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Rapid Responses: Rapid Responses published:
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Of carpets and lousy lingerie
- Jed Rowe (15 February 2002)
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FDA approval is needed for each hip protector
- Pekka A Kannus, Jari Parkkari, chief physician (18 February 2002)
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Another way to reduce to incidence of hip fracture
- Ben L Schutte (20 February 2002)
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Acceptability of hip protectors
- Jeni M McAughey, Margaret McAdoo (21 February 2002)
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Implementation
- Christopher W Frith (21 February 2002)
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Policy for protection?
- Clive E Bowman, Ian Ireland (21 February 2002)
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Compliance with hip protectors is a problem for Chinese geriatric patients in Hong Kong
- L. Wing Chu (23 February 2002)
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Hip Protectors - an Orthopaedic perspective
- Raman Thakur, Raj Shrivastava (2 March 2002)
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HIP PROTECTOR USE IN RESIDENTIAL HOME RESIDENTS
- Paul W Thompson, Carol Jones, Tracy Villar (11 March 2002)
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Question of availability
- Jacob Rozbruch MD (11 January 2003)
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Jed Rowe, Consultant geriatrician Well Balanced Clinic, Moseley Hall Hospital, Birmingham, B13 8JL
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It takes about forty years of wearing hip protectors to prevent 1 fracture so other strategies may be helpful. Hip protectors look like institutional underwear - white, plain and unfashionable. Making them more attractive might improve their acceptability. The alternative approach is to pad the floor. Carpet improves gait in older people [1] and in a small observational study dramatically reduced serious injury from falls [2]. Perhaps it's time for the Axminster trial of hip protection. 1. Wilmott M. The effect of a vinyl floor surface and a carpeted floor surface upon walking in elderly hospital in-patients. Age Ageing 1987;16:119-120. 2. Healey F. Does flooring type affect risk of injury in older in- patients. Nursing Times 1994;90:40-1. |
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Pekka A Kannus, Chief physician Accident and Trauma Research Centre, 33500 Tampere, Finland, Jari Parkkari, chief physician
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Dear Sir, Cameron's editorial was timely but needs to be commented upon. He acknowledges that many types of hip protectors are now marketed around the world, but does not systematically go through the scientific evidence which backs up each type of device. Knowing the peer-reviewed hip protector literature, one may suspect that very few of them has been studied systematically, beginning with the biomechanical antifracture efficacy in vitro and in actual falls, continuing with compliance with users, and ending with a user-control comparison in a randomized study. We see that assessment and verification of the fracture-preventing effect of any hip protection system should not deviate from the strict requirements the FDA and related institutions have put on each fracture- preventing drug. Now the situation in our nursing homes seems more like a wild west, although all know that any FDA-type approval should be based on a protector-specific application, which should show the biomechanical and clinical studies on which the effectiveness of this particular protector is based on. The FDA-type approval system of hip protectors would be in line with requirements of evidence based medicine, and important for the elderly users and those paying the protectors. Currently one should be worried about a situation where an older person is wearing a hip protector, falls and gets a hip fracture. Such a situation does occur (no 100% quarantee is available!)and is a catasthrophe for the person and may lead to legal actions against the manufacturer, dealer, or caregiver. In such a situation, these people should be well armed with scientific evidence that the the protector used has been proven to effectively reduce the force delivered to the femoral neck in a sideways fall, and, in a large-enough randomized trial, reduce the risk of fracture among the elderly protector users. Drs. Kannus and Parkkari belong to the inventor group of the KPH Hip Protector (Respecta, Helsinki, Finland). |
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Ben L Schutte, chiropractor Canberra, Austalia 2611
