Title: PATRICIA GLAHN V. CASTELLINI COMPANY, ET AL

State: kentucky

Issuer: Kentucky Supreme Court

Document:

IMPORTANT1yOTICE NOT TO BE P BUSHED OPINION THIS OPINION,LSDESIGNATED "NOT TO BE PUBLISHED. " PURSUANT TO THE RULES OF CIVIL PROCED "IREPROMULGATED BY THE SUPREME COURT, CR 76.28 (4) (c), THIS OPINION ISNOT TO BE PUBLISHED AND SMALL NOTBE CITED OR USED ASAUTHORITYINANY OTHER CASE INANY COURT OF THIS STATE. ,sultrat (90urf of 10 APPEAL FROM COURT OF APPEALS V. 2005-CA-1623-WC WORKERS' COMPENSATION NO . 02-87182 MEMORANDUM OPINION OF THE COURT AFFIRMING RENDERED : AUGUST 24, 2006 NOT TO BE PUBLISHED 2006-SC-0060-WC PATRICIA GLAHN APPELLANT CASTELLINI COMPANY AND WORKERS' COMPENSATION BOARD APPELLEES The claimant's application for benefits alleged physical and mental injuries from four work-related accidents . An Administrative Law Judge (ALJ) determined that her headaches and her cervical, thoracic, lumbar, and psychological complaints were not work-related ; that her partial rotator cuff tear was due to the fourth work-related accident ; that it resulted in a 6% impairment ; and that KRS 342.730(1)(c)1 was inapplicable . The Workers' Compensation Board (Board) vacated and remanded for additional findings regarding KRS 342 .730(1)(c)1 but affirmed in all other respects . The Court of Appeals affirmed, and we affirm . The claimant began working on the defendant-employer's potato/citrus line on October 2, 2000 . Her job involved running the potato machine, hanging bags of oranges or potatoes, and dumping bags of oranges or potatoes . It required her to lift bags and boxes weighing 50-100 pounds . She also operated fork lifts, a riding dolly, a hand dolly, and a reach truck . She alleged work-related injuries of October 16, 2001, (left shoulder, arm, neck, and back) ; December 10, 2001, (left hand) ; April 3, 2002, (hernia) ; and September 3, 2002, (right shoulder, arm, neck, back, psychiatric, and headaches) . The claimant returned to work without restrictions after all but the September 3, 2002, injury . She returned to light duty on September 4, 2002, but quit after about a month because her condition worsened . Focusing on medical evidence after the most recent injury, she asserted that she was totally disabled by depression, headaches, and pain in her neck, back, shoulder, and left hand . The claimant testified that she felt something pop in her shoulder while lifting 50- pound boxes of potatoes from above her head to the floor on September 3, 2002 . She went to St. Elizabeth Hospital where they took x-rays and gave her pain medication, muscle relaxers, and anti-inflammatories . The next day, she was examined at St . Elizabeth Business Health, at which time she had pain in the neck and trapezius area as well as headaches . Physical therapy made her symptoms worse, and she was referred to Dr . Hasan . Records from St . Elizabeth Business Health indicated that the claimant was treated for cervical, shoulder, and neck pain and for headaches . Dr. Hasan's Form 107 and medical reports indicated that he treated the claimant from November 7, 2002, through November 11, 2003 . A note from May 5, 2003, mentions complaints of neck pain . Dr. Hasan also noted that a cervical MRI performed on September 26, 2003, revealed spondylotic protrusion at C5-6 and C6-7, creating mild foraminal stenosis on the right at C5-6 and paracentral cord indentation at C6-7 . He assigned a 1 % impairment and stated that the claimant retained the physical capacity to return to the type of work she performed at the time of her injuries . Dr. Hasan referred the claimant to Dr. Kelly for pain management. He treated her four occasions between June 24, 2003, and August 8, 2003 . He received a history of the September 3, 2002, injury and of a February 21, 2003, surgery to repair a torn rotator cuff . The claimant complained of chronic pain in the upper trapezium and cervical region, described as a spasm . Dr. Kelly noted that she also developed persistent, severe, referred cervicogenic headaches but no photophobia . She also complained of numbness and paresthesia in both hands and of pain in the mid back and neck that radiated into the shoulders and sometimes into the back of the head, causing headaches . Dr. Kelly noted that upper limb EMG/NCV testing, performed on June 6, 2003, was normal and negative for carpal tunnel syndrome radiculopathy. He diagnosed the rotator cuff tear, cervical myofascial pain syndrome, and cervicogenic headaches . In his opinion, the described incident was consistent with the objective findings, including the physical exam and test results . The claimant had no similar condition before the incident ; therefore, the incident probably caused her complaints . He assigned an 8% impairment, attributing a 6% impairment