2011, Dr. Howard opined that the claimant had attained maximum medical improvement and released her from care to full duty without restriction. See Exhibit 7. Following the release, the claimant transferred positions within this employer to the "Honda Department." The claimant indicated that the "Honda Department" was not as physically demanding as her previous position as she was able to control the pace of the machine she worked with in that department, indicating the previous machine she worked with ran a faster, automated pace. The claimant settled her workers' compensation claim with her employer based on a 20% permanent partial disability of her right shoulder. See Exhibit 1.
On February 21, 2013, the claimant fell down a staircase at her home, landing on her right shoulder. On April 3, 2013, Dr. Smith performed a right shoulder arthroscopy with rotator cuff repair, subscapularis. See Exhibit 7. During her recovery from her second right shoulder
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surgery, the claimant complained of ongoing neck pain with headaches and bilateral upper extremity numbness. Dr. Hall opined that her left hand symptoms were consistent with carpal tunnel syndrome. On October 8, 2013, a cervical/thoracic spine MRI revealed C6-7 and T5-6 disc herniations. See Exhibit 7. On October 10, 2013, Dr. Jefferies performed a C7-T1 epidural steroid injection. On November 12, 2013, Dr. Jeffries opined that the claimant was not a surgical candidate for her cervical complaints and referred her for a neurological evaluation. After the 2013 shoulder surgery, Dr. Smith gave the claimant permanent work restrictions: "twenty-pound lifting restriction floor to waist and at counter level. No heavy lifting above countertop level." See Exhibit 7. Dr. Hall examined the claimant on the same date and noted, "She has had a lot of difficulty since her surgery. She has recovered a lot of her motion and function but continues to have pain. I definitely think she has multiple problems. She has a slight cervical disk herniation, I do not know if it is enough to cause pain into her shoulders. I think it may be contributing to her headaches." See Exhibit 7. On December 3, 2013, the claimant's treating neurologist prescribed Gabapentin for pain, noting that the claimant had headaches and mechanical limitations in her right arm following her February fall. See Exhibit 7. The claimant testified that she has remained on Gabapentin.
The claimant testified that she applied for Social Security Disability benefits after her 2013 injury and subsequent treatment, but she withdrew her SSDI application when her employer told her that they had a position available within Dr. Smith's restrictions. The claimant testified that she would rather work than be on disability, if she was able. On November 21, 2013, the claimant returned to work in a "repack" position taking rubber parts from boxes shipped to her employer and placing them into plastic bins for easier use in the productions lines. See Exhibit 4. She testified that she worked forty-hours a week in that position, with occasional overtime. The claimant testified that, though, her right shoulder was tender, she was able to perform the "repack" job until her August 17, 2015, injury. The claimant testified that she required assistance from co-workers regularly/hourly lifting lids/skids while performing the repack job. See Exhibit 6.
In February 2013, the claimant visited the University of Missouri Health Neurology Clinic for evaluation of headache, neck pain radiating to both shoulders, arms and forearms ongoing since February 2013. On February 7, 2014, the claimant underwent an EEG revealed abnormal findings "....suggestive of focal structural brain involvement on the left side and/or partial seizure disorder." See Exhibit 7. The claimant did not undergo further medical treatment for any neck/headache/radicular complaints until the alleged August 17, 2015, occurrence.
Raymond Cohen, D.O.
On September 12, 2016, Dr. Cohen, a neurologist, examined the claimant, took a medical history, and reviewed the claimant's medical records. With regard to the 2015 injury, Dr. Cohen diagnosed "cervical and upper thoracic myofascial pain disorder" and opined that the claimant suffered a "20% permanent partial disability of the whole person at the cervical spine, and a 5% permanent partial disability of the whole person at the thoracic spine." Dr. Cohen recommended that the claimant be restricted from any "repetitive twisting and turning of her head and neck, and no holding her head and neck in any type of awkward or sustained position." Dr. Cohen testified:
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Q....What - what does a cervical and upper thoracic myofascial pain disorder diagnosis mean?
A. That means that the part of the body that is being assessed - in her case, her her neck and upper thoracic spine, has symptoms consistent with that disorder, which means pain and aching, loss of motion, and an examination revealing tender areas that the condition is merely limited to the muscles of the particular area and also at times, the tendons and ligaments, but primarily that's a musculoskeletal condition.
Q...So, your estimation - the $8 / 17 / 15$ injury, are you of the opinion that that was a specific accident type injury? She jerked on the hand truck and - and had symptoms?
A. That was - acute injury in my opinion and happened at work, but yes.
Q. And are you of the opinion that the $8 / 17 / 15$ injury where she was jerking on a hand truck was the primary factor in relation to any other factors causing the cervical and upper thoracic pain disorder?
