Are Hip precautions effective in reducing dislocation rate and

Are Hip precautions effective
in reducing dislocation rate and aiding recovery in patients post THR?

There are many elderly patients seen within the community after being
discharged from hospital from undergoing a total hip replacement (THR) operation,
with approximately 160,000 total hip and knee replacements occurring each year
in the UK (National Joint Registry, 2017).  However, the number of patients discharged
with hip precautions is reducing. It can therefore be complicated for
physiotherapists to prescribe exercises to patients when some are limited to
certain movements and others aren’t. This can also affect advice that
therapists offer to patients and ultimately influence a patient’s recovery. Due to the
limited quality research in this area, further significant evidence around the
cost-benefit analysis of hip precautions can help guide clinicians in their
prescription to improve patient care and aid patients, along with their
physiotherapists, in their recovery back to functional activity (Chartered
society of physiotherapy (CSP), 2016). Duke university (2014) cite David
Sackett (1996), who defines evidence based practice as the “use of current best evidence in making
decisions about the care of the individual patient. It means integrating
individual clinical expertise with the best available external clinical
evidence from systematic research”. Since this definition could be considered
to lack temporal validity and may be less applicable for current practice, the
CSP, 2016, have consolidated past definitions to suggest that evidence based
practice involves “the integration of best research evidence, individual
clinical expertise and patient choice”. Further quality evidence around the
outcomes of patient recovery post THR with or without hip precautions can
benefit physiotherapists in their rehab programmes and advice given to patients
to provide more effective care.

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To
look into this topic a search was carried out within the databases of; AMED,
CINAHL Plus, MEDLINE and SPORTDiscus. The search terms included were; (Total
Hip Replacement OR THR OR arthroplasty OR arthroscopy) AND (Hip OR pelvis) AND
(Precautions OR Provisions OR Safety measures OR preventative OR rules) AND
(Rehab* OR recover* OR function OR healing) AND (Dislocation OR injury). In
order to consider strong levels of research the hierarchy of evidence
illustrates the different types of evidence and ranks them in terms of their
methodologies into those that are considered higher quality evidence to guide
research and then clinical practice (Borgerson, 2009). Systematic reviews made
up the majority of the results from this search. This is where the results of
several studies are collated, summarised and analysed to assess their quality
and support or negate a specific clinical question, therefore, making the
relevant evidence more accessible to clinicians and decision makers
(Gopalakrishnan and Ganeshkumar (2013). Systematic literature reviews are
classed as secondary evidence often drawing from primary research. They are
considered the higher level of research methodology on the hierarchy of
evidence (Borgerson, 2009), due to being based off primary evidence that has
been found through systematic literature searches and evaluated thoroughly, therefore,
has minimised the influence of bias in the findings. However, the idea that
Systematic reviews are the best form of evidence can be disputed. The process
of a thorough systematic review can take years to carry out and so can be
superseded by more current research. Moreover, the studies included in the
review must be appraised individually and this can affect the strength of the
results. At times, some consider a high quality randomised controlled trail
(RCT) to give more convincing findings for clinical practice (University of
Canberra, 2017). However, an RCT is only able to provide a single focus
whereas, Systematic reviews can take a broader approach to topics and cover
different cultures and setting making the findings increasingly appropriate and
generalisable to the target population (Evans, 2003). Systematic Reviews are
also able to identify when a gap in literature. By collecting and analysing research
around a topic we can discover these gaps. This guides many clinicians and
researchers and helps shape future research to improve upon the evidence
available and develop evidence based practice (Schlosser, 2006). Systematic
reviews can consist of qualitative, quantitative or mixed data. A Quantitative
approach consists of testing a hypothesis and seeking a causal explanation for
a certain question. Whereas, qualitative approaches focus on the understanding
of patient’s experiences. Both are vital to provide quality evidence based
approach to patient centred care (Holloway and Galvin, 2017). In researching
around the topic of the relevance of hip precautions post THR there is a
limited but increasing level of evidence to support that no hip precautions do
not increase the risk of dislocation and improves return to functional
activity. The discussion is spreading amongst health care professionals
supporting this. For example, members of the CSP debated this topic in a
conference, with the majority voting to abolish official hip precautions.
Further evidence into the cost- benefit analysis of hip precautions can guide a
clearer view on how best to treat patients in supporting their recovery and
rehab back to their functional level while maintaining safe care with patient
satisfaction (Clews, 2016).

