                   COURT OF APPEALS OF VIRGINIA


Present: Judges Elder, Frank and Humphreys
Argued at Chesapeake, Virginia


AGNES V. LANNING
                                               OPINION BY
v.   Record No. 2264-01-1                JUDGE ROBERT P. FRANK
                                             MARCH 26, 2002
VIRGINIA DEPARTMENT OF TRANSPORTATION


        FROM THE VIRGINIA WORKERS' COMPENSATION COMMISSION

          John R. Lomax (Berry, Ermlich, Lomax &
          Bennett, on brief), for appellant.

          Cheryl A. Wilkerson, Assistant Attorney
          General (Randolph A. Beales, Attorney
          General; Judith Williams Jagdmann, Deputy
          Attorney General; Gregory E. Lucyk, Senior
          Assistant Attorney General; Scott John
          Fitzgerald, Assistant Attorney General, on
          brief), for appellee.


     Agnes V. Lanning (claimant) filed a claim for benefits with

the Virginia Workers' Compensation Commission (commission)

alleging an injury by accident and development of the

occupational disease of carpal tunnel syndrome while working for

the Virginia Department of Transportation (employer).    The

deputy commissioner found a compensable ordinary disease of

life, but did not award any lost time or benefits.     The full

commission reversed the deputy commissioner, finding claimant

failed to meet her burden to prove that her carpal tunnel

syndrome was caused by her work.   For the reasons stated, we

reverse the commission and remand for further findings.
                              BACKGROUND

        The evidence is not controverted.

        Claimant alleges both an injury by accident on February 25,

2000, and the occupational disease of carpal tunnel syndrome.

Claimant began working for employer in 1982 as a toll collector.

In 1994, she was transferred to a clerical position, which

involved data entry, purchase orders, inventory, and

requisitions.    She testified that on February 25, 2000, she was

using her right hand to make her daily time entries when her

hand "wouldn't work."    She could not move her fingers.

        Claimant testified she began to feel "twinging and

tingling" in her right wrist six months prior to the February

25, 2000 incident, but did not seek medical attention until

after that incident.    While claimant has a home computer, she

"very seldom" used it.    She further testified her only activity

at home involving repetitive movement was light housework.    She

did not knit, garden, or work with hand tools.

        On March 3, 2000, claimant saw Dr. Frank G. Burns, Jr., her

primary treating physician.    Dr. Donald E. LaMarche, Jr.,

performed an electrodiagnostic study on March 17, 2000, and

diagnosed right-side carpal tunnel syndrome.    Dr. Burns

performed a carpal tunnel release on the right arm on April 11,

2000.    Due to complications, claimant underwent another carpal

tunnel release on August 25, 2000.



                                 - 2 -
     Dr. Burns first saw claimant in 1993, after she sustained a

severe injury to her left arm and hand while working at the toll

booth.   Dr. Burns performed surgery on her left shoulder.

However, for a while after the surgery, claimant was unable to

use her left arm at all, and she began having symptoms of right

hand carpal tunnel syndrome.   She had several "flare-ups" during

subsequent years.   In 1999 and 2000, her right hand symptoms

became much more severe.

     In his letter dated January 18, 2001, Dr. Burns indicated

claimant's "pain is related to her on the job injury and the

recurrences that she has had is related [sic] back to her

original injuries and having to use the right arm more."     Other

than this letter, no evidence directly addressed causation.

     The deputy commissioner found claimant had met her burden:

           All of the claimant's doctors agree that the
           claimant suffers from carpal tunnel syndrome
           and Dr. Burns causally related it to her
           work. It is clear to the Commission that
           the claimant had no significant exposure to
           the hazards of carpal tunnel syndrome
           outside of the work place and that her job
           entailed numerous repetitive activities
           exposing her to the danger. Outside the
           workplace, she performs no unusual
           activities and is not involved in extensive
           sports or recreational activities that could
           cause the problem. Based upon the
           persuasive and uncontradicted evidence, we
           find that she has met her burden of proving
           that her carpal tunnel syndrome was caused
           by her employment, and she has established
           all elements required by [Code] § 65.2-401
           by clear and convincing evidence, not a mere
           probability.


