Bridging the Gap

Evidence-based practice is a modern phrase. Is it always practical? Evidence-based practice, the conscious and systematic use of the best-available research evidence in making decisions about the care of individual patients, has become a hot topic over the last decade. Though it is not a mandate for daily practice, it can assist the clinician in the decision-making process about a particular intervention. Evidence-based guidelines should be a framework for best-practice that all clinicians should use as part of their professional responsibilities. There is a great lack of evidence-based practice in amputation indication and surgery and in prosthetic rehabilitation. Clinicians are expected to integrate clinical experience with conscientious, explicit, and judicious use of research evidence, along with patient preferences, to come to informed decisions about the well-being or quality of life of their patients. Every day, surgeons, physiatrists, prosthetists, physical therapists, psychologists, and other members of the multidisciplinary rehabilitation teams that are involved in the care of amputee patients have to make treatment choices. Worldwide, there are only a few clinical guidelines in the field of amputation and prosthesis prescription to help the clinician. However, none of these are completely evidence based. In the Netherlands, we are now working on evidence-based guidelines for lower-limb amputation and surgery. Participating clinicians include vascular, general, and orthopedic surgeons, prosthetists, physical therapists, psychologists, physiatrists, vocational physicians, and physicians for the elderly. Researchers who are experts in the field of literature databases and in performing systematic reviews are also participating. The industry and societies of amputee patients are involved in focus groups. With the help of these experts, we will draft the first national guidelines, which will then be "transformed internationally" at an International Society for Prosthetics and Orthotics (ISPO) consensus meeting. We hope to finish these guidelines by the spring of 2011. Up to now, the level of evidence has been very weak, so the opinions and clinical experience of the experts will form the basis of these guidelines along with patient preferences. From the view of evidence-based practice, the study of amputee patient care and the decision-making process for amputation should be based on qualitatively better research, so that the prosthetics profession does not fall behind other professions. Our patients have the right to get the best evidence-based rehabilitation treatment so that they can regain their ability to participate in activities and society. But what about evidence-based practice in war-torn regions such as Iraq and Afghanistan, or in regions devastated by natural disasters such as Haiti or Pakistan? Then we have to fall back on what is left over after the disaster or what is sent by aiding countries, nongovernmental organizations (NGOs), good samaritans, etc. Shortly after a disaster, international aid is quick to arrive. But after a while, people and organizations leave, and much of the money dwindles, leaving the people who desperately need help destitute. The world's focus shifts to other disasters, such as when the focus shifted to the sudden cholera outbreak in Haiti rather than continued earthquake relief. But what about physically disabled persons? After every crisis in an industrial country, we speak about post traumatic stress disorder, and we are all interested and want to help. What about in Haiti or Pakistan? What about the delivery of prostheses and orthoses in those countries? Even if those aids are available, is their application and care evidence based? Can we, as medical specialists, handle evidence-based practice in those situations? I applaud the volunteers who are working in Haiti or Pakistan, but under such dire conditions, do they have the luxury to think about evidence? No, they treat the patients and families as they were taught to, and in the best possible way so that the amputee patient can participate in society again—a society in which participation can be difficult for even able-bodied persons. Haiti, Pakistan, Iraq, and Afghanistan still have a long way to go to reach acceptable levels of participation possibilities. We have to realize that there is a big difference between working as a researcher and working in the field. ISPO and its members try to contribute to a world where all persons have equal opportunity for full participation in society. ISPO specifically supports resources in economically disadvantaged parts of the world by empowering O&P professionals as well as local rehabilitation workers via community-based rehabilitation strategies. It is up to us to bridge the gap between evidence-based research and daily field work. Jan HB Geertzen, MD, PhD, is the president of the International Society for Prosthetics and Orthotics (ISPO).

Bridging the Gap

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Pitt Schneider Elected to ACA Board of Directors

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CAF, Knights of Columbus, and Project Medishare Launch “Return to Sport” Program in Haiti

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