THERAPY-Magazin
Redesigning clinical treatment pathways for a best practice model for modern gait training
Discover how THERA-Trainer’s Complete Solution helps clinics modernize gait rehabilitation. By integrating evidence-based protocols and technology, therapy becomes more efficient, patient-centered, and economically sustainable—boosting outcomes and satisfaction.
Jakob Tiebel
Business Owner, N+ Digital Health Agency
What factors are particularly important for successful mobility rehabilitation following a stroke? Which rehabilitation measures have been proven to improve balance, standing and walking ability? What are the most likely strengths and what opportunities will there be for rehabilitation facilities by being more open to change? What are the current weaknesses and what risks need to be avoided?
The restructuring taking place in the German healthcare system over recent years has resulted in increasingly competitive conditions among hospitals and rehabilitation units [4]. A willingness to change is required in order to survive as a competitor against other service providers in the long term. Healthcare reforms have brought about significant changes in management and business administration. This has put many departments under pressure. There is a need for far-reaching restructuring measures, which must at least match the speed and scope of change in environmental factors and framework conditions [29, 34]. Optimisation measures have to be initiated and successfully implemented at lightning speed, since – just as in Darwin’s theory of evolution – those who will survive in the long term are not the ones who are largest and who defy everything, but the ones who manage to adapt fastest and most effectively to the changing conditions. As a result, those who wish to remain successful will need to change faster in the competitive environment, become more targeted, and develop more sustainably – and those who do not move with the times will be left standing [29].
The restructuring taking place in the German healthcare system over recent years has resulted in increasingly competitive conditions among hospitals and rehabilitation units [4]. A willingness to change is required in order to survive as a competitor against other service providers in the long term. Healthcare reforms have brought about significant changes in management and business administration. This has put many departments under pressure. There is a need for far-reaching restructuring measures, which must at least match the speed and scope of change in environmental factors and framework conditions [29, 34]. Optimisation measures have to be initiated and successfully implemented at lightning speed, since – just as in Darwin’s theory of evolution – those who will survive in the long term are not the ones who are largest and who defy everything, but the ones who manage to adapt fastest and most effectively to the changing conditions. As a result, those who wish to remain successful will need to change faster in the competitive environment, become more targeted, and develop more sustainably – and those who do not move with the times will be left standing [29].
According to Darwin’s theory of evolution, those who manage to adapt most quickly to changing conditions will prevail in the long term.
Neurological symptoms on the rise
After decades of very little change in the healthcare system, in recent years change has become one of the only remaining constants [30]. The structural developments of an ageing society, the increase in chronic diseases and the onward march of medical and technological progress have led to fundamental changes in the requirements of rehabilitation medicine. The shift in the morbidity spectrum towards chronic diseases means that neurological symptoms and syndromes, in particular, are on the increase. The most common treatments are for age-related diseases such as stroke, common illnesses such as polyneuropathy, neurodegenerative diseases including Parkinson’s disease and autoimmune diseases such as multiple sclerosis [2, 28, 35]. Stroke in particular is one of the most significant diseases in western industrialised nations. It is one of the most common causes of permanent restrictions to independence and quality of life [15, 27].
Taking into account the additional costs incurred from the loss of productivity, stroke is the disease with the highest burden on the healthcare system [8]. The epidemiological data on strokes and other neurological diseases forms an important basis for planning future care needs and using existing potential for optimisation, since the costs of treatment, rehabilitation and care are an increasing challenge for the healthcare system [15, 35].
After decades of very little change in the healthcare system, in recent years change has become one of the only remaining constants [30]. The structural developments of an ageing society, the increase in chronic diseases and the onward march of medical and technological progress have led to fundamental changes in the requirements of rehabilitation medicine. The shift in the morbidity spectrum towards chronic diseases means that neurological symptoms and syndromes, in particular, are on the increase. The most common treatments are for age-related diseases such as stroke, common illnesses such as polyneuropathy, neurodegenerative diseases including Parkinson’s disease and autoimmune diseases such as multiple sclerosis [2, 28, 35]. Stroke in particular is one of the most significant diseases in western industrialised nations. It is one of the most common causes of permanent restrictions to independence and quality of life [15, 27].
