Towards a rehabilitation continuum

Neurorehabilitation includes multiple therapies to improve mobility and strength, motor skills, cognitive functions of memory, attention, and processing and execution of functions, communication, and more. Important therapies are physiotherapy, occupational therapy, psychological therapy, and speech and language therapy.

600 Million people worldwide require neurorehabilitation, only 1/3 receive it in some form. After a traumatic incidence or accident causing brain or severe spinal cord injury a multi-disciplinary team of rehabilitation specialists provides rehabilitation in the acute phase and continues in sub-acute stages (first 6 months after injury). However this only applies to areas in developed countries where specialized rehabilitation hospitals and reference centers exist.

In rural areas and in many of the less developed countries there is no rehabilitation offer after intensive and primary care. After 2 years, in chronic condition, a continuation of further rehabilitation and functional training is not offered as a standard, though neurorehabilitation is currently only implemented as a time-limited intervention and not as a continuum of therapy and care.

Additional pressure to provision of neurorehabilitation is generated by the demographic challenge with its increasing numbers of survivors left untrained in chronic condition and left out from benefits of new interventions and technologies.

On the other hand a growing number of new advanced rehabilitation technologies such as robots or neuroprosthesis for sensory-motor rehabilitation are being developed and successfully implemented. They are considered as tools to overcome demographic challenge in rehabilitation. This overview here concentrates on advanced rehabilitation technologies for physiotherapy and occupational therapy mainly.

Current state

Current Advanced Rehabilitation Technologies (ART), e.g. rehabilitation robotic systems provide single functions like locomotion, planar or spatial 3D arm movements, arm weight compensation, or finger actuation. Combined with visual feedback, e.g. a smiley that informs the patient about his engagement level or visual instructions regarding the movement task these systems provide the following benefits over manual therapy:

1. The number of repetitions of the rehabilitation task, a key factor that has been shown to improve the functional outcome, can be increased.
2. The physical strain on the therapist and therefore a better control on quality from the therapist side can be improved.
3. The 1 to 1 therapy of manual rehabilitation can be increased to the treatment of multiple patients by one therapist at a time and therefore increase throughput and availability of therapy.
4. Motivation and engagement of the patient as well as personalization and increasing the patient’s responsibility towards a less-dependent actor can be promoted.

But still, current ART act singular, goal limited, and are not capable of delivering a synergic therapy taking into account multiple actors and therapies. Tools for functional movement assessment largely rely on therapist supervision and a hospital setting. The field is, though, clearly moving in direction of increasing the system autonomy and there are efforts from the industry to implement a holistic approach.

The need and limitations

Every neurological patient requires a specific set of exercises, personalized to his/her current state (intensity, difficulty, assistance level, etc.). The design of such exercises is dependent on the expertise of physicians and the therapists specialized in neurorehabilitation. Its implementation in the ART and requires additional, specific technical training of the operators. The combination of multiple therapies (physical, cognitive, behavioral, expression/speech) with ART lacks any level of integration and cooperation. Many therapies have not yet been complemented with ART or difficult to implement into technology. So, there is an undisputable need to co-act using competences and knowledge of the specialists, making them available to more users in a manner that automated and non-automated human knowledge can cooperate to the benefit of the user.

In order to promote deployment of ART outside of specialized hospitals in outpatient facilities or even at home and have them managed and adopted by different end users, the usability of ART must be achieved at a higher coordination level. ART need to be designed in such a way that they provide support to both the expert and lay users.

Market development

From the economic side ART looks very attractive. In the last years the market of ART is growing with considerable 2-digit growth rates. Conservative market reports estimate a Compound Annual Growth Rate (CAGR) of 20 %. The most optimistic estimate has been published by the Wintergreen Research report and foresees a growth in rehabilitation robotics, active prostheses and exoskeletons from $ 43.3 million (2014) to $ 1.8 billion (2020) US $ (CAGR 86 %).

The continuous growth of the rehabilitation robotics market indicates clinical and commercial impact of ART. As an example, the worldwide market leader Hocoma AG (CH) could increase clinical use of rehabilitation robotics as a result of strong activities in education and market presence. They founded in 2011 together with TECNALIA and 14 other ART companies the International Industry Society in Advanced Rehabilitation Technology (IISART) with the goal to promote, educate, standardize, and establish health economic date of the field.

In 2010 the global world market leader Hocoma AG (CH) successfully implemented around 350 rehabilitation clinics with robotic technologies, until the end of 2015 they could increase this number significantly to more than 1150 clinics worldwide. A particularly noticeable aspect is the increase of rehabilitation technologies within a hospitals: in 2010, around 1.3 Hocoma devices have been used on average, whereas in 2015 the amount is increased up to around 1.9 Hocoma devices per hospital unit. Tyromotion GmbH (AT), the other number 2 on the market could achieve similar figures.

Towards a rehabilitation continuum

In summary, Advanced Rehabilitation Technologies are supportive tools for therapists and other rehabilitation specialists that help them to provide rehabilitation training and assessment tasks in a more consistent manner. As multi-disciplinary field neurorehabilitation provides a multitude of therapeutic interventions, most of them have shown evidence that increased frequency and duration of the therapy improves the functional outcome.

The current ART are singular or manufacturer dependent platforms with very low inter-operability and high and complex user requirements. A further increase of the market penetration towards outpatient facilities and home use (telerehabilitation) requires ART with more intelligence, guidance, decision support, outcome prediction, and standardized interfaces.

The level of autonomy, multi-actor compliance, and user-friendliness needs to be increased. The level of perceived complexity needs to be decreased to a level that allows at least partial self-management in a rehabilitation continuum similar approach to what the fitness sector suggests.