Assistive Device
Revolution for the
Independence of Older
Adults in Japan
Care Robots and Other Technology
Innovations

Yoko Crume, Ph.D.

August 2018
ILC-Japan

ILC (International Longevity Center) is a non-profit organization
to study the trend of population aging with low -fertility from theinternational and interdisciplinary perspectives, to share thecenter's findings, to educate the public, and to make policy
recommendations to the government.
17 centers have been established to date in the world: in the
United States, Japan, France, the United Kingdom, Dominican
Republic, India, South Africa, Argentina, Netherlands, Israel,
Singapore, Czech Republic, Brazil, China, Germany, Canada andAustralia. These centers constitute an alliance (called ILC Global
Alliance) that promotes joint studies and symposia as well as
country-specific activities within the context of this loose
network.
ILC-Japan has been engaged in numerous studies concerning theethos of productive aging, and we have actively sought to share
our findings and educate the public since 1990. We aspire toserve as an international resource center and will continue toproactively initiate projects that contribute to an ideal aging
society, where all generations will support one another and live
happily.

ILC-Japan
KDX Nishishinbashi Buldg., 6th Floor,
3-3-1, Nishishinbashi, Minato-ku,
Tokyo 105-8446, JAPANURL: http://www.ilcjapan.org
E-mail: ilcjapan@mba.sphere.ne.jp
This report was first published in June 2018.

ABOUT THE AUTHOR
Yoko Crume received her B.S. degree from International Christian
University in Tokyo, Japan, and her M.S.W. and Ph.D. degrees from the
University of North Carolina at Chapel Hill in the United States. Her
professional career includes working as a clinical social worker at John
Umstead State Psychiatric Hospital, an administrator at the North Carolina
Division of Aging, and an Associate Professor at the Joint Master of Social
Work Program in North Carolina. Currently, she works as an aging service
consultant and researcher, and she is an active community volunteer in
Nashville, Tennessee. She can be reached at yokocrume@gmail.com.

1

Content
Acknowledgements ...................................... 3
Introduction .................................................. 3
History of AT development ........................... 4
Assistive Device and Care Robot................... 5
Factors Affecting AT Innovations in Japan .... 6
Policies and Programs to Promote AT
Innovations ................................................. 11
Older Adult’s Views .................................... 19
Examples of Japanese Assistive Device
Innovations ................................................. 20
Discussion ................................................... 29
Conclusion .................................................. 33
References: ................................................. 342

Acknowledgements
This research was supported by the Japan-United States Friendship
Commission, the Northeast Asia Council of the Association for AsianStudies, and the International Longevity Center-Japan (ILC-Japan). The
author also acknowledges ILC-Japan for its logistics assistance, photoacquisition, and publication. Finally, the author appreciates the insights andreview comments shared by John Campbell and Richard Crume.

Introduction
Assistive technology (AT) is the field that addresses the needs of people
with disabilities by integrating technological devices and services to restore,
improve, and maintain their daily functioning. The idea of integrating
devices and services was first introduced in the Individuals with Disabilities
Education Act of 1990 (IDEA) in the United States. However, the history ofassistive devices themselves can be traced back to the 5th and 6th
centuries BCE in China and Greece. Today, the AT field is at the onset of arevolutionary transformation, where scientific and technologicaladvancements in the robotics field will augment human functional
deficiencies so well that human disabilities may cease to exist in the future,according to Herr (2014). With this ambitious goal in mind, robotics
research and development programs in AT are well underway in Australia,
Canada, China, Denmark, France, Germany, Japan, New Zealand, South
Korea, Sweden, the United Kingdom, and the United States, and othercountries (e.g., China, India, and Russia) are not far behind.
The focus and extent of engagement in AT varies among nations,depending on their interests and research capabilities, with some countries
farther along than other. However, AT developments in Japan areespecially interesting because of the country’s focus on disabilities among
the older population and the strong linkage with Japan’s overall economic
redevelopment strategy. In this regard, Japan is at the forefront of AT
development—a number of new assistive devices for older adults are being
tested for functional and commercial viability, and some have already been
introduced into the marketplace.
This article describes the unique AT developments in Japan, examines thefactors that have influenced the direction of Japanese AT development,
and considers how the direction of research and development may help
attain Japan’s goals of promoting the health, wellbeing, and independenceof older adults while contributing to the restoration of national economic
viability. Lessons learned from the Japanese experience are importantbecause societal aging is a global issue and a major concern in many
countries.

3History of AT development
Today, Japan pursues one of the most active AT programs in the world.
However, Japan has not always been a leader in the field, and much of therecent progress has been built upon the accomplishments of other nations,especially the United States and several European countries. Further,
continuing interactions with the international community is important for
future developments in the AT field in Japan. Understanding the history of
AT adds perspective for the direction of future AT development in Japan.
The earliest recorded examples of AT use come from ancient Chinese stoneslates and Greek vases, which depict people with disabilities beingtransported in wheeled furniture. (Kamenetz, 1969) Making a device
specifically designed for people with disabilities comes much later, perhaps
in the Middle Ages, as exemplified by the three-wheeled wheelchair
invented in 1655 by a German paraplegic watchmaker, Stephen Farffler.
Another key development in the history of AT, the Braille system, wasinvented in the mid-19th century for people with visual impairments, andan updated version of the original Braille system is still in use today.
In the early- to mid-20th century, the emergence of disability as a social
concern triggered systemic responses in the United States and Europe. In
particular, the disabilities prevalent among young, wounded soldiers
returning from a succession of wars and conflicts attracted attention,
stimulating the development of more advanced assistive devices, such as
the Hoover cane (white canes designed to be used as mobility devices) andmotorized wheelchairs.
More recently, the Independent Living Movement, which started as a
grassroots, civil rights movement in the 1960s advocating for the rights ofpeople with disabilities, was highly influential in subsequent AT
development. The movement was instrumental in passing theRehabilitation Act in 1973 and the Americans with Disabilities Act in 1990.
These complementary U.S. laws not only established the norm for
nondiscrimination based on disability, but they also set the stage for future
AT innovations by requiring auxiliary aids to ensure people with disabilities
could benefit from the services they receive.
Two other pieces of legislation that were influential from this period were
the Technology-Related Assistance for Individuals with Disabilities Act of1988 (commonly called the Tech Act) and the aforementioned IDEA. The
former act clarified the American government’s intention to actively
encourage the application of advanced technology to assistive devices andservices to support the daily functioning and learning of people withdisabilities, and the latter act focused attention on the role of AT in
educating school children with disabilities.

4Legislation and resulting AT developments in the United States had asignificant influence on the international community, including publicationof the International Classifications of Functioning, Diseases, and Health(referred to as the ICF) by the World Health Organization (WHO) in 2001,
replacing the older and out-of-date International Classification of
Impairments, Disabilities, and Handicaps system. The ICF redefined aperson’s disabilities from the perspective of daily functioning and identified
the important role of assistive devices and technology as well as overall
improvements in the physical environment that can benefit everyone,
regardless of age or disability.
In 1950, shortly after the end of World War II (WWII), Japan enacted thePeople with Physical Disabilities Law as the first national program toprovide assistive devices to people with disabilities, primarily focusing on
wounded soldiers returning from the war. This legislation was followed in
1963 by the Welfare Law for the Aged, which mandated program
development to provide assistive devices to older adults who meet theservice requirement. Since then, many Japanese municipalities have also
initiated their own assistive device programs. Today, the Program to
Subsidize the Cost of Wearable Devices under the Law to Comprehensively
Support Daily and Social Living of Persons with Disabilities (commonly
called the Persons with Disabilities Comprehensive Support Law) is themain governmental vehicle to provide assistive devices in Japan, primarily
to people of all ages with severe disabilities.

Assistive Device and Care Robot
In Japan, the term “kaigo robotto” (long-term care or simply care robot) isoften used to describe the new group of innovative assistive devices
currently under development or recently entering the marketplace. The
term is used loosely and can mean both robots and other innovative
assistive devices that may not necessarily meet the current definition ofrobot. (Honma, 2017) While people often use the term robot, many people
have difficulty explaining exactly what it is. This is not surprising given that
the New Energy and Industrial Technology Development Organization(NEDO), a Japanese agency founded in 1980 to coordinate industrial
research and development activities, declares in its 2014 White Paper on
Robot that “there exists no perfect consensus definition of robot.” (NEDO,
2014)
The field of robotics is in constant flux, and the definition is constantly
shifting. However, for the purpose of this article, the functional definitionof a robot is “an intelligent machine that combines sensing,
thinking/controlling, and acting technologies.” (Ministry of Economy, Tradeand Industry [METI], 2008) “Sensing” refers to simulating the humansenses, such as seeing, hearing, smelling, and touching, and it has become5increasingly common for robotic systems to also be equipped with “superhuman” sensors, such as global positioning system technology. Robotic
system computers perform “thinking” and controlling duties that include
recognizing incoming information from the sensors, developing an action
plan, and coordinating actions. And an actuator transforms the energy
created by a motor or other mechanical device into the desired motion.
Japan particularly excels in sensing and controlling technologies.
The International Federation of Robotics (IFR, 2016) classifies robots into
two categories, industrial and service, where a service robot is defined as a“robot, other than industrial robot, that provides useful services to people
autonomously (or semi-autonomously).” The IFR further classifies service
robots into two use groups: professional and personal/domestic. Carerobots belong to the personal/domestic group, while robots used in
medical and rehabilitative services belong to the professional group. (Theprofessional group also includes disaster response robots, like those usedat the Fukushima Nuclear Power Plant following the historic 2011
earthquake and tsunami.)

