Western Occupational & Environmental Medical Association
Leading Occupational & Environmental Medicine

Welcome to the WOEMA WINDOW, our e-newsletter sent to members by email on a monthly basis. The newsletter links to this page. Below are the items that appeared in the December 2017 issue.


TBI & Persistent Post-Concussion Syndrome (PPCS)
By Eric Won, DO, MPH, MBA, FACOEM & Troy Ross, MD, MPH


Traumatic Brain Injuries (TBI) and Persistent Post-Concussion Syndrome (PPCS) are sustained from mild to severe damage to the brain tissue from accidents or assaults. Disturbance to brain function can be caused by direct or indirect force to the head – it is a functional rather than structural injury that results from shear stress to brain tissue caused by rotational or angular forces—direct impact to the head is not required.

In North America, over 1.7 million people suffer annually from TBI and the consequent medical care costs exceed $70billion USD. According to the World Health Organization (WHO), the global incidence for TBI is close to 10 million people annually. Brain tissue has minimal capacity for self-repair making it highly vulnerable to injury and often leading to permanent loss of function, chronic disease, and disability; profoundly impacting quality of life.

Headache is the most common symptom associated with concussion, other common symptoms include dizziness, balance disturbance, disorientation, photophobia, and depression. Loss of consciousness, once considered a signature of concussion, occurs in less than 10% of patients. Although there is no current consensus regarding classification of concussions, loss of consciousness will generally move a patient into the moderate-severe category of TBI. There is also no consensus on an instrument to measure symptom severity or progress over time, but the Rivermead Post-Concussion Questionnaire (RPQ16) appears to be gaining momentum as a potential standard across the industry. There are numerous symptoms checklists and computerized neuropsychological batteries that may also be employed to monitor progress.

The science and pathophysiology of TBI and PPCS is rapidly evolving as microscopic differences between military blast induced brain injuries (caused by shearing from over-pressurization), and sports concussions (due to blunt force trauma) are beginning to be better understood and characterized. Post-mortem analyses have demonstrated novel and distinct findings of junctional astroglial scarring from explosive concussions (Perl et al. 2017), versus findings of neurofibrillatory degeneration and diffuse axonal injury with repeated sports concussions (McKee et al, 2016). This differentiation may lead to potential differences in down range treatment protocols as well.

The first medical device FDA cleared for the assessment of TBI gained approval in 2016, the “BrainScope Ahead 300”. This device uses digital electroencephalogram (EEG) data and sophisticated algorithms to assess severity of injury.

Since there are currently no FDA approved treatments, clinical management following emergent assessment and stability is primarily focused on cognitive and physical rest. Symptom management may include analgesics for headaches, and gradual/monitored return to activities. The sector is growing with companies developing a pipeline of therapeutics for TBI including Cognosci, Medicortex, Amarantus BioScience Holdings, Aldagen, NeuroSciencePharmaceuticals, and the Newport Brain Research Laboratory / Brain Treatment Center. Increasing incidence of TBI due to sports injuries, accidents and military combatants around the world; as well as the current lack of effective therapeutics, are expected to drive the growth of the market.

TBI will be the subject of an educational session at WOHC 2018


FREE CME WOEMA Webinar Series 
Thursday, December 21 • 12:00 PM PST

Cannabis vs. Cannabinoid: The Politics of Medical Marijuana


The use of cannabinoid agonists in medical therapeutics has suffered from the persistent federal classification of cannabis as Schedule I substance.

The fact is that there are cannabinoid receptors distributed throughout the CNS and periphery, affecting hedonic tone, satiety, analgesia, anti spasm effects, inflammatory modulation and even immune status.  But herbal Cannabis has suffered a very different  reputation; at times even being equated to cocaine and heroin as a drug of abuse.  Clearly there is a regulatory disconnect between governmental control and societal perception.

 This talk will examine the importance distinction between herbal cannabis, with its’ complex alkaloid chemistry in terms of medical utility and it’s use as a recreational intoxicant.   As well, attendees will be able to make a reasoned discussion between getting pulled into this political debate and having a healthy interest in ongoing research into this very interesting class of compounds.

