Retraining walking over ground in a powered exoskeleton after spinal cord injury: a prospective cohort study to examine functional gains and neuroplasticity

Blocking the p38 MAPK Signaling Pathway in the Rat Hippocampus Alleviates the Depressive-like Behavior Induced by Spinal Cord Injury

Patients with spinal cord injury (SCI) may develop depression, which can affect their rehabilitation. However, the underlying mechanism of depression in SCI patients remains unclear. Previous studies have revealed increased p38 MAPK phosphorylation in the rat hippocampus after SCI, accompanied by depression-like behaviors. However, the role of the p38 MAPK signaling pathway in SCI-induced depression remains unclear. In this study, we used an aneurysm clip-induced rat SCI model to investigate whether p38 MAPK phosphorylation in the hippocampus is associated with depression-like behaviors in rats after SCI. Behavioral testing revealed that SB203580, a p38 MAPK signaling inhibitor, reduced depression-like behaviors. Western blotting and morphological analyses showed that SB203580 inhibited the activation of microglia and astrocytes in the hippocampus after SCI. Additionally, SB203580 reduced the expression of tumor necrosis factor α and increased p38 MAPK phosphorylation and the number of bromodeoxyuridine-positive cells in the hippocampus. These findings suggest that SB203580 can inhibit hippocampal remodeling and the neuroimmune response in the rat hippocampus after SCI. Therefore, the phosphorylation of p38 MAPK in the hippocampus plays a key role in the depression-like behaviors induced by SCI. The inhibition of p38 MAPK phosphorylation may represent a mechanism to protect against hippocampal injury induced by SCI.

Perspectives of wheelchair users with chronic spinal cord injury following a walking program using a wearable robotic exoskeleton

PURPOSE

To examine the perspectives of wheelchair users with spinal cord injury (WUSCI) regarding their participation in a 16-week walking program using a wearable robotic exoskeleton (WRE); and explore concerns and expectations regarding potential use of this device and intervention in the context of a home or community-based adapted physical activity program.

METHOD

Semi-structured interviews were conducted using a narrative research, 3 weeks post-intervention. Thematic analysis resulted in 6 themes and 21 subthemes.

RESULTS

Seven men and 4 women aged between 32 and 72 years were interviewed; 8 of them had a complete SCI. After the walking program, WUSCI reported positive psychological aspects (having fun and motivation) and experiencing improvements in physical aspects (strength, endurance, balance and flexibility, blood circulation and intestinal transit). The structural aspects of the WRE device were acceptable in a lab with research personnel (appearance, size, weight, and comfort). Participants had concerns about safety on uneven surfaces, and possibility of falling. They expressed the desire to use the WRE for more life habits than just walking.

CONCLUSION

This is the first study in which WUSCI report that the WRE should be implemented in initial rehabilitation. Lack of availability for community use after rehabilitation remains a concern.

User-centered design of a personal-use exoskeleton: a clinical investigation on the feasibility and usability of the ABLE Exoskeleton device for individuals with spinal cord injury to perform skills for home and community environments

Introduction

The ABLE Exoskeleton has been tested to be safe and feasible for persons with spinal cord injury (SCI) to complete basic skills in clinical settings but has not been tested for use in home and community environments. A user-centered design process was employed to test the feasibility of the current ABLE Exoskeleton (designed for clinical use) for persons with SCI to perform the basic and advanced skills required for home and community environments, to gain crucial feedback for the development of a novel personal-use exoskeleton.

Methods

In this prospective pretest-posttest quasi-experimental study across two SCI centers (Germany, Spain), in-and outpatients with SCI were included into a 22-session training and assessment protocol, utilizing the ABLE Exoskeleton. Feasibility and usability measures [level of assistance (LoA) for basic and advanced skills, donning/doffing-time and LoA] were recorded together with safety outcomes, and participant and therapist satisfaction with the device.

Results

10 participants (44.4 ± 24 years), with SCI from C5 to T11, (American Spinal Injury Association Impairment Scale A-D) completed the study. In 209 sessions, six device-related adverse events (pain and skin lesions) were reported. Average total time for don and doff was 10:23 ± 3:30 min. Eight participants were able to complete don and doff with minimal assistance or less. Independence to carry out all skills in the device increased significantly for all participants (p < 0.05). Participants with chronic SCI required a significantly (p < 0.05) lower LoA for six of the nine advanced skills than those in the sub-acute phase.

