The Effectiveness and Safety of Exoskeletons as Assistive and Rehabilitation Devices in the Treatment of Neurologic Gait Disorders in Patients with Spinal Cord Injury: A Systematic Review

Abstract

Study Design Systematic review. Clinical Questions (1) When used as an assistive device, do wearable exoskeletons improve lower extremity function or gait compared with knee-ankle-foot orthoses (KAFOs) in patients with complete or incomplete spinal cord injury? (2) When used as a rehabilitation device, do wearable exoskeletons improve lower extremity function or gait compared with other rehabilitation strategies in patients with complete or incomplete spinal cord injury? (3) When used as an assistive or rehabilitation device, are wearable exoskeletons safe compared with KAFO for assistance or other rehabilitation strategies for rehabilitation in patients with complete or incomplete spinal cord injury? Methods PubMed, Cochrane, and Embase databases and reference lists of key articles were searched from database inception to May 2, 2016, to identify studies evaluating the effectiveness of wearable exoskeletons used as assistive or rehabilitative devices in patients with incomplete or complete spinal cord injury. Results No comparison studies were found evaluating exoskeletons as an assistive device. Nine comparison studies (11 publications) evaluated the use of exoskeletons as a rehabilitative device. The 10-meter walk test velocity and Spinal Cord Independence Measure scores showed no difference in change from baseline among patients undergoing exoskeleton training compared with various comparator therapies. The remaining primary outcome measures of 6-minute walk test distance and Walking Index for Spinal Cord Injury I and II and Functional Independence Measure–Locomotor scores showed mixed results, with some studies indicating no difference in change from baseline between exoskeleton training and comparator therapies, some indicating benefit of exoskeleton over comparator therapies, and some indicating benefit of comparator therapies over exoskeleton. Conclusion There is no data to compare locomotion assistance with exoskeleton versus conventional KAFOs. There is no consistent benefit from rehabilitation using an exoskeleton versus a variety of conventional methods in patients with chronic spinal cord injury. Trials comparing later-generation exoskeletons are needed.

The Ability to Walk After a Spinal Cord Injury with Emphasis on Exoskeletons: A Review

“…Morganti et al [12] showed a significant positive correlation between the WISCI and SCIM (r=0.97, p<0.001).…”

“…This way, the patient's voluntary drive is integrated in the walking pattern. This mechanism could lead to neuronal plasticity and possibly result in increased mobility even when not wearing the exoskeleton [12].…”

“…Following SCI, the central nervous system is able to recover locomotor function with the help of functional locomotor training [10,11]. Literature shows that the greatest recovery occurs during the first year after a SCI; even with continuous rehabilitation therapy, there are often no further improvements seen [12]. To regain locomotor function, patients with incomplete SCI depend strongly on visual input to compensate for proprioceptive deficits and impaired balance.…”

“…after a complete lesion, and assist in SCI patients with mobility and to facilitate locomotion therapy. The purpose of exoskeletons is to facilitate standing and walking, as well as assist in rehabilitation [12]. However, different applications of exoskeletons exist; to provide mobility in complete SCI and as rehabilitation system for incomplete SCI.…”

“…Some are controlled by a joystick (Rex-Bionics, Lokomat, WPAL, and Kinesis), others have a posture controlled system (Re-Walk, EksoBionics, Indego). The HAL exoskeleton has electromyographic (EMG) control [12]. Despite the many different exoskeletons, the ultimate goal is to help patients to walk as naturally as possible.…”