To critically appraise the chosen study by van der Weegan, Kornuijt and Das
(2015) (see Appendix), the Critical Appraisal Skills Programme (CASP) was used
as a tool (CASP, 2017). The first section of the CASP checklist covers how the
validity of the result, starting with the research question itself. The
research question of this systematic review is focused and well explained to
clearly outline the topic being covered. There is a clear intervention
mentioned, ‘lifestyle restrictions and precautions’ as well as a clear primary
outcome measure, ‘dislocation rate’ at the focus of the review as well as
secondary outcome measures such as; ‘patient satisfaction and rate of return to
activities of daily living (ADLs). However, a weakness of the clinical question
is that a true comparison to the intervention is not mentioned within the
review. Based on the results of the review it can be identified that the
intervention of hip precautions and restrictions are being compared to having
none or more liberal precautions. If this was made clearer to the reader in the
title or abstract of the paper, it is much more transparent what the review is
considering. For example, Barnsley, Barnsley and Page (2015) state a clear
focused clinical question within the abstract of their work. The focussed
question is written as: “Does the application of Total Hip arthroscopy versus
unrestricted activities significantly decrease the risk of prosthetic
dislocation”. This question specifically mentions the comparison to guide the
reader in to a clearer outcome of what to expect to find in the review as well
as illustrating the topic in a more experimental methodology, presenting the
topic as more clinical and scientific. This can portray the review to appear as
more credible and valid research. Furthermore, both the review appraised (see Appendix)
and Barnsley, Barnsley and Page mention the population studied to be patients
who have had total hip replacement surgery, however, there is no mention on how
specific the populations studied were, such as; the age or gender of the
participants. This information could provide insight into whether a more
specific type of patient responds differently to having no or limited hip
precautions. For example, do younger participants have better outcomes? More
specific details on the population studied gives further information into the
practical applications of this systematic review.

Furthermore, associated with the validity of the results is the types of
studies that are included within the systematic review and how they are
collated and synthesised. A strength of this review is that the researchers
followed a respected, strategic, Preferred Reporting Items for Systematic
Review and Meta-Analysis (PRISMA) protocol to carry out the Systematic review.
This is to plan the review layout and ensure the quality of the systematic
review is of a high standard and to that all the essential areas are looked at
and reported on as well as reducing any control bias that may occur. This shows
the researchers put in the preparation to carry out an effective and organised
review of the research surrounding the clinical question. Further adding
credibility to the review (Moher et al, 2015). Moreover, the search strategy
was thorough within this review as two appropriate databases were searched
along with hand searching of systematic reviews and reference lists. Authors of
the studies were also contacted if needed. Two independent reviewers carried
out the screening process to select the relevant studies that would be
appropriate for the review. The use of independent reviewers prevents the risk
of investigator bias, further increasing the external validity of the
systematic review. The appropriate search terms were used to find relevant studies;
RCTs and comparative case studies were included where they involved primary THR
procedures, where they recorded how the patients were managed post-surgery as
well as a follow up. This inclusion and exclusion criteria ensure that the
studies being reviewed are relevant to the clinical question and improve upon
the objectivity of the review (Mallett et al, 2012). Another positive of their
extensive search is that studies involving English, Dutch and German languages
were included. This broadens the search to studies not specifically English
speaking. This can improve upon the external validity by making the results
more generalisable to a wider population and therefore more applicable to the
target population of patients undergoing THR as more nationalities and cultures
are involved within the research (Druckman et al, 2011).  

