Medical and Risk Trends for 2013

 

Each new year brings talk and speculation about what will be the “next big thing” during that year — a new medical procedure; a new change in laws; or increases in disability and reserving. Some common themes popping up on blogs and in discussion threads are about medical procedures and distracted driving hazard effecting risk management.
 
1.   Aggressive Total/Partial Joint Replacement Surgeries
 
Hip and knee joint replacements are among the most commonly performed surgical procedures in the United States, according the Center for Disease Control and Prevention. Between 1996 and 2006, total hip replacements increased by one third and total knee replacements by 70%.
 
Part of this new trend means doctors are finally realizing that months and months of physical therapy and other treatments are not resulting in outcomes patients’ desire. Injured people want to regain as nearly as possible most of their mobility and activity levels they enjoyed prior to an injury. This is particularly true of injuries taking years to develop before the joint finally gives out.
 
In addition, technology has changed, implants are better, more functional, and last longer and, depending on the comorbidities of the patient, recovery times have lessened. Therefore, physicians are going directly to joint replacement surgery, rather than waste a year on therapy.
 
Employers need to be aware of the actual causal relationship of joint failure to the issue of a workers compensation injury, keeping in mind most joint replacements are due to degenerative changes, not necessarily an occupational injury. The decision of whether or not an employer is liable for a workers comp claim can vary by state statute, meaning be very aware of all state statutes in every state where your company operates.
 
Rarely will a carrier opt to pick up a case with a joint replacement recommendation, since the costs are high, and the outcomes for total success can be limited. Be prepared to argue any case where a physician leans toward joint replacement following a workplace injury. Look for possible pre-existing conditions and be sure to have an independent medical examination (IME) done by a qualified and reputable physician.
 
 
2.   Increasingly Sophisticated Bionic Implants/Prosthetics
 
Great outcomes are rare for severe occupational injuries that include the loss of a limb since these cases are catastrophic in nature and carry a massive dollar reserve. The days of peg legs and hooks for hands are gone. Current prosthetics are capable of grasping objects with a mind/body connection doing the work, rather than plain mechanics.
 
Prosthetic limb advancements have grown exponentially over the years, but are very expensive. Prosthetic hands and arms are now like mini computers, with sophisticated wiring and performance. This leads to increased hazards and damage, wear and tear, and replacement/maintenance costs.
 
Some state statues only require replacement of a lost limb with a “suitable” prosthetic. But suitable to whom? Is it suitable to the claims adjuster, or suitable to the person affected by this life-changing injury? Unfortunately in many insurance claims, the best is not always something the carrier is prepared to pay for. The carrier’s opinion is to replace with a suitable device, a Ford Focus, not a Cadillac Escalade or Ferrari. So a lost limb can be replaced by the Ford Focus of limbs, not the Cadillac of prosthetic devices, or the latest/greatest thing out there.
 
Prosthetic eyes have also come a long way from the days when eye implants were riddled with infection potential and replacement eyes had little reality to what a natural eye looked like. Today’s eye prosthetics are incredibly life-like, although they do not replace vision. However, a good-looking prosthetic eye is a confidence builder and beneficial to a good appearance.
 
Be prepared to litigate over the issue of “type of replacement” and do not be surprised when it arrives after coverage for the Cadillac version of a prosthetic is disputed. Avoid legal problems by doing due diligence and get multiple opinions and recommendations for treatment as well as estimates on maintenance costs/repairs.
 
 
  1. Changing Demographics of the Workforce
 
Today businesses are doing more with less, leading to employees who are prone to more severe injuries with longer recovery times. Both the increase in obesity and aging adds to this statistic. It is not uncommon for workers compensation claims to increase when layoffs are rumored or forthcoming. Fear of losing a job may cause an employee to file a workers compensation claim over a minor injury and this spells disaster for the employer.
 
Employers must be aware of the risk. Every employer wants to run an efficient business, but employees can be over loaded by being asked to do more with less. What is the general consensus on the work floor? Are workers hearing about pending layoffs and not telling their managers about a potential injury for fear of repercussion or termination? Are workers asked to do more than one job when coworkers are laid off and not replaced? Failure to address these important questions can be dangerous and costly in the end and counter-productive to efficient management.
 
 
  1. Better Recovery that Limits Risk of Permanent Partial Impairment
 
Injuries reported and treated before they morph into major injuries result in reduced recovery time. Reduced recovery time lessens the risk of a permanent injury. In states where an impairment rating is used to pay the claimant additional monies, just opening the lines of communication can save a business/carrier a large sum of money over time.
 
Let us look at carpal tunnel as an example of early treatment as opposed to late treatment.
When a worker is treated at the onset of symptoms, treatment consists of splinting and medication. The problem can resolve on its own with little loss of work time and minimal medical cost. On the other hand, the longer a worker waits to get treatment, the worse the nerves become damaged, sometimes to the point where surgery will be of little benefit to resolve pain and restore function.
 
Some states have an almost automatic impairment rating once surgery is performed and costs can be very large not only in additional wage loss, but also in increased medical coverage. Some states cover reasonable, related, and necessary medical costs over a 10-year period, meaning it is hard to wipe an existing claim of this nature off the financial books. Promote early involvement/medical intervention when an injury happens in the workplace.
 
