In this new blog series, our lovely Nikki is taking over to tell us about her experience as a newly qualified physio and to describe the joys, fears and challenges she meets along the way. She'll also share her tips which might be useful to some of you too!
I am now halfway through my surgical placement. A large part of my caseload is working with patients who have had elective joint replacement surgery which has meant that there are time pressures and protocols to follow. As a result, I have to structure my caseload according to the multimodal rehabilitation framework, The Enhanced Recovery Programme (ERP).
The ERP programme’s focus is to reduce post-operative pain and to accelerate rehabilitation (Wainwright and Middleton, 2010) with one of its goals being immediate postoperative management and early mobilisation (NHS Institute for Innovation and Improvement, 2008). Therefore, I need to see patients on the ERP twice a day and aim for discharge in less than 4 days.
Although a prerequisite to elective orthopaedic surgery is to attend Joint School where patients are given information about what to expect on their orthopaedic journey, 9 times out of 10, it always seems a surprise patients when I ask them to get out of bed day 0/1 post total hip/knee replacement. Some laugh nervously as if I am telling a malicious joke and others simply refuse.
As per the post op note, I teach my patients the hip precautions they must abide by:
- No twisting on the operated leg
- No crossing your legs
- No bending to pick thing up off the floor (reducing the 90 degree angle at the hip)
These hip precautions are drummed into patients in Joint School, reinforced by me on Day 0/1 and then further reinforced by the Occupational Therapist when they provide the equipment in order to satisfy their precautions.
Consequently, I have come to realise that patients are absolutely terrified to move post op.
For some of my patients, this has made rehabilitation a complete battle and I can understand why - patients are being delivered conflicting information. They are being told do not perform these movements or else you will dislocate you new hip, as well as, you must get out of bed straight away and use your hip, you must do these exercises in order to strengthen your hip.
I have too many examples of case studies where patients have been affected by hip precautions.
Ideally, this is how physiotherapy post op. should go:
Day 0 post total hip replacement:
- Reiterate the importance of hip precautions
- Teach patient bed exercises
- Get patient up weight bearing and mobilising as pain allows (and whether their blood pressure allows following a spinal).
Typically, this is how it goes:
Day 0 post total hip replacement:
- Reiterate the importance of hip precautions → Patient becomes extremely anxious over what movements they can and can’t do.
- Teach patient bed exercises → Patient becomes extremely anxious over what movements they can and can’t do. → They constantly check whether the exercises they are doing are breaking any precautions.
- Get patient up to weight bear and mobilise as pain allows (and whether their blood pressure allows following a spinal). → Patient becomes anxious about getting out of bed in case they break hip precautions and exclaim that they can’t possibly stand on their new hip so early on because it must be delicate and might dislocate.
You get the picture.
I therefore decided to explore the evidence behind hip precautions and see by how much they actually do reduce the risk of dislocation.
- The termination of hip precautions could reduce patients’ length of stay (LOS) in hospital.
The average length of stay (LOS) for THR surgery is 5 days (National Joint Registry, 2013) however Guys and St. Thomas’ NHS Foundation Trust demonstrated that after not imposing hip precautions, this was reduced by 2.7 days (Cope, no date). With the current effort to shift patient care from an inpatient setting to the community (NHS Five Year Forward View), reducing LOS would result in a reduced waiting time for an operation as beds become free more quickly. As a result, the service will become more efficient.
- The removal of hip precautions could have cost implications.
A potential annual saving of up to £30,000 was predicted on issuing OT equipment in order to satisfy precautions at Guys and St. Thomas’ NHS Foundation Trust (Cope, no date). OTs could therefore focus resources on functional rehabilitation, not just to meet the requirements of hip precautions (Coole et al., 2013). This would subsequently benefit the patient, as they would receive a more personalised assessment.
- The removal of hip precautions could result in a quicker return to normal function
Evidence suggests that the removal of restrictions leads to a quicker return to normal function (Peak et al., 2005) and patients are able to ambulate with a reduced antalgic gait pattern (Ververeli et al., 2009). Furthermore, those who followed precautions report they feel unable to engage in social activities and subsequently suffer from emotional stress. (Peak et al., 2005). Consequently, it is suggested that the relaxation of hip precautions increases patient satisfaction (Peak et al., 2005).
So, do hip precautions actually reduce the rate of dislocation?
There is a considerable amount of research advocating that hip precautions do not result in an increased rate of dislocation (Restrepo et al., 2011; Talbot et al., 2002; Peak et al., 2002) and it has been suggested that therapists re-evaluate hip precautions with the MDT and surgeons (College of Occupational Therapists, 2012).
Six UK hospitals have already terminated the use of hip precautions following a primary THR. Therefore, in light of current research against their use, it seems as though the evidence should be examined and new standard guidelines should be put in place. The removal of hip precautions could have potential benefits for the members of the MDT, as well as patients and subsequently NHS Trusts.
- Cope, J. (n.d.). Life without hip precautions & Review of Elective Orthopaedic Enhanced Recovery Programme. Building the NHS of the Five Year Forward View. (2015). [online] Available at: https://www.england.nhs.uk/wp-content/uploads/2015/03/business- plan-mar15.pdf
- Coole, C., Edwards, C., Brewin, C. and Drummond, A. (2013). What do clinicians think about hip precautions following total hip replacement? The British Journal of Occupational Therapy, 76(7), pp.300-307.
- Iles, V. and Sutherland, K. (2001). Managing Change in the NHS. 1st ed. London: NCCSDO, pp.7-87.
- institute.nhs.uk. (2005). Improvement Leaders’ Guide Managing the human dimensions of change Personal and organisational development. [online] Available at: http://www.nhsiq.nhs.uk/media/2594818/ilg_-_managing_the_human_dimensions_of_change.pdf
- Peak, E. and Ciminiello, J. (2005). Relaxing hip precautions increased patient satisfaction and promoted quicker return to normal activities after total hip arthroplasty. British Medical Journal, 8, p.115.
- Restrepo, C., Mortazavi, S., Brothers, J., Parvizi, J. and Rothman, R. (2010). Hip Dislocation: Are Hip Precautions Necessary in Anterior Approaches?. Clinical Orthopaedics and Related Research, 469(2), pp.417-422.
- Talbot, N., Brown, J. and Treble, N. (2002). Early dislocation after total hip arthroplasty. The Journal of Arthroplasty, 17(8), pp.1006-1008.
- Ververeli, P., Lebby, E., Tyler, C. and Fouad, C. (2009). Evaluation of Reducing Postoperative Hip Precautions in Total Hip Replacement: A Randomized Prospective Study. Orthopedics, 32(12), pp.889-893.
- Wainwright, T. and Middleton, R. (2010). An orthopaedic enhanced recovery pathway. Current Anaesthesia & Critical Care, 21(3), pp.114-120.
About the author
Nikki is a newly-qualified physiotherapist with a previous degree in Human Communication Sciences, currently working in a busy university hospital in East London. She was the first ever to sign up to one of our seminars when we started back in 2015; now a year down the line, she's our first ever resident blogger! Expect to see (and read) more of her very soon!