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

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NATIONAL TRAINING/EDUCATION ARRANGEMENT IN PROSTHETICS AND ORTHOTICS IN CHINA:
ENHANCING INTERNATIONAL CO-OPERATION AND ESTABLISHING A NEW STYLE CENTRE WITH CHINESE CHARACTERISTICS

Lin Ren Wei

The China Training Centre far Orthopaedic Technologists (CHICOT) is a product of Sino-German co-operation. China provided funding of 100 million RMB and the German government also gave financial support. After five-years of sincere co-operation and hard co-working, a demonstration centre has been established, which has first-class international teaching, experimental and practical facilities for the training of technical orthopaedic personnel. CHICOT has the following features.

Firstly it is fitted to international standards. There are two kinds of certificate system whereby the students not only reach the level of secondary specialised school as specified by the National Education Committee and gain a school diploma through four-year studies but must also gain the secondary orthopaedic technician certificate through strict examination. Attention has been paid to international standards in the formulation of the teaching plan, teaching programme, teaching material selection and management.

Secondly, the building is high quality construction. The design of the building, technology of equipment and the arranging of pipes and power lines for supply of water, electricity and gas comply with international standards of architecture and environment, The practical workshop is fitted to the most advanced standards in the world. The fixed funds of CHICOT are the highest of all secondary schools of the country. Its equipment is not only first class by Asian standards, but also surpasses that of many schools of this kind of schools in Europe and America.

The third feature is the high quality of the teachers. On the one hand there are experts sent by the German government as technology teachers for the long term. On the other there are our own technology teachers who are first sent to the universities to read bachelor or postgraduate degrees, are then given technology training by German experts for three years in China which aims at combining theory and practice, and finally are sent to Germany for two years to gain the qualification certificate. After completing these three steps, they are qualified to teach at CHICOT.

The fourth is the new system. CHICOT broke with the closed traditional model and drew on advanced international experience to carry out the policy of open running of the school with a visiting professor system put into effect. In administrative management, there are only three functional departments for efficient normal running of the school.

CHICOT is an international co-operative school which has learnt from German occupational education, but also trains the students in the practice of the Chinese prosthetic service to enable them to master good special technology and to have good occupational morals and healthy bodies.

Applied and technical subjects are taught at CHICOT. The ratio between practical and theoretical subjects is 1.2:1. In keeping with practical nature of our prosthetics we include training practical skills such as forging, welding and so on to ensure basic ability training in bench work. Nationally produced materials are used for practical work, in maintenance and management of equipment and tools provided so that student may gain knowledge of both technology and management. In recent years, CHICOT has achieved wide international cooperation with scholars and leaders from America, Britain, Germany, Iceland, Sweden, Canada, France, Russia, Vietnam, Hong Kong and Taiwan.

To meet the needs of the prosthetic service in China, the Professional Introduction for Orthopaedic Technologist has been drawn up as the professional training standard for the national prosthetic/orthotic service. This is based on the four-year educational programme at CHICOT which will become the training centre for the orthopaedic professional qualification certificate for the nation will be responsible for the training of prosthetists and orthotists. Meanwhile training staff must be established in post and more then 200 of them have been trained. Foreign experts are invited to give lectures for 5 or 6 times each year, and 8 sets of teaching materials (almost 1 million words) have been translated.

CHICOT positively explores a new roads to co-operate medicine and prosthetics. Its clinic department has fitted more orthoses than prostheses. CAD/CAM technology has been used for providing assistance for patients in the countryside. Furthermore, a co-operative relationship with the Ottawa Rehabilitation Centre of Canada has been established to make early preparations for introducing a "far distance education system".

According to the needs of the service and society, and referring to international general methods, it is planned to transfer the secondary specialised technology education to higher specialised technology education in the next 10 or 15 years. An orthopaedic college or rehabilitation engineering college with four-year undergraduate course system will be established. Some new subjects will be added such as rehabilitation engineering, rehabilitation medicine, rehabilitation management, biomechanics, CAD- CAM application techniques, and compound materials. CHICOT will co-operate with famous orthopaedic colleges in the world in teacher and student exchange, teaching materials compiling, and communication exchange. The training aims at paying more attention to giving students the ability to develop accurate technology and to blaze new trails. The arranging of subjects will reflect the relationship between scientific technology and service. The compiling of teaching materials will take account of latest scientific knowledge. The distribution of class hours gives emphasis to scientific subjects. The examinations will measure skill in mastering new scientific ideas, new technology and new services needed by future leaders of orthopaedic science.

In accordance with regulations of the Ministry of Civil Affairs, CHICOT will develop into a national orthopaedic technology education research centre which possesses specialised education and training, scientific research of applied technology and communication development. It will be multi-functional with an orthopaedic clinic, a rehabilitation hospital, and a modular parts production capability. It will embody the industrial advantages of integrating teaching, scientific research, production and commerce. Combination of production and teaching, with products supporting teaching, will help to develop practical products and implementing open running of the school will lead to good social and economic benefits

Finally, representing China Society of Prosthetics and Orthotics, I loyally give our thanks and respects to those who have given help in constructing and developing CHICOT.

EDUCATING PROSTHETISTS AND ORTHOTISTS FOR THE 21ST CENTURY:
THE HONG KONG MODEL

Arthur F.T. Mak

Formal training of prosthetists and orthotists in Hong Kong started in the 1960s and for decades was the mission of the School of Prosthetics and Orthotics funded by the government. The training was organised as a three-year in-service programme. Students were recruited from the graduates of technical secondary school and technical institutes. Each student was trained to be technically and clinically competent in both prosthetics and orthotics. Included in the programme was a six-month clinical practice. Upon successful completion of their training at the Hong Kong School of Prosthetics and Orthotics, a prosthetics/orthotics graduate was awarded a government certificate equivalent to the level of higher diploma, and could also apply to the then British Institution of Surgical Technologists for licentiation in the UK. Nearly all the prosthetics/orthotics graduates would work in the prosthetics/orthotics departments at the local public hospitals. Short-term training programmes were organised occasionally to provide some kind of continuing education to serving prosthetists/orthotists.

Advances in technology have made many lasting impacts in the health care and rehabilitation community. Developments in biomedical engineering and rehabilitation engineering have led to improved diagnosis, new therapeutic modalities and more reliable measures for outcome evaluation. These advances are likely to come faster and across a wider front, affecting both institutional and home care.

Similar advances have also been happening in the area of prosthetics and orthotics. Examples include new materials with more appropriate weight, stiffness and strength; new designs for prosthetic joints; use of artificial intelligence in prosthetic control; programmable myoelectric prostheses; new socket designs; use of computer aided design and computer aided manufacture of prostheses and orthoses; etc.. How would a prosthetist/orthotist cope with all this new technology? How would a prosthetist/orthotist take part in or even lead these developments? How should our prosthetics/orthotics educational programmes better prepare our prosthetists/orthotists for the changes in the 21^st century?

People with disability are enjoying relatively more independence and community participation compared to the situation decades ago. Many of these improvements have been made possible with the help of a wide spectrum of assistive technology. Examples include various postural and mobility assistive technology; communicative assistive technology; cognitive assistive technology; and other assistive devices for daily living at home, at school and at work. While professionals from many engineering and clinical disciplines have contributed to these advances, prosthetists and orthotists, being the most technically oriented professionals in the clinical rehabilitation team, should take up the charge to contribute even more to the development and delivery of this rehabilitation technology in the future. After all, prosthetics in a broader sense can refer to all functional replacements of missing body parts whereas orthotics in a broader sense can refer to all augmentations of our body functions. How would a prosthetist/orthotist begin to offer a more general rehabilitation technology service at the clinic together with other rehabilitation professionals? How could our prosthetics/orthotics educational programmes better prepare our prosthetists/orthotists for these potential additional responsibilities?

