Researchers analysed twelve studies that looked at VR-enhanced rehab, and concluded it can offer long-term positive outcomes for patients with traumatic brain injuries (TBI), especially those with motor skills and cognitive deficits, and those experiencing difficulties with their balance.
One of the benefits of VR rehab is that it can provide a safe environment for people to practice skills with minimal risk of harming. Some VR platforms, the paper states, can model almost any type of environment that may be useful for rehabilitating motor skills including walking, balancing and moving on different types of terrain.
The researchers, from the College of Public Health at the University of Kentucky, US, looked at six studies that examined gait and balance. All six of the studies showed that VR-enhanced rehab made moderate improvements to TBI patients’ gait and balance.
The four studies researchers looked at that around VR’s effect on upper limb functioning was more limited, and drew mixed conclusions. The use of VR to enhance cognitive rehab had the least amount of supporting evidence. The six studies the researchers looked at measuring VR and cognitive rehab found limited evidence.
The researchers state that their review not only provides helpful data, but also shows the gaps in research. They concluded that their findings highlight a need for more research that can inform providers, policymakers and the public to draw conclusions about the effectiveness of VR-enhanced rehab, especially around newer, immersive VR-enhanced rehab.
“VR-enhanced rehabilitation has been utilized for almost two decades, yet data regarding its clinical effectiveness remain limited by multiple lower quality studies,” the paper states.
“This lack of data impacts the generalizability of findings and conclusions about such important factors as physical effectiveness, motivational improvement, and cost-effectiveness that healthcare providers, policymakers, and the affected public are able to draw.”
There needs to be more research in this area as newer VR tools become available in rehab, the researchers urge, to better understand how VR can help neuroplasticity, which is the brain’s ability to learn new things by making new neural connections.
“With the advent of newer generation VR tools utilising 3D visual and auditory stimuli such as mixed reality (MR) and immersive VR platforms, new hypotheses can be tested with the Hebbian theory of neural plasticity concepts at their core,” the study states.
Studies, the researchers say, now need to adapt to include more advanced and improved technology, which will allow new opportunities for clinical rehab.
“For example, in a healthy population, improvement potentials were found in balance and visuo-motor reaction time after MR action game play,” the study states.
There is a ‘dire need’ for future studies to improve the current understanding of the potential for VR-enhanced rehab, the researchers state. This is particularly the case in the US, whose healthcare system underperforms or ranks lowest across multiple health outcomes, including access and cost-efficiency, compared to other developed countries.
“Although we must be cognizant of the potential for initial higher costs associated with the purchase, maintenance, and staff training of some of these VR platforms to be incurred, many VR platforms could actually help provide more cost-effective care,” the paper states.
The researchers argue that more broadly available commercial VR systems could avoid altogether the need for more costly interventions.
Virtual rehab “effective” for stroke recovery, research shows
Since the beginning of the pandemic in March, therapists have adapted face-to-face services to comply with social distancing measures. While many patients and practitioners alike seemed to adapt well, now research has confirmed that it can be a practical way of delivering rehab for stroke patients.
A new paper, co-authored by Brodie Sakakibara, assistant professor at the Centre for Chronic Disease Prevention and Management has found that remote, virtual rehab works for people recovering from a stroke.
Six clinical trials were launched across Canada as part of a Heart and Stroke Foundation initiative, where people recovering from a stroke were given interventions including memory, speech and physical exercise training.
Researchers from each of the six trials found that the telerehabilitation was just as cost-effective as traditional face-to-face rehab, and that patients mostly reported that they were satisfied with their telerehab.
They reported in the paper, published in the Telemedicine and e-health journal, that patients were most satisfied, the researchers found, when there was some social interaction and clinicians were appropriately trained.
Overall, clinicians reported that they prefer face-to-face interaction, but will use telerehab where this isn’t possible.
“Telerehabilitation has been promoted as a more efficient means of delivering rehabilitation services to stroke patients while also providing care options to those unable to attend conventional therapy,” Sakakibara says.
“These services can be provided to remote locations through information and communication technologies and can be accessed by patients in their homes.”
