Energy Efficiency and Patient Satisfaction of Gait With Knee-Ankle-Foot Orthosis and Robot (ReWalk)-Assisted Gait in Patients With Spinal Cord Injury

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.

Design guidelines for movement-assistive clothing based on a comprehensive understanding of older adults' needs and preferences

This study aimed to explore the needs and wants of older adults in the context of movement-assistive clothing (MSC), with a focus on muscle strength and posture correction. A survey was conducted to understand the needs and wants of older adults, considering aspects of functions and designs, and to evaluate the comfort, safety, ease of use, usefulness, and intention of users to purchase and use products. A total of 408 individuals aged > 65 years participated in the study. The data were analyzed using descriptive analyses, such as mean, standard deviation, percentages, Cronbach's alpha, chi-square test, independent t-test, analysis of variance, and regression using IBM SPSS 27.0. Exploratory Factor Analysis was also conducted to test the hypotheses. Open-ended questions were extracted using major themes after color-coding. Based on the results, design recommendations were derived, including the development of pants and innerwear with casual, minimalist styles, featuring achromatic colors, and utilizing stretchy, breathable fabrics. Comfort, safety, ease of use, and usefulness emerged as critical factors influencing the purchase and use of MSC by older adults. This study aimed to establish design guidelines by understanding the needs and wants of older adults and considering the aspects of movement-assistive clothing to relieve musculoskeletal issues. Accordingly, these findings are expected to aid in the creation of wearable suits using flexible fabric artificial muscles for active musculoskeletal correction in older adults.

STELO: A New Modular Robotic Gait Device for Acquired Brain Injury-Exploring Its Usability

In recent years, the prevalence of acquired brain injury (ABI) has been on the rise, leading to impaired gait functionality in affected individuals. Traditional gait exoskeletons are typically rigid and bilateral and lack adaptability. To address this, the STELO, a pioneering modular gait-assistive device, was developed. This device can be externally configured with joint modules to cater to the diverse impairments of each patient, aiming to enhance adaptability and efficiency. This study aims to assess the safety and usability of the initial functional modular prototype, STELO, in a sample of 14 ABI-diagnosed participants. Adverse events, device adjustment assistance and time, and gait performance were evaluated during three sessions of device use. The results revealed that STELO was safe, with no serious adverse events reported. The need for assistance and time required for device adjustment decreased progressively over the sessions. Although there was no significant improvement in walking speed observed after three sessions of using STELO, participants and therapists reported satisfactory levels of comfort and usability in questionnaires. Overall, this study demonstrates that the STELO modular device offers a safe and adaptable solution for individuals with ABI, with positive user and therapist feedback.

A Self-Coordinating Controller with Balance-Guiding Ability for Lower-Limb Rehabilitation Exoskeleton Robot

The restricted posture and unrestricted compliance brought by the controller during human-exoskeleton interaction (HEI) can cause patients to lose balance or even fall. In this article, a self-coordinated velocity vector (SCVV) double-layer controller with balance-guiding ability was developed for a lower-limb rehabilitation exoskeleton robot (LLRER). In the outer loop, an adaptive trajectory generator that follows the gait cycle was devised to generate a harmonious hip-knee reference trajectory on the non-time-varying (NTV) phase space. In the inner loop, velocity control was adopted. By searching the minimum L2 norm between the reference phase trajectory and the current configuration, the desired velocity vectors in which encouraged and corrected effects can be self-coordinated according to the L2 norm were obtained. In addition, the controller was simulated using an electromechanical coupling model, and relevant experiments were carried out with a self-developed exoskeleton device. Both simulations and experiments validated the effectiveness of the controller.

Overview of the role of robots in upper limb disabilities rehabilitation: a scoping review

BACKGROUND

Neuromotor rehabilitation and improvement of upper limb functions are necessary to improve the life quality of patients who have experienced injuries or have pathological outcomes. Modern approaches, such as robotic-assisted rehabilitation can help to improve rehabilitation processes and thus improve upper limb functions. Therefore, the aim of this study was to investigate the role of robots in upper limb disability improvement and rehabilitation.