In view of these challenges ahead, the rehabilitation community in Hong Kong in the early 1990s demanded that the training of prosthetists/orthotists in the territory should be transferred from the School of Prosthetics and Orthotics to the Hong Kong Polytechnic University and the training should be upgraded to degree level. As we, at the Hong Kong Polytechnic University, were designing the curriculum for our new B.Sc. course programme in prosthetics and orthotics, we were very mindful of these challenges ahead and the type of prosthetists/orthotists that we need to train to meet these challenges. We are certain that our prosthetics/orthotics students need to be well taught the basic prosthetics/orthotics skills that are derived from many decades of clinical experience. We are certain that, as clinicians, our prosthetists/orthotists need to have a good foundation in life sciences. We were also certain that besides the traditional technical and clinical prosthetic and orthotic expertise, our prosthetics/orthotics students would need a more substantial preparation in material technology, mechanical engineering and electrical engineering. We understand that our prosthetics/orthotics students would need to appreciate how to apply this engineering expertise to the biomedical context and to clinical situations. These engineering subjects would need to be taught with many relevant clinical examples.

It is our objective to so equip our prosthetics/orthotics graduates that they can continue to learn to meet new challenges ahead. That is the reason for our introducing considerable independent learning experiences into our programme. All our prosthetics/orthotics students are required to take a subject on Methods of Investigation, a subject on Prosthetics/Orthotics Seminars & Project Proposals, and a 19-week independent study project. These are on top of other problem-based learning exercises that the students are exposed to throughout their three years of studies in our programme.

Our B.Sc. (Hons) curriculum in Prosthetics and Orthotics is a highly interdisciplinary one consisting of 6 main areas, namely:

1. Communication and General Studies;
2. Health Studies;
3. Engineering Studies;
4. Prosthetics and Orthotics;
5. Independent Learning and
6. Prosthetics and Orthotics Clinical Studies.

The detailed subjects in each area are:

Communication and General Studies

College Chinese

Elementary Putonghua

English for Academic Purposes

English in the Work Place

Holistic Health Care

General Study Elective I

General Study Elective II

Health Studies

Human Anatomy

Foundation Physiology

Pathophysiology

Orthopaedics, Traumatology and Rehabilitation

Engineering Studies

Introduction to Computing

Applied Mathematics

Bioelectrical Engineering I - Circuits and Systems

Bioelectrical Engineering II - Electronics

Biomechanics I - Statics and Dynamics

Biomechanics II -Mechanics of Tissues and Biomaterials

Biomechanical Design

Material Processing

Prosthetics and Orthotics

Introduction to Prosthetics/Orthotics Practice

Prosthetics/Orthotics Fabrication Skills

Upper Limb Orthotics

Lower Limb Orthotics

Spinal Orthotics

Upper Limb Prosthetics

Below Knee Prosthetics

Above Knee Prosthetics

CAD/CAM for Prosthetics/Orthotics

New Casting Methods for Prosthetics

Myoelectric Prosthetics

Reciprocating Gait orthoses

Independent Learning

Methods of Investigation

Prosthetics/Orthotics Seminars & Project Proposals

Prosthetics/Orthotics Independent Study Project

Prosthetics/Orthotics Clinical Studies

Clinical Attachment I

Clinical Attachment II

Our curriculum consists of about 3000 contact hours in total. About 1600 hours are related to prosthetics/orthotics specific practical training, about 600 hours of which are actually conducted in local hospitals as clinical attachments. These clinical studies were facilitated on site by specially appointed clinical educators and clinical mentors. Clinical mentorship is meant to be on a one-to-one basis as far as possible.

In September 1995, we enrolled our first cohort of 25 prosthetics/orthotics students into our University. Twenty of these students were admitted based on their results in the Advanced Level examinations, and the remaining five quotas were filled by transfers from other university programmes or graduates from technical colleges. We selected students from those in the engineering track as well as those in the life science track when we were sifting through the A-Level examinations. The first cohort of students as a group were academically ranked number 2 at admission into our Faculty of Health and Social Studies.

This cohort of prosthetics/orthotics students will be graduating this summer. We have planned to have an extensive evaluation of our course programme shortly afterwards. The evaluation will be carried out with active involvement of all parties concerned - our academic staff, fellow graduates as well as clinical colleagues from the hospitals.

This being the first B.Sc. (Hons) course programme in Prosthetics and Orthotics in Asia, we are conscious of the impacts that our degree course may bring to the region. This is especially important, as there are many models of prosthetics/orthotics education and training around the world, from in-service apprenticeship to postgraduate certificate level. What should our training strategies be in Asia? The socio-economic profiles vary greatly in Asia. In order that there may be enough rehabilitation professionals at different levels to meet the critical needs in our region now and that the level of these services can continue to improve in the years ahead, a multi-pronged approach would have to be taken. We believe a B.Sc. (Hons) course programme in prosthetics/orthotics has a place in Asia and such a programme should benefit more than Hong Kong alone. Collaboration among regional and global prosthetics/orthotics training programmes is important if we are keen to maximise the impacts of each of the programmes. The topic of international collaboration in rehabilitation personnel training continues to deserve quality attention among educators and front-line practitioners.

PROSTHETICS AND ORTHOTICS IN JAPAN

Eiji Tazawa

Introduction

Japan has 372,000km² of land area with a population of 122 million. It. is the 68th largest country in the world. It is very highly developed in light/heavy and light industries, as is well known.

The population of persons with disabilities in Japan is about 2,722,000 which is approximately 4.6% of the entire population of Japan. These disabilities include the physical, sensory, mental and internal.

Every single Japanese citizen is provided with some form of medical insurance, as well as extensive coverage for prosthetic and orthotic appliances, by the Welfare for the Disabled, Workmen's Accident Compensation Insurance, plus other agencies which provide funds for the provision of prostheses and orthoses.

The estimated number of prosthetic and orthotic facilities in Japan is about 550-600. The Japanese Orthotics and Prosthetics Association (JOPA) which is a group of private facility owners, has 350 members. The national or local government related facilities count about 40, and there are an unaccountable number of private facilities not registered with JOPA.

In 1954, the Japanese Orthotics and Prosthetics Association was founded and has been very active in many areas such as price negotiations with the Government and organising business seminars and scientific meetings.

According to a JOPA survey conducted in 1980, member facilities average about 10-12 prosthetic/orthotic (P & O) workers per facility. From this it can be safely estimated that the general number P&O workers in the field is about 6-7,000. Private facility groups range from one-man operations to 500 employees in one company. A very wild guess at the private groups' market share is more than 95% of orthotics cases and 90% of prosthetics cases in Japan.

Japan began an official National Examination for the Registration and Orthotists in 1989 under the Ministry of Health and Welfare. 2,358 have passed the exam. It is quite obvious that when the new laws for the Prosthetists and Orthotists examinations were set up, the Government needed to protect the people who had already been providing the health services with prosthetics and orthotics so the Prosthetists and Orthotists Examination Board allowed a 5-year transition period, whereby persons having more than 5 years experience with casting and fitting patients were eligible to do a 104 hour short-term course to be eligible to take the national exam, or a person could complete the 3-year diploma course which must be recognised by the Ministry of Health and Welfare.

As of April, 1997 there were five schools given recognition by the Government as official Prosthetics and Orthotics Educational Institutions. One such institution was started in 1982 as the National School of Prosthetics and Orthotics, with 10 students per year and was located within the college of the National Rehabilitation Centre for the Disabled (NRCD), which is the only National Centre in Japan. This centre has a hospital, research centre and vocational rehabilitation centre along with the college. Now, with the five schools, the capacity is 110 students per year. These schools' faculty members formed the Japanese Prosthetic and Orthotic Education Society to establish a network of information exchange and an improvement in teaching skills.

