Category Archives: Brain Injury

Psychosocial Issues: Costly Problems Delaying Recovery

According to the New Jersey Workers’ Compensation Rating & Inspection Bureau, over the most recent five-year period total incurred costs for head injuries were $113,000 per claim; per claim costs for concussions during the same period were $83,000. Those costs suggest a lot of time away from work for New Jersey’s head-injured workers.

Many of the injuries involved psychosocial issues not identified until well into the claim. Research shows that these issues significantly delay and impede recovering and returning to work.

With that as background, let us propose a thesis:

Our nation’s current system for treating injured workers with mental health issues is uncoordinated, overly fragmented, highly wasteful and does not focus enough on speedy return to work. There is a critical need for a more systemic approach as well as an integrated coterie of clinicians and practitioners, trained in workers’ compensation, whose goals are to provide compassionate treatment with a steady return to work trajectory. 

The issue is compounded by the way claim adjusters, supervisors, nurses and defense attorneys view psychological issues. No one wants to ”buy a psych claim,” and many  believe that referring a claimant for behavioral health treatment does nothing more than create a lifetime annuity for a psychologist. Time and again this view has been proven correct.

What to do about that? Ay, there’s the rub. For in that question lies a host of difficulties. These, for instance:

  1. Most mental health professionals do not understand workers’ compensation. They do not realize either its statutory requirements or the concept of maximum medical improvement. They have spent many years being trained to treat the entire person. The players are the patient and the therapist, and it is like sitting on a two-legged stool. They do not fathom that, in workers’ compensation, the stool has five legs, with the other three occupied by the employer, the treating physician and the claim adjuster.
  2. Too often, by the time an adjuster or nurse recognizes that psychosocial issues may be impeding recovery and return to work the claim may have gotten a little long in the tooth; it could be months old, or more.
  3. It can take a claim adjuster weeks, in rare cases, months, to find a psychologist and schedule an appointment. It can also take weeks or months for a report to make it back to the file. Moreover, finding a clinician with even a smattering of workers’ compensation knowledge or experience is often problematic (See 1, above).
  4. Because there is no mental health electronic health record system for workers’ compensation, every report is its own island, sometimes good, sometimes bad.
  5. Everything is paper-based, which wastes claim adjuster time and increases expense.¹
  6. Although psychologists understand the value of work as therapy, many see no reason to help coordinate early return to work with employers, claim adjusters or medical providers

These are deep and difficult considerations. Tomorrow, we’ll describe how we created an entirely new approach that successfully addresses each of them.

¹ Claim adjusters also report that a not insignificant number of these reports are essentially unreadable, because they are handwritten.

A Good History: The Devil Is in the Details

It has been my experience that taking an extensive history from an injured client about a head injury has to be more than just “what happened, where did you hit your head and what do you remember?”

One has to determine whether loss of consciousness occurred and, if so, for how long. If loss of consciousness was prolonged, has the injured worker experienced Post Traumatic Amnesia? Post Traumatic Amnesia refers to the time the head injury happened until when the patient is laying down consistent, recoverable memories. While head-injured workers may have islands of memory during this period, they often do not retain their memories consistently. Understanding and evaluating this is vital to providing the injured worker the appropriate services and treatment.

A real-life example will help to understand what I mean.

A patient recently was referred to me secondary to depression from a work­related accident. The history provided to me was that the worker had  slipped and fallen at work. When she was delayed in returning to work, a neurological evaluation concluded that her overall presentation was more impaired than would be expected for the type of injury she had suffered – a simple slip and fall. The suggestion then was that her problem was more psychological than neuropsychological or phsyical.