 
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com
 
Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com
 
©2013 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.  

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional about workers comp issues.

Do Not Be So Quick To Diagnose Carpal Tunnel

 

Disclaimer—This is not a medical article.  This is not meant to diagnose or treat a condition. This is merely a guide to use as potential reference to occupational cases.  Always consult your physician for advice on what your diagnosis may or may not be.
 
If I went to a doctor’s office and said my hands are numb, and he automatically diagnosed me with carpal tunnel and sent me for an EMG, I would be looking for another opinion right away.
 
Why? I know that just because I have numbness in my hands, the automatic diagnosis of carpal tunnel is premature.  Numbness can be caused by a multitude of issues, both possibly occupational in nature, and, more importantly, not occupational in nature.  The background of getting to the root cause of a condition can take a long time, and just cannot be made in one or two visits to the doctor, whether this is a hand specialist or just a general occupational physician.
 
Below we discuss a little about the warning signs of carpal tunnel, and some other conditions that could be the cause:
 
1.    Where is the Numbness?
Generally speaking, if a person says their entire hands are numb, chances are that just carpal tunnel is not the entire cause.  Median nerve compression, an indicator of carpal tunnel, will isolate itself to a combination of the thumb, pointer finger, middle finger, and maybe part of the ring finger.  If your whole hand is numb, you can have a combination of carpal tunnel and cubital tunnel, or many other issues genetic in nature all combined.  To make a diagnosis of just carpal tunnel is incorrect, and not a detailed enough analysis to fly for any adjuster out there.
 
Cubital tunnel, or ulnar nerve entrapment, will tend to be the ringer finger and little finger, and the entrapment will occur at the elbow area.  Cervical radiculopathy will remain in the neck/shoulder region, with numbness maybe going down the back of the arm and wrapping around the arm to the forearm and possible referring symptoms into the hand. 
 
2.    Is Carpal Tunnel Work Related?
This is a debate that has gone back and forth for years.  Many physicians state that the primary cause of carpal tunnel is genetic predisposition.  Other contributing factors are diabetes, pregnancy, smoking, obesity, and others.  Waking up at night is a huge indicator, since we all at some point tuck our wrists into the fetal position.  Once this occurs, the symptoms of numbness and pain reproduce, waking up from sleep. 
 
If a person says they have carpal tunnel but they are also sleeping though the night with no waking, chances are the nerve impingement is not at the wrist. Even if you sleep on your back and you know for a fact that you will never once sleep in this fetal position, I would beg to differ.  But again most doctors either agree or disagree with this theory. 
 
 
3.    You Have to Look at the Medical/Occupational History of the Claimant
This includes both work related and non-work related jobs and movements.  All kinds of things can contribute to carpal tunnel, including medications, past/current illnesses, family history of illness, pregnancy, timing and location of the numbness, and any contributing hobbies.  I heard of a case where a guy claimed to have carpal tunnel from his desk job, but then the adjuster discovered the claimant had a second job as a violinist in a community orchestra.  Certainly the postures and movements of a violin player can contribute to the progression of carpal tunnel symptoms, or even cubital tunnel.
 
Another large contributory player in the realm of hobbies is carpentry work.  Use of vibratory or torqued tools that vibrate can start symptoms that are then aggravated by work duties that could be repetitive in nature.  Even minor movements that are repetitive in nature can be a culprit.  So take the time to do a careful medical and non-medical investigation since all movements or hobbies with gripping or movements could be included as a risk factor.
 
4.    So is it Cubital Tunnel and Not Carpal Tunnel?
That will depend on the location of the numbness.  The elbow is the most common site for compression of the ulnar nerve.  This syndrome is stereotypically known to affect men more than women, but again this depends on the study you review. 
 
Symptoms will include pain and tenderness around the inside of the elbow radiating into the forearm and the ring/little finger with associated tingling, numbness, and burning.  These symptoms again may occur more frequently at night than during the day.
 
Cubital tunnel causes can be frequent bending of the elbow from pulling items or levers on machinery, constant direct pressure on the elbow over time from leaning on the elbow, sleeping with bent elbows, or from direct trauma to the elbow area such as a fracture.
 
5.    So Can Cubital Tunnel be Work Related or is it Genetic in Nature?
Depending on your study and your physician, it is hard to say whether this is more of a work related diagnosis or one that is more genetic in nature.  You must take the time to delve into the case, and take a careful history of all employments, job tasks, and also all tasks or hobbies that your claimant does outside of the workplace.
 
Summary
Any type of injury that has associated numbness cannot lead itself to a blanket diagnosis of just carpal tunnel alone, but more times than not in the work comp world we see it more and more.  All physicians and adjusters have to take the time to do a full workup of the case, involving every job task both inside and out of the workplace. 
 
