Thesis Nurs. 1997 D578d c.2 Dill , Paul J. Development of a clinical pathway for 1997. Development of a Clinical Pathway for Treatment of Lateral Epicondylitis in the Occupational Setting by Paul J. Dill Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Approved by: :isel Ph D., R.N. (fttee Chairperson of Edinboro University of Pennsylvania // Date / Mary L$u teller, Ph.D., CRNP Committee Member Date f Ik .> Table of Contents Chapter Page I. Introduction 1 Purpose of the Study 2 Statement of the Problem 2 Definition of Terms 4 Theoretical Framework 5 Application of Theory to Practice 7 Summary 8 II. Review of Literature Occupational Health 9 Clinical Pathways 10 Lateral Epicondylitis 12 Anatomy and Bio-mechanics 13 Differential Diagnosis 14 Treatment 15 Summary 15 III. Methodology 17 IV. Clinical Pathway for Lateral Epicondylitis Clinical Pathway I Clinical Pathway II Clinical Pathway III 19 20 20 Clinical Pathway IV 21 Summary 21 References 22 Appendixes Appendix A - Clinical Pathway I 25 Appendix B - Clinical Pathway II 26 Appendix C - Clinical Pathway III 27 Appendix D - Clinical Pathway IV 28 Abstract Development of a Clinical Pathway for Lateral Epicondylitis As a result of the human and economic toll associated with musculoskeletal disorders in the workplace, the National Institute for Occupational Safety and Health (NIOSH) declared occupational musculoskeletal disorders to be one of the 10 priority work related conditions (Morbidity and Mortality Weekly Report, 1983). The push for effectiveness and efficiency in health care has created a need to pursue models of care delivery that focus on outcomes, decrease utilization of clinical resources and promote patient satisfaction. Clinical pathways reflect accumulated knowledge from many disciplines, decrease variations in treatment, promote optimal outcomes and are cost effective. This project is to develop a clinical pathway to guide the practitioner in the management of lateral epicondylitis in the work setting. The clinical pathway is utilized to address the assessment and treatment of the patient. It serves as a tool to communicate with other health care providers, case managers, employers, and insurance carriers. The pathway is outcome oriented. The goal is to return the employee to regular duty work status, pain free. 1 Chapter I Introduction One of the greatest challenges of the occupational health practitioner today is the delivery of quality, cost effective, and efficient care in an arena that has multidimensional facets; managed care delivery systems, changes in workers compensation regulations, and corporate downsizings. Occupational health receives attention from many fields; health practitioners, employers, insurance administrators, government regulators, lawyers, economists, and the media. However, each operates in its own focused perspective. Each entity caters to a separate audience and has separate priorities in the utilization of workers compensation. Occupational health practitioners play a key role in this scenario, in the assessment and delivery of care to an injured employee and because the actions and decisions of health practitioners are pivotal to other entities. The practitioner's plan of care impacts the employee, other health care personnel, the employer, the insurance carrier, and must maintain the integrity of specific government regulations. In occupational health, the spectrum of issues the practitioner deals with ranges from implementing preventative measures for health and safety, to complying with regulatory agencies, to caring for accidents or illness in the actual work setting. The focus of this project is on one component within occupational medicine; managing the patient with lateral epicondylitis. Repetitive motion injuries, or more specifically; occupationally related motion disorders, continue to be a major and often perplexing part of any upper 2 extremity practice despite two decades of attention (Higgs, 1995). Numerous terms, including cumulative trauma disorder (CTD), have been used to describe this disorder. These disorders include a variety of clinical conditions, such as lateral epicondylitis, more commonly known as "tennis elbow". For research and statistical reporting purposes, these clinical conditions of the upper extremities are grouped together and categorized under the heading of cumulative trauma disorders. Purpose of the Study The purpose of the study was to design a clinical pathway to guide the practitioner with the management of lateral epicondylitis in the work setting. How the employee with lateral epicondylitis is managed is as important as the steps taken to prevent these injuries in the first place (Carson, 1993). The clinical pathway is utilized as a tool