Monthly Archives: April 2013

Fear of Pain Slows Whiplash Recovery

Fear of Pain Slows Whiplash RecoveryFor far too many victims of whiplash, the injury begins a physical and mental cycle that prolongs pain and harms the healing process. Research has shown that patients who have whiplash-associated disorder (WAD) often suffer from pain avoidance and fear. When patients are afraid of pain, they often restrict the movement in their neck muscles. When movement is avoided, the muscles involved may not heal properly. The further whiplash pain results in more fear and movement avoidance in many patients. This cycle can lead to longer recovery times and a higher risk of disability for WAD sufferers.

In a new study, researchers examined the role of fear after whiplash injuries and assessed the efficacy of three treatments for fear. The study included 191 patients with WAD who were still symptomatic three months after injury.

The patients were divided into three groups. In one group, participants were given an information booklet describing WAD and highlighting the importance of resuming physical activity and movement. The second group also received the booklet, but were also involved in a discussion with a clinician, who reinforced the information in the literature. The last group received the booklet plus therapy for fear desensitization,  including imaginary and direct exposure to the feared activities and movements. This group received three fear desensitization treatments of two hours each.

The study results showed that the group who received the exposure therapy had the best recovery. Not only did this group have the most significant reduction in fear; they also  reported less pain severity compared to the other two groups.

Due to this connection, the authors of the study concluded that it provided further evidence that fear of movement is tied to prolonged pain in WAD patients. They recommended that fear be treated, and they recognized that exposure therapy and educational interventions may help improve function and aide in recovery of whiplash.

References

Kamper S, Maher CG,  et al. Does fear of movement mediate the relationship between pain intensity and disability in patients following whiplash injury? A prospective longitudinal study. Pain 2012; 153: 113–119.

Meulders A, Vlaeyen JW. Fear reduction in subacute whiplash-associated disorders: the royal road to recovery? Pain 2013; 154(3): 330-1. doi: 10.1016/j.pain.2013.01.004.

Robinson J, et al. The role of fear of movement in subacute whiplash-associated disorders grades I and II. Pain 2013; 154(3): 393-401. doi: 10.1016/j.pain.2012.11.011.

Brain Injuries Cause Lasting Sexual Dysfunction

Brain Injuries Cause Lasting Sexual DysfunctionNew attention on brain injuries in the NFL and military has shed a light on the lasting consequences concussions can have people’s overall health and mental well-being. But less attention has been paid to how these mental, cognitive, and physical changes can affect a person’s sexuality. Over half of brain injury patients say their head injuries cause sexual dysfunction, and this dysfunction can become a chronic problem if left untreated.

“Considering the role of the brain in sexual function, it is not surprising that sexuality can be influenced by neurological diseases,” explained psychologist and brain-injury expert John Alexander Moreno of  the University of Montreal. “Brain injury can affect the processing of sexual stimuli, decrease or increase sexual desire, limit the expression and communication of affect, and interfere with intercourse.”

Moreno and colleagues recently performed a meta-analysis of the existing literature on brain injuries and sexuality.1 They describe how brain injuries can lead to a number of factors that impact sexuality including memory and attention deficits, reduced processing speed, communication disorders, and difficulties recognizing facial emotion.

Attention deficits can also reduce a person’s focus during sex and memory problems may mean that someone forgets a date or significant episode in a relationship. Personality changes after brain injury, as well as PTSD and psychosis, may lead to patients losing social contacts. Additionally, TBI patients may have difficulties interpreting social cues or exhibit a lack of initiation or indifference to sex, or become involved in unsafe sexual practices. Many TBI patients are also taking number of antidepressants, stimulants, and other medications that can decrease libido or arousal.

Since the symptoms of brain injuries can vary widely based on the individual and the severity of the injury, researchers in one study sought to determine what predicts sexual dysfunction after brain injury in study of 322 men and women with TBI.2

Compared to non-injured participants, men with TBI were more likely to report sexual dysfunction, arousal difficulties, trouble maintaining an erection, reduced energy for sex, and body image difficulties. Interestingly, women with TBI had similar levels of sexual activity compared to non-injured women, although they also had difficulties with arousal, vaginal lubrication, and reported more pain with sex. Predictors of sexual dysfunction after a head injury were depression, older age, milder injuries, and in women, endocrine disorders.

