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Physical therapy has evolved so much over the last century. From the early 1900s, when it was used to treat injured soldiers, to today, where there is a myriad of emerging rehabilitation technologies. Exoskeleton rehabilitation in physical therapy is a rapidly evolving field that offers hope for people with disabilities or injuries who are seeking to regain mobility and independence. Exoskeletons augment or enhance the physical capabilities of the user and have the potential to transform the way we approach rehabilitation. But, how effective are exoskeletons in helping people recover from injuries or disabilities? In this article, we will explore the current state of research on exoskeleton rehabilitation in physical therapy and consider the potential benefits.

What is An Exoskeleton, and How do Exoskeletons Work?

An exoskeleton is a wearable technology that is designed to augment or enhance the physical capabilities of the user. It is typically a metallic/carbon suit that is worn on the outside of the body and provides additional support or strength to the wearer.

Exoskeletons were first developed by General Electric in the 1960s, with funding from the United States Department of Defense, as a way to enable humans to lift heavy objects. [1] In the 1980s, scientists began to explore the use of exoskeletons for military purposes, giving soldiers additional protection and abilities during warfare. [2] Today, exoskeletons are being used in rehabilitation to help people recovering from injuries to stand and walk. [3] They are also being used in other industries like agriculture, construction, and manufacturing to help with repetitive manual tasks and reduce fatigue and pain in the back, neck, and shoulders. [4]

Exoskeletons typically consist of a series of interconnected joints and motors that are powered by a battery or other power source. They may also include sensors and control systems that enable the user to control the exoskeleton and adjust its movements. Some exoskeletons also include features such as haptic feedback, which can provide the user with tactile sensations to enhance their sense of touch and proprioception.

There are several different types of exoskeletons, each designed for specific purposes and applications. Lower limb exoskeletons are designed to be worn on the legs and are used to assist with walking or to provide additional support and stability for people who have difficulty standing or walking on their own. Upper limb exoskeletons are designed to be worn on the arms and are used to assist with lifting or other upper body tasks.

Exoskeletons are categorized into the type of power source they use. Some exoskeletons are powered by electricity, either from a battery or from an external power source. Others are powered by hydraulics, using pressurized fluid to move the joints and motors. There are also exoskeletons that utilize other types of power sources, such as pneumatic or mechanical systems.

1. Active Exoskeletons

An active exoskeleton is a type of exoskeleton that requires the user to provide some form of input or control in order to operate. Active exoskeletons typically use actuators to convert hydraulic, electrical, and air energy into mechanical energy that is used in movement. They also use sensors and control systems to enable the user to control the exoskeleton’s movements. Active exoskeletons may also include feedback systems, such as haptic feedback, to provide the user with information about the exoskeleton’s movements or the environment.

2. Passive Exoskeletons

Passive exoskeletons, on the other hand, do not require the user to provide any input or control in order to operate. They normally use springs and dampers to store energy generated during movement, which is then reused during motion. Passive exoskeletons are designed to provide support and assistance to the user automatically, without requiring any specific actions from the user. Passive exoskeletons may be used to provide additional stability and support to the user.

Both active and passive exoskeletons have their own advantages and disadvantages, and the choice between them depends on the specific application and the needs of the user. Active exoskeletons tend to be more complex and expensive than passive exoskeletons, but they offer more precise and flexible control for the user. Passive exoskeletons are simpler and cheaper, but they offer less control and may not be as effective in some applications.

Use of Medical Exoskeletons in Healthcare

Medical exoskeletons are designed for use in rehabilitation settings and are designed to help people with lower extremity weakness regain mobility and independence. They work by providing support and assistance to the user’s muscles and joints, allowing them to perform movements that they may not be able to do on their own. They may be used to help people with spinal cord injuries, stroke, or other neurological conditions to walk again. At Ekso Bionics, we primarily design medical exoskeletons that help patients recovering from brain injuries, spinal cord injuries, stroke, and Multiple Sclerosis walk again.

Medical exoskeletons may be used in a variety of settings, including hospitals, rehabilitation centers, and the user’s home. They may be used in conjunction with other physical and occupational therapy strategies to help patients regain their strength and mobility.

There is a growing body of research showing the effectiveness of exoskeletons in medical rehabilitation. Studies show that exoskeletons can improve walking speed, balance, and endurance in patients recovering from different conditions.

Effectiveness of Medical Exoskeletons

1. Enables Ambulation

Patients recovering from injuries normally have a hard time walking without assistance. They typically need help from their physical therapist and assistive devices to move around. But with the use of exoskeletons, they can walk for longer periods of time to strengthen their muscles. In a 2021 study investigating the effect of robotic exoskeletons on ambulation, researchers reported that patients who trained using exoskeletons in addition to a conventional standard care treatment walked twice the distance (more number of steps) as patients who only received the standard care treatment. [5]

In a randomized control trial studying the effect of exoskeletons on non-ambulatory patients, researchers reported that patients who trained using an exoskeleton walked more steps than those who received usual care. “The Ekso group walked an average of 592 steps per session while the usual care group walked 330 steps.” [6]

2. Improves Gait

Gait rehabilitation is one of the main focuses in physical therapy, and exoskeletons have demonstrated a lot of potential in improving gait. In a 2020 study investigating gait changes after exoskeleton training, researchers concluded that functional and neuromechanical improvements were achieved after four weeks of gait training. It goes on to say that “there could be potential long-term effects of improved loading and unloading, increased step length, and increased speed due to RE gait training.” [7]

3. Improves Balance

Balance is an important consideration in rehabilitation as balance deficiencies hugely limit activities of daily living. While there aren’t a lot of studies in this area, the few studies that have been conducted show a positive correlation with the use of exoskeletons in balance training. In a 2019 study investigating the effects of an Ekso Bionics exoskeleton on balance, researchers reported that exoskeleton rehabilitation showed a significant impact on balance in patients recovering from a stroke. [8] In a recent 2021 study, researchers reported that exoskeletons improved balance in patients affected by Multiple Sclerosis. [9]

4. Reduces Hospital Costs

Using exoskeletons in your rehabilitation center might help you manage your running costs. Following a budget impact analysis of exoskeletons, research shows that exoskeletons reduce locomotor training costs by $1,114 to $4,784 per year when used in 10% of annual locomotor training sessions. [10] These savings could be diverted to other departments or recouped back into the profits of the clinic.

5. Improves Quality of Life

Exoskeletons can lead to an increased quality of life for patients recovering from different injuries. This was demonstrated in a 2022 study that investigated the effect of exoskeleton training on the quality of life after two months. The researchers of this study reported that the training helped with pain, bladder management, and increased quality of life. [11] The use of exoskeletons also results in psychological benefits as patients can engage with each other at eye-level contact. [12]

6. Helps Attain Required Therapy Hours

In the US, patients in acute rehabilitation are required to get at least three hours of therapy five days every week. However, this is becoming increasingly difficult to meet due to the reduced availability of rehabilitation services. The pressure on the system is too much, but exoskeletons can help with this dilemma. Pam Lanter, PT, DPT, NCS, Manager of Rehabilitation Services at UH St. John says, “In just one session with the [exoskeleton], we’re able to accomplish what may have taken 5-10 sessions without it.” [13]

7. Reduces the Burden of Therapy on Therapists

Exoskeletons are also useful for physical therapists too. They help reduce the risk of workplace injuries and exhaustion. This results in better service delivery since you can take care of patients without fatigue. This assertion was confirmed in a 2021 study investigating the efficacy of exoskeleton rehabilitation for spinal cord rehabilitation. [14]

8. Improves Emotional Well-Being

Apart from physiological benefits, exoskeletons are also linked to psychological benefits. When Alex, who is recovering from a spinal cord injury he got while tobogganing, was asked about his exoskeleton rehabilitation sessions, he said, “It was amazing to be walking again. It really did a lot for my mental and emotional well-being, not to mention the huge health benefit of being vertical. I remember the first time standing up. This gave me something fun and exciting to look forward to every week in a time when I was dealing with a great deal of loss.” [15] Exoskeletons can give patients hope for the future and also increase their engagement and participation in rehabilitation. [16]

9. Helps Reduce Injury-Related Complications

Patients can develop secondary complications from their injuries due to prolonged sitting. Because of their decreased ability to walk, patients are at risk of developing osteoporosis, bone fractures, pressure sores, and blood clots. Medical exoskeletons benefit these patients by enabling them to stand and move their legs when they otherwise could not, helping to decrease these risks. Dr. Chester Ho, associate professor in the University of Calgary Department of Clinical Neurosciences and member of the Hotchkiss Brain Institute says, “exoskeletons may potentially promote recovery and reduce complications in spinal cord injury (SCI) patients by reducing loss of bone and muscle mass caused by spending so much time lying down, and also improve breathing and bowel function.” [15]

Conclusion

Exoskeletons are still a relatively new technology, and more research is needed to fully understand their potential and to determine the best ways to use them in rehabilitation settings. However, their benefits are undeniable. If you are looking for great exoskeletons for your clinic, feel free to check out our FDA-approved EksoNR.

We combine clinical and engineering expertise to create innovative robotics for rehabilitation centers. Our exoskeletons can be used in therapy by patients who are recovering from stroke, brain injury, spinal cord injury, or Multiple Sclerosis to regain the ability to walk. Contact us today to learn more about our products.

References:

1. Exoskeletons and robotic prosthetics: a review of recent developments | Emerald Insight https://www.emerald.com/insight/content/doi/10.1108/01439910910980141/full/html
2. LIFESUIT Exoskeleton Gives the Gift of Walking so They Shall Walk | IEEE Conference Publication | IEEE Xplore https://ieeexplore.ieee.org/document/6970309
3. WHEN WERE ACTIVE EXOSKELETONS ACTUALLY BORN? | International Journal of Humanoid Robotics https://www.worldscientific.com/doi/abs/10.1142/S0219843607001163
4. Exoskeletons – a review of industrial applications | Emerald Insight https://www.emerald.com/insight/content/doi/10.1108/IR-05-2018-0109/full/html
5. Robotic Exoskeleton Gait Training During Acute Stroke Inpatient Rehabilitation – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661791/
6. Efficacy of an exoskeleton-based physical therapy program for non-ambulatory patients during subacute stroke rehabilitation: a randomized controlled trial https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-021-00942-z
7. Kinetic Gait Changes after Robotic Exoskeleton Training in Adolescents and Young Adults with Acquired Brain Injury – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7641681/
8. Effects of Exoskeleton Gait Training on Balance, Load Distribution, and Functional Status in Stroke: A Randomized Controlled Trial https://pubmed.ncbi.nlm.nih.gov/32010039/
9. Can powered exoskeletons improve gait and balance in multiple sclerosis? A retrospective study https://pubmed.ncbi.nlm.nih.gov/33534272/
10. Budget impact analysis of robotic exoskeleton use for locomotor training following spinal cord injury in four SCI Model Systems | Journal of NeuroEngineering and Rehabilitation https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-019-0639-0
11. Full article: Improvement of quality of life after 2-month exoskeleton training in patients with chronic spinal cord injury https://www.tandfonline.com/doi/full/10.1080/10790268.2022.2052502
12. Users with spinal cord injury experience of robotic Locomotor exoskeletons: a qualitative study of the benefits, limitations, and recommendations – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488437/
13. Exoskeleton Enables and Enhances Movement in Physical Therapy Patients | University Hospitals https://www.uhhospitals.org/for-clinicians/articles-and-news/articles/2020/11/exoskeleton-enables-and-enhances-movement-in-physical-therapy-patients
14. Evaluating the Utilization and Efficiency of Wearable Exoskeletons for Spinal Cord Injury Rehabilitation | Shirley Ryan AbilityLab https://www.sralab.org/research/labs/cror/projects/evaluating-utilization-and-efficiency-wearable-exoskeletons-spinal-cord-injury-rehabilitation
15. Spinal cord injury patients may benefit from using exoskeleton earlier in treatment | News | University of Calgary https://ucalgary.ca/news/spinal-cord-injury-patients-may-benefit-using-exoskeleton-earlier-treatment
16. Efficacy of Overground Robotic Gait Training on Balance in Stroke Survivors: A Systematic Review and Meta-Analysis – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9221355/

