International Education: Closing the Gap

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By Betta Ferrendelli

As online and distance learning programs become more widespread, technology is also being leveraged to create more accessible and sustainable O&P education programs in developing and war-torn countries.

Though there continues to be a lack of contemporary prosthetic and orthotic services and trained professionals in many areas of the developing world, the International Society for Prosthetics and Orthotics (ISPO) and the World Health Organization (WHO) have spent the last dozen or more years trying to change that.

WHO reports that the combined populations of Africa, Asia, and Latin America totaled about 6 billion people as of 2010. It is estimated that roughly 30 million people in these countries need O&P devices—and the number of individuals who have been trained to provide services to those patients is about 180,000.

"P&O education globally has been on a steady upward slope for the last ten years, secondary to efforts by ISPO and support from USAID," says Robert Kistenberg, MPH, CP, LP, FAAOP, co-director of the master of science in prosthetics and orthotics (MSPO) program at the Georgia Institute of Technology (Georgia Tech), Atlanta. "That being said...there's still a very long way to go." Kistenberg is also president of the U.S. National Member Society of ISPO (US ISPO).

To help ensure that recipients of O&P care receive consistent, quality care around the world, "ISPO has...detailed appropriate education and training programmes for the full professional prosthetist/orthotist (Category I), orthopaedic technologist (Category II), and orthopaedic technician/bench worker (Category III)," according to the publication, "Guidelines for Training Personnel in Developing Countries for Prosthetics and Orthotics Services" (WHO, 2005). Currently, there are about 24 schools that provide varying levels of education and training in developing countries to personnel to fit, fabricate, and assess the biomechanical function of orthopedic appliances, according to WHO. Though these schools graduate about 400 individuals annually, WHO estimates that more than 75 percent of developing countries do not have P&O training programs, which results in a lack of coverage of O&P services to those in need.

According to Heinz Trebbin, MSc, CPO(d), an international consultant who has been instrumental over the last few decades in advancing global P&O education, there is a "huge" difference in the recognition of O&P education programs worldwide—from no formal education or recognition of the profession to advanced university-based programs. "Especially in developing countries, there is a huge need for education, and probably only about ten percent of these needs are met," says Trebbin, who now lives in Germany. "In most developing countries, the profession is not recognized formally, and this can be changed only through formal education. On the other hand, you see in some countries some very good programs but not enough scientific and theoretical content, and in other countries you see the opposite."

The best of both worlds, according to Trebbin, would be a mix of both, which would give "better treatment to our patients," he says.

Human Study e.V. is an O&P educational program designed to address the lack of contemporary physical medicine and rehabilitation services and trained professional practitioners in Southeast Europe. Photographs by Christian Schlierf.

While some might assume that developing and war-torn countries would be reluctant or unable to adopt technology in their education programs, the Internet is increasingly being used—and the advantages are plenty. According to Bryan Malas, MHPE, CO, director of the orthotics and prosthetics department at Children's Memorial Hospital, Chicago, Illinois, online learning programs are cost effective, can be done in real time, and are accessible to areas without formal educational programs. Additionally, the Internet creates opportunities for continued professional development, he says. "This is especially important for those practitioners who find themselves in more remote and isolated regions of the world," says Malas, who is the current education committee chairperson for ISPO. He was honored in March with the Outstanding Educator Award at the Annual Meeting & Scientific Symposium of the American Academy of Orthotists and Prosthetists (the Academy), held in Atlanta, Georgia.

"Over the last ten years, there has been substantial growth with the use of different educational models and concepts," Malas says. "Some of these concepts have been in existence in other medical training arenas and have found their way into O&P education."

Over the last decade, delivery methods have become more creative and offer more robust learning environments, he continues.

The Internet has changed the world of many practitioners in developing countries, which before had little or no access to information, Trebbin says. "You see now in many countries excellent clinics with high standards, and distance learning is growing and has been proven to be very useful and often the only possibility of education," he says.

According to Kistenberg, the ISPO-recognized school making the broadest use of distance education is Don Bosco University (UDB), San Salvador, El Salvador, Central America. It allows for a didactic content to be provided without being face to face, Kistenberg says. There's still a hands-on component required that is managed in the student's home country, and examinations are done face to face either by bringing the students to the campus or the faculty to the students, he says.

"[UDB] has been able to develop an educational model that has trained students from a large number of countries by distance," Kistenberg says. "The fact that examiners can't differentiate between the students who took the distance education courses and the students who attended the program in person is a testimony to the model and its effectiveness."

Balkan Program Incorporates Blended Learning

Working in coordination with UDB, the Human Study e.V. Prosthetics and Orthotics Blended Learning Upgrading Program (HS) in Southeast Europe is one ISPO-Category II education program that is making effective use of Internet technology. Funded through donations, HS is a humanitarian, nonprofit NGO located in Nuremberg, Germany. Its mission is to provide contemporary educational opportunities in areas of physical rehabilitation to indigenous health professionals in developing countries as well as those countries ravaged by wars and natural disasters, according to its founder, vice president, and program director, Christian Schlierf, CPO, Cat.I (Meister German).

Balkan students participate in a practical workshop seminar in Belgrade, Serbia, where they learn lowerlimb casting and fabrication techniques as well as production of lower-limb orthotic devices.

Schlierf says the HS concept was born through experiences he had while working with other humanitarian organizations in Kosovo and Bosnia from 2001 to 2006.

