Do hand therapists have a role in workplace-based education to manage tennis elbow? Beliefs about effective treatments among Australian hand therapists and medical practitioners

Abstract

BACKGROUND:

Lateral elbow tendinopathy (LET), commonly known as tennis elbow, is a prevalent work-related upper extremity musculoskeletal disorder. Medical practitioners and hand therapists manage LET with commonly available clinic-based treatments, despite no sound evidence to suggest long-term relief and functional restoration for workers with LET. Workplace-based rehabilitation is effective for injured workers with other health conditions, but no studies have investigated this rehabilitation approach in the management of LET.

OBJECTIVES:

(i) Identify, compare, and contrast Australian hand therapists’ and medical practitioners’ perceptions about the effectiveness of common treatments for LET, and (ii) obtain their views towards a hand therapist delivered workplace-based education approach.

METHODS:

In this cross-sectional study, 38 medical practitioners from Western Australia and 104 hand therapists around Australia completed online surveys. Independent t-tests were used to identify between-group differences in responses.

RESULTS:

Despite some between-group differences regarding the perceived effectiveness of common LET treatments, both groups believed education about LET pathology, activity modification, postures, and workplace recommendations were most effective. Most medical practitioners (81%) and hand therapists (71%) believed workplace-based education delivered by a hand therapist would be beneficial for patients with acute and chronic LET.

CONCLUSION:

Australian hand therapists and medical practitioners believed educational approaches were the most important component in the management of LET, and supported workplace-based educational interventions provided by hand therapists in the management of LET.

Keywords

Workplace therapy elbow tendinopathy tendinitis rehabilitation

1 Introduction

Lateral elbow tendinopathy (LET), also known as tennis elbow, is one of the most common work-related musculoskeletal disorders that has a direct correlation of increased risk with exposure to occupations requiring repetitive elbow flexion/extension for >1 hour per day [1, 2]. The prevalence of LET is estimated to be 1–3% in the working population [1]. LET is characterized by pain and tenderness over the outer surface of the elbow, and reduced grip strength and upper limb function, which affects a person’s ability to engage in work, self-care, and daily activities [3]. Previously thought to be an inflammatory condition, histological studies have confirmed that this condition progresses into a degenerative state characterized by an absence of inflammatory cells and therefore should be classified as a tendinopathy [3, 4]. LET is equally common in men and women, mostly affects those aged 35–55 years, with the average duration of a typical episode of symptoms ranging from six months to two years [3].

In Australia, medical practitioners and hand therapists are two groups of health professionals commonly involved in the assessment and management of patients with LET [5]. Patients with symptoms of LET typically seek advice first from their medical practitioner. If the injury is not work-related, the patient’s private health insurance may reimburse the costs related to assessment and treatment, or else the patient is liable for out-of-pocket expenses. If the injury is work-related, the medical practitioner will provide a First Medical Certificate that allows the injured worker to submit a workers’ compensation claim [6]. The medical practitioner, the employer, and the injured worker communicate with one another to identify suitable alternative work duties and develop a graduated return-to-work program [6]. In some instances, the injured worker may require a workplace rehabilitation provider to assist with their return to work program.

Fig. 1

Application of the International Classification of Disability, Functioning and Health: Interaction of concepts for patients with LET [11]. *CETO = common extensor tendon origin.

Workplace rehabilitation providers (also referred to as vocational rehabilitation providers) facilitate a return to work after injury [6]. They are commonly health professionals, such as occupational therapists, physiotherapists, exercise physiologists, or psychologists, who have expertise in addressing the physical, psychological, and/or workplace barriers that may prevent an injured worker returning to work. The costs of vocational rehabilitation services in the Western Australian workers’ compensation system are paid to a maximum of seven per cent of the total amount payable in lost wages (i.e. the ‘prescribed amount’) for each claim [7, 8]. Hand therapy and medical practitioner services are considered medical expenses and are paid to a maximum of 30 per cent of the prescribed amount [8].

