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Research Forum: Baccalaureate Student Research

Susan Kapp, CPO
George Wentz, CPO

ABSTRACT

Practitioners must have the ability to investigate and add to the orthotic and prosthetic body of knowledge. Likewise, the ability to critically review research is essential.

Recognizing this, the University of Texas Southwestern Medical Center at Dallas Prosthetics-Orthotics Program has, over the past eight years, designed its curriculum to culminate in a senior research project demonstrating the students' mastery of the essential tools required to perform research. It begins with coursework in statistics and computer skills prior to acceptance. Early in the prosthetics-orthotics curriculum, students are introduced to available campus resources. Students gain experience in research methods through a series of seminars and a scientific inquiry course. During their senior year, students conduct research and present the findings in written, oral and poster forms. Several senior projects have been published in professional journals. Established guidelines assist students and their faculty research advisers in successfully carrying out the projects.

Any student or faculty research endeavors at the university are monitored by the Institutional Review Board, Office of Grants Management and the program itself. Student researchers also may contribute to ongoing faculty research and conduct pilot studies. Graduates trained in research methods have the potential to make meaningful contributions to the field.

Introduction

Research remains a primary responsibility of universities. Since faculty members are expected to conduct research, the university is an excellent environment for students to learn research protocol. Many of the resources needed to conduct studies are available, including libraries, experienced researchers and measurement equipment. "Most departments in medical universities have full-time basic science researchers and statisticians who actively pursue clinicians to become involved with or conceptualize research projects" (1).

University students learn about research in incremental steps, possibly ending in a thesis or dissertation. The role of the university for prosthetics-orthotics students is to offer them basic knowledge and experience that eventually will allow them to conduct clinical research after graduation.

Recognizing the need for high-quality, independent prosthetic-orthotic research, the University of Texas (UT) Southwestern Medical Center's Prosthetics-Orthotics Program has structured its two-year curriculum to include training in designing and conducting research as well as critically evaluating research performed by others. It is necessary to constantly develop and improve the techniques used in clinical practice. According to Lunsford (2), "O&P professionals need to embrace a process of critical appraisal for the many orthoses they recommend as well as new ones they design." Validating research to provide better patient care requires considerable effort. These new techniques and components must be clinically tested while performance reports by developers are verified. As Payton states (3), "A widespread responsibility on the part of all professional practitioners should be to make some contribution, in some way, to the scientific validation of the concepts and principles on which practice is based. Research...is an attitude and a process used by professional people to increase practical knowledge and clinical skills."

While conducting research, students at UT Southwestern begin to develop organizational skills and refine written and oral communication skills. They learn to think analytically about their research questions. These skills are becoming increasingly essential for today's prosthetists and orthotists. As students spend more time developing analytical and problem-solving skills, there will be an attendant decline in emphasis on fabrication in the schools. These trends already are in evidence in the ABC certification examinations. A strong research emphasis in the undergraduate curriculum prepares new practitioners to be leaders in advancing the state of the art to benefit the patients who require orthotic and prosthetic services.

Initial Research Training

To concentrate on research techniques in the available time, a basic course in statistics is a prerequisite at the UT Southwestern Medical Center's Prosthetics-Orthotics Program. This course introduces students to concepts such as correlation of data, setting levels of significance, validity, reliability, subject selection and measurement scale selection. In addition, they learn about statistical tests to apply to the data, including but not limited to the chi-square, Mann-Whitney U, t-test and ANOVA. An introductory computer concepts course also is required.

Computer literacy has become mandatory in today's environment, and students should have the skills to access and manipulate data. Training in spreadsheet use, word processors and presentation software allows students to apply these skills to assignments. A library orientation to familiarize students with library resources, in particular on-line databases, is given at the beginning of the entering year. Internet access also is provided each student through the library, as is access to RECAL, a prosthetics-orthotics database.

Application of these skills begins with literature reviews, which are presented orally to the class and are mandatory for each major course. Students are required to choose and critically analyze current articles. Discussion of the articles by the students includes a statement of the problem, need for the study, methodology, subject selection, description of measurement tools and analysis used, results, and conclusions. During each major course, subject-appropriate term and pathology papers further develop library, writing and oral communication skills. Proper referencing is emphasized by requiring the use of the American Psychological Association referencing method for all written work.

