PHARMACY & TECHNOLOGY The THERA-Trainer Complete Solution for Gait Rehabilitation Redesigning clinical treatment pathways for a best practice model for modern gait training Jakob Tiebel, Melanie Grom hat factors are particularly Neurological symptoms on the rise are becoming increasingly important important for successful in order to reduce the consequences W mobility rehabilitation fol- After decades of very little change in of neurological diseases and to achie- lowing a stroke? Which rehabilitation the healthcare system, in recent years ve the best possible reintegration into measures have been proven to improve change has become one of the only re- daily life, employment and society, balance, standing and walking ability? maining constants [30]. The structural whilst keeping costs at a reasonable le- What are the most likely strengths and developments of an ageing society, the vel [35]. Experts overwhelmingly agree what opportunities will there be for increase in chronic diseases and the that this requires thorough optimisati- rehabilitation facilities by being more onward march of medical and techno- on in terms of effectiveness, transpa- open to change? What are the current logical progress have led to fundamen- rency and economic efficiency in order weaknesses and what risks need to be tal changes in the requirements of re- to guarantee high-quality care, despite avoided? habilitation medicine. The shift in the the tough financial conditions [1]. morbidity spectrum towards chronic In particular, the use of quality-as- The restructuring taking place in the diseases means that neurological sym- surance evidence-based measures is German healthcare system over recent ptoms and syndromes, in particular, being discussed as a potential soluti- years has resulted in increasingly com- are on the increase. The most common on [1], whereby it must be noted that petitive conditions among hospitals treatments are for age-related diseases the process of quality generation must and rehabilitation units [4]. A willing- such as stroke, common illnesses such inevitably be accompanied by a rest- ness to change is required in order to as polyneuropathy, neurodegenerative ructuring of context-relevant process survive as a competitor against other diseases including Parkinson‘s disea- flows in order to reconcile „values“ service providers in the long term. He- se and autoimmune diseases such as and „value“, i.e. a focus both on values althcare reforms have brought about multiple sclerosis [2, 28, 35]. Stroke from a medical and therapeutic point significant changes in management in particular is one of the most signifi- of view and value in the sense of go- and business administration. This has cant diseases in western industrialised al-oriented economic activity [31]. put many departments under pres- nations. It is one of the most common In this regard, healthcare facilities sure. There is a need for far-reaching causes of permanent restrictions to in- generally face more difficulties than, restructuring measures, which must dependence and quality of life [15, 27]. for example, purely business-oriented at least match the speed and scope of Taking into account the additional companies. Healthcare facilities have change in environmental factors and costs incurred from the loss of pro- much more complex characteristics. framework conditions [29, 34]. Opti- ductivity, stroke is the disease with The organisational structure of reha- misation measures have to be initiated the highest burden on the healthca- bilitation departments is usually based and successfully implemented at light- re system [8]. The epidemiological around functional units instead of pro- ning speed, since – just as in Darwin‘s data on strokes and other neurolo- cesses, and in patient care, the demand theory of evolution – those who will gical diseases forms an important for individuality is still higher than for survive in the long term are not the basis for planning future care needs standardisation. In many departments, ones who are largest and who defy and using existing potential for op- especially in the therapeutic discip- everything, but the ones who manage timisation, since the costs of treat- lines, there is also a lack of focus on to adapt fastest and most effectively to ment, rehabilitation and care are an business-oriented targets [4]. the changing conditions. As a result, increasing challenge for the health- those who wish to remain successful care system [15, 35]. Paradigm shift thanks will need to change faster in the com- to plasticity petitive environment, become more Values and value in therapy targeted, and develop more sustainably With regard to an evidence base, the – and those who do not move with the Given this background, questions re- proof that lifelong plasticity of the times will be left standing [29]. lating to effectiveness and efficiency nervous system forms the basis of Neurologie & Rehabilitation Supplement 1 - 2017 | S61 PHARMACY & TECHNOLOGY functional motor rehabilitation is one literature had not existed until then. with existing resources if the current of the decisive catalysts for the para- No other guideline provides such clear standard of therapy is not only to be digm shift in neurorehabilitation. Due and differentiated recommendations maintained, but even improved, given to the scientific findings on the ability for therapy for patients who are initi- the same funding base [9]. In clinical of the central nervous system to reor- ally unable to walk or whose walking practice, however, it has been shown ganise and the effectiveness of thera- is restricted in the acute, subacute or that on average, patients tend to recei- peutic interventions, neurology has chronic stage following a stroke [24]. ve too little therapy, are doing physical developed over the last 25 years from activity for less than two-thirds of the a discipline of observation to one of Device-based therapy vs. customised time within one treatment session, treatment [10]. The implementation individual treatment and do not achieve the number of of clinical approaches based on evi- repetitions necessary for changes in dence and guidelines has become in- Due to an explicit requirement for the neuroplasticity. Whether the focus of creasingly important. The knowledge use of electromechanical gait trainers, treatment is on the frequent repetition of neuroplasticity has cleared the way treadmills and similar, their import- of a functional activity depends very to use treatment techniques in a targe- ance in physiotherapy has increased much on the setting and the expertise ted manner to favourably influence the significantly. However, the possibili- and personal motivation of the treating restitution of functions after damage to ties that result from the targeted use therapist [16]. the brain. And so the view of the pati- of the apparatus are far from exhaus- ent has also changed fundamentally in ted. Even if the devices are available in Knowledge transfer – motor therapy [18]. Traditional treat- clinical departments, they are usually a big hurdle ment methods are increasingly rece- used only sporadically in gait therapy. ding [19]. They are being replaced by On the one hand, this is due to a lack The successful implementation of evi- approaches to treatment that are scien- of integration into the clinical routine dence-based guidelines into clinical tifically investigated, heavily geared to and, on the other hand, to the fact that practice does not appear to be quite models of learning theory and are far customised treatment is still regarded as trivial as commonly thought. In the more effective [18, 33]. as the higher-quality form of therapy specialist literature, various strategies and is therefore preferred [14]. The for implementation are set out and, in Differentiated recommen- modern device-based therapy pro- part, the subject of heated debates [11, dations for therapy cesses still contrast strongly with the 12, 13]. In general, a „mixed teaching usual ways of working in neuroreha- strategy“ is recommended, aimed at The treatment spectrum has also con- bilitation, which still tends to be do- ensuring effective knowledge transfer tinued to expand over the last decade minated by manual activities, close into clinical practice [13]. In this re- due to the use of device-based thera- contact with the patient and a holistic gard, Mehrholz refers to an implemen- pies and modern technologies [7]. In perspective on the treatment process. tation model by Lomas and Kitson, particular, there is good evidence for who propose a „teaching strategy via electromechanical-assisted standing Correct treatment focus? knowledge transfer“ [17, 21]. Under and gait therapy. In December 2015, this arrangement, the results from the guideline of the DGNR for the re- This is not only a business problem but science, research and development are habilitation of mobility after stroke also a therapeutic one. As important consistently integrated into the the- („ReMoS“) was published. In syste- predictors for achieving a positive out- rapeutic decision-making processes, matic literature research, the working come, in terms of keeping the degree with training being given without fail group reviewed more than 1,500 scien- of disability to a minimum following in the practical application [32]. But tific publications and selected around neurological damage, the earliest pos- who is available for these services? It 200 randomised controlled studies and sible initiation of therapy [6] and the seems that this