Factors Affecting AT Innovationsin JapanJapanese AT innovations today are fueled by the following four factors: (1)the global phenomenon of societal aging, particularly the aging trend inJapan; (2) incentives created by Japan’s existing programs for aging
services; (3) Japan’s search for a new industrial niche to bolster its
economic recovery; and (4) international influence and trade barriers.
These factors are described below.
Global Societal Aging and Japan. Societal aging is a global phenomenon.
The worldwide aging trend gained momentum in the mid-20th century,and between 1950 and 2000, the global average life expectancy increased
20 years, according to the United Nations (2002). This trend is expected tocontinue, and by 2050, the global average life-expectancy is projected toreach 75 years. Several countries known for longevity are expected toattain an average life-expectancy of 90 years even sooner. (Salomon et al.,
2012)
The global aging trend has been especially apparent in Japan, where the
combined effects of longevity and low fertility have accelerated societal
aging at an unprecedented rate in recent decades. (Cabinet Office of Japan,2017) In 2016, 34 million people, or 27.3% of the total Japanese population,
were already age 65 and older, and nearly half of them (17 million people,
or 13.3% of the total population) were 75 and older. Further, it is projectedthat the 65-and-older and 75-and-older populations will increase to 38.4%
and 25.5%, respectively, of the total population by 2065. The rapid increase6

in the oldest segment of the older population is particularly notable inJapan as well as in a number of other countries, mostly in Europe and partsof Asia, where the proportion of older adults is already high. (Salomon,
2012)
Many people believe that today’s older adults are healthier and maintaintheir daily functioning longer than any time in the past, as illustrated bypopular slogans like “today’s 70-year-old is yesterday’s 50-year-old.” These
claims are supported by the Health-Adjusted Life Expectancy (HALE)
statistics, which show an increase in the average number of years people
live in good health. However, because HALE statistics are increasing at a
slower rate than overall life expectancy, the years people live in less than
good health (or with disabilities) are also longer. (Salomon et al., 2012)
These statistics further support projections of a continuing expansion in the
demand for assistive devices.
Japanese Programs for Aging Services. In Japan, heightened concern overthe increasing need for caregiving for older adults began to emerge as earlyas the 1960s, when the original Welfare Law for the Aged was established.
(Campbell, 1992) Since then, Japan has developed numerous older adultpolicies and programs, often inspired by the "best practice" examples in
Scandinavia and other countries. The two most prominent Japanesepolicies and programs were the Elderly Health and Welfare Promotion 10year Plan of 1989 (commonly known as the Gold Plan) and the mandatory
public Long-term Care Insurance Program (LTCIP), started in 2000. The
primary purpose of the Gold Plan was to expand the capacity of services forolder adults, focusing on the development of home- and community-basedcare services and, to a lesser extent, to expand facility services to reducethe burden on family caregivers. The primary beneficiaries of the LTCIP areadults age 65 and older who become eligible for services once their service
need level is determined. Of particular interest is the inclusion of the
Welfare Equipment Rental Program (WERP) in the LTCIP, the first nationallyadministered assistive device rental program directly linked to older,home-residing beneficiaries. Other government programs also makeassistive devices available, although Ohashi (2014) notes that accessingthese programs can be confusing and difficult for older adults who had notused them previously, and they rarely take advantage of these programs.
The WERP was the first large-scale national program specifically designed
for the older population in Japan. The program rents out assistive devices
in 13 categories (e.g., wheelchairs, walkers, and hospital beds) to program
beneficiaries who have met the care-need criteria. The monthly out-ofpocket cost of renting a device is either 10% or 20% of its commercial
rental cost, depending on the beneficiary’s income. Today, this rental
program requires a plan of use to accompany each rental agreement toensure that the appropriate device is provided and properly used topreserve and enhance the user’s residual functional capacity. (Ohashi,

7

2013) The Association for Technical Aids (ATA) has initiated a training
program for assistive device planners who work with beneficiaries todevelop individualized assistive device use plans, and roughly 13,200
planners had been trained through 2015.
A concern raised about the WERP is that it does not offer individual rentals
to beneficiaries living in residential facilities. The LTCIP provides a lumpsum to these facilities, which, in turn, purchase assistive devices as a partof the standard equipment shared by their residents. Although the facilities
are free to purchase devices that meet the functional needs of eachindividual resident, little economic incentive exists under the current
reimbursement system to provide individually fitted assistive devices. As aresult, the facilities tend to purchase the more cost-effective, one-size-fitsall devices. This funding mechanism is a carryover from the pre-LTCIP days,
and Ohashi (2014) points out that because of this funding mechanism, theneed for individually fitted assistive devices has not been met for many
residents in care facilities.
Despite the limitations described above, the WERP is considered theprimary mechanism to make assistive devices accessible to older adults inJapan. Although the process of adding innovative assistive devices to the
WERP list of available rentable items has been slow, recent changes to thereview process may expedite the listing of devices in the future.
Economic Recovery. Since the end of WWII, the Japanese economy has
experienced remarkable growth, followed by contraction and slow
recovery. The 70-year history of the post-WWII economy can becharacterized in three phases (1) economic recovery following WWII,
leading to a high growth rate (1945 to the early 1970s); (2) becoming aleading industrial power and then moving into an overheated state known
as the bubble economy (mid-1970s to mid-1990s); and (3) a prolonged
period of deflation, stagnation, and slow recovery (mid-1990s to thecurrent time). Today, many are concerned about the economic future ofJapan in an environment of intensifying international industrial
competition while the nation is experiencing both an increasing older
population and overall population decline.
Japan’s current policies and programs for major economic revitalization
were first initiated in the 1990s, and there have been renewed efforts sincethen to update these policies and programs, as exemplified in the Strategy
for Japan’s Revitalization. (The Prime Minister’s Office, 2013) An interesting
recent elaboration upon this strategy involves the Society 5.0 vision, where
Japan would be able to solve a wide range of societal needs and create a“society centered around human beings where they live comfortably . . .
and pursue active life,” by mobilizing cyber technology. (Japanese Business
Federation, 2017; Cabinet Office of Japan, n.d.a) The Japanese government
has started implementing tasks aimed at this vision, including (1)8establishing program leadership at METI; (2) removing administrative
barriers among the ministries and agencies; (3) encouraging collaboration
among industry, academia, and government; (4) establishing fewer
regulations that stifle development; (5) providing large-scale governmental
investment; (6) promoting open innovation; (7) partnering with foreigncompanies and organizations; and (8) recruiting talent globally. It is
important to note that some of these tasks may not be easy for Japan, with
its history of success through strong internal bonding and emphasis on its
uniqueness. After all, it was not long ago when Japan was both admiredand ridiculed as “Japan Inc.” Nevertheless, these tasks highlight Japaneseambition to become an international powerhouse again in robotics ingeneral, and specifically in the AT field, with special attention to thecountry’s aging population.
International Influence and Trade Barriers. Japan has a strong tradition ofincorporating important, interesting, or useful aspects of other developed
countries into the fabric of Japanese society, often with substantial
adaptations. Innovations in AT are no exception, and this explains how
some AT innovations in both technology and policy got started in Japan.
In 1993, five years after the passage of the Tech Act in the United States,
Japan passed similar legislation called the Social Welfare Device Law topromote innovations in assistive devices. The influence of the Tech Act on
the subsequent Japanese legislation is undeniable, as Japanese policymakers recognized the U.S. approach as a solution for both its aging
population and struggling economy. At the same time, the new Japanese
law incorporated several new features specifically addressing the unique
circumstances in Japan, such as (1) focusing on the AT needs of the aging
population; (2) emphasizing the importance of interagency collaboration
between METI and the Ministry of Health, Welfare, and Labor (MHWL); and(3) adding assistive devices as a focus area of NEDO.
Another important influence relates to the presence of a trade barriercaused by the way Japanese handle assistive devices differently from othercountries, especially the European Union (EU), the United States, and China,
which represent huge potential markets for Japanese AT in the future.
These countries are similar in that they all treat assistive devices as medical
devices and require formal approval before allowing marketing of thedevices in their countries. This approval process often requires applicants
to submit detailed efficacy and safety data as a part of the application
packet. In contrast, Japan does not require such data for domestic
marketing, and data on product efficacy and safety become necessary only
when the product is marketed in countries where new assistive devices
must be approved first. The data requirements for assistive devices in the
EU, United States, and China are summarized below:

9EU. In the EU, all assistive devices must first obtain a registration for
medical devices called a “CE Mark,” as required by a binding agreement
among member nations. (Pelkmans, 1987) Depending upon the risks
involved, CE Mark applicants are required to provide one of several levelsof clinical and safety data to vouch for their product’s efficacy, safety, andpracticality. This requirement, in turn, promotes further development andenhancement of new product research, testing, and evaluation capacities.
Of particular interest is the pioneering user-driven innovation method,where product users are involved with product planning through final
clinical tests. The innovative products developed using this method areconsidered highly desirable because they are presumed to be closelyaligned with the realistic needs of users. Denmark and Sweden, two of theleading nations promoting this approach, have supported promising userdriven innovations from around the world, including Japan. (Development
Bank of Japan [DBJ], 2014; Organization for Economic Co-operation andDevelopment [OECD], 2012)
United States. The American market is considered potentially themost profitable destination for care robots and other innovative assistive
devices. However, to market an assistive device in the United States, it
must first receive approval as a medical device from the Food and Drug
Administration (FDA). There are three classes of approval, with the highestclass approval designated for high-risk devices. Normally, innovative
assistive devices fall into the medium-level approval range, and suchapplications are often required to be accompanied by extensive clinical andproduction data. In addition to FDA approval, being included on Medicare’s
Durable Medical Equipment (DME) list is considered highly desirable.
Medicare is a federal health insurance program primarily for adults age 65
and older, and the program pays 80% of the costs of approved DMEs. One
caveat is that increasingly, a specific DME becomes available tobeneficiaries only when it is on a list of equipment sellers who woncompetitive contracts from Medicare. To secure a coveted place on this list,
it has become important to establish the product’s desirability throughample supportive data prepared by a reputable third-party organization,
preferably American.
China. The Chinese regulatory environment is similar to that in the
United States and EU in that it also considers assistive devices as medical
devices and requires approval from the China Food and Drug
Administration (CFDA). While the CFDA application process is especiallychallenging for foreign applicants because of its complexity, the potential
importance of the Chinese market, particularly in the coming years, isundeniable.
Japan has not changed its regulatory policy for assistive devices (except forhearing aids, which are now considered medical devices). In fact, somerecent reports note that this Japanese approach (i.e., absence of regulatory10control for assistive devices) has helped Japanese companies expedite theprocess of developing and marketing their new assistive device products.
(Mouri, 2016a) Nevertheless, the importance of compiling data on a
product’s efficacy, safety, and practicality through clinical testing, as a partof the product development process, has been recognized, not only formarketing purposes, but more importantly, as a responsible practice for
manufacturers to follow. In particular, the user-driven innovation approach,as it is practiced in countries like Denmark and Sweden, seems to begaining traction. (DBJ, 2014)

Policies and Programs to
Promote AT Innovations
Shortly after the passage of the Welfare Device Law, the Japanese
government implemented the Program to Support Practical Application ofAssistive Devices for Solving Challenging Issues (shortened as SPAAD in thisarticle) in the 1993–1994 period. (NEDO, 2017a; NEDO, 2017b) Based on
the premise that public-sector support is essential because of the highbusiness risk and low profit margin associated with AT research anddevelopment, especially for smaller businesses, this program wasconceived to provide subsidies to promising innovation projects of up to$200,000 per year for 3 years (based on the exchange rate of $1 US = ¥100
used throughout this article). Many, but not all, of the projects that havebeen funded under this program involve robotics and assistive devices
specifically designed for older adults. According to NEDO (2017b), thisprogram is still in place, and as of 2016, subsidies have been provided to a
total of 222 projects, with roughly half of them (107) commercialized, as
shown in Table 1. However, only 5% of total projects have reported
commercial success so far.

Table 1. Summary of Innovation Projects Funded by NEDO (Through 2016)
Applications
Year
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006

AppliedAccepted

118
77
128
123
123
158
183
129
121
115
131
77
43

19
9
13
13
15
20
21
10
10
5
10
5
5

Subsidies(Unit:$ Million)
2.88
1.78
1.67
1.95
2.06
2.42
2.43
2.44
1.57
0.88
1.14
1.29
1.5

11

StatusMarketed
0
4
8
6
13
10
6
10
7
9
4
4
4

ProfitReported
0
0
1
1
1
2
0
2
1
0
0
0
1

Applications
Year

Applied

Subsidies(Unit:$ Million)
1.07
1.03
0.93
1.01
0.54
0.52
0.33
0.90
1.15

Accepted

2007
34
5
2008
56
7
2009
45
4
2010
75
11
2011
29
11
2012
45
7
2013
58
7
2014
34
7
2015
33
3
2016
38
3
Total
1,973
222
Source: NEDO (2017): 2017 SPAAD Plan

31.49

Status

2
1
2
3
4
4
4
3
0

ProfitReported
0
0
0
0
1
0
0
0
1

107

11

Marketed

Early on, the Japanese innovation effort was concentrated in the areas ofbasic research and infrastructure development, attracting little publicattention. The first robotic assistive device introduced to the domestic
market was My Spoon in 2002, designed to help people with upper limb
disabilities feed themselves by operating a joy stick. By the mid-2000s, newrobots developed by some of the nation’s most promising young “robot
doctor” entrepreneurs began to emerge in the marketplace, attracting
much media and public attention.
The government also stepped up its activities with the 2011 announcementof the Action Plan for Major Policies on Science and Technology by theCouncil for Science and Technology (CST), which later changed its name to
the Council for Science and Technology Innovation (CSTI). The CST/CSTI is
composed of the Prime Minister, cabinet ministers, and leading academics
and experts and serves as the nation’s control tower for science andtechnology policies. The Action Plan included the development of assistive
devices with a focus on devices that can be operated easily by older adults
and those with disabilities and that can help reduce the physical andmental burdens on family and professional caregivers. This part of the
Action Plan was intended, by 2020, to (1) slow the growth of older adults
needing caregiving; (2) increase opportunities for participating incommunity activities among older adults and people with disabilities; (3)reduce the caregiving burden while increasing the quality of care; and (4)enhance international economic and industrial competitiveness. In
summary, the Action Plan included clarifications of the goals andexpectations of assistive devices in achieving these goals. (CST, 2011)
Table 2 lists the most notable recent projects intended to (1) develop carerobot safety features and safety evaluation methods; (2) strengthen clinical
trial capabilities by linking care robot developers and long-term carefacilities; (3) identify priority areas for care robot development; (4) provide
subsidies to developers in priority areas and improve evaluation methods;(5) establish a national contest to identify projects focused on inexpensive

12

care robot development; and (6) provide subsidies to long-term carefacilities to purchase care robots.

Table 2. Recent Programs Designed to Promote Innovations in Assistive Devices
Projects
Practical Applications ofAssistive Devices and Care
RobotsSupporting Practical
Applications of Assistive
Devices and Care Robots
Identification of Priority Areas
in Long-term Care
Applications of Robot
Technology
Developing and Incorporating
Robotic Devices in Long-term
Care

5-Year Plan for Developing
Care Robots

Subsidies for Care Robot
Purchases

Content
Started in 2009 to provide $60 million over 5 years toestablish safety evaluation methods and develop carerobots incorporating safety features.
Started in 2011 with an annual budget of $8.3 million to
support activities linking developers and LTC facilities
and to conduct surveys and clinical trials. Consultation
services by professionals started in 2013.
Beginning 2012, identified (1) transfer assistance; (2)mobility support; (3) toileting assistance; and (4)monitoring devices for dementia patients as focus areas
for robot technology applications. In 2014, bathing
assistance was added to the list.
Started in 2013 with an annual budget of $30 million toprovide subsidies to companies and researchorganizations engaged in developing care robots in thefocus area listed above. Also included was a project tocultivate an environment suited for evaluating theeffectiveness and safety of new care robots.
Adopted by the Cabinet in 2013 to conduct an annual
national contest for developing inexpensive andmarketable care robots. Also announced was early
implementation of safety standards.
Started in 2014 to expand the market for robotic caredevices by providing $500 million to help LTC facilities.
Simultaneously, large-scale evaluation projects wereplanned at facilities using the robotic care devices
purchased with funds from this program.