The researchers also highlight a need for technology in stroke rehab to be easy to use and well suited to the user’s needs.
“The older adult of today, in terms of technology comfort and use, is different than the older adult of tomorrow,” Sakakibara says. “While there might be some hesitation of current older adults using technology to receive health and rehab services, the older adult of tomorrow likely is very comfortable using technology. This represents a large opportunity to develop and establish the telehealth/rehabilitation model of care.”
These findings are important because telerehab is becoming much more widely implemented.
“Prior to the outbreak, telehealth/rehabilitation was highly recommended in Canadian stroke professional guidelines, but was underused,” Sakakibara says.
“Now in response to COVID-19, the use of telerehabilitation has been accelerated to the forefront. Once these programs are implemented in practice, it’ll be part of the norm, even when the outbreak is over. It is important that we develop and study telerehabilitation programs to ensure the programs are effective and benefit the patients.”
Rehab groups call for pandemic-fuelled change
An influential group of rehab organisations has issued a set of recommendations to the Health and Social Care Select Committee (HSC) aout managing rehab amid COVID-19.
While the healthcare system rightly initially focused on saving lives and stopping the spread of the virus, there is an array of patients that remain with unmet needs which The Community Rehab Alliance, a consortium of 22 charities and professional bodies – has submitted a joint response addressing.
Having identified that many COVID-19 survivors are being discharged without any rehabilitation plan in place, the report gives a series of recommendations for services that support rehab across a range of conditions to aid getting the country back on its feet and back to work.
It has been argued that this is a time to learn from the pandemic to shape rehabilitation services for the future, as well as addressing the weaknesses within the arguably under-developed part of the current healthcare system.
Rehabilitation is the process of assessment, treatment and management of a patient’s condition, within which they are supported to reach their maximum potential for physical, cognitive, social and physical participation in society and quality of living. Rehab needs to empower people to recover and build up resilience at their own pace which, for COVID-19 survivors is wide-ranging.
While there are some excellent examples of regional and local responses and pathway development, overall planning and guidance on COVID-19-related rehabilitation appears inconsistent and disjointed. The Rehab alliances recommends a national, strategic approach including integrated care systems carrying out audits, agreement on common rehab needs assessment frameworks and building up multi-disciplinary community rehab teams with the skills and staff required.
By redeploying the workforce – permanent and temporary – back into the community, it is more possible and likely to deliver commitments that will increase step-down rehab capacity.
During the crisis, it hasn’t been only coronavirus patients who have required healthcare. Throughout the pandemic, people are still having falls and fractures, strokes, heart attacks, preparing for cancer treatment or recovering from it, having accidents and illnesses that result in spinal cord and brain injuries and having exacerbations and acute episodes related to long term conditions, including cardiovascular, respiratory, musculoskeletal, rheumatology and neurological.
In all these situations, early, timely and sufficiently intensive rehabilitation will often be critical to people’s long-term recovery and the level of wellbeing and independence people regain or maintain. For older people timely rehabilitation is key to support people to prevent decline, optimise independence, prevent hospital admissions and the need for long-term care. Rehabilitation enables people (including key workers) to return to work and participate in society after lockdown.
During the pandemic, some essential and time-urgent elements of rehabilitation have continued, while supporting shielding and social distancing.
Local managers need consistent advice and time to assess when rehabilitation interventions are essential and on how community rehabilitation can recommence fully. National support and guidance for the provision of telehealth and digital rehabilitation options where appropriate is necessary, with professionals bodies needing to play a critical role in providing guidance on how practice might be adapted from face-to-face rehab from outpatients centres to home, as well as finding alternatives to clinic-based appointments and services.
As services recommence, there should be a positive risk approach, supporting ongoing guidance on social distancing, testing for professionals and carers, PPE at the appropriate level, and prioritisation on the phasing in of aspects of services.
The pandemic is shining a light on the poor state of community rehabilitation provision. While there are many excellent services, access to rehabilitation is a postcode lottery, with services being under- resourced and under-developed for decades. Planning and commissioning is inconsistent, and there is significant variation in standards.