In another study involving heterosexual couples who were married before a brain injury, 47% said they were dissatisfied with the changes in their sexual activity after the injury.3

Moreno and colleagues also found that few studies have examined the role of sexuality in the treatment of traumatic brain injuries. In addition to recommending more research on the subject, they pointed out that sexuality should be addressed within the rehabilitation process to prevent TBI patients from developing sexual dysfunction. They recommended a holistic treatment approach to traumatic brain injuries which addresses sexuality along with the varied cognitive, psychological, and physical symptoms of the injury.

 

References

  1. Moreno JA, et al. Sexuality after traumatic brain injury: A critical review. NeuroRehabilitation 2013; 32: 69-85.
  2. Hibbard MR, et al. Sexual dysfunction after traumatic brain injury. NeuroRehabilitation 2000; 15(2), 107-120.
  3. Garden, F. H., Bontke, C., & Hoffman, M.  Sexual functioning and marital adjustment after traumatic brain injury. Journal of  Head Trauma Rehabilitation 1990;  5(2), 52-59.

Researchers Address the Opinion That Whiplash is a “Crash for Cash” Scam

Researchers Address the Opinion That Whiplash is a "Crash for Cash" ScamIs whiplash really a debilitating injury, or is it just a way for personal injury lawyers to win more money for their clients? Can a simple, low-speed, rear-end collision cause injury that lasts a lifetime?

A group of researchers recently collaborated to take a good look at the current research about whiplash-associated disorder (WAD). They sought scientific proof that WAD causes muscle degeneration, and their findings were published in the journal Manual Therapy.

About 50% of people with WAD never fully recover and up to 25% have a significant and lasting disability. The authors of the study questioned why some people do recover and others do not. They pointed out that risk factors for WAD developing into disability need to be identified, and they highlighted that such research could possibly help predict outcomes and determine treatment for WAD and other musculoskeletal traumas.

The study was able to utilize and review new measurement technology, and the authors said that a clearer picture is emerging about all the factors involved in patients with persistent WAD.

A recent investigation has found that people with higher pain levels show an accumulation of fatty muscle tissue on MRI scans. Muscle changes like that could be a result of muscle degeneration, especially when considered alongside other physical and psychological factors. The researchers involved said that more research should be conducted to investigate this.

Part of this study included careful analysis of previous findings, but the research team found much of it outdated and inconclusive. They urged for “larger scaled patient-centered quantitative studies on whiplash injuries across cultures.” This research wouldn’t only benefit medicine, but would also impact the understanding of WAD for the political, legal, and actuarial sectors.

The authors of the study also pointed out that the biological factors and evidence of muscle degeneration should not be the only factors scientists should consider when looking at WAD. The importance of psychosocial factors is becoming clear. Because of the complexities involved, a standardized reporting of whiplash should be established that includes measures of pain and disability, physical and social functioning, post-traumatic stress, and pain processing. Lastly, they recommended that for high-risk patients, specialized imaging should be considered.

Reference

Elliot JM, et al. Content not quantity is a better measure of muscle degeneration in whiplash. Manual Therapy 2013. doi: 10.1016/j.math.2013.02.002.

For more information about other whiplash research, see our video below.

 

Will Changes to Asbestos Claims Slow Down Litigation?

Will Changes to Asbestos Claims Slow Down Litigation?
Photo by Chris Potter

Wisconsin Rep. Andre Jacque has proposed a bill that would delay civil liability lawsuits related to asbestos. The change would require plaintiffs in asbestos cases to disclose whether they have also filed claims against now-bankrupt companies. Because many people with diseases related to asbestos have been exposed in a variety of places, working for a variety of companies, multiple claims for individual plaintiffs is fairly common.

The way things currently stand in Wisconsin, plaintiffs can file lawsuits against companies that are now bankrupt, but they don’t always disclose this in lawsuits against still-solvent companies. Rep. Jacque says that the proposed change will help ensure that each defendant pays their fair share for the plaintiff’s cancer or other illness.

However, some trial lawyers are claiming that the bill will simply slow down litigation, and the change might result in some plaintiffs dying before the lawsuit is finished. When questioned, Jacque called the accusation “sickening,” and he said that often times plaintiffs’ lawyers keep claims against bankrupt companies a secret, in the hope of maximizing their payout.

The bill would require plaintiffs to disclose that they have filed or plan to file a claim against a bankrupt company’s trust. It would also require documents related to other claims to be provided to the court. Any compensation to the plaintiff could be considered and used to reduce the amount of payout from solvent companies.

Other states that already have or are considering a similar bill include Ohio, Illinois, and Oklahoma.

