Month: November 2021

Strokes are the fifth leading cause of death in the United States and a major cause of long-term disability. Thankfully, great strides have been made in treating patients who have had strokes and been left with a disability. Ekso Bionics is leading the way with robotic exoskeletons to help those who have lost mobility due to stroke, spinal cord injury, or brain injury regain what they have lost.

What Is a Stroke?

A stroke occurs when part of the brain is deprived of oxygen. This can be caused by a blood clot blocking blood flow or by a rupture in the artery feeding blood to that part of the brain. Either way, if blood flow is not returned to the affected part of the brain quickly, the damage to the brain can become permanent. This can result in varying degrees of disability or death. 

There is also a type of stroke that is temporary. Known as a transient ischemic attack (TIA), these happen when the blood supply to the brain is cut off for only a short time. After experiencing a TIA, a patient may become clumsy or confused, but the effects are only temporary. Once blood flow returns to the brain, the effects of the TIA dissipate. It is still vital to see a doctor after having a TIA. People who frequently have these attacks may have a full-blown stroke later on. 

Immediate treatment can sometimes reverse the effects of a stroke. In the case of permanent stroke damage, rehabilitation with EksoNR exoskeleton can successfully return patients to a lifestyle similar to the one they enjoyed previously.  You can read more about the research on EksoNR and stroke in our Clinical Summary. This transformative device has been helping adults of all ages regain their mobility and their quality of life.

Health Effects of a Stroke

Because the brain controls almost all of our bodily functions, the range of effects from a stroke is very broad. Frequently, patients who have had a stroke have complete or partial paralysis to one side of their body, including the facial muscles. This can manifest as drooping eyelids, an inability to speak or chew food properly, and reduced mobility. 

Sometimes strokes do not affect a person’s limbs and muscles but rather the parts of the brain that control thinking, speech, hearing, or eyesight. In these cases, a patient may have a diminished ability to think clearly or logically. They may show personality changes or lose their memory. If the areas of the brain that control the senses are damaged, the result may be loss of taste, smell, hearing, or sight. 

Even with advances in understanding strokes, it is still somewhat unpredictable how a stroke will affect someone. If the patient’s symptoms include decreased mobility, even if it is severe, EksoNR robotic exoskeleton can be a powerful tool for reversing this potentially life altering side effect.

Stroke Treatments 

Stroke treatments fit into two categories: preventative treatments and rehabilitative treatments to regain what was lost. 

Preventative Stroke Treatments 

Immediate stroke treatments vary depending on how the stroke occurred. If a blood clot caused the stroke, then medications will be given to thin the blood and reduce the size of the clot. If a rupture or other brain bleed caused the stroke, steps would be taken to stop the bleeding and return blood flow to that part of the brain. 

In both instances, medication is often given to reduce the patient’s blood pressure. High blood pressure can be both a cause and a result of a stroke. 

Rehabilitative Stroke Treatments 

Rehabilitative stroke treatments begin after any chance of reversing the damage through medical means has passed. These treatments are designed to strengthen weakened muscles, reteach parts of the brain to take over for the damaged areas, and help the patient adapt to a new way of doing things. While physical, speech, and occupational therapy is a part of these treatments, new technology, like EksoNR, gives patients who have had a stroke that resulted in paralysis or loss of mobility more options, and hope. 
 

EksoNR is a robotic exoskeleton that the Food and Drug Administration has cleared for rehabilitation after stroke. It provides therapists the opportunity to work with patients’ brain plasticity and retrain their muscles and brains to regain lost mobility.  It has shown great success at helping thousands of patients leave their wheelchairs or walkers behind. 

EksoNR can be utilized both in walking and preGait modes. Pre-gait activities include those that work on balance, midline orientation, and prepare a patient for walking. 

The various gait-training modes offer support to the torso, hips, knees, and ankles while keeping the patient in a fully upright posture and providing varying amounts of power to one or both legs. EksoNR uses a gyroscope, sensors, and software that monitors the position of the EksoNR to ensure that training is done effectively and safely. As a patient progresses and regains midline orientation, coordination, and strength, EksoNR will reduce the output of power allowing the patient to progress so they can walk out of the device. 

The patients who use EksoNR exoskeletons post-stroke are kept apprised of their progress and must actively participate in the process to succeed. This might look like assisting with weight shifts, and may progress to the patient controlling all aspects of the steps they are taking. This involvement and positive progress reports can have a profound psychological effect on the patients, increasing their odds of improving outcomes.  