Discussion

This study shows that the ABLE Exoskeleton is safe, feasible and usable for people with SCI in respect to independent donning, doffing and performance of basic and advanced exoskeleton skills. The supervised exoskeleton use in the clinical environment was a highly valuable approach for identifying the challenging tasks and the necessary technological developments that need to be carried out for a personal-use exoskeleton, including a more independent sit-to-stand transition, faster speed of transitions between states and a richer display on the remote control for the user.

Clinical trial registration

https://clinicaltrials.gov/study/NCT05643313.

Lower-Limb Exoskeletons for Gait Training in Parkinson's Disease: The State of the Art and Future Perspectives

Gait dysfunction (GD) is a common impairment of Parkinson's disease (PD), which negatively impacts patients' quality of life. Among the most recent rehabilitation technologies, a lower-limb powered exoskeleton (LLEXO) arises as a useful instrument for gait training in several neurological conditions, including PD. However, some questions relating to methods of use, achievable results, and usefulness compared to traditional rehabilitation methodologies still require clear answers. Therefore, in this review, we aim to summarise and analyse all the studies that have applied an LLEXO to train gait in PD patients. Literature research on PubMed and Scopus retrieved five articles, comprising 46 PD participants stable on medications (age: 71.7 ± 3.7 years, 24 males, Hoehn and Yahr: 2.1 ± 0.6). Compared to traditional rehabilitation, low-profile lower-limb exoskeleton (lp-LLEXO) training brought major improvements towards walking capacity and gait speed, while there are no clear major benefits regarding the dual-task gait cost index and freezing of gait symptoms. Importantly, the results suggest that lp-LLEXO training is more beneficial for patients with an intermediate-to-severe level of disease severity (Hoehn and Yahr > 2.5). This review could provide a novel framework for implementing LLEXO in clinical practise, highlighting its benefits and limitations towards gait training.

Robotic locomotor training in a low-resource setting: a randomized pilot and feasibility trial

PURPOSE

Activity-based Training (ABT) represents the current standard of neurological rehabilitation. Robotic Locomotor Training (RLT), an innovative technique, aims to enhance rehabilitation outcomes. This study aimed to conduct a randomized pilot and feasibility trial of a locomotor training program within South Africa.

MATERIALS AND METHODS

Individuals with chronic traumatic motor incomplete tetraplegia (n = 16). Each intervention involved 60-minute sessions, 3x per week, for 24-weeks. Outcomes included feasibility measures and functional capacity.

RESULTS

17 out of 110 individuals initiated the program (recruitment rate = 15.4%) and 16 completed the program (drop-out rate = 5.8%) and attended sessions (attendance rate = 93.9%). Both groups showed a significant increase in upper extremity motor score (MS) and abdominal strength post intervention. Only the RLT group showed a significant change in lower extremity MS, with a mean increase of 3.00 [0.00; 16.5] points over time. Distance walked in the Functional Ambulatory Inventory (SCI-FAI) increased significantly (p = 0.02) over time only for the RLT group.

CONCLUSIONS

Feasibility rates of the intervention and functional outcomes justify a subsequent powered RCT comparing RLT to ABT as an effective rehabilitation tool for potentially improving functional strength and walking capacity in people with incomplete SCI.

Robot-Assisted Gait Training in Individuals With Spinal Cord Injury: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Spinal cord injury (SCI) rehabilitation emphasizes locomotion. Robotic-assisted gait training (RAGT) is widely used in clinical settings because of its benefits; however, its efficacy remains controversial. We conducted a systematic review and meta-analysis to investigate the efficacy of RAGT in patients with SCI. We searched international and domestic databases for articles published until April 18, 2024. The meta-analysis employed a random effects model to determine the effect size as either mean difference (MD) or standardized MD (SMD). Evidence quality was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Twenty-three studies with a total of 690 participants were included in the final analysis. The overall pooled effect size for improvement in activities of daily living was 0.24, with SMD (95% confidence interval [95% CI], 0.04-0.43; GRADE: high) favoring RAGT over conventional rehabilitation. Muscular strength (MD, 0.23; 95% CI, 0.02-0.44; GRADE: high), walking index for SCI (MD, 0.31; 95% CI, 0.07-0.55; GRADE: moderate) and 6 min walk test distance (MD, 0.38; 95% CI, 0.14-0.63; GRADE: moderate) showed significant improvement in the robot group. Subgroup analysis revealed that subacute patients and intervention periods >2 months were more effective. This meta-analysis revealed that RAGT significantly improved activities of daily living, muscular strength, and walking abilities. Additional studies are needed to identify the optimal treatment protocol and specific patient groups for which the protocol is most effective.

