1. Total Hip Replacement and Musculoskeletal disorder research Tosan Okoro NWORTH Seminar May 2012

2. Outline WCAT Trainee Trauma and Orthopaedics PhD commenced August 2009 Work supported by BCUHB Small Grants Scheme

4. The Evidence THR Indications 1 – Pain – Loss of mobility i.e. function Functional limitations that persist after THR 2 – Reduced muscle strength and postural stability – Reduced walking speed – Reduced stair climbing ability 1Trudelle-Jackson E et al. Arch Phys Med Rehabil 2004. 85;1056-1062 2Brander VA et al. Clin Orthop 1997;Dec(345):67-78.

5. The Evidence Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) physical function score over time after total joint replacement between low and high baseline function groups Fortin et al. Arthritis Rheum 2002; 46 (12): 3327-3330

6. The Evidence Effects of poor function – At 2 years after THR patients with low function 5x more likely to require assistance for activities of daily living (ADLs) than patients with high function 1 1. Fortin et al. Arthritis Rheum 2002; 46 (12): 3327-3330

8. Aims of study To assess early home-based progressive resistance training (PRT) after total hip replacement (THR) ?improves muscle strength and patient function vs. routine physiotherapy

9. But what is routine physiotherapy after THR Ethics committee approval Focus Group – 4 physiotherapists; minimum 5 years experience – Pre-, Post-operative and continuing rehabilitation themes discussed Questionnaire development Online survey of physiotherapists in the UK – CSP – National Joint Registry

10. European College of Sports Science (ECSS) Annual Congress, Liverpool, July 2011

11. Routine Physiotherapy Progressive resistance training – 73% aware of it prescribed by only 32% 74% of respondents did not refer patients for further treatment on discharge Resubmitted to Physiotherapy April 2012 European College of Sports Science (ECSS) Annual Congress, Liverpool, July 2011

12. Aims of study To assess early home-based progressive resistance training (PRT) after total hip replacement (THR) ?improves muscle strength and patient function vs. routine physiotherapy

13. Design Prospective single blinded RCT. Ethical approval Jan 2010 Stratification with age + gender Pilot Study NWORTH input

14. 1 outcomes Maximal voluntary contraction of quadriceps muscle Objective measures of physical function – Timed up and go – 6 minute walk – Gait speed – Stair climbing performance – Sit to stand score

15. Objective measures 6 minute walk test (6MWT) Gait speed (GS) Timed up and go (TUG) Sit to stand (ST) Stair Climb performance (SCP)

16. Sample size (n=10 per group) Maximal voluntary force in quadriceps muscle 10% improvement with exercise relative to controls 80% power; alpha 0.05 n=50 patients to recruit

17. Collaborations Prof Clare Stewart, MMU, Manchester Muscle Physiology

18. Recruitment

19. So far… ? Influence Function and Perceived Control in Patients awaiting Total Hip Replacement Surgery Living Situation Gender Surgical Experience European Health Psychology Society Annual congress, Crete, 2011

20. Preoperative Function RLOC TPB PBC Living alone > With Partner TPB PBC (p=0.085) RLOC INT (p=0.073) WOMAC PF (p=0.059) Gender Females > Males RLOC INT (p=0.075) History of previous surgery No effect European Health Psychology Society Annual congress, Crete, 2011

21. So what? ? Change locus of control to influence post- operative outcome Assess influence of control cognitions on function post-operatively

22. So far… 6 minute walk test (6MWT) Gait speed (GS) Timed up and go (TUG) Sit to stand (ST) Stair Climb performance (SCP) British Hip Society 2012

23. KEY: TUG(s) Timed up and Go in seconds STNumber of sit to stand performed from a chair in 30 seconds 6MWT (m)6 minute walk test in metres SCP(s)Stair climb performance in seconds GS (m/s)Gait speed in metres/second British Hip Society 2012

24. KEY: *P<0.05 TUG(s) Timed up and Go in seconds STNumber of sit to stand performed from a chair in 30 seconds 6MWT (m)6 minute walk test in metres SCP(s)Stair climb performance in seconds GS (m/s)Gait speed in metres/second

25. KEY: rWOMAC PFReduced Western Ontario and McMasters University Osteoarthritis personal function scale *P<0.05 TUG(s) Timed up and Go in seconds STNumber of sit to stand performed from a chair in 30 seconds 6MWT (m)6 minute walk test in metres SCP(s)Stair climb performance in seconds GS (m/s)Gait speed in metres/second

26. So what? rWOMAC PF better than OHS as a measure of ADLs and objectively measured physical disability Use of OHS as measure of impairment not appropriate

27. So far… Mental Health- Distress and Risk Assessment Method (DRAM) Main CJ, Wood PL, Hollis S, Spanswick CC, Waddell G. The Distress and Risk Assessment Method. A simple patient classification to identify distress and evaluate the risk of poor outcome. Spine (Phila Pa 1976) 1992 Jan;17(1):42-52.

28. British Hip Society 2012 * p<0.05

29. Effect of DRAM on Oxford Hip Score

30. Effect of DRAM on reduced WOMAC function scale (rWOMAC PF)

31. CONSORT FLOWCHART Data analysis in progress

32. Acknowledgements Supervisors A Lemmey P Maddison J G Andrew Musculoskeletal Research Group Orthopaedic Department Collaborators Physiotherapists

33. Thank you