Summer 2017

Not-So Science Fiction: Innovative Technologies in Workers' Comp

Fast Focus

As medical technology continues to evolve, fascinating new opportunities emerge which can potentially benefit the injured worker. Technologies such as brain-computer interface, 3D printing, exoskeletons, and virtual reality represent significant advancements that can improve patients’ function and quality of life. But with new technology comes new considerations for determining appropriate utilization in patient care.



Brain-computer interface (BCI) involves capturing electric activity in the brain (primarily through an electrode cap or an electrode implant in the brain) and sending it to a computer system that translates that activity into a command, which is sent to an external device.


Restored communication

BCI allowed patients suffering complete motor paralysis to answer yes –or– no questions by thinking their answer and having it displayed on a computer screen, partially restoring their ability to communicate.1

Enhanced mobility

  • BCI allowed a paraplegic subject to pilot an exoskeleton by simply thinking about walking.2
  • BCI was also used to bypass a paralyzed patient’s spinal cord, sending electric signals from his brain to a special sleeve of electrodes on his arm, allowing him to move his hands with a fair degree of accuracy.3


Currently, most BCI breakthroughs have been limited to laboratory settings, mainly due to portability limitations. The use of wires and special equipment makes the technology cumbersome to use in realworld settings, but there have been advances in wireless BCI.

Scientists were able to implant wireless electrode arrays in the brains and legs of paralyzed monkeys, and the brain array successfully bypassed the spinal cord and signaled the leg muscles to walk again. The experiment was so successful that the implantable components were approved for investigational applications in similar human research.4

So far the only FDA-approved piece of BCI technology is the NeuroPace chip. The chip, which was approved in 2013, uses BCI to scan the brain for electric activity related to seizures, sending a pulse to short-circuit such activity. This application may prove useful in workers’ comp for seizures related to post-traumatic brain injury. It also demonstrates that BCI can be used in real-world settings, paving the way for future applications.


This technology requires more development before any largescale implementation can occur, and so far it seems that implantable electrodes are more efficient than electrode caps. This of course requires delicate surgery, which can present its own risks. However, the potential benefits of BCI could possibly outweigh the risks, especially as the technology continues to evolve.



Three-dimensional (3D) printing refers to a manufacturing process that can create three-dimensional objects of almost any shape or geometry by printing out successive layers of thin material based on a digital model.


The gig economy has been a topic of debate among regulators nationwide, both at the state and federal levels. However, California in particular has led much of the way, inspiring other states to specifically follow suit – or block similar changes from happening in their states.

Skeletal healing

  • Special bone-like implants have successfully been accepted inside live animal test subjects, serving to scaffold injured areas and allow bone to grow around the implant, which will slowly biodegrade to promote healing.5

Surgical advancements

  • A patient’s spine can be digitally scanned and printed, allowing surgeons to better plan surgical procedures with an exact model.6
  • 3D printing can generate 100 square centimeters of skin in 35 minutes in order to treat burn injuries, surgical trauma, or general wounds.7

Drug therapy application

  • Research has shown that in 3D-printed tablets, drug release is impacted by the ratio between surface area and volume, which can be modified, allowing for custom geometries that can better serve patients.8


So far, only printing materials and a single antiepileptic drug, Spritam, have been FDA-approved. The FDA has released a draft guidance on 3D printing, but the guide is not meant for implementation. The sheer scale of customization available with 3D printing limits the FDA from monitoring 3D-printed devices for consistent clinical stability, especially as more players enter the market.


Similar to the issues of compound drugs, there is too much potential for small-scale customization with 3D printing. Regulatory boards would have great difficulty monitoring everything. And proper guidance and best practices are still undetermined.

Furthermore, in cases of harm resulting from 3D-printed devices, the question of liability is no longer limited to a sole manufacturer; the printer itself is put into question, as is the design template, the scanning system, the software that customized a device, the printing material, and much more. And even if 3D-printed devices are successfully used, there is still the possibility of encountering counterfeit devices and illegal reproductions.

While research points to potential medical benefits, there is still much to sort out regarding 3D printing and its application in the healthcare space.



Exoskeletons are wearable mobile machines that allow for limb movement in individuals who have restricted or diminished mobility, including paralysis.


Unprecedented mobility

  • The FDA has approved three different exoskeletons that help patients with paralysis stemming from spinal cord injuries to walk again, granting them an unprecedented increase in mobility and quality of life.

