Fall 2011 THE OFFICIAL PUBLICATION OF AWCCA, INC. In this … · 2015-06-25 · Carpal Tunnel...

T H E O F F I C I A L P U B L I C AT I O N O F A W C C A , I N C .

In this issue

Executive Summary

Carpal tunnel syndrome is a common

(prevalence approximately 5 percent) and

relatively minor condition for which highly

effective treatment is available. Most patients

with carpal tunnel syndrome can expect

a good outcome with surgical treatment.

Recent mass marketing of carpal tunnel

surgery has introduced some confusion

regarding treatment guidelines. While all

candidates for surgery are candidates

for open carpal tunnel release, not all

are candidates for endoscopic carpal

tunnel release. Adherence to appropriate

guidelines with regard to technique selection

and a transparent informed consent process

are necessary to ensure that all patients

receive optimal treatment.

Introduction

Arizona has witnessed a substantial increase

in direct-to-public medical mass marketing

recently. While advertising is anathema to

many physicians, the practice is permitted by

the Arizona Medical Board. Patients may be

confused by claims made in such advertising,

especially when the patient is in the process

of seeking treatment advice for the condition

featured in the advertisement. The situation

can become even more confusing for the

patient if the marketing tends to exaggerate

the severity of the condition or if it introduces

bias in presenting treatment options.

The purpose of this article is to review current

evidence-based treatment guidelines for

carpal tunnel syndrome (CTS). You may find

this information helpful when counseling

patients regarding their treatment options.

The American Academy of Orthopedic

Surgeons (AAOS) has published guidelines

for the diagnosis and treatment of carpal

tunnel syndrome. These can be reviewed in

detailed and summarized versions on the

AAOS website (http://www.aaos.org/Research/

guidelines/guide.asp.).

Once the diagnosis of carpal tunnel

syndrome is established, it may be helpful

to counsel the patient regarding underlying

co-morbidities (diabetes, thyroid disease,

obesity, etc.) and lifestyle contributors (diet,

tobacco, exercise). As part of that discussion,

especially in patients who may express alarm

due to what they have seen, heard or read in

the mass media and marketing campaigns,

a few words regarding the relatively minor

nature of the condition and the straight-

forward treatment available may be re-

assuring.

Evidence Based Treatment of Carpal Tunnel Syndrome

Continued on page 2…

Evidence Based Treatment of Carpal

Tunnel Syndrome ..................

President’s Message .............. Page 4

Fred Brick Memorial Foundation

Seeking 2012 Award

Nominees............................. Page 8

Let the AWCCA Job Referral Line

Work for YOU!… .................. Page 9

Helen Olson Named as

AWCCA Secretary….............. Page 9

“Public” Records?... Well,

Kinda. ................................Page 11

Kids’ Chance of Arizona Is Seeking

Scholarship Applicants!… ....Page 12

AWCCA Amends Bylaws… ..Page 13

AWCCA Offering Continuing

Education Credits… ............Page 14

The ABCs of ASTYM… .........Page 15

“Self Examination, Listening &

Mentoring: Fulfilling Activities for

Preventing Burnout”… .........Page 21

Fall 2011

By Paul M. Guidera, M.D., F.A.C.S.Arizona Hand & Wrist Specialists

www.AWCCA.org: Your L ink to the Ar izona Work Comp Indust r y

If you’re looking for information on AWCCA membership, upcoming events, past issues of The Examiner, links to AWCCA sponsor websites or contact information

for AWCCA Executive Committee Members, be sure to visit www.awcca.org.

For quick access to the most current AWCCA news, remember to bookmark www.awcca.org in your internet browser.

with mild or moderate CTS do well with

surgical treatment even after years of

symptoms.

There are two surgical techniques widely

utilized in this country: open carpal tunnel

release (OCTR) and endoscopic carpal

tunnel release (ECTR). Regardless of the

technique utilized, the goal is to increase

the available volume in the carpal canal,

thus “decompressing” the median nerve.

Open Carpal Tunnel Release

This is an outpatient procedure generally

performed under local anesthesia with

or without sedation. Some patients prefer

general anesthesia. A small incision is

made in the palm (usually less than 4 cm)

to expose the transverse carpal ligament

(TCL) which forms the roof of the carpal

tunnel. Under direct vision, the surgeon

incises the ligament and inspects the

contents. The incision is then closed.

Most patients will wear a bandage for a

few days and then begin using the hand

progressively thereafter. Post-operative

… Carpal Tunnel continued from page 1

Non-Surgical Management

In most cases, conservative treatment is

palliative and not curative. An exception

is pregnancy-related CTS, in which the

condition often resolves following delivery

and/or cessation of breast-feeding.

Patients with early or mild CTS can

be managed without referral using

neutral nighttime wrist splints. “Cockup”

splints sold by many merchants are not

appropriate as they typically maintain

the wrist in extension. This increases the

pressure within the carpal tunnel. A simple

and inexpensive solution is the use of a

cockup splint from which the palmar

metal bar has been removed. Daytime

use of splints is counter-productive and

should be discouraged.

There is also no curative role for adjunctive

treatments such as occupational

or physical therapy, acupuncture,

chiropractic or massage therapy. While

some patients may have transient relief

of symptoms of CTS during such activities,

there has been no long term benefit

demonstrated. Instead, these treatments

may increase overall costs and delay

definitive treatment.

Corticosteroid injection of the carpal

canal can be considered in some cases,

such as when the patient is not medically

stable for surgery or in some patients

who prefer to delay surgery. The results of

such injections are not predictable. One

comparative study demonstrated no long

term efficacy of corticosteroid injections.

Oral corticosteroids have not been shown

to be of benefit.