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Dr Cameron's form of prevention will probably reduce the incidence of fractures of the hip in the elderly who comply with the wearing of the device. Another way to reduce the incidence of hip fracture is to reduce the incidence of falls. One way of doing this is to improve the afferent proprioception which is sent to the vestibular nuclei. The upper cervical joints have have a great influence on balance through their proprioceptive discharge to the vestibular nuclei. Any disfunction of these joints can lead to poor balance. Restoration of upper cervical function with spinal manipulative therapy (chiropractic adjustments)can lead to better balance and therefore to lower incidence of falls. This inturn results in fewer hip fractures. |
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Jeni M McAughey, General Practitioner Skegoneill HC, 195 Skegoneill Av Belfast BT15 3LL, Margaret McAdoo
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Cameron rightly identifies adherence with the use of hip protectors as being one of the main drawbacks to their more general usage 1. Initial compliance rates of between 50 and 60% have been reported but as Cameron also points out there has been little research into the acceptability of hip protectors for patients living in the community 2,3.We have recently carried out a small study to assess acceptability in such a group. Forty- nine patients with osteoporosis living in inner city Belfast were provided with Safehip hip protectors. After six months the project nurse completed a questionnaire to assess usage rate and the factors influencing this. Initial acceptance rate was 59% reducing to 35% at six months. The patients rated the hip protectors poorly on bulkiness, heat and the tightness of the waistband; these were also the factors which most strongly influenced their decisions on wearing the hip protectors. They also disliked the plastic cover and the noise made on movement with the hip protectors in place. Overall appearance, appearance under tight clothes and looking after the hip protector were rated more favourably. Many patients felt it was difficult to get the hip protectors on and off, 48% rated it difficult or very difficult and 40% felt it was difficult or very difficult to get on and off to get to the toilet. It took longer to put on and take the protectors, especially initially. Similar factors have been noted in other studies 2,3,4. Very few of the patients were prepared to wear the hip protectors at night. Those who wore the hip protectors were almost three times more likely to believe the hip protectors offered protection from hip fractures (86%v30%). Two-thirds of patients wearing the hip protectors felt more confident about going out. Most patients, 93%, stated they would be likely or very likely to recommend hip protectors to a friend. Some problems were identified in patients who forgot the hip protectors in a nursing home environment, so it likely to be more of a problem with patients living at home who may also have a number of medications to remember. Compliance may be improved in this group if primary care workers in contact with the patients remind them on a daily basis about the use of hip protectors. References 1. Cameron ID Hip Protectors BMJ 2002; 324:375-6 2. Hindso K, Prevention of hip fractures using external hip protectors. Risk factors for falls, hip fractures, and mortality; and evaluation of the consequences of fear of falling among older orthopaedic patients. PhD thesis 1998; University of Copenhagan 3. Villar TMA, Hill P, Inskip H, Thompson P and Cooper C. Will elderly rest home residents wear hip protectors? Age Ageing 1998; 27:195-8 4. Cameron I, Quine S. External hip protectors: likely non-compliance among high risk elderly people living in the community. Archives of Gerontology and Geriatrics 1994 19 273-81 |
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Christopher W Frith, General Practitioner Greyfriars Surgery,Hereford. HR4 0BH
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Thank you for a practical and informative editorial, most relevant to the National Service Framework for the Elderly. Unfortunately hip protectors are not available on prescription, so the only way this could be implemented would be aa cumbersome process via Primary Care Trusts surgical stores and/or policing by the Residential/Nursing Home inspectorates. |
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Clive E Bowman, Medical Director BUPA Care Services, Bridge House, Outwood Lane, Horsforth, Leeds LS18 4UP, Ian Ireland