Taking into account the additional costs incurred from the loss of productivity, stroke is the disease with the highest burden on the healthcare system [8]. The epidemiological data on strokes and other neurological diseases forms an important basis for planning future care needs and using existing potential for optimisation, since the costs of treatment, rehabilitation and care are an increasing challenge for the healthcare system [15, 35].
Values and value in therapy
Given this background, questions relating to effectiveness and efficiency are becoming increasingly important in order to reduce the consequences of neurological diseases and to achieve the best possible reintegration into daily life, employment and society, whilst keeping costs at a reasonable level [35]. Experts overwhelmingly agree that this requires thorough optimisation in terms of effectiveness, transparency and economic efficiency in order to guarantee high-quality care, despite the tough financial conditions [1].
In particular, the use of quality-assurance evidence-based measures is being discussed as a potential solution [1], whereby it must be noted that the process of quality generation must inevitably be accompanied by a restructuring of context-relevant process flows in order to reconcile “values” and “value”, i.e. a focus both on values from a medical and therapeutic point of view and value in the sense of goal-oriented economic activity [31]. In this regard, healthcare facilities generally face more difficulties than, for example, purely business-oriented companies. Healthcare facilities have much more complex characteristics. The organisational structure of rehabilitation departments is usually based around functional units instead of processes, and in patient care, the demand for individuality is still higher than for standardisation. In many departments, especially in the therapeutic disciplines, there is also a lack of focus on business-oriented targets [4].
Given this background, questions relating to effectiveness and efficiency are becoming increasingly important in order to reduce the consequences of neurological diseases and to achieve the best possible reintegration into daily life, employment and society, whilst keeping costs at a reasonable level [35]. Experts overwhelmingly agree that this requires thorough optimisation in terms of effectiveness, transparency and economic efficiency in order to guarantee high-quality care, despite the tough financial conditions [1].
In particular, the use of quality-assurance evidence-based measures is being discussed as a potential solution [1], whereby it must be noted that the process of quality generation must inevitably be accompanied by a restructuring of context-relevant process flows in order to reconcile “values” and “value”, i.e. a focus both on values from a medical and therapeutic point of view and value in the sense of goal-oriented economic activity [31]. In this regard, healthcare facilities generally face more difficulties than, for example, purely business-oriented companies. Healthcare facilities have much more complex characteristics. The organisational structure of rehabilitation departments is usually based around functional units instead of processes, and in patient care, the demand for individuality is still higher than for standardisation. In many departments, especially in the therapeutic disciplines, there is also a lack of focus on business-oriented targets [4].
According to experts, effectiveness, transparency and efficiency must be optimised in order to ensure continued high-quality care.
Paradigm shift thanks to plasticity
With regard to an evidence base, the proof that lifelong plasticity of the nervous system forms the basis of functional motor rehabilitation is one of the decisive catalysts for the paradigm shift in neurorehabilitation. Due to the scientific findings on the ability of the central nervous system to reorganise and the effectiveness of therapeutic interventions, neurology has developed over the last 25 years from a discipline of observation to one of treatment [10]. The implementation of clinical approaches based on evidence and guidelines has become increasingly important. The knowledge of neuroplasticity has cleared the way to use treatment techniques in a targeted manner to favourably influence the restitution of functions after damage to the brain. And so the view of the patient has also changed fundamentally in motor therapy [18]. Traditional treatment methods are increasingly receding [19]. They are being replaced by approaches to treatment that are scientifically investigated, heavily geared to models of learning theory and are far more effective [18, 33].
With regard to an evidence base, the proof that lifelong plasticity of the nervous system forms the basis of functional motor rehabilitation is one of the decisive catalysts for the paradigm shift in neurorehabilitation. Due to the scientific findings on the ability of the central nervous system to reorganise and the effectiveness of therapeutic interventions, neurology has developed over the last 25 years from a discipline of observation to one of treatment [10]. The implementation of clinical approaches based on evidence and guidelines has become increasingly important. The knowledge of neuroplasticity has cleared the way to use treatment techniques in a targeted manner to favourably influence the restitution of functions after damage to the brain. And so the view of the patient has also changed fundamentally in motor therapy [18]. Traditional treatment methods are increasingly receding [19]. They are being replaced by approaches to treatment that are scientifically investigated, heavily geared to models of learning theory and are far more effective [18, 33].
