Affirmed by unpublished opinion per Grosse, J., concurred in by Ellington and Lau, JJ.

GROSSE, J.

A trial court is not required to give a party's proposed instructions as long as the instructions given correctly state the law and permit the parties to argue their case. Here, the instructions correctly defined industrial injury and occupational disease.

We review a jury verdict in a workers' compensation case to determine whether substantial evidence supports that verdict. Here, there was sufficient evidence to support the jury's finding that Stephanie Miller's right-sided carpal tunnel syndrome was caused by or aggravated by an industrial injury, or alternatively, arose naturally and proximately from the conditions of her occupation.

FACTS

Miller was certified as a Certified Nursing Assistant (CNA) in 1985 and worked in that position until December 18, 2003. On November 7, 2003, Miller was working with psychiatric patients at Valley General Hospital. Her duties included taking patients' vital signs, such as blood pressure, pulse, respiration, and temperature. Taking a patient's blood pressure involved wrapping a pressure cuff around the patient's arm and pumping up the cuff by squeezing a ball with her right hand. This was done for every patient at the beginning of every shift. When a patient fell, this process was repeated with the patient lying down, sitting up, standing, and again lying back down at least every 15 minutes for the first two hours after the fall and every 30 minutes for the next two hours. Miller was responsible for twelve patients on each 12 to 16 hour shift and she worked seven days a week.

At times patients would be combative and need to be restrained. Patients were bathed every morning and again during the shift if they became soiled. Bed linens were changed at least every other day and more often if needed. Miller made chart entries documenting the patients' vital signs, fluid intake, and food intake, and at times, entered these notes in the computer. All of these activities required the use of her hands and wrists.

Early in her shift on November 7, 2003, Miller grabbed the left arm of a patient who weighed well over 300 pounds who had become agitated and was combative with other patients. Miller grabbed the patient's left arm by placing her right arm under the patient's left arm pit and bending her elbow with her fingers pointing up and back towards her chin. This formed a "V" shape, locking the patient's left arm with hers. Another CNA grabbed the right arm of the patient. The patient lunged forward and to the left and then fell to the floor. The other worker let go of the patient's right arm but Miller was pulled forward by her right arm until she released the patient. Although Miller did not fall to the floor, she felt an instant burning down her right forearm, bicep, shoulder, and neck. She also felt a burning in her low back. Approximately 15 or 20 minutes later, Miller felt a throbbing inside of her right forearm and bicep area.

Miller reported the injury to her supervisor, who provided Miller with an "Employee Report of Incident" form which Miller completed. In that report, Miller stated she was helping an ambulatory patient with a walker move when the patient became resistant as she was being helped to her chair. The patient buckled and Miller felt a sharp pain shoot through the middle of her back that worsened as the night wore on. Miller checked the upper back as the only part of her body affected and did not check the blocks for neck, shoulder, wrist, or hand. As to the cause, Miller checked the block for lifting but not for a combative patient, and was unable to explain why she had done so.

During the next 24 hours, Miller continued to feel a burning and throbbing in her right forearm. The right side of her neck felt as if it had been torn. The top of her right shoulder to her neck and down her spine ached but did not burn. Even though these conditions worsened over the following days, Miller continued to work, working 12 hours on November 7, 8, 9, 12, and 14, 2003.

On November 20, 2003, Miller consulted Dr. Dennis Mann, D.O. Miller informed Dr. Mann that within a day or two of the incident she had begun to develop significant pain and muscle spasms in the right neck, upper back, and shoulder with some tingling paresthesias in the right hand and fingers. Dr. Mann prescribed physical and massage therapy. Miller told her massage therapist about the pain in her neck, lower back, right arm, forearm and numbness and tingling in her finger when she would lie down. Miller also told North Sound Physical Therapy that she was having frequent numbness in her fingertips of her right hand.

On November 24, 2003, Miller completed a "Self-Insurer Accident Report" in which she again stated that she was moving an independent and ambulatory patient when the patient buckled. She said she felt tearing in the muscles in her back and arm and these sensations worsened through the night. She indicated the parts of the body affected were her back, neck and right shoulder.