The availability of jobs is quite high and the Japanese Prosthetics and Orthotics Educator Society acts as a central employment point, that registers over 200 positions at various facilities every year. The estimated number of needed newcomers to the field is about 100-120 annually but currently the five schools have only been able to produce 70-80 graduates per year. Consequently the need for new prosthetists and orthotists in Japan is higher even than the estimated number because there is currently a shortage. This problem should reduce following the opening of a new school in April 1997.

The National School of Prosthetics and Orthotics is highly popular because it was established as a very modern system, with advanced equipment, especially in the research laboratory, as well as having very eligible faculty members from different universities and many doctors from various hospitals. Also, as it is a governmentally (nationally) funded school, tuition fees are very attractive compared with private schools. The National School of Prosthetics and Orthotics leads education in Japan. All of the other private schools are directed by graduates of the National School.

In 1976 the Society of Prosthetics and Orthotics Technicians was established in order to exchange information and skills. However, after the national examination was instituted, this Society disbanded so that a new professional Prosthetics and Orthotics group could be established. In 1993 the Japanese Academy of Prosthetics and Orthotics was founded with 1,000 members. It is the youngest, and has become the most active, scientific group in Japan.

There is another professional group related to prosthetics and orthotics which is "The Japanese Society for Prosthetics and Orthotics". This society is unique in that it is composed of multi-disciplinary professionals such as medical doctors, prosthetists/orthotists, physical therapists, occupational therapists and rehabilitation engineers. The Society has approximately 1500 members and holds scientific events, publishes journals, and co-operates with other professions like the Japanese Orthopaedic Surgeon Association, the Japanese Rehabilitation Medicine Association, Rehabilitation Engineer groups and Prosthetists / Orthotists groups. Member breakdown by profession is 45 % Prosthetists/Orthotists, 35 % Medical Doctors, 15 % Therapists and 5 % Engineers.

The Japanese Ministry of Health and Welfare is responsible for providing prosthetic and orthotic appliances, therefore, they are also in charge of controlling quality and safety of the prosthetic and orthotic components used in Japan. Every single prosthetic and orthotic component must be tested for safety such as mechanical strength and durability. This work is also done at the research department of the NRCD. After these tests have been completed and their quality proven, these components are listed for prescription and therefore become available for the manufacture of prostheses and orthoses. The Government's listed components are mechanical hips, knees, ankles, feet, etc. More than 80% of prosthetics components on this list are imported, but more than 90% of the listed orthotic components are Japanese products.

Changes in lifestyle have made a difference in disabilities and the changing economy affects social welfare. The prosthetics and orthotics field will continue to change with the growing demand for "quality of life" (QOL) and less in production. This will necessitate more patient-care related work instead of production work.

System for the Provision of Prostheses/Orthoses in Japan.

The Japanese constitution guarantees that, "All people shall have the right to maintain minimum standards of healthful and cultured lives". The state and municipalities have established systems based on various laws and they are enforcing these through health, social welfare and labour administration policies. These systems have been established so that all people will be able to receive treatment impartially, and people who are disabled by sickness or accident are entitled to rehabilitation and the opportunity to lead lives without prejudice.

The provision of prostheses and orthoses in, Japan is also a part of these systems. It is structured into the medical care system and the social welfare system. It may be roughly divided into two orders. One is social insurance, which includes health insurance, annuity insurance, workmen's accident compensation insurance, and the like, and guarantees, by law, the right of citizens to receive benefits through the payment of insurance premiums. The other is the social welfare order which is covered by taxes (national and local) and comprises the Law Concerning Welfare of the Person with Disabilities and the Child Welfare Law.

If orthoses or temporary prostheses for training are required in the treatment of illness or injury or in cases which require a prosthesis or orthosis that will be used continuously due to permanent disabilities, these systems, based on laws and backed up by some financial source, will be applied, ensuring that those people who need prostheses/orthoses are provided with them.

Disabled persons in Japan first became able to obtain prostheses/orthoses at public expense with the promulgation of the Law Concerning Welfare for the Disabled in 1950, and this commenced the public payment of benefits for prostheses/orthoses (Fig 1,2,3, and Table 1).

Job description of Prosthetists/Orthotists

Prosthetists /orthotists are expected to fulfil their responsibilities as the most important team member in the prosthetic/orthotic provision process from casting to fitting. More specifically, based on basic medical understanding, prosthetists/orthotists contribute to the decision making process in the prescription of devices and components. They must ensure that they are well informed regarding the suitability of components and new designs of prostheses/orthoses (Fig.4).

Prosthetists and Orthotists

National Registration for Prosthetists/Orthotists
In Japan, prosthetists/orthotists are considered medical professionals, and as such they must pass national examinations and receive a license from the Minister of Health and Welfare.
Medical care is important in terms of the physical well-being of a nation's citizens. For this reason, most countries have established systems which allow only those with a given level of knowledge and skill to practice medicine, thereby limiting the people who can be employed in medical care.

However, medical care is not provided by doctors alone. It is also difficult for doctors to be well versed in, and be able to handle, all duties. Consequently, as medicine has progressed and become more advanced and more specialised, a need has developed for people to perform supplementary duties to doctors in a variety of fields, and these people are expected to be specialised in their respective fields.

This situation has resulted in the legislation of the qualifications of co-medical practitioners in Japan. In conjunction with the development of rehabilitation medical care in recent years, prosthetists/orthotists are now expected to take on an important role in team medical care.

High quality prosthetists/orthotists with developed knowledge and skills centring around diversification in the needs of patients and disabled people requiring prostheses/orthoses, as well as medicine and engineering, have become vital. In response to this social background, the systematic education of prosthetists/orthotists started in 1982, and then in 1987 a national examination system was established in conjunction with the passing of the Prosthetists and Orthotists Law.

The law defines the duties of prosthetists/orthotists as: "Those people who have been issued a license by the Ministry of Health and Welfare, and use this name under the instructions of doctors to make castings of areas to which prostheses/orthoses are to be fitted, fabricate the prostheses/orthoses, and fit them to the body. " This definition expresses the specialised nature of prosthetists/orthotists.

The fact that the law also requires prosthetists and orthotists to have national registration makes clear the importance of prostheses/orthoses in medical care today, and the central role they play in rehabilitation medicine.

Furthermore, in team medical care, it is a premise that prostheses/orthoses are fabricated and fitted in accordance with the doctor's prescription. Close co-operation is necessary with physiotherapists and occupational therapists, and it is expected that they provide information to one another.

Prosthetists/orthotists, despite the regulations of the Law Concerning Health Nurses, Midwives and Nurses, are permitted to carry out, in an assisting role, casting of the area to which prostheses/orthoses are to be fitted, and fitting of these to the body.

Accordingly, while prosthetists/orthotists formally have a monopoly on their name through their qualifications, a recognised part of their duties is to assist in medical examinations which unqualified people must not do, so the occupation does have the aspect of a restricted monopoly on duties.

Licenses are classified, according to the issuing party into National Licenses and Prefectural Governor Licenses. The prosthetist/orthotist license system strives towards improving the quality of prosthetists/orthotists, and is a national license in order to standardise the level across the country

Incidentally, the national examination for prosthetists/orthotists tests the applicant's knowledge in the following subjects:

Concept of Clinical Medicine (includes clinical neurology, orthopaedics, rehabilitation medicine, physical therapy, occupational therapy, clinical psychology and related legislation)

Prosthetics/Orthotics Engineering

Mechanical Drawing Mechanics

Servo-Mechanics

System Engineering

Rehabilitation Engineering

Properties of Materials (including Dynamics of Materials)

Biomechanics of Prosthetics And Orthotics

Prosthetics and Orthotics Casting and Tracing

Prosthetics and Orthotics Fitting

Educational Institutes for Prosthetists/Orthotists

Education and training of prosthetists/orthotists is carried out in accordance with the Prosthetists and Orthotists Law and by graduating from one of the training schools specified by law, the person is qualified to sit for the national examination. If the candidate then passes the national examination carried out annually by the Ministry of Health and Welfare, he or she then acquires the license of prosthetist/orthotist.

