A multidisciplinary assessment and intervention for patients awaiting total hip replacement to improve their quality of life

Article Outline

• Summary
• Introduction
• Literature review
• Methods
• Results
  • Analysis of descriptive data
• Discussion
  • Interpretation of results
  • Strengths and limitations
  • Changes to practice
• Conclusion
• References
• Copyright

Summary 

The purpose of this small scale study was to determine the efficacy of undertaking a multidisciplinary assessment and intervention to improve the quality of life for patients waiting for a Total Hip Replacement. The waiting list at the time of this study ranged between 3 and 16 months. Patients on the waiting list for total hip replacement were recruited (n=89) then randomly allocated to an intervention group and a control group. The control group received no additional treatment. Those allocated to the intervention group received a multidisciplinary assessment and intervention. The physiotherapist assessed gait analysis and provided an exercise regime to follow, a physical assessment with pre-operative advice from the orthopaedic nurse specialist, pain control evaluation and advice from the nurse specialist in acute pain, and a home visit by the occupational therapist. Quality of life was assessed with the Arthritis Impact Measurement Score 2 and the Nottingham Health Profile. Questionnaires were administered post randomisation and pre surgery.

No definitive conclusions could be drawn on the basis of the inferential statistical results obtained. Statistical significance was shown for only three of the 21 domains assessed, and therefore the null hypothesis had to be accepted. Interpretation of the descriptive data collected during the health professional assessment did however yield important implications for future practice.

Keywords: Multidisciplinary assessment, Pre-operative total hip replacement, Total hip replacement, Joint arthroplasty, Osteoarthritis

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Introduction 

The benefits of Total Hip Replacement (THR) are well documented in the literature, and have been shown to improve health outcomes and quality of life for those who have undergone this type of surgery (Garellick et al., 1998, McMurray et al., 2002, Gogia et al., 1994). There has however been little study into the effects and impact on patients’ quality of life while they wait to undergo this type of surgery. One study investigating the impact of waiting on post-operative outcomes (Fortin et al., 2002) found that the longer the wait for THR the poorer the function at post-operative follow-up.

Historically in the author’s hospital the wait for THR has ranged from between 16 months for routine cases to 3 months for urgent cases. During the time between patients being listed for surgery and attending the pre-operative assessment clinic, patients stated that their general health and fitness had declined because of their reduced mobility and increasing disability. The ‘Avoidance Model’ (Steultjens et al., 2002) goes someway to explain this physical decline. This model is based on the theory that, pain experienced during activity causes a fear that pain will be produced on activity. This results in the person reducing their activity because of the fear of pain. The reduced activity then results in muscle weakness; this weakness results in reduced stability of the joints, which in turn causes actual physical disability. This leads to a downward spiral of increasing physical disability. Hurwitz et al. (1997) also suggests that this reduced mobility or ‘unloading’ of the joint may contribute to overall bone loss; causing potential limitations to the surgical options available. This identified the need to investigate the potential benefits of intervening with these patients whilst they were on the waiting list to improve their health outcomes whilst they wait for surgery.

The aim of the study is to determine the efficacy of multidisciplinary assessment and intervention for patients waiting for THR. Quality of life was determined through the use of two assessment tools, the Arthritis Impact Measurement Scales (AIMS2), and the Nottingham Health Profile (NHP).

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Literature review 

The search strategy used to identify current and relevant literature involved the use of the Medline, CINHAL, British Nursing Index and the Cochrane databases. The key terms used were; multidisciplinary assessment, pre-operative total hip replacement, total hip replacement, joint arthroplasty, and osteoarthritis. These terms were used individually and together to obtain the widest source of literature available. The themes that emerged from the relevant literature were based around physiotherapy involvement, occupational therapy involvement and pre-operative factors that have the potential to affect post-operative outcomes, as well as outcome measurement studies.

Arthritis, due to the destructive nature of the disease, causes severe distress and disability (Chan and Villar, 1996). Forrest et al. (1998) advocate that THR is the best treatment for advanced osteoarthritis that has failed to respond to conservative treatment, a view supported by Garellick et al. (1998) who, when assessing life expectancy and quality of life, propose that treatment with THR relieved pain and improved quality of life.

