                    COURT OF APPEALS OF VIRGINIA


Present: Judges Fitzpatrick, Overton and Senior Judge Duff
Argued at Alexandria, Virginia


FAIRFAX COUNTY SCHOOL BOARD
                                          MEMORANDUM OPINION * BY
v.       Record No. 2771-96-4          JUDGE JOHANNA L. FITZPATRICK
                                               JUNE 17, 1997
LISA M. LEWIS PUEBLA


         FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION

           Michael N. Salveson (Hunton & Williams, on
           briefs), for appellant.
           Thomas W. Ullrich for appellee.



     On appeal from the decision of the Virginia Workers'

Compensation Commission awarding Lisa Puebla (claimant) benefits,

Fairfax County School Board (employer) contends that the

commission erred in (1) imposing an improper burden of proof on

employer and (2) finding that claimant's medical problems are

causally related to her industrial accident.   For the following
                                                      1
reasons, we reverse the decision of the commission.
                              BACKGROUND

     On October 26, 1993, claimant suffered minor injuries when

the school bus in which she was riding as an attendant stopped

suddenly and caused her to fall.    She suffered a contusion to the

head, dizziness, contusions to both knees, and a cervical strain.

     *
      Pursuant to Code § 17-116.010 this opinion is not
designated for publication.
     1
      Because we reverse on the causation issue, we do not
address the burden of proof issue for purposes of this appeal.
The commission found this injury to be compensable, and awarded

her benefits.

     Following her accident, claimant received treatment from

several physicians.   Dr. Kerry Lewis (Dr. Lewis) treated claimant

for her cervical injury.   His notes following claimant's first

visit on November 1, 1993 reflect the following impressions:
          Exam of skull reveals slight tenderness in
          the right temporal area. There is no
          significant soft tissue swelling . . . .
          Neck-supple w/ good ROM. . . . Chest wall
          reveals tenderness along the left anterior
          ribcage . . . . Abd-massively obese,
          nontender, no organomegaly. . . . Exam of
          left knee reveals tenderness . . . . There is
          good ROM w/o instability.

     On March 11, 1994, Dr. Lewis concluded that he "[w]ould feel

at this point that [claimant] has no physical limitations based

on her prior neck injury . . . . I feel there are no physical

limitations related to her neck injury currently."   He reiterated

this conclusion in correspondence dated April 12, 1995 to Linda

Glassco, claims specialist:   "[A]t that time that [claimant]

exhibited no significant physical limitation based on her prior

neck injury.    I felt [] [claimant] was fully capable of doing

secretarial work which required tasks such as filing or sitting

at a desk.   I have not had contact with her or spoken to her

since that last visit." Finally, Dr. Lewis stated as follows:
          I believe [claimant] did suffer a cervical,
          thoracic and lumbar strain as a result of her
          accident on 10/26/93. It appears that [she]
          has, in general, recovered from her cervical
          and lumbar strain. There is no objective
          evidence of current injury. . . . I feel that
          [claimant] is capable of performing sedentary



                                  2
             tasks such as secretarial work. I do not
             feel she is capable of further work as a
             school bus attendant. I feel the inherent
             instability of moving about on a traveling
             bus is not in her best interest and leaves
             her open to further falls and possible
             additional injury.


(Emphasis added.)

     Claimant's orthopedic surgeon, Dr. Rubin D. Cabrera (Dr.

Cabrera), examined her and on November 5, 1993, he noted that she

was overweight, and at the time of her accident weighed "about

312 lbs."    He diagnosed claimant with "contusion of head.

Dizziness.    Contusion of both knees with more pain on the left

than before.    Obesity -- thyroid problem."   On February 4, 1994,

Dr. Cabrera found that "[e]xamination of the knee revealed that

examination is still difficult because of the thickness of the

subcutaneous fat in this patient.      There is a normal ROM.   There

is diffuse tenderness.    Patient is walking, using a cane."    Dr.

Samuel R. Sawmiller examined claimant on February 8, 1994, for a

second opinion regarding her knees. He concluded as follows:
               This patient has pre-existing arthritis
          in her knee, primarily patella femoral,
          secondary to her weight. She has obviously
          sprained the left knee and this has set off a
          vicious cycle of pain, synovitis, aggravated
          by the weight which has caused her to do most
          of the work with the right knee that has now
          made the right knee sore.