The prosthetics/orthotics schools in Japan, regulated by the law are as follows:
(1) A three-year course which applies to high school graduates (people eligible to enter university)
(2) A two-year course which applies to people who have spent at least a year studying at a university, (four years at a vocational high school), vocational high school or at a school or training school prescribed by ministerial order of the Ministry of Health and Welfare, and who have studied subjects specified by the Ministry of Health and Welfare.

Those persons, who have graduated from such prosthetics and orthotics schools, are eligible to sit the examination. People who have graduated from overseas schools of prosthetics and orthotics, or people who have received a prosthetist and orthotist license overseas considered equivalent or higher by the Ministry of Health and Welfare, are also eligible.

There are currently five schools in Japan (one national school and four private schools), each of which has a three-year course. While two and one-year training courses are legal, these do not exist at the moment. The maximum intake of each of these schools for one grade ranges from 10 to 30 people, giving a total of 110 people in the schools. The National School has 10, two other private schools have 20 per class and the other two have 30.

In the five year period from 1988, when the Prosthetist and Orthotist Law wag passed, to 1993, exceptions were applied as a transitional measure for those people who were currently involved in the fabrication and fitting of prostheses and orthoses.

The curriculum of the Prosthetics and Orthotics Course
The basis of education is firstly knowledge about medicine. It was discussed in the previous section that from the nature of their duties, the occupation is classified as a medical care occupation, and prosthetists and orthotists are expected to have knowledge of biomechanics and of illnesses and their treatments. Medical specialisations are taught to deepen understanding in these areas.

Next is the engineering knowledge necessary for the fabrication of prostheses and orthoses. The engineering specialisation teaches students about mechanics and the materials and mechanisms that comprise prostheses and orthoses.

Firstly there is an outline of prosthetic and orthotic techniques, followed by biomechanics, tracing in casting, fitting and professional management for each of lower limb prosthetics, upper limb prosthetics, spinal orthotics, upper limb orthotics and lower limb orthotics.

In addition, second and third year students are made to undergo eight weeks of clinical affiliation. Students are assigned to Prosthetics and Orthotics facilities throughout the country where they undertake practical education.

The students are also required to undertake independent research project. The objective of this is to develop abilities such as conceptual and creative power, testing methods and report writing that will benefit research and development in the future. The training and education of prosthetists and orthotists is not only the development of human resources who are involved actively in clinical work. It must also develop professionals who are involved in education and in research and development.

At Prosthetics and Orthotics schools, the above types of education are implemented, but at the end of each school year strict evaluations are carried out to establish whether students have reached a given level in each subject, and there are examinations to establish whether students will graduate or go on to the next year.

Finally, we must not forget that personal character is an important factor in the make up of prosthetists and orthotists. As an occupation involved in supporting patients and people with disability who are often in a disadvantageous position, prosthetists and orthotists must be of a trustworthy character. For this reason, it should be noted that developing character is also an important part of education.

While each of the training schools has formed its own curriculum, in accordance with the Prosthetist and Orthotist Law, the curriculum of the College of the National Rehabilitation Center for the Disabled is shown in Table 2 as an example.

Postgraduate Education
The Prosthetists and Orthotists Law was promulgated in 1987. The following year national examinations were carried out and, when the period of transitional measures ended in May 1993, the "Japanese Academy of Prosthetists & Orthotists" was established as an organisation of licensed practitioners.

In the era in which the national registrations system did not exist, the fabricators of prostheses/orthoses were regarded as technicians rather than medical care professionals. These people had formed an organisation called the "Japanese Society of Prosthetics and Orthotics Technicians", through which the technical skills were promoted.

This association was established on the premise of contributing to the diffusion and improvement of health care, and to enhance the social position of prosthetists and orthotists. It was mentioned earlier that the original idea in having a national qualification system was to reassure the country's citizens that persons holding such qualifications had achieved a given level of knowledge and expertise in that particular field.

By pursuing their own speciality and strengthening it, they are able to acquire the recognition of society which enables them to improve their place in that society. Prosthetists and orthotists are therefore expected to make an effort to study information and techniques even after they have achieved their qualifications.

From such an awareness, activities were developed with the goals of postgraduate education, enhancing lifelong education, and improving the social position of prosthetists and orthotists. These activities include the staging of study sessions such as annual scientific meetings, hands on practical seminars, educational seminars, maker tie-up seminars etc., plus the publication of academic journals. Through these activities, members strive towards acquiring advanced principles and expertise, which in turn proves useful in carrying out clinical work.

Incidentally, as at October 1997, the Society had 1,190 members (qualified persons), in addition to student members, subscription members and supporting members, giving a total of 1,481 members.

The Japanese Society of Prosthetics and Orthotics (JOPA), holds both scientific study sessions and academic meetings and issues academic journals, thereby working towards the enhancement of knowledge and expertise.

Table 1. Laws, Systems, and the Current Situation Concerning Prostheses/Orthoses

Table 2 Curriculum of Training Course for Prosthetists and Orthotist
at the National Rehabilitation Center for the

hrs

1. LIBERAL ARTS

1. SCIENCE AND MATHEMATICS

   MATHEMATICS	30
   PHYSICS	30
   STATISTICS	30
   	90

2. HUMANITIES

   PSYCHOLOGY	30
   ART	30
   	60

3. SOCIAL SCIENCE

   HUMAN DEVELOPMENT	30
   SOCIAL WELFARE	30
   	60

4. FOREIGN LANGUAGE

   ENGLISH	120
   	120

5. HEALTH SCIENCE & PHYSICAL EDUCATION

   PHYSICAL EDUCATION	60
   	60

SUB TOTAL

390hrs

2. SPECIALIZATIONS

PART 1

MEDICINE

PUBLIC HEALTH	15
INTRODUCTION OF MEDICINE	15
ANATOMY	90
PHYSIOLOGY	105
INTRODUCTION OF PATHOLOGY	45
FUNCTIONAL ANATOMY	165
KINESIOLOGY	90
CLINICAL MEDICINE	15
CLINICAL NEUROLOGY	30
ORTHOPEDICS	105
REHABILITATION MEDICINE	60
PHYSICAL THERAPY & OCCUPATIONAL THERAPY	30
CLINICAL PSYCHOLOGY	15 15

SUB TOTAL

780hrs

ENGINEERING

MECHANICAL DRAWING	30
ENGINEERING OF MACHINERY	30
COMPUTER PRACTICE	45
PROPERTY OF MATERIALS	45
DYNAMICS OF MATERIALS	45
SERVO-MECHANICS	30
SYSTEM ENGINEERING	30
PHYSICS OF PROSTHETICS AND ORTHOTICS	75
	360

SUB TOTAL

1140hrs

PART 2

INTRODUCTION OF PROSTHETICS & ORTHOTICS	15
PROSTHETICS & ORTHOTICS TECHNIQUES	135
BIOMECHANICS OF PROSTHETICS & ORTHOTICS	105
PROSTHESES & ORTHOSES CASTING AND TRACING	540
PROSTHESES & ORTHOSES FITTING	465
PROFESSIONAL MANAGEMENT PROSTHETICS & ORTHOTICS	60
RELATED LAWS & REGULATIONS	30
INDEPENDENT RESEACH	30
CLINICAL AFFILIATION	180

SUB TOTAL

1740hrs

TOTAL

3270hrs

YEARLY SCHEDULE OF 3 YEARS

hrs

1ST YEAR

LIBERAL ARTS

MATHEMATICS	30
PHYSICS	30
PSYCHOLOGY	30
ART	30
HUMAN DEVELOPMENT	30
ENGLISH I	60
PHYSICAL EDUCATION	60
PUBLIC HEALTH	15

SPECIALIZATION (PART 1)