A survey by Kili et al. (2003) using the Harris Hip Score summarised up the impact of arthritis, for individuals waiting for THR, as enduring pain and disability that gets progressively worse whilst on a waiting list. This certainly seems to be the view held by Gilbey et al. (2003), who suggest that the increased pain and deterioration in function leads to a decrease in mobility and independence. Crowe and Henderson (2003) agree, showing a decrease in quality of life before surgery with increased anxiety regarding the forthcoming surgery.

The multidisciplinary assessment and intervention planned for this study involved the use of a physiotherapist, an orthopaedic nurse specialist, an occupational therapist and a nurse specialist in acute pain.

Physiotherapy for patients, incorporating hip strengthening and gait training, whilst waiting for surgery, works by strengthening the joints pre-operatively and by improving gait function so that excess stress is not placed upon unaffected joints causing them to deteriorate (Hurwitz et al., 1997). Wang et al. (2002) also suggest that patients with arthritis generally exhibited decreased levels of cardiovascular fitness and endurance because of pain and inactivity and that appropriately planned exercise programmes were well tolerated.

Pain experienced by individuals with arthritis has an enormous impact on their quality of life. The pain associated with arthritis, according to Gogia et al. (1994), is the main factor that severely limits the functional status of this group. Knutsson and Engberg (1999), when evaluating changes in quality of life following THR surgery, concluded that the majority of patients were of the view that it was more important to reduce pain than it was to receive any overall increase in quality of life. Pain was shown, through gait compensation studies of patients with osteoarthritis, to be correlated to decreased walking speeds, step rates and single limb stance, whilst also causing the individual to alter their gait pattern (Hurwitz et al., 1997). It is therefore an imperative that pain is managed appropriately for this patient group (Bliven and Kippes, 1999).

Occupational therapists assess patients on an individual basis to determine the aids they may require to enable them to return home safely. They can also play an important part in assisting patients to deal with functional constraints that disease processes such as arthritis may have for them individually. Crowe and Henderson (2003) investigated the impact of undertaking a detailed assessment and administration of relevant equipment pre-operatively. Results presented a positive outcome for patients who received this treatment in relation to reduced levels of anxiety, and their increased preparation for discharge once surgery had been completed. Davidson (1999) found similar results, adding that patients expressed the view that this equipment would have been useful during the long wait for surgery.

The nurse’s role in the study was to obtain a comprehensive medical history and perform a physical assessment of the patient, to ensure fitness for surgery, referring any patients with conditions that could potentially delay their surgery to be assessed and treated by the relevant medical practitioner whilst on the waiting list. This would ensure that when the patient presented to pre-assessment after their time on the waiting list no further delays were encountered. Patients were also counselled regarding their forthcoming surgery and discussions were entered into regarding discharge planning to ensure that once surgery had been undertaken their were no unforeseen circumstances that could potentially delay discharge.

There is a wide range of literature supporting the introduction of individual clinics run by nurses (Jackson, 2003), physiotherapists (Dakker-White et al., 1999) and occupational therapist (Spalding, 1999). However there appears to be little evidence within the literature of multidisciplinary collaboration in addressing the care of patients whilst they wait for surgery.

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Methods 

The research question under investigation in this study was: ‘Does the use of a multidisciplinary assessment and intervention for patients waiting for a Total Hip Replacement improve their quality of life?’ The null hypothesis states that the implementation of a multidisciplinary assessment and intervention between addition to the waiting list and surgery will have no impact on patient’s perceived ‘quality of life’.

The design in this study comprises a before and after two group design (Robson, 1993). For the purposes of this study quality of life was assessed through the Nottingham Health Profile (NHP) (Hunt and McKenna, 1989), which is a quality of life questionnaire, and the Arthritis Impact Measurement Scale 2 (AIMS2) (Meenan et al., 1992) which is a disease specific measurement questionnaire. The use of questionnaires, as a data collection method, has the advantage of removing the potential for ‘interviewer effect’. The use of outcome measures is a critical component to the implementation of evidence-based medicine (American Academy of Orthopaedic Surgeons, 2004).

The NHP is a health dimension profile rather than a single measure of health (Rissanen et al., 1995). Lescoe-Long et al. (1996) in their pre and post-test study, using the NHP, following 35 total joint replacement patients suggest that the NHP is the most content valid of the office appropriate instruments for assessing treatment related change in quality of life for patients with osteoarthritis.

