Research at Hand Works Occupational Therapy
Hand Works Occupational Therapy Staff therapist Thuy (“Twee”) Tran is in the process of
compiling her final study proposal on Lateral Epicondylitis (LE) for her PhD post graduate
studies. Below is a brief summary of the proposed study. Currently, Hand Works is presenting at
medical centres across the Perth metropolitan area to further inform GPs about this study. We
would really appreciate feedback and input from GPs, other allied health professionals,
occupational physicians and workers compensation case managers. Please contact us if you
would like us to visit your medical centre.
About Lateral Epicondylitis
Work-related upper extremity disorders are a common problem in working populations in
Western countries. LE is one of the most prevalent disorders, with an estimated prevalence of 13% in the general population and even more common among the working population and is
reported to be one of the three most common work-related upper extremity disorders with an
incidence of 0.4-0.7%. LE is commonly characterised by pain and tenderness over the outside of
the elbow, impacting on grip strength and hand function. The average duration of a typical
episode of LE is between six months and two years and LE is common in both men and women
aged 40- 60 years. Other risk factors for developing LE reported in the literature include repetitive
and forceful motions of the wrist and arm for more than two hours/day, handling tools over 1kg,
handling loads heavier than 20kg for more than 10 times a day, activities demanding high hand
grip forces, and the use of vibrating tools.
Current Treatments
At least 40 different treatment modalities aiming to reduce pain and increase function have been
described Popular treatments include exercise and mobilization, topical or oral non-steroid antiinflammatory drugs, acupuncture (needle, laser or electro), orthoses (counterforce brace, wrist
extension orthosis), corticosteroid injections, autogolous blood injections, platelet rich plasma
injections , and surgery. Recent reviews of the literature on the effectiveness of common
treatments for LE have demonstrated weak clinical evidence to support long term benefits.
Workplace Intervention
Since the 1990s, there have been many studies that critically examined the clinical and cost
benefits of a work-site health promotion approach to managing multifactorial health problems. A
review of work site programs concluded that there is growing evidence that work site based
programs can yield acceptable financial returns to employers. A comprehensive review of the
benefits of work based interventions for cardiovascular risk shows that the environmental factors
and social support networks in workplaces may make disease prevention programs in these
settings more efficacious than similar programs offered in the clinical settings. However, no
literature currently exists regarding the prevention of risk factors for the development of LE in the
work place.
Proposed Research Question
The research question for this study is:
”What is the impact a workplace-based hand therapy intervention on the return to work
outcomes of injured workers with LE compared to a clinic-based hand therapy
intervention?”
Objectives of the Study
The primary objectives of the study are to determine the impact of a workplace-based
intervention on claims duration, claims cost and durable return to work status of the injured
worker. The secondary objectives of this study are to determine the impact of a workplace based
intervention on an injured worker’s pain level, grip strength, function and satisfaction level.
Proposed Methodology
This PhD project will include a systematic review, a randomised controlled trial (RCT) of injured
workers with LE, and descriptive studies of referring GPs and the experiences of injured workers.
The RCT will involve a comparison group (Group A) receiving usual care for the treatment of LE
from a private hand therapy practice. The intervention group (Group B) will also receive usual
care from the same hand therapy practice, plus a workplace based assessment by the hand
therapist to provide education and strategies within the injured workers work environment will be
conducted. The study aim to include 180 participants in total, based on an α-level of 0.05, 1-β of
0.8 which will make it possible to discover a standardised difference of 0.4 between the two
groups.
Sampling and Study Methods for the RCT
Participants will be injured workers with a current worker’s compensation claim for work-related
LE, will be recruited by referral from GPs within the Perth metropolitan area and sequentially
randomised into Group A and B. Group B will have usual treatment at the hand therapy practice,
plus the therapists will conduct a workplace assessment at the participant’s work place within the
first two weeks of the initial appointment. Group A will also receive the usual treatment at the
hand therapy practice plus a follow- up telephone call within the first two weeks of the initial
assessment to minimise the potential for a Hawthorne effect. Focus groups and interviews will be
organised to understand how GPs diagnose and manage injured workers with LE and to
recognise injured workers experiences of being in the workers compensation system.
Outcomes for the RCT
The primary outcomes of this study (claims cost, claim duration and durable return to work status
of the injured worker) will be measured from the participant’s first date of receiving a medical
certificate to the date when they are discharged by the GP from the workers compensation
system. The claims costs and duration will be calculated by liaising with the appropriate
insurance companies. The secondary outcomes will be addressed by having both groups A and
B complete the same initial assessment. This includes demographic questions (e.g. age, marital
status, salary), symptoms (e.g. severity of pain based on visual analogue scale, ultrasound
results (report provided by radiologists), grip strength using the Jamar dynamometer, function
using the Disability of the Hand and Shoulder Assessment (DASH), satisfaction with daily
occupations using the Canadian Occupational Performance Measure) and employment status
(e.g. place of employment, job requirements, work hours). The primary and secondary outcomes
will be re-assessed at the six weeks, three months, six months and twelve months follow- ups.
Inclusion and Exclusion Criteria for the RCT
Participants may be male or female and aged 18 to 65 years of age. To be included in the study,
the participant must be experiencing symptoms and clinically diagnosed with LE characterised by
lateral elbow pain reproduced on resisted middle finger test and resisted wrist extension for no
longer than 12 months. They must have ultrasound evidence of the LE condition as determined
by the radiographer. They must submit a claim for worker’s compensation related to the LE
injury. Participants must not have had any physical intervention (defined as any intervention that
was physical in nature), any corticosteroid and/or blood injections, or previous surgeries for the
management of LE within the past 6 months. The GPs shall continue to prescribe pain
medication for pain relief if indicated as per usual to participants in the study.
Significance of Study
The study findings will directly benefit all key stakeholders in the worker’s compensation system
with the aim to improve return to work outcomes and claims costs. Furthermore, by
understanding how GPs assess and manage injured workers with LE and recognising the
experience of injured workers through the workers compensation system, Hand Therapists will
be provided with a more holistic evidence-based approach to treatment of these injured workers.