Cardiopulmonary function after robotic exoskeleton-assisted over-ground walking training of a patient with an incomplete spinal cord injury: Case report

[New technologies and robotics]

The development of increasingly more complex computer and electromotor technologies enables the increasing use and expansion of robot-assisted systems in trauma surgery rehabilitation; however, the currently available devices are rarely comprehensively applied but are often used within pilot projects and studies. Different technological approaches, such as exoskeletal systems, functional electrical stimulation, soft robotics, neurorobotics and brain-machine interfaces are used and combined to read and process the communication between, e.g., residual musculature or brain waves, to transfer them to the executing device and to enable the desired execution.Currently, the greatest amount of evidence exists for the use of exoskeletal systems with different modes of action in the context of gait and stance rehabilitation in paraplegic patients; however, their use also plays a role in the rehabilitation of fractures close to the hip joint and endoprosthetic care. So-called single joint systems are also being tested in the rehabilitation of functionally impaired extremities, e.g., after knee prosthesis implantation. At this point, however, the current data situation is still too limited to be able to make a clear statement about the use of these technologies in the trauma surgery "core business" of rehabilitation after fractures and other joint injuries.For rehabilitation after limb amputation, in addition to the further development of myoelectric prostheses, the current development of "sentient" prostheses is of great interest. The use of 3D printing also plays a role in the production of individualized devices.Due to the current progress of artificial intelligence in all fields, ground-breaking further developments and widespread application possibilities in the rehabilitation of trauma patients are to be expected.

Safety and Feasibility of a Novel Exoskeleton for Locomotor Rehabilitation of Subjects With Spinal Cord Injury: A Prospective, Multi-Center, and Cross-Over Clinical Trial

Objective

To evaluate the safety, walking efficiency, physiological cost, don and doff time cost, and user satisfaction of Ai-robot.

Design

Prospective, multi-center, and cross-over trial.

Subjects

Paraplegic subjects (n = 40) with T6-L2 level spinal cord injury.

Methods

Subjects who could walk independently using Aiwalker, Ailegs, and hip knee ankle foot orthosis (HKAFO) for 6 min within 30 days of training underwent 10 sets of tests. In each set, they completed three 6-min walk test (6MWT) sessions using the three aids in random order.

Results

Skin lesions, pressure sores, and fractures, were the main adverse events, likely due to a lack of experience in using exoskeleton systems. The average 6MWT distances of the Aiwalker, Ailegs, and HKAFO groups were 134.20 ± 18.74, 79.71 ± 18.06, and 48.31 ± 19.87 m, respectively. The average heart rate increases in the Aiwalker (4.21 ± 8.20%) and Ailegs (41.81 ± 23.47%) groups were both significantly lower than that in the HKAFO group (62.33 ± 28.32%) (both p < 0.001). The average donning/doffing time costs for Ailegs and Aiwalker were significantly shorter than that of HKAFO (both p < 0.001). Satisfaction was higher in the Ailegs and Aiwalker groups (both p < 0.001).

Conclusion

Subjects with paraplegia below T6 level were able to ambulate safely and efficiently with Ai-robot. The use of Ai-robot should be learned under the guidance of experienced medical personnel.

Comparison of Efficacy of Lokomat and Wearable Exoskeleton-Assisted Gait Training in People With Spinal Cord Injury: A Systematic Review and Network Meta-Analysis

Objective

Lokomat and wearable exoskeleton-assisted walking (EAW) have not been directly compared previously. To conduct a network meta-analysis of randomized and non-randomized controlled trials to assess locomotor abilities achieved with two different types of robotic-assisted gait training (RAGT) program in persons with spinal cord injury (SCI).

Methods

Three electronic databases, namely, PubMed, Embase, and the Cochrane Library, were systematically searched for randomized and non-randomized controlled trials published before August 2021, which assessed locomotor abilities after RAGT.

Results

Of 319 studies identified for this review, 12 studies were eligible and included in our analysis. Studies from 2013 to 2021 were covered and contained 353 valid data points (N-353) on patients with SCI receiving wearable EWA and Lokomat training. In the case of wearable EAW, the 10-m walk test (10-MWT) distance and speed scores significantly increased [distance: 0.85 (95% CI = 0.35, 1.34); speed: −1.76 (95% CI = −2.79, −0.73)]. The 6-min walk test (6-MWT) distance [−1.39 (95% CI = −2.01, −0.77)] and the timed up and go (TUG) test significantly increased [(1.19 (95% CI = 0.74, 1.64)], but no significant difference was observed in the walking index for spinal cord injury (WISCI-II) [−0.33 (95% CI = −0.79, 0.13)]. Among the patients using Lokomat, the 10-MWT-distance score significantly increased [−0.08 (95% CI = −0.14, −0.03)] and a significant increase in the WISCI-II was found [1.77 (95% CI = 0.23, 3.31)]. The result of network meta-analysis showed that the probability of wearable EAW to rank first and that of Lokomat to rank second was 89 and 47%, respectively, in the 10-MWT speed score, while that of Lokomat to rank first and wearable EAW to rank second was 73 and 63% in the WISCI-II scores.

Conclusion

Lokomat and wearable EAW had effects on the performance of locomotion abilities, namely, distance, speed, and function. Wearable EAW might lead to better outcomes in walking speed compared with that in the case of Lokomat.