METHODS

This scoping review was conducted by search in PubMed, Web of Science, Scopus, and IEEE (January 2012- February 2022). Articles related to upper limb rehabilitation robots were selected. The methodological quality of all the included studies will be appraised using the Mixed Methods Appraisal Tool (MMAT). We used an 18-field data extraction form to extract data from articles and extracted the information such as study year, country, type of study, purpose, illness or accident leading to disability, level of disability, assistive technologies, number of participants in the study, sex, age, rehabilitated part of the upper limb using a robot, duration and frequency of treatment, methods of performing rehabilitation exercises, type of evaluation, number of participants in the evaluation process, duration of intervention, study outcomes, and study conclusions. The selection of articles and data extraction was made by three authors based on inclusion and exclusion criteria. Disagreements were resolved through consultation with the fifth author. Inclusion criteria were articles involving upper limb rehabilitation robots, articles about upper limb disability caused by any illness or injury, and articles published in English. Also, articles involving other than upper limb rehabilitation robots, robots related to rehabilitation of diseases other than upper limb, systematic reviews, reviews, and meta-analyses, books, book chapters, letters to the editor, and conference papers were also excluded. Descriptive statistics methods (frequency and percentage) were used to analyses the data.

RESULTS

We finally included 55 relevant articles. Most of the studies were done in Italy (33.82%). Most robots were used to rehabilitate stroke patients (80%). About 60.52% of the studies used games and virtual reality rehabilitate the upper limb disabilities using robots. Among the 14 types of applied evaluation methods, "evaluation and measurement of upper limb function and dexterity" was the most applied evaluation method. "Improvement in musculoskeletal functions", "no adverse effect on patients", and "Safe and reliable treatment" were the most cited outcomes, respectively.

CONCLUSIONS

Our findings show that robots can improve musculoskeletal functions (musculoskeletal strength, sensation, perception, vibration, muscle coordination, less spasticity, flexibility, and range of motion) and empower people by providing a variety of rehabilitation capabilities.

Satisfaction analysis of overground gait exoskeletons in people with neurological pathology. a systematic review

BACKGROUND

People diagnosed with neurological pathology may experience gait disorders that affect their quality of life. In recent years, research has been carried out on a variety of exoskeletons in this population. However, the satisfaction perceived by the users of these devices is not known. Therefore, the objective of the present study is to evaluate the satisfaction perceived by users with neurological pathology (patients and professionals) after the use of overground exoskeletons.

METHODS

A systematic search of five electronic databases was conducted. In order to be included in this review for further analysis, the studies had to meet the following criteria: [1] the study population was people diagnosed with neurological pathology; [2] the exoskeletons had to be overground and attachable to the lower limbs; and [3]: the studies were to include measures assessing either patient or therapist satisfaction with the exoskeletons.

RESULTS

Twenty-three articles were selected, of which nineteen were considered clinical trials. Participants diagnosed with stroke (n = 165), spinal cord injury (SCI) (n = 102) and multiple sclerosis (MS) (n = 68). Fourteen different overground exoskeleton models were analysed. Fourteen different methods of assessing patient satisfaction with the devices were found, and three ways to evaluate it in therapists.

CONCLUSION

Users' satisfaction with gait overground exoskeletons in stroke, SCI and MS seems to show positive results in safety, efficacy and comfort of the devices. However, the worst rated aspects and therefore those that should be optimized from the users' point of view are ease of adjustment, size and weight, and ease of use.

The effect of training using an upper limb rehabilitation robot (HEXO-UR30A) in chronic stroke patients: A randomized controlled trial

BACKGROUND

Upper limb robotic rehabilitation can be beneficial to the patients when applied appropriately. HEXO-UR30A is a novel exoskeletal type upper limb rehabilitation robot that provides continuous passive motion to the shoulder joint.

OBJECTIVE

The purpose of this study is to evaluate the effectiveness of HEXO-UR30A on the patient's functional change, spasticity, and range of motion (ROM).

