CLAIM NO. F001426
Before the Arkansas Workers’ Compensation Commission
OPINION FILED FEBRUARY 21, 2002
Upon review before the FULL COMMISSION in Little Rock, Pulaski County, Arkansas.
Claimant represented by HONORABLE ZAN DAVIS, Attorney at Law, Little Rock, Arkansas.
Respondent represented by HONORABLE CAROL WORLEY, Attorney at Law, Little Rock, Arkansas.
Decision of the Administrative Law Judge: Reversed.
OPINION AND ORDER
The claimant appeals to the Full Workers’ Compensation Commission an Administrative Law Judge’s opinion filed March 28, 2001. The Administrative Law Judge found that the claimant failed to prove by a preponderance of the evidence that she sustained a compensable injury to her cervical spine or neck on January 13, 2000. After reviewing the entire record de novo, the Full Commission reverses the opinion of the Administrative Law Judge.
I. HISTORY
The parties stipulated that Sharon Ferren, age 52 (DOB: 2-3-49), sustained a compensable injury to her lower back on January 13, 2000. Ms. Ferren testified:
Q. Tell me how that occurred, please ma’am.
A. I was at the computer, scanning out the throwaways. . . . to put them in the box. And then I would take this box and carry it over here behind my table for Goodwill to pick up. And when I went down for that box and I came back up, it stopped me about midstream. I just went into severe pain. . . .
Q. What were you feeling at that time?
A. I was just hurting all over. My legs were hurting. I was — I was just in pain. . . .
Q. Where were you hurting?
A. I just hurt all over. I just — my back just hurt me so bad. It wasn’t specifically a spot. You know I just hurt. It hurt all on my insides, you know, it was just hard to move. It’s hard for my body to move.
The record indicates that the claimant began treating with Dr. Citty on January 13, 2000. Dr. Citty’s office note indicates that the claimant complained of “severe low back pain” and she was assessed with “Acute low back strain R/O HNP.” The claimant submitted a First Report Of Injury Or Illness on or about January 14, 2000, where she reported an injury to her back. The claimant stated on the report that she “Picked up a box of throw-aways felt sharp pain in left side of back hip leg.”
Dr. Citty’s follow-up office note on January 19, 2000 again contained a notation of low back pain, and Dr. Citty’s recorded impression on January 25, 2000 continued to be “low back pain.” An MRI of the lumbar spine taken January 26, 2000 showed “Generalized bulging of the disk with broad dorsal disk protrusion at L4-5 causing significant flattening of thecal sac and moderate impingement on neuroforamina bilaterally.”
The claimant filled out a WCC Form N on February 9, 2000. The claimant wrote that she had injured her back. Dr. Anthony E. Russell wrote on February 11, 2000:
Ms. Ferren presents today for evaluation of low back pain with radiation into both lower extremities. Ms. Ferren has suffered significant pain since an incident that occurred at work several weeks ago. The patient apparently works at a garment inspection facility and had bent over to pick up several items when she “felt a pop” in her back. Shortly afterwards she developed excruciating pain in the low back with radiation into both hips and down the legs. This seems to be worse on the left than the right. She notes that it is associated with numbness in the legs. The numbness does not fit a particular dermatomal pattern. She states that it involves the entire leg on the left.
Dr. Russell stated that he could find nothing on the claimant’s MRI scan to explain her bilateral lower extremity complaints.
The claimant presented to White County Medical Center Emergency Department on April 30, 2000, complaining of headache, chest pain, and back pain. For the first time of record since her January 13, 2000 low back injury, the medical record also contains a notation of “chronic neck pain and low back pain since a ruptured disc was reported back in January.” An x-ray of the claimant’s chest taken April 30, 2000 was normal.
The claimant now asserts that she experienced ongoing neck problems in addition to low back problems while treating with Dr. Citty, and Dr. Citty appears to have clarified the confusion in a letter written to Dr. Ronald N. Williams on July 3, 2000:
In reviewing the records on Mrs. Sharon Ferren pertaining to her cervical and thoracic discomfort, we have one recorded episode in January on the 25th of her having chest wall pain. My nurse confirms the fact that on several occasions there were complaints of neck and upper thoracic pain and this is alleged true by the patient. Primarily her symptoms have been referrable to the low back, however, I feel it is important to proceed with MRI studies of the thoracic and cervical spine referrable to this injury. [Emphasis ours.]
The following impression resulted from an MRI of the cervical spine taken July 11, 2000:
There are mild degenerative changes on the left side at the C5-6 level as well as a small central disc herniation at the C6-7 level.
Dr. Williams, a neurosurgeon, wrote on July 11, 2000 that there was nothing on diagnostic testing which indicated that surgery would be required.
Ms. Ferren claimed entitlement to additional workers’ compensation. The claimant contended that she was entitled to additional benefits related to her neck complaints. The respondents contended that treatment for the claimant’s neck was not causally related to her compensable lower back injury.
After a hearing before the Commission, the Administrative Law Judge found that the claimant failed to prove by a preponderance of the evidence that she sustained a compensable injury to her cervical spine or neck on January 13, 2000. The Administrative Law Judge also found that the claimant failed to prove by a preponderance of the evidence that her neck pain was a compensable consequence of the January 13, 2000 compensable low-back injury. The Administrative Law Judge therefore denied and dismissed the claim for additional benefits; claimant appeals to the Full Commission.