to address the assessment and treatment of the patient, and to give direction to other health care providers, case managers, employers, and insurance carriers. The pathway is outcome oriented. The goal is to return the employee to regular duty status, pain free. Statement of the Problem The 1996 edition of the National Safety Council Accident Facts reports from the Bureau of Labor Statistics (BLS) that over 514,000 occupational illnesses were recognized or diagnosed in 1994. CTD, in the same year, accounted for 330,000 (64%) of all occupational illnesses, up from 18% in 1980, making them one of the leading and fastest growing occupational diseases in the United States. According to data reported by the National Council on Compensation Insurance, arm injuries 3 averaged in excess of $11,000 per worker compensation claim. The overall total costs for all unintentional injuries (both work and non-work related) in 1995 was $434.8 billion, with $241.7 billion of that going to wage and productivity losses, and other employer costs. Over 90,000 days away from work in 1994 were due to repetitive motion injuries. Although there are millions suffering with CTD, a great deal of controversy exists about the true incidence of the diseases, jobs and job tasks at risk for causing CTD, treatment issues, ergonomic interventions, prevention strategies and even the definition for CTD (Zenz, Dickerson, & Horvath, 1994). The diagnosis and treatment for the CTD patient can vary depending upon whom is the treating practitioner. For example, a hand surgeon may diagnose the patient with epicondylitis, whereas a thoracic surgeon may diagnose the same clinical presentation as thoracic outlet syndrome. There appears to be little consistency with either treatment modalities or outcome analysis (Higgs & MacKinnon, 1995). This supports the need for utilization of a clinical pathway for lateral epicondylitis. As a result of the human and economic toll associated with musculoskeletal disorders in the workplace, the National Institute for Occupational Safety and Health (NIOSH) declared occupational musculoskeletal disorders to be one of the 10 priority work related conditions (Morbidity and Mortality Weekly Report, 1983). Part of the NIOSH strategy includes development of a better understanding of the occurrence, presentation, treatment, and rehabilitation of these disorders (Himmelstein et al. 1995). Development of a clinical pathway for lateral epicondylitis will help to address 4 these areas. In line with the NIOSH recommendations, there are three reasons lateral epicondylitis was selected for clinical pathway development: 1. Prevalence; epicondylitis is one of the fastest growing musculoskeletal injuries today. 2. Cost; the workers compensation payout currently exceeds $2 billion yearly. 3 Management; there are marked variations in overall and individual case management of epicondylitis. Definition of Terms The following terms are defined as they are used in this text: 1. Lateral Epicondylitis is inflammation of the tendon attaching to the extensor muscles of the forearm. 2. Case Management is a systematic approach to coordination of services to occupational health clients through efforts of assessing providers, treatments, and developing treatment plans which improve quality and efficacy while controlling costs and monitoring outcomes. (Lukes & Wachs, 1996). 3. Clinical Pathway is a standard plan of care which times, sequences, and integrates the outcome driven interventions used by each profession and department and guides the practitioner in monitoring and facilitating progress towards desired outcomes (O'Toole, 1992). 4. Cumulative Trauma Disorder (CTD) is an injury to a specific body part due to repetitive or sustained motion of that body part (Higgs et al. 1995). 5. Occupational Injury is any injury such as a laceration, fracture, sprain, 5 amputation, etc. which results from a work accident or from a single instantaneous exposure in the work setting (Zenz et al. 1994). 6. Occupational Illness is any abnormal condition or disorder other that one resulting from an occupational injury, caused by exposure to environmental factors associated with employment. It includes acute and chronic illnesses or diseases that may be caused by inhalation, absorption, ingestion, or direct contact (Zenz et al. 1994). 7. Phalens Sign is for detection of carpal tunnel syndrome. The wrist is either fully extended or fully flexed for 30 to 60 seconds (O’Toole, 1992). 8. Tennis Elbow Strap (TES) is a non-elastic strap tightened around the upper forearm which functionally moves the origin of the forearm extensor muscles distally, thereby reducing stress and friction at the lateral humeral epicondyle (Chop, 1989). 