Reaching Out

Robert Kistenberg is a clinical specialist consultant with Paradigm Outcomes. He is also the co-director and prosthetics coordinator at Georgia Institute of Technology. In the “Today” show segment, Aimee Copeland demonstrates her use of the advanced partial forearms and hands customized for her by Kistenberg.

Copeland’s new prosthetic hands and forearms were custom-designed by Kistenberg and manufactured by Touch Bionics to address her bilateral upper limb amputations. The prosthetics would ordinarily cost more than $100,000 each, but since Copeland is acting as a spokesperson for the company, they are complimentary. She will be the first woman ever to use the technology on both arms.

Aimee’s Story

Copeland is a Georgia graduate student who escaped to the woods with some friends for the weekend and wound up in an accident on a homemade zip line. Her wounds went from minor to life threatening when she was diagnosed with necrotizing fasciitis—a fast-spreading, flesh-eating bacteria. To save her life, doctors amputated portions of all four limbs.

In the “Today” show segment, Copeland showed off tasks she has already learned to do with her new digits—from chopping strawberries to shaking hands. Kistenberg praised Copeland as a “fast learner” who is “smart and very adept.” She is quickly picking up the muscle movements required to manipulate the prosthetic limbs. With time and practice, she should be able to “use them without thinking about it” to do the things most people take for granted—like driving a car, cooking, cleaning, or opening doors.

Upcoming Chapters…

You can keep up with Aimee’s progress on her website. Kistenberg will share more of his expertise during an upcoming Paradigm webinar about amputations in August. To find out more about the webinar or for information on Paradigm’s approach to managing cases involving amputations and prosthetics, contact us via our website or call 888-621-6602. We also invite you to join our social communities on LinkedIn, Twitter, Facebook and YouTube.

Not that long ago, amputation and prosthetics meant a very different life for those affected. Their mobility may have been compromised by confining them to a wheelchair or crutches; amputation of an upper extremity may have significantly limited their ability to complete daily activities. Fortunately, the quality of life for amputees has improved in recent years, thanks to advances in technology that give prosthetic devices more functionality and physical capabilities resembling that of natural limbs.

So how do you best manage cases involving amputation and prosthetics?

Accidents and Catastrophic Injuries in Trucking

Trucking, part of the transportation industry, is second on that list. About 500,000 trucking accidents happen annually in the United States, according to Legal Info. Sixty-eight percent of trucking-related fatalities happen in rural areas, not in cities. Fatigue and long hours on the road are considered risk factors in trucking, according to a 1992 article in the Journal of Public Health Policy.

In the 1992 study, over one thousand long haul tractor-trailer drivers were interviewed by a research team over four months, and almost three-quarters of the respondents said they self-reported violations of Hours-of-Service rules. Two-thirds said they “routinely” drive more than legal weekly maximums. Those long hours in the driver’s seat lead to decreased attentiveness and heightened rates of fatigue, creating prime conditions for unwanted accidents and catastrophic injuries.

Of the five occupations with the most catastrophic injuries, transportation has the highest rates of multiple trauma, spinal cord injury, and traumatic brain injuries. Among truckers, common co-morbidities like obesity, sleep apnea, smoking, diabetes, and high blood pressure can make treatment options and outcomes more difficult to manage.

Trucking Safety

The American Trucking Association reported an 84 percent increase in miles traveled by large trucks, as well as a 41 percent increase in the number of registered large trucks, between 1986 and 2006. Over the same time span, the number of large trucks involved in fatal crashes declined by 5 percent, according to the same source. Legal changes and industry self-regulation may be contributing to increased safety ratings among truckers. Still, the nature of truck driving—long hours in a large, heavy vehicle carrying variable cargo—makes trucking a particularly hazardous occupation.

Catastrophic injuries are life altering and employees in these catastrophic occupations are at increased risk for major disruptions to income and well-being. When accidents happen, protect your employees and your bottom line with proven care management services from Paradigm.

Paradigm Outcomes is always ready to assist with complex medical cases. For more information on our full-service offerings or to find out more about catastrophic care management, please contact us through our website or call (888) 621-6602. We also invite you to join our social communities on LinkedIn, Twitter, YouTube and Facebook.