Course Sequencing

The curriculum for the research projects at UT Southwestern includes scientific inquiry and seminar III and IV courses in a progression that first provides instruction on conducting scientific research and then guides students through all phases of the research endeavor as they apply to the topic chosen for investigation.

A series of four seminars, each two semester credit hours, has been designed to expand topics presented in other prosthetics-orthotics courses by using adjunct faculty and guest lecturers from within the prosthetics-orthotics profession and related fields. To be a proficient practitioner, prosthetics and orthotics students must possess knowledge beyond those technical and clinical skills necessary to fabricate and fit a prosthesis or orthosis. These courses are designed to provide an avenue for augmentation and expansion of those basic skills. Topics include history, ethics, roles of health professionals within the multidisciplinary team and disease entities. Administration and management for a prosthetics-orthotics practice, new developments and concepts in prosthetics and orthotics, and methods of patient education are presented.

The courses teach students to recognize the importance of keeping abreast of current developments and of critically analyzing new concepts, methods, materials and components in prosthetics and orthotics. They also teach students methods with which to conduct basic research in the field as well as how to contribute by reporting findings at professional meetings and publishing articles in professional journals.

The courses require junior-level students to write two term papers and senior students to produce a full research project. The seminar in prosthetics and orthotics III course is taught in the first semester of the senior year. Students are required to write a proposal and begin work on the project. Monthly meetings are required with faculty advisers.

The seminar in prosthetics and orthotics IV course is taught in the sixth and last semester. Students are required to complete the acquisition of all data for the project and complete the final written report. The results of the project then are presented orally in a research forum. This environment simulates presentation at a national convention. Students prepare professional-looking visual aids and present their research in a large auditorium. The quality of many of these presentations rivals those at national conventions. To date, several projects have been presented at professional meetings and published in professional journals.

Scientific Inquiry Course

Physical therapy faculty teach the one-semester-hour course entitled scientific inquiry, with prosthetics-orthotics faculty serving in an advisory capacity to students. This course introduces students to the components of research design and guides them in the critical analysis of current research. The rationale for this course concerns the need for prosthetics-orthotics graduates to have an understanding of valid research techniques so they can evaluate published studies through statistical analysis and make determinations as to their validity.

During this course, students are provided the opportunity to identify and evaluate the appropriateness of research designs found in the current research literature and to initiate the process of research design by preparing a research proposal. Course content includes basic research concepts, introduction to research design, measurement of reliability and validity, descriptive research, correlational research, two-group design and three-group design. Prosthetics-

orthotics faculty members advise students in the writing of a research proposal. Students learn to identify the components of research designs found in current literature and evaluate the appropriateness of these research designs. Students choose a topic of interest and prepare research proposals, including a project budget and consent forms for obtaining approval to use human subjects through the university's Institutional Review Board (IRB).

Since this is a learning exercise and will not be carried out, students are encouraged to develop proposals without the limitation of funding, time and subject availability.

Senior Projects

In the senior year of the program, students are required to design and complete a research project. The project may take one of several formats: an educational or instructional project, experimental research, or a historical overview of the selected topic. The first chapter, which consists of the introduction, statement, significance, purpose, assumption, limitations, hypothesis and methodology, is completed within the first semester. The final report is completed during the last semester and is presented orally to the faculty, students and allied healthcare professionals.

Funding may be established and allocated to students to complete their projects when special equipment or supplies are indicated. Each faculty member is assigned to serve as an adviser to two or more students. The project is academically challenging and motivates students to continue to produce quality research and presentations, which are important to the future of prosthetics and orthotics.

The purpose of the project is to demonstrate the students' ability to prepare a bibliography, gather data, use original source material, draw conclusions and present the material in a form that shows adequate command of the English language. The material is presented in a final written report to the prosthetics-orthotics faculty and as an oral presentation to the local medical community. This project generally will follow the methods presented in the scientific inquiry course. Experimental research using human subjects requires IRB approval. Students must follow the university guidelines established by the IRB.