A. That's correct. See Dr. Cohen deposition, pages 41-44.
With regard to the 2016 occurrence, Dr. Cohen diagnosed bilateral carpal tunnel syndrome (status post bilateral surgical release) as well as right hand trigger fingers involving the ring and small finger. Dr. Cohen recommended restricting the claimant from repetitive gripping, grasping, keeping the hands in any type of awkward positions, and avoiding exposure to vibration as well as a restriction of no lifting greater than 10 pounds with either hand except on an occasional basis as a result of this injury. See Exhibit 2.
With regard to pre-existing conditions, Dr. Cohen diagnosed prior shoulder surgeries and a seizure disorder. Dr. Cohen opined that the claimant suffered a 40 % pre-existing permanent partial disability of the right shoulder and a 20 % pre-existing permanent partial disability attributable to her seizure disorder. Dr. Cohen opined that the pre-existing conditions were a hindrance to her employment or re-employment. See Exhibit 2.
Dr. Cohen opined that the claimant's pre-existing permanent partial disabilities combined synergistically with her permanent partial disabilities from the 2015 and 2016 occurrences. He opined that the claimant "would have difficulty working in any occupation in which she had to do a significant amount of lifting with the right arm of 20 pounds over the shoulder, any repetitive right shoulder work with lifting of 20 pounds over the shoulder, any repetitive right shoulder work with lifting of 20 pounds from the floor to the chest level."
He also opined that the claimant "would have difficulty in any occupation in which she worked around heights, dangerous equipment over-the-road driving, working on ladders or heights, or any similar work with regard to the seizure disorder. Dr. Cohen opined, "Due to this combination of disabilities, it is my opinion Ms. Miller is permanently and totally disabled and not capable of gainful employment in today's open labor market." He opined that the claimant "would benefit from additional treatment for the trigger fingers in her right hand. I would recommend she see a hand surgeon for a steroid injection. If this or a repeat injection does not stop the triggering, then a release of the trigger fingers in her right hand would be indicated. I
Issued by DIVISION OF WORKERS' COMPENSATION
Linda M. Miller
Injury No.: 16-024233
would recommend she have treatment for her chronic right shoulder and neck pain. She has obtained some relief with the TENS unit. She should be on muscle relaxant as well as anti-inflammatory agent. She will need to be followed by a physician to prescribe those medications. Additionally, I would recommend she continue to be on an anti-seizure medication such as Gabapentin or Lyrica for the chronic right-sided neck and right upper extremity pain." See Exhibit 2.
David Brown, M.D.
On July 3, 2017, Dr. Brown examined the claimant, took a medical history, and reviewed the claimant's medical records. He opined that the claimant's trigger finger condition in her left middle and ring fingers were not "causally related to her work activities" for this employer. See Exhibit C.
Michael Nogalski, M.D.
On December 8, 2015, Dr. Nogalski examined the claimant. At the time of his examination, the claimant complained of tenderness around the trapeziial area and pain from the neck down to the shoulder. She felt as though her arm was dropping. See Dr. Nogalski deposition, pages 7, 9, 10.
Dr. Nogalski diagnosed right-sided upper extremity and shoulder girdle neuropathic pain without any specific mechanical findings to support shoulder issues with respect to the rotator cuff, stability issue or labral issues. See Dr. Nogalski deposition, pages 25. He recommended more extensive EMG/NCS and MRI studies to evaluate the thoracic spine. See Dr. Nogalski deposition, page 26. He did not recommend any further evaluation or medical treatment specifically related to the claimant's right shoulder. See Dr. Nogalski deposition, page 27. Dr. Nogalski opined that the August 2015 work injury was not the prevailing factor regarding the claimant's current right shoulder condition. See Dr. Nogalski deposition, page 27. Dr. Nogalski testified the claimant required the same shoulder restrictions as set forth by Dr. Smith previously. He found she was at baseline level based on her exam. See Dr. Nogalski deposition, page 30.
Dr. Nogalski opined that the claimant had no objective findings of neuropathic pain related to the August 17, 2015, work injury and her cervical symptoms appeared to be were degenerative and spondylotic in nature. He did not observe any objective correlations with the studies. He did not recommend any additional medical treatment for the 2015 work injury. See Dr. Nogalski deposition, page 36. He found no permanent partial disability resulting from the 2015 work injury. See Dr. Nogalski deposition, page 37.
