Effectiveness and acceptability of a newly designed hip protector: a pilot study

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Abstract

Hip fracture has a significant economic and personal cost, involving hospital admission and functional impairment for elderly people. To assess the benefit of using a newly designed hip protector (new material and new design) to prevent fracture in a realistic setting, a randomised intervention-control design was used to trial the effectiveness of pads worn by high falls risk residents (n=71) in nursing home for 9 months. 40 residents were in the intervention group and 31 were in the control group. A profile of falls, including time of day, and orientation was obtained to demonstrate the potential effectiveness of the protectors for injury prevention. Acceptance of the hip protector was also surveyed amongst nursing home staff and residents. One hundred and one falls and six fractures occurred in the control group. In contrast, one hundred and ninety one falls and three fractures occurred in the hip protector (pads) group. The three fractures in the protector wearing group occurred when pads were not in place. This was extrapolated as 1 in every 16.8 falls and 1 in every 63.7 falls resulting in fracture in the two groups, respectively. The relative risk of fracture was 0.264 (95% CI=0.073–0.959) when the fracture incidence rate in the intervention group (three fractures per 191 falls) was compared to the control group (six fractures per 101 falls). This is a statistically significant result and implies that this newly designed hip protector is effective in preventing hip fracture. The majority of falls occurred during the day, which was when protectors were worn in this study, but the data on orientation was incomplete, with direction unknown in 74% of falls. Compliance was an issue, which was interpreted as only 50.3% of falls recorded with protectors in place. Dementia was identified as the explanation for this as the pads were often removed by these residents who comprised the majority of participants. Perception of low risk was the primary barrier to residents accepting the intervention. Comfort of protectors was not a significant concern for staff or residents, and only staff described appearance as an issue. In conclusion, the newly designed hip protector is protective against fractures in a realistic setting. Compliance and acceptance of the protectors will ultimately determine the viability of this prophylaxis.

Introduction

Fracture of the hip has been recognised as a significant problem in the elderly population from both an economic perspective, and in terms of the personal impact on the individual experiencing the injury. The impairment in function associated with the fracture, and surgical intervention alters the lives of individuals, increasing the likelihood of permanent institutionalisation five times for previously community dwelling elderly (Cumming et al., 1996). Pre-fracture levels of physical functioning are not regained by more than half the injured patients, and fractured neck of femur increases mortality in the elderly significantly (Butler et al., 1996; Fox et al., 1996).

In the majority (60–90%) of fractures direct trauma is the aetiology (Cummings and Nevitt, 1989), which indicates the importance of addressing falls in the elderly. However, this is a complex issue as most falls are multifactorial in cause, including, lower limb weakness, gait instability, vision, cognitive and functional impairments as well as the effects of medication (Rubenstein et al., 1994). External factors have been found to be unreliable determinants of risk, as multiple hazards have been implicated in fractures (Clemson et al., 1996). Therefore, the value of a secondary prophylaxis is suggested as a fracture prevention, to mediate the impact of the fall, when it inevitably occurs.

Hip fracture risk is known to be reduced by a larger body mass index as increased soft tissue appears to absorb the impact of a fall and protect the femur (Hayes et al., 1991; Robinovitch et al., 1995). Even in a direct fall onto the hip in the elderly, research has shown that natural padding is insufficient to attenuate the force, and other mechanisms such as reflex contraction of the quadriceps protect the hip fracture (Robinovitch et al., 1995).

As a solution to the prevention of fracture, several clinical trials have demonstrated that external hip protector is effective in protecting the hip, as no fractures occurred in subjects while wearing the appliances (Lauritzen et al., 1993; Tracey et al., 1998). However, the compliance rate is only about 50% (Lauritzen et al., 1993; Tracey et al., 1998) and it drops to about 30% (Tracey et al., 1998) in the long term. The design of these hip protectors are such that they have to be worn with underpants to cover a small area over the greater trochanter. Any movement of the protector may mean that the covering position may be shifted. Therefore, the hip protectors are quite tightly fitted and this may explain a significant proportion of people feeling the discomfort (Tracey et al., 1998). Furthermore, the polypropylene material used is quite hard which may add to the discomfort.

We therefore designed a new hip protector using softer material, which is fitted to the inner surfaces of trousers or tracksuit pants. The hip protectors also cover the greater trochanters but have the propensity to allow for some movement, and hence may cause less discomfort. Our aims are to find out both the effectiveness and acceptability of this newly designed hip protector.

Section snippets

Participants

Subjects were drawn from nine nursing homes and the criteria for inclusion was that the nursing home staff identified the residents as high falls risk. This was not on the basis of particular diagnosis, or any formal evaluation of falls risk, but the perception of the staff themselves. The subjects or the person responsible was then asked to sign consent to participate. Therefore, the purposes of the study were clear to participants and/or the guardians, and involvement was voluntary. Random

Effectiveness of protectors

Fifty of the 71 subjects had fallen with a total 292 falls recorded. Nine fractures occurred with none of the eight residents wearing protectors at the time of injury (one resident fractured both hips 1 month apart). 101 of the falls and six of the fractures were recorded in the control group. This may be interpreted as a risk of 1 in every 16.8 falls resulting in a hip fracture. The protector group in comparison accounted for three of the fractures and 191 of the falls with an extrapolated

Discussion

Ultimately the aim of this study was to implement protectors in a realistic setting and record data as to their effectiveness. This data has supported the value of pads worn to prevent fracture of the hip as no fractures occurred while they were in place. Furthermore, the reduction of relative risk of hip fracture in this new hip protector (RR=0.264) is comparable or marginally better than the old design (RR=0.44) by Lauritzen (Lauritzen et al., 1993). As most falls occurred during the day,

Conclusion

The descriptive data about falls and fractures in a realistic trial in nursing homes indicates the viability of protectors as a valid instrument in the prevention of fractured hips as none occurred while the device was in place. However, further information regarding the profile of falls, especially direction of fall, would increase the evidence for the potential effectiveness of this device. Potential barriers to implementation include compliance, and attitudes to perceived risk.

Acknowledgements

The authors express their gratitude and thanks to Calare Nursing Home, Orange; Cudal Memorial Hospital; Eugowra Memorial Hospital; Mater Misericordiae Nursing Home, Forbes; Moyne Eventide Home, Canowindra; Niola Nursing Home, Parkes; Wontama Nursing Home, Orange; Sir Joseph Banks Nursing Home, Botany; Camelot Nursing Home, Maroubra for their co-operation and help.

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