Dr. Tetsuya Asakawa: Building a Comprehensive Rehabilitation System in China

China’s elderly population has now surpassed the 200 million mark, accounting for 14.8% of the country’s total population. Among this demographic, 70 million individuals require rehabilitation and long-term care services. However, due to various constraints, China’s rehabilitation industry still lags behind that of developed countries. On September 13, Professor Tetsuya Asakawa, a specialist in neurological rehabilitation from Japan, shared his insights on rehabilitation at the VCBeat Think Tank Rehabilitation Special Event and offered numerous constructive proposals for improving China’s rehabilitation system.

In fact, it has always been Tetsuya Asakawa’s dream to popularize rehabilitation knowledge in China, train professional rehabilitation personnel, educate families and patients, and ultimately establish a comprehensive rehabilitation system.

Tetsuya Asakawa

What Is Rehabilitation Training?

Rehabilitation training encompasses both active and passive rehabilitation. In a broad sense, training includes all measures capable of improving patients’ activities of daily living (ADL) and functional abilities. According to the Japanese concept, if a patient has respiratory impairment, physician-led respiratory management and training are referred to as respiratory rehabilitation. For certain patients with urinary dysfunction, training aimed at promoting urination function is also considered rehabilitation. Furthermore, the broad concept of rehabilitation extends to include rehabilitation-related policies, government-level collaboration, and medical insurance systems.

The active rehabilitation training referred to by Tetsuya Asakawa is a narrow concept, referring to specific exercises such as walking, climbing stairs, and urination performed by patients themselves with the assistance of rehabilitation therapists.

Rehabilitation activities mainly consist of three components. The first is Physical Therapy (PT). As a primary form of physiotherapy, PT involves exercises targeting the whole body or specific parts to alleviate symptoms or improve function. It focuses on fundamental patient capabilities, such as muscle strength, walking ability, stair climbing, balance, cycling, and outdoor walking training, representing the most basic level of rehabilitation. The second is Occupational Therapy (OT). OT is a rehabilitative approach that involves purposeful and selected occupational activities. It entails the evaluation, treatment, and training of patients with physical, mental, or developmental impairments or disabilities who have varying degrees of loss in self-care and work abilities. OT targets activities of daily living (ADLs), providing training in tasks such as bathing, cooking, and dishwashing to promote self-sufficiency. The third component is Speech Therapy (ST), which primarily addresses language disorders and swallowing difficulties.

Asakawa Tetsuya stated that rehabilitation is a systematic project requiring the coordination of doctors, nurses, rehabilitation therapists, caregivers, and even family members. It can only be successfully completed with institutional support. Furthermore, rehabilitation is time-sensitive; for instance, the optimal window for post-stroke rehabilitation is within six months, after which the effectiveness of treatment declines.

The Importance of Neurological Rehabilitation Training

Akira Asakawa stated that rehabilitation training for the nervous system is critically important. First, damage to the central nervous system is irreversible; brain cells cannot tolerate ischemia and hypoxia for more than six hours. Beyond this six-hour window, irreversible cell death occurs. Once the corresponding brain cells die, the neural functions and functional circuits they support are also lost, resulting in irreversible neurological impairment. This can lead to conditions such as hemiplegia, aphasia, and cognitive disorders, which severely compromise patients' quality of life and cause significant inconvenience to both patients and their families.

However, both neurons and neural circuits exhibit a certain degree of plasticity. Although dead neurons and neural circuits cannot be regenerated, new neurons and neural circuits can be established through specific interventions, thereby partially or fully restoring the patient’s neurological function.

It is understood that the most prominent therapy for neural cell and circuit regeneration is currently stem cell transplantation, which remains in the clinical trial phase and is still far from reliable clinical application. Therefore, the only feasible approach at present is to provide timely and appropriate rehabilitation therapy to patients, with the aim of promoting the regeneration of new neural circuits and correcting peripheral changes caused by neuronal damage.

Comparison of Rehabilitation Systems in China and Japan

After conducting on-site visits to multiple hospitals in Beijing, Shanghai, Guangzhou, Shenzhen, and other cities, Tetsuya Asakawa found that China’s rehabilitation system is not particularly conducive to patient recovery.

