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O&P Research: A Question of Quality—or Quantity?
By Judith Otto Take a little trip with an Internet search engine
and see what you come up with under "Prosthetic Research." Your
findings (or lack thereof) will likely illustrate one of the major
problems with P&O research today.
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Mark Geil, PhD |
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When Mark Geil, PhD, Georgia Institute of
Technology, Atlanta, conducted such a search using MedLine, he
found that 17 of the 20 articles were on dental prosthetics or
prosthodontics. Of the three that were on limb prosthetics, he
reports, two came from academia and one from a round table funded
by the Department of Veterans Affairs (VA) and the National
Institutes of Health (NIH). "It does give you an indication that
among the index of literature, the impact from P&O
practitioners is lacking," he notes.
Is this what's wrong with O&P research? Or are we
overreacting? Are there really any problems with O&P
research?
Responding to generalized grumblings that the quality of
research in O&P leaves a lot to be desired, and that much of
the important and relevant research to date has come from outside
the profession, The O&P EDGE asked leaders in the field for
insights and opinions.
Tom Gorski, CAE, executive director of the American Academy of
Orthotists and Prosthetists (AAOP), points out that the need for
more and better research is being addressed by the Academy's
Project Quantum Leap, which encompasses a series of activities to
advance the profession as a whole.
"Within the next year," said Gorski, "We'd like to host a
research agenda conference, drawing together 20 to 25 top people in
the industry-each experts in their particular area-to meet for two
to three days to discuss what is already out there, and what is
lacking."
Such a conference would yield a clearer picture of the current
state of affairs in O&P, and is sorely needed, since the
findings of the last conference were printed in 1992 as P&O
Research for the 21st Century, Gorski explained. "Although this
book is about ten years out of date, it is probably-sadly!-still
current."
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Don Katz, CO, FAAOP |
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Don Katz, CO, FAAOP, Academy president-elect and
liaison to the Academy's Research and Development Committee,
further explains that Project Quantum Leap is seeking federal
funding to help support O&P education. "We hope to fund and
spur applied research," emphasized Katz. "That is, research which
is immediately applicable to clinical practice, with
patient-specific objectives. I believe one of the primary purposes
of a profession is to develop a knowledge base that will positively
impact our ability to care for those that require our services.
"Our intention is to help fund consensus conferences on Clinical
Standards of Practice (CSOP). Each conference on a specific topic
will determine our current belief system, and thus help define our
research priorities for the future.
"Findings should be as literature-based as possible, but when
there is no literature available, clinicians have little to fall
back on to help them establish treatment protocols."
Each conference takes nearly one to two years to execute, says
Katz: nine months to organize the meeting, recruit faculty, and
start them writing manuscripts; then 12 months of editing points of
consensus and priorities from the conference itself, and
determining how and where to publish results.
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Georgia Tech MSPO student Dave Fritz uses callipers to record anthropometric data before gait analysis. Body segment parameters are used to translate marker oordinates to more useful joint center coordinates. |
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The first conference was hosted in February 2002,
and focused on the orthotic treatment of idiopathic scoliosis and
Scheurmann's kyphosis. Resulting materials are now in the final
editing process, Katz reports, and he will present the preliminary
results at the Academy meeting in San Diego, CA, March 19-22. The
goal of these conferences is to increase the body of knowledge in
literature so that it can be referenced, Katz noted.
An infinite number of topics are available for these CSOP
conferences, since by the time the primary subjects are covered, it
will be time to revisit them and explore new findings and beliefs,
Katz said. If successfully financed, the conferences will be a
continuous, ongoing process, and a first step to spurring
additional research efforts, he explained, adding, "This is not a
destination, but a process."
Katz points out that, more than 20 years ago, the majority of
research that influenced O&P was done by physicians such as
orthopedic surgeons. "During the last 20 years, this is becoming
less and less the case. This has left a void to be filled. This
research can be done by other medical disciplines, but they are
less tuned in' to the needs of providing orthoses and
prostheses."
Applied Research: O&P Involvement
For orthotists and prosthetists to become more involved with
applied research is an achievable goal, Katz believes, "but I don't
think the way we've tried to accomplish this has been effective to
date. I'm one of those pushing hardest for success in this area,
but there must be a shift in our primary education for orthotists
and prosthetists to make this a goal. Structured education on how
to conduct applied research is to some extent woven into the
current prosthetic/orthotic curriculum, but more is needed if a
true priority shift, or new paradigm, within our profession is to
occur."
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Mike Raney, PhD, CO |
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Mike Raney, PhD, CO, current chair of the Academy
R&D Committee, shares Katz's passion for educating and
involving orthotists and prosthetists in applied research by
providing them with the tools to do so.
Raney has written a 27-page paper-A Guide to a Simple Research
Project-which has recently been made available on the Academy's
website, (www.oandp.org). It offers a broad overview of
how to do a quantitative research project. Although it was written
to help O&P residents with their required research projects, it
is relevant to others in O&P who are interested in research,
says Raney.
Raney has circulated a Research Interest Survey, intended to
explore the research interests and needs of Academy members. The
survey also took inventory of the research knowledge levels of the
respondents, and asked what research questions members thought were
important to O&P.
