Interview: Volker Hömberg, president of the World Federation for Neurorehabilitation

Its mission to drive awareness, provide education and encourage research collaboration is supported by a global network of 5,000 members worldwide, 38 special interest groups and around 45 affiliated national societies.

NR Times spoke to president Volker Hömberg to take stock of the current state – and future outlook – of the neuro- rehab field globally.

What is your general view of the state of the global neuro-rehab field right now?

The World Health Organisation (WHO) has estimated that 2.4 billion people need access to some form of rehabilitation. This is very much in contrast to the available resources, especially of course, in low-middle income countries.

When you look at the number of patients per physician, for example in Sub Saharan Africa, this is about 5,000 to one.
Of course, the situation is tenfold better

in richer countries in Western parts of Europe, as well as in the United States, Canada, Korea, Japan and Australia.
But nevertheless, we have a tremendous gap between what is needed and what is available in terms of resources we can use, personnel and technology-wise, and in almost every respect.

The classical way of thinking especially in the richer countries is that after a stroke, for instance, you have a chance to go to a rehabilitation place for a couple of weeks, then you go home and eventually have some aftercare available.

In most developed countries you have access to some sort of inpatient and/or outpatient setting for rehabilitation. Rehabilitation is always multidisciplinary, so you need physicians, nurses, therapists and so forth.

However, many countries in the world – I would say the majority of them – don’t have the ability to use this ‘classical’ approach. Over the last two decades we have accumulated a lot of knowledge. We have derived many perspectives and techniques from neuroscience and have rooted our activities in evidence- based medicine.

We now have to find an innovative means of rolling out this knowledge on a much broader scale.

How important are digital technologies when improving access to neuro-rehab in developing countries?

One way of doing this is to use what we call community or family-based rehabilitation, in the sense that you make caregivers and relatives part of an ongoing rehabilitation programme. In order to facilitate that, we using digital communication technologies more and more.

If there was anything good to come from the COVID-19 pandemic then it probably was that we have learned and developed skills in using digital communication tools. Even in very low-income countries, the access to digital technologies is fairly good. Even if they don’t have a sufficient supply of good water, they still have a sufficient supply of internet.

The costs, for instance, for a day of online connection in India is only a small percentage of what is paid in western countries.

We therefore feel that digital technology allows us to bring forward the spread of knowledge, procedures and skills for neuro-rehab.

Can you give us some insight into the types of projects you are currently working on at the WFNR?

We have one ongoing project which aims to use digital communication technology, and also artificial intelligence [AI] to emulate a complete rehabilitation setting, with all the elements involved, including interaction with a multidisciplinary team augmented with AI allowing the patient or caregiver a free dialogue with the avatars involved as well as an appropriate selection of recommended exercises or procedures in a “custom-tailored “ way. This is a work in progress and at the moment we are adding more and more text information and avatarised interventions.

The digital representation can be used from every smartphone or tablet provided a stable internet connection is available. In addition, all information can also be used with immersive 3D virtual reality, using appropriate goggles.

At the moment the WFNR is starting to roll this out in multiple countries around the world.

It’s a significant endeavour, with multiple components. One is just to increase the level of community-based rehabilitation (CBR) and family-based rehabilitation (FBR). In areas where there are already existing CBR and FBR structures, we can start to apply digital technologies more easily.

I think within the next six to 12 months, we will see major progress on this.

What is your view on the role of technology in neuro-rehab in general, and where have you seen particular success?

There is a lot of enthusiasm for using more advanced technologies. I mentioned digital communication technology, but apart from this, we also have direct therapy-oriented technologies.

One example is intelligent mechanical training devices often called “robots”. Robots are useful for particular patients in particular circumstances under particular preconditions, but they are not the only solution to motor rehabilitation and certainly not a necessary precondition for decent motor rehabilitation.

These robots have very nice features helping high frequency intensive repetitive treatment (they do not tire out) and offer a good computerised environment for easy adjustment of task difficulties as well gamification of the motor training.

My personal view is that they can be very useful, if affordable, especially for severely affected inpatients in early stages to speed up recovery.

VR and AR technologies are used more and more in cognitive, motor and pain- control rehab. They’re certainly useful and the signals we get from the available data are promising, but not yet completely convincing.

If these technologies are embedded into gaming environments, this combination may help to keep patients motivated and hence increase the adherence to exercises.

In neuro-rehab the aspect of intrinsic motivation has unfortunately long been neglected. In the meantime, the interest in motivational aspects is increasing and more research is being done. Brain computer interfaces (BCIs) are also promising.

The principal idea here is to pick up some signals from the brain—usually by EEG technology— and by making the patient ‘think’ about something, enabling them to control external devices such as an exoskeleton on the paretic side to allow for bimanual activity.

This is of course a ‘prosthetic’ approach but beyond this BCI may be helpful to re-establish brain networks and pathways and might also have a ‘true’ therapeutic dimension in the sense that they may help to restructure the brain of patients.

Many centres around the world are working on the BCI issue.