INTRODUCTION OF MEDICINE	15
ANATOMY I	15
ANATOMY II	15
ANATOMY III	30
PHYSIOLOGY I	30
PHYSIOLOGY II	30
PHYSIOLOGY LABORATORY WORK	45
OUTLINE OF FUNCTIONAL ANATOMY	15
FUNCTIONAL ANATOMY I (SPINAL ORTHOTICS I)	15
KINESIOLOGY	45
KINESIOLOGY LABORATORY WORK	45
MECHANICAL DRAWING	30
COMPUTER PRACTICE	45
PROPERTY OF MATERIALS	45
DYNAMICS OF MATERIALS	45
PHYSICS OF PROSTHETICS AND ORTHOTICS	30
LABORATORY WORK OF PHYSICS FOR PROSTHETICS & ORTHOTICS	45

SPECIALIZATION (PART 2)

INTRODUCTION OF PROSTHETICS & ORTHOTICS	15
PROSTHETICS & ORTHOTICS TECHNIQUES	105
BIOMECHANICS OF PROSTHETICS & ORTHOTICS (SPINAL ORTHOTICS I)	15
PROSTHETICS & ORTHOTICS CASTING AND MEASUREMENT I (SPINAL ORTHOTICS I)	60
PROSTHETICS & ORTHOTICS FITTING I (SPINAL ORTHOTICS I)	60
FABRICATION LABORATORY WORK I (PROSTHETICS & ORTHOTICS TECHNIQUES)	90

SUB TOTAL

1,185hrs

2ND YEAR

STATISTICS	30
ENGLISH (PART 2)	30
FUNCTIONAL ANATOMY (PART 2)	75
CLINICAL MEDICINE	15
CLINICAL NEUROLOGY	30
ORTHOPEDICS	105
REHABILITATION MEDICINE	60
CLINICAL PSYCHOLOGY	15
ENGINEERING OF MACHINERY	30
SERVO-MECHANICS	30
PHYSICS OF PROSTHETICS AND ORTHOTICS (PART 2)	45
BIOMECHANICS OF PROSTHETICS & ORTHOSES (PART 2)	60
CASTING AND TRACING OF PROSTHESES & ORTHOSES (PART 2)	195
FITTING OF PROSTHESES & PROSTHETICS & ORTHOTICS (PART 1)	30
CLINICAL AFFILIATION (PART 2)	135

SUB TOTAL

1,080hrs

3ND YEAR

SOCIAL WELFARE	30
ENGLISH (PART 3)	30
INTRODUCTION OF PATHOLOGY	45
FUNCTIONAL ANATOMY (PART 3)	75
PHYSICAL THERAPY & OCCUPATIONAL THERAPY	30
SYSTEM ENGINEERING	30
REHABILITATION ENGINEERING	30
BIOMECHANICS OF PROSTHETICS & ORTHOTICS (PART 3)	75
CASTING AND TRACING OF PROSTHESES & ORTHOSES (PART 3)	210
FITTING OF PROSTHESES & ORTHOTICS (PART 3)	210
PROFESSIONAL MANAGEMENT PROSTHETICS & ORTHOTICS (PART 2)	60
RELATED LAWS & REGULATIONS	30
INDEPENDENT RESEACH	30
CLINICAL AFFILIATION (PART 3)	135

SUB TOTAL

1,020hrs

TOTAL

3,285hrs

Go to the Contents

NATIONAL TRAINING EDUCATION ARRANGEMENT IN PROSTHETICS AND ORTHOTICS IN KOREA

Jung Soon Shin

The concept of rehabilitation for disabled people, and programmes to provide such rehabilitation, in the modern sense, were introduced in Korea during the Korean War that broke out in June 1950. The brutal war brought heavy casualties to both civilians and members of the Armed Forces. Consequently, persons with disabilities were "mass-produced", but there were neither adequate government programmes, nor facilities to take care of them.

It is really an irony that the war, which caused such great suffering on the one hand, should provide such an opportunity for growth and change on the other hand. It was from this opportunity that developments in the field of prosthetics and orthotics began in Korea.

Before discussing training and education for prosthetics and orthotics, I would like to briefly review the development of rehabilitation in Korea.

A Historical Review of Medical Rehabilitation in Korea

The many casualties, soldiers as well as civilians, from the Korean War which began in June 1950, as well as the many children who developed poliomyelitis called for urgent treatment strategies. To meet these needs a Prosthetic Department and Brace Shop were established at Severance Hospital in April 1953 with financial support from Korea Church World Service (KCWS), the United Presbyterian Mission and many other overseas aid organisations. A Polio Clinic was also established in November 1954. The clinical achievements of the Polio Clinic were highly valued and the importance of this project was widely recognised in Korean society. This was the beginning of the process that led to the construction of the Children's Rehabilitation Centre which opened in October 1959.

A vocational rehabilitation centre was established in May 1954 with financial support from KCWS and by the dedicated effort of Dr. Reuben A. Torry, Jr. an American missionary. The importance of this project was recognised and in order to promote a more effective rehabilitation project, Yonsei University and KCWS agreed to integrate the Prosthetic Department of Severance Hospital and the Vocational Rehabilitation Centre to make one centre, the Amputee Rehabilitation Centre, which was built on the campus of Yonsei University and dedicated in October 1963. In March 1968, the Amputee Rehabilitation Centre and the Children's Rehabilitation Centre were united as the Rehabilitation Centre of Yonsei University Medical Centre and this grew to be the Rehabilitation Hospital of today.

On the other hand, in 1953, Dr Howard A. Rusk, Chairman of the American Korean Foundation and General Coulter, Director of the United Nations Korea Reconstruction Agency (UNKRA) met with officials of the Korean Government and a decision was made to reorganise the Korea Veterans Convalescent Hospital in Pusan as the National Rehabilitation Centre. After a year of preparation and with financial help from UNKRA and the American-Korean Foundation, the National Rehabilitation Centre was opened. A rehabilitation team from overseas came and worked at the Centre. Particularly, at this time, Mr. Baker from England began manufacturing prostheses and orthoses as well as giving on- the-job training in these techniques. However, for various reasons, the National Rehabilitation Centre in Pusan was closed in 1968. It was reopened in 1986 at its present location in Seoul. New construction completed in 1994 expanded the Centre.

The Korea Veterans Hospital was established in 1962, but it did not have an amputee clinic. Therefore, a Prosthetic and Orthotic Department was set up at the National Vocational Rehabilitation Centre for Veterans that was located in Suwon. From here prostheses and braces were supplied to disabled veterans, Some time later this Prosthetic and Orthotic Department was moved to the Korea Veterans Hospital in Seoul. In 1983 this hospital moved to a new location and in the spacious area of the newly constructed building the Prosthetics and Orthotics Centre has been able to expand.

In October 1950, a Prosthetic and Orthotic Department was established at the Army Hospital in Pusan and a technical aid group consisting of eight American Military Officers who were qualified prosthetists and orthotists came to the hospital to carry out the manufacture of prostheses and orthoses as well as to train Korean soldiers in these techniques.

