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The subacromial bursa is a small fluid filled sac located at the top, outer aspect of the shoulder designed to reduce friction between the acromion and the tendon of the supraspinatus muscle.  While elevating the arm, rotating the shoulder, lifting, pushing, pulling or lying on the shoulder forces are placed on the subacromial bursa.  This can also occur with a direct impact or fall onto the point of the shoulder. Irritation and/or inflammation of the bursa can occur over time with repetitious movements or suddenly with a direct blow to the point of the shoulder or a fall onto the shoulder. 

Symptoms include pain at the top, front, back or outer aspect of the shoulder, which can sometimes radiate into the upper arm as far as the elbow.  Less severe cases may experience an ache or stiffness in the shoulder which increases with rest following activities that placed strain on the bursa.  However, as the condition progresses symptoms may increase during the activity or sport.   

Although the condition can be diagnosed through a thorough subjective and objective physical examination, an ultrasound is usually used to confirm the diagnosis.  Further diagnostics such as x-ray, CT or MRI can assist in the diagnosis of other conditions which may be present and assess the severity of the condition.

Generally, Subacromial Bursitis can be treated conservatively beginning with rest to the shoulder and diligently performing exercises.  Physical therapy using ultrasound and cryotherapy to reduce inflammation is also helpful.  If that didn’t provide adequate pain relief, then steroid injections could be tried.  Surgery is a “last resort” type of care in the form of an arthroscope to visualize and repair any damaged structures.

Subacromial bursitis often occurs in conjunction with other shoulder conditions such as rotator cuff tear, tendinopathy, shoulder impingement or shoulder instability.  These are usually of slow onset because the result of repetitive activities at work, but subacromial bursitis can also come about acutely, for example as the result from a direct blow to the shoulder or a fall on the shoulder.

These types of injuries are slow to heal and for that reason can result in high treatment costs and increased employee missed time from work.  Often whether or not the claimant heals completely or at all is subjective and the success of treatment falls strongly on the claimant’s compliance.  This makes surveillance a great option in cases of high suspicion because if you catch your guy in the middle of 18 holes with no apparent shoulder problems, then you really have something!

7/3/2018

   

What a great country we live in!  I have been to more countries then I can count on two hands and it always feels great to come back home to the United States.  It is easy to take our freedom for granted until we see how other people around the world live – afraid to speak their mind in public, small living spaces without all the amenities we take for granted. 

On this great day, join me in saluting the great men and women of the armed forces who defend our freedom every day and to those who have sacrificed their lives so our freedom would not be taken from us. 

Let freedom ring!

5/2/2018 in Medical Conditions
 

Low back pain is an extremely common condition world-wide.  In fact, regardless of cause it is the leading reason for job disability.  One in ten persons experience it and for the majority the pain becomes chronic in nature.  Research published in the journal of Pain Medicine has found that massage may provide lasting relief for chronic low back pain.

The study involved 104 people with chronic back pain who were referred by their doctors to licensed massage therapists.  They attended 10 sessions over a 12 week period and the therapists used techniques customized to the individual, rather than all using the same technique.  At the end of the study, more than 50% of participants reported improvement in their back pain.  In fact, their scores on a standard screening test dropped below the threshold for disability.  For many, their improvements lasted.  More than three months following treatment, 75% reported that they still felt better.

While it is suggested that massage directly reduces inflammation in the muscles, more research is needed to figure out exactly how it works to reduce pain. 

Reference:  Real-World Massage Therapy Produces Meaningful Effectiveness Signal for Primary Care Patients with Chronic Low Back Pain: Results of a Repeated Measures Cohort Study, Pain Medicine, Volume 18, Issue 7, July 2017, Pages 1394-1405.

3/22/2018 in Medical Conditions
 
   

Chronic low back pain (CLBP) of a minimum three months duration is the second leading cause of disability worldwide; as such it represents a major welfare and economic problem.  In the last 10 years, the incidence of CLBP has increased by more than 100% and continues to increase dramatically in the aging population.  It is responsible for more global disability than any other health condition.  So, whether you are processing worker’s compensation or personal injury claims, low back pain is a condition to be reckoned with.