It is impossible to ignore the number of people affected by spinal cord and brain injuries and the need for new rehabilitation solutions. Each year more than seventeen thousand people in America are affected by spinal cord injuries, and about 1.5 million are affected by brain injuries. [1] As a result, 1 in 50 people in America, or nearly 5.4 million individuals, live with paralysis. [2]

Medical exoskeletons have been making waves in the healthcare industry, offering new hope for individuals with spinal cord and brain injuries. This industry has grown significantly in recent years, reaching a size of approximately $480 million in 2019, and is projected to reach $11.4 billion by 2027. [3] These wearable devices provide support to the body and can help patients regain mobility and independence. In this article, we delve into the impact of medical exoskeletons on both patients and physical therapists, exploring the ways in which these devices are revolutionizing rehabilitation and changing the lives of those affected by debilitating injuries.

What are Exoskeletons?

An exoskeleton is a wearable device that is designed to augment the strength and mobility of the human body. It is typically worn on the outside of the body and consists of a series of rigid frames or shells that are attached to the body using straps or other types of support. Some exoskeletons are powered by motors or hydraulics, while others rely on the user’s muscles to move.

Exoskeletons can be classified into two main categories: passive and active. Passive exoskeletons do not have any power source of their own and rely on the user’s muscle power to move. Active exoskeletons, on the other hand, have a power source and can assist or augment the user’s movements.

Exoskeletons are used in a variety of applications, including medical rehabilitation. Medical exoskeletons are designed to assist individuals with mobility impairments, such as spinal cord injuries or other brain injuries, to walk again. There are several different types of medical exoskeletons available, each of which works in a slightly different way. Some common features of medical exoskeletons include:

• Sensors: Many medical exoskeletons have sensors that detect the user’s movements and adjust the device accordingly. For example, sensors may be used to detect when the user is attempting to take a step and provide additional support and power to the leg muscles.
• Motors or hydraulics: Some medical exoskeletons have motors or hydraulics that provide additional power and support to the user’s muscles.
• Control systems: Most medical exoskeletons have a control system that allows the user to operate the device. This may be a handheld controller or a computer interface that the user can use to adjust the device’s settings and control its movements.
• Support structures: Medical exoskeletons often have support structures, such as frames or shells, that are attached to the body using straps or other types of support. These structures help to distribute the weight of the device and provide additional support to the user.

Overall, medical exoskeletons work by detecting the user’s movements and providing additional support and power to the muscles as needed. This can help individuals with mobility impairments walk again or perform tasks that may otherwise be difficult or impossible.

Types of Medical Exoskeletons

There are several different types of medical exoskeletons available, each of which is designed for a specific type of injury or application. [4] Some common types of medical exoskeletons include:

• Lower limb exoskeletons: These devices are designed to assist with walking and are typically worn on the legs and feet. They may have sensors that detect the user’s movements and provide additional power and support to the leg muscles as needed.
• Upper limb exoskeletons: These devices are designed to assist with upper body movements and are typically worn on the arms and shoulders. They may have sensors that detect the user’s movements and provide additional power and support to the arm muscles to help the user lift or carry objects.
• Hybrid exoskeletons: These devices combine features of both lower limb and upper limb exoskeletons, providing support for both the legs and arms. They may be used to assist with walking and upper body movements.

Medical exoskeletons are typically used in rehabilitation settings, such as hospitals or physical therapy clinics. Physical therapists may work with patients to adjust the settings on the exoskeleton and guide patients through exercises and activities to help them regain strength and mobility.

In addition to assisting with mobility, medical exoskeletons may also have other benefits for patients. For example, they may help to improve muscle strength, reduce spasticity, and prevent pressure sores. They may also have psychological benefits, such as increasing the patient’s confidence and independence.

Impact of Exoskeletons on Patients

1. Improves Muscle Strength and Spasticity:

Patients who are recovering from brain injuries including strokes usually tend to have reduced muscle strength in their legs. They are also likely to experience muscle stiffness and pain as a result of damage to specific areas of the brain. This is a common occurrence because leg muscles atrophy as a result of lack of use.

Physical therapy can help in this case, and in a 2021 study, research showed that exoskeletons could improve grip strength, quadriceps strength, and lower limb motor function. [5] Another 2019 study showed that exoskeletons significantly improved muscle strength and reduced spasticity. [6] In a 2020 study investigating the impact of a lower limb exoskeleton robot on the muscle strength of tibialis anterior muscle in stroke patients, researchers concluded that exoskeletons have the potential to improve muscle strength and lower limb motor function. [7]

2. Improves Gait:

Gait training is a physical therapy technique that involves practicing walking patterns with the aim of improving mobility. It is often used to help people who have difficulty walking due to neurological conditions, such as stroke or cerebral palsy, or due to injuries or surgeries that have affected their ability to walk.

According to research, exoskeletons are effective in gait training as they are calibrated to help the wearer achieve natural gait. They also offer more gait repetitions compared to traditional rehabilitation methods. According to one study, “By the end of the training, the gait pattern of the patients improved and came closer to a healthy subject’s gait pattern.” [8]

Exoskeletons like EksoNR have built-in features that help regulate and observe leg movement to promote gait development and help patients balance, squat, weight shift, and even step in place before walking.

3. Improves Quality of Life:

Beyond the physical benefits of exoskeletons, they also have the ability to enhance the patient’s life. It helps them to do things that they were not able to do before. For instance, it helps patients (even those with severe injuries) to exercise in an upright position. [5]

In some cases, it also gives patients the ability to walk. Physical therapist Kyle McIntosh says, “The exoskeleton lets patients take actual steps, which is not only more realistic but much less cumbersome,” McIntosh also says, “Every step is different with this device, so patients learn from their mistakes in real time. Patients really like to use the device; it gives them hope.” [9]

4. Helps with Bladder and Bowel Function:

Exoskeletons come with other associated benefits, like improved bowel function. Researchers propose that the upright postures and physical activities that patients engage in while in exoskeletons play an important role in bowel motility. [10] In a 2019 study, researchers concluded that “patients who gained the ability to stand and walk with an exoskeleton often developed better endurance, improved their bowel and bladder control, and were less likely to develop urinary tract infections.” [11]

5. Boosts Patient Moods:

According to patient feedback, exoskeletons offer hope and motivate patients to participate in their recovery journey. According to a 2021 study, patients’ moods were reported to have improved during the rehabilitation phase. There was also a decrease in fatigue and an improved quality of life. [5]

Other patients also cherish the ability to have eye-to-eye conversations with other people while wearing the exoskeletons. Additionally, since exoskeletons are a “new” invention, more patients are excited to try them out, which increases engagement levels. [11]

Patient Success Stories as a Result of Exoskeleton Rehabilitation

1. Megan’s Story

Megan’s life took a turn in December 2015 when she had a stroke in her spinal cord. In 2016, she underwent a resectioning procedure, after which she was diagnosed with a T-12- incomplete spinal cord injury (iSCI). After her injury, Megan relied on a wheelchair to move around, but with hard work and physical therapy, she moved from a wheelchair to a wheeled walker to a cane and ankle foot orthoses (AFO). This was a huge win because her doctors had told her she would always depend on a wheelchair for movement.

Megan was still unsatisfied with her progress; in 2017, she learned about Ekso Bionics. While looking for rehabilitation help, she came across a study that wanted to compare Ekso rehab with traditional rehab for patients with incomplete spinal cord injuries. Megan signed up for the study and started participating in the trial in 2018. She was using Ekso for three days per week for 12 weeks, and by the twentieth session, Megan was walking without any assistance. And by the thirty-six session, she had achieved her recovery goal: golfing.

Interestingly, Megan still can’t feel her legs from the waist down, but from the Ekso training sessions, she has built up her leg muscles that keep her walking unassisted. Read Megan’s detailed exoskeleton rehabilitation recovery story.

2. Kylie’s Story

In 2019, Kylie was in a coma. She had suffered an acquired brain injury plus multiple internal injuries. Once she regained consciousness, she began physical therapy, where she was able to attain incredible levels of self-initiated movement while using the EksoNR.

Her physical therapist, Erin, shared, “In the first session, we took maybe ten steps. And now she’s walking over 1,200 steps.” This recovery journey is considered massive for patients who are recovering from ABI. Read Kylie’s full recovery story.

3. Kathy’s Story

Kathy was diagnosed with Multiple Sclerosis more than 20 years ago, and her symptoms have worsened over time. She got a chance to participate in a research study assessing the effectiveness of the EksoGT exoskeleton in MS rehabilitation, and when interviewed, she said, “My walking speed has increased, my endurance has improved, my gait is more normal and I get intermittent periods of my leg getting signals from my brain.” Read more about Kathy’s exoskeleton rehabilitation story and the research study.

Impact of Exoskeletons on Physical Therapists

1. Reduces Physical Burden on Physical Therapists

Traditional physical rehabilitation methods are labor-intensive and require a hands-on approach from therapists. This exposes them to work injuries and exhaustion. In a traditional setting, a patient may require two or three physical therapists to manually guide their limbs which can be unsafe. [12] Exoskeletons reduce the number of therapists needed to attend to a patient and minimizes exposure to injuries. This can help physical therapists offer better care to patients without being limited by fatigue.

2. Reduces Hospital Costs

Exoskeletons can help physical therapists reduce clinical costs. According to a 2020 budget impact analysis of exoskeletons, exoskeletons reduced locomotor training costs by between $1,114 and $4,784 per year when used in 10% of annual locomotor training sessions. [13] This is a considerable amount of money when you consider the long-term implications.

What Other Physical Therapists Think About Exoskeleton Use

1. “We’re finding that patients are progressing far beyond what we’ve ever been able to get them to because we have this means to get people up earlier.” – Dr. Christina Kwasnica, MD, Medical Director, Barrow Neurological Institute.

