Winter Injuries: Get the Whole Story
Thorough medical reports are the best tools for evaluating and treating injuries.With winter just around the corner, medical providers — as well as Pinnacol Assurance’s claims and medical staff — can expect to see more common winter injuries and ensuing workers’ compensation claims.
- Various knee injuries — fractures, tears to the menisci and/or ACL, severe sprains and more
- Snow shoveling-related injuries — low-back strains, arm strains and sprains, shoulder strains and sprains with potential rotator cuff or labral tears, and even heart attacks
- Slip and fall injuries — head, back and arms/wrists (e.g., FOOSH, or fall on outstretched hand)
Certainly, all of these injuries can and do occur on the job. But winter — especially here in Colorado — can create hazardous conditions anywhere: home driveways, sidewalks, supermarket parking lots and more. Additionally, many of the outdoor winter activities that so many Coloradans enjoy are inherently risky, including skiing, snowboarding and snowmobiling.
Ascertaining the mechanism of injuryAs in all injuries, winter injuries require a methodical examination approach to determine not just the severity of the injury and appropriate course of treatment. Confirming the mechanism of injury — i.e., what actually happened — is critical for knowing if an injury is work-related, pre-existing or an exacerbation of a previous condition.
Pinnacol Nurse Specialist Audra Cruz explains that Pinnacol’s staff relies on thorough, detailed medical reports in determining the mechanism (and severity) of any injury, as well as treatment guidelines.
“We rely on all sides of the story, particularly the observations and expertise of our medical providers,” said Cruz. “It’s essential to know as much as possible about the injury and the injured worker’s medical history to manage the claim and treatment effectively.”
Here are some things for providers to keep in mind for preparing thorough medical reports:
- Obtain a detailed medical history for the injured worker; this involves asking a lot of questions. Find out about previous injuries, specifically prior medical treatments and/or surgeries to the involved body part.
- Ask about the injured worker’s hobbies and physical activities, too, such as skiing or other winter sports. Sometimes, casual open-ended questions such as “Have you ever fallen before?” or “Has that knee ever bothered you in the past?” can yield important clues about previous injuries.
- Look for evidence of previous injuries in exams and MRIs, e.g., old tissue scarring, degenerative findings, acute versus chronic symptoms, and other clues such as retractions when viewing shoulder MRIs. Take note of any prior medications in the injured worker’s history as well.
Does it all add up?In the end, does the mechanism of injury match the diagnosis? Sometimes, an unlikely story (e.g., a knee injury suffered by simply “walking up stairs”) might have a more probable explanation, such as a recent weekend of hard skiing.
In all cases, include all relevant information in your reports, and be sure to highlight and/or explain any areas of interest so your points are clear to Pinnacol staff.
“This information is used for so many claims decisions, from treatment protocols to potential work restrictions and establishing financial reserves to cover potential claims costs,” said Pinnacol Claims Specialist Kathy Duncan. “Our goal is always to evaluate claims fairly and accurately. The more detailed information providers can give us, the better we can do our jobs.”
Addressing Prescription Drug Abuse
From Pinnacol's Medical Director
October 2013Pinnacol Assurance supports and is participating in the launch and one-year strategic plan development of the Colorado Consortium for Prescription Drug Abuse Prevention. The kick-off meeting of the Consortium took place Sept. 24, 2013, at the University of Colorado Skaggs School of Pharmacy. As we are unfortunately aware, Colorado is ranked as the second-worst state in the United States for prescription drug abuse, with more than 255,000 residents misusing prescription drugs. Deaths due to prescription drug misuse have increased fourfold between 2000 and 2011.
The Consortium has been tasked with lowering the current 6 percent prevalence rate of drug misuse to 2.5 percent by the year 2016. This reduction would prevent 92,000 Coloradans from misusing prescription drugs. The Consortium will be working to meet specific quarterly goals in each of the six work group areas and produce a specific Colorado Plan in one year. As Pinnacol’s medical director, I serve on the Provider Education work group, which is tasked with developing a plan for effective dissemination of information regarding best practices around prescription drug management. One of the six work groups created by the Consortium, the Provider Education work group has 16 members comprising representatives of the Colorado Medical Society, Colorado health agencies, providers, academic organizations and insurers. During the first quarter of 2014, the work group is expected to create an evaluation plan of the progress in provider education.