References

Lawmaker defends asbestos lawsuit changes. The LaCross Tribune; April 4, 2013.

Richmond T. Wisconsin lawmaker defends change to asbestos lawsuit rules. Insurance Journal; April 9, 2013.

Turner H. Possible changes to asbestos litigation. LawyersandSettlements.com; April 22, 2013.

FDA Questions Safety of Robotic Surgery Amidst Malpractice Claims

FDA Investigating Safety of Robotic Surgery Amidst Malpractice Claims
Doctors showing the da Vinci robot system in tour of Ft. Belvoir Community Hospital; Photo by Sgt. Bernardo Fuller, Courtesy of US Army Medicine

What’s trendiest thing in the operating room these days? A multi-million dollar robot called da Vinci that uses robotic arms operated by a surgeon to perform procedures previously done by hand. The robot is supposed to improve accuracy and decrease recovery time but critics point to several safety concerns over the device. They also argue that there still isn’t enough research to know whether robotic surgeries are as good as or better than conventional ones.

Now the FDA has launched an investigation into the safety of da Vinci Robot Surgeries, after an increase in reports of deaths and freak accidents tied to the device.

The latest of such cases involves a Colorado surgeon, Dr. Warren Kortz, who was recently charged with 14 counts of unprofessional conduct by the Colorado Medical Board after a series of failed surgeries using the da Vinci robot.

Between 2008 and 2010, the state alleges that Kortz left sponges and instruments inside of patients after closing, tore blood vessels, injured patients through improper padding and positioning, and subjected patients to overly long surgeries, according to The Denver Post.

In one case, Kortz used the da Vinci robot system to harvest kidneys from a 22-year old woman named Shanti Lechuga who sought to donate the kidneys to her ailing brother. The surgery had to be aborted after the robotic arm injured Lechuga’s aorta, and Kortz was forced to convert to traditional manual surgery to save her life. Later, X-rays revealed that the Kortz had left a sponge inside her body, causing nerve damage. Since the kidney removal had to be aborted, Lechuga’s brother had to wait for another six months for a kidney donation. Lechuga has since filed a da Vinci robot lawsuit against Kortz.

While such freak accidents may be rare, a spokesperson from the FDA told CBS News that the number of such reports are increasing, although they still can’t quantify that number and are still investigating why. The increase may be due to better awareness among doctors and hospitals about the need to report such issues. It also may be due to the growing popularity of the da Vinci robot itself. Nearly 400,000 surgeries involved a da Vinci robot last year, triple the number from 2008, according to robot manufacturer, Intuitive Surgical Inc.

With each da Vinci robot costing upwards of $2.5 million, hospitals are often under pressure “to get their money’s worth” by performing more and more robotic procedures, even if it isn’t in the best interest of the patient.  Although thousands of surgeries are conducted safely using the da Vinci robot each year, the Colorado lawsuit makes it clear that robotic surgery presents potential new risks for patients.

Sting Operations Make Streets Safer for Pedestrians

Sting Operations Make Streets Safer for PedestriansPolice commonly conduct “sting operations,” in which they ticket drivers who fail to yield to pedestrians in crosswalks.

In one such operation this month, drivers in Fort Lee, New Jersey, were issued $230 tickets, and many of them were outraged. Some insisted they didn’t see the undercover officer pedestrians, and others claimed the operation was a scheme to generate revenue.

Fort Lee has a problem with pedestrian safety, and this was the latest attempt to address it. Last year, 68 people were hit by drivers, and four of them died. The Fort Lee police have tried cracking down on jaywalkers, but many pedestrians there are hit in marked crosswalks. This string operation was set up to focus instead on changing driver behavior.

While many drivers are similarly upset by tickets with large fines, research suggests that these programs work.

In a study in Miami Beach, officers set up a program similar to Fort Lee’s, with the goal to increase awareness of pedestrians and cause more drivers to yield to them. They used decoy pedestrians, informational flyers, and written and verbal warnings, in addition to issuing citations. The experiment was for two weeks, where data was collected at crosswalks before, during, and after the string operations were conducted.

The results showed that the percentage of drivers yielding to pedestrians in the targeted crosswalks increased following the introduction of the enforcement program.

Even more profound, they found that the increased safety was sustained for a period of one year with only minimal enforcement. Additionally, it was discovered that the safety improvements spread at least to a small degree to other “untreated” crosswalks near the string operations.

So, do pedestrian safety stings work to increase public safety? Much to the chagrin of angry drivers, it appears they do.

