Technology in Rehabilitation (Part 2): The therapists view

In the last article, I examined technology in rehabilitation from the perspective of the developer. I pointed to some of the barriers to development and the difficulties of commercialising these types of products. In this article, we consider technology in rehabilitation from the therapist point of view.

In the UK we have therapists working in the NHS and in the private sector and I acknowledge there will be differences in wants and needs. For this reason we will stick to what we see as general principles and what we believe are fundamental drivers.

What do therapists want and need?

In recent years, the international therapy community has begun to realise the potential of digital and advanced health technologies to benefit both patients and clinicians. As a business, we are keen to see this potential realised as we develop products and distribute them. As I am not a therapist, it is definitely the case that I might be hallucinating some of this content. In my defence, I can say that we do work routinely with many therapists in the NHS and the private sector so we have some insight into their views, their frustrations and their requirements .

I believe that the primary driver for every therapist I ever met is to assist their patients in optimising their rehabilitation. There will of course be variation in attitudes and beliefs about how this is best achieved. As in any field, some therapists might be attracted by the “shiny new thing” and some will resist change. In discussing new and unfamiliar technology with therapists we find their questions understandably focus on three areas - Is this safe (absolutely fundamental), is it effective (with evidence that supports this contention) and what’s the cost? (Ideally as low as possible).

For all clinicians, digital technologies may improve measurement of patient status and help with goal setting which can be particularly challenging in rehabilitation. In addition, there may be an opportunity to create workflow efficiencies, provide greater control over how self-management information and resources are delivered, and expand options for how and where care is delivered. As we learned during the Covid pandemic, it is possible to use technology to support people in their home environment without compromising quality of care.

I should also say that the best technology brings not just hope of some recovery but actually lives up to it’s promise.

So here is a question for you - Will physical therapists be needed in the future?

I remember joining a University department in the early 1980’s and one day a word processor machine was wheeled in. The bosses secretary had been trained to use it. The general secretaries were somewhat nervous about this because they were used to typing everything for the staff and this technology seemed to promise efficiencies that they could not match. Maybe their services would not be needed? As we all know, in a few short years we were all typing (with varying degrees of proficiency) as every desk typically had a personal computer. The secretaries role changed but they were needed just as before. The actual volume of typing going on expanded dramatically.

I believe that therapists will be needed in any and every rehabilitation scenario that counts. The role of the therapist will change but I expect they will always have a role.

Word processor technology created new opportunities for many of us. We do need a similar revolution in rehabilitation. There are so many people with a need and very little chance of receiving support for rehabilitation.

It’s not going to be possible for people to “help themselves” unless they have guidance and access to expertise. Technology should be able to deliver greater efficiencies and just like the word processor, at the very least greatly increase the amount of therapy going on. (I know that quantity isn’t everything - we will get to quality shortly)

Can technology substitute for skills?

There is another reason why technology cannot replace the therapist. It is incredibly difficult to use technology to replace the total package of skills and insights that a good clinician brings to the situation.

As a bioengineering student I remember listening to Professor Heinz Wolff in 1972 who lectured us on why technology was often only slowly adopted or even resisted in clinical practice. The reason he pointed to, was a common underestimation of human capability. His view was that engineers too often thought it necessary to provide technology with greater capability than that actually needed to do the job. The result was an embarrassment of rich, yet meaningless, information that clinicians did not know how to act on.

Heinz described this as the “1600 effect” illustrated here as a guiding principle for technology development. (Think Roman numerals)

As an example of the pitfalls, Heinz described two doctors: one excellent and one not so good. The excellent doctor is able to use both tacit, qualitative, knowledge and experience plus quantitive knowledge and integrate all of these sources when viewing the patient. The not so good doctor does not have the sensitivity to pick up the spectrum of impressions through his senses and misses important insights.

Imagine for a second placing your “educated” finger on a patient’s pulse. Available to you is a lot of information about the pulse rate, rhythm, strength of flow, blood pressure, skin temperature, tremor and sweating. An engineer would struggle to produce the array of equivalent equipment and if we just rely on pulse rate information, we are likely missing important insights.

Therapy too is a field where experience and tacit knowledge count and it is hard to replace this with technology. I know that people talk about the promise of AI and how this might bring a revolution in health care. My advice is not to hold your breath. Unless an AI system is ‘sentient’ it will rely on machine learning, which in turn relies on measurement and classification of examples of success and failure so that it learns good from bad. This means we are back with the challenge of how to measure in a situation that relies on both tacit and objective knowledge.