While innovations in assistive devices have never been limited to theapplication of robotic technology, the emphasis has always been on carerobots, and in the 2013 5-year Plan, METI and MHLW jointly prioritized five
types of care robots for development and market expansion as acomponent of Japan’s larger revitalization strategy, as shown in Table 3.
The table also shows the number of the projects supported by this programas of 2017. The types of support rendered by the program depend on need
and range widely from technology application and clinical data collection tomarketing strategy development. (METI, 2017a; METI, 2017b; MHLW,
2013)

13

Table 3. Care Robot Categories under Assistive Robot Development 5-year Plan
PurposeConditions for Subsidies

Wearable

Assist transfer
to/from bed,
wheelchair, orcommode Reduces caregiver load Caregiver can put on
without help

Subsidized Casesand Examples
Approved cases: 5
Example: HAL® byCyberdyne Co.

Nonwearable

Assist transfer
to/from bed
and wheelchair Caregiver operates
without help Hanging type lift notincludedApproved cases: 8
Example: SASUKE
by Muscle Actuator
Motor Co.

Outdoor
Use

Supportoutdoor walking
and shopping User can operate
without help
 Supports maintaining
walking ability
 Safe power-assist on
slope

Approved cases: 12
Example: RT.2 by
RT. Works Co.

Equipment TypeTransfer
Assistance

Mobility
SupportWearable Outing Assistance (2017 addition with no further information
available)
IndoorUse

Support indoor
activities(especiallytoileting) Supports maintaining
walking ability
 Operable by user orwith no more than one
person assisting OK to combine withother devices

Approved cases: 7
Example: Cuddling
Robot by Sanyo
Homes Co.

Approved cases: 10
 Can be set up in a
Example: Wrapponroom
by Japan Safety Co.
 Prevents smell
dispersion into theroom
Self-care Assistance for Toileting (2017 addition with no further information
available)
Bathing Support
Support getting  Operable by bather or Approved cases: 5
in/out ofwith no more than one Example: Wells bybathtub
Sekisui Homes
person assisting Can be removed when Techno Co.
other family membersbath No renovation
involved
Monitoring Facility
Monitors
Approved cases: 21
 Information sharing
Use
multiple
Example: "nonfunction among care
residents
touching, nonproviding teamsimultaneously
restraining
members
and alerts caremonitoring bed" by Operable 24/7
providers when  Can be linked to other Ideauest Co.
intervention isequipment andwarranted
softwareHome
Platform for
Approved cases: 14
 Can monitor multiple
Usehome use to
Example: Imairumo
rooms simultaneously
ToiletingSupport

Disposal

In-room
disposal of
excretion

14

Equipment Type

PurposeConditions for Subsidies

Subsidized Casesand Examples
HI by SOLXYZ Co.

 Can be used inbathroom and darkrooms Can be used by carerecipient to alertfamily caregiver Can be personalized toreflect care recipient’s
activity pattern
ProviderUse of Robotics to Enhance Service Provision (2017 addition with no further
Supportinformation available)
Source: Nursing Robot Portal Site (2017): List of Robots
monitor andalert for falling
accidents at
home

According to information available from The Japan Agency for Medical
Research and Development (AMED, 2017), 68 care robot development
projects received funding and support from the 5-year Plan. Of these, 11
are now commercialized in the market place, as shown in Table 4.

Table 4. List of Commercialized Care Robots Supported by Robot Care 5-year
Plan
Priority Area
Wearable Transfer
Assistance

Product
Company
HAL® Lumber Type for CareCYBERDYNE Co.
SupportMuscle Suit Care Type
Kikuchi Seiskusho Co.
Non-wearable Transfer Transfer Assistance Hug T1
Fuji Machinery Co.
Assistance
Rishone Plus (integrated electric
Panasonic AgeFree Co.
bed/wheelchair)
Robohelper Sasuke
Muscle Actuator Motor Co.
Outdoor Mobility
Robot Walker RT.2
RT. Works Co.
SupportRobot Walker Flatia
Kawamura Cycle Co.
Toileting Support
Portable Flush Toilet Kyuretto
Aron Chemicals Co.
Monitoring System for Three-dimensional electronic
Noritsu-Precision Co.
Care Facilities
mattress monitoring system
Silhouette monitoring sensor
King Securities Co.
Owlsight monitoring system
Ideaquest Co.
Source: METI (2017): [METI/AMED Project to Promote Care Robot Development and Use:A list of Commercialized Products]

As new products started to appear on the market, regulators anddevelopers increased their awareness of the need to address safety andefficacy issues. As discussed earlier, this was deemed necessary for
expansion to the global market. Around the same time, the public’s
concerns over safety was heightened following the reports of injuries anddeaths among older adults while using assistive devices. Although thosecases were not directly caused by care robots or other new innovations,the public started demanding better accountability. The steps taken in
response include (1) METI initiating the Assistive Device-specific Japan
Industrial Standards (JIS) Mark program in 2008; (2) MHLW partnering with
ATA to conduct the Project for Clinical Evaluation of Assistive Devices; and15

(3) NEDO collaborating with other nations to establish ISO13482, the firstinternational safety standard for personal care robots. (Aizawa, 2014;
MHLW, 2017)
Both JIS Mark and the Project for Clinical Evaluation are voluntary testing
programs. Unlike the international standards for other products already inplace, ISO13482 is mostly qualitative rather than involving the quantitative
testing of products, partially due to the newness of the field. For thisreason, the reputation and credibility of the testing agency are importantfor confidence in the safety of the product. Two of the four case examples
presented in this article, HAL® and RT.2, were among the first recipients ofcertification under ISO13482.
The national policies and programs in Japan have also impacted local policy
and program development. Of special interest are two regional/municipal
participants in the Comprehensive Special Zones for Local Revitalization
Program: the Sagami Robot Industry Special Zone and the Okayama New
Health Care Special Zone. Special zones are designated by the national
government to implement pioneering initiatives that are designed to
improve local conditions in a specific way envisioned by the locality. Oncedesignated, special zones receive special privileges, such as regulatory
exceptions, tax exemptions, and fiscal allocations for goal attainment.
Sagami and Okayama are noteworthy because they have incorporated thepromotion of assistive device innovations into their respective project
scopes. (Cabinet Office of Japan, n.d. b)
The Sagami Robot Industry Special Zone implemented a rental program forinnovative assistive products in 2010 to help expand their use in residential
care facilities in the region and, at the same time, support local companies
developing care robot products. Initially, seven assistive robots wereselected for the rental project, including HAL® and Paro (discussed later inthis article). In 2011, the Kanagawa Welfare Service Association (2011)
published a report that included a set of recommendations from 28
participating care facilities, as summarized in Tables 5. Key
recommendations were to (1) make the devices more affordable; (2) gain abetter understanding of the frontline needs; (3) increase information on
safety; (4) make the devices more user-friendly; (5) provide information on
cases and use data; (6) reduce the preparation time before devices can beused with new patients; and (7) change the management style to be more
open to new approaches. The report noted that some devices were viewed
as “unnecessarily ostentatious,” and some interviewed expressed doubt
about the appropriateness of “machine-assisted care.”16

Table 5. Summary of Responses on Challenges for Introducing Robotic Support
Response Category
Product-SpecificConcerns

Too expensive

21

Cost
performance Lacking clearly demonstrated
benefits

9

Functionality

 Not sufficiently finalized as apractical product Lacking sufficientunderstanding of the needs incare facilities
 Too elaborate and too muchpreparation time needed foruse

9 Not clear if safety is adequately
addressed

8

Ease-of Use Required staff time for use

5

Basic
Information

 Too little information aboutcare robot itself

6

Case Examples

 Lacking information onevidence of utility and caseexamplesManagement Attitude

View toward Care

Facilities
Responding

Cost

SafetyGeneralInformation

Main Concerns4 Lacking funds to invest
 Lacking proactive stance tosolve challenges facing care
workers and clients6 Belief that robots cannot carefor clients like humans

5

Source: Kanagawa Welfare Service Association (2011): [Report on the Model Project for
Promoting Long-term Care and Medical Robots].

