Comparative trials on hybrid walking systems for people with paraplegia: an analysis of study methodology

Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso Bionics

STUDY DESIGN

Prospective quasi-experimental study, pre- and post-design.

OBJECTIVES

Assess safety, feasibility, training characteristics and changes in gait function for persons with spinal cord injury (SCI) using the robotic exoskeletons from Ekso Bionics.

SETTING

Nine European rehabilitation centres.

METHODS

Robotic exoskeleton gait training, three times weekly over 8 weeks. Time upright, time walking and steps in the device (training characteristics) were recorded longitudinally. Gait and neurological function were measured by 10 Metre Walk Test (10 MWT), Timed Up and Go (TUG), Berg Balance Scale (BBS), Walking Index for Spinal Cord Injury (WISCI) II and Lower Extremity Motor Score (LEMS).

RESULTS

Fifty-two participants completed the training protocol. Median age: 35.8 years (IQR 27.5-52.5), men/women: N = 36/16, neurological level of injury: C1-L2 and severity: AIS A-D (American Spinal Injury Association Impairment Scale). Time since injury (TSI) < 1 year, N = 25; > 1 year, N = 27. No serious adverse events occurred. Three participants dropped out following ankle swelling (overuse injury). Four participants sustained a Category II pressure ulcer at contact points with the device but completed the study and skin normalized. Training characteristics increased significantly for all subgroups. The number of participants with TSI < 1 year and gait function increased from 20 to 56% (P = 0.004) and 10MWT, TUG, BBS and LEMS results improved (P < 0.05). The number of participants with TSI > 1 year and gait function, increased from 41 to 44% and TUG and BBS results improved (P < 0.05).

CONCLUSIONS

Exoskeleton training was generally safe and feasible in a heterogeneous sample of persons with SCI. Results indicate potential benefits on gait function and balance.

Benefits of FES gait in a spinal cord injured population

STUDY DESIGN

Review.

OBJECTIVES

This review article investigated the objective evidence of benefits derived from functional electrical stimulation (FES)-assisted gait for people with spinal cord injury (SCI). Both FES and gait have been proposed to promote not only augmented health and fitness, but specific ambulatory outcomes for individuals with neurological disabilities. However, due to small sample sizes and the lack of functionality of the intervention, it has not been widely used in clinical practice. This review assessed whether there is sufficient evidence to encourage a more widespread deployment of FES gait within the rehabilitation community.

METHODS

Hand searches and online data collection were performed in Medline and Science Direct. Specific search terms used included SCI/paralysis/paraplegia and tetraplegia with electrical stimulation/FES, gait and walking.

RESULTS

The searches generated 532 papers. Of these papers, 496 were excluded and 36 papers were included in the review. Many reported benefits were not carefully investigated, and small sample sizes or different methodologies resulted in insufficient evidence to draw definitive conclusions.

CONCLUSIONS

FES gait can enhance gait, muscle strength and cardiorespiratory fitness for people with SCI. However, these benefits are dependent on the nature of the injury and further research is required to generalize these results to the widespread population of SCI individuals. Proof of the functionality and further evidence of the benefits of FES gait will assist in FES gait gaining clinical acceptance.

The orthotic effect of functional electrical stimulation on the improvement of walking in stroke patients with a dropped foot: a systematic review

OBJECTIVE

Analysis of the available evidence on the improvement of walking in stroke patients with a dropped foot when using peroneus stimulation.

METHODS

A systematic review was performed to identify trials that investigated the orthotic effect of functional electrical stimulation (FES) on walking in stroke patients with a dropped foot. Two independent raters scored the methodological quality of the included articles. Walking speed and physiological cost index (PCI) were selected as the primary outcome measures. Studies that measured walking speed were pooled and a pooled difference including confidence interval was calculated.

RESULTS

Eight studies were included in the review, of which one was a randomized controlled trial. Methodological score ranged from 8 to 18 out of 19. Six studies measured walking speed. The pooled improvement in walking speed was 0.13 m/s (0.07-0.2) or 38% (22.18-53.8).

CONCLUSIONS

The present review suggests a positive orthotic effect of functional electrical stimulation on walking speed.