9. Tinels Sign is a tingling sensation radiating from the wrist to the hand along the median nerve (Seidel, Ball, Dains, & Benedict, 1995). 10. Unintentional Injury is the preferred term for accidental injury in the public health community. It refers to the result of an accident (National Safety Council, 1996). Theoretical Framework The focus of Dorothea Orem's theory is on "self-care". This is defined as "the practice of activities that maturing and mature persons initiate and perform, within time frames, on their own behalf in the interest of maintaining life, healthful functioning, continuing personal development and well being." (Orem, 1995, p. 461). 6 Self-care is not limited to a person providing care for himself/herself but it includes care offered by others on behalf of the person. Nursing care is therapeutic self-care designed to supplement self-care requisites in the absence of capabilities to do self care. Nursing actions are based upon the three variations in Orem's nursing systems: wholly compensatory system, partly compensatory system, and supportive educative system. Orem's philosophy and definition of nursing are similar to those of the American Association of Occupational Health Nurses (AAOHN). The AAOHN's scope of practice (1994) for occupational health nurses is: Occupational health nursing is the specialty practice that provides for and delivers health care services to workers and worker populations. The practice focuses on promotion, protection, and restoration of workers' health within the context of a safe and healthy work environment (AAOHN, 1994, p. 4). Occupational health nursing practice is autonomous, and occupational health nurses make independent nursing judgments in providing occupational health services. The foundation of occupational health nursing practice and Orem's theory is the nursing process, even though the terms used to define the process are different. The occupational health nurse collects and analyzes data pertaining to the patient's health status, makes nursing diagnoses, plans for nursing care, prescribes nursing actions, implements planned care, and evaluates care given. This correlates with Orem's nursing system in which the nurse assesses the patient's self-care agency and therapeutic self-care demand. The nurse can then determine the self-care deficits, 7 design and prescribe nursing care and execute and evaluate the planned care. Application of Theory to Practice Nursing care of an occupationally injured patient can illustrate Orem's theory as it applies to occupational nursing. A patient presents to the Occupational Health Clinic with an elbow injury. After the occupational nurse performs a physical assessment of the patient, they then assess the patient's therapeutic self-care demand to determine self-care deficits and plan for nursing care. The nurse can obtain information pertaining to the patient's health status and/or injury by becoming familiar with the work environment, consulting with the physician, reviewing with the patient for history and physical information and/or ordering (via protocol) any diagnostic and laboratory testing. Data is then analyzed to determine the patient's ability to meet self-care requisites and therapeutic self-care demands. Reviewing with the patient their past medical and occupational history, in conjunction with their current injury, can provide valuable information. This data may indicate a health deviation and need for therapeutic self-care. Good history taking can also provide information pertaining to developmental self-care requisites. Assessing the patient's perceptions and expectations of their occupational injury, along with other collected information can help determine the patient's actual or potential self-care deficits. Deficits may include knowledge, self-concept, anxiety relating to lack of work, the inability to care for family, and neurological systems. The trend for today's employers is to be concerned with both the emergency health situations of the work force and health promotion/wellness and primary 8 prevention. To implement a successful program of this nature, employers are turning to occupational health settings for direction and answers (Wassel, 1995). The challenges of occupational health nurses evolve from not only their unique settings but also from their knowledge or theoretical base from which they work. Orem’s Self-Care Deficit Theory is applicable to occupational nursing and it can be used as a theoretical foundation for occupational nursing. It assists the nurse in meeting both the needs of the employer and the patient. Orem's theory of self care nursing practice is significant to occupational health since nurses are in a strategic position to promote the health and