6.2 Technologies

Mobile applications (apps) like apps, web-based programs, videoconferencing, and social media are software programs that are developed for and used via mobile operating systems or mobile devices, such as smartphones, tablets, computers or smartwatches. Mobile applications serve to provide users with similar services to those accessed on PCs or laptops (adapted from [4]). 

Mobile applications can be applied in various contexts for rehabilitation. Apps and web-based programs for example can be used to provide exercise and relevant information for the client. Furthermore, it can be applied to remind clients of their therapy appointment in order to improve therapy adherence. Videoconferencing is used to communicate with the rehabilitation professional and to get feedback on exercise performance. 

Users are overall satisfied with mobile phone delivered interventions and motivated to use it, the digital services seems to be effective to improve the quality of life [7], depression [8] and produces minimal costs [7,9–11]. Besides all these positive results, there are also barriers, such as clients' low Internet skills and lack of access to functional devices.

Mobile applications are well known for rehabilitation by people living in Sub-Saharan Africa. Stakeholders from Rwanda have good experiences with apps in rehabilitation, especially for clients with low back pain. Stakeholders believe that apps are very useful in increasing client engagement in rehabilitation. The stakeholders added also, that videoconferencing is still in the piloting phase, but not implemented in rehabilitation yet.

Apps, web-based programs, and videoconferencing are considered as the most important technologies for rehabilitation in Sub-Saharan Africa for the future. 

Text messaging or texting, is the act of composing and sending electronic messages, typically consisting of alphabetic and numeric characters, between two or more users of mobile devices, laptops, or another type of compatible computer. Text messages may be sent over a cellular network or may also be sent via satellite or internet connection. The term originally referred to messages sent using the Short Message Service (SMS). It has grown beyond alphanumeric text to include multimedia messages using the Multimedia Messaging Service (MMS) and Rich Communication Services (RCS), which can contain digital images, videos, and sound content, as well as ideograms known as emoji (happy faces, sad faces, and other icons), and instant messenger applications (usually the term is used when on mobile devices). 

Text messaging can be used as a therapy reminder to improve therapy adherence, as a motivator to promote physical activity, as a digital supported intervention, and as a client education on the knowledge of diseases.

While text messaging interventions seemed to be acceptable for the users and have proven to be successful and effective in improving health outcomes some challenges were also identified. These challenges include technical issues, slow speed, lack of digital literacy of the clients, doubts about its effectiveness, and costs [12–14]. 

Text messaging rehabilitation interventions display the most digital applied rehabilitation intervention in Sub-Saharan Africa. Text messaging could be used via an app like WhatsApp or via a mobile phone. Look at chapter 2 for a best practice example from Uganda where SMS in combination with phone calls were applied as a therapy reminder [15,16].

Relevant stakeholders believe that SMS is a powerful tool, especially in rural areas, because it does not require an internet connection. In addition, participants emphasize that SMS is less dependent on literacy and therefore accessible and usable by more people. However, they also explained that the functions of SMS are limited and can therefore only used to a limited extent.

Television (TV) is a method of recording moving images, transmitting them as a data stream and displaying or reproducing them almost simultaneously. Television is conceived and produced as a mass medium and broadcasts live or after recording to a mass audience with a time delay.

Radio as an abbreviation for broadcast receiver refers to a device for receiving radio broadcasts. In conventional radios, these are transmitted from a broadcasting transmitter by means of terrestrial transmission (such as aerial television) via electromagnetic waves or as high-frequency electrical signals via broadband cable (such as cable television). 

TV and radio programs can be developed specifically to educate clients about their medical conditions, rehabilitation exercises, self-care techniques, and healthy lifestyle behaviors. These programs may feature expert interviews, testimonials from clients, instructional videos, and interactive content to enhance learning and comprehension. TV and radio programs can broadcast health-related content, including news segments, talk shows, and public service announcements, that address topics relevant to rehabilitation and chronic disease management. This information can raise awareness, promote preventive measures, and encourage clients to seek appropriate rehabilitation services. It can also incorporate motivational content, success stories, and encouragement to inspire clients to stay committed to their rehabilitation goals and overcome challenges. Hearing about the experiences of others who have successfully recovered or improved their health can boost morale and motivation among patients. 

Television and radio broadcasts ensure wide accessibility of rehabilitation content, reaching clients in remote or underserved areas where internet access or digital devices may be limited. This allows for equitable access to information and support for all clients, regardless of their technological capabilities.

Stakeholders from Sub-Saharan Africa consider TV & Radio as an important technology for rehabilitation in Sub-Saharan Africa. They explained that TV and radio are already used for public health campaigns and for prevention of specific health conditions. The coverage of TV and radio is good in Sub-Saharan Africa and it has the possibility to reach many people without using another specific digital technology because most people own TV and/or radio. 

Gamification is an umbrella term that refers to the application of game-typical elements to non-game contexts, such as rehabilitation or the work environment, to improve adherence, engagement, or productivity levels. (adapted from [17]) like game consoles, video/computer games etc. 

Serious Games and Exergames are examples of Gamification. While Exergames are defined as any digital games that request physical movements and reactions (adapted from [18]), Serious Games are a goal-oriented application to adopt specific content or skills in an implicit way. The intention of a serious game is to combine serious aspects with the playful aspects of digital games in a coherent and simultaneous way (..) (adapted from [20]).

Gamification elements are often applied for rehabilitation in the western world. The biggest advantage of that technology is that clients could be easily engaged and motivated in therapy. Serious games could also provide specific exercises based on clients’ aims. The training process is monitored, and the training plan is adapted accordingly. On the downside are the high costs for the additional hard/software, that it requires certain skills for client and the rehabilitation professional to operate, that the healthcare professional should monitor the compliance with the prescribed tasks at a regular basis to make adaptions to the rehabilitation plan, and that the acceptance remains unclear [4]. 

