Academy Society Spotlight: How Clinicians Begin to Advance Research
May 2021 Issue
Payers and other key stakeholders are increasingly expecting more evidence to support and justify healthcare decisions. Evidence-based practice is an approach to healthcare in which clinicians incorporate scientific evidence with their clinical expertise to make knowledgeable clinical decisions to provide optimal care for their patients.1 The ability to consume, integrate, and apply research and literature into clinical practice is a valuable yet challenging skill for prosthetists and orthotists. It is advantageous for clinicians to learn how to understand, differentiate, and discuss research and outcome measures when applied to evidence-based practice.
Research is the process of discovering and validating knowledge, based on theory, and requires a systematic process based on the scientific method. As clinicians, we believe the work we do makes a difference in our patients' lives, and research is a way in which we can prove it. As O&P professionals embrace evidence-based practice, a working knowledge of how to conduct, interpret, and apply research is critical. The generalizable knowledge produced through sound research provides valuable resources for clinicians to make optimal choices for their patients.
Clinical research helps direct clinical decisions, impacting the well-being of its recipients.2 When research is not conducted properly, it can lead to false information, which could negatively impact patients.
There is a distinct difference between applying evidence-based practice clinically and conducting the research that forms the basis of evidence-based practice. Yet both are equally impactful for clinical care. Through the experiences and wisdom of others, I will address evidence-based practice and collaborative research efforts.
The Purpose of Evidence-based Practice
With patients at the forefront of our care, clinicians place great value on appropriately meeting the specific needs and goals of individual patients. Evidence-based practice allows O&P practitioners to integrate scientific knowledge into clinical decisions for patients, and the ability to find information to support actions is becoming increasingly necessary. Utilizing published research to provide patient care establishes confidence from patients, collaborating physicians, therapists, financial payers, and stakeholders.
Evidence-based Practice and Outcome Measures
MacDermid et al. defined evidence-based practice in five steps: 1) ask a clinical question, 2) find the optimal evidence to answer that question, 3) appraise evidence for its validity and usefulness, 4) integrate appraisal results with clinical expertise and patient values, and 5) evaluate the outcomes.3 Clinicians must critically evaluate literature and translate previous studies into their clinical decision-making.
Begin by asking a clinical question. The questions that arise in your patient encounters can act as the driving force for gathering evidence to find a solution. An example of a clinical question would be: "How effective are microprocessor knees in preventing stumbles and falls when compared to nonmicroprocessor knees?" As you review the literature to answer this clinical question, you will likely find a study conducted by Kahle et al. reporting participants had a 59 percent decrease in stumbles and a 64 percent decrease in falls after using a C-Leg over a 90-day acclimation period compared to patients' reported stumbles and falls while using a nonmicroprocessor knee.4 The scientific research reported provides support to answer a specific clinical question and be integrated into clinical decision-making for individual patient plans.
While this is just one example, consistently performing literature reviews on various clinical topics is critical to evidence-based practice. A great place to access relevant O&P literature is through the American Academy of Orthotists and Prosthetists (the Academy) O&P IQ database.5 O&P IQ was created to assist clinicians interested in evidence-based practice and provides a hub of literature to support decisions and answer challenging questions.
The integration and evaluation of patient outcomes involves implementing outcome measures, either performance-based or patient-reported, to address a patient's status.3 Start by choosing the attributes of an outcome measure that address your question. Performance-based and self-reported measures that assess physical impairment, functional ability, and global health status of patients are necessary to understand overall health and make clinical-decisions.
The Academy's Outcome Measure Toolkit is one resource available to assist Academy members in selecting appropriate measures.6 Additionally, the Academy has published a series of how-to videos that may help clinicians implement new outcome measures with ease.7 The Shirley Ryan AbilityLab has also provided the Rehabilitation Measures Database with over 500 measures used by physicians, clinicians, therapists, and physical medicine and rehabilitation researchers globally.8
Collecting outcome measures in O&P clinical work allows clinicians to use quantifiable data for tracking the patient-specific effect of a treatment modality and provides justification for payers for the treatment plan. However, incorporating outcome measures into a clinical workday may be challenging, and choosing which measure to use may not be well understood. It is important to consider what outcome measures are appropriate, how to incorporate these measures, and how the results might answer a clinical question.
Consider patient populations, timing, and your end goal. Create a strategy to outline the required procedures for your chosen measures to ease their implementation into your clinical practice.3 Rehearse the application of these measures a few times and assess their feasibility and effectiveness in answering your clinical question. Consider reaching out to other healthcare specialists, such as physical and occupational therapists, and work to complete these measures as a team. Once you decide the measures to use and outline the implementation process, determine when you aim to review your measures (i.e., three months, six months, one year, etc.). Document each measure within your healthcare database and review the collected data over time. Reviewing documentation is necessary for observing and understanding trends.
How to Begin Engaging in Research
Many researchers would explain that participation in research on any level (i.e., volunteering time to provide clinical insight, helping recruit participants, etc.) can be challenging as it requires your time and resources.
You should firmly determine your desire before offering to participate in research. Once you determine your purpose, this vision will help carry you through the hard moments of various research activities. Phil Stevens, MEd, CPO, FAAOP, emphasizes that in his clinical work he can empower individual patients, but in his research work, he can empower entire populations. By using your clinical expertise to systematically address the challenges your patients face, you are effectively serving those in need on a larger scale. Whether research participation has been a passion for years, or it's a new desire to help answer a question for your patients, find your reason and let it drive you forward.
