Overground Robotic Exoskeleton Research Articles

Physical therapist burden delivering gait training for a patient with lateropulsion after stroke during inpatient rehabilitation: a single-case design

Background/Aims Gait training for patients with lateropulsion after stroke improves outcomes (eg reduced lateropulsion and improved function) but can be burdensome on the physical therapist. This study describes the physical therapist burden and performance of a patient with moderate lateropulsion during three gait training approaches during inpatient rehabilitation. Methods A physical therapist delivered gait training (one session each of overground robotic exoskeleton, overground supported walking, and body weight-supported treadmill training) for a patient with lateropulsion (scoring 8 out of 17 on the Burke Lateropulsion Scale). Outcomes were physiological burden (heart rate, metabolic equivalents, respiratory exchange ratio and energy expenditure), which were measured via a wearable metabolic system and perceptual burden (National Aeronautics and Space Administration Task Load Index) on the physical therapist. Patient performance (step count, time walking, time spent upright and time in moderate-to-vigorous intensity) was recorded. Results During overground robotic exoskeleton gait training, the physical therapist's physiological metrics included an average heart rate of 116 beats per minute (minimum–maximum: 98–127, time in moderate-to-vigorous intensity was 0%), average metabolic equivalents of 3.2 (minimum–maximum: 1.7–4.3), a respiratory exchange ratio of 0.79 (minimum–maximum: 0.70–0.93), an energy expenditure of 228 kcal/hour and a perceptual burden of 33.3. The patient walked 228 steps, spent 15.4 minutes upright, 8.7 minutes walking and achieved 0% in moderate-to-vigorous intensity. During overground supported walking, the physical therapist's metrics included an average heart rate of 145 beats per minute (minimum–maximum: 113–164, time in moderate-to-vigorous intensity was 87%), average metabolic equivalents of 4.7 (minimum–maximum: 2.7–6.0), a respiratory exchange ratio of 0.96 (minimum–maximum: 0.81–1.16), an energy expenditure of 343 kcal/hour and a perceptual burden of 60.8. The patient walked 588 steps, spent 19.6 minutes upright, 10.5 minutes walking and achieved 38% in moderate-to-vigorous intensity. During body weight-supported treadmill training, the physical therapist's metrics included an average heart rate of 112 beats per minute (minimum–maximum: 69–137, time in moderate-to-vigorous intensity was 34%), average metabolic equivalents of 3.9 (minimum–maximum: 3.2–4.4), a respiratory exchange ratio of 0.89 (minimum–maximum: 0.82–0.95), an energy expenditure of 281 kcal/hour and a perceptual burden of 32.5. The patient walked 682 steps, spent 16.0 minutes upright, 10.0 minutes walking and achieved 0% in moderate-to-vigorous intensity. Conclusions As concordance between physical therapist burden and patient gait performance was low in this study, future efforts to identify gait training approaches that minimise therapist burden while maximising outcomes for the patient with lateropulsion are necessary for the health of both. Implications for practice Physical therapists may consider advanced technology use such as overground robotic exoskeletons to reduce the burden during the provision of gait training for patients with lateropulsion. Gait training performance of patients with lateropulsion may vary across different gait training approaches with low correspondence to therapist burden.

OVERGROUND ROBOTIC EXOSKELETON GAIT TRAINING INTENSITY IN PATIENTS WITH SCI

https://youtu.be/nreyPHEQASg BACKGROUND High-intensity gait training during inpatient rehabilitation (IPR) promotes functional recovery following spinal cord injury (SCI) and may be achieved with overground robotic exoskeleton gait training (OEGT). Due to neuromuscular and autonomic impairments associated with SCI, assessing intensity through heart rate response and perceived exertion during gait training may be inaccurate. Wearable metabolic systems (WMS) have been used to directly measure intensity using oxygen consumption (VO2) with SCI. However, the use of WMS to assess OEGT intensity during OEGT in IPR is unexplored. PURPOSE: To describe the use of WMS to measure physiological intensity of OEGT in patients with motor incomplete SCI during IPR. METHODS This observational study included adults aged 18 to 85 admitted to IPR with diagnosis of motor incomplete SCI who were eligible to initiate OEGT. OEGT intensity, duration, and step count were assessed during 1 OEGT session performed within 1 week of gait training initiation following IPR admission. Intensity was assessed by rate of perceived exertion (RPE) and VO2. VO2 was measured using a WMS worn during OEGT and expressed in metabolic equivalents (METs). Moderate and high intensity were defined as ≥ 3 and ≥ 6 METs, respectively, with 2.7 mL/min/kg of VO2 = 1 MET. RESULTS 4 participants [3 males; 1 non-Hispanic white, 2 Hispanic white, 1 Black] were aged 52±8.4 years with a body mass index of 28.4±3.2. Participants’ SCI characteristics were 3 diagnosed ASIA Impairment Scale (AIS) C, 1 AIS D; 2 tetraplegia and 2 paraplegia admitted within 30.5 [range=8-56] days after SCI. Duration of OEGT sessions (n=4) was 15:57 [range=10:23-19:43] minutes and participants completed 512 [287-761] steps. RPE was 4 [2-6], VO2 was 7.3 [3.05-15.6], and METs were 2.72 [1.1-5.8]. Three participants achieved ≥3 METs and ≥6 METs for 79-89.6% and 4.2-54.8% of the OEGT session, respectively. VO2 was highest in the AIS D participant. CONCLUSIONS WMS use was demonstrated to feasibly obtain intensity data of OEGT in adults with SCI during IPR. Future research should consider the utility of WMS to assess the capacity of OEGT to promote high-intensity gait training in this population during IPR.