Students are responsible for choosing a research topic that interests them. Suggestions for topics may be obtained from faculty or clinical supervisors. Students are encouraged to choose topics that are experimental and can realistically be completed with limited resources and time. Use of outside research facilities, lab equipment and materials is discouraged. Instead, students are encouraged to use program facilities and materials and to use innovative approaches that do not require sophisticated equipment.

As stated by Gavin and Patwardhan (1), "Frequently, ambitions are much greater than accessible funding and equipment for the beginning researcher. To start out, it is best to conduct studies that don't require significant funding and can be done in the lab or at the home." To encourage creativity, any testing apparatus necessary should be designed and built by the students. These projects are seen as pilot studies, and students should have control over each phase. The logistical challenges students must overcome when using outside facilities make in-house projects much more practical.

Research Advisers

Faculty members act as research advisers to two or more students. Comprehensive guidelines have been developed for both students and advisers. Significant efforts are made to ensure students receive a valuable experience and select a topic that is interesting yet not beyond the scope of their abilities. Advisers mentor students through two semesters of investigative work and final presentation. The duties of faculty advisers include consulting on the details of student research projects and serving as a contact point in the program for outside vendors and institutional facilities required in the project. Faculty advisers also are responsible for grading the proposal, intermediate report, final report and oral presentation. Monthly meetings are held with students to review progress and maintain project flow. Faculty members must commit a significant amount of time to successfully guide the student through the process.

Senior Project Organization

The project is divided into six components: the abstract, the formal written proposal, the preliminary written report, the final written report, the oral presentation and the poster presentation.

Completing an abstract is an important first step. Topic approval is based on submitted abstracts. Five references also are required to be submitted with the abstract. Advisers are assigned upon topic approval.

The formal written proposal, including IRB forms, should follow the format shown in Table A .

The preliminary written report should follow the format shown in Table B .

The final written report is an updated version of the written report (see Table B) with emphasis on results and discussion.

In the oral presentation, students are evaluated based on the following:

• content/knowledge of material
• clarity/organization
• speaking ability/eye contact
• visual aids
• ability to answer questions
• length of presentation
• appearance

The objective of the poster presentation is to inform prosthetists-orthotists of recent student research at UT Southwestern while acquiring exposure for the students and the program. Posters may be displayed at local, state or national meetings. A yearly "Poster Competition" is held in conjunction with the annual meeting of the Texas Chapter of the American Academy of Orthotists and Prosthetists. In past years, graduates have entered into competition posters summarizing their senior research. In return for entering the competition, the meeting registration fee is waived. The executive board of the Texas Chapter of the Academy judges the posters, and the first-place entry wins a plaque. Many entrants from previous competitions have been asked to present their research at professional meetings.

Evaluation of Outcomes

The UT Southwestern Medical Center's Prosthetics-Orthotics Program uses several methods to evaluate the expectations of the educational research objective. The goal is to educate students about valid research in the prosthetics and orthotics profession and guide them toward becoming active in research endeavors and dissemination of the results. Evaluation of the objective involves three organizations within UT Southwestern: Southwestern Allied Health Sciences School, the Office of Grants Management and the IRB.

Research projects and their results are closely monitored by the program. The Office of Grants Management follows and evaluates the use of any grants awarded to students or faculty. The university's IRB annually reviews ongoing projects to ensure compliance with regulations pertaining to the use of human subjects in research. The faculty follow each research project and evaluate the progress through mandatory advisorial meetings and ongoing written reports. The program requires presentation of projects at a professional gathering and advocates publication and continuation of research.

A partial list of past senior projects completed during the course of the UT program appears in Appendix A at the bottom of this page.

Student Researchers for Ongoing and Pilot Projects

Long-term projects involve ongoing research of topics whose scopes require longer than the one-year span allotted to student projects at UT Southwestern. Projects are selected by faculty members according to interest and need for investigation of the topic. Students are required to spend one semester contributing to the completion of one project under the direction of the responsible faculty member who serves as the principal investigator for the project.

Student research also has been used by Scottish Rite Hospital for Children and other medical institutions as pilot work. Students establish protocols and produce initial data, which then are used in the submission of major research grants.