METHODS

We included stroke patients with upper limb hemiparesis of age > 19 years with spasticity grading of modified Ashworth scale < 3 and Brunnstrom recovery stage ≥ 4. The efficacy of the robot was investigated based on a rehabilitation program for 3 weeks. Patient's functions were compared before vs after treatment and between the HEXO group vs control. We conducted the Fugl-Meyer Assessment of the Upper Extremity, modified Barthel index, modified Ashworth scale, ROM, and Motricity Index upper limb. Patients' satisfaction was evaluated using a questionnaire after every 10 sessions of training.

RESULTS

In the HEXO group, the Fugl-Meyer assessment for shoulder improved significantly (P value = .006*) compared with the control group (P value = .075). Both groups showed significant improvement (P value < .05) in Motricity Index upper limb after treatment. There were some improvements in the passive and active ROM. Patients in the HEXO group reported high satisfaction with upper limb rehabilitation.

CONCLUSION

These results show that HEXO-UR30A can improve functional ability in chronic stroke patients. Moreover, the high satisfaction in patients might promote active involvement in upper limb rehabilitation.

Effects of lower limb exoskeleton gait orthosis compared to mechanical gait orthosis on rehabilitation of patients with spinal cord injury: A systematic review and future perspectives

OBJECTIVE

We aimed to systematically evaluate the walking efficiency of lower limb exoskeleton gait orthosis and mechanical gait orthosis in patients with spinal cord injury.

DATA SOURCES

Databases searched included: Web of Science, MEDLINE, Cochrane Library and Google Scholar.

STUDY SELECTION

Articles published in English from 1970 to 2022 investigating the impact of lower limb exoskeleton gait orthosis versus mechanical gait orthosis on gait outcomes in patients with spinal cord injury were considered.

DATA EXTRACTION

Two researchers independently extracted data and filled out predesigned forms. Information including authors, year of study, methodological quality, participant characteristics, intervention and comparison details, outcomes and results. The primary outcomes were kinematic data; the secondary outcomes were clinical tests.

DATA SYNTHESIS

Data synthesis using meta-analysis was not possible due to the diversity of study designs, methodologies, and outcome measures.

RESULTS

A total of 11 trials and 14 types of orthotics were included. The information gathered generally supported the gait improving effects of lower limb exoskeleton gait orthosis and mechanical gait orthosis in both kinematic data and clinical tests among patients with spinal cord injury.

CONCLUSIONS

This systematic review compared walking efficiency of patients with spinal cord injury wearing powered exoskeleton gait orthosis and non-powered mechanical gait orthosis. Due to the limited quality and quantity of the included studies, more high-quality studies are needed to verify the above conclusions. Future research should focus on improving trial quality and comprehensive parametric analysis of subjects with different physical conditions.

Functional Improvement and Satisfaction with a Wearable Hip Exoskeleton in Community-Living Adults

Demand for wearable devices and supportive technology is growing as these devices have the potential to enhance physical function and quality of life in users. The purpose of this study was to investigate usability and satisfaction after performing functional and gait exercise with a wearable hip exoskeleton in community-living adults. A total of 225 adults residing in the local community participated in this study. All participants performed 40 min of exercise once with a wearable hip exoskeleton in various environments. The EX1, which functions as a wearable hip exoskeleton, was used. Physical function was assessed before and after exercise with the EX1. After completing exercise with the EX1, the usability and satisfaction questionnaires were evaluated. Gait speed, timed up and go test (TUG), and four square step test (FSST) showed statistically significant improvements after exercise with the EX1 in both groups (p < 0.05). In the 6 min walking test (6MWT), a significant increase was observed in the middle-aged group (p < 0.05). In the short physical performance battery (SPPB), there was a significant improvement in the old-aged group (p < 0.05). On the other hand, positive results in usability and satisfaction were noticed in both groups. These results demonstrate that a single session of exercise with the EX1 was effective in improving physical performance of both middle- and old-aged adults, with positive feedback from most of the participants.

Advances in the clinical application of orthotic devices for stroke and spinal cord injury since 2013

Stroke and spinal cord injury are common neurological disorders that can cause various dysfunctions. Motor dysfunction is a common dysfunction that easily leads to complications such as joint stiffness and muscle contracture and markedly impairs the daily living activities and long-term prognosis of patients. Orthotic devices can prevent or compensate for motor dysfunctions. Using orthotic devices early can help prevent and correct deformities and treat muscle and joint problems. An orthotic device is also an effective rehabilitation tool for improving motor function and compensatory abilities. In this study, we reviewed the epidemiological characteristics of stroke and spinal cord injury, provided the therapeutic effect and recent advances in the application of conventional and new types of orthotic devices used in stroke and spinal cord injury in different joints of the upper and lower limbs, identified the shortcomings with these orthotics, and suggested directions for future research.