                               - 3 -
The deputy commissioner further found, however, that claimant's

medical records did "not support any period of disability."

     The full commission reversed the deputy's award, finding:

            although Dr. Burns has stated that her
            carpal tunnel syndrome is related to her
            work, this is insufficient to establish by
            clear and convincing evidence that her work
            caused her carpal tunnel syndrome. In prior
            cases, we have held that a medical opinion
            that a condition is "compatible" or
            "related" to work is insufficient.

(Emphasis in original.)    The commission did not determine if any

period of disability existed.

                               ANALYSIS

                      I.   Evidence of Causation

     On appeal, we construe the evidence in the light most

favorable to the party prevailing below.     R. G. Moore Bldg.

Corp. v. Mullins, 10 Va. App. 211, 212, 390 S.E.2d 788, 788

(1990).    The commission's finding of fact on the issue of

causation will be upheld if supported by credible evidence.      See

James v. Capitol Steel Constr. Co., 8 Va. App. 512, 515, 382

S.E.2d 487, 488 (1989); Ingersoll-Rand Co. v. Musick, 7 Va. App.

684, 688, 376 S.E.2d 814, 817 (1989).

     Code § 65.2-400(C) provides "the condition[s] of carpal

tunnel syndrome are not occupational diseases but are ordinary

diseases of life as defined in [Code] § 65.2-401." 1   Code



     1
         Code § 65.2-401, "Ordinary disease of life" coverage,
reads:

                                 - 4 -
§ 65.2-401 provides that the elements required to prove a

compensable ordinary disease of life must be "established by

clear and convincing evidence, (not a mere probability)."   The

narrow issue before this Court, therefore, is whether claimant

proved by "clear and convincing evidence" that her carpal tunnel

syndrome was caused by her employment.



          An ordinary disease of life to which the
          general pubic is exposed outside of the
          employment may be treated as an occupational
          disease for purposes of this [Workers'
          Compensation] title if each of the following
          elements is established by clear and
          convincing evidence, (not a mere
          probability):

          1. That the disease exists and arose out of
          and in the course of employment as provided
          in § 65.2-400 with respect to occupational
          diseases and did not result from causes
          outside of the employment, and

          2.   That one of the following exists:

               a. It follows as an incident of
          occupational disease as defined in this
          title; or

               b. It is an infectious or contagious
          disease contracted in the course of one's
          employment in a hospital or sanitarium or
          laboratory or nursing home as defined in
          § 32.1-123, or while otherwise engaged in
          the direct delivery of health care, or in
          the course of employment as emergency rescue
          personnel and those volunteer emergency
          rescue personnel referred to in § 65.2-101;
          or

               c. It is characteristic of the
          employment and was caused by conditions
          peculiar to such employment.


                               - 5 -
           For an ordinary disease of life to be
           compensable, a claimant must prove by "clear
           and convincing evidence, (not mere
           probability)" that the disease (1) arose out
           of and in the course of his employment, (2)
           did not result from causes outside of the
           employment, and (3) follows as an incident
           of an occupational disease, is an infectious
           or contagious disease contracted in the
           course of the employment listed in Code
           § 65.2-401(2)(b), or is characteristic of
           the employment and was caused by conditions
           peculiar to the employment. Code
           § 65.2-401; see also Lindenfeld v. City of
           Richmond Sheriff's Office, 25 Va. App. 775,
           784, 492 S.E.2d 506, 510 (1997).

Great E. Resort Corp. v. Gordon, 31 Va. App. 608, 612, 525

S.E.2d 55, 57 (2000).

     We have defined "clear and convincing evidence" as:

           "that measure or degree of proof which will
           produce in the mind of the trier of facts a
           firm belief or conviction as to the
           allegations sought to be established. It is
           intermediate, being more than a mere
           preponderance, but not to the extent of such
           certainty as is required beyond a reasonable
           doubt as in criminal cases. It does not
           mean clear and unequivocal."

National Fruit Prod. Co. v. Staton, 28 Va. App. 650, 654, 507

S.E.2d 667, 669 (1998) (quoting Fred C. Walker Agency, Inc. v.

Lucas, 215 Va. 535, 540-41, 211 S.E.2d 88, 92 (1975)) (emphasis

in original), aff'd, 259 Va. 271, 526 S.E.2d 266 (2000) (per

curiam).