A back injury in an already degenerating spine can create CLBP.  How?  Healthy disks have a gel-like substance inside of them that acts as a “shock-absorber,” but as disks degenerate, they shrink, making them less able to buffer against motion.  As disks collapse, they begin to compress the spinal nerves that run through them.  Additionally, when gel leaks out of a disk (herniation), it results in bulges that can compress nerves or the spinal cord itself. 

Recent research has shown that people with disk degeneration have lower levels of a protein called SPARC (secreted protein acidic and cysteine rich).  This protein regulates cell growth and binds calcium, and is responsible for several biological processes, namely bone development.  It is believed that less SPARC results in accelerated rates of disk degeneration along with low back pain and radiating leg pain.  Mice lacking SPARC had an increased number of nerve fibers that were supplying disks and areas around disks which could explain how disk degeneration causes back pain.  Degenerating disks have been found to have high levels of NGF (nerve growth factor), which attracts pain-sensing fibers to the area, which increases the subject’s sensation of pain.

But, the most troubling discovery is that over time, chronic low back pain leads to changes in the dorsolateral prefrontal cortex (DLPFC) of the brain.  This area of the brain is involved in higher order processes such as conscious decision making, reasoning, working memory, inhibition, as well as outcome prediction. 

The good news is that recent test subjects who positively responded to treatment had a reversal of changes to the brain.  Research is continuously providing new information concerning chronic low back pain.  In fact, there are drug therapies designed to block NGF that are currently in clinical trials, and if proven successful will be a brand new way of treating pain not only for the back but other areas of the body as well. 

For more detailed information go to:  http://relief.news/deciphering-chronic-low-back-pain/

Thank you to our guest blogger, J. Jay Goodman, MD, General and Vascular Surgery.  It is highly unlikely that the development of an abdominal wall hernia can be attributable to a single strenuous event. A specific type of abdominal wall hernia referred to as an epigastric hernia (fatty hernia of the linea alba) is defined as a fascial defect of the midline and represents a congenital defect in the fascia between the rectus abdominal musculature. These hernias must lay in the midline between the lower edge of the sternum (xiphoid) and the umbilicus. An umbilical hernia is a separate type of anatomic defect.

The linea alba is embryologically formed by the midline junction of the rectus abdominis sheaths. Epigastric hernias begin as small protrusions of preperitoneal lipomas. An epigastric hernia tends to have small defects (less than 2.0cm) and are difficult to palpate in an obese individual.  The  hernia can appear spontaneously, and many are asymptomatic. Pain may develop from entrapment of preperitoneal fat or the omentum.

Work activities do not affect the onset or progression of epigastric hernias. If preperitoneal fat or intraabdominal tissue enter these small defects, the pre-existing anatomic pathology may manifest itself. If the hernia strangulates during work activities and emergency surgery is needed, one should relate the emergency need for surgery to the work activity. The work activity does not cause the hernia defect and does not accelerate the deterioration of the hernia.

Once an epigastric has been identified regardless of symptoms, it should be repaired surgically so that a complex emergency repair is avoided.

Dr. Goodman is available to do IMEs in the Milwaukee and Fox Valley areas.  Contact Medical Systems for more information or to schedule.

11/30/2017 in Treatment

Guest Blogger:  Dennis Brown, MD

On July 2, 2017, the prestigious “Journal of American Medical Association” (JAMA) published an authoritative medical study regarding radiofrequency denervation (ablation) procedures for chronic low back pain titled "Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain," which concluded "The findings do not support the use of radiofrequency denervation to treat chronic low back pain from these sources" (facet joints, sacroiliac joints or a combination of facet joints, sacroiliac joints, or intervertebral disks).
 
It is medically probable radiofrequency denervation is not medically reasonable or necessary for the treatment of chronic low back pain.

