In this fascinating QLI webinar, Brad Dexter, DPT provides a comprehensive overview of robotic exoskeletons. Get an in-depth look at some of the products that are on the market today, learn about some of the benefits of robotic exoskeletons, find out who is a good candidate, and get a glimpse into the future of this amazing technology.

Speaker: Brad Dexter, DPT

Video Transcription


Fun topic today for me, at least. Hopefully it’s fun for you guys too. We’re going to be looking at Robotic Exoskeletons. Really just wanted to give you guys an overview of what is currently on the market, what’s being used. Perhaps you guys are familiar with some of the devices on your end. But then, wanted to just discuss that from a therapy standpoint. Why we would be using them, and discuss maybe even some future trends, future directions of some of these devices as well.

The Chasm Between Early Market and Mainstream Market Exoskeletons


So we certainly, like any other facility too, we have tours, we have people that are interested in some of the equipment that we have. And you know, when I’m thinking about the world of exoskeletons, where I normally began, when I’m having conversations about exoskeletons, is with this curve, right?


I think, it seems like some of the exoskeletons that are currently on the market have jumped the chasm that you see on this slide within the rehabilitation realm. So as a rehabilitation product, some of these have jumped to the chasm and are being directed toward rehabilitation facilities that are serving populations with neurological types of injuries. And those devices have been proving themselves to be a great mode for therapists to be able to utilize, to challenge individuals when it comes to retraining walking patterns. Something for you to keep in mind for later in the presentation here is that some of these devices are also getting approval for home use. And I think we’re really right in this early market range for something like that. So there’s really not a ton of research, not the strength or the body of research out there right now that needs to be there.


It’s being worked on. There are several studies that are happening. But there are a number of other things that are maybe preventing those devices from jumping that chasm and becoming more of a mainstream type of product. If you discuss this with some of the inventors, the engineers on some of these devices and certainly individuals that perhaps have neurological types of injuries, I think the end game is that they would want to see these devices replace a wheelchair. You know, it seems very futuristic to think about that, but I think that would be the large scope vision. Are we close to that? We’re not really close to that right now. But, I think that would be the large vision. There was a commercial on… Maybe it was during the holiday season last year, where there was a grandfather that put these bionic legs on and stood up and he was dancing with his granddaughter in the living room.


And, something like that I think is where a lot of these companies are going, and what they would ultimately like to see out there on the market. So I put this into the presentation just to give a vision for where some of this is at currently. Really, like I said, in the rehab side of things, we’re really probably in this early majority, we’ve jumped from early adopters of the devices into an early majority for rehabilitation use. But in terms of home use, which again, we’ll talk about a little bit later in the presentation, there’s very few of those out there currently, and it’s really on that early market, early side of the bell curve.

Exoskeletons from the Physical Therapist Point of View


So, I want to take a look at this from a physical therapist point of view. When I’m working with the people that we’re serving at QLI, and I know colleagues of mine that are using some of these devices, what they are thinking and what they’re being trained on with these exoskeleton devices is for either pre-gait exercise. And when I say gaits, I’m talking about walking, just to clarify that word. And so they’re either working on pre-gait or they’re working on walking gait specific movements. So when I think about walking, the visual that you have in front of you right now is what I’m thinking about. Right? Very basically, we have stance phase and we have swing phase. And I’m delving into this because this is how some of these robots are designed. So there’s stance phase and there’s swing phase.


You can imagine if you were to stand up right now and you were to just walk across the room and slow your walking down, you could feel that, oh, there is a stance phase where I’m standing on one side and my opposite leg is starting to swing through to take a step, right? During stance phase, you have heel strike, where your foot is hitting the ground, and then your body weight shifts forward in this loading response. As you continue propelling yourself forward, you move into that mid-stance phase. And then body momentum continues carrying forward into terminal stance, where you go into a push off or a pre swing at the end of stance phase. And when you leave pre-swing and you go into toe-off, that’s the beginning of swing phase on that side. So you can see toe-off, you can see mid swing, where the foot is above the ground, and it’s advancing forward, into terminal swing where then the entire process repeats itself.


