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

Editorial: Evidence-Based Practice and Amputee Rehabilitation

Gordon W. Bosker, MEd, CPO, CPed, FAAOP
Daniel Carlisle, MD
Glenn Klute, PhD
Bill Rogers, MS

Introduction

Major limb amputation has an impact on nearly every aspect of an individual's life, from his or her physical ability to perform vocational and recreational activities to psychological well-being. To enhance or restore these essential facets of an individual's life, the clinician must temper the patient's expectations with reality by striking an appropriate balance between the individual's physical and cognitive capabilities and available prosthetic technology. The last decade has seen tremendous advances on both ends of the scale. Patient awareness, facilitated by the Internet, has kept pace with advances in rehabilitation and prosthetic technology, placing an even greater burden on the prosthetist to be informed, trained, and immediately able to apply (or reject) new technologies purported to benefit the amputee. Evidence-based clinical practice is important, as is its integration into the resources available to practitioners to enhance the physical and psychological well-being of amputees. However, the Internet can be a "double-edged sword," not only for the patient but also for the practitioner. Appropriate information review can aid in optimizing rehabilitation.

General Approach to the Amputee's Rehabilitation

Every day, prosthetic practitioners are faced with a decision about what components and socket design should or could be used on an amputee to enhance his or her full potential for rehabilitation. Practitioners go through a list of questions regarding patient information, such as vocational and recreational activities, functional and cognitive characteristics, and intrinsic and extrinsic factors that could influence prosthetic usage and care. Simply stated, it is identifying the problem, gathering evidence appropriate to solving the problem, and then developing the best solution for the patient. While this approach is common, many practitioners are finding their prior personal experience is insufficient to develop the best solution, and that a better approach includes using clinical research. This approach is known as "evidence-based practice."

Evidence-Based Practice

Evidence-based practice, also known as evidence-based medicine (EBM) or evidence-based research, emerged in the early 1990s when investigators from McMaster University, Hamilton, Ontario, Canada, began using the term. They defined EBM as "a systematic approach to analyze published research as the basis of clinical decision making."¹ However, identification and use of research findings does not necessarily improve clinical practice. Research data can be distorted in the design and reporting of the experiments or by technical and commercial bias. To address this issue, Sacket et al. further defined the term in 1996 by stating EBM is "the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients."² Sacket's definition places the onus of ethical responsibility on the practitioner to evaluate and understand evidence before accepting it as a possible solution. Another source for ethical responsibility should come from the patient, as each individual has a certain value system, and it should be a part of the overall decision.

To understand the process more thoroughly, consider the formulation of clinical questions. The practitioner has to understand the diagnoses of the patient and what intervention may be required, evaluate any comparison of prior patients, and understand the outcome the patient and practitioner desire. An example of this could include the following questions for a 50-year-old diabetic patient who recently lost his leg due to vascular inefficiency.

1. What is the possibility of the patient having a breakdown on the non-involved side?

Is there evidence to suggest patient education on preventative foot care for persons with diabetes can be effective in preventing a second limb amputation? Is there evidence to suggest specific footwear can be effective in lowering the risk of foot injuries or lesions and hence lowering the long-term incidence of amputation?

2. What other co-morbidities does the patient have, and how would they affect rehabilitation?

Is there evidence to suggest a particular approach to physical therapy would accelerate a return to independent living following amputation? Is there evidence to indicate certain therapies should be avoided due to associated co-morbidities?

3. What type of foot would give the patient the best capability for mobility?

Is there evidence to suggest prescription of a particular prosthetic foot, as it might transition the patient from household to community ambulation?

With the rapid pace of technology innovation in prosthetic devices and the varying approaches to therapy, the prior personal experience of the practitioner may be insufficient to optimize the patient's rehabilitation. Appropriate use of clinical research resources can help, but an important first step is to identify specific information and appropriate evidence that will narrow the possible solutions to the clinical problem.²

The next step for the practitioner is to locate the best evidence available for the specific clinical questions. For most practitioners, textbooks, libraries, and the Internet, combined with their exper­ience, have become very valuable resources.

Textbooks to Internet

While textbooks can be an excellent starting point when searching for evidence, the material can be outdated even before it has been released for print, unless the particular information or content does not change; e.g., the anatomy of the foot. Most professionals receive journals, but only the best libraries have them all completely up to date. Fortunately, the Internet has become a valuable resource, giving the practitioner access to thousands of journals^3,4 and textbooks⁵ instead of just a few. If the intent is to find up-to-date evidence, the Internet is certainly an appropriate tool.