Exoskeleton-based exercises for overground gait and balance rehabilitation in spinal cord injury: a systematic review of dose and dosage parameters

BACKGROUND

Exoskeletons are increasingly applied during overground gait and balance rehabilitation following neurological impairment, although optimal parameters for specific indications are yet to be established.

OBJECTIVE

This systematic review aimed to identify dose and dosage of exoskeleton-based therapy protocols for overground locomotor training in spinal cord injury/disease.

METHODS

A systematic review was conducted in accordance with the Preferred Reporting Items Systematic Reviews and Meta-Analyses guidelines. A literature search was performed using the CINAHL Complete, Embase, Emcare Nursing, Medline ALL, and Web of Science databases. Studies in adults with subacute and/or chronic spinal cord injury/disease were included if they reported (1) dose (e.g., single session duration and total number of sessions) and dosage (e.g., frequency of sessions/week and total duration of intervention) parameters, and (2) at least one gait and/or balance outcome measure.

RESULTS

Of 2,108 studies identified, after removing duplicates and filtering for inclusion, 19 were selected and dose, dosage and efficacy were abstracted. Data revealed a great heterogeneity in dose, dosage, and indications, with overall recommendation of 60-min sessions delivered 3 times a week, for 9 weeks in 27 sessions. Specific protocols were also identified for functional restoration (60-min, 3 times a week, for 8 weeks/24 sessions) and cardiorespiratory rehabilitation (60-min, 3 times a week, for 12 weeks/36 sessions).

CONCLUSION

This review provides evidence-based best practice recommendations for overground exoskeleton training among individuals with spinal cord injury/disease based on individual therapeutic goals - functional restoration or cardiorespiratory rehabilitation. There is a need for structured exoskeleton clinical translation studies based on standardized methods and common therapeutic outcomes.

Exoskeleton-Assisted Rehabilitation and Neuroplasticity in Spinal Cord Injury

Spinal cord injury (SCI) results in neurological deficits below the level of injury, causing motor dysfunction and various severe multisystem complications. Rehabilitative training plays a crucial role in the recovery of individuals with SCI, and exoskeleton serves as an emerging and promising tool for rehabilitation, especially in promoting neuroplasticity and alleviating SCI-related complications. This article reviews the classifications and research progresses of medical exoskeletons designed for SCI patients and describes their performances in practical application separately. Meanwhile, we discuss their mechanisms for enhancing neuroplasticity and functional remodeling, as well as their palliative impacts on secondary complications. The potential trends in exoskeleton design are raised according to current progress and requirements on SCI rehabilitation.

Opportunities and challenges in the development of exoskeletons for locomotor assistance

Exoskeletons can augment the performance of unimpaired users and restore movement in individuals with gait impairments. Knowledge of how users interact with wearable devices and of the physiology of locomotion have informed the design of rigid and soft exoskeletons that can specifically target a single joint or a single activity. In this Review, we highlight the main advances of the past two decades in exoskeleton technology and in the development of lower-extremity exoskeletons for locomotor assistance, discuss research needs for such wearable robots and the clinical requirements for exoskeleton-assisted gait rehabilitation, and outline the main clinical challenges and opportunities for exoskeleton technology.

Integrated Neuroregenerative Techniques for Plasticity of the Injured Spinal Cord

On the slow path to improving the life expectancy and quality of life of patients post spinal cord injury (SCI), recovery remains controversial. The potential role of the regenerative capacity of the nervous system has led to numerous attempts to stimulate the SCI to re-establish the interrupted sensorimotor loop and to understand its potential in the recovery process. Numerous resources are now available, from pharmacological to biomolecular approaches and from neuromodulation to sensorimotor rehabilitation interventions based on the use of various neural interfaces, exoskeletons, and virtual reality applications. The integration of existing resources seems to be a promising field of research, especially from the perspective of improving living conditions in the short to medium term. Goals such as reducing chronic forms of neuropathic pain, regaining control over certain physiological activities, and enhancing residual abilities are often more urgent than complete functional recovery. In this perspective article, we provide an overview of the latest interventions for the treatment of SCI through broad phases of injury rehabilitation. The underlying intention of this work is to introduce a spinal cord neuroplasticity-based multimodal approach to promote functional recovery and improve quality of life after SCI. Nonetheless, when used separately, biomolecular therapeutic approaches have been shown to have modest outcomes.

