Expert view: The future of rehab robotics

With over 20 years experience in the medical device industry, Stephen Ruffle, commercial director at Thor Assistive Technologies, has been a key player in bringing some of the major breakthroughs of the sector to those who need them most. He sat down with NR Times to share his insights.

Starting out as a wheelchair designer, before becoming a mobility specialist and eventually investigating the emergence of Exoskeleton devices, Stephen Ruffle, has seen some significant technological advances in neurorehabilitation over the last two decades.

Over the course of his career, Stephen has introduced a number of new neurorehabilitation devices to the UK from around the world, including the ReWalk 6.0 Personal Exoskeleton in 2015, helping them reach the patients who stand to benefit.

He went on to establish Thor Assistive Technologies with his business partner Neil Shorthouse, which trains, supports and supplies its partners with innovative rehabilitation devices, based on using robotics to improve exercise dose, repetitions and engagement - all of which has been proven to help build neuroplasticity and improve overall recovery.

Here, Stephen, discusses the important role that these devices have in neurorehab, the major breakthroughs he has seen, and the challenges still to be tackled by the market.

NRT: Stephen, it’s now eight years since you introduced the ReWalk to the UK market, what changes have you seen in that time in regards to patient accessibility?

SR: At that point, a lot of the focus was on personal exoskeletons, the ReWalk, for example, is specifically designed to be a personal exoskeleton for everyday use. But alongside that, you've also now got a range of exoskeletons that are specifically designed for rehabilitation in clinical settings.

I spent two or three years doing talks about neuroplasticity and repetitions intensity, to demonstrate how these devices can improve outcomes for people with neurorehabilitation needs.

Now that seems to be accepted. I'm not finding that I have to convince people that using robotic therapies increases repetitions and the ability to improve neuroplasticity. The studies have been done, it's a proven system. Now, a lot of clinics are recognising the need to move in this direction. We are now introducing 2 new ExoSkeletons to the UK and Ireland Market, the ExoMotus M4 from Fourier Intelligence and the ExoAtlet II. Both offer unique features crucial to Rehabilitation and take the technology to a new level.

The amount of individuals that have either the funding, or the inclination, to get their own personal exoskeleton is obviously a far smaller market but it still exists.

NRT: Can you talk a bit more about the benefits of these devices?

SR: The one thing that's unique with the exoskeleton is the ability to actually impact the bone which helps to maintain bone mass. That's something that's almost impossible to recreate anywhere else, and has been proven in a number of studies.

Then there are the associated benefits of standing and walking, including things like bowel and bladder regime changes, respiration, digestion and spasm relief.

Physical activity also helps to prevent the hamstrings from shrinking, for example, so it helps people to keep themselves viable for whatever may happen in the future.

Some people want to go down this route for practical reasons. I had a farmer, for example, who wanted to use his device where he couldn't access his wheelchair.

More commonly I have also had people suffering very severe spasms, who are on a lot of medication. Regular walking helps in reducing that medication and enables them to deal with the situation naturally.

When we talk about recovery, particularly in relation to spine injury, there's no cure at the moment for paralysis, but there are medical benefits and even for people's mental health. The fact that they feel like they are participating has a really positive effect.

NRT: Do you find there is a lot more research to support these benefits now?

SR: Yes, we have completed clinical trials and I'd say most manufacturers now, if they have their CE mark, will generally have some clinical data, in which they can prove against control groups, the improvements that they've seen, whether it be in stroke or MS spasticity, as they tend to be focused in one way or the other.

NRT: What are the main challenges preventing wider take-up of these devices?

SR: There can be a reluctance to pursue exoskeletons. They're not for everybody and after their injury people have to adjust to their new situation, they need to learn wheelchair skills, for example, as they are going to spend most of their time in that situation.

I think it’s when people move further into their neurorehabilitation process that they recognise the medical benefits associated with using exoskeletons.

[However,] the main difficulty facing most of the equipment is the price point. Most of these products are still produced in quite low volumes and it goes without saying that if you're making fewer components, it makes it more expensive.

NRT: What is being done to tackle this problem and try to bring costs down?

SR: We have seen an improvement recently. I'm seeing a couple of devices coming onto the market, from countries such as Italy and Spain, that are trying to bring the price point down.

Elsewhere, Fourier Intelligence is building a portfolio of products and reengineering them with common components.

The more that the industry can work together, not only does it mean that you can bring costs down, but you get a commonality, so if one physio understands the ARM device, they will also be able to understand the wrist device and the ankle device, which I think is really key.

NRT: Is there anything in particular that Thor Assistive Technologies is doing to tackle this?

SR: We are now starting to offer a Rental and Lease service to help make the devices more accessible.
We've run trials with a couple of centres now.

The equipment attracts people to the facility and they can see three or four people a day and charge them accordingly, so over the month we can show that a rental can bring in a significant profit for the business.

For most places it is all about cash flow and expenditure. There are some advantages with renting, in that it doesn't become a capital expense and the service will be maintained throughout the rental period. It allows a lot more flexibility in that facility, they can see which devices generate interest and that tends to encourage them to expand.

NRT: What do you think are the most exciting areas of technological development at the moment?

SR: We are starting to do a lot of work now with electromyography, or EMG. If you've got somebody who's had a stroke or is paralysed with brachial plexus injury, for example, if the person initiates the thought of movement, so they want to lift their arm, the brain sends an electrical signal to the muscle. The most exciting products in this field are the Luna EMG and Stella Bio from EgzoTech

If that muscle signal is damaged, like in a brachial plexus, they won't have the ability to lift their arm, but the signal from the brain that still goes to the bicep. What an EMG device does, it picks up the intent, and then the robotics reward by lifting the arm.

On the rehab side of things, the brain sends the signal to the muscle, it’s picked up and rewarded and then the brain gets the positive feedback which can help in that relearning process.

Now we're integrating EMG into robotics so that the signal can then be transferred to movement, which can really help somebody with very limp, placid limbs.

NRT: What do you think the future holds for the market?

SR: With exoskeletons the focus is on trying to get them lighter, easier to use and less expensive. I think it has reached that point where the development is there, it's proven that people can walk independently with an exo and now it comes down to the cost and practicality.

I’m probably most excited about EMG and I know there's a lot of work going on at the moment with brain implants as well. Most people with a brachial plexus injury, for example, will have the option to have their arm amputated, because in reality, it’s a lost limb.

Whereas, if we can offer them movement through an exoskeleton, Stimulation or rehabilitation robotics, there's no reason why you can't implant that technology. In the future, that's what we'll be looking at.

The moment you can show people that they do have activity, that gives them the encouragement of knowing there is something there to work with.

In five years time, we may be looking at exoskeletons and saying, ‘remember when we used to strap people into robots?’.

Thor Assistive Technologies will be attending various events including Naidex 2024, the MINT conference organised by Hobbs Rehabilitation in London in April and ACPIN during May to demonstrate their innovative product range.