The Internet provides access to a wealth of resources such as virtual libraries and databases, allowing for the dissemination and retrieval of evidence and electronic communities to aid in networking and collaboration. Computer technology is broadening choices for the mode of delivery, content, and access because information can be stored and transmitted anywhere.⁶ Use of the Internet facilitates access to all citizens a reasonable level of healthcare and promotes the efficiency of the healthcare system.⁷ However, the practitioner and patient must be careful with an overabundance of "unfiltered" data because evidence and data alone do not immediately translate into evidence-based practice. Some would argue that the Internet is becoming a commodity that steals the practitioner's control, knowledge, and skill⁸ in assisting the amputee because of the misinformation presented on certain websites. One method of evaluating information content can be summarized by the acronym "PP-ICONS."⁹

1. Problem: The clinical question.

2. Patient: Is the study group similar to your patient?

3. Intervention: Treatment.

4. Comparison: What is it being tested against?

5. Outcome: What are the results of the study?

6. Number of Subjects: Does it have enough subjects or power to make an analysis?

7. Statistics: Few in number and easy to understand.

By using the simple PP-ICONS method, the practitioner may comprehend the relevance or clinical importance of available information and use it to make a clinically sound judgment for the amputee.

Practitioners looking for a specific research article are finding several journals that relate to orthotics and prosthetics. Several hundred journals can be found on websites such as PubMed³ or OVID,⁴ and most of these journal articles provide enough information to determine the validity and relevance of the findings. Examples include the American Journal of Physical Medicine & Rehabilitation (AAPMR), Clinics in Prosthetics and Orthotics, Journal of Biomechanical Engineering (JBE), and the Journal of Prosthetics and Orthotics (JPO), among others. Practitioners and amputees alike are using the Internet to assimilate a problem-centered learning area and directly address the life experiences of the practitioners and amputees.¹⁰

Wholesalers and manufacturers of prosthetic and orthotic devices are also using the Internet—not only for information about their specific products but also for online distance learning targeted at practitioners. Össur, headquartered in Reykjavik, Iceland, claims to be "the first manufacturer to provide the industry in North America with an online continuing education program."¹¹ Össur's website includes continuing education credits for the practitioner and the end user (the amputee) who can take the same course and receive the same information. This approach of disseminating of information has heralded a new era. Still, patients and practitioners alike must learn to examine information for bias and other limitations related to information quality.¹²

Research

Research has become the highest priority for the prosthetic industry due to the advancements of the prosthetic devices developed in the last decade. Third-party payers are becoming more reluctant to reimburse for these new devices because of the lack of "evidence" that proves the devices do indeed enhance the capability or function of the amputee. According to the Code of Ethics for the Prosthetist,¹³ practitioners "provide competent services and shall use all efforts to meet the patient's prosthetic requirements. Upon accepting an individual for prosthetic services, the prosthetist shall assume the responsibility for evaluating that individual; planning, implementing, and supervising the patient; reevaluating and changing the program."¹³ If practitioners cannot prove to the payers that these new devices are not "experimental," then reimbursement from these companies will become even more difficult. The only way this problem can be eliminated is through research, particularly evidence-based research.

Conclusions

Evidence-based practice can play an important role in optimizing the rehabilitation of the amputee, but it comes with two important caveats: no clinical research is ever perfect, and both the practitioner and the patient must learn to evaluate the quality of information. The tools and information are readily available; it is the practitioner who adds value through appropriate use.

References

1. Claridge JA, Fabian TC. History and development of evidence-based medicine. [Historical Article. Journal Article] World Journal of Surgery. 2005, 29(5):547-53, May.

2. Sackett DL, Straus SE, Richardson WS, et al., Evidence-based Medicine: How to practice and Teach EBM, 2nd ed. Edinburgh: Churchill Livingstone, 2000.

3. PubMed. 2006. Available at: www.pubmedcentral.nih.gov/. Accessed Jan 18, 2007.

4. Ovid. 2007. Available at: www.ovid.com. Accessed Jan 18, 2007.

5. NOAH. 2007. Available at: www.noah-health.org/en/other/online.html. Accessed Mar 2, 2007.

6. Rudestam KE, Schoenholtz-Read J. Handbook of Online Learning: Innovations in Higher Education and Corporate Training, Sage Publications, Inc., Thousand Oaks, CA, 2002.

7. Nunes R. Evidence-based medicine: a new tool for resource allocation? [Journal Article] Medicine, Health Care & Philosophy. 2003;6(3):297-301.

8. Parikh MA. Beyond the Web: Leveraging Multiple Internet Technologies, Idea Group Publishing, Hershey, PA, 2003.

9. Flaherty RJ. A Simple Method for Evaluating the Clinical Literature, American Academy of Family Physicians, 2004, Available at: www.aafp.org/fpm/20040500/. Accessed Jan 8, 2007.

10. Orthotics and Prosthetics Listserv. Available at: www.oandp-l.org/. Accessed Dec 20, 2006.

11. Ossur—Life Without Limitations. 2007. Available at: www.ossur.com. Accessed Feb 15, 2007.

12. Delisa, JA, Gans BM, Walsh NE. Physical Medicine and Rehabilitation: Principles and Practice, 4th Ed, Lippincott Williams & Wilkins, Philadelphia, PA, 2004:1325-1354.

13. Code of Ethics for the Prosthetist. 1997. Available at: www.geocities.com/tigamike/ethics.html. Accessed Feb 8, 2007.