Technology in Rehabilitation (Part 1) : The developers view

Working in rehabilitation can be extremely rewarding. Especially when we see clients with a catastrophic injury getting their lives back on track with the help of products and services we provide. But we learned long ago that technology or products alone are not a ‘magic potion’ - they are often important but need to be considered as just part of the solution. This is especially true when these medical devices are used in therapy to produce functional recovery as opposed to assistive technology.

In a series of articles we are going to explore issues around how therapy and technology can work together effectively. In this first article, we will look at rehabilitation from the point of view of the developers of technology. In subsequent articles we will consider the perspectives of clinicians and of patients. By taking these various perspectives we hope to provide an improved understanding of how to achieve better outcomes for everyone by highlighting where the real barriers to progress are.

What rehabilitation technology is for

We are thinking of rehabilitation technology as “the systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of, and address the barriers confronted by, individuals with disabilities…”

In this scenario, products are ‘tools’ used by clinicians that need to be set up and optimised for individual patients. Physical rehabilitation is still widely perceived as dominated by a face-to-face interaction between a therapist and patient but thanks to technology developments, this picture has been changing.

The Icone upper limb robot relies on haptic feedback and gamified software

Virtual reality and augmented reality, wearable devices, robotics, mHealth apps and other communication and information technologies have promised a great deal in the battle to overcome physical disability. The aim is to enhance the prospects for functional recovery as well as allow rehabilitation to take place outside of the clinic. As an example, emerging robotics technology such as the Icone Upper Limb Robot now allow advanced upper limb rehabilitation to be carried out in a home or small clinic whereas a few years ago these were installations only suitable for major hospitals and the larger clinical setting.

Mind the gap

Excellent technology, great therapy (and therapists) combined with appropriate knowledge can achieve great things for health care. Unfortunately this is not yet the reality for everyone. It is not hard to see a massive need for effective products and services so if we are new to the field we might wonder what the problem is. Surely where there is a high demand there should be an opportunity to meet this for technology developers?

There is often a gap between the potential for functional recovery and what actually is achievable in clinical practice. There are many reasons for this gap. Of course, lack of resource, limited accessibility to technology and lack of know-how are major barriers to recovery but other barriers to progress can be more subtle. The NHS can provide excellent acute care but will often struggle to provide comprehensive rehabilitation services that are both necessary and sufficient to enable recovery. There is a growing amount of private therapy provision but a majority of people that need therapy may not be able to afford this.

So before you start to develop something…

In the beginning

Once upon a time I had my PhD, lots of enthusiasm and was working in a small team in a rehabilitation centre in Canada. We had lots of ideas for products and services but were frustrated at how difficult it was to bring these ideas to life for the benefit of patients. We tried licensing our ideas and explored ‘spin-off’ companies but primarily we learned lots about how businesses could fail. We understood the needs of clinicians and patients but did not speak or understand the language, or the imperatives, of business. Looking back, we were undercapitalised, blinded by our good ideas and did not understand that, expensive as it was, product development was the least costly stage in getting our ideas to fruition.

Just this morning I came across an article, dated 2012, that was looking to identify technological advances that would improve mobility for spinal cord injured persons in ten years time. The article was nicely written but didn’t really live up to its title as it avoided making any concrete predictions. What it did emphasise was that technology held great promise to ameliorate disability but there were significant barriers to apply and deploy it. What struck me was that the barriers to progress seemed to be very much the same as those I met back in the 1970’s.

The perils of developing high-tech rehabilitation products

Imagine you are going to develop a new high-tech product for the rehabilitation market. Lets start out by visualising a very simple model of what you are trying to do. We could think of this as looking to transform a situation in the present in order to achieve a future goal.

We need to do this by adding resources (money, people, know-how etc) into the present that allow the future goal to be reached. It’s a transformation process that looks easy but carries lots of unknowns. We quickly discover that life has this way of putting barriers in the way whenever we have a goal.
You could say that this is nature’s way of preventing us from making big mistakes; some of us are too dumb to listen though, and press on.

The positives and negatives

Working on high-tech product development has many advantages. It is intellectually stimulating and the work can even be glamorous and attract media attention. When aiming to do something that benefits humanity we can feel uplifted and strongly motivated to succeed. However, the reality is that there are probably faster and more certain ways to get rich. The reason for this is that all technology businesses are subject to particular traps - and these can be especially demanding for rehabilitation technology.

Defining the present situation that we want to disrupt seems easy but this requires careful attention. You need to understand the advantages and disadvantages of current practice and who are the stakeholders of the present ways of working? What is the level of clinician knowledge and their attitudes and beliefs for example?

Perhaps the most obvious pitfall for developers is to pick a future goal that no one really needs or is too technically challenging. You would think it obvious that developers should interact with patients and clinicians before committing to a course of action. Co-creation models of product development can help spot some problems at an early stage but in themselves do not eliminate commercial risk.

Let’s examine some of the key barriers.

The paradigm barrier

At any point in time there is a prevailing view of things that is accepted as the ’truth’ or way of doing things - a paradigm. This is true in the world of science and research and it is true in business. For example - The world was flat - until it wasn’t.

In 2003, the media told the world that the mapping of the human genome was complete - except that it wasn’t (there were huge gaps in the sequence - gaps that it turns out are extremely important).

We once believed that we simply lost brain cells as we got older and couldn’t replace them - until we found out that wasn’t the case. Now we know that neuroplasticity is important but I’m quite certain we don’t really have a clear picture of how to exploit this yet to overcome disability.

