Modern rehabilitation: Tailored to the individual patient and assisted by robots

Rehabilitation is the silent hero of the healthcare system. After all, it typically helps people to transition back into life again. Whether it’s artificial cruciate ligaments after a sports injury, a permanent disability after an accident or recovery after a stroke – no matter whether a condition is reversible or not, rehabilitation tries its best to prepare people for a self-determined life and make participation a reality again. But what exactly does modern rehabilitation entail in the year 2018? What are its features and advantages? And what are some alternative approaches?

Dr. Helga Seel, Managing Director of the Federal Association for Rehabilitation (Bundesarbeitsgemeinschaft Rehabilitation, BAR) in Frankfurt is able to answer some of these questions. "Rehabilitation is a process that is not just about approving or rejecting an application but about providing personalized support. This also includes counseling patients about available benefits and options. It focuses on answering questions such as who is involved? What is the general framework? How restricted is participation and what are the services to improve the participation aspect?"

Meanwhile, there are several institutions in Germany that are responsible for rehabilitation issues. The responsible service provider has to be determined on a case-by-case basis and is subject to many factors. Age and a potential job situation, as well as the cause of the illness, play an important role. The responsible rehabilitation service provider may vary depending on the incident. That being said, despite the difficulties in determining the responsible authority – which is something that still needs improvements in the future – the task of the individual responsible body remains the same: "Needs recognition and assessment are the keywords in this setting. The consultants must be able to determine rehabilitation eligibility. The sooner this need has been identified, the higher the chances for the patient to prevent or minimize participation restrictions. Another aspect is to focus on needs assessment, meaning to identify relevant services."

Dr. Seel continues: "As a general rule, the sooner a patient accesses the relevant support services, the less time and effort is needed for rehabilitation. This is first and foremost beneficial for the patient. But – and this is something that is definitely worth noting – early assistance services are often also less expensive."

Thanks to rehabilitation measures, annually more than 100,000 people remain fit for work, who might otherwise quite possibly have left the labor force early and would have retired. In other words, there are also financial reasons the state welfare system must consider. After all, any rehabilitation measure, regardless of the type, is less expensive than having to pay for a lifetime of care. That’s also why the motto is "Rehabilitation before long-term care". However, Dr. Seel points out that "once care has become necessary, it doesn’t automatically mean that rehabilitation measures are out of the question. Rehabilitation measures can also help improve the quality of life of patients in care settings." After all, it’s not just older people who are affected by care issues but also children and adolescents.

It is a well-known fact that when it comes to care settings, adequate access to rehabilitation measures is a key mechanism of allowing older people to live a self-determined life for as long as possible or caring for them in familiar surroundings. Needless to say, it’s important for rehabilitation, medical supply, and care facility to go hand in hand in this scenario. Health improvement is only possible if all pieces of the puzzle fall into place. Transitions from care settings to rehabilitation and vice versa must be seamless and the therapies tailored to the patient and his/her life. Combined with the necessary medical supplies, the concept is integrated and beneficial for patients.

In general, all rehabilitation patients are entitled to personalized and custom-designed types of therapies. "One must always find what’s best for the individual patient and assess the existing general framework. While outpatient rehabilitation services might be better suited for one patient, another patient is better served in an inpatient setting. We now have a wide range of options that allow for a targeted approach. Things have changed in a positive way in recent years." Meanwhile, rehabilitation providers have also come to see themselves as service providers. After all, applicants are entitled to great services because they pay insurance premiums. "However, a service mindset obviously doesn’t mean that this is just about making all the patient’s wishes come true. Emphasis is placed on what’s feasible, what services the rehabilitation provider is able to provide or where applicants can be actively referred to if the provider is not the relevant authority."

In addition to the service sector, there is also a financial aspect and this is where things get tricky for Germany at the moment. Right now, the German rehabilitation market is vast, both in terms of inpatient and outpatient facilities. And it is costly when it comes to personnel costs for the different therapies. Meanwhile, rehabilitation providers have a fixed budget. Right now, the German Statutory Pension Insurance Scheme (German: "Rentenversicherung") pays for most rehabilitation measures. The Statutory Long-term Care Insurance (German: "Pflegeversicherung"), which is not a rehabilitation provider is the beneficiary of these measures. Dr. Seel explains the predicament: "Rehabilitation providers are investing to make sure that patients don’t become long-term care cases and are able to live a self-determined life as long as possible. In other words, rehabilitation providers are paying the tab, while the Statutory Long-term Care Insurance saves money. Meanwhile, rehabilitation providers also have to operate economically and manage the funds entrusted to them by the insured parties."

