Research has multiple important functions. For instance, it describes standard and novel aspects of clinical practice, characterizes the state of education of a profession, demonstrates what late-breaking techniques and devices are being used in laboratories and in the field, and ultimately represents a profession's body of knowledge. It is becoming increasingly apparent that research in P&O and other clinical healthcare practice fields is intimately linked to reimbursement, as evidenced by the recent trend of outcome-based and evidence-based practice.
As a profession evolves, so must its pedagogical strategies, practice techniques, and, of course, its research. Examples in P&O include active, as opposed to passive, learning and a movement toward the clinically based, entry-level master's degree. In practice, there is an increasing discussion, consideration, and hopefully implementation of outcome measures in patient care decision making. Research in P&O is also evolving. With the wars in Iraq and Afghanistan, the rehabilitation sciences, including P&O, have seen increased research funding. Staggering advances in P&O technology in the previous decade have brought with them additional burdens on the various payers of healthcare services, including the Department of Veterans Affairs (VA), Medicare, Medicaid, commercial insurers, and individuals. There has also been an increased sensitivity to the research methods used to assess the efficacy of the devices in affecting patient function and quality of life.
So how is P&O research advancing to the next level? Research will advance as the profession trains literature consumers to be more critical. As P&O education moves to the clinically based, entry-level master's degree, this is one anticipated outcome. Master's degree graduates will be able to critically appraise literature and be able to discern between studies that were conducted with high levels of rigor and control compared to work that is at risk of the influence of bias. These graduates will also be able to discern between the appropriateness of the conclusions of a study given its design; for example, if a study was experimental in nature, as opposed to observational, and if a conclusion of a causal relationship between component function and outcome is appropriate. Moreover, improved literature consumers will ideally have a sense of the effect of sample size, study power, and larger concepts such as threats to internal and external validity. Ultimately, the envisioned literature consumer of tomorrow will be able to make determinations about the applicability of results to their own patient caseload.
It is reasonable to assume that if there is a more critical consumer audience using and evaluating the literature, then those creating the work would improve the product—the research and its processes. What is necessary to do this? The number of individuals with advanced and terminal research training is limited. The number of programs providing this training is also limited. However, with the increased focus on the rehabilitation and movement sciences, specifically in the case of P&O, a few new programs providing this advanced research training and mentorship have emerged and will continue to do so. This will provide increased opportunities in terms of the number of educational institutions and mentors available for acquiring this training. Similarly, as there is a slight increase in the number of educational institutions with a focus in P&O research, the competition for research funding increases, which under basic capitalist principles means that ideally the best ideas, best methods, and best overall return on investment will be funded. The positive outcomes from this should be the emergence of higher-quality research proposals.
So exactly what does a high-quality research proposal look like?
Methodologies in prosthetics have historically left room for improvement. Some classic problems in P&O research include limited funding, non-blind and non-random study designs, small sample sizes, research teams lacking a full complement of multidisciplinary members, and use of non-validated/unreliable outcome measures, among other issues. This is not to say that these issues have not previously been addressed or are completely remedied by today's research; however, the field is beginning to pay closer attention to them. For instance, in answer to the historic problem of small sample sizes, rather than jumping to non-strategically selected large sample sizes, P&O researchers today are improving at reporting the rationale for a sample size in terms of a priori determined (or observed) power or, conversely, disclosing their limitations relative to their sample size and the associated implications. Similarly, researchers seem to no longer be satisfied accepting the notion that P&O devices can only be studied in non-randomized and non-blinded formats—the more difficult format being the inability or difficulty of blinding. Some devices are far more conducive to blinding than others. Consider studies of liners and feet components that could be fit on a patient or as part of the patient's device and incorporate some element of blinding. Doing so could potentially change the grade of a particular piece of research evidence by a complete letter (i.e. from grade B to grade A evidence). The addition of randomization and blinding also tends to add to the complexity of a study and thereby could have major consequences in terms of the cost and/or duration of the study, but as the cliché states, "the easy way is probably not the right way."
Other factors helping to take P&O research to the next level have been catalyzed by professional associations such as the American Academy of Orthotists and Prosthetists (the Academy). The Academy publishes the Journal of Prosthetics and Orthotics (JPO), a prominent source where one can find contributions to the profession's scientific body of knowledge. The Academy also has as part of its structure a research council (RC). The RC has many ongoing initiatives to facilitate research and to improve consumerism. The RC has a number of committees within it to advance research initiatives, such as reviewing O&P resident research projects, discussing the cataloging and implementation of outcome measures, and creating secondary knowledge resources. The Academy, largely through the RC, also oversees the ongoing development of the State-of-the-Science Conferences, which have contributed to and/or created numerous JPO supplement issues and One-Day Seminars.
Research in P&O is advancing to the next level. This is the product of a ground swell of factors. The positive outcomes of advancing our profession's research will be higher-quality studies, advanced technologies, improved research consumerism, and more. These are unquestionably wonderful gains for the profession; however, the single most important gain is improved P&O care for the next patient on your schedule.
M. Jason Highsmith, DPT, CP, FAAOP, is an assistant professor at the School of Physical Therapy & Rehabilitation Sciences at the University of South Florida, Tampa. He is jointly appointed as a research associate at the James A. Haley Veterans' Administration Hospital, Tampa, Florida.
Jason T. Kahle, CPO, FAAOP, is an assistant in physical therapy at the School of Physical Therapy & Rehabilitation Sciences at the University of South Florida, Tampa.
Society Spotlight is a presentation of clinical content by the Societies of the American Academy of Orthotists and Prosthetists (the Academy) in partnership with The O&P EDGE.