The medical practitioner may treat the patient with LET or refer them to a hand therapist. Hand therapists, who usually have a degree in occupational therapy or physiotherapy, merge occupational therapy and physical therapy theories and practice, and combine comprehensive knowledge of upper limb anatomy, biomechanics, and musculoskeletal function. Hand therapists use specialized skills in assessment, planning, and treatment to prevent dysfunction, restore function, and/or reverse the progression of pathology in the upper limb, so as to improve an injured worker’s ability to participate fully in meaningful activities [9].

Many treatments used to manage LET reported in the research literature primarily focus on the physiological management of pain, strength, and function. Treatment methods typically include provision of orthoses, exercise programs, use of electrical stimulation technologies, corticosteroid injections, blood injections, pain medications, and surgical options [10, 11]. Reviews of the effectiveness of common treatments for LET have reported there is weak clinical evidence to support long-term benefits in sustaining pain reduction and maintaining grip strength and function, and to date there is no gold standard method of treatment [12, 13].

Previous cross-sectional studies that explored the perceived effectiveness of LET treatments by hand therapists and medical practitioners focused on clinic-based treatments only, and rarely discussed the work environment nor had consideration of risk factors that may contribute to the exacerbation of LET symptoms [14 –16]. MacDermid et al. surveyed almost 700 American hand therapists and concluded that patient education, stretching, and activity modification were effective in the management of LET, and that most therapists agreed that the duration of symptoms and the patient’s type of work occupation were important factors for symptom resolution [14].

Health professionals involved in the treatment of injured workers with LET in Australia are guided by the clinical framework guidelines governed by the Australian federal government [5]. The framework’s underlying principles incorporate the International Classification of Functioning, Disability and Health (ICF) [17], which considers health and disability at the individual and population levels, the environmental factors (e.g. social and physical work environments), and personal factors (e.g. physiological, psychological, and cognitive factors) that impact a person’s functioning and participation in activities. The application of the biopsychosocial approach of the ICF supports a holistic approach in the management of injured workers with LET because it considers other factors in addition to changes to the function and structure of the body (Fig. 1).

The findings of a qualitative analysis of the ICF and factors impacting on early return to work suggested that health professionals should consider the environmental factors when planning return to work interventions [18]. To date, no cross-sectional studies have accounted for other contextual factors during the treatment of LET, such as the injured worker’s physical and social environments at home and in the workplace. A recent systematic review of workplace interventions in return-to-work programs for musculoskeletal disorders, pain-related conditions, and mental illness found moderate to strong evidence that lost-time from work was reduced when interventions comprised a multi-domain approach and included interventions such as graded activities, service coordination, and work modification components [19]. Workplace-based rehabilitation has many benefits in the return to work process for injured workers for other health conditions [19 –21], but no studies have investigated the effectiveness of this intervention approach specifically for the management of LET.

Combining a hand therapist’s specialized knowledge and skills in upper limb rehabilitation with an approach that considers the injured worker’s social and physical environments provides a more holistic approach to the management of work-related LET. To date, there is no empirical evidence about the preferred practice trends of hand therapists and medical practitioners in the Australian context, and no studies have investigated medical practitioners and hand therapists’ beliefs about a workplace-based rehabilitation approach for injured workers with LET that is delivered by hand therapists. This cross-sectional study aimed to (i) identify, compare, and contrast Australian hand therapists’ and medical practitioners’ perceptions about the effectiveness of common treatments for LET, and (ii) obtain their views towards a hand therapist delivered workplace-based education approach.

2 Methods

2.1 Study design

This was a cross-sectional study with a convenience sample using online surveys.

