A framework for aligning the perspectives of device developers, rehabilitation researchers, and clinicians
Robotic device use in rehabilitation has been significantly increasing worldwide over the past 15 years, and yet the evidence and knowledge to maximize effectiveness is still lacking. Despite ongoing efforts, significant disconnects remain between inventors/developers of devices; scientists/researchers who study them; and then the clinician/patient dyad who are the end users. What are the sources of these incongruities, and how can we eliminate them to get all these parties “on the same page” and working together?
Due to differences in education and professional development, the three groups identified above each have unique perspectives from which they consider robotic devices and their application. These differing approaches arise from the professional roles and identities of each group and are unlikely to change. Although viewing a complex enterprise such as motor rehabilitation from different perspectives can be beneficial, the lack of a common framework among these groups is a significant obstacle to maximizing effectiveness. A shared framework among these three groups would facilitate consideration and communication across the enterprise including device development, testing and research, and clinical applications to individuals with motor dysfunction.
To understand what a shared framework such as this might look like, we must first consider the different perspectives that these three groups currently have.
Device developers: A focus on the technology
Developers of devices used for rehabilitation of motor function are focused, of course, on the devices themselves. They have fundamental knowledge of the possibilities that can be provided by continually advancing technology and materials. Importantly, they seek to get input from researchers and clinicians about their needs, although this input may be suboptimal due to the challenges discussed herein. One significant aspect for focus of device development has been increasing the options and customizability of different devices. Developers have heard, primarily from clinicians, that devices must be able to be adjusted or “tuned” to meet differing needs of individuals and are using their technological expertise to build more and more advanced options and parameters into their devices. Whether the options/parameters included are optimal, and how they will be used by the other two groups, is discussed below.
The clinician/patient dyad: A focus on the individual
Here, we identify the clinician and the end-user as one unit, optimally working in a harmonized fashion, representing the endpoint of the application of the device. We first recognize the importance of the patient, or end-user, to whom all the efforts of the rehabilitation enterprise are directed. The patient is the only one who can provide critical feedback about their subjective experience using the device. This may include physical comfort or pain issues, but also includes psychological aspects such as how the use of the device feels. It is important to recognize that this will be highly dependent on expectations provided regarding the device, which will have been provided by the clinician. Thus, although we acknowledge the critical importance of the patient in our model, we identify the clinician as the key focus in this dyad. It is the clinician who will set the expectations of the patient, and, in turn, interpret the subjective reports of the end-user in the context of the use of the device. Furthermore, it is the clinician who, through their clinical expertise, must understand the needs of their individual patient and their individualized dysfunction. They must then be able to identify what they want to achieve for that patient, and how they think a particular device can help them achieve it. Although this focus on the individualized needs of individual patients is an integral focus of the training and experience of clinicians, the process by which this occurs remains hidden.
Clinical reasoning is the term we use to identify what clinicians do, yet this does not tell us how clinicians go about deciding the specifics of the intervention they will apply for a particular patient and how this relates to the individualized presentation of that patient. Much of this process is intuitive and implicit, with the clinician themselves potentially having only partial explicit awareness of this process. Here, again, we can look to an explicit framework through which this process can be considered and communicated, including to our two other groups, the developers, and the researchers.
Rehabilitation researchers: The critical connection
Research scientists should serve as the primary link between the device developers and the clinician. With a foot in both worlds, researchers should be able to understand the technical side of the developers as well as have a grasp on the needs of the patients, the end users. Critically, we also rely on the scientific expertise of researchers to be able to study how the outputs of the developers, the devices themselves, have an impact on the end-user, through the treatment strategies offered by the clinician. First, we try to identify the process by which researchers consider the devices and the particular functions they provide, with their ever-increasing parameters available, and how these align with the needs of the clinician/patient. Again, we recognize the lack of an explicit framework to make this connection. A way to clearly identify how different device options map on to different needs of users would aid researchers in their aim to optimize this connection. Secondly, we recognize a disconnection in the current researcher role. While the randomized controlled trial (RCT) remains the primary tool of researchers, we recognize the control identified here relates to standardizing the way treatments are delivered, so that they can be appropriately analyzed within this model. And yet, this is distinctly at odds with the individualized approach that we have highlighted for the clinician. While the clinician would never consider providing the same treatment to the variable needs and characteristics of different patients, the RCT model requires the researcher to standardize the intervention offered. This, in essence, devalues the individualized needs of the particular patient and the expertise of the clinician in identifying and customizing to these needs. While the rehabilitation research community has begun to recognize these limitations of the RCT and offer more sophisticated options such as adaptive designs and increasingly complex techniques for analysis of interventions, this is an area which needs further attention.
Andrew PACKEL
Andrew PACKEL
Physical Therapist, Neurology Certified Specialist
Andrew Packel is a board-certified specialist in neurologic physical therapy with extensive experience working with stroke and traumatic brain injury patients. He currently works at MossRehab and has a particular interest in optimizing interventions to improve walking, including the use of robotics and technology. He has been involved in many research projects and publications and has given presentations on these topics.
2 Responses
As for the attached article, it is well written. I do not necessarily agree with the point, that having a standardisation in RCT eliminates any individualised approach. However, that is the author’s opinion and it is a white-paper, so they do not need to pass peer review – and he did invite the readers to respond to his statement/question. So, I think it is great.
Here are some few comments from me:
1. The problem covered in the document is a very relevant and complex problem.
2. One thing that needs to be added to this discussion is how people who pay for the therapies align with the three components/groups the paper discusses. The selected three groups of people are very relevant, but in my books, the most important is the one who is paying for it all, and this is healthcare systems or third-party payers. This should be discussed in the document. These people have to be considered, if not in the first place, then definitively among the most relevant individuals/groups that are defining how this entire field will evolve. The entire story becomes irrelevant if they have no incentives to pay for the therapy/devices.
3. The document opens the topic for discussion and puts some of the elements that need to be discussed, but it needs to provide concrete and specific answers on how to address the problems identified. I was expecting hard-core recommendations. Maybe this is what you want to get to during subsequent meetings. However, I would instead propose the solutions and have people argue about the proposed solutions and complain about them, than leave it open to a discussion because then one cannot control that discussion as well as when some concrete answers are already offered.
4. Also, the definition of the developer vs researcher relationship may not be the most accurate one. The author assumes that the developer is not a researcher. This assumption may not be accurate as the first robotic systems were all developed by researchers. It was only in generations 2 and 3 of the robotic systems that the developers, who were not scientists themselves, started developing systems. Also, there are two types of researchers – (i) those who are engineers and have developed the systems and may or may not have tested them with patients, and (ii) those researchers who are clinicians and potential users and who typically do RCTs and trials with devices but do not fundamentally understand the engineering aspects of the technology.