Surgical Indications

Most patients with symptomatic CTS

unresponsive to conservative measures

and/or with symptoms lasting more than

seven weeks are surgical candidates.

In addition, patients with mild CTS who

prefer early surgical intervention should

be considered for surgical referral.

Although some marketers may claim that

“nerve damage” will occur after just a

few weeks of symptoms if surgery is not

performed, many hand specialists regard

this claim as unscientific, and there is

substantial evidence that most patients Continued on page 3…


splinting is not required in most cases.

All candidates for carpal tunnel surgery are

candidates for OCTR. The advantages of

OCTR include a clear view of the contents

of the carpal tunnel and high likelihood of

complete division of the ligament. Intra-

canal pathology such as tenosynovitis,

ganglions or other tumors and exostoses

can be managed concurrently. The

incidence of complications specific to

carpal tunnel release has consistently

been reported as very low. The incidence

of re-operation for persistent symptoms

following OCTR is also very low. A small

number of people undergoing OCTR

will report tender scars (“pillar pain”),

however this is typically self-limited and

of short duration. The extensive skin scars

purported to result from OCTR in recent

advertisements do not reflect the incisions

used by most hand surgeons over the last

20 years.

Endoscopic Carpal Tunnel Release

Endoscopic techniques have been

reported in the mainstream hand surgery

literature for more than 20 years. There

are two endoscopic techniques: the

single portal (Agee) technique in which

a single 1-2 cm incision in made near

the wrist flexor crease, and the two portal

(Chow) technique in which a second

incision is made in the mid palm. All other

techniques are simply modifications of

these. Regardless of ECTR technique, a

small endoscope with a blade assembly

is introduced into the carpal tunnel and

the TCL is divided from within. Incisions

are closed and a bandage applied for

a few days, after which the patient may

begin progressive use of the hand. ECTR

is usually performed under a general

anesthetic although peripheral blocks

can be used.

The advantage of ECTR, notably the

single portal technique, is avoidance of

an incision in the palm. Some authors

have reported a lower incidence of

pillar pain the patients undergoing ECTR.

Several studies have demonstrated

an earlier return to work following ECTR

in patients without associated civil or

workers’ compensation litigation. Most of

the relative disadvantages of ECTR relate

to the narrow field of view of the camera

during the procedure. Disadvantages of

ECTR include reports of iatrogenic injury

to the median nerve or its branches,

ulnar nerve or ulnar artery; incomplete

division of the TCL requiring revision with


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and assist you in putting a plan of care together to get your injured worker back to work.

The AWCCA Executive Committee wishes each of you Happy Holidays and a safe and prosperous 2012!

AWCCA Mission Statement:

The purpose and objectives of this

association shall be to promote

the general welfare of its members

by developing close relationships

among those engaged in

the handling of workers’

compensation claims; to promote

cooperation by mutual exchange

of experiences and information

and discussions thereon and, to

educate its members.

The Examiner is published

quarterly by AWCCA, Inc., P.O.

Box 44941, Phoenix AZ , 85064-

4941. All articles appearing in this

publication contain the opinions

of the authors and not necessarily

the opinions of AWCCA, Inc., its

officers or editors. AWCCA, Inc.

encourages the submission of

new ads and articles, subject to

editing. Signed letters to the editor

are welcome. AWCCA, Inc. seeks

to provide a forum for the free

exchange of ideas and opinions.

Yes, Virginia…There IS Still A U.S. Post Office!All U.S. mail correspondence including checks, membership applications, hard copies of Letters to the Editor of

The Examiner and other items addressed to the organization or its officers should be sent to:

AWCCA, Inc.P.O. Box 44941

Phoenix, AZ 85064-4941

As we reach the end of 2011, I would like to personally thank the members of our

organization, and acknowledge what their many contributions have allowed AWCCA to

accomplish collectively this past year. The donations to our various charities totaled in

excess of $75,000 which is a record amount for AWCCA. Our charities have been adversely

impacted by the downturn in the economy, and they need us more than ever. It becomes

more of a challenge each year to be able to keep this up, but we know how important it is

to those who rely on us. I consider it a privilege to be associated with such a wonderful,

dedicated group of people who understand the importance of giving back and making the

lives of others just a little bit better, and their futures brighter.

Many thanks to Molly Jones, this year’s Vice President, and Cathie Chavez, this year’s

Treasurer, for their dedication to AWCCA. Molly returns to the AWCCA Board after having

served previously, and is responsible for arranging for our guest speakers for our dinner

meetings, and coordinating the continuing education credits through the IEA, as well as

managing the insurance coverage for the organization. Cathie is new to the Board this year

and is responsible for keeping our finances organized, which also involves the tracking of

all membership registrations and committee volunteers. She works with our accountant

and Helen Olson, last year’s Treasurer, in the processing of our income taxes. Speaking

of Helen Olson, I am delighted to announce that she has agreed to step in as our interim

Secretary, to replace Josie Leonard, who recently elected to step down for the balance of

the membership year. We miss Josie, and the exemplary job she did for AWCCA, and wish

her the very best until she is able to return.

