Case Name: MARTIN COUNTY SCHOOL BOARD and Gallagher Bassett Insurance Service, Appellants, v. Ray Lee McDANIEL, Appellee
Court: Florida District Court of Appeal
Jurisdiction: Florida
Decision Date: 1984-09-13
Citations: 465 So. 2d 1235
Docket Number: No. AW-274
Parties: MARTIN COUNTY SCHOOL BOARD and Gallagher Bassett Insurance Service, Appellants, v. Ray Lee McDANIEL, Appellee.
Judges: ERVIN, BOOTH, SMITH, SHIVERS, WIGGINTON, ZEHMER and BARFIELD, JJ., concur.
Reporter: Southern Reporter, Second Series
Volume: 465
Pages: 1235–1244

Head Matter:
MARTIN COUNTY SCHOOL BOARD and Gallagher Bassett Insurance Service, Appellants, v. Ray Lee McDANIEL, Appellee.
No. AW-274.
District Court of Appeal of Florida, First District.
Sept. 13, 1984.
On Rehearing En Banc Feb. 27, 1985.
Rehearing Denied April 22, 1985.
Micheál A. Edwards, West Palm Beach, for appellants.
Robert H. Schott of Gamba, Junod & Schott, Palm City, for appellee.

Opinion:
NIMMONS, Judge.
Claimant hurt his back unloading furniture for his employer on September 4, 1981. The employer and servicing agent (E/S) appeal from an order of the deputy commissioner ordering wage loss benefits. We reverse because the deputy's finding of a permanent physical impairment is not supported by competent substantial evidence.
In Trindade v. Abbey Road Beef 'N Booze, 443 So.2d 1007, 1012 (Fla. 1st DCA 1983), we held:
[F]or purposes of determining eligibility for wage loss benefits in accordance with Section 440.15(3)(a) and (b), the existence and degree of permanent impairment resulting from injury shall be determined pursuant to the [AMA] Guides, unless such permanent impairment cannot reasonably be determined under the criteria utilized in the Guides, in which event such permanent impairment may be established under other generally accepted medical criteria for determining impairment.
And in Maggard v. Simpson Motors, 451 So.2d 529 (Fla. 1st DCA 1984), we stated:
Although we have held that medical testimony on the issue of permanent impairment need not necessarily be based on the AMA Guides, Trindade v. Abbey Road Beef 'N Booze, 443 So.2d 1007 (Fla. 1st DCA 1983), we have not gone so far as to approve a permanent impairment rating based on the claimant's subjective complaints of chronic pain. We now hold that the existence and degree of perma nent physical impairment must be proved by testimony based on the AMA Guides, unless such impairment cannot reasonably be determined under the criteria utilized in the Guides. In such cases, permanent impairment may be proved by testimony based on the Manual for Evaluation of Permanent Physical Impairment of the American Academy of Ortho-paedic Surgeons, as authorized by Rule 38F-3.175, Florida Administrative Code, or by testimony based on "other generally accepted medical criteria for determining impairment."
Trindade, supra, at 1012.
The deputy commissioner found in his order that both Dr. DiBartolo, the primary treating orthopedic surgeon, and Dr. Murphy, another orthopedic surgeon who performed an independent medical examination on the claimant, based their opinions of a 5% permanent physical impairment upon the Orthopedic Surgeons Manual referred to above. However, the fact is that, although both doctors agreed on a diagnosis of "chronic lumbar strain" and that the permanent impairment they described was not covered under the AMA Guides, Dr. Murphy did not rely upon the Orthopedic Guides or any other such source for the determination of impairment. We summarize Dr. Murphy's deposition testimony and his written report received in evidence.
Murphy stated in his report that the claimant demonstrated no limitation of motion; that the x-rays showed no bony abnormality, no instability of the lumbar spine, and the disc spaces to be well preserved; and that lower leg neurological examination was within normal limits. Murphy's report recounted the history of the claimant's accident and claimant's continuing complaints of pain in the back and legs. The report stated that "no objective findings for [claimant's] complaints" were found and that Murphy felt claimant was "able to perform normal custodial duties with the limitation of weight lifting." Nevertheless, Murphy concluded in his report that he would go along with Dr. DiBartolo's opinion of a 5% permanent impairment rating and prognosis of continued pain. Murphy's deposition testimony included the following:
Q What would be the basis of the five percent rating?
