A Call to Improve Advanced Science Content: Part III
September 2002 Issue
Editor's Note: In the previous articles in this series, Dr. Neumann called for a strengthening of advanced science courses in O&P education in seven areas: biomechanical tissue factors; biomechanical gait factors, physiologic factors, psychophysical factors, motor control factors, material strength factors, and economic factors. This article discusses the last three areas and presents Dr. Neumann's recommendations and conclusions.
Motor Control Factors
Motor control factors of importance in O&P include hand-eye coordination, balance, and the ability to reprogram muscles and learn new motor activities. Despite the potential importance of this area, there is little scientific literature on motor control in the context of O&P clinical work.
It is somewhat surprising that Fitt's Law, which identifies the trade-off between the speed of a movement and the accuracy of the movement-one of the fundamental concerns and guiding principles in the design of man-machine interactions and controls-is never mentioned in O&P scientific literature. Fitt's Law is helpful in understanding the limitations of upper-extremity prostheses and the importance of the speed with which terminal devices open and close.
The balance skills of a patient are also important to O&P outcomes for the lower extremity, and influence component selection as well as alignment. The sense of balance worsens with increasing age and can be affected by specific pathologies. Balance assessment is an emerging specialization in the field of physical therapy, with amputees being one of the populations of interest. It may be desirable to introduce O&P students to the concepts and experimental methods employed in assessing balance skills, in order to better understand how balance affects the patient and to foster effective communications with balance specialists.
Material Strength Factors
Material strength factors will not be addressed here at length, except to note that, as mentioned below, both an excellent textbook and continuing education courses are currently available.
Based on my engineering knowledge of materials and my experience in the lab, I have concluded that many laminated sockets are probably over-designed. However, because consistent quality control is somewhat difficult to achieve during fabrication, and lawsuits are costly, it is probably better to err on the side of conservative design.
Weight and bulk remain important concerns though, and it would be desirable to introduce students to the basic strength properties of composite materials, which are influenced by the direction in which the fibers in the matrix run. Also, an overview of the scientific methods used to determine stress patterns in components would be valuable, along with examples and interpretations of the stress patterns found in components when they are placed under the loads associated with gait.
Economic factors in the context of O&P science concern measuring and comparing the cost-effectiveness of alternative designs and components. Research in this area has rarely been conducted explicitly in the context of O&P decision-making. However, subjective cost-effectiveness judgments are made by practitioners whenever the choice of a brand-name component is based on an estimate of whether the performance, initial cost, fabrication problems, maintenance requirements and cost, and expected life of the component merits its selection. Thus, students should be exposed to the concepts underlying the science used to make economic evaluations and comparisons of alternatives.
Recommendations and Conclusions
Because the essential content of O&P advanced science coursework has not been fully identified yet for each of the seven areas, it is not possible at this time to recommend the precise number of credits needed to provide students with a minimally useful background. Also, accreditation criteria are shifting from credit hour requirements to outcomes assessment, and innovative teaching methods tend to make it more difficult to measure content in terms of credit hours. However, I estimate that eventually it would involve the equivalent of between six and nine credit hours to cover the areas adequately. Initially, the amount of relevant material readily available might limit content to less than six credits, but as knowledge is developed, it might easily approach nine credits.
Identification of the content should be undertaken by a team comprising individuals working directly in O&P with backgrounds in traditionally strong science-based disciplines, including engineering, medicine, and kinesiology, and professionals from related healthcare disciplines such as orthopedic surgery, vascular surgery, plastic surgery, physical therapy, and occupational therapy, who have an appreciation of-and a vested interest in-the clinical aspects of O&P.
A balance should exist between educators, individuals with extensive O&P clinical experience, and individuals who primarily have research backgrounds and interests. A major challenge will be to establish a mechanism for ensuring that the content of the educational materials remains current, since O&P is highly interdisciplinary, and advancements in measurement techniques and scientific knowledge are evolving rapidly in most of the seven areas.
A sequence of advanced science courses could be more easily integrated into the bachelor of science programs than the short-duration certificate programs. For the certificate programs, a "just-in-time" or "integrated" approach might be appropriate. Several engineering programs are experimenting with these types of curricula, in which the advanced science topics are presented "as needed" during the various stages of an open-ended design problem which is introduced early in the academic program; however, the logical progression from basic science to engineering science to application is maintained.
The author notes that progress has been made in the development of course content in the area of materials science through the publication of a book by T. Lunsford, and continuing education workshops have been developed and offered recently through the American Academy of Orthotists and Prosthetists (AAOP) in the areas of materials science and gait analysis. But from a instructional perspective, elements of this material should be presented prior to, or integrated with, third-level clinical experiences in academic programs.
The author recognizes that National Commission on Orthotic and Prosthetic Education (NCOPE) guidelines specify only a minimum content for advanced science, that institutions can choose to exceed them, and that some already have. However, all the educational programs should be motivated to improve their advanced science course materials, and accreditation guidelines can be an extremely strong and effective motivator.
The goals of the advanced science component should be:
1) to develop in students the ability to interpret and apply scientific principles for the prescribing, fitting, and aligning of prostheses and orthoses in a clinical setting;
2) to develop a level of scientific knowledge that enables graduates to understand the advances being made in O&P-specific domains of science by related disciplines such as engineering, medicine, physical therapy, and kinesiology; and
3) to develop skills that enable graduates to evaluate the potential contribution of these scientific advances to clinical practice.
Achieving these goals will improve the capabilities of the practitioner, strengthen the position of the O&P profession within the healthcare field, create a more stimulating environment for students and faculty in O&P programs, attract stronger interest from the related disciplines, and possibly encourage more graduates of the programs to continue their education at the Masters or PhD level.
Edward S. Neumann, PhD, PE, CP, professor of Civil and Environmental Engineering at the University of Nevada, Las Vegas (UNLV), is currently involved in efforts to establish a degree program in biomedical engineering at UNLV. He is developing and teaching courses in prosthetic systems, assistive technology, and ergonomics.