Assistive devices, hip precautions, environmental modifications and training to prevent dislocation and improve function after hip arthroplasty (Review)

Background: Total hip arthroplasty (THA) is one of the most common orthopaedic operations performed worldwide. Painful osteoarthritis of the hip is the primary indication for THA. Following THA, people have conventionally been provided with equipment, such as raised toilet seats and chairs, and educated to avoid activities that could cause the hip joint to be in a position of flexion over 90 degrees, or adduction or rotation past the midline. These aspects of occupational therapy have been advocated to reduce the risks of prosthesis dislocation. However, the appropriateness of these recommendations has been questioned. Objectives: To assess the effects of provision of assistive devices, education on hip precautions, environmental modifications and training in activities of daily living (ADL) and extended ADL (EADL) for people undergoing THA. Search methods: We searched MEDLINE (1946 to April 2016), EMBASE (1947 to April 2016), the Cochrane Library including CENTRAL (Issue 4 of 12, 2016), Database of Reviews of Effects (DARE), Health Technology Assessment (HTA), Economic Evaluations Database (EED), CINAHL, PEDro and CIRRIE from inception to April 2016. In addition we checked Controlled Clinical Trials, Clinicaltrials.gov, the National Institutes of Health Trial Registry, theWorld Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and the OpenGrey database from inception to April 2016. Selection criteria: We included randomised controlled trials (RCTs), quasi-RCTs and cluster-RCTs that evaluated the effectiveness of the provision of assistive devices, education on hip precautions, environmental modifications, or training in ADL and EADL for people undergoing THA. The main outcomes of interest were pain, function, health-related quality of life (HRQOL), global assessment of treatment success, reoperation rate, hip dislocation and adverse events. Data collection and analysis: We used standard methodological procedures recognised by Cochrane. We conducted a systematic literature search using several databases and contacted corresponding authors, appraised the evidence using the Cochrane risk of bias tool, analysed the data using a narrative analysis approach (as it was not possible to conduct a meta-analysis due to heterogeneity in interventions), and interpreted all outcomes using the GRADE approach. Main results: We included three trials with a total of 492 participants who had received 530 THA. The evidence presented with a high risk of performance, detection and reporting bias. One study (81 participants) compared outcomes for participants randomised to the provision of hip precautions, equipment and functional restrictions versus no provision of hip precautions, equipment or functional restrictions. Due to the quality of evidence being very low, we are uncertain if the provision of hip precautions, equipment and functional restrictions improved function measured using the Harris Hip Score at 12 month follow-up, or health-related quality of life (HRQOL) measured by the Short Form-12 at four week follow-up, compared to not providing this. There were no incidences of hip dislocation or adverse events in either group during the initial 12 postoperative months. The study did not measure pain score, global assessment of treatment success or total adverse events. One study (265 participants; 303THAs) evaluated the provision of hip precautions with versus without the prescription of postoperative equipment and restrictions to functional activities. Due to the quality of evidence being very low, we are uncertain if perceived satisfaction in the rate of recovery differed in people who were not prescribed postoperative equipment and restrictions (135/151 satisfied) compared to those prescribed equipment and restrictions (113/152) (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.75 to 0.93; 265 participants, one trial; number needed to treat for an additional beneficial outcome (NNTB) = 7). Due to the low quality evidence, we are uncertain if the incidence of hip dislocation differed between participants provided with hip precautions with (1/152) compared to without providing equipment or restrictions post-THA (0/151) (RR 2.98, 95% CI 0.12 to 72.59). The study did not measure pain, function, HRQOL, re-operation rates or total adverse events. One study (146 participants) investigated the provision of an enhanced postoperative education and rehabilitation service on hospital discharge to promote functional ADL versus a conventional rehabilitation intervention in the community. This study was of very low quality evidence. We were uncertain if the provision of enhanced postoperative education and rehabilitation improved function at six months follow-up, when assessed using the Objective and Subjective Functional Capability Index (146 participants, one trial; P > 0.05; no numerical results provided) compared to conventional rehabilitation. The study did not measure pain score, HRQOL, global assessment of treatment success, hip dislocation, re-operation rate or total adverse events. Authors’ conclusions: Very low quality evidence is available from single trials, thus we are uncertain if hip precautions with or without the addition of equipment and functional restrictions are effective in preventing dislocation and improving outcomes after THA. There is also insufficient evidence to support or refute the adoption of a postoperative community rehabilitation programme consisting of functional reintegration and education compared to conventional rehabilitation strategies based on functional outcomes. Further high-quality trials are warranted to assess the outcomes of different occupational therapy interventions both in the short and longer-term for those who undergo THA. An assessment of the impact of such interventions on pain and restriction on personal ADL, EADL and instrumental ADL is needed, and also of functional integration-type interventions rather than just hip precautions,equipment and restrictions

Rest Pain and Movement-Evoked Pain as Unique Constructs in Hip and Knee Replacements

