The Power of Healing Sleep After a Traumatic Personal Injury

By Steven J. Anglés, Attorney at Law

People suffering from sudden injury following a traumatic event find themselves dealing with a host of issues from the injury, beyond obvious pain: stress, work problems, anxiety, household concerns, and burdened family obligations.  One common thread we hear over and again is that the person injured “just can’t sleep.”  A common consequence of a traumatic personal injury is the interruption of normal and restful sleep cycles.

Disturbed sleep can of course be from the inability to get comfortable due to pain, or it can result from the inability to calm one’s mind after experiencing the event, resulting in conditions such as post traumatic stress disorder (PTSD). This can also disrupt the body’s regular and predictable rhythm sleep cycles, making it more difficult to recover from the initial injury. A recent study helps answer the question of whether sleep within 24 hours after a traumatic event actually helps in the mental processing of stress and trauma, or, instead solidifies emotional reactions and memories of the traumatic event, leading to what is known as “intrusive emotional memory formation”.[1]


First, it is important to revisit the various stages of the sleep cycle[2]. In healthy adults, sleep typically begins with what is known as “NREM” sleep, or non-rapid-eye-movement sleep. NREM sleep can be broken down into three distinct stages: N1, N2, and N3. The N1 stage often lasts just one to seven minutes, with the N2 stage lasting 10 to 25 minutes, while the N3 stage generally lasts 20 to 40 minutes, and is referred to as “slow-wave” or “deep” sleep. As these stages progress, brain waves slow down, become more synchronized, and eyes remain still. Finally, the typical sleep cycle results in REM, or rapid-eye-movement sleep, which comprises about 20 to 25% of total sleep in typical healthy adults.


Researchers at the Department of Psychology at the University of Zürich and the Psychiatric University Hospital Zürich performed an interesting study, published in December 2016[3]. 65 healthy participants were asked to view several pieces of film in a laboratory setting: one which was considered “neutral”, and one considered to be “traumatic”. The study participants were then randomly assigned to either a group that slept after the film viewing or a second group that remained awake instead. A portion of the participants in the sleep group were fitted with electroencephalograms (an electrophysiological monitoring method to record electrical activity of the brain, commonly known as an “EEG”). The participants were then asked to record the images that troubled them for several days in a diary, causing them to see the trauma in their mind’s eye, reawakening unpleasant feelings and thoughts. The quality of these memories were thought to resemble those of patients suffering traumatic injury, such as patients who experience PTSD.

Although all of the study participants reported experiencing intrusive memories in the week after viewing the traumatic film, the group that slept within 24 hours of the distressing film experienced fewer and less severe levels of traumatic memories compared to the group that did not sleep. As the week following the viewing went on, the effects became more pronounced. The group that slept spent longer in the N2 stage of sleep, as opposed to just the N1 stage. This group also showed a lower number of fast parietal sleep spindles[4] on EEG, and more rapid eye movement.


The study’s results suggest that patients who sleep soon after trauma may experience fewer and less distressing recurring emotional memories than those who do not sleep. As a result, sleep may have a protective effect in the aftermath of traumatic experiences by weakening emotions connected to an existing memory, providing context for traumatic recollections, and help processing the information before it is stored in long-term memory. These important implications can help offer an early, less-invasive alternative to minimize traumatic memories following the injury.   People suffering from impaired sleep or traumatic memories following such an event should always seek help from a medical professional.


Changes in behavior and environment are the first line to treating sleep difficulties. Here are some tips for changes related to the daytime and nighttime.

Daytime Suggestions

  • Set an alarm to try to wake up at the same time every day.
  • Include meaningful activities in your daily schedule.
  • Get off the couch and limit TV watching.
  • Light aerobic exercise every day, as able. People with TBI who exercise regularly report fewer sleep problems.
  • Try to get outdoors for some sunlight during the daytime. If you live in an area with less sun in the wintertime, consider trying light box therapy.
  • Don’t nap more than 20 minutes during the day.