Short-term Training Courses in the Early Period

In April 1953, about six months before the establishment of the Prosthetic Department at Severance Hospital, two American missionaries came to Korea and gave a three month short-term training course on production techniques for prosthetics in the programme. Then, a prosthetics course was set up as a four-month short-term training course in the Vocational Training Department of the Vocational Rehabilitation Centre for Amputees which had been established by KCWS in the city of Daejon. Under the same two American missionaries, a total of fourteen men completed the course in manufacturing techniques of prostheses and orthoses. This course was held a total of three times. As prosthetic departments were established at Severance hospital in Seoul, the Presbyterian Hospital in Chonju, and Donsan Presbyterian Hospital in Daegu,

In April 1953, about six months before the establishment of the Prosthetic Department at Severance Hospital two American missionaries came to Korea and gave a three month short-term training course on production techniques for prosthetics. Five Koreans participated in the programme. Then, a prosthetic course was set up as a four-month short-term training course in the Vocational Training Department of the Vocational Rehabilitation Centre for Amputees which had been established by KCWS in the city of Daejon. Under the same two American missionaries, a total of fourteen men completed the course in the manufacture techniques of prostheses and orthoses. This course was held a total of three times. As prosthetic departments were established at Severance Hospital in Seoul, the Presbyterian Hospital in Chonju, and Donsan Presbyterian Hospital in Daegu, the trainees from this programme were dispatched to each of these places. Therefore, it can be said that, in the early period, a large number of the prosthetists and orthotists who worked in Korea were trained either at the Prosthetic Department of Severance Hospital, the Vocational Rehabilitation Centre in Daejun, or at the National Rehabilitation Centre's prosthetic course.

At the National Rehabilitation Centre in Pusan, Mr. Baker started with on-the-job training which evolved into a prosthetic course as part of the vocational training department. This short-term training course, with a duration of four months, produced several trainees but it only lasted for three courses.

As one of the vocational training programmes for disabled veterans at the National Vocational Rehabilitation Centre for Veterans in Suwon, a three-month, training course on the manufacture of prostheses and orthoses was started in August 1963. Twelve trainees completed the course, and nine of them are still working in the field of prosthetics and orthotics with the basic training which they received at that time (Table 1).

International Training

For the purpose of training talented people who could accept leadership roles as competent prosthetists and orthotists in Korea, KCWS arranged for Mr. SW Song and Mr. KM Chung to he trained in the United States for one year in 1955. After their return, they gave guidance and training to personnel in the field and generally promoted the development of prosthetics and orthotics while working at Severance Hospital.

In 1965, Mr. KH Kim from the Rehabilitation Centre of Yonsei University Medical Centre was sent to the Kowloon Rehabilitation Centre in Hong Kong for a three-month period of training. Mr. MD Chun from the National Rehabilitation Centre was sent to the United States for a one year training course in 1957, and Mr. TK Kim from the Prosthetic Department of the Korean Army Hospital was sent to the Prosthetic Department of Walter Reed Army Hospital in the United States for one year of training. Also in 1977, Mr. JH Park from the Korean Army Prosthetic Department was sent to the United States for one year of training. In 1983, Mr. YS Park from the Korea Veterans Hospital received two years of training in the Prosthetics and Orthotics Course at New York University. All of these internationally trained people are working actively in their respective centres and making important contributions to the development of Prosthetics and Orthotics in Korea.

The World Rehabilitation Fund (WRF) is the organisation which has contributed the most to short-term international training programmes in the field of Prosthetics and Orthotics in Korea. The WRF sponsored two people to be trained in Hong Kong in 1974 and 1975, and 14 people to be trained in Taiwan for four to six months in 1979, 1980, 1981 and 1988.

In the Korea Veterans Hospital, one person per year from 1976 to 1978 was sent to the Kawamura Orthopaedic Appliance Co. in Osaka, Japan for six months of training, and in 1983 and 1984, one person, each year, was sent to the National Rehabilitation Centre in Japan for four months of training. From 1996 up to the present, three people each year have been sent to the Otto Bock School of Prosthetics and Orthotics for three months of training. Two persons were also sent to the Labour Accident Prosthetics and Orthotics Centre in Nagoya, Japan in 1988 for six months, and one person was sent to the United States in 1990 for one year of training at a hospital operated by the Worker's Medical Corporation under the Ministry of Labour.

Training Programmes in Korea

The members of the Executive Board of the Korean Academy for Rehabilitation Medicine, regretting the fact that the absence of school for Prosthetics and Orthotics, as well as the lack of a certification system in Korea, were the main reasons that there was no progress in the field of Prosthetics and Orthotics, decided to take an active role in educating people about this field during the International Year of Disabled Persons (IYDP), 1981. The Korean Academy of Rehabilitation Medicine in conjunction with the Executive Members of the Korea Orthotics and Prosthetics Association (not a branch of ISPO) gave a successful training course for 60 persons for six days from August 24 to 29, 1981. This training programme was carried out for two years, and thereafter, it has been given every year up to the present. Most of the work for the course is done by the Korea Orthotics and Prosthetics Association but they have been assisted by the Korean Academy of Rehabilitation Medicine and other associated international organisations.

Problems of Establishing a School for Prosthetics and Orthotics

The Korean Academy for Rehabilitation Medicine and the Korean Orthopaedic Association have submitted a proposal to the Korean Ministry of Health and Social Affairs demanding action and advocating the need to provide a certification system for prosthetists and orthotists in order to promote development in this field. In order to support the certification system, there is a need to establish a school for prosthetics and orthotics that would cultivate proficient prosthetists and orthotists. In 1980 when project preparations were actively under way for the 1981 IYDP, the Korean Academy of Rehabilitation Medicine again submitted the proposal to the Ministry of Health Social Affairs and demanded the establishment of a certification system and a training school. However, unfortunately, the proposal did not receive a positive response from the Ministry.

In 1975, when Yonsei University was planning to expand the University by opening the Wonju Campus, I was deeply involved in the project. At that time, most of the physical therapy schools had a 2-year curriculum, but I had always thought there was a need for a 4-year curriculum. Therefore, I submitted a plan for a curriculum for a 4-year physical and occupational therapy course, as well as a curriculum for a 4-year prosthetics and orthotics training course for the Wonju Campus. I advocated strongly for these programmes. However, in the end, a 4-year course for physical and occupational therapy and a. 4-year course for biomedical engineering were established instead of one for prosthetics and orthotics.

For several years now our government has been developing a five-year plan designed to promote the Welfare of Disabled People (1998-2002), and recently this plan has almost come to its final conclusive stage. Due to a demand from the general public and from the Korea Orthotics and Prosthetics Association, and owing to the efforts of people associated with the project, I am happy to report that a plan to establish an undergraduate programme for prosthetics and orthotics is included in the five-year Plan. We hope that these plans will become a reality as soon as possible.

Conclusions

As you very well know, prostheses that amputees have to wear and orthoses that people with various diseases and disabilities have to use have very important roles in the field of rehabilitation. Better quality products and better qualified technicians are needed in order to provide better fitting prostheses and orthoses for each and every one of the patients and disabled persons who need them. Therefore, the establishment of a training school and the development of a certification system for prosthetists and orthotists are extremely important. Unfortunately, the realisation of these dreams has not yet been possible; due to lack of effort on the part of various medical societies including the Korean Academy for Rehabilitation Medicine and the Korean Orthopaedic Association, as well as a lack of interest on the part of the government.

The Korean Academy for Rehabilitation Medicine is planning to conduct educational programmes consisting of lectures on the basic sciences and technical practice for prosthetists and orthotists by working more closely with the Korea Orthotics and Prosthetics Association.

Furthermore, in order to realise the establishment of a school for prosthetists and orthotists and the development of a certification system, I believe that the Korean Academy of Rehabilitation Medicine, in particular, but in conjunction with the Korean Medical Association, will have to have a strong policy promoting this plan.

NATIONAL TRAINING/EDUCATION ARRANGEMENT IN PROSTHETICS ORTHOTICS IN PAKISTAN

Naseer M. Akhtar

At the time of emergence of Pakistan, medical facilities in general and facilities for training, as well as manufacturing, in prosthetics and orthotics were practically non existent because most of the facilities had been left behind in remaining part of India. There was no industrial base either. So whatever development has taken place has started from scratch. During much of this period the fields of orthotics and prosthetics received very little attention from the Government, NGOs or the private sector. For a long period the only manufacturing was provided by the private sector. The first manufacturing facility, established under the Pakistan Army in Rawalpindi, originally manufactured artificial limbs for Second World War victims. Later, facilities for manufacturing orthoses were also established to meet the requirements of families of armed personnel as well as civilians. This continues to be one of the major manufacturing facilities in Pakistan.

