The introduction of Hybrid Assistive Limb robotic therapy not only speeds up patients’ recovery but also significantly eases the burden on therapists at Normah Medical Specialist Centre. The world’s first cyborg-type robot allows them to track patients’ progress over time.
Innovative Healing
This is the second part of a three-part series on robotic therapy.
Being a therapist is hard work. It requires additional schooling, usually involves long hours, and can be emotionally draining.
However, being a therapist is also incredibly rewarding. Witnessing the tireless efforts and smiling faces of clients who successfully make progress from month to month is a meaningful experience for them.
In addition to assisting patients in their recovery, therapists also act as motivators, tirelessly providing encouragement to their patients.
With the existence of the Hybrid Assistive Limb (HAL) robotic therapy, the first robotic therapy service in Borneo developed by Cyberdyne, it is now easier for therapists at Normah Medical Specialist Centre (NMSC) to track their patients’ progress over time, thanks to the information provided by the robotic device.
In fact, according to Caroline Adriaanse, Chief Physiotherapist/Occupational Therapist at NMSC’s Rehabilitation Department, the HAL devices have significantly increased the number of repetitions a patient can perform over the past two years.
“With the HAL robotic device, we can provide high-intensity training to patients — more repetitions of movement can be performed than with conventional exercises — and we see tremendous recovery in patients within a shorter period of time.
“In fact, that is also the reason why we (NMSC) prefer to use Cyberdyne HAL robot suits compared to other types of robotic devices,” she told Sarawak Tribune.
She also noted that by utilising the HAL robotic device, the therapists noticed reduced physical strain, as they can set a time for a patient to walk on the treadmill with a support system, or the patient can flex and extend their arm or leg in the Single Joint robot without the therapists having to hold their arm or leg.
With that, they were also able to give a concurrent robotic therapy session to another patient without being physically overburdened.
Apart from therapists, Adriaanse said that their patients also enjoy the benefits of this robotic therapy, noting significant improvements, especially when stroke and spinal cord injury patients are referred to them early (less than six months after diagnosis).
“Robotic therapy helps them improve their gait pattern and balance faster than conventional therapy.
“The majority of our patients improve their mobility status from a fully dependent level to being able to ambulate with a walking aid or even walk without any walking aid.
“We have noticed that even patients with chronic stroke who use the robotic devices can develop a better walking pattern and endurance and improve their range of elbow movement.
“The combination of repetitive, task-specific training and feedback accelerates neuroplasticity and motor learning.
“These robotic devices provide external feedback, which helps patients to be more engaged and motivated, as they can see their progress and are more compliant during therapy.
“They are tolerating longer and more intensive rehabilitation sessions with robotic assistance compared to conventional therapy.
“The ability to perform high repetitions may have allowed for faster strength gains and endurance building,” she said.
Say yes to recovering faster
According to Adriaanse, robotic therapy has advantages over conventional therapy, where therapists might become fatigued or introduce variability in repetitions, because robots can maintain exact movement patterns over long periods.
This consistency, she said, helped patients relearn movements more effectively, reinforcing neuroplasticity — the brain’s ability to rewire itself after injury.
“Our walking robot, the HAL Lower Limb, is used together with a body weight support system, which allows patients to engage in walking training at a much earlier stage in a safe environment, even if they don’t have good trunk control and standing endurance yet.
“This is difficult to achieve in conventional therapy, as more manpower is required to support the patient while simultaneously guiding the lower limb movement passively.
“Early intervention is linked to better outcomes, as it prevents secondary complications like muscle atrophy and joint stiffness, promoting faster recovery.
“The HAL Lower Limb can track a patient’s performance over time with high precision. This helps therapists measure range of motion, speed, and assistance provided by the robot, allowing them to adjust treatment and be more goal-oriented in their approach,” explained the chief physiotherapist.
Difficulties working with robots
As patients present with different levels of movement abilities and varying body sizes, Adriaanse noted that the HAL robotic devices must be adjusted to fit comfortably on each patient, ensuring that the assistance provided aligns with the treatment goals.
“The fitting of HAL, especially the Lower Limb type, is complicated and time-consuming. Therefore, therapists must be trained to operate the device.
“Due to the design of the devices, not every patient is suitable for using them. Each candidate must be assessed by the therapist to ensure that the individual is safe to use the device,” she said.
Elaborating, she stressed that not all patients were immediately comfortable with using the HAL robotic devices; some felt anxious about the idea of walking with a robot, as it looks quite cumbersome.
Hence, Adriaanse said that they must begin with a clear explanation and demonstration to reassure such patients about the safety and effectiveness of the therapy.
Apart from that, currently, only four of their therapists have conducted HAL user training. This situation places more demands on those therapists, as the others must rely on them to fit and program the robotic devices.
Therefore, they aim for more therapists to receive HAL user training soon to meet the growing demand.
Regarding malfunctions, she noted that there had only been a few issues with the devices over the last two years.
“On-site, we do not have engineers who can service the devices, so we depend on the technical support team from Cyberdyne in Peninsular Malaysia.
“We are really grateful because they have been wonderful in advising and helping us troubleshoot, and we have learned that it is important to check all the devices daily.
“On top of that, one of the drawbacks of using this robot suit is that the monthly operational cost of the devices is quite high.
“We need to be able to treat enough patients to generate sufficient revenue — this means we must manage a double caseload along with the necessary paperwork.