Nighttime Suggestions

  • Try to go to bed at the same time every night and set your alarm for the next day.
  • Follow a bedtime routine. For example, put out your clothes for morning, brush your teeth and then read or listen to relaxing music for 10 minutes before turning out the light.
  • Avoid caffeine, nicotine, alcohol and sugar for five hours before bedtime.
  • Avoid eating prior to sleep to allow time to digest, but also do not go to bed hungry, as this can also wake you from sleep.
  • Do not exercise within two hours of bedtime but stretching or meditation may help with sleep.
  • Do not eat, read or watch TV while in bed.
  • Keep stress out of the bedroom. For example, do not work or pay bills there.
  • Create a restful atmosphere in the bedroom, protected from distractions, noise, extreme temperatures and light.
  • If you don’t fall asleep in 30 minutes, get out of bed and do something relaxing or boring until you feel sleepy.


If your sleep problems persist, talk to your doctor to explore safe and effective solutions. Evaluation of sleep problems should include a thorough history of such problems, medication review, an assessment of your bedtime routines, and a comprehensive medical evaluation. Before recommending any action, your physician will explore with you a variety of possible causes for your sleep problems, including pain, post-traumatic stress, anxiety or depression. If necessary, he or she may recommend a polysomnographic evaluation (also known as a sleep lab). Based on your symptoms, medical history and specific needs, your doctor will be able to make a personalized treatment plan to help you achieve restful sleep, including non-medication, medication, and even natural remedies.

If sleep problems are related to a traumatic injury, then a consultation with an experienced personal injury attorney may reduce stress by answering questions and providing guidance in a sometimes difficult and confusing legal and insurance process.




[3] “Effects of Sleep after Experimental Trauma on Intrusive Emotional Memories” by Birgit Kleim, PhD; Julia Wysokowsky, MSc; Nuria Schmid, MSc; Erich Seifritz, MD; and Björn Rasch, PhD in Sleep. Published online December 2016 doi:10.5665/sleep.6310

[4] A sleep spindle is a burst of brain activity that occurs during stage to sleep. It is considered to be a period where the brain is inhibiting processing to keep the sleeper in a more tranquil state.

Insurance Premiums and the Myth of Liability Insurance “Crises”

By Jacob W. Gent, Attorney at Law

Imagine an industry that sold a product so important that each and every person and business in America needed it.  A product so important that the industry could threaten a state’s economy by pulling it from the market.  An industry not accountable to any federal agency, regulated only by often powerless state agencies, and exempt from anti-trust laws that police price-fixing and collusion with competitors. Add to this: this industry is legally permitted to keep its financials secret from regulators, law makers and the public; allowing it to advance its own political and legislative agenda at the expense of the American public.

This industry exists.  It is the property/casualty insurance industry which provides auto and homeowners insurance for individual consumers, medical malpractice insurance for physicians, and liability insurance for businesses and local governments.

Over the last four decades, the insurance industry has manufactured so-called “liability insurance crises” to drastically raise premium rates making insurance unaffordable or unavailable for many individuals, businesses, and professions.  During each of these “crises,” the insurance industry blamed a ‘litigation explosion/runaway jury award epidemic’  to justify rate hikes and called upon lawmakers to enact ‘tort reform’ laws which strip away victims’ rights and impose unjustified and crippling caps on damages juries can award to victims. These reforms, they argued, were the only way to reduce escalating premiums.

Yet studies have shown that there is no evidence to support the “litigation explosion/runaway jury award” argument.[1] Nor is there any evidence to prove that the passage of tort reform laws has reduced insurance premiums.[2]

For example, tort reform measures enacted in the mid-1980’s failed entirely to lower insurance rates in the following years, despite the promises to legislature and the voting public that it would.[3]  Indeed, states with little or no tort law restrictions saw similar changes in insurance premiums as compared with states that had not imposed significant restrictions on victims’ rights.[4]

Contrary to the industry’s justification; it is not a ‘litigation explosion’ which caused rate increases but the industry’s own “boom and bust” economic cycle at the root of the alleged “liability insurance crises.”  Due to anti-competitive (yet entirely legal) underwriting practices and the relatively unchecked power in setting premium rates and establishing reserves for future claims payments,[5] insurance companies  undergo a self-made cycle of “hard” and “soft” markets.[6]

To understand this boom and bust cycle, one must first understand that insurance companies make the most of their money from investment income by investing premium dollars received from policyholders in the stock market.  Specifically, they invest the “float” that occurs in the time between when premium dollars are received by the insurer and when losses are paid out by the insurer.[7]  Insurers engage in fierce competition for market share and premium dollars to invest, resulting in the underpricing of policies during periods when the market is strong, high interest rates are present, and/or insurers’ profit margins are robust.  This is called a “soft market.”  When the stock market plummets, interest rates drop, and/or cumulative prices cuts cause profits to fall, insurers begin increasing premiums and reducing coverage, creating a “hard market” and a corresponding “liability insurance crises” for policyholders.[8]