If you are interested in exploring clinical research, begin by reaching outside of your practice to work alongside someone with established research experience and find a way to partner on an ongoing study. Determining your area of interest helps direct next steps. Areas of interest may be based on device design, etiology, or patient population. Within these categories, there is likely a world of professionals with established research designs and plans centered on your area of interest. By volunteering to assist with a research study, you are engaging in the opportunity to discover your research interests. If you are interested in the efficacy of a certain device and its success with your patients, reach out to a manufacturer and offer your time and resources. Volunteering your time, expertise, and clinical resources is a great way to gain experience in O&P research. As Eric Weber, CPO/L, FAAOP, says, this allows you "to dip your toes in the water and feel what it's really like to be involved in research."
In clinical practice, "if you're going to do research, you really do need strong partners. It is really hard to do good research in private practice orthotics and prosthetics on your own," says Mark Hopkins, PT, CPO, MBA. Practitioners are often limited by their clinical duties, financial resources, and time to complete research tasks. Through partnerships with universities, manufacturers, and other researchers, a clinician can participate in research effectively and efficiently.
Hopkins, who has academic affiliations with Johns Hopkins University and the University of Maryland Medical School in addition to private practice, notes these relationships have opened the doors to his strong contribution and participation in research. Through his experiences, he has grown to understand there are generally two groups to network within—academia and industry.
Partnering with academic institutions or manufacturers opens doors to potential longstanding research projects and sustained relationships. Hopkins says, "The first place to start is to make an offer, even if it's low-level." One example is helping to recruit research participants. Recruitment is always challenging when conducting human subject research studies, and if you can help recruit participants, you are a valuable resource to other researchers. By making an offer, you might form a partnership that will grow and lead to more research opportunities in the future.
O&P device manufacturers might benefit from clinical collaboration. Brian Kaluf, CP, FAAOP, emphasizes the importance of reaching out to leaders in the O&P profession to offer your clinic as a resource for product development. Manufacturers are often in need of clinical facilities and willing participants to trial new products. Joining with manufacturers to test out new components and devices provides a competitive advantage for any clinic that participates in this type of product testing. These companies may begin to view you and your facility as a go-to location for future products.
Whether through academia or industry, participation will likely beget more participation. Perhaps you will consider formal research training, such as a doctoral training. But, even if you don't, working with a partner such as a researcher, physician, or manufacturer can develop relationships that may provide more opportunities in the future. These partnerships are valuable and necessary for both clinicians and researchers. Working as a team allows practitioners to participate in effective research for the benefit of the O&P profession. Taavy Miller, PhD, CPO, states that, "collaboration with researchers and partners that cut across discipline are very important, including physicians based in hospitals, academic researchers, and manufacturers, as each role brings a unique skillset, expertise, and critical perspective. Orthotists and prosthetists are a part of the clinical care system and bring a rich perspective and experience."
There is much more I could say regarding evidence-based practice and participation in research. However, by highlighting the purpose, initial steps, and methods for engaging in evidence-based practice and research opportunities, I hope this information acts as a catalyst for any research-minded clinician. As you take steps toward your O&P goals, remember that each person plays an important role in providing the highest level of care for our patients. Clinical expertise, scientific evidence, and collaboration are all necessary components of healthcare. As O&P continues to flourish, let's work alongside one another to encourage optimal care for patients through evidence and teamwork.
The author would like to acknowledge and thank Seth O'Brien, CP, FAAOP; Mark Hopkins, PT, CPO, MBA; Jason Kahle, MSMS, CPO, FAAOP; Brian Kaluf, CP, FAAOP; Taavy Miller, PhD, CPO; Phil Stevens, MEd, CPO, FAAOP; and Eric Weber, LCPO, FAAOP, for their shared time, experiences, and insight for the writing of this paper.
Emily Hurst is a prosthetist resident at Shirley Ryan AbilityLab. She is a member of the Academy's Lower Limb Prosthetics Scientific Society.
Academy Society Spotlight is a presentation of clinical content by the Societies of the Academy in partnership with The O&P EDGE.
McKibbon, K. A. 1998. Evidence-based practice. Bulletin of the Medical Library Association 86(3):396-401.
Vickers, A. J. 2008. Basic introduction to research: how not to do research. Journal of the Society for Integrative Oncology 6(2):82-85.
MacDermid, J. C., R. Grewal, N. J. MacIntyre. 2009. Using an evidence-based approach to measure outcomes in clinical practice. Hand Clinics 25(1):97-111. doi: 10.1016/j.hcl.2008.11.001.
Kahle J. T., M. J. Highsmith, S. L. Hubbard. 2008. Comparison of nonmicroprocessor knee mechanism versus C-Leg on Prosthesis Evaluation Questionnaire, stumbles, falls, walking tests, stair descent, and knee preference. Journal of Rehabilitation Research & Development 45(1):1-14. doi: 10.1682/jrrd.2007.04.0054.
Prosthetists. American Academy of Orthotists and Prosthetists. AAOP O&P IQ. https://opiq.oandp.org.
American Academy of Orthotists and Prosthetists Outcome Measures Toolkits. https://www.oandp.org/page/research.
American Academy of Orthotists and Prosthetists How To Videos. https://www.oandp.org/page/research.
Shirley Ryan AbilityLab. Rehabilitation Measures Database. https://www.sralab.org/rehabilitation-measures.