Summary

As with any medical profession, hard data are required to support a new or existing treatment protocol. The importance of valid research cannot be overemphasized. If orthotics and prosthetics is to continue as a profession rather than an art form, individuals within the profession must train their own experts to conduct research in the field.

The two years spent at the university are an ideal time for future practitioners to develop research-oriented attitudes. The University of Texas Southwestern Medical Center at Dallas Prosthetics-Orthotics Program seeks to graduate board-eligible practitioners who will be active contributors to the field and who are capable of conducting valid clinical research and critical review.

Suggested Reading

Domholdt E. Physical therapy research: principles and applications. Philadelphia: W.B. Saunders Co., 1993.

Portney LG, Watkins MP. Foundations of clinical research: applications to practice. East Norwalk, Conn.: Appleton & Lange, 1993.

Shott S. Statistics for health professionals. Philadelphia: W.B. Saunders Co., 1990.

Appendix A: Partial List of Senior Projects Completed at UT Southwestern

• The Effect of Prosthetic Training on the Functional Ability of the Upper-Extremity Prosthetics User
• A Comparison of Polycentric Hydraulic Knee Units
• Potential Benefits of a Transradial Swim Fin
• Upper-Extremity Residual Limb Sensitivity Compared to the Contralateral Sound Side in Unilateral Transradial Amputees
• Comparing Differences in Dynamic Alignment of the Same Patient Between Prosthetists
• Prevalence of Back Pain Among Persons Who Have Undergone Unilateral Upper-Extremity Amputations
• The Amount of Vertical Displacement of Five Suspension Sleeves Measured Statically
• Rocker Bottom Versus Flat-Soled Shoes: A Comparison of Energy Expenditure When Used in Conjunction with Bilateral Solid Ankle-Foot Orthoses
• Investigating the Differences in Hardness as the Ratio of RTV Silicone, Foam and Catalyst Is Varied
• The Patellar-Tendon-Bearing Orthosis: A Comparative Study on Plantar Pressure Relief of Two Thermoplastic Designs
• Application of Electromagnetic Adherence to the Suspension of Transtibial Prostheses
• Postoperative Hydrotherapy with the Prosthesis for the Transtibial Amputee
• A Comparison of Polypropylene and Carbon-Laminated Posterior Leaf Spring Ankle-Foot Orthoses
• Cost vs. Function of Three Different Ankle Reinforcement Modifications
• A Comparison of the Efficiency of Prosthetic Cabling Systems
• A Comparison of Various Laminating Resins
• The Shape Memory Alloy (SMA) Powered Terminal Device
• A Comparison of Rigid Removable Dressings and Early Postoperative Prostheses
• An Alignment Fixture for the Syme Prosthesis
• Energy Expenditure Required of Three Different AFO Designs
• Comparison of the Cyclic Fatigue Point of Colored Polypropylene vs. Natural Polypropylene
• The Accuracy of Vacuum-Shaped Polypropylene After Extreme Heating
• The Effectiveness of the UCBL Foot Orthosis With and Without Medial Posting for the Treatment of Calcaneovalgus
• A Comparison of Volumetric and Diametric Changes in Prosthetic Materials
• Voluntary Closing Terminal Device: A Viable Option-Can Long-Term Users of VO-TD Learn to Function with VC-TD?
• Inversion-Eversion Capabilities of Twelve Prosthetic Feet
• A Retrospective Study and Literature Review Comparing Three Treatment Modalities for Cerebral-Palsied Children, Including Serial Casting, Botox, and the Combined Efforts of Serial Casting and Botox
• A Body-Powered, Hydraulic-Controlled Prehensor to Replace the Conventional Cable-Driven System in Upper-Extremity Prosthetics
• The Effect of Increased Sensory Feedback on Muscle Site Isolation Contraction Training Directed at Myoelectric Arm Prostheses

References:

1. Gavin TM, Patwardhan AG. Getting started in prosthetic-orthotic research. JPO 1993;5:4:112-4.
2. Lunsford TR. Types of clinical studies. JPO 1993;5:4:105-11.
3. Payton OD. Research: the validation of clinical practice. Philadelphia: F.A. Davis Co., 1989.