These boom/bust cycles occur nationwide, regardless of a state’s particular tort law regime.  Each time such a crisis occurs, insurers routinely blame state tort laws as the root cause.  Lawmakers, under pressure from the insurance industry, respond to the insurance “crises” as if the carriers were the victims, rather than the creators of the problem.  These “tort reform” laws passed in response to the self-created insurance crises are designed to increase insurance company profits, and restrict an injured party’s access to justice, or place limitations on damages to compensate injured victims.[9]   Lawmakers have passed these measures based on incomplete and/or inaccurate information provided by the insurance industry and its lobbyists, as federal and state laws do not require insurance companies to reveal information that could be used to fairly examine the actual financial health of the industry.[10]  Moreover, under state law, insurance companies are permitted to conceal important information that would inform lawmakers about the claims insurers raise during times of alleged crises to justify drastic rate hikes.  Such withheld data includes the amount of reserves held by insurers to pay future claims, the amount paid for different types of claims, actual sums paid to victims, and the amount insurers pay in cases involving multiple defendants.[11]

What can be done to remedy this situation?  To start,

  1. Congress and state legislatures should require insurance companies to disclose substantially more meaningful data regarding their actual financial well-being which justify the industry’s huge premium increases and limitations on coverage during hard markets.
  1. States should pass laws and regulations requiring insurers to provide information on premium and investment income, reserves held, and actual claim payouts and expenses incurred.
  1. Congress should also repeal the federal anti-trust exemption under the McCarran-Ferguson Act to ensure all domestic and foreign insurers and reinsurers comply with federal anti-trust prohibitions applicable to other industries. By prohibiting price fixing and monopolies, the resulting competition in the insurance marketplace would yield lower premiums and expanded availability of coverage to consumers.
  1. At the state level, legislators should enact stronger regulation and oversight of the insurance industry.
  1. States should repeal anti-competitive laws and provide increased resources to underfunded and understaffed insurance compliance departments so they can be pro-active in investigating, reviewing, and approving any proposed premium increases. States should also repeal anti-rebate and anti-group laws which prohibit insurance agents from offering discounts to policyholders and the formation of groups to negotiate favorable premiums based to economies of scale.[12]

Part of the mission of Adler ♦ Giersch ps is to promote public awareness of insurance and legal issues affecting those who have been injured by the negligence of others or by insurers that do not act in good faith in handling personal injury claims.  Our consultations are complimentary and confidential.

[1] See e.g.: Adler Giersch, ps-The Advocate, Civil Litigation by the Numbers: The Truth Insurance Companies Don’t Want You to Know About of “Runaway Juries” and “Frivolous Lawsuits” (June 2016).

[2] See Center for Justice & Democracy, Premium Deceit: The Failure of “Tort Reform” to Cut Insurance Prices (1999).

[3] See Americans for Insurance Reform, Repeat Offenders: How the Insurance Industry Manufactures Crises and Harms America (December 2011).

[4] See Americans for Insurance Reform, Stable Losses/Unstable Rates 2016 (November 2016).

[5] The McCarran-Ferguson Act of 1944 exempts the insurance industry from anti-trust laws, allowing it to on components of insurance prices and prohibits any federal regulation or Federal Trade Commission scrutiny of the insurance industry.

[6] See Americans for Insurance Reform, Repeat Offenders: How the Insurance Industry Manufactures Crises and Harms America (December 2011).

[7]Id. For example, there is about a 15 month lag in auto insurance claims, while in medical malpractice, the lag is anywhere between 5 and 10 years.

[8] See Americans for Insurance Reform, Premium Deceit 2016: The Failure of “Tort Reform” to Cut Insurance Prices (November 2016).

[9] Id.

[10] Id.

[11] See Americans for Insurance Reform, Repeat Offenders: How the Insurance Industry Manufactures Crises and Harms America (December 2011).

[12] Id.


