Funding/financial disclosures. The authors have no conflict of interest relevant to the content of this letter. No funding was received for the preparation of this letter.

Innov Clin Neurosci. 2022;19(4–6):8–9.

Dear Editor:

In the neuroscience field, the last 10 years have been dominated by the “great mantra” of neuroplasticity. Researchers and clinicians wanted to have a seat at the roundtable of neurorehabilitation, as the field needs to be confident with robotics, virtual reality, and other high-tech tools, and they had to find the funds for neurorehabilitation gyms full of different tools. Nearly all the experts agree that to pursue neuroplasticity, it is mandatory to partake in early, intensive, repetitive, and task-oriented training.1 Most of the applicability of these concepts has been put to the test by the SARS-CoV-2 infection.  

Due to the pandemic, the neurorehabilitation scene has changed, as acute management of patients with COVID-19 has been considered more important than functional recovery of neurological patients. Moreover, the use of in-hospital devices has decreased, with an increase in home rehabilitation, mostly due to socioeconomic issues related to the pandemic.2 Although the COVID-19 challenge still exists, it is improving, and we are recovering some of our freedom of movement, in part thanks to the vaccination campaign.3 However, we need to rethink our beliefs about robotics in neurorehabilitation. How are we to deal with neuroplasticity while protecting our frail patients? How should we deal with the increasing number of people needing rehabilitation and treat them in a safe manner in the gym setting?

On August 25, 2020, Business Wire wrote, “The rehabilitation robots’ market is expected to register a compound annual growth rate (CAGR) of over 25 percent during 2020 to 2024.”2 At the beginning, robotic devices were mainly used for research purposes, and only a few hub centers were provided with robotic rehabilitation. Over the past few years, more rehabilitation centers have implemented robotic services, considering the potentially better functional outcomes robotic rehabilitation offers patients. Moreover, because a positive cost-effectiveness ratio of the main robotic device is predictable, the use of robotics in clinical practice is expected to increase. Unfortunately, no data are available on the prevalence of robotic devices, although the use of innovative technology is higher in Europe and North America than other parts of the world.2

However, because of the extensive spread of COVID-19 across the globe, the industry declared that the pandemic had a negative impact on innovative technology in rehabilitation. The prevalence of strokes, brain and spinal cord injuries, and neurological diseases has been an instrumental factor in influencing the growth of the rehabilitation robot market.2 Nonetheless, a market crash was inevitable due to the tremendous impact of lockdowns, supply chain disruptions, demand destruction, and change in customer behavior, as well as the reorganization of healthcare systems around the world.

Most people agree with the sad truth that the risk of COVID-19 will be a companion for a long period, as the medical and psychological complications of COVID-19, while still unclear, will likely be heavier than expected, and the healthcare system must be ready to face the challenge with new answers.

The main questions remain. How must the healthcare system change without losing the benefits of robotic rehabilitation, while adapting to manage a larger population of patients? Is the hub and spoke model ready for retirement? Should we treat only rehabilitation center inpatients? What about the neurological outpatients? We must consider what happened the last few years due to the lockdown period to answer these questions. 

Physiatrists and neurologists have provided practical guidelines to treat patients with long-term consequences of COVID-19 because they have spent much time in intensive care units (ICUs) and were presented with symptoms of postintensive care syndrome (i.e., dyspnea, anxiety, depression, prolonged pain, impaired physical and cognitive function, and poor quality of life). Thus, a holistic approach to manage cardiopulmonary, neurological, and psychiatric sequelae should be considered.5 Nonetheless, the situation for neurological patients not affected by COVID-19 and requiring rehabilitation has been even worse. To face the pandemic, healthcare systems all over the world have changed their organization methods. Many wards dedicated to chronic diseases and/or rehabilitation have been converted into acute wards to manage medical and neurological complications of COVID-19. In particular, early discharge from rehabilitation units of COVID-19-negative patients was performed, shortening their rehabilitation plan when medical conditions and proper aids permitted. In the case of COVID-19 positivity, most of the patients were transferred to COVID-19 hospitals, waiting for remission, or to specific nursing homes or long-term care wards. New admissions to neurorehabilitation wards were suspended or temporarily reduced, then scrupulous pre-admission screenings to test for COVID-19 were implemented, also differentiating the pathways of COVID-19-negative patients.4

