New Frontiers for Emerging Technologies: Robots as a Tool to Support Therapy during the Pandemic
The COVID-19 pandemic has irrevocably altered the delivery of healthcare services and caused a shift in patient’s expectations. New areas in Social Assistive Robotics (SAR) have garnered increased attention from investors and care providers alike as a potential tool to support clinical care areas, by promoting physical distancing and reducing contagion rates. Social robotic platforms have been used for gait neurorehabilitation in the past, though the pandemic has dramatically increased the scope and replication opportunities the technology presents. In the context of upper and lower limb rehabilitation the robot’s primary purpose is to monitor the physiological progress of the patient while allowing for social interaction with a remotely-stationed care provider during the sessions. Multiple clinical validation sessions were conducted in rehabilitation centers across the globe. Results showed that the use of SAR positively impacts the patients’ physiological progress by correcting stance and posture while dispensing advice and encouragement and promoting the patient’s feeling of positive reinforcement. Patients have found the SAR platform both helpful and secure. Care providers also acknowledged the important role the robot plays within neurorehabilitation therapy, and further praised SAR as a vital tool promoting physical distancing without sacrificing vital patient support throughout the pandemic. Industry forecasters suggest increased usage and wider applications of this technology both during and in the aftermath of the pandemic.
Healthcare services were forced to establish strategies promoting physical distancing while continuously providing adequate support to their patients. As physical distancing and isolation procedures were adopted, new studies corroborated positive outcomes where these measures were adopted, including a decrease transmission rates, reduction in peak incidence, and a marked drop in intrahospital interactions. Widespread concerns emerged around possible alternatives to classical rehabilitation practice that would enable the provision of neurorehabilitation services during the COVID-19 pandemic, as patients with disabilities and chronic / progressive conditions require constant monitoring and care. Social Assistive Robotics (SAR) saw increased attention in terms of funding and research as a newfound momentum pushed the exploration of new technologies to support the general population’s health during the pandemic.
The current global pandemic validates SAR applications, as they play a critical role in supporting the rehabilitation’s continuity. SAR and Assistive Robotics (AR), beyond providing physical assistance to patients, also offer users cognitive support and social interaction. These categories of robots need to perform tasks with a high degree autonomy in order to achieve sufficient levels of interaction. SAR and AR based applications are developed and enhanced in multiple clinics and educational facilities. Positive effects on patient’s motivation and higher adherence to medical treatments have been shown to increase with AR enabled reliability, support and interaction. In the context of COVID-19, medical research has been focused on two main applications of SAR; patient monitoring and connecting care providers to patients using teleoperations. SAR offered a method that sustains social distancing protocols while serving as a remote health monitoring tool in high-risk areas, aiding both patients and healthcare staff. SAR has been further applied in hospital environments to enhance patient’s mental state and well-being.
A social robotic platform for neurorehabilitation using Lokomat was developed during the COVID-19 pandemic. Lokomat is a device that combines bodyweight support systems with a robotic orthosis in order to assist the gait of a patient by using repetitive specific tasks. This platform allows the measurement of different parameters: the patients’ strength, mechanical arduousness and range of motion. These parameters provide feedback to the physiotherapist so that changes to the therapy can be made in accordance with the goals and progress of each individual patient. Yet, some parameters deemed essential to the rehabilitation process including heart rate, posture, and patient’s fatigue level may not be reliably measured and recorded by the Lokomat, and clinicians usually monitor these parameters directly using external equipment, visual cues and verbal communication with the patient. Monitoring the patient’s heart rate permits the observation of a patient’s physical progress in terms of cardiovascular functionality, while correcting the spinal posture ensures the correct application of a given therapy while decreasing muscle fatigue. In this respect SAR constitutes a valuable complementary tool, automatizing these parameters, providing feedback and a means to interact with patients during therapy in times when physical distancing has become the new norm.