Biopsychosocial effects and experience of use of robotic and virtual reality devices in neuromotor rehabilitation: A study protocol

BACKGROUND

Robot-assisted therapy (RAT) and virtual reality (VR)-based neuromotor rehabilitation have shown promising evidence in terms of patient's neuromotor recovery, so far. However, still little is known on the perceived experience of use of robotic and VR devices and the related psychosocial impact. The present study outlines a study protocol aiming to investigate the biopsychosocial effects and the experience of use of robotic and non-immersive VR devices in patients undergoing neuromotor rehabilitation.

METHODS

Adopting a prospective, two-arm, non-randomized study design, patients with different neuromotor diseases (i.e., acquired brain injury, Parkinson's Disease, and total knee/hip arthroplasty) undergoing rehabilitation will be included. In a real-world clinical setting, short- (4 weeks) and long-term (6 months) changes in multiple patient's health domains will be investigated, including the functional status (i.e., motor functioning, ADLs, risk of falls), cognitive functioning (i.e., attention and executive functions), physical and mental health-related quality of life (HRQoL), and the psychological status (i.e., anxiety and depression, quality of life satisfaction). At post-intervention, the overall rehabilitation experience, the psychosocial impact of the robotic and VR devices will be assessed, and technology perceived usability and experience of use will be evaluated through a mixed-methods approach, including both patients' and physiotherapists' perspectives. Repeated measures within-between interaction effects will be estimated, and association analyses will be performed to explore the inter-relationships among the variables investigated. Data collection is currently ongoing.

IMPLICATIONS

The biopsychosocial framework adopted will contribute to expanding the perspective on patient's recovery within the technology-based rehabilitation field beyond motor improvement. Moreover, the investigation of devices experience of use and usability will provide further insight into technology deployment in neuromotor rehabilitation programs, thereby maximising therapy engagement and effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05399043.

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.

The Effects of Lower Limb Orthoses on Health Aspects of the Spinal Cord Injury Patients: A Systematic Review Using International Classification of Functioning, Disability, and Health (ICF) as a Reference Framework

Background: One of the most important approaches in the rehabilitation of spinal cord injury (SCI) patients is the use of different orthoses. To date, no review has been published that analyzed the effects of orthoses on health aspects of spinal cord injury clients using the International Classification of Functioning, Disability and Health (ICF). Methods: A systematic literature search was done in some databases, including Medline, PubMed, Cochrane centered register of the controlled trial (CCTR), Cochrane database of systematic reviews (CDSR), a database of abstracts of reviews of effects (DARE), Embase, Google Scholar, and ISI Web of Knowledge. SCI was used in conjunction with terms like orthotic device, mechanical orthoses, external power orthoses, assistive devices, and functional electrical. The time frame for this search was from 1970 to 2022. Results: A total of 200 papers were found. Based on the titles and abstracts, 100 related papers were detected. After careful evaluation of the papers, 47 studies were selected for final analysis-53 papers were excluded due to duplication, non-English language, and lack of full-text. Conclusion: The results of 32 studies (70% of studies) support the efficiency of orthoses in walking and standing of SCI patients. In most of the included studies, the efficiency of orthoses was evaluated mostly based on body functions and structures, and their impact on other outcomes such as participation and quality of life (QoL) of SCI patients was unclear.