Miller continued to work for Valley General until mid-December 2003 doing lighter duty. She continued to experience a tingling and numbness in her two right fingers especially when she took patients' blood pressure. Miller testified that Dr. Mann told her not to work until she was fixed and stable, and she has not yet been released to return to work by Dr. Mann.

Dr. Mann's initial diagnosis did not include carpal tunnel syndrome even though some of Miller's reported symptoms were consistent with that diagnosis. He diagnosed her condition as acute sprain or strain on the thoracic area.

On December 1, 2003, Miller complained of discomfort in the right scapular and thoracic areas, chest, neck, and right shoulder, but did not complain of numbness in her right hand. She voiced similar complaints on December 22, 2003, and January 9, 2004. Dr. Mann found no evidence of carpel tunnel syndrome at this time even though some of these symptoms were consistent with such a diagnosis.

Dr. Mann recounted that on February 2, 2004, Miller had told him that she felt a generalized numb, tingling feeling throughout her right hand, especially when that hand was elevated. Dr. Mann found these symptoms similar to those Miller had reported in her initial visit with him. He referred Miller to Dr. Clay Wertheimer, an orthopedic surgeon.

In March 2004, Miller saw Dr. Wertheimer and described her injuries as severe pain in her right shoulder and tricep area, and numbness and tingling in her fingers on the right side. Dr. Wertheimer felt the problem could be a brachial plexus injury or thoracic outlet syndrome and recommended an MRI, which turned out relatively normal. Dr. Wertheimer recommended that Miller be referred to a neurologist and undergo a cervical magnetic resonance imaging (MRI).

Miller saw Dr. Kutsy, a neurologist, who performed an electromyogram nerve conduction velocity study (EMG-NCV) which indicated severe right carpal tunnel syndrome, while the cervical MRI was essentially normal.

Based on the EMG-NCV test results, Dr. Mann concluded that Miller suffered from right carpal tunnel syndrome and found that the carpal tunnel condition was, on a more-likely-than-not basis, caused by the November 7, 2003 industrial injury. He based this diagnosis on his conclusion that the November 7, 2003 injury had "lit up" and made symptomatic an underlying and asymptomatic carpal tunnel condition. Dr Mann testified that most carpal tunnel is caused by repetitive grasping, gripping, and twisting, which causes hyperextension and hyperflexion of the wrist. Dr. Mann referred Miller to Dr. Harold McCutchan, a hand surgeon, for evaluation. Dr. McCutchan first saw Miller on May 7, 2004. He recommended Miller undergo surgery for severe right carpel tunnel syndrome.

Dr. Mann informed Miller that she could not return to work at a job that required using her right upper extremity for pulling, pushing, lifting, carrying, grasping, or similar activities until her carpal tunnel syndrome had been surgically corrected. He agreed that any cervical strain, right shoulder strain, or low back strain related to the November 7, 2003 incident was fixed and stable, and required no further treatment or award for a permanent partial disability.

Dr. McCutchan testified that after examining Miller, he concluded that she had severe right carpal tunnel syndrome and that she had had the condition before the industrial injury. Dr. McCutchan's chart note of September 1, 2005, indicated that it would be reasonable to assume that more-likely-than-not Miller's carpal tunnel syndrome was secondary to the November 7, 2003 injury in the right upper extremity or that the injury at least exacerbated or lit up the underlying carpal tunnel condition. His testimony, however, was somewhat more equivocal than his written notes. He testified that the tingling and numbness that Miller reported in the right hand and fingers within the first 24 to 48 hours after injury could have been due to problems with the neck or brachial plexus as well as carpal tunnel syndrome.

In response to a hypothetical that included a patient experiencing a burning sensation in the forearm after injury, Dr. McCutchan's response was "perhaps" such a burning sensation could indiciate a worsening of the patient's carpal tunnel syndrome. Only after an additional hypothetical in which a patient described a tearing sensation in the forearm with the development of pain and paresthesia afterwards could Dr. McCutchan conclude that the hypothetical patient's preexisting carpal tunnel condition would have, on a more-probable-than-not basis, become worse because of an accident.