Different studies show the capabilities of SAR in post-stroke patients to support rehabilitation procedures following the cognitive approach protocols. Social care robotic platforms aiding post-stroke patients through contactless assistance have been designed roughly ten years ago to assist remote care provision. Pilot studies before the pandemic were designed to test the technology – mobile robots supported various therapies via key measurements, but they also provided encouragement and reminders. The researchers found that welfare robots were well-received by stroke survivors and positively impacted their willingness to undergo rehabilitation. Currently, a SAR device designed for upper limb rehabilitation therapy has been used in some European clinics.
These ‘social robots’ have enhanced interface features, and assist care providers by employing physiological parameters for monitoring and feedback. Some researchers have engaged a humanoid robot to assist cerebral palsy patients during motor training activities. This particular robot was designed to support young children. While indications that patients enjoy and value their interactions with the robot abound, the technology was slow to expand to other areas of rehabilitation before the advent of the global pandemic. In a post-covid world, rehabilitation scenarios in which SAR devices are essential have become quasi-ubiquitous. Beyond ensuring the continuous treatment of physically distanced patients, these devices increase patient motivation and willingness to complete the procedures. Similarly, in pediatric rehabilitation, researchers have highlighted the beneficial effects of using robots to actively engage young patients while increasing their commitment to perform the exercises. In 2020 a humanoid robot was created to guide patients (via imitation) through complex postures and exercises. Depending on the patients’ performance, the robot would either congratulate or correct the users.
The SAR and AR technological improvements since 2020 will pave the way to further progress in alternative rehabilitation approaches and even spill-over into new med-tech areas where they would be instrumental in promoting patient health.
The COVID-19 pandemic has drastically changed most aspects of health care delivery. To protect health care workers and patients from disease transmission, policies were altered to enable widespread use of telecommunications technology in lieu of in-person clinical visits. Rehabilitation delivery was dramatically altered as physical therapists turn to telehealth modalities to help them continue current patient treatment and potentially access remote populations. The shift to telerehabilitation further provides a unique learning opportunity for researchers and clinical experts as it fuels innovations optimizing health care delivery.
Telehealth is an umbrella term that encompasses a wide array of modalities, including both clinical and nonclinical services. Telerehabilitation is traditionally more explicitly related to clinical rehabilitation services with an emphasis on evaluation, diagnosis and treatment.
Telerehabilitation may be provided in a variety of ways, including:
The US Department of Veterans Affairs was an early adopter of telerehabilitation for the provision of remote services including physical therapy. These DVA services were rapidly accelerating even prior to the pandemic. Covid 19 created a need for safer public health delivery and established new guidelines and precautions. The uptake of telerehabilitation in health systems across the globe was hampered by restrictions, regulations and reimbursement policies. Recent changes currently permit the use of telerehabilitation for physical therapy on a much wider scale. These unprecedented circumstances provide unique research opportunities to study the implementation and outcomes of telerehabilitation.
Several medical reviews conclude that telerehabilitation is effective for patients with multiple sclerosis, musculoskeletal conditions and osteoarthritis. It is also suitable for various stages of motor function recovery. New studies suggest that telerehabilitation may further reduce health care costs, improve treatment adherence, expand physical function and thus quality of life. Most telerehabilitation studies evaluate the outcomes of synchronous, real-time time rehabilitation, although there is some evidence that asynchronous telemedicine can also be effective for specific patient populations, such as those following total joint replacement.
As the technology becomes more widely available, additional studies will emerge to address pressing questions about the feasibility, safety, and effectiveness of telerehabilitation modalities across subgroups of patient populations and environmental settings. Harnessing the power of data and analytics to learn what works best and eventually feed that knowledge back to patients, clinicians, other professionals, and stakeholders will create a continuous cycle of quality improvement. The data systematically integrates evidence established via iterative learning inherent to these modalities helping stakeholders in establishing its appropriate use for physical therapy delivery.
