Link to Figures Show Figures
	Article Text Figures References
	Send Link Send HTML Article

Researching Published Information

John W. Michael, MEd, CPO, FISPO

ABSTRACT

The foundation for credible scientific research is careful review of published information and previous research as noted in available literature. This paper will discuss methods to ferret out prosthetic and orthotic knowledge from its sometimes arcane locations.

Introduction

In 1974, the late Bert R. Titus, CPO, asked: "Where may I find literature on prosthetics and orthotics?" He answered his own question by quoting a 1972 publication that stated, "Until relatively recently, there was essentially no professional literature to be found pertaining to the field of prosthetics and orthotics" (1).

Fortunately, in the past two decades, a significant amount of information about O&P has been published domestically and abroad.

Since O&P is a clinical science, practitioners tend to dismiss research as irrelevant to daily tasks. Nothing could be further from the truth! Good research and thorough literature reviews frequently turn up obscure but insightful information that can be readily applied to patient management.

As both the complexity of our techniques and the challenges we face increase, it is no longer enough to simply polish skills learned in school. We must become scientific thinkers, question the status quo and share our experiences and ideas in written form.

Robert A. Day, in his entertaining and insightful treatise entitled How To Write A Scientific Paper, quoted the dean of Columbia College on the risk of abdicating scientific responsibilities: "In the complexities of contemporary existence the specialist who is trained but uneducated, technically skilled but culturally incompetent, is a menace." (2)

Why Review Literature?

In addition to being the foundation for scientific research, literature review has a more immediate importance in clinical practice: It is the least expensive, most widely available tool to reduce the ambiguity inherent in difficult clinical fittings. For example, translumbar amputation (TLA; surgical removal of the pelvis and lower limbs) has been successful only in recent decades (3).

How should the practitioner respond to the patient who says, "My oncologist has recommended translumbar amputation for inoperable cancer, and I want to know if there is a chance I could return to work when I get a prosthesis?" Few of us can answer from personal experience, but using the techniques discussed in this article will] reveal at least 19 references specifically discussing prosthetic fitting of this amputation, including eight on returning to gainful employment and one documenting 20 years of productive employment following TLA (4).

How should the TLA socket be de signed, and what is an appropriate static alignment if functional limbs are to be attached? A careful literature search would reveal that Bernard Simons, CPO, and his colleagues have reported 11 socket design criteria and bench alignment guidelines for this amputation level based on successful clinical experience (5).

Literature review also is an excellent way to sharpen clinical effectiveness. Imagine your surprise when a young lady with a hip disarticulation amputation comes to your office. Her X-rays document complete excision of the femur but examination reveals four inches of redundant tissue distal to the ischium. Her prescription reads, "Please fit with suction prosthesis."

As this article explains, perusal of a computerized database devoted exclusively to O&P literature (RECAL), cross-indexing the words "hip disarticulation" and "suction," would reveal within less than 15 seconds the existence of an article published in the Journal of Bone and Joint Surgery describing precisely such a case 40 years ago (6) (see Figure 1 ). Prior to discussing the prescription with the physician, reading pertinent papers and studying photographs of the prostheses would help clarify the diagnosis.

Since the reports were published only in surgical literature, few prosthetists are likely to be aware of this technique; however, the prescribing physician may have heard about it during residency. Literature review is the best method would reveal dozens of articles on flail arm orthoses, including several pertinent reports by Wynn Parry (published in the European literature only) (8).

In these reports, 70 percent of patients continue to use the arm orthosis one year after fitting (9). Careful study of previous successes and failures, as noted in the literature, would form an excellent foundation for innovation. This is far more likely to aid the brachial plexus survivor than designing an orthosis blindly from scratch.

Finding Information

Two commonly omitted steps in efficient fact finding are:

• analyzing the problem carefully, and
• consulting a professional librarian.

Analyzing the problem with colleagues often helps sharpen your focus. For example, the clinical management of spina bifida is inherently multidisciplinary due to the complexity of the disorder. Reviewing just O&P journals would be insufficient; many creative orthotic approaches are described in orthopedic, therapy and neurology literature. A general biomedical data base such as MEDLINE will include citations from all related areas (see Appendix 1 ). Since spina bifida is common among western Europeans, review of Europe an texts and articles might be productive. It is crucial to consider all pertinent synonyms and related words to ensure a complete search. Discussion with colleagues could reveal that the same pathology has different names in different cultures: spina bifida, spina bifida cystica, meningemyelocele and myelomeningocele all refer to the basic condition.