Okayama City’s goal for its Special Zone project is to make Okayama an
age-friendly place to live, and as a part of this effort, the City initiated an
assistive device rental project for their older residents in 2014. The primary
project goal is to promote innovative assistive devices, including carerobots selected by Okayama City, such that they can be added to the list of
the LTCIP’s WERP, thus making the devices available nationally. The
program also includes items from locally-based companies, such as Power
Assist Gloves (designed to assist hand-grip by pneumatic power) by Daiya
Industries to promote local innovations. In a way, the Okayama program
seeks to serve as a trial-run for new promising products, and for this reason,
the rental fees are set at 10% of the commercial rental fees, consistent
with the national rental program. The city has been compiling andanalyzing the findings from user surveys in collaboration with rental device
makers, local universities, and the MHWL. Assistive devices are selected forthis program by the city, and the monthly rental fees are shown in Table 6.
(Okayama City, n.d.)17

Table 6. Assistive Devices in Okayama City’s Rental Program
Monthly
Rental Fee
Bathing AssistanceShower Onyoku Chair Sekisui Home
$5.00
Communication Robots ParoIntelligent System$20.00Hand AssistancePower Assist GloveDaiya$17.00
Medication AssistanceFukuyaku-shien Robo Carepot$15.00Okusuri-nondene
Kamiden$8.00
e-Okusurisan
Eisai$10.00
Monitoring
Odayaka Time
F.S.C.
$16.00Toilet Assistance
WrapponJapan Safety$8.00
WalkerACSIVE
Nanbu$10.00Kaisoku Walker
Welfan$3.50
Posture Correction
Trunk Solution
TSC$14.00Indoor Ramp
Heartful Slope
Nakashima$8.50
Source: Okayama City (2018). [Okayama Special Zone Project: Cutting-edge Assistive
Device Rental]
Category

Product

Company

According to a report by Okayama City (2016), a total of 52 people, forexample, used the program to rent Paro for an average rental period of 6.1
months in the two-year period between 2014 and 2016. The reportconcluded that a significant degree of reduction in problematic behaviors
among the clients was observed by family caregivers. Also, the caregivers
reported a reduction in psychological burden of caregiving. Further, thereport noted that 32% of the clients discontinued the rental of Paro within
the first two months, suggesting the importance of ensuring the device isappropriate for use by the client. For this reason, the report recommended
improving the education and assessment process before renting out Paro.
In 2016, RT.2 (no longer available from the Okayama rental program)became one of the first robots to be included in the LTCIP’s WERP, giving
Okayama bragging rights about its role in securing AT equipment
acceptance.
In general, the findings from both Sagami and Okayama, along with several
other regions, are preliminary, and it remains unclear which new assistive
devices may prove to be successful as commercially viable products.
However, the commercialization of these products is progressing, andlessons learned from early innovations are influencing how policies andprograms need to be strengthened in the coming years. In 2014, Prime
Minister Shinzo Abe convened the Conference for Starting Robotic
Revolution and set a domestic sales goal of $500 million/year for medical
robots (needing official approval as medical devices) and assistive robots(needing no special approval in Japan) combined. (Honma, 2017) Of thisamount, the sale of the care robots was projected to reach $150
million/year. (Mouri, 2016b)

18

Older Adult’s Views
According to the 2016 White Paper on Labor and Welfare by MHWL, 72.7%
of older Japanese want to continue living independently in their homes as
they grow older (MHLW, 2016), and another survey reports that 68% of
older adults favor using assistive devices to make their daily living easier.
(Cabinet Office of Japan, 2014) In another survey, this time not limited toolder adults, 60% of the survey respondents favored the use of care robots.
(Cabinet Government Public Relations Office of Japan, 2014) According tothis survey, while the most frequently cited reason for favoring care robots
was the expectation for “reducing caregiver burden” (64%), other reasons
were associated with the hope of increasing independent lifestyle options,such as “being freed from pleasing caregivers” (42%), “increasing selfsufficiency” (36%), and “preventing physical and mental decline” (21%).
Surveys involving older adults and aging tend to focus on the frailty andeconomic hardships in later years, and more surveys are needed focusing
on older adults’ views and plans toward independent living and the use oftechnology. It would be especially interesting to capture the shifting viewsof dankai-no-sedai (the Japanese baby boomers born between 1946 and1949). Like their counterparts in the United States, this age group is known
to be better educated, have more professional experience and willingness
to explore new ways, and be more comfortable with technological shift.
How this generation responds to care robots and other assistive device
innovations as they approach their 7th decade is an important factor forthe success of assistive device innovations in Japan. Although little
information is currently available on this generation’s view toward carerobots and other assistive devices, a survey report from the Cabinet Officeof Japan (2013) supports this group’s proactive views toward their life andliving as older adults.
A noticeable trend is the proliferation of the word “independence” invirtually every program, law, and regulation associated with aging anddisabilities in Japan. Although the term is not new, caution is needed inusing the term because independence has long been understood in Japanas the responsibility of a young person to become economically self-reliant.
In contrast, the concept of independence has been nurtured in the UnitedStates and elsewhere as the right of older adults and people withdisabilities to live independently. For this reason, experts (Kanbe, 1995;
Ohashi, 2014) urge caution when using this term, particularly in Japan, inthe context of older adults. Further discussion on the topic ofindependence is warranted, especially involving older adults themselves, tobetter understand what assistive device innovations are desirable and how
they can be made available to and affordable for older adults.

19

Examples of Japanese Assistive
Device Innovations
The SPAAD played an important role in the development of innovative
assistive device products since 1993 (especially in its early days), with
noticeable overlaps with the Care Robot 5-year Plan occurring later.
Approximately half of the projects subsidized through the SPAAD havebeen commercialized, although only a few have reported profits to date. It
is interesting to note that recently a new focus area has been added to thisprogram that targets innovations for “older adults with manageabledisabilities” who are experiencing disability-related inconveniences but do
not meet the service criteria of the long-term care insurance program. Thisis an example of the new emphasis on developing assistive devices that are
helpful for older adults in maintaining their daily functioning andcommunity living. This recent development is consistent with the global
trend, even though some critics have pointed out that there has been noconcrete evidence so far that demonstrates the effectiveness of assistive
robots in enhancing independent living among older adults and lightening
caregiver burdens, according Mouri (2016a).
All four case examples discussed in this section (RT.2 , HAL®, Paro, andcomuoon) have received technical and financial support through the
SPAAD, highlighting the success of innovations involving public-private
partnerships. Even though these four examples alone may not depict theentirety of AT development in Japan, each has attracted much publicattention and are considered early successes. As the examples illustrate,
many (but not all) new assistive devices adopt a name taken from Englishthat seems to reflect a global ambition to convey a new direction awayfrom traditional assistive devices. In this section, the spelling andcapitalization of product and company names are those commonly used by
the companies in their brochures. All photos used in this section are
copyrighted and used with permission of the owners.

RT.2

Of the four examples
presented in this article, RT.2,
developed by RT.Works, is the moststraightforward innovation. RT.2,
along with its predecessor RT.1,
were pioneers in the field of robotic
walkers. Although their designs are
Permission by RT.Works
different, both models share the © RT. Works co.,ltd.
same robotic functions, and for this reason, they are sometimes considered
the same innovation. (RT.Works, as the Original Equipment Manufacturer
or OEM, also provides the robotic component of Little Keypass, a robotic
walker sold by another company Kowa.)

20

Rt.2 is a 4-wheel walker with a big shopping basket in front that can serve
as a seat. It weighs about 20 lbs. and can be collapsed for transportation.
By adding robotic functions to the frame, RT.2 is designed to make outdoor
walking easier and more comfortable for those with walking difficulties.
Sensors send road information to its control system, which supplies power
to the wheels to help users negotiate the ups and downs of streets so thatwalking is safer and less exhausting. The core robotic technology employedin RT.2 includes (1) a six-axis sensor to gather information on groundconditions and user movement; (2) handle grip sensors to collectinformation on user movement; (3) a real-time control mechanism
responding to information sent from the sensors; and (4) a lithium ion
battery as the power source. RT.2, as with RT.1, meets ISO13482, thesafety requirement for personal care robots.
Fujii (2017), the lead developer for RT.2, noted that the core technologies
used in RT.2 could have easily been applied to a robotic wheelchair instead,but he and his colleagues chose the walker because they liked the idea of adevice that helps older adults maintain their ability to walk, and for thatreason, they focused their attention on making their walker easy and safe
to use and visually attractive. They believed these qualities might give
users a sense of independence and confidence.
Additionally, Fujii (2017) noted in an interview with the author that RT.2 isa lighter and more practical version of the previous model, RT.1, withchanges made to meet the specifications of the LTCIP. Further, he notedthat although he is happy with the overall changes, the requested removalof Internet of Things (IoT) access embedded in the device was adisappointment. The IoT would have enabled RT.2 to automatically send an
emergency alert in case of an accident, and it could have allowed daily
walking data to be sent to a health care provider, as is the case with RT.1.
Further, the walker could have easily checked directions and the weather
forecast and even make phone calls without having to reach for a smart
phone or iPad.
In the same interview, Fujii stated that the domestic demand for a walker isaround 200,000, and sales of 10,000 units would be considered a huge
success. However, the current rental total remains 500 to 600 units. (At thetime of interview, RT.Works was finalizing an indoor model that would
allow a user with walking difficulties to move around indoors rather thanusing a wheelchair or depending on a caregiver for walking assistance.)
The RT robotic walkers received the 2016 Robotic Award in the category ofbest small business venture along with the aforementioned Little Keypass.
The Robot Award is an honor bestowed on promising development efforts
from co-sponsors METI and the Japan Machinery Federation. The award

21noted, as the reason for selection, RT’s technological competence
responding to clearly identified social needs.

HAL® HAL®, an abbreviation of Hybrid Assistive© CYBERDINE INC.

