Knee implants you thought would last decades may only last 3 years.
Today’s post comes from guest author Brenda Fulmer from Pasternack Tilker Ziegler Walsh Stanton & Romano.
Although we have noticed an increase in the number of joint replacement procedures undergone by our clients over the past several years, very few have ended with a bad result.
If you feel that you or someone you know may have a defective knee implant, contact our office to discuss your case and receive a referral to an attorney that handles this type of claim.
Zimmer is an international medical device manufacturer based in northern Indiana. It was founded in 1927, and focuses on the manufacture of products for orthopaedic surgeries. Zimmer’s sales in 2009 were $1.76 billion, and it is estimated that the NexGen family of knee implants make up about 2% of the overall sales of Zimmer.
Flex implants are not lasting nearly as long as intended.
The Zimmer NexGen Knee Implant is not a specific device, but rather a family of devices. Within this NexGen device family, there are different models of implants: NexGen CR-Flex, NexGen LPS-Flex, NexGen High Flex, NexGen LPS, NexGen MIS.
Unlike most knee implants, the Zimmer NexGen CR-Flex is attached without the use of cement, which may cause the system to loosen or detach completely.
The Zimmer NexGen CR-Flex implant was designed to give patients better range of motion than the customary NexGen device. Scientific studies have been accumulating for years with regard to concerns over the safety of the NexGen CR-Flex. Interestingly, the U.S. Continue reading Drug Watch: Zimmer Knee Implants Plagued With Failure→
How Much of the Savings Came Out of the Pockets of Workers?
September 17, 2012: The Washington State Department of Labor & Industries (L&I) today announced it is proposing no increase in the average rate for workers’ compensation insurance. If adopted, this would be the second straight year with no increase in workers’ comp rates.
“Had the Governor and the Legislature not adopted the 2011 reforms, I wouldn’t be making this proposal today,” said L&I Director Judy Schurke. “In fact, without those reforms, we would be facing a rate increase. Instead, we’re able to keep rates down for Washington’s businesses and workers.” Savings due to reforms are beating expectations. L&I is now projecting the reforms passed in 2011 will save $1.5 billion over four years, $300 million higher than originally estimated.
While the reforms play an important part in lowering costs, Schurke pointed to additional factors responsible for lower costs in 2013, including:
Fewer claims in high hazard industries like construction are resulting in fewer long-term disabilities;
Overall claim frequency, or the number of claims per 100 workers, has gone down by 6.2 percent;
L&I has held medical cost growth below 4 percent over the past five quarters and expects continuing to do so in 2013 with the new provider network and health technology assessments;
L&I is resolving claims more quickly as a result of Lean and other improvements.
Today’s proposal would mean an additional $82 million is placed in the State Fund reserves by the end of 2013. In the past, the State Auditor issued strong warnings about the consequences of maintaining inadequate reserves. Schurke also acknowledged the reserves are critically low by industry standards due to increased liabilities, investment losses and drawing down the reserves to hold down rates during the recession.
The Workers Compensation Advisory Committee (WCAC), which has been working with L&I on a plan to rebuild the reserves, endorsed L&I’s proposal to hold rates steady in 2013 and begin rebuilding the reserves. Washington is the only state where workers pay a substantial portion of premiums. Workers will pay about 24 percent of the premiums in 2013. The proposal to keep rates flat in 2013 is an average for all Washington employers. Individual employers may see their rates go up or down, depending on their recent claims history and changes in the frequency and cost of claims in their industry.
Every year in Washington, about 100,000 claims are filed for medical costs and lost wages due to work-related injuries, illnesses and deaths. Each year, L&I must review premium rates and make adjustments to cover the anticipated costs of claims that occur in the next year.
Public hearings on the proposed rates will be held in:
Tukwila, Oct. 23, 10 a.m., L&I office.
Bellingham, Oct. 23, 1 p.m., Public Library Lecture Room.
Richland, Oct. 25, 10 a.m., Community Center Activity Room.
Tumwater, Oct. 26, 10 a.m., L&I Auditorium.