It is very rapidly moving forward, for the simple reason that the controller technology is developing at high pace. When we started with BCIs 20 years ago, it took a week before a patient learned to move a cursor and today within minutes a patient can control an exoskeleton or a keyboard just by “thinking”.

It remains to be seen how far fully implanted intracranial and intraspinal devices will offer additional features, especially in patients with high level quadriplegia.

How much has neuro-rehab advanced in terms of new treatment and recovery options over the last 25 years?

Looking at progress in neuro-rehab over the last two decades, we have undoubtedly learned a lot; not least from elementary neurosciences and behavioural sciences,

A good example is the implementation of general rules of learning in the development of new training techniques. This implementation of motor learning rules, however, is not applicable in patients with severe impairments who cannot move at all.

Here we are still lacking a good means of reaching a real impairment-oriented rehabilitation. We certainly know how to better handle brain plasticity, but we have not yet found real game-changers.

Prominent examples for game- changers in medicine are the introduction of penicillin for infectious disorders or mRNA vaccines for dealing with COVID-19 problems.

We do not have comparable game- changers in neuro-rehab. My impression is that, while the number of very good papers published each year in the field of neuro-rehab treatments is steadily increasing, nevertheless they don’t move us significantly forward.

It looks very much as we are stirring the old stew all the time without coming to real innovative types of treatments. This might be due to the fact that we are trapped in the restraints of concepts as ‘evidence based medicine’ based on group statistical biometry originally designed for pharmaceutical studies but which are not so good for dealing with the inhomogeneities in studies with training techniques.

In addition, these epistemological approaches are not good for individualised or focal medicine as they often wash out clear individual treatment responses. In this sense we need an epistemological rethinking.

To what extent can pharmacological approaches help to facilitate recovery?

For a long time, finding pharmacological approaches to facilitate recovery after brain injury or stroke was discouraging. Millions of dollars have been spent on these endeavours without much success.

On the other hand, over the last decade we have seen that certain groups of drugs have a good impact on facilitating recovery.

There are two classes of substances which have been shown to be helpful: One class is antidepressant drugs—not used to treat depression but to facilitate brain recovery. The other type of drugs are multimodal neuropeptides.

These neurotrophic factors may help the brain to reorganise. It was demonstrated that they alleviate motor problems after stroke and multiple sequelae of TBI. Our latest data, which is yet to be published, shows that it may also be helpful in patients with language disorders.

These substances always work in combination with some sort of training or therapeutic interaction. There are however still remaining enigmas in the field.

We are seeing a shift towards more personalised medicine now in neuro- rehab. What is your view on this and how it fits in with current care?

This is another challenge in the field of neuro-rehab, and it is a similar challenge to that in many fields of medicine in general —how to find ways for focalised or personalised types of interventions.

I think it is an emerging field. We are still very attuned to evidence-based medicine for good reasons. Nobody will deny that evidence-based medicine is a very useful tool, but this is not always pertinent to what we do in rehabilitation.

Rehabilitation is based on training techniques. It’s used in human interaction and is, of course, somewhat different from just getting a drug or a pill. What would be most desirable is to have sufficient biomarkers or data by which you can marshal ways of treatment oriented to a particular patient.

This is still very difficult to achieve, but there is light on the horizon. The concept of precision medicine is of course very much in opposition to what we have done for so many years adhering evidence-based medicine, which is primarily based on mass data.

We are still lacking really good biomarkers, but I think we will be able to solve this problem in the not too distant future.

What other significant changes have you seen in terms of approaches to neuro-rehab?

We started to see the introduction of case managers around 30 years ago, not just the physician, not just a therapist, not just a psychologist, but an individual with a different role to play, and that will certainly continue moving forward.

More services are recruiting lay people from the community, rather families, surrounding patients to engage in the process of rehabilitation.

It’s true that the rehab process is not just a couple of weeks, it is a lifelong process which has to be taken care of, and that means that you also have to educate the community to deal with conditions such as cerebral palsy, multiple sclerosis, Parkinson’s disease, and Alzheimer’s disease in later life.

We need to find ways really to teach and educate the community how to deal with these healthcare issues.

And finally, how has the WFNR evolved over the last 25 years?

WFNR now has around 45 national societies across the globe and around 5,000 individual members and that number is still increasing. We have physicians, therapists and nurses, but in addition, we also have sociologists, philosophers and economists today, because [neuro-rehab works on] a broad societal basis. Rehabilitation goes beyond medicine.

It’s also an influence on political decisions. We are very proud to work with the WHO and fortunately, last year, the World Health Assembly came up with the idea to have an intersectoral global action plan for neurological disorders and epilepsy.

We are happy that the WHO has mounted the horse for going beyond just communicable diseases and looking at chronic diseases, as well as brain health.

Brain health goes very much beyond neuro-rehab and is more on the prevention than the rehab side of the medal.

It is a universal problem to keep your brain healthy and well-working for as long as possible.

We are very happy to support such brain health initiatives. At WFNR over the last couple of years we have very much increased our level of activity and the number of projects.

Therefore, we will have to rely on donations and other forms of income more and more. We welcome donations and sponsorship from the general public and private donors who wish to support our foundation to bring our initiatives forward.