Technology-assisted balance assessment and rehabilitation in individuals with spinal cord injury: A systematic review

BACKGROUND: Balance is a crucial function of basic Activities of Daily Living (ADL) and is often considered the priority in Spinal Cord Injury (SCI) patients’ rehabilitation. Technological devices have been developed to support balance assessment and training, ensuring an earlier, intensive, and goal-oriented motor therapy. OBJECTIVE: The aim of this systematic review is to explore the technology-assisted strategies to assess and rehabilitate balance function in persons with SCI. METHODS: A systematic review was conducted in the databases PubMed, Scopus, IEEE Xplore, Cochrane Library, and Embase. Full reports on Randomized Clinical Trials (RCTs) of parallel-group or cross-over design and non-RCTs were included according to the following criteria: i) publication year from 1990 to 2021; ii) balance considered as a primary or secondary outcome; iii) population of individuals with SCI with age over 18 years old, regardless of traumatic or non-traumatic lesions, Time Since Injury, lesion level, Asia Impairment Scale score and gender. The methodological quality was determined for each included study according to the recognized Downs and Black (D&B) tool. RESULTS: Nineteen articles met the inclusion criteria and were included in the analysis. Four articles focused on balance assessment while 15 targeted rehabilitation interventions to improve balance by using Treadmill-Based Devices (TBD), OverGround Devices (OGD) and Tilt Table Devices (TTD). Statistically significant effects on balance can be found in TBD subcategory, in the hip-knee guidance subcategory of OGD and in the study of TTD category. CONCLUSION: Although different studies reported positive effects, improvements due to technology-assisted rehabilitation were not greater than those obtained by means of other rehabilitation therapies. The heterogeneity, low methodological quality, and the small number of the studies included do not allow general conclusions about the usefulness of technology-assisted balance assessment and training in individuals with SCI, even if significant improvements have been reported in some studies.

Robot Assisted Gait Training in a Patient with Ataxia

Background: Ataxia is a neurological sign characterized by motor coordination during gait/voluntary limb movements impairment. Ataxic gait leads to disability and worsening of quality of life; physiotherapy intervention is recommended to improve motor function. Recent studies showed benefits due to repetitive robotized assisted gait training using a static exoskeleton in patients affected by acquired ataxias. The aim of the study was to perform a preliminary evaluation of the short-term effects of overground UAN.GO^®-assisted gait training in an adult patient with ataxia but with no clear genetic pattern. Methods: This case report study was conducted on a single male adult patient, who presented ataxic spastic gait, posterior chain tightness, pes cavus, and unstable standing position. The patient underwent two preliminary sessions to take part in the study. Treatment protocol planned 10 sessions and each one lasted 80 min, 60 of which were spent in gait training using the mobile overground exoskeleton UAN.GO^®. At T1 (start of the study) and T10 (final evaluation) assessments using the Scale for the Assessment and Rating of Ataxia, Berg Balance Scale, 6-Minute Walking Test, and Likert Scale were administered. Space-time parameters of gait cycle were also evaluated: left and right step length, stance and swing percentages. Results: improvements on the Scale for the Assessment and Rating of Ataxia, Berg Balance Scale, and in the distance travelled at 6-Minute Walking Test emerged. The patient gave a positive opinion towards the treatment, showed by Likert Scale results. Kinematic gait analysis showed more physiological step length, stance and swing percentages, joint angles. The patient completed the training program with an excellent compliance. Discussion: Since these encouraging outcomes were obtained, it is possible to consider robot-assisted gait training performed with UAN.GO^® as a therapeutic option to improve motor and functional performance in patients with ataxic gait.

Rehabilitation Program for Gait Training Using UAN.GO, a Powered Exoskeleton: A Case Report

Background: Spinal cord injury is characterized by the interruption of neural pathways of the spinal cord, with alteration of sensory, motor, and autonomic functions. Robotic-assisted gait training offers many possibilities, including the capability to reach a physiological gait pattern. Methods: A training protocol with UAN.GO^®, an active lower limb exoskeleton, was developed. A participant having D10 complete SCI was recruited for this study. The training protocol was composed by 13 sessions, lasting 1.5 h each. The effectiveness of the protocol was evaluated through the mobility performance during the 6 MWT, the level of exertion perceived administrating Borg RPE at the end of each 6 MWT. Furthermore, time and effort required by the participant to earn a higher level of skills were considered. Results: A significant improvement was registered in the six MWT (t₀ = 45.64 m t₁ = 84.87 m). Data referring to the mean level of exertion remained stable. The patient successfully achieved a higher level of independence and functional mobility with the exoskeleton. Discussion: The findings from this preliminary study suggest that UAN.GO can be a valid tool for walking rehabilitation of spinal cord injury patients, allowing the achievement of greater mobility performances.

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.