2. “From my own experience, either therapists are physically carrying these patients across the gym at great expense to their own bodies, or they’re just not able to mobilize these patients; so many of our patients are very weak, and therapists absorb much because of the burden. The therapists I work with are now able to do so much more using Ekso.” – Dr. Craig DiTommaso, MD, FAAPMR Medical Director, Kindred Rehabilitation Hospital Northeast Houston.

3. “Ekso, if qualified, is a more efficient intervention than the body-weight supported treadmill that we do for ABI patients. In terms of logistical manpower, the control of the quality of the gait pattern and repetition for motor learning. I do think that Ekso is a good intervention for early mobilization, tapping into neuroplasticity expediently and more successfully. – Edward Cruz, PT, DPT, Physical Therapist, University of Texas Southwestern Medical Center.

4. “We went from taking 20 steps with three physical therapists to taking hundreds of steps in a session with one.” – Diane Patzer, DPT Physical Therapist, Rehabilitation Institute Of Michigan.

5. “We were able to see immediate impact on the patient’s ability to perform bed mobility, transfers, and independence with all functional activities after one session with the device. This device has greatly improved our patient’s outcomes while decreasing physical assistance required by staff members.”- Duncan Monger. PT, DPT, CBIS, Regional One Health Inpatient Rehabilitation Hospital

Conclusion

In conclusion, medical exoskeletons have a positive impact on both patients and physical therapists. For patients, these devices provide support and assistance with mobility, allowing them to perform daily activities with greater ease and independence. For physical therapists, exoskeletons serve as useful tools for rehabilitation and training while lowering costs. More research is needed to fully understand the long-term effects of using medical exoskeletons. However, the bottom line remains that exoskeletons will continue improving and becoming a bigger and bigger part of physical therapy.

For the last 10+ years, we have been developing technology that helps patients walk again. Our efforts have yielded great results with happy physical therapists and satisfied patients. Our FDA-approved exoskeletons are used in over 400 centers worldwide to help patients who are recovering from stroke, brain injury, spinal cord injury, or Multiple Sclerosis. Contact us today to make an inquiry or learn more about our products.

References:

1. Report to Congress: Traumatic Brain Injury in the United States | Concussion. https://www.cdc.gov/traumaticbraininjury/pubs/tbi_report_to_congress.html#:~:text=Traumatic%20brain%20injury%20(TBI)%20is,people%20are%20hospitalized%20and%20survive
2. Paralysis statistics – Reeve Foundation https://www.christopherreeve.org/living-with-paralysis/stats-about-paralysis
3. Worldwide market for exoskeletons 2027 | Statista https://www.statista.com/statistics/888936/global-exoskeleton-market/
4. Exoskeletons for Personal Use After Spinal Cord Injury. https://pubmed.ncbi.nlm.nih.gov/31228407/#:~:text=Robotic%20exoskeletons%20can%20allow%20individuals,for%20personal%20mobility%20or%20exercise
5. Physiotherapy using a free-standing robotic exoskeleton for patients with spinal cord injury: a feasibility study | Journal of NeuroEngineering and Rehabilitation https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-021-00967-4
6. Retraining walking over ground in a powered exoskeleton after spinal cord injury: a prospective cohort study to examine functional gains and neuroplasticity – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868817/
7. Impacts of a lower limb exoskeleton robot on the muscle strength of tibialis anterior muscle in stroke patients https://www.researchgate.net/publication/344023059_Impacts_of_a_lower_limb_exoskeleton_robot_on_the_muscle_strength_of_tibialis_anterior_muscle_in_stroke_patients/fulltext/5f519787a6fdcc9879c9cc2f/Impacts-of-a-lower-limb-exoskeleton-robot-on-the-muscle-strength-of-tibialis-anterior-muscle-in-stroke-patients.pdf
8. Robot Assisted Gait Training With Active Leg Exoskeleton (ALEX) | IEEE Journals & Magazine https://ieeexplore.ieee.org/document/4663875
9. Spinal cord injury patients may benefit from using exoskeleton earlier in treatment | News | University of Calgary https://ucalgary.ca/news/spinal-cord-injury-patients-may-benefit-using-exoskeleton-earlier-treatment
10. Changes in Bowel Function Following Exoskeletal-Assisted Walking in Persons with Spinal Cord Injury: An Observational Pilot Study – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7145720/
11. Robotic Exoskeletons May Provide Health Benefits for People with Spinal Cord Injuries | National Rehabilitation Information Center https://naric.com/?q=en/content/robotic-exoskeletons-may-provide-health-benefits-people-spinal-cord-injuries
12. How can powered exoskeletons restore walking ability after stroke? – Physics World https://physicsworld.com/a/how-can-powered-exoskeletons-restore-walking-ability-after-stroke/
13. Budget impact analysis of robotic exoskeleton use for locomotor training following spinal cord injury in four SCI Model Systems | Journal of NeuroEngineering and Rehabilitation https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-019-0639-0

According to the World Health Organization, rehabilitation is “a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments” (WHO, 2011). Drawing from this definition, neurological rehabilitation is a program that helps patients with neurological conditions recover or increase functionality within their environment. Neurological rehabilitation is important as it improves independence, increases the quality of life, and manages symptoms. Neurological rehabilitation programs are customized to the individual and differ depending on the areas affected by the condition.

How Does Neurorehabilitation Work?

Rehabilitation, in general, is primarily rooted in “neuroplasticity.” Neuroplasticity is the ability of the brain to adapt its activity in response to internal and external stimuli. This may include structural and functional changes. It may also involve changes in neural connections. Neuroplasticity allows the brain to learn new things and adapt to new situations, especially after injuries like stroke or traumatic brain injury (TBI). You see, the brain is not “fixed.” It changes with every experience and impression, meaning that new connections are continuously being formed as we continue learning. This learning and relearning quality is what drives rehabilitation.

The goal of every neurorehabilitation program is to restore health, independence, and functionality as much as possible using the best rehabilitation strategies. While the approach used differs from patient to patient, the steps in the process are very similar. The first step of every program is a comprehensive assessment using specific tests to understand the extent of the injury and the patient’s abilities. These tests are then used to create a treatment plan and are also used to set realistic rehabilitation goals. Once the assessment is complete, rehabilitation begins and continues until the desired results are achieved.

Phases of Neurological Rehabilitation

The neurorehabilitation process is made up of different phases, which are based on the severity of the injury and the patient’s symptoms. Each phase is measured using the Barthel Index (a measure of performance in activities of daily living). The treatment a patient receives is based on the stage they are in within the rehabilitation process.

• Long-Term Acute Care Hospital (LTACH): This is the first level of critical care after inpatient hospital stays. In this phase, patients require intense clinician supervision and management. It normally involves vent management, tracheostomy care, and wound infection care.
• Acute Rehab: In this phase, patients are required to participate in three hours of skilled therapy (PT, OT, speech & language therapy) per day. This is the biggest distinguishing factor between acute rehab and subacute rehabilitation. This phase normally involves shorter stays with the goal of transitioning to home therapy or subacute rehabilitation.
• Subacute Rehabilitation in Skilled Nursing Facilities: In this stage, patients are stable but not independent enough to be in the home setting. They are taken through therapy but are not required to fulfill the rigorous therapy demands of acute rehab. There is less oversight in this stage, with one nurse being assigned to many patients.
• Long-Term Care Facility or Nursing Home: Nursing home care is for patients who aren’t able to receive the necessary care they need at home. These patients require more supervision and help with activities of daily living like eating, bathing, dressing, etc. They do not require thorough care but may require medication management from nurses.
• Home with services: Patients in this phase are more functional and have more independence compared to patients in the other phases. At the same time, they do have home health aids as required.

Conditions That Can Benefit From Neurological Rehabilitation

Rehabilitation may be beneficial for neurological conditions like:

• Traumatic brain injuries.
• Spinal cord injuries.
• Hemorrhagic strokes, ischemic strokes, subdural hematoma, and transient ischemic attacks (TIAs)
• Structural or neuromuscular disorders, such as Bell’s palsy, cervical spondylosis, carpal tunnel syndrome, brain or spinal cord tumors, peripheral neuropathy, muscular dystrophy, myasthenia gravis, and Guillain-Barré syndrome
• Functional disorders like headache, seizure disorder, dizziness, and neuralgia
• Brain Infections like polio, meningitis, brain abscesses, and encephalitis.

Neurodegenerative diseases like multiple sclerosis, Alzheimer’s disease, amyotrophic lateral sclerosis (ALS), Parkinson’s disease, and Huntington’s disease.

What Does a Neurological Rehabilitation Program Consist Of?

Neurorehabilitation programs are multifaceted and are made up of multiple activities that are customized to a patient based on their condition. Some of the most common activities in neurological rehabilitation programs include:

• Help with activities of daily living (ADLs), such as eating, housekeeping, bathing, writing, cooking, and dressing.
• Stress and depression management techniques.
• Pain management.
• Speech therapy to help with speaking, reading, writing, or swallowing.
• Help with obtaining assistive mobility devices that promote independence.
• Bladder and bowel control retraining.
• Nutritional management and counseling.
• Mobility activities like muscle control, spasticity management, gait training, range of motion, balance, and coordination.
• Cognitive improvement activities that help with problems such as concentration, attention, memory, and poor judgment.
• Social and behavioral skills retraining.
• Patient and caregiver education and counseling.
• Participation in community support activities.
• Vocational counseling.

Who Is a Part of a Neurological Rehabilitation Team?

For successful outcomes, neurological rehabilitation teams are multidisciplinary and are made up of different specialists. It is important to note that the rehabilitation team only provides specialized therapy and is different from the patient’s primary care team. Neurorehabilitation teams may include any or all of the following specialists:

• Neuropsychologists – These are specialists who treat patients with cognitive and/or behavioral issues related to brain injury, stroke, or other illnesses. They also work with patients who need help coping and adjusting to changes in their physical capabilities. Neuropsychologists may recommend other treatments like cognitive therapy and stress management.
• Physical therapists – Physical therapists mainly deal with mobility challenges, like range of motion, balance, pain, gait impairment, and coordination. The main goal of physical therapists is to help patients recover mobility.
• Occupational therapists – They are normally involved in helping patients recover their ability to function normally and independently carry out their activities of daily living. They help patients perform activities like dressing, eating, bathing, etc.
• Speech-language pathologists – In case a patient’s speech is impaired, speech-language pathologists help them recover their speaking skills. Loss of speech is common among those who have had a stroke, brain injury, or other changes to the nervous system. Speech-language pathologists also work with patients who have difficulty swallowing.
• Therapeutic Recreation Specialists – These are certified professionals who provide recreational, therapeutic services like swimming, art therapy, and music therapy, among others. They create recreation-centered medical programs for the patient’s emotional, social, and physical well-being.