Despite the fact that the rehabilitation sector has grown in recent years - also as far as the number of cases are concerned - rehabilitation facilities have a fixed daily care allowance allotted for each patient and thus find it increasingly difficult to stay on budget. Individual therapies are labor intensive. Rehabilitation facilities employ a variety of medical specialists, physical and occupational therapists, speech therapist etc. Since therapies are sometimes time-consuming, strenuous and involve repetitive movements, robot-assisted or technology-assisted assistance systems have found their way into German rehabilitation facilities over the past years. For example, in places where several physical therapists used to arduously assist stroke patients in learning how to walk again in the past, today an assistance system often takes on this task. In these cases, it only takes one therapist who monitors the exercises, while the patient is maneuvered by a robot or assisted in making targeted and gentle movements aimed at recovery.

Many companies have specialized in these types of robot-assisted systems. Tyromotion is one of them. The Graz-based company is one of the world’s leading providers of robotics and computer-assisted rehabilitation products. The Austrians supply –among others- doctor’s offices in Germany and the U.S. There are countless companies like Tyromotion that supply rehabilitation facilities with therapeutic assistance systems. The RehaCentrum Hamburg uses devices from Hocoma for example.

Robot-assisted therapy systems are especially common in neurology to treat stroke patients for example. "Neurological rehabilitation has recognized the significance of neuroplasticity in the implementation of therapeutic concepts. This is why new therapeutic solutions and particularly technical processes or robot-assisted systems were further developed and increasingly introduced in rehabilitation facilities," explains Dr. Gabriele Bender, Medical Director and Chief Physician of the Neurological Rehabilitation Department at RehaCentrum Hamburg in an interview with REHACARE.com. That being said, this usually relates to hospitals that can afford this type of equipment since "occupational or physical therapy facilities are generally unable to pay for these devices."

"In my view, a combination of conventional therapy methods and modern technical or electromechanical devices is the most promising method to achieve a successful rehabilitation outcome," says Dr. Bender but adds that, "self-training on a regular basis is also very important, which is something the patient should do at home and outside of the therapy setting on the weekends or even after rehabilitation. Patients with a high level of self-motivation, who embark on regular self-training achieve far better treatment results than patients, who only take part in prescribed therapy sessions." This is also the reason the market for technical devices that are controlled via smartphone apps or that monitor exercise execution is growing.

Modern rehabilitation is not just about a potential increase in outpatient options or dispute resolution over responsibilities of rehabilitation providers. It is also about using technology more sensibly. Several studies have shown the positive impact of robot and technology-assisted assistance systems in rehabilitation. David Ram, CEO of Tyromotion knows the benefits. In a REHACARE.com interview "Putting patients at the center of modern rehabilitation", he says "Rehabilitation patients often have big goals but typically only make small progress. Thanks to accurate assessments of the therapy sessions, even the smallest progress becomes visible for patients, which significantly boosts motivation. Integrated therapeutic games also keep patients motivated and encourage them to do more repetitions. The patient’s focus turns away from therapy and to the therapeutic games, which causes pain and limitations to take a back seat, allowing therapy to become more motivating and challenging." Like Dr. Bender of the RehaCentrum, he also emphasizes a combination of therapist and machine: "Progressive rehabilitation is not just based on state-of-the-art therapy equipment, but also requires 'human-machine interaction': the experience and expert knowledge of therapists supports robot and sensor-assisted therapy devices."

Patients benefit from the new technical helpers on their path to rehabilitation and recovery. This also applies to therapists, whose daily workload can be eased by robotic assistance. And this, in turn, benefits the rehabilitation providers and ultimately the welfare state. That’s one of the many reasons why a lot of money is currently being invested in the rehabilitation sector. Incidentally, no system is better than the German one when it comes to promising rehabilitation measures. This is also underpinned by the fact that by now, patients from abroad are increasingly being referred to Germany to make the best possible rehabilitation measures available to them.

Even though rehabilitation has become more modern and updated in recent years, the patients in rehabilitation facilities are mostly older people. This is something Dr. Seel can also attest to: "Of course, it is typically older persons who need these services – think demographic changes. The older you get, the higher the likelihood of you being in need of rehabilitation measures. Having said that, rehabilitation is actually not age-related. There are no age limits because young people can also be affected. Whether it’s a three-month-old baby with shaken baby syndrome or a teenager who had an accident with his motor scooter and now suffers from traumatic brain injury – nobody gets spared. No matter how healthy we are at the moment, everything can change in an instant. In other words, rehabilitation concerns all of us."