The effect of using telerehabilitation for treatment is likely to vary according to the patient’s condition and its severity. With sufficient planning to consider equipoise in care delivery, available capacity for research in practice during or after the pandemic, and appropriate methodological expertise, more rigorous study designs including pragmatic trials and hybrid implementation-effectiveness studies should be considered. Ultimately, if telerehabilitation interventions can yield outcomes equivalent to those of traditional care and are equally or more cost-effective, there would be strong evidence in support of sustaining telerehabilitation as a care delivery option after the pandemic subsides. It would be interesting to observe the effects of telerehabilitation service in improving health care infrastructure and efficiency of delivery, particularly for certain patient groups. Stakeholder involvement and innovative study strategies would be instrumental in designing and conducting research. Real world experiences should be used to integrate studies - as part of clinical practices - which would in turn accelerate the evaluation, approval and integration of the technology. It would also help researchers and practitioners in identifying best practices for telerehabilitation that are more likely to be adopted and scaled up both during and after the pandemic subsides. The new normal for rehabilitation services is likely to include telerehabilitation with variations according to differences in policies and particular health systems.
After a cerebral-vascular accident, the patient has a much better chance of recovering limb function if his or her medical treatment is supplemented with a rehabilitation therapy that uses robotic devices. The intervention needs to take place very early on, in the first couple of weeks to make a difference. Adding virtual reality technology further increases the patient’s chances of recovery. Robotic rehabilitation therapy is without question a very effective new tool in clinical practice. Still, being a relatively new field, research teams all over the world are finding new ways to improve the technology.
Studies focus on advancements and future avenues in upper limb rehabilitation, where the results are most promising. There are two approaches in tackling the limitations of current robotic systems for the upper limb:
More bang for your buck
Technical limitations and a hefty price tag make hardware improvements difficult. Even if we could successfully engineer the perfect upper limb rehabilitation robot, would it be worth it? Perhaps sometime in the near future it might, but the material cost and outsized upfront investment is a deterrent, not to mention the added mechanical limitations that will need to be overcome and the space necessary to house a robot that has 27 motors to move 27 degrees of freedom (to better recreate human movement). Making the “perfect robot” is costly and limited in usability.
Moreover, the structure of the existing systems is more than adequate, especially if we consider the ratio of development effort to clinical advantage; even minor mechanical improvements will require prodigious development efforts, time and money.
Lower-hanging fruit and better use-value
While the existing hardware systems are believed to be adequate (if not sufficient), can we cay the same about the current software? It turns out that therapeutic applications of upper limb rehabilitation systems require more work. Fortunately, the desired advances are relatively easy to implement, and they have the potential to have a significant impact. Perfecting the therapeutic software’s usability and functionality holds great potential. It will lead to better systems for monitoring and standardizing successful protocols. This would in turn integrate and streamline expert knowledge that would likewise become available to a larger patient pool. Improving the existing software systems will also increase the patient’s motivation to train, boosting the odds of recovery.
A common cross-system software platform will further facilitate collaborative work on future therapeutic advances. As healthcare systems are under pressure to reduce costs, robots will become an ever more essential part of modern rehabilitation therapies.
Robot-assisted therapy is a promising innovative rehabilitation technology for patients with motor disorders. As with any other therapy, motivation is key. To be successful, a therapy regimen needs an active contribution, earnest effort and steadfast commitment by the patient. Creating a supporting environment for the patient to produce the right kind of movement goes hand in hand with any rehabilitation practice. Advancements in technology have ushered a new era adding virtual reality, augmented reality and customizable games to rehabilitation therapy. VR, AR and custom-created games can be used separately or combined to help maintain the interest of the patient and provide critical motivation to perform motion exercises.
The benefits of integrating games, VR/ AR and other breakthrough technologies
Traditional rehabilitation therapy is physically and emotionally draining. If patients are exhausted and fail to be stimulated by the therapy their motivation will decrease, leading to a less than optimal result. Trials suggest that robot-assisted therapies have been more successful in retaining patients’ interest and motivation. They are especially effective when combined with VR, AR and customized games. Integrating these technologies into robot-assisted rehabilitation increases engagement and motivation while immersing the patient into rhythmic task-oriented exercises. This ‘gamification’ of the rehabilitation experience can deliver intensive, repetitive movements while sustaining the patients’ interest and lessening the burden on the therapist. Robot-aided therapy also uses wearable devices (from wrist monitors and electrodes to exoskeletons) that can relay real-time feedback. This feedback can be used to refine the therapy while tracking patient’s progress. Rehabilitation robots are ‘smart’ devices built to encourage interaction. They use sensor-based systems to assess movement and positioning, and are able to detect any change in force and motion, no matter how small. Active-assistive robotic technologies are great for storing data, measuring any number of parameters, which is critical for treatment planning and evaluation.
