Rousmaniere: How Spinal Cord Injury Care Has Improved
Tom, a Colorado firefighter on a rescue mission in 1990, survived a severe work accident that dealt him a spinal cord injury. He’s now afflicted with quadriplegia — a term that is being replaced by “tetraplegia.” Tom’s workers’ comp insurer, Pinnacol Assurance, St. Anthony Hospital (acute care), and Craig Hospital, a national leader in spinal cord rehabilitation, worked with Tom from emergency response through his recovery. Today he is the full-time manager of community television programs for the city of Golden. (The National Council on Compensation Insurance (NCCI) has told his story recently in a case profile.)
Tom’s recovery was outstanding, exceptional for that time. This degree of recovery is more common today. The workers’ comp system has come to expect it.
I Iearned about this from Kenneth Hosack, who has spent his career in administration of catastrophic injury rehab at Craig Hospital, in Englewood, CO. Close to retirement, Hosack received a rehab industry lifetime achievement award this spring for his work.
The patient of today has a much better chance of survival. She or he will probably recover to a higher level of quality of life than in the past. And today, the science of spinal cord and the nervous system recovery is of leaps and bounds in discovery and treatment trials.
Workers’ comp pays for about 10% of all spinal cord injury cases in the country. But we may be best prepared to support “SCI” patients. This is thanks to the industry’s intense use of nurse case managers, vocational rehab specialists, and medical directors, all focused on maximum recovery.
As there is no central registry of SCI injuries in workers’ comp, no one knows with certainty how the number and severity of SCIs may have changed. We know that the national rate of SCIs has declined between 1993 and 2012 by 27% among working age men in the general population. That’s attributed entirely to driving safety.
Comprehensive figures for work injuries are also missing for serious burns, brain injuries, and multiple traumas in workers’ comp. We do know that permanent total disability cases account for 0.5% of work injuries and make up 7% of losses. We know that the treatment a serious SCI costs is in excess of one million dollars.
I polled a dozen experienced case managers about how treatment of serious injuries may have evolved in the past few decades. They told me that best practice standards have improved. Actual treatment remains pretty inconsistent, especially for spinal cord injury cases. Yet spinal cord injury rehab, they say, has seen the most dramatic improvement among the major catastrophic conditions.
Until World War II, the prognosis for a person with SCI was simply death. Today’s treatment is grounded on a national network of specialist hospitals and an interdisciplinary care approach. These advances began to appear in earnest in the 1970s.
Had Tom sustained his injury in, say 1993, the chance of death or total paralysis would have been much higher than today. Once admitted to an acute care hospital, patients then faced fatal risks from respiratory, bladder and other complications. Since the 1990s, the risk of death has declined by 70%. That’s mainly thanks to antibiotics.
Stabilizing the spine at the site of injury, and use of backboards, came in the 1990s. Improved emergency response and early intervention have reduced the number of “complete” SCIs, or tetraplegia, thereby preserving some mobility among the more severely injured patients.
Twenty-five years ago, a patient would have spent almost double the number of days as an inpatient then he or she would today. In 1990, the median acute care hospital stay for a person with SCI was 15; in 2016, it was 11. Inpatient rehab days declined from 58 to 35.
At Craig Hospital in 1993, upwards of half of inpatient admissions had been in acute care or nursing facilities for more than 90 days prior to transfer. In 2017, inpatients with SCI were being transferred to Craig after an average of 22 days.
Hosack told me about a multi-center study which looked at many independent variables and their effect on optimal overall patient outcomes. The greatest single variable that correlated with outcome was the number of hours the patient participated in therapeutic recreation in rehabilitation. He said, “Not only medicine, physical therapy, occupational therapy, case management, but also recreation, counts. This finding underscores the importance of psychosocial factors on outcome.”
Treatment advances today includes immediate care techniques to reduce nerve damage. And there are promising trials on nerve regeneration, such as with cellular therapy. Some are working on thought control systems that enable the patient to bypass the spinal cord to send instructions to limbs. Adaptive technology such as exoskeletons holds some promise. Wheelchair technology has improved.
No one is talking about a cure, yet many in rehab are excited about the potential for these kinds of advances.
ABOUT THE AUTHORS
Peter Rousmaniere is widely known throughout the workers’ compensation industry, both for his writing and consulting experience. Based in the picture perfect New England town of Woodstock, VT, he is a regular on the conference circuit, and is deeply in tune with trends and developments within the industry. His passion is writing and presenting on issues largely related to immigration, and he maintains a blog on the subject at www.workingimmigrants.com.