Modern device-based therapy processes still contrast heavily with the usual ways of working in neurorehabilitation.
Differentiated recommendations for therapy
The treatment spectrum has also continued to expand over the last decade due to the use of device-based therapies and modern technologies [7]. In particular, there is good evidence for electromechanical-assisted standing and gait therapy. In December 2015, the guideline of the DGNR for the rehabilitation of mobility after stroke (“ReMoS”) was published. In systematic literature research, the working group reviewed more than 1,500 scientific publications and selected around 200 randomised controlled studies and systematic reviews in accordance with the highest quality criteria and incorporated these into the guideline. The use of conventional and electromechanical-assisted gait therapy in particular, as well as the targeted training of strength, endurance and balance with regard to improving standing and walking ability in the different stages following a stroke, were investigated on the basis of the data. Such an intensive and differentiated analysis of available literature had not existed until then. No other guideline provides such clear and differentiated recommendations for therapy for patients who are initially unable to walk or whose walking is restricted in the acute, subacute or chronic stage following a stroke [24].
The treatment spectrum has also continued to expand over the last decade due to the use of device-based therapies and modern technologies [7]. In particular, there is good evidence for electromechanical-assisted standing and gait therapy. In December 2015, the guideline of the DGNR for the rehabilitation of mobility after stroke (“ReMoS”) was published. In systematic literature research, the working group reviewed more than 1,500 scientific publications and selected around 200 randomised controlled studies and systematic reviews in accordance with the highest quality criteria and incorporated these into the guideline. The use of conventional and electromechanical-assisted gait therapy in particular, as well as the targeted training of strength, endurance and balance with regard to improving standing and walking ability in the different stages following a stroke, were investigated on the basis of the data. Such an intensive and differentiated analysis of available literature had not existed until then. No other guideline provides such clear and differentiated recommendations for therapy for patients who are initially unable to walk or whose walking is restricted in the acute, subacute or chronic stage following a stroke [24].
Device-based therapy vs. customised individual treatment
Due to an explicit requirement for the use of electromechanical gait trainers, treadmills and similar, their importance in physiotherapy has increased significantly. However, the possibilities that result from the targeted use of the apparatus are far from exhausted. Even if the devices are available in clinical departments, they are usually used only sporadically in gait therapy. On the one hand, this is due to a lack of integration into the clinical routine and, on the other hand, to the fact that customised treatment is still regarded as the higher-quality form of therapy and is therefore preferred [14]. The modern device-based therapy processes still contrast strongly with the usual ways of working in neurorehabilitation, which still tends to be dominated by manual activities, close contact with the patient and a holistic perspective on the treatment process.
Due to an explicit requirement for the use of electromechanical gait trainers, treadmills and similar, their importance in physiotherapy has increased significantly. However, the possibilities that result from the targeted use of the apparatus are far from exhausted. Even if the devices are available in clinical departments, they are usually used only sporadically in gait therapy. On the one hand, this is due to a lack of integration into the clinical routine and, on the other hand, to the fact that customised treatment is still regarded as the higher-quality form of therapy and is therefore preferred [14]. The modern device-based therapy processes still contrast strongly with the usual ways of working in neurorehabilitation, which still tends to be dominated by manual activities, close contact with the patient and a holistic perspective on the treatment process.
Correct treatment focus?