The THINC Study

The research was headed by Dr. Gunjan Y. Parikh, a fellow at the National Institute of Neurological Disorders and Stroke. He and several associates evaluated 256 patients enrolled in a study implemented at two hospitals: Washington (D.C.) Hospital Center and Suburban Hospital in Bethesda, Md. The study, termed the Traumatic Head Injury Neuroimaging Classification (or THINC) study, evaluated 256 patients during initial emergency room visits for head injuries and in the crucial first hours of treatment. The findings were released on March 12, 2012, just before their presentation at the American Academy of Neurology Annual Meeting (March 16 to 23 in San Diego), where the research was presented for the first time.

New Imaging Protocols

The THINC study implemented imaging protocols: an MRI within 48 hours of presentation at the hospital with acute head injury, followed by visits at 4, 30, and 90 days­—even if patients didn’t receive a positive diagnosis for concussion. Protocols at follow-up visits were intensive: diffusion-weighted imaging (DWI), T2-weighted MRI, fluid-attenuated inversion recovery (FLAIR), and three-dimensional tracking imaging (3-DTI).

Surprising Results

Of the 256 patients, 104 had evidence of hemorrhage in the brain. These patients received more detailed brain scans (using advanced MRI technologies) within an average of 17 hours after injury. 20 percent of those 104 patients showed imaging evidence of microbleed lesions, while 33 percent had linear lesions that suggest vascular injury. These linear lesions, new evidence of vascular injury in TBI, were associated with injury to surrounding or adjacent brain tissues. Microbleed lesions, on the other hand, were distributed throughout the brain after mild TBI.

Putting Research Into Practice

The team’s research findings have multiple implications for treatment of TBI. Dr. Parikh and his team found evidence of trauma indicative of mild TBI and long-term impacts even in patients that would have been sent home untreated using traditional diagnostic protocols.

The results also have implications for doctors who see diffuse axonal injury (DAI) on a regular basis. In cases of diffuse axonal injuries, which often happen due to the shearing forces in auto accidents or falls, trauma to the brain is widespread rather than in a narrow location as with focal brain injury due to direct impact. DAI has been thought to be one of the most common causes of coma or persistent vegetative state after TBI. However, as Dr. Parikh told Doug Brunk of ACEP News, “Not everything that we’re calling diffuse axonal injury is diffuse axonal injury.” In many cases, targeting therapies to vascular injury rather than to assumed DAI may drastically improve patient outcomes.

Dr. Parikh is quick to point out that this research is preliminary and difficult to replicate due to the exigencies of working with TBI in clinical settings. Still, the research findings are important to the successful treatment of both mild and severe TBI, so further research along these lines should be forthcoming in future years.

At Paradigm, we work to keep abreast of the latest traumatic brain injury research and other relevant medical topics. Connect with us on LinkedIn and Facebook to stay up to date on the latest workers’ compensation and complex care management news.

Traumatic brain injuries (TBIs) can be life threatening or cause lifelong damage and can be difficult to detect in the field. New military research may be closing in on a test that Army medics could use to detect brain injuries on location.

Diagnosing Brain Injuries

Traumatic brain injuries at the cellular level can be almost impossible to detect. The Army’s news service reported Col. Dallas Hack, Director of Combat Casualty Care in Fort Detrick, Md., said it’s difficult to know whether an individual has damage to brain cells or tissues. In assessing a patient’s condition, doctors or medics ask questions, perform balance tests, or ask him or her to follow a moving object with their eyes.  That means the patient must be awake and active to participate, and the field circumstances must be conducive for adequate testing. This is not always possible.

The Future of Diagnosis for Traumatic Brain Injuries

Researchers at Hack’s facility are investigating ways to detect damage to brain cells that are similar to current methods used for testing blood sugar levels. “We have some articles that have now been published in peer reviewed literature that show a really good sensitivity and specificity,” said Hack.

The Army plans to file for Food and Drug Administration approval of the test once the current clinical trials are complete, which should be by the end of 2013, Hack said.

Military and Industry Leaders Working Together

The current clinical trials are a combined endeavor between the U.S. Army and private interests. The team collaboration was designed through the Military Health System Research Symposium, where researchers from the University of Florida and members of the Walter Reed Army Institute of Research first met in 2001 to discuss the project.

Benefits for Private Sector Treatment in Brain Injury Cases

Private research personnel and funding are already being channeled into this enterprise. Such a test could enable quick, efficient hospital care and immediate treatment for brain injuries. First responders or even law enforcement officers could administer the test at accident scenes, leading to early identification of TBI and maximizing patient outcomes by  allowing hospital staff to concentrate on appropriate patient care during the crucial first minutes after admission.

The April issue of Risk & Insurance Magazine is a great place to begin preparing for the conference. Their annual show feature covers emerging risks and other articles on a range of industries. Pick up a free issue from their booth #1501, only a couple of rows over from Paradigm at booth #1913.