Limb, is a group of wearable robots from the
CYBERDYNE Company, and they are perhaps themost talked about assistive robots today in Japan.
Unlike RT.2, which had been commercialized in a
relatively short period, the history of HAL®
development overlaps the entire period of
robotic applications in assistive devices in Japan.
HAL® research started in 1991 with the goal ofdeveloping an innovative medical device forpeople with mobility challenges, a primary goal Permission by CYBERDINE
that remains the same today. (CYBERDYNE, 2018) While maintaining his
focus on medical devices, Yoshiyuki Sankai, HAL® developer and Professor
at Tsukuba University, was able to expand the scope of his work to include
the development of assistive devices for the older population. Doing sooffered the most favorable environment to pursue his goal of developing
HAL®, given the Japanese interest in combining solutions for the aging
population and economic revitalization. Multipurpose functionality is thehallmark of HAL®, and the inclusion of assistive device development waswell within reach for Sankai. Once HAL® was commercialized in Japan as an
assistive device in 2008, Sankai moved quickly to arrange the clinical datacollection necessary for HAL® to be approved as a medical device. This
strategy worked well for HAL®, and it received approval as a medical device
in a very short period, between 2013 and 2017, in Japan, Europe, and theUnited States.
Sankai claims that HAL® is the first cyborg-type robot in the world. (Lazarte,
2014; Tateyama, 2017) A cyborg robot, unlike a humanoid, does not makeits own decisions for action. Instead, HAL® interprets the minds of thewearers from their movements and other information, helping them tocarry out their intended actions, such as walking or lifting. As noted above,
HAL® was first commercialized as an assistive device, and the rental
program started in 2009 by CYBERDYNE, a venture enterprise for
production and distribution of HAL®.
A key component of HAL® is a bioelectric signal sensor (BES) that includes
electrodes attached to the wearer’s skin for detecting a minute amount ofbioelectrical signal as a way of capturing the brain's intention for action,such as walking. HAL® also includes a Cybernic control system, which is ahybrid control system that integrates and controls HAL®’s movement.
Cybernics is a new discipline founded by Sankai to "integrate human, robot,
and information" (CYBERDYNE, 2018), and the use of Cybernic technology

22allows HAL® to assist human movement smoothly in accordance with thewearer's intention, according to Sankai.
Medical HAL® (Lower Limb Type) is the center of attention today.
Treatment using Medical HAL® is based on Sankai's theory calledinteractive biofeedback, which involves the formation of a closed loop
initiated by BES signals and is useful in the treatment of patients withcertain types of diseases and related conditions. (Sankai and Sakurai,
2017a; Sankai and Sakurai, 2017b) Based on clinical trial findings that havedemonstrated its efficacy and safety, Medical HAL® is now approved foruse as a medical device for neurorehabilitation in Japan, the United States,and some European countries.
CYBERDYNE, along with other participating developers in NEDO’s 5-year
Plan for Developing Care Robots, is credited in helping the development
and publication of the international safety standard for personal carerobots, ISO13482. This opportunity also helped HAL® engineers make
improvements to HAL®’s own safety features, becoming the first personalcare robot in the world to receive the ISO13482 certification. (Furukawa,
2014)
Sankai has become a cultural icon in Japan. His talent and vision havegarnered people's admiration as one of the best-known innovators
representing the Japanese robotics industry. In 2009, the Japanese
government invited him as one of 30 prominent scientists/engineers toparticipate in the Funding Program for World-Leading Innovation R&D on
Science and Technology (or FIRST for short), providing a total of $100
million to share among the 30 participants to pursue their research anddevelopment projects identified as most promising. This funding, alongwith many other governmental funding awards along the way, has financed
and boosted HAL®'s ambitious undertaking. Further, in the 2015 White
Paper on Science and Technology, HAL® products as group were recognized
as one of eight innovations that had impacted everyday life in Japan.
(Ministry of Education, Culture, Sports, Science, and Technology [MEXT],
2015) These examples show Sankai's major contributions as one of themost talked-about innovators in Japan.
Today, of all robots, HAL® is probably best known. CYBERDYNE has a
network of exhibit halls and showrooms and actively promotes the HAL®
brand, attracting not only those who contemplate using HAL® as a medical
or assistive device, but also a wide range of visitors and even groups ofschool children. In 2016, Medical HAL® was awarded the coveted Robot
Award in the MHLW Minister category, and in 2017, an insurance company
started to feature HAL® in its TV commercials, followed by anannouncement of Medical HAL® receiving FDA approval for use in twotreatment categories. With these successive attention-getting

23

developments, anticipation continues to increase for HAL®'s commercial
success.

Paro Like HAL®, Paro, acommunication
robot
developed with older
adults with dementia in
mind, is considered anearly international success
Permission by Intelligent Systemstory. Some may even © Intelligent System Co., ltd.
argue that Paro is more successful than HAL® internationally because it has
already been tested and used in more than 30 countries. Another similarity
with HAL® is that Paro is increasingly pursuing its therapeutic (i.e., medical)
potential, using its success as an assistive device as a springboard. The
name Paro came from “Paasonaru Robotto,” Japanese pronunciation of theterm “personal robot.”Paro looks like a stuffed animal resembling a harp seal baby. It is around 24
inches tall and weighs 5.5 pounds, and by design, it “feels soft and has theweight and size of an easy-to-hold baby,” according to promotional
publications. Internally, it is a communication robot with “feeling, thinking,and acting” functions. Takanori Shibata, a robotics engineer at the National
Institute of Advanced Industrial Science and Technology (AIST), initiated his
work with Paro in 1993, the year the Assistive Device Act was enacted.
Then, in 2004, he founded a venture company named Intelligent Systems
for production, marketing, and maintenance services for Paro. Paro
received the coveted Robot Award in the service robot category in 2006,
the award program’s inaugural year, highlighting the hope it represented
for the industry.
The core idea for Paro came from the kinship people develop toward
animals, and Shibata proposed that an animal-like robot could be very
useful to people with dementia if it can offer the same (or a similar) senseof connectedness with alive animal without the care and challenges realanimals demand. In choosing a baby seal as the model, Shibata (2012) used
the findings from a psychological experiment showing that people would
be more accepting of an animal-shaped robot that is cute but less familiar
than the ones that they know well, like dogs and cats. Shibata made surethat Paro is appealing to the visual, auditory, and tactile senses of theperson who holds it by incorporating realness (e.g., using the recorded
sound of a baby seal) and perceived desirability (e.g., softness of the snowwhite fur). To achieve the desired assistive effects and also ensure its
safety for users whose physical and mental functioning may have been
compromised, close attention was paid to selecting the materials andsewing techniques.

24

Paro is equipped with several types of sensors, a computer that is twice thecapacity of a common laptop, and quiet-type actuators that move sevenparts of the body. The battery, once charged, lasts 5 hours. These
components are integrated and programmed to approximate how a real
pet animal might respond to a human. Paro even has the limited capacity
to learn how to respond to certain cues, for example, responding to thename the user gives it.
Initially, Paro was marketed domestically as a pet alternative for older
adults who do not have access to pets. Its price was set at around $4,000,
taking affordability into consideration, according to Shibata (2012). The
idea of using Paro in a setting similar to animal therapy caught theimagination of Danish. Specifically, the Dementia Center in Copenhagenoffered Paro a spot in its care robot evaluation project, which received
funding from a national project called “Be Safe” during the years 2006 to
2008. Animal therapy, developed in the United States in the early 1970’s, isa therapeutic method based on the idea that interactions between animals
and humans are beneficial to humans physically, physiologically, andmentally. Since the 1980s, a number of researchers have published test
results that support the efficacy of animal therapy, while some caution thatanimal therapy needs further structural development before it can berecognized as an established psychological treatment method. (Fine & Beck,2010; Kruger & Serpell, 2010)
Shibata coined the term “robot therapy” to distinguish therapy using Parofrom the animal therapy. The Danish expectation for Paro was highbecause although animal therapy is well accepted in Denmark, there havebeen concerns about the high costs and risks associated with using live
animals. Paro was thought to have the potential to address these concerns.
The successful experience at the Dementia Center led to a dissemination
offer from the Danish Technological Institute (DTI), a highly respected
technological research center. However, Shibata and the Dementia Center
were concerned about DTI’s lack of experience and expertise in the areasof dementia care and working with older population, and Shibata accepted
the offer only after DTI had agreed to (1) recruit the Paro project director
from the Dementia Center to lead the DTI project; and (2) partner with
Shibata and his group at the AIST in Japan. Based on this agreement, in
2009, DTI embarked on activities to promote and sell Paro in Europe,
including expansion to Germany, France, Holland, Scandinavia, and othercountries. The joint promotional effort involved convening user
conferences, developing training programs for Paro-based therapeutic
activities, and building a network of Paro-using therapists and advocates.
DTI named the combined activities the “Paro model” and applied themodel to help promote other care robots, but these efforts were largely
unsuccessful, according to Shibata (2018).

