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

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By Judith Otto

Research requires three factors: expertise, time, and money, points out Darrell Clark, CO, director of Orthotics, Rancho Los Amigos, Downey, California.

Darrell Clark, CO
Darrell Clark, CO

"Many baccalaureate programs that are university-based often have resources in terms of faculty members who have PhDs and outside expert help from kinesiologists, for example," Clark says. "O&P certificate courses often don't have those kinds of resources, unless they are based at a major university. Even in the university setting, there are limits: budgetary restraints often don't allow the necessary specialized curriculum space; and even educators don't always have a strong background in grant writing to gain funding."

And it's no surprise, Clark agrees, that one can't do research without funding. "In a typical individual practice, where reimbursements are being pushed ever lower, it's hard to justify the cost. And since research is expensive, that investment needs to be recouped, usually in higher charges for patient service."

He points out that the California state government is looking at a $30 billion deficit; state residents are looking at decreased services and increased taxes--which may reflect a nationwide problem shared by 20-30 other states that may also be in dire financial straits. "That O&P is perceived as not important enough for the indigent population to deserve," Clark notes, "is reflected in mass proposals to eliminate O&P benefits from Medicaid services in a number of states." In this kind of climate, it is hardly realistic to suppose that funding for O&P research will materialize without dedicated, persistent, and cogent advocacy, Clark warns. Manufacturers can and do finance research in the form of product development, but inarguably they have a vested interest. They "want a reward somewhere down the road," Clark says.

Nerrolyn Ford, PhD, BP&O, British Columbia Institute of Technology (BCIT), Burnaby, British Columbia, Canada, agrees that the problem is not a question of quality in O&P research.

"I'm not sure that it's fair to say that the quality of research within P&O isn't so good--I would say that it's the quantity. Traditionally, we have not been an academic profession, and it's the academics that typically have the skills to do the research. It's only been in the last ten years that we've really started to look at increasing the level of education in P&O, and we're still in the very early stages.

Nerrolyn Ford, PhD
Nerrolyn Ford, PhD

"It's a big area, and a lot of research needs to be done, so other well-established professions that are equipped with the necessary research skills have taken the initiative," Ford continues. "They have these skills because the level of qualification for these professions is higher--the educational background that they have includes some research training and some major research projects, which typically in the past we have not included in our educational system."

In Canada, Ford explains, there are three well-established schools teaching O&P--all at the diploma level: BCIT, Montmorency in Quebec, and George Brown College, Toronto, Ontario. All three schools have been established for about 20 years.

What can we do to get where we need to be?

"We're on the right track," said Ford. "At the moment, we're seeing a wave of schools increasing the level of education. I don't think that every prosthetist or orthotist needs to have a higher level of education. We don't need a profession full of researchers; it's not what we're really about. But we must have opportunities for those people who wish to go on to higher levels of education, e.g. Masters degrees and PhDs.--and those degrees have to be in prosthetics and orthotics, not kinesiology or biomechanics."

P&O is also lacking in opportunities for graduate program alumni to do research, Ford points out. "There are no established research facilities where they can work once they've graduated. So after they get these degrees, they work in clinical practice again, because that's all that's available." BCIT has two PhD programs in P&O. "We're the only two in Canada," says Ford. "We do some applied research and development; I have a grant, as well."

How hard are grants to get?

"People do need the skills to write the grants--and I'm fairly new to this as well," Ford says. "I'm looking for mentors to help me improve my research--and where do you find them? There are very few prosthetists and orthotists with this kind of research experience--often you have to go outside the profession."

And how does one get a grant?

Gary G. Bedard, CO, clinical marketing manager, Becker Orthopedic, Troy, Michigan, was chairman of the American Academy of Orthotists and Prosthetists (AAOP) Fabrication Sciences Society (FSS) when he wrote his proposal for a research study in April 2001: A Preliminary Report on Measuring the Rate of Polypropylene Recrystallization After Clinical Thermoforming Through the Use of Differential Scanning Calorimetry.

"In essence," Bedard explained, "in the thermoforming process, there is a certain level of controversy regarding proper cooling at the end of the process. Improper cooling can actually weaken the polypropylene. Findings showed a decrease in strength of up to 16 percent." (Hence, this was a topic of interest and applicable value.)

