The reality of robots: Helping patients walk again

Robotic technologies in the field of neuro-rehabilitation are increasingly associated with improved patient outcomes. While the technology certainly aids the patient in learning how to walk again, perhaps a significant contribution to the process has gone unrecognized. The technology also has the potential to augment the work of the physical therapist in ways that might otherwise be impractical at best and impossible at worst. A recent example is the surge in adoption of robotic exoskeletons used to rehabilitate patients following a stroke, spinal cord or traumatic brain injury.

Rehabilitation after a stroke or spinal cord injury (SCI) can be grueling and expensive. According to the Canadian Heart and Stroke Foundation, stroke patients spend more than 639,000 days in acute care and 4.5 million days in residential care facilities, totaling $3.6 billion on an annual basis. Spinal Cord Injury Canada reports there are more than 86,000 people living with SCI in Canada—with an estimated 4,300 new cases each year, also resulting in an annual price tag of $3.6 billion. Worst of all, the gap between the hope and reality of rehabilitation for patients often times can’t be bridged. But that may soon change with new robotic tools to augments health care providers’ rehabilitative arsenal.

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The International Collaboration On Repair Discoveries (ICORD) will shortly be ushering in a new chapter in neuro-rehabilitation research with their recent acquisition of the Ekso™ robotic exoskeleton. ICORD is an interdisciplinary research center at the University of British Columbia and the Vancouver Coastal Health Research Institute focused on SCI and looking for more effective means of functional recovery and improved quality of life after SCI. There will soon be a new face of rehabilitation with robotic exoskeletal suits helping humans (patients and therapists alike) do the work to walk again.

Robotic Suit 3Ekso, a wearable robot designed by the Richmond, California-based company Ekso Bionics™, enables individuals with lower extremity paralysis or weakness to stand up and walk over ground with a natural, full weight-bearing, reciprocal gait. Walking is achieved by the user’s weight shifts to activate sensors in the device which in turn initiate steps. Battery-powered motors drive the legs, replacing as much – or as little – of the patient’s deficient neuromuscular function as is required to achieve ambulation.

“Ekso is an exciting technology for us because it provides us with a strategy to investigate the overall health benefits of getting patients with complete SCI up and walking again, including the possibility of relieving the many associated secondary complications of SCI,” commented Tania Lam, PhD, Principal Investigator at ICORD and an Associate Professor in the School of Kinesiology at the University of British Columbia. “The addition of the Variable Assist feature also opens up whole new research opportunities for investigating new gait training strategies for incomplete SCI patients. It helps to relieve some of the physical burden of doing over-ground gait training for patients while enhancing the physical therapist’s ability to conduct the rehab session. The therapist can focus on the quality of the stepping pattern without having to worry about maintaining the patient’s correct posture or supporting them. Everyone can focus on the actual act of walking.”

As a principal investigator at ICORD, Dr. Lam is continuously looking for ways to improve gait training. “We are very interested in pursuing research comparing over-ground gait training with the Ekso to current gait training strategies, such as body-weight supported treadmill training. Over-ground walking requires you to propel the body forward, not just stay in one place, which is what you get with a treadmill. The Ekso brings us closer to real-life walking contexts of going from Point A to Point B, supporting the foundation of actual walking, which requires integration with balance and postural control.”

Dr. Lam added, “We’re at the beginning stages but we’re very excited about the possibilities this new platform could provide. We also look forward to continued advances in the technology which could allow people to practice more skilled walking tasks, like walking up stairs or stepping over objects, that more closely align with real-world situations people encounter.”

Ekso’s innovative, task-based platform is designed as a practical and efficient means for physical therapists to help patients produce proper bio-mechanical alignments while re-learning proper gait patterns and weight shifts, and to achieve higher step dosage than what might be possible with traditional over ground gait training methods. This means therapists who may otherwise have opted to “pass” on gait training with the most acute patients to focus on smaller, more achievable rehabilitation goals now have a practical option to get them up and walking over ground under as much of their own power as possible. For patients further along in their recovery, it allows therapists to provide a more personalized and progressive care plan.

Aside from the clinical benefits, the latest version of Ekso also hosts practical benefits to clinics, making it easy to integrate into their practice and provide rehabilitation to a wide variety of patients in a single day. The device takes up no more floor space than a patient sitting in a chair and the detachable batteries can be charged from a standard wall outlet. While the technology accommodates a vast spectrum of patient sizes and clinical presentations, adjustments between patients can be done in less than five minutes.

The type of rehab a patient receives can have dramatic impacts on the time to recovery and the percent of recovery. Typically, physical therapists have the resources to utilize gait-training techniques, such as parallel bars or KAFOs, but these can be impractical for the patient as well as the staff. Conversely, body weight-supported treadmills can be complicated to install and set up, take up considerably more floor space, and don’t necessarily require patients to engage in the therapy, therefore slowing the rehabilitation trajectory.

All that’s required is a robotic suit, no larger than an actual person, instead of a team of trained specialists, expensive infrastructures built to house past robotic rehab systems, and special electrical requirements. The patient merely straps the robotic suit over his clothing and begins to walk. This enables individuals with lower body weakness to achieve mobility, strength, or endurance not otherwise possible. “Ekso is filling a gap in the rehabilitation continuum, so we’re looking forward to uncovering how this can be used most effectively in the care plan. The possibilities are exciting,” Dr. Lam stated.

“Companies have been building robots as a solution for paralysis for well over a decade,” says Ekso Bionics CEO Nathan Harding.  “The one thing we’ve come to realize is that the difference between a cool prototype and a viable product is huge. No one needs technology for the sake of technology.”

With the Ekso bionic suit, the company has developed a meaningful therapeutic robot that is both sophisticated and user-friendly. Added Harding, “It’s designed to work within the constraints of a real healthcare setting, and we feel it marks the beginning of a new chapter for both patients and practitioners. The goal was to design something that could help therapists get their patients walking on day one and yet help them progress along a rehabilitation program. It was important too that it was easy and efficient for therapists to use with a wide variety of patients.”

While ICORD is the first facility in western Canada with an Ekso, there are more than 40 systems placed in North America, Europe and South Africa. ICORD will initially use the bionic suit to conduct research studies in people with SCI. The wearable robot uses force and motion sensors to monitor the patient’s gestures and motion, and uses this information to intelligently interpret the intent and strength of the patient and translate it into appropriate action. It allows patients to walk in a straight line, stand from a sitting position, stand for an extended period of time, or sit down from a standing position. These seemingly simple acts might also be applied to a much broader patient population unlocking an entirely new approach to patient care, which could dramatically reduce healthcare costs and enhance lives.

In addition to helping those with some level of paralysis, the Ekso bionic suit could also provide benefits by getting patients who’ve been hospitalized up and out of bed sooner. Early ambulation may be directly tied to reduction in risk of deep vein thrombosis and even hospital-acquired pneumonia. In essence, this rehabilitative tool could get patients home faster and keep them healthier. That obviously translates to reduced healthcare costs.

The reality of leveraging therapeutic robotics to help deliver an affordable and effective healthcare system has never been closer. “To get people safely up and mobile could reduce secondary medical complications during the acute care phase but also over the lifetime of the patient,” Dr. Lam pointed out. “Many of the secondary complications that arise over the long term come from patients sitting all the time.” With the rise of obesity, an aging population and chronic health conditions, mobility aided by robotic exoskeletons could be a defining driver of mental, physical and even financial health.