O&P Research: A Question of Quality—or Quantity?

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By Judith Otto

Take a little trip with an Internet search engine and see what you come up with under "Prosthetic Research." Your findings (or lack thereof) will likely illustrate one of the major problems with P&O research today.

Mark Geil, PhD
Mark Geil, PhD

When Mark Geil, PhD, Georgia Institute of Technology, Atlanta, conducted such a search using MedLine, he found that 17 of the 20 articles were on dental prosthetics or prosthodontics. Of the three that were on limb prosthetics, he reports, two came from academia and one from a round table funded by the Department of Veterans Affairs (VA) and the National Institutes of Health (NIH). "It does give you an indication that among the index of literature, the impact from P&O practitioners is lacking," he notes.

Is this what's wrong with O&P research? Or are we overreacting? Are there really any problems with O&P research?

Responding to generalized grumblings that the quality of research in O&P leaves a lot to be desired, and that much of the important and relevant research to date has come from outside the profession, The O&P EDGE asked leaders in the field for insights and opinions.

Tom Gorski, CAE, executive director of the American Academy of Orthotists and Prosthetists (AAOP), points out that the need for more and better research is being addressed by the Academy's Project Quantum Leap, which encompasses a series of activities to advance the profession as a whole.

"Within the next year," said Gorski, "We'd like to host a research agenda conference, drawing together 20 to 25 top people in the industry-each experts in their particular area-to meet for two to three days to discuss what is already out there, and what is lacking."

Such a conference would yield a clearer picture of the current state of affairs in O&P, and is sorely needed, since the findings of the last conference were printed in 1992 as P&O Research for the 21st Century, Gorski explained. "Although this book is about ten years out of date, it is probably-sadly!-still current."

Don Katz, CO, FAAOP
Don Katz, CO, FAAOP

Don Katz, CO, FAAOP, Academy president-elect and liaison to the Academy's Research and Development Committee, further explains that Project Quantum Leap is seeking federal funding to help support O&P education. "We hope to fund and spur applied research," emphasized Katz. "That is, research which is immediately applicable to clinical practice, with patient-specific objectives. I believe one of the primary purposes of a profession is to develop a knowledge base that will positively impact our ability to care for those that require our services.

"Our intention is to help fund consensus conferences on Clinical Standards of Practice (CSOP). Each conference on a specific topic will determine our current belief system, and thus help define our research priorities for the future.

"Findings should be as literature-based as possible, but when there is no literature available, clinicians have little to fall back on to help them establish treatment protocols."

Each conference takes nearly one to two years to execute, says Katz: nine months to organize the meeting, recruit faculty, and start them writing manuscripts; then 12 months of editing points of consensus and priorities from the conference itself, and determining how and where to publish results.

Georgia Tech MSPO student Dave Fritz uses callipers to record anthropometric data before gait analysis. Body segment parameters are used to translate marker oordinates to more useful joint center coordinates.
Georgia Tech MSPO student Dave Fritz uses callipers to record anthropometric data before gait analysis. Body segment parameters are used to translate marker oordinates to more useful joint center coordinates.

The first conference was hosted in February 2002, and focused on the orthotic treatment of idiopathic scoliosis and Scheurmann's kyphosis. Resulting materials are now in the final editing process, Katz reports, and he will present the preliminary results at the Academy meeting in San Diego, CA, March 19-22. The goal of these conferences is to increase the body of knowledge in literature so that it can be referenced, Katz noted.

An infinite number of topics are available for these CSOP conferences, since by the time the primary subjects are covered, it will be time to revisit them and explore new findings and beliefs, Katz said. If successfully financed, the conferences will be a continuous, ongoing process, and a first step to spurring additional research efforts, he explained, adding, "This is not a destination, but a process."

Katz points out that, more than 20 years ago, the majority of research that influenced O&P was done by physicians such as orthopedic surgeons. "During the last 20 years, this is becoming less and less the case. This has left a void to be filled. This research can be done by other medical disciplines, but they are less tuned in' to the needs of providing orthoses and prostheses."

Applied Research: O&P Involvement

For orthotists and prosthetists to become more involved with applied research is an achievable goal, Katz believes, "but I don't think the way we've tried to accomplish this has been effective to date. I'm one of those pushing hardest for success in this area, but there must be a shift in our primary education for orthotists and prosthetists to make this a goal. Structured education on how to conduct applied research is to some extent woven into the current prosthetic/orthotic curriculum, but more is needed if a true priority shift, or  new paradigm, within our profession is to occur."

Mike Raney, PhD, CO
Mike Raney, PhD, CO

Mike Raney, PhD, CO, current chair of the Academy R&D Committee, shares Katz's passion for educating and involving orthotists and prosthetists in applied research by providing them with the tools to do so.

Raney has written a 27-page paper-A Guide to a Simple Research Project-which has recently been made available on the Academy's website, (www.oandp.org). It offers a broad overview of how to do a quantitative research project. Although it was written to help O&P residents with their required research projects, it is relevant to others in O&P who are interested in research, says Raney.

Raney has circulated a Research Interest Survey, intended to explore the research interests and needs of Academy members. The survey also took inventory of the research knowledge levels of the respondents, and asked what research questions members thought were important to O&P.

"We sent out the research interest survey, via fax, to about 1,000 Academy members," Raney explained. "Our response rate of about 17 percent was typical for a faxed survey. We would have liked to have every member respond on this important topic. About 20 percent of the respondents listed one or more research questions they thought were important. It appeared that not a lot of thought has been done on what research topics are important to O&P."

