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ORIGINAL ARTICLE
a patient becomes symptomatic of epicondylitis, certain routine year 2002 and ending by July 31, 2003, were eligible for the
activities cause an increase in symptoms, misleading the pa- study. Fifty-one patients were excluded because of concurrent
tient (and doctor) to think that the activity “caused” the disor- treatment for complicating injuries not involving the elbow. A
der and should be avoided even when use of the arm, despite total of 4614 patients remained for inclusion in subsequent
pain, may in actuality lead to a more rapid recovery. analyses.
The primary goal of treatment of epicondylitis should be the
patient’s rapid and enduring return to full functioning. For Splinting
splinting to be recommended in the context of evidence-based Splinting was identified from the electronic records for pa-
medicine, it would be prudent to show that patients with splints tient visits. A variety of restraints was provided to these pa-
show faster and more sustained improvements in pain and/or tients, at their treating provider’s discretion, to reduce move-
function than patients without splints. Specific to occupational ment and apply supportive tension to the elbow/wrist and
medicine and workers’ compensation, patients with splints associated extensor muscles. Because the comparison of inter-
would need to have less time off work, less duty restrictions, est in this study was splints versus no splints (rather than
shorter treatment durations, and lower medical costs than pa- comparisons of splints applied to the elbow versus both the
tients without splints. To date, we know of no studies that elbow and wrist), patients were counted as receiving a splint if
address each of these work-related outcomes relative to splint- they received any restraint to the elbow, forearm, or wrist
ing. areas—including braces, splints, straps, and wrap bandages.
The purpose of this article was to evaluate the effects of
splinting on outcomes for injured workers with epicondylitis. Evaluation of Splinting Differences
Specifically, retrospective analyses of patients were undertaken To control for pretreatment differences between patients
to identify pretreatment differences in splinted and nonsplinted who did and did not receive splints, the first step was to identify
patients on background and initial injury characteristics, to and quantify observed differences. Table 1 presents summary
statistically control for these differences, and to estimate the information on available background characteristics and initial
effects of splinting on functional and treatment outcomes most condition for patients who did and did not receive splints.
relevant to occupational medicine. Independent t tests and chi-square tests were conducted to
assess group differences. No significant differences were ob-
METHODS served for patient age (measured in years), the type of initial
treating provider (primary care physician [MD or DO] vs
Participants physician assistant), patient marital status (single, married),
The patient population in this study consisted of patients and the existence of any prior injury claim within the network
receiving primary care for lateral or medial epicondylitis (In- (yes, no). Significant differences were observed for severity
ternational Classification of Diseases, 9th Revision, codes ratings by the initial treating provider (patients with moderate
726.31 or 726.32) at any clinic within a nationwide network of to severe ratings were more likely to receive splints than
253 occupational medical centers. This network, owned and patients with mild ratings), gender (higher rates of splinting for
operated by Concentra Inc, sees approximately 7% of US females versus males), diagnosis (higher rates of splinting for
workers’ compensation patients. Patient records were retrieved patients with lateral versus medial epicondylitis), for treatment
from the proprietary internal information management system, lag (higher rates of splinting for patients treated within 1wk of
which contains patient demographic and injury information, as injury vs those treated ⬎1wk), for drug screen (higher rate of
well as transaction-level treatment, diagnostic, billing, and splinting for patients who received a drug screen, an optional
outcomes information. All patients who were of legal working service provided during the initial visit at the discretion of the
age (at least 16 years old) and who received primary injury care employer or governing laws of the area), and for geographic
at the centers with treatment episodes beginning in calendar region (patients in the west and southeast regions received
splints more than patients in the south, midwest, and east score subclasses, there were no remaining statistically signifi-
regions). cant differences between splinted and nonsplinted patients on
any of the covariates. Figure 1 displays side-by-side boxplots
Statistical Control of Pretreatment Differences of the propensity scores for splinted and nonsplinted patients
In a retrospective study of usual care patterns, it is not within each of the 5 subclasses. The degree of symmetry in the
reasonable to presume that splinting decisions were made at medians, the similarity in the size of the boxes, and the length
random, that patients had an equal chance of having a splint of the whiskers further support the adequacy of the final pro-
versus not having a splint, or that pretreatment differences pensity score model for reducing pretreatment differences on
among patients were uncorrelated with outcome prognoses. In observed covariates.