I again want to express my appreciation to SelectNet providers who work with great professional skill to care for injured workers and manage their pain medication requirements according to the best medical practices.
Clinic Performance Initiative (CPI) Appeals Period Extended
October 2013Pinnacol Assurance has revised the dates for the official data review and appeals period to be Oct. 16, 2013, through Dec. 2, 2013, in order to protect the integrity of Clinic Performance Initiative (CPI) performance results, communicate the revised performance ratings, and allow participating providers the opportunity to review and appeal any and all changes.
Upon finalization of the CPI metrics in December, we’ll proudly publish our Summit Elite Designations in the SelectNet Directory, which indicate the primary care providers that have earned five-star CPI ratings for two consecutive data review and appeals periods. In addition to this designation in the SelectNet Directory, we’ll be including links to these providers’ websites to give directory viewers access to more details about their practices.
Please be sure to review your CPI metrics and contact your provider relations specialist with any questions. Thank you for your patience and continued commitment to our injured workers. CPI performance results are an important measure that reflects the quality work and standards of our SelectNet providers, and we appreciate your cooperation in supporting accurate reporting for this initiative.
Compounded Topical Pain Medications
Contributed by Carrie Renehan, R.Ph., ITC Compounding and Natural Wellness PharmacyWhen treating a workers’ compensation patient, the main goal is to help the patient feel better and get back to work. Often, physicians resort to prescribing narcotics for the patient’s pain. While this can be a highly effective treatment for certain patients, for others it becomes disastrous. Narcotic addition is very prevalent. Too often, narcotic use results in extended disability and added medical costs. Compounded topically applied medications can serve as an alternative to narcotic treatment.
- What is so special about these gels?
- Why are doctors prescribing them?
- Are they helpful?
Compounded topical pain medications allow for physicians to give their patients a product that contains multiple pharmaceutical drugs in one compound, which maximizes efficacy with minimal side effects.
There are numerous advantages to this treatment, but the primary one is that it targets various pain receptors at once. Applying the medication directly to the painful area allows for a more concentrated drug reservoir in this area while decreasing systemic side effects, including drowsiness, kidney and liver problems, gastrointestinal irritations, headaches and others that are attributed to oral medication. These compounds are also nonaddictive and can reduce the risk of drug interactions.
This chart looks at the most commonly prescribed topical pain medications, their modes of action and uses.
As you can see, prescribing a combination of the above medications in one cream allows for targeting multiple pain receptors without potentially causing narcotic addiction. ITC Compounding and Natural Wellness Pharmacy’s experience has been that the patients are able to achieve the desired pain relief without the side effects or opioid dependence, and they’re able to return to work more quickly. These alternative methods of pain relief have been well-received and appreciated by both practitioners and patients.
The Benefits of Modified Duty
Workers' Comp Coordination
October 2013Modified duty is an excellent way for injured workers to participate in their recovery in a way that is meaningful to their organization while their injuries heal. Employers need to plan for this possibility and offer modified duty tasks that take injured employees' physical restrictions into consideration.
Before an injury ever occurs, Pinnacol policyholders are encouraged to create modified duty task lists for their employees. This advance preparation helps bring their injured worker back to work quickly.
Here are a few benefits of offering modified duty work:
- The injured workers stay connected to their employers.
- It allows injured workers to focus on what they can do rather than on being disabled.
- It decreases deconditioning because injured workers are working.
- Injured workers can maintain a normal work routine that contributes to their financial stability and mental well-being, which is beneficial to their relationships, both at work and at home.
Here are some tips for SelectNet providers to consider when addressing return to work:
- Request copies of preplanned task lists from the employer to familiarize yourself with possible modified duty work, prior to the initial visit.
- Tour the employer’s business or job site to see what type of work is performed, or view photos if a visit is not possible.