"We sent out the research interest survey, via fax, to about
1,000 Academy members," Raney explained. "Our response rate of
about 17 percent was typical for a faxed survey. We would have
liked to have every member respond on this important topic. About
20 percent of the respondents listed one or more research questions
they thought were important. It appeared that not a lot of thought
has been done on what research topics are important to
O&P."
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Georgia Tech MSPO students Mark Holowka and Kristen Andrews attach reflective markers in preparation for a kinematic motion analysis of Paralympic gold medalist Shea Cowart. Photo by Nicole Capello |
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From the survey, Raney said, the R&D Committee
will develop a research networking list or database. The database
would include skill levels, interest in mentoring, willingness to
advise on residency projects, willingness to participate in
research, and more. About 80 percent of the respondents indicated
that their facilities would be interested in participating in a
research project.
Raney has also helped to write the Research Reference Guide, a
compilation of a series of articles on research methodology that
were originally presented over a two-year period in the Journal of
Prosthetics & Orthotics. The Guide, which can be found in the
Members Only section of the Academy website, includes the JPO
article series and provides links to some other websites offering
helpful research guidance.
"The basic problem is that most fields teach research and
statistical methods at the graduate level," says Raney, "but
O&P has only two Masters programs and no PhD programs in this
country. Most O&P professionals with knowledge of research were
trained in research in other fields."
"Is research by O&P professionals of poor quality? No-
research by O&P professionals just isn't being recognized as
such," according to Raney. "While there are numerous O&P
professionals participating in research, they are generally part of
a team led by researchers from other fields," he explained. "It is
widely accepted that the people who are best qualified to do
research in a field are those with intimate clinical knowledge and
experience. In O&P, this would be the practitioners." Thus very
few of the important questions facing O&P have been
answered-and we need researchers to answer them.
"It's not going to happen fast," he concludes. "We're just
starting to take the first steps down a long road. I feel it's very
important that we involve consumers of O&P research (i.e.
practitioners) in this process." Hopefully, reading articles on new
possibilities for care and treatment will spur their interest in
applied research, he noted, adding, "All the research does no one
any good if it isn't read by practitioners and integrated into
their daily practices."
Quantification: Getting the Numbers
Quantification problems in O&P can be troubling, according
to Mark Geil. "There's not really a lot of quantification routinely
used in clinical practice," he points out, noting that there are
ways to quantify many attributes about human movement that could be
routinely carried out. "We would then have 10-20 years' worth of
data, and we could do retrospective studies and post hoc analyses.
But until that body of numbers and data exists, everything we are
doing is prospective-it's hit or miss. If we need a certain idea
about an outcome of treatment-and it's never been quantified in the
past-that makes it difficult, based on the numbers you need for the
experiment, to make a case for any change clinically."
Geil agrees that when we compare the body of literature in
prosthetics and orthotics to similar bodies of literature elsewhere
in allied health and in disciplines such as biomechanics, it's
certainly lacking. "There is almost a youthful naiveté," Geil
reflects. "What we know is far less mature than what is known in
other similar fields."
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Bilateral amputee and 100m world record holder Shea Cowart participates in instrumented gait analysis at Georgia Tech to determine the biomechanics of her running stride. Twenty-one reflective markers are traced in three dimensions by specially filtered cameras. Photo by Nicole Cappello |
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"That's good and bad. We don't know as much as we
wish we did, but it also opens the door for a lot of research
questions that have yet to be answered, and therefore a lot of
opportunities to improve the quality of patient care."
"Generally speaking, we are lacking knowledge of some
fundamental issues," he says. "We still don't have an adequate
biomechanical model of a prosthetic foot. We're out there designing
and producing them for amputees, based on a lot of pretty bold
assumptions about knowledge that we've never quantified. What are
amputees' specific goals for walking with a prosthesis? That's
something that we could design for-if we knew what it was.
"We've never quite understood issues relating to metabolic
energy use for amputees engaged in various activities," Geil
continues. "And the list could go on."
Georgia Tech has taken the first step to help address the lack
of O&P research by implementing its landmark masters program.
The program includes teaching how to do research-how to formulate a
hypothesis, how to read and understand a manuscript, and how to
write their own-and then actually do it. "You can take a research
methods course, but until you're actually in the lab collecting
data, it doesn't have a lot of real-world meaning," Geil points
out. "Our students in their first semester have already conducted
their own instrumented gait analysis, based on their own research
idea from start to finish-from calibration of the cameras all the
way through processing of the data. We're making sure they have
those skills, so that when they become practitioners and they have
an idea or question about a certain device or treatment, they have
the knowledge to get answers to those questions."
At least for the present, in a world where few answers exist in
the sparse O&P archives, the solution would seem to lie in
equipping practitioners with skills sufficient to answer their own
questions.
Geil agrees. "We're also teaching quantification as a part of
clinical practice. We've got a lot of CAD/CAM systems-maybe it's
important to document the volume of residual limb or the shape of
the planar surface of the foot routinely with every patient you
see, whether you're going to treat them that way or not. If those
numbers start to accumulate over time, then we can answer questions
that we didn't know existed when we were accumulating those
numbers."
Editor's note: The current state of O&P research is a
many-faceted subject. Upcoming articles will present more views and
possible solutions from leaders in the field. One thing we all know
for sure: today's research will impact tomorrow's practice. Judith Otto is a freelance writer based in Holly Springs, Mississippi. 
Table Of Contents - March 2003
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