“Luckily, with strong teamwork, we have overcome many challenges during our first year of operating the robotic therapy.
“Now, we would not want to work without the robotic devices, as all our therapists recognise the benefits of using the Cyberdyne HAL robotic devices on patients and also experience job satisfaction when they observe patients’ improvements,” she pointed out.
Strong spirit necessary to heal oneself
Adriaanse asserted that a patient’s cognitive or mental status could interfere with their ability to engage in therapy or follow instructions.
Additionally, she noted that emotional factors like depression, anxiety, or a lack of motivation may hinder patients’ progress, even with robotic therapy.
She pointed out that some patients undergoing this robotic therapy treatment experience stagnant recoveries because they might not receive therapy as consistently as required due to scheduling difficulties or personal circumstances.
“Breaks in therapy can disrupt progress, as robotic therapy depends on consistent, high-intensity rehabilitation needed for neuroplasticity,” she said.
She claimed that some of their patients live in rural areas, and due to transportation issues, they cannot frequently attend therapy.
As a result, she said their progress is not as good or as fast as that of other outpatients who can attend regular rehabilitation sessions.
Bringing new hope
The first Neuro-Robotics Rehabilitation and Cybernics Centre in Malaysia has been successfully established at the PERKESO Tun Razak Rehabilitation Centre in Melaka by the Social Security Organisation (PERKESO) in partnership with Cyberdyne Inc from Japan.
According to PERKESO’s rehabmalaysia.com website, the facility is outfitted with the HAL Robot Suit, the newest neurorobotic technology from Cyberdyne Inc Japan.
The Chief Executive Officer of Cyberdyne Inc, Prof Dr Yoshiyuki Sankai, invented the robot suit to help people who have suffered spinal cord injuries, strokes, traumatic brain injuries, multiple sclerosis, and neurodegenerative diseases regain their ability to walk, particularly those who are paralysed or have weakened limbs.
Thanks to NMSC’s collaboration with PERKESO, individuals who qualify for the organisation’s benefits are entitled to these robotic sessions without worrying about costs.
With a valid referral from their treating doctor and a successful application, patients will receive a Guarantee Letter from PERKESO, covering all associated expenses.
PERKESO Chief Medical Officer Dr Nur Liyana Kahar told Sarawak Tribune that since the partnership started in September 2022, a total of 114 contributors have been admitted to NMSC for Neuro-Robotics Rehabilitation.
She said that 60 per cent of them had made a successful transition back to employment and a productive life.
“We exclusively provide Neuro-Robotics Rehabilitation treatment to contributors covered by the Invalidity Scheme and Employment Injury Scheme.
“Employers bear the full responsibility of ensuring that every employee is registered with us to provide protection under our schemes. The contributions, however, are paid by both parties.
“Self-employed individuals can opt for the Self-Employment Social Security Scheme, established under the Self-Employment Social Security Act 2017.
“All Malaysian citizens and permanent residents who work for themselves to earn a living, regardless of age, are eligible for this plan.
“Individuals have two options for registering: they can use the Matrix portal or download the Prihatin app,” she explained.
Speaking about the rehabilitation programme application procedure, Dr Nur Liyana said that referrals from treating doctors can be submitted via the PERKESO system.
Additionally, eligible contributors may submit their applications to the nearest PERKESO office, along with the required supporting documentation.
“Applications will be processed immediately, provided that all required documents are complete.
“Upon approval, a guarantee letter will be issued to facilitate their participation in the rehabilitation programme at NMSC.
“Please keep in mind that contributions under our rehabilitation programme will not be accepted from those who do not meet the eligibility requirements or who submit incomplete documents.
“In the meantime, the PERKESO Rehabilitation Centre will review the case and provide additional assistance for cases that require further evaluation,” she explained.
Dr Nur Liyana continued by pointing out that the partnership between the PERKESO Rehabilitation Centre and NMSC marked a noteworthy advancement in Sarawak’s rehabilitation services.
She added that this partnership aimed to improve the quality of care and accessibility for PERKESO’s contributors by employing cutting-edge neuro-robotic technologies.
The initiative also helped ease the financial strain of transportation and medical expenses for individuals in need.
“It is worthwhile to continue this initiative because it greatly improves the quality of care provided to contributors in Sarawak, thereby easing their return to work and reintegration into society.
“The programme’s expansion to more hospitals in Sarawak, however, will depend on how well the existing partnership works, what resources are available, and the overall demand for these services,” she explained.
Meanwhile, speaking about the Cyberdyne robotic suits at NMSC, Adriaanse said their rehabilitation department has three types of devices: the HAL Lower Limb, HAL Single Joint, and HAL Lumbar.
“The Lower Limb type is a gait training device intended to improve ambulation and correct abnormal walking patterns.
“We need to use a body weight support system when using it, such as a treadmill with a body weight support system or a specialised walker called the All in One Walker.
“For the Single Joint type, it is designed for concentrative training of elbow or knee joint movements.
“With the correct setting for the patient, the therapist can target between 100 to 300 repetitions. Consistent repetition helps re-establish communication between the damaged parts of the brain and the body, which is crucial in stroke rehabilitation.
“Meanwhile, the Lumbar type assists the wearer in transitioning from sitting to standing and vice versa, strengthening the core muscles,” she said.
Overall, PERKESO’s contributors in the Land of the Hornbill are extremely fortunate to benefit from these robotic therapy sessions without having to travel far or, more importantly, worry about the cost, thanks to this significant collaboration.