Many hobbies or activities outside of work can be the culprit of the cause of these issues, including the way you sleep, the way you drive your car, any hobbies the person partakes in, and so on.  Don’t be quick to accept the diagnosis and rush a person in for surgery.  Explain to your claimant the risk factors both in and out of the workplace, and that you just want to make sure you target the actual problem so it can be corrected and the person can move on with their lives, hopefully in a pain-free fashion.
 
 
Author Rebecca Shafer, JD, President of Amaxx Risk Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker, and publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality, and manufacturing. She is the author of the #1 selling book on cost containment, Workers Compensation Management Program: Reduce Costs 20% to 50%. Contact:RShafer@ReduceYourWorkersComp.com
 
Editor Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. www.reduceyourworkerscomp.com. Contact: mstack@reduceyourworkerscomp.com
 
©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.  

Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional about workers comp issues.

Kansas Division for Workers Comp Takes Huge Step In Ankle Replacement

 

Privately Held Company Engineers Product
 
Small Bone Innovations, Inc. (SBi), a privately held orthopedics company focused on arthroplasty and joint-related trauma technologies and treatments for the small bones and joints, reported that the Kansas Dept. of Labor’s Division for Workers Compensation (DWC) recently adopted guidelines specifying the use of SBi’s STAR total ankle replacement implant when meeting certain patient guidelines. It is the only total ankle system being recommended by the Division based upon its adopted medical treatment guidelines.
 
According to the U.S. Bureau of Labor Statistics (BLS) for 2010, there were approximately 300 reported cases in Kansas of foot and ankle disability claims among private sector employees.
 
The STAR ankle is reportedly the only total ankle replacement system approved through the U.S. Food and Drug Administration's (FDA) Premarket Approval (PMA) process.
 
 
Greater Clinical Success, Shorter Operating Time
 
In the PMA process, the STAR ankle's safety and effectiveness was compared with ankle fusion in a multi-center, multi-year, Investigational Device Exemption (IDE) study. The IDE study results, published in 2009, reportedly demonstrated STAR to be superior in efficacy and comparable in safety to fusion. The IDE and other subsequent studies reportedly show that the STAR ankle has better pain relief, greater clinical success, less blood loss and a shorter operating time than fusion.
 
Michael Simpson, president & CEO of SBi, noted “Nationwide, patients suffering from acute arthritis are demanding the preservation of joint function and anatomical motion in addition to pain relief. As occurred with hips and knees more than a decade ago, ankle replacement is quickly becoming the future for baby boomers who want to maintain an active lifestyle.
 
 
Mainstream Product Covered by Medicare
 
The fact that the STAR has become a mainstream treatment covered by Medicare and major private insurers is a huge step, literally, in the direction of fulfilling patient demand,” he added.
 
Anthony Viscogliosi, founder & executive chairman of SBi added “Kansas joins Texas as one of the first states to adopt the latest disability management guidelines for workers compensation programs that specify the STAR ankle as the only suitable ankle replacement solution.
 
As a result, we are raising the level and content of communications with patients and their primary care physicians in these states to enhance knowledge and understanding of the STAR ankle’s benefits.”
 
According to SBi, leading foot and ankle surgeons in Kansas have already been trained and certified in the STAR procedure and are performing total ankle arthroplasty procedures. Nationwide, more than 700 surgeons are qualified to perform the procedure and in excess of 20,000 patients worldwide have received the STAR ankle, the company noted. 
 
 

Author Michael B. Stack, CPA, Director of Operations, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher.  www.reduceyourworkerscomp.com Contact mstack@reduceyourworkerscomp.com

 

 

 

 


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©2012 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact us at: Info@ReduceYourWorkersComp.com.

British Manufacturer Sentenced after Worker Has Hand Crushed

A British manufacturing firm has been sentenced after a worker's hand was crushed in a metal press at a St Helens factory, according to a report from the Health and Safety Executive (HSE).
 
 
Barry Kelleher lost his little finger and part of the palm on his right hand as a result of the incident at Crane Building Services and Utilities. The 47-year-old from Leigh also needed two skin grafting operations.
 
 
The owner of the factory, Crane Ltd, was prosecuted by HSE after an investigation found the machine could still be operated when a workers hand was underneath the mould. Note:  Physical guards and light curtains generally prevent a workers hand from entering the pinch point area.
 
 
Knowsley Magistrates Court in Huyton was told the machine had been installed at the factory on Delta Road in St Helens in 1967, but had not been upgraded to comply with modern health and safety laws.
 
 
Kelleher does not remember the incident on Jan. 19, 2011, which occurred while he was using the press to mold metal parts, used by the gas industry.
 
 
However, the HSE investigation concluded that the most likely explanation is that he inadvertently pressed the foot pedal on the machine while his hand was under the mould.
 
 
Crane Ltd pleaded guilty to a breach of the Provision and Use of Work Equipment Regulations 1998 by failing to prevent workers from being able to access the dangerous parts of the machine while it was operating.
 
 
The company, of West Road in Ipswich, was fined $15,530 and ordered to pay $7,080.77 in prosecution costs.
 
 
Kelleher was off work for seven weeks as a result of his injuries, before returning to work initially for one day a week.
 
