April 2007 • Vol. 3, No. 2
	Advancing Orthotic and Prosthetic Care Through Knowledge

Evidence-Based Practice: Talking the Talk, Walking the Walk

Everyone in O&P is talking about evidence-based practice (EBP) these days, or so it seems. Like many other O&P clinicians, you may be wondering about a few key questions. Exactly what is EBP? Why is it such a hot topic right now? How will EBP affect the O&P profession and your practice?

Believe it or not, the concept actually has its roots in the late 18th century. In his book Ethics and Evidence-Based Medicine, Kenneth Goodman traces it to Thomas Beddoes, an English physician who practiced then. Concerned about potential harm to patients from existing treatment approaches, Beddoes called for collecting, sharing, analyzing, and publishing medical data to improve patient care.

The modern EBP movement began in the late 1950s and 1960s, when epidemiological methods were first applied to clinical research. "It was originally called clinical epidemiology, but that was so dull the originators coined the term ‘evidence-based medicine,'" explains Ed Neumann, PhD, PE, CP, professor of civil engineering and director of the Center for Disability and Applied Biomechanics at the University of Nevada at Las Vegas. "Internal medicine adopted it as an academic teaching model, and much of the medical profession moved to adopt this standard."

In O&P, the essential premise of EBP is that it integrates the best-available scientific research with a clinician's expertise to make patient care decisions. Academy Research Council Chair Scott Cummings, PT, CPO, FAAOP, identifies three key components of EBP:

• Scientific evidence
• Practitioner experience
• Patient values

"There's objective research data available for practitioners to reference," Cummings says, "but evidence-based practice doesn't ignore the vast experience of each practitioner. And it doesn't ignore that the patient is part of the process," he explains. Neumann adds, "To my thinking, the biggest misconception is to consider evidence-based practice a big research project versus a thought process. Scientific findings must be incorporated into a clinician's own thought processes."

Stefania Fatone, PhD, BPO (Hons), research assistant professor in the Prosthetics Research Laboratory and Rehabilitation Engineering Research Program at Northwestern University, Chicago, Illinois, concurs. "The scientific evidence is not used in a vacuum. Each patient will present with unique characteristics. Evidence-based practice is the judicious use of knowledge in the context in which you're practicing. It's not like a cookbook. You still need to use your knowledge as a clinician."

EBP Now a Buzzword

That being said, scientific evidence has been the most difficult EBP piece to come by in O&P as well as the allied health professions as a whole. "EBP has gotten to be the buzzword in a lot of different medical areas," observes Brian Hafner, PhD, research director of the Prosthetics Research Study at the University of Washington, Seattle. "In reality, it's rare." In fact, as recently as 1992, the Institute of Medicine estimated that only 2–25 percent of medical decisions were evidence based. One reason this number isn't higher is that randomized clinical trials—the gold standard of research—are time-consuming and expensive. Another reason is that only relatively recently has internal pressure for improving and standardizing clinical decision-making combined with external pressure from insurers and third-party payers accelerated the implementation of EBP across the allied health professions.

Hafner points out that insurers are driving much of the move toward EBP in O&P. "They're looking for justification for the intervention, especially with devices becoming more expensive," he says. "There's a big differential between the current standard of care and new options." Cummings shares this view, noting, "I think the days of insurance companies paying because we put it on a bill are over. We need to document and support what we do."

In addition to EBP's practical value from a business standpoint, it also provides an approach to defining and raising the standards of patient care. "It improves the overall quality of care and proves that what we do is appropriate and effective," says Academy President Gary Berke, MS, CP, FAAOP. Fatone adds, "Part of the rationale is that it tries to standardize care and improve the quality of care by grounding it in science. If you put evidence in the equation in a more systematic way, you'll provide better care in the context of how you apply it."

Christopher Hovorka, MS, CPO, clinical director of the Master of Science in Prosthetics and Orthotics (MSPO) program in the School of Applied Physiology at the Georgia Institute of Technology (Georgia Tech), Atlanta, points out, "In other professions, they have critical pathways—a sequence of evidence-based procedures that are well substantiated and which the profession agrees are the best approaches to care. We don't have that now, but the State-of-the-Science Conferences are a step in the right direction."

SSCs Identify Research Priorities

For the past three years, the Academy's State-of-the-Science Conferences (SSCs), funded by a U.S. Department of Education grant, have been convening cross-disciplinary panels of experts to identify research priorities and expand the O&P knowledge base by offering clinical guidance about scientifically validated practice fundamentals. The SSCs also define best practices and encourage their swift implementation both in the field and in O&P educational programs by disseminating the proceedings and developing the findings into online professional continuing education courses.

"Practitioners can put that document on their desk and refer to it, using the information to help guide their patient care," Cummings points out. "We need more of that—something very tangible." Berke also sees the SSCs as providing a solid foundation for building a stronger, more research-focused future for the profession. "We're getting a handle on what we have to study so we can move forward with the research that needs to be done," he says. "On a basic level, the SSCs are the beginning of evidence-based practice."

EBP not only helps practitioners justify their current treatment decisions, it also enables them to change and improve patient care when new evidence supports a different approach. As Berke explains, "Evidence-based practice can mean altering the way you take care of a person or pathology based on what has been researched." And providing care based on the latest knowledge is critical, Fatone notes. "It's a way of providing care based on current knowledge versus knowledge gained at a different point in time. For example, if you graduate in 2000 but you're practicing in 2010, you may need to change. You need to keep abreast of new developments and not just rely on your mentor or what you've been taught in the past."