This is not only a business problem but also a therapeutic one. As important predictors for achieving a positive outcome, in terms of keeping the degree of disability to a minimum following neurological damage, the earliest possible initiation of therapy [6] and the highest possible intensity of therapy is described [20, 23]. A daily treatment duration of up to three hours is recommended, depending on the patient’s physical capacity [3]. Studies on the dose-response relationship have shown that providing more therapy time and maximizing active exercise-oriented training time can significantly improve the functional outcome of neurological patients [9, 20]. Therapists are therefore called upon to boost performance with existing resources if the current standard of therapy is not only to be maintained, but even improved, given the same funding base [9]. In clinical practice, however, it has been shown that on average, patients tend to receive too little therapy, are doing physical activity for less than two-thirds of the time within one treatment session, and do not achieve the number of repetitions necessary for changes in neuroplasticity. Whether the focus of treatment is on the frequent repetition of a functional activity depends very much on the setting and the expertise and personal motivation of the treating therapist [16].
This is not only a business problem but also a therapeutic one. As important predictors for achieving a positive outcome, in terms of keeping the degree of disability to a minimum following neurological damage, the earliest possible initiation of therapy [6] and the highest possible intensity of therapy is described [20, 23]. A daily treatment duration of up to three hours is recommended, depending on the patient’s physical capacity [3]. Studies on the dose-response relationship have shown that providing more therapy time and maximizing active exercise-oriented training time can significantly improve the functional outcome of neurological patients [9, 20]. Therapists are therefore called upon to boost performance with existing resources if the current standard of therapy is not only to be maintained, but even improved, given the same funding base [9]. In clinical practice, however, it has been shown that on average, patients tend to receive too little therapy, are doing physical activity for less than two-thirds of the time within one treatment session, and do not achieve the number of repetitions necessary for changes in neuroplasticity. Whether the focus of treatment is on the frequent repetition of a functional activity depends very much on the setting and the expertise and personal motivation of the treating therapist [16].
Knowledge transfer – a big hurdle
The successful implementation of evidence-based guidelines into clinical practice does not appear to be quite as trivial as commonly thought. In the specialist literature, various strategies for implementation are set out and, in part, the subject of heated debates [11, 12, 13]. In general, a “mixed teaching strategy” is recommended, aimed at ensuring effective knowledge transfer into clinical practice [13]. In this regard, Mehrholz refers to an implementation model by Lomas and Kitson, who propose a “teaching strategy via knowledge transfer” [17, 21]. Under this arrangement, the results from science, research and development are consistently integrated into the therapeutic decision-making processes, with training being given without fail in the practical application [32]. But who is available for these services? It seems that this problem is still not resolved and is largely left to the commitment of individuals.
The successful implementation of evidence-based guidelines into clinical practice does not appear to be quite as trivial as commonly thought. In the specialist literature, various strategies for implementation are set out and, in part, the subject of heated debates [11, 12, 13]. In general, a “mixed teaching strategy” is recommended, aimed at ensuring effective knowledge transfer into clinical practice [13]. In this regard, Mehrholz refers to an implementation model by Lomas and Kitson, who propose a “teaching strategy via knowledge transfer” [17, 21]. Under this arrangement, the results from science, research and development are consistently integrated into the therapeutic decision-making processes, with training being given without fail in the practical application [32]. But who is available for these services? It seems that this problem is still not resolved and is largely left to the commitment of individuals.
Search for orientation in therapy
Many clinics are still far from meeting the requirements of the theoretical models given in the literature. The therapists involved in the treatment would have to be given much more consistent and effective specialist knowledge. Finally, the paradigm shift has led to a completely altered understanding of the role of therapists [7]. For many therapists, the structural changes in clinical practice and the lack of knowledge transfer are triggering a search for orientation. Habitual, learned approaches in treatment, which were considered correct, are suddenly being called into question, and concerns that in future modern treatment robots might take over differentiated therapeutic work entirely and make specialist therapeutic skills superfluous often lead to “rejection out of self-preservation” [5, 25]. Individualised treatment will continue to be a key component in the therapy strategy. It can only be optimized and supported by the standardization of treatment pathways and the use of technology-based procedures that comply with the guidelines.