Kristine Skahan
On November 11, 2016, Ms. Skahan, a vocational expert, interviewed the claimant and reviewed documents pertaining to the claimant's medical history and condition. Ms. Skahan testified that, prior to the 2015 and 2016 injuries, the claimant was working at "light" duty (twenty-pounds) as defined by the Dictionary of Occupational Titles based upon the restrictions assigned by the claimant's 2013 right shoulder surgeon Dr. Smith: 20 pound floor to waist and counter level with no heavy lifting above countertop level" and that such pre-existing shoulder conditions would have been a hindrance or obstacle to employment. Ms. Skahan administered
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the WRAT-IV test as well as a Pain Assessment Scale. Ms. Skahan testified that the restrictions as prescribed by Dr. Cohen would place the at a less than sedentary position. Ms. Skahan concluded that the claimant did not have any transferable skills, citing her work history, lack of technological skills and physical restrictions. Ms. Skahan concluded that the claimant was permanently and totally disabled/unemployable in the open labor market due to the 2015 and 2016 injuries in combination with the claimant's pre-existing physical conditions. Ms. Skahan opined that the claimant would not qualify for funds for a retraining plan to sedentary work due to her age and total restrictions.
She testified that the claimant had a total loss to the competitive and open labor market due to a combination of the preexisting injuries to her right shoulder, combined with her work-related injury on August 17, 2015, and her "work-related occupational repetitive trauma disorder up through 1/1/16 while working as a re-packer for Henniges Automotive Sealing Systems." See Skahan deposition, page 38. She opined that the claimant's difficulties and symptoms related to her pre-existing right shoulder injury were a hindrance to her performing her regular job. See Skahan 1/8/17 report, page 15. She testified that she based her conclusion solely on Dr. Cohen's restrictions. See Skahan deposition, page 46.
Benjamin Hughes
Benjamin Hughes, a vocational expert, reviewed a number of records and concluded that the claimant could expect to work at the light level when observing the Dictionary of Occupational Titles. He testified that he found no specific set of restrictions to remove the claimant from employability. Considering all physician's restrictions, he testified that the claimant could expect to be successful in a number of sedentary/light jobs or be able to return to any previously held position from her past, depending on the specific physician recommendation. He testified that the claimant is capable of full-time work. See Hughes deposition, pages 19, 20 and report. He testified, "I think, when you look at the numerous restrictions and comments given by Dr. Cohen, in this case, that she would still be able to perform some sedentary jobs, again from the perspective of the DOT. This would include things as information clerk, working as a customer service rep, security guard, surveillance system monitor, storage facility rental clerk, parking lot attendant, cashiering or ticket sales, ticket taking." See Hughes deposition, page 20.
MEDICAL CAUSATION
"The claimant in a workers' compensation case has the burden to prove all essential elements of her claim, including a causal connection between the injury and the job." Royal v. Advantica Restaurant Group, Inc., 194 S.W.3d 371, 376 (Mo.App.W.D. 2006) (citations and quotations omitted). "Determinations with regard to causation and work relatedness are questions of fact to be ruled upon by the Commission." Id. (citing Bloss v. Plastic Enterprises, 32 S.W.3d 666, 671 (Mo.App.W.D.2000)). Under the statute, "[a]n injury by accident is compensable only if the accident was the prevailing factor in causing both the resulting medical condition and disability. "The prevailing factor" is defined to be the primary factor, in relation to any other factor, causing both the resulting medical condition and disability. § 287.020.2. On the other hand, "[a]n injury is not compensable because work was a triggering or precipitating factor." Id. Awards for injuries "triggered" or "precipitated" by work are nonetheless proper if
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the employee shows the work is the prevailing factor in the cause of the injury. Thus, in determining whether a given injury is compensable, a work-related accident can be both a triggering event and the prevailing factor."
The claimant testified that she held many positions with this employer involving repetitive use of her upper-extremities full-time. Training records contained in the personnel file reveal "clipping wires, end cap assembly, clip assembly, packing/labeling, trimming, bracket assembly and Injection Molding." See Exhibit 4. The claimant testified that some of her earlier jobs also required lifting up to sixty pounds several times an hour. See claimant deposition, page 24. She testified that this included cutting with machines, clippers, and scissors and assembly at this employer's factory and that her hands "were sleeping and weren't waking up." See claimant deposition, page 36. Dr. Verdine, the treating hand surgeon, opined, "She does appear to have bilateral carpal tunnel syndrome. These do appear to be work related in nature... I have recommended sequential bilateral carpal tunnel release..." See Exhibit 7. Dr. Cohen opined that the claimant's bilateral carpal tunnel syndrome was "an occupational disease (repetitive trauma disorder) from the patient's work." He also opined that the claimant's work was the prevailing factor causing this condition. See Exhibit 2. Dr. Enkvetchakul opined, "Based on the information available, it is my opinion that Ms. Miller's carpal tunnel syndrome (median neuropathy at the wrist) is related to her 27 years of work at Henniges Automotive." See Exhibit 7.
Based on the evidence, the claimant sustained her burden to prove that her work for this employer caused her bilateral carpal tunnel syndrome and this issue must be ruled in favor of the claimant.
