This month, a handful of kiwis attended the 12th World Congress of Physical & Rehabilitation Medicine in Paris. Quelle chance! For me, this was in part about my work with Cochrane Rehabilitation. Prior to the World Congress, I hosted a two-day meeting in Paris with 18 rehabilitation experts from 12 different countries to workshop a series of projects examining methodological issues in the development of a scientific evidence base for rehabilitation. Specifically, we were discussing the challenges associated with systematic reviews and meta-analysis of clinical trials about rehabilitation interventions. This two-day meeting was funded in part by a Catalyst Seeding grant from the Royal Society Te Apārangi. We had a strong contingent from New Zealand attending this workshop including: A/Prof Jean Hay-Smith, A/Prof Will Taylor, A/Prof Nic Kayes, Dr Rachelle Martin, and myself. One outcome from this meeting will be a series of papers for a Special Issue of the European Journal of Physical & Rehabilitation Medicine to be published early next year. Keep an eye out for it. :-)
[A/Prof William Levack, A/Prof Nic Kayes, and Dr Rachelle Martin embrace the spirit of gonzo journalism at the trade display stands in the`12th World Congress of the International Society of Physical and Rehabilitation Medicine]
One thing that is always fascinating at these large international conferences are the trade displays on offer (see our YouTube video above). Increasingly these trade displays feature the very latest products on the market for robotics, virtual reality, computer games, and other technological devices to aid rehabilitation. There appears to be four main arguments that the developers behind these products propose as reasons to purchase their goods. Firstly, they argue that these technological aids help increase the amount of therapy time for patients. (However, they often still require supervision to implement.)
Secondly, it is proposed that 'gamification' of therapy, i.e. making therapy into a computer game, makes rehabilitation more interesting and engaging for patients, so sustains their attention longer. (This is an assumption worth testing: Is interest in these games really easier to sustain over the long term in comparison to standard exercise regimes?)
Thirdly, these technologies often offer increased precision. So, a robotic exoskeleton on a treadmill with overhead sling suspension might be able to alter the amount of weight that a patient takes through their legs by half of one percent, while providing data, to the minutest of degrees, on how much work a patient is actually investing in the activity. (Again it is worth questioning assumptions: Is this level of control over movement actually beneficial for recovery in the long run, or is it simply important to just be doing something of anything to make gains in rehabilitation.)
Fourthly, some of these technologies are designed to aid movement when patients are too impaired to even initiate any muscle activity - the example of the robotic exoskeleton and sling suspension once again. While "more" is almost always better in rehabilitation, we are yet to see really compelling evidence to indicate the patients using these fancy technologies actually achieve better health outcome in comparison to good ol' fashioned therapy with trained rehabilitation providers. For instance, the Cochrane reviews on both a) treadmill training with body weight support and b) virtual reality based therapy for people with stroke are equivocal in their findings. Treadmill training does not seem any better outcomes overall in comparison to tradition physical rehabilitation after stroke when it comes to regaining the ability to walk independently. Although treadmill training may result in improvements walking speed and walking endurance after stroke (for people are already able to walk a bit), these benefits are really quite small, and not sustained in the long term. Therapy based on virtual reality interventions are also not more beneficial that conventional therapy if offered in the same amount and intensity. If virtual reality activities are used to provide MORE therapy for individual patients (i.e. on top of conventional therapy) - surprise, surprise - this results in better health outcomes. The same however could be reasonably expected of MORE conventional therapy on top of conventional therapy. As noted above, in the case of rehabilitation, more is often better.
Nevertheless, there are some really interesting and innovative ideas being proposed by technology for rehabilitation. Anything that extends therapy opportunities is surely good. The question to ask is what extra benefit is being gain from the money being spent and are their other things, (more therapist hours? community gym membership? peer mentoring?) that might be equally worth spending money on.
William Levack is an Associate Professor of Rehabilitation at the Rehabilitation Teaching & Research Unit, University of Otago, Wellington, New Zealand. Twitter: @DrLevack