O&P Education's Final Frontier

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Fueled by fast-paced advances in technology and research, O&P education is entering its final frontier: PhD.













"In early 2002, there were no entry-level master's programs in P&O in the United States, and only a very small group of individuals who were directing P&O-relevant research possessed a PhD in a topic area related to P&O," Christopher Hovorka, MS, CPO, LPO, FAAOP, points out as he reflects on the rapid progress of O&P education.

"Fast forward to today," he continues. "As a profession, we have examined and now have implemented an elevated credential; that is, an entry-level master's degree. In addition, there are at least two established PhD programs that are training scientists with applied knowledge in P&O." One of those programs is the Georgia Institute of Technology (Georgia Tech), Atlanta, doctor of philosophy degree (PhD) in applied physiology with a focus on prosthetics and orthotics; the other is the University of Washington (UW), Seattle, PhD in rehabilitation science.

"Seize the Day"

Hovorka, co-director of the master of science in prosthetics and orthotics (MSPO) program at Georgia Tech, sees an unparalleled opportunity waiting at that frontier. The O&P profession is uniquely poised to "seize the day" and become the profession to bridge the gap between developers of advanced technologies and users.

Citing such advances as neuroprosthetics, robotics, and externally powered orthoses, along with such landmark surgical techniques as osseointegration and targeted muscle reinnervation (TMR), Hovorka says, "What limits this technology now and in the future is the challenge of how to define and implement the optimal device user interface. If you talk to engineers and others who are developing these new applied technologies about how you can program them to be meaningful and effective to the patient, they're struggling with that."

This is not only a tremendous opportunity for the O&P profession, but it is also essential to its future, Hovorka says. "Prosthetists and orthotists work with people who wear technology. We can capitalize on expanding our knowledge of the new technology to better understand how to program it to the patient user as part of our scope of practice. Physical and occupational therapists and physicians are not trained on how to design and optimize certain wearable technology to the user—we are!

"That's why we need people who are trained at the PhD level to begin to organize a focused effort to develop a body of knowledge in this area," Hovorka continues. The National Institutes of Health (NIH) agrees with that need, and to begin these efforts, NIH funded the development of Georgia Tech's PhD program in applied physiology with a focus on P&O. "The purpose of [this PhD program] is to train scientists to investigate and uncover how to optimize certain wearable technology to the user," Hovorka explains. "It is the hope that other university programs training scientists with applied knowledge in P&O will continue what began at Georgia Tech. Expanding the number of persons with a PhD who possess P&O-relevant knowledge and skills can help to translate a wider scope of technology that produces clinically meaningful device user interfaces for patients."

Why O&P Needs PhDs

Fueling future technological advances is just one side of the argument. The researchers and educators interviewed for this article point out other benefits individuals with an O&P-focused PhD bring to the table:

  • These individuals combine research science and clinical expertise, bridging the gap between bench (laboratory) science and clinical practice.
  • PhD-trained researchers have the scientific training to generate high-quality outcomes research for evidence-based practice (EBP). "The need for better objective outcome measures is now widely recognized within the profession and by research funding agencies," the Advanced Education & Research Training Initiative (AERTI) 2009 report states. "Several clinicians have earned academic master's and doctoral degrees since 2004, and a significant number are currently enrolled in the master's and PhD programs."
  • Individuals with PhDs have a greater ability to obtain research grants. Most foundations, the Department of Defense (DoD), and other federal agencies prefer PhDs or medical doctorates (MDs) as grant recipients and principal investigators (PIs), and some require these credentials, according to Jonathan Day, CPO, immediate past president of the National Commission on Orthotic & Prosthetic Education (NCOPE). Day is chief of orthotics and prosthetics and clinical assistant professor in the Department of Orthopedic Surgery and Rehabilitation at the University of Oklahoma Health Sciences Center, Oklahoma City.
  • Because individuals with PhDs can serve as PIs, they can direct and control research to accomplish specific O&P objectives. Most rehabilitation-related research is currently directed by individuals with advanced degrees in other professions. Because of this, the research is often geared toward their specialties; for example, biomedical engineering or physical therapy, even though prosthetists or orthotists may be involved. "In order for the profession of P&O to direct the body of knowledge, we need PhD-trained individuals to help guide that effort and be supported through grant funding," Hovorka says.
  • Individuals with PhDs have more influence on university policies, decisions, and the allocation of resources—factors that affect O&P education and research. "The non-PhD has very limited power and little weight with respect to internal university decision making and the development of policy, especially policy that allocates resources within a university," says Edward Neumann, PhD, PE, CP, FAAOP, professor and past chair, Department of Civil and Environmental Engineering and former director of the Center for Disability and Applied Biomechanics at the University of Nevada, Las Vegas.
  • PhD-trained individuals can effectively help to translate knowledge from research to patient care applications. "There's a lot more research out there than many people realize," says Mark Geil, PhD, associate professor of biomechanics at Georgia State University (Georgia State), Atlanta. "It's sometimes in obscure places, typically because it has been produced by researchers in fields that are a couple of steps removed from clinical practice. That's why it's so valuable to have individuals willing to dig through those articles, pull out the most clinically relevant points, and summarize them in more accessible arenas." (Editor's note: For more information about knowledge translation, read "Knowledge Translation: Getting Information from the Laboratory to the Treatment Room".)