Ren et al. (1999) portray the AIMS2 as a reliable and valid instrument when used among groups with osteoarthritis and advocate its use, because of its simplicity, in clinical trials. The purpose of the AIMS2 was to produce a health status questionnaire that would be sensitive to improvements produced by arthritis therapy (Meenan et al., 1992). For this reason it is ideally suited to this study.

Randomisation was done using a randomisation table that was computer generated. Participates were given a study number after they agreed to join the trial and this number corresponded to a numbered sealed envelope containing the group identification.

The target population was all patients currently maintained on the waiting list for a primary THR across four Consultant’s waiting lists within an NHS Healthcare Trust. All patients on the waiting list with a potential for a 6-month wait or more were contacted and invited to participate in the study. The method of contact was by letter, which contained an information sheet outlining the study type and how randomisation occurred. Sample size was determined based on a pilot study of the AIMS2 questionnaire.

Clinicians within the department were then consulted as to the level of improvement that would need to be shown for the intervention to have been considered successful. They proposed an improvement of between 20% and 30% was sufficient for them to consider the improvements made valid. A halfway point of a 25% improvement was set for the purposes of this study. It was decided to use clinical judgement as the standard for deciding the percentage of improvement as there were no previous studies undertaken that could offer any guidance in this area. The power of the study was set at 90%. Stats Direct © Software was used to calculate the number needed to treat (NNT), based upon the expected standard deviation (taken from pilot study), the percentage of improvement anticipated and the power of the study, (NNT=30 in each group). The number then included in the study was adjusted to cater for the anticipated attrition rate.

The role of the individual health care professionals within the clinic is outlined in Table 1.

Table 1. Intervention by members of multidisciplinary team

The method of data collection was through the administration of the questionnaires pre and post intervention. Participants in the treatment group were asked to complete the questionnaires prior to their assessment and the control group were given a copy to complete post randomisation with self-addressed envelopes to return them to the researcher. Post-test questionnaires were sent to both groups (with self-addressed and stamped envelopes) before surgery took place.

Data analysis was undertaken using the Stats Direct © Software. Data was entered into the software package by the researcher.

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Results 

Data was analysed using the two sample t-test. This test is more generally applied to give confidence to judgments made from small samples, such as the case in this study. The accepted probability value (p-value) for the purposes of this study was set as p=0.050. The scores obtained for each domain within the AIMS2 and the NHP have not been aggregated as total scores. The scores are devised to be calculated with each domain represented by its own individual score. For this reason the difference between groups based on their pre minus the post-test results are presented in this study.

Letters were sent to 208 patients on the primary THR waiting list of four Orthopaedic Consultants. Of the 208 only 93 patients agreed to participate in the study, four were excluded based on the exclusion criteria. The exclusion criteria only covered those not cognitively fit to complete the questionnaire and those living in Nursing homes. This left 89 patients eligible to continue in the trial. Of the total 89 (100%), 43 (48.31%) were randomly allocated to the intervention group and 46 (51.69%) to the control group.

Of the 89 patients recruited to the study only 66 (74.16%) were included in the final analysis. Of the total participants, from the intervention group (N=43), two failed to attend their appointment, and eight were lost to follow-up, leaving 33 (76.74% of the intervention group) participants from the original 43 completing the study. In the control group (n=46), two had been placed on the wrong waiting list, and 14 were lost to follow-up, leaving 30 (65.22% of the control group) participants completing the study.

Table 2 shows the age and gender distribution of the study participants. The mean age difference between the two groups was not statistically significant but there were a higher percentage of females than males within the study sample. The male/female proportion within the study reflects the same percentages contained within the THR waiting list across all four consultants (females 60% and males 40%). This indicates that the sample is representative in terms of gender of the target population under investigation. The sample also represented 50% of the target population, as the combined THR waiting list for all four Consultants was 124 patients.

Table 2. Age and gender distribution

Variable	Treatment group n=33	Control group n=30
Age in years– mean (±SD)	70.33 (±8.12)	65.8 (±10.55)
Males (%)	10 (30.3%)	12 (40%)
Females (%)	23 (69.7%)	18 (60%)

Table 3 shows that statistical significance was only shown in two domains that of hand and finger function (p=0.025) and arthritis pain (p=0.050). However as Bland (2000) suggests caution must be used when attempting to attach importance to lone significant results among a group of non-significant ones, as is the case in this situation. The results may in fact have occurred by chance.