Building Awareness and Understanding

To use scientific evidence effectively, practitioners need to become well-educated consumers of research. "They need to be able to go to the scientific literature available to them in magazines and journals, critically evaluate a single piece of evidence, put together several pieces, and then make some controlled changes in their practice," Hafner says. "Then they need to stand back and learn from this." Neumann outlines a four-step EBP framework for clinicians:

1. Formulate a good clinical question.
2. Search for evidence to answer it.
3. Evaluate the quality of the evidence.
4. Figure out how to apply the findings to individual patients using your own knowledge.

Under Neumann's leadership, the Academy's Research Education Committee has been working to build awareness and understanding of EBP among practitioners. "Our goal is not to make everyone researchers but better consumers of research," he explains. "We're helping them understand what they need to know to make good decisions for their patients." His free paper presentation at the Academy's Annual Meeting in San Francisco titled "Implementation of Evidence-Based Practice in O&P" was designed to give practitioners the ability to see how EBP fits in the context of their practices, as well as help them expand their knowledge base.

"I want practitioners to look at their clinical decision-making from a new perspective," Neumann explains. "The best example would be to question where your knowledge base comes from. Is it experience, manufacturers' information, aggressive reading of research articles, or consulting with colleagues? And what is the quality of that source of knowledge? As clinicians, we tend to go on experience. Our perspective may be at risk of being too narrow."

The Academy's meeting had a total of three stellar EBP sessions. The instructional course focusing on "Establishing Evidence-Based Practice in O&P Focusing on the Orthotic Management of Stroke" was presented by an international panel of speakers including Jim Campbell, PhD, CO, FAAOP; Roy Bowers, CPO; and Gert Kwakkel, PhD. By using the orthotic management of stroke patients as an example, this experienced panel of international presenters reviewed available evidence and debated the quality and usefulness of evidence-based research in O&P. Mark Geil, PhD, also lead a session on EBP titled "Evidence-Based Practice: Justifying Patient Care." He discussed how the vast majority of practitioners must become well-equipped consumers of the emerging scientific research driving EBP.

Education and Training: The Key

The evolution of the O&P educational paradigm reflects the new emphasis on research as an integral part of training future practitioners. One of the earliest changes occurred in 1994, when the National Commission on Orthotic and Prosthetic Education (NCOPE) mandated that all O&P residents complete a research project. Neumann's committee works closely with NCOPE to support this component. In addition, according to Hovorka, educating a cadre of practitioners familiar and comfortable with research is the goal of the master's-level program at Georgia Tech. "We want to create scientifically savvy and knowledgeable clinicians," Hovorka explains. To achieve this, the program teaches students how to formulate research questions and how to develop processes to answer them. Each student is paired with a faculty mentor to guide his or her two years of research.

"They're learning the process of the scientific method in a controlled way," Hovorka says. "We're asking them to apply concepts in class, in the lab, and then in practice. Our goal at the master's level isn't to create scientists who will be lead investigators in a research study. We're grooming generalist practitioners who appreciate research." He noted that while some students may choose to pursue a career in research, each graduate will be well prepared to make solid contributions as a member of a research team.

Educating current and future clin­icians to become better consumers of research presents one challenge to the O&P profession. Enhancing the volume and quality of O&P research presents an even larger one. "The science is new and young and developing," Fatone notes. "We're a new profession. Until recently, we were technicians who made things, not clinicians responsible for the care of patients. We haven't had a culture to do research. But now there's a growing appreciation within the field that research is valuable."

Fatone explains that the ability to generate guidelines for clinical care requires synthesizing available evidence to determine which treatments produce the best outcome. "Therefore, you want multiple studies that come to the same conclusions. If you can take half a dozen studies with the same conclusions, now you have a strong base. But you can only have confidence in results from methodologically rigorous studies," she says. "We need to produce several studies on the same topic. For O&P, that's difficult because we're still in our infancy as far as producing good quality research."

Expanding the body of O&P research requires restructuring the traditional educational model, including establishing advanced degree programs such as the two new doctoral-level programs now open to O&P candidates at Georgia Tech and the University of Washington. "We have to support advanced degrees to prepare students for being part of the research process," Cummings notes. "Most of us just don't have the research background, and although it's valuable to collaborate, we don't want to rely on other allied health professionals to define how we do our research."

Ongoing Process

Developing a solid base of highly trained O&P researchers will take time, of course. Meanwhile, the Academy continues to take other concrete steps to support research and the move to EBP, such as partnering with the American Orthotic & Prosthetic Association (AOPA) on an Outcomes Research Project. Although still in the planning stages, the joint steering committee is exploring the development of smaller studies that might involve information gathered from such sources as literature reviews or a survey of practitioners to produce outcomes on a shorter timeline than full-scale research projects require. "We want to produce some information pretty quickly that practitioners can use on a daily basis," explains Cummings, a member of the steering committee.

Given the small size of the profession, this type of teamwork is particularly valuable. "AOPA has stated that over time the need for outcomes research has moved to its front burner. We want to make sure we don't duplicate efforts, so we can do more together," Berke says. Financial support of the process is also crucial. The Academy has already earmarked one-third of its resources toward promoting research, and EBP and the Research Council's Grants Committee is focusing its efforts on identifying funding sources so that research money will be available to the O&P community. Grants Committee Chair Fatone notes that funding pilot studies can be an investment in helping researchers to successfully win larger grants, eventually yielding a higher quantity and quality of research.

Although making evidence-based practice a reality in O&P will be an ongoing process over many years, the Academy's multifaceted approach continues to generate positive momentum. "It's exciting how far we've come in the past year," Berke observes. "By advancing educational criteria, putting an emphasis on becoming better consumers of research, focusing on outcomes research, and looking at funding for long-term studies, we're starting to elevate the role of evidence-based practice."