Robotic rehabilitation isn’t just about machines. It’s about the partnership between dedicated therapists and determined patients learning to move again. In this second instalment of a three-part series on robotic therapy, we explore how the Hybrid Assistive Limb (HAL) combines cutting-edge technology with the expertise and empathy of therapists, helping patients take their first steps towards recovery — both physically and emotionally.
Neuroplasticity in motion
Being a therapist is demanding work. It requires years of specialised training, long hours on the rehabilitation floor, and a deep well of patience and empathy.
Yet for the therapists at Normah Medical Specialist Centre (NMSC) in Kuching, seeing patients regain their independence — sometimes taking their first steps in months — is the greatest reward.
These days, their mission has been transformed by technology: the Hybrid Assistive Limb (HAL) robotic therapy system.
Developed by Japanese company Cyberdyne, the HAL exoskeleton is the first robotic therapy service of its kind in Borneo. It offers stroke and spinal cord injury patients the chance to accelerate recovery while also easing the physical demands placed on therapists.
According to Caroline Adriaanse, chief physiotherapist and occupational therapist at NMSC’s Rehabilitation Department, the HAL devices have proven invaluable since they were introduced almost three years ago.
“With the HAL robotic device, we can give high-intensity training to patients — more repetitions of movement can be performed than with conventional exercises — and we see tremendous recovery in patients within a shorter period of time,” she told Sarawak Tribune.
So what exactly makes this technology so effective?
The HAL Lower Limb system, for example, works in combination with a body weight support harness, allowing patients to begin walking practice at a much earlier stage — even when they lack trunk control or standing endurance.
By detecting faint bioelectrical signals from the wearer’s muscles, the exoskeleton assists and reinforces voluntary movement.
“The ability to perform high repetitions may allow for faster strength gains and endurance building.
“This consistency helps patients relearn movements more effectively, reinforcing neuroplasticity — the brain’s ability to rewire itself after injury,” Adriaanse added.
A new dimension in therapy
Before HAL arrived, therapists needed to guide patients’ limbs manually and support their weight, often requiring several staff at once.
Now, one therapist can supervise the session while the robot maintains precise movement patterns and records detailed performance data.
“This is difficult to achieve in conventional therapy because we need more manpower to support the patient and, at the same time, passively guide the lower limb movement.
“Robotic therapy helps improve gait and balance much faster. We notice our patients are able to tolerate longer and more intensive rehabilitation sessions because the robot assists them consistently.
“We also benefit as therapists. With HAL, we’re less physically overburdened. We can set the device to help the patient walk on the treadmill or move their arm in the Single Joint robot. That frees us to monitor or assist other patients at the same time,” Adriaanse explained.
HAL’s impact extends beyond practical benefits. It also has a powerful motivational effect. Because the system tracks performance in real time — measuring speed, range of motion and assistance levels — patients can see their progress and feel more engaged in their rehabilitation.
This higher level of engagement, combined with intensive training, has led to noticeable improvements in mobility for many of our patients.
“The majority of our patients improve their status from full dependency to being able to walk with an aid, or even unaided.
“Even chronic stroke patients have developed better walking patterns, endurance and range of movement in their arms.” Adriaanse shared.
The combination of repetitive, task-specific training and external feedback seems to accelerate progress, especially for patients referred early — ideally within six months of diagnosis.
Early intervention prevents complications like muscle atrophy and joint stiffness and allows patients to start rebuilding strength before patterns of immobility become entrenched.
Yet, technology is only part of the picture.
“The cognitive or mental status of a patient can interfere with their ability to engage in therapy or follow instructions.
“Emotional factors — like depression, anxiety or lack of motivation — also play a big role. Strong spirit is necessary to heal oneself,” the chief physiotherapist explained.
She noted that patients from rural areas often face logistical challenges that disrupt consistent treatment.
“Some patients could not come frequently because of transport difficulties. Their progress was not as good or as fast as other outpatients who attended regular sessions.
“Breaks in therapy can disrupt recovery because robotic rehabilitation depends on consistent, high-intensity engagement to promote neuroplasticity,” she said.
Learning to trust the robot
Despite the clear benefits, integrating HAL into everyday practice has not been without obstacles. For some patients, the prospect of walking with a robotic suit is daunting.
“Not all patients are immediately comfortable. The device looks quite cumbersome, and some are anxious about using it.
“We always start with a clear explanation and demonstration to reassure them about its safety and effectiveness,” Adriaanse said.
Fitting the exoskeleton is a complex process that she must tailor to each patient’s size, movement ability and treatment goals.
She explained that fitting the device, especially the Lower Limb type, was often complicated and time-consuming. It required specialised training to operate correctly, and not every patient was suitable to use it.
Currently, only four therapists at NMSC have completed the HAL user training, which has placed additional demands on them.
“The other therapists depend on us to fit and programme the device, so our workload is higher. We plan to train more staff soon to meet the growing demand,” she said.
Aside from training and patient selection, there are logistical and financial considerations.
“One of the drawbacks of using this robot suit is that the monthly operation cost is quite high. We need to be able to treat enough patients to cover expenses, which means coping with a higher caseload and the necessary paperwork,” Adriaanse explained.
