ISPO: Painting a Brighter Picture for P&O Education Worldwide

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By Miki Fairley

In 1970, a new development began to fuel better care worldwide for persons who suffer from neuromuscular and skeletal impairments. A group of farsighted rehabilitation professionals, including surgeons, prosthetists/orthotists, physical and occupational therapists, and engineers, founded the International Society for Prosthetics and Orthotics (ISPO) in Copenhagen, Denmark.

The multidisciplinary organization comprises men and women who have a professional interest in the clinical, educational, and research aspects of prosthetics, orthotics, rehabilitation engineering, and related areas. ISPO is a nongovernmental organization (NGO) in special consultative status with the Economic and Social Council of the United Nations (UN) and is in official relations with the World Health Organization (WHO), which means that ISPO is recognized as an important voice on matters related to orthotics and prosthetics in general with a focus on educational and practice standards worldwide.

One of ISPO's most important contributions to international rehabilitation care has been assisting in standardizing and upgrading the education and skills of P&O professionals and technicians worldwide. ISPO/WHO categories and the knowledge and skills sets for each level grew from a 1990 "summit conference" held in Alexandria, Egypt. The meeting brought together personnel from WHO, ISPO, seven P&O schools in developing countries, and organizations involved in the development and support of P&O training programs in developing countries.

From left: Albina Shankar, director of Mobility India; Dr Sarwar, Pakistan Institute of Prosthetics and Orthotic Science; Dan Blocka, ISPO education chair; and Ritu Ghosh, deputy director of Mobility India, look over the curriculum of the Category II single-discipline course at the recent inspection carried out by ISPO. Photo by Carson Harte.
From left: Albina Shankar, director of Mobility India; Dr Sarwar, Pakistan Institute of Prosthetics and Orthotic Science; Dan Blocka, ISPO education chair; and Ritu Ghosh, deputy director of Mobility India, look over the curriculum of the Category II single-discipline course at the recent inspection carried out by ISPO. Photo by Carson Harte.

The society has detailed appropriate education and training programs for the credentialed, professional prosthetist/orthotist and for the orthopedic technologist trained at a slightly lower level. ISPO also provides examiners and advice for programs seeking an ISPO/WHO category status that attests to the quality and level of their training.

"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, whose focus is in the area of manufacturing and assembly," according to ISPO.

"It must be emphasized 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 [are desirable] for those involved in patient care [and the support of manufacturing and assembly] in the developed and the developing world respectively."

(Editor's note: Detailed information on the educational and other requirements needed to meet the ISPO standards for each category can be found on the ISPO website: Some graduates of Category II P&O schools in developing nations can upgrade to Category I under programs created in cooperation with Category I universities and schools.

International P&O: A Dynamic Picture

The international P&O scene is growing, dynamic, and steadily raising the bar for patient care-and ISPO is helping to make that happen.

In his Interim Report August 2006, ISPO President Harold G. Shangali noted a rise in the number of requests the ISPO Executive Board is receiving for "advice and/or evaluation of training and education programs at different levels in the industrial and developing countries&which have applied for ISPO/WHO Category-II or Category-I accreditation." Countries represented include Argentina, Togo, Sri Lanka, Ghana, Tanzania, Pakistan, El Salvador, France, Cambodia, Germany, Ethiopia, Thailand, and India. "Many of these programs are either part way through the process or have been advised to review the structure of their respective curricula in order to meet the basic requirements," the report says.

ISPO Accreditation Categories

Category I Prosthetist/Orthotist (or equivalent term).

Entry requirement: University entry level (or equivalent, 12-13 years schooling).
Training: Three to four years (formal, structured) leading to university degree (or equivalent).

Category II Orthopaedic Technologist (or equivalent term).

Entry requirement: "O" level (or equivalent-the usual requirement for paramedical education in developing countries, normally 11 years schooling).
Training: Three years (formal, structured)-lower than degree level.

Category III Prosthetic/Orthotic Technician (or equivalent term).

Entry requirement: Elementary school diploma.
Training: On the job.