There must be a plan to meet the wave of pent-up demand for health and care services that have been delayed due to the coronavirus outbreak, as well as meeting demand for additional mental health services.
As part of this plan, the Rehab Alliance recommends that there is a strategy to expand both community rehabilitation provision and, where necessary, retain planned additional capacity for step-down (bedded) rehabilitation units.
Through the forthcoming NHS People Plan, deliver an expanded rehabilitation workforce, including allied health professionals with advanced practice skills, support workers and care assistant trained to add capacity, sports and exercise professionals, postural stability instructors, coaches working in the voluntary sector and rehabilitation medicine doctors.
Because COVID-19 is a multi-systemic condition, with significant physical and mental health consequences, it illustrates very well the continued importance of shifting an approach to rehabilitation away from one that is based on neat medical specialisms and condition silos.
The experience of Covid-19 recovery should provide an impetus to adopting a personalised, multi-condition, biopsychosocial approach that can respond to the needs of increasing numbers of people having multiple conditions impacted by multiple factors. This approach needs to support greater inclusion of vulnerable and hard-to-reach groups, who have the worst health outcomes and experience barriers to services. This includes people with learning difficulties, dementia and serious mental illness.
Services need to make reasonable adjustments to make them accessible – for example, adapting communication.
The pandemic has necessitated a shift at scale to online management systems in the community and tele-health. As services get back to normal, it is highly likely, this could be continued to make this a much more prominent option for people in how they access and receive services.
This must be appropriate, evidence based and result in increase choice and access, not in greater marginalization of some groups and increased health inequality.
Learning from the experience of the pandemic should be captured by robust research and shared so that evidence underpins the future shape of rehabilitation. These should include the perceptions of the patients, staff and carers as well as their clinical effectiveness.
So while there is a certain amount of support available, the necessity to address and reform the rehabilitation services available throughout the UK is significant and immediate.
The Rehab Alliance, which includes industry bodies and charities such as Age UK, the Royal College of Psychiatrists and the UK Acquired Brain Injury Forum, is working to see a change across all rehab services offered nationwide to combat the challenges faced as a result of COVID-19 and strengthen those survivors in the best possible way, setting a new standard and practice in services that will better serve residents across the board.
A 20-year adventure in rehab robotics
Tech pioneer Hocoma has long been pushing the boundaries of innovation in rehab. Now marking its 20th anniversary, it plans to step up its ability to drive better patient outcomes, as Deborah Johnson reports.
Back in 2000, the world was a very different place, particularly in terms of technology.
Many of the high-tech innovations we now accept as standard were not yet launched and healthcare remained one of the most traditional markets around.
Yet into this climate, Hocoma launched the prototype of its pioneering Lokomat, a robotic medical device which provides repetitive and highly physiological gait training to patients, enabling even some of the most impaired to learn to walk again.
While it has gone on to become one of the world’s leading robotic medical devices, in 2000, it was a significant and controversial disruption into a long- established and relatively low-tech rehab scene.
Clemens Muller, global head of clinical and scientific affairs at Hocoma, says: “Twenty years ago, gait rehabilitation was completely different.
Therapists had to physically move patients’ legs – a manual task that can be very tiring and requires huge effort, particularly when you are doing it many times a day.”
Gery Colombo, a trained electrical engineer with an interest in neural rehabilitation, founded Hocoma alongside Peter Hostettler, an economist, and Matthias Jörg, a biomedical engineer.
“The founders realised the need for a change to this way of doing things and to find a better solution,” says Clemens.
“They wanted to establish a venture which could use their specialist knowledge and go in a particular direction, with a purpose and intention.
“The goal was to change rehab as it was known. This was absolutely new; in fact so new and innovative that the world of healthcare rehabilitation wasn’t really ready for it.
“This was a challenging phase but one in which Hocoma needed to be really entrepreneurial with a very clear vision and focus and to keep on going.
“It did take a little while until it was accepted and it was a long journey for the founders.”
Despite the initial challenges of launching such a high- tech product, over the past two decades, the Lokomat has become one of the most widely used gait rehabilitation devices in the world.
It has helped to set an industry standard in rehab products for people with brain injury, stroke and other neurological disorders.