Georgia Tech MSPO students Mark Holowka and Kristen Andrews attach reflective markers in preparation for a kinematic motion analysis of Paralympic gold medalist Shea Cowart.  Photo by Nicole Capello
Georgia Tech MSPO students Mark Holowka and Kristen Andrews attach reflective markers in preparation for a kinematic motion analysis of Paralympic gold medalist Shea Cowart. Photo by Nicole Capello

From the survey, Raney said, the R&D Committee will develop a research networking list or database. The database would include skill levels, interest in mentoring, willingness to advise on residency projects, willingness to participate in research, and more. About 80 percent of the respondents indicated that their facilities would be interested in participating in a research project.

Raney has also helped to write the Research Reference Guide, a compilation of a series of articles on research methodology that were originally presented over a two-year period in the Journal of Prosthetics & Orthotics. The Guide, which can be found in the Members Only section of the Academy website, includes the JPO article series and provides links to some other websites offering helpful research guidance.

"The basic problem is that most fields teach research and statistical methods at the graduate level," says Raney, "but O&P has only two Masters programs and no PhD programs in this country. Most O&P professionals with knowledge of research were trained in research in other fields."

"Is research by O&P professionals of poor quality? No- research by O&P professionals just isn't being recognized as such," according to Raney. "While there are numerous O&P professionals participating in research, they are generally part of a team led by researchers from other fields," he explained. "It is widely accepted that the people who are best qualified to do research in a field are those with intimate clinical knowledge and experience. In O&P, this would be the practitioners." Thus very few of the important questions facing O&P have been answered-and we need researchers to answer them.

"It's not going to happen fast," he concludes. "We're just starting to take the first steps down a long road. I feel it's very important that we involve consumers of O&P research (i.e. practitioners) in this process." Hopefully, reading articles on new possibilities for care and treatment will spur their interest in applied research, he noted, adding, "All the research does no one any good if it isn't read by practitioners and integrated into their daily practices."

Quantification: Getting the Numbers

Quantification problems in O&P can be troubling, according to Mark Geil. "There's not really a lot of quantification routinely used in clinical practice," he points out, noting that there are ways to quantify many attributes about human movement that could be routinely carried out. "We would then have 10-20 years' worth of data, and we could do retrospective studies and post hoc analyses. But until that body of numbers and data exists, everything we are doing is prospective-it's hit or miss. If we need a certain idea about an outcome of treatment-and it's never been quantified in the past-that makes it difficult, based on the numbers you need for the experiment, to make a case for any change clinically."

Geil agrees that when we compare the body of literature in prosthetics and orthotics to similar bodies of literature elsewhere in allied health and in disciplines such as biomechanics, it's certainly lacking. "There is almost a youthful naiveté," Geil reflects. "What we know is far less mature than what is known in other similar fields."

Bilateral amputee and 100m world record holder Shea Cowart participates in instrumented gait analysis at Georgia Tech to determine the biomechanics of her running stride. Twenty-one reflective markers are traced in three dimensions by specially filtered cameras.  Photo by Nicole Cappello
Bilateral amputee and 100m world record holder Shea Cowart participates in instrumented gait analysis at Georgia Tech to determine the biomechanics of her running stride. Twenty-one reflective markers are traced in three dimensions by specially filtered cameras. Photo by Nicole Cappello

"That's good and bad. We don't know as much as we wish we did, but it also opens the door for a lot of research questions that have yet to be answered, and therefore a lot of opportunities to improve the quality of patient care."

"Generally speaking, we are lacking knowledge of some fundamental issues," he says. "We still don't have an adequate biomechanical model of a prosthetic foot. We're out there designing and producing them for amputees, based on a lot of pretty bold assumptions about knowledge that we've never quantified. What are amputees' specific goals for walking with a prosthesis? That's something that we could design for-if we knew what it was.

"We've never quite understood issues relating to metabolic energy use for amputees engaged in various activities," Geil continues. "And the list could go on."

Georgia Tech has taken the first step to help address the lack of O&P research by implementing its landmark masters program. The program includes teaching how to do research-how to formulate a hypothesis, how to read and understand a manuscript, and how to write their own-and then actually do it. "You can take a research methods course, but until you're actually in the lab collecting data, it doesn't have a lot of real-world meaning," Geil points out. "Our students in their first semester have already conducted their own instrumented gait analysis, based on their own research idea from start to finish-from calibration of the cameras all the way through processing of the data. We're making sure they have those skills, so that when they become practitioners and they have an idea or question about a certain device or treatment, they have the knowledge to get answers to those questions."

At least for the present, in a world where few answers exist in the sparse O&P archives, the solution would seem to lie in equipping practitioners with skills sufficient to answer their own questions.

Geil agrees. "We're also teaching quantification as a part of clinical practice. We've got a lot of CAD/CAM systems-maybe it's important to document the volume of residual limb or the shape of the planar surface of the foot routinely with every patient you see, whether you're going to treat them that way or not. If those numbers start to accumulate over time, then we can answer questions that we didn't know existed when we were accumulating those numbers."

Editor's note: The current state of O&P research is a many-faceted subject. Upcoming articles will present more views and possible solutions from leaders in the field. One thing we all know for sure: today's research will impact tomorrow's practice.

Judith Otto is a freelance writer based in Holly Springs, Mississippi.