In addition to Molly, Cathie, Helen and me, the Executive Committee is now made up

of the following associate members: Past President, Donell Hewitt; Interim Secretary,

Helen Olson; Members-at-Large, Carol Bair, Linda Barton, Susan Franzen, Debbie Hill,

Grace Nolan, Dave Stewart and Joseph Strange; Webmaster, Trevor Smith; Examiner

Editor, Jim Gill; Holiday Party Chairpersons, Susan Williams and Sam Lloyd; Job

President’s MessageBy Tara Shields, AWCCA President


Referral Coordinator, Joseph Strange;

Spring Seminar Chairpersons Erin Finn

and Dawn Ripa; and Golf Tournament

Committee Chairpersons, Sam Lloyd and

Liz Florez. One other person who cannot

go unmentioned is Maryann Karstendiak

with Encore Unlimited. Even though

she has relocated out of state, Maryann

continues to assist us each month with the

CEU Credit submissions, dinner meeting

reservations, and last minute e-mail

blasts. These individuals, along with the

members of the various committees, all

work tirelessly to make certain the Holiday

Party, Seminar and Golf Tournament go off

without a hitch, that the Examiner goes out

on time, and that no detail is overlooked.

Year after year, they volunteer and work on

fine-tuning the processes, and pass their

knowledge along to the next team taking

over as the chairpersons. We would, very

simply, be lost without these outstanding

committees!

As you know, we have had a number of

issues with the various e-mail blasts that

have gone out over the past few months.

Although we have tested and tested to

determine the reason some individuals

did not receive the communications,

we have not been able to pin-point the

source of the problem. That being said,

there have been numerous complaints

concerning the fact that information did

not reach some members. I would ask

that if anyone has complaints, that they

do not make them to other members

or to our committee chairpersons. The

chairpersons are working very hard to meet

their deadlines, and their jobs are difficult

ones under the best of circumstances. The

chairpersons are not responsible for the

failure of the delivery of the e-mails; that is

my responsibility, and so I would request

that you contact me directly in that regard.

My contact information is available on the

website, and I have committed to making

certain that the website is kept as current

as possible with information regarding the

dates and times of each dinner meeting

and other events. The website address has

not changed in many years, and our dinner

meetings have always been held on the

second Tuesday of each month, at least as

far back as I can remember. The suggestion

was made that we eliminate monthly e-mail

blasts altogether in the future, post the

dinner meeting announcement, and ask

that members simply refer to the website

for dates and times, since there are some

members who prefer not to receive any

e-mails. I don’t think that is feasible, but

it tells us that there is no perfect answer to

this issue. We are doing our best to correct

the situation and in the interim ask for your

patience, that you go to the website, http://

www.awcca.org/, for information and

please contact me at [email protected]

or [email protected] with any concerns

and suggestions.

Please remember to mark your calendars for

the the Spring Seminar on Friday, February

10th, 2012, and the Golf Tournament on

Friday, May 4th, 2012.

I wish you all a Happy Holiday and a Safe

and Happy New Year!

Tara Shields

… President’s Letter continued from page 4

Paul J. Gleason, PTPrincipal

[email protected]

Sports Injury,Industrial & Orthopedic

Rehabilitation

www.PTComplete.com

Physical Therapy Complete, PLLC375 E. Virginia Avenue, Suite BPhoenix, AZ 85004-1220Phone 602 264-5323Fax 602 264-5302

2009 BC Redo.qxd:PTC Cards 11/18/09 7:22 AM Page 1

Rebecca Lollich MA, CRC

Vocational ConsultantLabor Market Expert

office 480-451-5228fax 480-515-1576e-mail [email protected] E. Bell RoadSte. 107, Box 505Scottsdale, AZ 85260

PHOENIX • TUCSON • ALBUQUERQUE • DENVER • LAS VEGAS(602) 395-9500 (520) 885-8536 (505) 821-5100 (303) 721-0101 (702) 451-5100

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Streaming Video is available to our clients via e-mailOver 25 Years Experience • Licensed • Bonded • Insured

open surgery; intraoperative conversion

to an open procedure due to technical

problems; persistent median nerve

symptoms due to missed mass lesions

or other pathology and an inability to

effectively treat associated conditions

such as rheumatoid tenosynovitis.

For these reasons, a patient considering

ECTR should receive detailed informed

consent from the surgeon regarding the

additional relative risks of ECTR. Some

surgeons have abandoned ECTR in

favor of OCTR due to reports of higher

complications rates associated with

ECTR.

Not every candidate for CTR is a

candidate for an endoscopic technique.

Contra-indications include severe

median neuropathy, rheumatoid or other

proliferative tenosynovitis, known soft tissue

or osseous lesions of the carpal tunnel,

prior history of wrist fracture, prior history

of wrist surgery (especially prior open or

endoscopic carpal tunnel surgery) and

inadequate wrist extension.

At present, there is a financial incentive

to both surgeons and surgical facilities to

perform ECTR as most insurers (including

CMS) reimburse ECTR at significantly

higher rates. In addition, the facility

cost per ECTR case is also higher, since

the blade assembly used during ECTR

is a single use item. Depending on the

brand of the assembly, the cost ranges

from approximately $200 to over $1,200.

This introduces potential bias on the

part of device makers and marketers to

promote ECTR. For these reasons, ECTR

may increase pressure on the health care

dollar. Some argue that the potential

for earlier initial recovery from ECTR

negates the increased medical costs.

This is not borne out, however, when one

considers that ECTR does not guarantee

a faster return to productivity in workers’

compensation cases.

Most studies have demonstrated no

difference in outcome between OCTR

and ECTR at six weeks postoperative in

uncomplicated cases. Success rates,

defined as symptomatic relief, in patients

without associated litigation range from

80-95 percent.




References

Agee JM, McCarroll HR Jr, Tortosa RD, Berry DA, Szabo RM, Peimer CA. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. J Hand Surg [Am]. 1992 Nov;17(6):987-95.

Armstrong T, Devor W, Borschel L, Contreras R. Intracarpal steroid injection is safe and effective for short-term management of carpal tunnel syndrome. Muscle Nerve 2004 Jan;29(1):82-8.

