ISPO An Asian Prosthetics and Orthotics Workshop '98 in Japan Final Report

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Papers

ISPO EDUCATION PHILOSOPHY

John Hughes

Introduction

It is interesting to speculate that in the developed world the prosthetist/orthotist is the last professional member of the clinic team whose education and training has not yet evolved to a more or less uniformly accepted level. This was highlighted in the European Community where the "open market" of 1992 with the intention of the free movement of professionals from one country to another has led to a study of the reality of standards of practice and training in this field. It is literally true that in Europe the training of the individual who fits and provides prosthetic or orthotic devices varies from, at one extreme, honours degree level to, at the other, virtually no structured or organised training at all!

Of course all professions are evolutionary bodies and most will have come through a similar stage. The astonishing thing is that this profession with its key role in the treatment of the physically disabled should be at this stage of its evolution at the end of the twentieth century.

It is also true, however, that order is beginning to emerge from the chaos. Increasingly it is being recognised by national and international agencies that the prosthetist/orthotist is not an artisan or tradesman, but a highly skilled professional with an understanding of the theory behind his practice. Perhaps of most importance is that those within the profession trained in the old traditional ways have themselves recognised the need for change.

ISPO and its forerunner ICPO, the International Committee on Prosthetics and Orthotics have expended and continue to expend more effort and resources on prosthetist/orthotist education than in any other area. The Society believes that the provision of adequate numbers of trained professionals is central to the development of an appropriate service. So far as the non-industrial world is concerned, without the existence or establishment of an education and training system, external aid efforts can only have short term effects. Further, the Society promotes the development of formal structured training programmes which satisfy standards developed in a number of consensus workshops organised for that purpose over several years by the Society. These standards have been developed recognising the realities of the availability of resources.

Background

The philosophy of the Society in respect of the education of the prosthetist/orthotists has been developed in a series of meetings which encompassed considerations of both the industrial and developing worlds. These meetings were formal meetings with wide international representation and with reports published as follows:

1

United Nations (1969). Report of the United Nations inter-regional seminar on standards for the training of prosthetists: Denmark 1-9 July, 1968 - New York UN.

2

Hughes, J. Ed (1976). International Study Week on Prosthetic/Orthotic Education, Glasgow, Scotland 1974 - HMSO, Edinburgh.

3

ISPO (1985). Report of ISPO Workshop on prosthetics and orthotics in the developing world with respect to training and education and clinical services, Moshi, Tanzania 6-12 May, 1984 - Copenhagen, ISPO.

4

ISPO (1987). Report of ISPO Workshop on training and education in prosthetics and orthotics for developing countries, Jonkoping, Sweden 12-16 August, 1985 - Copenhagen, ISPO.

5

ISPO (1988). Report of ISPO Workshop on up-grading in prosthetics and orthotics for technicians from developing countries trained on short courses, Glasgow, Scotland 1925 July, 1987 - Copenhagen, ISPO.

The philosophy of the Society was harmonised with that of the World Health Organisation in the WHO Consultation on the training of personnel for prosthetic and orthotic services in developing countries in Alexandria, Egypt in 1990 and a report produced:

World Health Organisation (1990). Guidelines for training personnel in developing countries for prosthetic and orthotic services. WHO/RHS/90.1 - Geneva, WHO.

The philosophy and more importantly, the assistance in helping to implement the philosophy continues to develop within the Society through the work of its Education Committee.

ISPO Categorisation

A major difficulty encountered in this field is that of nomenclature. Different titles are used in different areas for the same kind of worker and this confusion is made worse by differences introduced by language and translation. This led ISPO to develop a categorisation system which would be based on the levels of education and training provided and would avoid dependence on titles.

The categories may be displayed as follows:

The Society's education philosophy encompasses these three categories and has been concentrated on Category I and II professionals who take part in patient care activities as opposed to Category III workers who are only concerned with manufacture and assembly.