well being of the employee toward self care. The substance of Orem's theory is that all competent adults are responsible for their own behaviors. Appropriate nursing interventions can foster and enhance positive behaviors. Summary It is demonstrated how repetitive motion injuries are taking a human and economic toll on todays workforce. The problem is involving the employee, employer, health care practitioner, insurance regulators and government agencies. Each group is attempting to address the problem from a narrow perspective. The assumptions, limitations and definitions are listed. The conceptual framework is based upon Dorothea Orem's Theory of Self Care, in conjunction with the nursing process and the AAOHN's scope of practice. Development of a clinical pathway for lateral epicondylitis will assist in addressing the prevalence, cost and management of the condition of lateral epicondylitis. 9 Chapter II Review of the Literature This project examines the literature for information pertaining to the development of a clinical pathway for lateral epicondylitis in a occupational setting. Pertinent literature was reviewed relating to occupational health, clinical pathways and lateral epicondylitis in preparation for this study. Occupational Health The World Health Organization (WHO) defined occupational health as: The promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention among workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological equipment; and, to summarize: the adaptation of work to man and of each man to his job (Zenz, Dickerson, & Horvath, 1994, p. 13). This definition represents the same challenge to practitioners today as it did when it was written in 1950. Zenz et al. (1994) states that occupational health is based on preventative medicine and that the broad purpose of occupational medicine is the promotion and maintenance of the physical and mental health of all persons at work. Much progress has been made in occupational health in the past four decades and occupational medicine has become a specialty in its own right (Zenz et al. 1994). Being recognized as a specialty is an important concept, and it is best summarized by Herington and Morse in their analogy of comparing a work related and a non-work related injury: “Practitioners often find that the workplace and the patient's occupation are important variables in the formation of a thorough patient history, differential diagnosis, and management of follow up care” (Herington & Morse, 1995, p. 11). Clinical Pathways The high cost of health insurance, job related illness, injury, and disability is the focus of corporate America (Dees & Anderson, 1996). According to Dees and Anderson, corporations are being forced to reduce health care related expenditures. These reductions related to health care are passed on to practitioners, who are faced with delivering quality care in a competitive, more cost effective manner. Developing clinical pathways are an essential skill for today's health care practitioner, because they aid in delivering quality care in an efficient and cost effective manner (Underwood, 1996.) Clinical pathways provide a method that is effective for increasing continuity of care and decreasing variability in practice (Medina, 1994). Medina elaborates that they provide a mechanism for true evaluation of practice efficacy, they are a vehicle for cost effectiveness and continuous quality improvement. By allowing examination of standard practices while highlighting inefficient systems within a facility, they help 10 identify areas for potential improvement, such as decreasing time off work for an injured employee. Medina (1994) continues by addressing the issue of variance between practitioners. Not only do clinical pathways increase quality and consistency of care between practitioners, they also set clear guidelines and goals to facilitate patient movement throughout the health care system in a cost efficient manner. Clinical pathways differ from other clinical management strategies because of their multidisciplinary approach. "Clinical pathways reflect the accumulated knowledge from many disciplines and, in effect, map out the progression of suggested interventions expected to promote optimal outcomes for patients with similar problems” (Crummer & Carter, 1993, p. 30). Traditionally, health care practitioners have developed their own standardized protocols to guide treatment of specific clinical conditions. According to Ebener, Baugh and Formella (1996), clinical algorithms and plans of care have varied between and among disciplines, and this heterogeneity fragments overall patient management. Ebner et al. explains how nursing's case management model seeks to reduce this fragmentation