Overground Robotic Exoskeleton Gait Training Intensity In Patients With Spinal Cord Injury During Inpatient Rehabilitation

Overground Robotic Exoskeleton Gait Training Intensity In Patients With Spinal Cord Injury During Inpatient Rehabilitation

Overground Robotic Program Preserves Gait in Individuals With Multiple Sclerosis and Moderate to Severe Impairments: A Randomized Controlled Trial

ObjectiveTo determine how overground robotic (OR) training added to ongoing rehabilitation affects gait speed, lower extremity function, functional mobility, and fatigue in individuals with multiple sclerosis (MS) and moderate to severe gait impairments. DesignRandomized controlled trial. SettingOutpatient setting at the Multiple Sclerosis Association of Bizkaia, an association serving MS patients in Bizkaia, Spain. ParticipantsIndividuals with MS (N=36) participated in this interventional study. Inclusion criteria were age of 18 years or older, Expanded Disability Status Scale score between 4.5 and 7, and the need for assistive devices for walking outdoors. InterventionsThe control group (CG) engaged in an ongoing rehabilitation program consisting of weekly 1-hour individualized sessions. The intervention group (OR group) also participated in this program in addition to a twice-weekly individualized and progressive OR gait training intervention for 3 months, aiming to reach a maximum of 40 minutes by the end of the 3-month period. Main Outcome MeasuresPrimary outcome was the 10-meter walking test (10MWT). Secondary variables included the Short Physical Performance Battery, the timed Up and Go (TUG) test, and the Modified Fatigue Impact Scale. ResultsThe OR group maintained 10MWT performance and significantly improved on the TUG test (P=.049, medium effect size) without increasing fatigue perception. The CG demonstrated a decline on the 10MWT (P=.044, small effect size) and reduced fatigue (P=.024, medium effect size). No time per group interaction was observed for any variable. ConclusionThe evaluated intervention could preserve gait speed and significantly improve functional mobility without increasing perceived fatigue in participants. Thus, OR exoskeletons could be considered a tool to deliver intensive practice of good-quality gait training in individuals with MS and moderate to severe gait impairments. Further studies are necessary to confirm these preliminary results.

An Overground Robotic Gait Training Program for People With Multiple Sclerosis: A Protocol for a Randomized Clinical Trial.

Maintaining the ability to walk is one of the significant challenges in people with multiple sclerosis (MS) for keeping a good quality of life as the disease and the aging process progresses. Overground robotic (OR) wearable exoskeletons are promising tools for gait rehabilitation, but currently there is no evidence of their clinical effects on patients with MS. The present study aims to determine the effects of an OR intervention in people with MS and moderate to severe walking disabilities and ascertain if benefits are maintained over a follow-up period of 3 months. This randomized controlled trial will include 36 participants with MS. Inclusion criteria are: older than 18 years, definitive diagnosis of MS, 4.5–7 points on the EDSS (Expanded Disability Status Scale), and needing one or two canes or crutches for walking outdoors. Subjects in the control group will receive conventional physiotherapy sessions at ADEMBI (Asociación de Esclerosis Múltiple de Bizkaia) provided to control spasticity, maintain articular range and exercise balance. Subjects in the intervention group will receive the same physiotherapy but also participate in a progressive OR gait training program assisted by the EksoTM exoskeleton. The program consists of twice a week individually supervised sessions in two setting modalities: PreGait and ProStepPlus. The training parameters (duration, speed, cadence, length of steps) will be set during the first session and the progression and intensity of the intervention will be adapted to the tolerance of each participant. The primary outcome of this study is gait speed. Secondary outcomes will include physical and cognitive performance tests, clinical, fatigue and quality of life assessments, and changes in the plasma levels of inflammatory cytokines. The present trial is the first analyzing the effectiveness of an OR intervention for gait training in patients with MS. It will help clarify the applicability of robotic technologies to clinical practice, extending the functionality and quality of life of people with MS to face a successful aging process. (ACTRN12619000014156; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376548).