Vancouver, Oct. 29, 10 a.m., Red Lion at the Quay, Quayside Portside Room.
More information regarding the rate proposal is available at www.Rates.Lni.wa.gov. The final rates will be adopted in early December and go into effect Jan. 1, 2013.
“Evidence-based coverage decisions have reduced unnecessary care and avoided $27 million in annual costs.”(Emphasis added.)
Translation: Denying requested treatment costs the State less than authorizing it. – Ed.
Background Information:
On average, workers’ comp rates have increased less than 3 percent per year since 2006. This is lower than L&I’s anticipated rate of medical and wage inflation.
When calculated as a percentage of payroll, which is how rates are calculated in other states, the proposed 2013 overall rates would be equal to a 2.2 percent reduction.
Without savings from the reforms, the 2013 break-even rate would have been about 4 percent instead of minus 4.2 percent. The break-even rate is the amount needed to cover projected costs for the next year. L&I will use the difference between the break-even rate and zero – $82 million – to begin restoring the workers’ comp reserves.
The elements of the 2011 workers’ compensation reforms have various effective dates, beginning in 2011 and continuing through 2013. Savings estimates are now at $1.5 billion over four years, with continued savings in future years.
As a result of Lean and other initiatives, we are seeing a downward trend in the duration of younger claims.
L&I has held medical cost growth below 4 percent over the past five quarters and estimates doing so in 2013 with the new provider network and health technology assessments. Our medical costs are 26 percent less than the average workers’ comp program in the U.S.
Evidence-based coverage decisions have reduced unnecessary care and avoided $27 million in annual costs.
In 2011, the number of long-term disability claims per 100 workers fell by 6.2 percent, the largest decline since 1995. Long-term disabilities account for 85 percent of workers’ comp claim costs.
When hiring picks up in construction and other high-risk industries, we can expect an increase in long-term disability injuries. That’s why it’s important to examine safety practices now and be ready to bring more people back to work safely.
Workers’ comp insurance rates are based on the likelihood of an injury. Rates for almost half of the job classifications will change 1 percent or less next year.
Today’s post comes from guest author Matthew Funk from Pasternack Tilker Ziegler Walsh Stanton & Romano. Washington State claims can include conditions diagnosed after the initial filing of a claim, as well. Please feel free to contact us to discuss the specifics of your case if you are facing a similar situation.
The Appellate Division Third Department issued a decision (Searchfield v. Lowe’s Home Centers) that is interesting case because it pertains to the establishment of an injury that was originally misdiagnosed.
In October 2005, an employee was injured at work while lifting a hot water heater. As a result of the injury the employee went to the emergency room. He was diagnosed by an emergency room physician with myofascial strain of the legs and hips.
A November 2005 physician’s report diagnosed the claimant with hip/thigh sprain and sciatica. The later medical reports focused on the groin, lower back and leg pain.
In July 2006, a Law Judge established the claim for a work related injury to the claimant’s lower back. However, the employee continued to report worsening symptoms in his hip area.
In 2009, the claimant saw an orthopedic surgeon. The doctor performed a MRI of the right hip. The MRI revealed a right hip labral tear that required surgury. According to the surgeon the claim was originally misdiagnosed and the claimant had, in fact, sustained injuries to his right hip as a result of the October 2005 accident.
The claimant applied for a hearing to amend the claim for the right hip.
The Judge ruled that the right hip claim was time barred (pursuant to Workers’ Compensation Law Section 28). This states that a claim for a causally related condition must be made within two years of the date of accident.
On appeal the Board Panel reversed and the Appellate Division affirmed the Board Panel.
The Appellate Division stated that the early medical reports reflect initial concerns relating to the claimants hips. Also, there was supporting medical evidence that the claimant’s ongoing pain was the result of a labral tear in the right hip, a condition which is often misdiagnosed as a low back injury. The Court went on to add that the claimant could not have filed a claim for a causally related right hip injury at the time of the accident because it was not properly identified and diagnosed.