Cyril Touhy, Managing Editor of Risk & Insurance, offers a detailed preview of the annual convention online. Among the many issues covered during the four day event, Touhy expects earthquakes to be popular topic of discussion. The conference does take place in Los Angeles, after all. If that’s not your area of interest, there’s bound to be something for you among more than 100 sessions across 11 categories. Read his article, “Ready, Set, Action!” for more recommendations.

The President of RIMS, John R. Phelps, offered his advice to conference attendees in a recent blog post, “Connecting Flight to LA.” He writes, “Leading up to the conference, I’ve been asked several times ‘what advice do you have for someone who has never been to the RIMS Annual Conference & Exhibition.’ My advice for the risk professionals that are committed to improving themselves in order to increase the value they bring to their companies is to develop a plan before they go.” That sounds like good advice for us all. Read the full article for more thoughts on his organization’s big event.

When formulating your plan for the conference, check out the Risks of 2013 as forecasted by Senior Editor Jared Wade and the rest of the team at Risk Management. Preparing for the future is a great way to minimize risk and position yourself for success. We particularly enjoyed Marcia Carruthers’ contribution to the series, “Shifting to a Disability Demographic,” where she wrote, “Corporate attention to disability, as a risk factor and a key area of concern, has increased dramatically over the last 20 years, and this trend must continue. Smart employers will begin to prepare now for this new demographic.”

With all those sessions and exhibitors competing for your attention, you may want to check out the RIMS ‘13 Mobile Application for your smartphone and tablet devices. The app aims to help you plan your time, navigate the exhibit hall, follow the buzz on social media, and connect with vendors and attendees. We used it last year and are eager to check out the new features.

We hope you enjoy the conference. Be sure to visit us in booth #1913.

Paradigm Outcomes is always ready to assist with complex medical cases. For more information on our full-service offerings, please feel free to contact us through our website or call (888) 621-6602. We also invite you to join our social communities on LinkedIn, Twitter, YouTube and Facebook.

A new traumatic brain injury study by researchers at the University of Oklahoma found that the symptoms of brain injury could last for at least eight years after the injury. That’s a far cry from the prevailing wisdom that concussions and minor brain injuries heal in a short time with rest. The study found that traumatic brain injury symptoms, such as headaches, memory problems, dizziness, and depression, could last much longer than previously thought.

Brain Injuries Can Cause Lasting Symptoms

The study was presented at the yearly meeting of the American Headache Society. Researchers examined 500 U.S. military veterans who were diagnosed with traumatic brain injury during deployment. The research team administered tests to gauge severity and occurrence of post-concussion syndrome—the collection of brain injury symptoms that includes headaches, coordination problems, dizzy spells, depression, and judgment or memory problems.

The veterans who participated in the study were divided into two groups based on when their injury happened: those whose injuries occurred within four years of the testing date, or those that occurred five-to-eight years before the study. They found no improvement in symptoms for veterans whose injuries were older.

In the group whose injuries were more recent, about half the veterans reported mild-to-moderate headaches. The other half had persistent trouble with severe headaches. The percentages were almost the same for veterans with older injuries—45 percent reported mild headaches and 50 percent reported problems with severe headaches. That pattern continued for the other symptoms: dizziness, coordination, depression, and decision-making problems. Symptoms were worse for veterans who had multiple head injuries, suggesting a cumulative effect.

Treating Traumatic Brain Injury

Brain injuries result in both physical and psychological problems. “We have to recognize that people who may have head injuries may look the same, but they often are not going to act the same,” said Dr. James R. Couch, a professor of neurology at the University of Oklahoma medical school and the lead author. “You’ve got to stabilize the patient’s interaction with family and try to create the best milieu for the patient to be able to return to employment, stay with the family and return to self-respect.”

For more information about managing traumatic brain injuries, contact us via our website or call 888-621-6602. We also invite you to join our social communities on LinkedIn, Twitter, Facebook and YouTube.

U.S. News & World Report recently reported on 167 service members who have remained on active duty after a major limb amputation. Some have returned to battle situations, while others are now working behind the lines in “support roles.” John Fergason, chief of prosthetics at the Army Center for the Intrepid in Houston, told U.S. News: “When we have someone we know wants to return, their rehab is geared that way.”

Innovation Out of Tragedy

“Unfortunately, when you have war, you have casualties, but with that comes innovation,” Fergason said.