So, the folks that we’re working with, with say a spinal cord injury or a traumatic brain injury. Could be a stroke. Perhaps it’s multiple sclerosis, Parkinson’s, we’re looking at disorders of gait, disorders of movement. And ultimately I’ll be breaking some of this down in my mind, and I’ll try to figure out what aspect of gait, of walking do we need to work on? Perhaps I have an individual that is really good in stance phase. So they’re able to control their ability to push their body weight upright, but they’re unable to initiate or get their leg all the way through swing phase. Another example might be someone that has a little bit of motion at the hip, where they could perhaps initiate swing, but as soon as maybe the foot hits the ground, they’re unable to push their body weight back up against gravity. And that could be from any type of diagnosis, it could be from a spinal cord injury, or it could be from a stroke or brain injury, so on and so forth.


So, normally breaking this down, and figuring out what are my deficits, what are the challenges that I have? And from a therapeutic standpoint, now, what mode of exercise or what therapeutic intervention do I need to apply to the individual that I’m working with to get success? All right. So I’m going to come back to this again in a little bit, but I wanted you to see that in your mind, and know that these devices that we’re going to go into are all based off of this gait pattern. And they’re going to operate off of this gait pattern.

Exoskeleton Product Overviews



So, let’s dive into some of the products, the players. So to say. I’m going to start off with the EksoGT by Ekso Bionics. This is one, just so you guys know, I’m most familiar with this device. I’ve been using this device for the longest period of time, and have seen it evolve over the years too. Many of these devices that we’re going to see in this presentation actually began in the early 2000s.


You know, if you look over the course of history, a lot of innovation and technology is derived from or through times of war. And in particular, nearly 2000s, obviously we were in a war in the Middle East at that time. And there were government grants to develop robotic exoskeletons, to assist some of our troops that were over there in carrying heavy equipment, over long distances, rough terrain. And, so many of them maybe got their start out of grants like that. Ekso Bionics in particular was one of those companies. They’re based out of California, and their device has evolved from what they originally began doing with it, for use for our troops to the rehabilitation setting at this point. They do have a line for the upper extremity, for repetitive use types of movements within the industry setting. You know, if you’re carrying heavyweight, or if you’re doing the same movement over and over, they have a device that offloads the weight of the arm and eases what the arm is doing over a long period of time.


But this device, what we’re talking about today is more of the gait training devices. Another aside would be that historically within physical therapy there have been individuals that have maybe used knee, ankle, foot orthosis, that would stabilize their knee and maybe help them walk with straight legs, if they have the ability to at least flex or advanced the leg from the hip. There were other individuals that used reciprocating gait orthosis. So, if they perhaps had a spinal cord injury in their low back, and were unable to move their legs anymore, maybe they would get a reciprocating gait orthosis, that would allow them to do some amount of residential walking. All of the research on that says that it’s terribly energy inefficient. Most people, when they’re using those types of orthosis, it’s very difficult because they’re bearing much of their weight through their arms.


And then they’re using muscles that aren’t normally used to advance a leg to advance a leg. So, those devices have some amount of spring loading to them. And then you use different muscle groups to get the legs to advance. Not a great device for community ambulation or getting up and downstairs, or even walking relatively long distances within the residential setting. And so, you don’t see as many of those anymore. They can be great to get people up into a standing position. But I would say some of these devices have also evolved from those types of orthosis. And so there’s some amount of mimicking there too. So the EksoGT by Ekso Bionics is actually the first exoskeleton that’s been cleared by the FDA for both stroke and spinal cord injury. And for spinal cord injury, it’s really an injury at the level of C seven and below.


Now, I’ll tell you with this device and with any of the other devices, they’re used outside of that FDA clearance too, within the rehabilitation settings. You have an individual that is spotting from behind with this particular device, and with the EksoGT you have to determine whether or not an individual is appropriate for the device. Do they have appropriate range of motion in their lower extremities? Do they have any damage to their skin pressure ulcers that would be compromised due to the placement of any of the straps or portions of the device? Do they have the ability to use their upper extremities to help with weight shifting side to side or manage an assistive device? Do they fit the parameters of the device itself? So do they meet the height requirements? So we’re looking at five foot two, to up to six foot four. Do they meet the weight requirements?


