Opinion ID: 2032428
Heading Depth: 1
Heading Rank: 2

Heading: + b (1-a)

Text: where: A is the greater percentage whole body loss of the first body part; and B is the lesser percentage whole body loss otherwise payable for the second body part. Minn.Stat. § 176.105, subd. 4(c) (1984) (emphasis added). The corresponding provision in the permanent partial disability schedules states: where an impairment must be rated under more than one category, the ratings must be combined using the A + B (1-A) formula of section 176.105, subd. 4(c). Minn.Rules § 5223.0010, subp. 2 (emphasis added). The rules also state that the disability determination shall not be based on the cumulation of lesser included categories. Id. Based on the language of the statute and the rule, the employer makes this argument: Body part is the equivalent of category and lesser categories are conditions affecting the particular body part or category. Ratings may not be assigned to one body part or category under more than one section and cumulated under the statutory formula. The brain is the only applicable body part or category involved here, the employer contends; the sections describing various impairments are merely lesser categories. Thus, the employer concludes, to assign ratings under more than one section of the brain category is to impermissibly cumulate lesser included categories. Both the compensation judge and the WCCA rejected the employer's argument. While we agree that the employer's position rests on a misinterpretation of the statute and the disability schedules, we can accept neither the declaration of WCCA majority that as a scientific medical fact each segment of the brain constitutes a separate body part nor its determination that employee's several impairments are the result of trauma to separate segments of the brain. The permanent partial disability schedules themselves, Minn.Rules 5223.0010 through 5223.0250, refer only to the brain as an organ. There is no reference to separate parts of the brain. It is, of course, generally recognized that different parts of the brain are specialized to perform different functions. But although it may not be inaccurate to identify a particular segment of the brain as the area primarily associated with a function such as vision, to say, as does the WCCA majority, that each function is controlled by a separate and distinct part of the brain and, hence, by a separate body part strikes us as impermissible over-simplification in disregard of the vast network of interconnections within the brain. The physiology of the human body and the relationship between trauma and disability are subjects about which the law has traditionally looked to expert medical opinion testimony. The testimony of the several medical experts who participated in the evaluation of employee's condition established the causal relationship between his brain injury and his impairments only in a general way. There was no attempt to link individual functional impairments with trauma to a specific segment of the brain. To supplement the record by judicial notice of the particularity of function within an organ as complex as the brain seems to us presumptuous. That the brain must itself be regarded as a single body part does not, however, validate the employer's position, for the employer's argument ignores the definition of category at Rule 5223.0020, subp. 9: `Category' means a permanent partial disability as described in this chapter and the corresponding percent of disability to the whole body for that permanent partial disability. Moreover, the employer's argument gives inadequate consideration to the basis for payment of compensation for permanent partial disability: economic recovery compensation or impairment compensation is payable for permanent functional loss of use or impairment of function. Minn.Stat. § 176.021, subd. 3 (1984). See also Moes v. City of St. Paul, 402 N.W.2d 520, 525-26 (Minn.1987). Section 176.105 focuses not on the body part which sustained direct injury but rather on the resultant permanent functional disability. An example illustrates how limiting the application of the disability schedules according to the number of injured body parts frustrates the goal of compensating multiple functional impairments in terms of disability of the whole body. Subpart 6 of the central nervous system schedule involves dysfunction of the hypoglossal nerve and contains two sections: A. swallowing impairment, and B. mechanical disturbances of articulation. Minn.Rules § 5223.0060, subp. 6. Assume two employees suffer work-related injuries to their hypoglossal nerve. The injury to the first employee causes a swallowing impairment requiring her diet to be restricted to liquids (6(A)(2), 25 percent) and also disturbs her speech so that it is not easily understood by nonfamily members (6(B)(2), 10 percent). The second employee suffers only a swallowing impairment requiring his diet to be restricted to liquids (6(A)(2), 25 percent). It is apparent that although each employee has sustained direct injury to only one body part, the first employee has suffered two distinct functional impairments with greater resultant disability to the body as a whole than has the second employee. The directive for interpretation of the disability schedules contained at Minn. Rules § 