Rehabilitation has been defined as the ‘sleeping giant’ of medicine, thus further efforts to improve its quality care standards are required [Citation1]. Accordingly, there is on one side a need to optimize the trade-off between the number of people treated, the intensity and length of treatment, and the health-care costs on the other. As such, this objective is not easy to achieve, especially when considering the complexity of neurological disorders like stroke, traumatic brain injuries, Parkinson’s disease, and multiple sclerosis.
To obtain an increment in efficacy, a deeper knowledge of the involved complex neural mechanisms is needed. In addition to pathophysiological mechanisms, also biopsychosocial factors, biological and genetic expression factors related to the recovery of the independency of a person should be explored.
Over the last 20 years, the neurorehabilitation theory has undergone a revolution due to the influence of advancements in neuroscience and neurotechnology. These gave rise to the introduction of some principles like the massed task practice, the top–down approach, and to the diffusion of new technologies like virtual reality systems, neurorobots, muscle and neural electromagnetic stimulators, and wearable devices [Citation2].
We recently had the opportunity to redesign a neurorehabilitation gymnasium in accordance with the most recent and important neuroscientific findings and technological solutions. Being inspired by virtual systems’ design which is based on the 3I principles of immersion, interaction, and imagination [Citation3] and by the design in robotics usually defining the 3Ds, dull, dirty, and/or dangerous work performed by robots [Citation4], we also implemented an approach based on 3 Ts: therapy, technology, and translationality.
1. Therapy
Despite neuroscientific findings and technological development, in most of the rehabilitation gymnasiums, therapy is still mainly based on physical coding practices derived by several different conventional approaches such as Bobath [Citation5], Kabat [Citation6], and Brunnström [Citation7]. Most of these approaches were developed in the 1950s, i.e. many years before the most important findings on neurorecovery mechanisms. Furthermore, these approaches often lack clear scientifically evident bases. There are two main problems in testing the efficacy of these coding practices: first, comparison between one of them versus spontaneous recovery (i.e. absence of rehabilitation) has been considered unethical; second, the need of a standardized treatment for designing a randomized controlled trial contrasts with the concept of adaptability of the therapy, customized, and tailored on patient’ s conditions. This is also known as ‘the effectiveness paradox’ [Citation8,Citation9]. Potential economic pressure may increase confusion in this already complex scenario, with implications on ethical issues and threatening the scientific value of newly proposed interventions. Some studies compared one of the above-mentioned approaches with the other, finding that none of the competing ‘school of thought’ is more effective than another [Citation10]. Despite all these problems, the medicine community agrees in considering these approaches as standard interventions in rehabilitation. In addition to this, neurorehabilitation is still mainly pathology-defined and based on therapists’ expertise and skills.
To overcome these issues, neurorehabilitation interventions should be continuously updated and should evolve in accordance with neuroscientific findings about neuromotor physiology and brain plasticity, and with the possibilities offered by new technological devices. This implies a straightforward translational approach: from neuroscience and neuroengineering to neurorehabilitation. Two clear examples of changes in therapies could be the constraint-induced movement therapy driven by neuroscience studies [Citation11] and brain–computer interfaces (BCIs) developed in the field of neurotechnology and adapted to neurorehabilitation [Citation12].
Notably, the relationship between therapy and technology is sometimes conflicted, accompanied by skepticism [Citation13] or by an excessive optimism about the benefits that can be derived from the use of new technological devices for neurorehabilitation [Citation14].
2. Technology
The integration between new technologies, recent neuroscientific findings, and conventional rehabilitation techniques is challenging. Often, new technological devices have been commercialized despite the lack of a clear proof of their effectiveness and/or a clear definition of user guidelines.
All technological devices utilized for neurorehabilitation should take into account the so-called laws of neurorobotics [Citation8]: (i) high benefit/risk ratio, (ii) involvement of the therapist into the patient-technological device loop (the device should be a tool in the hands of therapist), and (iii) transparent human–machine interface (technological devices should be an artificial intelligence as a support for human intelligence).