We’re looking at 220 pounds as the maximum weight. And I’ll tell you, we’ve used this with people very small. We’ve used it with people very tall. We’ve also had people in it that are right at that 220 pound mark. The overall lifespan of this device is right around four years, or they’ll say around 2 million steps as well. Which again, depending on how quickly you do all of those steps, perhaps that lifespan is a little longer. What I’ve been learning with our use of some of this equipment over the years is much like our smartphones. The smartphone itself might not change, but your software might update. And sometimes your software might update and you might require a new platform or a new phone to support that software. Right? And so just like any other technology, as their platform evolves and changes, maybe becomes a little bit more powerful, you have to upgrade the entire device to manage the software too.


So, Ekso in particular has done a nice job of incorporating the computer in it to be able to allow software changes to be updated within that computer. I’m sure at some point in time that will advance. It will change. And we in particular will need to update our device in order to accommodate software changes too. But those are things to think about from a rehabilitation standpoint in particulars, that you have to adjust with the technology if you want to keep it around as well. This particular device has the ability to provide maximal assistance in both lower extremities. So if I get someone in the device, I could program it to say, I want you to give this person every single step. So I could do that.


Or I could take away some of that support. I could do a right affected side. So say my left side was normal with the individual that I’m working with, but the right side was the only side that was affected. So that could be honestly, someone with a spinal cord injury, a brain injury, a stroke. You have some amount of weakness just on one side. With the one side that is affected, I would basically design what I want the step to look like in the computer. So from a physical therapist, point of view, I’m coming back to that swing phase aspect. I’m going to say, I want the step to be this long. And I want the step to be this high. And I want the step to happen this quickly, right?


And then, because I’ve designed this program, so that it’s just a right affected program the left side is going to be freed up. So they have normal strength in that leg. They would be able to step normally through with the device and the right leg then, the motors in the right leg would help propel the right leg through the step pattern. Right? What happens if I have an individual that perhaps they can stand up on their own. Maybe they have a strong side and they have a weak side, but the weak side is actually able to step through. Well, from a PTs point of view, I may want to design their walking program then to essentially challenge that step. So I might want to provide some total resistance through the step itself. In that case, I might open up the robot and go into a mode called two free. In that mode both of the legs would have the ability to let the user step through entirely on their own. But I can also change the amount of resistance that I’m giving through that step, or I could amplify the individual’s movement too.


So if they’re at a point with that weak side where they need a little bit of help to get through, I can amplify the movement to make the step look better for them. If they’re at a point where they can step through, but perhaps I want to strengthen that leg through the entirety of the stepping pattern, I may add some resistance to that side. So there’s a lot of variability in a lot of different programming that can happen with the EksoGT and as you see, as we go through some of these other devices, we can do that as well. I do want to mention, as we go along, if you guys have questions on particular devices, I’m happy to answer those as we go through. So feel free to shoot those off to us at any point. And my colleagues here will help me identify those questions and we can try to answer them for you in the moment too.


The end goal with any of these devices is can we get away from them? So I’m using them from a rehabilitation standpoint to retrain that stepping mechanism, to retrain walking, with the intent that it acts as maybe an on ramp to get to overground walking, maybe that’s with body weight support, or maybe that’s without body weight support or exoskeleton. And they can just go straight to overground walking. We do you have a question here before we leave the EksoGT? What is the cost of the EksoGT? I can speak to what we paid for ours a couple of years ago, and we upgraded our device. At that point. It was about $80,000 to upgrade. When we originally got our device around five years ago, it was close to $160,000 to get the device. Have another question asking, can you use this for retraining someone with a stroke? And answer to that question is absolutely.


So where I was speaking about being able to design the robot. So you could do say a right affected or a left affected side. You can have the robot working unilaterally. So an individual with a stroke would be able to utilize this. Their normal leg would be freed up and their involved side after a stroke would get the support from the robotic exoskeleton. The whole point of these robots is that as a therapist, we’re always trying to get a specific type of movement. So we know what normal walking looks like. We know what normal stepping looks like. We’re trying to normalize that movement as much as possible. And if you guys, any of you that have worked with individuals with these neurologic types of injuries, you can pretty easily recognize movement that’s been affected by these injuries. And so we’re just trying to normalize that by affecting the quality of the movement, designing a specific trajectory of walking.