Overground robotic training effects on walking and secondary health conditions in individuals with spinal cord injury: systematic review

Overground powered lower limb exoskeletons (EXOs) have proven to be valid devices in gait rehabilitation in individuals with spinal cord injury (SCI). Although several articles have reported the effects of EXOs in these individuals, the few reviews available focused on specific domains, mainly walking. The aim of this systematic review is to provide a general overview of the effects of commercial EXOs (i.e. not EXOs used in military and industry applications) for medical purposes in individuals with SCI. This systematic review was conducted following the PRISMA guidelines and it referred to MED-LINE, EMBASE, SCOPUS, Web of Science and Cochrane library databases. The studies included were Randomized Clinical Trials (RCTs) and non-RCT based on EXOs intervention on individuals with SCI. Out of 1296 studies screened, 41 met inclusion criteria. Among all the EXO studies, the Ekso device was the most discussed, followed by ReWalk, Indego, HAL and Rex devices. Since 14 different domains were considered, the outcome measures were heterogeneous. The most investigated domain was walking, followed by cardiorespiratory/metabolic responses, spasticity, balance, quality of life, human–robot interaction, robot data, bowel functionality, strength, daily living activity, neurophysiology, sensory function, bladder functionality and body composition/bone density domains. There were no reports of negative effects due to EXOs trainings and most of the significant positive effects were noted in the walking domain for Ekso, ReWalk, HAL and Indego devices. Ekso studies reported significant effects due to training in almost all domains, while this was not the case with the Rex device. Not a single study carried out on sensory functions or bladder functionality reached significance for any EXO. It is not possible to draw general conclusions about the effects of EXOs usage due to the lack of high-quality studies as addressed by the Downs and Black tool, the heterogeneity of the outcome measures, of the protocols and of the SCI epidemiological/neurological features. However, the strengths and weaknesses of EXOs are starting to be defined, even considering the different types of adverse events that EXO training brought about. EXO training showed to bring significant improvements over time, but whether its effectiveness is greater or less than conventional therapy or other treatments is still mostly unknown. High-quality RCTs are necessary to better define the pros and cons of the EXOs available today. Studies of this kind could help clinicians to better choose the appropriate training for individuals with SCI.

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.

Exoskeletons for Mobility after Spinal Cord Injury: A Personalized Embodied Approach

Endowed with inherent flexibility, wearable robotic technologies are powerful devices that are known to extend bodily functionality to assist people with spinal cord injuries (SCIs). However, rather than considering the specific psychological and other physiological needs of their users, these devices are specifically designed to compensate for motor impairment. This could partially explain why they still cannot be adopted as an everyday solution, as only a small number of patients use lower-limb exoskeletons. It remains uncertain how these devices can be appropriately embedded in mental representations of the body. From this perspective, we aimed to highlight the homeostatic role of autonomic and interoceptive signals and their possible integration in a personalized experience of exoskeleton overground walking. To ensure personalized user-centered robotic technologies, optimal robotic devices should be designed and adjusted according to the patient's condition. We discuss how embodied approaches could emerge as a means of overcoming the hesitancy toward wearable robots.

Gait robot-assisted rehabilitation in persons with spinal cord injury: A scoping review

BACKGROUND

Many robots are available for gait rehabilitation (BWSTRT and ORET) and their application in persons with SCI allowed an improvement of walking function.

OBJECTIVE

The aim of the study is to compare the effects of different robotic exoskeletons gait training in persons with different SCI level and severity.

METHODS

Sixty-two studies were included in this systematic review; the study quality was assessed according to GRADE and PEDro's scale.

RESULTS

Quality assessment of included studies (n = 62) demonstrated a prevalence of evidence level 2; the quality of the studies was higher for BWSTRT (excellent and good) than for ORET (fair and good). Almost all persons recruited for BWSTRT had an incomplete SCI; both complete and incomplete SCI were recruited for ORET. The SCI lesion level in the persons recruited for BWSTRT are from cervical to sacral; mainly from thoracic to sacral for ORET; a high representation of AIS D lesion resulted both for BWSTRT (30%) and for ORET (45%). The walking performance, tested with 10MWT, 6MWT, TUG and WISCI, improved after exoskeleton training in persons with incomplete SCI lesions, when at least 20 sessions were applied. Persons with complete SCI lesions improved the dexterity in walking with exoskeleton, but did not recover independent walking function; symptoms such as spasticity, pain and cardiovascular endurance improved.

CONCLUSION

Different exoskeletons are available for walking rehabilitation in persons with SCI. The choice about the kind of robotic gait training should be addressed on the basis of the lesion severity and the possible comorbidities.

