Abstract
In 1994, the ISPO consensus conference on lower limb orthotics management of cerebral palsy concluded that the main goal of orthoses for CP is to prevent and/or correct deformities, improve dynamic efficiency of gait, and support and facilitate training in skills (ISPO, 1995). This conference raised a number of discussions whereupon in 1995 the International Society for Prosthetics and Orthotics (ISPO), in collaboration with the Leahy War Victims' Fund of the United States Agency for International Development (LWVF-USAID) and the World Health Organization (WHO), made the first attempt at drawing experts from different government and non-government international and national organizations to describe and discuss the different prosthetics technologies practiced in developing countries (ISPO, 1996).
These discussions led to further challenges but, most notably, a consensus was reached on the definition of “Appropriate technology: a system providing proper fit and alignment based on sound biomechanical principles which suits the needs of the individual and can be sustained by the country at the most economical and affordable price”. This definition was endorsed at the next ISPO/LWVF-USAID/WHO in 2000 and further recommendations related to service provision, project protocol development, update of technology, as well as appropriate orthotics technology were made (ISPO, 2001).
The implementation of appropriate technology following the recommendations of these two conferences has made a significant improvement to the quality of life of people with disabilities in developing countries. There has been an increasing use of thermoplastics and different designs of components in the provision of conventional, contemporary, or hybrid lower limb prostheses and orthoses. As in industrial countries, there has been an explosion in technological advances in developing countries. This has encouraged and motivated professionals to embark on initiatives applying new materials, components, and designs to improve the technology and at the same time meet the required treatment objectives. However, consideration of appropriate technology in orthotics has not received the same attention as in prosthetics and there is therefore a great need to discuss and reach a consensus on the assessment/evaluation, prescription, design, and principles of fabrication of lower limb orthoses for the entire spectrum of impairments of lower limb functions. ISPO, LWVF-USAID, and WHO in collaboration with key representatives from other organizations and institutions have scheduled the next consensus conference to be held in Hanoi, Vietnam in March 2006 to review and make recommendations on the technology and the practice of lower limb orthotics in developing countries.
Another area that the Society has begun to be involved with is the provision of wheelchairs in developing countries. It goes without saying that some organizations, e.g. Motivation-UK, Whirlwind-USA, CIR-USA, Handicap International (HI), and ALIMCO-India, amongst others, have exemplary achievements in ensuring that quality of life is attained through the provision of appropriately-designed wheelchairs suitable for individual pathologies and needs, which also open the doors for equal opportunities of employment for people with physical disabilities. However, there is still much controversy regarding the wheelchair technology related to the prescription criteria, service provision, standards, distribution, financing, user's issues, and training of personnel in developing countries.
Although the profession related to wheelchair technology in developing countries started taking a positive path only a few years ago, it has already started to tackle the enormous challenges found and created an awareness amongst professionals in the field of rehabilitation medicine, government and non-government institutions, policy makers, and people with disabilities themselves. In particular, the specific areas of concern to all are the gaps too often found in the provision of overall rehabilitation for people in need of wheelchairs. The presentations made on the need for establishing appropriate wheelchair training, production, and distribution of wheelchair services during the ISPO World Congress in Hong Kong (Beattie et al. 2004) have provoked a consciousness of the deficiency of such services required for people with physical disabilities in developing countries. Appropriate wheelchair technology for developing countries was either given very low priority or taken for granted in that any design of wheelchairs was seen to be appropriate for anyone in need regardless of the cause or severity of disability.
Over the years, most wheelchair users from developing countries did not have the choice of been provided with individually-designed wheelchairs to fit their requirements. Instead, they were provided with donated and standardized wheelchairs. Although this is a worthwhile service for medical, health, and general public requirements to enable the transfer of the individual with disabilities from one point to another, it should surely never be concluded that this is a life-long solution for the individual's proper rehabilitation. It is important to remember that it is the wearer of the shoe who knows where it is tight and not the shoe provider or supplier.
The continuing growth in the understanding of both appropriate technology and education in this field of rehabilitation medicine has, to a certain extent, resulted in the raising of consumer awareness in terms of their role in determining their treatment courses. There have been parallel conferences of different groups of people with disabilities in Helsinki, Finland (WHO, 2003), Johannesburg, South Africa (WHO, 2003), and Geneva, Switzerland (WHO, 2005), amongst others, addressing the equalization of opportunities and their role in determining what is best for their own quality of life. This is also a vivid challenge to us to revisit the approach of the entire practice of wheelchair provision, thereby opening ourselves to an inclusion principle to optimize the services rendered to people with physical disabilities.
Once again, ISPO in consultation with LWVF-USAID, WHO, and other organizations/institutions has appreciated the need to gather expert views of experiences of the different technological approaches as well as the experiences and opinions of the users. A consensus conference has been scheduled to be held in November 2006 with the probable venue being Bangalore, India. It is hoped that such a conference will help make recommendations on guidelines for service provision, acceptable quality and standards, distribution, financing, and finally establishment of such facilities in developing countries.
The outcome of these consensus conferences, containing detailed reports including presentations of consultants, syndicate, plenary discussions, and finally the consensus recommendations, will be published and made available to ISPO collaborating organizations, institutions, and all those involved in lower limb orthotics and wheelchair service provision and training in developing countries.