The utilization of an overground robotic exoskeleton for gait training during inpatient rehabilitation-single-center retrospective findings.

Overground robotic exoskeleton gait training is increasingly utilized during inpatient rehabilitation yet without clear guidelines. We describe clinical characteristics associated with robotic exoskeleton gait training and examine outcomes of people with spinal cord injury and stroke who completed usual rehabilitation care with or without robotic exoskeleton gait training. Retrospective review of medical records over a 36 months period. Inpatients with spinal cord injury or stroke and ≥1 robotic exoskeleton gait training session were included. After obtaining a complete list of robotic exoskeleton gait training participants, medical records were reviewed for comparable matches as determined by gait functional independence measure score <4, age 18-100 years, meeting exoskeleton manufacturer eligibility criteria, and participating in usual care only. Functional independence measure was collected on all patients. For spinal cord injury, we collected the walking index for spinal cord injury II. For stroke, we collected the Stroke Rehabilitation Assessment of Movement Measure. Fifty-nine people with spinal cord injury (n = 31 robotic exoskeleton gait training; n = 28 usual care) and 96 people post-stroke (n = 44 robotic exoskeleton gait training; n = 52 usual care) comprised the medical record review. Fifty-eight percent of patients with spinal cord injury and 56% of patients post-stroke completed 5+ robotic exoskeleton gait training sessions and were included in analyses. Robotic exoskeleton gait training dosage varied between our patients with spinal cord injury and patients post-stroke. Robotic exoskeleton gait training utilization during inpatient rehabilitation required consideration of unique patient characteristics impacting functional outcomes. Application of robotic exoskeleton gait training across diagnoses may require different approaches during inpatient rehabilitation.

Budget impact analysis of robotic exoskeleton use for locomotor training following spinal cord injury in four SCI Model Systems

BackgroundWe know little about the budget impact of integrating robotic exoskeleton over-ground training into therapy services for locomotor training. The purpose of this study was to estimate the budget impact of adding robotic exoskeleton over-ground training to existing locomotor training strategies in the rehabilitation of people with spinal cord injury.MethodsA Budget Impact Analysis (BIA) was conducted using data provided by four Spinal Cord Injury (SCI) Model Systems rehabilitation hospitals. Hospitals provided estimates of therapy utilization and costs about people with spinal cord injury who participated in locomotor training in the calendar year 2017. Interventions were standard of care walking training including body-weight supported treadmill training, overground training, stationary robotic systems (i.e., treadmill-based robotic gait orthoses), and overground robotic exoskeleton training. The main outcome measures included device costs, training costs for personnel to use the device, human capital costs of locomotor training, device demand, and the number of training sessions per person with SCI.ResultsRobotic exoskeletons for over-ground training decreased hospital costs associated with delivering locomotor training in the base case analysis. This analysis assumed no difference in intervention effectiveness across locomotor training strategies. Providing robotic exoskeleton overground training for 10% of locomotor training sessions over the course of the year (range 226–397 sessions) results in decreased annual locomotor training costs (i.e., net savings) between $1114 to $4784 per annum. The base case shows small savings that are sensitive to parameters of the BIA model which were tested in one-way sensitivity analyses, scenarios analyses, and probability sensitivity analyses. The base case scenario was more sensitive to clinical utilization parameters (e.g., how often devices sit idle and the substitution of high cost training) than device-specific parameters (e.g., robotic exoskeleton device cost or device life). Probabilistic sensitivity analysis simultaneously considered human capital cost, device cost, and locomotor device substitution. With probabilistic sensitivity analysis, the introduction of a robotic exoskeleton only remained cost saving for one facility.ConclusionsProviding robotic exoskeleton for over-ground training was associated with lower costs for the locomotor training of people with SCI in the base case analyses. The analysis was sensitive to parameter assumptions.

Mobility and Cognitive Improvements Resulted from Overground Robotic Exoskeleton Gait-Training in Persons with MS.