Ashworth NL, Carpal Tunnel Syndrome, Retrieved 09/22/2010,

http://www.emedicine.com/pmr/topic21.htm, Last updated November 30, 2006.

Atroshi I, Larsson GU, Ornstein E, Hofer M, Johnsson R, Ranstam J. Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomized controlled trial. BMJ. 2006 Jun 24;332(7556):1473.

Bury TF, Akelman E, Weiss AP. Prospective, randomized trial of splinting after carpal tunnel release. Ann Plast Surg 1995 Jul;35(1):19-22.

Cook AC, Szabo RM, Birkholz SW, King EF. Early mobilization following carpal tunnel release. A prospective randomized study. J Hand Surg [Br ] 1995 Apr;20(2):228-30.

Dammers JW, Roos Y, Veering MM, Vermeulen M. Injection with methylprednisolone in patients with the carpal tunnel syndrome: a randomized double blind trial testing three different doses. J Neurol 2006 May;253(5):574-7.

Demirci S, Kutluhan S, Koyuncuoglu HR, Kerman M, Heybeli N, Akkus S, et al. Comparison of open carpal tunnel release and local steroid treatment outcomes

SUMMARY: SURGICAL GUIDELINES

Procedure Contra-Indications

OCTR No specific contra-indications

ECTR Proliferative Tenosynovitis (i.e., Rheumatoid Arthritis)

Severe OA basal joint

Hamate Non-Union

Prior Wrist surgery (especially prior CTR)

Altered wrist anatomy (i.e., Trauma)

Severe median neuropathy with or without thenar wasting

Inadequate wrist extension

Mass lesion (ganglion or other tumor)

Isolated motor branch compression

in idiopathic carpal tunnel syndrome. Rheumatol Int 2002 May;22(1):33-7.

Burke J, Buchberger DJ, Carey-Loghmani MT, Dougherty PE, Greco DS, Dishman JD. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. J Manipulative Physiol Ther 2007 Jan;30(1):50-61.

Ferdinand RD, MacLean JG. Endoscopic versus open carpal tunnel release in bilateral carpal tunnel

syndrome. A prospective, randomized, blinded assessment. J Bone Joint Surg Br. 2002 Apr;84(3):375-9.

Finsen V, Andersen K, Russwurm H. No advantage from splinting the wrist after open carpal tunnel release. A randomized study of 82 wrists. Acta Orthop Scand 1999 Jun;70(3):288-92.

Hui AC, Wong S, Leung CH, Tong P, Mok V, Poon D, et al. A randomized controlled trial of surgery vs. steroid injection for carpal tunnel syndrome. Neurology 2005 Jun 28;64(12):2074-8.

O’Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev 2003;(1):CD003219.

Macdermid JC, Richards RS, Roth JH, Ross DC, King GJ. Endoscopic versus open carpal tunnel release: a randomized trial. J Hand Surg [Am]. 2003 May;28(3):475-80.

Palmer DH, Paulson JC, Lane-Larsen CL, Peulen VK, Olson JD. Endoscopic carpal tunnel release: a comparison of two techniques with open release. Arthroscopy 1993;9:498-508.

Scholten RJ, Gerritsen AA, Uitdehaag BM, van GD, de Vet HC, Bouter LM. Surgical treatment options for carpal tunnel syndrome. Cochrane Database Syst Rev 2004;(4):CD003905.

Siegmeth AW, Hopkinson-Woolley JA. Standard open decompression in carpal tunnel syndrome compared with a modified open technique preserving the superficial skin nerves: a prospective randomized study. J Hand Surg [Am ] 2006 Nov;31(9):1483-9.

Trumble TE, Diao E, Abrams RA, Gilbert-Anderson MM. Single-portal endoscopic carpal tunnel release compared with open release : a prospective, randomized trial. J Bone Joint Surg Am. 2002 Jul;84-

A(7):1107-15.

Ucan H, Yagci I, Yilmaz L, Yagmurlu F, Keskin D, Bodur H. Comparison of splinting, splinting plus local steroid injection and open carpal tunnel release outcomes in idiopathic carpal tunnel syndrome. Rheumatol Int 2006 Nov;27(1):45-51.

Vasen AP, Kuntz KM, Simmons BP, Katz JN. Open versus endoscopic carpal tunnel release: a decision analysis. J Hand Surg [Am]. 1999 Sep;24(5):1109-17.

Verdugo RJ, Salinas RS, Castillo J, Cea JG. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev 2003;(3):CD001552.

Wong KC, Hung LK, Ho PC, Wong JM. Carpal tunnel release. A prospective, randomized study of endoscopic versus limited-open methods. J Bone Joint Surg Br. 2003 Aug;85(6):863-8.

The Fred Brick Memorial Rehabilitant

of the Year Award is presented annually

to an injured worker who has overcome

significant obstacles and has reached his

or her highest rehabilitation potential.

“Highest potential” is relative to each

injured worker and should not be

misconstrued as securing and retaining

competitive employment. Awards are

also distributed for each injured worker

nominated.

While this award and recognition

ceremony began under the IARP State

Chapter, AWCCA subsequently agreed

to keep the tradition of this special event

by carrying the torch and continuing

the award to injured workers. AWCCA

has graciously committed to continued

support of the award fund. Other money

is solicited from various community

members, such as carriers, law offices,

medical and rehabilitation facilities,

as well as individuals. Be it $10.00 or

$1,000.00 this money makes the Fred Brick

Rehabilitation Award possible.