A further suggestion would be that, as specific rules are defined for clinical trials prior to drug commercialization, similar criteria should be defined to assess the efficacy of newly proposed motor rehabilitation treatments [Citation15]. Also, technological devices should undergo the same evaluation road map before their commercialization [Citation8,Citation14].
Moreover, according to the above-mentioned second law, technologies should be a tool in the hands of therapists, with the aim, for example, to boost certain specific aspects of rehabilitation such us intensity, participation, engagement, and feedback. In this scenario, it is central not to consider a technological device as therapeutic ‘per sé’ [Citation16].
3. Translationality
Patients undergoing a comprehensive rehabilitation program require the services provided by a health-care team in terms of comprehensive assessment, treatment planning, treatment delivery, provision of equipment, and fitting of rehabilitative and adaptive devices, in order to pursue the best restoration of functions for each given patient [Citation17]. The rehabilitative team should pledge the interaction of multiple professionals to provide the breadth of services needed by people with physical and cognitive impairments. There is the need of a multidisciplinary team, and we would add the need of professionals with interdisciplinary skills, each one expert in a specific field, but able to actively interact in a proactive manner with other professionals. This would allow the cooperation (and not the competition) of transdisciplinary team. Indeed neurorehabilitation should be based on neuroscience and exploit the products of neuroengineering, in accordance with the principle of translationality.
4. The 3T approach put into practice
Our team, composed of neurologists, physiatrists, therapists, bioengineers, nurses, psychologists, and other professionals, has recently put into practice the 3Ts approach to design and implement a prototype of a neurorehabilitation gymnasium in our Hospital, that is the Scientific Institute for Research, Hospitalization and Health Care. The gymnasium is organized as to reflect and actuate an ideal pathway from most to less disabling condition.
We have included many commercial technological devices, from robots for upper and lower limbs to virtual reality systems, from electromagnetic systems of central and peripheral stimulations to electromechanical systems for mobilization. Furthermore, in accordance with the principle of translationality, the gym is endowed with new devices driven by BCI technology supporting a mental imagery training that has been designed and implemented according to the principles of user-centered design and responsible technology principles [Citation18,Citation19]. Planning this gymnasium, we were aware that just few evidences exist about the higher efficacy of these devices especially with respect to intensive goal-oriented tasks. However, according to the second law of neurorobotics, we have considered each one of these devices as one more chance to give in the hands of the clinical staff and especially physiotherapists. We assert the inappropriateness of testing the efficacy of a device, instead of testing the efficacy of how the device is used. This assertion is in line with previous studies highlighting the importance of identifying the best candidates for each kind of technological rehabilitation solution [Citation20,Citation21]. Analogously, our 3T approach aims at identifying the best therapy for each kind of patient. Among the technological devices, we included instrumented movement analysis systems (inertial measurement units [Citation22], an optoelectronic system for gait analysis, and a baropodometric platform) for an objective progressive assessment of rehabilitation outcomes, and for quantitatively driving the clinical decision-making process.
Hence, the overall aim of our 3T approach is to take into account the different determinants of neurorehabilitation (therapy, technological devices, and translationality) for providing more possibilities of function recovery acting on neuroplasticity.
In this view, technology should not be considered as a panacea for disability, conversely the efficacy of technology-assisted treatments depends on the ability to tailor the right therapeutic strategy on the right person at the right time, as already suggested for robot usage [Citation20,Citation21] or already usually done for drugs. Thus, it is fundamental to identify the prognostic factors (eventually including molecular profiling) for good recovery outcome, factors that could play a different role with respect to different technologies. This approach based on personalized medicine is difficult to test following the principles of evidence-based medicine built on the results of randomized controlled trials. However, we hypothesize that if the twentieth century was the time of the evidence-based medicine, the twenty-first century could be the century of personalized medicine, in which adaptable techniques will provide user-friendly and customized therapies taking into account physical, psychological [Citation23], and even biological factors for translating the more recent neurological discoveries and technological developments into the optimal approach.
The future should carefully take into account the lesson from the past: ‘It’s far more important to know what person the disease has than what disease the person has’ [Hippocrate; Coo, 460 a.D. – Larissa, 377 a.D.].
Declaration of interest
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
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References
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