First, family members of patients generally lack knowledge about rehabilitation and are unfamiliar with the concepts of early and timely rehabilitation.

Second, China lags behind Japan in rehabilitation equipment, supplies, and hardware. For instance, to prevent foot drop (and contractures) in stroke patients, it is generally recommended that the foot be maintained in a dorsiflexed position. While Japan offers leg orthoses in various sizes, China still advises patients to wear traditional cloth shoes. Furthermore, Akira Asakawa noted that after participating in several domestic rehabilitation expos, relevant manufacturers informed him that customized rehabilitation devices for individual patients are not currently available in China.

Third, China faces a significant shortage of rehabilitation professionals. In Japan, rehabilitation roles are highly specialized, with physicians, dedicated rehabilitation nurses, physical therapists (PT), occupational therapists (OT), speech-language pathologists (ST), and care workers each fulfilling distinct responsibilities. This division of labor is designed to optimize patient recovery, forming a scientifically robust and efficiently operating system. While China’s system includes rehabilitation physicians and dedicated nurses, it lacks an adequate number of qualified therapists and care workers. Currently, domestic care workers in China are largely not subject to a comprehensive access or assessment framework. In contrast, all care workers in Japan must complete 150 hours of training, including 30 hours of clinical practice, and obtain licensure by passing the required examinations before they can formally begin providing care.

Fourth, China’s rehabilitation system remains imperfect. In Japan, neurological rehabilitation has received substantial attention and has been incorporated into the National Health Insurance scheme. Rehabilitation services across the acute, inpatient, and maintenance phases are all supported by insurance coverage and prioritized by various sectors within local communities. This comprehensive system involves the government, insurance providers, hospitals, and volunteer organizations. Therapeutic interventions begin as early as during ambulance transport following disease onset, continue through specialized hospitals, then transition to home-based care or rehabilitation hospitals, and finally extend to nursing homes or patients’ residences, forming a long-term, continuous process. In contrast, China’s current rehabilitation framework does not yet fully span the entire continuum of care.

In the view of Tetsuya Asakawa, with the development of the economy and medical standards, neurological rehabilitation is gradually receiving increased attention in China. Within the “Standardized Stroke Treatment” system led by Huashan Hospital, neurological rehabilitation has been assigned a highly important role. The current framework involves tertiary Grade A hospitals (for initial diagnosis and acute-phase rehabilitation), secondary hospitals (specializing in rehabilitation), and community health service centers (providing home-based care). However, due to various constraints at the present stage, a comprehensive, society-wide social rehabilitation system has not yet been established. Compared with Japan, there remains considerable room for improvement.

Opportunities and Challenges

Asakawa Tetsuya stated that the aforementioned issues are unavoidable challenges facing China’s medical rehabilitation sector, and with the aging population, problems within the rehabilitation system urgently need to be addressed.

First, the shortage of talent has become a bottleneck constraining the development of China’s rehabilitation sector. Tetsuya Asakawa stated, “Even the most clever housewife cannot cook without rice. To build a high-quality rehabilitation hospital, I must first address the issue of rehabilitation professionals. Currently, it is extremely difficult for me to find rehabilitation therapists in China who meet my standards, so I may initially recruit some therapists from Japan.” More important than importing rehabilitation professionals, however, is to strengthen talent training and establish a comprehensive, multi-tiered rehabilitation training system. Establishing such a system should not be limited to training rehabilitation physicians; it must also cultivate highly specialized rehabilitation nurses, rehabilitation therapists (including physical therapy, therapeutic exercise, and speech therapy), and nursing assistants. This training can be conducted in collaboration with foreign medical universities, drawing on their experience, standards, and textbooks.

Second, Tetsuya Asakawa suggested that the Chinese government should establish an elderly care and rehabilitation system tailored to China’s national conditions. Meanwhile, society as a whole—including academia, the investment community, and the general public—should develop a comprehensive understanding of elderly care and rehabilitation. Since rehabilitation services are closely tied to everyone’s vital interests, their healthy development is difficult to achieve without broad societal awareness and support; ultimately, it is every individual who would suffer from such shortcomings.

