Lecture 3
The Future of Prevention: Building Scalable Pathways to Health and Independence in Asia

Yoshihiro YASUNAGA

Global Sales Director, CYBERDYNE Inc.;  

CEO, Robocare Center; 

Visiting Researcher, Department of Gerontology, University of Tokyo; 

Professor, Fukushima Medical University

Visiting Lecturer, Waseda University

Yoshihiro YASUNAGA graduated from Dokkyo University’s Faculty of Economics, Department of Business Administration. After working at Tyco Healthcare Japan and ON Semiconductor Technology, he joined CYBERDYNE in 2008. Initially responsible for IPO preparations, he later moved to the sales department. In 2015, he completed a master's program at The Open University of Japan. In 2019, he entered the University of Tsukuba’s Graduate School of Comprehensive Human Sciences, Doctoral Program in Clinical Sciences. He assumed his current position in January 2024. He holds US qualifications as a Certified Public Accountant, Certified Management Accountant, and Certified Internal Auditor.

(1) Introduction to the lecture

Norie KAWAHARA opened third lecture of the Spring 2026 semester of the Surviving Cancer in Asia: Cross-boundary Cancer Studies lecture series by drawing the threads of the previous two sessions into the day’s theme. In the first lecture, Dr. Shinjiro Nozaki had asked participants to look beyond a narrow medical understanding of prevention, showing that prevention is bound up with universal health coverage, primary health care, population aging, financing, and the long-term sustainability of society. In the second, Dr. Zainab Shinkafi-Bagudu had moved the discussion further by reminding participants that the “last mile” is never only technical, but social, cultural, economic, and political. Her example of the BEAUTY and Health Project in Malaysia had shown that prevention becomes real only when it enters trusted everyday spaces and helps people move from awareness to action.

These earlier lectures led directly to the starting question for the third lecture: if prevention is valuable, how is it actually to be designed? Dr. Kawahara suggested that the answer begins with a simple but powerful idea: at the core of prevention lies not only medical technique but the design of human behavior change. Knowledge alone does not change how people live; sustained change requires successful experience and self-efficacy, namely the conviction that “I can do this.” The social value of prevention is therefore also a public value: it allows scarce healthcare resources to be focused where they are most needed, while helping people sustain participation in work, family life, and community. Prevention is not merely a tool for cost control but a way of protecting productivity, social participation, and human dignity.

There remains, however, a persistent gap between knowledge and action. Health information is often abstract and does not translate naturally into the concrete decisions of daily life; in an age of information overload, more information can produce hesitation rather than confidence. Prevention must therefore be designed to be concrete, memorable, and usable, and one powerful route is lived experience. When people feel change in their own bodies, when feedback is immediate, and when the experience is shared with others, positive behavior begins to feel normal. Behavior change is therefore not only individual but relational and social, shaped by the environment in which people act. Sustainable change rarely begins with a giant leap; it begins with a small win — one short walk, one better lunch, one evening with a little more sleep — that becomes proof that “I can begin” and “I can continue.” Self-efficacy is not praise from outside but inner conviction built through repeated experience.

Dr. Kawahara observed that there is a paradox in motivation: it is often assumed that motivation comes first and action follows, but in practice many people need one successful action before motivation can begin. The hardest step is from zero to one.    

The question for the lecture is therefore whether technology can help a person to cross that first threshold — whether it can help someone feel in the body that “I can move,” “I can start,” “I am not trapped here forever.” 

It is at this point that robotic technology enters the discussion, not as a machine that replaces human will but as a technology that may help to restore and restart it. To explore that future, Dr. Kawahara welcomed Dr. Yoshihiro Yasunaga of CYBERDYNE Inc., a fellow director of the Asia Cancer Forum whose collaboration in Malaysia and elsewhere continues to grow.

(2) The Future of Prevention: Building Scalable Pathways to Health and Independence in Asia

Yoshihiro YASUNAGA opened by setting the demographic and fiscal backdrop for his work. In Japan, already approximately 30% of the population is already aged 65 or older, and social security expenditure continues to rise as the population ages. Among advanced and Asian economies, Japan has the highest level of population aging, but population aging is also progressing globally. He explained that he had joined CYBERDYNE because, while working in Fukushima Prefecture, he had seen at first hand a community in which the aging rate had already reached 30% eighteen years ago, including elderly people caring for other elderly individuals. That experience had given him a strong motivation to apply advanced technology to the challenges of a super-aged society, to support the independence of older adults, and to contribute to the reduction of social security costs. 