to a cervical condition and a 2% impairment to pain and headaches . Dr. Grefer, an orthopedic surgeon, began treating the claimant on October 27, 2003 . His testimony consisted of a Form 107 and medical records through July 19, 2004 . His initial diagnosis was a spinal strain/sprain ; cervical, thoracic, and lumbar disc disease with spurring and a disc protrusion at C6-7 . In his opinion, the September 3, 2002, incident aggravated a pre-existing, dormant, degenerative disc disease. He assigned a 21% impairment based on the cervical and thoracic spine and a 5% impairment based on the lumbosacral spine . Moreover, he thought the claimant could not perform any type of gainful employment at that time . Dr. Sheridan performed an independent medical examination for the employer on February 17, 2004 . His report indicated that he took a history, examined the claimant, and reviewed her medical records . They included his previous report from January 2, 2003, as well as reports from St . Elizabeth Business Health, Dr. Samer Hasan (including the operative report), Dr. John Kelly, Dr. Michael Grefer, physical therapy reports, and the report of a September 16, 2003, MRI . Dr. Sheridan indicated that the claimant reported the four work-related incidents and stated that her present complaints were bilateral intermittent trapezial pain and occasional paresthesia in her left hand . Among other things, his physical examination included observations and tests of the neck, cervical spine, shoulders, and upper extremities . In his opinion, the October 16, 2001, incident caused an acute left shoulder strain that had resolved with no permanent impairment . The December 10, 2001 incident caused a crush injury and contusion of the left hand from which she had recovered without impairment . Likewise, the April 10, 2002, incident caused no permanent impairment . In contrast, the September 3, 2002, injury to her right shoulder caused a partial rotator cuff tear and aggravated pre-existing conditions . Dr. Sheridan assigned a 6% impairment to the condition and imposed work restrictions . In his opinion, the headaches, cervical pain, depression, and anxiety that the claimant alleged were not directly related to the September 3, 2002, shoulder injury. In a supplemental report of March 25, 2004, Dr . Sheridan stated that at neither the 2003 nor 2004 exam did the claimant complain of low back pain . He reviewed physical therapy reports ; Drs . Grefer's reports from October 27, 2003, through March 16, 2004 ; a January 20, 2004, bone scan ; and a February, 2004, EMG and nerve conduction study . Having done so, he indicated that he had not changed his opinion that any low back complaints were not work-related . He also indicated that his physical findings regarding the cervical spine differed from Dr. Grefer's and that he thought they warranted no impairment rating . Ms. Hirschfield, a Licensed Clinical Social Worker provided psychological counseling . She reported that the claimant suffered from major depression, alcohol abuse, and chronic shoulder pain . She rated the claimant's prognosis as fair/limited . On May 4, 2004, Dr . Roebker performed a psychological evaluation on the claimant's behalf . A Ph.D . and a licensed psychologist, he interviewed her, took a history, and administered diagnostic tests that assessed academic achievement, intellectual and verbal capacity, and personality (MMPI) . Dr . Roebker's report stated that the results of the MMPI were valid and that the clinical code supported the presence of major depression . He also diagnosed alcohol abuse that was in remission . He attributed the claimant's psychological complaints to the September, 3, 2002, injury, explaining that she was depressed and having difficulty coping due to the loss of her ability to work as well as the health, financial, and lifestyle changes that resulted from her injury and limits . Dr . Roebker assigned a 20% impairment and stated that there was no pre-existing active impairment . In his opinion, she did not retain the physical capacity to return to her former work and could not perform even sedentary work . He felt she required ongoing treatment for depression . Dr . Madrigal, a Ph.D . and licensed psychologist, evaluated the claimant for the employer on May 12, 2004 . His report contained a brief narrative as well as various statements, which appeared to be answers to questions . Dr . Madrigal stated that the claimant did not suffer from major depression or any type of pain disorder. He also stated that her alcoholism was in remission and had not been caused by any of the work-related incidents . Although the claimant moved to strike Dr. Madrigal's report because the questions were not of record, the employer submitted the questions with its response . The motion was overruled . In a supplemental report of May 20, 2004, Dr . Madrigal took issue with Dr . Roebker's findings . He stated, in pertinent part, as follows : Dr . Roebker performed a very exhaustive and thorough evaluation ; however, I respectfully disagree with his conclusions . Although he makes an excellent case in the vocational side of his evaluation, in which he states that Ms . Glahn has no transferable skills, I do not see evidence to support the presence of Major Depressive Disorder . The MMPI-2 profile is not available but judging by Dr. Roebker's analysis, it does not appear to support such a major affective disorder. Results from the MMPI-2 I administered to her, do not support the presence of any psychopathology. On the other hand the symptoms he noted in the interview with Ms . Glahn are very similar to the ones I noted and they represent a normal reaction to a life setback but do not constitute a Major Depressive Disorder . (emphasis added) . There is apparently no question that the claimant suffered at some point from an Alcohol Abuse, but Dr. Roebker mentions some contradicting information gathered from Ms. Hirschfield's notes and reports and Ms. Glahn's report that are similar to the ones I found (although I did not specifically noted [sic] in my report), in which the claimant denied any history of alcohol abuse while in the notes there is a mention to a prior history. Also, she eventually had other unrelated medical problems that made it impossible for me to establish a certain and direct causal link between her alcohol abuse and her injury of September 3, 2002, as it is clear that [s]he had no psychological consequences from the previous ones . In summary, after reviewing Dr . Roebker's report, 1 remain firm on the opinions expressed in my above mentioned report . After summarizing the evidence, the AU stated : I have considered the lay and medical evidence, not only as summarized herein, but in its entirety . With regard to psychological complaints, I am more persuaded by the medical opinions of Dr . Madrigal . I find that psychological complaints are not related to any work injury . Dr. Madrigal did an appropriate exam and medical opinions are well supported by objective medical findings and by plaintiffs history . With regard to physical complaints, I am more persuaded by the opinions of Dr. Sheridan who did an exam that yielded objective medical findings that support his opinions . Plaintiff points out numerous times in various medical records where plaintiff makes various complaints. However, any diagnosis based merely on complaints of symptoms but not supported by objective medical findings is insufficient for the purposes of KRS Chapter 342 . Gibbs vs. Premier Scale Co . , Ky., 50 S.W .3d 754 (2000) . In the present case, the objective findings do not persuade me that there is a work related cervical, thoracic, psychological, lumbar or headache related injury . I find that those complaints are not work related . Relying on Cepero v. Fabricated Metals Corp ., 132 S.W .3d 839 (Ky. 2004), the claimant asserts that the medical reports from Drs . Sheridan and Madrigal were an inadequate basis for the ALJ's decision . She characterizes Dr. Madrigal's report as being "indefensible ." She asserts that he did not administer an MMPI, himself, and that he acknowledged he did not examine the raw data from which Dr . Roebker based his conclusions . Moreover, his report did not contain a medical history, a treatment history, the results of any diagnostic testing, nor any psychological analysis to indicate that he was aware of and considered such information . Therefore, it could not be considered substantial evidence . Likewise, she asserts that Dr. Sheridan's report was based on a "largely incomplete history" that focused on her shoulder complaints and that he did not review medical records from St. Elizabeth Business Health and Dr . Hasan documenting her secondary complaints . Therefore, his conclusions were not within reasonable medical probability, and his opinion regarding causation could not constitute substantial evidence . An injured worker has the burden to prove every element of a claim for benefits, including causation . Magic Coal Co. v . Fox , 19 S.W.3d 88, 96 (Ky. 2000) . KRS 342.285 designates the ALJ as the finder of fact, which means that the ALJ, rather than the Board or a reviewing court, has the sole discretion to determine the quality, character, and substance of evidence. See Paramount Foods . Inc . v. Burkhardt , 695 S .W .2d 418 (Ky . 1985) . If the party with the burden of proof fails to convince the ALJ, that party's burden on appeal is to show that the favorable evidence was so overwhelming that no reasonable person could fail to be persuaded by it . Magic Coal Co. v. Fox, supra ; Special Fund v. Francis , 708 S.W.2d 641, 643 (Ky . 