Another question came in, have you seen these used in workers comp cases yet? I’m going to save that question for the end. So I’m just going to leave you hanging there. Okay. Does insurance cover it? Another question? That’s great. I’m going to come back to that in a couple slides. And one more question. You said there was a 220 pound weight limit on this particular device. Is there a device that does something similar for heavier individuals? What I know of right now for the devices that are off tether, you don’t need a body weight support system with them. Most of them are right around that 220 or 230 pound maximum weight capacity. And some of that is just, when you’re trying to design something that’s not too heavy and you’re putting these smaller motors on it, so they’re not huge. There’s only so much that you can safely do with those smaller motors.


And so there is, I’m getting ahead of myself towards the end of the presentation here, but future directions are going to require getting things to be stronger, but smaller and more durable.



I’m going to move on to the next product, which is the Indigo. The Indigo is developed by a company called Parker Hannifin. You know, one of the things that I like in particular about this device is how lightweight it is. For a reference point, the EksoGT that we were just looking at weighs around 50 pounds. So as a therapist that is putting that device together and helping get it onto an individual to use it with them, the weight of that, you don’t really feel it when you’re walking, but as a therapist, you can feel the weight.


The EksoGT weighs around 50 pounds. The Indigo weighs right around 23 pounds. So it’s very lightweight, it’s modular. So what I mean by that, if you look at this picture, we can break it down into different components, right? You can look at the bottom part of the leg and where it attaches at the knee joint, and you can detach those parts from one another. Same thing with the upper leg component, where it says indigo, on there. You can detach that upper leg component from the hip and pelvis part of the device. So really, the picture that you see in front of you there is five different parts. It’s the pelvic part, both of the upper legs and both of the lower legs. And so their design is very unique. One, because it’s lightweight, but two, because it is modular. So that gives it the ability to break down, to be carried.


In a case, a user of this device is able to put it on say in their manual wheelchair and would be able to get up from their manual wheelchair, using the device on their own too, once they were trained with it. This is FDA approved for both stroke and spinal cord injury. And it’s FDA approved for both helm and clinical use. It’s labeled more from a T3 to T5 spinal cord injury. The reason that it’s at that point for the spinal cord, they’re really looking at full upper extremity use. So if you remember back to the EksoGT, they had a C7 and below basically. And when they identified that for FDA approval, it was really someone that has triceps and would be able to manage an assistive device on their own. With this particular device, you can see it does not have a back support that comes all the way up the back.


It’s really just that pelvic support. And so, in order to use it a little bit more independently, the user needs to have a little bit better trunk control and good arm use to be able to manage an assisted device. Right now in the US, electrical simulation is being utilized in the indigo within research studies. So that is not FDA approved currently, but it is being used at certain sites within research studies. I believe in Europe, electrical stimulation is being incorporated within regular therapy sessions with individuals. You might ask why are we incorporating electrical stimulation into this?


They’re looking at any of these designers of these products, these companies are looking at how do we access the motor system even more efficiently? So we’re able to help an individual, maybe amplify their movement, or take a better looking step to retrain those stepping patterns. But how can we get the specific muscle groups at specific times to fire so that we can retrain the motor system even better, even more efficiently? So that’s one reason why they are starting to incorporate some electrical stimulation. If the indigo is lighter, is it durable? That’s one question that just came in. And another one is how often has the patient fallen while using the Indigo. If out in public, how do they get up, assuming with assist of people around them? To answer the first question. Is it more durable? I’m getting away all my answers here, too.


You guys are great with your questions. But, I’m going to repeat myself at the end of the slideshow. I think, overall durability is something that needs to be incorporated into these from material science standpoint, moving forward. They have done a great job, but you can imagine if these are being utilized within a rehabilitation setting where many people are using them throughout the day, over time, some of those products are going to break down a little bit more. So speaking with, and I have not used the indigo on a regular basis personally, but have several colleagues that I’ve consulted that use it on a regular basis. And, I think they would say that the Ekso is probably slightly more durable than the Indigo. It’s not way out there more durable, right. But there is a little bit more durability to that because it’s not modular.


So the folks that I’ve spoken with that have been using this device usually say there are some repairs more often that need to happen with the device too. Just so you guys know, you guys will have access to this slideshow at the end of it too. To answer the other question. How often has a patient fallen while using the Indigo? I can’t answer that question specifically. I know the falls on a lot of these devices are fairly low. They’ve done a really nice job from a safety standpoint, training therapists and for the small number of people that have gotten these devices for home use, they have to go through a large series of tests to be deemed safe and do training with either family members or with a therapist that are going to be either spotting them or providing supervision while they’re walking with them.