Clinical Trial of Stem Cell Therapy Restores Arm, Hand Movement for Paralyzed Man

By: Melissa D. Carter, Attorney at Law

According to the National Spinal Cord Injury Statistical Center, each year, there are approximately 17,000 new cases of spinal cord injury in the United States, with motor vehicle collisions being the leading cause.[1]  A spinal cord injury, or “SCI,” is an insult to the spinal cord resulting in a change, either temporary or permanent, in the cord’s normal motor, sensory, or autonomic function. Patients with spinal cord injury usually have permanent and often devastating neurologic deficits and disability.

Many scientists are increasingly optimistic that advances in research will someday make the repair of spinal cord injury possible, based on current research findings ongoing around the world. A recent clinical trial has seen positive outcomes that may lead to allowing many people with a spinal cord injury to enjoy more productive, independent lives.

One young man and a team of researchers from Keck Medical Center at University of Southern California (USC) are the latest example of how the emerging fields of neurorestoration and regenerative medicine may be on track to improve the lives of thousands of people who have suffered a severe spinal cord injury.

21-year old Kristopher Boesen was paralyzed from the neck down and required assistance to simply breathe on his own following a catastrophic injury from a motor vehicle collision in March, 2016.  Spinal cord injury patients typically undergo surgery to stabilize the spine, but generally cannot restore motor or sensory function.  His medical team sent him to the Neurorestoration Center at USC for an experimental stem cell treatment in April, overseen by Dr. Charles Liu.  The result was jaw dropping: Mr. Boesen regained the use of his arm and hand.[2]

The experimental injection procedure involved 10 million AST-OPC1 cells directly into Mr. Boesen’s damaged cervical spinal cord. The experimental study tested a procedure that could improve neurological function, remove the permanency of a paralysis diagnosis and significantly improve the daily lives of patients with severe spinal injuries.

The stem cell injection procedure was in group, “Phase 2,” of a clinical trial called SCIStar[3]  that is currently looking at the safety and efficacy of escalating doses of AST-OPC1 cells developed by Fremont, California based Asterias Biotherapeutics.  AST-OPC1 cells come from embryonic stem cells by carefully converting them into oligodendrocyte progenitor cells (OPCs), which are found in the brain and spinal cord that support the healthy functioning of nerve cells.  Prior studies have shown AST-OPC1 cells to produce neurotrophic factors, to stimulate vascularization and induce remyelination of denuded axons.  These are all critical factors in the survival, regrowth and conduction of nerve impulses through axons at the injury site, per Asterias.

In 2009, President Barrack Obama lifted the restriction on embryonic stem cell research imposed by former President George W. Bush, allowing American scientists to further the work in the area of stem cell research and medical advancements.

Two weeks after his injection, Mr. Boesen began to show signs of improvement.  Within three months, he was able to use his arms and hands to hug his friends and family, feed himself, use his cell phone, write his name and operate his motorized wheelchair.

The SCIStar trial released early results in September, 2016, which are encouraging.  The sample is still very small and, beyond Mr. Boesen, has shown positive outcomes for other enrollees as well.  The current sample includes two groups of patients (“Phase 1” and “Phase 2”) whom have all lost all movement below their injury site and experience severe paralysis of the upper and lower limbs.  The Phase 1 group consists of three people who received a dose of 2 million stem cells; the Phase 2 group has five people who received a dose of 10 million stem cells.  The first group reported one improved upper extremity motor level on one side of the body in one patient, and one improved upper extremity motor on both sides in the other two patients.  The second group saw two improved motor levels on both sides in four patients and two levels of improvement on one side in two patients.  The fourth patient in the second group improved one level on one side.  There are no measurable negative side effects in any of the participants to date.[4]

Beyond Keck Medicine of USC, additional participants in this ongoing clinical trial include Indiana University in Indianapolis; Medical College of Wisconsin in Milwaukee; Rush University Medical Center in Chicago; Shepherd Center in Atlanta; and Stanford University/Santa Clara Valley Medical Center in California.  To qualify for participation in the experimental clinical trial, enrollees must be 18 to 69 years old, in stable condition and between 14 and 30 days following the injury.  All locations are currently recruiting.

The next round of data will be released at the six-month mark in January, 2017.  To follow this study and its tracked results, visit the SCIStar group at

If you would like more information related to spinal cord injury, including treatment options, insurance coverages, and rehabilitation locations, please contact the attorneys at Adler Giersch, PS.