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Hip Protectors – BMJ 2002 Volume 324 375-376 Sir, From the perspective of fall management in care home we make an observation and raise the contentious issue of funding with reference to the UK. Critical success factors for hip protector use are accurate fitment and compliance; both can be difficult in Care Homes in the context of an increasing prevalence of dementia. Furthermore, the wearing hip protectors may be confounding and an impediment to the promotion of continence. A more environmental approach in Care Homes could be as effective and less intrusive. The mechanical assault on a hip from a fall could be reduced by the properties of flooring. Floor coverings in institutional setting are inevitably a compromise somewhere between homeliness, clinical appropriateness (largely maintenance of cleanliness) and cost. Floor coverings are available and could be further developed with cushioning, as has been the case for reducing head injury in children’s playgrounds. Environmental design and technology has much unexploited potential for unobtrusive risk management. Individual’s will certainly need 3 sets of protectors an estimated initial outlay of £120 per individual and wear and tear are likely to mean several replacements over time that together with the added care to ensure appropriate placement and compliance significantly add to the cost. Whilst this may be justified the question who pays remains unclear. Presently, we are, on occasion obliged to provide hip protectors from social care monies and observe only sporadic investment by health services. In the UK the justification for and funding of hip protectors cuts across health technology assessment and the work of the National Institute of Clinical Excellence. Perhaps the “coming of age” of hip or environmental protection will be signalled by a suggestion that funding be withdrawn from Orthopaedic trauma and rehabilitation programmes to facilitate this preventative care. Hip protectors illustrate that an integrated approach to the health and care of older people is necessary rather than a sterile debate of health vs. care are fundamental to yield outcome improvement. Clive Bowman Medical Director bowmanc@bupa.com Ian Ireland Head of Quality Irelandi@bupa.com BUPA Care Services Bridge House Horsforth Leeds LS18 4UP |
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L. Wing Chu, Consultant Division of Geriatric Medicine, University Department of Medicine, Queen Mary Hospital,Hong Kong
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We read with interest the Editorial written by Dr. Ian D. Cameron in the 16 Feb issue of BMJ on the subject of "hip protectors (HP)". The efficacy of hip protectors in successfully reducing hip fractures is positive only if the hip protectors are worn and properly worn. We totally agree with Dr Cameron's comment that " adherence with the use of hip protectors is an important area that requires further investigation and discussion".(1) The compliance with the use of the hip protectors is only 24% in the first clinically proven effective hip protectors.(2) We did a pilot study to evaluate the acceptability, compliance and efficacy of external hip protectors (SAFEHIP) among geriatric in-patients in the Queen Mary Hospital of Hong Kong. The primary objective of the present pilot study was to evaluate the acceptability and compliance. High fall-risk geriatric patients with abnormality in one or both of the two screening tests (i.e. tandem walk test or lower limb weakness) were recruited. From 28 February to 9 November 1999, 96 subjects were recruited. They were randomised into the hip protectors (n=47) and control (n=49) groups. All recruited subjects were monitored daily to assess the acceptability and efficacy of HP. There was no difference in the baseline characteristics between the two groups. In the questionnaire survey, 40% of HP subjects said they would accept the hip protectors because of its protection value. 51% felt that it was comfortable or tolerable to wear. In the direct clinical assessment and evaluation, 8% of subjects encountered skin problems (i.e. itchiness, redness or hotness). In terms of actual compliance, 12.8% of HP subjects wore it throughout the study period. Only 21.3% of them wore it most of the time. Because of the absence of falls in all subjects, the efficacy of HP in protecting against fall-related hip fracture could not be evaluated in this pilot study. Because of the low compliance, we did not continue the full-scale study and focus on reducing the intrinsic and extrinsic risk factors for falls in our geriatric patients' falls prevention programme. In conclusion, the acceptability of external hip protectors was only fair among Chinese elderly in-patients. At present, the use of HP might not be a practical approach in the prevention of fall- related hip fracture among Chinese geriatric in-patients in Hong Kong. Future research should focus on improving the comfort, acceptability and compliance of hip protectors without compromising their clinical efficacy. Dr. Leung Wing Chu, FRCP (Edin.), FRCP (Glas.)