Valley General presented medical testimony of Dr. Francis Fleming, a plastic surgeon who reviewed Miller's records but did not examine or treat her. Dr. Fleming concluded that on a more-probable-than-not basis, the carpal tunnel syndrome condition preexisted the November 7, 2003 industrial injury, but that it was asymptomatic at that time. Dr. Fleming testified he was unable to determine when Miller developed the carpal tunnel syndrome, but that severe carpal tunnel syndrome usually occurs over a long period of time, when there is not a precipitating incident. Dr. Fleming concluded that the industrial injury did not cause Miller to develop carpal tunnel syndrome.

Miller's last day of employment at Valley General was December 18, 2003. She remained unemployed until her claim was closed on August 22, 2005. Miller had experienced a right hand or wrist injury while working for Valley General in February 2003 when a patient had grabbed her right arm and twisted it. She missed no work, but the arm was sore, bruised, and swollen for approximately one week. Earlier, Miller had fallen off a quadrunner and bumped her left elbow, for which she saw a Dr. Yates on November 3, 2003. Miller saw Dr. Yates again complaining of back pain caused by heavy lifting and a lot of stress as she was moving from one house to another.

Miller did some basic computer work for her husband, typing bills on blank sheets of paper, 10 or 15 minutes, once a month. He had a full time job and also did some jobs on the side if he had time.

Miller's employment history stated that she worked as a CNA at Madeleine Villa Convalescent Center from April 9, 1984 to July 3, 1999, providing basic care for the elderly, and for Favorite Nurses from June 1999 to the date of her application for employment at Valley General on November 1, 2001.

Married with four children, Miller enjoyed gardening but could not keep up with it after the injury. Miller had driven a car with a stick shift from 2003 to 2004, but sold it when she could no longer drive it because the fingertips of her right hand would go numb.

The jury returned a special verdict finding that Miller's carpal tunnel syndrome arose naturally and proximately from conditions of her employment or was the result of an industrial injury.

ANALYSIS

Standard of Review

A superior court's review of a determination of the Board of Industrial Insurance Appeals (BIIA) is de novo and includes the right to a jury trial. The party seeking review bears the burden of demonstrating that the BIIA's decision was improper. In workers' compensation litigation, live witnesses appear only before the BIIA. During superior court proceedings, the record is closed and the parties' attorneys read the transcript to the jury. As noted in Rogers v. Department of Labor and Industries, a jury applies the standards set forth in RCW 51.52.115:

The Board's decision is prima facie correct under RCW 51.52.115, and a party attacking the decision must support its challenge by a preponderance of the evidence. On review, the superior court may substitute its own findings and decision for the Board's only if it finds from a fair preponderance of credible evidence, that the Board's findings and decision are incorrect.

This court reviews the record to determine whether substantial evidence supports the jury's verdict. Substantial evidence is defined as a quantum of evidence sufficient to persuade a rational, fair-minded person that the premise is true.

Sufficiency of Evidence

Valley General argues that the entire verdict should be reversed because insufficient evidence supports the finding that Miller's right-sided carpal tunnel syndrome was an occupational disease. Although Valley General couches its arguments in terms of the trial court's failure to hold as matter of law that there was insufficient evidence to submit the matter to a jury, it made no motion for a directed verdict or for a judgment notwithstanding the verdict.

The jury heard testimony from three physicians: Dr. Mann, Miller's treating physician; Dr. McCutchan, the hand specialist; and Dr. Fleming, Valley General's medical expert. Valley General argues that there is no evidence establishing a causal relationship between the industrial injury and the alleged disability, and that the medical testimony proffered to establish a causal relationship between an industrial injury and an alleged condition or disability must be phrased in terms of medical probability, not possibility.

Medical testimony that an incident could cause, might cause, or possibly could cause such a condition is not sufficient. While Dr. McCutchan's testimony was equivocal at times, it still had indications, both in his original written chart notes and in response to hypothetical questions that more-probable-than-not, the carpel tunnel syndrome was lit up by the industrial injury.