 
Kelleher was one of more than 3,800 workers who suffered a major injury while at work in the manufacturing industry in Great Britain in 2010/11. Another 27 lost their lives.
 
Note: machines should be designed so that when body parts are in or near a pinch point, the machine will not operate; machines are then said to be "fail safe." If an adjuster sees such an injury, they must make serious inquiry into whether the machine manufacturer should be brought into the situation as a third party or subrogee.
 
 
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.
 
Our WORKERS COMP BOOK:  www.WCManual.com
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Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact  Info@ReduceYourWorkersComp.com.

Conservative Primary Care in Chiropractic Practice

By David C. Radford, DC
David R. Seaman, DC
James F. Winterstein, DC
Robert C. Jones, DC
 
 
In Part I of this three-part series, we discussed the history of the chiropractic profession and the issue of primary care, both past and present (see ACA News, January 2012, Page 29). In Part II, we discussed the implementation of conservative primary care, the clinical methods we can use in daily practice to address co-morbidities and how to move our patients toward preventive medicine and wellness based upon the elements of a good patient history (see ACA News, February 2012, Page 28).
 
 
In Part III, we look at the physical examination in light of the patient’s history and expand on implementation of conservative primary care services that we can provide within our current scope of practice. The utilization of doctors of chiropractic (DCs) to coordinate patient care should help reduce our nation’s health care costs by preventing and managing chronic illness1. The importance of the interview process during the subjective history taking comes to light at the first encounter. The specific details we ferret out during the subjective history taking help us start to make a mental checklist of differential diagnoses and what we will need to consider so we may narrow the diagnosis into a rational hypothesis. This mental triage process helps direct us through the patient’s examination and to plan the diagnostic procedures we may want to perform or order. Let’s use the example of a fairly comprehensive office visit as a review exercise. [WCx]
 
 
The Office Visit
Every new patient encounter, change in condition or break in care should include the vital statistics in the office visit. These objective measurements include the height, weight, body mass index (BMI), heart rate or pulse, respiratory rate, blood pressure and pulse oximeter measurement of oxygen saturation. If any of the vital signs are not within normal limits, they should be tracked on a regular basis to determine if a specialist consultation and/or further medical intervention is needed, as this is part of our role. The health-promoting influence of primary care has been accumulating and holds true in both cross-national and within-national studies2. In some situations, we may be the only physician seeing the patient on a regular basis, making it even more important that we track abnormal vitals, direct our care to reduce illness, and prevent end-organ damage and premature death. Obesity, adult-onset diabetes, vitamin D deficiency, hyperlipidemia, hypertension, tobacco, alcohol, drugs, and use of excessive medications are co-morbidities that we see every day. Following the patient encounter, we should be able to describe the patient in detail, including his or her emotional state. It is helpful to note if the patient appeared to be pleasant and cooperative, if he or she was well groomed and what his or her mood was like: good, somber, anxious or depressed. Patients frequently present to a DC in pain, and are often seeking manual medicine. The understanding of the patient’s emotional state gleaned through the history and examination helps us grasp mental health in relationship to pain, which aids in our biopsychosocial approach to care of the patient.3 Assessing the mental health of our patients also gives indications of whether there may be symptom amplification, symptom modification due to mental overlay (i.e., depression often increases pain and creates avoidance patterns), co-dependence on a practitioner and the overall likelihood of whether the patients will engage successfully in our treatment plan.
 
 
Trauma
If there was trauma, did the patient hit his or her head? If there was head trauma, was there a loss of consciousness, blurred or double vision, an associated headache or changes in the ability to remember things or difficulty with concentration? Furthering the discussion, has there been any loss of sleep or sleep disturbance? Have there been unusual emotional changes or mood swings? Is the patient clearly oriented to time, place and person, and is the patient a good historian? Are short- and long-term memory, cognition and general fund of knowledge good? Are the attention span and concentration good? At this point, do you need to set aside time for a mini-mental status examination? Does examination of the head and cranial nerves suggest a need for imaging of the head or perhaps a neurological consult?
 
 
Cardiac/Thoracic
In general, can you describe the patient as being well developed and well nourished? If not, what is the patient’s appearance? A patient who is not nutritionally sound does not have the nutrient building blocks to respond to the physical changes your treatment plan may require. This is an opportunity to discuss diet and lifestyle changes. Based on the patient history, risk factors, vital statistics, appearance of the skin, color of the membranes and body build, do you suspect any cardiovascular problems or chest disease? When you listen, is the chest clear to auscultation in all lobes? Is there any tactile fremitus? Does the cardiac exam demonstrate normal S1 and S2 heart sounds? Are there S3 or S4 sounds? Are the heart rate and rhythm unremarkable, or are there murmurs, rubs or gallops? Is there any peripheral edema? If so, we need to describe the extent and severity in our notes. Based on the auscultation of the heart and lungs, do we need further testing or a specialty consultation? If the female patient is seen regularly by a gynecologist or internist, the breast examination can be discussed as being up to date, and charted as being deferred. Continuing with the thoracic/chest examination, is the trachea in midline? Is there thyroid enlargement or a palpable nodule? Is there hoarseness? Does the patient need an EENT consult? Does auscultation of the carotid arteries reveal good up strokes, and are they negative for bruit? Is there any jugular vein distention? Is there any indication that the patient would be at increased risk for spinal manipulation of the neck?
 