Multiple sclerosis (MS) is a non-traumatic, immune-mediated neurodegenerative disease of the central nervous system (CNS), affecting more than 2 million individuals globally and approximately one million in the United States [1], [2]. This autoimmune inflammatory disease of the CNS featuring both neuroinflammatory and neurodegenerative aspects [3], often results in mobility and cognitive impairment. Rehabilitation has been suggested as the best [4], and perhaps, one of few methods for restoring function in MS [5]. The goal of the present investigation is to examine the effects of 4 weeks of supervised, over-ground gait training using a robotic exoskeleton (RE) compared with a control condition (conventional gait therapy, CGT) in persons with MS with ambulatory and cognition disabilities. Four subjects (mean age=50 years, three females) with relapsing-remitting MS (RRMS) participated in this study and completed a total of eight sessions (1-hour/session) gait training in a standard therapy gym either using a RE supervised by an RE training physical therapist (PT) or with the CGT supervised by a PT. Outcome measures (walking speed and temporal-spatial parameters) were measured on a level surface without RE using an instrumented walkway, for both groups, pre- and post-intervention. The two participants in the RE group were also tested in the same testing environment, while wearing a RE pre- and post-intervention. Cognitive processing speed was assessed using the Symbol Digit Modalities Test (SDMT) pre- and post-intervention. Subjects in the RE group tested without a RE increased average walking speed, stride length, and step length with decreased stride width and step time bilaterally after the 8-session of RE training. The two participants in the CGT group only had modest improvements in walking performance. Furthermore, while the CGT group had no improvements in the processing speed (SDMT scores), an average of 80% improvement in the processing speed was noted in the RE group.

Locomotor training using an overground robotic exoskeleton in long-term manual wheelchair users with a chronic spinal cord injury living in the community: Lessons learned from a feasibility study in terms of recruitment, attendance, learnability, performance and safety

BackgroundFor individuals who sustain a complete motor spinal cord injury (SCI) and rely on a wheelchair as their primary mode of locomotion, overground robotic exoskeletons represent a promising solution to stand and walk again. Although overground robotic exoskeletons have gained tremendous attention over the past decade and are now being transferred from laboratories to clinical settings, their effects remain unclear given the paucity of scientific evidence and the absence of large-scale clinical trials. This study aims to examine the feasibility of a locomotor training program with an overground robotic exoskeleton in terms of recruitment, attendance, and drop-out rates as well as walking performance, learnability, and safety.MethodsIndividuals with a SCI were invited to participate in a 6 to 8-week locomotor training program with a robotic exoskeleton encompassing 18 sessions. Selected participants underwent a comprehensive screening process and completed two familiarization sessions with the robotic exoskeleton. The outcome measures were the rate of recruitment of potential participants, the rate of attendance at training sessions, the rate of drop-outs, the ability to walk with the exoskeleton, and its progression over the program as well as the adverse events.ResultsOut of 49 individuals who expressed their interest in participating in the study, only 14 initiated the program (recruitment rate = 28.6%). Of these, 13 individuals completed the program (drop-out rate = 7.1%) and attended 17.6 ± 1.1 sessions (attendance rate = 97.9%). Their greatest standing time, walking time, and number of steps taken during a session were 64.5 ± 10.2 min, 47.2 ± 11.3 min, and 1843 ± 577 steps, respectively. During the training program, these last three parameters increased by 45.3%, 102.1%, and 248.7%, respectively. At the end of the program, when walking with the exoskeleton, most participants required one therapist (85.7%), needed stand-by or contact-guard assistance (57.1%), used forearm crutches (71.4%), and reached a walking speed of 0.25 ± 0.05 m/s. Five participants reported training-related pain or stiffness in the upper extremities during the program. One participant sustained bilateral calcaneal fractures and stopped the program.ConclusionsThis study confirms that larger clinical trials investigating the effects of a locomotor training program with an overground robotic exoskeleton are feasible and relatively safe in individuals with complete motor SCI. Moreover, to optimize the recruitment rate and safety in future trials, this study now highlights the need of developing pre-training rehabilitation programs to increase passive lower extremity range of motion and standing tolerance. This study also calls for the development of clinical practice guidelines targeting fragility fracture risk assessment linked to the use of overground robotic exoskeletons.