by utilizing clinical pathways to coordinate and monitor patient care. By reducing fragmentation, you reduce costs and improve efficacy. Pathways provide the framework for professional collaboration, communication, and documentation. They also emphasize vigilance over institutional resource consumption and promote timely and effective patient care strategies from multiple providers. Of the authors cited in this review, most agree on the concept of clinical 11 pathway development and utilization. Capuano (1995) addresses both the current state and the anticipated future of our health care environment by emphasizing that health care practitioners focus on quality outcomes as well as cost. This push for effectiveness and efficiency in health care has caused those in the field to pursue models of care delivery that focus on outcomes, decrease utilization of clinical resources and promote patient satisfaction. This demand for cost efficiency and high quality patient care appears to drive the need for clinical pathway guidelines. Medina summarizes this best, stating "as managed care becomes more prevalent, clinical pathways offer an opportunity to standardize patient care and maximize efficiency; and they are a concrete tool to help ensure quality care” (Medina, 1994, p. 44). Lateral Epicondylitis Lateral epicondylitis describes the pattern of pain most commonly seen at the origin of the wrist extensors from the lateral epicondyle (Gellman, 1992). Gellman addresses epicondylitis by categorizing two groups of patients with lateral epicondylitis; (1) a younger group with sports related injury and (2) an older group with epicondylitis as a result of work related injury or overuse syndrome. The older group tends to be more difficult to treat due the fact that they usually do not have the option to curtail or stop their participation in the activity that is aggravating the condition. He describes the incidence for the work related diagnosis at 59 per 10,000 workers. Chop describes epicondylitis as a similar syndrome of occupational overuse with the incidence being the highest in the 35 to 55 year old group. Although he 12 considers the diagnosis to be straight forward, treatment can be difficult. Foley also agrees that epicondylitis in the older patient is more commonly related to occupation (Foley, 1993). A common theme throughout the literature is that lateral epicondylitis is the result of occupational overuse due to repetitive motion (Chop, 1989; Gellman, 1992; Foley 1993). The economics of this condition are felt by employers and insurance regulators. According to the National Safety Council (1996), cumulative trauma disorders (CTD) have risen 46% since 1980, making epicondylitis one of the fastest growing occupational injuries today . With each CTD case costing over $11,000, the total cost for 1995 is well over two billion dollars. Anatomy and Biomechanics. The elbow joint consists of the articulations between the distal humerus, the proximal radius and ulna (Seidel, Ball, Dains, & Benedict, 1995). The joint itself is both a hinge and a pivoting joint, which makes it capable of flexion, extension and rotation. Normal range of motion is from 0 to 145 degrees of flexion and from 75 degrees of pronation to 85 degrees of supination (Herington & Morse 1995). The extensor muscles of the wrist originate in the lateral epicondyle and supracondylar line of the humerus (Seidel et al. 1995). The three wrist extensors that originate on the lateral side of the elbow are the brachioradialis, the carpi radialis longus and the carpi radialis brevis (Foley, 1993). According to Chop (1989), when abusive or repetitive forces occur, tendinitis develops in the region of the origin of the extensor carpi radialis brevis. Microscopic tears may develop, degeneration of the tendinous origin along with soft tissue 13 adhesions are formed in response to repetitive movements; the area becomes edematous and congested with nerve endings. Elbow extension, combined with ulnar movement of the wrist, causes the forearm extensor mass, especially the extensor carpi radialis brevis, to rub and roll over the lateral epicondyle and radial head. The patient's history and physical findings on exam, include the location and reproducibility of the pain, usually establish the diagnosis of lateral epicondylitis (Gellman, 1992; Chop, 1989; Foley, 1993). On examination, the patient complains of tenderness to palpation just distal and slightly anterior to the lateral epicondyle of the humerus (Chop, 1989). Having the patient attempt supination of the affected extremity against resistance, with the wrist in extension, reproduces the pain in the lateral epicondyle (Gellman, 1992). One of the most reliable physical signs of lateral