Many clinics are still far from meeting the requirements of the theoretical models given in the literature. The therapists involved in the treatment would have to be given much more consistent and effective specialist knowledge. Finally, the paradigm shift has led to a completely altered understanding of the role of therapists [7]. For many therapists, the structural changes in clinical practice and the lack of knowledge transfer are triggering a search for orientation. Habitual, learned approaches in treatment, which were considered correct, are suddenly being called into question, and concerns that in future modern treatment robots might take over differentiated therapeutic work entirely and make specialist therapeutic skills superfluous often lead to “rejection out of self-preservation” [5, 25]. Individualised treatment will continue to be a key component in the therapy strategy. It can only be optimized and supported by the standardization of treatment pathways and the use of technology-based procedures that comply with the guidelines.
Lack of integration has expensive consequences
It can therefore be stated that strategic approaches to the effective integration of guidelines into clinical practice are hardly practised in reality. In addition, therapists still have major reservations about device-based training approaches, although they have been well studied scientifically. Existing devices are usually used only sporadically and lack clear definition. This in turn leads to poor utilisation, which ultimately makes a very expensive investment appear uneconomical.
It can therefore be stated that strategic approaches to the effective integration of guidelines into clinical practice are hardly practised in reality. In addition, therapists still have major reservations about device-based training approaches, although they have been well studied scientifically. Existing devices are usually used only sporadically and lack clear definition. This in turn leads to poor utilisation, which ultimately makes a very expensive investment appear uneconomical.
From evidence to clinical practice – a best practice model
With the THERA-Trainer Complete Solution for Gait Rehabilitation, medica Medizintechnik GmbH has brought a complete device-based concept for neurological rehabilitation onto the market. The company is thus addressing the challenge, faced by many clinics, of offering scientifically established and effective therapies despite the lack of resources, cost pressures and time constraints. With the multi-phase group therapy concept, which offers the opportunity to train strength, endurance, mobility, balance, standing and walking in a task-oriented manner, using the latest robotics and computer technology, the requirements of the guidelines for the rehabilitation of mobility following a stroke can be consistently implemented in everyday clinical practice.
An individual solution is developed with each customer and is tailored to the current operational reality of the clinic. Through an in-depth analysis of the initial situation and the customised design of the solution, the care processes in gait training are effectively optimised and the utilisation of the training and therapy equipment increased. The Complete Solution is not a substitute for therapists, but instead facilitates and supports their work. In addition, it enables a single therapist to treat several patients at the same time.
With the THERA-Trainer Complete Solution for Gait Rehabilitation, medica Medizintechnik GmbH has brought a complete device-based concept for neurological rehabilitation onto the market. The company is thus addressing the challenge, faced by many clinics, of offering scientifically established and effective therapies despite the lack of resources, cost pressures and time constraints. With the multi-phase group therapy concept, which offers the opportunity to train strength, endurance, mobility, balance, standing and walking in a task-oriented manner, using the latest robotics and computer technology, the requirements of the guidelines for the rehabilitation of mobility following a stroke can be consistently implemented in everyday clinical practice.
An individual solution is developed with each customer and is tailored to the current operational reality of the clinic. Through an in-depth analysis of the initial situation and the customised design of the solution, the care processes in gait training are effectively optimised and the utilisation of the training and therapy equipment increased. The Complete Solution is not a substitute for therapists, but instead facilitates and supports their work. In addition, it enables a single therapist to treat several patients at the same time.
The overall solution facilitates the work of therapists, maximises the likelihood of patient success and systematically establishes current research results into everyday clinical practice.
An efficient solution approach for modern gait training
With the Complete Solution concept, THERA-Trainer primarily addresses the described organisational and process weaknesses in clinics. With this approach, previously unused economic potential in clinics can be utilised, while at the same time achieving effectively better treatment outcomes. The focus is not on the individual products, but on an optimised therapy process and the full set of devices as a complete solution. The innovation lies in integrating these products intelligently into a high-efficiency setting.
The overall solution facilitates the work of therapists, maximises the likelihood of patient success and systematically establishes current research results into everyday clinical practice. Thus, by restructuring the therapy processes of a clinic and implementing standardised treatment pathways, the therapy frequency can be increased without an over-concentration of resources, in order to achieve the best possible outcome for patients while simultaneously releasing existing economic potential.