The FSS receives an annual budget which is typically used for conducting workshops at the national meeting. However, last year the FSS board decided to approach the Academy with the idea that practitioners could request grants instead, Bedard explains. Bedard's grant was the first awarded by the Academy, and he presented his findings at the 2002 Academy meeting. "They told me I was the first one who had ever applied for a grant to do research," he said. The Academy is now prepared to consider similar funding requests to support research directly applicable to O&P, Bedard noted. "Since this grant was awarded through the auspices of the FSS, I look at it as potentially being a model that the board could use to stimulate activity in the various societies. If practitioners know small grants are available to conduct research, it might prompt them to be more involved with these societies."

Bedard agrees that most O&P research is done by those outside the field, and, like others, believes one of the major reasons is that there aren't enough graduate programs in O&P. Research is not typically the focus of a baccalaureate program, but rather, of a graduate degree program, Bedard notes. "Consequently, because we don't yet have a PhD program, it will be years before we have a body of graduates in the field who are in institutional settings and who can write the grants, bring in the funding, etc."

Meanwhile, Bedard suggests, the Academy can support O&P research either by providing grants to PhDs who have an O&P clinician on their research team or by developing a road map to help the O&P practitioner/researcher in conducting his/her research with expert help and guidance.

The machining center is integral in prototyping.  Photo courtesy of Fillauer Inc.
The machining center is integral in prototyping. Photo courtesy of Fillauer Inc.

Gerald Stark, BSME, CP, FAAOP, director of education & technical support, Fillauer Inc., Chattanooga, Tennessee, has also served as a prosthetic instructor at Northwestern University, Chicago, Illinois, so he understands both sides of the research picture. "About 10 percent of what most researchers do is directly applicable to product development," he says. "True research is answering more altruistic questions. However, if we don't produce products, we're not successful." However, research labs can attempt to answer questions that increase the overall body of knowledge, which may or may not evolve into products, he noted.

Manufacturers face different challenges, he points out. "We gamble that what we do will develop into a viable profit. We try to minimize our risk by using marketing to guess well. We look at L-Codes and see what has been successful--and what's missing. Certainly we'd like to see more unique products, but working with smaller quantities of 100 or less limits our return on investment for new products."

Then there's that troubling question that Stark also attempts to answer: What IS research?

"In our case, it's tinkering, inventing, trying to see what works," he says. "Research labs may frown on that method because their goals are different. At Fillauer, we have been doing research of the tinkering variety, just like the average O&P practitioner must tinker to develop solutions for his patient.

More practitioners would like to tinker, but need partnerships with machinists and engineers to do so," he adds. Manufacturers are investing more in research and product development, and that money usually translates into what products people will see in the future, Stark said. Manufacturers also are developing symbiotic partnerships with research labs that help both groups: "Products are developed on sound scientific concepts, and research labs can show how studies directly benefit the profession, increasing their chances for funding."

Ideas for research come from everywhere, Stark finds. About half of Fillauer's product ideas are generated by people outside the company. At seminars, he makes it a point to ask practitioners what is the one thing they wish they had--a perfect springboard into practical research directions.

Professionals involved in O&P come from a variety of backgrounds, thus seeing patient needs from a variety of perspectives, Stark notes. "This creates some interesting discussions, since we are engineers, anatomists, kinesiologists, athletic trainers, physical therapists, and occupational therapists."

John Michael, MEd, CPO, FISPO, FAAOP, president of CPO Services, Portage, Indiana, recently reflected on the need for more O&P research in his "Corner" at oandp.com. Reporting on the 2002 Annual Meeting of the UK National Member Society of the International Society for Prosthetics and Orthotics (ISPO), Michael commented, ""&As we move further into the 21st century, the plethora of similar choices and conflicting manufacturers' claims strengthen my conviction that EBP (evidence-based practice) is the best available tool to determine what's best for our patients and to add more credibility to our practices. I would encourage every P&O society to follow the lead of our UK colleagues in this regard, as good research is quite difficult to conduct and moves knowledge forward in very small steps. Practitioners need to start doing clinical research now to insure that the next generation of practitioners will have a sufficiently large body of evidence to face tomorrow's challenges."