25

Paro’s success in Denmark and other European countries enhanced its
potential, and at the same time, it served as a wake-up call for Japan,
whose approach to assistive device innovation had been characterized astechnology-driven, where the primary motivation comes from developer’s
application ideas rather than user input, as noted by DBJ (2014). Concerns
about the Japanese approach had already surfaced, as indicated in the
Sagami report (Kanagawa Welfare Service Association, 2011). The concerns
were not specifically directed to Paro, but its experience in Europe andlater in the U.S. served as a catalyst for increasing Japanese awareness ofthe need for better data on the device’s efficacy, safety, and practicality tomake it more marketable. It was also instructive that even a highly
regarded organization such as DTI in a country with advanced social
welfare programs can benefit from the capacity-building brought about by
the Paro project. Under Shibata’s leadership, since 2012, AIST has hosted
nine international symposia in Japan with professionals and practitioners
interested in Paro and robot therapy, and it has expanded its scope toinclude children with learning disabilities and disaster survivors, such as
those who experienced the historic 2011 earthquake and tsunami.
It has already been pointed out that with care robots and assistive devices
the safety and practicality factors are just as important as the use of
cutting-edge technology and eye-catching newness. From this perspective,
it is interesting to note that the level of AI used in Paro is “appropriate”
rather than cutting-edge. The Danish Council of Ethics (2016) has notedthat high-powered AI is not necessarily required to create an emotionalbond between human and robot, using Kismet (developed by MIT) andParo as examples. The Council has also pointed out that the ethicalquestions raised in reviewing communication robots like Paro involve (1)whether the robot enhances or replaces human involvement; and (2) thenature of therapeutic benefits based on “deception.” Recognizing that (1)risks always exists even when replacing human involvement is not intended,and (2) not all “deceptions” are bad or unethical, the Council
recommended that Paro be used under the guidance of a responsible
individual (care provider or caregiver) who is capable of protecting the
dignity of the user.
Today, according to Shibata (2017), 5,000 Paro devices are in use in over 30
countries. In the U.S., the FDA approved Paro as a Class II medical device
for symptom-management of people with dementia as well as for treating
depression and pain. It is also approved for use in rehabilitation of stroke
victims. Medicare and some private insurance cover biofeedback therapy
with Paro, with a doctor’s prescription. (In biofeedback therapy, thepatients learn how to utilize their mind to alleviate headaches, pain, andother physiological and physical problems and has been gaining popularity
in the United States.) The findings from a randomized controlled trial (RCT)
using Paro at the University of Texas concluded that Paro was effective inthe management of problem behaviors among patients with dementia. The

26

same study also reported that Paro was effective in reducing the use ofpain medications. (Peterson et al., 2016) Further, the cluster-RCT by Joneset al. (2018) found Paro effective in controlling low to moderate agitation
episodes, and another cluster-RCT by Jøranson et al. (2016) reports adecreased need for using psychotropic medication. Lane et al. (2016) also
found less need for medication in an 18-month study conducted among 23
veterans in a United States Veterans Admiration long-term care facility.
Currently, the Chinese University in Hong Kong is conducting an RCT on
Paro-based symptom management in cases of older adults with dementia.
(Yu et al., 2015)

comuoon Although care robots are at the © universal sound design inc.
forefront of Japanese efforts for innovation inassistive device, other types of devices are also
being developed. For example, a new listening
device called comuoon focuses on improving
the hearing environment by being placed at
locations where important daily conversations
take place. With comuoon, the innovation is in Permission by universal sound design
sound technology. According to Shinichiro Nakaishi (2017), the comuoon
developer, the device is especially useful for older adults with presbycusis,
a hearing impairment that is one of the most common age-related
functional declines. The unusual name, comuoon, was made up from two
English words, communication and cocoon, with the first letter “c” uncapitalized, according to Nakaishi (2017).
The comuoon unit is a two-part system that includes a small, vertical,
microphone and an equally small, egg-shaped speaker. On a desktop, themicrophone is positioned in front of a person with normal hearing, and the
speaker faces the person with presbycusis. For example, at a doctor's office,the microphone should be placed directly in front of the doctor, and the
speaker should face directly toward the patient. This configuration securesthe most efficient collection and delivery of spoken words to the personwith presbycusis, and thus, increases the likelihood of successfulcommunication between the doctor and patient, Nakaishi (2017) notes.
Other use locations may include clinics and hospitals, the customer
windows at banks and government offices, the living room at home, or aclassroom at school. The device can even be installed in a taxicab to aid
driver-passenger conversation.
The central feature of comuoon is a small, innovative speaker that delivers
clear sound to the listener during face-to-face conversation. This isachieved by reducing the use of noise-causing glue, incorporating a honeycomb shaped vibration plate capable of reproducing better conversationrange sounds, recessing the position of the vibration plate to prevent
sound scattering, and providing an egg-shaped inside wall that reducessound distortion. These features allow sounds that are loud and clear to be27

delivered to the person with hearing impairment but not to others in thevicinity. This is a departure from the concept behind hearing aids, which is
to make incoming sound primarily by making it louder but not necessarily
successful in making it clearer. Nakanishi’s innovation focuses on
reproducing clear sound.
The issue of hearing impairment among the older population is especiallyrelevant in Japan. Ohashi (2014) points out that “Japan has neglected tosupport people’s right to adequate hearing” because it has failed todesignate the hearing aid as a medical device requiring personal fitting bytrained professionals, and it does not provide a financial assistanceprogram for hearing impairment, as the United Kingdom and some othercountries have done. Ikeda (2017) notes that these factors have resulted in
the low utilization of hearing aids in Japan and the equally low satisfaction
rates among users. Japan started to ameliorate this problem in 2017 byadopting revisions to the Drug and Medical Device Law, designating
hearing aids as medical devices for the first time. Masuda (2017), however,points out that even with a pair of well-fitted hearing aids, people withpresbycusis hear only on average about 70% of the words spoken to them.
Recognizing the challenge of addressing the technical and social issues
regarding hearing aid use, Nakanishi developed comuoon as a new
approach to improve hearing by stepping away from the hearing aid andimproving the hearing environment. Relieved from the constraints of thehearing aid, this new approach allowed Nakanishi to concentrate on
reproducing clear sound in a way that he believes has not beenaccomplished with conventional hearing aids. (Nakaishi, 2017) His
approach of seeking an environmental solution to disability is consistent
with the ICF direction. Further, the primary focus on people experiencing
minor to moderate hearing problems (in the range of 20–70 dB) is
consistent with the recent Japanese government direction of paying closer
attention to assistive devices that are useful for older adults with minor tomoderate disabilities. Interestingly, Nakanishi noted during his 2017
interview with the author that his most recent development activities
involve a new-generation hearing aid incorporating comuoon innovations.
He indicated that when this developmental work is completed, people will
have the option of relying on comuoon in the environment, wearing the
new generation hearing aid, or using both, depending upon the degree of
their hearing impairment.
While data supporting the efficacy and practicality of comuoon are still
limited, the Tokyo Metropolitan Industrial Technology Research Institute(2016) conducted a sound pressure test and concluded that the comuoon
speaker was superior in increasing the volume of conversation range sound(1000 Hz to 2000 Hz). And a study team from Kyushu University reported
improvement in the mild-to-moderate range, hard-of-hearing outpatient
population when they engaged in conversation using comuoon. (Noda et28

al., 2015) The most recent finding is from a magnetoencephalographic
study that showed improved sound intelligibility when hearing-impaired
study participants using comuoon heard easy-to-confuse pronunciations.
The study, conducted by the Hearing Rehabilitation Study Group at
Hiroshima University’s Space Regenerative Medical Center and published in
the NeuroReport journal, demonstrated the importance of sound clarity inimproving conversational hearing. Based on these findings, Nakagawa et al.
(2017) concluded that improving sound intelligibility using comuoon isbeneficial to the hearing-impaired. Comuoon is currently in use in a study
at a dementia group home in Japan to improve conversational frequencies
among its residents with auditory impairment. If proven useful as arehabilitative tool, the door may open for medical use, like HAL® and Paro.
*”RT.2” is a registered trademark of RT. WORKS co., ltd.
“CYBERDYNE”, “ROBOT SUIT”, “ROBOT SUIT HAL”, “HAL”, “Hybrid Assistive Limb” are registered trademarks
of CYBERDYNE INC.
“Mental Commit Robot” is a registered trademark of National Institute of Advanced Industrial Science andTechnology.
“Paro” is a registered trademark of Intelligent System Co., ltd.
“Comuoon” is a registered trademark of universal sound design Inc.