This case is important as it allowed the amendment of a claim for a serious injury that misdiagnosed early on in the case. You can find the entire court decision here.
DLI Notice of Workshops on the Stay at Work Program
The following was released by DLI as a public notice:
The Department of Labor & Industries (DLI) has reimbursed more than 1,000 employers almost $5.5 million to help retain injured workers in light duty jobs, but many businesses around the state remain uncertain how the program can benefit them. To help, L&I is holding workshops across the state to explain the new Stay at Work program, which provides up to half of a worker’s base wages for up to 66 days or $10,000 per claim if the employer places their injured workers in light-duty or transitional work.
The free, 90-minute workshops provide an overview of the program, explain how to apply for the reimbursements, the requirements, benefits, and how participation can help reduce claim costs for participating businesses. To sign up for a workshop or learn more about the program, visit www.StayatWork.Lni.wa.gov, or call 1-866-406-2482.
The current workshop schedule is:
Yakima – Sept. 11 from 9 -10:30 a.m. and 2 – 3:30 p.m., 15 W. Yakima Ave., Suite 100.
Everett – Sept. 13, from 10 - 11:30 a.m., 729 100th St. SE.
Kelso – Oct. 8, from 9 – 10:30 a.m. and 2 – 3:30 p.m., 711 Vine St.
Everett – Nov. 8, from 10 – 11:30 a.m., 729 100th St. SE.
Spokane – Dec. 11, 9 – 10:30 a.m. and 2 – 3:30 p.m., 901 N. Monroe St., Suite 100.
Ultimately, Stay at Work is projected to save $32 million annually by keeping workers on the job and reducing the chance of long-term disability. And getting injured workers out of their homes and back in the workplace has additional benefits – studies show that people off work longer than six months have only a 50 percent chance of ever returning to their job, while those who get back to work enjoy faster recovery times and improved lifelong health.
Trust your instincts – if things don’t feel right, they likely are not right. Seek guidance prior to accepting or declining an offer of light-duty employment.
DLI Information for Injured Workers
The following is excerpted from the DLI website section on this topic:
The Department of Labor and Industries will reimburse your employer 50% of your base wages if they are able to find an eligible light-duty job for you. DLI will also cover expenses such as training and tools related to the light-duty job. If your employer offers you a job that your doctor approves and you choose not to accept it, you won’t be eligible to receive time-loss compensation. However, you aren’t required to accept any job that would exceed the restrictions set by your doctor.
DLI offers this cheery video – one of three – on the topic of the Stay at Work Program:
Our Perspective
As the DLI notice, above, indicates, it seems that many employers are not aware of the benefits available to them under this relatively new program, including significant incentives to offer accommodation to injured workers.
We have seen both success stories and nightmares surrounding light-duty job offers from employers. When applied appropriately and administered with a sense of caring, a light-duty job can be beneficial to an injured worker. Returning to work can improve morale, maintain healthcare benefits for the worker and/or their families, and assist with a gradual return to full duties. However, some offers of light-duty work are engineered to drive a worker to quit after accepting the job, which can remove the worker’s eligibility for time loss compensation. Or, in other cases, the job may start out as light duty but the tasks requested may slide back towards regular duty levels, either intentionally or through habit, leading to increased symptoms or new injuries.
Trust your instincts – if things don’t feel right, they likely are not right. Seek guidance prior to accepting or declining an offer of light-duty employment.
Today’s post comes from guest author Leonard Jernigan from The Jernigan Law Firm.
On January 13, the North Carolina Department of Labor announced that 53 people died on the job in North Carolina in 2011. Labor Commissioner Cherie Berry was quoted as saying: “the real tragedy is that all of the these fatalities could have been avoided.” I wholeheartedly agree. 53 deaths is 53 too many. When I see news stories about explosions and other tragic events that needlessly harm or kill workers, often spewing toxic chemicals into the surrounding environment harming entire communities, I can’t help but think about how it all could be avoided if companies embraced a culture that puts safety first and simply followed the proper guidelines and procedures. I see companies spend a lot of time and money to fight the Occupational Health and Safety Administration (OSHA) over fines and penalties but rarely see the same effort being put into protecting their workers in the first place.