our example, patients with more severely rated injuries were Finally, to estimate outcome differences between splinted
more likely to receive splints, but we might also expect patients and nonsplinted patients while controlling for background co-
with more severe injuries to miss work, to require more duty variates, the within-subclass means and standard errors (SEs)
restrictions, to incur more medical charges, and to have longer for the 2 groups were calculated and then used to compute
treatment durations than less severe cases even before splinting overall differences and standard errors.28,33 The outcomes of
decisions. Thus, an immediate comparison of these outcomes interest were the percentage of cases put on limited duty or
for patients with and without splints would be misleading. taken off work by the treating provider (as distinct from the
Propensity score methodology is a statistical approach used percentage of patients who elect to take off work or are taken
in observational studies to control simultaneously for multiple off work by their employers), treatment duration (from the first
pretreatment covariates to create equivalent groups of patients date of service to the last date of service), the percentage of
who did and did not receive a particular treatment.27-31 The patients who completed their care in the network (eg, released
propensity score represents the conditional probability of re- from care to full duty by the network vs opting out), and the
ceiving a particular treatment—in our study, a splint— given percentage of paients referred to specialists. Limited duty rates,
observed covariates. Simply put, the propensity score reduces lost time rates, and treatment durations are standard measures
the differences between patients on several variables to a of the effectiveness of medical management in workers’ com-
one-number summary. If 2 patients, one who received a splint pensation cases. Treatments that minimize these measures
and one who did not, have the same propensity to receive a while improving patient function and symptoms are preferred.
splint (predicted from a set of potential confounding variables), Referral to a specialist generally indicates the failure of con-
then they would not systematically differ with respect to the servative treatment efforts to yield adequate improvement. The
predictor variables.29,31 That is, these variables would not help final outcome, completion rate, is potentially indicative of
predict which of these 2 patients received the splint. As in a patient and/or employer satisfaction with care, in addition to
randomized experiment, the treatment assignment would be success of care. If large disparities in completion rates exist
independent of these predictor variables. Thus, observed dif- between treatment groups, the treatment with the higher com-
ferences in outcomes for these patients could not be attributed pletion rate would be preferred (assuming the treatment is
to the pretreatment differences on the predictors because they effective).
were balanced at the start. Similarly, if patients are divided into In addition to the main hypothesis, splinting versus not
equally sized subclasses based on the magnitude of their pro- splinting, the effect of PT was also assessed. The medical
pensity scores, it has been shown that the average treatment model of the network in our study favors aggressive therapeutic
effect within subclasses (the difference between splinting and interventions—including strength training, patient education,
not splinting within a given range of propensity scores) will be manual therapy, and electrotherapeutic modalities—so the
an unbiased estimate of the true treatment effect.27-28,32 splinting effect needed to be measured in the presence or
absence of PT interventions. Propensity scores for splinting
were reestimated separately for patients who did and did not
Estimating Propensity Scores and Treatment Effects receive PT. For patients who received therapy, the lag from
In our study, the propensity to receive a splint was estimated initiation of the episode of care to the initiation of PT was also
by using a logistic regression model with splint (yes, no) as the included as a covariate in the model. Models were estimated
dichotomous dependent variable and the demographic and pre- and evaluated for adequacy of covariate and overall score
treatment covariates described earlier as predictors. Modeling balance by using the methods described earlier for the main
proceeded iteratively. Once a solution was estimated, the re- comparison. Not all the same main effects and interactions
sulting propensity scores (conditional probability of receiving a were included in these models, although balance on all the
splint) were divided into 5 equally sized subclasses based on covariates and the resulting estimated propensity scores were
their rank (ie, patients with the lowest propensity scores in the verified. The within-subclass means and SEs were then calcu-
first subclass, patients with the highest propensity scores in the lated and used to assess the splinting effect for patients with
fifth subclass). Then the success of the model at achieving and without PT.