Secondary health conditions

  • The increased mobility afforded by exoskeletons can reduce secondary conditions that result from excessive sitting in wheelchairs, such as blood clots, bone deterioration, pressure sores, and problems with urinary, respiratory, cardiovascular, and digestive systems.


Beyond the three exoskeletons currently on the U.S. market, medical exoskeletons have been developed and approved for use in various countries across Europe and Asia, and distribution rights could lead to foreign exoskeletons entering the U.S. market after initial testing and approval.

In fact, Korean automotive giant Hyundai, having already developed exoskeletons for labor purposes, has begun developing medical exoskeletons for individuals with lower spinal cord injuries.9 Hyundai is one of many automotive companies to have developed labor-related exoskeletons, and they could be the first of many industry outsiders to shift their technology to medical applications. And the automotive industry likely won’t be the only new player in the exoskeleton field. Market research predicts that 97% of the total market for wearable exoskeletons will soon be geared towards medical and rehabilitation purposes,10 and so it is very likely that even more exoskeletons will be available in the near future.


Exoskeletons are incredibly expensive. ReWalk, one of the foremost exoskeleton brands, averages $65,000, and exoskeletons are slowly but surely being paid for by workers’ comp insurers. ReWalk reported in August of 2016 that 18 units were paid for by comp insurers, with 20 more units pending review.11 As the technology evolves and becomes more prevalent, insurers will face more decisions regarding appropriate utilization of these devices – a task that may prove difficult since there are currently no best practices in place or even a clinical consensus.

Payers will need to understand the limitations and nuances of each specific model, which can impact its appropriateness. For example, certain exoskeletons are only indicated for specific spinal cord injuries, while others have specific physical parameters that a patient must fall into, such as height requirements, a maximum weight limit, and hip and pelvis dimensions.

The high specificity and cost of these devices will likely require an individualized, case-by-case decision process when determining their appropriate application, one that weighs the cost-benefit in a particular patient.



Virtual reality (VR) is the use of computer technology to generate realistic images, sounds, and other sensations to create an immersive environment which users can interact with, often with special hardware.

The healthcare industry has strongly embraced applications for VR, some of which include: constructing a virtual anatomy of the patient for diagnosis purposes; sophisticated surgical simulations that enable surgeons to practice and perfect delicate procedures; and human simulation software that trains doctors and nurses to interact with patients in a 3D environment.


Combating drug addiction

  • The University of Houston has a VR program that puts patients into scenarios that would normally trigger drug use, manipulating the virtual environment to pinpoint triggers and practice therapeutic techniques to prevent relapse.12 This program is currently working with heroin users, indicating potential applications for patients addicted to prescription opioids.

Physical rehabilitation

  • Studies have demonstrated patients’ willingness to better embrace treatment when the physical therapy experience is interactive and entertaining, particularly with deeper levels of immersion.
  • Use of VR programs during rehabilitative treadmill exercises resulted in improved gait, mobility, and posture.13
  • The Nintendo® Wii™ has been used as a rehabilitative tool for post-stroke patients with hemiparesis, resulting in improvements in passive movement, pain scores, motor function of the upper limb, balance, and physical function.14

Pain reduction/distraction

  • VR has shown effectiveness in reducing chronic pain, so long as patients are able to seriously immerse themselves in their virtual environments.15
  • An assessment of 17 research studies composed of 337 patients found strong evidence that VR could immediately reduce shortterm pain, with moderate evidence for short-term effects on physical function.16
  • A different study found that patients experienced a 60% decrease in pain levels during a five-minute VR session. After the session, they continued to experience a 33% reduction in pain levels compared with before the session.17


This technology is still very new, and clinical applications are still primarily in the research stage. There are currently no clinical, evidence-based guidelines on the use of VR technology, and it will be some time until a larger clinical consensus is formed.


First and foremost, the scientific community has still not fully understood the impact of VR technology in clinical settings. Critics have pointed out that VR’s use in addiction therapy could unnecessarily agitate patients, and that rehabilitative simulations could lose their appeal with enough repetition.

But assuming VR is proven safe and effective, these VR devices are expensive. While there are cheaper VR options available, VR is most effective when it is deeply immersive with features such as smellstimulating machines and mechanical feedback, which of course demands an increase in quality that comes with higher costs.

Virtual Reality in the Workplace

Virtual reality can effectively be applied to help injured workers from their injury, but what about using VR to avoid work-related injuries in the first place?