OBJECTIVE: There is limited information about the extent to which the association between preoperative and chronic postoperative pain is mediated via pain‐on‐movement or pain‐at‐rest. We explored these associations in patients undergoing total hip replacement (THR) and total knee replacement (TKR). METHODS: A total of 322 and 316 patients receiving THR and TKR, respectively, were recruited into a single‐center UK cohort (Arthroplasty Pain Experience) study. Preoperative, acute postoperative, and 12‐month pain severity was measured using self‐reported pain instruments. The association between preoperative/acute pain and chronic postoperative pain was investigated using structural equation modeling (SEM). RESULTS: Patients with high levels of preoperative pain were more likely to report chronic pain after THR (β = 0.195, P = 0.02) and TKR (β = 0.749, P < 0.0001). Acute postoperative pain‐on‐movement was not associated with chronic pain after TKR or THR after adjusting for preoperative pain; however, acute pain‐at‐rest was associated with chronic pain after THR (β = 0.20, P < 0.0002) but not TKR after adjusting for preoperative pain. Analysis of pain‐at‐rest and pain‐on‐movement highlighted differences between THR and TKR patients. Chronic pain‐at‐rest after THR was weakly associated with pain‐at‐rest during the preoperative (β = 0.11, P = 0.068) and acute postoperative period (β = 0.21, P < 0.0001). In contrast, chronic pain‐on‐movement after TKR was strongly associated with the severity of pain‐on‐movement during the preoperative period (β = 0.51, P = 0.001). CONCLUSION: SEM illustrated the different patterns of association between measures of pain over time in patients undergoing THR and TKR for osteoarthritis. These findings highlight the importance of future work that explores the mechanisms underlying pain‐on‐movement and pain‐at‐rest

Trajectories of Pain and Function after Primary Hip and Knee Arthroplasty:The ADAPT Cohort Study

BACKGROUND AND PURPOSE:Pain and function improve dramatically in the first three months after hip and knee arthroplasty but the trajectory after three months is less well described. It is also unclear how pre-operative pain and function influence short- and long-term recovery. We explored the trajectory of change in function and pain until and beyond 3-months post-operatively and the influence of pre-operative self-reported symptoms. METHODS:The study was a prospective cohort study of 164 patients undergoing primary hip (n = 80) or knee (n = 84) arthroplasty in the United Kingdom. Self-reported measures of pain and function using the Western Ontario and McMaster Universities Osteoarthritis index were collected pre-operatively and at 3 and 12 months post-operatively. Hip and knee arthroplasties were analysed separately, and patients were split into two groups: those with high or low symptoms pre-operatively. Multilevel regression models were used for each outcome (pain and function), and the trajectories of change were charted (0-3 months and 3-12 months). RESULTS:Hip: Most improvement occurred within the first 3 months following hip surgery and patients with worse pre-operative scores had greater changes. The mean changes observed between 3 and twelve months were statistically insignificant. One year after surgery, patients with worse pre-operative scores had post-operative outcomes similar to those observed among patients with less severe pre-operative symptoms. Knee: Most improvement occurred in the first 3 months following knee surgery with no significant change thereafter. Despite greater mean change during the first three months, patients with worse pre-operative scores had not 'caught-up' with those with less severe pre-operative symptoms 12 months after their surgery. CONCLUSION:Most symptomatic improvement occurred within the first 3 months after surgery with no significant change between 3-12 months. Further investigations are now required to determine if patients with severe symptoms at the time of their knee arthroplasty have a different pre-surgical history than those with less severe symptoms and if they could benefit from earlier surgical intervention and tailored rehabilitation to achieve better post-operative patient-reported outcomes

Radio source stacking and the infrared / radio correlation at microJy flux densities

We investigate the infrared / radio correlation using the technique of source stacking, in order to probe the average properties of radio sources that are too faint to be detected individually. We compare the two methods used in the literature to stack sources, and demonstrate that the creation of stacked images leads to a loss of information. We stack infrared sources in the Spitzer extragalactic First Look Survey (xFLS) field, and the three northern Spitzer Wide-area Infrared Extragalactic survey (SWIRE) fields, using radio surveys created at 610 MHz and 1.4 GHz, and find a variation in the absolute strength of the correlation between the xFLS and SWIRE regions, but no evidence for significant evolution in the correlation over the 24-um flux density range 150 uJy - 2 mJy. We carry out the first radio source stacking experiment using 70-um-selected galaxies, and find no evidence for significant evolution over the 70-um flux density range 10 mJy - 100 mJy.Comment: 11 pages, 12 figures. Accepted for publication in MNRA

Evaporation, seepage and water quality management in storage dams: a review of research methods

One of the most significant sources of water wastage in Australia is loss from small storage dams, either by seepage or evaporation. Over much of Australia, evaporative demand routinely exceeds precipitation. This paper outlines first, methodologies and measurement techniques to quantify the rate of evaporative loss from fresh water storages. These encompass high-accuracy water balance monitoring; determination of the validity of alternative estimation equations, in particular the FAO56 Penman- Monteith ETo methodology; and the commencement of CFD modeling to determine a 'dam factor' in relation to practical atmospheric measurement techniques. Second, because the application of chemical monolayers is the only feasible alternative to the high cost of physically covering the storages to retard evaporation, the use of cetyl alcohol-based monolayers is reviewed, and preliminary research on their degradation by photolytic action, by wind break-up and by microbial degradation reported. Similarly, preliminary research on monolayer visualisation techniques for field application is reported; and potential enhancement of monolayers by other chemicals and attendant water quality issues are considered