He indicated that the lecture would proceed in three stages: first, the work that has been done with the “Hybrid Assistive Limb” (HAL) technology to date in treatment and rehabilitation; second, the expansion into the Asia-Pacific region with Malaysia as a hub; and third, the future of HAL in prevention.

CYBERDYNE Inc. and the HAL Device

CYBERDYNE Inc. was established in 2004 as a University of Tsukuba spin-off; its founder and CEO, Dr. Yoshiyuki Sankai, also serves as Professor at the University of Tsukuba. The company name combines “Cyber,” from Cybernics, with “dyne,” meaning power. Its product portfolio extends beyond HAL to include cleaning and transportation robots, a small living-support communication robot, and bio-signal sensing devices.

  HAL — the Hybrid Assistive Limb — is offered in three principal forms: the lower limb type, the single joint type, and the lumbar type. CYBERDYNE describes HAL as a wearable cyborg that delivers Cybernics Treatment, an innovative method for treating brain–nerve–musculoskeletal disorders (Figure 1). 

Fig. 1 Overview of HAL technology 

Bioelectric signals from the wearer’s skin surface are detected by sensors, processed by signal processing and artificial intelligence in real time, and used to drive the device in synchrony with the wearer’s intention; the device thus moves as if it were part of the wearer’s own body. The mechanism of action rests on an interactive bio-feedback loop: when a person intends to move a limb, signals travel from the brain through the spinal cord and nerve cells to the muscles, and information about the resulting movement returns to the brain via sensory pathways. Disease or injury can damage this loop, but even in patients with paralysis, faint signals leak onto the skin surface and can be read. Repeated exchange of signals through HAL reinforces synaptic connections and drives relearning, which is the essence of Cybernics Treatment. The devices have been exported to over 24 countries.

Work with HAL to Date: Treatment and Rehabilitation

In Japan, HAL’s principal indication has been progressive neuromuscular disease, for which a treatment session of approximately 30 minutes is reimbursed by the national health insurance system at around US$250. Indications have since expanded to include spinal cord injury, stroke, and Parkinson’s disease, and HAL has been approved as a medical device in the United States and Europe. Walking function improves even after the device is removed: a published case series of 55 chronic spinal cord injury patients undergoing 60 sessions of HAL Treatment showed average 10-meter walking speeds doubling from 0.14 to 0.28 m/sec, with 24 of 55 patients (43.6%) becoming less dependent on walking aids. 

In Germany, HAL is now covered by the public workmen’s compensation insurance scheme, with a course of 60 sessions of 1 to 1.5 hours each, at €500 per session, fully reimbursed. The German government has also funded the next stage of evidence development, a randomized controlled trial preparatory to inclusion in the public statutory health insurance system. 

In the United States, HAL is approved for spinal cord injury, stroke, and progressive neuromuscular disease, and is the only medical device explicitly indicated for the improvement of gait function. A 2025 systematic review by Chiu et al in Global Spine Journal, comparing actively controlled and passively controlled exoskeletons across 27 studies and 591 patients, found that HAL was the only device to show improvements across all outcomes of interest — mobility, continence, pain, and quality of life — providing evidence of genuine functional recovery rather than assisted movement alone.

Beyond hospital-based use, the Robocare Center group operates 18 outpatient Neuro HALFIT facilities across Japan, providing one-hour, out-of-pocket sessions at approximately US$110, and has so far supplied over 400 HAL units to hospitals and rehabilitation centers nationwide (Figure 2).

Fig. 2 Overview of usage of HAL in Japan

Approximately 42% of patients seen at Robocare facilities have a cerebrovascular condition, and a further 23% spinal cord injury or related spinal disease; the introduction of a small-size HAL has also opened the service to children. Following recent FDA clearance for cerebral palsy and the small-size model, the pediatric HAL was introduced for the first time in the United States at West Virginia University.

Dr. Yasunaga next turned to the question of why HAL is able to deliver immediate, observable effects. In a typical paralyzed patient attempting finger extension, the flexor signal activates inappropriately at the same time as the extensor signal, blocking voluntary movement. After only 60 minutes of HAL exercise, the inappropriate flexor signal subsides and voluntary extension becomes possible. Imaging shows that, before HAL use, the brain is over-active and inefficient, while afterwards activation is appropriately concentrated in the relevant areas. Whereas muscle training requires sustained effort over weeks, the brain itself can change immediately. Randomized controlled studies in spinal cord injury and stroke have confirmed superior outcomes for HAL compared with conventional therapy.