A stroke is a medical emergency, capable of damaging the brain through interruption of its blood supply. There are many symptoms of stroke including difficulties walking, speaking, and understanding, as well as numbness of the face, arm, or leg. When it comes to treating subacute stroke in an inpatient rehabilitation setting, Dr. Crissy Voigtmann (Doctor of Physical Therapy and board-certified Neurological Clinical Specialist), Dr. CJ Curran (Doctor of Physical Therapy, certified brain injury specialist and board-certified Neurological Clinical Specialist), and Jose Dominguez (Director of Rehabilitation, Orlando Health) give professional insight on EksoNR, the first FDA-cleared exoskeleton for stroke and spinal cord injury, and the only FDA-cleared exoskeleton for acquired brain injury.

Orlando Health ORMC Institute for Advanced Rehabilitation (IAR) is a CARF accredited inpatient and outpatient rehab unit partnered with Ekso Bionics since 2019. Currently, they have four Level-Two trained therapists at the inpatient rehabilitation, and two Level-Two trained therapists at their outpatient rehabilitation.

What is EksoNR?

Currently, EksoNR is the only exoskeleton that is FDA-cleared for acquired brain injury. It is the first FDA-cleared exoskeleton and extremely adaptive with short-term implications as well as long-term ones. The device is capable of progressing through programming as a stroke patient progresses in recovery. This gives the long-term capability to adapt from session to session, not only for patients with strokes but spinal cord injuries or TBI.

Who can benefit from EksoNR?

In 2020, IFR had 310 stroke patients arrive at the unit. On average, they had a 1.58 acuity level, based on a case-mix index equation that determines the acuity level for inpatient rehab. Typically a stroke patient stayed at the unit for 15.7 days. In order to determine mobility scores upon admission, Crissy and CJ used Care (formerly known as FIM), which is a standardized test that all inpatient rehabilitation facilities have to use for all diagnoses. 

Additional Care scores from the facility include:

• Average Care Score: 2.9 (Max Assist)
• Average Walking Score (per 50ft): 2.2 (Max Assist)
• Average Walking Score (per 150ft): 1.7 (Total Assist)
• Average Stair Score: 1.2 (Total Assist)

At IAR, these scores were what the average numbers looked like for all stroke patients and are important to know to where those who used Ekso started from at baseline. 

[The following is condensed from the full webinar of Dr. Crissy Voigtmann and Dr. CJ Curran.]

What were the deciding factors in having Ekso a part of the program at Orlando Health?

As Dr. Crissy Voigtmann and Dr. CJ Curran were in the decision-making process of having Ekso become a part of their program, they were asking themselves: “Are we doing enough? Are we providing these patients with enough repetitions at a high enough intensity level to elicit the neural change that needs to happen during this short length of stay that we have?”

In general, the answer to the questions they asked was no. They ultimately decided there was not an exact dosage that has been established for intensity or for repetition, but there was a growing body of evidence that demonstrates for gait in particular; that stepping practice needs to be in the thousands a day for optimal improvement.

Observational studies have shown that in inpatient rehab facilities (places that have stroke programs), stroke patients are taking an average of 250 steps a day. To further reinforce that point, these same studies have shown that stroke patients on average spend greater than 50% of the day in bed and greater than 60% of their time alone. 

Not only were they not utilizing the active time with these folks to provide high-intensity therapy that is necessary for neural training, but even during the passive time, they realized they were not providing the necessary environment, whether it be with engagement or stimulation that is necessary for improvement as well. 

They determined the best solution was integrating Ekso into their program. This was the bridge. This bridged the gap between that dilemma and that solution. For them, Ekso allowed them to accomplish those goals on day one and early, especially for their folks who are significantly impaired, the ones with a lot of deficits. These were folks, in their experience, that are really difficult to gait train. These are the people that unfortunately tend to fall through the cracks and would get low level therapy or low intensity therapy otherwise.

How has Ekso changed training for the patients?

Because of Ekso, they were able to get individuals up early and on their feet for extended periods of time, participating in high-intensity therapy from the very beginning. There are certain positions that would take two or three therapists, or three pairs of hands, to get a patient to accomplish. But one therapist is able to do it whilst focusing on other deficits as well, thanks to Ekso.