1986) . A finding that favors the party with the burden of proof must be upheld on appeal if it is supported by substantial evidence, but substantial evidence will not necessarily compel a favorable finding even in the face of less substantial contrary evidence . Id . In Cepero , supra , an ALJ found the worker to be credible and relied on medical opinions that his knee injury was work-related ; however, the opinions were based on an erroneous medical history that failed to include a previous non-work-related knee injury that would only have healed after a surgery that was not performed . Upholding a decision to reverse the award, the court adopted a portion of the Board's opinion, stating as follows : [In] cases such as this, where it is irrefutable that a physician's history regarding work-related causation is corrupt due to it being substantially inaccurate or largely incomplete, any opinion generated by that physician on the issue of causation cannot constitute substantial evidence. Medical opinion predicated upon such erroneous or deficient information that is completely unsupported by any other credible evidence can never, in our view, be reasonably probable . Furthermore, to permit a ruling of law to stand based upon such evidence that is not reliable, probative and material would be fundamentally unjust . We therefore conclude that the opinions . . . do not measure up as substantial evidence, and it was error for the AU to blindly elect to adopt their flawed conclusions to support any ruling of law . It was the claimant's burden to convince the AU that she injured her spine and that any or all of her injuries caused major depression . She failed to do so. She asserts that the medical opinions favoring her employer were not supported by substantial evidence ; therefore, the AU erred by relying on them as a basis for finding that her psychological complaints were not work-related and that there was no work- related cervical, thoracic, lumbar, or headache related injury . There is no argument that the claimant failed to offer substantial medical evidence of causation . The AU simply found the employer's experts to be more persuasive . Therefore, their testimony must have constituted no less than substantial evidence in order to overcome the claimant's evidence. This appeal concerns whether it did under the Ce ero, supra , standard . There was no affirmative evidence that an opinion Dr . Madrigal or Dr. Sheridan offered was based on an erroneous or incomplete history or on otherwise incomplete data . Although Dr. Madrigal's reports were very brief, nothing indicates that he was missing any vital diagnostic information . His reports clearly indicate that he examined the claimant, reviewed Ms . Hirschfield's and Dr. Roebker's reports, and disagreed with Dr . Roebker's conclusions . Contrary to the claimant's assertion, they clearly indicate that he administered an MMPI-2 . Also contrary to the claimant's assertion, Dr. Sheridan's reports indicate that he reviewed records from St . Elizabeth Business Health and Dr . Hasan as well as physical therapy reports, a 2004 bone scan and nerve studies, records from Dr . Kelly, and records from Grefer through March 16, 2004 . He examined the claimant on two occasions (about a year apart) and noted that at neither time did she report low back pain . In February, 2004, she complained only of bilateral intermittent trapezial pain and occasional paresthesia in her left hand . Dr . Sheridan noted that his physical findings regarding the cervical spine differed from Dr. Grefer's and did not warrant an impairment rating . After reviewing the most recent records, he remained convinced that any low back complaints were not work-related . Unlike the situation in Ce ero, supra, it is not irrefutable that Dr. Madrigal's and Dr. Sheridan's opinions were based on a substantially inaccurate or largely incomplete history and unsupported by other evidence in the record . Under such circumstances, it was for the ALJ to weigh the conflicting medical evidence and decide whom and what to believe, taking into account such factors as the completeness of an expert's report . The evidence regarding the disputed injuries was not so overwhelming as to compel findings in the claimant's favor. The decision of the Court of Appeals is affirmed . Lambert, C .J .; Graves, Mcanulty, Roach, Scott, and Wintersheimer, JJ ., concur . Minton, J ., not sitting . COUNSEL FOR APPELLANT : Gregory N . Schabell Busald, Funk & Zevely, PSC 226 Main St P.O . Box 6910 Florence, KY 41022-6910 COUNSEL FOR APPELLEE, CASTELLINI COMPANY : Jennifer L. Chesser-McGrath J. L. Sallee, Jr. David D. Black Dinsmore & Shohl, LLP 1900 Chemed Center Cincinnati, OH 45202