In our initial session, I took a very extensive and detailed history of the actual events . The accident report said she slipped on water and fell in the hallway and had been out of work since then. The history was woefully incomplete. It did not tell me anything about what kind of fall, what was going on surrounding the event and what happened after the event. From talking with her, this is what I learned and what should have been in the history I’d been given: She was a kindergarten teacher. She was walking 20+ kindergarteners in a line down a hallway. This was the first week of school and the children did not know what to do, so she had to help them stay together in a line in order to follow her . This was when she slipped on a puddle of water from a nearby water fountain, fell on the floor, hit her head and lost consciousness. I asked her what she remembered when she awakened into consciousness. She told me there was someone standing over her asking her something.

She was cloudy about the event.   I asked if there was anyone in the hall? “No.”  Any children? “No.” Any other teachers? “No.” Any nurse? “No.”

So, I learned that when she regained consciousness, the hallway was cleared of everyone with the exception of the person who was standing over her trying to talk to her.

If you extrapolate from that to try to determine the duration of her loss of consciousness, you would conclude that from the time she slipped, fell and lost consciousness, the following would most likely have occurred : The kindergarteners would have been upset, anxious and crying. Another teacher would have had to notice that, gather the children and take them into another room. This would have taken at least a few minutes. Meanwhile, a colleague would presumably try to get the nurse. And, finally, while all of this was going on, someone would stay with her. This would be the person who was standing over her trying to talk to her when she awakened from her loss of consciousness.

This history now suggested that at the very least, she had  lost consciousness for around 10-15 minutes and awakened to a vague sense of someone asking if she were all right. She told me she does not remember what she replied. She thinks she said she was okay. She was confused, dazed and disoriented.

There was no ambulance called, and she was sent home.  She slept the rest of the weekend. While she had ‘islands of memory” over the next couple of weeks, she was not laying down consistent memories , suggesting a protracted Post Traumatic Amnesia.

Clinically, all of this presented a very different picture from the one I had been given initially. From a simple slip and fall with a neuropsychological testing that looked too impaired for someone who just had a slip and fall, this woman clearly had a head injury.  She had a positive loss of consciousness of 10-15 minutes, islands of memory and Post Traumatic Amnesia for a couple of weeks.

My report to the case manager was that this was a  woman who had suffered a very serious injury. By the time she got to me, she had been struggling for weeks with no services for the head injury. Her deficits included neurocognitive dysfunction, post-traumatic vestibular dysfunction and post-traumatic visual dysfunction.       Much of the delay in treatment had to do with an initial assessment in which the history was incomplete and the conclusions less than accurate. If a complete history had been taken at the beginning, she could have been helped with these issues and would have improved more rapidly. The accident analysis and narrative failed this woman and she paid the price.

The bottom line to this is that we at WCPN know the importance of taking a very detailed history. Of course, this is important for any accident, but even more so for accidents involving head injuries, which by their very nature are psychologically problematic. For us, getting the history right is the first essential step in treating our patients sooner, faster,smarter.

Retrograde Amnesia: Why Doesn’t The Injured Worker Remember The Accident?

After the recent and horrid AMTRAK crash just outside Philadeiphia authorities determined the train was traveling more than twice as fast as the speed limit allowed. Media then focused on the engineer’s claim that he had “no recollection of the crash.” This phenomenon of not being able to remember an accident is not uncommon in  the field of neuropsychology.

In my years of practice working with head injured workers, I have noted that with an altered state of consciousness or a positive loss of consciousness, inevitably, the injured party has no recollection of the actual incident. This phenomenon is called Retrograde Amnesia. It is classified under Post Traumatic Amnesia ( PTA), which I  will discuss in a future post. Retrograde Amnesia is a partial or total loss of the ability to recall events that have occurred during the period immediately preceding the brain’s injury. Retrograde Amnesia targets the most recent memories. Ribot ‘s Law  suggests that  there is a pattern of destroying new memories before older ones because  the neural pathways of the new  memories are  not as strong as the older ones,  which  have been strengthened by years of retrieval. Basically, what happens is that the injured worker loses the memory of and access to the events that occurred immediately before the injury.