epicondylitis is increased pain when the middle finger is extended against resistance or against attempts to force flexion (Chop, 1989). Anatomically, this is due to the insertion of the extensor carpi radialis brevis into the third metacarpal; resistance applied to the middle finger causes the fascial origin of the muscle to tighten, and the pain is markedly worse (Chop, 1989). Differential Diagnosis. Three main areas to consider when making a differential diagnosis would be neuropathic, inflammatory or orthopedic (Chop, 1989; Foley, 1993; Gellman, 1992). Performing an in-depth history and physical is usually enough to diagnosis lateral epicondylitis or rule out other conditions (Gellman, 1992). Although no test is diagnostic for lateral epicondylitis, other measures may be employed. Radiographs are not generally required initially, but can be utilized to rule 14 out fractures, calcium deposits or arthritis (Chop, 1989; Gellman, 1992). A normal erythrocyte sedimentation rate argues against the presence of systemic inflammatory states (Chop, 1989). Tinel or Phalen's test will help to rule out carpal tunnel syndrome (Seidel, 1995). According to Gellman, the tenderness or pain of epicondylitis is distinct from that of radial nerve entrapment syndrome. With nerve entrapment, the patient complaint is of a vague, diffuse aching, located more in the forearm vs. the localized tenderness seen with epicondylitis which is located directly over the epicondyle. Treatment. Treatment of lateral epicondylitis starts with patient education (Higgs & MacKinnon 1995). Education should address a description of the disorder, work restrictions, physical therapy and medications. Patients diagnosed with lateral epicondylitis related to occupational activities should be involved in a formal physical therapy program (Foley, 1993). A physical therapy program should begin after the pain has subsided, consist of stretching exercises of the extensor forearm muscles, proceed to strengthening exercises and prevention techniques (Foley, 1993; Chop, 1989.) The literature also supports the utilization of non-steroidal anti-inflammatory agents, especially in the early course of treatment (Foley, 1993; Chop, 1989; Gellman, 1992) The average duration of symptoms is from six to twelve weeks before the patient is pain free (Foley, 1993.) Summary In summary, occupational health is a specialty practice of medicine. The 15 16 variables encountered in the work setting play a key role in the delivery of care and in the overall management of the case. The literature suggests that clinical pathways serve as a tool to (a) eliminate variables in delivery of care, (b) add quality and (c) decrease costs. In addition to setting clear guidelines, clinical pathways are outcome oriented and define care from a multidisciplinary approach. Lateral epicondylitis is an expensive disease in the work setting. It is most often caused by repetitive or cumulative trauma. This project, by developing a clinical pathway, may improve the delivery of care in an occupational setting and decrease variables and cost. This benefit may then be passed on to the employee and employer. Chapter III Methodology Key points from chapters one and two are as follows: (a) epicondylitis is one of the fastest growing and costly occupational diseases of the 1990's (National Safety Council, 1996), (b) clinical pathways are a medical management approach to clinical conditions that assist in communication and are cost effective (Underwood, 1996), (c) clinical pathways provide an effective method for increasing continuity of care and decreasing variability in practice (Medina, 1994), and (d) corporate America continues to turn to health practitioners for assistance in reducing health care related expenditures (Dees & Anderson, 1996). Clinical pathways differ from other clinical management strategies because of their multidisciplinary approach (Crummer & Carter, 1993). “Clinical pathways reflect the accumulated knowledge from many disciplines and, in effect, map out the progression of suggested interventions expected to promote optimal outcomes for patients with similar problems” (Crummer & Carter, 1993, p. 33). The clinical pathway for lateral epicondylitis was constructed with a review of the literature and input from occupational nurses, practitioners, physical therapists, employers and employees. Based on this, the need for a clinical pathway for lateral epicondylitis becomes obvious. The clinical pathway is to assist the practitioner with the management of lateral epicondylitis in the work setting; its presentation, treatment, and rehabilitation. The clinical pathway is utilized as a tool to address the assessment and treatment of the patient, and to provide