Employers, I challenge you to make safety as much of a priority as profits. Stop wasting time and money fighting against worker safety and instead focus your efforts on saving lives.
It may be hard to believe given my chosen profession as a workers’ compensation lawyer but if I had my way, workers’ compensation lawyers like me would be obsolete. We’d go the way of horse-drawn carriages and 8-tracks. We exist because many companies treat worker safety as an afterthought. The workers’ compensation system provides employers with immunity from lawsuits for most on the job injuries — they are required to buy workers’ compensation insurance, so why bother spending more to protect workers if they get no return on that money spent? Continue reading Imagining A World With No Workers’ Compensation Lawyers→
The Washington State Department of Labor & Industries (DLI) has cited the BP Cherry Point petroleum refinery in Blaine for six violations, including one “willful violation,” of workplace safety and health rules related to management of pipeline and refinery processes. The proposed penalties total $81,500.
A willful violation is the most significant civil classification that can be issued.
A willful violation is the most significant civil classification that can be issued. It is used when DLI alleges that the violation was committed with intentional disregard or plain indifference or substitution of judgment with respect to worker safety and health regulations.
DLI began the inspection in February after a major fire caused the refinery to shut down for a period of time. One employee was nearby when the fire erupted, but he was able to escape without harm.
The fire occurred when a corroded “deadleg” pipe ruptured. Deadlegs are pipes that aren’t often used but still must be monitored for integrity for when they are needed to carry material used in the refining process.
DLI cited the company for a “willful” violation for not ensuring that inspection and testing procedures for process piping followed recognized and generally accepted good engineering practices for all deadleg piping circuits. The proposed penalty for the willful violation is $65,000.
The five additional violations cited were for failing to comply with Process Safety Management standards, the requirements for managing hazards associated with processes that use highly hazardous chemicals.
The company has until Sept. 13 to appeal the citation. A copy of the citation is available upon request.
For more information about this or other DLI news, click here.
For those of you — particularly the younger generation voters — who watched the pageantry of the Republican National Convention and saw the platform of the Tea-Party-dominated Republican Party, you may find it enlightening to put that platform in the historical context of what the Republican Party used to stand for – supporting workers’ rights, securing benefit programs and securing the rights of labor unions.
Here is the platform of the Republican Party of 1956, when President Dwight D. Eisenhower was seeking re-election to a second term:
“The Eisenhower Administration will continue to fight for dynamic and progressive programs which, among other things, will:
Stimulate improved job safety of our workers, through assistance to the States, employees and employers;
Continue and further perfect its programs of assistance to the millions of workers with special employment problems, such as older workers, handicapped workers, members of minority groups, and migratory workers;
Strengthen and improve the Federal-State Employment Service and improve the effectiveness of the unemployment insurance system;
Protect by law, the assets of employee welfare and benefit plans so that workers who are the beneficiaries can be assured of their rightful benefits;
Assure equal pay for equal work regardless of sex;
Federally-assisted construction, and maintain and continue the vigorous administration of the Federal prevailing minimum wage law for public supply contracts;
Extend the protection of the Federal minimum wage laws to as many more workers as is possible and practicable;
Continue to fight for the elimination of discrimination in employment because of race, creed, color, national origin, ancestry or sex;
Provide assistance to improve the economic conditions of areas faced with persistent and substantial unemployment;
Revise and improve the Taft-Hartley Act so as to protect more effectively the rights of labor unions, management, the individual worker, and the public. The protection of the right of workers to organize into unions and to bargain collectively is the firm and permanent policy of the Eisenhower Administration.”
Thomas Holmes and Richard Rahe in 1967, examined the medical records of over 5,000 medical patients as a way to determine whether stressful events might cause illnesses. Patients were asked to tally a list of 43 life events based on a relative score. A positive correlation was found between their life events and their illnesses.
Their results were published as the Social Readjustment Rating Scale (SRRS), known more commonly as the Holmes and Rahe Stress Scale.