 
Abdomen
Before we palpate the abdomen of the patient, we should have determined through the history if there were any reported bowel, bladder, liver, gallbladder, spleen or pancreatic concerns? It is not at all uncommon for pathology of the abdomen to refer pain to the flank and back. Are the bowel sounds normal, or is there an absence of normal bowel sounds that could suggest an obstruction? Are the superficial reflexes present at the four quadrants? Is the abdomen non-tender or tender to palpation, and if tender, where? Is the liver or spleen enlarged? Are there any abnormal pulses or masses on abdominal palpation? If there is flank or chronic back pain, should we order a routine urinalysis, a CBC and ESR or imaging studies? If the patient is seen regularly by a family practice doctor or an internist, the male’s prostate and for both sexes the rectal examination, can be discussed and charted as being deferred, or the exam can be performed if necessary based upon the chief complaint. [WCx]
 
 
Gastrointestinal
A wide variety of abnormalities contribute to indigestion and to the development of gastrointestinal complaints. This is sometimes a complex issue, and the role of testing for H. pylori infection in GERD remains controversial. The implications of test results with false positive and false negative results remain incompletely understood. Patients with chronic digestive problems may have had diagnostic testing, including endoscopy and colonoscopy with biopsy. If these studies have been done, do we know that life-threatening pathologies have been ruled out? We suggest looking at the role of obesity, diet and lifestyle in our patients with gastrointestinal complaints, and refer the reader to the relevant patient education resources provided at eMedicine’s website for heartburn, GERD and reflux disease. In difficult cases that are non-responsive to conservative care, a referral to a gastroenterologist for co-management is most appropriate.
 
 
Pain/Posture
On your intake paperwork, did the patient complete a pain drawing? Was the severity of the pain indicated on the 11-point 0 to 10 centimeter pain scale, or did you simply ask the patient to rate the pain on a 0 to 10 scale for you? It is important to chart the description as to the nature and character of the pain problem, either using a key to types of pain on the pain diagram, or simply ask the patient to describe the nature and character of the pain. As you watched the patient move, did facial expressions during testing suggest pain; did he or she grimace, or show a facial expression of distress? As the patient sat still or moved, did he or she moan or cry out in pain? It is important to chart how pain was characterized by the patient for our record. Is the patient’s pain drawing anatomical; is it free from signs of embellishment? Do we see or suspect Waddell signs; are there any issues of secondary gain? Describe the patient’s standing or sitting posture and movement from sitting to standing. Is it normal or is there a Tripod or Minor’s sign? Is the stance and gait normal/abnormally wide, stable or unstable? Do we want our patient to do a tandem walk to better assess balance? Is he or she able to walk on his or her heels and toes and squat with good strength? To test proximal muscle strength, is the patient able to duck walk? Is Patrick’s figure four sign negative for hip disease? Palpate the area of concern for tenderness with appropriate pressure and percussion. Does the patient have a facial expression of distress with this type of provocative testing? Note the patient’s skin color and turgor. Are they normal? Is any lymphadenopathy noted? Is there any palpable mass or tenderness in the supraclavicular fossa, axilla or groin? It is helpful as a starting point in care to record all abnormal spine or joint motions using the appropriate measuring device, goniometer for joints and the inclinometer for the various regions of the spine. Based on the history and red flags, is imaging indicated? Are there signs of inflammation? Is the problem unilateral and focal, or is it bilateral and symmetrical, involving multiple joints and tissues? Is there an indication to look at the serum biomarkers for inflammation or autoimmune disease? The medications routinely used should be discussed, and while botanicals and more natural alternatives may be useful, we realize they are not all entirely free from side effects and they can interact with prescription medications and represent a good topic for further discussion.
 