Discussion
In Japan, 40 years have already passed since concern about the issues of anaging society first surfaced. When one looks back on this passage of time, it
is hard to overlook the way Sawako Ariyoshi's 1972 bestseller, Koukotsuno-hito (the title of its English translation is The Twilight Years), symbolized
the public's focus on the plight of the daughter-in-law, the designatedcaregiver in traditional Japanese families. At a time when derogatory terms
were used to describe the condition we now call dementia, the novel
brought awareness and empathy to this illness, but more poignantly, itbrought attention to the question, "who is going to care for them?" Then,in 1995, another bestseller, Kouraku, by Shuichi Sae, depicted the social
confusion and fear appearing after traditional caregiver assumptions began
to fall apart.
At about this same time, the Japanese government became very concerned
about the country’s future economic outlook. For example, the oncedominant Japanese industrial robot sector was starting to face serious
competition from an increasing number of countries, and that affected thecompetitiveness of other major sectors, such as automobiles. Facing thesechallenges, Japan decided it was in its best interests to maintain its robot
leadership and to work to assume a pioneering role in the up-and-coming
service robot sector. The resulting Japanese service robot development
strategy was multifaceted but included the importance of developing thecare robot in meeting the caregiving needs of the older population. Whilethe idea of applying advanced technology to innovate assistive devices had
already been established in the United States five years earlier, choosing

29

the aging population as the focus of its effort reflected Japan’s domestic
priority and formed the foundation for subsequent development.
The innovation activities focusing on care robots have been consistently led
by the Japanese government since the enactment of the Welfare Device
Law in 1993. The main features of this effort included linking the needs ofan aging society with economic revitalization, promoting inter-ministrycollaboration between METI and MHLW, and clarifying NEDO’s active
involvement, and these features continue as the programmatic framework
today.
Initially, the care robot development effort was led by METI and robot
engineers, with relatively limited influence from MHLW. METI’s active
involvement brought new resources and talent to the field of assistive
devices, even though their understanding of the needs for assistive devices
among the growing numbers of older adults and their caregivers was
sometimes lacking. The critics labeled Japan’s effort, especially in its earlydays, as technology-driven, with the primary focus on the application ofrobotics to create a new industrial venue.
Japan’s developmental efforts were aided by its unique regulatoryenvironment, where assistive devices are not subjected to the regulatory
approval process, as are medical devices. This lax approach allowed
assistive device innovators to expedite the development process,sidestepping the need to compile and publish data on efficacy, safety, andpracticality, thereby saving time and money. However, in the case of Paro,
Shibata and his colleagues have been placing an emphasis on collecting andpublishing clinical data from early on in its development (Shibata, 2001;
Saito, 2003; and Shibata, 2003). As innovations in assistive devices
proliferate today, the experiences gained by them and others will be
invaluable in developing a new process whereby consumers of assistive
devices can be assured of their quality and benefit.
The need for collecting clinical data became apparent in the mid- to late2000s. This is when the initial attempt was made to launch promising
Japanese care robots into the global marketplace, first into the EU market,
where a new assistive device must first receive a CE Mark as a medical
device before it can be marketed. Marketing in the United States and China,
two of the other major trading targets for the care robot industry, also
required data collection because these countries also handle assistive
devices as medical equipment and require governmental approval prior tomarketing.
Facing this challenge, Paro had a lucky break, which was receiving an
invitation from the Dementia Center in Copenhagen, Denmark, toparticipate in its care robot evaluation project, funded through the national
Be Safe project. As a communication robot, Paro embodied Japanese30creativity, sensitivity, and product quality, and the Danes quickly saw its
potential as a therapeutic tool for older adults with dementia. This
collaboration was highly successful, leading to a partnership with the highly
regarded DTI that served as a focal point for establishing Paro as atherapeutic tool and increasing its brand recognition internationally. The
arrangement was mutually beneficial for DTI, which gained valuable
experience in working with the older population and dementia. However,the DTI’s efforts to apply these methods to promote other care robots
likewise has not been very successful.
The systemic implications presented by the overseas experiences of Paroand other care robots include (1) the value of collaborative partnerships
with established research and evaluation organizations overseas to explore
and secure marketing options; (2) the need to develop domestic
assessment and evaluation capacities specifically targeting assistive
devices; and (3) the timeliness of reevaluation of the technology-driven
paradigm. The value of collaboration with overseas partners has been wellrecognized, and the trend to maximize the benefits of such collaboration is
expected to continue and grow.
The most important outcome of the overseas experience with Paro andother care robots is recognition of the importance of developing domestic
capacity to assess and evaluate the efficacy, safety, and practicality of thecare robots and other new assistive devices. Consequently, since 2009, thenational government has implemented a number of programs to promoteand support data capacity building activities in collaboration with a wide
range of organizations. These activities include developing evaluation
methods at universities and research institutes, publishing voluntarystandards focusing on the efficacy, safety, and utility of assistive devices,training evaluation professionals, and building new testing and evaluation
facilities. The infrastructure for testing and evaluation, when fully
developed, is envisioned to support a balanced approach to productdevelopment for assistive devices, benefitting both domestic users andoverseas marketing initiatives.
Japan’s extensive involvement in publishing the ISO13482 standard for carerobots was intended to help Japan become an important destination for
testing and evaluating the effectiveness and safety of new assistive devices,
especially care robots. However, one obstacle for Japan in assuming thisrole has been the Japanese regulatory policy of separating assistive devices
from medical devices, a distinction not practiced by other countries.
Revisiting this policy is important for marketing considerations, but more
importantly, because differences between the two types of devices havebecome increasingly murky, as demonstrated by the medical and assistive
device versions of HAL®. Currently, however, there is little such discussion
in Japan. Instead, the current strategy attempts to close the regulatory gap
between Japan and other countries by instituting a series of voluntary31

standards by various organizations. It is yet to be seen whether thisapproach will work.
As the role of clinical testing and evaluation expands, so does the role andresponsibility of MHLW in this and related areas to ensure that the effort
and resources being poured into the development of care robots and otherassistive device innovations result in making assistive devices more userfriendly, safe, and affordable. Especially, in the coming years, the WERP
under the LTCIP will increase its role as the primary venue for care robot
domestic distribution. Japan has already added five innovative products tothe approved assistive device rental list—a toileting assistance device in2012 and four robotic walkers, including RT.2, in 2016. The effectiveness ofthe WERP as a venue for new products will depend on the timeliness of thereview process, which still needs much enhancement. The WERP also
needs to be extended to older adults residing in the facilities to ensure they
have the equal access to individually selected and fitted assistive devices,
including care robots.
The roles the municipalities and local organizations have played areimportant, too. In addition to the two special district projects in Sagami
and Okayama, a number of other cities and their partners have started
their own programs to promote the use of care robots and collect user
feedback. Unfortunately, the collection and dissemination of these data
seem to lack coordination and, as a result, these efforts do not seem tocumulate effectively. Thus, it is important to further improve thecoordination of collecting and sharing feedback from users.
This raises a fundamental question about the intended users andbeneficiaries of innovations in care robots and other assistive devices.
Historically, the primary burden of societal aging has been placed on the
caregiver, particularly in Japan. As mentioned, Japan’s focus was initially on
the plight of family caregivers, and later, as professional care expanded,
the concern began to shift to the physical and mental stress of the care
workers. The timing of the care robot development in its early days roughly
overlapped this period. Thus, it was natural to expect the focus of assistive
device innovations, including care robots, to be on reducing care worker’s
physical and mental stress.
More recently, the policy focus has shifted again. Today, an increasingemphasis has been placed on policies and programs that are supportive of
the independent living of older adults in the community. This emphasis is
the reflection of many factors discussed in this article. Yet, in Japan, as
some experts have pointed out, the concept of independent living is notnecessarily clearly understood as a right older adults are entitled to or
should expect. This may explain why today relatively little effort is evident
to actively engage older adults having minor functioning issues with theprocess of developing care robots and other assistive device innovations. In

32this regard, a good starting point for Japan would be a thorough review of
the user-driven innovation practiced in northern European countries, suchas Denmark and Sweden, followed by Japan’s unique contributions, as has
been Japan’s practice in the past with innovations originating overseas.

Conclusion
The Japanese government has led a national effort over the past 25 years
to promote assistive device innovations centered around the developmentof care robots, under the premise that these devices can help solve thesocietal aging challenge while contributing to the restoration of national
economic vitality. This article described the care robot’s unique history inJapan, examined the factors that have influenced the course ofdevelopment, and considered how these efforts may ultimately help Japan
attain its dual goals. Today, Japan is in the process of rolling out the fruitsof these initial efforts, with the four assistive innovations introduced in thisarticle showcasing the breadth of ingenuity and technological strength of
the Japanese effort. However, it is still unclear if these or other currently
available devices will prove to be successful in the long run and able tocontribute to one or both of the goals of aiding societal aging and theeconomy. The only certainty is that the future of older adulthood can nolonger be imagined without the presence of care robots and other
innovative assistive devices.

33

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