How physiotherapy tools equipped with robots are paving the way for faster recovery of neurological patients

Representational image. IANS

A neurological injury is an injury to the brain or spinal cord or even the peripheral nerves. It has devastating consequences on the sufferer. These can be acquired or could be the result of a traumatic event such as a fall or a road traffic accident. The five most common neurological conditions (the “big 5”) are Stroke, spinal cord injuries, traumatic brain injuries, multiple sclerosis and Parkinson’s disease. At present India has the highest rate of head injuries in the world, with more than one million individuals having serious head injuries.

When a neurological injury occurs chances of healing of the damaged part are slim to non-existent (unlike muscles and bones, neurological tissues do not heal). Some neurological injuries are so severe that neuro-surgical treatment is required. For instance, if a brain hemorrhage is so large that it is causing life threatening complications then it has to be surgically evacuated. Traumatic brain injuries and traumatic spinal cord injuries usually need surgical stabilization and that too preferably within the “golden hour”.

Most neurological injuries result in paralysis, partial or complete

Paralysis, or inability to move one’s limbs to desire, is one the major fallouts of a neurological injury. For those who suffer from a cardiac event or heart attack, if the individual reaches a hospital on time and survives the episode they usually walk out of the hospital after discharge and slowly resume their lives. Comparatively those individuals with a neurological injury are wheeled out of the hospital in a wheelchair with an accompanying caregiver or nurse since they are unable to physically look after themselves, walk, talk or sometimes even comprehend normally. Their discharge marks the beginning of hours, days, weeks and months of neurological rehabilitation.

Hours of therapy (movement therapy- whether physical or occupational therapy) have to be put in during the “golden period”. This is usually the first 3-6 months’ post event- since recovery is at its peak at this time.

What is recovery based on? Motor re-learning. Or simply put to teach the non-damaged parts of the brain and spinal cord to take over function by sprouting new pathways. This is an oversimplified definition of neuroplasticity that forms the basis of recovery from neurological damage.

Therapy aims at achieving sitting, standing, walking, grasping and reaching. These actions then form the basis of most activities of daily living such as combing one’s’ hair, shaving, walking to the toilet amongst others.

For those individuals who have undergone brain or spine surgery, acute care rehabilitation is begun in the Intensive Care Unit at the bedside immediately post-surgery. They are then made to practise sitting Once this is achieved then acclimation to standing begins.

Once they are able to sit, they can start practising reach and grasp activities and fine motor skills. Once they are acclimated to standing, they can be further taken on for robotic gait training.

Just like a child falls several times before they learn to walk fluently and also swimming, cycling, driving and other activities need practice before they are “learnt”- motor relearning after a neurological injury takes immense and intense amounts of practice.

Practice means repetition

Repetition is the mother of learning and the father of action which makes it the architect of accomplishment – Zig Ziglar

Robot assisted rehabilitation provides a far higher quantity of repetitions than manual therapy does. Brain-computer Interface interprets and translates brain activity into controlled signals of an external device- for instance an exo-skeleton or an end effector type robot. There are robots that train walking (gait training) and there are those that train reaching out and those that train the fine motor skills that are needed for say, grasping a potato chip and eating it or typing on a keyboard or combing one’s hair.

Robots have the capacity to deliver high intensity and high dosage training protocols that are quantifiable. They work on the principle of active observation and proprioceptive feedback. Robot assisted movement is “seen” and the brain uses this as a learning tool. Secondly even passively performed movements by the robot provide proprioceptive and haptic feedback to the brain which further enhances recovery.

Assistive exoskeletons are effective clinical tools to improve quality of life in severely paralysed patients. These are used in daily clinical applications to enhance neuroplasticity which is associated with neurological recovery.

The biggest advantage of neuro-technology is repetition which enables motor re-learning. A word of caution: robotics or other forms of neurotechnology are not magical restoration of neurologically damaged parts and should not be portrayed as such. A recent write up by Liam Drew in Nature (Abandoned: the human cost of neurotechnology Failure-December 2022) explores this aspect.

Even if robotic rehabilitation does not promise return to normalcy, there are several advantages this therapy offers to the severely afflicted paralyzed patient. These include the benefits that antigravity postures such as standing and walking confer to humans- increase in bone density, improved bowel movements, decrease in pain, improved cholesterol and sugar metabolism, less rate of cardiovascular diseases, reduction of spasticity, decreased tendency to pressure sores.

At present there are more pros than cons to robot assisted rehabilitation and it does seem to be the way of the present and the near future of neurological rehabilitation.

It is crucial to combine robotic rehabilitation with other therapeutic modalities in order to provide feedback and motivation to the patient. It is important for the patient to value meted out therapy in order for it to be effective. Seeing is after all believing.

Neurotechnology has grown 500 per cent in the last 10 years and is expected to expand much further in the coming decade. The next challenge would be to set up biomarkers or an algorithm that monitors therapy meted out by the plethora of robots that are available today in order to find the most effective ones. Robotic rehabilitation is not a replacement of human therapists. It is a very useful adjunct to neurological rehabilitation.

The author is a Consultant Physiotherapist and Team-Lead Neurological Rehabilitation, SIr H N Reliance Foundation Hospital, Mumbai. Views expressed are personal. 

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