     Claimant contends the treating physician's opinion that her

pain is "related" to her work was sufficient to prove causation

between the disease and the workplace.   Employer contends the


                               - 6 -
word, "related," is not proof of causation by "clear and

convincing evidence."   The commission agreed with employer,

finding that simply "relating" carpal tunnel syndrome to work

conditions was insufficient to establish by clear and convincing

evidence that claimant's work caused her disease.

     Dr. Burns traced his treatment of claimant to March 31,

1993, for an injury to her left arm and shoulder "when somebody

at the toll booth grabbed her arm and about pulled her out of

the toll booth."   Because of the injury and resulting surgery to

her left shoulder, Dr. Burns indicated claimant "started having

symptoms of right carpal tunnel syndrome."   This condition began

in May 1994, when claimant had to use her right arm more

frequently.   Dr. Burns related that claimant had "flare ups of

this off and on over the years and it became much more severe in

1999, and in 2000."   He opined that this injury:

           goes all the way back to her original
           injury[. W]e have put a lot of stress and
           strain on her right arm and over the years
           she has developed carpal tunnel syndrome,
           which has become worse with the type of
           computer work she is now doing. I think her
           pain is related to her on the job injury and
           the recurrences that she had is related
           [sic] back to her original injuries and
           having to use the right arm more, and also
           the work she is doing now, using the
           computer.

     The commission focused solely on Dr. Burns' use of the

word, "related," without considering the totality of his medical

opinion.


                               - 7 -
        We agree with the commission that a bare assertion that a

condition is "work-related" does not meet the "clear and

convincing" standard.    The fact that a condition is "related to"

the workplace is not proof by itself of causation.      However, the

evidence here includes more than a bald assertion of a

relationship between claimant's work and carpal tunnel syndrome.

        While he employed the words, "related" and "related back,"

Dr. Burns explained he believed claimant's present problem with

carpal tunnel syndrome was caused by her original injury at the

toll booth.    The "injury" became worse due to her constant use

of the computer in her new position.      He did not merely assert

that the injury was related to her job; he explained how her

prior and present work conditions resulted in the injury.

Additionally, no evidence proved claimant had carpal tunnel

syndrome or experienced symptoms related to that condition prior

to her work for employer, and the evidence proved no causes

outside her employment contributed to that condition.      In this

context, Dr. Burns' opinion could be considered clear and

convincing evidence that claimant's condition was caused by her

work.

        "We will not substitute form over substance by requiring a

physician to use magic words . . . when the record is void of

any evidence of non-employment factors responsible for [the

condition]."    Island Creek Coal Co. v. Breeding, 6 Va. App. 1,

11-12, 365 S.E.2d 782, 788 (1988).       As Commissioner Diamond said

                                 - 8 -
in the dissent, "[t]he Commission should not require the use of

talismanic words to find causation."

     We are cognizant of the standard of review.   However, the

commission did not properly evaluate the evidence in this case.

Rather than viewing Dr. Burns' medical opinion in its entirety,

the commission addressed only his use of the word, "related," in

its decision.   We cannot affirm a decision that emphasizes the

use of one word to the exclusion of considerations of the

context within which the word is used and other evidence in the

record.

                     II.   Period of Disability

     We now turn to the question of whether claimant is entitled

to disability from April 11, 2000, the date of surgery, until

October 2, 2000, the date when claimant returned to work.    The

deputy commissioner found the medical records do not support any

period of disability.   The commission did not consider

disability.

     In order for us to review a decision of the commission, the

commission must make a finding, even if the deputy commissioner

previously made a factual ruling.   See Goodyear Tire & Rubber

Co. v. Pierce, 5 Va. App. 374, 377, 363 S.E.2d 433, 434 (1987).

As the commission did not address claimant's appeal of the

deputy's finding that the evidence showed no period of

disability, we must remand this issue for further findings by

the commission.

                                - 9 -
     For the reasons stated above, we reverse the commission's

opinion and remand for the commission to determine if the

entirety of the medical evidence is sufficient to show

causation.   The commission also must make a finding regarding

the period of disability, if causation is found.

                                            Reversed and remanded.




                              - 10 -