Table 3. Difference between groups in mean score (mean=pre minus post scores) for Arthritis Impact Score

Domain	Treatment group	Control group	p-Value	95% CI for difference
	n=33 Mean (SD)	n=30 Mean (SD)
Mobility	−0.35 (1.71)	0.31 (1.74)	0.139	−1.537 to 0.219
Walking and bending	−0.14 (2.09)	0.75 (1.50)	0.060	−1.810 to 0.037
Hand and finger function	0.45 (1.63)	−0.35 (1.05)	0.025	0.105 to 1.504
Arm function	−0.08 (1.11)	−0.68 (1.67)	0.094	−0.105 to 1.313
Self-care tasks	−0.25 (1.79)	−0.14 (1.95)	0.825	−1.047 to 0.837
Household tasks	−0.23 (1.50)	−0.13 (1.99)	0.805	−0.990 to 0.772
Social activity	−0.71 (2.01)	0.08 (1.37)	0.074	−1.670 to 0.080
Support from family	−0.03 (2.00)	0.52 (2.53)	0.340	−1.696 to 0.594
Arthritis pain	−0.09 (1.61)	0.74 (1.69)	0.050	−1.665 to 0.000
Work	−0.37 (1.17)	0.44 (1.62)	0.051	−1.409 to 0.004
Levels of tension	0.09 (1.65)	0.00 (1.55)	0.823	−0.719 to 0.901
Mood	−0.12 (1.48)	0.08 (1.23)	0.555	−0.894 to 0.485
Satisfaction with health	−0.04 (1.32)	−0.38 (1.54)	0.343	−0.376 to 1.062
Current and future health	−0.61 (2.43)	−0.44 (2.44)	0.793	−1.388 to 1.065
Arthritis impact	0.00 (2.25)	0.58 (1.82)	0.266	−1.622 to 0.455

Table 4 presents the results of the difference between pre and post-test scores for the NHP. However, again caution must be used when interpreting these results due to multiple domains tested within the profile.

Table 4. Difference between groups in mean score (mean=pre minus post scores) for Nottingham Health Profile

Domain	Treatment group	Control Group	p-Value	95% CI interval for difference
	n=33 Mean (SD)	n=30 Mean (SD)
Energy	−9.48 (35.59)	6.67 (34.66)	0.07	−33.87 to 1.59
Pain	−1.46 (22.58)	4.93 (22.77)	0.27	−17.82 to 5.05
Emotional	1.90 (13.67)	2.65 (18.25)	0.85	−8.83 to 7.32
Sleep	−5.70 (24.54)	5.98 (27.02)	0.08	−24.67 to 1.31
Social	4.61 (14.33)	−3.73 (14.37)	0.02	1.10 to 15.57
Physical	−0.47 (12.47)	1.44 (23.13)	0.68	−11.15 to 7.34

Analysis of descriptive data 

The information presented in this section is an analysis of the data collected during the assessment of the intervention group by the members of the multidisciplinary team.

The physical assessment identified eight (24.24%) patients had a cardiac irregularity that required further investigation before surgery could commence, and seven (21.21%) that were referred back to the General Practitioner for blood pressure control pre-operatively. A total of four (12.12%) were identified pre-operatively as requiring the support of the Intermediate care team post-operatively.

Physiotherapy assessment of current gait patterns of the 33 in the intervention group, showed 14 (42.42%) used mobility aids, of these nine were using their mobility aids incorrectly and needed them adjusted to improve gait and functional support. Exercise instructions were given and reinforced with a handout at time of assessment.

On assessment by the nurse specialist for acute pain, 12 (36.36%) were not taking their medication in the most effective way only taking medication on a sporadic basis. Pain control as presented by 11 (33.33%) was insufficient and they were advised of suitable alternatives and referred back to see their General Practitioner to discuss possible alterations to their medications.