There are two excellent sources for synonyms and subject headings. Medical Subject Heading (mesh) is the key to searching the biomedical literature from the National Library of Medicine (NLM), including MEDLINE. MeSH contains an alphabetical list with cross referenced subject headings and categorized listings called tree structures (see Figure 2 , Figure 3 and Figure 4 ) (2). A similar resource for O&P terms is available from the University of Strathclyde as the RECAL thesaurus (see Figure 5 and Figure 6 ).

The novice researcher is sometimes intimidated by new, unfamiliar tools. The most effective solution is to consult with a professional librarian. Just as prosthetics and orthotics has grown into a complex profession, so has library science. Today's librarian is no longer just a person who shelves books. Many have master's degrees (or higher) and are trained to help you search for crucial information.

Regular consultation with your community librarian will save countless hours of searching for information. Even a small library can usually obtain reprints of virtually any available information. Medical libraries will likely have all information of interest on hand.

Computerized Searching

Many clinicians are familiar with computerized information through experience with word processing or electronic billing systems. But lack of computer experience should not be a barrier. Searching a computerized database is no more difficult than operating a microwave oven and is less confusing than programming a VCR. Once again, the professional librarian can be a valuable asset as both teacher and consultant.

The two most relevant databases for O&P information are MEDLINE from the National Library of Medicine (NLM) near Washington, D.C. and RECAL from the University of Strathclyde in Glasgow, Scotland. Both are available to American researchers using IBM-compatible computers. Many libraries have computers available to patrons for a modest charge.

MEDLINE

The easiest access to MEDLINE is via the PC-compatible program called Grateful Med (see Appendix 2 ). Although most medical libraries have the program available through computer stations, individual copies of the program are inexpensive and allow anyone with a computer modem to conduct searches from his/her home or office. Grateful Med is available for Macintosh users as well and offers these features:

• allows formulation of a search plan before dialing the NLM, with no time pressure
• presents search options clearly and provides extensive onscreen help from a single keystroke
• on command, dials and connects to the NLM without separate communications software
• automatically conducts the search to specified parameters, disconnects the modem and records the results.

MEDLINE is an excellent source of paramedical literature outside the confines of O&P. There is a nominal fee for the database search, but the time savings far outweigh the cost.

One researcher states, "The Grateful Med has turned a half-hour's worth of work into 53 seconds of computer time that costs 71 cents (10)." The average cost of two million searches conducted to date has been less than $2.50 (see Appendix 2 ).

RECAL

RECAL is the only database dedicated exclusively to O&P. This powerful tool contains abstracts and citations for all English-language articles about O&P published within the past decade and selected earlier classics. In addition to reviewing all English language European and North American O&P journals (including the Journal of Prosthetics and Orthotics, Clinical Prosthetics & Orthotics, Prosthetics & Orthotics International, Journal of Rehabilitation Research & Development, Journal of the Association of Childrens' Prosthetic and Orthotic Clinics, and Orthopedie Technique), RECAL also abstracts relevant articles from the Journal of Bone and Joint Surgery, the American Journal of Occupational Therapy, Physical Therapy, Archives of Physical Medicine and Rehabilitation and related periodicals (see Appendix 1 ).

Although most references are available in professional or medical libraries, the University of Strathclyde maintains a complete inventory of every reference on the database. Any article, however obscure, is available by fax or mail.

Personal computer users with a hard disk may purchase the entire database and have unlimited access without additional charges. Investigators also can contact the Strathclyde librarian by phone or fax to request a personalized search for a fee.

NAHL

A third source for O&P information is the Nursing and Allied Health Literature database. Available on CD-ROM disk in larger libraries, this source abstracts various journals, proceedings and dissertations from allied health fields, including physical and occupational therapy. Although it contains limited O&P information, it is a useful source for patient management protocols and low temperature orthotic designs (see Appendix 1).

Cross Referencing

The goal of the literature search is to be certain the researcher has uncovered all significant published information about the topic (11). The second phase of the literature review is to obtain copies of pertinent papers and texts and search them for further clues. Many articles list additional references and suggested readings. Checking these references may reveal a number of additional sources. Some will be only indirectly related to the original search topic but may contain useful information and hence are termed secondary sources (12). Also, run a search using the names of all key authors who may have published an article containing important information for your search. Only when all major articles have been cross-referenced without discovering any new citations can the search be considered complete.