2.2 Participants

Australian hand therapists who were qualified occupational therapists or physiotherapists, registered as full or associate members of the Australian Hand Therapy Association (AHTA), and had clinical experience practicing hand therapy within the past five years, were invited to participate in this study. Full members of the AHTA have a minimum of three years’ equivalent full-time experience in hand therapy post-graduation with a minimum of 3,600 hours of experience as a practising hand therapy clinician within the last five years and at least 300 hours of professional development or education within the last five years, or those with current certified hand therapist credentials. Associate members of the AHTA are hand therapists with a letter of recommendation from a full member. Medical practitioners recruited to this study included general practitioners and sports physicians. They were required to have treated upper limb conditions in the past five years, to be eligible for inclusion in the study.

The hand therapists were recruited via an email containing the study information and the online survey link. The email was sent by the first author to the Secretariat of the AHTA, who forwarded the email to all associate and full members in Australia (N = 599). Of those, 336 (56%) opened and read the email information about the study, and 104 completed the survey (i.e. 30% response rate based on the 336 hand therapists who opened the email). The researchers were unable to recruit medical practitioners across Australia in a similar manner through the Australian Medical Association. Instead, the first author emailed the study information and survey link to the Practice Managers of 231 medical clinics across metropolitan Perth, Western Australia and asked them to forward the email to the medical practitioners at their respective clinics. At the time of the survey, these medical practices referred patients to the private hand therapy practice (comprised of seven practice locations) where the first author worked. Due to this method of survey distribution, an accurate response rate for the medical practitioners could not be calculated.

2.3 Outcome measures and procedure

A pilot survey of 13 hand therapists at a multi-centred private hand therapy practice in Perth identified common treatments currently used to manage patients with LET. The collated list of treatments from this survey, in combination with a search of the available published scientific literature [10 , 22], were used to develop the items in the online surveys administered to participants in this study. Two surveys were developed for this study; one for the hand therapists and the other for the medical practitioners. The hand therapists’ survey consisted of 16 questions and the medical practitioners’ survey comprised 20 questions.

Demographic questions were common to both surveys. Questions included the respondent’s professional discipline; years of experience treating upper extremity disorders; and information about their LET patients including gender, estimated number of LET cases treated each month, number of work-related cases of LET treated under the Western Australian workers’ compensation insurance scheme, and if their LET patients were treated in a private or public health service.

Questions about common treatments for LET were presented separately for the acute and chronic stages of the condition, respectively in both surveys. Acute LET was classified as the presence of symptoms for <3 months, and symptoms lasting for 3+ months were classified as chronic LET [23]. Participating hand therapists and medical practitioners were asked to rate their perceived level of effectiveness of common forms of LET treatments on a scale of 0–10; where 0 indicated ‘not effective’ and ‘10’ indicated ‘most effective’. Hand therapists were asked to rate their level of agreement (where 0 indicated ‘strongly disagree’ and 10 indicated ‘strongly agree’) with the statement: “I routinely educate LET patients on their condition, postures to avoid, and provide recommendations for activity modification specific to their work and leisure activities”.

Hand therapists and medical practitioners were asked about their attitudes towards having hand therapists conduct workplace-based interventions for injured workers in the acute and chronic stages of LET. Hand therapists were asked to list any pros and cons of having a hand therapist complete a workplace-based intervention as part of the management of LET among injured workers. Additional questions in the medical practitioners’ survey asked how frequently they referred LET patients to a vocational rehabilitation provider and the main reasons for referral.

The surveys were pilot tested for face and content validity by a panel of experts. The expert panel for the hand therapist survey included two occupational therapists specialising in hand therapy (one working in a private clinic and the other in a public clinic) and three occupational therapy academicians who were experienced in teaching and researching in this field. The medical practitioner survey was reviewed by a general medical practitioner and the same three occupational therapy academicians. Amendments were made to the content and wording of the final version of the surveys using the feedback from the expert panels. The online surveys were administered using Qualtrics software (www.qualtrics.com) and were available online for a period of six months for data collection.

