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Research: Getting to the Next Level
By Judith Philipps Otto 
What will be the state of orthotic and prosthetic research five
years from now? What will help take the profession to the next
level?
Some leading educators offer their insights.
Mark Geil, PhD , assistant professor, School of
Applied Physiology, Georgia Institute of Technology, Atlanta,
comments, "It's hard to predict the future. We're doing what we can
to teach research and encourage our students to answer questions
and solve problems through sound research mechanisms. If they're
taught research adequately, they will have a big impact.
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Mark Geil, PhD |
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"Anecdotally, what I've seen in some of the
offerings, for example, from the Academy [American Academy of
Orthotists & Prosthetists] in some of its courses in material
science and gait analysis, enthusiasm is really strong among
existing practitioners," Geil observes. The more training that can
take place, the better equipped practitioners will be to add to the
knowledge base, he points out.
Geil encourages defining who is involved in O&P from a
research perspective, noting that research comes best from a
multidisciplinary team, "just like we do clinical care in a
multidisciplinary team."
Sidney Fishman, PhD , served as chairman of the
New York University (NYU) Department of Prosthetics & Orthotics
and has spent over 40 years in prosthetic/orthotic research,
development, and education. Fishman is troubled by the inability of
people to agree on the various meanings and implications of
"research."
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Sidney Fishman, Phd |
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As Fishman defines it, " Basic
research is a scholarly activity usually conducted by
individuals who are specifically educated to scientifically
investigate matters for the purpose of developing new knowledge.
Such organized basic research is usually planned and supervised by
research scientists in university settings.
"At present, there is no structure within the P&O fields to
support this formal expensive type of activity," he says, adding
that most individuals involved in research have academic training
in other fields or overseas. The minimal funding currently
available to P&O comes from outside foundations or the
government, which require persons to have academic degrees, Fishman
notes. "The present educational structure within P&O in no way
prepares it to achieve any real research progress as a recognized
investigatory pursuit," he concludes.
Basic research may be confused with the efforts of manufacturers
and drug companies to pursue promising ideas to produce new
products, Fishman points out. "This is normally identified as
research and development . In this sense of the
word, there is absolutely nothing wrong with the state of research
in P&O. New products are evolving, a number of which have merit
and which are then integrated into clinical practice."
Research and development sometimes involves investigation which
requires a specialized background not related to O&P clinical
care, such as the development of CAD/CAM, Fishman explains. "It
makes no sense for an orthotist or prosthetist to want to be
involved in that kind of research, except when the equipment is
ready for clinical application."
Researchers conducting studies for O&P clinical
applications, known as clinical research or outcome studies, should
not evaluate their own work, Fishman advises, since results would
likely be dismissed as non-objective. "That's good and bad," he
adds. "We don't know as much as we wish we did, but [this type of
research] opens the door for a lot of research questions that have
yet to be answered--and, therefore, a lot of opportunities."
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Dudley Childress, PhD |
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Dudley Childress, PhD , professor
of Physical Medicine & Rehabilitation and Biomedical
Engineering, Northwestern University, Chicago, Illinois, also
believes that the multidisciplinary team approach to research is
advantageous. "Research in P&O in the United States mainly
began after World War II and was mostly interdisciplinary, with
prosthetists, orthotists, engineers, scientists, therapists,
orthopedic surgeons, and other professionals cooperating in the
national program."
Since not many clinicians have time for research, they are not
usually principal investigators (P.I.s), Childress points out.
However, this situation is changing, he adds. In Childress'
laboratory, three prosthetists/orthotists with PhD degrees are
beginning to write grants and pursue research. Childress sees a
trend for more orthotists and prosthetists to obtain advanced
degrees for research and also for more persons with PhDs to take
P&O training. "There are probably five or six
practitioners--maybe as many as ten--in the United States who have
their PhDs and who are certified prosthetists and orthotists. And
that number will likely increase."