Aims of Neurological Rehabilitation

1. To prevent complications

Neurological conditions may lead to more complications if left unchecked. The complications can cause a deterioration of the conditions themselves or even be life-threatening in some instances. Secondary complications can also interfere with recovery and curtail rehabilitation. Enrolling in rehabilitation helps prevent these complications and also helps specialists identify them before they become a problem.

2. To teach adaptive strategies

One of the main roles of rehabilitation is to teach patients how to function normally and enable them to perform activities of daily living despite their condition. Physical therapists normally assess the patient’s impairment and develop plans on how to help the patient function in their usual environment. Physical therapists may also create strategies to reduce disability.

3. To facilitate function in a normal environment

Sometimes, patients are unable to attain premorbid function, necessitating the need for family caregivers and community-based service providers after being discharged from the hospital. Rehabilitation is great for teaching patients and caregivers how to live with new changes, as it can take a lot of mental and physical energy to adapt.

Approaches to Neurological Rehabilitation

There are a variety of techniques that are used in neurological rehabilitation. They include:

• Bobath approach: Also known as neuro-developmental treatment (NDT), this technique focuses on attempting movement patterns with a physical therapist’s help. This approach relies on motor learning, and the movement patterns are repeated until each component is perfect. Another emerging technique that leans on movement patterns is robotic exoskeletons. According to a 2020 study, they provide a high dose of repetition of movement while improving balance and stability. [1]
• Brunnstrom approach: This technique is a popular movement therapy approach that is used to improve functional movement. It uses a synergic pattern of muscular movements to promote recovery.
• Carr and Shepherd approach: This method is all about functional movements. It involves performing and practicing movements repeatedly and correctly until the desired outcome is achieved.
• Gait re-education: A lot of patients suffer from gait deficiencies after injury, hence the need for gait rehabilitation. A physical therapist normally identifies and corrects any variations that are present during walking. Exoskeletons, which are an emerging technique in gait rehabilitation, can automatically train gait, which reduces a physical therapist’s involvement. They lead to “increased dosing of gait training without increasing the duration of training during acute stroke rehabilitation.” This is important because it helps patients increase their training intensity without additional therapy time. [1]
• Transfer rehabilitation: This method is specifically helpful for patients who are still in the early stages of recovery. It teaches them the techniques they need to perform transfers. For instance, bed-to-chair transfers. The transfer movements are practiced until the patient can confidently perform them.
• Mobility rehabilitation: This is a huge part of any rehabilitation program, and it involves developing ways for a patient to move around independently and safely. It involves exercises like balance exercises, range of motion exercises, and stretches — all of which are intended to help a patient recover their mobility skills.
• Contracture management: Patients tend to have tight muscles and normally need help releasing the strain in their lower limbs for proper recovery. Some of the common contracture management strategies used include: splinting, weight bearing, and casting.
• Equipment and adaptations assessment: After an injury, assistive mobility devices like wheelchairs and walkers may be recommended to facilitate independence. Physical therapists normally provide these recommendations during the rehabilitation process. Read more about mobility devices that are recommended for patients recovering from a stroke.

Conclusion

Neurological rehabilitation is an integral part of recovery that cannot be done alone. With the help of family, friends, community, and the medical team, patients can recover from their injuries and learn how to reintegrate into society.

Ekso Bionics is committed to creating rehabilitation exoskeleton technology that helps patients walk again, and in the last ten years, our efforts have led to thousands of happy patients and physical therapists. Ekso Bionics has a global footprint, with our medical exoskeletons being used in over 400 centers worldwide. If you’d like to learn more or talk to us, visit our contact page, and we’ll get in touch with you shortly.

Reference:

1. Robotic Exoskeleton Gait Training During Acute Stroke Inpatient Rehabilitation – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661791/

According to the U.S. Pain Foundation, about 50 million people experience pain daily. [1] A survey conducted by the Centers for Disease Control reports that 20.4% of adults experience chronic pain, and about 7.5% experience pain that’s so severe that it frequently interferes with their work or life. [2] This calls for an effective pain management solution. Enter physical therapy. Physical therapy isn’t just about mobility recovery and recovering from injuries. Physical therapy plays an important role in the management and treatment of pain too. And with the looming opioid crisis, it’s a highly recommended alternative as it has no side effects and is a more sustainable treatment method for patients with chronic pain.

How Does Pain Relief Through Physical Therapy Work?

Physical therapy goes beyond treating pain. It identifies the source of pain in the body and treats it from the point of origin. The body is an interconnected system that works through different forces and pressure points. Nerves and blood vessels are attached to all organs and musculoskeletal structures in the body. Nerve pain in one area could be the result of muscle compression in a different area of the body. Resolving the strain in that specific muscle group could help restore fluidity, make the area limber, and reduce pain. Physical therapy restores balance and flexibility to ensure that blood vessels and nerves are not hindered.

Is Physical Therapy a Better Pain Management Strategy?

Due to the opioid epidemic, alternative pain management solutions are a growing concern among the medical community. Opioids are known to cause severe side effects among patients suffering from chronic pain, the biggest ones being abuse and addiction. According to the National Institute on Drug Abuse, about 10.1 million people misused opioids in 2019. [3] Tamara Dangerfield, MPT, a physical therapist with the University of Utah Health, says, “Taking a pill may seem like a great option for people when they hurt and just want the pain to go away, but we have seen huge detrimental effects on people who have come to rely solely on opioids for pain control. Opioids are only effective at treating these types of pain for short periods of time and in long-term situations become less and less effective with huge risks and side effects.” [4]

“The prevalence of chronic pain and the increasing use of opioids—which have led to addiction and fatalities — have led to increased efforts to address chronic pain in other ways,” explains Ben Gilbert, PT, MS, MBA, OCS, Cert. MDT, Director, Outpatient Rehabilitation, Main Campus at Burke Rehabilitation Hospital. [5] The biggest alternative method to reduce opioid dependence is physical therapy. It is normally recommended as a blended approach where patients can get drug support for pain management but are also enrolled in physical rehabilitation facilities that help them manage their pain in a better way. Physical therapy isn’t a one-time shortcut to pain relief. It is the opposite. It relieves pain over time and is a more long-term solution. This makes it a great solution for patients who want to avoid opioid dependence. According to Tamara, physical therapy is a better choice, especially for patients with prolonged musculoskeletal conditions.

Types of Physical Therapy

There are different types of physical therapy techniques used in managing pain. They are classified into:

Passive physical therapy: In passive treatment techniques, the patient is normally stationary, while therapy treatments are applied to the body to alleviate pain.

Active physical therapy: Active rehabilitation methods involve patient movement and participation and may be more effective for longer periods.

Passive Physical Therapy Treatment Techniques

1. Heat/cold application – This involves the application of heat and/or cold, which helps reduce muscle spasms and inflammation.
2. Transcutaneous electrical nerve stimulator (TENS) – This method involves the use of electrodes to deliver a mild electric current in the affected area. The electric impulses send signals to the brain, which stimulate the production of endorphins, a natural painkiller.  Electrical nerve stimulation also helps in muscle relaxation, which contributes to pain relief.
3. Laser therapy – Laser energy is projected into a specific area to accelerate tissue healing and reduce inflammation.
4. Iontophoresis – This transdermal drug delivery technique uses an electric current to deliver steroids under the skin membrane, which helps reduce pain and inflammation.
5. Ultrasound – This method uses ultrasound waves to penetrate the soft tissues and reduce muscle tension and pain.
6. Massage therapy – Massages help relax the muscles, improve blood circulation, and relieve pain.

Active Physical Therapy Treatment Techniques

1. Range of motion exercises – Range of motion exercises involve the movement of joints to increase flexibility and stretch muscles and other tissues. It’s also great for sensory stimulation. Range of motion exercises can be passive, active, or active-assisted. Exoskeletons may be used for range of motion rehabilitation but splinting is typically the gold standard.
2. Dynamic lumbar stabilization – After an injury, back muscles weaken and sometimes atrophy, hence the need for dynamic lumbar stabilization exercises. The goal of these exercises is to build back strength, reduce tension and increase flexibility. Exercises may include knee-to-chest stretch and back flexion stretch, which help relieve neck and back pain.
3. McKenzie approach – These exercises are focused on spine extension and pain alleviation. The exercises move the pain from the legs and arms to the back, which is able to tolerate pain better.
4. Aquatic exercise – This exercise, as the name suggests, is conducted in a pool. It relies on the water’s buoyancy to relieve pressure from the patient’s body. This allows patients to exercise their neck, back, leg, and shoulder muscles with less pain.
5. Targeted and general conditioning – This technique involves the use of endurance, stretching, and strengthening exercises to relieve pain in a specific area of the body.

The Importance of Physical Therapy in Pain Management

1. Little side effects

Physical therapy pain management techniques have little to no side effects. Common approaches like aquatic exercise, range of motion exercise, electrical stimulation, and ultrasound are non-invasive methods and have a low risk of side effects. This, however, cannot be compared to surgery and medication. Pain medication, for instance, can lead to addiction and dependence.

It may surprise you that physical therapy’s side effects are actually positive. They include “improved mood, blood pressure, weight control, bone density, endurance, strength, and sleep.” [4]

2. Holistic pain management

Physical therapy focuses on treating the root cause of pain instead of temporarily masking the pain. Pain medication temporarily provides relief by covering the pain for a short period of time but doesn’t fix the real issue in the body that is causing the pain. On the other hand, physical therapy identifies where the pain originates and then provides specific treatment strategies to alleviate pain in that specific area of origin.

3. Physical therapy is customized

Physical therapy regimens are completely customized to fit the patient’s schedule, lifestyle, and recovery goals. Physical therapists create structured individual plans that help manage pain and reduce inflammation while encouraging healing and recovery.

4. Contributes to improved physical health

Physical therapy is an active process that requires patient participation. In addition to pain alleviation, physical therapy strengthens muscles, tendons, and ligaments, improves range of motion, restores balance, and promotes healing.

5. Other benefits

It is reported that patients who take up physical therapy to manage their pain normally have lower outpatient and pharmacy costs. They also have lower out-of-pocket medical expenses and are more likely to avoid an opioid prescription. [5]

Conclusion

Physical therapy has a variety of treatment methods available. This means that there is something for everyone. If a patient doesn’t respond to a specific treatment method, your physical therapist will help you try another one until they find the one that gives them their desired results. Patients can also combine several methods and modify their rehabilitation regimen.

Physical therapy is the only risk-free and safe choice that’s focused on long-term pain relief. The medical community advances that it is a better option for patients with long-term musculoskeletal conditions compared to painkillers.

Ekso Bionics is a distinguished exoskeleton manufacturer that creates modern rehabilitation solutions that help patients learn to walk again. Our exoskeletons are used in more than 400 rehabilitation centers globally. Learn more about us or make an inquiry today to learn how you can procure our FDA-approved exoskeletons.