- Prescribe work restrictions following each visit when appropriate.
- Consider a gradual return to full-time work if the injured worker is not able to work a part-time schedule.
- Contact the employer when questions arise to ensure a safe return to work.
Modified duty is a powerful tool to manage the cost of claims, help injured workers safely return to work and help facilitate a strong working relationship with treating physicians.
Remember, Pinnacol is here to help. You can review additional information about Pinnacol’s return-to-work resources and services on our website at Pinnacol.com/Employer/Getting-Back-To-Work, or call 303.361.4000 to speak to a return-to-work consultant.
No Correlation Between Occupational Driving, Spine Damage
Conclusive medical studies refute outdated assumptionThere is a long-held belief in the medical (and workers’ compensation) community that long-term exposure to vibration and jolting — the conditions experienced by truckers and other professional drivers — could cause a back injury or accelerate a back condition, specifically disk damage in the lumbar area.
One of the most compelling studies on this topic is "Occupational driving and lumbar disc degeneration: A case control study", spearheaded by Tapio Videman, M.D., a Heritage Senior Scholar of Rehabilitation Medicine at the University of Alberta. In this study, 45 male monozygotic twin pairs were analyzed for disc degeneration with a lumbar MRI. In each pair, one twin brother was an occupational driver while the other pursued a different occupation.
Among the study’s findings: “Disc degeneration did not differ between occupational drivers and their twin brothers. We also did not identify any overall tendency for greater degeneration or pathology in occupational drivers than (in) their twin brothers.”
Study after study of occupational drivers — including rally race car drivers, tractor operators, military vehicle operators and over-the-road truck drivers — have concluded that there is no causal relationship between degeneration in the lumbar spine and vibrations (jolting) experienced while operating a vehicle. Some studies suggest the jolting might actually be beneficial, as it circulates fluid in the discs of the lumbar spine — and that heredity/genetics, inactivity, smoking, arthritis and other issues are more credible causes of lumbar degeneration.
According to longtime Pinnacol Assurance SelectNet provider Hugh H. Macaulay, M.D., there are no studies that support a relationship between vibration and disk degeneration.
“The evidence is clear,” said Dr. Macaulay. “Additionally, it’s important to remember that we can no more look at a back MRI and assume the cause of back issues than we can look at a picture of someone’s face and assume their personality type. Images do not define function.”
Recently, Pinnacol went to hearing over a claim involving a career truck driver claiming that his lumbar degeneration — including spondylolisthesis, herniated discs, annular tears, stenosis and foraminal narrowing — was work-related. After reviewing the studies noted below (and others), the administrative law judge could not assign causation of the injured worker’s ailments to his job according to the medical evidence, resulting in a ruling favorable to Pinnacol.
Recommended reading for providers
Here are three studies that have changed how physicians view the causes of lumbar degeneration:
- Occupational driving and lumbar disc degeneration: A case control study
- The long-term effects of rally driving on spinal pathology
- Whole body vibration and low back pain (literature review)
“Medical knowledge is always evolving, and these studies represent the current accepted evidence about occupational driving and lumbar disc degeneration,” said Dr. Macaulay. “I suggest that SelectNet physicians review them.”
Chronic Pain: Is it All in Their Heads?
Why and how to refer for psychological servicesContributed by Daniel Bruns, Psy.D. and Dawn Jewell, Psy.D.,
Health Psychology Associates, P.C.
When an injured worker is referred to us for a psychological evaluation, one of the statements we commonly hear is, "I don’t need to be here. I have a real injury, and this pain is not in my head." As psychologists who specialize in treating chronic pain within the workers’ compensation system, we hear this almost daily. This statement illustrates an important aspect of treating patients with chronic pain.
Pain is by far the most common reason patients seek medical care: Something hurts.1 Despite the cost and prevalence of chronic pain, few professionals are trained to treat this condition. A recent study found that no American medical school requires a class in pain, and only 3.4 percent of them even offer it as an elective course.2 The same appears to be true for psychologists and other health care professions. As a result, most health care professionals are unfamiliar with pain research and treatment methods.