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Scott Hornbeak, CPO, FAAOP |
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Scott Hornbeak, CPO, FAAOP ,
director, O&P Program, California State University-Dominguez
Hills, agrees that those who get NIDRR (National Institute on
Disability Research & Rehabilitation) funds from the Department
of Education are mostly PhDs, and therein lies the future hope for
O&P clinicians. "If more O&P clinicians can obtain PhDs, we
will have much greater access to government research funds,"
Hornbeak says. "Presently some of the best clinical O&P
research is done by O&P practitioners working for PhDs who are
able to obtain grant funding. Of course, O&P practitioners are
seldom recognized as the primary authors of the paper that is
eventually published, and often their significant contribution is
underrated. We've got a long way to go."
O&P is a latecomer to higher education in general, Hornbeak
notes, with 1984 being the first time the American Board for
Certification in Orthotics & Prosthetics (ABC) required a
bachelors degree. "Because of that, many of the orthotists and
prosthetists who were new to higher education were latecomers to
this exposure to formal research methods. My perspective is that we
are just now coming up to speed with undergraduate and certificate
programs which require formal instruction in research methods."
Hornbeak perceives this stage as part of O&P's transition
from a vocation or trade to an allied health profession. Because of
that transition, certified orthotists and prosthetists have not
contributed much to the body of knowledge, he explains, noting that
much of the literature in prosthetics and orthotics has come from
professionals in other disciplines, such as therapists, physicians,
or other PhDs. "However, universities [offering O&P education]
are doing a much
better job now of recognizing the need for formal research
education," he points out.
"First of all, it's important for the practitioners of orthotics
and prosthetics simply to be able to read and interpret the
literature," Hornbeak continues. To do this, practitioners need to
understand the basic concepts of research design, he says, adding
that a goal at CSUDH is to teach research methods, so students can
understand what is being written in the Journal of Prosthetics
and Orthotics (JPO) , published by the Academy, along with
other articles from clinical publications in related disciplines
such as physical medicine and orthopedics.
The Cal State curriculum includes a basic research methods
course similar to what is required for a bachelors degree in
nursing. Students are assigned to develop a research question and
write a proposal. During their residency, they are assigned to
carry out a formal research project, as defined by their proposal.
"We look at this project as very practical," Hornbeak explains. "We
have a lot more buy-in from our students when it's not just some
abstract course they think they're never going to use."
Most applicants are unprepared for a formal research class,
Hornbeak says. "Only some of our students come in with a formal
statistics class. If they don't have this, a number of our students
don't understand the validity of data." Although statistics and
probability courses are not currently prerequisites in most O&P
programs in order to take a research class, such a requirement
should be considered, according to Hornbeak. "It is required in
some bachelors degree programs, including CSUDH's undergraduate
degree, but it's not required for O&P education in general. So,
if you ask how research can be improved, some of it can be done
through prerequisite work."
Hornbeak continues, "Overall, teaching about research in allied
health is a way that practitioners can validate their clinical
practice, and that is something that is lacking in O&P--a lot
of the practices in O&P are [the results of] hearsay, rumors,
and unproved opinions."
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Susan Kapp, CPO |
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Susan Kapp, CPO , associate
professor and director, Prosthetics & Orthotics, University of
Texas Southwestern Medical Center, Dallas, points out the
importance of imbuing students with an understanding and
appreciation of what goes into research. "Teaching students to
recognize valid research and its effect on patient care is
crucial."
Kapp describes a course entitled "Health Care Research," which
discusses the process and theory of research and takes students
through developing a research proposal such as would be submitted
to a funding agency. "They obviously have to understand the
components of research and valid statistics and how to select
subjects, etc.," Kapp explains. "They also learn about the
importance of the Institutional Review Board (IRB) and having the
IRB monitor human subject research."
The topics students select may be carried on to their senior
year and even beyond graduation into their residency. "It's about
half and half," says Kapp. "Students complete their project while
at the school, but also may choose to take it on into
residency."
Noting that these are pilot projects, Kapp continues, "We want
students to get the experience of going through the process--this
is the most important aspect. Outcome is important, of course but
there's the question of validity. Student researchers don't have
the resources or funding available to carry out complex and lengthy
projects.