Nominees for the 2012 Rehabilitant

of the Year Award are currently being

solicited. If you have a candidate in

mind, your nomination should include

information concerning the nature of the

injury, the medical treatment, obstacles

experienced, descriptors of support (i.e.-

family, community, etc.) as well as the

final outcome. This information will be

given to the audience the evening of the

award. Recognition of the nominees and

winner(s) will be made at the May AWCCA

dinner meeting being held this year on May

8th, 2012. Recipients will receive a cash

prize as well as a certificate of recognition.

If you know of someone who should be

nominated for this recognition, please

complete and submit the nomination form

with a detailed narrative no later than

April 2nd, 2012 to Erin Finn at: efinn@

youroptimalcare.com. Forms can be found

by visiting the AWCCA Website, clicking

on “Forms” and selecting “Affiliate Forms”.

For further questions or to become a

member of our great committee, please

call Erin Finn at 602-908-1188.

Fred Brick Memorial Foundation Seeking 2012 Award NomineesBy Erin Finn, Chairperson, Fred Brick Memorial Foundation

Helen Olson Named

as AWCCA

SecretaryAt its November 15th meeting, the

AWCCA Executive Committee voted

to name Helen Olson of Republic

Indemnity as its interim Secretary

replacing Josie Leonard of SCF Arizona

who had previously resigned from the

Committee. Helen is a past President of

AWCCA in addition to having served in

several positions within the organization

over the years. Most recently, she

concluded a term as AWCCA Treasurer

in the spring of 2010.

Are you a claim manager looking for an

experienced senior examiner? A doctor

looking for a qualified billing clerk? A work

comp attorney looking for a paralegal? Or

perhaps an adjuster, private investigator

or voc rehab consultant looking for a new

opportunity in the work comp industry? If

so, Joe Strange, the AWCCA’s Job Referral

Coordinator, is waiting to hear from you.

As a no-cost service to employers and

employees in the Arizona workers’ com-

pensation industry, industry professionals

can post job openings or short professional

bios on the AWCCA website for positions in

workers’ compensation claims adjusting. In

addition, the Job Referral Line can also be

Let the AWCCA Job Referral Line Work for YOU!

used by medical professionals, vocational

rehabilitation companies, private investi-

gators, IME or DME companies or any other

insurance-related organization that has a

job opening. And, industry professionals in

any insurance-related field can post their

bios using the AWCCA’s website.

The AWCCA offers an excellent, cost-free

way to match up qualified employees with

ANY job opportunities in the Arizona work-

ers’ compensation industry.

To post an opening or a bio, or to learn

more about the AWCCA’s Job Referral Pro-

gram, contact Joe Strange via e-mail at

[email protected] or, by phone at

480-483-4323.

There are also some government agencies

that still don’t provide web access and,

therefore, it necessitates an onsite visit,

although there’s no guarantee that you’ll

be provided the documents that you seek.

Snail mail is also an option if you don’t have

tight time constraints but that rarely is the

case with investigations.

I know of no company that gathers and

disseminates information that does not

utilize fee-based research facilities. The

“free” internet sites are usually bait-and-

switch and offer only teaser information to

your initial inquiry. Even if you ding your

credit card for $7.50, the results you’re

provided with could have probably been

found on your own if you’d only known

where to look.

In the next issue of The Examiner, we’ll

explore some of the most popular free

sites utilized by our firm and other research

companies that we have found in the past

10 years. Have a wonderful holiday season

and see you next issue.

“Public” Records?… Well, Kinda.With apologies to the late Andy Rooney,

“So have you ever wondered how ‘public’

our public records are?” Our government

claims they’re public and our taxes pay

to gather, categorize, and maintain these

documents, but there’s no real promise that

we can view them.

The term “public records’ is somewhat of

a double entendre because what’s actually

available to Joe Lunchbox is limited and

therefore, quite often restricted. Anyone

who’s tried to obtain a police report can

testify to this. The document is usually

not available until weeks or months after

the incident and then, it’s heavily redacted.

Birth and tax information? Forget about

it without a subpoena—and that’s a whole

other plate of spaghetti. What about a DMV

report? The United States Supreme Court

ruled 11 years ago that drivers’ records

are not “public” records, even though the

public (you and me) pay to maintain them.

This makes access to a state’s department

of transportation information sketchy at

best from jurisdiction to jurisdiction.

So what can the average individual hope

to learn? Like everything else in today’s

litigious society, that depends on what

you’re looking for and how hard you’re

willing to dig.

There’s a lot out there that’s readily available

on the internet 24/7, and honestly, most

everything our investigation firm needs

is now online (thanks, Al Gore). Gone,

thankfully, are the days when someone

had to physically go in person from court

to agency to district to attempt to gather

even the most basic information. Some

companies, and quite a few law firms, had

clerks sitting all day in government record

rooms manually writing and, later, typing

case numbers, names of involved parties,

and dispositions to take back to the office.

Not so much anymore, although there

are still several advantages to this type of

running around. If you like to actually see

and physically hold your paycheck in your

hands rather than use direct deposit (right,

Mom?), then this method is still for you.

By Michael A. Nathe, Certified Surveillance Expert, President, Nathe & Nathe Investigations.

Kids’ Chance of ArizonaIs Seeking Scholarship Applicants

By Grace Nolan, Kids’ Chance of Arizona VP of Scholarships

Kids’ Chance of Arizona is looking for scholarship applicants and we need the assistance of the workers’ compensation community. Through the kindness, generosity and support of the community at our fundraising events this year, Kids’ Chance has money for scholarships!

About Kids’ Chance of Arizona

Kids’ Chance is a 501 (c)(3) organization that was formed for the purpose of educating the children of Arizona’s injured workers. The mission of Kids’ Chance is to fulfill the dreams of these children and help

them reach their potential by providing them with educational scholarships.