"A profession benefits from having members from different types and levels of education, training, and skill," says Brian J. Hafner, PhD, assistant professor in the UW Department of Rehabilitation Medicine. He explains that PhD-level training fosters a number of skills that could benefit the O&P profession:

  • The ability and skill to design, conduct, and disseminate research that is relevant to advancing the field.
  • The ability to interact and collaborate with investigators with advanced degrees in related fields.
  • The ability to serve on review panels for federal agencies; for example, NIH, National Science Foundation (NSF), National Institute on Disability and Rehabilitation Research (NIDRR), Department of Veterans Affairs (VA), DoD, etc., and help to determine what kinds of research projects are funded in O&P.
  • The ability to take on tenure and promotion-track positions within academic institutions and lead new and existing academic programs.
  • The ability to help educate, train, and mentor the next generation of O&P practitioners and researchers.

There is plenty of room for PhDs in O&P education and research, according to Hafner and Geil. "O&P is far below critical mass in terms of numbers of active researchers," Geil says. "Ironically, I believe this presents a barrier to research funding. One might expect that when resources are scarce, it's better to have fewer people competing for them. I think the opposite is true for O&P. Federal agencies are reluctant to fund research they consider nascent or risky. A healthy and active body of literature will make these agencies more likely to invest in what's considered an established discipline."

Allied healthcare fields and related disciplines rely heavily on faculty with advanced degrees such as a PhD or MD to train entry-level professionals, Hafner explains. Educators with advanced degrees are positioned not only to mentor graduate students, but also to obtain funding to support their educational expenses. Securing grants that support research assistantships and fellowships for graduate students generally requires a faculty member with a PhD, Neumann adds.

Institutions and accrediting entities also have requirements regarding the minimum education level of faculty members who teach in master's and PhD-level education programs, Day points out.

Mark D. Muller, MS, CPO, FAAOP, president of the American Academy of Orthotists and Prosthetists (the Academy) and an instructor in the California State University, Dominguez Hills (CSUDH) P&O program, agrees that the need for faculty with advanced degrees is urgent as entry-level master's degree programs roll out. He cites a specific need for more doctorates in education (EdDs) and clinical doctorates, such as a possible future doctorate in prosthetics and orthotics (DPO). "Most of the current educators are experienced practitioners who teach clinical techniques very well," Muller says. "But all too often, we don't know how to teach or why we teach. Advanced degrees in education, instructional design, or a clinical DPO would enable our educators to have a better understanding of adult learning styles, how to use various media and instructional design to optimize learning, and be able to make clinically relevant research possible—not just teach how to make a device, but teach why it can make outcomes better."

Barriers to Progress

Although innovative research can come from areas outside traditional academically based science programs, it can be difficult to launch, Neumann says. "To secure a federal grant, academic researchers have to embed themselves in the existing scientific literature and build upon previous work. This can make it difficult to see opportunities in the present or ways to shift existing paradigms of thought. Clinicians who are keen observers of patients and their problems may be in a good position to advance the state of the art. The doctoral-level specialist in an academic program may be best equipped to provide the intellectual tools necessary to help the clinician map the way….

"However," Neumann continues, "there must be strong linkages between clinicians and academicians who hold PhDs and tenure-track positions."

Neumann says the reimbursement methodology for clinical care is a systemic barrier impeding O&P education and research progress. "O&P is one of the few medical specialties where reimbursement is based on a physical product rather than a service performed. My ophthalmologist bills for his services to examine my eyes and prescribe glasses, but the purchase of the glasses is separated from the exam and prescription with respect to billing and insurance reimbursement. The fact that O&P clinicians are not reimbursed for services is probably the reason why the question of whether there is a role for a PhD…even exists."