Physiotherapy using a free-standing robotic exoskeleton for patients with spinal cord injury: a feasibility study

BACKGROUND

Evidence is emerging for the use of overground lower limb robotic exoskeletons in the rehabilitation of people with spinal cord injury (SCI), with suggested benefits for gait speed, bladder and bowel function, pain management and spasticity. To date, research has focused on devices that require the user to support themselves with a walking aid. This often precludes use by those with severe trunk, postural or upper limb deficits and places the user in a suboptimal, flexed standing position. Free-standing exoskeletons enable people with higher level injuries to exercise in an upright position. This study aimed to evaluate the feasibility of therapy with a free-standing exoskeleton for those with SCI, and to determine the potential health-related benefits of this intervention.

METHODS

This 12-week intervention study with 12-week waitlist control and 12-week follow up, provided people with SCI scoring < 5 on the mobility section of the spinal cord independence measure (SCIM-III) twice weekly therapy in the REX (Rex Bionics, Auckland, NZ), a free-standing lower limb robotic exoskeleton. The primary outcome measure of interest was function, as measured on the SCIM-III. A battery of secondary outcomes was included. Participants also completed a survey on their perceptions of this treatment modality, to determine acceptability.

RESULTS

Forty-one potential participants were screened for eligibility. Two females (one ASIA A, one ASIA C) and one male (ASIA B) completed all 24 intervention sessions, and the follow up assessment. One participant showed positive trends in function, fatigue, quality of life and mood during the intervention phase. Grip and quadriceps strength, and lower limb motor function improved in another. Two improved their percentage of lean body mass during the intervention phase. Remaining results were varied across patients, time points and outcomes. The intervention was highly acceptable to all participants.

CONCLUSION

With three of 41 potential participants being eligible and completing this study, our results show that there are potential benefits of exercise in a free-standing exoskeleton for people with severe mobility impairment due to SCI, for a small subset of patients. Further research is warranted to determine those most likely to benefit, and the type of benefit depending on the patient characteristics. Trial registration The trial was registered prospectively on 20 April 2018 at www.anzctr.org.au/ (ACTRN12618000626268).

Cybernic treatment with wearable cyborg Hybrid Assistive Limb (HAL) improves ambulatory function in patients with slowly progressive rare neuromuscular diseases: a multicentre, randomised, controlled crossover trial for efficacy and safety (NCY-3001)

Background

Rare neuromuscular diseases such as spinal muscular atrophy, spinal bulbar muscular atrophy, muscular dystrophy, Charcot-Marie-Tooth disease, distal myopathy, sporadic inclusion body myositis, congenital myopathy, and amyotrophic lateral sclerosis lead to incurable amyotrophy and consequent loss of ambulation. Thus far, no therapeutic approaches have been successful in recovering the ambulatory ability. Thus, the aim of this trial was to evaluate the efficacy and safety of cybernic treatment with a wearable cyborg Hybrid Assistive Limb (HAL, Lower Limb Type) in improving the ambulatory function in those patients.

Results

We conducted an open-label, randomised, controlled crossover trial to test HAL at nine hospitals between March 6, 2013 and August 8, 2014. Eligible patients were older than 18 years and had a diagnosis of neuromuscular disease as specified above. They were unable to walk for 10 m independently and had neither respiratory failure nor rapid deterioration in gait. The primary endpoint was the distance passed during a two-minute walk test (2MWT). The secondary endpoints were walking speed, cadence, and step length during the 10-m walk test (10MWT), muscle strength by manual muscle testing (MMT), and a series of functional measures. Adverse events and failures/problems/errors with HAL were also evaluated. Thirty patients were randomly assigned to groups A or B, with each group of 15 receiving both treatments in a crossover design. The efficacy of a 40-min walking program performed nine times was compared between HAL plus a hoist and a hoist only. The final analysis included 13 and 11 patients in groups A and B, respectively. Cybernic treatment with HAL resulted in a 10.066% significantly improved distance in 2MWT (95% confidence interval, 0.667–19.464; p = 0.0369) compared with the hoist only treatment. Among the secondary endpoints, the total scores of MMT and cadence at 10MWT were the only ones that showed significant improvement. The only adverse effects were slight to mild myalgia, back pain, and contact skin troubles, which were easily remedied.

Conclusions

HAL is a new treatment device for walking exercise, proven to be more effective than the conventional method in patients with incurable neuromuscular diseases.

Trial registration: JMACTR, JMA-IIA00156

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.

Effects of Wearable Powered Exoskeletal Training on Functional Mobility, Physiological Health and Quality of Life in Non-ambulatory Spinal Cord Injury Patients

BACKGROUND

Spinal cord injury (SCI) is a serious clinical condition that impacts a patient's physical, psychological, and socio-economic status. The aim of this pilot study was to evaluate the effects of training with a newly developed powered wearable exoskeleton (Hyundai Medical Exoskeleton [H-MEX]) on functional mobility, physiological health, and quality of life in non-ambulatory SCI patients.