                  There is little question that this
             patient had problems although asymptomatic
             prior to the injury and that these knees will
             never, ever be resolved to normal knees.

                  It is my feeling that this patient
             should probably not be back in a school bus
             at any time in the foreseeable future just


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          because of the difficulty of dealing with a
          moving bus and getting in and out through the
          entryway.


Additionally, he noted that "[t]he only constructive suggestion I

have is weight loss but I see no reason to offer further

injections or orthopaedic treatment of this knee" and that "[a]t

the present time I don't see how this patient can work on a

school bus.   She will be employable at a sedentary type job where

she does not have to stand or walk."
     Dr. Thomas Fogarty, a psychiatrist, examined claimant on

March 23, 1994, and determined that:
          [T]his is a 27 year old woman who has a prior
          history of significant depression which had
          gone untreated. She is currently on a
          complicated regimen of medications, which she
          cannot take due to side effects. . . . It is
          very difficult to determine what is causing
          her headache at this time. It could very
          well be improved with alteration of her
          medicine or regimen.


He later examined claimant upon her admission to the hospital on

October 16, 1994 for seizures. He found that:
          [T]he patient had significant illness
          behavior which was compounded by her
          psychosocial situation and family dynamics.
          Approximately three days prior to discharge,
          she developed a generalized shaking and at
          times unresponsive and invariable way [sic].
           She was seen in neurologic consultation as
          well as by the house physician, who agreed
          that the patient probably had pseudo
          seizures. As the behavior persisted, it
          appeared to be goal directed with secondary
          gain suggesting a conscious and willful
          aspect of her behavior consistent with
          malingering . . . . [I]t was felt that
          continued inpatient hospitalization would
          lead to further regression in her behavior
          . . . . It became clear that she did not want



                                 4
             to return to her part time position. It was
             emphasized that she could not return to full
             time employment at this point as a bus aide,
             nor could she be expected to be fully
             compensated without working . . . .

                  . . . She was discharged with a
             diagnosis of cervical and lumbar myofascial
             pain, bilateral knee pain of unclear
             etiology, prescription medication abuse,
             somatoform pain disorder and atypical
             depression rule out conversion disorder
             versus malingering.


     On December 8, 1995, more than two years after claimant's

compensable injury, Dr. Cabrera saw claimant for yet another

complaint.     His notes reflect the following events:
             [Claimant] says that on December 1, 1995,
             both of her knees locked up for about 6
             minutes. Since that day, they occasionally
             give out and she has constant pain. . . .

                    *      *    *    *    *    *    *

             Examination shows that she has good ROM of
             both knees. She has no crepitation and no
             instability of the collateral ligaments. I
             could not find any evidence of effusion.
             . . .

             I had told [claimant] during the examination
             that I did not see any relationship between
             the accident and her present symptoms. I
             believe she needed investigations.


(Emphasis added.)       Finally, Dr. Cabrera examined claimant on

January 18, 1996, and concluded that both knees were "normal."

Dr. Cabrera further indicated that claimant's initial compensable

knee sprain had healed, that the symptoms claimant complained of

"are subjective symptoms, but they could have a pathological

basis due to [claimant's] overweight," and that she could "return




                                     5
to a sedentary type of work from the orthopedic point of view and

her knee problems."

     On March 14, 1996, employer requested the commission to

suspend or terminate claimant's benefits, on the grounds that her

disability at the present time was unrelated to the industrial

accident.   Upon review, the deputy commissioner determined that

claimant's benefits should be reinstated.   The deputy

commissioner found as follows:
          A review of the evidence leads us to conclude
          that the employer has failed to establish
          that [claimant's] compensable injury no
          longer contributes to her disability. While
          it is clear from the medical records that the
          employee suffers from several medical
          problems, the records further show that as a
          result of her compensable injury, the
          employee has sustained knee problems
          complicated by a pre-existing condition.

     The full commission agreed that the "employer's evidence

fails to show she has recovered from other injuries of the

accident" and found that,
          the fact that the claimant's condition has
          generally healed does not show that the
          injury in question has resolved. Neither
          does the absence of objective evidence
          necessarily mean there is no actual injury
            . . . .