communication to other health care providers, case 17 18 managers, employers, and insurance carriers. The pathway is outcome oriented to returning the employee to regular duty status, pain free. Managing the employee with lateral epicondylitis is as important as the steps taken to prevent these injuries. Research from the review of literature has shown that the average duration of symptoms for lateral epicondylitis is from six to twelve weeks before the patient is pain free (Foley, 1993). The clinical pathway for lateral epicondylitis addresses this time frame for average duration of symptoms and the outcome addresses returning the employee to a pain free, regular duty status. The clinical pathway is designed to address the initial evaluation and the subsequent follow up visits according to this time sequence. Chapter IV Clinical Pathway for Lateral Epicondylitis The clinical pathway for lateral epicondylitis is set up to address the initial evaluation of the patient and the subsequent follow up visits. Clinical Pathway I (Appendix A) is for use with the initial injury/assessment. Clinical Pathway II (Appendix B) can be utilized for the time frame between two to eight weeks post­ start of treatment. Pathway III (Appendix C) for eight to twelve weeks post-start of treatment and Pathway IV (Appendix D) for cases continuing past the twelve week duration. Since research has shown that the average duration of symptoms for lateral epicondylitis is from six to twelve weeks (Foley, 1993), the clinical pathway is designed to mirror this time frame. Clinical Pathway I Clinical Pathway I (Appendix A) begins with the diagnosis of lateral epicondylitis. The diagnosis for lateral epicondylitis is based upon physical examination and the patient's history (Chop, 1989; Foley, 1993). These two components aid in the actual diagnosis and assist in ruling out the differential diagnoses. The review of literature shows that diagnostic testing is not initially clinically indicated with the diagnosis of lateral epicondylitis (Gellman, 1992, Chop, 1989; Foley, 1993). Conservative measures of work restrictions, use of a tennis elbow strap (TES) and prescription for non-steroidal anti-inflammatory medications (NSAIDs) is recommended (Gellman, 1992; Chop, 1989; Foley, 1993). The TES helps move the 19 origin of the forearm extensor muscles distally, reducing stress and friction at the lateral humeral epicondyle (Chop, 1989). Based upon the average duration of symptoms, it is important to educate the patient on this aspect of their care and to provide assurance that recovery is expected. Clinical Pathway II Clinical Pathway II (Appendix B) focuses on the patient who has not improved with conservative measures. Re-evaluation of the patient ensures that the treatment being prescribed is satisfactory and that the patient is progressing as anticipated (Zenz, Dickerson, & Horvath, 1994). Ordering diagnostic tests, either x-ray or lab work, is to confirm the diagnosis of lateral epicondylitis and rule out the differential diagnoses. Three main areas to consider when making a differential diagnosis are neuropathic, inflammatory or orthopedic (Chop, 1989; Foley, 1993; Gellman, 1992). Radiographs of the affected extremity are to rule out fractures, calcifications or arthritis (Gellman, 1992). Lab studies, especially a sedimentation rate, are to rule out a systemic inflammatory process (Chop, 1989). Referral for physical therapy (PT) is important to restore muscle function, increase strength and return to full activities (Chop, 1989; Foley, 1993; Gellman, 1992). Clinical Pathway III Once again, re-evaluation of the history, physical and treatment modalities, along with the patient response to treatment is addressed. In Clinical Pathway III (Appendix C) the emphasis is on obtaining a work site ergonomic evaluation for the patient who is not responding to aforementioned measures. On site work evaluations 20 provide the employer and employee with suggestions to change equipment or techniques involved in performing components of (he patient's employment tasks (Chop, 1989; Foley 1993). Clinical Pathway IV Clinical Pathway IV (Appendix D) is utilized to address the patient who does not respond to the treatments discussed. For the patient who has had the differential diagnoses ruled out, has negative lab and x-ray results, has been on non-steroidal anti­ inflammatory medications, work restrictions/limitations but continues with symptoms, a referral to an orthopedic practitioner should be considered (Chop, 1989; Foley, 1993; Gellman, 1992). Clinical Pathway IV (Appendix D) allows the practitioner who is treating the patient past a three month rehabilitative time frame the option of referring the patient. This provides