References:

1. U.S. Pain Foundation https://uspainfoundation.org/
2. Chronic Pain and High-impact Chronic Pain Among U.S. Adults, 2019 https://www.cdc.gov/nchs/products/databriefs/db390.htm
3. Opioid Crisis Statistics | HHS.gov https://www.hhs.gov/opioids/about-the-epidemic/opioid-crisis-statistics/index.html
4. What to Know About Physical Therapy for Pain Management – Burke Rehabilitation Hospital https://www.burke.org/blog/2019/12/what-to-know-about-physical-therapy-for-pain-management/198
5. Pain Relief Through Physical Therapy | University of Utah Health. https://healthcare.utah.edu/healthfeed/postings/2016/11/pain_relief.php#:~:text=Pain%20relief%20through%20physical%20therapy%20is%20based%20in%20the%20knowledge,for%20other%20types%20of%20pain

Robotic exoskeletons are not a far-removed idea from our imagination, thanks to pop culture. Exoskeletons have been featured in films like Edge of Tomorrow [1], where Tom Cruise’s strength is augmented using a combat jacket [2], Marvel’s Iron Man [3], where Tony Stark’s abilities are amplified using AI and mechanics, and Avatar [4] where the AMP suit [5] is used to navigate Pandora. And now, they are no longer just part of science fiction but are a part of our reality. In 2014, Julian Pinto, who is completely paralyzed in his lower extremities, made history by kicking off the World Cup in Brazil with a robotic exoskeleton that was created by a team of more than 150 researchers. [6]

The robotic exoskeleton industry is experiencing a boom as more use cases are developed in new industries, and experts predict it will be worth $1.8 billion by 2025. [7] This article will cover everything you need to know about exoskeletons, including interesting little-known facts about exoskeletons. 

What is an Exoskeleton?

An exoskeleton is a wearable device or a suit that works alongside the user to enhance their strength and amplify their performance. It is usually worn on the body. Exoskeletons use a combination of robotics and biomechatronics to enable body independence and are designed to provide support rather than replace functionality. In physical rehabilitation, they help patients relearn skills. In construction, they reduce the amount of energy expended and make repetitive tasks easier. And in the military, they are used to help soldiers carry heavier loads over longer distances. 

The first exoskeleton-like device was invented by a Russian inventor known as Nicholas Yagn in 1890. It had a spring-operated design that was intended to be used by the military to run and jump, but it didn’t make it to production. However, that was just the beginning of what would later become a growing industry. In 1960 General Electric created a 1,500-pound exoskeleton called the Hardiman (Human Augmentation Research and Development Investigation). Unfortunately, it was too heavy and large, so the project was shelved. [8]

In 2000, engineers at UC Berkeley, backed by The Defense Advanced Research Projects Agency (DARPA), created a pair of robotic legs that were meant to reduce the energy used in carrying heavy loads over long distances. [9] Finally, there was a successful break into functional exoskeleton designs. 

Today, robotic exoskeletons are more diversified and have undergone multiple iterations to create complex and advanced designs with various features and applications. For instance, Ekso Bionics creates exoskeletons used for neurorehabilitation, military research, and industrial uses. 

Types and Classifications of Exoskeletons

There are different types and classifications of exoskeletons which depend on the body part where they are worn and how they are powered. 

Exoskeleton Classification

• Full body – A full body exoskeleton is an exosuit that is used for strength augmentation in the military and rehabilitation.
• Upper extremity – An upper-extremity exoskeleton is one that supports the arms and potentially the torso. It can further be broken down into shoulder joints, elbow joints, the wrist, and even fingers. 
• Lower extremity -This is an exoskeleton that is used to support the legs. It comes in different configurations like hip, knee, or ankle only, hip-knee, knee-ankle, or hip-knee-ankle. 

Types of Exoskeletons

1. Powered exoskeletons

These are exoskeletons that rely on batteries and electric cable connections to work. One great example of a powered exoskeleton is the EksoNR, which uses two sets of long-lasting, rechargeable lithium-ion batteries. Powered exoskeletons are divided into static and dynamic exoskeletons. 

• Static exoskeletons: These exoskeletons require that the actuators be on at all times in order for the device to run well.
• Dynamic exoskeletons: Dynamic exoskeletons do not need actuators to be on, which makes them more energy efficient. 

2. Passive exoskeletons

These exoskeletons do not require electrical power in order to run. They rely on other mechanisms in order to work and are good for: 

• Weight redistribution: The springs in the exoskeleton plus the locking action redirect an object’s weight into the ground.
• Energy capture: ankle spring-clutch exoskeletons may help improve walking efficiency. 
• Dampening: Some exoskeletons are used as shock absorbers and vibration reducers. 
• Locking: Some exoskeletons can be locked into place, which allows users to stay in one position for a long time.

3. Pseudo-passive exoskeletons

These are exoskeletons that have all the features of a powered exoskeleton but do not provide actuation. E.g., the C-brace by Ottobock. 

4. Hybrid exoskeletons

These exoskeletons typically have all the features of a powered exoskeleton but use the input of the muscles as actuators. 

9 Interesting Facts About Medical Exoskeletons and Other Exoskeletons

1. Exoskeleton rehabilitation is one of the best ways for patients with mobility challenges to relearn walking.

Exoskeletons simulate natural gait during rehabilitation which initiates powerful brain signals that thanks to brain plasticity, can help patients recover their ability to walk. Exoskeletons also simulate natural gait by using drives in the hip and knee joints which move the wearer’s legs. Exoskeletons can be used by the patient independently or with the help of a therapist. They contain a predesigned program that helps therapists control the level of speed and power based on the patient’s needs. Exoskeletons can also be customized to an individual by adjusting the size. 

2. Training with exoskeletons positively influences a patient’s mental health.

Patients who train with exoskeletons report improved moods, morale, and mental health after just a few sessions. This can come from the ability to have conversations at eye level with other people. Exoskeletons also give hope to patients who were completely immobilized as they are able to walk again during training. 

Standing in vertical positions also has benefits like better blood circulation and lung volume, which contribute to better overall health. Exoskeletons make the training more exciting as they are a far more advanced way of rehabilitation and tend to give patients confidence which can reduce depression and other mental health issues. 

3. Some exoskeleton models can be controlled by the patient’s thoughts.

This is not science fiction, we promise. You see, exoskeletons normally have different types of control systems like buttons, tablets, and smart crutches, which help the patient control the amount of support they receive from the exoskeleton. The most advanced control method in the world today is a brain activity interface that helps the patients actuate the exoskeleton using their thoughts. This allows for improved neural plasticity, which may contribute to the speed of recovery. “Hybrid Assistive Limb (HAL) works by using small sensors on the skin that detect minor electrical signals in a patient’s body,” explains Brooks Rehabilitation director of clinical technology Robert McIver, “As those signals are detected by the robot, it responds with a movement at the joint. It is the only system that I have come across where the patient’s nervous system acts on an external device.” [10]

Other exoskeletons like the EksoNR have touchscreen controls that help clinicians set goals and alter assistance levels for patients of all different functional levels. Physical therapists can also easily access the medical device’s database to analyze complex movement patterns and record patient progress. 

4. Some exoskeletons are made using the same materials as airplanes.

All exoskeletons use different materials in their build. The most common being carbon fiber and metal. Others are made from materials like steel alloys and aluminum which are heavy and rigid. All exoskeleton materials should be strong enough to support patients when in a vertical position. 

5. Exoskeletons are not exclusively for lower limbs.

Did you know that there are different types of exoskeletons? As highlighted above, exoskeletons are divided into full-body, upper-body, and lower-body exoskeletons. Exoskeletons can also cover a specific body part like the hip, knee, elbow, and even finger. Ekso Bionics is continually iterating exoskeleton designs to create more efficient and effective solutions. 

6. Exoskeletons are used in the medical, military, construction, and automotive industries. 

There are two types of exoskeletons; medical exoskeletons and industrial exoskeletons. Medical exoskeletons are normally used in rehabilitation to help patients regain mobility, while industrial exoskeletons are used to augment human performance. Industrial exoskeletons are meant to make work easier for the wearer. You can read up on the use of exoskeletons in construction here. 

Industrial exoskeletons were first developed in the 1900s when they were used in the military. They have since then found applications in construction, automotive, and agriculture. They are very mainstream, so much so they are considered a part of personal protective equipment (PPE) for some automobile companies like Ford. 

7. Exoskeletons were first featured in pop culture in 1919.

A lot of people tend to think that exoskeletons are a 21st-century idea, but in truth, it was existent even in the 20th century. Exoskeletons were first depicted in The Master Mystery, which is a 1918 American mystery silent film.

8. Exoskeletons are used in sports.

Apart from medical and industrial applications, exoskeletons have found a new, fun application in the world of sports. As crazy as that sounds, Jonathan Tippett is pioneering an exoskeleton racing sport where racers control a 14 feet tall prosthesis and compete against other players. [11] The prosthesis relies on the leg, arm, hand, and feet movements of the user to move. It is powered by a lithium-ion battery and can run up to 20 mph. This sport is referred to as mechanical racing. 

9. You can use exoskeletons to be supersized.

Fancy having an exosuit that makes you ten times bigger than you already are? Now you can get one. Skeletonics create 10 feet tall exosuits that can turn you into a giant. Without the use of batteries or motors, all joints and limbs, including fingers, can move with precision mechanically. They utilize kinetic energy instead of electricity to power the exoskeletons. [12]

Conclusion

Just when you’ve learned everything there is to know about exoskeletons, a new exoskeleton is developed, or a new use case is created. That’s the beauty of being in the middle of a developing and fast-growing industry. At Ekso Bionics, we aim not just to be the leaders in exoskeleton technology but also to make exoskeletons that help patients regain full mobility. 

We always aim to develop disruptive wearable robotics in the medical arena, and so far, we’ve helped thousands of patients with lower extremity disabilities take over 200 million Ekso-aided steps. We are at the forefront of shaping new devices for neurorehabilitation with FDA-cleared exoskeletons for MS, stroke, SCI, and other brain injuries. To learn more about Ekso Bionics, click here. 