New Study Identifies Why Accelerated Bone Healing Occurs In Traumatic Brain Injury Patients

By: Arthur D. Leritz, Attorney at Law

Every year, traumatic brain injury (TBI) contributes to a substantial number of deaths and permanent disability.  Often, a traumatic brain injury does not occur in isolation to other traumatic injuries to other parts of the body.  For example, a TBI is often a part of an acute poly-trauma, in which a person suffers multiple serious injuries at once, such as a head injury and fracture to one or more bones in the leg (femur, tibia, fibula) from a car crash.[1]

A September, 2016 study shows a correlation between poly-trauma patients suffering from TBI and bone fractures to a different part of the body actually results in quicker speed of healing for the bone fractures.[2]   This has long been a theory,[3] but now researchers believe they have isolated the cause:  Hypoxia-Inducible factor 1-a (HIF-1a)

How the study was done:

The study was done at a University Hospital over the course of three years and involved 58 patients.  Of those patients, 25 had long bone fractures (femur, tibia or fibula) and were also diagnosed with TBI.  All fractures were treated with surgery.  Serum samples were taken over a period of six months and x-rays were taken at regular intervals.  The researchers found that the group with a diagnosis of long bone fracture and TBI had a shorter time to union of the bone than the other group that did not have TBI.

Here is how the researchers believe why it works:

During a bone fracture, the local blood vessels that innervate the bone are also immediately severed, causing a hematoma which isolates the area from perfusion.  The healing process begins by increasing a specific set of genes[4] which are responsible for anaerobic energy metabolism and matrix synthesis of the fracture repair process.  These target genes are under strict control of a newly identified transcription factor, hypoxia-inducible factor-1 (HIF-1), which has two sub-parts, a and b.  The researchers believe that the elevated HIF-1a serum levels in the TBI group with fracture was due to the flow of newly formed HIF-1a from the injured brain into the circulatory system from injured neural tissue or as part of a central nervous system response to brain injury.

The researchers did stress that this study alone is not sufficient to draw too many conclusions and that more research is needed with a larger study group to identify the exact mechanism for how the nervous system controls bone remodeling.

The consequences of this study may have an impact on injured poly-trauma patients who also have a personal injury claim, as the presence of TBI may explain an unexpected recovery time from fractures.  While the study confirms a faster bone fracture healing rate for those that also have to endure a traumatic brain injury, it does not in any way suggest that those poly-trauma patients recover faster from the brain injury related symptoms, or other non-fracture poly-trauma injuries, than TBI patients without fractures.

The attorneys at Adler Giersch stay current on medical research that impacts our understanding of trauma and personal injury cases as it allows us to better advocate for our clients. Effective and tough advocacy happens best when we connect the medical-legal worlds on behalf of those with traumatic injuries caused by the negligence or recklessness of others.  If we can assist with a complimentary consultation simply give us a call.


[1] National Hospital Discharge Survey (NHDS), 2010; National Hospital Ambulatory Medical Care Survey (NHAMCS), 2010; National Vital Statistics System (NVSS), 2010. All data sources are maintained by the CDC National Center for Health Statistics.

[2] Sang, et al.  Elevated levels of hypoxia-inducible factor-1α in patients with fracture and concomitant traumatic brain injury.  Annals of Clinical Biochemistry 2016; ACB-16-211.R1.

[3] Bidner SM, Rubins IM, Desjardins JV, et al. Evidence for a humoral mechanism for enhanced osteogenesis after head injury. J Bone Joint Surg Am 1990;72(8):1144-9.

[4] heme oxygenase-1 (HO-1), vascular endothelial growth factor (VEGF), inducible nitric oxide synthetase (iNOS) and leptin.

Intraoperative Monitoring: Improving Patient Safety with Improved Surgical Outcomes

By Steven J. Anglés, Attorney at Law

Patients who have been traumatically and severely injured as a result of another person’s negligence may ultimately need surgery to get long-lasting relief from their pain, symptoms and residuals. One common concern shared by our clients and their providers alike is the question of safety during a surgical procedure. Patients undergoing operations under general anesthesia may have little idea of multi-faceted measures in place to improve patient outcomes by monitoring their condition during surgery.  The fields of medicine and technology have combined in many ways, and one in particular is the use of intraoperative neurophysiological monitoring (IOM or IONM).