What we can do quite practically today is design technology to be used by therapists as a tool - allowing us to take advantage of the best of what humans can do and what technology can offer. I believe this is what skilled therapists would want.

Tools to enhance rehabilitation

In a number of the products we deal with, there is an opportunity for a therapist to use the product as a precision tool to create a result. The products can be setup based on the individual clinical need utilising the therapist’s know-how of the condition and of the underlying technology. Once the product is setup for an individual the execution of the therapy can be supervised by someone else.

As an example, we have clients all over the UK who use a RehaMove FES Cycling system. Clients use these as a way of enhancing benefits such as cardiovascular function, reducing pressure sore risk, improving muscle tissue quality and preserving bone density etc. The technology has a long and strong evidence base and the stimulation it delivers can be fine tuned to the needs of the individual user. A knowledgeable person such as a therapist can establish the training regime and fine tune the settings over time. However, the therapist is not needed to supervise a routine session. The client or care team can easily learn how to perform the routine exercise session. The therapist acts more like a coach or trainer and can monitor progress from a distance whilst relying on technology to deliver something not possibly by other means.

The Icone upper limb robot is another example. This product has a small footprint and sits easily on a table, yet it was developed to implement the protocols of the best researched upper limb robotic system designed for clinic use (the MIT Manus upper limb robot). It has a great evidence base and is significantly less expensive than it’s parent. It also provides something that the therapist cannot deliver unaided - a comprehensive and validated measurement of upper limb function. The therapist can review the status of the patient and establish a battery of training exercises that are “gamified” to enhance user compliance. However, a therapy assistant can actually deliver the prescription once its programmed - it is not necessary for the therapist to carry out the routine tasks of therapy delivery.

The Icone Upper limb robot deployed in a home environment

Another interesting aspect of this technology is it is designed to be capable of deployment in a patient’s home whilst linking securely to a cloud-based server. This allows a therapist to remotely supervise a patient - create a prescription and monitor performance. The software is automatically kept up to date by this cloud server deployment.

As a final example, our partners at More Rehab used the Indego Exoskeleton with a young lady, Alice. She had experienced a brain injury and expectations for functional recovery were low. Then in a series of sessions with the Indego, expectations for the extent of her recovery were transformed. In this video, her stepfather and therapists at More Rehab tell us her story, her rehabilitation and the particular benefits of walking therapy with the Indego exoskeleton.

Alice’s story featuring therapy with the Indego Exoskeleton

What you see at work is a therapist using experience and knowhow to use this technology as a tool.

The therapist has belief and infuses this into the situation. A feature of the Indego Exoskeleton software is it’s ability to balance the effort of the user with the support of the product. When Alice was weak and in the early stage of her therapy the motors in the exoskeleton were providing just enough support to make walking possible. As she became stronger this balance was adjusted by the therapist so she was always benefiting from an exercise effect and taking advantage of her potential for recovery. If the exoskeleton was just moving her legs with no work being done by Alice she would not benefit as much - if fact she is likely to get weaker rather than recover.

Taking advantage of technology

We have discussed my strong impression that therapists need technology that is both safe and effective and should complement and augment what they can do by themselves. It is not in my view always a good idea to think of technology as something that will replace the skills and expertise of the human. Technology for therapy we have come to expect should facilitate restitution. Although our knowledge of neuroplasticity is still inadequate we are right to expect that more is possible now than in the past.

In the diagram here, Im assuming that we are deploying rehabilitation technology to assist with the achievement of a rehabilitation goal. Technology can be visualised as underpining progress and we would expect to see it’s deployment frequently and with sufficient intensity. As we often hear, to capitalise on neuroplasticity an intervention needs to be specifically targeted, Intensely and Frequently applied. We will explore neuroplasticity in detail in future articles.

What the therapist brings are the Skills and Knowledge to drive improvement. The relationship of the client with the patient is necessary and sufficient to ensure Engagement. Rehabilitation is not something the patient receives passively. It is something they must engage with.

Conclusion

Rehabilitation for many will appear as a long and difficult journey that no one ever wants to make. Technology can help make that journey more productive, efficient and effective but it is only part of the picture. In my view the therapist needs technology to serve as a tool to make rehabilitation more efficient and effective. It should allow the clinician to deliver better and more predictable outcomes for many more people.