To measure stress according to the Holmes and Rahe Stress Scale, the number of “Life Change Units” that apply to events in the past year of an individual’s life are added and the final score will give a rough estimate of how stress affects health.
Note: the table, below, is from the Wikipedia page on this subject. For a fee of $5.00, you can go directly to Dr. Rahe’s website and obtain the full test materials as well as background information and details of this and other products and services available.
To measure stress according to the Holmes and Rahe Stress Scale, the number of “Life Change Units” that apply to events in the past year of an individual’s life are added and the final score will give a rough estimate of how stress affects health.
Life event
Life change units
Death of a spouse
100
Divorce
73
Marital separation
65
Imprisonment
63
Death of a close family member
63
Personal injury or illness
53
Marriage
50
Dismissal from work
47
Marital reconciliation
45
Retirement
45
Change in health of family member
44
Pregnancy
40
Sexual difficulties
39
Gain a new family member
39
Business readjustment
39
Change in financial state
38
Death of a close friend
37
Change to different line of work
36
Change in frequency of arguments
35
Major mortgage
32
Foreclosure of mortgage or loan
30
Change in responsibilities at work
29
Child leaving home
29
Trouble with in-laws
29
Outstanding personal achievement
28
Spouse starts or stops work
26
Begin or end school
26
Change in living conditions
25
Revision of personal habits
24
Trouble with boss
23
Change in working hours or conditions
20
Change in residence
20
Change in schools
20
Change in recreation
19
Change in church activities
19
Change in social activities
18
Minor mortgage or loan
17
Change in sleeping habits
16
Change in number of family reunions
15
Change in eating habits
15
Vacation
13
Christmas
12
Minor violation of law
11
Score of 300+: At risk of illness.
Score of 150-299+: Risk of illness is moderate (reduced by 30% from the above risk).
Score 150-: Only have a slight risk of illness.
Recommended methods for relieving chronic stress include exercise (which can be modified to accommodate physical restrictions after an injury), meditation, music therapy, breathing techniques, and such simple things as companionship – from a pet, friend or family member.
Stress is how the body reacts to a real or imagined stressor — a stimulus that causes stress. Acute stressors affect a bodily organ in the short term; chronic stressors over the longer term. Chronic stress is the state of prolonged tension from internal or external stressors which may cause various physical manifestations such as asthma, back pain, arrhythmias, fatigue, headaches, irritable bowel syndrome, ulcers, and suppression of the immune system. Chronic stress takes a more significant toll on the body than acute stress. It can raise blood pressure, increase the risk of heart attack and stroke, and induce symptoms of anxiety and depression.
The Three Stages of Stress – From Acute to Chronic
Alarm: In this first stage, when the threat or stressor is first identified or realized, the body’s stress response is in a state of alarm. During this stage, adrenaline is produced in order to bring about the flight-or-fight response, causing sweating, raised heart rate, etc. The body’s resistance to the stressor drops temporarily below the normal range and some level of shock may be experienced. There is also some activation of the HPA Axis, producing cortisol, as discussed in our last post.
Resistance: If the stressor persists, the body must find some means of coping with the stress. Although it begins to try to adapt to the strains or demands of the environment, the body cannot keep this up indefinitely, so its resources are gradually depleted. As it attempts to cope with the condition that is causing the stress, the mind may try to focus on the problem, which can actually exaggerate the awareness of the problem and make it seem difficult to overcome.
Exhaustion: third stage. At this point, all of the body’s resources are eventually depleted and the body is unable to maintain normal function. The initial symptoms may reappear (sweating, raised heart rate, etc.). Long-term damage may result, as the body’s immune system becomes exhausted, and bodily functions become impaired. The result can manifest itself in obvious illnesses such as ulcers, depression, diabetes, digestive system problems or cardiovascular problems. It can also manifest as a chronic pain syndrome, guarding/avoidance behavior, and/or sleep disturbance. Hopelessness can set in.
