The proportion of the world population over 65 years of age is climbing. Life expectancy in this age group is increasing, and disabling illnesses now occur later in life, so the burden on the working–age population to support health care costs of aging populations continues to increase. These demographic shifts portend progressively greater demands for cost effective health care, including long-term care and rehabilitation. The most influential change in physical rehabilitation practice over the past few decades has been the rapid development of new technologies that enable clinicians to provide more effective therapeutic interventions.
New rehabilitation technologies can provide more responsive treatment tools or augment the therapeutic process. However, the absence of education about technological advancements and apprehensions by clinicians related to the role of technology in the treatment delivery process puts us at risk of losing the benefit of an essential partner in achieving successful outcomes with the physically disabled and aging population. There are two reasons that may explain why rehabilitation practitioners do not play an integral role in the development and evaluation of these new technologies. First, the engineers who develop these technologies do not recognize the value they could derive by consulting with rehabilitation professionals in order to make their machine-user interfaces more efficient, user friendly, and effective for specific disabilities. Second, many rehabilitation professionals are uncomfortable with technology and fear that it may take the place of individualized interactions with patients.
Funding challenges, a lack of public awareness about technology's potential, a shortage of trained experts, and poor collaboration among researchers, clinicians, and users are often the cause for an absence of clinical trials that demonstrate the value of near-term and future rehabilitation applications. If technology transfer is to become successful, we need to establish collaborative interactions in which the goals of each discipline become overlapping with the skills and goals of the other fields of endeavor and of the consumer. The rapid rise of technological development is pushing the market place and it is essential that rehabilitation specialists oversee the quality and validity of these new applications before they reach the consumer.
It is clear from the chapters in this book that improvements in technology depend on interdisciplinary cooperation among neuroscientists, engineers, computer programmers, psychologists, and rehabilitation specialists, and on adoption and widespread application of objective criteria for evaluating alternative methods. The goal of this book is to bring ideas from several different disciplines in order to examine the focus and aims that drive rehabilitation intervention and technology development.
Specifically, the chapters in this book address the questions of what research is currently taking place to further develop rehabilitation applied technology and how we have been able to modify and measure responses in both healthy and clinical populations using these technologies. In the following sections we highlight some of the issues raised about emergent technologies and briefly describe the chapters from this book that are dedicated toward addressing these issues.
1. Does Training with Technology Add to Functional Gains?
Before we can develop a successful intervention, we need to determine what the end goal is. A number of different therapeutic technologies are already available for use in clinics, but their value to the treatment program is not well defined. Developers and clinicians must consider whether a technological device better targets diagnostic or therapeutic interventions. Does it serve as an extension or repetition of conventional therapeutic interventions? Do we want it to perfectly replicate the actions of a therapist or to assist or augment the actions of the therapist? For example, as stated by Reinkensmeyer in his chapter, there has been a rapid increase in the number of robotic devices that are being developed to assist in movement rehabilitation, yet it is still not well understood how these devices enhance movement recovery, and whether they have inherent therapeutic value that can be attributed to their robotic properties. Chapters by Frisoli et al. and Piron et al. present results of clinical trials that demonstrate improvements in functional outcomes on standard clinical scales when compared with more traditional clinical interventions which would suggest value in adding technology to therapeutic interventions.
2. Are there Rules that Govern Recovery of Function?
Are learning rules for recovery similar to those for skill acquisition? In particular, should we be concerned mostly with error reduction or feedback enhancement? If we are concerned with recognition of movement error, do we try to increase or decrease that error for learning? How do we instruct patients to attend not only to the error, but also to their own kinematics? If functional recovery depends on plasticity of the central nervous system, can the use of technology enhance this plasticity? If we are attempting to promote plastic changes in the nervous system, then motor learning principles most likely should be adhered to and rules for learning need to be defined including the optimal length and frequency of the intervention and how much interference plays a role in learning. Cameirao et al. use virtual reality to engage patients in task specific training scenarios that adapt to their performance thereby allowing for an individualized training of graded difficulty and complexity. Deutsch provides an overview of virtual reality gaming based technologies to improve motor and cognitive elements required for ambulation and mobility in different patient populations. Levin et al. and Merians et al. demonstrate how movement retraining can be optimized by combining virtual reality with haptic devices if important motor learning elements such as repetition, varied task practice, performance feedback and motivation are incorporated. Riva et al. discuss development of a new open source system that uses the principles of motor learning within real life context in order to increase generalization of recovered motor and cognitive behaviours. Using a combination of robotics and virtual reality, Sanguineti et al. demonstrated functional gains by tailoring their intervention to the different degrees of impairment and adapting the intervention as performance changed thereby exploiting the nervous system's capacity for sensorimotor adaptation.