The schools/programs that have recently been evaluated and accorded recognition are Tumaini University, Tanzania, Category I, and the Hong Kong Polytechnic University, Category I.

"In addition, there has been consultation on distance learning courses in prosthetics and orthotics which have become increasingly popular; e.g., University Don Bosco (UDB), University of Hong Kong, TATCOT, Norwegian Centre of Telemedicine (NST) amongst others," Shangali says in the report.

With the support of the Leahy War Victims Fund (LWVF) of the U.S. Agency for International Development (USAID), ISPO has awarded 83 out of 103 scholarships to students in various programs, according to the ISPO report. For Category I, 17 scholarships have been awarded to candidates enrolled in the University of Strathclyde, Glasgow, Scotland; two to UDB, Soyapango, El Salvador; and 14 to Tumaini University. Category II scholarships include 51 awarded to candidates enrolled in UDB, TATCOT, the Pakistan Institute of Prosthetic and Orthotic Sciences (PIPOS), the Vietnamese Training Centre for Orthopaedic Technologists (VIETCOT), and the Cambodian School of Prosthetics and Orthotics (CSPO). Fifteen single-discipline scholarships have been awarded for TATCOT and VIETCOT programs. The scholarships will all continue up to the 2010/2011 academic year.

Disability in Developing Nations

According to the CSPO website ( ), an estimated 80 percent of the world's disabled people live in low-income countries. Most are poor and find accessing health and rehabilitation services difficult, which can lead to their exclusion from society. "In many low-income countries, there is a severe lack of expertise in the area of prosthetics and orthotics," the website points out. "Yet these skills are vital for physically disabled people, whether man or woman, adult or child, civilian or military. Frequently they are amongst the poorest of the poor.

"With appropriate rehabilitation services the majority of disabled people can become contributors to society, and allocating resources to their rehabilitation is an investment.'?"

Editor's note: There is an inspiring story behind each international P&O program; however, due to space constraints, we are only able to cover a limited number. For more information about global P&O education, visit


Students at the Cambodian School of Prosthetics and Orthotics (CSPO) in their final year at work in the CSPO clinic. Photo by Carson Harte.
Students at the Cambodian School of Prosthetics and Orthotics (CSPO) in their final year at work in the CSPO clinic. Photo by Carson Harte.

CSPO was established in 1994 by the Cambodia Trust in Phnom Penh and is the only prosthetics and orthotics school in the world to hold ISO 9001:2000 certification. It is managed by the United Kingdom (UK)-based charity Cambodia Trust in collaboration with its main donor partners: the Nippon Foundation, based in Japan; LWVF, United States; and the UK Department for International Development.

"CSPO is located in Cambodia, which is one of the poorest countries in the world, but since we started the school in 1994, we have established educational resources to share with and help other low-income countries that also need these special professionals," notes the website.

The school has indeed become a regional focal point for O&P education, with students from 13 nations: Afghanistan, Democratic People's Republic of Korea (DPRK), East Timor, Georgia, Indonesia, Iraq, Japan, Kiribati, Malaysia, Nepal, Papua New Guinea (PNG), and the Philippines, as well as Cambodia. International graduates usually return to their home countries and use their expertise to develop national prosthetics and orthotics services.

CSPO students learn academic subjects, technical skills, and clinical expertise in a multicultural learning environment. With a mix of nationalities in both the student body and faculty, students learn how to work with people from different cultures.

CSPO, a Category II school, has developed and continues to develop in-house training manuals, all of which are based upon ISPO/WHO Guidelines.

Students enroll in a three-year, full-time diploma program. During the first two years, students undertake practical and academic training. Subjects covered include prosthetics, orthotics, anatomy, pathology, physiology, and psychology, and are taught in English as a common base, due to the variety of students' native languages. In the final year, students work under a lecturer's supervision in the clinic attached to the school.

Altogether, the students complete about 5,000 hours of instruction over the course of three years, including 1,000 hours of clinical practice in Cambodia Trust's teaching clinic.