Comparing walking with knee-ankle-foot orthoses and a knee-powered exoskeleton after spinal cord injury: a randomized, crossover clinical trial

Recovering the ability to stand and walk independently can have numerous health benefits for people with spinal cord injury (SCI). Wearable exoskeletons are being considered as a promising alternative to conventional knee-ankle-foot orthoses (KAFOs) for gait training and assisting functional mobility. However, comparisons between these two types of devices in terms of gait biomechanics and energetics have been limited. Through a randomized, crossover clinical trial, this study compared the use of a knee-powered lower limb exoskeleton (the ABLE Exoskeleton) against passive orthoses, which are the current standard of care for verticalization and gait ambulation outside the clinical setting in people with SCI. Ten patients with SCI completed a 10-session gait training program with each device followed by user satisfaction questionnaires. Walking with the ABLE Exoskeleton improved gait kinematics compared to the KAFOs, providing a more physiological gait pattern with less compensatory movements (38% reduction of circumduction, 25% increase of step length, 29% improvement in weight shifting). However, participants did not exhibit significantly better results in walking performance for the standard clinical tests (Timed Up and Go, 10-m Walk Test, and 6-min Walk Test), nor significant reductions in energy consumption. These results suggest that providing powered assistance only on the knee joints is not enough to significantly reduce the energy consumption required by people with SCI to walk compared to passive orthoses. Active assistance on the hip or ankle joints seems necessary to achieve this outcome.

The Outcomes of Robotic Rehabilitation Assisted Devices Following Spinal Cord Injury and the Prevention of Secondary Associated Complications

Spinal cord injuries (SCIs) have major consequences on the patient’s health and life. Voluntary muscle paralysis caused by spinal cord damage affects the patient’s independence. Following SCI, an irreversible motor and sensory deficit occurs (spasticity, muscle paralysis, atrophy, pain, gait disorders, pain). This pathology has implications on the whole organism: on the osteoarticular, muscular, cardiovascular, respiratory, gastrointestinal, genito-urinary, skin, metabolic disorders, and neuro-psychic systems. The rehabilitation process for a subject having SCIs can be considered complex, since the pathophysiological mechanism and biochemical modifications occurring at the level of spinal cord are not yet fully elucidated. This review aims at evaluating the impact of robotic-assisted rehabilitation in subjects who have suffered SCI, both in terms of regaining mobility as a major dysfunction in patients with SCI, but also in terms of improving overall fitness and cardiovascular function, respiratory function, as well as the gastrointestinal system, bone density and finally the psychosocial issues, based on multiple clinical trials, and pilot studies. The researched literature in the topic revealed that in order to increase the chances of neuro-motor recovery and to obtain satisfactory results, the combination of robotic therapy, a complex recovery treatment and specific medication is one of the best decisions. Furthermore, the use of these exoskeletons facilitates better/greater autonomy for patients, as well as optimal social integration.

The Cardiorespiratory Demands of Treadmill Walking with and without the Use of Ekso GT™ within Able-Bodied Participants: A Feasibility Study

Individuals with neurological impairments tend to lead a predominantly sedentary lifestyle due to impaired gait function and mobility. This may be detrimental to health by negatively impacting cardiorespiratory fitness and muscular strength, and increasing the risk of developing secondary health problems. Powered exoskeletons are assistive devices that may aid neurologically impaired individuals in achieving the World Health Organisation's (WHO) physical activity (PA) guidelines for health. Increased PA should elicit a sufficient cardiorespiratory stimulus to provide health benefits to exoskeleton users. This study examined the cardiorespiratory demands of treadmill walking with and without the Ekso GT™ among able-bodied participants. The Ekso GT™ is a powered exoskeleton that enables individuals with neurological impairments to walk by supporting full body mass with motors attached at the hip and knee joints to generate steps. This feasibility study consisted of one group of healthy able-bodied individuals (n = 8). Participants completed two 12 min treadmill walking assessments, one with and one without the Ekso GT™ at the same fixed speed. Throughout each walking bout, various cardiorespiratory parameters, namely, volume of oxygen per kilogram (kg) of body mass (V˙O2·kg-1), volume of carbon dioxide per kg of body mass (V˙CO2·kg-1), respiratory exchange ratio (RER), ventilation (V˙E), heart rate (HR), and rate of perceived exertion (RPE), were recorded. Treadmill walking with Ekso GT™ elevated all recorded measurements to a significantly greater level (p ≤ 0.05) (except RER at 1 km·h-1; p = 0.230) than treadmill walking without the Ekso GT™ did at the same fixed speed. An increased cardiorespiratory response was recorded during treadmill walking with the exoskeleton. Exoskeleton walking may, therefore, be an effective method to increase PA levels and provide sufficient stimulus in accordance with the PA guidelines to promote cardiorespiratory fitness and subsequently enhance overall health.