The only training which was available in the beginning was of the apprenticeship type and this was provided in the army manufacturing centre. The trained personnel at this centre had received their training abroad, usually in England, as Indo-Pakistan had been its colony before Independence.

The first ever facilities for training technicians was established by setting up a school for Prosthetics and Orthotics in King Edward Medical College/ Mayo Hospital Complex with the personal efforts of the author in collaboration with U.N.D.P. This was established in a new building which also housed the Prosthetic/Orthotic Workshop set up a few year earlier in 1977.

The intake of students for the two year course was from among the holders of mechanical diplomas from high school and people who had completed high school education with a certificate in vocational training in the field of mechanical engineering, iron smith work, or leather technology. The course comprised of 60% practical and 40% theoretical training by doctors from the Orthopaedic Department and a Swedish expert in prosthetics and orthotics who was overall in charge of the course and had previously been engaged in the army centre for improving the facilities. At the end of the course the trainees were awarded diplomas by the Technical Board of the Province.

The course went very well for the first two batches because those trained in this course were absorbed either as trainees in the same school or got jobs as prosthetic and orthotic technicians in the workshop or another workshop established in Multan, attached to the local Medical College. The training programme was part of the overall programme for setting up of the prosthetic/orthotic centres in different part of the Province/Country. However, the plan for establishing these centres which had been approved by the Government was going to be funded partly by U.N.D.P. This plan was shelved due to financial constraints in the country and withdrawal of support by U.N.D.P. The school at present is holding only short courses for technicians working in various prosthetic/orthotic centres in the country. Efforts are also being made to restart the regular course. One reason for a boost in developing the facilities during that period for rehabilitation in general was the keen interest by the then President, General Zia ul Haq, who happened to have a disabled child.

Then the Afghan war came and Pakistan was flooded with the refugees coming in from the war-hit areas bringing with them amputees and paralytics in large numbers. This attracted the attention of various international agencies as well as individual countries and the Federal Republic of Germany and the Red Cross set up facilities for taking care of amputees and those with other war disabilities. Initially the facilities mainly assembled components manufactured abroad but later a very good prosthetic/orthotic manufacturing unit was established by the Federal Republic of Germany, with local participation, and this continues to be a very good manufacturing unit for prosthetics and orthotics.

Six years ago a training college was also established to produce graduates in prosthetics/orthotics affiliated to the University of Peshawar. Three batches of these graduates have come out and the fate of 80 graduates (BSc in Prosthetics/Orthotics) thus produced is uncertain. There may become a problem in providing jobs for these graduates unless facilities for manufacturing prostheses and orthoses, where these graduate could be employed, are established country-wide.

NATIONAL TRAINING ARRANGEMENT IN PROSTHETICS AND ORTHOTICS IN THAILAND

Therdchai Jivacate

Prosthetic and orthotic training in Thailand started in 1977 under the responsibility of the Ministry of Health. This was a two-year course. Students enrolled in the programme had to finish high school and were awarded a certificate as prosthetic and orthotic technicians when they graduated. The two-year course comprised basic anatomy, biomechanics, principles of prosthetics and orthotics, upper and lower limb prostheses and trunk and lower limb orthoses. Before they graduate, each student must make at least one of each type of prosthesis and orthosis. Because students had to learn many subjects in a short period of time and there was less practical work with patients, they were not successful in making prostheses and orthoses for the disabled. This course had been run for 15 years and about 200 prosthetic/orthotic technicians graduated. Many of them changed their profession and only 100 of them are currently working in this field and mainly in the central part of the country. They can make only uncomplicated trans-tibial and trans-femoral prostheses.

SUBJECT		CREDITS
General Basic		77
	Language and Social Studies	14
	Mathematics	6
	Basic Science	9
	Basic Engineering	24
	Basic Techniques	24
Professional		40
	Medical Science	12
	Prosthetics and Orthotics	28
Elective		6

Details of Each Subject

Language and social studies		14 credits
	Technical English I & II	6
	Human Relations	3
	Psychology	3
	Health Administration	2

 

Mathematics		6 credits
	Applied Mathematics	3
	Applied Statistics	3

 

Basic Science		9 credits
	Chemistry	3
	Physics	3
	Psychology	3

 

Basic Engineering		24 credits
	Heat Fluid Technology	3
	Fluid Power Technology	3
	Mechanics of Materials	3
	Electrical Technology	3
	Electronic Technology	3
	Computer Technology	3
	Safety Engineering	3
	Management	3

 

Basic Techniques		24 credits
	Drawing	3
	Engineering Workshop I	3
	Engineering Workshop II	3
	Engineering Workshop III	3
	Practical Work I	6
	Practical Work II	6

 

Medical Science		12 credits
	Structure and Functions of the Human Body	4
	Pathology and Aetiology of Disability I	2
	Pathology and Aetiology of Disability II	2
	Rehabilitation Medicine	4

 

Prosthetics and Orthotics		28 credits
	Lower Limb Orthotics and Orthopaedic Shoes I	3
	Lower Limb Orthotics and Orthopaedic Shoes II	3
	Spinal Orthotics	4
	Lower Limb Prosthetics I	4
	Lower Limb Prosthetics II	4
	Lower Limb Prosthetics III	4
	Upper Limb Prosthetics I	3
	Upper Limb Prosthetics II	3

 

Electives		6 credits
	Computer Programming	3
	Special Orthotics	3
	Rhythmic Activities	3

When students graduate they get to a Diploma in Prosthetic and Orthotic Technology. The school can accept 20 students each year, but so far only 10-15 have enrolled each year and when they graduate about half of them then enrol for a bachelor degree in engineering. This course was temporarily stopped for re-evaluation last year after it had been running for only five years.

NATIONAL TRAINING/EDUCATION ARRANGEMENT IN PROSTHETICS AND ORTHOTICS IN TAIWAN

Jin-Shin Lai

Jin-Shin Lai In Taiwan, rehabilitation medicine developed in the decade of 1950. At that time a Department of Physical Medicine and Rehabilitation was set up in very few medical centres, such as the Veteran General Hospital (VGH), the National Taiwan University Hospital (NTUH) and the Cheng-Shin Rehabilitation Centre (CSRC). All of them were located in northern Taiwan. An amputee service programme was one of the branches of the rehabilitation medicine course, so prosthetic and orthotic workshops were established sequentially. The latest of them to be established was the Prosthetics and Orthotics Workshop of NTUH in 1971. During the decades of 1960s & 1970s, the orthotics division served the poliomyelitis and stroke patients; while the prosthetics division treated the amputees, about half of whom were the victims of "Blackfoot Disease". Blackfoot Disease was an endemic peripheral vascular disease found among the inhabitants of a limited area along the southwest coast of Taiwan, where artesian well water with a high concentration of arsenic had been used for more than eighty years. After tap water was provided in that area, this endemic disease decreased significantly and is under control now.

Although currently we have more than twenty public and private workshops to serve the disabled patients who need prostheses and orthoses in Taiwan, there have been no official educational programmes or schools for prosthetics and orthotics technicians up to now. You may wonder how prosthetics and orthotics products could be properly made. In Taiwan, most of the prosthetics and orthotics technicians learned the techniques in informal ways such as watching the skilled technician's performance and then practising under his supervision or instruction. Repeated practice made them better and better. Most of them had graduated from junior high school, so their major handicap was a shortage of anatomical and related medical knowledge. This was compensated by some seminars or training courses, which were held by medical centres or our National Prosthetics and Orthotics Association in Taiwan, which was established in 1989. Before 1989, VGH, NTUH and CSRC had each organised several training courses. Some of them were organised or assisted by WHO specialists. In addition to these, some technicians who worked in the medical centres went to USA, Germany or Japan to attend prosthetics and orthotics short-term or certificate programmes. After 1989, seminars were regularly held every year (see Table 1) by our National Prosthetics and Orthotics Association in Taiwan. These academic activities promoted the level of prosthetics and orthotics in Taiwan very effectively. So the National Central Health Insurance Bureau started to make contracts with the private prosthetics and orthotics workshops instead of with only very few workshops in the medical centres.