Compiling the Results

Compiling the results of a thorough literature search gives the researcher a much clearer view of the problems ahead. Carefully summarizing current thinking helps clarify where additional information is most needed. Often, the reviewer will note changes in the approach to a given problem that will affect the planned research (13).

For example, the researcher with an interest in orthotic management of acute poliomyelitis will discover that the pace of new developments in the United States dropped sharply following widespread availability of the Salk/ Sabin vaccines. Within the past few years, however, there has been growing interest in determining how best to manage the sequelae to poliomyelitis that appear in the later decades of life. Such information may lead the researcher to redirect the investigation to focus on the most pertinent, current aspects of the problem, such as on the "post-polio syndrome" in the United States.

Publishing the Literature Review

Although literature review is a fundamental step in scientific research, it also can be a worthwhile goal in itself. A well-documented and thorough review of current clinical thinking often highlights present state-of-the-art and may, therefore, form the basis for a textbook chapter.

Historical reviews of how O&P clinical practices have changed are always of interest and may be published in professional journals or as separate monographs. And careful searches for information about uncommon conditions such as Van Nes Rotationplasty can add significantly to O&P's body of knowledge and have an immediate influence on clinical care.

Even when the literature search turns up information that adversely affects the proposed topic (most commonly, that the research question has been answered) it can have positive results. Nothing is more embarrassing than to publish what you believe is an original concept only to learn it has been previously reported. On the other hand, to document that a previous idea can be enhanced by modern materials or technology may be a genuine contribution to advancing clinical science.

Conclusion

Published information about O&P clinical procedure has grown exponentially over the past two decades and continues to increase. Dozens of journals published throughout the world contain important information about our field. Today's challenge is to locate the information when it is needed.

Modern library resources, and particularly computerized databases such as RECAL and MEDLINE, provide the curious clinitician with the access to literally millions of published articles. Within seconds, today's prosthetist orthotist can retrieve summary information about virtually any clinical problem and its treatment. This allows us to build on the knowledge of our predecessors rather than start from scratch and to further advance the field.

Conducting a literature review has much of the same intrigue and challenge as deciphering a Sherlock Holmes mystery, but with a more practical payoff: clinically useful knowledge. It remains the most inexpensive and most widely available tool to reduce the ambiguity inherent in modern clinical practice.

References:

1. Titus BR. Spreading the word. Orthotics & Prosthetics 1974; 4:4:1.
2. Day RA. How to write a scientific paper. Physiotherapy Canada 1980; 32:1:1.
3. Aust JD, rage CP Hemicorporectomy J of Surgical Oncology 1985; 30:226-30.
4. Gruman G, Michael JW. Translumbar amputation: prosthetic considerations. In Bowker JH, Michael JW (editors). Atlas o limb prosthetics: surgical, prosthetic an rehabilitation principles. 2nd ed. St. Louis Mosby Year Book 1992:563-8.
5. Simons BC, Lehman JE, Taylor N et al Prosthetic management of hemicorporec tomy. Orthotics & Prosthetics 1968; 22:63 8.
6. Hutter CG. Suction-socket prosthes for a hip-disarticulation amputee. JBJS 1953; 35:230-2.
7. Prince B, Makrides L, Richman J. Re search methodology and applied statistics the literature search. Physiotherapy Cana. da 1980; 32:4:206-10.
8. Michael JW, Nunley JA. Brachial plexus injury: surgical advances and orthotic/pros. thetic management. In: Bowker JH, Mi chael JW (editors). Atlas of limb prosthetics: surgical, prosthetic and rehabilitation principles. 2nd ed. St. Louis: Mosby Year Book 1992:293-310.
9. Wynn Parry CB. Brachial plexus injuries. British JHM 1984:32:130-9.
10. HEADlines 1991; 2:4:31.
11. Makrides L, Richman J. Research methodology and applied statistics: general principles and basic concepts. Physiotherapy Canada 1980; 32:3:135-9.
12. Currier DP. Elements of research in physical therapy. Baltimore: Williams & Wilkins, 1990: 38.
13. Literature or how to read more articles than you ever want to see in your entire life. Research in physical medicine and rehabilitation 1989: 68:2:101.