In relation to the occupational therapy input the intervention group received an individualised home visit prior to admission; the equipment required was delivered pre-operatively so that patients could become familiar with its use. Those patients in the intervention group required on average a total of three visits/interventions by the occupational therapists compared to the control group which required an average of 4.4 visits per individual. The equipment delivered to both groups was similar, which was to be expected as both groups were undergoing the same operation, equipment requirements were likely to be the same for both groups.

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Discussion 

Interpretation of results 

In this situation, the null hypothesis of no difference between the intervention and control groups must be accepted. Statistical significance has only been shown in two domains, that of Hand and Finger function and Arthritis Pain (p=0.025 and p=0.05, respectively). However as stated previously care must be taken when interpreting these results as there is a possibility that they occurred by chance.

There can be no comparisons between other similar studies, as no such studies have been undertaken. Bland and Altman (1995) suggest that when there is no evidence of statistical significance between two groups, you should ask whether the absence of evidence means that there is in fact no information at all. Clark-Carter (2003) indicates that the views on statistical significance are changing and that significance cannot be considered, on its own, as an adequate measure of the value of research studies, and that a combination of types of evidence is required to demonstrate the value of studies.

Recruitment to the study was difficult, (participant flow data Fig. 1), 208 patients were invited to participate, but only 89 were successfully recruited. The explanation behind the high number (n=22) of participants lost to follow-up during the study can be attributed to several factors. Firstly, a change to the admission process took place and Consultant’s secretaries no longer called the patients for surgery, this was now done by a centralised unit, and so the transfer of information between those being admitted and the researcher was lost, resulting in patients being admitted before they had completed their second questionnaires. The second reason was due to the introduction of a waiting list initiative, where surgeons put on extra lists and undertake more work. Some of this work was undertaken in an adjacent hospital. This resulted in patients being operated on much sooner than anticipated, and in different locations.

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• Figure 1. 

  Study participant flow.

The groups with statistical significance in the AIMS2 score are, hand and finger function and arthritis pain, and in the NHP score it was the social domain. The statistical findings for the hand and finger function cannot be explained by the intervention, and can only be presented as occurring by chance. The reasons for the improvement in the arthritic pain domain could be associated with the advice and recommendations given by the nurse specialist for acute pain. However if this were the case it would be anticipated that significance would have been shown in both scales for the pain domain, and it was not. The findings in the social domain within the NHP could be related to the psychological benefits of interacting with the staff at the hospital and not feeling that they are alone addressing psychological needs combined with the therapeutic interventions for the intervention group.

The borderline significance in the walking and bending category may be related to the percentage (64.28%) of the treatment group that used mobility aids who were using them incorrectly when they attended the assessment clinic, and this was corrected for them before they left the clinic. Work was the other domain within the AIMS2 that showed evidence of borderline significance. The actual number of participants that were still working was quite low (intervention group n=4, control group n=5), and because of this no firm conclusions can be drawn. In the NHP the borderline domains were sleep and energy. The importance of this could be related to the improvement in pain control. If there were an improvement in patients overall pain experience then this may assist in facilitating a better nights sleep and so consequently may increase energy levels.

Another factor that must be taken into account is what Robson (1993) calls the impact of susceptibility. This is when the impact of participating in a study and feeling involved alters the participants’ perception of the situation under study. This could certainly be the case in this instance. Patients had already stated that they had felt lost and alone on the waiting list with no contact from any healthcare professionals. The fact that they were contacted and attended the hospital, whether in the control or the intervention group, may have affected their perception and so affected their results. Parahoo (1997) described this as the Hawthorne effect.

Strengths and limitations 

Limitations of the study evolve around several areas. Firstly, the study was based on the expectation of detecting a 25% increase in functional ability of the treatment group. Clinicians determined the 25% figure because there were no previous studies. It may have been however, that this figure was too high to detect the type of change likely to have been seen, considering the intervention was not treating their arthritis but attempting to assist in its management. Whether this was indeed the case can only be determined by further larger scale studies.

Secondly, neither of the two data collection tools addressed patient satisfaction with the new intervention. Telephone conversations relayed to the researcher by participants in the intervention group highlighted their pleasure in the new service, and how they felt they were no longer being ignored whilst they waited for surgery. It may be that the improvements felt by the participants related to the quality of the service they received and how this made them feel. The experimental research methodology was based on a positivist paradigm, using observable and quantifiable results (Shih, 1998), so the benefits of the intervention may not have been measurable through the methodology used.

