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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
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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. (AAOHN) (1994),
Standards of Occupational Health Nursing Atlanta, GA.
Barker, L. Randol, M.D., Burton, John R., M.D., Zieve, Philip D., M.D. (1994).
Principles of Ambulatory Medicine (4th ed.). Baltimore: Williams and Wilkins .
Carson, Roberta (1993). Proper medical management can reduce cumulative
trauma disorder incidence. Occupational Health and Safety, 62 41-44.
Capuno, Terry, M.S.N., R.N., (1995). Clinical pathways: Practical approaches,
positive outcomes. Nursing Management, 26, 34-37.
Chop, William, M.D. (1989). Tennis elbow. Postgraduate Medicine, 86 (5),
301-308.
Crummer, M.B., Carter, V. (1993). Critical pathways-the pivotal tool. Journal of
Cardiovascular Nursing, 7, 30-37.
Dees, Janice P.,M.S.N., Anderson, NoraL., M.Ed, M.S.N., R.N. (1996). Case
management - a management system for quality and cost effective outcomes. Journal of
American Association of Occupational Health Nurses, 44 (8), 385-390.
Ebener, M. Kathleen, M.S.N., Baugh, Kathleen, R.N., Formella, Nancy, M.S.N.
(1996). Proving that less is more: linking resources to outcomes. Journal of Nursing Care
Quality, 10, 1-9.
Foley, Anthony E.M.D. Tennis elbow (1993). American Family Physician, 48,
281-288.
Gellman, Harris. M.D. (1992). Tennis elbow (lateral epicondylitis). Orthopedic “
Clinics of North America, 23, 75-82.
Herington, Thomas N., M.D., Morse, Linda H., M.D. (1995) Occupational
Injuries. New York: Mosby.
Higgs, Philip E., M.D., MacKinnon, Susan E., M.D. (1995) Repetitive motion
injuries. Annual Review of Medicine 46. 1-16.
Himmelstein, Jay S., M.D., Feuerstein, Michael, PhD, Stanek, Edward J., PhD,
Koyamatsu, Kim, M.D., MSPH, Pransky, Glenn S., M.D., MOccH, Morgan, William,
M.D., Anderson, Karen O , Phd (1995). Work-related upper-extremity disorders and
work disability: Clinical and psychosocial presentation. Journal of Occupational and
Environmental Medicine, 11, 1278-1286.
Lukes, Eileen, R.N, Wachs, Joy E., R.N. (1996). Keys to disability management.
American Association of Occupational Health Nurses Journal 44_ 141-146.
Medina, Lisa, R.N. (1994). Clinical pathway development in home care. Caring
Magazine 24 44-48.
National Safety Council. (1996) Accident Facts 1996 Edition. Itasca, II: Author.
Library of Congress Catalog Card Number: 91.60648.
Morbidity and Mortality WeeklyReport. (1983). 24 - 32, Leading work related
diseases and injuries - United States. Center for Disease Control. Atlanta, Ga.
Orem, Dorothea (1995). Nursin&Concepts of Practice; (5,hed.). New York:
Mosby.
O'Toole, Marie, M.S.N. (1992), Encyclopedia & Dictionary of Medicine-
24
Nursing, & Allied Health (5th ed.) Philadelphia: Saunders.
Seidel, Henry M., M.D., Ball, Jane R.N., Dains, Joyce R.N., Benedict, G. William,
M.D. (1995). Mosby's Guide to Physical Examination. (3rd ed.) Baltimore: Mosby.
Underwood, Robin O.T. (1996). Developing Critical Pathways. Occupational
Therapy Practice, 8, 23-26.
Wassel, Mary Lou M.Ed, RN, COHN, (1995). 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.
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. (AAOHN) (1994),
Standards of Occupational Health Nursing Atlanta, GA.
Barker, L. Randol, M.D., Burton, John R., M.D., Zieve, Philip D., M.D. (1994).
Principles of Ambulatory Medicine (4th ed.). Baltimore: Williams and Wilkins .
Carson, Roberta (1993). Proper medical management can reduce cumulative
trauma disorder incidence. Occupational Health and Safety, 62 41-44.
Capuno, Terry, M.S.N., R.N., (1995). Clinical pathways: Practical approaches,
positive outcomes. Nursing Management, 26, 34-37.
Chop, William, M.D. (1989). Tennis elbow. Postgraduate Medicine, 86 (5),
301-308.
Crummer, M.B., Carter, V. (1993). Critical pathways-the pivotal tool. Journal of
Cardiovascular Nursing, 7, 30-37.
Dees, Janice P.,M.S.N., Anderson, NoraL., M.Ed, M.S.N., R.N. (1996). Case
management - a management system for quality and cost effective outcomes. Journal of
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Ebener, M. Kathleen, M.S.N., Baugh, Kathleen, R.N., Formella, Nancy, M.S.N.
(1996). Proving that less is more: linking resources to outcomes. Journal of Nursing Care
Quality, 10, 1-9.
Foley, Anthony E.M.D. Tennis elbow (1993). American Family Physician, 48,
281-288.
Gellman, Harris. M.D. (1992). Tennis elbow (lateral epicondylitis). Orthopedic “
Clinics of North America, 23, 75-82.
Herington, Thomas N., M.D., Morse, Linda H., M.D. (1995) Occupational
Injuries. New York: Mosby.
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injuries. Annual Review of Medicine 46. 1-16.
Himmelstein, Jay S., M.D., Feuerstein, Michael, PhD, Stanek, Edward J., PhD,
Koyamatsu, Kim, M.D., MSPH, Pransky, Glenn S., M.D., MOccH, Morgan, William,
M.D., Anderson, Karen O , Phd (1995). Work-related upper-extremity disorders and
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Environmental Medicine, 11, 1278-1286.
Lukes, Eileen, R.N, Wachs, Joy E., R.N. (1996). Keys to disability management.
American Association of Occupational Health Nurses Journal 44_ 141-146.
Medina, Lisa, R.N. (1994). Clinical pathway development in home care. Caring
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National Safety Council. (1996) Accident Facts 1996 Edition. Itasca, II: Author.
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Morbidity and Mortality WeeklyReport. (1983). 24 - 32, Leading work related
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Mosby.
O'Toole, Marie, M.S.N. (1992), Encyclopedia & Dictionary of Medicine-
24
Nursing, & Allied Health (5th ed.) Philadelphia: Saunders.
Seidel, Henry M., M.D., Ball, Jane R.N., Dains, Joyce R.N., Benedict, G. William,
M.D. (1995). Mosby's Guide to Physical Examination. (3rd ed.) Baltimore: Mosby.
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(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.