Breakthrough technologies are emerging globally, and rehabilitation therapists and clinical researchers are eager to integrate them in their practices. Electromyographic biofeedback (EMG-BFB) uses electrodes that are placed on the patient's muscles and these electrodes respond to any muscle activation by generating a feedback signal. Functional electrical stimulation (FES) uses low-energy electrical pulses that artificially produce body movements in individuals affected by paralysis caused by an injury to the central nervous system. Major advancements in VR technology, notably the arrival of the 6th and 7th generation gaming systems (including the Nintendo Wii and the Xbox 360 Kinect) allowed for more realism to be added to VR.
While VR provides a complete immersion experience shutting out the physical world, AR simulation therapies include real world physical objects in the virtual world adding digital elements to a live view and typically allowing for more control in a patient’s interaction with the virtual objects (through the interaction with the real world physical objects).
Combined with robotic devices, these new technologies will enhance the rehabilitation treatment’s effectiveness while producing massive amounts of data for clinical evaluations that will pave the way for future improvements.
Harnessing VR technology
Studies have shown that the vast majority of patients prefer games-assisted therapies since they find them more engrossing and easier to follow. Making the treatment more game-like turns an intensely repetitive task into an engaging challenge, inspiring patients to participate in therapeutic exercises. VR has produced immense benefits, particularly in poststroke rehabilitation. VR allows therapists to create tailor-made training programs that correspond to the patient’s interests. By offering the right incentives retention is increased and the patient is more dedicated to the rehabilitation process. The patients are encouraged to actively interact with the hardware and simulation software, in some cases virtual rehabilitation may even take place in a patient’s home. Telerehabilitation is another interesting new technology offering real-time rehabilitation services over the internet. Patients can have access to professional medical advice from their homes using a VR device.
Coupling the gaming elements with robotic devices will enhance rehabilitation treatments and occupational therapy in two important ways:
If you wish to read more, here are some fascinating articles that can be accessed online:
Not science fiction
While rehabilitation robots have been around since the 80’s they still haven’t found widespread use in our hospitals, unlike the service robots that are quite common in our homes and factories. Rehabilitation with robots is nonetheless an established method recommended in many national guidelines. Robot-mediated therapy is showing promising results, quickly gaining traction and sparking interest among clinicians and researchers. This innovative rehabilitation practice makes it easier to create intensively repetitive, individually adaptive, and easily measurable physical training sessions. Essentially using key elements of motor skill training, the robots can be programmed to repeat actions with a specific target so that the patient can relearn a range of movements.
In the context of stroke
The number of stroke patients rises every year across high‐income countries and developing economies. While the medical ramifications of an aging population are considered obvious, it is important to note that the number of people at risk has been growing sharply for all age groups and ethnicities. These days there is a much higher probability of stroke for young adults. Factors like stress and health conditions that increase stroke risk are on the rise.
According to the WHO, stroke is the second leading cause of death and the third leading cause of disability in the world. Rehabilitation therapies for stroke patients require prolonged sessions in inpatient units. Successful rehabilitation depends on having access to a rehabilitation center and being able to commit to intense occupational and physical therapy 5 to 6 days per week. Working therapists are overwhelmed by the increasing numbers of patients. Training specialized medical personnel to deal with the challenge will be costly and will take time.