5223.0010, subp. 2, recognizes that more than one category may be necessary to represent the disabling condition, and the rule directs that categories are to be selected to avoid double compensation for any part of a condition and that the ratings should be combined using the formula A + B (1-A) contained in section 176.105, subd. 4(c). That formula is designed to ensure that when an injury causes two or more functional impairments the percentage for all functional disability combined does not exceed the total for the whole body. Minn.Stat. § 176.105, subd. 4(c) (emphasis added). The formula is based upon the principle that each impairment acts not on the whole person, but on the unimpaired portion that remains after other impairments have been taken into account. AMA Guides to the Evaluation of Permanent Impairment viii (2d ed. 1984). The use of the formula in conjunction with the schedules permits the value of each impairment to be determined separately according to the categories established in the schedules and then combined in relationship to the whole body. See Zweber v. Rosemount, Inc., 419 N.W.2d 70 (Minn.1988). Accordingly, we hold that where the assignment of permanent partial disability ratings under two or more sections of the brain injury subpart of the central nervous system schedule is necessary to represent the employee's disablement, the ratings for the two or more categories of impairment may be combined using the statutory formula. [1] Of course, levels of severity under one category of impairment may not be cumulated. The record before us in this case supports the determination that it is necessary to assign ratings under more than one section of the brain injury schedule in order to properly represent the employee's disabling condition. Our conclusion that where brain dysfunction causes functional losses of use or impairment of different kinds, rating under more than one category may be necessary to the proper evaluation of disability does not, however, mean that multiple ratings are always appropriate. The rule specifically directs selection of the category most closely resembling the condition if more than one category may be applicable. Minn.Rules 5223.0010, subp. 2 (1984). When resort to more than one category is necessary to the proper rating of an employee's impairments, the categories must be identified and selected with care in order to avoid exaggeration of the disability in its entirety. Brain injuries possess a particular potential for exaggeration of the percentage of permanent partial disability of the body as a whole. The AMA Guides recognize that evaluation of central nervous system impairment is difficult because of the complex relationships between the brain and the mind. It is impossible to avoid consideration of associated mental, emotional and personality processes. AMA Guides to the Evaluation of Permanent Impairment 61 (2d ed. 1984). The absence of clear lines of demarcation presents the possibility of duplication or overlap. Moreover, the categories for evaluating impairments resulting from injury to the brain are established in terms of restrictions or limitations of the employee's ability to perform the activities of daily living rather than in terms of specific diagnoses. See Minn.Rules 5223.0060, subp. 8 and 8(B) communication disturbances, receptive, 8(C) complex integrated cerebral function disturbances, 8(D) emotional disturbances and personality changes, 8(E) psychotic disorders, and 8(F) consciousness disturbances. The inability to live independently or the need of supervision or direction in some activities may be the result of one particular category of impairment or it may be the product of the combination of several types of impairment. In either case if the fact that the injured employee is unable to live independently or requires supervision or direction is used to increase the severity level rating of more than one impairment, the result is likely to violate the rule against double compensation. Minn.Rule 5223.0010, subp. 2 (1984) (Where more than one category is necessary to represent the disabling condition, categories shall be selected to avoid double compensation for any part of a condition.)
The employer also contends that even if the condition resulting from the employee's brain injury may properly be rated under more than one category, the ratings adopted here are not justified by the evidence. The following table illustrates the ratings made by the compensation judge under subpart 8 of the central nervous system schedule and the WCCA's affirmance or modification of each rating: Rating Category Comp Judge WCCA 1. 8(C) complex integrated cerebral function disturbances 50% 70% 2. 8(F) consciousness disturbances -0- 40% 3. 8(A) communications disturbances, expressive -0- 10% 4. 8(G) motor dysfunction 15% 30% 5. 8(D) emotional disturbances and personality changes 65% 65% 6. 8(I) epilepsy 10% 10% 7. 