II. ADJUDICATION
A claimant has the burden of proving the compensability of her claim by a preponderance of the evidence. Georgia-Pacific Corp. v. Carter, 62 Ark. App. 162, 969 S.W.2d 677 (1998). An accidental injury is caused by a specific incident, identifiable by time and place of occurrence. Ark. Code Ann. § 11-9-102(4)(A)(i) (Supp. 2001). For an accidental injury to be compensable, the claimant must show that she sustained an accidental injury; that the injury caused physical harm to the body; that the injury arose out of and in the course of employment; and that the injury required medical services or resulted in disability or death.Id. Additionally, the claimant must establish a compensable injury by medical evidence, supported by objective findings. Ark. Code Ann. §11-9-102(4)(D). “Objective findings” are those findings which cannot come under the voluntary control of the patient. Ark. Code Ann. §11-9-102(16). The requirement that a compensable injury be established by medical evidence supported by objective findings applies only to the existence and extent of the injury. Stephens Truck Lines v. Millican, 58 Ark. App. 275, 950 S.W.2d 472 (1997).
In the present matter, the Full Commission reverses the Administrative Law Judge’s finding that the claimant failed to prove by a preponderance of the evidence that she sustained a compensable injury to her cervical spine or neck on January 13, 2000. In this regard, Dr. Citty’s contemporaneous medical reports might understandably have led the respondents to question the claimant’s story that she was hurting over time in her neck, as well as her lower back after the incident. After all, Dr. Citty’s several follow-up reports did not mention any ongoing neck complaints in the January through March period. Nevertheless, Dr. Citty’s letter of July 3, 2000 to Dr. Williams should have cleared up any confusion on the respondents’ part, since at that time, Dr. Citty corroborated that the claimant had been making neck complaints in his office.
Furthermore, we note that Dr. Citty opined on July 3, 2000 that it was important to proceed with thoracic and cervical spine MRI studies referrable to the claimant’s injury. Likewise, Dr. Williams rendered an opinion in a August 24, 2000 letter that the lifting incident on January 13, 2000 caused the claimant’s need for medical care at issue, assuming that he had an accurate medical history. Certainly, the claimant’s medical records and testimony both appear to be consistent with the history described by Dr. Williams. In addition, we agree with the claimant’s attorney that the respondents have failed to present any expert medical opinions, or other credible medical evidence, to rebut the explanation and opinion in Dr. Citty’s July 3, 2000 letter, or to rebut the opinion in Dr. Williams’ August 24, 2000 letter. Furthermore, we note that the claimant’s alleged neck injury is supported by objective medical findings of a disk herniation at the C6-7 level of the spine.
Therefore, after conducting a de novo review of the entire record, and for the reasons discussed herein, we find that the claimant proved by a preponderance of the credible evidence that she sustained a compensable neck injury, in addition to her admittedly compensable low back injury in the incident on January 13, 2000, and the respondents are liable for the related medical expenses.
All accrued benefits shall be paid in a lump sum without discount and with interest thereon at the lawful rate from the date of the Administrative Law Judge’s decision in accordance with Ark. Code Ann.§ 11-9-809 (Supp. 2001).
The claimant’s attorney is entitled to the maximum statutory fee on the medical benefits awarded herein, one-half of which is to be paid by the claimant and one-half to be paid by the respondent, pursuant to Ark. Code Ann. § 11-9-715(a). See Coleman v. Holiday Inn, 31 Ark. App. 224, 792 S.W.2d 345 (1990). For prevailing on this appeal before the Full Commission, the claimant’s attorney is hereby awarded an additional attorney’s fee in the amount of $250 in accordance with Ark. Code Ann. § 11-9-715(b)(1).
IT IS SO ORDERED.
______________________________ ELDON F. COFFMAN, Chairman
______________________________ SHELBY W. TURNER, Commissioner
Commissioner Wilson dissents.
DISSENTING OPINION MIKE WILSON, Commissioner
I respectfully dissent from the majority opinion finding that the claimant’s neck problems are causally related to the claimant’s compensable January 13, 2000, back injury. In my opinion, the majority’s reliance on the letter from Dr. Citty of July 3, 2000, is misplaced. Dr. Citty’s letter is based upon the conversations that he had with a nurse stating that she said that the claimant complained of neck problems previous to the first indication of any neck problems in the medical records. The record indicates that there were no recorded complaints of neck pain made to anyone prior to April 30, 2000, when the claimant first stated she was having problems with her neck.
Dr. Citty’s letter, dated July 3, 2000, in and of itself cannot support the finding that the claimant sustained a compensable neck injury at the same time that she sustained the admittedly compensable back injury. The medical records are void of any notation whatsoever of any complaints of neck pain or neck problems prior to April of 2000. The notation in Dr. Citty’s letter does not qualify as a medical opinion. It is only a vague reference to an unidentified witness who allegedly claimed to have heard the claimant complain of neck pain at some unspecified time before July 3, 2000. In my opinion, this correspondence hardly constitutes corroborating evidence. Further, Ms. Karen Thomas testified that she saw or spoke with the claimant on the phone approximately one week following the claimant’s admittedly compensable January 13, 2000, injury and that the claimant never related having any neck problems. Ms. Thomas testified that she first learned of the claimant’s neck complaints sometime in April, 2000. Therefore, after I consider all the evidence, I cannot find that the claimant proved by a preponderance of the evidence that her neck problems were causally related to her compensable back injury. Accordingly, I must respectfully dissent from the majority opinion awarding benefits.
_______________________________ MIKE WILSON, Commissioner