On the other hand, a weakness of the systematic
review by van der Weegan, Kornuijt and Das (2015) (see appendix), is that out
of the six studies included, only three were RCTs and the rest were comparative
cohorts. This is due to the lack of primary research on this topic, due to
this, the level of evidence is weakened. As suggested by Melnyk and
Fineout-Overholt (2005, cited by Cedarville university, 2017) RCTs are
considered the strongest quality of primary research, a review consisting of
RCTs would be considered much higher quality and more credible to clinical
professionals. This use of studies could be justified by the quality of the
individual evidence. Data extraction is an essential part of the process of
gathering the relevant information from each of the studies to review their
quality and compare between. A strength of the review by van der Weegan,
Kornuijt and Das (2015) (see appendix), is that an independent reviewer carried
out this process using a standardised data extraction form. This is to ensure
all the relevant data is collected and reduces the risk of any errors and
therefore improve the accuracy of the data recorded to review. This includes
content such as; the year, number of participants, surgical procedures, follow
up and outcome measures of each study. The authors of this review have
presented this in the form of the table to make it easily to compare between
the studies and therefore assess and analyse the different studies efficiently.
After data extraction has occurred the assessment of the quality of these
studies can be looked at in more detail to evaluate the rigor of the evidence. However,
a weakness of this review is that there is limited evidence of the quality of
the selected studies being assessed. In contrast the review by Barnsley,
Barnsley and Page (2015) state that a quality assessment was carried out by
independent reviewers using the JADAD criteria. However, there is no comment on
the outcome of this to explain if the studies are of high quality or not.
Furthermore, Berger and Alperson (2009) explain the JADAD criteria to be
limited in what is assessed. This therefore reduces the validity of the quality
assessment carried out, influencing the credibility of the review.         

The variation that occurs between the studies can affect the synthesis of the
results. Van der Weegan, Kornuijt and Das (2015) (see appendix) address the
variations that occur within the studies and how this lead to pooling of
results to occur only between the number of procedures and observed
dislocations. For example; amongst the studies used there is a variation of
different surgical procedure that are carried out. This can be considered a
strength as the results therefore become more generalisable to multiple THR
procedures. However, out of the 6 studies only three included the same
procedure for both the restricted and unrestricted groups. This reduces the
internal validity of the results as we cannot be sure if the dislocations that
did occur were influenced by having a different surgical procedure or by the
level of precautions the patients had. In contrast, Barnsley, Barnsley and Page
(2015) compared two RCTs that both included the same THR surgical approach.
This makes the results between the two RCTs easier to directly compare the
results and have a greater internal validity. This becomes much more systematic
and therefore more reliable. Furthermore, differences occurred in the
precautions that the patients received in each study. Although there were
consistencies within the restricted groups. Three studies involved patients in
the unrestricted group adhering to slight restrictions such not being allowed
to sit crossed legged. While the other unrestricted groups were not given any
precautions. This yet again makes direct comparisons amongst the studies to be
more difficult. As the clinical question is addressing whether precautions
prevent dislocation the studies that are not comparing with no restrictions are
less valid, therefore reducing the credibility of the results.              

The overall result of this review is that, on
average, not having hip precautions or strict lifestyle restrictions did not
increase the rate of dislocation. This is shown in the statistics that in the
restricted group out of the 528 participants there were eight dislocations
observed (1.5%) compared to six dislocations (1.0%) in the non-restricted group
of 594 participants (see, appendix, van der Weegan, Kornuijt and Das, 2015). This
result is again reiterated by Barnsley, Barnsley and Page, (2015) that hip
precautions had no significant effect in reducing dislocation. Although, the
authors of this review discuss that despite the outcome measures being
generally better in the unrestricted group of each study, increasing the
reliability of the evidence, but this is only seen as significant in some of
the studies. For instance, in four of the studies, time to resume to
activities, such as; driving and walking without an aid, was significantly
shorter in the unrestricted group. The strength of such results is supported by
Barnsley, Barnsley and Page, (2015) who also found that there was a faster
return to functional activity without strict hip precautions. However, a
limitation of the results gained from the review is there is a lack of
confidence intervals or P-values used to test the significance of the outcomes
as well as their statistical plausibility to assist with clinical relevance (du
Prel et al, 2009).
  