2.4 Study ethics

The Human Research Ethics Committee at Curtin University in Western Australia provided approval for the study. On the first screen of the online survey, participants were provided with information about the study purpose; perceived benefits and risks; the estimated time required to complete the survey; the voluntary nature of their participation; and the contact details of the researchers if they had any questions. Immediately following presentation of the study information, participants were asked to respond to a question asking for their consent to participate.

2.5 Data analysis

All survey data were imported into the Statistical Package for the Social Sciences (SPSS, version 22). Descriptive statistics were used to analyse respondents’ demographic information. Frequencies of responses were calculated to summarise categorical data and multiple-choice response options. Multiple responses were allowed for some questions and so totals of these frequencies may exceed 100 per cent. Between-group differences for questions common to both surveys were determined using independent t-tests. The non-parametric Mann-Whitney U test was also used on the data and produced similar results. A critical alpha of.05 was used to determine statistical significance. Free text responses reporting any pros and cons of having a hand therapist complete a workplace-based intervention were grouped using content analysis.

3 Results

3.1 Participant demographics

Online surveys were completed by 104 hand therapists from around Australia and 38 medical practitioners from Western Australia. A summary of the respondents’ demographic information is shown in Table 1.

Table 1
Demographic characteristics of survey respondents (N = 142)

Hand therapists (n = 104) Medical practitioners (n = 38)

Profession Occupational therapists: 70% General practitioners: 90%

Physiotherapists: 30% Sports physician: 10%

Experience <4 years: 25% <10 LET patients: 5%

4–9 years: 30% 10 > 49 LET patients: 45%

10+ years: 45% 50+ LET patients: 50%

LET caseload <5 new cases/month: 65% <5 new cases/month: 79%

5–9 new cases/month: 32% 5–9 new cases/month: 16%

10–15 new cases/month: 3% 10–15 new cases/month: 5%

15+ new cases/month: 0% 15+ new cases/month: 0%

Gender of LET patients treated Males: 32% Males: 58%

Females: 18% Females: 10%

Equal numbers of males and females: 50% Equal numbers of males and females: 32%

Payment source Workers’ compensation: 64% Workers’ compensation: 20%

Private: 27% Private: 76%

Other (e.g. public hospital): 9% Other (e.g. public hospital): 4%

Practice context Private clinic: 84% Private clinic: 100%

Hospital: 15%

Patient’s workplace: 1 %

	Hand therapists (n = 104)	Medical practitioners (n = 38)
Profession	Occupational therapists: 70%	General practitioners: 90%
	Physiotherapists: 30%	Sports physician: 10%
Experience	<4 years: 25%	<10 LET patients: 5%
	4–9 years: 30%	10 > 49 LET patients: 45%
	10+ years: 45%	50+ LET patients: 50%
LET caseload	<5 new cases/month: 65%	<5 new cases/month: 79%
	5–9 new cases/month: 32%	5–9 new cases/month: 16%
	10–15 new cases/month: 3%	10–15 new cases/month: 5%
	15+ new cases/month: 0%	15+ new cases/month: 0%
Gender of LET patients treated	Males: 32%	Males: 58%
	Females: 18%	Females: 10%
	Equal numbers of males and females: 50%	Equal numbers of males and females: 32%
Payment source	Workers’ compensation: 64%	Workers’ compensation: 20%
	Private: 27%	Private: 76%
	Other (e.g. public hospital): 9%	Other (e.g. public hospital): 4%
Practice context	Private clinic: 84%	Private clinic: 100%
	Hospital: 15%
	Patient’s workplace: 1 %

3.2 Treatments for LET

The 19 different LET treatments reported by respondents are shown in Table 2. There were significant differences between the two disciplines in their mean ratings of the effectiveness of common treatments in the acute and chronic stages of LET.