The way that health care professionals most commonly interpret pain is by using something called the biomedical model. This model states simply that pain results from tissue damage, and people who report pain in the absence of tissue damage do so because of mental illness or because they are lying. However, research does not support this interpretation. In contrast, research has consistently shown that pain is best explained by something called the biopsychosocial model. This model states that pain results from a combination of biological, psychological and social factors.
When treating patients with chronic pain, health care professionals who think in terms of the biomedical model will sometimes (consciously or unconsciously) imply that patients’ pain symptoms are "all in their head." It is important to remember, though, that the phrase "all in your head" is not a scientific statement – it is an idiom that dictionaries define as being synonymous with "imaginary." What science tells us, however, is that to think of chronic pain as imaginary is incorrect. An example may be helpful here.
Suppose a worker has the great misfortune to have a hand traumatically amputated. Suppose this worker then complains of severe pain in the missing hand, so-called "phantom pain." So where is this pain? The patient says, "I have pain in my hand." Obviously though, the patient has no hand, so this is impossible. But would it be correct to say, "That pain is all in your head."? This implies that the pain is imaginary and not objectively real. This is not true either. What is true is that the patient had a catastrophic injury that, in turn, has created a disorder of the sensory system.
Chronic pain disorders in general have similarities to the above example. For a number of complex reasons, physical injuries can sometimes produce sensory disorders, which result in chronic pain, even after the original injury has healed. These sensory disorders are more likely to occur when the patient is also suffering from a high level of psychological distress. Research on the biopsychosocial nature of pain has yielded findings that are remarkable and counterintuitive, but true nevertheless. A few of these findings are as follows:
- Pain has biological, psychological and social components, and effective treatments for pain must address all three of these components.2
- Chronic pain is associated with the brain “rewiring” itself.3 The brain can shrink in size and appear to age rapidly.4
- Chronic pain may result when the brain "memorizes" severe pain and replays it in an infinite loop, even after peripheral stimulation of pain nerves have stopped.5
- The most common treatment for pain, opioid (narcotic) analgesics, have significant risks. In fact, the number of accidental deaths from prescription opioids each year exceeds the number of deaths from cocaine and heroin combined.6
- A review of the evidence determined that psychological tests are the scientific equal of medical tests7, and they can sometimes exceed the ability of medical tests to predict the outcome of surgery and medical treatments for pain.8,9
- Psychological treatments to improve pain coping skills can produce improvements in functioning that equal those of surgery in some patients10, but surgery is 168 times more expensive than psychological treatments and involves significant risks.11
- Thus, psychological treatments are safe, effective and economically conservative treatments for pain but are generally underutilized.9
The Colorado Chronic Pain Medical Treatment Guidelines state unequivocally that all patients with chronic pain should be referred for psychological services. Initially, concerns were raised that this would “open Pandora’s Box” and lead to increased costs. However, the reverse is actually the case: Research on pain has shown that psychological assessments and treatments are as valuable to the recovery process as x-rays and physical therapies. Additionally, a recent study concluded that by switching to the biopsychosocial model, Colorado’s workers’ compensation system saved an estimated $859 million in 2007 alone.11
The state's chronic pain guidelines use the biopsychosocial approach and recommend referrals to a psychologist be made in a nonjudgmental way. If you say, “The pain is all in your head! You need to see a psychologist!” the patient will probably be offended and may refuse the referral. It would be more helpful to say, “My goal is to address how you are doing both physically and emotionally. Having you see a psychologist is an important part of a comprehensive treatment plan and will help me better understand you and your symptoms.” Patients usually respond positively to this approach, feeling that their doctor genuinely cares about them.
Overall, the biopsychosocial approach to pain treatment is based on sound science and provides better care at a reduced cost. Patients perceive it as more compassionate care. It is a better approach, and that is not imaginary.