Chronic Stress and Cortisol
When the body’s HPA-axis cannot overcome a challenge and/or is chronically exposed to a threat, this system becomes overtaxed and can be harmful to the body and brain. An increased level of cortisol is one of the most dangerous outcomes of chronic stress.
Cortisol is an important hormone in the body, secreted by the adrenal glands and involved in some of the following functions: proper glucose metabolism, regulation of blood pressure, insulin release for blood sugar maintenance, immune function and inflammatory response. Normally, cortisol is present in the body at higher levels in the morning and is at its lowest level at night. Although stress is not the only reason that cortisol is secreted into the bloodstream, it has been termed “the stress hormone” because it’s also secreted in higher levels during the body’s ‘fight or flight’ response to stress, and is responsible for several stress-related changes in the body. Small increases of cortisol have some positive effects: a quick burst of energy for survival reasons, heightened memory functions, a burst of increased immunity, lower sensitivity to pain, and helping to maintain homeostasis in the body.
People are biologically ‘wired’ to react differently to stress.
While cortisol is an important part of the body’s response to stress, it is important that the body’s relaxation response be activated so the body’s functions can return to normal following a stressful event. Unfortunately, in our current high-stress culture, the body’s stress response is activated so often that the body doesn’t always have a chance to return to normal, resulting in a state of chronic stress, thus producing high chronic cortisol levels.
Higher and more prolonged levels of cortisol in the bloodstream like those in chronic stress have been shown to have negative effects, such as:
Impaired cognitive performance (loss or poor concentration, inability to complete tasks or heightened confusion in mildly stressful situations
Suppressed thyroid function
Blood sugar imbalancessuch as hyperglycemia
Decreased bone density
Decrease in muscle tissue
Higher blood pressure
Lowered immunity and inflammatory responses in the body, slowed wound healing, and other health consequences
Increased abdominal fat, which is associated with a greater amount of health problems than fat deposited in other areas of the body.
When people feel stressed, stress hormones can be over-secreted, dramatically affecting the brain. Cortisol also plays a large part in post-traumatic stress disorder (PTSD) and memory. In a 2002 article in Biological Psychiatry regarding cortisol, PTSD and memory1, cortisol was noted to work with epinephrine (adrenaline) to create memories of short-term emotional events. This effect may serve as a means to help a person remember what situations to avoid in the future. However, long-term exposure to cortisol damages cells in the hippocampus and can create impaired learning ability. It has been shown that cortisol inhibits memory retrieval of already stored information.
Cortisol secretion varies among individuals. People are biologically ‘wired’ to react differently to stress. One person may secrete higher levels of cortisol than another in the same situation. Studies have shown that people who secrete higher levels of cortisol in response to stress also tend to eat more food, and food that is higher in carbohydrates, than people who secrete less cortisol.
1“Depression. What happens in the brain?” Biological Psychiatry, 2002
Today’s post is the first in a multi-part series about stress, covering first the biology of stress and the effects of chronic stress on the body.
Stress is a term that is commonly used to explain — or explain away — much in our world. We live in a time of multifactorial stress: the economy; keeping, losing or getting jobs; housing, food, medical and dental care; personal and familial safety; fear or anger over political or governmental decisions; injuries and/or disabilities. At times, stress can be overwhelming when it seems we are losing control over our lives and our futures.
The following is an overview of the biology of stress to help better understand how stress can control such a large part of our health. There are many types of stress and those will be investigated after first laying out a basic understanding of what stress is and the physiologic mechanisms of stress.
The term stress is derived from the Latin word stringere, “to draw tight.”
The term stress is derived from the Latin word stringere, “to draw tight.” It had been used almost solely in the field of physics to define the internal distribution of a force exerted on a material body, resulting in strain — or stress — such as a rubber band pulled tautly. In the 1920s, stress started to be used in both biology and psychology, referring to a mental strain or a harmful external agent that could cause illness. Interestingly, in an early example, researcher Walter Cannon used the term strain/stress in 1926 to refer to external factors that disrupted homeostasis.1
The idea of stress and homoeostasis is intriguing for it is widely known that the incredible human system strives to maintain homeostasis, or equilibrium. So, it makes great sense that maintaining equilibrium is central to the idea of stress. This is true with all biological and most biochemical processes. The body always attempts to maintain this steady state of being; however, environmental factors, internal or external, continually challenge and disrupt this equilibrium (homeostasis) causing the body to constantly strive for balance. Environmental factors causing the body continued strife are generally called stress. Stress can be simply moments or events from which the body returns to equilibrium or it can turn into chronic stress where the body is constantly trying to reach homeostasis against resistance.