Who are the candidates for Ekso?

The stroke patients primarily receiving early Ekso intervention:

• Dense Hemiparesis: 0-⅖ MMT throughout affected lower extremity
• Pusher Syndrome
• Significant Postural Control and Awareness deficits
• Motor planning and Sequencing deficits

Other patient specific factors leading to early Ekso utilization:

• Obesity/Height (under 220lbs, under 6’5” approximately) 
• Impulsivity
• Cognitive deficits 

The overall message is these patients are individuals who are very difficult to manually facilitate. They are very difficult to provide the manual techniques that are necessary to hit high repetitions or to hit high intensity levels. As a result, they are going into the exoskeleton. 

Stay Tuned For More Blogs About EksoNR or  Click Here to View The Webinar in Full 

[The following is condensed from the full webinar of Dr. Crissy Voigtmann and Dr. CJ Curran.]

The Institute For Advanced Rehabilitation (IFR, Orlando Health) is a CARF accredited inpatient and outpatient rehab unit partnered with Ekso Bionics in 2019. With the utilization of EksoNR (the first FDA cleared exoskeleton) in the rehabilitation of patients, they were able to narrow down the typical patient profile and measure their progression via outcomes from using EksoNR.

Average Stroke Patient Statistics 

The following data represents the “average” scoring of all of their 310 stroke patients. It is provided so that anyone may look over and compare this data with those they tended to put into the exoskeleton. When patients are referred to as going into the exoskeleton, please note that it means at the exoskeleton’s maximum assistance level.

Now, their outcome measures. The postural assessment scale for stroke (PASS) is a stroke specific outcome measure that is determined by movement of the patient: they’re sitting, they’re rolling in bed, they’re standing, and then picking up something off the floor, as well as single limb stance. Typically that score is out of 36. Their average PASS score on admission for all patients with stroke was a 20.7, which indicates significant deficit. 12.4 is the average PASS score for their stroke patients going into Ekso, so they are even more impaired than the average patient they saw on the floor. 

The Berg is out of 56 with the benchmark being 45; you can see the patients come in a lot lower level than that at 16.6. The Berg for the exoskeleton candidates is 4.9, meaning they can sit and maybe be transferred by one person – that’s generally a five out of 56 on the Berg. Some patients who get into the exoskeleton can sit independently and some cannot; again, as you can see reflected in the data, their gait is almost not a gait. It is very, very slow, 0.04 meters per second, if they are even ambulatory.

Average Care Score for Mobility on Admission for all CVA:

Transfers: 2.9

Gait: 2.2 for 50 feet and 1.7 for 150 feet

Stairs: 1.2

Average Outcome Measure Performance on day of evaluation for all CVA

PASS: 20.7

BBS: 16.6

10 MWT: 0.24 m/s Self Selected Speed and .33 m/s Fast Speed

Average Care Score for mobility on admission for patients using ekso:

Transfers: Total (1)

Gait: Total (1) for all ambulation

Stairs: Total (1)

Average Outcome Measure Performance on day of evaluation for patients using Ekso

PASS: 12.4

BBS: 4.9

10 MWT: 0.04 m/s Self Selected Speed and 0.04 m/s Fast Speed

How often is the exoskeleton used on the floor?

Generally, given that their length of stay is about 15 days, they were (on average) getting people into the exoskeleton four times during their stay.  However, that really depends on the type of patient and their situation. They have had people in as many as 12 times during their stay.

The average number of total steps taken per patient during their stay is 1,354 with an up and walking total of at least 11 minutes per session, but the average uptime is more than half the session. That means more than half of the session is where the patient is actually standing and in a weight bearing position. They may be working on pre-gait activities. They may be working on just standing tolerance and co-treating with OT or speech. So they do utilize it longer than that 11 minutes, but that’s active walking time.

What were the deciding factors in having Ekso a part of the program at Orlando Health?

As Dr. Crissy Voigtmann and Dr. CJ Curran were in the decision-making process of having Ekso become a part of their program, they were asking themselves: “Are we doing enough? Are we providing these patients with enough repetitions at a high enough intensity level to elicit the neural change that needs to happen during this short length of stay that we have?”

In general, the answer to the questions they asked was no. They ultimately decided there was not an exact dosage that has been established for intensity or for repetition, but there was a growing body of evidence that demonstrates for gait in particular; that stepping practice needs to be in the thousands a day for optimal improvement.

