March 2006 • Vol. 2, No. 1
	Advancing Orthotic and Prosthetic Care Through Knowledge

Research Paves the Road to Evidence-Based Practice

Orthotics and prosthetics research improves patient outcomes, it validates O&P care, promoting timely reimbursement by insurers, and it's even fun, say O&P practitioners involved in research. So why isn't there more of it?

Experts cite plenty of reasons for the current lack of research, ranging from the O&P educational model, to time and funding limitations, to the difficulty of structuring well-designed studies. But these same experts also believe the future of the O&P profession depends on addressing these challenges now and creating a framework that will enhance the volume and quality of research over the next several years.

"In the future, we need to be operating more from a scientific perspective rather than only relying on experience. We would like to reference an empirical body of knowledge to base care on," observes Scott Cummings, PT, CPO, FAAOP, of Next Step Orthotics and Prosthetics in Manchester, New Hampshire. "The long-term goal is for our profession to evolve into evidence-based practice, which is crucial for two reasons—to improve care, and to demonstrate the efficacy of O&P care to third-party payors."

The key to making evidence-based practice a reality, of course, is research. "We're looking for research to justify what we do," says American Academy of Orthotists and Prosthetists President-Elect Gary Berke, MS, CP, FAAOP. "For example, is there evidence to back up using one device or technique over another? We have a clinical base, backed by years of experience. But we need to establish a baseline of scientific knowledge we haven't had in the past."

Increasing O&P research capacity and output clearly requires time, money, and energy. AAOP is the logical choice to spearhead an increased emphasis on research in the profession, according to Berke, who chairs the Academy's new Research Council, established after last summer's board meeting to advance research through several pathways, including identifying funding sources, supporting research education, and promoting standardization and protocol development. "As the only professional, member-based O&P organization, we have an obligation to our patients," Berke says. "Research allows us to be better practitioners. The more we understand the effects of our care, the better our outcomes will be."

Maximizing research efforts and putting the findings into practice also requires collaboration with other organizations, schools, and private corporations that share the same goal. "We're not going it alone, but we want to be in front leading the way," says Cummings, chair of the Research Council's Grants Committee.

First and foremost, the Research Council plans to heighten awareness of the need for—and value of—research among practitioners, and at the same time help them become better consumers of research. Research Council Vice Chair Don Katz, CO, LO, FAAOP, a former president of the Academy, emphasizes, "We will succeed in evidence-based research if and only if we as a profession strive to be more literate, critical readers of manuscripts, and to understand what a well-structured study is versus one that is not well-structured."

Katz points out, however, that all allied health professions face a similar challenge understanding research. "We're not alone. Not every MD or orthopedic surgeon understands all the research. I've certainly heard a physician or therapist say, 'This study proved this,' then read the paper and said, 'I wouldn't hang my hat on it'," he observes. And while it's important for practitioners to be able to identify and understand the components and outcomes of a good study, those are only the first steps. As Cummings notes, "Practitioners need to be able to digest the information and turn around and use it effectively in their practice."

This emphasis on practical applications helps fuel the drive to involve O&P clinicians more directly in research, currently conducted primarily by people outside the profession. "There's certainly a need to increase the clinical relevancy of research," Katz says. "We want prosthetists and orthotists as investigators on projects. This will ultimately have a positive influence on patient outcomes, so everyone wins."

He believes direct involvement will strengthen O&P credibility as well as help attract valuable research dollars. "Research is important if we're going to have parity with other healthcare professions and maintain our profession's stature," Katz claims. "And, it will give us that many more opportunities in the future to influence key decision-makers. If we went to NIH (National Institutes of Health) now to ask for research money, they might say, 'What's an orthotist?'"

Don Shurr, PT, CPO, who has spent his career working in research at the University of Iowa, observes, "There's a lot of research going on out there, but it's disjointed. We need to get more involved in projects." When that happens, he notes, O&P practitioners can influence not only the direction of the research, but also the journals in which it is published, helping to assure that clinicians can access it. Shurr, who was a physical therapist before entering O&P, has been hooked on research since he wrote his first paper in 1971. "It's great fun," he says.