Due to the expected climate of the ageing population, the demand for total hip
replacements in the UK is increasing dramatically. Moreover, as the outcomes of
THR procedures are improving, the demand in the younger populations (under 50)
is also developing, adding further stress onto the NHS as more patients are
receiving this treatment and so increasing the need for more efficient and
effective rehabilitation (NHS England, 2013). This therefore makes the topic of
hip precautions involvement in recovery after a THR procedure very relevant and
with further evidence on this clinical topic it becomes much more applicable to
clinicians and their patients. However, due to the participation age of this
systematic review by by van der Weegan, Kornuijt and Das (2015) (see appendix),
covering patients over 55, the results have a reduced generalisability to the
increasing number of younger patients receiving THR (NHS England, 2013) and so
reducing the practical applications of these results. Moreover, the variations
of outcome measures across the reviewed studies suggest further benefits of
reducing the precautions and restrictions subscribed to patients. The studies
cover criteria such as; measuring hip function, pain, return to carrying out
ADLs, length of hospital stay etc. Although, different studies included
different outcome measures to assess the results, the relevant areas are
covered. However, without the repeatability of these outcomes the reliability
is limited, reducing the credibility of this review and therefore more consistency
across the studies in terms of outcome measures would improve this (Lachin,
2004).

With an increasing volume of evidence
suggesting that hip precautions do not decrease the likelihood of dislocation
this reduces the likelihood of this risk occurring with more liberal
precautions. Moreover, the review by van der Weegan, Kornuijt and Das (2015)
(see appendix), provides evidence to support not prescribing hip precautions to
patients has also shown benefits such as; faster return to functional
activities. This is supported by Ververeli et al (2009) who found that patients
receiving fewer restrictions had a faster recovery to walking with a stick,
walking without aid and a faster return to driving when compared to patients
prescribed with standard hip precautions. Moreover, Peak et al (2005), as
reviewed by Barnsley, Barnsley and Page (2015) suggests this also reduces the
financial costs spent as a shorter stay is needed in hospital as well as fewer
equipment being provided to patients such as raised toilet seats and rails.
Moreover, as patients recover quicker and return to work sooner, the patient
satisfaction rates are improved also. This supports reducing the level of
precautions prescribed post THR. On the other hand, some clinicians, based upon
their experience do believe hip precautions are essential and not worth the
risk. Smith and Sackley (2016) suggest that the majority of clinicians in the
UK are following the standard protocol of prescribing hip precautions and
providing equipment to support these restrictions. This is reiterated by
Drummond, et al (2012). However, these sources also suggest a variation in the
length of time these precautions are prescribed for. Supporting the need for
further research on the most effective rehabilitation process for patients post
THR (Drummond, et al, 2012). Moreover, many would argue the consequences of
dislocation such as; increased mortality rate and increased cost of care are
not worth the risk of not prescribing hip precautions (Cunningham, Beck and
Peterson 2017). However, with further research to support the reliability of
this review by van der Weegan, Kornuijt and Das (2015) (see appendix) suggesting
hip precautions are not effective in reducing dislocation, further research is
likely needed to address other factors that can influence dislocation. For
instance; this review shows some evidence to suggest different surgical
approaches may in fluence the rate of dislocation. With growing evidence around
this topic, the benefits appear to outweigh the risks.     

For future developments on this topic there is certainly a demand for more primary
research such as; RCTs. Moreover, with a greater evaluation and quality
assessment of these studies the data collated can be chosen more selectively
from studies with greater rigor. This will mean that Systematic literature
reviews can then take place including more quality primary research and improve
the rigor and reliability of the conclusions drawn from this. With more consistent
high quality primary evidence this will encourage new guidelines and
consistencies to develop in clinical practice (Francke et al, 2008).

In conclusion, the overall findings of this
review are that Hip precautions are not effective in reducing the rate of hip
dislocation in patients post THR. Moreover, that there are further benefits to
prescribing more liberal/ no precautions such as; faster recover to functional
activities, improved patient satisfaction and reduced financial costs. With
further high-quality research supporting this evidence the standard protocol
for aftercare post THR could be developed to become more effective and efficient
without increasing risk of dislocation simply by reducing the lifestyle
restrictions prescribed to patients (van der Weegan, Kornuijt and Das, 2015). Leading
to a large impact on thousands of patients across the UK as well as the health
care professionals involved in the procedure and aftercare (NHS England, 2013). 

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