Observational studies have shown that in inpatient rehab facilities (places that have stroke programs), stroke patients are taking an average of 250 steps a day. To further reinforce that point, these same studies have shown that stroke patients on average spend greater than 50% of the day in bed and greater than 60% of their time alone. 

Not only were they not utilizing the active time with these folks to provide high-intensity therapy that is necessary for neural training, but even during the passive time, they realized they were not providing the necessary environment, whether it be with engagement or stimulation that is necessary for improvement as well. 

They determined the best solution was integrating Ekso into their program. This was the bridge. This bridged the gap between that dilemma and that solution. For them, Ekso allowed them to accomplish those goals on day one and early, especially for their folks who are significantly impaired, the ones with a lot of deficits. These were folks, in their experience, that are really difficult to gait train. These are the people that unfortunately tend to fall through the cracks and would get low level therapy or low intensity therapy otherwise.

A Case Study with EksoNR

Almost 60% of the patients are stroke patients. They found that the EksoNR does such a good job, that typically they’re ambulatory at the end of their rehabilitation, and they move on to their outpatient clinic. An incomplete spinal cord would be their second highest diagnosis in terms of volume. 

Take into consideration the progress of one of their patients, Sarah. She is a 62 year old female. She had multiple ischemic strokes in her right hemisphere. She also presented with pusher syndrome. With pusher syndrome, the difficulties that arise in therapy are because of misunderstanding of midline orientation: they are persistently laterally leaning, and/or they’re pushing themselves over onto their weak side. This is very challenging to treat because they are going towards a limb that is hemiperetic and does not support their body. Just getting that patient to take a step is difficult because their weight shifting is so impaired.

Sarah is also a tall and large woman, which makes it even harder for a therapist to facilitate gait. She had left neglect. Her admission was very early after her stroke, just five days post-stroke, so all of the therapy was new for her. In addition to her challenges, she was also a braille user.

Her admitting outcome measure scores PASSwas a 12 out of 36, and she was non-ambulatory, requiring maximal assistance for her bed mobility and her transfers, while being dependent for gait. They were able to get her in the Ekso three times. She didn’t take a ton of steps. They were a little bit limited in her length of stay and her time, but these steps were very effective and these sessions were very effective. They allowed the exoskeleton to facilitate those steps. When they put on the Ekso, it was just one therapist and the tech or an aide. They were able to spend more time standing doing pre-gait. The clinicians were treating that pusher syndrome by having her shift her weight onto her limb more. They recall that was a significant moment for this patient.

The data for her outcome scores are below so that you can compare her admission to her discharge:

Admission:

BBS: 5/56

PASS: 12/36

10 MTW: 0m/s

Max A bed mobility and transfers; dependent for gait

Discharge:

BBS: 17/56

PASS: 29/36

10 MTW: SS 0.15m/s; FP 0.15m/s

SBA Bed Mobility, SBA for 10 feet of gait and transfers, Min A gait >150 feet and 4 stairs

Crissy Voigtmann received her Doctor of Physical Therapy from the University of St. Augustine in 2014. She’s a board certified neurologic clinical specialist. She works as a full-time clinician serving patients with brain injury, stroke, neuro oncology, and incomplete spinal cord injury, and spearheads program development for locomotor training for all neurologic patients in the inpatient rehab setting at Orlando Health’s Institute for Advanced Rehabilitation.

What were the first steps toward introducing EksoNR in a rehab program?

When the doctors at Orlando Health first got the exoskeleton, they were collaborating and came up with this idea of having a lead locomotor person.  Dr. Voigtmann became the lead person just to help bridge the gap between their non-Ekso therapists on the floor, with either pairing them with an Ekso therapist or with Dr. Voigtmann herself. They were afforded that ability just by creating the role of lead locomotor therapist at the clinic.

The other first step was a designated area off to the side of the gym, so that the exoskeleton has everything there that it needs.  There you will find all evaluation forms and data collection sheets and the measuring tools. Everything is in one spot, so that if someone thinks, “This is a great patient for Ekso. I want to do quick measurements,” the opportunity is available to them. They get that patient on the mat, take the measurements, and that allows them the opportunity to get the patient into the Ekso the next session if the current session is unavailable. They have found that it is a nice way to keep everything in one place.

How do you refer patients to EksoNR?