balance on the covariates was evaluated by looking at within-
and across-subclass differences between splinted and non- RESULTS
splinted patients for each covariate (using analysis of variance
or logistic regression as appropriate). The initial main effects
model that included all the covariates alone (and no interac- Splinting Main Effect
tions) did not result in balance— defined as no significant main Table 3 summarizes differences in outcome measures for
effects for splinting or interaction effects of splinting and patients with and without splints. Means and SEs for each
subclass on all covariates. This model was refined by adding outcome measure are presented for splinted versus nonsplinted
clinically reasonable and/or statistically significant covariate patients within propensity score subclasses and averaged across
interactions. The final model, presented in table 2, includes all subclasses. Significance test results, noted in the last row of the
significant main effects, plus the main effects used in the table, refer to the overall mean difference observed for splint-
included interactions. By using this model, balance was ing versus not splinting (calculated as a 2-tailed z test, signif-
achieved on all covariates, meaning that, within propensity icant at P⬍.05).
NOTE. Hosmer and Lemeshow goodness of fit: 82 test⫽4.39, P⫽.820. Omnibus model 23
2
test⫽140.46, P⬍.001.
Abbreviation: SE, standard error.
Overall significant differences between splint groups were treatment duration. Patients with splints had higher rates of
found for rate of limited duty, number of medical visits, med- limited duty within each subclass and overall (range, 7%–20%)
ical charges, total primary care charges (includes PT), and than nonsplinted patients. Typical duty modifications and re-
strictions prescribed by the treating physician involved lifting
restrictions and limitations on time spent doing forceful or
repetitive tasks. Patients with splints also had an average of 1
more medical visit within and across all subclasses, higher
medical charges (expected given the additional medical visit),
higher total charges (PT plus medical), and treatment durations
that were an average of 12 days longer than patients without
splints. Differences in rates of lost time, the percentage of
patients completing care, and the percentage of patients re-
ferred out to specialists were not statistically significant.
These results do not suggest an advantage for splinting from
an outcomes perspective. With the adjustments included for
pretreatment differences, these results suggest that splinted
patients had worse outcomes in terms of treatment duration,
return to activity, and medical costs without improving rates of
care completion than did patients without splints. However, the
significant differences in total charges (which include therapy
charges) do suggest a need for further investigation of the
hypothesis that therapy interventions contribute to higher costs
and longer treatment durations.
NOTE. Values mean ⫾ SE unless otherwise indicated. N⫽4595. Marital status, which was included in the propensity score estimation, was not
provided by 19 patients. Thus, their propensities were not estimated and included in this set, although they were included in later analyses.
Abbreviations: Avg, average; Ltd, limited; NS, not significant; Refd, referred.
*Subclasses of equal size were created according to the ranked propensity score; within subclasses, patients with and without splints have
similar propensity scores; overall estimates were produced using direct standardization methods with subclass total weights.34,41
were again observed for rates of limited duty, number of the differences in treatment duration observed in the overall
medical visits, and medical charges. As with the overall results, population. But the consistency of results independent of ther-
outcome differences did not favor splinting. Patients without apy suggests that splinting does not promote, and may even
splints were less likely to have limited duty, had fewer medical impede, optimal outcomes.
visits, and had lower medical charges than their splinted coun-
terparts. However, no differences in treatment duration were ob- DISCUSSION
served, in contrast with the overall results presented in table 3. A treating provider’s main reasons for prescribing a splint
Table 5 presents analogous comparisons for splinting and are, presumably, to rest the arm and to alleviate pain or dis-
not splinting in patients who received PT. Again, statistically comfort. However, no good correlation between a patient’s
significant differences in limited duty rates, medical visit subjective pain ratings and his/her ability to work or to perform
counts, and medical charges were observed, and worse out- certain physical activities has been established, nor has a cor-
comes for splinted patients were shown. In addition, splinted relation been found between the decrease in symptoms and the
patients received an average of 1 more therapy visit than rate of return to work.34,35 In addition, prescribing a splint is
nonsplinted patients and had higher overall charges for therapy. likely to necessitate movement restrictions that may further
The total treatment duration difference was not significant, impede recovery and contribute to disability in those cases in
which suggests that additional therapy, either alone or in com- which the job activities, which may lead to discomfort, do not
bination with additional medical visits, may be responsible for actually cause the condition. Such restrictions can have an
Table 4: Estimated Outcome Differences Between Groups, Splint Versus No Splint for Cases Without PT*
% Completed
No. of Avg MD Charges Care Avg Treatment % Refd Out
Subclass Splint Patients % Ltd Duty % Lost Time Avg MD Visits ($) (full duty release) Duration to Specialist
*Subclasses of equal size were created according to the ranked propensity score; within subclasses, patients with and without splints have similar propensity scores; overall estimates
4.89⫾0.26 684.57⫾41.59
5.97⫾0.23 886.53⫾37.18
5.30⫾0.30 707.88⫾41.79
6.46⫾0.25 931.13⫾39.60
5.59⫾0.37 728.77⫾44.20
6.65⫾0.24 946.81⫾36.17
5.44⫾0.34 642.31⫾37.65
6.64⫾0.22 828.20⫾27.27
6.56⫾0.53 735.46⫾56.28
7.65⫾0.27 894.93⫾29.46
5.56⫾0.37 699.85⫾44.76
6.67⫾0.24 897.56⫾34.27
psychologically.36 Splint use sends a powerful message, not
Charges ($)
Avg PT
P⬍.01
only to the patient but also to family and colleagues, that the
patient has an injury and that the injured arm needs to be rested.