Economic factors and clinical outcomes
Using robot devices for rehabilitation will help with the shortage of therapists today and prevent bigger obstacles tomorrow. Research on the development of upper limb rehabilitation robots is particularly promising. Important aspects of rehabilitation training can be replicated adapting the robots for high-intensity functional exercises. The devices are created to support a wide array of movements, from flexing elbows vertically to extending and flexing shoulders elbows horizontally. Most models deliver forces to the subject’s limb while working movements of the arm that involve several joints. Robot devices for rehabilitation will support therapists for inpatient and outpatient care. Some are portable and can even be rented and used from the patient’s home with minimal guidance.
Looking into the economic benefits of this kind of rehabilitation is important, research on clinical outcomes even more so. A study performed in Germany, revealed that robotic group therapy would cost less than half per session than the standard individual arm therapy, and would have largely the same results. Purchasing robotic devices is limited by their high cost, but if they are used in new forms of clinical practice where therapists can assist a larger number of patients at the same time, the benefits will outweigh the costs. It would allow a greater number of patients access to high-quality treatment while lowering health care costs.
Rehabilitation robotics – therapies that work
Robot-mediated therapies used for the recovery of the upper limb have been commercially available for some time. Since the early 90’s robotic devices have been available to clinics and hospitals, the most familiar models were the MIT-Manus (the American InMotion Arm Robot) and the Swiss-made Armeo Power. The more we see evidence that robotic rehabilitation consistently improves patient outcomes, the more widespread their adoption will be. Robot-therapy for stroke survivors is associated with consistent improvements in arm function, upper limb motor function and strength.
Robotic devices can replicate regimens designed by therapists and administer them as many times and for as long as they are needed. They can provide interactive training that is adjusted over time. From high-intensity sessions to task-specific and goal-oriented training, rehabilitation robots offer versatile and adaptive regimens.
This intensive motor training with robotic devices for patients recovering from stroke will become increasingly available in rehabilitation centers. As more patients have access to treatment that improves their quality of life at a lower aggregate cost, savings in healthcare will free up resources for other critical areas. In the meantime, more research and clinical studies are needed to further corroborate the positive results of robotic devices used in rehabilitation.
If you wish to read more on these innovative therapies, here are some links to interesting studies:
Despite the staggering pace of development in the field of rehabilitation robotics, therapists are in no danger of being replaced by the machines. For now, human beings are needed to direct the robotic devices in what has been appropriately named robot-assistive therapy. Until machine intelligence systems that can reliably and accurately make decisions are developed, we will need human beings with the particular expertise and competence to use the equipment. In all current robot rehabilitation facilities, the robotic device does not replace therapists, rather, the therapist creates the rehabilitation regimen using the robot to speed up the patient’s recovery.
It is, of course, impossible to predict how fast artificial intelligence will evolve within the next couple of decades. Perhaps in 15 years machine intelligence would have progressed sufficiently, and creative thought processes and decision-making skills will no longer be the exclusive domain of human beings. For the time being, the usage of robotics in rehabilitation, and more generally in most branches within the medical field, is assistive to the therapist. That does not mean that the devices are not essential in refining and facilitating the work of medical staff. They can provide deeper insights, more precise and objective data that illuminate the very principles of rehabilitation, and what actually makes a patient’s recovery successful. A greater understanding of the underlying mechanisms of the therapy will in turn reveal more information on key neurological and biomechanical factors essential in radically improving the odds for recovery.
Human and machine intelligence unite
While still at a relatively embryonic stage in its development, artificial intelligence (AI) is steadily entering the workspace in medical facilities, both clinical and research-oriented. AI devices are broadly defined as intelligent systems that are acquiring the ability to learn and even think. Though, largely unfounded, the fear that smart machines will make humans obsolete in the work space (once they become more involved in the decision-making process) is still growing. It is more likely that AI devices will be complementary, augmenting the capabilities of humans, rather than replacing them altogether. Smart devices will continue to enhance our ability to address complex problems.