Thus, neurological patients suffered from a lack of physical exercise and cognitive engagement, as well as social isolation, and this could be the scenario in front of us in the upcoming years. There are particular concerns around the increased vulnerability of patients living with a chronic disease, including those with Parkinson’s disease and dementia, who might also have medical complications, including pneumonia, besides a worsening of their motor-cognitive problems.6,7 Moreover, management of neurological sequaele following acute diseases, including stroke and traumatic brain injury, was also reduced by the pandemic, with a worsening of both patient and caregiver quality of life.5–7  

From the point of view of healthcare professionals, one of the issues has been and will be the hygienic maintenance of the robotic equipment. The appropriate hygenic treatment between two patients slowed the routine. But the “gnomes” of technology never sleep; the big robot we saw in these years must probably leave the place to smaller brothers (i.e., soft robots) able to be used at home with the help of the caregivers and the remote presence of the therapist.

Telerehabilitation has been one of the most successful answers to this period, and the great experience of the previous months has given us some good tips on refining the way to deliver it.8 

Guidance is an important part of the treatment session; the relationship with the therapist helps the patient train correctly and more carefully. The modern telerehabilitation platforms consider this a hot point and give the therapeutic team the opportunity to be in touch with the patient and the caregivers. 

Thus, a positive consequence of the pandemic has been the large diffusion of communication technology and the habit to use it even at older ages. This means that in a couple of years, the adherence of the patient with these new tools should increase dramatically and, at the same time, this large field test will help the manufacturers offer friendlier and more flexible instruments.

In conclusion, if on one hand, the pandemic forced us to reduce the physical contact and training with robotic devices, on the other hand, people have had the opportunity to improve their technological skills with the use of home devices.  

It is possible that the COVID-19 pandemic has led innovative technology to move from hospital to home to treat the patients in a safer environment. Nonetheless, robotics could not be so easily replaced, and future patient-tailored training should take into consideration not only the cost-effectiveness ratio,9 but also the potential effects of this new and unfortunately long-lasting disease.


  1. Braun RG, Wittenberg GF. Motor recovery: how rehabilitation techniques and technologies can enhance recovery and neuroplasticity. Semin Neurol. 2021;41(2):167–176.
  2. Business Wire. COVID-19 pandemic impact on global rehabilitation robots market 2020–2024 Technavio. 25 August 2020. Accessed 26 Apr 2022.
  3. Tardiolo G, Brianti P, Sapienza D, et al. Are we paving the way to dig out of the “pandemic hole?” A narrative review on SARS-CoV-2 vaccination: from animal models to human immunization. Med Sci. 2021;9(3):53. 
  4. Calabrò RS, Manuli A, Naro A, Rao G. How Covid 19 has changed neurorehabilitation in Italy: a critical appraisal. Acta Biomed. 2020;91(4):e2020143.
  5. Barker-Davies RM, O’Sullivan O, Senaratne KPP, et al. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med. 2020;54(16):949–959.
  6. Jaiswal V, Alquraish D, Sarfraz Z, et al. The influence of coronavirus disease-2019 (COVID-19) on Parkinson’s disease: an updated systematic review. J Prim Care Community Health. 2021;12:21501327211039709.
  7. Moretti R, Caruso P, Giuffré M, Tiribelli C. COVID-19 lockdown effect on not institutionalized patients with dementia and caregivers. Healthcare (Basel). 2021;9(7):893. 
  8. Calabrò RS. Teleneurorehabilitation in the COVID-19 era: what are we doing now and what will we do next? Med Sci (Basel). 2021;9(1):15.
  9. Calabrò RS, Müller-Eising C, Diliberti ML, et al. Who will pay for robotic rehabilitation? The growing need for a cost-effectiveness analysis. Innov Clin Neurosci. 2020;17(10–12):14–16.

With regards,

Rocco Salvatore Calabrò, MD, PhD, and Nicola Fiorente, MD

IRCCS Centro Neurolesi, “Bonino-Pulejo”, in Messina, Italy and Polimedica Fisio&Sport in Cittadella (PD), Italy