Objectives: Upon completion of this educational activity, participants will be able to:

  • Examine the complex pharmacology of this class of drug
  • Define the difference between pharmaceutical cannabinoids and herbal cannabis
  • Make an informed decision as to how far into the ‘medical marijuana’ issue they might want to go and at what personal as well as professional risks they incur

Dr. Douglas Gourlay did his medical training at McMaster University, completing his fellowship in Anesthesiology in 1990.  Following a fellowship in addiction medicine, he has focused his practice to the assessment and management of risk in the treatment of chronic pain. He has written extensively and speaks on the topic of patient-centered strategies in the management of risk. He is the Former Director, Pain and Chemical Dependency Division, Wasser Pain Management Centre, Toronto as well as the Director of Lab Services, Center for Addiction and Mental Health, Toronto, Ontario. He currently is an educational consultant, writing and speaking on the subjects of Risk Management and Drug Testing.


Renew Your WOEMA Membership Today 




Renew your ACOEM/WOEMA membership for 2018.  WOEMA members receive access to Free CME Webinars every other month, discount registration fees for the Western Occupational Health Conference (WOHC), The monthly WOEMA Window newsletter, and more. Don’t lose your valuable connection to our OEM community – renew today!


WOEMA is pleased to announce the Anne Searcy, MD Public Service Award

The Anne Searcy, MD Public Service Award is named in honor of Anne Searcy, MD, who was an esteemed colleague and member of WOEMA’s Board of Directors and co-chair of the Legislative Committee, and received the Johnstone Award posthumously in 2015. She was a respected leader in the Workers’ Compensation industry and a tireless advocate of evidence-based medicine and sound public policy and practices throughout her career. Trained in Family Practice, with many years of hands-on experience in clinical Occupational Medicine, she served as the Associate/ Executive Medical Director of the Division of Workers’ Compensation Medical Unit between 1995 and 2008. In her capacity as Executive Medical Director, she dealt with the division’s medical and health-related programs, including development of treatment guidelines, fee schedules, and management of the programs for Qualified Medical Evaluators, Medical Provider Networks, utilization review, health care organizations and spinal surgery second opinions, and chaired the DWC Medical Evidence Evaluation Advisory Committee. She also supervised studies related to workers’ compensation medical services and analyzed and implemented new legislation and policies in conjunction with the DWC administrative director. Through her dedicated work, she demonstrated the importance of public service and advocacy in improving access to evidence-based health care.

This award is to be presented to a WOEMA member or other deserving nominee who has made notable achievements to protect and advance the health and safety of workers and/ or the environment through his/her work within a governmental or public agency service and/or through volunteer public policy advocacy. Members may receive this award when approved by the WOEMA Board. This award will be presented only when a qualified candidate is apparent from time to time; it is not required to be awarded annually.

 Award was adopted by the WOEMA Board of Directors on September 13, 2017


Getting Patients Back to Normal

Sponsored by Concentra



Using changes in the activity status to move a patient/case closer towards functional restoration is a practice that can help patients smoothly renormalize their lives after they are disrupted by a work injury.

Training in medical school and residency (outside of occupational medicine programs) often includes little to no discussion or training in how to write appropriate work restrictions or limitations when taking care of injured workers.

This lack of training/education might well be one of the reasons that some physicians simply take patients off work until they are ready to return to their regular duties–it’s quick and easy, and you don’t have to worry about determining risk (which is used in prescribing restrictions) or capacity (which is used in describing limitations).

At Concentra, we have found that thinking through risk and capacity at every recheck, and then using objective measures of progress (patient can now lift 30# whereas he could only lift 20# at the previous visit) to advise the patient to do as much more as medically appropriate, helps to promote an “ability” mindset.

Patients get better faster when signs of improvement are noted and celebrated at every visit, and are used to encourage the patient to keep increasing activity levels. As physicians and patient advocates, we are sometimes tempted to be overly protective, but the evidence supports that advancing work activity as quickly as medically possible (rather than allowing patients to be off work until they are “back to 100%”) leads to shorter case duration, and allows patients to resume their normal lives sooner.

*There is a very useful chapter on “How to Think About Work Ability and Work Restrictions: Risk, Capacity, and Tolerance” in the book edited by Talmage, Melhorn and Hyman titled AMA Guides to the Evaluation of Work Ability and Return to Work.


Save the Date for WOHC 2018



Mark your calendar! WOEMA is pleased to announce that the Western Occupational Health Conference will take place September 12-15, 2018 in San Francisco, CA. The conference will be held at the Park Central Hotel in the heart of downtown San Francisco.