Gamification is an emerging trend in some countries in Sub-Saharan Africa, but is not yet used for rehabilitation in Rwanda and Ethiopia, as relevant stakeholders reported. Maybe because of the high cost of purchasing the required technology (hardware and software) or because the application requires certain skills from the client and the therapist to operate it.

3D printing is a process of making three-dimensional objects from a digital file. The creation of a 3D printed object is achieved using additive processes. In an additive process, an object is created by laying down successive layers of material until the object is created. Each of these layers can be seen as a thinly sliced cross-section of the object [21]. 

3D printing can be used to manufacture individualized prostheses. Compared to conventionally manufactured prostheses, this new technology could shorten the manufacturing time and thus reduce costs. However, the cost of purchasing the 3D printer is very high. 

This technology is not yet widespread in Sub-Saharan Africa.

However, there is one project carried out in Uganda, Tanzania, Cambodia [22] where 3-D printers moved to a rural area where prosthetics were directly printed for people with transtibial amputation almost without waiting time. Even though the effectiveness of 3D printed prostheses is comparable to conventionally manufactured prostheses and the usability of usual manufactured prostheses scores better, relevant interest groups, consider 3D printing as important for rehabilitation, as it can reduce the cost of producing prostheses.

Virtual reality (VR) is an interface involving real-time stimulation and interactions of an embedded subject through multiple sensorial channels, based on a synthetic environment in which the subject feels their presence (e.g., a helmet with a screen inside, or gloves fitted with sensors) (adapted from [23]). 

Augmented reality (AR) is a user interface that combines the real world with three-dimensional and interactive elements in real time. Suitable systems are designed to display AR as if it were part of the real world. An enhanced version of the real physical world is achieved through the use of digital visual elements, sounds, or other sensory stimuli delivered via technology (adapted from [24]). 

VR and AR are used to improve physical functioning, fitness, balance, postural control, vestibular dysfunction, range of motion, gait and anxiety. It is liked because it promotes engagement and motivation in rehabilitation. Nevertheless, it is in its infancy and requires further investigation with regard to their effectiveness. Dizziness and motion sickness may also occur during use and not all systems are commercially available and not at low costs [4]. 

Virtual/augmented reality is not well known for rehabilitation in Sub-Saharan countries and are not considered as important technologies for rehabilitation. In one project in Nigeria, people with chronic low back pain use a virtual reality headset to reduce costs. The findings suggest that the virtual reality intervention was cost saving for people with chronic low back pain [25].

Artificial Intelligence (AI) refers to systems that displays intelligent behavior by analyzing their environment and taking actions – with some degree of autonomy – to achieve specific goals. AI is human-designed software that operates in the digital and possible physical dimensions by collecting (e.g., via sensors) and evaluating data. Machine learning algorithms can be used in AI solutions, which focus on the use of data to imitate the way that humans learn, gradually improving its accuracy (adapted from [26, 27,3]). Examples for AI are chatbots, conversational agents, virtual humans and machine learning algorithms.

AI and machine learning processes can be used as diagnostic and prognostic tools in rehabilitation. Abdollahi et al. [28] used for example a wearable system of sensors and machine learning processes to classify clients with nonspecific low back pain into subgroups according to quantitative kinematic data, for example, trunk motion– and balance-related measures. Based on this home assessment, a personalized rehabilitation plan can be created following practical guidelines.

Another example for the application of AI is a home-based monitoring system. For example, Chae et al. [29] developed a home-based rehabilitation system based on a smartwatch, as well as an app and AI processes that can recognize and record the type and frequency of rehabilitation exercises conducted by the client. This can facilitate participation in home training and improve the functional scores of patients with chronic stroke.

Chatbots and conversational agents are key technologies for AI and machine learning processes in rehabilitation. They could simulate and process human conversations. They enable communication via text or audio on websites, apps, or telephone and are used for psychoeducation and encouraging self-adherence by providing information and motivation.

AI has the potential to predict adherence and client conditions but there are doubts that some decisions could be taken over from AI and machine learning algorithms or healthcare professionals could be replaced. In addition, more research is needed to proof its effectivity [4]. 

Ai is not well known in Sub-Saharan Africa but important stakeholders think it is an emerging trend for rehabilitation. Currently it is more popular to use AI in education, however not implemented yet in rehabilitation in Rwanda and Ethiopia in this context. 

Sensors are devices capable of sensing and/or responding to a physical stimulus (e.g., heat, light, sound, pressure, magnetism, or a specific motion) and transmitting the resulting pulse (e.g., to measure or actuate a control). The sensor usually consists of a transducer element, which responds directly to the measured parameter and produces a usable signal output, and its related electronics (adapted from [30]). Examples for sensors are smartwatches, inertial sensors, photosensors, GPS etc. 

Sensors are mostly used for diagnostic purposes to measure, assess, capture, or track movement and posture; some sensors can predict falls; and providing biofeedback [4]. Sensors are highly represented for rehabilitation in the western world. Kwon et al. [31] for example developed an app for clients with COPD and monitored their heart rates and blood oxygen saturation via sensors embedded in smartphones. An alarm function alerts the client regarding any critical health status during physical activity, such as when the values (SPO2 and heart rate) fall below certain thresholds. Thus, the client has the opportunity for self-monitoring, that is, to receive feedback on the correlation between physical activity and body reactions to adjust such behavior as needed. Healthcare professionals can also estimate these data using a dashboard where the data are collected. After 6 weeks, the application led to a significant reduction in symptoms associated with COPD compared with the control group. The intervention group’s self-assessment of the impact of the disease also improved significantly.

Sensors are not commonly used technologies for rehabilitation in Sub-Saharan Africa.