To complement the clinical pathway, Dr. Yasunaga has also established a HALFIT Tourism program for international patients. Most patients have lived with their condition for many years, and the program is intended to combine HAL therapy with the experience of visiting Japan; patients have come from over 33 countries. The first international patient travelled from Australia after attending a lecture by Dr. Yasunaga in Germany. Following a course of approximately 14 sessions over three weeks, the patient improved markedly, and a Robocare-style facility (RoboFit) has subsequently been established in Australia, with multiple centers now in operation. 

Dr. Yasunaga noted personally that a road traffic accident four years ago had left him a spinal cord injury patient himself, and that he had used HAL during his own post-surgical recovery.

The HAL Lumbar Type was originally developed to assist caregivers and warehouse workers in lifting heavy loads, but Dr. Yasunaga decided to redirect it to rehabilitation because sit-to-stand exercise is highly effective for activities of daily living. Studies in stroke, frailty (with and without Parkinson’s disease), and chronic low back pain have shown significant short-term improvements in 10-meter walking speed, Timed Up and Go, step length, the 30-second chair stand test, and pain scores, with effects sustained at one and three months. For cerebral palsy patients, restoring the ability to stand up unaided through Lumbar Type training can transform domestic independence before lower limb gait training is introduced.

Expansion into the Asia-Pacific Region with Malaysia as a Hub

Dr. Yasunaga then turned to the regional expansion of HAL across the Asia-Pacific, centered on Malaysia. The first installation in the region beyond Japan took place in November 2018, when the Social Security Organisation of Malaysia (Pertubuhan Keselamatan Sosial, PERKESO; English name SOCSO) adopted 24 units of HAL. SOCSO is a compulsory scheme covering Malaysian and foreign workers, providing disability pension, survivor’s pension, medical coverage, and occupational injury compensation, and so was well-positioned to integrate HAL into commuting-related and occupational rehabilitation. The introduction of HAL was driven by three considerations: a shortage of rehabilitation staff, the need for more effective and efficient rehabilitation through advanced technology, and the importance of standardizing rehabilitation practice.

Approximately 200 HAL devices are now installed in Malaysia, with 13 facilities providing HAL therapy, all reimbursed by SOCSO. CYBERDYNE Malaysia Sdn. Bhd. was established in 2022 and has since seen rapid growth in service volume. SOCSO is currently constructing the National Centre for Neuro-Robotics and Cybernics in Bandar Meru Raya, Ipoh, Perak, in northern Malaysia, which will be the largest medical complex in Southeast Asia, with capacity to treat approximately 700 patients. The Centre is scheduled to open in June 2026 and will house 65 HAL units. 

The Malaysian operation is not only a domestic provider but a regional hub for sales promotion and training across the Asia-Pacific and the Middle East. From this base, HAL has also been deployed in public hospitals in Indonesia, India and Thailand.

The Future of HAL: Prevention

Dr. Yasunaga moved to the third and central element of his lecture: the application of HAL to prevention. The macro-level argument is straightforward: healthcare costs continue to rise as populations age, and existing systems are strong on treatment but weak on prevention, producing a structure in which treatment expenditure escalates without limit. 

The fundamental issue, however, is not cost but quality of life: a life without disease delivers freedom from pain, freedom of movement, the ability to participate in society, and independence. Reducing healthcare expenditure is only a result; the true goal is a better quality of life. Prevention itself is multifactorial — encompassing nutrition, exercise, sleep, stress management, and social participation — but exercise is one of its core components.

Despite the universal recognition of the value of exercise, exercise is not implemented because of barriers to initiation and to adherence, rather than because of any deficiency in awareness. Initiation is blocked by physical demand, by pain and fear, and by uncertainty about how to start. Adherence is undermined by the absence of immediate results, by lack of enjoyment, and by competing claims on time. A further set of physical limitations — aging, frailty, chronic pain — means that many people who would like to exercise cannot. The persistent issue is therefore not the quality of exercise on offer but adherence to it.