A Wearable Soft Robotic Exoskeleton for Hip Flexion Rehabilitation

Leg motion is essential to everyday tasks, yet many face a daily struggle due to leg motion impairment. Traditional robotic solutions for lower limb rehabilitation have arisen, but they may bare some limitations due to their cost. Soft robotics utilizes soft, pliable materials which may afford a less costly robotic solution. This work presents a soft-pneumatic-actuator-driven exoskeleton for hip flexion rehabilitation. An array of soft pneumatic rotary actuators is used for torque generation. An analytical model of the actuators is validated and used to determine actuator parameters for the target application of hip flexion. The performance of the assembly is assessed, and it is found capable of the target torque for hip flexion, 19.8 Nm at 30°, requiring 86 kPa to reach that torque output. The assembly exhibits a maximum torque of 31 Nm under the conditions tested. The full exoskeleton assembly is then assessed with healthy human subjects as they perform a set of lower limb motions. For one motion, the Leg Raise, a muscle signal reduction of 43.5% is observed during device assistance, as compared to not wearing the device. This reduction in muscle effort indicates that the device is effective in providing hip flexion assistance and suggests that pneumatic-rotary-actuator-driven exoskeletons are a viable solution to realize more accessible options for those who suffer from lower limb immobility.

A systematic review on the usability of robotic and virtual reality devices in neuromotor rehabilitation: patients' and healthcare professionals' perspective

BACKGROUND

The application of virtual reality (VR) and robotic devices in neuromotor rehabilitation has provided promising evidence in terms of efficacy, so far. Usability evaluations of these technologies have been conducted extensively, but no overviews on this topic have been reported yet.

METHODS

A systematic review of the studies on patients' and healthcare professionals' perspective through searching of PubMed, Medline, Scopus, Web of Science, CINAHL, and PsychINFO (2000 to 2021) was conducted. Descriptive data regarding the study design, participants, technological devices, interventions, and quantitative and qualitative usability evaluations were extracted and meta-synthetized.

RESULTS

Sixty-eight studies were included. VR devices were perceived as having good usability and as a tool promoting patients' engagement and motivation during the treatment, as well as providing strong potential for customized rehabilitation sessions. By contrast, they suffered from the effect of learnability and were judged as potentially requiring more mental effort. Robotics implementation received positive feedback along with high satisfaction and perceived safety throughout the treatment. Robot-assisted rehabilitation was considered useful as it supported increased treatment intensity and contributed to improved patients' physical independence and psychosocial well-being. Technical and design-related issues may limit the applicability making the treatment difficult and physically straining. Moreover, cognitive and communication deficits were remarked as potential barriers.

CONCLUSIONS

Overall, VR and robotic devices have been perceived usable so far, reflecting good acceptance in neuromotor rehabilitation programs. The limitations raised by the participants should be considered to further improve devices applicability and maximise technological rehabilitation effectiveness.

TRIAL REGISTRATION

PROSPERO registration ref. CRD42021224141 .

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.

Effect of Reciprocating Gait Orthosis with Hip Actuation on Upper Extremity Loading during Ambulation in Patient with Spinal Cord Injury: A Single Case Study

Reciprocating gait orthosis (RGO) is a traditional passive orthosis that provides postural stability and allows for independent upright ambulation with the assistance of walking aids, such as crutches, canes, and walkers. Previous follow-up studies of patients with RGOs have indicated a high frequency of nonusage. One of the main reasons for avoiding the use of RGOs is the excessive upper extremity loading induced by walking aids. The purpose of this study was to investigate the effect of hip actuation on the upper extremity loading induced by crutches when ambulating with an RGO. One female individual with a chronic complete spinal cord injury classified as ASIA A participated in this study. We compared the upper extremity loading during ambulation when individualized hip assistive forces were applied on the RGO (POWERED condition) and when wearing the RGO without actuation (RGO condition). Upper extremity loading was assessed by measuring the forces acting on the crutches. Compared with the RGO condition, the average upper extremity loading per unit distance and per unit time were lower for the POWERED condition by 15.21% (RGO: 0.307 ± 0.056 and POWERED: 0.260 ± 0.034 %bw·m−1) and by 21.19% (RGO: 0.120 ± 0.020 and POWERED: 0.094 ± 0.011 %bw·s−1), respectively. We believe that a substantial reduction in upper extremity loading during ambulation provided by hip actuation holds promise to promote long-term RGO use and enable patients with paraplegia to perform frequent and intensive rehabilitation training. As this is a single case study, subsequent studies should aim to verify this effect through a higher number of patients and to different injury levels.