References:

1. Edge of Tomorrow https://www.imdb.com/title/tt1631867/?ref_=nv_sr_1?ref_=nv_sr_1
2. Combat Jacket https://allyouneediskill.fandom.com/wiki/Combat_Jacket
3. Iron Man https://www.imdb.com/title/tt0371746/
4. Avatar https://www.imdb.com/title/tt0499549/?ref_=nv_sr_2?ref_=nv_sr_2
5. Amplified Mobility Platform https://james-camerons-avatar.fandom.com/wiki/Amplified_Mobility_Platform 
6. Paraplegic in robotic suit kicks off World Cup – BBC News https://www.bbc.com/news/science-environment-27812218
7. ABI Research Predicts Robotic Exoskeleton Market to Expand at 39% CAGR and Reach $1.9 Billion in 2025 https://www.abiresearch.com/press/abi-research-predicts-robotic-exoskeleton-market-e/
8. Exoskeletons History – part 3 https://www.mechatech.co.uk/journal/exoskeletons-history-part-3
9. On the Mechanical Design of the Berkeley Lower Extremity Exoskeleton (BLEEX) https://bleex.me.berkeley.edu/wp-content/uploads/hel-media/Publication/On%20the%20Mechanical%20Design%20of%20the%20Berkeley%20Lower%20Extremity%20Exoskeleton%20-%20IROS05.pdf
10. HAL: The Japanese cyborg medical exoskeleton helping US patients walk again https://www.medicaldevice-network.com/analysis/hal-japanese-cyborg-medical-exoskeleton-helping-us-patients-walk/
11. World’s Largest Exoskeleton Racing Mech https://www.youtube.com/watch?v=euvMHPll23M
12. Skeletonics https://www.skeletonics-us.com/

Stroke, as defined by the World Health Organization, is an accident to the brain that has “rapidly developing clinical signs of focal or global disturbance to cerebral function, with symptoms lasting 24 hours or longer, or leading to death, with no apparent cause other than of vascular origin and includes cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage”. [1]

Stroke is ranked as the 5th leading cause of death worldwide and the leading cause of disability, with a new stroke happening every 40 seconds. [2] In the United States alone, approximately 800,000 people experience a stroke each year, and about two-thirds of this population require rehabilitation to get back to their lives. With the growing need for stroke rehabilitation each year, we aim to break down what stroke rehabilitation entails and highlight some of the modern physical therapy treatment techniques you can incorporate into your stroke rehabilitation program as a physical therapist. 

The Effectiveness of Stroke Rehabilitation

Stroke rehabilitation is a program of different therapy techniques put together with the aim of helping a patient relearn lost skills, optimizing how a patient functions, and increasing their level of independence in order to achieve the best quality of life. 

Effective stroke rehabilitation requires you to work closely with your patients, altering the different types of therapy depending on their needs and changing the intensity and time of their program based on their progress. Successful stroke rehabilitation depends on: 

• Physical factors like the severity of the stroke.
• Emotional status of the patient, for example, motivation, resilience, persistence, grit, consistency, etc. 
• Social support, for example, from family and friends. 
• Curative elements like early rehabilitation and the skills of the stroke rehabilitation team. 

These factors have been practically proven to impact the success of rehabilitation in real-world scenarios. In a 2017 randomized control trial, researchers concluded that rehabilitation combined with early supported discharge (ESD) “seems to reduce death and institutional care and to improve patients’ chances of living at home 5 years after stroke compared to traditional stroke care. There is a trend toward an improved functional outcome in the ESD group.” [3] 

One of the important elements of successful rehabilitation that has been proven in neurorehabilitation is focused repetitive practice. It’s the same element we use when learning new skills like writing, playing a musical instrument, or sports. Research shows that functions located in areas of damage are normally moved to other regions of the brain, and carefully directed practice can help in the rewiring of brain circuits in the new areas. [4]

According to research, early rehabilitation is associated with better outcomes, irrespective of the severity of the stroke. Thus, physical therapy should be offered early in the recovery process. In addition, if rehabilitation happens in a different location from acute care, the transition should be seamless. A review by Harutoshi Sakakima et al. alludes to physical exercise being a prototypical precondition stimulus that provides brain protection effects. [5]

There are many treatment methods that can be incorporated into a stroke rehabilitation program, but for this article, we will specifically focus on physical therapy techniques that aid in upper and lower extremity function recovery. 

Physical Therapy Treatment Techniques

There are many treatment techniques that can be used in upper limb and lower limb rehabilitation. Therefore, these ideas are not an exhaustive list of what’s available.

Lower Limb Rehabilitation: Gait and Mobility

Gait recovery is a primary goal in any rehabilitation program for patients recovering from stroke and can be achieved using the following interventions:

• Body Weight Supported Gait Training: This training method helps a patient control their weight, balance, and posture by using a harness that is mounted from a metal frame or ceiling. It can take place over a treadmill or over the ground. When using a treadmill, the patient is secured using a harness for fall prevention and then set up over a treadmill. Body weight-supported treadmill training provides more control over the ambulation speed, environment, and allows therapists to offer cues for proper gait dynamics. 

Therapists can control the effort required by patients during training by weighting or unweighting the patient using the suspension system. Unweighted training reduces the amount of weight borne by the patient and makes the patient feel lighter. This, in effect, makes the patient expend less effort during the training sessions.

Body weight can, however, be added back during training depending on the patient’s progress and abilities. Therapists can also help with stance with swing phases of gait, posture, knee control, heel strike, and limb advancement. Research reports that body weight-supported treadmill training can help improve motor function and balance. Additionally, it helps enhance gait quality compared to traditional gait training methods.  [6]

• Electromechanical Assisted: Electromechanical-assisted gait training is commonly used as a supplementary training technique for overground training. It’s great for completely immobilized patients as it helps them intensely practice complex gait cycles without overexertion on the therapists part. Robotic exoskeletons are popular in this category as they help increase movement during training while reducing therapists’ burden. They require less manpower for the same mechanical therapy that traditional rehabilitation methods use. Since the exoskeleton does most of the work, the therapist only needs to set the patient up in the device and supervise them. [7] 

Apart from increased repetition, exoskeletons can help patients relearn the proper walking technique from the start of the rehabilitation. They also offer other benefits like sensory feedback, weight support, and real-time control and monitoring features. Robotic exoskeletons are also advantageous in helping patients increase their range of motion. [8]

EskoNR is a leading robotic exoskeleton in use in rehabilitation clinics around the world. It is cleared by the Food and Drug Administration for rehabilitation and offers unique features to help patients learn to walk again. It provides different gait training modes that support the knees, ankles, hips, and torso and helps the patient maintain an upright posture. You can use it in the preGait mode or walking mode depending on the recovery level of your patient. The preGait mode contains activities that help prepare patients to take their first steps, like balancing and midline orientation. As a patient progresses in their recovery, the EksoNR reduces the support offered, allowing for more control and stability, eventually leading them to walk without the device. 

• Rhythm Cueing: Rhythm cueing involves the synchronization of movement to a uniform sound. Rhythmic cues are used to guide movement and influence motor execution, but they don’t have to be strictly rhythmic. According to research, rhythmic cueing can help improve timing in motor tasks that have complex timing and in conditions that affect how an individual perceives time with regard to movement. Having external rhythm can also help by supporting the mechanisms of the brain that are associated with keeping time. [9]

Successful gait training with rhythmic cues requires auditory inputs from different parts of the motor control system like the cerebellum, cerebral cortex, nervous system, and brainstem. Additionally, to achieve success, the gait must be well linked with the acoustic rhythm, and the speed of the metronome must be right. [10]

• Overground walking: Overground walking, also known as overground gait training, involves observing a patient’s walking pattern on a solid surface while cueing them to perform different activities that can help improve their gait. This is a simple and easy technique to incorporate into your rehabilitation program as it doesn’t require complex technology and can be done in a variety of locations. 
• Orthotics: Orthotics deals with the design of custom artificial braces and splinters that can be used to correct, support, or stabilize a body structure. One common type of orthosis used in lower extremity rehabilitation is an ankle foot orthosis. KNGF Clinical Guidelines recommend it for individuals whose mobility is affected by drop foot during the swing phase of walking. [11]
• Functional Electrical Stimulation (FES): This is a rehabilitation technique that uses low-energy pulses to activate weak muscles and nerves. Functional electrical stimulation has been in use since 1960. It relies on electrodes to stimulate the relaxation and contraction of muscle groups. One important and interesting thing to note is that it’s the nerves and not the muscles that are stimulated, as they have lower current requirements compared to muscles. Some of the factors that affect how electrical stimulation works include the size of the surrounding tissue and the distance between the nerve fiber and electrode.

FES application in rehabilitation settings is important because it helps promote motor recovery by providing visual and sensory feedback. It also helps avoid disuse atrophy, a common stroke complication resulting in muscle fiber changes. FES can help by correcting the muscle fiber changes by changing the type II glycolytic fibers back to type I oxidative skeletal muscle fibers.

• Balance Training: A stroke can cause weakness in one side of the body, leading to balance impairment. Hence the need for balance training and weight-shifting exercises. Researchers reviewed literature published between January 2006 and February 2010 and concluded that balance training is an effective technique for rehabilitating patients with stroke. [12]
• Stair Training: Stair training is a great training method for mobility rehabilitation as it helps patients recover their range of motion in slopped environments. In a 2017 study investigating the effects of stair task training on walking ability in stroke patients, thirty-six patients with stroke were selected randomly and divided into two groups: the experimental group and the control group. The study reported that the gait training group that used the 10-cm high stairs showed the biggest improvement in balance and muscle activities compared to the other group. These results conclusively showed that stair training is a viable rehabilitation technique in clinical environments and can be used to improve patients’ walking ability. [13]

In a 2021 randomized controlled study investigating the efficacy of lateral stair walking training in patients with chronic stroke, it was revealed that lateral stair walking improves hip muscle strength and gait in patients. Thus, stair walking can be added to rehabilitation programs to aid gait and balance improvement. [14]

• Strength Training: Strength training is a versatile technique that can be used to rehabilitate both the upper and lower extremities. While there isn’t a specific strength training approach for lower extremity rehabilitation, progressive exercise has been shown to help improve muscle strength and is recommended by Australian Stroke Foundation guidelines (2017) and the AHA guidelines (2010). [15] Although resistance training effectively improves strength, there is limited evidence supporting its influence on walking parameters. [15] [16] Common strength training exercises used in physical therapy target the quadriceps and hamstrings. 

Upper Limb Rehabilitation Practices

• Bilateral Arm Training: Bilateral arm training is a form of intensive training that involves performing movement patterns or activities with both hands at the same time but independently of one another. These movements or activities may also be cyclic. This method was created in response to CIMT’s (Constraint Induced Movement Therapy) known drawbacks, which include its inability to allow for the practice of bilateral skills, especially those involved in functional activities that are by their very nature bimanual. Both bilateral and unilateral training have the same positive effects. The severity of upper limb paresis and the timing of the intervention following the stroke, however, may affect the outcome of the intervention. 
• Constraint-Induced Movement Therapy: The goal of constraint-induced movement therapy (CIMT) is to encourage patients with hemiplegic stroke to practice moving their affected limb while restraining the unaffected limb. 

• Robot-Assisted Arm Training: Robot-centered training involves the use of mechanical devices to offer active, passive, and resistive limb movement. This method is great for extended treatment periods and can be customized to the needs of the patient by using their movement as feedback. Though there is limited evidence on the use of robot-assisted arm movement, it can be combined with other conventional therapy methods to provide better rehabilitation outcomes. According to a 2018 study, “People who receive electromechanical and robot-assisted arm training after stroke might improve their activities of daily living, arm function, and arm muscle strength.” [17]
• Strength Training: Strength training is designed to increase muscle strength and endurance. According to research, strength training has the ability to improve strength and function in the upper extremity without increasing pain in patients with stroke. [18] However, the intensity of strength training doesn’t affect outcomes, as shown in a recent study. Common strength training exercises that are commonly used in upper limb training include bridges, tricep dips, weight-bearing leans, tabletop lateral pushing exercises, tabletop forward pushing exercises, and bicep curls. For effective strength training, all the training exercises should be adjusted to the level of the patient’s ability.