Reference

Goodyear S. Police sting for drivers who don’t yield in crosswalks: Does it really work? The Atlantic Cities April 9, 2013. TheAtlanticCities.com.

Van Houten R, Malenfant J. Effects of a driver enforcement program on yielding to pedestrians. Journal of Applied Behavior Analysis 2004; 37(3): 351.

Assessing Liability in Auto Injury Cases Involving Medical Malpractice

Assessing Liability in Auto Injury Cases Involving Medical MalpracticeWhat happens when a personal-injury case involved both medical malpractice and an auto collision? Who is liable: the doctor or the driver?

Answering these questions are crucial in determining appropriate compensation, since medical malpractice claims will need be litigated separately from auto-injury cases. A recent case study highlighted how forensic investigators handled such a case for a woman injured in a motor vehicle collision in China.

A 48-year old woman was sent to a county hospital after injuring her right knee and thorax in an auto collision. Doctors could not identify any fracture with X-ray imaging, and diagnosed her with a soft-tissue contusion. She wore a plaster slab for 21 days, after which she resumed functional exercise. Although her thorax symptoms improved, she continued to experience knee pain. When she visited the hospital again three months later, X-ray and MRI imaging showed that she did have a fracture of the right tibia outer place, right meniscus, and effusion of the right tibia outer plate. Doctors recommended that she receive an open reduction and internal fixation for the fractures, but she declined treatment due to loss of trust.

She then went to a different hospital, where she was diagnosed with traumatic arthritis and treated with knee-replacement surgery. A month after surgery, she prosecuted the driver and the insurance company for personal-injury compensation.

However both the driver and the insurance company argued that the woman’s knee pain and dysfunction resulted from medical malpractice rather than the collision. Misdiagnosis led to a delay in treatment, and the knee-replacement surgery was inappropriate for her symptoms, resulting in unnecessarily high medical costs.

The court requested judicial expertise to determine liability. Forensic investigators carefully examined the woman’s medical records and concluded that the knee fracture was primarily caused by the auto collision. Based on the WHO International Classification of Disability and Health, they estimated that the crash accounted for 60% of the responsibility, the misdiagnosis for 30%, and the premature surgery for 10%.

This case study suggests a potential strategy for assessing liability in complex personal-injury cases. “Comprehensive and careful analysis would be helpful to determine the responsibility and resolve the compensational debate judicially,” the researchers concluded.

Reference

Chen J and Xio W. Assessment of the responsibility between a road traffic accident and medical defects after the traffic accident injury of knee joint. Journal of Forensic and Legal Medicine 2012; 19: 168-170.

Doctors Warn of Brain Injuries from Boston Bombings

Doctors Warn of Brain Injuries from Boston BombingsMost news stories of the Boston Marathon bombings have featured heart-wrenching images of runners with lost limbs and serious wounds. But a number of runners may be suffering from more invisible injuries: concussions.

Shock waves from the explosion likely resulted in head injuries among bystanders and runners alike, even in those who weren’t directly struck by an object.

Mild traumatic brain injuries often go undetected after an explosion as doctors scramble to treat more life-threatening wounds. Although concussions are generally assumed to be “mild” a growing body research shows that they can having lasting consequences on cognitive function and emotional well-being. Left untreated, a victim with a TBI may go for months without realizing the cause of their memory problems, headaches, sleep disturbances, and mood swings.  Symptoms of brain injuries can easily be confused with PTSD, further complicating proper diagnosis and treatment.

In the past, it was believed that a single explosion could not result in lasting brain damage. But in recent research, scientists discovered that veterans who sustained a single concussion from a blast had similar brain damage compared to NFL players with a lifetime of concussions. Another new study of Afghanistan veterans showed that soldiers with brain injuries often suffer from more severe symptoms than soldiers injured by blunt force.

An explosion is like getting hit with the impact of several head injuries at once, explained Dr. Lee Goldstein, a leading brain-injury scientist from Boston University who was interviewed in The Huffington Post. A blast in urban setting will have a different effect than one in the desert however, since shock waves can bounce off of buildings and concentrate in certain pockets. As a result, someone who was three feet away from the explosion may not have a concussion while someone ten feet away does, Goldstein elaborated.

Dr. Jeff Bazarian, a brain-injury expert from the University of Rochester Medical Center, said we should learn from the lessons of 9/11 victims. After healing from visible injuries, it was the lingering effect of brain injuries that presented the biggest obstacle for recovery in these patients.