Table 2
Mean levels of perceived effectiveness of common treatments used in the acute and chronic phases of LET reported by hand therapists (HT) and medical practitioners (MP)

Treatments for LET Acute mean HT Acute mean MP p Chronic mean HT Chronic mean MP P

Wrist orthoses 6.9 4.3 <0.001* 5.0 4.4 0.375

Counterforce braces 5.6 4.5 0.045* 5.5 4.6 0.115

Corticosteroid injections 4.2 5.3 0.049* 3.6 4.3 0.210

Autologous blood injections 3.0 4.1 0.030* 4.2 4.2 0.997

Platelet rich plasma injections 3.2 4.0 0.116 4.3 4.0 0.668

Stretching 5.9 5.8 .922 6.1 5.6 0.313

Concentric exercises 3.8 5.1 0.031* 5.1 5.0 0.781

Eccentric exercises 6.4 5.5 .112 7.3 5.6 0.003*

Soft tissue therapy 7.0 4.3 <0.001* 6.7 4.2 <0.001*

Trigger point therapy 6.7 3.7 <0.001* 6.3 3.8 <0.001*

Heat pack 5.3 4.6 .211 6.1 3.7 <0.001*

Cold pack 4.5 3.9 .246 2.8 2.7 0.941

Taping 5.8 4.3 0.004* 5.7 3.6 0.000*

Education - LE pathology 8.7 6.8 <0.001* 8.7 6.1 0.000*

Education - positions to avoid 8.9 6.7 <0.001* 8.6 6.8 0.000*

Education - work recommendations 8.8 7.2 <0.001* 8.7 6.8 0.001*

Education - activity modification 9 7.5 <0.001* 8.7 6.7 <0.001*

Pain medication 4.1 4.9 .161 3.6 4.2 .208

InterX™ neurostimulation 3.9 1.7 <0.001* 3.7 2.0 0.002*

Treatments for LET	Acute mean HT	Acute mean MP	p	Chronic mean HT	Chronic mean MP	P
Wrist orthoses	6.9	4.3	<0.001*	5.0	4.4	0.375
Counterforce braces	5.6	4.5	0.045*	5.5	4.6	0.115
Corticosteroid injections	4.2	5.3	0.049*	3.6	4.3	0.210
Autologous blood injections	3.0	4.1	0.030*	4.2	4.2	0.997
Platelet rich plasma injections	3.2	4.0	0.116	4.3	4.0	0.668
Stretching	5.9	5.8	.922	6.1	5.6	0.313
Concentric exercises	3.8	5.1	0.031*	5.1	5.0	0.781
Eccentric exercises	6.4	5.5	.112	7.3	5.6	0.003*
Soft tissue therapy	7.0	4.3	<0.001*	6.7	4.2	<0.001*
Trigger point therapy	6.7	3.7	<0.001*	6.3	3.8	<0.001*
Heat pack	5.3	4.6	.211	6.1	3.7	<0.001*
Cold pack	4.5	3.9	.246	2.8	2.7	0.941
Taping	5.8	4.3	0.004*	5.7	3.6	0.000*
Education - LE pathology	8.7	6.8	<0.001*	8.7	6.1	0.000*
Education - positions to avoid	8.9	6.7	<0.001*	8.6	6.8	0.000*
Education - work recommendations	8.8	7.2	<0.001*	8.7	6.8	0.001*
Education - activity modification	9	7.5	<0.001*	8.7	6.7	<0.001*
Pain medication	4.1	4.9	.161	3.6	4.2	.208
InterX™ neurostimulation	3.9	1.7	<0.001*	3.7	2.0	0.002*

Maximum level of perceived effectiveness = 10; *denotes statistical significance p = .05. Not all participants rated every intervention method. Mean values are based on completed responses.

3.3 Acute stage

Respondents from both disciplines believed education on activity modification, work recommendations, positions to avoid, and pathology of LET were among the most effective interventions. Conversely, both disciplines rated the use of InterX™ neurostimulation as one of the least effective treatment methods for management of LET. Hand therapists generally rated therapy techniques including soft tissue therapy, trigger point therapy, taping, and prescription of wrist and counterforce orthoses as more effective than the medical practitioners, with the exception of concentric strengthening exercises. More invasive treatment options, such as corticosteroid injections, platelet rich plasma injections, and autologous blood injections were rated higher by medical practitioners than the hand therapists; although still at the lower end of effectiveness.