"This experience is meant to be an exercise in understanding and
appreciation," she adds. "It's important for clinicians to
recognize valid research, so that when we read journals and hear
manufacturers' claims, we look at those things more
critically."
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Mark Edwards, CP |
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Mark Edwards, CP , director,
Prosthetics Education, Northwestern University
Prosthetics-Orthotics Center (NUPOC), notes that Northwestern has
been participating in O&P research and research education since
shortly after its beginning in 1958. Its philosophy is that basic
science research related to prosthetics and orthotics could lead to
developments in technology. However, researchers would have to
start with a foundation, Edwards points out.
Most education programs, including Northwestern's, are at the
baccalaureate or post-baccalaureate level, and there is little time
in the curriculum for students to do research, Edwards comments.
Since residencies require a research project, Edwards adds,
"Hopefully, as the residencies evolve and students become
knowledgeable of research and research methods in their primary
education, then research can develop and improve the profession.
Through multiple students doing similar projects or adding on to
previous research from other students, we can get more research
coverage in specific areas."
Graduate students in the biomedical engineering program and
rehabilitation engineering program at Northwestern are looking at
gait, componentry for both prosthetic knees and feet, and at
upper-limb prosthetic use, as well as outcome measurements,
according to Edwards. "Our students who are involved in the
practitioner program are writing a research proposal guided by the
faculty. Hopefully, they can bring the project into their
residency--follow up, collect the data, and do the actual
experiment. We guide our students to look for projects which will
begin to measure the efficacy or quality of care they are
giving."
Research projects are currently in their infancy, since students
were not required to do research before the mid-90's, when the
schools had to provide research in their curriculum, Edwards
explains. "I believe that the level of research and the quality of
the projects will improve over time. We are in an evolutionary
period. We're getting better students, getting them to understand
research, and getting them to focus in on a particular type of
research project.
"I hope that we're producing students who want to expand the
body of knowledge of the profession, so that if they find something
interesting in their residency research project, they will continue
in research and do some publishing and presentation," Edwards
concludes.
What's the Prognosis for O&P Research?
The prognosis is hard to predict, says Geil. "The things we can
predict are not always the best indicators of what will happen with
research." Although there's a lack of advanced degrees in the field
now, that situation is changing, Geil points out: "We are the first
entry-level masters program in P&O; you'll see more coming.
More thorough instruction on how to do research and actually
conducting it would typically be involved with obtaining an
advanced degree." Practitioners with advanced degrees doing a
research project in their residency program will contribute a
significant impact, he believes.
"It's going to take time for these programs to develop--for
these students to graduate--for these advanced training courses to
have an impact," Geil continues. "These efforts are all relatively
new, so we're going to need to give them at least five years to see
what sort of impact they'll have. But beyond that, I think we've
got some real momentum going."
"So many practitioners are too busy making a living," reflects
Hornbeak. "Any solution probably needs to happen as joint projects
between the academic world and the manufacturers' research
teams."
"Although lack of graduate programs and a lack of academic
centers that specialize in O&P research has been a
handicap in the past, Northwestern and the University of
Washington have been focused on P&O research for a long
period of time," Edwards says. The closing of the P&O
programs at New York University (NYU) and the University of
California-Los Angeles (UCLA), where much of the research was done
early on, was a setback, he says. "I believe that future
practitioners and academic facilities will bring forward research
to where it once flourished."
What Can We Do to Precipitate Progress?
"Practitioners or residency directors who are sponsoring
residents need to allow them to do a quality research project,"
suggests Edwards, "and to allow time for them to do research during
their residency so we can get quality projects to NCOPE [National
Commission on Orthotic & Prosthetic Education]. Ultimately
these projects will bring about increased awareness of research and
improve the quality of care."
Judith Philipps Otto is a freelance writer who has also
assisted with marketing and public relations for various clients
within the O&P industry. A graduate of the University of
Missouri School of Journalism, Columbia, she has been a newspaper
writer and editor and has won national and international awards as
a broadcast writer-producer. Her home is in Holly Springs,
Mississippi. 
Table Of Contents - November 2003
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