                   *    *    *    *    *    *    *

                 The burden is on the employer, as the
            moving party in these proceedings, to prove
            that the medical evidence preponderates to
            establish that the claimant's disabling
            medical problems are unrelated to her work
            injury. We agree with the Deputy
            Commissioner that the employer failed to
            satisfy its burden of proof in this case, and
            the June 7, 1996 Opinion is AFFIRMED.



                                  6
7
                         CAUSAL CONNECTION

     Employer argues that no credible evidence supports the

commission's finding that claimant's ongoing medical problems are

causally related to the industrial accident.   We agree.

     In its application for review of claimant's award on the

grounds of change in condition, the burden was upon employer, the

party alleging such change, to prove its allegations by a

preponderance of the evidence.   See Great Atlantic & Pacific Tea
Co. v. Bateman, 4 Va. App. 459, 464, 359 S.E.2d 98, 101 (1987).

     The commission's finding with respect to the casual

relationship between an accident and an injury is generally

binding on appeal, if based on credible evidence.   C.D.S. Constr.

Services v. Petrock, 218 Va. 1064, 243 S.E.2d 236 (1978);

Ingersoll-Rand Co. v. Musick, 7 Va. App. 684, 688, 376 S.E.2d

814, 817 (1989).   Additionally, if reasonable inferences may be

drawn from credible evidence, they also will be upheld on appeal.

 See Tumlin v. Goodyear Tire & Rubber Co., 18 Va. App. 375, 378,

444 S.E.2d 22, 23 (1994).   Causation is established when it is

apparent to the rational mind upon consideration of all the

circumstances that a causal connection exists between the work

conditions and the resulting injury.   See, e.g., Bradshaw v.

Aronovitch, 170 Va. 329, 335, 196 S.E. 684, 686 (1938); Marketing

Profiles, Inc. v. Hill, 17 Va. App. 431, 434, 437 S.E.2d 727, 729

(1993).

     It is undisputed that, on October 26, 1993, claimant



                                 8
suffered minor injuries to her knees, head, and spine in a

work-related accident.   It is also undisputed that claimant

suffers from obesity and ailments related to her weight

condition.   However, the record unequivocally establishes that

all of claimant's treating physicians determined that any effects

of claimant's industrial accident have long since dissipated.

Under familiar principles, the opinions of treating physicians

are entitled to great weight.   See, e.g., Pilot Freight Carriers,
Inc. v. Reeves, 1 Va. App. 435, 339 S.E.2d 570 (1986).      Thus, we

hold that there is no connection between the work-related

injuries and claimant's current complaints.

     Dr. Lewis' records indicate that, as of March 11, 1994,

claimant had "no physical limitations related to her neck injury"

that occurred on October 26, 1993, and that she had generally

"recovered from her cervical and lumbar strain."   Dr. Sawmiller's

diagnosis of claimant as of February 1994 was that she had

"pre-existing arthritis in her knee" and that "this patient had

problems . . . prior to the injury."   He also found that

claimant's "knees will never, ever be resolved to normal knees."

Dr. Fogarty examined claimant for possible neurological

problems, and found that "[i]t is very difficult to determine

what is causing her headache" and that "[t]he patient had

significant illness behavior . . . [that] appeared to be goal

directed with secondary gain suggesting a conscious and willful

aspect of her behavior consistent with malingering . . . ."     He



                                 9
determined that claimant's ultimate diagnosis upon discharge was

"cervical and lumbar myofascial pain, bilateral knee pain of

unclear etiology, prescription medication abuse, somatoform pain

disorder and atypical depression rule out conversion disorder

versus malingering."    Finally, Dr. Cabrera determined that

claimant's December 1995 knee complaints "had no relationship" to

her earlier work-related injury.      He also found that claimant's

initial compensable knee sprain had healed.
     Accordingly, the evidence supports employer's allegation of

change in condition.    No credible evidence and no inferences

therefrom support the commission's conclusion that claimant's

current complaints are causally related to her October 26, 1993

accident.   Rather, the medical evidence confirms that claimant's

obesity and related difficulties existed prior to her compensable

injury and would "never, ever" be "resolved," regardless of the

healing of her October 1993 injury.     The evidence fails to

establish that claimant's current problems are causally related

to her 1993 accident.

     The decision of the commission is reversed.

                                                           Reversed.




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