In the years he supported P&O projects in Kosovo and Bosnia, Schlierf says he "learned a lot about the way non-governmental organizations operated, and I had to deal with the advantages and disadvantages of these operations." Schlierf is a co-founder of the national member society of ISPO in Bosnia and an evaluator and inspector for ISPO of O&P schools worldwide.

One of the biggest obstacles he experienced when dealing with NGOs was the decision-making process, which he describes as being remote, abstract, and poorly executed. So much so, that Schlierf says it helped to drive his intention to organize a structure that could operate on a less bureaucratic level. "Those years were great training for me," Schlierf recalls. "I always had the desire to do something more effective and more sustainable."

In 2005, Schlierf invited his closest friends to join him in helping to fund a humanitarian organization that would provide a legal foundation upon which to operate in the future—a necessary first step in building the framework for an ISPO-recognized O&P school. The humanitarian organization was established one year later, after which Schlierf took the next step, and, with his mentors Sepp Heim in Germany and Dan Blocka, BSc(Hons), CO(c), FCBC, in Canada—both former ISPO presidents—determined how a sustainable education program could be formed and established in the Balkan region.

"Chris has developed a flexible learning model that meets the [ISPO] standards," Blocka says. "He's quite driven and passionate, and he has worked hard to make this happen."

Blocka and Heim connected Schlierf with UDB, where a Category II program had been developed in the late 1990s. By consulting with UDB, Schlierf was able to address some of the foundational problems and issues associated with providing P&O education and services. "With this guidance, we formed a partnership between UDB, ISPO, and HS and prepared the first [class] of Balkan students to start in February 2008," he says.

Many previous O&P NGO programs had not been successful in war-torn countries because their mission was not aimed at longer-term, sustainable, accredited educational training of clinicians, and the usual stockpile of donated supplies and components were typically exhausted by the time the NGOs moved on to the next crisis in another country, Schlierf says.

Schlierf visited all the P&O facilities in the Balkan region he could identify in 2006 and 2007 to introduce them to the HS idea and to attract them and their technicians to join the program. Since 2007, HS has been delivering an ISPO Category II education program for orthopedic technicians in cooperation with UDB. This five-semester education program is designed for technicians who are already on the job but have never received a complete, formal, and certified education in O&P science, Schlierf says. The HS program enables the technicians to study from home or their work location without changing their life circumstances as is necessary when following studies in a centralized location, Schlierf says.

The 30-month, 4,800-hour course covers all areas of prosthetic and orthotic sciences. The education program is delivered as a blended learning program, using a combination of different educational tools and media, including an Internet-based virtual classroom in addition to extensive practical workshop lectures and demonstrations. Practical and theoretical examinations conclude each semester. The education program culminates with a final examination. Successful evaluations can lead to a professional ISPO accreditation with a Category II designation and a diploma from UDB.

All of the students in the inaugural HS class successfully passed the theoretical and prosthetic practical exams, and all but one student passed the orthotic practical exam. Students graduated in December 2010. (The student who did not pass the orthotic portion successfully passed and earned his diploma in June 2011.)

Based on the success of the first class, HS initiated a second class of the P&O training program in the Balkan region in July 2010 with graduation set for early 2013, Schlierf says.

"[HS] has done some great things in supporting O&P education in Central America and Southeast Europe," Malas says. Trebbin adds, "The start of the second course shows the interest of professionals." Blocka agrees. "The blended learning model has merit," he says. "It will only get better within the next five to ten years."

Distance Learning: Here to Stay?

There is no question that technology related to the delivery of education programs will continue to advance, Malas says. Kistenberg agrees. "I only see the application expanding," he says.

ISPO will continue to play the role it always has, Malas notes. The ISPO Education Committee has an e-learning subcommittee that is looking at this and other delivery methods for short courses and continued professional development, he says, adding that ISPO's Education Committee is in the early stages of putting together a global educators meeting, with the goal of achieving greater collaboration among programs.

"An electronic platform can assist with real-time collaboration and sharing of knowledge," he says—"something we hope to put into place that programs across the globe can use."

Betta Ferrendelli can be reached at

Category II Programs Dot the World Landscape

During the mid 2000s, Category II O&P education programs started to increase substantially worldwide, according to Bryan Malas, MHPE, CO, director of the orthotics and prosthetics department at Children's Memorial Hospital, Chicago, Illinois. "Many programs across the globe have partnered with non-governmental organizations (NGOs) in varying capacities," he says.

In addition to the UBD program in Latin America and HS in the Balkans, there are a host of other ISPO-recognized Category II programs making their mark around the world. To name a few: The Cambodian School of Prosthetics and Orthotics (CSPO), Phnom Penh, established in 1994 by the United Kingdom-based Cambodia Trust; Mobility India (MI), Bangalore; and the Sri Lanka School of Prosthetics and Orthotics (SLSPO), Ragama, established in 2004 by the Cambodia Trust in partnership with the Sri Lankan Government and the Nippon Foundation of Japan. The International Committee of the Red Cross Special Fund for the Disabled (ICRC/SFD) also provides raw materials and equipment, physiotherapy training sessions, and scholarships for students to attend three-to-four-year P&O Category I and Category II certification training programs.

According to the Cambodia Trust website, "In many low-income countries there is a severe shortage of local staff with the skills and experience to provide the rehabilitation services needed by persons with disabilities. This can be as a result of poor healthcare systems which have been destroyed during times of conflict, lack of training opportunities, or disabled people's issues being low on development agendas." It goes on to state, "Building local capacity is an essential step toward building sustainable rehabilitation [and O&P] services for persons with disabilities and reducing reliance on expatriate expertise."