References: - 1. Ian D Cameron. BMJ 16 Feb. 2002;324:375-76 2. Lauritzen JB, Petersen MM, Lund B. Effect of external hip protectors on hip fractures. Lancet 1993;341:11-3. |
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Raman Thakur, staff grade William Harvey Hospital, Ashford, Kent, TN24 0LZ, Raj Shrivastava
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We will like to make these comments about the editorial on hip protectors by Cameron1. Although some hip fractures occur due to a fall on the side of the hip, the more common mechanism is an external rotation force on the neck of the femur2,3. Osteoporosis is a significant predisposing factor4. In fact, while walking a patient might develop a fracture of the femoral neck first resulting in a subsequent fall. Whereas hip protectors could be effective in preventing fractures resulting from a direct fall on the greater trochanter, obviously these are ineffective in preventing hip fractures due to external rotation forces. Hip fracture prevention needs a multifactorial approach involving improving the physical and mental health of the patient, making the environment safe to decrease the risk of falls and treating other risk factors like osteoporosis. Use of hip protectors should not be considered as an easy solution for this difficult problem. Until further evidence becomes available, hip protectors should not be encouraged for routine use considering additional cost implications. However, their use in clinical trials should be encouraged. Reference: 1. Cameron I. Hip Protectors BMJ 2002; 324: 375-6 (16th February) 2. Ordway C, Levin PE and Dee R. Traumatic Injury to the Lower Limb in Adults. In Dee R, Mango E, Hurst LC. Eds. Principles of Orthopedic Practice. Vol.2. McGraw-Hill, Inc. 1989 3. Smith LD. Hip Fractures. The Role of Muscle Contraction or Intrinsic Forces in the causation of Fractures of the Femoral Neck JBJS 35A, No.2: 367-83.1953 4. Stevens J, Freeman PA, Nordin BEC, Barnett E: The Incidence of Osteoporosis in Patients with Femoral Neck Fractures. JBJS 44B: 520-7, 1962. Raman Thakur, Staff grade
Raj Shrivastava, Consultant
We would like to declare that we have no competing interest. |
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Paul W Thompson, Consultant Rheumatologist Poole Hospital, Poole, Dorset BH15 2JB, UK, Carol Jones, Tracy Villar
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We have previously demonstrated that adherence with hip protectors is achievable at a level that is likely to result in reduction of hip fractures but were unable to assess usage in subjects with cognitive dysfunction, confusion or incontinence because of ethical issues in a controlled trial [1]. The establishment of a hip protector service in Dorset has allowed us to study these factors in an observational study. Residential homes in Poole were approached offering their residents hip protectors. Assessments were made of falls risk (modified STRATIFY score), cognitive function, confusion and urinary continence. Residents were offered hip protectors free of charge. Assessment of adherence was made after 1 week and 3, 6 and 12 months. 47 residential homes with 783 beds are taking part. 813 residents have been identified, mean(SD) age 88(7) years, F:M 4.6:1. Of the 802 residents who were offered protectors, 583 expressed an interest and 554 were wearing them at 1 week. Of the 321 residents so far assessed at 3 months 199 were wearing protectors every day. 69% of incontinent subjects (n=161) compared to 55% of continent, 68% of demented subjects (n=149) compared to 57% of non-demented and 75% of always confused (n=79), 55% of sometimes confused (n=143) and 61% of never confused were wearing protectors every day. There was correlation between the risk of falling and adherence (STRATIFY score 0=43%, 1= 58%, 2=66%, 3=59%, 4=72% and 5=77%). Extrapolating the results to all residents suggests 42% adherence at 3 months, a level likely to results in reduced hip fracture incidence and greater than in our previous study. The higher adherence among cognitively impaired, confused, and those at high risk of falling supports our concept that hip protectors are worn by those at greatest risk of fracture [2]. This work is administered by Osteoporosis Dorset (Registered Charity No. 1023507) and funded by Dorset Health Authority and Poole Social Services). References 1. Villars MTA, Hill P, Inskip H, Thompson PW, Cooper C. Will elderly rest home residents wear hip protectors? Age Ageing. 1998;27:195-8. 2. Thompson PW, Jones C, Dawson JA, Davies F. Adherence with hip protectors in elderly persons requiring domiciliary care is greater in fallers than non fallers. Age Ageing, 2000;29:459. |
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Jacob Rozbruch MD, Orthopaedic Surgeon New York, NY 10021
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I am a practicing Orthopaedic Surgeon. This seems like a very good idea. Why have I not been "bombarded" by sales people trying to sell them? J. Rozbruch MD Competing interests: None declared |
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