Application of biomimetic HPLC to estimate lipophilicity, protein and phospholipid binding of potential peptide therapeutics

Peptide therapeutics are new modalities offering several challenges to drug discovery. They are generally less stable and permeable in vivo. The characterization of their lipophilicity cannot be carried out using the traditional in silico or wet octanol/water partition coefficients. The prediction of their in vivo distribution and permeability is also challenging. In this paper, it is demonstrated that the biomimetic properties such as lipophilicity, protein and phospholipid binding can be easily assessed by HPLC using chemically bonded protein and immobilized artificial membrane (IAM) stationary phases. The obtained properties for a set of potential therapeutic peptides with 3 to 33 amino acids have been analysed and it was found that similar characteristics of the properties could be observed as for small molecule drugs. The albumin binding showed correlation with their measured lipophilicity on the C-18 stationary phase with acidic peptides showing stronger than expected albumin binding. The (IAM) chromatography revealed peptide membrane affinity, which was stronger for positively charged peptides (containing arginine) and showed correlation to the alpha-1-acid glycoprotein (AGP) binding, which was also stronger for positively charged compounds. The in vivo volume of distribution and drug efficiency of the peptides have been estimated using the models developed for small molecules. One of the candidate linear peptides has been assessed in various cellular and in vivo assays and the results have confirmed the estimated cell partition and brain to plasma ratio. It can be demonstrated, that up to 21 amino acids, the peaks of the peptides obtained on the protein phase were symmetrical and narrow. The interaction of larger peptides with the protein stationary phases resulted in wide peaks showing multiple equilibrium processes with slow kinetics during chromatography. The larger peptides showed narrow and symmetrical peaks on the IAM column enabling the quantification of peptide - cell membrane interactions

Effect of local anaesthetic infiltration on chronic postsurgical pain after total hip and knee replacement:The APEX randomised controlled trials

Total hip replacement (THR) and total knee replacement (TKR) are usually effective at relieving pain; however, 7% to 23% of patients experience chronic postsurgical pain. These trials aimed to investigate the effect of local anaesthetic wound infiltration on pain severity at 12 months after primary THR or TKR for osteoarthritis. Between November 2009 and February 2012, 322 patients listed for THR and 316 listed for TKR were recruited into a single-centre double-blind randomised controlled trial. Participants were randomly assigned (1:1) to receive local anaesthetic infiltration and standard care or standard care alone. Participants and outcomes assessors were masked to group allocation. The primary outcome was pain severity on the WOMAC Pain Scale at 12 months after surgery. Analyses were conducted using intention-to-treat and per-protocol approaches. In the hip trial, patients in the intervention group had significantly less pain at 12 months postoperative than patients in the standard care group (differences in means: 4.74; 95% confidence interval [CI]: 0.95-8.54; P = 0.015), although the difference was not clinically significant. Post hoc analysis found that patients in the intervention group were more likely to have none to moderate pain than severe pain at 12 months than those in the standard care group (odds ratio: 10.19; 95% CI: 2.10-49.55; P = 0.004). In the knee trial, there was no strong evidence that the intervention influenced pain severity at 12 months postoperative (difference in means: 3.83; 95% CI: −0.83 to 8.49; P = 0.107). In conclusion, routine use of infiltration could be beneficial in improving long-term pain relief for some patients after THR

Locating the Youngest HII Regions in M82 with 7 mm Continuum Maps

We present 7mm Very Large Array continuum images of the starburst galaxy M82. On arcsecond scales, two-thirds of the 7mm continuum consists of free-free emission from HII regions. In the subarcsecond resolution map, we identify 14 compact sources, including 9 bright HII regions with N_Lyc > 10^51 sec^-1. Four of the HII regions have rising spectra, implying emission measures > 10^8 cm^-6 pc. Except for one compact source with peculiar features, all other compact radio sources are found in dust lanes and do not have optical or near-infrared continuum counterparts. Four regions of extended, high brightness (EM > 10^7 cm-6 pc) radio emission are found in our high resolution map, including some as large as ~2", or 30 pc, representing either associations of small HII regions, or sheetlike structures of denser gas. The good correlation between 7 mm emission and Spitzer IRAC 8 micron continuum-removed PAH feature suggests that PAH emission may track the recently formed OB stars. We find an excellent correlation between molecular gas and star formation, particularly dense gas traced by HCN, down to the ~ 45 pc scale in M82. We also find star formation efficiencies (SFEs) of 1-10% on the same scale, based on CO maps. The highest SFE are found in regions with the highest dense gas fractions.Comment: 18 pages, 10 figures. Accepted for publication in A