Cardiorespiratory demand and rate of perceived exertion during overground walking with a robotic exoskeleton in long-term manual wheelchair users with chronic spinal cord injury: A cross-sectional study

BackgroundMany wheelchair users adopt a sedentary lifestyle, which results in progressive physical deconditioning with increased risk of musculoskeletal, cardiovascular and endocrine/metabolic morbidity and mortality. Engaging in a walking program with an overground robotic exoskeleton may be an effective strategy for mitigating these potential negative health consequences and optimizing fitness in this population. However, additional research is warranted to inform the development of adapted physical activity programs incorporating this technology. ObjectivesTo determine cardiorespiratory demands during sitting, standing and overground walking with a robotic exoskeleton and to verify whether such overground walking results in at least moderate-intensity physical exercise. MethodsWe enrolled 13 long-term wheelchair users with complete motor spinal cord injury in a walking program with an overground robotic exoskeleton. Cardiorespiratory measures and rate of perceived exertion (RPE) were recorded by using a portable gas analyzer system during sitting, standing and four 10m walking tasks with the robotic exoskeleton. Each participant also performed an arm crank ergometer test to determine maximal cardiorespiratory ability (i.e., peak heart rate and O2 uptake [HRpeak, VO2peak]). ResultsCardiorespiratory measures increased by a range of 9%–35% from sitting to standing and further increased by 22%–52% from standing to walking with the robotic exoskeleton. During walking, median oxygen cost (O2Walking), relative HR (%HRpeak), relative O2 consumption (%VO2peak) and respiratory exchange ratio (RER) reached 0.29mL/kg/m, 82.9%, 41.8% and 0.9, respectively, whereas median RPE reached 3.2/10. O2Walking was moderately influenced by total number of sessions and steps taken with the robotic exoskeleton since the start of the walking program. ConclusionOverground walking with the robotic exoskeleton over a short distance allowed wheelchair users to achieve a moderate-intensity level of exercise. Hence, an overground locomotor training program with a robotic exoskeleton may have cardiorespiratory health benefits in the population studied.

Satisfaction and perceptions of long-term manual wheelchair users with a spinal cord injury upon completion of a locomotor training program with an overground robotic exoskeleton

Aim: The main objectives of this study were to quantify clients’ satisfaction and perception upon completion of a locomotor training program with an overground robotic exoskeleton.Methods: A group of 14 wheelchair users with a spinal cord injury, who finished a 6–8-week locomotor training program with the robotic exoskeleton (18 training sessions), were invited to complete a web-based electronic questionnaire. This questionnaire encompassed 41 statements organized around seven key domains: overall satisfaction related to the training program, satisfaction related to the overground robotic exoskeleton, satisfaction related to the program attributes, perceived learnability, perceived health benefits and risks and perceived motivation to engage in physical activity. Each statement was rated using a visual analogue scale ranging from “0 = totally disagree” to “100 = completely agree”.Results: Overall, respondents unanimously considered themselves satisfied with the locomotor training program with the robotic exoskeleton (95.7 ± 0.7%) and provided positive feedback about the robotic exoskeleton itself (82.3 ± 6.9%), the attributes of the locomotor training program (84.5 ± 6.9%) and their ability to learn to perform sit–stand transfers and walk with the robotic exoskeleton (79.6 ± 17%). Respondents perceived some health benefits (67.9 ± 16.7%) and have reported no fear of developing secondary complications or of potential risk for themselves linked to the use of the robotic exoskeleton (16.7 ± 8.2%). At the end of the program, respondents felt motivated to engage in a regular physical activity program (91.3 ± 0.1%).Conclusion: This study provides new insights on satisfaction and perceptions of wheelchair users while also confirming the relevance to continue to improve such technologies, and informing the development of future clinical trials.Implications for RehabilitationAll long-term manual wheelchair users with a spinal cord injury who participated in the study are unanimously satisfied upon completion of a 6–8-week locomotor training program with the robotic exoskeleton and would recommend the program to their peers.All long-term manual wheelchair users with a spinal cord injury who participated in the study offered positive feedback about the robotic exoskeleton itself and feel it is easy to learn to perform sit–stand transfers and walk with the robotic exoskeleton.All long-term manual wheelchair users with a spinal cord injury who participated in the study predominantly perceived improvements in their overall health status, upper limb strength and endurance as well as in their sleep and psychological well-being upon completion of a 6–8-week locomotor training program with the robotic exoskeleton.All long-term manual wheelchair users with a spinal cord injury who participated in the study unanimously felt motivated to engage in a regular physical activity program adapted to their condition and most of them do plan to continue to participate in moderate-to-strenuous physical exercise.Additional research on clients’ perspectives, especially satisfaction with the overground exoskeleton and locomotor training program attributes, is needed.