Effectiveness and acceptability of a newly designed hip protector: a pilot study
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.
References (12)
- et al.
External hip protectors: likely non-compliance among high risk elderly people living in the community
Arch. Gerentol. Geriatr.
(1994) - et al.
Cohort study of risk of institutionalisation after hip fracture
Aust. NZ J. Public Health
(1996) - et al.
Effect of external hip protectors on hip fractures
Lancet
(1993) - et al.
The risk of hip fracture in older people from nursing homes and institutions
Age Ageing
(1996) - et al.
Case-control study of hazards in the home and risk of falls and hip fractures
Age Ageing
(1996) - et al.
A hypothesis: the causes of hip fractures
J. Gerontol.
(1989)
Cited by (67)
Falls as risk factors for fracture
2020, Marcus and Feldman’s OsteoporosisFacilitators of and barriers to hip protector acceptance and adherence in long-term care facilities: A systematic review
2015, Journal of the American Medical Directors AssociationCitation Excerpt :In addition, a significantly greater proportion of individuals assigned soft pad hip protectors (63%) were considered 24-hour users compared with those provided hard dome hip protectors (43%) after 12 months of follow-up.66 The most prevalent hip protector-level barrier of both acceptance and adherence was discomfort, named in 16 studies.54,55,57–61,65–67,73–78 For example, Burl et al61 (2003) reported that, despite attempts to optimize fit, a few individuals would not wear hip protectors because they complained of discomfort.
Falls as Risk Factors for Fracture
2013, Osteoporosis: Fourth EditionThe effect of positioning on the biomechanical performance of soft shell hip protectors
2010, Journal of BiomechanicsAdherence to Hip Protectors and Implications for U.S. Long-Term Care Settings
2010, Journal of the American Medical Directors AssociationDevelopment of a new design of hip protectors using finite element analysis and mechanical tests
2008, Medical Engineering and Physics