Because good physical conditioning is helpful to the healing
process of nontraumatic injuries as well as to job performance
under healthy circumstances, it is all the more important to
Avg PT
P⬍.01
Visits
16.2⫾2.4
21.4⫾2.0
22.2⫾2.9
21.7⫾1.9
22.2⫾3.3
24.7⫾1.9
18.5⫾3.2
27.5⫾2.0
28.0⫾4.4
34.8⫾2.0
21.4⫾3.3
26.0⫾2.0
Specialist
NS
teristics were identified and controlled for by using propensity
score methods. The obtained results suggest that the presumed
benefits of splinting— commonly including alleviation of dis-
Table 5: Estimated Outcome Differences Between Groups, Splint Versus No Splint for Cases With PT*
injuries. Back pain studies have found that patients who remain
active despite back pain do better than those who rest.37,38
Similarly, it has been reported that, in chronic back pain
patients who experience increased pain during the first month
1045.22⫾52.86
1351.29⫾44.40
1171.23⫾57.11
1499.28⫾49.27
1221.17⫾65.18
1545.47⫾54.14
1128.03⫾55.22
1465.46⫾40.42
1279.69⫾86.21
1614.10⫾44.32
1169.16⫾64.49
1495.22⫾46.75
P⬍.01
P⬍.01
3.36⫾0.12
4.19⫾0.11
3.98⫾0.19
4.82⫾0.13
4.14⫾0.18
4.92⫾0.14
4.26⫾0.22
5.28⫾0.14
4.97⫾0.33
6.05⫾0.15
4.14⫾0.22
5.05⫾0.14
65.4⫾3.2
77.5⫾2.0
76.3⫾3.0
87.5⫾1.6
81.5⫾3.0
84.9⫾1.6
80.1⫾3.3
87.4⫾1.5
82.2⫾3.7
87.3⫾1.4
77.1⫾3.2
84.9⫾1.6
P⬍.05
228
435
207
457
162
502
146
516
107
558
850
2468
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Overall
population—91% of patients without splints started PT within www.bls.gov/news.release/osh.nr0.htm. Accessed November 29,
a week of beginning care versus 88% with splints. To the 2004.
extent that early therapy makes a difference in outcomes and 4. Kurppa K, Viikari-Juntura E, Kuosma E, Huuskonen M, Kivi P.
correlates with splinting decisions, the observed differences Incidence of tenosynovitis or peritendinitis and epicondylitis in a
could have been incorrectly labeled as splinting effects. Sec- meat processing factory. Scand J Work Environ Health 1991;17:32-7.
ond, the measure of severity used in the propensity score model 5. Viikari-Juntura E, Kurppa K, Kuosma E, et al. Prevalence of
was dichotomous and, as such, might not achieve fine discrim- epicondylitis and elbow pain in the meat-processing industry.
inations between patients of differing injury severity. But pa- Scand J Work Environ Health 1991;17:38-45.
tients with mild severity were less likely to be referred to a 6. Chiang HC, Ko YC, Chen SS, Yu HS, Wu TN, Chang PY.
physical therapist for supervised exercise sessions or applica- Prevalence of shoulder upper-limb disorders among workers in the
tion of modalities and were more likely to be given instructions fish-processing industry. Scand J Work Environ Health 1993;19:
on a home exercise regimen. The fact that differences between
126-31.
splinted and nonsplinted patients persisted independent of re-
7. Byström S, Hall C, Welander T, Kilbom A. Clinical disorders and
ceipt of therapy services offers some evidence that the differ-
ences have been appropriately labeled and that reduction of pressure pain threshold of the forearm and hand among automo-
selection bias because of severity has occurred. bile assembly line workers. J Hand Surg [Br] 1995;20:782-90.