The balance of our body systems can be disrupted (stressed) by events from such disparate sources as a life-threatening situation or a simple insult, resulting in disequilibrium. Stress can bring on a cascade of biological reactions as the body attempts to bring the body/mind back to equilibrium, using incredible energy and resources in the process. The body’s fight or flight response recruits the body’s energy stores and focuses all resources on overcoming the event challenging homeostasis. Chronic stress can start a chain of events, called a cascade, within us. Whether stress is from internal or external forces, or both, we can become ill or, if already ill or injured, we can become worse as a result of stress in our lives.
Hans Selye in his book, The Stress of Life, (New York: McGraw-Hill, 1956 – still considered a standard and oft cited in review of the stress literature but, unfortunately, out of print today) described stress as something that “…in addition to being itself, was also the cause of itself, and the result of itself.” First to use the term in a biological context, Selye continued to define stress as “the non-specific response of the body to any demand placed upon it.”
The intensity and duration of stress changes depending on the circumstances and emotional condition of the person suffering from it.
The intensity and duration of stress changes depending on the circumstances and emotional condition of the person suffering from it. Both negative and positive stressors can lead to stress. Some stressors might include: the workplace, unemployment, or performance pressure stress from project deadlines; noise, temperatures, or environmental issues including a lack of control over environmental circumstances; food, air and/or water quality, housing, health, or mobility; struggles with difficult individuals, relationship problems, or major life events, such as injury or disability.
Stress in humans is a method of reacting to difficult and possibly dangerous situations. The “fight-or-flight” response when one perceives a threat helps the body exert energy to fight or run away. In the fight-or-flight response the adrenal glands release epinephrine, causing the blood vessels to constrict and heart rate to increase. Cortisol (to be discussed in detail later) is released in stress and its purpose is to raise the glucose levels in the blood. Glucose is the main energy source for human cells and its increase during time of stress gives immediate energy for overactive cells. The release of these hormones is intended to be temporary. Someone under stress for long periods of time may have adverse health effects later on, such as hypertension and increased risk of cardiovascular disease. The biology of stress is very similar to that described, albeit in less detail, in our three part article on Worry (May 2012).
In the physiology of stress, the central nervous system works closely with the body’s endocrine system to regulate mechanisms of equilibrium.
In the physiology of stress, the central nervous system works closely with the body’s endocrine system to regulate mechanisms of equilibrium. The sympathetic nervous system (nerves responsible for regulating many homeostatic mechanisms) becomes primarily active during a stress response, regulating many of the body’s functions in ways that make the body more adaptive to its environment. The brain works in network carrying information about a stressful situation across many regions of the brain and back.
The major players of stress in the brain include: the hypothalamus, the amygdala, the hippocampus, the pituitary gland and regions of the brain called locus coreruleus and rafe nucleus. The hypothalamus is located above the brainstem. Its primary function is to help link the body’s nervous and endocrine systems using neural inputs and outputs to and from other regions of the brain to make regulated secretions of hormones into the body’s blood stream. It has a far-reaching and long-lasting effect on physiological processes such as metabolism. During a stress response, the hypothalamus secretes corticotropin-releasing hormone that stimulates the pituitary gland initiating regulated stress response pathway.
The amygdala, part of the brain’s limbic system, is part of this neural network and plays a role in the processing of emotions in the stress response mechanisms of anxiety or fear (as discussed in the article “Worry” May 2012).
