Training Persons with Spinal Cord Injury to Ambulate Using a Powered Exoskeleton

Abstract

Powered exoskeletons have become available for overground ambulation in persons with paralyses due to spinal cord injury (SCI) who have intact upper extremity function and are able to maintain upright balance using forearm crutches. To ambulate in an exoskeleton, the user must acquire the ability to maintain balance while standing, sitting and appropriate weight shifting with each step. This can be a challenging task for those with deficits in sensation and proprioception in their lower extremities. This manuscript describes screening criteria and a training program developed at the James J. Peters VA Medical Center, Bronx, NY to teach users the skills needed to utilize these devices in institutional, home or community environments. Before training can begin, potential users are screened for appropriate range of motion of the hip, knee and ankle joints. Persons with SCI are at an increased risk of sustaining lower extremity fractures, even with minimal strain or trauma, therefore a bone mineral density assessment is performed to reduce the risk of fracture. Also, as part of screening, a physical examination is performed in order to identify additional health-related contraindications.Once the person has successfully passed all screening requirements, they are cleared to begin the training program. The device is properly adjusted to fit the user. A series of static and dynamic balance tasks are taught and performed by the user before learning to walk. The person is taught to ambulate in various environments ranging from indoor level surfaces to outdoors over uneven or changing surfaces. Once skilled enough to be a candidate for home use with the exoskeleton, the user is then required to designate a companion-walker who will train alongside them. Together, the pair must demonstrate the ability to perform various advanced tasks in order to be permitted to use the exoskeleton in their home/community environment.

Robotic Rehabilitation and Spinal Cord Injury: a Narrative Review

“…Several individual studies on specific exoskeletons and feasibility have been conducted. For example, the systems ReWalk [27,29,[39][40][41][42], Ekso [39,43,44], Indego [45,46], Exo-H2 [47], Arke [48], and X1 Mina [49] have been found to be practical for use. In addition to investigations of feasibility, several reviews have explored outcomes that relate to the efficacy of EAW.…”

Haptic Cues for Balance: Use of a Cane Provides Immediate Body Stabilization

“…Powered exoskeletons enable persons with various walking problems to ambulate over the ground. Several of these devices require the use of crutches to ambulate and maintain balance (Wang et al, 2015 ; see Asselin et al, 2016 ). Beyond their obvious mechanical effects (Bateni and Maki, 2005 ), crutches are a critical source of somatosensory inflow that provides information about body orientation with respect to the supporting surface through “extended physiological proprioception” (Simpson, 1974 ).…”

Systematic Review on Wearable Lower-Limb Exoskeletons for Gait Training in Neuromuscular Impairments

“…We found only one study [66] reporting falls, which occurred in three patients: two of them when they were starting to ambulate with forearm crutches, and the other patient fell down during a sit-to-stand transition (because of mechanical programming errors as mentioned in the original study). A total of 18 studies reported mild to moderate adverse events such as orthostatic hypertension [115,116], skin abrasions [21, 48, 64-66, 90, 110, 117-123], fatigue of the upper extremities [116,120], low back pain [66,91], and other adverse events such as urinary tract infections [119], talus fracture [119], dizziness [90], calcaneus fracture [116] and severe knee hyperextension [116]. Studies also described that skin abrasions were reduced using padding and size adjustments, and that fatigue of the upper extremities improved with practice.…”