Thirdly, the study did not measure compliance with the advice and exercise regime offered to the individual participants. The results obtained may in fact represent poor compliance rather than no measurable difference between the two groups. However, Wang et al. (2002) demonstrated that patients with arthritis did tolerate and comply with exercise programmes. A measure of concordance would need to be built in to further studies, supplemented with explanation of reasons for non-concordance to improve the professional’s understanding, to assess the impact of this type of intervention.

Changes to practice 

As a result of the study several changes to practice have already taken place. One of these has been the introduction of Occupational and Physiotherapy services into the pre-operative assessment clinic. Both groups of therapists found benefits to their practice of seeing these patients pre surgery to determine post surgery requirements. This study also added support for the proposed introduction of a pre-operative health-screening service. The patients who are now being listed for surgery will be asked to fill out a health assessment questionnaire, this highlights any potential health problems that might require pre-operative investigation, and if problems are identified they can be addressed whilst the patient waits, rather than causing delay just prior to admission.

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Conclusion 

The statistical results of the study did not offer any definitive conclusions that should be implemented in terms of the intervention offered during this study. However there are three implications for practice that have arisen as a result of the assessments by members of the multidisciplinary teams. It was highlighted that 64.28% of those using mobility aids were using them incorrectly, or required a different aid.

The second implication would be the setting up a medicines advisory service that would offer advice regarding the most effective and appropriate use of the patient’s medication at the time that it is prescribed or dispensed, whether this is in the hospital, GP surgery or the chemist. The acute pain nurse specialist assessment identified 36.36% of the intervention group as failing to take their medication in the most effective way.

Thirdly, this research has highlighted the need, and perhaps identified the core components, of a health-screening tool that could be used by multi-professional healthcare practitioners for all members of the population, especially those referred for surgical procedures.