The case for HAL in prevention rests on a body of evidence accumulated through Lumbar Type studies. In a frailty-prevention program of ten short-term sessions, twice weekly over five weeks, in adults with a mean age of about 75, the HAL group recorded a 36% improvement in 10-meter walking speed and a 93% improvement in the Locomotive 5 score, against minimal change in the control group (p < 0.001) (Figure 3). 

Fig. 3 Use of HAL Lumbar Type in frailty prevention activities 

In a study of chronic low back pain, immediate improvements were observed in pain VAS and hip flexibility after a single session, with no adverse events. In frailty patients with and without Parkinson’s disease, five sessions of biofeedback core exercise produced significant gains in 10MWT, step length, TUG, and the 30-second chair stand test that were sustained at one- and three-month follow-up. A pilot study of HAL Lumbar Type exercise therapy in nine diabetic patients (mean age 69), undertaken twice weekly for four weeks, achieved 100% intervention completion and significant improvements in the sit-to-stand test and in lipid-metabolism markers (total cholesterol, LDL, and non-HDL cholesterol). Patients reported being surprised at how easily they could stand up, that the exercise was not strenuous, and that an exercise habit had developed. 

A more recent single-arm study of ten older adults at a Nagoya day-care rehabilitation facility (Yakabe et al., Cureus 2026) found that four weekly sessions of approximately ten minutes each produced a 21.8% reduction in TUG that was sustained at one month, descriptive gains in muscle mass and basal metabolic rate and a reduction in body fat percentage, and consistent within-session improvements in self-reported motivation, standing difficulty, and body heaviness on visual analogue scales. 

The same logic has been applied beyond patient populations: HAL has been used by an Olympic silver medalist in cycling and by professional athletes in baseball, soccer, rugby, boxing, fencing, volleyball, golf, and tennis.

Dr. Yasunaga emphasized that the prevention program is also being deployed in everyday social settings. Local-government-led prevention sessions are being run for community-dwelling older adults, and in March 2026 Tokyo Dome Sports introduced HAL Lumbar Type into Tokyo Dome Fitness Club — the first comprehensive fitness club in Japan to do so — at 9,900 yen per 60-minute personal session delivered by Japan’s first comprehensive-fitness-club HAL-certified trainers. 

Group-format programs have moved beyond squats to incorporate front and side lunges and lunge walks to prevent monotony and sustain engagement, and the work has been featured in NHK programming on healthy life expectancy. 

To extend reach beyond physical facilities, an Integrated Cybernics System has been developed that connects HAL devices in the home with professional staff at facilities and Robocare Centers via cloud-based remote service over LTE/5G, allowing supervised use of the device at home. The system can be combined with the Cyvis M100, a compact Holter electrocardiograph and medical vital sensor approved as a medical device in Japan in November 2024, which provides up to ten days of continuous ECG measurement on a single charge alongside acceleration, posture, skin temperature, humidity, and air-pressure data, automatically transmitted to a secure cloud.

The regional translation of this prevention agenda is most advanced in Thailand. The Director-General of the Ministry of Public Health visited CYBERDYNE in August 2025, and in February 2026 the Thailand Institute of Geriatric Medicine signed an agreement to promote Cybernics medical and healthcare innovation, with the Ministry committing to social implementation following initial validation in frailty prevention because measurable effects can be achieved within a short duration. A government-funded randomized controlled trial of the Lumbar Type, aiming towards future insurance reimbursement, is currently awaiting ethical approval. The trial will compare three arms: traditional exercise; HAL alone; and HAL combined with traditional exercise.

Dr. Yasunaga summarized the underlying behavioral mechanism in terms drawn from Bandura’s self-efficacy theory. A short HAL session produces an immediate success experience, whereby patients can stand more easily, walk more quickly, and feel lighter, which builds self-efficacy (“I can do this”), which in turn triggers a brain-reward response that reinforces the behavior, leading to an exercise habit and to lasting improvements in muscle mass, basal metabolic rate, and functional outcomes.   

HAL therefore reverses the conventional logic of exercise: rather than effort yielding ability over time, immediate ability becomes the success experience that drives behavioral change. Dr. Yasunaga concluded by noting that he wishes to extend healthy life expectancy and help reduce social security costs through HAL-based exercise programs.

(3) Student Assignment

Students were set the following assignment. 

“Technology as a Redesign of Society”

Based on today’s lecture, discuss whether technology transforms individual behavior or reshapes social structures, using the HAL system developed by Cyberdyne as a concrete example.