3. Using the Body's Own Signals to Augment Therapeutic Gains
Another rapidly advancing area of technology for rehabilitation is the application of the individual's own residual sensory and motor signals to augment function. Although wheelchairs are still the most popular assistive device for patients with spinal cord injuries and disabling neurological conditions, many users encounter difficulties in controlling their powered wheelchairs. The wheelchair represents an assistive device that, in large part, requires the person to adapt to the technology rather than having the technology fit the abilities of the individual. Bonato discusses the emerging use of miniature sensors that can be worn by the patient to measure and transmit information about physiologic and motor functions. Carabalona et al. explore research on brain-computer interfaces and discuss how technologies that are driven by or access the signals initiated by each patient can support activity in their environments.
4. Technology Incorporates Cognition and Action
Clinicians often voice concerns about using technological interventions because they appear to replace the human interaction which is believed to be a prime factor in the success of rehabilitation programs. Rehabilitation clinicians work with patients using a combination of verbal, visual, and physical interaction as well as a variety of treatment tools and techniques. Delivering equivalent interventions to patients through technological devices presents significant obstacles, but also presents numerous opportunities to enhance the quality, consistency, and documentation of care received. Several chapters in this book explore how rehabilitation technology offers the capacity to individualize treatment approaches by monitoring the specificity and frequency of feedback, providing standardization of assessment and training, and presenting treatment within a functional, purposeful and motivating context. Antonietti presents the field of music therapy as a tool of the mind, using cognition and emotion as the avenue towards accomplishing goals for rehabilitation. Gaggioli et al. demonstrate how virtual reality can be successfully used to support motor imagery techniques for mental practice in stroke rehabilitation. Keshner and Kenyon discuss how cognitive processes such as perception and spatial orientation can be accessed through virtual reality for the assessment and rehabilitation of perceptual-motor disorders.
5. Technology Enhances the Impact of Rehabilitation Programs
One of the greatest challenges for healthcare in the coming decade will be accessibility to the increasing numbers of individuals who are unable to travel to rehabilitation facilities or who do not have local rehabilitation facilities that provide the health maintenance and extended care they require. Additionally, most of the responsibility for caring for individuals with physical or psychological disabilities will fall on their family or on health care aides who do not have the training to provide wellness and rehabilitation interventions. The chapters in this book that address improved access to care and extending the reach of medical rehabilitation service delivery all emphasize the importance of human factors and user-centered design in the planning, developing, and implementation of their systems. Brennan et al. present a brief history of tele-rehabilitation and tele-care and offer an overview of the technology used to provide these remote rehabilitation services. Mataric et al. demonstrate how combining the technology of non-contact socially assistive robotics and the clinical science of neurorehabilitation and motor learning can promote home-based rehabilitation programs for stroke and traumatic brain injury. Weiss and Klinger discuss the practical and ethical considerations of using virtual reality for multiple users in co-located settings, single users in remote locations, and multiple users in remote locations.
Although new technologies and applications are rapidly emerging in the area of rehabilitation, there are still issues that must be addressed before these can be used both effectively and economically. First, we need to demonstrate that these devices are effective through clinical trials. Second, we must determine how to build devices cheaply enough for mass use. Lastly, we need sufficiently educated physicians and therapists to drive the technology development and applications. Although considerable engineering knowledge is required to understand the potential capabilities of the various technologies, engineering alone will not determine the usefulness of these systems. The chapters we have included in this book clearly demonstrate that in order to design appropriate system features and successful interventions, developers and the users need to be familiar with the scientific rationale for motor learning and motor control, as well as the motor impairments presented by different clinical populations. Ultimately, the impact of these new technologies will depend very much on mutual communication and collaboration between clinicians, engineers, scientists, and the people with disabilities that the technology will most directly impact.
Emily A. Keshner, Temple University, Philadelphia, PA, USA
W. Zev Rymer, Northwestern University, Chicago, Illinois, USA