Although the nature of the Boston bombings is still being investigated, experts recommended that doctors monitor victims for signs of PTSD and brain injuries.

Car Crashes Pose Serious Risks for Pregnant Women

Car Crashes Cause Serious Risks for Pregnant Women Traumatic events are the leading cause of non-obstetrical death in pregnant women, and create complications in 1 in 12 pregnancies. While a number of studies have examined trauma in pregnancy, uncertainties remain about how to best treat and monitor pregnant patients with traumatic injuries. A new literature review sought to fill this gap by providing a meta-analysis of the most recent research on overall incidence, risk factors, outcomes, and treatment of trauma in pregnancy.

The authors found that domestic violence and motor vehicle collisions (MVCs) are the most common causes of trauma during pregnancy. The overall incidence rate for auto collisions in pregnancy is approximately 207 cases per 100,000 pregnancies. Auto collisions are one of the leading causes of both maternal and fetal mortality, with an estimated mortality rates ranging from 1.4 per 100,000 to 3.7 per 100,000 pregnancies.

Improper seatbelts continues to be one of the most significant risks factors for adverse events in pregnancy. This reflects the results of a new study that showed that 25% of fetal deaths resulted in collisions in which the woman was not wearing a seatbelt.

Another major risk factor is intoxication. In a cohort of pregnant women at one trauma center, 43.5% of patients were intoxicated at the time of admission. (In comparison, 41% of  non-pregnant fatalities from MVCs are alcohol-related).

The main obstetrical concern is that auto accidents can place strain on the uterus, which can cause placental abruption. An estimated 40% of severely-injured pregnant patients suffer from placental abruption. The authors explain how this damage can occur:

” The impact of an MVC can generate substantial forward displacement of the uterus. This motion builds both negative pressure and a “contrecoup” effect, mechanisms that along with maternal body folding over the abdomen are enough to markedly increase intraabdominal pressure and result in forces powerful enough to cause placental shearing and subsequent abruption.”

The researchers also examined common treatment approaches. They emphasized that pregnancy should not lead to underdiagnosis or undertreatment due to “unfounded fears of fetal effects.” In cases of major trauma, they recommended that clinicians first address maternal instability through life support and coordination with emergency room providers, a trauma team, and obstetricians. Once maternal stability has been achieved, fetal stability will likely follow. Minor trauma like bruising, contusing, or lacerations can be managed with limited laboratory, radiological, and fetal evaluation.

Understanding how to better manage trauma in pregnancy could improve treatment of auto injuries in pregnant patients.

 

Reference

Mendez-Figueroa H, et al. Trauma in pregnancy: an updated systemic review. American Journal of Obstetrics and Gynecology 2013; [E-pub ahead of print]

Treatments Often Fail Kids with Traumatic Headache

Treatments Often Fail Kids with Traumatic Headache The number of kids diagnosed with concussions is on the rise, yet questions still linger about which treatments are effective for pediatric patients with brain injuries. Like adults with brain injuries, children with TBIs often suffer from posttrauamtic headache but few studies have examined how these symptoms may affect children differently.

Researchers from the University of Calgary in Canada recently studied a cohort of children with brain injuries to evaluate the characteristics and treatment of posttraumatic headache in kids. The study included 670 children with head injuries and 120 children with injuries other than TBI.

Within the first two weeks after a concussion, 11% of TBI kids said they suffered from headache. Although this number dropped to 7.8% three months later, the majority of kids with posttraumatic headache were still suffering from head pain well after sustaining a brain injury. This echoes the results of another recent study showing that adults can still suffer from posttraumatic headache for up to a year after the injury.

Of the children who had posttraumatic headache, 56% had a history of headache, 18% had migraine prior to the injury, and 82% had a family history of headache. The most common headache was migraine followed by tension-type, cervicogenic, and occipital neuralgia.

Medications typically prescribed to children included amitriptyline, flunarizine, topiramate, and melatonin. While the overall treatment response rate was high (64%), a number of children did not respond to medication. This suggests the need for additional research on effective treatment of headache in children with TBI.

The researchers recommended that kids with persistent posttraumatic headache be referred to a specialist, especially in cases that aren’t typical of one of the primary headache disorders.

 

Reference

 Kuczynski A, et al. Characteristics of post-traumatic headaches in children following mild traumatic brain injury and their response to treatment: a prospective cohort. Developmental Medicine and Child Neurology. 2013 Apr 5. doi: 10.1111/dmcn.12152. [Epub ahead of print]