The hippocampus, also a part of the brain’s limbic system, plays an important role in memory formation. The hippocampus includes networks from the cerebral cortex, hypothalamus, and amygdala. During stress, the hippocampus responds in cognitive processes such as prior memories that can have a great influence on enhancing, suppressing, or even independently generating a stress response, as in PTSD. The hippocampus is an area in the brain that is susceptible to damage brought upon by chronic stress.
The locus coreruleus is the principle site of synthesis of the neurotransmitter norepinephrine which plays an important role in the sympathetic nervous system’s fight-or-flight response to stress. The rafe nucleus primarily synthesizes the neurotransmitter serotonin, whose role is mood regulation, particularly when stress is associated with depression and anxiety. It may also play a part in modulating the sensation of pain. The pituitary gland is located at the base of the brain just under the hypothalamus and releases various hormones that play significant roles in regulating homeostasis. During a stress response, the pituitary gland releases hormones into the blood stream that modulate stress response systems.
Additional players include the adrenal glands and the spinal cord. The adrenal gland is a major organ of the endocrine system, located directly on top of the kidneys, and is chiefly responsible for the synthesis of stress hormones released into the blood stream during a stress response. Cortisol is the major stress hormone released by the adrenal gland. The adrenal gland can also release norepinephrine during a stress response. Here, norepinephrine acts as a hormone in the endocrine system.
The spinal cord has a critical role in transferring stress response neural impulses from the brain to the rest of the body. In addition to the blood hormone signaling system initiated by the hypothalamus, the spinal cord communicates to the rest of the body by innervating the peripheral nervous system (nerves outside the brain). Some nerves of the central nervous system exit the spinal cord and stimulate peripheral nerves, which in turn engage the body’s major organs and muscles in a fight-or-flight manner.
The HPA Axis
The HPA axis (hypothalamic–pituitary–adrenal axis) is an exceedingly important multi-step biochemical process in which information is transmitted from one area of the body to the next via chemical messengers. Each step in this pathway not only passes information along to stimulate the next region but also receives feedback from chemical messengers produced later in the pathway to either enhance or suppress earlier steps. Thus, it is one method a biochemical pathway can regulate itself (as briefly discussed in the Worry Article May 2012.)
When the hypothalamus receives signals from one of its many inputs about conditions that deviate from an ideal homeostatic state, such as alarming sensory stimulus, emotionally charged event, or energy deficiency, this becomes the initial step of the stress-response cascade. The hypothalamus is stimulated by its inputs and then proceeds to secrete corticotropin-releasing hormones that are transported to the target, the pituitary gland, via short blood vessels system, to which it binds and causes the pituitary gland to, in turn, secrete its own messenger, adrenocorticotropic hormone, systemically into the blood stream. When adrenocorticotropic hormone reaches and binds to its target, the adrenal gland, the adrenal gland in turn releases the final key messenger in the cascade, cortisol.
Cortisol, once released, has widespread effects in the body. During an alarming situation in which a threat is detected and signaled to the hypothalamus from primary sensory and limbic brain structures, cortisol is one way the brain instructs the body to attempt to regain homeostasis – by redistributing energy (glucose) to areas of the body that need it most, that is, toward critical organs (the heart, the brain) and away from digestive and reproductive organs.
After enough cortisol has been secreted to best restore homeostasis, and the body’s stressor is no longer present or the threat is no longer perceived, the heightened levels of cortisol in the body’s blood stream eventually circulates to the pituitary gland and hypothalamus to which cortisol can bind and inhibit, turning off the HPA-axis’ stress-response cascade. This prevents additional cortisol from being released. This is a normal, healthy stress mechanism in response to a situation or stressor that threatens homeostasis.
However, if the response to emotional pressure is suffered for a prolonged period, over which an individual perceives he or she has no control, stress becomes chronic. If this continues for a long time, it can cause damage to an individual’s physical and mental health.
To be continued…
1‘‘Physiological regulation of normal states: some tentative postulates concerning biological homeostatics.’’ W. B. Cannon. (IN: A. Pettit (ed.). A Charles Richet: ses amis, ses collègues, ses élèves, p. 91. Paris: Éditions Médicales, 1926.