METHODS

Participants received 60 minutes of walking training with a powered exoskeleton 3 times per week for 10 weeks (total 30 sessions). The 6-minute walking test (6MWT) and timed-up-and-go test (TUGT) were performed to assess ambulatory function. The physiological outcomes of interest after exoskeleton-assisted walking training were spasticity, pulmonary function, bone mineral density, colon transit time, and serum inflammatory markers. Effects of walking training on subjective outcomes were estimated by the Korean version of the Falls Efficacy Scale-International and the 36-Item Short-Form Health Survey version 2.

RESULTS

Ten participants finished 30 sessions of training and could ambulate independently. No severe adverse events were reported during the study. After training, the mean distance walked in the 6MWT (49.13 m) was significantly enhanced compared with baseline (20.65 m). The results of the TUGT also indicated a statistically significant improvement in the times required to stand up, walk 3 m and sit down. Although not statistically significant, clinically meaningful changes in some secondary physiological outcomes and/or quality of life were reported in some participants.

CONCLUSION

In conclusion, this study demonstrated that the newly developed wearable exoskeleton, H-MEX is safe and feasible for non-ambulatory SCI patients, and may have potential to improve quality of life of patients by assisting bipedal ambulation. These results suggest that the H-MEX can be considered a beneficial device for chronic non-ambulatory SCI patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04055610.

Wearable robotic exoskeleton for gait reconstruction in patients with spinal cord injury: A literature review

Objectives

Wearable robotic exoskeletons (WREs) have been globally developed to achieve gait reconstruction in patients with spinal cord injury (SCI). The present study aimed to enable evidence-based decision-making in selecting the optimal WRE according to residual motor function and to provide a new perspective on further development of appropriate WREs.

Methods

The current review was conducted by searching PubMed, Web of Science, and Google Scholar for relevant studies published from April 2015 to February 2020. Selected studies were analysed with a focus on the participants’ neurological level of SCI, amount of training (number of training sessions and duration of the total training period), gait speed and endurance achieved, and subgroup exploration of the number of persons for assistance and the walking aid used among patients with cervical level injury.

Results

A total of 28 articles (nine using Ekso, three using Indego, ten using ReWalk, one using REX, five using Wearable Power-Assist Locomotor) involving 228 patients were included in the analysis. Across all WREs, T6 was the most frequently reported level of SCI. The amount of training showed a wide distribution (number of training sessions: 2–230 sessions [30–120 min per session]; duration of the total training period: 1–24 weeks [1–5 times per week]). The mean gait speed was 0.31 m/s (standard deviation [SD] 0.14), and the mean distance on the 6-min walking test as a measure of endurance was 108.9 m (SD 46.7). The subgroup exploration aimed at patients with cervical level injury indicated that 59.2% of patients were able to ambulate with no physical assistance and several patients used a walker as a walking aid.

Conclusion

The number of cervical level injury increased, as compared to the number previously indicated by a prior similar review. Training procedure was largely different among studies. Further improvement based on gait performance is required for use and dissemination in daily life.

The translational potential of this article

The present review reveals the current state of the clinical effectiveness of WREs for gait reconstruction in patients with SCI, contributing to evidence-based device application and further development.

Robotic lower extremity exoskeleton use in a non-ambulatory child with cerebral palsy: a case study

PURPOSE

With few treatment options available for non-ambulatory children with cerebral palsy (CP), a robotic lower extremity gait trainer may provide a non-invasive addition to conventional treatment options. This case study investigates the usage and impact of robotic lower extremity gait trainer use in a participant with CP over the initial 3 months of use.

MATERIALS AND METHODS

This prospective case study involves a 7-year old female (GMFCS V) with CP (registered clinical trial: NCT04251390). The participant used a Trexo Home robotic gait trainer (Trexo) in the community with assessments occurring in the home and school. Trexo usage and bowel movements (BMs) were tracked daily. Postural control and lower extremity range of motion (ROM) and spasticity were evaluated prior to Trexo use and weekly to biweekly thereafter.

RESULTS

The participant used the device an average of 46 min/week, over 3.3 d/week. BM frequency increased from 0.4/d at baseline, to 1.2 (±0.5)/d during Trexo use. There were no diffuse systematic changes in postural stability, ROM or muscle spasticity, but specifically head control and spasticity in the knee flexors had improvements.

