The value of translation became apparent to me several years ago while my wife and I were traveling through Europe. Having spent several days in Oxford, our original travel plans had us going on to London, where we would board a high-speed Chunnel train that would take us under the English Channel to Paris in a few short hours. However, the day before our train was scheduled to depart, a fire in the Chunnel shut down that route. Our three-hour train ride was replaced by a 24-hour assortment of disjointed train, ferry, and taxi rides, interspersed with dragging our heavy roller-board luggage across several miles of cobblestone walkways.
English, a bit of patience, and some common courtesy will generally get you where you want to go if you stick to major cities in Europe. However, the same cannot be said of some of the smaller, out-of-the-way cities. When my wife and I found ourselves in a small train station in the port town of Calais on the northeast coast of France, translation, in any form, would have been greatly appreciated. The information we needed was all around us, but because we did not speak the local language, we had no way to access it.
Things worked out, but we felt an indescribable sense of relief when we stepped off the train in Paris and rendezvoused with my wife's parents who were then living in France and spoke fluent French. At least for that day, the challenges of translation were behind us.
Most O&P professionals would agree that the ultimate goal of O&P research is to enhance the lives and well-being of our patients. While there will always be a need for more research, in recent years there has been a significant increase in available O&P research findings. Unfortunately, there also is a large disconnect between the laboratory and the treatment room. With few exceptions, the researchers in our field provide very little patient care, and most of our patient care providers have very little involvement in research.
The value of any O&P-related research ultimately depends on the degree to which the relevant findings permeate the clinician's decision making. Even the most elegant research designs are of limited value if they fail to inform clinical care. As the research in our industry becomes more abundant, the next challenge we will face is one of translation—converting important research findings into formats that are accessible and accessed by clinical decision makers.
A Question of Usefulness
Knowledge translation plays an important role in keeping healthcare information useful. The usefulness of a piece of medical information to a given practitioner is a product of its relevance and validity, divided by the amount of work required to obtain it.1–2 Such usefulness can be represented by the following equation:
Usefulness = (relevance x validity)/work
Before considering the components of this equation, a general observation should be made. If clinicians do not view a given piece of information as useful, it will not be mastered or incorporated into clinical decision making. The content of most primary knowledge sources is rarely seen as useful, which is why most practitioners are often ill-informed on much of the latest published research findings.
Relevance: The relevance of a given insight into clinical practice depends largely on how often a clinician comes in contact with the associated question or concern. The relevance of medical information in O&P is complicated by the fact that most practitioners are generalists, seeing a broad range of patient presentations that require a host of different interventions. This is especially true in orthotic practice, where a range of interventions across the lower limb and spine are routinely encountered (Figure 1). For practitioners whose daily patient loads span such a broad continuum of care, the relevance of a single piece of information affecting a single specific patient population can be justifiably questioned. The same information is more relevant to a specialist who encounters the population in question with greater regularity. This reality might help explain why practitioners who specialize in a given patient population, such as scoliosis, cranial remolding, or upper-limb prosthetics, tend to be more informed on recent literature and advanced techniques.
Validity: This idea represents the likelihood that a given piece of medical information will apply to the cases placed before practitioners. As with relevance, validity faces inherent challenges in O&P care. Unlike pharmaceutical interventions, where very quantifiable doses can be administered to extremely large groups, the O&P world contends with too many variables to make this approach viable. In their attempts to quantify the effects of an intervention, researchers may narrow the variability of the study population by applying strict exclusion criteria. By doing so, their findings will apply to a narrower range of patients. Alternately, researchers may broaden the inclusion criteria to increase the number of subjects, but this increases the number of variables that affect the outcomes, making it more difficult to isolate the treatment effects. Because of the variability in individual patients, including strength, range of motion, spasticity, and compliance, and additional variability in the material strength, joint angles, and component properties, it is extremely difficult for medical information to obtain high validity in clinical practice.
Work: The last variable reflects the amount of effort required for clinicians to obtain a given piece of medical information. While relevance and validity are challenged by their lower values, work is generally plagued with very high values. The first challenge is one of access. According to the last Practice Analysis of Certified Practitioners in the Disciplines of Orthotics and Prosthetics, performed and published by the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC), only 20 percent of ABC-certified practitioners work in a hospital or university setting.3 Even for these professionals, who have access to published research through their affiliations, the process of seeking out relevant, valid literature is difficult and time-consuming. The process requires one or more initial database searches, skimming numerous abstracts, pulling up promising studies, and reading and understanding lengthy academic papers that may use unfamiliar statistical terminology. For the remaining 80 percent of the field, the process is further complicated by a lack of access to the majority of pertinent academic literature. Without hospital or university affiliations, clinicians who have made the time to investigate a given article must often pay fairly substantial access fees.
