DEPARTMENT OF DEFENSE - CONGRESSIONALLY DIRECTED MEDICAL RESEARCH PROGRAMS

Perspectives for Robotic Exoskeleton Use in Persons with Spinal Cord Injury Across Rehabilitative and Community Settings

Posted March 25, 2022

Allen Heinemann, Ph.D., Shirley Ryan AbilityLab

Allen Heinemann, Ph.D., Shirley Ryan AbilityLab Allen Heinemann, Ph.D.
Shirley Ryan AbilityLab

The integration of robotic exoskeletons in rehabilitation and community settings is an extremely promising new avenue for improving locomotor function and quality of life in Veterans and civilians with spinal cord injuries (SCIs). However, due to rapid technological development and the rising costs of health care, it is crucial to carefully evaluate the clinical utility of exoskeletons, associated cost vs. conventional therapy, community accessibility, and most importantly, how they can best meet the needs and priorities of persons with SCIs. To address these key issues, Dr. Allen Heinemann at the Shirley Ryan AbilityLab (https://www.sralab.org/) was awarded a Fiscal Year 2016 Spinal Cord Injury Research Program (SCIRP; https://cdmrp.army.mil/scirp) Qualitative Research Award from the Congressionally Directed Medical Research Programs (Award # W81XWH-17-1-0157). His grant focused on examining the perspectives, wants, needs, and perceived challenges for exoskeleton prescription in rehabilitative and community settings for civilians and Veterans with SCIs and their care partners. To accomplish this important task, Dr. Heinemann and his team engaged three key stakeholder groups: prospective exoskeleton users with SCI (Heinemann et al., 2020), current exoskeleton users with SCI (Kinnett-Hopkins et al., 2020), and clinicians who guide rehabilitative training and prescription (Ehrlich-Jones et al., 2020). In the following sections, we highlight some of Dr. Heinemann’s important findings across these three focus groups (Note: Readers are highly encouraged to follow each of the paper links above and read the numerous participant quotes and identified themes for a more complete perspective).

Prospective Users of Robotic Exoskeletons for SCI Rehabilitation and Community Use:

The first set of focus groups involved examining the perspectives of individuals with SCI who are potential users of robotic exoskeletons at three regional rehabilitation hospitals (see Heinemann et al., 2020). The final sample included 35 adults with SCI, diverse in terms of race and ethnicity but predominantly male (17% female), which likely reflects the majority of new SCI cases in the United States. Participants were shown several video clips of research participants engaging in rehabilitative activities with exoskeletons and recorded narration of features and costs. After viewing these videos, participants engaged in a moderated discussion about their positive and negative perspectives regarding exoskeleton usage and cost. Several themes that were important to prospective exoskeleton users were identified after coding the focus groups transcripts and are summarized in the table below:

Positive Themes / Benefits Negative Themes / Challenges  
Psychological benefits:
  • Potential users said that being upright and eye-level during parenting, work tasks, and conversations with others was a huge positive.
Physical benefits:
  • Posture correction, stretching, weight bearing, prevention of pressure wounds, reduction of spasticity, and improving bowel and bladder function.
  • Augmenting existing rehabilitative therapies for greater functional recovery.
Exorbitant costs:
  • The majority of individuals with SCI felt as though these devices are cost-prohibitive and that the small businesses involved may be risky.
Decreased independence:
  • All of the robotic exoskeleton systems available require a caregiver to help with the long process of taking it on and off, and there are associated risks with falling.
  • Battery life is fairly short for someone with an SCI (at an average of 6 hours in one case), further necessitating additional trainers or caregivers to be present to facilitate use.
Device limitations across environments and tasks:
  • Current technology does not fare equally well across environments; problems can arise in extreme temperatures, uneven terrain, and security settings.
  • While exoskeletons do allow significantly enhanced mobility, it doesn’t make all activities possible and it’s not a “magic bullet.”

                                                                      Manufacturer recommendations identified from prospective users  
  • The primary considerations focused on cost, battery life, and independent use. Focus group participants recommended increased warranties and part replacement plans given the exorbitant cost.
  • It was recommended that manufacturers focus on improving exoskeletons to facilitate everyday tasks for those with SCI. In other words, prioritizing what is meaningful for this community by engaging them during the development process.
  • Participants suggested that manufacturers consider partnerships with clinics so that the financial burden isn’t completely on the user (e.g., via facility-owned exoskeleton devices for rehabilitation, or rental programs).

Current users of robotic exoskeletons in SCI rehabilitation:

The second set of focus groups involved examining the perspectives of individuals with SCI who are current users of robotic exoskeletons at three regional rehabilitation hospitals (see Kinnett-Hopkins et al., 2020). The final sample included 28 adults with SCI who were predominantly white (61%) and male (32% female). Participants were involved in a moderated discussion of the physical and psychological benefits, limitations, and challenges the users have experienced with their robotic exoskeletons across different types of tasks. Several important themes are captured in the table below:

Positive Themes / Benefits Negative Themes / Challenges    
Psychological benefits (including improved parenting and relationship intimacy):
  • Several users described how “fun” and “cool” being able to walk in a robotic exoskeleton was, as was being able to walk for the first time in years for some participants.
  • Users reported great benefit in interacting with others at eye-level and doing simple tasks (e.g., one user said, “I just felt like I was mother again. And then when I got to look at my husband, and honestly I remember when I was over there with my husband and he kissed me just standing up, and he had tears in his eyes ... usually you’re rolling and they’re walking.”)
Physical benefits:
  • Improved bowel/bladder function and control.
  • Significantly reduced pain when using the robotic exoskeleton (e.g., one user said, “Usually I walk in and my pain level is about a 6-7, while I’m walking in the suit it’s gone as low as 2 to zero, which is great.”).
  • Improved balance and mobility after several usages of the suit. (e.g., one user said, “Immediately, I mean, I was able to take I think maybe 30-something steps the first day and I was like, wow, that’s great, and now we’re working our way up past like 1,200 or something like that if it’s a good day.”)
Availability:
  • Due to limited access, Food and Drug Administration hurdles, and associated costs, participants had the most experience using exoskeletons in research settings, making generalizability to community settings more difficult.
Independence:
  • Exoskeletons can be intimidating and difficult to use at first and require significant training and caregiver availability.
  • Required to have a companion at almost all times due to safety and difficulty of use (e.g., fall risk, pressure ulcers, and skin compromise).
Unmet expectations and device limitations:
  • Most devices require both hands, limiting the usefulness of exoskeletons for work tasks, automobile access, and going up stairs, etc.
  • There was a lot of praise for exoskeletons in therapy settings, but current users generally thought the usefulness of exoskeletons for everyday tasks was extremely limited and sometimes inferior to a wheelchair setup.
  • Users noted that the public sometimes focuses on things like “being able to stand” whereas that may not be the most meaningful aspect to anyone with an SCI (a parent might prioritize abilities to do other things than walking, for example).

                                                                                      Priorities for manufacturers identified from current users  
  • Greater mobility, faster speed, lighter weight, and ability to walk up and down stairs were mentioned frequently.
  • Ability to use the robotic exoskeleton safely and quickly without a caregiver present, with appropriate safety features preventing complications like pressure ulcers or falls.
  • Compatibility with wheelchairs so users do not feel limited to one system.
  • Reduced cost, increased availability, and accessible training.

Clinician and administrator perspectives about robotic exoskeleton development and utilization:

The final set of focus groups and interviews described the experiences of clinicians who use robotic exoskeletons in their practice with the purpose of guiding clinical decisions and training strategies related to robotic exoskeletons (see Ehrlich-Jones et al., 2020). The final sample included 40 clinicians across three regional rehabilitation hospitals and one VA Medical Center; these clinicians were asked about their preferences, experiences, training strategies, and clinical decisions related to the utilization of robotic exoskeletons in physical rehabilitation for their patients with SCI. In general, clinicians reported that persons with SCI need to be coached with realistic expectations for improving function, especially when considering the vastly different starting points for different individuals. Moreover, users need to have a high compliance mindset with instructions and safety precautions. Clinicians generally agreed with users that needing a caregiver for putting it on, using it, and taking it off was a major drawback to current exoskeletons. They also emphasized the need for increased safety precautions, accessibility, and better caregiver training for the adoption of this technology in clinics and community settings.

Conclusion:

By examining the lived experiences and key perspectives of different stakeholder groups (prospective and current robotic exoskeleton users and associated clinicians), Dr. Heinemann’s SCIRP study reveals the enormous potential of robotic exoskeleton utilization in the SCI community, but also several key areas that are priorities for future development for individuals with SCI. Indeed, the development of these technologies can rapidly and unintentionally outpace or become divorced from the desires and needs of users with SCI. This work emphasizes the importance of maintaining focus on the lived experiences, priorities, desires, and needs of those with SCI, especially as these rehabilitative technologies rapidly develop. Indeed, this SCIRP study suggests that these key perspectives should be centered across research, policy, and clinical practice discussions. It’s also important that we carefully examine who is involved in this process and to actively make it be equitable and inclusive. For example, while not a weakness of the studies, in both the prospective and current user studies (Heinemann et al., 2020 and Kinnett-Hopkins et al., 2020), women comprised only 17% and 31% of the sample, respectively, which makes sense as new SCI cases are more likely to skew male. Despite this, a common theme discussed was how the development of these technologies skews more male-involved (in users, research participants, design considerations, etc.) and thus, the treatment needs and perspectives of minority groups are not as frequently or thoroughly captured to guide clinical practice discussions, creating unintentional disparities. In summary, these stakeholder focus group studies suggest that while robotic exoskeletons may represent a promising future for SCI rehabilitation and community integration, they have a long way to go and many improvements to make before they are the standard of care for individuals with SCI.


References:

1. Heinemann AW, Kinnett-Hopkins D, Mummidisetty CK, et al. 2020. Appraisals of robotic locomotor exoskeletons for gait: Focus group insights from potential users with spinal cord injuries. Disabil Rehabil Assist Technol 15(7):762-772. doi: 10.1080/17483107.2020.1745910. Epub 2020 Apr 7. PMID: 32255369.

2. Kinnett-Hopkins D, Mummidisetty CK, Ehrlich-Jones L, et al. 2020. Users with spinal cord injury experience of robotic locomotor exoskeletons: A qualitative study of the benefits, limitations, and recommendations. J Neuroeng Rehabil 17(1):124. doi: 10.1186/s12984-020-00752-9. PMID: 32917287; PMCID: PMC7488437.

3. Ehrlich-Jones L, Crown DS, Kinnett-Hopkins D, et al. 2021. Clinician perceptions of robotic exoskeletons for locomotor training after spinal cord injury: A qualitative approach. Arch Phys Med Rehabil 102(2):203-215. doi: 10.1016/j.apmr.2020.08.024. Epub 2020 Nov 7. PMID: 33171130.

Links:

Public and Technical Abstracts: Evaluating the Utilization and Efficiency of Wearable Exoskeletons for SCI Rehabilitation

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Last updated Thursday, March 24, 2022