TEMPORARY DISABILITY
Compensation must be paid to the injured employee during the continuance of temporary disability but not more than 400 weeks. Section 287.170, RSMo 1994. Temporary total disability benefits are intended to cover healing periods and are unwarranted beyond the point at which the employee is capable of returning to work. Brookman v. Henry Transp., 924 S.W.2d 286, 291 (Mo.App. E.D. 1996). Temporary awards are not intended to compensate the Employee after the condition has reached the point where further progress is not expected. Id. Section 287.020.7, RSMo 2000, defines the term "total disability" as used in workers' compensation matters as meaning the "inability to return to any employment and not merely mean[ing the] inability to return to the employment in which the employee was engaged at the time of the accident." The test for entitlement to TTD "is not whether an employee is able to do some work, but whether the employee is able to compete in the open labor market under his physical condition." Thorsen v. Sachs Electric Co., 52 S.W.3d 611, 621 (Mo.App. W.D. 2001). Thus, TTD benefits are intended to cover the employee's healing period from a work-related accident until he or she can find employment or his condition has reached a level of maximum medical improvement. Id. Once further medical progress is no longer expected, a temporary award is no longer warranted. Id. The claimant bears the burden of proving his entitlement to TTD benefits by a reasonable probability. Id.
Temporary total disability awards are designed to cover the employee's healing period, and they are owed until the claimant can find employment or the condition has reached the point
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of maximum medical progress. When further medical progress is not expected, a temporary award is not warranted. Any further benefits should be based on the employee's stabilized condition upon a finding of permanent partial or total disability. *Shaw v. Scott*, 49 S.W.3d 720, 728 (Mo.App. W.D. 2001). The Missouri Supreme Court ruled that if "additional treatment was part of the claimant's rehabilitative process, then he or she is entitled to TTD benefits pursuant to Section 287.149.1 until the rehabilitative process is complete. Once the rehabilitation process ends, the commission then must make a determination regarding the permanency of a claimant's injuries."
The plain language of section 287.149.1 does not mandate the commission arbitrarily rely on the maximum medical improvement date to deny TTD benefits, if the claimant is engaged in the rehabilitative process. Instead, whether a claimant is engaged in the rehabilitative process is the appropriate statutory guidepost to determine whether he or she is entitled to TTD benefits under the plain language of Section 287.149.1. It is plausible, and likely probable, that the maximum medical improvement date and the end of the rehabilitative process will coincide, thus, marking the end of the period when TTD benefits can be awarded. However, when the commission is presented with evidence, as here, that a claimant has reached maximum medical improvement yet seeks additional treatment beyond that date for the work-related injury in an attempt to restore himself or herself to a condition of health or normal activity by a process of medical rehabilitation, the commission must make a factual determination as to whether the additional treatment was part of the rehabilitative process. If the commission determines the additional treatment was part of the claimant's rehabilitative process, then he or she is entitled to TTD benefits pursuant to section 287.149.1 until the rehabilitative process is complete. Once the rehabilitation process ends, the commission then must make a determination regarding the permanency of a claimant's injuries. *Greer v. Sysco Food Servs.*, 475 S.W.3d 655, 668-69 (Mo. Banc 2015).
The Court, thus, requires a detailed analysis of the claimant's medical treatment to determine whether the claimant is entitled to temporary total disability benefits. In this case, the claimant worked full time with accommodations for other health conditions in 2014 and 2015. The claimant described the work as "menial" in her deposition. When asked to elaborate, the claimant cited dusting, cutting little pieces of labels, collating and stapling 1500 copies of a five-page document. The claimant testified that her last day of work for any employer was on January 22, 2016. On March 21, 2016, Dr. Verdine commenced active medical treatment of the claimant's condition, and the defense initiated payment of temporary total disability benefits, which continued through August 4, 2016, for a total of $7,958.14.
The claimant contends that she is entitled to additional temporary total disability benefits from January 23 to March 20, 2016, because her employer terminated her from her "menial" work position and she was unemployable in the open labor market pending treatment of her bilateral carpal tunnel syndrome.
Given the medical records describing the claimant's condition, her employer's conclusion to terminate the claimant from even "menial" work, and the description of the claimant's medical
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condition by Dr. Verdine and Dr. Enkvetchakul during that time, it is logical to conclude that no employer would employ the claimant pending her surgical procedures to cure and relieve her medical condition. Kristine Skahan's testimony certainly adds additional credence to this conclusion. Based on the weight of the evidence, the claimant is awarded temporary total disability benefits from January 23, 2016, to August 4, 2016, 27-5/7 weeks, (11,088.49) and the employer has a credit for payment of 7,958.14. Therefore, the claimant is awarded the balance of $3,130.45.