A The basis would be of the basis of, of, on pain and suffering and subjective symptoms.
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But, using his symptom, you know, but using his symptomatic symptoms, his subjective symptoms, you know, I do feel that he does have, does have a disability, and therefore I think there, that there is other criteria under which you measure a disability. And I think that the patient has, you know, pain and discomfort from his, you know, has — I don't know whether its scarring of nerves or whatever, you know, in his low back, you know, that produces chronic strain symptoms. But that's the way he is, that's, you know, that's how I came up with this five percent disability.
Dr. Murphy had the benefit of the neurological report of Dr. Hooshmand, a neurologist whose report was received in evidence. The report states that Dr. Hooshmand's neurological examination revealed no abnormal findings. Hooshmand concluded:
Whatever injury the patient has had in the past has not left any residual, and the patient has reached maximum medical improvement with no residual of any disability. The main problem the patient has at this time is obesity, which would be helped by losing weight. Otherwise the patient has no other problems and should be able to go back to work with no limitations or restrictions.
Dr. DiBartolo, claimant's primary treating physician, testified on deposition that the only objective finding he was able to make regarding the symptoms of which the claimant continued to complain was "some muscle spasm on one or two occasions" in the early part of his treatment but that the muscle spasm had not continued. Dr. DiBartolo, therefore, conceded that his permanent impairment rating was based upon the claimant's subjective complaints of pain and not upon any objective findings. However, Dr. DiBartolo testified that the claimant had a 5% permanent impairment under the Orthopedic Surgeons Manual (OSM). It is abundantly clear from the record though that Dr. DiBartolo was misapplying the OSM. The following excerpts from the OSM, which was received in evidence before the deputy, will help to demonstrate the doctor's erroneous reliance upon that Manual:
LOW LUMBAR
1. Healed sprain, contusion
A. No involuntary muscle spasm, subjective symptoms of pain not substantiated by demonstrable structural pathology 0 [%]
B. Persistent muscle spasm, rigidity and pain substantiated by demonstrable degenerative changes, moderate osteoarthritic lipping revealed by x-ray, combined trauma and pre-existing factors 10
C. Same as (B) with more extensive osteoarthritic lipping 15
D. Same as (B) with spondylolysis or spondylolisthesis Grade I or II, demonstrable by x-ray, without surgery, combined trauma and pre-existing anomaly 20
E. Same as (D) with Grade III or IV spondylolisthesis, persistent pain, without fusion, aggravated by trauma 35
F. Same as (b) or (c) with fusion laminectomy, pain moderate 25
2. Fracture

3. Neurogenic Low Back Pain — Disc Injury
A. Periodic acute episodes with acute pain and persistent body list, tests for sciatic pain positive, temporary recovery 5 to 8 weeks 5
B. Surgical excision of disc, no fusion, good results, no persistent sciatic pain 10
C. Surgical excision of disc, no fusion, moderate persistent pain and stiffness aggravated by heavy lifting with necessary modification of activities 20
D. Surgical excision of disc with fusion, activities of lifting moderately modified 15
E. Surgical excision of disc with fusion, persistent pain and stiffness aggravated by heavy lifting, necessitating modification of all activities requiring heavy lifting 25
Dr. DiBartolo's testimony shows how he misapplied the OSM:
Q [Y]ou felt he had a five percent total body disability as a result of the chronic low back syndrome and would require only aspirin to relieve the pain. The rating, the five percent rating, doctor, what was that based on?
A. It is based on my evaluation of the patient and with reference to the [Orthopedic Surgeons Manual], And the section that was referred to was the last page of the manual where they mention that a person with a chronic back injury who is required to in some way alter the, his activities because of the back problem What I was looking at, this paragraph [3]C refers — I took a section of that, it said — this particular problem deals with excision of a disc, I'm sorry— yes, excision of a disc, but the second part is moderate persistent pain and stiffness necessitating modification of activities. Of course, they give a twenty percent disability. What I considered as part of that was that the patient had no excision of a disc, but that he had moderately persistent pain and stiffness, and it was aggravated by heavy lifting and necessitated modification of activities. So I felt as though this was close to the situation he had without the disc pathology.