For many practitioners, however, getting involved in research is easier said than done. "Most of us probably don't even have a good idea of how to turn clinical questions into numbers," Cummings says. "We need to disseminate information about grants, steps to reviewing research, steps to get involved—where do you start?" Unfamiliarity with the research process also contributes to a fear of research and a reluctance to pursue it. And given the reality that a PhD is generally required of researchers applying for grants, the lack of O&P practitioners with PhDs poses problems.

As a result, teaming up with researchers in other fields makes the most sense right now. "Either we produce PhDs or we give interested practitioners access to PhDs with a team approach," Cummings says.

Shurr points out, "The key to the whole process is ideas. You don't have to be in a university. You just have to ally yourself with others who have the space, equipment, resources, money, grad students, time, and access to equipment."

However, even when clinicians find someone with whom to partner, they are often so busy making ends meet that carving time out for research presents a major challenge. "If you have to work 10- and 12-hour days to make the same income you worked 7 and 8 hours for in past years, there may not be time in an 8-to-5 day," notes Katz, who usually completes the majority of his research analysis and manuscript writing during evenings and weekends. Ironically, research findings would help assure fair and timely reimbursement for financially squeezed practitioners—if only they could make the time for research.

Ideally, a growing number of O&P professionals will eventually serve as principal investigators as well as co-investigators on research projects. "We'd like to be steering our own ship," Cummings says. "We need more O&P research by O&P professionals." Achieving this goal requires restructuring the O&P educational model, which historically has not incorporated a research component. As Katz notes, "One of the huge reasons we have such a gap in our research is that we haven't been educated as researchers." But that's changing, slowly but surely.

In 1994, the National Commission on Orthotic and Prosthetic Education (NCOPE) mandated that all O&P residents complete a research project, marking a major stride forward. "When the accrediting body emphasizes research, that puts it in front of residents and resident directors," Shurr says. Adds Cummings, "The new residents and the research they do will percolate up," influencing the entire profession. In addition, through Project Quantum Leap (PQL), the Academy is fostering the development of the academic and clinical environments necessary to establish advanced degree programs in the United States, including academic doctoral programs. Over time, these shifts in the educational paradigm will contribute to improving and increasing research.

In the meantime, also as part of the PQL initiative, the Academy's State-of-the-Science Conferences (SSCs) have been convening cross-disciplinary panels of experts to identify research priorities in a number of areas—an essential step toward strengthening the science required to support evidence-based practice. "A problem well-defined is a problem half-solved," notes Katz, referring to the oft-repeated Ralph Waldo Emerson quote. "We need to determine what to study, and how to study it better. And we need to share this with others in other fields who might be doing research. They want to do research that's useful, and to make sure their research will make a difference."

Shurr believes the SSC findings also will help prioritize funding requests, noting, "These conferences identify the needs as we see them from a clinical perspective, and sway people who make decisions."

Another objective of the SSCs is to define and encourage best practices by offering clinical guidance about practice fundamentals that have been scientifically validated. "Participants evaluate the existing literature and rank it," says Berke. "Once that happens, we can say, 'This is what we know now. What can we draw from this and where do we go from here?'" Berke, who co-chaired the Post-Operative Management of the Lower Extremity Amputee SSC, notes that participants discovered a lack of supporting science. "We could only come up with consensus on what we are doing now and what we need to know to move forward."

While the SSCs identify and prioritize research needs, they also highlight one of the most significant challenges facing O&P researchers: the huge number of variables that make it extremely difficult to structure a well-designed study. "The more we get seasoned researchers around the table to critique the literature," Katz explains, "it becomes clear how difficult it is to design a study to withstand scientific muster. The confounding variables are staggering." He notes, for example, that researchers trying to determine the impact of a given prosthetic design on an amputee's gait must consider gender, age, limb length, socket fit, prosthetic alignment, and weight, among many other variables. Plus, recruiting an adequate number of participants to satisfy the requirements of Institutional Review Board (IRB)-approved studies can present a challenge to researchers, depending on the topic and geographic distribution of the patient population. "You need a large enough number of patients to have statistical significance and clinical relevancy," Katz points out.

Despite the many challenges, Academy leaders are firmly convinced that promoting and supporting O&P research will be well worth the effort in terms of improved patient care and heightened professional credibility. "Research is how the profession moves itself forward," Shurr says. "Clearly there's a need for all practitioners to support any and all research happening around them. We need to prove what really works—our success depends on producing patient-related outcomes that are beneficial and cost-effective."