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References 

1. American Academy of Orthopaedic Surgeons (nd) Improving musculaskeletal care in America. Osteoarthritis of the knee: Evidence-based resources. <http://www3.aaos.org/research/imca/OakneeContents/OA_knee_m3_4.htm> (retrieved 23.02.04.).
   • View In Article
2. Bland JM. An Introduction to Medical Statistics. New York: Oxford University Press; 2000;
   • View In Article
3. Bland JM, Altman DG. Multiple significance tests: the Bonferroni method. British Medical Journal. 1995;310:170
   • View In Article
4. Bliven CE, Kippes C. Depression, social support, and quality of life in older adults with osteoarthitis. IMAGE: Journal of Nursing Scholarship. 1999;31(3):221–226
   • View In Article
5. Chan CLH, Villar RN. Obesity and quality of life after primary hip arthroplasty. The Journal of Bone and Joint Surgery. 1996;78-B(1):78–81
   • View In Article
6. Clark-Carter D. Effect size. The missing piece of the jigsaw. The Psychologist. 2003;16(12):636–638
   • View In Article
7. Crowe J, Henderson J. Pre-arthroplasty rehabilitation is effective in reducing hospital stay. The Canadian Journal of Occupational Therapy. 2003;70(2):88–96
   • View In Article
8. Dakker-White G, Carr AJ, Harvey I, Woolhead G, Bannister G, Nelson I, et al. A randomised controlled trial. Shifting the boundaries of doctors and physiotherapists in orthopaedic outpatient departments. Journal of Epidemiological Community Health. 1999;53:643–650
   • View In Article
9. Davidson T. Total hip replacement: an audit of the provision and use of equipment. British Journal of Occupational Therapy. 1999;62(6):283–287
   • View In Article
10. Forrest G, Fuchs M, Gutierrez A, Girardy J. Factors affecting length of stay and need for rehabilitation after hip and knee arthroplasty. The Journal of Arthroplasty. 1998;13(2):186–190
    • View In Article
    • Abstract
    • Full-Text PDF (405 KB)
    • CrossRef
11. Fortin PR, Penrod JR, Clarke AE, St-Pierre Y, Joseph L, Bélisle P, et al. Timing of total joint replacement affects clinical outcomes among patients with osteoarthritis of the hip or knee. Arthritis and Rheumatism. 2002;46(12):3327–3330
    • View In Article
    • MEDLINE
    • CrossRef
12. Garellick G, Malchau H, Herberts P, Hansson E, Axelsson H, Hansson T. Life expectancy and cost utility after total hip replacement. Clinical Orthopaedics and Related Research. 1998;346:141–151
    • View In Article
13. Gilbey H, Ackland TR, Wang AW, Morton AR, Trouchet T, Tapper J. Exercise improves early functional recovery after total hip arthroplasty. Clinical Orthopaedics and Related Research. 2003;408:193–200
    • View In Article
    • CrossRef
14. Gogia PP, Christensen CM, Schmidt C. Total hip replacement in patients with osteoarthritis of the hip: improvement in pain and function. Orthopaedics. 1994;17(2):145–150
    • View In Article
15. Hunt, S., McKenna, S., 1989. The Nottingham Health Profile: English Source Version. The European Group for Quality of Life and Health Measurement.
    • View In Article
16. Hurwitz DE, Hulet CH, Andriacchi TP, Rosenberg AG, Galante JO. Gait compensations in patients with osteoarthritis of the hip and their relationship to pain and passive hip motion. Journal of Orthopaedic Research. 1997;15:629–635
    • View In Article
17. Jackson R. Advancing nursing practice for orthopaedic outpatients. Journal of Orthopaedic Nursing. 2003;7:10–14
    • View In Article
18. Kili S, Wright I, Spencer Jones R. Change in Harris Hip Score in patients on the waiting list for total hip replacement. Annuals Royal College of Surgeons England. 2003;85:269–271
    • View In Article
19. Knutsson S, Engberg IB. An evaluation of patients’ quality of life before, 6 weeks and 6 months after total hip replacement surgery. Journal of Advanced Nursing. 1999;30(6):1349–1359
    • View In Article
    • MEDLINE
    • CrossRef
20. Lescoe-Long M, Long MJ, Johnston DWC. Quality of life improvement in patients with osteoarthritis: the potential for office-based assessment. Arthritis Care and Research. 1996;9(3):177–181
    • View In Article
21. McMurray A, Grant S, Griffiths S, Letford A. Health elated quality of life and health service use following total hip surgery. Journal of Advanced Nursing. 2002;40(6):663–672
    • View In Article
    • MEDLINE
    • CrossRef
22. Meenan RF, Mason JH, Anderson JJ, Guccione AA, Kazis LE. The content and properties of a revised and expanded Arthritis Impact Measurement Scales health status questionnaire. Arthritis and Rheumatism. 1992;35(1):1–10
    • View In Article
    • MEDLINE
    • CrossRef
23. Parahoo K. Nursing Research. Principles, Process and Issues. Hampshire: Palgrave; 1997;
    • View In Article
24. Ren XS, Kazis L, Meenan RF. Short-form Arthritis Impact Measurement Scales 2: tests of reliability and validity among patients with osteoarthritis. American College of Rheumatology. 1999;12(3):163–171
    • View In Article
25. Rissanen P, Aro S, Slätis P, Sintonen H, Paavolainen P. Health and quality of life before and after hip or knee arthroplasty. The Journal of Arthroplasty. 1995;10(2):169–175
    • View In Article
    • Abstract
    • Full-Text PDF (597 KB)
    • CrossRef
26. Robson C. Research in the Real World. Oxford: Blackwell; 1993;
    • View In Article
27. Shih F-J. Triangulation in nursing research: issues of conceptual clarity and purpose. Journal of Advanced Nursing. 1998;28(3):631–641
    • View In Article
    • MEDLINE
    • CrossRef
28. Spalding NJ. The assessment of surgical priority by occupational therapists. British Journal of Occupational Therapy. 1999;62(5):229–231
    • View In Article
29. Steultjens MPM, Dekker J, Bijlsma JWJ. Avoidance of activity and disability in patients with osteoarthritis of the knee. Arthritis and Rheumatism. 2002;46(7):1784–1788
    • View In Article
    • MEDLINE
    • CrossRef
30. Wang AW, Gilbey HJ, Ackland TR. Perioperative exercise programs improve early return of ambulatory function after Total Hip Arthroplasty. American Journal of Physical Medicine and Rehabilitation. 2002;81(11):801–806
    • View In Article