In all of the medical colleges in Taiwan, prosthetics and orthotics were regularly taught in the School of Medicine, School of Physical Therapy and School of Occupational Therapy. So I personally believe that these professionals will be qualified to attend the certificate programmes and licence examination in the future in Taiwan. Our present tasks and goals are as follows;

1. To set up an official School of Prosthetics and Orthotics in a college or university
2. To establish certificate programmes
3. To establish registration of Prosthetics and Orthotics Technicians (or Professionals) and a licence process.

Table 1 Seminars (National Prosthetics and Orthotics Association in Taiwan)

NATIONAL TRAINING EDUCATION ARRANGEMENT IN PROSTHETICS AND ORTHOTICS

Ha Anh, M.D.

Training in orthopaedics and prosthetics in Vietnam includes:

• Training at school
• Short training (theory and practice)
• Practice at workshop
• Examination of level of competence of the orthopaedic worker

Training and education in prosthetics and orthotics in Vietnam

Training at the school:
In 1979 West Germany helped Vietnam to train orthopaedic and prosthetic workers. The training school for orthopaedic workers had trained two kinds of workers for one period from 1979 to 1981. During this period 165 workers graduated. As the number of workers was then sufficient for the needs of all centres in Vietnam the training school for orthopaedic workers discontinued training. The training included:

• theory (1 year); anatomy (skeleton ); alignment biomechanics
• practice (1 year) included fabrication of:
  • trans-tibial prosthesis
  • trans-femoral prosthesis
  • orthosis and footwear

After graduating, the orthopaedic workers have been employed at all orthopaedics centres in Vietnam. They only use the simple techniques which they learned at school. The major specialisations of orthopaedic workers in Vietnam were found in a survey (1995) to be:

The short training programme
Since 1991, with the helps of NGOs, a short term training programme has been operated for orthopaedic workers. The short training course consists of:

• a seminar on orthotic techniques for polio children
• anatomy and basic sciences
• trans-tibial and trans-femoral socket design and alignment protocols.
• thermoplastic fabrication.

The Orthopaedic Rehabilitation Institute teaches the short training course which provides for the exchange of professional experience gained in the field through presentation of papers, practical demonstration of special techniques with patients, introduction to recent technical advances in fitting people who are physically disabled and adaptation of technology to different environments in Vietnam.

The special training course
Each of the NGOs helping in Vietnam brings new techniques in orthotics and prosthetics which the orthopaedic worker must learn. Such new techniques are being introduced as follows:

• ICRC have been helping HCM orthopaedic centres to make orthotic and prosthetic devices using polypropylene technology
• MSVLAC have been helping Tam Diep centres in providing Jaipur limbs
• POC Hanoi has been using CAD-CAM techniques introduced by POF.

The examination of orthopaedics workers
Every year MOLISA organises an examination which is open to all orthopaedic workers in Vietnam. If they have worked at their level for three years they can take an examination to upgrade to a higher level. Before taking the examination, they must have attended the short training course.

Vietnam Technician Orthopaedic Training Centre -VIETCOT

From September 1997 this centre has been following ISPO training guidelines. This school was set up with German assistance. After three years training in this school the highly trained personnel have the necessary theoretical and practical skills to give a high standard of service to patients and have the potential of teaching and training others in more advanced techniques of orthopaedics and prosthetics.

Now Vietnam has two types of worker who are the products of the two distinct training systems:

• Orthopaedic workers who were trained at the short training course or received practical training in orthopaedic workshops
• Technicians who trained at VIETCOT

Upgrading the orthopaedic workers who trained by the short course to the level recommended by ISPO is difficult but we are trying to operate some form of short training to upgrade the standard of the orthopaedic workers.

DISCUSSION 2

Reported by Brendan McHugh

It was felt that there was a need for a process by which an orthopaedic technologist (Category II) might convert to a prosthetist/orthotist (Category I).

The typical BSc degree course in Prosthetics and Orthotics did not lend itself to free movement of students between prosthetics/orthotics and other subjects because of the unique clinical component of the course. Students from other courses might be eligible for exemptions from one or more subjects in the Prosthetics/Orthotics syllabus.

Higher degrees such as MSc. and PhD were not a substitute for Category I or Category II education and training.

It was noted that one-year courses in prosthetics and orthotics respectively were available in TATCOT. The entry requirement for these was the same as for the Category II course. It was anticipated that, in the future, three successfully completed one-year courses might be amalgamated to give a Category II qualification.

An advantage of this modular type of course was the possibility to respond to urgent needs. For example, following war, there would be a large demand for expertise in prosthetics. On the other hand, where poliomyelitis was prevalent, orthotics would be the dominant requirement. It would be possible to train in one year to meet the urgent need and then later complete the remaining components of the Category II course.

The cost of training could be a prohibitive factor if help were not available from government or elsewhere. In Tanzania, about one third of funding came from the government. In China, the school provided consultancy to factories which, in turn, gave manpower and components to the school.

In its early years the school in Tanzania had been government funded. Then the recurrent fund (approximately 30%) was gradually reduced to zero leaving only the human resource fund. Income now came from short term training programmes and from component production and supply to other countries in the region.

The school in Cambodia, with 36 students, required a total budget of around USD10,000 per student. Currently, the school was supported by five non-governmental organisations. As regards long-term sustainability, costs would reduce when locally trained personnel took over the school and there was the possibility of income from overseas students.

Many academic institutions recruited staff who had a track record of research and publication. It was recognised that qualified prosthetic/orthotic personnel may not satisfy this criterion and yet were vital to any course in prosthetics and orthotics.

It was noted that the prosthetic/orthotic professions were male dominated in many countries and that this could deter female patients from attending for prosthetic or orthotic treatment. For example a survey of 4000 recipients of prosthetic/orthotic devices in India had revealed that 3200 of these were men. It was reported that in the schools in Glasgow and Hong Kong, there were equal numbers of male and female students.

In Japan there were five schools including four private schools which charged students fees equivalent to those normally levied by universities. These private schools needed 20-30 students per year for viability.

The school in Hong Kong was considering the addition of elective subjects such as seating, cognitive aids and communication aids to the curriculum. There was some concern that this might encroach on the time needed for the essential prosthetics/orthotics content of the course.

It was suggested that the fear of losing trained prosthetics/orthotics personnel to other countries might be a deterrent to setting up good training courses. It was stressed that good education and training were essential and that the way to keep highly trained professionals was to ensure that they were valued by the community. Often prosthetics/orthotics personnel who moved abroad returned home after gaining experience in another country.

The question of forming a "College of Teaching Fellows" was raised and it seemed that this may become possible using the ISPO Professional Register.

There was some misunderstanding about the roles of workers in Categories I, II and III. It was clarified that Category III workers were bench hands or technicians. They were important to the rehabilitation process but were not qualified to treat patients. Category I and Category II personnel were qualified to treat patients and it would be sensible to avoid having them do bench work which should be he responsibility of Category III workers.

The idea of introducing a grade, with a level of education and training inferior to Category II, to treat patients, was considered unacceptable. This would reduce standards and patients would not receive good quality treatment and rehabilitation. It would build up the problem of a glut of under-qualified workers in the future.

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 : National Training and Education Arrangements in Prosthetics and Orthotics -

Editors:
Eiji Tazawa
Brendan McHugh