It must be emphasised that this is not an attempt to describe all of those who work in this field throughout the world. It is a description of the levels of education and training which the Society believes meantime represent the desirable levels for those involved in patient care in the developed and the developing world respectively and in the support function of manufacture and assembly.

For the industrial world, the Society believes that the Category I professional prosthetist/orthotist should, for the future, be educated and trained at University Degree level or equivalent. It further believes that although there are many different approaches that can lead to this level of training and education any course must consist of:

1. teaching of theoretical subjects
2. closely supervised practical instruction
3. structured and controlled clinical experience

Category I Professional - Industrial World

The four year honours degree (B.Sc.) course offered in the National Centre for Training and Education in Prosthetics and Orthotics in the University of Strathclyde in Glasgow is based on the ISPO philosophy and is recognised by ISPO as being at the appropriate level.

The first three years take place on the main campus in special purpose-built accommodation. During these three years the students carry out their theoretical studies and undergo practical training in the fitting and fabrication of prosthetic and orthotic devices working with "professional patients", that is patients acting as subjects for the students and not being fitted as part of their treatment. The normal University year of 30 weeks is extended by 10 weeks to accommodate the large instructional element.

The theoretical studies account for 1864 hours with an emphasis on Life Sciences, Mechanics/Biomechanics, Clinical Studies and Prosthetics/Orthotics Science. The closely supervised practical instruction which is subject based accounts for 1620 hours and covers all areas of prosthetics and orthotics.

The final year consists of 46 weeks of clinical practice, 23 weeks in prosthetics, 23 weeks in orthotics, during which students are exposed to a structured broadening of their prosthetic and orthotic experience under appropriate supervision. In effect they are learning to apply to "real patients" undergoing treatment, the techniques they learned during the first three years. The clinical placements are undertaken in hospital centres which meet specified criteria and having applied for this status have been inspected and approved for that purpose. This represents 1610 hours of clinical experience.

It is of interest to note that the practical and clinical elements of this four-year course account for about 65% of the total study. It is not a "theoretical" course only. This high proportion of practical/clinical work is achieved without sacrificing theoretical content by extending the teaching year and by the provision of the year's clinical placement. It should also be noted that all aspects of the work are assessed with the same rigour. The theoretical subjects are assessed in a conventional manner using course work, class tests and end of session examinations. The subject based clinical teaching also makes use of class tests and end of term examinations but additionally lays great stress on continuous assessment by the instructor. The clinical placement involves continuous assessment by the supervisor on site, essay type assignments, and a one day clinical examination carried out in the Centre, at the end of each half year placement, using external examiners. The grade of honours is based on third and fourth year performance.

The majority of students are school leavers, with twelve or thirteen years of schooling and normal University entry requirements with a strong science base. There are numerous other routes to entry, such as study in further education classes to obtain an equivalent entry qualification. Such a method would be suitable for a mature entrant. A recent expansion of the National Centre now permits an annual intake of twenty-eight students. Students have from the start been normally about equally divided between male and female.

It may be of interest to note in passing that the National Centre is accommodated on campus in about 3,200 square metres of purpose-designed classrooms and clinical and workshop space. It has a full-time staff of about fifty including ten prosthetist/orthotists. In addition to offering an Honours Degree Course, it provides about 20 short courses, of one or two weeks duration, each year for qualified clinic team members, and also operates a clinical service unit in a general hospital which provides for the needs of about 1,500 patients including 600 amputees.

Additionally, a whole range of new post-graduate offerings is available, from distance learning Postgraduate Diplomas to Masters and Doctorates by instruction and research.

Category II Professional - Developing world

The prosthetist/orthotist in the developing world, like his counterpart elsewhere, also needs to understand biomechanics and anatomy. He needs to understand materials and how to handle them. He must have clinical and practical skills.

It could sensibly be argued that with less resources of all kinds, more difficult conditions and probably more difficult problems, the prosthetist/orthotist for the developing world needs to be better trained than his opposite number in the industrial world. The reality of course is that most developing countries cannot yet afford the investment in training to the highest level when this is considered against their many other areas of essential spending. Clearly a compromise is needed to accept the reality of limited resources while at the same time producing a worker who has adequate skills and understanding and can make a useful contribution in the clinic.