8(B) communications disturbances, receptive -0- -0- Of the ratings on which the compensation judge and WCCA concur, the employer attacks only the rating for emotional disturbances and personality changes [8(D)]. Where, as here, the WCCA affirms a finding of fact, this court will affirm unless, viewing the evidence in the light most favorable to the findings, we conclude that the finding is manifestly contrary to the evidence. Hengemuhle v. Long Prairie Jaycees, 358 N.W.2d 54, 60-61 (Minn. 1984). Under this standard the 65 percent rating for emotional disturbances and personality changes must be affirmed. Dr. Lawrence Farber, a neurologist, and Dr. Philip Haber, a clinical psychologist who performed psychometric testing required under 8(D), concurred in the opinion that the employee suffered emotional disturbance as a result of his injury and that the diagnostic description corresponding to a 65 percent rating fitted employee's condition. Although Dr. Matthew Eckman, employee's treating physician, regarded employee's depression as most likely situational, a neurological consultant who participated with Dr. Eckman in an evaluation of employee's condition considered some residual mood changes a very likely result of the injury. On this record it cannot be said that the 65 percent rating for emotional disturbance and personality change is manifestly contrary to the evidence. We agree, however, with the employer's contention that the WCCA exceeded its authority when it substituted its 70 percent rating for the compensation judge's 50 percent rating for complex integrated cerebral function disturbances [8(C)] and interposed a 40 percent rating for consciousness disturbances [8(F)]. The WCCA may not substitute its view of the evidence for that adopted by the compensation judge if the compensation judge's findings are supported by evidence that a reasonable mind might accept as adequate. See Jacobowitch v. Bell & Howell, 404 N.W.2d 270, 274 (Minn.1987). The compensation judge adopted Dr. Matthew Eckman's rating of 50 percent for complex, integrated cerebral function disturbances based on his observations as employee's treating physician and on reports by and consultations with other health care professionals, including a clinical psychologist, occupational therapist, neurologist, and speech pathologist. Included in Dr. Eckman's report, which was prepared one month before the compensation hearing, are these comments under the heading cognitive dysfunction: employee appeared to demonstrate adequate judgment and control during his week of observation and was not impulsive or noticeably unsafe in his daily living tasks. The report shows a full scale IQ of 80 and that the employee reads at the fifth grade level and functions at the eighth grade level in mathematics. The report indicates that the employee can make coffee by following written directions for the use of a coffee-maker with which he was unfamiliar. The report recommends that the employee be given more responsibility for household tasks such as cooking and laundry. The WCCA, however, rejected Dr. Eckman's evaluation out of hand and adopted Dr. Farber's rating of 70 percent on the ground that the evidence of record is uncontroverted that the employee is not capable of living alone. In fact, Dr. Eckman recognized that the employee needed supervision by a responsible adult on a regular basis, but his comments concerning the employee's dependence with respect to daily living activities appear to be based on the totality of functional impairments caused by the injury. Employee's inability to live alone was recognized in the rating assigned for emotional disturbances. Given the employee's level of cognitive functioning, if only impairment of memory, judgment, or other higher level cognitive abilities are considered in assessing employee's need for supervision, a reasonable mind could accept as adequate the evidence supporting the conclusion that employee has a moderate level of impairment of higher level cognitive abilities as a result of injury and, were that his only impairment, he could live alone with some supervision. Minn.Rules § 5223.0060, subp. 8(C)(3) (1984). The fallacy in the WCCA's analysis is repeated in its 40 percent rating for consciousness disturbances. The diagnostic description for this rating is mild or intermittent decreased level of consciousness manifested by periodic mild confusion or lethargy, a score of 16 to 28 on the Kenny scale. Minn.Rules § 5223.0060, subp. 8(F)(1) (1984). Dr. Farber, in consultation with Dr. Haber, assigned a 40 percent rating under this category, based primarily on employee's 24.6 score on the Kenny Self-Care Evaluation in July 1985. Dr. Farber also based his rating on what he described as periods where he [the employee] would get out of it and confused, although this description appears to come from employee's mother rather than Dr. Farber's personal observation. Dr. Eckman, on the other hand, did not assign any rating for consciousness disturbances. Employee's 27.7 Kenny score in May 1986 appears linked to his motor dysfunction rather than any periodic mild confusion or lethargy, and the score on the Kenny scale is part of the diagnostic description on which the rating for employee's motor dysfunction rests. Dr. Eckman noted some lethargy and problems with attention span, but he thought them caused by employee's sedentary lifestyle, and he recommended increased stimulation through participation in a sheltered workshop. Considered as a whole and in conjunction with the other ratings, the record contained substantial evidence to support the compensation judge's finding that no permanency rating was appropriate for consciousness disturbances. The WCCA improperly