Over the years we have seen many of our Kids’ Chance scholarship recipients graduate and pursue rewarding careers. We have several doctors, a pilot, a number of teachers and many who have chosen to continue their education beyond the graduate level.

How You Can Help

Kids’ Chance is looking for scholarship applicants and we need your help. If you are an adjuster, applicant or defense

attorney you may be in a position to direct a potential candidate and help them pursue their dreams.

If the thought has occurred to you to make a candidate scholarship submission to Kids’ Chance, you may have only considered a new or recent traumatic workers’ comp case and thought these children are much too young for a college scholarship. However, at a recent AWCCA Board meeting, a new perspective for identifying qualified candidates was discussed. AWCCA Vice President Molly Jones pointed out that each year, Annual Report of Income forms are mailed to loss of earning capacity (LEC) recipients or their attorneys. Many of those old LEC claimants may have had young children at the time the LECs were established; however, the children of long-term LEC recipients may now be eligible and in need of financial assistance in order to fund their education.

Kids’ Chance would like your assistance in identifying worthy candidates that may be hiding in those old claim files. Adjusters may even wish to include one of the Kids’ Chance brochures along with the Annual Reports of Income to the injured workers, or they may wish to direct the injured workers to the Kids’ Chance website at kidschanceaz.org.

Help us spread the word!

For more information contact:

Carol Baird President of Kids’ Chance Arizona(602) 331-1035

Grace Nolan, VP of Scholarships(602) 515-2681

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dinner meeting allowed the Examiner Editor, the Job Referral Coordinator, and the Chairpersons of the Golf, Holiday Party, Seminar Committee, and Membership Committees to become voting members of the Executive Committee.

For a copy of the current AWCCA, Inc. Constitution and Bylaws, visit to the AWCCA website at: www.AWCCA.org and click on the “Organization Documents” tab.

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AWCCA Amends BylawsIn order to increase meaningful participation on the AWCCA Executive Committee, an amendment to the organization’s Bylaws was presented for a vote of the Regular Members at the October 2011 dinner meeting. The amendment passed unanimously.

Previously, the AWCCA, Inc. Bylaws stated that “The administration and management of this organization shall be by an Executive Committee which shall be composed of the President, Vice-President, Secretary, Treasurer, Immediate Past President, up to

three (3) Regular Members At Large and up to four (4) Associate Members At Large nominated to the Executive Committee by the Executive Committee.”

At it’s June, 2011 meeting, the AWCCA Executive Committee recommended an amendment that would also grant Committee membership to “the Chairperson of each of the organization’s standing committees as designated by the Officers and Members At Large”. The general membership’s approval of the proposed amendment at the October

education credits were offered for

attendance at the December, 2011 Holiday

Party and no credits will be offered for

the May, 2012 dinner meeting when the

program will honor recipients of the Fred

Brick Memorial Rehabilitant of the Year

awards.

For further information, please contact

AWCCA President Tara Shields at

[email protected].

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Continuing education credits benefit

dinner meeting and seminar attendees

who have earned their WCCP (Workers’

Compensation Claims Professional)

designation in meeting their annual

six-hour continuing educational

requirement.

Continuing education credits were

offered for the September, October and

November, 2011 dinner meetings and will

be offered for the January, March and

April 2012 dinner meetings as well as the

February, 2012 Seminar. No continuing

AWCCA Offers Continuing Education Credits

For the third consecutive year, the AWCCA

is offering continuing education (CE)

credits for attendance at its monthly dinner

meetings and annual seminar. Credits are

offered through AWCCA’s arrangement

with the Insurance Educational

Association (IEA). Credits will be offered

for attendance at the 2012 AWCCA Spring

Seminar and for all monthly dinner

meetings at which educational topics are

presented during the 2011-12 meeting

year. The AWCCA began offering

continuing education credits at the end of

2009.

The ABCs of ASTYM

In my first years of physical therapy practice, I

found one of the most frustrating conditions to

treat was tennis elbow (lateral epicondylitis).

It seems so easy at first glance. It is just a

small area of pain to the outside of the

elbow. As a therapist, I tried everything I knew

to treat patients with this condition including

ice, ultrasound, massage, elbow and wrist

braces, stretching and even complete

rest and immobilization. Sometimes there

was success; often times residual pain

and symptoms. Despite my best efforts, it

seemed to take a long time for patients to

get better, and often, the symptoms would

not completely go away. Those of you who

have experienced this pain or know others

who have had it know that it can be quite

intense.

However, my approach to treating tennis

elbow, and many other soft tissue conditions

changed after my introduction to ASTYM.

ASTYM (pronounced: “A-stim”) stands for “a

stimulation” of the body’s healing response. It

is a specialized form of soft tissue mobilization

used in physical or occupational therapy

treatment. It incorporates the use of specially

designed rigid acrylic tools to massage and

stimulate muscles, ligaments, and tendons.

ASTYM is primarily directed towards the

healing of chronic tendon disorders, scar

tissue and fibrosis. This treatment effectively

and safely stimulates affected soft tissues to

heal and regenerate at a cellular level. It

provides a controlled trauma above, below

and at the level of pain and dysfunction. It

initiates dysfunctional tissue remodeling and

re-absorption while promoting regeneration of

healthy tissue. The direction of the treatment

techniques are applied parallel to the healthy

fibers. Thus the unhealthy tissue receives the

stimulation it needs to regenerate and heal,

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and that healthy tissue then remains healthy.

The use of ASTYM is very effective for

treating chronic tendonitis conditions.