With the Complete Solution concept, THERA-Trainer primarily addresses the described organisational and process weaknesses in clinics. With this approach, previously unused economic potential in clinics can be utilised, while at the same time achieving effectively better treatment outcomes. The focus is not on the individual products, but on an optimised therapy process and the full set of devices as a complete solution. The innovation lies in integrating these products intelligently into a high-efficiency setting.
The overall solution facilitates the work of therapists, maximises the likelihood of patient success and systematically establishes current research results into everyday clinical practice. Thus, by restructuring the therapy processes of a clinic and implementing standardised treatment pathways, the therapy frequency can be increased without an over-concentration of resources, in order to achieve the best possible outcome for patients while simultaneously releasing existing economic potential.
Pilot project: effective use through clear processes
An initial pilot project was launched last year in collaboration with one of Germany’s largest healthcare providers. The first THERA-Trainer Complete Solution in Germany was installed in the neurological centre at MEDIAN Klinik in Magdeburg. The close cooperation showed that with clearly defined processes, effective use can be achieved, generating high patient motivation and satisfaction. This can be seen as an example for many neurological departments. Prof. Dr. Michael Sailer, Medical Director of MEDIAN Klinik in Magdeburg, confirms that a differentiated use of the complete solution was made possible with professional support. The process of carrying out a preliminary analysis of a department’s therapy processes, followed by the creation of new therapeutic pathways, is of vital importance for cost-effective use.
An initial pilot project was launched last year in collaboration with one of Germany’s largest healthcare providers. The first THERA-Trainer Complete Solution in Germany was installed in the neurological centre at MEDIAN Klinik in Magdeburg. The close cooperation showed that with clearly defined processes, effective use can be achieved, generating high patient motivation and satisfaction. This can be seen as an example for many neurological departments. Prof. Dr. Michael Sailer, Medical Director of MEDIAN Klinik in Magdeburg, confirms that a differentiated use of the complete solution was made possible with professional support. The process of carrying out a preliminary analysis of a department’s therapy processes, followed by the creation of new therapeutic pathways, is of vital importance for cost-effective use.
The development of new technologies and their practical use can significantly increase frequency of therapy for patients and boost training motivation.
Opportunity for intensive cooperation between the rehabilitation sector and industry
In recent years, especially in the field of neurological rehabilitation, the industry is undergoing an unbroken process of change: The path is leading away from traditional therapeutic treatments to comprehensive evidence-based concepts. Due to the development of new technologies and their practical use, therapy frequency can be significantly increased for the patient and the motivation to train is boosted.
Adapted to individual customer needs, THERA-Trainer develops a standardized treatment process taking into account all interest groups. This is therefore about more than just devices – the process is crucial. Initial studies show a significant increase in efficiency. An unprecedented form of cooperation with the industry has therefore opened up, paving the way for setting new standards. It is now up to clinical departments to seize this opportunity.
In recent years, especially in the field of neurological rehabilitation, the industry is undergoing an unbroken process of change: The path is leading away from traditional therapeutic treatments to comprehensive evidence-based concepts. Due to the development of new technologies and their practical use, therapy frequency can be significantly increased for the patient and the motivation to train is boosted.
Adapted to individual customer needs, THERA-Trainer develops a standardized treatment process taking into account all interest groups. This is therefore about more than just devices – the process is crucial. Initial studies show a significant increase in efficiency. An unprecedented form of cooperation with the industry has therefore opened up, paving the way for setting new standards. It is now up to clinical departments to seize this opportunity.
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Jakob Tiebel
Business Owner, N+ Digital Health Agency
Jakob Tiebel studied applied psychology with a focus on health economics. He has clinical expertise from his previous therapeutic work in neurorehabilitation. He conducts research and publishes on the theory-practice transfer in neurorehabilitation and is the owner of Native.Health, an agency for digital health marketing.
Melanie Grom
Public Relations Manager at THERA-Trainer
Melanie Grom worked in public relations at THERA-Trainer. She focused on sharing information and insights about the introduction of equipment-based circuit training in neurological rehabilitation in Germany, contributing to the establishment of innovative therapeutic approaches.
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