The solution pioneered mainly by GTZ, the German Overseas Aid Agency, is the so-called Orthopaedic Technologist. With entry at O-level, or equivalent (10 or 11 years schooling), which is the usual requirement for paramedical education in the developing world and a course of three years duration at lower than University Degree level, this individual is clearly less well qualified than his counterpart from the better schools in the industrial world. However this approach marked a significant step forward and ISPO agreed to adopt the concept and has spent much effort further developing and formalising the approach.

It is recognised that for the meantime training in Category I does not exist anywhere in the developing countries and is only available in the industrial world. Despite this it is felt important that some personnel in developing countries should be trained to this level to provide leadership for the prosthetic/orthotic profession and be responsible for education and training within their own countries. It is anticipated, however, that the majority of the clinical service will be provided by Category II personnel who should work under Category I direction, wherever possible.

The concept of Category II responsibilities is regarded as an interim solution for the developing world although it is recognised that a dynamic situation exists.

The question concerning the extent of instruction to be offered in the fabrication of components to Category I and II practitioners has also been considered. In general, industrial world components are not available in the developing world. Although these components can be made by Category II orthopaedic technologists, they can also be made by Category III individuals and/or a variety of craftsmen. Therefore, it is possible for this time consuming activity to be reduced in the training of the Category I and II practitioner, provided that the products available consistently meet appropriate specifications.

It is also significant that the World Health Organisation has now agreed that this is the minimum level at which developing countries should be aiming and recognise that the long term aim should be for the degree level professional. Of course, the clinical load in the developing world is also very much different from that of the developed world - the different causes and incidence of amputation, the continuing presence of diseases now eradicated from the developed world, particularly poliomyelitis and leprosy. This has led WHO to suggest, in the short term, a further development of the orthopaedic technologist theme with orthotics technologists and prosthetics technologists trained in a single discipline and with a consequent reduction in course length permitting more people to be trained more quickly and in the areas of greatest need.

Support for Category II Programmes

ISPO has now developed an Information package which contains a Professional Profile, a Code of Ethics, Learning Objectives of a Course for Category II, and an Examination specification.

In response to a need indicated by a number of Governmental and Non-Governmental Organisations, the Society has developed a system of "recognition" of Category II training programmes. The process involves scrutiny of curricula, facilities and resources and inspection of premises and, where practicable, examination procedures following which those centres which satisfy the guidelines are recognised for a period of three years. Any Category II professional who completes a course which has ISPO recognition will be registered by the institution with ISPO and will thereafter be entitled to describe him or herself as

ISPO Registered Orthopaedic Technologist
(Category II)

Conclusion

This presentation has concentrated on the prosthetist/orthotist because of the special training problems of this group. Of course, ISPO is aware of the need to educate other members of the team, particularly the surgeons and is currently offering a series of courses on amputation and prosthetics in different parts of the world.

However, the biggest challenge is to find some way to produce prosthetists and orthotists, adequately trained, and in sufficient numbers to tackle the world's problems. Different attempts have been made to put numbers to this problem to bring its magnitude into focus. Most are, because of the absence or poor quality of information at best guesses. However, to give an order to the problem, it is probable that in the developing world there is a need for about 20,000 trained professionals and a current provision of at most 2,000.

ISPO remains committed to the continued developed of structured prosthetist/orthotist training throughout the world. The long-term aim is the availability of the highest level of professional for patient care. The Society recognises that compromise may be necessary in the allocation of resources and strives to ensure in these circumstances the provision of adequate levels of treatment.

Commemorating the Mid-Point of Asia and Pacific Decade of Disabled Persons
ISPO An Asian Prosthetics and Orthotics Workshop '98 in Japan Final Report
- Papers : ISPO Education Philosophy -

Editors:
Eiji Tazawa
Brendan McHugh