Third, establishing a multi-tiered medical rehabilitation network is a crucial guarantee for the successful development of rehabilitation services. Within the rehabilitation system, rehabilitation physicians are among the most essential components, serving as the prescribers of rehabilitation plans. Rehabilitation therapists act as the implementers of these plans. In addition, caregivers play a vital role, as they are staff members who interact with patients on a daily basis—often even more directly than family members do.

Tetsuya Asakawa's Rehabilitation Business Plan

Despite the numerous challenges facing the rehabilitation sector in China, Asakawa Tetsu stated, “All my future rehabilitation endeavors will center on one core objective: enhancing patients’ ability to perform activities of daily living (ADLs) independently.” He further explained that the desired rehabilitation outcomes are achieved through targeted training and the use of assistive devices, leveraging patients’ remaining functional capacities to maximize independence in daily life and minimize the risk of complications. For instance, for hemiplegic patients who retain mobility only on one side of their body, pulling up trousers after using the toilet with just one hand and one foot presents a significant challenge. To address this, specially designed trousers can be developed to allow patients to easily pull them up and put them on using only one hand and one foot, thereby facilitating self-care and reducing the caregiving burden on family members.

In Tetsuya Asakawa’s plan, the first step is to conduct training and health education. “My goal is to ensure that patients and their families understand the importance of rehabilitation and recognize the need to initiate timely, standardized, and appropriate rehabilitation immediately after onset, rather than seeking unproven remedies or so-called miracle drugs, or pursuing other inappropriate treatments.”

Second, we must provide training for caregivers. “We are aware of the ‘Yuesao’ (postpartum care specialist) model currently prevalent in China. Given that Yuesaos command substantial incomes, the caregiver profession can draw lessons from this model by implementing standardized training prior to employment. Furthermore, management should leverage mobile internet technologies to establish standardized and regulated workflows, enabling real-time monitoring of caregiver performance. Additionally, I am currently developing a set of instructional materials for caregivers. The scope of medical knowledge required for caregiving is extensive; our goal is for Chinese caregivers to possess a scientific understanding of medical concepts comparable to that of their Japanese counterparts. However, recognizing the differences in national contexts between Japan and China, I am tailoring these textbooks to align with China’s specific circumstances while incorporating the depth and breadth found in the Japanese system.”

In the future, the rehabilitation enterprise envisioned by Tetsuya Asakawa will integrate with three fields: mobile internet, wearable devices, and robot-assisted rehabilitation.

“Specifically, mobile internet connectivity is reflected in the management and dispatch of our caregivers. For instance, when I dispatch a caregiver, I can monitor via our app whether they have arrived at their post in real time, require them to upload images of their work as it happens, and enable patients and their families to provide timely feedback on their satisfaction with the caregiver. Should caregivers encounter emergencies—such as a patient suddenly falling and being too heavy for one person to lift, or other special circumstances—they can promptly contact our base-based experts for guidance.”

Regarding wearable devices, their application is more prevalent in patients with Parkinson’s disease. Certain motor assessments for these patients, such as akinesia and daily activity levels, can be measured using wearable devices. By integrating this device with motion analysis software, the resulting data can inform treatment strategies.

Third, improve the training and certification mechanisms for rehabilitation therapists. “Currently, rehabilitation therapists do not have a licensure system comparable to that of physicians, nor is there a physician-style registration framework. I aim to provide training for rehabilitation therapists; as previously mentioned, this role does not necessarily require a medical doctorate or master’s degree in medicine, but rather hinges primarily on diligence and professional dedication.”

Furthermore, Tetsuya Asakawa is considering establishing a series of high-end Japanese-style rehabilitation centers, developing and applying rehabilitation-related equipment and pharmaceuticals, introducing advanced Japanese rehabilitation technologies, and founding research institutes. “The ideal scenario involves collaborative patient assessment by specialist physicians and rehabilitation physicians, with specialists selecting patients, rehabilitation physicians prescribing treatment plans, rehabilitation therapists implementing the interventions, and caregivers and nurses providing support, ultimately forming a system conducive to patients’ long-term recovery.”