Many of the usefulness challenges facing the O&P community are unlikely to go away. While a minority of clinicians in large metropolitan centers may be able to specialize their caseloads, the majority of orthotists and prosthetists will continue to be generalists, treating a broad range of patients with an equally broad range of interventions. Thus, relevance will continue to pose a challenge to the usefulness of medical information. Similarly, the patients we treat will continue to present with a range of characteristics in their primary and treatment diagnoses. O&P devices are unlikely to homogenize, and clinicians will continue to see a variety of subtleties in device design and attributes. Thus, validity will likewise pose a continued challenge to the usefulness of new medical insights. With these factors destined somewhat to lower values, the usefulness of developing medical information relative to O&P care will be determined largely by the work required to obtain it.
This work is decreased when knowledge that is tucked away in the pages of an obscure academic publication is translated from its primary form into a more accessible secondary form.
Secondary Knowledge Sources
In contrast to the difficulties associated with obtaining medical information from primary knowledge sources; i.e., the original research articles, secondary knowledge sources translate that knowledge into formats that remove many of these barriers. They do so by summarizing research findings and placing them in context with similar findings. In O&P, several secondary knowledge sources have been developed as potential resources for clinicians in search of useful medical information.
State of the Science Conferences: Beginning in 2004 and funded by a grant from the U.S. Department of Education, the American Academy of Orthotists and Prosthetists (the Academy) began hosting State of the Science Conferences (SSCs). To date, ten such conferences have been held, spanning a broad range of O&P topics (Table 1). Because of their federal funding, the proceedings of these conferences have been made openly available on the Academy's website at www.oandp.org/jpo, making them a valuable secondary knowledge source.
Literature Updates: Begun by Samuel Phillips, CPO, the Academy's Literature Updates are intended to keep busy clinicians updated on new research findings. Hundreds of academic journals are published every month. Periodic updates are performed in which the PubMed database is searched for those articles relative to O&P care. The titles of the articles that pass this screening process are sent out in a periodic e-mail to the Academy's e-mail distribution list. Each article title is hyperlinked to the article's abstract or, when available, to the full-text article itself. These article lists are archived on the Academy website for later viewing.
A similar weekly literature update that is specific to the cerebral palsy patient population is prepared and distributed by the Cerebral Palsy Alliance. Persons interested in receiving these e-mail updates can subscribe free of charge at www.cpresearch.org/subscribe/researchnews. Although few of the abstracts are directly related to the orthotic management of cerebral palsy, the update is a valuable resource for clinicians who frequently treat this population and want to stay abreast of the latest research findings.
O&P Atlases: Periodically revised and updated, the American Academy of Orthopaedic Surgeons (AAOS) Atlas of Orthoses and Assistive Devices, 4th Edition, and the Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles, 3rd Edition, remain two of the profession's most useful secondary knowledge sources. Talented, experienced clinicians have authored the individual chapters, translating available medical information into succinct, informed reflections on their respective topics.
The American Academy of Orthotists and Prosthetists Annual Meeting & Scientific Symposium: While people tend to think of knowledge sources in print form, the annual meetings of the Academy and similar organizations can provide useful information. Once the time is set aside, active listening is all that is required to receive updates on the developing techniques within our field. With each passing year, the content of these meetings improve, reflecting more and more science, while also acknowledging the value and insights of clinical experience.
As more high-quality O&P research is performed and published, the profession must continue to recognize that the ultimate purpose of this research is to benefit patients. To that end, the full benefit of any O&P-related research is not realized until it permeates the decision making of individual clinicians and ultimately affects individual patients. There is a continued need for the translation of developing medical information into formats that are more readily accessible to today's busy practitioners. Without knowledge translation, we will be stuck in a train station without a clear understanding of which train to board.
Phil Stevens, MEd, CPO, FAAOP, is in clinical practice with Hanger Prosthetics & Orthotics, Salt Lake City, Utah. He can be reached at
- Slawson, D.C., A.F. Shaughnessy, and J.H. Bennett. 1994. Becoming a medical information master: feeling good about not knowing everything. Journal of Family Practice 38(5):505–13.
- Slawson, D.C., and A.F. Shaughnessey. 1997. Obtaining useful information from expert based sources. British Medical Journal 314(7085):947–49.
- Whiteside, S.R., M. J. Allen, W.J. Barringer, et al. 2007. Practice Analysis of Certified Practitioners in the Disciplines of Orthotics and Prosthetics. Alexandria: American Board for Certification in Orthotics, Prosthetics and Pedorthics.