Dr. Mann, the treating physician, testified that the carpel tunnel syndrome was more-probable-than-not related to the industrial injury. There may be one or more proximate causes of a condition or disability. For a worker to recover benefits under the Industrial Insurance Act, the industrial injury must be a proximate cause of the alleged condition or the disability for which benefits are sought. The law does not require that the industrial injury be the sole cause of such condition or disability. The fact that Valley General's expert witness disagrees with their position is a matter for the jury — the fact finder. Here, there was substantial evidence for the jury to find that the injury was a proximate cause of the alleged condition.

Instructions

Jury instructions are reviewed de novo, and "an instruction that contains an erroneous statement of the applicable law is reversible error where it prejudices a party." Jury instructions are sufficient when they allow parties to argue their case theories, do not mislead the jury and, when taken as a whole, properly inform the jury of the law to be applied. Whether to give a particular jury instruction is within the trial court's discretion. We review a trial court's refusal to give a requested instruction for an abuse of discretion. "A trial court abuses its discretion if its decision was manifestly unreasonable, or its discretion was exercised on untenable grounds, or for untenable reasons." There is no abuse of discretion here.

The instructions given by the court adequately informed the jury of the law and informed them of the law that was to be applied in reaching their decision. Valley General's instructional arguments are tied in with its argument that there was insufficient evidence to sustain the jury's verdict. In particular, Valley General argues that the only premise on which the jury could find Miller's carpel tunnel to be an occupational disease would be if the jury relied on Dr. Mann's medical testimony regarding carpel tunnel syndrome, which was based on hypothetical questions. But the instructions given adequately describe an expert witness and inform the jury that it can examine the basis upon which an expert forms his or her opinion and the source of the witness's information, i.e., a hypothetical. The court's instructions permitted counsel to argue the hypothetical and the problems associated with it in closing argument, which Valley General did. Instructions which permit the party to argue their theory to the jury are acceptable.

In particular, Valley General contends it was error for the court to not give its proposed instruction 12, regarding the requirements a jury needs to find in order to determine that a condition constituted a compensable industrial injury. The court's given instruction 12 used language taken directly from the statute which defines the term "injury." The trial court was not required to give Valley General's additional statement that if the jury failed to so find, it would not be an industrial injury. Again, Valley General was able to argue this to the jury.

Valley General also argues that it was error to not give its proposed instruction 13, which defined occupational disease according to RCW 51.08.140 and which permitted Valley General to argue its theory that the carpel tunnel was idiopathic and would have occurred anyway as proffered by Valley General's expert, Dr. Fleming. Valley General once again ties this instructional argument in with its sufficiency of the evidence argument. But evidence was presented that would allow the jury to find that Miller's work involved tasks in which she repetitively used her wrists. Valley General argues that the instructions failed to advise the jury that it was to consider only whether Miller's employment with Valley General was the cause of her condition, not her 21-year work history. This is clearly erroneous. The last injurious exposure rule for workers who suffered an occupational disease as defined by the statute, provides that the employer during the most recent exposure bearing a causal relationship to the employee's disability is liable for the entire amount of the award.

Valley General also contends that the court erred in not giving its proposed instruction 5. But that instruction is identical to paragraph 5 of the court's instruction 1.

Valley General next contends the instructions that the court did give were erroneous. In particular, it complains about instructions 19, 20, and 21. Court's instruction 19:

You should give special consideration to testimony given by an attending physician. Such special consideration does not require you to give greater weight or credibility to, or to believe or disbelieve such testimony. It does require that you give any such testimony careful thought in your deliberations.

This instruction is in accordance with the law. In Hamilton v. Department of Labor and Industries, a similar instruction was used and examined in the context of a workers' compensation claim. The Hamilton court specifically stated that the instruction was proper because it was an accurate statement of a longstanding rule of law in workers' compensation cases. In Chalmers v. Department of Labor and Industries, the case Valley General relies on to support not giving such an instruction, is inapposite. There, the court found that the treating physician's testimony relied on an erroneous factual basis. Such is not the case here.

Valley General assigns error to instructions 20 and 21 that deal with total disability. Court's instruction 20:

Total disability is an impairment of body which renders a worker unable to perform or obtain a gainful occupation with a reasonable degree of success and continuity. It is the loss of all reasonable wage earning capacity.