Effectiveness of powered exoskeleton use on gait in individuals with cerebral palsy: A systematic review

Background

Cerebral palsy (CP) is a leading cause of childhood disability. The motor impairments of individuals with CP significantly affect the kinematics of an efficient gait pattern. Robotic therapies have become increasingly popular as an intervention to address this. Powered lower limb exoskeletons (PoLLE) are a novel form of robotic therapy that allow the individual to perform over-ground gait training and yet its effectiveness for CP is unknown.

Purpose

To determine the effectiveness of PoLLE use on gait in individuals with CP.

Method

A systematic search of eight electronic databases was conducted in March 2020. Studies included children (0–18 years) and or adults (18+ years) diagnosed with CP who used a PoLLE for gait training. This review was conducted and reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement, with the methodology registered with PROSPERO (CRD42020177160). A modified version of the McMaster critical review form for quantitative studies was used to assess the methodological quality. Due to the heterogeneity of the included studies, a descriptive synthesis using the National Health & Medical Research Council (NHMRC) FORM framework was undertaken.

Results

Of the 2089 studies screened, ten case series and three case studies met the inclusion criteria highlighting the current evidence base is emerging and low level. A range of PoLLEs were investigated with effectiveness measured by using a number of outcome measures. Collectively, the body of evidence indicates there is some consistent positive evidence on the effectiveness of PoLLE in improving gait in individuals with CP, with minimal adverse effects. While this is a positive and encouraging finding for an emerging technology, methodological concerns also need to be acknowledged.

Conclusion

With rapidly evolving technology, PoLLEs could play a transformative role in the lives of people impacted by CP. Ongoing research is required to further strengthen the evidence base and address current methodological concerns.

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 rehabilitation exoskeletons of the lower limb: analysis of versatility and adaptability

PURPOSE

To analyse the versatility and adaptability of commercially available exoskeletons for mobility assistance and their adaptation to diverse pathologies through a review of clinical trials in robotic lower limb training.

DATA SOURCES

A computer-aided search in bibliographic databases (PubMed and Web of Science) of clinical trials published up to September 2020 was done.

METHODS

To be selected for detailed review, clinical trials had to meet the following criteria: (1) a protocol was designed and approved, (2) participants were people with pathologies, and (3) the trials were not a single case study. Clinical trial data were collected, extracted, and analysed, considering: objectives, trial participants, number of sessions, pathologies involved, and conclusions.

RESULTS

The search resulted in 312 potentially relevant studies of seven commercial exoskeletons, of which 135 passed the preliminary screening; and 69 studies were finally selected. Of the 69 clinical trials included in the review about 50% involved Spinal Cord Injury participants, while roughly 25% focussed on stroke and two trials corresponded to patients with both disorders. The rest were composed of neurological diseases and trauma disorders.

CONCLUSIONS

The use of a single wearable robot for different medical conditions in various diseases is a challenge. Based on this comparative, the properties of the exoskeletons that improve the working ability with different pathologies and patient conditions have been evaluated. Suggestions were made for developing a new lower-limb exoskeleton based on various modules with a distributed control system to improve versatility in wearable technology for different gait pattern progression.Implications for rehabilitationWearable robotic exoskeletons for gait assistance have been analysed from the perspective of adaptation to different diseases.This paper emphasizes the importance of personalized therapies and adaptive assistive technology.Suggestions were made for a new modular exoskeleton capable of addressing the issue of low versatility characterizing currently wearable assistive technology.