IOM is the monitoring of nerve health and function in the spine and the brain for patients undergoing vascular surgery, neurosurgery, or orthopedic surgery. IOM can be used for operations including:

  • Operations of the spine, including fusion, discectomy, or laminectomy;
  • Operations of the brain, including craniotomies;
  • Vascular surgery;
  • Facial nerve surgery

The first documented use of this of monitoring was in 1935, primarily for patients suffering from epilepsy.[1] The potential applications for this technology grew over the years, and advances in computer networking and integrated communication systems helped IOM to evolve.

Through IOM, neurodiagnostic procedures can help determine whether any nerves have become compressed, or if the brain or spinal cord has any reduced vascular flow, allowing the surgical team to take immediate and corrective actions to prevent a bad outcome. Essentially, IOM acts as an early warning system for surgeons to gain reliable insight into a patient’s condition during surgery, adding a layer of safety to the measures already in place that monitor cardiac and respiratory function while a patient is anesthetized. For example, the diagram below shows normal brainstem electrical response.  If the amplitude, shape, or timing of the responses were to change from a patient’s “baseline” response during surgery, it could signal a neurological dysfunction.


Normal brainstem auditory evoked potentials (BAEP)[2]


How it Works:

The IOM team is typically composed of the surgeon, clinical neurophysiologist, anesthesiologist, and an IOM monitoring technologist.[3] The neurophysiologist is a specialist trained in bioelectrical activity that attaches sensors to the patient to monitor the activity of the muscles, nerves, and brain. The neurophysiologist and surgeon receive information from the technologist who observes and records using monitoring equipment, and interpret the results in real time during the course of the procedure. Interestingly, some members of the team, such as the technologist, can monitor the patient’s neurological activity remotely, even from another location entirely. The information received also assists the anesthesiologist, who may not only need to make adjustments during the course of the operation, but also gives the anesthesiologist information on which anesthetics to use prior to surgery. (Anesthetics can affect the brain’s metabolism, which can alter recordings of brainwaves, causing interference with intraoperative monitoring.)[4]

IOM uses a number of different methods each with very specific applications.  Several modalities or methods of monitoring can also be used together within the same surgery. For example, electrodes on a patient’s scalp during an electroencephalography test (EEG) to evaluate brain waves can be used in conjunction with an electromyography test which monitors the peripheral nervous system. In this way, a surgical team could simultaneously monitor the patient’s brain activity as well as the bundles of nerve fibers or axons conducting information to and from the central nervous system.


Since the use of IOM is normally reserved for more complex surgeries, its availability may be limited. Different medical organizations will have specific guidelines as to when IOM use is necessary or appropriate, and not all organizations may offer it as an option for patients. Additionally, adding IOM to the cost of a surgical procedure may not necessarily qualify for reimbursement under some insurance policies. For example, one large national health insurance provider specifies in its plans that “IOM billed by the surgeon, assistant surgeon, or anesthesiologist will be denied as included in the surgical or anesthesia reimbursement…” but “IOM performed by a physician (MD or DO), other than the surgeon, assistant surgeon, or anesthesiologist…may be eligible for reimbursement.”[5] Remote IOM by a physician may only be eligible for reimbursement to the monitoring physician if the time spent does not exceed a certain number of minutes and a technician is physically present in the operating room.

While intraoperative neurophysiological monitoring may not be required or recommended by surgeons in a majority of cases, it continues to be an important safety consideration worthy of discussion with patients.


[1] Kim S-M, Kim SH, Seo D-W, Lee K-W. Intraoperative Neurophysiologic Monitoring: Basic Principles and Recent Update. Journal of Korean Medical Science. 2013;28(9):1261-1269. doi:10.3346/jkms.2013.28.9.1261.

[2] Intraoperative Neurophysiological Monitoring, Medscape, Mar 17, 2016

[3] Kim S-M, Kim SH, Seo D-W, Lee K-W. Intraoperative Neurophysiologic Monitoring: Basic Principles and Recent Update. Journal of Korean Medical Science. 2013;28(9):1261-1269. doi:10.3346/jkms.2013.28.9.1261.

[4] American Clinical Neurophysiological Soceity; Guideline 11A: Recommended standards for neurophysiologic intraoperative monitoring – principles; 2009.