Conclusion

All these training methods can be incorporated into a rehabilitation program in different combinations and at different times. The key to maximizing their effectiveness is tailoring them to your patient’s individual needs and abilities. When introduced early, they can help improve results and boost the success rate of your program. Above all, intensive practice is an important factor irrespective of the technique you choose. 

Ekso Bionics is a leading medical exoskeleton manufacturer on a mission to help patients learn how to walk again. EksoNR was one of the first FDA-approved medical exoskeletons for stroke rehabilitation. It is the exoskeleton of choice for many physical therapists and is available in rehabilitation clinics around the world. If you would like to procure an exoskeleton for your clinic, contact us by clicking here. 

References:

1. Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6288566/#B1
2. Acute Stroke – StatPearls – NCBI Bookshelf  https://www.ncbi.nlm.nih.gov/books/NBK535369/
3. Stroke unit care combined with early supported discharge improves 5-year outcome: a randomized controlled trial  https://pubmed.ncbi.nlm.nih.gov/21474806/
4. Post-Stroke Rehabilitation Fact Sheet | National Institute of Neurological Disorders and Stroke https://www.ninds.nih.gov/post-stroke-rehabilitation-fact-sheet
5. Endogenous neuroprotective potential due to preconditioning exercise in stroke – PMC  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6992848/#!po=18.4211
6. The Effect of Body Weight Support Treadmill Training on Gait Recovery, Proximal Lower Limb Motor Pattern, and Balance in Patients with Subacute Stroke – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4663281/
7.  Lower-Limb Robotic Rehabilitation: Literature Review and Challenges https://www.hindawi.com/journals/jr/2011/759764/
8. Robot-aided assessment of lower extremity functions: a review | Journal of NeuroEngineering and Rehabilitation | Full Text https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0180-3
9. Immediate Effects of Rhythmic Auditory Stimulation with Tempo Changes on Gait in Stroke Patients – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3996403/
10.  Walking to the beat of different drums: Practical implications for the use of acoustic rhythms in gait rehabilitation – ScienceDirect https://www.sciencedirect.com/science/article/pii/S0966636211000786
11. What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3913786/
12.  The effect of balance training on balance performance in individuals poststroke: a systematic review https://pubmed.ncbi.nlm.nih.gov/20716987/
13. Effects of stair task training on walking ability in stroke patients – PMC

Multiple Sclerosis (MS) is a leading cause of disability, affecting more than a million people in the US. There is no cure for MS, but there are treatments that can help slow the progression of the disease. [1] Exoskeletons present a more advanced and better rehabilitation solution for patients with MS to recover their mobility skills. And with the recent FDA approval, they might become an integral rehabilitation method in rehabilitation centers. This article explores multiple sclerosis, its causes, symptoms, and the application of exoskeletons in the treatment of MS. 

What is Multiple Sclerosis?

Multiple sclerosis is an inflammatory neurological condition that affects the central nervous system – optic nerves, spinal cord, and brain. It is commonly diagnosed in people who are between 20 years and 40 years. There is no known cause for MS, but research has shown that certain factors trigger the immune system to attack the central nervous system. The attack destroys myelin and damages the underlying nerve fiber. This disrupts communication signals from and to the brain, producing symptoms like memory problems, fatigue, paralysis, numbness, blindness, pain, etc. MS symptoms manifest differently in each patient, and they may be temporary or long-term. While there is no cure, medication and physical therapy can be used to manage its effects.

What Causes Multiple Sclerosis?

While the cause of MS has not been identified yet, researchers believe that different factors trigger it. Some factors under research include: 

1. Immunological factors: Abnormal immune response causes damage to the central nervous system. T cells and B cells are the two most prominent cells involved in the abnormal immune response. 
2. Environmental factors: According to research, MS occurs in areas that are farther away from the equator. Evidence shows vitamin D plays a critical role, and low vitamin D levels present a risk factor in developing the condition. Some scientists use sun exposure to explain the north-south distribution of MS, saying that people closer to the equator are exposed to more sunlight, hence lower MS prevalence. [2] However, epidemiologists are studying more patterns to establish a clear relationship.

Researchers believe smoking also plays a critical role in MS. Some studies show that smoking increases the risk of developing MS and contributes to severe symptoms and faster disease progression. [3]

3. Infectious factors: MS is associated with many bacteria and viruses. Some of the bacteria and viruses under investigation in the development of MS include: canine distemper, Chlamydia pneumonia, human herpesvirus 6 (HHV-6), measles, and Epstein-Barr virus (EBV). A recent study shows that previous infection with EBV puts you at a higher risk of developing MS. [4]
4. Genetic factors: MS is not passed down from one generation to another. However, researchers are investigating the genetic risk of inheritance. The risk of developing MS in a general population sample is about one in seven hundred and fifty, but the risk increases when first-degree relatives like parents and siblings have MS.

What Are the Symptoms of Multiple Sclerosis

Multiple Sclerosis symptoms are different in each person, and they can change over time. Some people only experience one symptom, while others experience numerous symptoms. Some of the symptoms commonly observed in people with MS include: 

• MS Hug (Dysesthesia): This is the feeling of squeezing around the torso. It can be likened to a tight blood pressure cuff around the arm and is the most common first symptom.
• Fatigue: Occurs in 80% of patients and interferes with work performance and engagement at home. 
• Numbness or Tingling: People with MS typically experience numbness of the body, arms, face, and legs. 
• Vision Problems: This is a common first symptom in many people and can include eye problems like neuromyelitis optica, poor contrast, blurred vision, and pain when moving the eyes. 
• Cognitive Changes: Cognitive changes can affect the ability to learn, recall, solve problems, pay attention, focus attention, and process information. This affects more than 50% of people with MS. 
• Emotional Changes: Emotional changes result from neurologic changes, but sometimes they can be a result of the stress of living with the condition. These changes can be in the form of irritability, anxiety, mood swings, and uncontrollable laughing or crying. 
• Walking (Gait) Difficulties: These mobility impairments are due to factors like fatigue, spasticity, and muscle weakness, among others, but medication, physical therapy, or assistive devices like exoskeletons can resolve them.
• Spasticity: This is the condition where there’s increased muscle stiffness and tone, which affects movement. It may also be accompanied by discomfort and pain

Exoskeletons for Multiple Sclerosis

An exoskeleton is an external device a patient wears to enhance their endurance and support their mobility. It can be battery-powered or mechanical. It is used to help the wearer stand, walk, sit and move their legs. Battery-powered exoskeletons manipulate the knee and hip joints to initiate movement while the wearer gains balance support using their upper limbs. The wearer can operate the exoskeleton on their own or with the help of a physical therapist. Exoskeletons are great for rehabilitation because they can be customized to a patient’s specific needs and abilities. 

EksoNR is the first and only exoskeleton cleared for the rehabilitation of people with MS by the FDA. It can also be used by patients recovering from a stroke, spinal cord injury, or acquired brain injury. EksoNR is uniquely different from other exoskeletons because it is not just an assistive device that provides all the power a patient needs to walk. Instead, its main focus is to help patients “walk out of the device and back into their communities”- Ekso Bionics Chairman and CEO Steven Sherman.

EksoNR is preprogrammed with specific movements that patients require during rehabilitation, like marching, weight shifting, squatting, and stepping. It also has therapist-programmed settings that can help set the amount of assistance based on the patient’s needs. Additionally, it has a cloud-based dashboard that records session data (speed, walking time, and distance) in real time. EksoNR is a game changer in rehabilitation, and it can help patients develop better balance, coordination, endurance, gait quality, and quality of life. 

Benefits of Exoskeletons

Using exoskeletons in physical therapy can help improve gait quality, muscle strength, and cognitive ability. 

1. Improved Gait Quality

In a study involving ten patients with MS, conducted by Kessler Foundation, patients were rehabilitated using an Ekso Bionics exoskeleton, and their recovery progress was compared to participants who used conventional gait training methods. The outcomes studied in this case were walking endurance, functional mobility, brain connectivity, and cognitive processing speed. After four weeks, the patients who used the exoskeleton were shown to have outperformed those who used conventional gait training methods. Additionally, these results were also corroborated by MRI brain scans.  [5]

In a 2021 randomized controlled trial investigating how exoskeletons affect gait speed and functional mobility in individuals with multiple sclerosis (MS), the researchers concluded that exoskeletons could help preserve gait speed and improve functional mobility.  [6]

2. Increased Exercise Intensity

Over-exertion is a big concern for people with MS because it contributes to the progression of the disease. The question then becomes, how can patients train without overexerting themselves? Another part of this puzzle is attending to patients who might not be able to achieve the required intensity in their exercise program. According to Brian M. Sandroff, Ph.D., lead investigator and a Senior Research Scientist at the Kessler Foundation’s Exercise Neurorehabilitation Research Laboratory, “One of the big problems is that people with MS who have a severe disability status in terms of walking might not be able to exercise at a sufficient intensity to elicit benefits.” [7]

Exoskeletons offer the solution in these two instances as they can help patients train intensely without over-exertion, as evidenced in a 2021 study. [6] They can also help patients with severe mobility disabilities to attain the required intensity for their progress. An exoskeleton like EksoNR allows physical therapists to customize the steps in each session, thereby reducing the possibility of over-exertion.

3. Improved Muscle Strength

Exoskeletons are extremely helpful and can help patients with different degrees of injury increase their muscle strength. They can also help patients with leg weakness to stand, walk, squat, and perform other movements. In a 2015 study of patients with spinal cord injuries, patients were shown to achieve walk times ranging from 28 to 94 minutes, with some averaging a speed of up to 0.21m/s. [8]

4. Improved Cognitive and Emotional State

Exoskeleton benefits go beyond physical improvements. They also affect a patient’s mental abilities. The direct involvement required from patients during the rehabilitation period can produce a psychological effect. Some exoskeletons like EksoNR keep track of a patient’s progress, and showing patients positive progress reports can help improve their hope and boost their morale.

Testimonial

Kathy Miska was diagnosed with MS more than 20 years ago. Over the past few years, Kathy’s symptoms have worsened and impacted her ability to walk. But thanks to exoskeletons, she can now practice and improve her mobility skills. She is one of the patients with MS at Cleveland Clinic’s Mellen Center for Multiple Sclerosis, participating in a study investigating the effectiveness of exoskeletons in MS rehabilitation.

Kathy reports, “My walking speed has increased, my endurance has improved, my gait is more normal, and I get intermittent periods of my leg getting signals from my brain,” After completing a total of 24 hours in the Ekso exoskeleton, over eight weeks, Kathy says, “I feel like I have really made progress. My posture looks better, and my walking has improved. Hopefully, this will get me stronger. It’s encouraging.” [9]

Conclusion

Introducing advanced technology in your rehabilitation center will help your patients achieve better treatment outcomes and improve the quality of their life. We’d like to point out that the exoskeleton is not intended to take over the work for the patient but to stimulate “nerve memory” so that the muscles can be activated. We aspire to help patients recover their walking ability and walk right back into their lives. 