From an analytical standpoint, smart systems clearly have greater computational power and information-processing capacity. Think of all the applications and algorithms that extend human cognition, sorting through complexity and masses of information, using a large number of parameters to draw and extrapolate conclusions. Predictive analytics, for instance, uses complex programs and calculations to integrate data, produce analyses and evaluate optionality, considerably shortening the amount of time human researchers would have to spend crunching the numbers. Humans are however better at intuitive analyses and responses, along with some other holistic though-processes that help in dealing with problems that are plagued with uncertainty and equivocality. Most psychologists would agree that much of human cognition is not a linear outcome of careful information processing. In fact, much of our decision-making process is informed by the subconscious, driven by more by intuition than methodical rational thought or logical inference. How many times have you heard of someone’s superior intuition, when a person relied on their gut feeling or business instinct? From a psychological viewpoint, intuitive decision-making is the realm of creativity, sensitivity and imagination, the place where past experiences and judgments are unconsciously recalled.
The consensus among researchers claims that the partnership between smart machines and humans is and will continue to be synergistic, combining intuitive decision-making with analytic intelligence. A recent study of cancer detection in the images of lymph node cells demonstrates the potential benefits of combining inputs of smart systems and experts. In the study, when only smart devices were employed, there was an error rate of 7.5%. Pathologists had a significantly lower rate of error (at 3.5%). Interestingly, when the pathologists used to the AI systems to refine their decision-making process there was an 85% reduction in the error rate (down to a mere 0.5%).
In addition to beneficial synergies that can lead to better healthcare results, it is important to consider the bigger picture – health economics and the issue of funding. Introducing more robots to rehabilitation clinics is not only beneficial, it is becoming a necessity. Stroke rates are snowballing globally. In 2010, 33 million people were living as stroke survivors. If current trends continue, by 2030 there will be 70 million, and 4 out of 5 survivors will leave the hospitals with limited function and long-term disability. The burden of stroke from an economic standpoint is among the highest of all neurological conditions. In the first year following a stroke, the mean total direct health care cost per stroke survivor in Germany is about U.S.$ 21,500 (divided between inpatient/outpatient rehabilitation - 37%, and medical care plus services - 54%); on average lifetime costs are 3.6 times higher than rehabilitation costs within the first year. Indirect costs (like loss of productivity) slightly surpass the direct costs. In addition to the growing number of stroke survivors worldwide, there is a shortage of physiotherapists. In some countries, like Germany and France, there are considerably more job vacancies than candidates as students flock to jobs that are less physically demanding and offer higher paychecks. The robotic devices will help address this imbalance between the inadequate supply of therapists and rising patient demand.
The fear of therapists dreading the thought of being replaced by a machine in the not so distant future is unjustified. A combination of smart technologies and therapists’ input will help the healthcare sector cope with future challenges.
Neurorehabilitation: Recent Developments
The face of robot-assisted neurorehabilitation has progressively transformed over the last few years. While traditional neurorehabilitation procedures treating the most common neurological conditions such as stroke, spinal cord injury, Parkinson's disease, spasticity, severe brain injury and cognitive disorders may have limited effectiveness, new technologies have reportedly significantly improved the effectiveness of rehabilitation strategies for theses ailments. Robot-assisted training may be supplemented with new and emerging technologies to further increase the improvement of function for patients including the application of virtual and augmented reality and non-invasive brain stimulation (NIBS) or a form of functional electrostimulation. When paired with robot-assisted technologies these tools enhance both the intensity and quality of neurorehabilitation by manipulating brain excitability and plasticity. Other new technologies can further help recover the wellbeing and increase the quality of life of patients during and after rehabilitation therapy including various forms of assistive technology and domotics.
Novel applications of advanced technologies for neurorehabilitation have a beneficial effect on reliable measurements plasticity. The functional MRI, high-density EEG and near infrared spectroscopy are rapidly confirming outcome measures. The creation of translational and back-translational models ensures the formation of a solid neurobiological evaluating current approaches to disorders. New approaches during the acute phase of neurological ailments, most crucially research on the most appropriate timing of the intervention, play an important role in further optimizing neurorehabilitation.