They tried to come up with a referral system. For example, their unit has nine teams, so nine teams of PT/OT and they only have four Ekso-trained therapists. What do they do with the other teams? They paired up with an Ekso clinician in order to have the opportunity to propose, “Can we switch this patient off? You see one of mine and I’ll see one of yours.” With this method, they could optimize the number of patients getting into the exoskeleton and get the benefits of early gait training.

What else has helped EksoNR be successful in inpatient rehab?

At IFR, they have been very fortunate to have really engaged rehab aides in their unit. They went through training sessions with them on how to do wrenching techniques, how to size the Ekso, how to clean it, and even sometimes how to write down some of the data on a data collection sheet for them if time is critical.

They have been essential in the setup, the breakdown, and taking all of the information. They’re also really skilled at using the Ekso controller so that they don’t have to pull in too many more people. Essentially, there would be a physical therapist who is Ekso-certified and then a tech for each session. That really helps to make it effective; cost efficient for the company, and also time efficient.

Stay Tuned For More Blogs About EksoNR or  Click Here to View The Webinar in Full 

Who are the candidates for Ekso?

The stroke patients primarily receiving early Ekso intervention:

• Dense Hemiparesis: 0-⅖ MMT throughout affected lower extremity
• Pusher Syndrome
• Significant Postural Control and Awareness deficits
• Motor planning and Sequencing deficits

Other patient specific factors leading to early Ekso utilization:

• Obesity/Height (under 220lbs, under 6’5” approximately) 
• Impulsivity
• Cognitive deficits 

The overall message is these patients are individuals who are very difficult to manually facilitate. They are very difficult to provide the manual techniques that are necessary to hit high repetitions or to hit high intensity levels. As a result, they are going into the exoskeleton. 

Stay Tuned For More Blogs About EksoNR or  Click Here to View The Webinar in Full 

[The following is condensed from the full webinar of Dr. Crissy Voigtmann and Dr. CJ Curran.]

While EksoNR (the first FDA-cleared exoskeleton for ABI, stroke and spinal cord injury) is a technological advancement that has changed the way patients with stroke experience rehabilitation, it is not without its own difficulties. The Institute For Advanced Rehabilitation (IFR, Orlando Health), has been partnered with Ekso Bionics since 2019. Dr. Crissy Voigtmann and Dr. CJ Curran utilized EksoNR with certain patients and found some difficulties that they were not at first prepared for.

The Generation Gap

With stroke comes increased age. Typically speaking, some of the older individuals are not as comfortable with technology. It becomes very apparent once they get into EksoNR and they’re fearful. Their anxiety can become a pretty significant barrier to try to get them acclimated to this level of technology. Not only that, but also from a deficit standpoint, individuals that have attention deficits or engagement deficits just want to go along for the ride once they are in the suit, and it can be really tough to get them to actively engage in the process of their rehabilitation.

The patients are motivated, they want to do it, but as they tried to convey what the suit is capable of or what the progression looks like, some of the patients really struggle to grasp what that next step is or what that progression will be.

Another element that caught them off guard initially was incontinence. A lot of patients have not been up against gravity for an extended period of time in a while. That has been something that they have prepared for now, and especially in advance, before they even start the session(s).

How do you fix the challenges that patients face with EksoNR?

Luckily most of the issues faced are solved through individualized education, demonstration of the device, or even allowing the patients to observe other stroke patients get into the device and complete a gait training session. 

They have also implemented slow gradual exposure. Sometimes that looks like doing the evaluation, they get them up, and all they do for that session is weight shifting. It might not have been what the clinicians had planned that day, but it got then the buy-in they needed so that they could do a full gait training session the next day.

 As an inpatient rehab unit, they are very fortunate to work as an interdisciplinary team. Sometimes the solution has been doing co-treats with occupational therapy or with speech therapy, or even neuro-psychology depending on what the root causes for the difficulty of the patient to engage with the device and complete the session that they needed them to.

What are the most difficult barriers to overcome?

The patient specific barriers are the most obvious, but they have found that it’s sometimes the environmental or the clinical barriers that are the most difficult to overcome. Some environmental and clinical barriers can be as concrete or as tangible as spatial limitation, but they can also be as difficult to solve for a variety of different reasons such as scheduling issues or time constraints.

Stay Tuned For More Blogs About EksoNR or Click Here to View The Webinar in Full