Several of the residents at the care home where I work have recently suffered falls, and one enthusiastic young staff member raised the issue of whether hip protectors would be helpful. Which was a very good question. I vaguely remember reading a BMJ article some years back in which hip protectors were discounted as being of minimal practical use, but, since the question had been raised, I thought I should brush up on the matter.
I started by plugging ‘hip protectors’ into Search on Pubmed, started reading through the main reviews that popped up, and found a reference to a Cochrane review on the topic. This looked promising, so I looked it up and found their conclusion was that there was ‘moderate quality evidence’ for the following:
In older people living in nursing care facilities, providing a hip protector
– probably decreases the chance of a hip fracture slightly
– may increase the small chance of a pelvic fracture slightly
– probably has little or no effect on other fractures or falls
In older people living at home, providing a hip protector
– probably has little or no effect on hip fractures
(Cochrane Database Syst Rev 2014;(3):CD001255)
Of course, in this context what I’m looking at is the result for older people in nursing (or residential) care facilities, so this looked promising. I looked further to find out what was meant by that ‘slightly’, and apparently NNT works out at about 100. (This means, in plain English, that if you’re an elderly person in a care home wondering what the odds are that wearing hip protectors will prevent a hip fracture you otherwise would have sustained, they’re about 1 in 100. Or, to put it another way, if you could give 100 such people hip protectors and then look into a crystal ball to see what would have happened if they hadn’t had them, for probably 99 of those people the outcome would be much the same, but one lucky person would have their hip fracture prevented by the protectors.)
(The proportion may in practice be even lower, because there was then some complicated stuff about the relative risk changing if the studies at highest risk of bias were excluded, but they didn’t rework the NNT. The RR changed from 0.82 to 0.9, which I think makes the NNT come out at half the amount, which would be one in 200 – but feel free to correct me.)
I went through the details of the studies to see whether the intervention had been in high-risk patients only or in care home residents generally, and the answer was that it depended on the study. (Also, of course, different studies had different criteria for what counted as ‘high risk’.) It’s therefore possible that recommending hip protectors only to patients at high risk of falls would lead to greater effectiveness overall.
One notable point was that a lot of care home residents didn’t want to wear the protectors long-term. In some cases, this was due to side-effects such as skin irritation; in a lot of cases, it seemed to be because they either didn’t understand the significance or weren’t that bothered.
Another point is that there are different types of hip protector – hard, soft, and types that are supposed to shunt the force away from the hip, or something impressively complicated-sounding. I did some arithmetic with the figures given and found that the RR for the three groups that only used soft protectors (there was one that used both hard and soft) came out as 0.38, and the RR for the two that used shunters came out as 0.44. Obviously those are a lot better than the RR given for the total, but I don’t know whether I’m missing anything obvious that I should have taken into account when analysing this. Have to say that soft ones sound more comfortable, though I don’t know whether it makes any difference in practice.
Conclusion? I won’t be recommending them wholesale, but I might well discuss hip protectors as an option with my higher-risk patients. If anyone does decide to have them, I’ll probably recommend the soft ones.