Overground robotic training effects on walking and secondary health conditions in individuals with spinal cord injury: systematic review

Abstract

Overground powered lower limb exoskeletons (EXOs) have proven to be valid devices in gait rehabilitation in individuals with spinal cord injury (SCI). Although several articles have reported the effects of EXOs in these individuals, the few reviews available focused on specific domains, mainly walking. The aim of this systematic review is to provide a general overview of the effects of commercial EXOs (i.e. not EXOs used in military and industry applications) for medical purposes in individuals with SCI. This systematic review was conducted following the PRISMA guidelines and it referred to MED-LINE, EMBASE, SCOPUS, Web of Science and Cochrane library databases. The studies included were Randomized Clinical Trials (RCTs) and non-RCT based on EXOs intervention on individuals with SCI. Out of 1296 studies screened, 41 met inclusion criteria. Among all the EXO studies, the Ekso device was the most discussed, followed by ReWalk, Indego, HAL and Rex devices. Since 14 different domains were considered, the outcome measures were heterogeneous. The most investigated domain was walking, followed by cardiorespiratory/metabolic responses, spasticity, balance, quality of life, human–robot interaction, robot data, bowel functionality, strength, daily living activity, neurophysiology, sensory function, bladder functionality and body composition/bone density domains. There were no reports of negative effects due to EXOs trainings and most of the significant positive effects were noted in the walking domain for Ekso, ReWalk, HAL and Indego devices. Ekso studies reported significant effects due to training in almost all domains, while this was not the case with the Rex device. Not a single study carried out on sensory functions or bladder functionality reached significance for any EXO. It is not possible to draw general conclusions about the effects of EXOs usage due to the lack of high-quality studies as addressed by the Downs and Black tool, the heterogeneity of the outcome measures, of the protocols and of the SCI epidemiological/neurological features. However, the strengths and weaknesses of EXOs are starting to be defined, even considering the different types of adverse events that EXO training brought about. EXO training showed to bring significant improvements over time, but whether its effectiveness is greater or less than conventional therapy or other treatments is still mostly unknown. High-quality RCTs are necessary to better define the pros and cons of the EXOs available today. Studies of this kind could help clinicians to better choose the appropriate training for individuals with SCI.

Efficacy of Overground Robotic Gait Training on Balance in Stroke Survivors: A Systematic Review and Meta-Analysis

“…These factors may suggest that o-RAGT devices allow an increment in patient motivation, participation and attention. In recent years, various powered overground exoskeletons have been commercially developed to assist and allow overground walking [ 31 , 45 ]. o-RAGT efficacy on balance function was partially considered in a single meta-analysis that did not include only full leg EXOs and in which the devices were mostly associated with BWS.…”

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

“…In practice, at the moment, there is a wide variety of exoskeletons, stationary (Lokomat) or autonomous support systems for hip and knee, hip-knee-ankle, or a single joint. A systematic review (2021) identified 25 autonomous exoskeletons, of which only 6 had FDA approval (Ekso, HAL, Indego, REX, ReWalk and SMA) [ 18 ] ( Figure 3 ) [ 3 ].…”

“…Autonomous exoskeletons such as Ekso, Indego, and ReWalk were used in the treatment. The results show an improvement in intestinal function [ 3 ].…”

“…Following SCI, an irreversible motor and sensory deficit occurs (spasticity, muscle paralysis, atrophy, pain, gait disorders, pain) [ 2 ]. This pathology has implications on the whole organism: on the osteoarticular, muscular, cardiovascular, respiratory, gastrointestinal, genito-urinary, skin, metabolic disorders and neuro-psychic systems [ 3 ].…”

Comparison of the dynamics of exoskeletal-assisted and unassisted locomotion in an FDA-approved lower extremity device: Controlled experiments and development of a subject-specific virtual simulator

“…The ReWalk (ReWalk Robotics, Yoknaem, Israel) was the first lower extremity device to receive Food and Drug Administration (FDA) approval in 2014, followed by the Ekso (Ekso Bionics, Richmond, CA) and Indego (Parker Hannifin, Cleveland, OH) in 2016, and the Keeogo (B-temia Inc., Quebec City, Canada) in 2020. Prior studies have demonstrated the ability of individuals with neurological disorders who have partial impairments to those who are completely non-ambulatory to walk independently in robotic exoskeletons [8][9][10][11][12][13][14][15][16][17][18][19]. Exoskeletal-assisted locomotion (EAL) has been shown to improve functional and motor recovery [8], mobility [9,10,15,16], chronic pain [20], muscle spasticity [20][21][22], cardiovascular health [13,23], bowel function [24], bladder function [21,22], and quality of life [21].…”