3.4 Chronic stage

Hand therapists and medical practitioners believed that education on LET pathology, positions to avoid, activity medication, and work recommendations were the most effective treatment methods in the chronic stages if LET (Table 2). Both disciplines rated the use of InterX™ neurostimulation as one of the least effective LET treatments. Hand therapists believed the following therapies were effective for chronic LET: eccentric exercises, soft tissue therapy, trigger point therapy, taping, and the application of heat packs; more so than the medical practitioners.

3.5 Education

Hand therapists strongly agreed (mean agreement rating of 9.5 out of 10) that they routinely educated patients with LET on pathology, postures to avoid, and provided recommendations for activity modification specific to work and leisure activities.

3.6 Workplace-based intervention

A majority of hand therapists’ respondents (71%) reported that they felt it would be valuable for a hand therapist to complete a workplace-based intervention in the acute and chronic stages of LET; however, 74% of hand therapists surveyed reported that they had never conducted a workplace-based intervention. Hand therapists believed there were benefits to providing injured workers with LET specialized, personalized, and contextualized education and recommendations that were specific to their occupations and focused on preventing postures that may aggravate their symptoms. Hand therapists also believed that there is potential for better communication between the key stakeholders in the RTW process (worker/patient, employer, vocational rehabilitation professionals, and insurers) regarding modifications to job tasks/roles and agreement on the return to work plan. Hand therapists have specialized knowledge of LET pathology, and because they already treat the injured worker in the clinic, any recommendations they provide at the workplace can be specific to the injured worker’s physical work environment job demands to provide a more holistic approach to their hand therapy interventions.

Hand therapists in this study identified the potential barriers to having a hand therapist conduct worksite visits, including the extra time and costs associated with travel to the worksite; less time available to see other patients in the clinic; and the time required for documenting the findings and recommendations of the worksite visit. Some hand therapists reported they had limited confidence and experience in providing worksite recommendations, and some believed that providing worksite recommendations should be the sole responsibility of vocational rehabilitation providers.

Sixty-one per cent of medical practitioners reported that they had previously referred their LET patients to a vocational rehabilitation provider. Main reasons for referral were to identify suitable work duties; the injured worker’s rehabilitation required application of specialist knowledge; or the injured worker was not progressing as well as anticipated. Eighty-one percent of medical practitioners believed that having a hand therapist conduct a workplace-based intervention would be valuable in the acute and chronic stages of LET. The majority (71%) of medical practitioners reported that they had never previously requested a hand therapist to conduct a workplace-based intervention.

4 Discussion

4.1 Study participants

The medical practitioners and hand therapists in this study had varying levels of experience treating patients with LET; therefore, the responses reflect a range of expertise.

A majority of respondents in both disciplines had worked in a private clinic and treated more compensable work-related cases of LET than non-work related LET cases. The respondents reported that they treated almost equal numbers of males and females with an LET diagnosis; findings that are similar to a Finnish population-based study regarding prevalence of LET between genders [1].

The physical practice in which hand therapists and medical practitioners typically work supports a medical model of care that assumes clinical outcomes of pain reduction, and improved grip strength and range of motion will result in improved overall functional performance in important activities of daily living with limited consideration of the impact of environmental factors.

The hand therapists in the study were either occupational therapists or physiotherapists. An opportunity exists for these allied health professionals to extend beyond their usual clinic-based practice and adopt a more holistic approach to manage work related LET. This concept is supported by a previous study that investigated empowerment of occupational therapists to become evidence-based work rehabilitation practitioners [24]. The authors of that study believed that occupational therapists have become key professionals in the management of work durability because of their interaction between workers’ capacities and the environmental demands influencing work disability [24]. Having a hand therapist playing an active role at the injured worker’s workplace supports a more holistic treatment approach that is consistent with the ICF framework [17].