CMS Responds to Opioid Epidemic
From Pinnacol's Medical Director
July 2013The Colorado Medical Society (CMS) is taking the lead among physician organizations to develop a provider response that addresses Colorado’s opioid abuse epidemic. CMS President Jan Kief, M.D., told Governor John Hickenlooper in January that “the threat to patient safety suggests that the current methods of pain management and opioid prescribing practices require an exhaustive review and, where indicated, reforms.” She further assured the governor that he has the full cooperation of the CMS in addressing the growing epidemic. Colorado is ranked number two nationally in non-medical prescription drug abuse, which affects six percent of people over age 12.
The platform document currently being drafted by the work group will be forwarded to the Medical Society House of Delegates for final review and approval in September. It will be available to all CMS members beginning Aug. 11 for review. Thus far, the platform document begins with the goal: “To assure access to compassionate, evidence-based care for patients who suffer from acute and chronic pain.” It recognizes the need for all stakeholders — such as providers, payers and regulators — and elected officials to work collaboratively to address the opioid issue. Among the areas addressed in the draft are:
- Improvement in usage and effectiveness of the Colorado Prescription Drug Monitoring Program (PDMP)
- The appropriate role of professional review and law enforcement
- The requirements of the Colorado Board of Medicine
- Development of an appropriate public health strategy, including use of community-based programs
- Development of and support for professional and public education
“The more attention the platform gets from practicing physicians the better,” said Alfred Gilchrist, the CMS CEO. “The issue is very complex with many interrelated parts. We learn something new every time our work group is convened or when we meet with individual physicians.” Physicians interested in an immediate review of the draft platform document can obtain a copy by emailing Gilchrist directly at Alfred_Gilchrist@CMS.org.
An opioid prescribing member survey will soon be sent to CMS members. I urge all SelectNet physicians who are CMS members to complete and return the survey.
In my meetings with SelectNet providers, I have heard your input regarding the challenges of pain management and opioid prescribing. I have attempted to communicate your concerns while serving as a member of the CMS work group. The inappropriate use of opioid medications will not be turned around overnight. However, the relationship and trust between a provider and patient is the key component to combating this epidemic.
Ed Leary, M.D.
Court Sets Standard for Firefighter Cancer Claims
July 2013The recent case of Town of Castle Rock v. Industrial Claim Appeals Office involved a worker who had worked as a firefighter, engineer and paramedic for the Town of Castle Rock since November 2000. He served as a firefighter in Albuquerque, New Mexico, before moving to Colorado. During his off hours, he worked in construction — and sometimes outdoors — framing and building decks. In 2011, the worker was diagnosed with malignant melanoma on his right outer calf. He underwent three surgeries to remove the growth and subsequently was released to work full duty. He appears to be cancer free.
The administrative law judge (ALJ) ruled that to overcome the presumption, a specific non-work-related cause of the cancer had to be established. The employer’s expert testified that the injured worker’s various other exposures and risk factors placed him at far greater risk of developing melanoma than his activities as a firefighter. The ALJ ruled that the expert’s opinion was insufficient to overcome the presumption. The ALJ noted that the statute required showing “by a preponderance of the medical evidence that such condition or impairment did not occur on the job.” The ALJ interpreted this to mean an employer must show that an injured worker’s cancer comes from a specific cause not occurring on the job. The introduction of other risk factors was not enough. The Industrial Claim Appeals Office (ICAO) affirmed the ALJ’s ruling.
The employer and its insurer argued that the ALJ and ICAO misinterpreted the statute. They asserted that the ALJ should have considered the evidence of risk factors it introduced to determine whether the presumption was overcome. The Colorado Court of Appeals agreed. The court held that evidence of risk factors can be sufficient to overcome the presumption under this language and that it was an error to require the employer to prove a specific, non-work-related cause of the injured worker’s cancer. The court noted that the standard applied by the ALJ and ICAO is nearly insurmountable because the cause of most cancers cannot be determined. Such a standard would amount to a strict liability statute mandating that every firefighter who develops one of the prescribed cancers is entitled to workers’ compensation coverage.
The court of appeals concluded that an employer may overcome the statutory presumption of compensability with specific risk evidence demonstrating that a particular firefighter’s cancer probably was caused by a source outside work. It sent the case back to the ALJ to review the evidence under the standard it had articulated and to issue a new order.