While technical malfunctions have been rare, they are not unheard of.
“Over the last two years, we have had only a few device malfunctions. We don’t have engineers on site, so we rely on Cyberdyne’s technical support team in Peninsular Malaysia.
“Thankfully, they have been very responsive in helping us troubleshoot. We’ve learned that it is essential to check all devices daily,” she said.
Despite these challenges, the team has no regrets about adopting the technology.
With strong teamwork, Adriaanse and her colleagues overcame many difficulties during their first year of robotic therapy.
Now, she feels they would not want to work without the robotic devices, as everyone notices the benefits for patients and experiences a sense of job satisfaction in seeing their progress.
The future of rehabilitation
As the centre looks ahead, the goal is to continue expanding access to robotic therapy while maintaining the human connection that makes rehabilitation effective.
“Robotics are not a replacement for therapists. They are tools that enable us to deliver more consistent, precise treatment.
“But it still takes compassion, encouragement and a patient’s own determination to recover,” Adriaanse emphasised.
At the end of the day, it is that blend of technology, skill and spirit that helps patients reclaim their independence — one step, one movement, and one triumph at a time.
Covered robotic rehab for Sarawakians
Following the pioneering introduction of Cyberdyne’s HAL exoskeleton technology at NMSC, more patients in Sarawak are now able to benefit from this advanced neuro-robotic rehabilitation — without bearing the financial burden themselves.
This has been made possible through a significant collaboration between the Social Security Organisation (PERKESO) and the centre, which allows eligible contributors to undergo robotic therapy fully funded under PERKESO’s social protection schemes.
According to PERKESO chief medical officer Dr Nur Liyana Kahar, the partnership, which began in September 2022, has already brought tangible improvements to patients recovering from severe neurological injuries.
“Since this collaboration started, 114 of our contributors have been admitted to NMSC for Neuro-Robotics Rehabilitation — about 60 per cent of them have successfully transitioned back to work and regained a productive life,” she told Sarawak Tribune.
She explained that PERKESO provides coverage for contributors under the Invalidity Scheme and Employment Injury Scheme.
“Employers are responsible for registering their employees under these schemes, while contributions are paid by both employers and employees,” she noted.
In addition to salaried workers, self-employed individuals can also enrol under the Self-Employment Social Security Scheme, which was established under the Self-Employment Social Security Act 2017.
“All Malaysian citizens and permanent residents who work for themselves to make a living are eligible for this plan, regardless of age,” she added.
To access these benefits, applications can be made through referrals submitted by treating doctors via the PERKESO system or by visiting their nearest office with the necessary supporting documents.
“Applications are processed immediately if all required documents are complete. Once approved, a guarantee letter will be issued so patients can begin their rehabilitation at NMSC without delay.
“For cases that require further evaluation, we will review them carefully and provide any additional assistance needed,” she explained.
Beyond individual cases, Dr Nur Liyana emphasised that the collaboration holds particular importance in Sarawak, where access to highly specialised neuro-rehabilitation services has long been limited.
“It is worthwhile to continue this initiative because it greatly improves the quality of care provided to our contributors in Sarawak, thereby easing their return to work and reintegration into society,” she observed.
However, she noted that expanding the programme to more hospitals in the state will depend on how well the existing partnership functions, the resources available, and the overall demand for the service.
Building on this foundation, Dr Nur Liyana highlighted that having a trusted partner in Sarawak has been essential to the success of the programme so far, with NMSC playing a key role in delivering specialised neuro-robotics rehabilitation.
At the centre, therapists have already gained valuable experience incorporating robotic devices into their daily rehabilitation programmes — experience that has been instrumental in helping patients regain confidence and independence.
Meanwhile, Caroline Adriaanse, who leads NMSC’s neuro-rehabilitation team, described how the HAL exoskeletons are used in practice.
“Our department has three types of Cyberdyne devices: the HAL Lower Limb, Single Joint and Lumbar,” she explained.
According to her, the Lower Limb device is primarily used for gait training to improve patients’ walking patterns and endurance.
To achieve this, therapists combine it with a body weight support system such as a treadmill with suspension or a special walker, depending on each patient’s needs.
Beyond gait rehabilitation, the Single Joint model focuses on concentrated training of elbow or knee movements.
With the correct settings, therapists can target between 100 and 300 repetitions in a single session — a level of consistent repetition that is vital to re-establish communication between damaged areas of the brain and the body, especially after a stroke.
The Lumbar type, meanwhile, assists patients in standing up from a seated position, supporting core muscle strength and balance.
Although fitting and programming the devices requires specialised training and time, Adriaanse emphasised that the gains in patients’ mobility and independence have been well worth the effort.
She pointed out that, thanks to the partnership with PERKESO, individuals no longer face the barrier of cost — a crucial factor for many families seeking advanced rehabilitation.
“This collaboration really helps patients access the therapy they need without worrying about expenses,” she said, adding that patients often express amazement at being able to take their first steps again.
Together, the dedication of NMSC’s team and PERKESO’s commitment to social protection have not only removed financial obstacles but also restored hope for countless families striving to regain their independence.
In the concluding part of this series, we will hear the personal stories behind these successes — powerful reminders that determination, technology and compassionate support can help rebuild lives.