VR is currently being used to promote workplace safety by allowing employees to develop safe working habits in simulated environments that mimic real working conditions, just like how pilots have been using flight simulators to train for decades. Taking this a step further, the implementation of crisis scenarios can teach employees what to do in an emergency, such as safe evacuation techniques that can be used in a collapsing mine or trench.

Furthermore, VR technology can create better training materials. For example, if an employee were working with heavy machinery, an interactive, three-dimensional VR schematic could be far more educational than a two-dimensional paper diagram, and that improved understanding of the machinery could prevent serious injury.


  1. Chaudhary U, Xia B, Silvoni S, Cohen LG, Birbuamer N. Brain-computer interface-based communication in the completely locked-in state. PLoS Biology. Jan 2017; 15(1). U, Xia B, Silvoni S, Cohen LG, Birbuamer N. Brain-computer interface-based communication in the completely locked-in state. PLoS Biology. Jan 2017; 15(1).
  2. Do AH, Wang PT, Chun SN, Nenadic Z. Brain-computer interface controlled robotic gait orthosis. J Neruoeng Rehabil. Dec 2013; 10:111. doi: 10.1186/1743-0003-10-111.
  3. Bouton CE, Shaikhouni A, Annetta NV, et al. Restoring cortical control of functional movement in a human with quadriplegia. Nature. May 2016; 533: 247-259. doi:10.1038/nature17435.
  4. Capogrosso M, Milekovic T, Borton D, et al. A brain-spine interface alleviating gait deficits after spinal cord injury in primates. Nature. Nov 2016; 539: 284-288. doi:10.1038/nature20118.
  5. Jakus AE, Rutz AL, Jordan SW, et al. Hyperelastic “bone”: a highly versatile, growth factor-free, osteoregenerative, scalable, and surgically friendly biomaterial. Sci Tranl Med. Sep, 2016; 8: 358. doi: 10.1126/scitranslmed.aaf7704.
  6. Jackson B. Firefly lights the way for spine surgery with 3D prints. 3D Printing Industry. Oct 27, 2016. Accessed Feb 21, 2017.
  7. Cubo N, Garcia M, del Cañizo JF, Velasco D, Jorcano JL. 3D bioprinting of functional human skin: production and in vivo analysis. Biofabrication. Dec 2016; 9:1. doi: 10.1088/1758-5090/9/1/015006.
  8. Goyanes, A, Martinez PR, Buanz A, et al. Effects of geometry on drug release from 3D printed tablets. Intl J Pharm. Oct 2015; 494(2): 657-653.
  9. Hyundai motor leads personal mobility revolution with advanced wearable robots. Hyundai USA website. Jan 2017.
  10. Wearable robots, industrial exoskeletons: market shares, market strategies, and market forecasts, 2016 to 2021. WinterGreen Research. 2016.
  11. Goodman E. Exoskeletons become a reality for patients, payers. WorkCompCentral. August 2016.
  12. UH moment: unique virtual reality lab expands, tackles heroin addiction. University of Houston website. July 28, 2014. Accessed Feb 21, 2017.
  13. Shema SR, Brozgol M, Dorfman M, et al. Clinical experience using a 5-week treadmill training program with virtual reality to enhance gait in an ambulatory physical therapy service. Phys Ther. Sep 2014; 94 (9): 1319-1326.
  14. da Silva Ribeiro NM, Ferraz DD, Pedreira E, et al. Virtual rehabilitation via Nintendo Wii® and conventional physical therapy effectively treat post-stroke hemiparetic patients. Top Stroke Rehabil. Feb 2015; 22: 299-305. doi: 10.1179/1074935714Z.0000000017.
  15. Wiederhold BK, Gao K, Sulea C, Wiederhold MD. Virtual reality as a distraction technique in chronic pain patients. Cyberpsychol Behav Soc Netw. June 2014; 17 (6): 346-352.
  16. Garrett B, Taverner T, Masinde W, Gromala D, Shaw C, Negraeff M. A rapid evidence assessment of immersive virtual reality as an adjunct therapy in acute pain management in clinical practices. Clin J Pain. Dec 2014; 30 (12) 1089-98. doi: 10.1097/AJP.0000000000000064.
  17. Jones T, Moore T, Choo J. The impact of virtual reality on chronic pain. PLoS One. Dec 2016; 11 (12).


Since 2010, the semi-annual RxInformer clinical journal has been a trusted source of timely information and guidance for workers’ comp payers on how best to manage the care of injured worker claimants and plan for the challenges that lay ahead. The publication is an important part of Healthesystems’ proactive approach to advocating for quality care of injured workers while managing the costs associated with treatment.