Some examples include medial and lateral

epicondylitis, carpal tunnel syndrome,

DeQuervain’s syndrome, plantar fasciitis,

Achilles tendonitis, patellar tendonitis

(jumper’s knee), and shin splints. In the

ASTYM training program and literature, these

conditions are described more accurately

as tendinosis or tendinopathy. The “-itis” of

tendonitis implies an inflammation process.

However, once these conditions have been

ongoing for weeks or months, it is not likely

there is still an acute inflammation. Studies

have shown that these tissues become

more degenerative in nature and may have

minimal active inflammation. There are

some who feel that this may be why many

traditional anti-inflammatory treatments

(ice, NSAIDs, rest) are not effective for these

chronic conditions.

Another area where ASTYM treatment is

beneficial is management of scar tissue

following injury and surgery. The treatment

is not necessarily performed directly over the

scar tissue. It can be used effectively around

the scarring to mobilize the other tissues

attaching to it. By mobilizing these adjacent

tissues, a patient can achieve improved

mobility, flexibility and functional status, as

well as relief of pain from adherent scars.

ASTYM is different from traditional massage.

It puts more specific force over the involved

tissues to create a stronger healing response.

It also has the benefit of placing less stress

on the therapist’s hands and fingers which

can become tired and sore from repetitive

massaging. During an ASTYM massage, the

special instruments glide over the skin and

tissues. If there is a restricted area of tissue

or other problem area, there will be a slight

roughness. These areas of dysfunctional

tissue and fibrosis can be felt by the therapist

and patients.

An ASTYM treatment of one injured area will

typically last 10-15 minutes. The treatment

can be painful at times and should be

adjusted accordingly to the patient’s

tolerance. Many patients report that the

treatment feels good and they experience

warmth in the tissues. Frequently, increased

flexibility is noted immediately after treatment.

In addition to treating the symptomatic area,

ASTYM treatment also addresses other areas

in the chain of movement that may be

… The ABCs of ASTYM continued from page 15


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damaged by the condition. This includes

compensatory areas, such as the tissue

that may be overused by limping or other

abnormal movement patterns due to pain

or limited function.

ASTYM treatment is recommended twice per

week initially with at least 48 hours between

treatments. This allows for recovery of the

affected tissues. However, regular physical

therapy visits can occur more frequently

as appropriate for additional exercise,

strengthening and functional retraining.

Patients can experience soreness, bruising

and some increased pain after their first

treatments. Approximately 25 percent of

patients will have some mild to moderate

bruising. Generally, as the treatments

progress, these side effects are decreased

or eliminated.

ASTYM is only one part of a more

comprehensive therapy program.

Performance Dynamics, the company

that created ASTYM, has researched and

designed various protocols for treating many

common soft tissue injury conditions. These


protocols are then customized to meet each

individual patient’s needs. A typical treatment

session includes an active warm-up with

basic exercises such as stationary bike, upper

body ergonometer or treadmill activity. Next,

stretching of involved muscle groups is done.

The ASTYM techniques are then performed.

Additional manual therapy techniques

including other joint or soft tissue mobilization

may be included at this time. Subsequently,

additional stretching is performed, followed

by a comprehensive strengthening and

functional exercise program. It is essential to

perform the strength and functional exercises

to facilitate tissue regeneration following the

ASTYM. Ice pack or electrical stimulation may

be used at the end of the session as needed

for patient comfort.

As with many conditions, another key

component to success with treatment is

performance of regular home exercises.

This may include certain strengthening or

muscle re-education exercises, or a series

of stretches to be performed throughout

the work day. Performance Dynamics has

recommended against the use of braces

and other support wraps while undergoing

treatment. Their philosophy is to attempt to

return to normal movement patterns and

functioning as quickly as possible.

ASTYM certification is available to physicians,

chiropractic physicians, and physical and

occupational therapists. It consists of a three-

day course covering treatment techniques

for the upper and lower extremity and spine.

Performance Dynamics is one of three

companies offering training and providing

tools for this type of “instrument-assisted soft-

tissue mobilization”. TherapyCare Resources

Inc. teaches the Graston technique and

Carpal Therapy Inc. has called their program

“SASTM”.

Various research studies have been

conducted to document the effectiveness

of treatment. These range from histological

studies of animal tendons to clinical trials

and case studies. Additionally, Performance

Dynamics maintains a large database

of outcomes reported by their certified

providers. In all cases, the research and

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outcomes indicate ASTYM as an effective

treatment method.

Most insurance companies will pay for ASTYM

treatment. It is billed with the CPT code 97140

for manual therapy for soft tissue mobilization.

The treatment is most effective when utilized

as a component of a full physical therapy

program including specific exercises.

In my two years as a certified ASTYM provider,

I have seen the most success treating medial

and lateral epicondylitis (golfer’s or tennis

elbow), DeQuervain‘s tenosynovitis, and

Achilles tendonosis. Other conditions that

have responded well, but not as quickly,

include hamstring strains, plantar fasciitis, and

patellafemoral pain. Most of my patients

tolerate the treatment with mild to moderate

pain initially, with less pain and discomfort

after several sessions. While ASTYM is not

a cure-all procedure, I have found it to be

a valuable treatment option for stubborn

tendinopathy and scar tissue conditions.

Patients who may not be appropriate for

ASTYM include those with skin breakdown

around the treatment site, those with thin

or delicate skin, and those patients on

blood thinning medications. As mentioned,

some bruising can be a normal treatment

response reaction and should not be cause

for concern. If bruising is persistent or painful,

other treatment options may be more

appropriate.