Another limitation of this study is that differences between 8. Ritz BR. Humeral epicondylitis among gas and waterworks em-
types of splints were not assessed. The main hypothesis of this ployees. Scand J Work Environ Health 1995;21:478-86.
study was that any type of splint involves restriction of move- 9. Kurvers H, Verhaar J. The results of operative treatment of medial
ment and would result in longer treatment durations, higher epicondylitis. J Bone Joint Surg Am 1995;77:1374-9.
costs, and more time away from work than no splint at all. By 10. Moore J, Garg A. Upper extremity disorders in a pork processing
extension, under this hypothesis, splints creating greater re- plant: relationships between job risk factors and morbidity. Am
striction of movement and worn for longer periods of time Ind Hygiene Assoc J 1994;55:703-15.
might result in worse outcomes than splints with less restriction 11. Tichauer E. Biomechanics sustains occupational safety and health.
of movement worn for shorter periods of time. These questions Ind Eng 1976;8:44-5.
were beyond the scope of our analysis but would make for 12. Descatha A, Leclerc A, Chastang F, Roquelaure Y. Medical
informative future follow-up investigations. epicondylitis in occupational settings: prevalence, incidence and
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CONCLUSIONS 13. Dimberg L, Olafsson A, Stefansson E, et al. The correlation
The challenge in occupational medicine, particularly with between work environment and the occurrence of cervicobrachial
respect to workers’ compensation, is for providers to maximize symptoms. J Occup Med 1989;31:447-53.
the health and well-being of their patients while showing their 14. National Institute for Occupational Safety and Health. Bernard
cost-effectiveness to employers and payers in the present en- BP, editor. Musculoskeletal disorders and workplace factors: a
vironment of ever-escalating medical costs. Critical to the critical review of epidemiologic evidence for work-related mus-
success of such efforts is an evaluation of “what works” be- culoskeletal disorders of the neck, the upper-limb, and low back.
cause cheaper procedures are not cost-effective if they inflate 2nd printing. Cincinnati: NIOSH; 1997.
total medical and indemnity costs by prolonging treatment 15. Jackson M. Evaluating and managing tennis elbow. Your Patient
duration and increasing duty restrictions and time off work.
Fitness 1997;11(2):104i-104l.
The findings of our study provide evidence that splinting
16. Chard M, Hazleman B. Tennis elbow: a reappraisal. Br J Rheu-
epicondylitis patients does not necessarily lead to better out-
comes and, in fact, may have adverse effects. Splinted patients matol 1989;28:186-90.
had higher rates of limited duty, more medical visits, higher 17. Jobe F, Ciccotti M. Lateral and medical epicondylitis of the
medical costs, and longer treatment durations than similar elbow. J Am Acad Orthop Surg 1994;2(1):1-8.
patients without splints. Nonetheless, these results should not 18. Hay E, Paterson S, Lewis M, Hosie G, Croft P. Pragmatic ran-
replace high-quality RCTs of splinting; rather, they should domized controlled trial of local corticosteroid injection and
encourage their conduct, to determine under what conditions or naproxen for treatment of lateral epicondylitis of the elbow in
for which patients, if any, splinting produces better outcomes, primary care. BMJ 1999;319:964-8.
including long-term function and productivity. Additional stud- 19. Hudak I, Cole D, Haines T. Understanding prognosis to improve
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paired with splinting versus not splinting in practice, to verify Rehabil 1996;77:586-93.
that the effect observed is correctly attributed to splinting.41 20. Smidt N, van der Windt D, Assendelft W. Corticosteroid injec-
Finally, the effects of splinting decisions on actual versus tions, physiotherapy, or a wait-and-see policy for lateral epicon-
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