Neuropsychologically, here’s how memory storage works, in part. The hippocampus, which deals with memory consolidation (particularly episodic or event memory) is responsible for  transferring information from short-term to long-term storage. It quickly stores new information that it will then transfer to the neocortex for long-term storage. When an event such as a blow to the head results in an altered state of consciousness and/or loss of consciousness, the information about events that have just happened is not immediately transferable – and it may never be. It is as if those events never happened.

Retrograde amnesia usually involves minutes,  sometimes hours,

A study by Cartlidge and Shaw in 1981 showed that the duration of Retrograde Amnesia usually progressively decreases. It is particularly distressing for the injured worker because of the disquieting sense of not knowing exactly what happened. In my clinical experience it is highly unusual that the particular event memories are ever regained totally.

So, what can we take away from this? Well, in retrospect, the media should have cut Brandon Bostian, the train’s engineer, a little slack when he “claimed” to not remember the crash or the events leading up to it. He might or might not have been at fault, we won’t know until the investigation is complete, but he nearly certainly wasn’t lying about his loss of memory. And, by the way, he’s probably not the only person who lived through the crash and has lost memory of it. Second, workers’ compensation claim adjusters should, as part of their training, learn about Retrograde Amnesia. Why? Because, as I’ll describe in a future post, considering this psychological phenomenon early on in a head injury case can significantly shorten the disability and lower its cost.

That’s the sooner, faster, smarter way.

Neuropsychological Testing reports – What they should be saying about injured workers!

As a neuropsychologist with over 37 years of neuropsychological testing experience I have a keen appreciation for the time and cost of neuropsychological testing. A key question to me is what value does this expensive assessment have to the injured worker or to his payor of medical services?

In answering this question I am reminded of a case several years ago as Clinical Director of Cambridge Rehabilitation Services. Called on to consult by a private disability insurance carrier, this man had been a top salesman in New Jersey for a national company for many years. Unfortunately he suffered a brain injury from which he physically recovered but left him with mild cognitive impairments. The referral included his medical reports and a Neuropsychological Test report. This report was not from a local neuropsychologist but by a leading expert from New York. The expert, well published and a professor, made many correct observations and conclusions about my patient.   However, it was my belief that the report missed the mark on informing his disability insurance carrier about his rehabilitation potential in terms of return to work.

I went over the test data and concluded that the expert, retained by claimant’s attorney on behalf in his disability claim, presented a very static view of his capabilities.   As with many Neuropsychological Test reports I have reviewed over the years, several critical work related questions went unaddressed. The expert simply opined the claimant had suffered cognitive impairments and that returning to his job “as is” was not possible. With the simple “yes he is disabled” conclusion, a disability “payout” was inevitable with this report in hand.

After an interview with the claimant, I imagined a very different outcome for him, one that he was eventually very pleased with in the long term.

My report to his insurance carrier pointed out several missing factors left unaddressed in the prior report.

  • Job related cognitive limitations – The specific cognitive changes causing his loss of work functions
  • Potential benefits of rehabilitation efforts– the specific interventions and their projected benefits to improving his work product
  • Emotional and motivational factors– the personality factors which could be tapped into and leveraged to assist him in perservering with a rehabilitation program that would assist him in accepting personal changes
  • A specific time line for return to work and projected costs– a detailed outline of the time and cost of the rehabilitative efforts.

His insurance carrier offered him our cognitive rehabilitation program in lieu of a full and permanent disability payout, with the option of the payout if the program failed. He chose the rehab offer.

Our team of a neuropsychologist, speech pathologist and cognitive therapist went to work on an intensive basis with interventions in his work environment itself. Remediation efforts attacked his critical cognitive weaknesses that blocked him from success and within 3 months he returned to work. While his work output was still diminished (after all he had been national top salesman for several years, allowing quite a bit of leeway), he was happy he could see himself successful earning a living, competing in the workplace as he always had.

The full cost of our cognitive rehab program was less than 4 months of the disability payments that would have been paid to him had our interventions not been successful! A net win-win for all.