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Spungen AM, Dematt EJ, Biswas K, Jones KM, Mi Z, Snodgrass AJ, Morin K, Asselin PK, Cirnigliaro CM, Kirshblum S, Gorman PH, Goetz LL, Stenson K, White KT, Hon A, Sabharwal S, Kiratli BJ, Ota D, Bennett B, Berman JE, Castillo D, Lee KK, Eddy BW, Henzel MK, Trbovich M, Holmes SA, Skelton F, Priebe M, Kornfeld SL, Huang GD, Bauman WA. Exoskeletal-Assisted Walking in Veterans With Paralysis: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2431501. [PMID: 39230903 PMCID: PMC11375472 DOI: 10.1001/jamanetworkopen.2024.31501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/24/2024] [Indexed: 09/05/2024] Open
Abstract
Importance Robotic exoskeletons leverage technology that assists people with spinal cord injury (SCI) to walk. The efficacy of home and community exoskeletal use has not been studied in a randomized clinical trial (RCT). Objective To examine whether use of a wheelchair plus an exoskeleton compared with use of only a wheelchair led to clinically meaningful net improvements in patient-reported outcomes for mental and physical health. Design, Setting, and Participants This RCT of veterans with SCI was conducted at 15 Veterans Affairs medical centers in the US from September 6, 2016, to September 27, 2021. Data analysis was performed from March 10, 2022, to June 20, 2024. Interventions Participants were randomized (1:1) to standard of care (SOC) wheelchair use or SOC plus at-will use of a US Food and Drug Administration (FDA)-cleared exoskeletal-assisted walking (EAW) device for 4 months in the home and community. Main Outcomes and Measures Two primary outcomes were studied: 4.0-point or greater improvement in the mental component summary score on the Veterans RAND 36-Item Health Survey (MCS/VR-36) and 10% improvement in the total T score of the Spinal Cord Injury-Quality of Life (SCI-QOL) physical and medical health domain and reported as the proportion who achieved clinically meaningful changes. The primary outcomes were measured at baseline, post randomization after advanced EAW training sessions, and at 2 months and 4 months (primary end point) in the intervention period. Device usage, reasons for not using, and adverse events were collected. Results A total of 161 veterans with SCI were randomized to the EAW (n = 78) or SOC (n = 83) group; 151 (94%) were male, the median age was 47 (IQR, 35-56) years, and median time since SCI was 7.3 (IQR, 0.5 to 46.5) years. The difference in proportion of successes between the EAW and SOC groups on the MCS/VR-36 (12 of 78 [15.4%] vs 14 of 83 [16.9%]; relative risk, 0.91; 95% CI, 0.45-1.85) and SCI-QOL physical and medical health domain (10 of 78 [12.8%] vs 11 of 83 [13.3%]; relative risk, 0.97; 95% CI, 0.44-2.15) was not statistically different. Device use was lower than expected (mean [SD] distance, 1.53 [0.02] miles per month), primarily due to the FDA-mandated companion being unavailable 43.9% of the time (177 of 403 instances). Two EAW-related foot fractures and 9 unrelated fractures (mostly during wheelchair transfers) were reported. Conclusions and Relevance In this RCT of veterans with SCI, the lack of improved outcomes with EAW device use may have been related to the relatively low device usage. Solutions for companion requirements and user-friendly technological adaptations should be considered for improved personal use of these devices. Trial Registration ClinicalTrials.gov Identifier: NCT02658656.
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Affiliation(s)
- Ann M. Spungen
- Spinal Cord Damage Research Center, James J. Peters Veterans Affairs (VA) Medical Center, Bronx, New York
- Departments of Rehabilitation and Human Performance and Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ellen J. Dematt
- VA Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point
| | - Kousick Biswas
- VA Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point
- Department of Epidemiology and Public Health, Division of Biostatistics School of Medicine, University of Maryland, Baltimore
| | - Karen M. Jones
- VA Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point
- Now retired
| | - Zhibao Mi
- VA Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point
| | - Amanda J. Snodgrass
- VA Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, New Mexico
- University of New Mexico, College of Pharmacy, Albuquerque
| | - Kel Morin
- Spinal Cord Damage Research Center, James J. Peters Veterans Affairs (VA) Medical Center, Bronx, New York
- VA Providence Healthcare System, Providence, Rhode Island
| | - Pierre K. Asselin
- Spinal Cord Damage Research Center, James J. Peters Veterans Affairs (VA) Medical Center, Bronx, New York
| | - Christopher M. Cirnigliaro
- Spinal Cord Damage Research Center, James J. Peters Veterans Affairs (VA) Medical Center, Bronx, New York
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark
| | - Steven Kirshblum
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark
- Kessler Institute for Rehabilitation and The Kessler Foundation, West Orange, New Jersey
| | - Peter H. Gorman
- Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - Lance L. Goetz
- Richmond VA Medical Center, Richmond, Virginia
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond
| | - Katherine Stenson
- VA St Louis Health Care System–Jefferson Barracks, St Louis, Missouri
- Departments of Orthopaedics and Neurology, Division of Physical Medicine and Rehabilitation, Washington University School of Medicine, St Louis, Missouri
| | - Kevin T. White
- James A. Haley Veterans’ Hospital, Tampa, Florida
- Department of Physical Medicine and Rehabilitation, University of South Florida, Tampa
| | - Alice Hon
- VA Long Beach Health Care System, Long Beach, California
- Department of Physical Medicine and Rehabilitation, University of California Irvine
| | - Sunil Sabharwal
- VA Boston Health Care System, Boston, Massachusetts
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | | | - Doug Ota
- VA Palo Alto Health Care System, Palo Alto, California
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Bridget Bennett
- VA North Texas Health Care System, Dallas
- Department of Physical Medicine and Rehabilitation, The University of Texas Southwestern Medical Center, Dallas
| | | | - Denis Castillo
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
- Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee
| | - Kenneth K. Lee
- Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin
- Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee
| | - Byron W. Eddy
- Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - M. Kristi Henzel
- Louis Stokes Cleveland VA Medical Center, Cleveland, Ohio
- Department of Physical Medicine & Rehabilitation, Case Western Reserve School of Medicine, Cleveland, Ohio
| | - Michelle Trbovich
- South Texas Veterans Health Care System–Audie Murphy Division, San Antonio
- Department of Rehabilitation Medicine, University of Texas Health Science Center, San Antonio
| | - Sally A. Holmes
- Michael E. DeBakey VA Medical Center, Houston, Texas
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Felicia Skelton
- Michael E. DeBakey VA Medical Center, Houston, Texas
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
| | - Michael Priebe
- VA Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point
- Now retired
- Charlie Norwood VA Medical Center, VA Augusta Health Care System, Augusta, Georgia
| | - Stephen L. Kornfeld
- Departments of Rehabilitation and Human Performance and Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Spinal Cord Injury/Disorders Service, James J. Peters VA Medical Center, Bronx, New York
| | - Grant D. Huang
- VA Cooperative Studies Program Central Office, VA Office of Research and Development, Washington, DC
| | - William A. Bauman
- Departments of Rehabilitation and Human Performance and Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Now retired
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Tang L, Shushtari M, Arami A. IMU-Based Real-Time Estimation of Gait Phase Using Multi-Resolution Neural Networks. SENSORS (BASEL, SWITZERLAND) 2024; 24:2390. [PMID: 38676007 PMCID: PMC11054798 DOI: 10.3390/s24082390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/26/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024]
Abstract
This work presents a real-time gait phase estimator using thigh- and shank-mounted inertial measurement units (IMUs). A multi-rate convolutional neural network (CNN) was trained to estimate gait phase for a dataset of 16 participants walking on an instrumented treadmill with speeds varying between 0.1 to 1.9 m/s, and conditions such as asymmetric walking, stop-start, and sudden speed changes. One-subject-out cross-validation was used to assess the robustness of the estimator to the gait patterns of new individuals. The proposed model had a spatial root mean square error of 5.00±1.65%, and a temporal mean absolute error of 2.78±0.97% evaluated at the heel strike. A second cross-validation was performed to show that leaving out any of the walking conditions from the training dataset did not result in significant performance degradation. A 2-sample Kolmogorov-Smirnov test showed that there was no significant increase in spatial or temporal error when testing on the abnormal walking conditions left out of the training set. The results of the two cross-validations demonstrate that the proposed model generalizes well across new participants, various walking speeds, and gait patterns, showcasing its potential for use in investigating patient populations with pathological gaits and facilitating robot-assisted walking.
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Affiliation(s)
- Lyndon Tang
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON N2L 3G1, Canada; (M.S.); (A.A.)
| | - Mohammad Shushtari
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON N2L 3G1, Canada; (M.S.); (A.A.)
| | - Arash Arami
- Department of Mechanical and Mechatronics Engineering, University of Waterloo, Waterloo, ON N2L 3G1, Canada; (M.S.); (A.A.)
- KITE Institute, University Health Network, Toronto, ON M5G 2A2, Canada
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Maggio MG, Bonanno M, Manuli A, Calabrò RS. Improving Outcomes in People with Spinal Cord Injury: Encouraging Results from a Multidisciplinary Advanced Rehabilitation Pathway. Brain Sci 2024; 14:140. [PMID: 38391715 PMCID: PMC10886543 DOI: 10.3390/brainsci14020140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 02/24/2024] Open
Abstract
Spinal cord injury (SCI) consists of damage to any segment of the spinal cord extending to potential harm to nerves in the cauda equina. Rehabilitative efforts for SCI can involve conventional physiotherapy, innovative technologies, as well as cognitive treatment and psychological support. The aim of this study is to evaluate the feasibility of a dedicated, multidisciplinary, and integrated intervention path for SCI, encompassing both conventional and technological interventions, while observing their impact on cognitive, motor, and behavioral outcomes and the overall quality of life for individuals with SCI. Forty-two patients with SCI were included in the analysis utilizing electronic recovery system data. The treatment regimen included multidisciplinary rehabilitation approaches, such as traditional physiotherapy sessions, speech therapy, psychological support, robotic devices, advanced cognitive rehabilitation, and other interventions. Pre-post comparisons showed a significant improvement in lower limb function (Fugl Meyer Assessment-FMA < 0.001), global cognitive functioning (Montreal Cognitive Assessment-MoCA p < 0.001), and perceived quality of life at both a physical and mental level (Short Form-12-SF-12 p < 0.001). Furthermore, we found a significant reduction in depressive state (Beck Depression Inventory-BDI p < 0.001). In addition, we assessed patient satisfaction using the Short Form of the Patient Satisfaction Questionnaire (PSQ), offering insights into the subjective evaluation of the intervention. In conclusion, this retrospective study provides positive results in terms of improvements in motor function, cognitive functions, and quality of life, highlighting the importance of exploring multidisciplinary approaches.
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Affiliation(s)
- Maria Grazia Maggio
- IRCCS Centro Neurolesi Bonino-Pulejo, Cda Casazza, SS 113, 98123 Messina, Italy
| | - Mirjam Bonanno
- IRCCS Centro Neurolesi Bonino-Pulejo, Cda Casazza, SS 113, 98123 Messina, Italy
| | - Alfredo Manuli
- A.O.U. Policlinico "G. Martino", Via Consolare Valeria, 98124 Messina, Italy
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