Reference:  Johan N. S. Juch, MD; Esther T. Maas, PhD; Raymond W. J. G. Ostelo, PT, PhD, et l Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain The Mint Randomized Clinical Trials, JAMA. 2017;318(1): 68-91.doi:10.1001/jama.2017.7918

 
   

Lack of support is the most difficult and critical problem to address because it is often a major factor in an ALJ’s decision that an IME report was not credible.  Unfortunately, not all doctors agree on what constitutes adequate support.  Thus, the cover letter writer may receive an IME report and conclude that the expert did not support her answers sufficiently, but be faced with a headstrong expert who disagrees.  Although difficult, this scenario can be overcome.

First, the IME vendor should work with the writer to explain to the expert the importance of citing relevant evidence, professional experience, and medical literature in the report. The IME vendor should be able to explain to the expert that a conclusory answer without any sort of explanation as to how and why the expert reached the conclusion will not pass muster with the “trier of fact” (ALJ).  In truth, experts want to write effective, credible reports because they know that good reports generate more business opportunities.  Thus, experts will often be receptive to requests to strengthen their conclusions if the evidence and literature supporting their opinion is obvious and available. 

Second, the cover letter writer is typically the person who is most familiar with the claim being addressed, which puts the cover letter writer in the best position to point to the hard evidence and literature that supports the expert’s conclusions.  While no IME vendor will tell an expert what to write or what evidence to use, the IME vendor should convey the writer’s concerns to the expert.  This would include asking the expert to consider specific relevant evidence or literature in their answers.  Ultimately what the cover letter writer and the expert consider to be important evidence may differ, but in cases where the expert’s answer is wholly unsupported they are likely to be receptive to requests to clarify or amplify if the cover letter writer can explain why the answer is problematic unless the expert provides additional support.

No IME vendor can guarantee a perfect report.  However, we should expect responsive, consistent, and well-supported IME reports.  In judging the report, we should not ask whether the report is favorable but instead whether the expert reached a reasonable and well-supported conclusion from the available evidence.  If they did not, your IME vendor can and should work with you to repair deficiencies in the report.  Ultimately, those requesting IME reports have the right to expect to receive a reasonable and credible report based on the evidence made available to the expert. 

Do you have any ideas on how to strengthen the cover letter so these types of problems are minimized?

 

Inconsistent responses to your questions in IME reports can sometimes be tricky if the responses do not directly contradict one another.  However, if an expert offers two opinions that directly contradict one another, you should expect your IME vendor’s quality assurance editors to catch the issue and resolve it before it gets to you.  Occasionally, direct contradictions slip past even the most detail-oriented editors (usually due to report length).  In such cases, the expert will sometimes correct direct contradictions in their review of the report.  Direct contradictions usually result from the expert misspeaking while dictating the report and are easily fixed.

The harder inconsistency issues arise when the expert doesn’t directly contradict themselves, but provides more than one opinion on the same issue and the statements are ambiguous or vague.  Often, the ambiguity or vagueness arises between statements in the general impression section of the report and the specific questions section.  A somewhat frequent example is when the expert states in the general impression section that the examinee continues to suffer from subjective complaints that, in the absence of evidence to the contrary, relate to the injury or exposure in question.  The expert then states the examinee sustained no permanency in answer to a specific question.  The expert may see no inconsistency in these answers, but the cover letter writer undoubtedly will.  In cases where the doctor is following the AMA Guides, this may not be an issue because the Guides explicitly allow for zero permanent impairment in cases where there is no objective evidence of injury and only subjective complaints.  And usually this is what the expert means when stating subjective complaints relate to the accident or exposure but no permanency resulted. 

In these more difficult cases, the IME vendor’s Quality Assurance editors should make every effort to pick up on such inconsistencies and go back to the expert to obtain an explanation of their position and provide clarity, but these are more difficult to catch than direct contradictions.  In such cases, it is certainly fair to point out the ambiguity to the doctor and to ask for clarification on their opinion. 