The ASTYM website (www.ASTYM.com) has a

listing of providers that you can look up by

name, company, city or zip code. According

to Performance Dynamics “There is evidence

confirming ASTYM’s effectiveness in the

medical literature. In addition, there is a large

body of outcome evidence collected from

independent clinicians across the country

that also confirms the effectiveness of ASTYM

treatment, and shows what results a patient

can expect for each diagnosis in a real world

setting.” Much of this information is available

to the public, insurance companies and

other health care professionals through their

website.


“SELF EXAMINATION, LISTENING & MENTORING:FULFILLING ACTIVITIES FOR PREVENTING BURNOUT”

This article is the last of a three-part series discussing fulfilling activities not frequently mentioned in mainstream literature as methods to avoid burnout. In part one of this series, self-examination was discussed as one of those activities. Part two offered thought-provoking information concerning the benefits of effective listening as another vital component to avoiding burnout.

Burnout is a state of emotional, mental, and physical exhaustion caused by excessive and prolonged stress. Burnout can threaten our jobs, our relationships, and our health. Burnout occurs when we feel overwhelmed and unable to meet constant demands. In large part, this can occur when we experience chronic miscommunication resulting from ineffective listening styles.

The third suggestion for avoiding burnout is mentoring others. Zen priest Suzuki Roshi said, “In the beginner’s mind, there are many possibilities. In the expert’s, there are few.” Working with others provides an opportunity for seeing things from a different perspective. This of course requires an open mind, and the willingness to consider others’ viewpoints. In turn, there results fertile ground for a reciprocal learning process. This relationship allows us to back off of restrictive “right” and “wrong” categories, and move into a more flexible vantage point to determine the best action when considering each matter.

The word “mentor”, a transitive verb, dates back as recently as 1976. For a definition, we

find the following at www.merriam-webster.com/dictionary:

“To serve as a mentor, also see TUTOR; ‘tü-tor’ (noun); date 14th Century – a person charged with the instruction and guidance of another; a private teacher: (verb) date 1592

– to teach or guide usually in a special subject or for a particular purpose (coach).”

So while the word, “mentor” is fairly recent, the concept is not. The concept described as a tutor dates back to the 14th century.

The U.S. Department of Health and Human services acknowledges the significant benefits of having an organizational mentoring program. So much so they have a formal program which can be accessed for more details at: https://mentoring.hhs.gov/Programoverview.aspx.

According to an Ezine article by Carl Mueller found at: http://EzineArticles.com/109135, the following is noted:

“Mentoring is a great way to give back to your industry and to help a less-experienced person in your field at the same time. Becoming a mentor is satisfying because the

person you are helping is letting you know that you are someone they admire and hold in high regard. It’s also a great way for you to grow professionally. You might be able to help a less experienced person in your industry not only answer the same questions you had when you were in their position, you might help them avoid some of the mistakes you made as well. Plus, it can also assist in your own career. When the person you are mentoring asks questions and causes you think about the answers you give them, it can help you reflect on where you are in your own career and what areas you need to improve upon...Mentoring is really an endorsement for you because it says that someone looks up to you and views you as someone they can learn from. If you look at the opportunity the right way, you can learn from being a mentor as well.”

However, noted theologian Ralph Sockman wisely states, “Be careful that victories do not carry the seeds of future defeats.” It is in the giving, not the taking of credit, where we experience the relief from burnout. Getting outside of ourselves to help another grow results in a lifting of our spirits. Our attachment to proprietary recognition for achievement separates us from others, thus defeating the purpose of mentoring.

Indeed as former President of the United States Woodrow Wilson advised, “You are not here merely to make a living. You

PART THREE - MENTORINGBy Lisa Clapp, MA, CRC, CEA


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… Self Examination continued from page 20

are here in order to enable the world to live more amply, with greater vision, with a finer spirit of hope and achievement. You are here to enrich the world, and you impoverish yourself if you forget your errand.”

An honest desire to be helpful to another will help to develop a relationship where the whole is greater than the sum of the parts. Author William Arthur Ward aptly noted:

“Flatter me and I may not believe you.Criticize me, and I may not like you.

Ignore me, and I may not forgive you.Encourage me, and I may not forget you.”

Helping others to achieve their potential creates a lasting and salient satisfaction that contributes to all of humanity. In Choices and Illusions, Eldon Taylor quotes Martin Luther King as having said “I can never be what I ought to be, until you are what you ought to be.” In other words, our interdependence upon each other for being what we “ought to be” is a formula for “self” realization.

Not taking credit for others’ accomplishments is important. The flip side of that is just as important to our mental well-being We must also avoid burdening ourselves with others’ shortcomings or failures. Fixing problems for another before they have had a chance to see the challenge through adds undue stress to the role of mentor. Furthermore, we often deny the other the opportunity to learn important lessons. Having faith, that everyone is capable of learning through the process helps to alleviate any morbid sense of responsibility for perfection. In his book Change Your Thoughts, Change Your Life, Wayne Dyer, PhD advises, “Instead of believing that you know what’s best for others, trust that they know what’s best for themselves.”

By approaching those entrusted to your mentorship, without motives or expecting something in return, you serve them truthfully and reap contentment and joy by virtue of the action alone. To many, this level of humility may seem a tall order. In practicing this, we are challenged to avoid “contempt prior to investigation” forcing ourselves to remain open to the unfolding of something new and outside of our control. More often than not, we find the experience not only less stressful, and painful, but that it actually contributes to our overall sense of well being.

In the course of helping others through mentoring, we find inner strength and peace of which we were previously unaware. Renowned businessman Darwin P. Kingsley wrote, “You have powers you never dreamed of. You can do things you never thought you could do. There are no limitations in what you can do except the limitations of your own mind.”

Fall 2011 THE OFFICIAL PUBLICATION OF AWCCA, INC. In this … · 2015-06-25 · Carpal Tunnel...

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