A worker is totally disabled if unable to perform or obtain regular gainful employment within the range of his or her capabilities, training, education and experience. A worker is not totally disabled solely because of inability to return to his or her former occupation. However, total disability does not mean that the worker must have become physically helpless.

If, as a result of an industrial injury or disease, a worker is able to perform only special work not generally available or odd jobs, then the worker is totally disabled, unless the employer shows that some special kind of work which he or she can perform is available to the worker on a reasonably continuous basis.

Total disability is permanent when it is reasonably probable to continue for the foreseeable future.

Court's instruction 21:

You are instructed that if the Plaintiff was totally disabled as the result of her industrial injury or disease combined with other conditions related or not related to the industrial injury, then Plaintiff is entitled to compensation for the combined effects.

Interestingly, the jury found no disability, either total or temporary. Valley General argues that this somehow provided a benefit to Miller because the jury found that the carpel tunnel syndrome was a related condition. But a jury is presumed to follow the instructions, and the instructions here were lawful and permitted the parties to argue their theory of the case.

Finally, Valley General contends that the trial court should have offered its proposed verdict form which prefaced each question with the phrase: "Was the Board of Industrial Appeals correct." Instruction 8, offered by the court, clearly stated that the "findings and decision of the Board of Industrial Insurance Appeals are presumed correct." And "[t]he burden of proof is on the claimant to establish by a preponderance of the evidence that the decision was incorrect."

Moreover the verdict form itself provided in part:

INTERROGATORY NO. 1: Was Stephanie Miller's symptomatic right-sided carpal tunnel syndrome proximately caused by the injury of 11/7/03 or was it a condition that arose naturally and proximately from the distinctive conditions of her occupation as of 8/22/05?

ANSWER: ________ (Yes or No)

In order for you to reach a verdict on this question it is not necessary that five or more jurors agree on whether it was an injury or a disease, only that five or more agree it was one or the other.

Thus, it was clear that the jurors had to agree on which basis they found causation. And because the record before us contains substantial evidence on which the jury could find either basis, there was no error.

Attorney Fees

The reasonableness of an attorney fee award is reviewed under an abuse of discretion standard. A trial court abuses its discretion only when its decision is manifestly unreasonable or based on untenable grounds. If a fee shifting statute does not indicate how a fee award is to be calculated, Washington courts use the lodestar method, multiplying the attorney's reasonable hourly rate by the number of hours reasonably expended. This amount may be enhanced for a number of reasons, including risks associated with cases taken on a contingency basis. The lodestar method is used to calculate legal fees in workers' compensation cases. RCW 51.52.130 provides for attorney fees when an appeal in the superior or appellate court reverses or modifies the BIIA's decision and grants additional relief to the worker. Washington case law permits a court to add a multiplier to a lodestar fee as a contingency adjustment under circumstances discussed in Bowers v. Transamerica Title Insurance Co.

The trial court awarded $34,125 in fees based on an hourly fee of $350 and a lodestar multiplier of 1.5. Valley General does not dispute the time spent, only the hourly rate and the multiplier. The trial court issued findings of fact in support of its award of fees and costs. Equating the work done with "partner level work," the court found the $350 hourly fee to be reasonable. The court also found the work to be exceptional and that the risky contingency fee basis here was worthy of a 1.5 multiplier. Such fees may be enhanced for a number of reasons, including the risks associated with cases taken on a contingency basis as here. In awarding the multiplier, the court noted, as did the Supreme Court in Brand, that the "purpose behind the award of attorney fees in workers' compensation cases is to ensure adequate representation for injured workers who were denied justice by the Department [of Labor and Industries]." In addition to the risk, the trial court found both the high quality of the trial work and the experience of Miller's attorney warranted the multiplier. The issue is not whether this court would award a different amount, but whether the trial court abused its discretion. Valley General has failed to show abuse of discretion.

Valley General also argues that the trial court erred in striking the brief it proffered to the court the morning the attorney fees/cost motion was set to be argued. While not admitting the brief, the court did permit Valley General to argue all of its points orally, including the cases cited in the brief. The exclusion of the brief was well within the discretion of the trial court.

We affirm the trial court. Additionally, we grant Miller her attorney fees and costs on appeal, provided she complies with RAP 18.1.

WE CONCUR.