4.2 Clinical treatments

Commonly used treatments identified in this study are those described in the literature including corticosteroid injections [25], blood injections [26, 27], InterX™ neurostimulation [28], orthoses [29, 30], and exercise programs [31, 32]. Reviews of the effectiveness of common clinical treatments of LET have yielded inconclusive evidence to support their long term efficacy with some authors stating that LET can resolve over a 12–18 month period without treatment using a ‘wait and see’ approach [13, 33].

In this study, medical practitioners generally rated more invasive treatments, such as corticosteroid injections (CSI),as more effective than did the hand therapists to manage acute stage LET. The prescription of CSI to treat LET is still very common in medical practice, despite strong research evidence that the use of CSI provides effectiveness only in the short term, has poorer outcomes compared to a wait and see approach, and results in high recurrence rates [22 , 34]. Despite these findings, a recent survey of 291 orthopaedic surgeons from around the world identified the most popular modalities of LET treatment were non-steroidal anti-inflammatory medications (43%) and corticosteroid injections (30%) [15]. Medical practitioners may continue to prescribe CSI to treat acute and chronic LET because they may believe the condition is inflammatory in nature, and may not have current knowledge of histopathological studies that have consistently demonstrated that the affected tendon was characterized by a dense population of fibroblasts, disorganized and immature collagen, and an absence of inflammatory cells; all of which are consistent with a degenerative process [23].

Hand therapists in our survey rated the prescription of eccentric exercises and application of heat to treat chronic LET significantly higher than the medical practitioners. These findings are consistent with the extensive research evidence that supports the use of exercise in the chronic stages of LET; and specifically, that eccentric exercise is the most effective in improving symptoms when compared to concentric exercises and stretching. A systematic review of 12 studies concluded that the inclusion of eccentric exercise as part of a multimodal therapy program improved outcomes for LET patients [35]. Furthermore, our survey findings are similar to the survey of American hand therapists who rated a home exercise program as the most effective treatment for chronic LET and the second most effective for acute LET [14].

A recent review identified four main grades of LET pathology, with grade 1 being the mildest form of tendinopathy and grade four being the worst requiring surgical repair. All the treatments suggested by the authors for all stages of pathology were clinic-focused such as physical therapy, blood injections and surgery [36]. Given that occupational risk factors have been identified as contributing to LET pathology [37], we believe that treatments to manage LET across all stages of pathology should address the activity and environmental factors of the ICF.

4.3 Education

Our survey results indicated that medical practitioners and hand therapists rated educational approaches as the most effective treatment method for injured workers with acute and chronic stage LET.

Hand therapists routinely educated injured workers about LET pathology and postures to avoid and provided recommendations for activity modification specific to their work and leisure activities. Findings reported from a large survey of American hand therapists were that most treatments for LET included education as an element of standard therapy, but the content and context of education provided was not clear [14].

The respondents in our study indicated that education revolved around the principles of activity modification, postures to avoid, work recommendations, and education about LET pathology. The importance of educating patients about LET was also discussed in the findings of another study involving 120 physiotherapists in Scotland [16]. Almost two-thirds of those therapists reported that their patients with LET had a poor understanding of their health condition, and the authors postulated that these patients may have poorer outcomes if they are not provided with education about their condition [16]. MacDermid and colleagues proposed that future research needs to identify and incorporate the educational “active ingredients” to develop a well-defined educational intervention [14]. Hand therapists frequently practice using a prescriptive approach; however, it is important to empower injured workers with LET through education to enable them to take an active role to self-manage their symptoms. The findings of our study of Australian hand therapists and medical practitioners suggest that interventions for injured workers with LET should include educational components for self-management that also consider the physical, cognitive and social environmental factors of the ICF.