Neurological rehabilitation programs dealing with diseases, injury, or disorders of the nervous system can be performed on an inpatient or outpatient basis, and at times a combination of both. In addition to the neurologist (or neurosurgeon), orthopedist (orthopedic surgeon), physical or occupational therapist and other rehabilitation specialists, a number of skilled professionals can be included in the neurological rehabilitation team; psychologists/psychiatrists, physiatrist and internists, other specialty doctors, registered dietitians, speech and language therapists, audiologists, social workers and case managers, as well as recreational therapists among others.
Complementary activities that may be used in combination with robotic neurorehabilitation therapies include:
Neuro Rehabilitation Disorders:
While evidence-based medicine was, to a degree, somewhat difficult to apply in the field of neurorehabilitation, there is a renewed interest in data-driven systematic reviews and meta-analyses, and a recent increase in participation and interest in consensus conferences. Furthermore, new randomized controlled trials exploring and evaluating combined drug and physiotherapy treatments are emerging, lending more visibility in the field of neurorehabilitation in general, while improving function and reducing symptoms for the individual patient.
Assistive devices in low-income countries
One of the major hurdles that impede widespread access to the robotic rehabilitation technology is its cost. Despite the appearance of some cheaper models in 2017-2018, the recent Coronavirus Covid-19 Pandemic will cause production delays and potential closures that might result in supply shocks, favoring the survival of companies with a larger moat. It is perhaps too early to speculate on the exact price-effect of the pandemic, but most experts agree that a price increase tendency seems probable. The most widely used robots in rehabilitation clinics within the US are highly priced (to the tune of $70,000 for the lower range and up to 360,000 USD on the higher end). Adding the hidden costs like taxes, shipping and maintenance, as well as installation and training expenses, the real price is even higher.
While investments in hardware are somewhat easier secure in developed economies, in low and middle-income countries there are additional considerations that prohibit this kind of long-term investment. More generally, low-income countries face limitations in delivering assistive technology due to cost, availability, and infrastructure problems. More than 80% of all stroke deaths occur in these lower-income economies. Stroke survivors (approximately 3/4rths of the afflicted) suffer long-term impairment, severe disability, and reduced participation or handicap. Moreover, within lower-income countries, assistive devices are accessible only through expensive private services, inaccessible to the majority of patients. According to the WHO a mere 5% of the population in need within low-income countries have access to essential rehabilitation services. Looking beyond the statistics, the long-term burden of stroke has severe consequences for individuals, families and societies.
With the relentless aging of the population and increased risk factors for cardiovascular disease on a global scale, the economic burden of stroke is expected to increase despite advances in preventive care. In order to account for this rise in the population at risk, efforts to address and reduce disability must be undertaken. The health sector in developing economies suffers through budget constraints and insufficient resources to implement a wide usage of clinic-based rehabilitation robots, even thought the long-term societal cost (including human cost) outweighs the initial investment. The use of robotic devices has the potential to reduce hospital stays, lessen the burden on therapists and doctors while increasing the effectiveness and efficiency of treatments. Assistance programs and development subsidies are insufficient to address the rising need of financing, but there are other more sustainable ways to facilitate the adoption of assistive technologies. Policies and measures that facilitate the production of these devices (exception to patent rights, charitable donations, debt alleviation strategies among others).
Creating sustainable strategies for the production of assistive devices is in itself problematic. Policies to recommended for implementation on a national level include the training of local professionals for quality production. Educational facilities that encourage specific training while enlisting the help of national associations and professional groups will further encourage the creation of a nascent community centered on rehabilitation. Training a professional workforce would not only facilitate local production; it would enable the provision of the technology within the country for the population in need at a much lower cost, but also to other developing nations that might not have the means to import the technology. The locally trained staff would increase access to services that would ensure a chance for a higher quality of life, a chance to participate in community life and be a productive member within that community for the victims of stroke and other disabling maladies. In order to make assistive technology more affordable and accessible, community-based rehabilitation programs could be designed.