Obviously, it was improper for the doctor to rely upon paragraph 3C inasmuch as the diagnosed condition was a chronic lumbar strain with only subjective complaints of pain which were not verified by any objective findings. As the doctor himself testified, the claimant had no surgical disc excision. The other portions of the OSM are reproduced above to demonstrate that none of the other specified categories is amenable to an interpretation which would support a finding of permanent impairment based upon the evidence summarized previously in this opinion.
Counsel for E/S, on cross-examination, also drew Dr. DiBartolo's attention to a section of the OSM which categorizes degrees of pain and suggests the manner in which pain should be considered as a contributing factor in determining permanent impairment. There are four gradations of pain: Grade I (Mild) to Grade IV (Very Severe). Grades I and II provide:
Grade I — Mild: When there is a firm conviction established through thorough observation and clinical tests that pain actually exists even though there may be no organic manifestations. Pain of this degree does not contribute to physical impairment.
Grade II — Moderate: When the examination reveals definite evidence of a pathological state of the involved structures that would reasonably produce the degree of pain indicated to be present. This degree of pain might require treatment and could be expected to contribute in a minor degree to permanent physical impairment.
Dr. DiBartolo said that he "would perhaps classify his pain as moderate rather than mild." However, it is apparent that lacking in this case is any "definite evidence of a pathological state of the involved structures that would reasonably produce the degree of pain indicated to be present," a criterion under that pain category.
Appellee suggests that Dr. DiBartolo's testimony, in which DiBartolo stated that, in rendering his opinion on permanent impairment, he was relying upon his experience as an orthopedic surgeon, was sufficient to sustain the deputy's finding of permanent impairment. After Dr. DiBarto-lo's deposition testimony that his opinion of permanent impairment was based upon his interpretation of the OSM, he responded to claimant's attorney's question as follows:
Q And in so rating, you utilized your experience as an orthopedic surgeon who's treated many bad backs?
A Yes.
Stripped of the erroneous reliance upon the OSM, such testimony, in our view, does not constitute "other generally accepted medical criteria" as contemplated in Trindade v. Abbey Road Beef 'N Booze, supra, and Maggard v. Simpson Motors, supra. See also Brandon v. Hillsborough County School Bd., 447 So.2d 982 (Fla. 1st DCA 1984) (J. Nimmons, specially concurring). Compare Florida Sheriff's Youth Fund v. Harrell, 438 So.2d 450 (Fla. 1st DCA 1983) (Orthopedic Surgeon's Manual relied upon — objective manifestations of impairment, recurrent spasm, noted). Our opinion should not be read as a holding that a physician's opinion must, in all instances, be predicated upon a generally accepted permanent impairment manual or guide. We simply hold that a doctor's bare opinion of permanent impairment under circumstances such as these where the opinion is based in part upon an erroneous interpretation of the OSM and in part upon unverified subjective complaints of pain does not constitute "other generally accepted medical criteria" as contemplated by the above authorities.
We have not ignored the testimony of the psychologist whose deposition was introduced at the hearing on behalf of the claimant. Assuming, without deciding, that Dr. Barthet's testimony would be competent, relevant and material on the issue of a permanent physical impairment, he admitted that there would need to be further testing of the claimant before he could give an opinion as to whether the claimant's condition was a "permanent problem."
In sum, there was no competent substantial evidence to support the deputy's finding of a permanent physical impairment. The order awarding wage loss benefits must therefore be reversed. In view of the resolution of the above issue in appellant's favor, we need not address the appellant's other point or appellee's point on cross-appeal.
Reversed.
JOANOS, J., concurs.
ERVIN, C.J., dissents.
. The deputy commissioner recognized in his order that there was an "absence of objective findings" and that the opinions of both doctors were based upon the claimant's subjective complaints.
. On September 29, 1983, the Department of Labor and Employment Security promulgated Rule 38F-3.175, Fla.Admin.Code, which adopted the OSM as the applicable guides when the injury is to the knee, hip, shoulder, or elbow and the resulting permanent condition is not a permanent impairment under the AMA Guides. Since the parties have not raised the question as to whether the OSM can now be used in workers' compensation proceedings with respect to back injuries and since we have concluded that the evidence does not support a finding of permanent impairment under the OSM, we deem it unnecessary to resolve that question.