4.4 Workplace-based intervention by hand therapists

The majority of hand therapists (71%) and medical practitioners (81%) in our study agreed that having a hand therapist complete a workplace-based education intervention would be valuable in the acute and chronic stages of LET. The workplace-based education may include LET pathology, postures to avoid, and recommendations for activity modification specific to work and leisure activities; educational content that were reported by hand therapists and medical practitioners in our study as the most effective treatments for injured workers with LET. Education to reduce occupational risk factors including forceful activities, high force combined with high repetition, awkward postures, and hand-arm vibration are associated with symptoms of LET [37], and workload modification should be considered, especially for workers in manual and strenuous occupations [1].

Traditionally, vocational rehabilitation providers in Australia perform worksite assessments and develop return to work programs; whereas hand therapists provide clinic-based treatment and are seldom involved at the workplace. However, given the hand therapists in our study most often treat work-related LET cases, there exists potential for them to adopt a holistic treatment approach consistent with the ICF, and use their specialized knowledge of the hand and upper limb to support injured workers at the workplace. Combining the skill sets of medical practitioners, vocational rehabilitation providers, and hand therapists uses a biopsychosocial approach in the management and return to work of injured workers with LET.

4.5 Benefits of workplace-based rehabilitation

Inclusion of our survey question about hand therapists providing specialized workplace-based education for injured workers with LET was based on existing empirical evidence to support workplace-based interventions for other health conditions. For example, comprehensive reviews of the benefits of workplace-based interventions for back pain identified 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 clinical settings [38, 39]. A recent systematic review about the effectiveness of workplace interventions in return-to-work programs for musculoskeletal and pain-related conditions, and mental illness found moderate to strong evidence that lost time from work was reduced when interventions comprised a multi-domain approach and included health-focused interventions such as graded activities, service coordination, and work modification components [19]. Although that study was not specific to injured workers with LET, the findings support workplace-based return to work interventions.

Good communication between stakeholders is important for early return to work outcomes following a work-related injury [18]. Hand therapists in the current study reported that having hand therapists deliver workplace-based education interventions facilitated open communication among key stakeholders in the workers’ compensation process.

The novel concept of hand therapists delivering a workplace-based educational intervention for injured workers with LET has potential benefits, but also challenges. Hand therapists in our study were concerned about the extra time and costs involved with implementation of a workplace-based approach. These challenges are similar to those reported by others, including limited time, space, and issues with reimbursement for services in occupation-focused interventions [40]. However, if the use of hand therapists to deliver workplace-specific education is found to be cost-effective, there is potential for reimbursement of associated time and costs within the Australian workers’ compensation legislation [7]. Further research using randomized controlled trials is warranted to determine the efficacy and cost-effectiveness of hand therapist-delivered education interventions in the workplace to manage LET.

4.6 Study limitations

The limitations of this study include small sample size and low and undefined response rates across the two samples. Not all treatments included in the survey were selected by respondents; therefore, the survey items may not include all the different types of treatments used to manage LET. The medical practitioners surveyed were recruited from Western Australia only and so their responses may not be representative of medical practitioners from all Australian States and Territories. These methodological issues should be considered when interpreting the findings of this study.

5 Conclusion

Our study found that (i) the majority of hand therapists and medical practitioners believed education to be the most effective treatment for injured workers with acute and chronic LET; and (ii) hand therapists and medical practitioners believed that having a hand therapist conduct a workplace-based education intervention would be beneficial in the acute and chronic stages of LET. Based on these findings, we propose future research to determine the effectiveness of workplace-based education interventions delivered by hand therapists as part of a holistic approach to the management of work-related LET.

Conflict of interest

None to report.

Footnotes

Acknowledgments

We would like to thank Richard Parsons for assistance with data analysis; the hand therapists involved in piloting the survey, Courtenay Harris, and Mathilda Bjork for providing feedback in the development of the surveys. Thanks to the Australian Hand Therapy Association for distributing the survey to their members and the Western Australian Occupational Therapy Association for advertising the study in their newsletter.

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