The development of appropriate and sustainable technologies that can respond to the needs of patients may be produced and offered for an affordable price. Governments should encourage local production of components and the usage of locally sourced materials, further adding to sustainable economic development within the nation or region. To improve access for other developing nations the development of these technologies should be documented and made available where needed.
While poverty is the most significant constraint influencing rehabilitation outcomes in low-income countries, higher health costs, insurance limitations, insufficient staffing and time to provide more services are limiting the administration of quality care in middle-income countries as well. Even in developed nations, like the USA, rehabilitation outcomes are rendered inferior as a disproportionately large number of the population is without access to rehabilitation technologies and has no recourse to services and skilled clinicians. While assistive technologies are not a panacea for all the issues that plague low-income societies, the integration of lower-cost robotic technologies would improve accessibility and opportunity, alleviating poverty and facilitating the functional independence of stroke survivors by improving access to rehabilitation services for poverty-stricken communities worldwide.
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Every year, nearly five million people across the world are afflicted by a stroke (according to the World Heart Federation – WHF). The WHF further expects a significant increase in stroke mortality rates over the next 20 years. These rates might triple in Sub-Saharan Africa, Latin America and the Middle East. Neofect – a Seoul-based health-care technology company, recently released its latest smart rehabilitation solution for stroke patients that need assistance relearning hand motion. The company creates diagnostic and therapy devices for upper extremity rehabilitation. Their devices are used both in rehabilitation facilities and in homecare settings specifically for hand, arm and shoulder therapy. Their approach is to create portable functional devices that are based on biofeedback processes, in which even the slightest movement of the patient’s arm or hand can be visualized on monitors and optimized through movement tasks. In addition to their guided software solutions for further rehabilitation in the patient’s home, Neofect also produces professional software solutions for clinics and rehab facilities that may be used in individual and group therapy sessions.
Neofect's product, the Rapael Smart Glove, is a lightweight wearable rehabilitation glove designed to assist with the recovery of hand and arm movement for stroke patients. Therapies to regain movement focus on repetitive iterations and coordination of hand and arm movements in the company’s proprietary virtual reality-type setting. The glove is equipped with built-in sensors ensuring precise measurements of the rehabilitation exercise movements. The smart glove has sensors that capture (in terms of inertial measurement units) every motion of hand and wrist movements. In addition, bending sensors can detect pliable movement alterations in any direction. All sensors are connected to a system that tracks and calculates individual finger movement. An application is available to further improve usability.
Neofect’s strategy is to add gamification elements in order to increase motivation and ensure long-lasting patient engagement for otherwise monotonous exercise regimens. The gamification elements are designed to maintain patient interest, providing lasting motivation for the entire duration of the rehabilitation therapy. The glove is created to encourage neural plasticity via individualized/customized exercises supplemented with gamification elements.
Within the gamification mode, key design elements are focused on ensuring user-retention and compelling interest. The games are updated each month and are created specifically for a targeted rehabilitation session emphasizing a particular set of movements. For example, an exercise that simulated the squeezing of an orange is created to target finger flexion and extension, while a wine-pouring exercise helps retrain forearm pronation and supination.
Another key element that would support and further advances in the neurorehabilitation field focuses on tracking and data analysis. The system records all form of therapy and practices used for and by the patient while uploading all the relevant data so that both the patient and their physical therapist can monitor all forms of progress. Updates and training tasks are based on the patient's activity level and the system can create new exercises and tasks based on patient’s data and advancement.
The Rapael glove is a prime example of the ingenuity that will fuel progress in the field of robot assistive rehabilitation devices. Beyond being an innovative product, it is one of the most affordable products available on the market. Patients can rent the device for less than a 100 US dollars per month, while hospitals can purchase the glove for 15,000 USD (Tyromotion’s Armadeo costs $100,000). The lower price tag would increase access to quality care and help therapists achieve better clinical outcomes for their patients.
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Neurorehabilitation Robotics Ltd. is a private company focused on delivering effective and measurable primary care to patients suffering from different forms of neural damage by supplementing traditional therapy with robotics-assisted protocols.
Neurorehabilitation Robotics Ltd