Hocoma recently installed its 1,000th Lokomat.
But it has also built on the success of its flagship product by launching an array of other devices.
Among its product portfolio is the Erigo, which assists with patient mobilisation in the earliest stages of rehabilitation; its Armeo range, which supports the recovery of arm and hand function; and its Valedo products that targets back pain.
The business is headquartered in Switzerland but works in 27 countries worldwide – and believes it is changing the lives of people in clinics across the globe.
Clemens says: “I think there are three drivers behind innovation in healthcare – social aspect, which includes demographic changes and the shift from using products which are based on evidence rather than just experience; the technology changes in the world as a whole; and the clinical changes, which are moving on quickly and have changed dramatically to encompass robotics and exploit the previously unused potential of this way of therapy.
“These drivers have changed, and continue to change, the landscape of the world in which we work. Hocoma has always been at the front pushing the boundaries and helping to change the resistance there was at the beginning of our journey.
“When you went to a rehab conference 15 or 20 years ago, there was only one tech provider there, which was us.
“But if you compare that to now, there can be anything up to 20 companies at an event, including start-ups that are working in technology fields like robotics or sensor-based equipment, offering products for inpatients and outpatients, for acute needs. So there is a huge selection now available.
“There is also the demand from the market to integrate technology. The key for us has always been how to integrate this technology into a routine of therapy to use it to its full potential.
“It is about not only being engineering-driven but understanding how to use that to make a bridge to the rehab world and understand the link to the human world – bringing the know-how and capability and opening that up for the needs of patients.
“As a market, we do need to do more homework in that area.
“Lots of clinics already have integrated the technology they are using very successfully, and with our products it makes us proud to see how the patient is being supported to the highest level.
“I have seen this happening in many clinics around the world and it gives me goosebumps to see how happy patients are with how it is working for them. It also makes a huge difference to the work and demands placed on the therapist, and that is something that also makes us so proud.”
Now celebrating its 20th anniversary, Hocoma’s ambition for the future is to continue changing lives and reaching out to millions more around the world.
A strategic move in achieving this came in 2017 when Hocoma joined its now-parent company DIH – bringing it under the same roof as other rehab technology developers including Motek.
“We have always been a pioneer since we were established so we will continue this with new and better solutions to benefit people’s lives.
“Our focus is on bringing solutions which are innovative, high quality, effective and efficient.
“The future for us will of course be affected by the healthcare market in general. We are seeing a rapid demographic change around the world and this will mean a change in the healthcare approach.
“There will be a search for solutions.
“With the huge move towards digitalisation through the Industrial Revolution 4.0, there will be a greater role played by artificial intelligence and virtual reality.
We will continue to develop as a business so we can continue to be at the front of what is happening.
“Traditionally, we have come up with a new innovation every year, which could be a new product launch, or else new features or a new version of an existing product, but we are always developing what we have to make it the best it can be.
“We are always learning by doing and have a network of research and academic partners all over the world and this enables us to come up with great products which deliver solutions.
“We are planning heavily in our development team and are continuing to develop our launch plan and product road map.
“We hope the global coronavirus outbreak and the shutdown we are seeing around the world does not affect our plans too much in the short-term, but we will have to see how that develops and adapt to that as we need to.”
As a business which has helped to change traditional practices and approaches in rehab globally, one area in which Hocoma would like to push for further change is in widening patient access to its own products, and other high-tech solutions.
“At the moment, it is not a given that all patients and all clinics will have access to our products. Of course technology has its price, but we need to address that at some point.
“We need to work with clinics and insurance companies to try and find a solution here and to shape the future of rehabilitation.
“It is important to find optimal solutions which increase access to technology, to improve the quality of rehab, while looking at the cost effectiveness of such products.
“Over the next five to 10 years, there are going to be more stroke, cerebral palsy and traumatic brain injury patients who are needing innovative solutions and our goal is to develop more solutions which will benefit them and the therapists.
“When money and costs are involved it can often be a long journey, but we believe if all stakeholders got together to find a way of best dealing with this, together we could deliver the best rehab to patients, and this is something we would like to be involved in delivering.”
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