Although the perception of O&P practitioners as being primarily product purveyors appears to be changing, it still likely impedes recognition of O&P as a profession and as a promising career, along with keeping remuneration at lower levels compared to other allied healthcare professions. Another challenge is presented by the current tough economic climate.

Proactive Approach Seeks Solutions

In the face of these challenges, the O&P profession has been developing a proactive, unified approach to education and research. Fueled by U.S. Department of Education grants to the Academy, two strategic planning conferences were held in 2004. Attended by leading clinicians and representatives of universities and research centers involved in P&O, these conferences culminated in the Advanced Education & Research Training Initiative (AERTI). The plan had a twofold goal: (1) train future scientific and academic leaders in the P&O field; and (2) improve the quality of applied P&O research, education, and, ultimately, patient care.

In July 2009, a multidisciplinary, multinational group of clinicians, researchers, and educators met in Chicago, Illinois, to review the 2004 AERTI Report, evaluate its recommendations in light of the profession's evolution during the five-year period, and make suggestions for accelerating progress.

"The progress toward the goals identified in these reports has been nothing short of profound," Geil, a participant in AERTI 2009 and co-editor of the final report, told The O&P EDGE. "I remain amazed at how much has been put in place and how rapidly it has happened." He adds, "The second report identified remaining barriers to progress, and these have been taken into consideration as groups like the Academy move forward in strategic planning." (For more information, visit

Although the Academy's multi-year grant has expired, the profession is forging ahead.

The master's degree programs are stepping stones in the profession's education, research, and clinical care progress, and some of them are in a fragile state, as academic institutions nationwide continue to struggle with shrinking endowments and/or decreased state funding. In August 2010, representatives of clinician and technician programs and other stakeholders convened at St. Petersburg College (SPC), Clearwater, Florida, for a summit conference titled "Building Sustainable Education Programs," with the goal of working together to manage challenges faced by O&P education programs. (For more information about this conference, read "Sustainable O&P Education: Are O&P Academic Programs at Risk?"  The O&P EDGE, December 2010)

For the last several years, educators also have been meeting during the Academy's Annual Meeting & Scientific Symposium to discuss challenges and find solutions. Another meeting is planned for this year's Academy meeting, giving educators the opportunity to come together, evaluate current progress, and define future goals, Muller says.

Investing in the Future

"The P&O schools are currently under-funded and understaffed," Hovorka says. "Unfortunately that hasn't changed in years, but one positive thing that has changed is the landscape for discussing the need for education and how that will impact our profession for the future." He points to statistics showing the population needing O&P care is increasing, while the number of new prosthetists and orthotists appears to be fewer than the number who are retiring. "It is likely that the workforce in O&P is facing a shortage," he says. "I would appeal to the O&P profession—product manufacturers, clinicians, and other stakeholders—to give back to the schools, either by donating time for classroom or laboratory teaching, serving as preceptors for student clinical practice rotation, collaborating in research, or by making monetary donations to the programs."

Such internal support mechanisms are not uncommon in allied healthcare professions. Hovorka points out that the physical therapy profession has created endowments and scholarships managed by the American Physical Therapy Association (APTA) as a centralized entity. He praises the Orthotic and Prosthetic Education and Research Foundation (OPERF) and the Center for Orthotics and Prosthetics Learning and Outcomes/Evidence-Based Practice (COPL). Among other benefits, these organizations have enabled researchers without a doctorate or other advanced degree to pursue research. Muller cites some instances in which these organizations funded non-PhD-holding individuals to conduct small pilot studies. These studies demonstrated the value of the research objectives, which lead to funding from larger entities to expand the studies.

Hovorka says that he would like to see OPERF and COPL expand their roles.

Besides OPERF and COPL, many scholarships, fellowships, and training opportunities are available for students who are interested in advanced education in O&P, Hafner says. For instance, students often receive tuition reimbursement and stipends for serving as teaching assistants (TAs) or research assistants (RAs). Fellowships that provide support for multiple years of education may be available from federal agencies such as NSF ( or private foundations such as the Hertz Foundation ( The NIH Loan Repayment Program ( may provide assistance in repaying student loans for those conducting research at nonprofit institutions.

Positive Outlook

In addition to using research in related fields, the O&P profession is coming together to support education and take charge of O&P-directed research. These changes may well be the start of O&P education's next—and final—frontier: PhD.

Miki Fairley is a freelance writer based in southwest Colorado. She can be reached at

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