“The person doesn’t have to worry about the prosthetic device, they’re worrying about the task in front of them,” said Kevin Carroll, vice president of prosthetics at Hanger, a company that makes artificial limbs. “If they want to go back to be with their troops, that’s an option for many soldiers these days.”

Every military branch has separate protocols for allowing soldiers with amputations to return to work. Soldiers pass requirements specific to the tasks they perform. Soldiers returning to battle must be able to perform at least as well as their fellow soldiers, and many perform even better. Individuals who can’t perform the same tasks after their amputations as they did previously are reassigned to different duties.

Despite the advances in technology, it’s a soldier’s drive that enables him or her to return to work. Often, lower-tech options are used in battle situations to avoid the possibility of prosthetics failure at a crucial moment.

For information about how Paradigm successfully manages cases involving amputations, contact us via our website or call 888-621-6602. We also invite you to join our social communities on LinkedIn, Twitter, Facebook and YouTube.

Back-Up Brain Systems

Robert Mason, senior research psychologist at CMU, and Chantel Prat, assistant professor of psychology at the University of Washington, designed the research study to increase understanding of the brain’s function during periods of injury. They used cutting-edge functional resonance imaging (fMRI) techniques to understand how 16 healthy adults adapted to injury in the region of the brain that governs language comprehension, known as the Wernicke area.

According to the study, when one area of the human brain is injured and unable to function normally, secondary brain areas become “back-ups,” replacing the functions of the injured area and closely-related parts. This adaptability means that the brain has the ability to rebound from serious injury.

Changes in Brain Activity after Brain Injury

The researchers used Transcranial Magnetic Stimulation, or TMS, during the fMRI scans to temporarily disable the Wernicke area of the study subjects’ brains. The method simulates brain injury without causing any lasting damage.

Mason, the lead author on the study, told News Medical that the impaired brain region and “partners” that work with it slowly regained their normal range of activity as the TMS wore off; during that time, a back-up team of brain areas was still working to coordinate activity. “This means,” he said, “that for some period of time, there were two cortical teams operating simultaneously.”

According to Mason, the results explain why a person’s performance is sometimes improved by exposure to TMS. When back-up brain areas come online, they coordinate areas close to the site of the injury and spots that are a mirror image of the injured location (called contra-lateral areas), with a frontal area in charge of organizing and giving commands.

Practical Applications

The involvement of a “frontal executive area” to identify and coordinate back-up areas is a critical component in the brain’s ability to adapt to injury. Understanding the ways the human brain adapts has implications for therapy, pointing to ways people can train their brains to facilitate easier and quicker recovery times.

At Paradigm, we work to keep abreast of the latest traumatic brain injury research and other relevant medical topics. Connect with us on LinkedIn and Facebook to stay up to date on the latest workers’ compensation and complex care management news.

Understanding Pain and Stress

University of Montreal research team Vachon-Presseau et al. titled the pain study “The Stress Model of Chronic Pain: Evidence from Basal Cortisol and Hippocampal Structure and Function in Humans.” The researchers found stress management to be top priority for individuals with a smaller-than-average hippocampus. They also found a strong correlation between the size of the hippocampus and vulnerability to stress. Dr. Pierre Rainville told Rick Nauert of Psych Central, “Our research sheds more light on the neurobiological mechanisms of this important relationship between stress and pain.”

The researchers found links between cortisol, size of the hippocampus and pain in 16 individuals with back pain (compared to an 18-person control group). Cortisol, also known as the “stress hormone,” was higher in individuals with smaller hippocampal volume—and patients with higher cortisol levels were more likely to report chronic pain.

The Feedback Loop between Anatomy, Stress and Pain

In addition, the study found that patients with higher cortisol levels and smaller hippocampal size also experienced more activity in a region of the brain related to anxiety over the anticipation of pain. Patients who experience more chronic pain and higher levels of stress also tend to manifest heightened anxiety that can lead to greater pain experience, in a feedback loop that links anticipation of pain, stress and pain itself.

The study supports a theoretical “chronic pain vulnerability model” in which some people with a confluence of physical, hormonal and psychological proclivities are more likely to develop chronic pain. Those same characteristics can lead to greater suffering due to chronic pain over time. Breaking the feedback loop by learning to manage stress through meditation, writing, exercise or other classic stress management techniques can physically alter a vulnerable patient’s experience of recurring pain.

Paradigm Outcomes is always ready to assist with managing your company’s emerging and chronic pain claims. Fill out our contact form if you have a case you would like to refer to Paradigm. Make sure to follow us on LinkedIn and Twitter.