The expert in our example could clarify their opinion by stating something to the effect of, “While the examinee continues to register subjective complaints, there is no objective evidence of injury or impairment; hence, it is my opinion that the examinee has sustained no permanent impairment/partial disability as a result of the accident in question.”

Have you encountered these types of inconsistencies in IME reports and if so how did you resolve them?

 

Post-traumatic stress disorder (PTSD) is a condition of persistent mental and emotional distress occurring as a result of injury or severe psychological shock, typically involving disturbance of sleep and constant vivid recall of experience, with dulled responses to others and to the outside world.  Symptoms typically include nightmares or flashbacks, avoidance of situations that bring back the trauma, heightened reactivity to stimuli, anxiety or depressed mood.  The condition may last months or years, with triggers that can bring back memories of the trauma accompanied by intense emotional and physical reactions.  PTSD is fairly common in the US; more than 3 million cases are diagnosed per year. 

Of motor vehicle accident survivors, 9% develop PTSD.  Research conducted to identify at-risk individuals disclosed the following:

Pre-existing factors for the likelihood of development of post motor vehicle accident PTSD include:

  • Poor ability to cope in reaction to traumatic events
  • The presence of a mental health problem (most commonly depression)
  • Poor social support

Accident related variables:

  • Seriousness of physical injury
  • Loss of significant others

Post-accident predictors are:

  • The rate of physical recovery from injury
  • Level of social support
  • Level of active re-engagement in work and social activities

The difference between MVA-related PTSD is an increased likelihood of being injured or developing chronic pain syndrome.  As a result, many people rely on their primary care physicians for treatment and do not seek out psychological treatment for some time.  It is important to identify PTSD symptoms early and seek appropriate psychological treatment so symptoms to not become chronic.

Behavior therapy, cognitive therapy and medications have proven effective for treating MVA-related PTSD.  It may also be useful for the claimant to work with a chronic pain specialist to help manage the physical pain caused by injury.  These treatments can be provided in conjunction with one another.

To learn more about Post Traumatic Stress Disorder in Civil Litigation, register for our complimentary luncheon presentations by Terence Young, PsyD, a Board Certified Neuropsychologist scheduled to take place on October 19th at Rare on the Square in Madison, and October 26th at the Capital Grille in Milwaukee.  See our Seminars/Events page for more information and to register.  These presentations will offer CLE credit and space is limited, so register today!

 

Unresponsive reports are typically the easiest to resolve because most physicians will clarify answers that truly do not answer the question that has been asked.  It can be more difficult if the question of responsiveness is one of degree rather than an either/or situation.  In most cases, the best way to address responsiveness is to simply tell your IME vendor precisely what about the expert’s answer to a question is not response.  This is especially crucial when the lack of responsiveness is not intuitive or obvious to a reader who is not intimately familiar with the claim or the evidence.  For example, the case of a physician who is asked for a specific end of healing date and states that the claimant reached an end of healing but doesn’t state the date on which end of healing was reached is easy. 

On the other hand, a case in which the expert is asked a general question about the type, frequency, and duration of future treatment needed in which the expert responds that the claimant will need ongoing treatment for up to six additional months may not be responsive in the cover letter writer’s view, but the unresponsiveness is not likely to be obvious to the IME vendor’s Quality Assurance editor. In this case, the most efficient way to resolve the issue is for the cover letter writer to state the problem with the answer as directly as possible, i.e. “We need to know whether the recommendation for a series of three lumbar epidural steroid injections, which the claimant has not yet undergone, are reasonable, necessary, and related to the injury.”  In this example, the expert’s statement that ongoing treatment should be continued for six months is not wholly responsive because a new treatment modality has been proposed.  Another way to address this situation would be to ask the expert a question targeted to the proposed treatment, i.e. “Dr. X has recommended the claimant undergo a series of three lumbar epidural steroid injections.  We are interested in your opinion on whether the recommended series of three lumbar epidural steroid injections are reasonable, necessary, and related to the injury.”

What’s your strategy for fixing the unresponsive report?  

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