substituted its own rating for this category. On the other hand, the WCCA correctly set aside the compensation judge's findings and interposed ratings in three categories: communications disturbances, expressive; motor dysfunction, upper extremities; and loss of vision. The witnesses uniformly recognized that employee's speech was slurred and mildly dysarthric although it was quite understandable. The diagnostic description of an expressive communication disturbance given a 10 percent rating is a mild speech disturbance not significantly impairing the ability to be understood, such as    mild dysarthria. Minn.Rules § 5223.0060, subp. 8(A)(1) (1984). Accordingly, the record does not substantially support the failure to award a 10 percent rating for this category of functional impairment, and we affirm the WCCA's substituted rating of 10 percent for communications disturbances, expressive. There also seems to be no question that the employee was entitled to a 15 percent rating for motor dysfunction of the upper extremities as well as the 15 percent rating the compensation judge awarded for motor dysfunction of the lower extremities. All of the health care professionals who examined the employee noted his impaired digital dexterity. Employee's score of 27.7 on the Kenny scale is within the range of diagnostic description of the 15 percent rating. Moreover, it appears from the compensation judge's discussion of employee's various impairments in the memorandum attached to his findings that the omission of a rating for the upper extremities was the result of oversight rather than a zero rating. Accordingly, we affirm the WCCA's rating of 15 percent for motor dysfunction of the upper extremities. We observe, however, that motor dysfunction impairments are to be rated as provided in subpart 7 of the schedule, which sets out separate ratings for upper and lower extremities for combination pursuant to the statutory formula. Therefore, the 15 percent rating for the upper extremities and the 15 percent rating for the lower extremities should not have been added together to produce a single motor dysfunction rating but should have been listed separately and combined using the formula A + B (1-A). With that modification we affirm the WCCA award for motor dysfunction. Dr. Marshall Petersen, optometrist, tested employee's visual efficiency and concluded that a 36 percent disability of the whole body was appropriate under the eye schedule. See Minn.Rules § 5223.0030, subp. 6 (1984). The compensation judge declined to assign a disability rating for vision loss on the ground that no rating was permissible under the eye schedule because the vision loss was attributable to the brain injury, not to employee's eyes. While the compensation judge apparently was correct in relating employee's visual deficiency to the injury to his brain rather than an injury to his eyes, that employee has sustained some functional loss of vision is uncontroverted. Since there is no reference in subpart 8 of Rule § 5223.0060, the brain injury portion of the central nervous system schedule, or, in fact, in any part of section 5223.0060 to a rating based on vision loss or impairment, it seems to us that the WCCA's 36 percent disability rating for vision impairment represents a correct interpretation of the disability schedules. Finally, based on our examination of the record, we cannot say that the ratings assigned with respect to employee's epilepsy [subp.8(I)] or that the rejection of employee's proposed separate ratings for communications disturbances, reception [subp. 8(B)], limitation of ankle motion [Rule 5223.0170, subp. 7(A)(4)], or rigidity of back [Rule 5223.0070, subp. 2(A)(3)] are manifestly contrary to the evidence. The ratings of 6 percent for limitation of elbow motion [Rule 5223.0120, subp. 2(C)(1)] and 6 percent for shortening of lower extremity [Rule 5223.0170, subp. 2(C)] are not challenged. In summary, we affirm in part and reverse in part the WCCA's ratings of the various categories of impairment sustained by employee. The separate ratings, as modified by this opinion, are these: 1. 5223.0060, subp. 8(D) emotional disturbances and personality changes 65% 2. 5223.0060, subp. 8(C) complex integrated cerebral function disturbances 50% 3. 5223.0030, subp. 6 loss of vision 36% 4. 5223.0060, subp. 8(G) motor dysfunction upper extremities 15% lower extremities 15% 5. 5223.0060, subp. 8(A) communications disturbances, expressive 10% 6. 5223.0060, subp. 8(I) epilepsy 10% 7. 5223.0120, subp. 2(C)(1) limitation in motion of elbow 6% 8. 5223.0170, subp. 2(C) shortening of lower extremity 6% Calculated pursuant to the statutory formula A + B (1-A), these combined ratings result in a rating of 94.21 percent disability of the body as a whole. In conclusion, we observe that neither the concept of permanent partial disability nor the statutory formula for combining multiple impairments [A + B (1-A)] will permit a rating of 100 percent permanent partial disability of the body as a whole. Minn.Stat. § 176.105, subd. 4(c) (1984). The disability rating for an individual in a persistent vegetative state is 99 percent. Thus, fairness dictates that each employee's condition as a whole must be kept in perspective so that the aggregate award falls within a relatively appropriate range of impairment compensation.