CONCLUSIONS

Data and anecdotal reports suggest that regular use of the Trexo Home robotic gait trainer has positive outcomes on frequency and quality of BMs, and may improve head control, and knee flexor spasticity. Larger controlled studies are needed to evaluate the impacts of Trexo use in children with CP.Implications for RehabilitationNon-ambulatory children with CP can use and may experience benefits from using a robot-assisted gait trainer (RAGT).Constipation, aspects of balance and focal spasticity may improve.

Lower limb rehabilitation robotics: The current understanding and technology

BACKGROUND

With the increasing rate of ambulatory disabilities and rise in the elderly population, advance methods to deliver the rehabilitation and assistive services to patients have become important. Lower limb robotic therapeutic and assistive aids have been found to improve the rehabilitation outcome.

OBJECTIVE

The article aims to present the updated understanding in the field of lower limb rehabilitation robotics and identify future research avenues.

METHODS

Groups of keywords relating to assistive technology, rehabilitation robotics, and lower limb were combined and searched in EMBASE, IEEE Xplore Digital Library, Scopus, Web of Science and Google Scholar database.

RESULTS

Based on the literature collected from the databases we provide an overview of the understanding of robotics in rehabilitation and state of the art devices for lower limb rehabilitation. Technological advancements in rehabilitation robotic architecture (sensing, actuation and control) and biomechanical considerations in design have been discussed. Finally, a discussion on the major advances, research directions, and challenges is presented.

CONCLUSIONS

Although the use of robotics has shown a promising approach to rehabilitation and reducing the burden on caregivers, extensive and innovative research is still required in both cognitive and physical human-robot interaction to achieve treatment efficacy and efficiency.

Dynamic Margins of Stability During Robot-Assisted Walking in Able-Bodied Individuals: A Preliminary Study

Background: Gait analysis studies during robot-assisted walking have been predominantly focused on lower limb biomechanics. During robot-assisted walking, the users' interaction with the robot and their adaptations translate into altered gait mechanics. Hence, robust and objective metrics for quantifying walking performance during robot-assisted gait are especially relevant as it relates to dynamic stability. In this study, we assessed bi-planar dynamic stability margins for healthy adults during robot-assisted walking using EksoGT™, ReWalk™, and Indego® compared to independent overground walking at slow, self-selected, and fast speeds. Further, we examined the use of forearm crutches and its influence on dynamic gait stability margins. Methods: Kinematic data were collected at 60 Hz under several walking conditions with and without the robotic exoskeleton for six healthy controls. Outcome measures included (i) whole-body center of mass (CoM) and extrapolated CoM (XCoM), (ii) base of support (BoS), (iii) margin of stability (MoS) with respect to both feet and bilateral crutches. Results: Stability outcomes during exoskeleton-assisted walking at self-selected, comfortable walking speeds were significantly (p < 0.05) different compared to overground walking at self-selected speeds. Unlike overground walking, the control mechanisms for stability using these exoskeletons were not related to walking speed. MoSs were lower during the single support phase of gait, especially in the medial-lateral direction for all devices. MoSs relative to feet were significantly (p < 0.05) lower than those relative to crutches. The spatial location of crutches during exoskeleton-assisted walking pushed the whole-body CoM, during single support, beyond the lateral boundary of the lead foot, increasing the risk for falls if crutch slippage were to occur. Conclusion: Careful consideration of crutch placement is critical to ensuring that the margins of stability are always within the limits of the BoS to control stability and decrease fall risk.

Exoskeleton home and community use in people with complete spinal cord injury

A consequence of a complete spinal cord injury (SCI) is the loss of gait capacity. Wearable exoskeletons for the lower extremity enable household and community ambulation in people with SCI. This study assessed the amount, purpose, and location of exoskeleton use in the home and community environment, without any restrictions. The number of steps taken was read from the exoskeleton software. Participants kept a daily logbook, and completed two user experience questionnaires (Quebec User Evaluation of Satisfaction with assistive Technology (D-QUEST) and System Usability Scale (SUS)). Fourteen people with a complete SCI used the ReWalk exoskeleton a median of 9 (range [1-15]) out of 16 ([12-21]) days, in which participants took a median of 3,226 ([330-28,882]) steps. The exoskeleton was mostly used for exercise purposes (74%) and social interaction (20%). The main location of use was outdoors (48%). Overall, participants were satisfied with the exoskeleton (D-QUEST 3.7 ± 0.4) and its usability (SUS 72.5 [52.5-95.0]). Participants with complete SCI report satisfaction with the exoskeleton for exercise and social interaction in the home and community, but report limitations as an assistive device during daily life.