Ekso Bionics is at the forefront of creating the best quality medical exoskeletons. Our mission is to create accessible mobility solutions for patients recovering from a stroke, brain injury, spinal cord injury, and MS. Would you like to outfit your rehabilitation center with one of our exoskeletons? Contact us at 510-984-1761 or request a free demo online. 

References: 

1. Landmark Study Estimates Nearly 1 Million in the U.S. Have Multiple Sclerosis https://www.nationalmssociety.org/About-the-Society/News
2. Vitamin D | National Multiple Sclerosis Society https://www.nationalmssociety.org/Research/
3. Multiple Sclerosis and Smoking https://nms2cdn.azureedge.net/cmssite/nationalmssociety/media/
4. Study Provides Strongest Evidence Yet for the Role of Epstein-Barr Virus in Triggering Multiple Sclerosis https://www.nationalmssociety.org/About-the-Society/News/
5. A pilot randomized controlled trial of robotic exoskeleton-assisted exercise rehabilitation in multiple sclerosis https://www.msard-journal.com/article/
6. Overground Robotic Program Preserves Gait in Individuals With Multiple Sclerosis and Moderate to Severe Impairments: A Randomized Controlled Trial https://pubmed.ncbi.nlm.nih.gov/33316225/
7. Robotic Exoskeleton Therapy Shown To Improve Mobility And Cognition In People With MS https://www.forbes.com/sites/gusalexiou/2021/05/30/
8. Time and Effort Required by Persons with Spinal Cord Injury to Learn to Use a Powered Exoskeleton for Assisted Walking https://pubmed.ncbi.nlm.nih.gov/26364280/
9. Robotic Device May Make Walking Easier for Multiple Sclerosis Patients https://my.clevelandclinic.org/patient-stories/

Stroke is the leading cause of disability.[1] In a report published by the CDC, about 795,000 people in the U.S have a stroke every year, with 610,000 being first strokes and nearly 185,000 being repeat strokes. [2] This results in reduced mobility, balance, and coordination. Stroke also limits social interaction and activities of daily living (ADLs) due to impaired mobility and balance.

If you are recovering from a stroke, you’ll generally be subjected to a few weeks of inpatient rehabilitation which targets the recovery of independent ambulation. After rehabilitation at the hospital, you’ll be discharged and given a cane, brace, walker or wheelchair, depending on the progress of your recovery.

Stroke Mobility Aids

Mobility devices are apparatuses that support the user’s mobility and help them move around. These include walkers, canes, wheelchairs, and even orthotics. They may help increase your independence, reduce residual disability, and slow the decline of certain functions.

1. Rolling Walker

Rolling walkers help support mobility by providing balance and supporting the leg muscles. To move forward, apply force with your arms and make a step in the direction you wish to go. There are two types of walkers: 2-wheel walkers and 4-wheel walkers. Some walkers have seats which can allow you to take a break anywhere.

Walkers are a great mobility device for people who are not entirely immobile. However, when using a walker, the body uses the hips for balance instead of the ankles. This inadvertently leads to reduced ankle sway, which results in decreased ankle strength and flexibility, prompting a decline in mobility.

2. Cane or Quad Cane

Canes are normally used to steady the body while in motion, contributing to improved balance and lower risk of falling. The quad cane is the best option for people who need a little support —using a cane when walking increases your base of support, providing you increased balance. When in motion, it causes your center of gravity to shift in the cane’s direction. This reduces postural sway which aids in mobility and balance.

3. Wheelchair

Wheelchairs are great mobility devices if you are completely immobilized or get fatigued easily. There are different chair designs and options available in the market, but the most important thing is to ensure that a wheelchair is specifically designed for your needs and environment. The comfort of the person using the wheelchair is vital because poor fit can lead to discomfort. It can also cause back injuries, reduced mobility, skin breakdown, and affect how well they can propel the chair. Therefore, always consult with a healthcare professional in order to get the type of wheelchair that addresses your specific needs.

4. Orthotics

An orthosis is an artificial external device that is created to support a joint or body part. It is normally used to offer the wearer stability, protection, and support. An orthosis varies depending on the area of the body they are being worn and can be fabricated or custom-made. Ankle-foot orthoses are commonly prescribed to individuals recovering from a stroke. They are used to improve gait by providing support to the knee and ankle, helping to keep your toes from dragging on the ground when swinging that leg, and keeping you steady over that foot when you are putting weight on it. The main function is to help you become more independent with your activities of daily living (ADLs) and mobility. Just like a wheelchair, selecting the right device is essential to get the best support and results.

There are also orthoses that can be used if your muscles have become tight. Two types may help assist you in stretching and recovering the lost range of motion:

• Static orthosis: It cannot move and is normally used to apply force to a joint and hold it in a position to increase the passive range of motion.
• Dynamic orthosis: It is mobile and is worn to support the proper movement of a joint.

When prescribed, orthoses are used to maintain range of motion, manage pain, prevent contractures, protect tissues, support weaker muscles, prevent unwanted movement, and increase function.

Exoskeletons for Stroke Recovery

Walkers, canes, wheelchairs, and orthotics are great devices for mobility. However, not all individuals recovering from a stroke will be able to practice walking or use them in their daily life, especially if they need more assistance from their therapist. This is where the exoskeleton comes in. An exoskeleton is a powered robotic gait training device that is used to support the movement of lower limbs through repetitive overground walking practice.

One such exoskeleton that the FDA approves for the rehabilitation of individuals recovering from a stroke, brain injury, spinal cord injury, and MS is EksoNR. It re-trains the user’s brain and the muscles on how to walk again by ensuring the most natural gait pattern is achieved during rehabilitation. EksoNR is currently available for use in more than 400 rehabilitation centers around the world.

EksoNR’s Features and Benefits

EksoNR contains special features designed to help you regain mobility quickly and effectively. They include:

1. Pre-ambulatory tools – This is a set of programs designed to help you make a step, squat, balance, and shift your weight before walking. It helps form the foundation of necessary movements.
2. Adaptive gait training – EksoNR contains sensors and software that monitor and correct leg movements to reduce compensatory gait patterns.
3. Smartassist software – Your physical therapist can customize the amount of support EksoNR offers in the swing and stance phases of walking, depending on your impairment level.
4. Clinician control – With EksoNR, it is possible to set training goals and change the assistance levels for each leg based on the goals you have set and the feedback after the session.
5. Posture support – To help maximize rehabilitation sessions, EksoNR provides support by ensuring proper postural alignment as you move.
6. Data capture – Your physical therapist can access all session data and analytics on the cloud-based dashboard that saves progress and data in real-time.

Ekso Bionics has had massive success in mobility rehabilitation. According to a health professional, Dr. Jennifer Cohen, MD, “Ekso helps us get patients up, out of bed, and ambulatory as soon as possible.” Duncan Monger, PT, DPT, CBIS, also says, “We were able to see an immediate impact on the patient’s ability to perform bed mobility, transfers, and independence with all functional activities after one session with the device. This device has greatly improved our patient’s outcomes while decreasing physical assistance required by staff members.”

Benefits of Exoskeletons

The impact of exoskeletons on stroke recovery is undisputed. They can help in gait training, ambulation, and improve motivation, among other related benefits.

1. Ambulation

If you are recovering from a stroke, you may experience gait deficits like reduced mobility, speed, and asymmetrical walking patterns, which affect your ability to ambulate. Robotic exoskeletons help with correcting gait deficits which help with ambulation. They are used for gait training, guiding weight shifts, and improving step patterns and cadence.

In a study investigating the effects of robotic exoskeletons on functional ambulation in adults with stroke, it was reported that exoskeletons help increase functional ambulation. Additionally, it’s an effective way of providing high-dose therapy without increasing the duration of training. [3]

2. Gait Rehabilitation

Traditionally, gait training involves exercising on a treadmill with the assistance of physical therapists. On the other hand, exoskeletons help you improve your gait by practicing your walking movements repetitively and correctly with anatomically aligned motors. This also aids in the strengthening and recovery of leg muscles and improves coordination. Exoskeletons also track progress and document improvement, which can be used to analyze your rehabilitation progress. According to a recent study, combining exoskeletons and conventional gait training therapy may lead to better results and a more efficient gait.  [4]

3. Improved Motivation

Rehabilitation sessions with exoskeletons include walking time which is a huge morale and motivation booster, especially if you cannot move. Moving and holding conversations at eye level in an exoskeleton is empowering and may help improve your enthusiasm. This can lead to more steps per session and increased functional independence. [5]

4. Reduces Burden on Physical Therapists

Rehabilitation can sometimes be taxing and very exhausting for therapists. Fangshi Zhu, Senior Biomedical Research Scientist at the University of Texas Health, says, “Traditional therapy usually involves two or three physical therapists manually guiding a patient’s impaired limb to follow and reinforce the desired trajectories, which can be very labor-intensive and even unsafe.” [6] This limits results as physical therapists cannot provide enough high-dose, task-specific repetitive gait training during the acute stages of recovery.

With exoskeletons, you only need one physical therapist to guide you through an exercise. This frees up physical therapists to attend to more people. Additionally, exoskeletons can deliver so many gait repetitions during the acute recovery phase, which helps in positive rehabilitation outcomes.

Conclusion

There are many mobility devices available for people who are recovering from a stroke. However, they are not the foolproof solution in mobility rehabilitation. For example, wheelchairs cannot help you practice your walking skills. In fact, sitting all day may negatively impact mobility skills. Exoskeletons are purposely built for rehabilitation and can assist you in developing your mobility, strength, and balance.

Ekso Bionics is a leading exoskeleton manufacturer which has been making the best-in-class medical exoskeletons for over a decade. Our mission is to create mobility solutions that help individuals recovering from a stroke, brain injury, spinal cord injury, and MS walk again. To learn more about the exoskeletons we create to benefit a variety of conditions, contact us at 510-984-1761 or request a free demo online.

Appendix:

1. The global burden of stroke: persistent and disabling https://pubmed.ncbi.nlm.nih.gov/30871943/
2. Stroke Facts | cdc.gov https://www.cdc.gov/stroke/facts.htm
3. (PDF) Effect of robotic exoskeleton gait training during acute stroke on functional ambulation https://www.researchgate.net/publication/350507385_Effect_of_robotic_exoskeleton_gait_training_during_acute_stroke_on_functional_ambulation
4. Robotic Exoskeleton Gait Training in Stroke: An Electromyography-Based Evaluation https://www.frontiersin.org/articles/10.3389/fnbot.2021.733738/full
5. Robotic Exoskeletons May Provide Health Benefits for People with Spinal Cord Injuries | National Rehabilitation Information Center https://naric.com/?q=en/content/robotic-exoskeletons-may-provide-health-benefits-people-spinal-cord-injuries
6. How can powered exoskeletons restore walking ability after stroke? – Physics World https://physicsworld.com/a/how-can-powered-exoskeletons-restore-walking-ability-after-stroke/