 
Motor/Sensory
For the motor and sensory examination, we record muscle strength by the Medical Research or Kendall Scales (graded 0 to 5) (R/L). In the assessment, are the limbs symmetrical in bulk, strength and tone? If you record the grip strength by dynamometer, always indicate if the patient is right- or left-handed. Are the muscle stretch reflexes symmetrical at the deltoid, biceps, triceps, brachioradialis, wrist, patella, hamstring and ankle? Is the radioperiosteal reflex normal? Is side-to-side evaluation of sensation over the dermatomes using pinprick and light touch intact or altered? Are good joint position and vibratory sense observed distally at the great toes? Do the patient’s feet look healthy? Is there an indication for further testing, metabolic laboratory or electrodiagnosis? If these are abnormal, is an internal medicine consultation indicated? The number of specialist consultations has doubled over the past decade, from 4.8 percent in 1999 to 9.3 percent in 2009. While some policymakers are concerned about this added cost of specialization, many physicians in ambulatory primary care4,like chiropractic physicians, understand our expertise is primarily musculoskeletal medicine and manual therapies, and while we recognize our limits, we also understand our responsibilities as physicians. If there is a spine problem, is the Valsalva maneuver provocative for disc occlusion pain in the cervical, thoracic or lumbar spine? Is there evidence of nerve root tension in the arm or leg? The list of orthopedic and neurological tests can be long, and all examination findings help paint a picture that tells the patient’s story. If plain films or advanced imaging were deemed clinically necessary, how do they correlate with the chief complaint? If a trial of manual therapy and spinal manipulation is indicated, is the patient responsive? If it is essential to the examination, do the patient’s cranial nerves appear to be grossly intact? Are the sclera anicteric, and are the conjunctiva normal? Are the pupils equal and active? Are they reactive to light and accommodation? Is visual acuity corrected? Are the visual fields full? If a funduscopic examination was not performed, was it because there was no complaint to suggest increased intracranial pressure? If it was performed, was the funduscopic examination benign with no exudates? Is there hemorrhage or papilledema to suggest increased intracranial pressure? Are the teeth in good repair? Is a consultation needed with an eye specialist or a dentist? Are there any Long Tract signs? Is the plantar response flexor or extensor, and is Oppenheim’s sign negative? Is there any clonus, or a Hoffman’s sign? Are the finger- to-nose, finger-to-finger and heel-to-shin tests normal? Is there any evidence of downward drift? Is Romberg’s sign absent? Is the patient safe at home? Is the patient at risk of falling at home? If so, does the family know, and is further testing or assistance indicated? Are pulses present at the wrists, ankles and dorsum of the feet? Are the hands and feet warm and dry? Do you observe any cyanosis or clubbing of the distal digits? Do the nails appear smooth with good color and capillary refill? Are there any bruises or cutaneous rashes? Does the bruising reflect a trauma or a clotting problem? If present, does the rash represent a focal response, or is it a more generalized process? [WCx]
 
 
Plan Appropriate Care
You have given this patient a comprehensive physical examination, and based upon the patient’s history, your findings and any special tests, you should be able to plan appropriate care and make necessary referrals for secondary or tertiary care. Of course, not every patient being seen in chiropractic medicine needs a comprehensive evaluation, but if we happen to be the first-choice physician, we have an obligation in our role of primary care physicians to triage the patient and provide not only the best possible care, but make appropriate referrals when necessary. This obligation occurs not only at the point of an initial office visit but also when there is a change in symptoms, an additional chief complaint or an office return after a break in care. The accessibility of the nation’s chiropractic physicians for conservative primary care of non-institutional patients5 using the primary care model should enable the DC to become more involved in the discussion of cost-effective health care policy. It has been found that provider continuity is one of the most important explanatory variables related to the total health care cost.6
 
 
Dr. Radford is the director of the Chiropractic Clinic of Solon, Dr. Winterstein is the president of National University of Health Sciences, Dr. Jones is the president of New Mexico Chiropractic Association and ACA’s delegate to New Mexico and Dr. Seaman is a professor of clinical sciences at National University of Health Sciences’ Florida campus. Drs. James Lehman and Michael Taylor also contributed to this article. Contact for more information at DCR8888@aol.com or phone: (440)-248-8888; www.acatoday.org.
 
 
References
1) Kravet SJ, Shore AD, Miller R, Green GB, Kolodner K, and Wright SM. Health care utilization and the proportion of primary care physicians. American Journal of Medicine, 2008 Feb; 121(2): 148-6.
2) Starfield B, Shi l, Machiko J. Contribution of Primary Care to Health Systems and Health. Milbank Quarterly, 2005, 83: 457-502.
3) Lumley MA, Cohen JL, Borszcz GS, Cano A, Radcliffe AM, Porter LS, Schubner H, and Keefe FJ. Pain and Emotion: A Biopsychosocial Review of Recent Research. Journal of Clinical Psychology, 2011 September: 67: 942-968.
4) Barnett ML, Song Z, and Landon BE. Trends in Physician Referrals in the United States, 1999-2009. Annals of Internal Medicine. 2012;172 (2): 163-170.
5) Shi L, Starfield B, Politzer R, and Regan J. Primary care, self-rated health, and reductions in social disparities in health. Health Services Research. 2002 June; 37(2): 529-50.
6) De Maeseneer JM, De Prinis L, Gosset C, and Heyerick J. Provider continuity in family medicine: does it make a difference for total health care costs? American Family Medicine. 2003 Sep-Oct; 1(3): 144-8. 

 


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University Fined for Putting Individuals at Risk of Exposure to Asbestos

Lincoln University in Great Britain has been fined for putting staff, students and contractors at risk of exposure to asbestos.
 
 
According to the Health and Safety Executive (HSE), the failings came to light in February of 2010 when a lecturer became trapped in a room after a door lock broke. She enlisted the help of a colleague to release her and once freed, they noticed debris around the door handle. (WCxKit)
 
 
They notified the university's health and safety department which examined the door and others in the area, and discovered most were lined with asbestos insulating board (AIB), and that some were damaged.
 
 
The university notified HSE, which carried out its own investigation. It was found that a number of areas across the university's estate had been subject to asbestos surveys over a number of years and many areas were found to contain asbestos-containing materials or even asbestos debris, yet no remedial action had been taken.
 