The success and impact of CSPO's O&P training program has garnered international media recognition. For instance, BBC reporter Guy de Launey says, "It is graduation day at Cambodia's School of Prosthetics and Orthotics [September 12, 2006]. Over the past three years the students have been learning how to make artificial limbs. They are badly needed in Cambodia, where there are tens of thousands of landmine survivors.

"But the school's fame has spread around the world, giving the classes an international flavor. The CSPO is a rare international success story for Cambodia. The class of 2006 will bring the overall number of graduates to more than 100 in the past decade."

CSPO Broadens Reach

First-year students work on a transtibial socket. Photo by Carson Harte.
First-year students work on a transtibial socket. Photo by Carson Harte.

In 2005 the school embarked on an ambitious path where its most talented graduates entered a new training course held in conjunction with La Trobe University, based in Melbourne, Australia.

Successful graduates of the new bachelor's degree program, funded through the Nippon Foundation and NZAID (New Zealand), will form the nucleus of the future lecturers and leaders of CSPO and Cambodia's rehabilitation services. Due to graduate this summer with the Category I upgrade are nine students from four countries: Cambodia, Laos, Pakistan, and Sri Lanka, says Carson Harte, Cambodia Trust's executive director.

In addition, the Cambodia Trust and CSPO may soon be starting another educational program. A proposal for the development of a P&O education program in Indonesia has been submitted, says Harte. Under this proposal, Indonesia, with financial support from the Nippon Foundation and technical support from Cambodia Trust, would begin a multi-stage program. The first stage would be educating a cadre of teachers at the ISPO/WHO Category I level, who would then be qualified to teach O&P practitioners and technicians. The eventual goal would be to establish several P&O schools within key polytechnics of health across the nation. Currently, Indonesia has comprehensive health services, except in the area of prosthetics and orthotics.

According to ISPO/WHO figures, Indonesia needs 1,275 clinical orthotists/prosthetists, backed up by technicians for fabrication. These clinicians would work as part of the rehabilitation team along with doctors, physical therapists, and social service workers.

Sri Lanka

The Sri Lanka School of Prosthetics and Orthotics (SLSPO), established in 2004 in collaboration with the Sri Lankan Ministry of Health, the Nippon Foundation, and Cambodia Trust, is bringing rays of rehabilitation hope to a country with a troubled history of civil conflict.

There are about 160,000 disabled people in Sri Lanka who need prostheses and orthoses, including many landmine survivors and other victims of conflict. It is estimated that Sri Lanka needs a minimum of 115 prosthetists/orthotists to meet the need. However, there are currently only 12 Sri Lankans in the entire country who trained overseas to international standards-ten of whom were trained at CSPO, according to the SLSPO website ( ). More than 90 percent of people who require prosthetic or orthotic care have limited access to appropriate services.

The SLSPO course includes two years of practical and academic training plus one year of supervised clinical placement. The course is a three-year, full-time diploma program and includes about 4,600 hours of study. During the first two years, students undertake practical and academic training in prosthetics, orthotics, anatomy, pathology, physiology, and psychology. Like the CSPO program, all classes are taught in English, again due to the variety of ethnic groups and languages.

Based upon the philosophy of the Nippon Foundation, which is funding the project, of promoting bridges of friendship that go beyond the barriers of politics and religion, SLSPO includes students from all over the island.

At the request of the Ministry of Health, the second recruitment (Intake 2006) was opened to those already working in the field. Thirteen students were accepted from both government and NGO sectors.

Both Cambodia and Sri Lanka have seen the establishment of professional organizations: the Cambodian Association of Prosthetists and Orthotists and the Sri Lankan Association of Prosthetics and Orthotics.

Training professionals within developing nations is a cornerstone of the Cambodia Trust mission. The organization points out, "The training of local capacity reduces reliance on expatriate expertise and helps to ensure the sustainability of rehabilitation services for disabled people."

Miki Fairley is contributing editor for The O&P EDGE and a freelance writer based in southwest Colorado. She can be contacted via e-mail at