Requirements: 

Select one primary lens from the following four:

i) Body (enhancement or restoration of physical capability)

ii) Behavior (habits and decision-making)

iii) Institutions (insurance, employment, subsidies)

iv) Culture (preventive awareness and social norms)

Explain the impact of HAL in two stages:

Step 1: What changes at the individual level?

Step 2: As a result, what changes occur at the level of social structure?

Conclude by clearly answering the following question:

Ultimately, what changes — the individual, society, or both?

(4) Discussion

Dr. Kawahara noted that the lecture had been not only a story about robotics, but a story about the design of possibility, and about how a person may recover not only movement but also the feeling of “I can,” which connects deeply with the lecture series theme of the social value of prevention. She asked, given that HAL has been developed primarily in rehabilitation, what is the main barrier to its expansion into prevention.

Dr. Yasunaga replied that the principal barrier is financial. Rehabilitation is delivered to patients who, even when paying out of pocket, are willing to spend on improving function. Prevention, in Japan, is normally subsidized by government, and so out-of-pocket prevention services struggle to find a market unless they can secure such public support. There is also a behavioral barrier: once a person has fallen ill, they will work seriously to recover function, but for prevention motivation is much weaker.

Dr. Kawahara asked about the future potential of the technology in mental health, noting that mental health has become a global challenge affecting both individuals and social productivity, and acknowledging the significant ethical considerations involved.

Dr. Yasunaga answered that CYBERDYNE’s current focus is rehabilitation, and that the company always works in cooperation with medical doctors. Although physicians who work with HAL frequently observe that the device appears to have a positive effect on mental state, this is outside their primary research focus and the company does not at present have a dedicated mental-health program; the relevant research community would need to be engaged separately.

Mr. Ikram, a participant from Malaysia, asked how the rapid and successful deployment of CYBERDYNE technology in Malaysia had been made possible. Dr. Yasunaga responded that SOCSO had initiated HAL therapy and that KPJ Healthcare hospitals had also adopted the device for rehabilitation. Although the immediate goal in those settings is return-to-work for stroke, spinal cord injury, and back pain patients, there is now an explicit move towards prevention. Because Malaysia hosts a large number of HAL devices and CYBERDYNE Malaysia has seven local staff, it is much easier to conduct trials and pilots there than in other parts of the Asia-Pacific region.

A student asked whether patients who complete a course of HAL rehabilitation need to continue using the system periodically over the long term. Dr. Yasunaga replied that the answer depends on the underlying condition. In stroke, which is generally non-progressive, patients who reach their functional goals typically discontinue HAL use. In progressive neuromuscular disease, function may improve initially and then decline gradually, in which case continued use is appropriate. At Robocare Centers, where the service is paid out of pocket, many users continue to attend after their disease-specific goals have been achieved, using HAL for the prevention of further deterioration in elderly age.

A student asked whether new devices were under development. Dr. Yasunaga indicated that current research includes a finger device and the development of lighter machinery, with patient data also being used to refine usage and experience through the application of artificial intelligence. 

A student asked about the experience of introducing HAL into healthcare systems with very different structures across the Asia-Pacific region. Dr. Yasunaga acknowledged that it is impossible to understand each national system in full, and that the most important factor is, similarly to Dr. Kawahara’s own experiences, the cultivation of trusted local partners who understand the social and institutional landscape of each country.

A student asked about the ECG capability of CYBERDYNE’s devices in relation to her own research on heart rate variability. Dr. Yasunaga explained that, although HAL itself uses electromyographic signals, the underlying electrical signal type is similar across EMG, ECG, and brain signals, so that with appropriate software changes the same hardware family can detect ECG. Cyvis M100 is precisely such a medical device for healthcare use, capable of real-time ECG and posture detection with data transmitted to a smartphone. 

Dr. Kawahara closed by asking Dr. Yasunaga what he believed was most important for students who wish to contribute globally, and what values had guided his own career. Dr. Yasunaga answered that his work is driven by personal passion: his father had had cancer and, after treatment, had suffered from poor quality of life. His own commitment to changing such conditions for patients has been the source of his work, and that passion has resulted in him being able to draw good colleagues and friends from all over the world. 

Dr. Kawahara concluded that the day’s lecture had shown not only a remarkable technology but a vision of how society itself can be redesigned to support health, dignity, and prevention, and observed that the question of how such technology may be integrated into real-world systems and everyday life is precisely what the lecture series will continue to explore.