Walking is an issue of mind over matter – how robots assist rehabilitation

Humans are living longer than ever but still want to continue to live independently as they age. Meanwhile, our motor and cognitive abilities decline as we age, sometimes as the effects of a stroke. The number of people in need of long-term care is growing at breakneck speed. At the same time, fewer and fewer young people choose stressful careers as caregivers. Robots could help bridge the resulting elder-care gap.

It is estimated that the number of people requiring care will increase more than 30 percent by the year 2030. Many need help due to a disability. Stroke is a leading cause of disability in adulthood and affects 17 million people worldwide each year. Those who survive a stroke often suffer severe motor impairment, requiring comprehensive rehabilitation to regain movement in paralyzed arms or legs. An inpatient rehabilitation program typically takes three weeks and only garners short-term improvements. At the same time, intensive long-term rehabilitation therapy isn’t always an option due to the high cost and lack of treatment staff. Rehabilitation robotics could help bridge the gap.

Robots are used for tasks that are repetitive and require strength. They are able to perform these tasks faster than humans with the same level of accuracy and they don’t get tired. One application of robots is neurological rehabilitation because the loss of motor skills such as walking or grasping must be recovered through massed practice and repetition of exercises. As is the case with all other motor skills, walking is a question of mind over matter. Repetition is key in this case, allowing the brain to "reprogram" the motion sequence. This is a time-consuming process and requires the strength of both patient and therapist. "We cannot achieve this through hands-on or manual therapy," explains Michael Klein, Therapy Management and Planning Services at Helios Klinik Hattingen. Yet a robot is able to do this over an extended period of time. Research has studied robot-assisted stroke rehabilitation for the past 20 years. According to experts, robots can help compensate for the resource shortage in this area in the intermediate term.

Robotics can also be a great way to help patients with severe motor impairments. Inability or difficulty to walk, poor posture, uncoordinated upper limb movement or impaired cognitive functions can exacerbate conventional therapy and even make many exercises difficult or impossible. Robot-assisted systems can overcome these types of obstacles by supporting and supervising the desired movements. Robots give power and strength where none exists.

There are essentially two types of robot-assisted therapy in neurological rehabilitation. The first one uses exoskeleton-based technology, where an exoskeleton is adapted to the patient's body and moves the arms and legs. The second type involves end effector-based technology that moves the extremities using foot plates (pedals) or grips. This is a direct motor skill approach since the patient must control the system on his or her own. In other words, he or she is required to perform the respective movements. Both technologies are used for shoulder and upper limb exercises or to improve gait and partly utilize virtual reality settings. For example, the patient sees a cup of tea on the monitor and is asked to reach for it. This playfully exercises the corresponding arm and hand movements and gives the patient instant gratification. What's more, disguising physical therapy exercises as fun-to-play video games is more motivating. The Armeo robotic arm byHocoma helps patients to initiate up to one thousand repetitive movements per hour. AMADEO by tyromotion is a similar robotic and computer-assisted rehabilitation system used for hand and finger therapy.

Apart from robot-assisted therapy, service robots are another alternative for inpatient and hospital settings. While they are not directly involved in the therapy process, they perform tasks such as transporting or moving patients or helping them to go to the bathroom. In doing so, they eliminate time-consuming and often physically strenuous routine manual tasks for human employees.

Having said that, a service robot will never fully replace a human caregiver and a robot-assisted device will never be a substitute for a physical therapist - and they are actually not meant to be. The idea is not to eliminate, but to complement and assist healthcare staff. The robots are merely used for time-consuming, tedious and strenuous tasks. Less physical work for medical staff frees up their time to enhance decision-making in the clinical workflow, to provide counseling and to motivate patients. Robots are unable to match what human beings can achieve. Most robotic systems specialize in performing one task and humans use them for purposes that benefit them. "Robots are a powerful tool for physical therapists. The robot doesn't replace a staff member, but the staff member utilizes the robot to speed up the patient's rehabilitation process and recovery," Klein describes the role and function of the robot. It allows patients to be treated at a higher training intensity, while the cost stays the same. This also has a positive impact on therapeutic success. Studies have shown that robot-assisted devices tend to help patients improve and recover walking skills following a stroke faster than the exclusive use of conventional measures.

It is essential that therapists monitor the exercises and ensure that they are done correctly. A robot is not (yet) able to do this on its own. Michael Klein also believes that robots are unable to fully replace human beings. "We will always need human beings – and in our case therapists – with the respective knowledge and skills to use the robots." This skill and knowledge will continue to be the foundation for successful and effective therapy, but it must also include technical proficiency. That's why it is crucial to make robots and other digital technologies an integral part of education and training. Digitization will increasingly lead to major changes in the physical therapy profession – shifting away from physical work and moving towards guidance, motivation, and coaching of patients.