closure for the pathway. Summary The clinical pathway for lateral epicondylitis addresses the patient in the work setting who has been diagnosed with lateral epicondylitis. It demonstrates the multidisciplinary approach to the problem of lateral epicondylitis in the work setting, involving the employee, the employer, practitioners, and physical therapists. It demonstrated how the clinical pathway can reduce fragmentation of care by coordinating and monitoring patient outcomes. By reducing fragmentation, costs are reduced and efficacy is improved (Ebner, Baugh, & Formella, 1996). Ebner identifies professional collaboration, framework for clinical pathways. communication, and documentation as the 21 References 22 American Association of Occupational Health Nurses, Inc. 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Occupational health nursing and the advent of managed care, American Association of Occupational Nurses, 48, 23-28. Zenz, Carl, M.D , Dickerson, 0. Bruce, M.D., Horvath, Edward, P., Jr., (Eds.) (1994). Occupational Medicine (3rd ed.). St. Louis: Mosby. 25 Appendix A Clinical Pathway I 1 ? Employee presents with arm/elbow pain. ___ I? + 2 Perform focused medical history and physical exam. Physical exam to r/o differential diagnosis. 3 Diagnosis Lateral ^Epicondylitis? no yes 4 Differential diagnosis established. 6 Diagnostic testing is not clinically helpful in the first four weeks of symptoms. 5 Exit pathway and address 7 1. Recommend work/personal alterations to avoid arm aggravation/irritation. 2. Order tennis elbow strap. Educate patient on use of strap. 3. Utilization of prescription/ non-prescription NSAIDs. 8 Provide assurance that recovery is expected. Support return-to-work/modified duties or required daily activities. " " I . 9 Recheck in 7 to 14 days.* Notes: r/o for rule out, NSAIDs for non-steroidal anti-inflammatory drugs. *Refer to Clinical Pathway II. 26 Appendix B Clinical Pathway II 10 Review H&P, perform focused physical exam. 11 Review compliance with medications, work restrictions and treatment modalities. 12 Has the condition? 14 Improved 1 17 15 Symptom Free Decrease in Symptoms 16 ▼ 18 Return to regular duty. 25 Deteriorated 21 Status Quo Continue Meds & TES. Lift some work restrictions. + 22 Provide assurance that recovery is expected. I 20 Re-evaluate in 2-4 weeks.* 27 22 Continue Meds, TES, maintain @ same work restrictions. 23 19 Consider trial of PT for 2-3 weeks. 26 Consider differential diagnosis: 1. X-ray. 2. Lab work (sedimentation rate) Consider trial ofPTfor2-3 weeks. 24 Re-evaluate in 2-4 weeks.* Is differential diagnosis ruled < out? yes no 29 Consider changing Meds, increasing work restrictions, continue TES and trial of PT. I 30 Re-evaluate in one week.* 28 Exit pathway and address clinical situation. Notes: H&P for history and physical, TES for tennis elbow splint, PT for physical therapy, Meds for medication. *Refer to Clinical Pathway III. 27 Appendix C Clinical Pathway III 31 Review H&P, perform focused physical exam. 32 Review compliance with medications, work restrictions and treatment modalities. 33 Has the condition? 34 40 Improved r~ Status Quo "3 Deteriorated 47 37 41 Symptom Free Decrease in Symptoms Provide assurance that recovery is expected. 36 38 42 35 ▼ 46 Continue Meds, TES, PT and work restrictions. I Return to regular duty. Continue Meds, TES and PT. Lift some work restrictions. 39 Re-evaluate in 2-4 weeks.* Continue Meds, TES. 43 48 Consider on-site work evaluation as soon as possible. Consider greater work restrictions. 49 44 Consider on-site work evaluation. Recheck after on-site evaluation/ sooner if needed.* 45 Re-evaluate in 1-2 weeks.* Notes: TES for tennis elbow support, PT for physical therapy, H&P for history and physical, Meds for medications. *Refer to Clinical Pathway IV. 28 Appendix D Clinical Pathway IV 50 Review H&P, perform focused physical exam. I 51 Review compliance with medications, work restrictions and treatment modalities. 52 Has the condition? r~ 53 Improved 59 Status Quo — 54 Symptom Free 55 Return to regular duty. 56 ~T 57 Continue Meds, TES and PT (Home exercises) 58 Re-evaluate in 2-4 weeks. Deteriorated I 60 Decrease in Symptoms V 64 Provide assurance that recovery is expected. 61 ContinueMeds, TES, maintain @ same work restrictions. 65 Continue Meds, TES, PT and work restrictions. I 66 Refer to orthopedic practitioner.* 62 Consider referral to orthopedic practitioner.* 63 Re-evaluate in 2-4 weeks. Notes: H&P for history and physical, TES for tennis elbow support, PT for physical therapy, Meds for medications. *Consider referral to orthopedic physician when employee’s symptoms persist longer thank 3-6 months with conservative care and differential diagnoses have been ruled out.