Knowledge Gaps in Biophysical Changes After Powered Robotic Exoskeleton Walking by Individuals With Spinal Cord Injury—A Scoping Review

In addition to helping individuals with spinal cord injury (SCI) regain the ability to ambulate, the rapidly evolving capabilities of robotic exoskeletons provide an array of secondary biophysical benefits which can reduce the complications resulting from prolonged immobilization. The proposed benefits of increased life-long over-ground walking capacity include improved upper body muscular fitness, improved circulatory response, improved bowel movement regularity, and reduced pain and spasticity. Beyond the positive changes related to physical and biological function, exoskeletons have been suggested to improve SCI individuals' quality of life (QOL) by allowing increased participation in day-to-day activities. Most of the currently available studies that have reported on the impact of exoskeletons on the QOL and prevention of secondary health complications on individuals with SCI, are of small scale and are heterogeneous in nature. Moreover, few meta-analyses and reviews have attempted to consolidate the dispersed data to reach more definitive conclusions of the effects of exoskeleton use. This scoping review seeks to provide an overview on the known effects of overground exoskeleton use, on the prevention of secondary health complications, changes to the QOL, and their effect on the independence of SCI individuals in the community settings. Moreover, the intent of the review is to identify gaps in the literature currently available, and to make recommendations on focus study areas and methods for future investigations.

Cardiorespiratory Responses to 10 Weeks of Exoskeleton-Assisted Overground Walking Training in Chronic Nonambulatory Patients with Spinal Cord Injury

Exercise intensity of exoskeleton-assisted walking in patients with spinal cord injury (SCI) has been reported as moderate. However, the cardiorespiratory responses to long-term exoskeleton-assisted walking have not been sufficiently investigated. We investigated the cardiorespiratory responses to 10 weeks of exoskeleton-assisted walking training in patients with SCI. Chronic nonambulatory patients with SCI were recruited from an outpatient clinic. Walking training with an exoskeleton was conducted three times per week for 10 weeks. Oxygen consumption and heart rate (HR) were measured during a 6-min walking test at pre-, mid-, and post-training. Exercise intensity was determined according to the metabolic equivalent of tasks (METs) for SCI and HR relative to the HR reserve (%HRR). Walking efficiency was calculated as oxygen consumption divided by walking speed. The exercise intensity according to the METs (both peak and average) corresponded to moderate physical activity and did not change after training. The %HRR demonstrated a moderate (peak %HRR) and light (average %HRR) exercise intensity level, and the average %HRR significantly decreased at post-training compared with mid-training (31.6 ± 8.9% to 24.3 ± 7.3%, p = 0.013). Walking efficiency progressively improved after training. Walking with an exoskeleton for 10 weeks may affect the cardiorespiratory system in chronic patients with SCI.

Exoskeleton-assisted walking improves pulmonary function and walking parameters among individuals with spinal cord injury: a randomized controlled pilot study

BACKGROUND

Exoskeleton-assisted walking (EAW) is expected to improve the gait of spinal cord injury (SCI) individuals. However, few studies reported the changes of pulmonary function (PF) parameters after EAW trainings. Hence, we aimed to explore the effect of EAW on PF parameters, 6-min walk test (6MWT) and lower extremity motor score (LEMS) in individuals with SCI and to compare those with conventional trainings.

METHODS

In this prospective, single-center, single-blinded randomized controlled pilot study, 18 SCI participants were randomized into the EAW group (n = 9) and conventional group (n = 9) and received 16 sessions of 50-60 min training (4 days/week, 4 weeks). Pulmonary function parameters consisting of the forced vital capacity (FVC), forced expiratory volume in 1 s (FEV₁), forced expiratory flow (FEF), peak expiratory flow, and maximal voluntary ventilation, 6MWT with assisted devices and LEMS were reported pre- and post-training.

RESULTS

Values of FVC (p = 0.041), predicted FVC% (p = 0.012) and FEV₁ (p = 0.013) were significantly greater in EAW group (FVC: 3.8 ± 1.1 L; FVC% _pred = 94.1 ± 24.5%; FEV₁: 3.5 ± 1.0 L) compared with conventional group (FVC: 2.8 ± 0.8 L; FVC% _pred = 65.4 ± 17.6%; FEV₁: 2.4 ± 0.6 L) after training. Participants in EAW group completed 6MWT with median 17.3 m while wearing the exoskeleton. There was no difference in LEMS and no adverse event.

CONCLUSIONS

The current results suggest that EAW has potential benefits to facilitate PF parameters among individuals with lower thoracic neurological level of SCI compared with conventional trainings. Additionally, robotic exoskeleton helped walking.

TRIAL REGISTRATION

Registered on 22 May 2020 at Chinese Clinical Trial Registry (ChiCTR2000033166). http://www.chictr.org.cn/edit.aspx?pid=53920&htm=4 .

The Effects of Powered Exoskeleton Gait Training on Cardiovascular Function and Gait Performance: A Systematic Review

Patients with neurological impairments often experience physical deconditioning, resulting in reduced fitness and health. Powered exoskeleton training may be a successful method to combat physical deconditioning and its comorbidities, providing patients with a valuable and novel experience. This systematic review aimed to conduct a search of relevant literature, to examine the effects of powered exoskeleton training on cardiovascular function and gait performance. Two electronic database searches were performed (2 April 2020 to 12 February 2021) and manual reference list searches of relevant manuscripts were completed. Studies meeting the inclusion criteria were systematically reviewed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. n = 63 relevant titles were highlighed; two further titles were identified through manual reference list searches. Following analysis n = 23 studies were included. Data extraction details included; sample size, age, gender, injury, the exoskeleton used, intervention duration, weekly sessions, total sessions, session duration and outcome measures. Results indicated that exoskeleton gait training elevated energy expenditure greater than wheelchair propulsion and improved gait function. Patients exercised at a moderate-intensity. Powered exoskeletons may increase energy expenditure to a similar level as non-exoskeleton walking, which may improve cardiovascular function more effectively than wheelchair propulsion alone.