 
Lincoln University Higher Education Corporation, of Brayford Pool, Lincoln, pleaded guilty to two counts of breaching Regulation 5(1) of the Management of Health and Safety at Work Regulations 1999 at Lincoln Magistrates Court. The university was fined $15,629 and ordered to pay $19,939.77 costs.
 
 
After the hearing at Lincoln Magistrates Court, HSE inspector Edward Walker noted, "Exposure to asbestos fibers is a well-known health hazard that results in approximately 4,000 deaths a year. (WCxKit)
 
 
"The university had an asbestos management plan but had failed to follow it and failed to take appropriate steps to manage the risks associated with asbestos over a number of years, putting staff, students and contractors at risk of potential exposure."
 
 
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.
 
 
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©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

Texas Man and Maryland Woman Sentenced on Workers Comp Fraud Charges

Texas Mutual Insurance Company reported recently that a Travis County district court sentenced Thomas Mikulenka of League City, Texas on workers compensation fraud-related charges.
 
 
The court sentenced Mikulenka to three years deferred adjudication and 100 hours of community service. Mikulenka was also ordered to pay $7,221 in restitution to Texas Mutual. (WCxKit)
 
 
Mikulenka reported a job-related injury while working as an electrician for IGC Construction, Inc. in Houston. He claimed he was unable to work as a result of the injury, and Texas Mutual began paying income benefits to him.
 
 
Meanwhile, Texas Mutual uncovered evidence that Mikulenka was working as a laborer while receiving income benefits.
 
 
Investigators call this type of scam double-dipping because claimants collect benefits for being too injured to work when, in fact, they are gainfully employed. Texas law requires claimants to contact their workers comp carrier when they return to work. (WCxKit)
 
 
Left unchecked, double-dipping and other workers comp fraud can lead to higher premiums for all Texas employers.
 

 

Maryland Woman Sentenced in Nevada Workers Comp Fraud Case 

A Maryland woman has been sentenced to 2 ½ years in a Nevada state prison for attempting to defraud her employer’s workers compensation insurer of $20,000 while at a professional conference at the Las Vegas Hilton, according to Nevada Attorney General Catherine Cortez Masto’s office.

 
 
Tamara Thompson-Johnson, 45, was ordered to pay $20,000 in restitution, $4,000 in extradition costs and serve 2 ½ years in a Nevada prison after pleading guilty to making false statements to obtain workers comp benefits from her employer, officials say. (WCxKit)
 
 
According to officials, Thompson-Johnson claimed she was injured at the Las Vegas Hilton when a vase, dislodged by an intoxicated person, fell from its pedestal. Although she refused medical treatment at the scene, she reported to security that she had been struck by the vase and checked herself into a hospital.
 
 
The Nevada General Attorney’s office says Thompson-Johnson hired a lawyer and requested a claim for compensation from the Las Vegas Hilton. Her claim was turned down when surveillance footage of the incident surfaced showing that the vase narrowly missed Thompson-Johnson.
 
 
Although her lawyer ceased representing her Thompson-Johnson filed another claim through her employer’s workers comp carrier Travelers Insurance, claiming the vase hit her on the back of her head, neck and back, leaving her disabled. As a result she was paid $20,000 on her fraudulent claim.
 
 
According to the Nevada Attorney General’s office, Thompson-Johnson was extradited from Maryland when she did not appear for court hearings in Las Vegas.
 
 
She pleaded guilty to one felony count of making false statements or representations to garner benefits and was sentenced in November. (WCxKit)
 
 
Along with a 2 ½ year jail sentence, she was ordered to pay $20,435 in full restitution to Travelers Insurance, $4,005 in extradition costs and to reimburse the state $1,000 for costs in connection to the case and was ordered to disclose her conviction to present and future employers and insurers.
 
 
 
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.

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©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com

Study Addresses Dangers of Proximity to Battery Manufacturing Units

A recent report looks at the dangers faced by both children living in close proximity to battery manufacturing units on the developing world and workers who work in such facilities.
 
 
A new study reported in the Journal of Occupational and Environmental Hygiene claims children living close to battery manufacturing units in the developing world were 13 times more apt to have lead traces in their blood than their U.S. counterparts.(WCxKit)
 
 
Health officials point out that lead poisoning damages the central nervous system, the kidneys, and the cardiovascular reproductive systems, along with leading to low hemoglobin percentages. In children, it can retard learning, make them hyperactive and even lead to violent behavior.
 
 
The researchers, using data from studies published between 1993 and 2010, also discovered that battery industry workers in the developing world had three times higher blood lead levels than their U.S. counterparts.
 
 
Children and workers in developing countries face significant risks of lead poisoning, which can cause lifelong health problems,” commented Perry Gottesfeld, executive director of Occupational Knowledge International (OK International) and study author. “Without major improvements, we expect that lead poisoning cases will continue to increase as the industry grows.”
 
 
The battery industry uses approximately 80 percent of the global lead output. The demand is being led by huge demand for batteries in vehicles, solar power systems, cellular phones and for back-up to power supply.(WCxKit)
 
 
According to The World Health Organization (WHO), 120 million people are over-exposed to lead – approximately three times the number infected by HIV/AIDS – and 99 percent of the most severely affected live in the developing world.
 

Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.

Learn the ABCs of WORKERS COMP:  www.WCManual.com
 
WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php

 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact  Info@ReduceYourWorkersComp.com.

What are Working Alone Rules in Saskatchewan

The killing of a convenience store employee in Saskatchewan in June has spurred the provincial labor federation to support a petition to change regulations for retail employees working alone, according to a report from the Canadian OH&S News.
 
 
Many delegates attending the Saskatchewan Federation of Labour's (SFL) annual Occupational Health and Safety Conference recently strongly supported and signed a petition calling for the introduction of "Jimmy's Law" into the provincial legislature, says Larry Hubich, president of the SFL. The proposed law is named after Jimmy Wiebe, who was murdered at a gas station convenience store on June 20 in Yorkton. (WCxKit)
 
 
It would require employers to schedule two employees to work together between the hours of 10 or 11 p.m. and 6 a.m. or provide protective barriers between lone workers and the public.
 
 
The incident that prompted the petition occurred in the early morning hours. Members of the Yorkton RCMP received a report of a man who had been found deceased in the Shell Canada convenience store by a customer, says Corporal Rob King, a spokesman for the Saskatchewan RCMP division. Four days after, King says, the Yorkton RCMP detachment charged Kyle Furness, 20, with first-degree murder in connection with the homicide of the 50-year-old worker, an employee of the store for more than 10 years.
 
 
Jimmy's Law is modeled after similar working alone regulations in British Columbia which were introduced in 2008, but have not yet come into effect because of the complexity of the issue, according to Megan Johnston, a spokeswoman for WorkSafeBC. That year, however, BC introduced a separate pay-then-pump requirement following the death of a young gas station attendant.
 
 
"Grant's Law" – named after Grant De Patie, who was dragged to his death while trying to prevent the theft of gas from a station in Maple Ridge, BC – requires mandatory pre-payment of fuel at all gas stations in BC, Johnston says.

 

Wayne Hoskins, president of the Western Convenience Stores Association (WCSA) in Surrey, BC, says it's important to note the distinction between mandatory pre-payment of gas and the requirement for multiple workers or barriers. "While Grant's Law was well-intended, it refers to outside, or ex-store, and not in-store coverage," Hoskins explains.
 
 
In British Columbia, the working alone regulations – known as the Late Night Retail Safety Procedures and Requirements – consist of an engineering control (barrier) or administrative control (extra staff), Johnston says. Hoskins says that a third option has also been proposed: additional training, testing and certification. This option, a combination of both engineering and administrative controls, will be presented to WorkSafeBC's board of directors in October. (WCxKit)
 
 
Ontario is another jurisdiction considering a mandatory pre-paid policy for gas stations following a recent gas-and-dash incident. A  gas attendant Hashem Rad, 62, was struck by a vehicle that took off with unpaid gas at a Petro-Canada station in Mississauga, Ontario. Rad was taken to hospital, where he succumbed to his injuries the following day.
 
 
 
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.

WORKERS COMP MANAGEMENT BOOK:  www.WCManual.com
 
 

 

WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

Australian Employee Crushed to Death in Industrial Blender

A Western Sydney manufacturing company and its director were recently fined a total of $127,400 and ordered to pay WorkCover’s legal costs after a high powered industrial blender was turned on with a man inside it.
 
 
According to a report from the WorkCover Authority, FIP Brakes International (FIP) produces industrial sized brake pads, as well as other products, for trains and other railway vehicles and employs around 60 people mainly based at its facility in Wetherill Park. Its managing director is Chris Katakouzinos. (WCxKit)
 
 
A machine operator was killed when he was cleaning out an industrial blender at FIP’s premises.
The power to the machine had not been isolated and the machine became operational with the worker still inside. He died at the site with extensive crush injuries and lacerations.
 
 
A WorkCover investigation found a significant number of safety failings:
 

1.      The machine should not have been able to operate while its front

       doors were open. 

2.      The safety switches were either broken or malfunctioning. 

3.      The machine’s electrical power supply had not been turned off. 

4.      The machine operator should not have been working alone. 

5.      The machine was not properly maintained. 

6.      The operator was not given proper training.

 
 
FIP and its director were charged with breaches of the Occupational Health and Safety Act 2000.
 
 
In handing down her finding in the Industrial Court, Justice Backman said the incident was foreseeable and that there were serious deficiencies in the company’s systems. (WCxKit)
 
 
They both pleaded guilty. FIP was fined $117,000 and Mr. Katakouzinos $10,400. The court ordered them to pay WorkCover’s legal costs.
 

 
Author Robert Elliott, executive vice president, Amaxx Risk Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers Compensation costs, including airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: Info@ReduceYourWorkersComp.com.

WORKERS COMP BOOK:  www.WCManual.com
 
 

 

WORK COMP CALCULATOR:  www.LowerWC.com/calculator.php
 
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues.
 
©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact Info@ReduceYourWorkersComp.com.

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