A new paradigm is born when the prevailing one cannot explain a certain phenomenon and a new one is offered that can explain it better. This can sometimes be due to the efforts of a single person but typically is more likely a process of lengthy evolution (or revolution).

New ways of doing things are often strongly resisted by those who have a vested interest in the status quo. This doesn’t mean that those resisting change are bad people - we are all influenced by our personal experience much more than the experience of others. One person in a position of influence can prevent wide adoption of your product simply because of their lack of belief in the principal technology of your intervention.

As a business, Anatomical Concepts works with international partners and we often see great differences in how products are accepted in different markets. I used to think that because clinical problems are the same everywhere, a product that worked well in one country would also do well in the UK. It’s not so simple. For example, we work with biofeedback and neurofeedback and brain training software that is strongly accepted in Europe, North America and Asia but not keenly adopted in the UK; in part because the principles are not taught as part of clinician training here.

As a developer contemplating your new, emerging rehabilitation technology you should understand where your offering will fit in the current market. You are going to be meeting resistance from existing ways of doing things whether you know it or not.

The Indego exoskeleton can serve as both a therapy and an assistive device

Technology adoption barrier

It’s common to think that new technologies are appearing faster these days but actually most technologies are the product of a long and protracted development cycle sometimes lasting decades. In rehabilitation today, we see products such as the Indego exoskeleton that are founded on ideas explored by the military back in the 1970’s and 1980’s. Pioneers that bring such technology into rehabilitation now wonder whether they will ever make a profit. It is tough to be a pioneer. You might notice that stealing technology is accepted business practice - it is easy to steal because it is primarily based on intellectual property that is extremely difficult to protect. Many a great idea failed initially because the timing wasn't right

In 2022, there were approximately 118 exoskeleton developers and of course, very few of these will survive. Most of these have realised that they will not be able to thrive by offering products to the rehabilitation market and have focused on industrial applications that may be more lucrative.

Economics barrier

Products always succeed for economic reasons rather than technical ones. Many years ago a rule of thumb was that technology needed to offer a 10 to 1 cost advantage to end users for it to overturn the existing structure of an industry. In the 1980’s I was interested in machine vision and machine learning and it was common to hear talk from engineers who believed that just about every boring job could be carried out by autonomous robots. Hundreds of companies pursued this dream but few survived because the technology was difficult to build and operate, expensive to purchase and difficult to maintain. Sometimes inferior technology can win if the service and distribution approach results in an offer that is better value for the customer.

If you look closely you can see technology trends that appear like the latest fashions only to disappear for a decade before they finally take root. Right now we see AI applications being boosted as the latest and greatest solution to our problems.

Government and regulatory barriers

The government directly or indirectly controls technology. This is because sometimes it purchases it, sometimes it funds it and sometimes because it regulates it. This causes both opportunities and threats to business.

In the UK we have the NHS which logic would dictate should be a key adopter for rehabilitation technology. However, the developer of technology will typically find selling to the NHS challenging.

Typically for rehabilitation technology, there is not one central purchasing route to the NHS; hospitals will often have their individual processes that vary. In the USA, qualifying veterans can have an exoskeleton such as the Indego provided by the government. In the UK, the only persons who can afford such technology are those with insurance or other support following a catastrophic injury.

Carrying out R&D and developing new technologies and products has often been looked upon favourably by governments. In my lifetime I have seen government incentives to attract inward investment so that firms from overseas setup such R&D facilities and bring well-paid jobs. Once these incentives expire though it is no surprise that firms typical move to some other country. Many UK manufacturing sectors have declined in recent decades as firms found it more cost-effective to off-shore these tasks to lower wage economies. The recent Covid pandemic has shown that this can produce vulnerabilities - for example, semiconductor chip shortages and global supply chain disruptions. We may see greater opportunities now to carry out R&D and manufacture locally as governments respond to the changing world order and the climate agenda.

In addition, purchasers of what we create demand both evidence of effectiveness and a keen price. Medical device regulations can be significant barriers to would be developers. In the 1980’s I thought we were moving toward more harmonised international standards so that the regulatory framework would be much the same in the USA as in Europe or Asia. This is great for developers as it smooths the opportunity to offer products internationally. Unfortunately, this harmonisation is not looking likely.

The newly revised European medical device regulations have become much more complex and we could argue are now a deterrent to innovation in a field such as rehabilitation. It is quite right that safety comes first but a testing regime should be appropriate to the level of risk. The balance for testing and evidence of efficacy has shifted toward making this a very difficult journey for smaller companies. For those of us in the UK, deviation from the European regulatory regime because of Brexit is creating additional costs and uncertainties.

Conclusion

It’s clear that there is a massive need to deliver rehabilitation in the UK. People are living longer but are not necessarily healthier. People dealing with a neurological condition have expectations that the NHS will provide essential services for free at the point of delivery but these expectations will not easily be met. We need improved models of care that use technology and enable people to help themselves to some degree, but would-be developers should beware of becoming a solution looking for a problem. We can’t do market research on something that is genuinely new or not on the market yet. We only have a chance if we can answer some deceptively simple questions.

1) Does healthcare know that it needs your technology?- by need I mean absolutely must have. When times are tough as they are right now your product must ideally fit in to the structures and processes that already exist.

2) Who are the competitors? If there are no competitors it may be there is no market.

3) Does using your technology require your customer to change? People resist change as a rule unless it is their idea. Healthcare professionals are as resistant to change as anyone else.

4) Does your technology offer a performance or cost advantage? Only slightly better performance might not be good enough. If your product cost is much higher than the competition there must be a compelling reason for this.