The lifespan on this particular device is right around five years. You’ll see, that’s a theme as we go through some of these devices too.



The next one I want to talk about is the ReWalk. The ReWalk is, I think one that’s actually been on the market for maybe the longest period of time right now. So more people might be accustomed to, or have heard of the ReWalk before. This one is FDA approved for home or clinical use as well. So home or rehabilitation use. So again, Indigo and ReWalk are the only ones that have both rehabilitation and home approval through the FDA. This is labeled as spinal cord injury, levels T7 to L5. And again, lifespan is five years. These devices, they all have sensors or accelerometers that are going to help with driving the movement of the robotics system. But the user has to be involved in that.


So here, with this device, an individual with a spinal cord injury would be… If they didn’t have any movement in their legs and they were using this, they would have to shift their weight side to side, using their arms to ultimately get a step to propel the device forward at that point. I do want to differentiate again, because when we’re using these devices, we’re not just using them with individuals that can’t move their legs. We’re using them with a lot of individuals that are needing retraining of walking. And, that’s why it’s important that with the programming in these devices, we’re able to design what that walking looks like, so that we can retrain their motor system. And I’m going to get to some really fancy principles with you guys here in a little bit on what we’re trying to achieve during our therapy sessions as well.


So, ReWalk is another one of the players that is on the market. Someone asked a question earlier about, has insurance covered these devices? To my knowledge, because ReWalk and Indigo are the only devices approved for home use by the FDA, my understanding is that the ReWalk is only one of those devices that has gotten approval through commercial insurance. I’m not sure necessarily how they’ve done that. And I don’t know that the numbers are high on that. But I do know that has happened through commercial insurance.



The last one that I wanted to highlight in this discussion is the HAL. So it’s the Hybrid Assistive Limb. This is made by a company called Cyberdyne, which is originally out of Japan. The thing that sets this robotic device apart is that it relies on bioelectric signals to drive the movement.


So coming back to the other devices, we were just talking about the EksoGT, the Indigo, and the ReWalk. All of those are designed to move based off of a weight shift. There’s some amount of user input. So, the individual being in the machine, making the step happen by the strength that they have in their leg, and or accelerometers that are in these devices. The how is going to move off of basically signals that are coming from the muscle groups. So, if you want to take a step, there’s a specific muscle that you need to fire in order to take a step. So it’s going to be relying on the brain generating that signal to initiate that step. And what that does, you know, we’re always talking from a therapy standpoint about what can we do from the bottom up? So what can we do to affect the body to drive this process of neuroplasticity or change within the nervous system? But also what can we do from the top down? So what can we do in the brain to generate movement in the appropriate place?


And oftentimes, there’s a roadblock somewhere in the nervous system that is preventing the signal to get through, right? So that’s what sets us apart, is it’s being driven off of bioelectric signal. This has been FDA approved for spinal cord injury from level C4 to L5. And from T11 to L5. You can see the C4 to L5 is an ASIA C or ASIA D type of injury. And T11 L5 is the ASIA A or ASIA B. Again, that’s just differentiating an individual with an ASIA C or ASIA D type of injury. It’s probably going to have a little bit more lower extremity movement, even with a higher level spinal cord injury. Whereas an Asia, a or Asia B type of injury, if it was a higher level injury, they wouldn’t have enough support through their arms or their trunk, but because they are T11 through L5, they’re going to have trunk and arm support to be able to support themself in the device.


Lifespan of this is five years. We’re doing a demo on this product here in a couple weeks, and I’m looking forward to seeing it and using it a little bit more in person. I’ve seen it, and been able to trial it in a couple different conferences over the last year. But this is one that has really just come out in 2018, and has been stateside since the beginning of 2018.

Other Options


Few of the things that I just wanted you guys to be familiar with. Rex Bionics is a very large device. My take on it is, it seems like a really fancy stand table. That’s not a knock to their company or anything. I think there’s a lot that you can do in it from a therapy standpoint, but it’s not necessarily incorporating long distance walking, and it’s not necessarily generating, allowing the individual to generate or produce lower extremity movement.


The Phoenix SuitX is a newer one that they’re seeking FDA approval based out of California. Their spin is at their device. They’re trying to get a device that has a better price point. So their price point is around $30,000, which is a lot lower than some of the other ones. The Indigo I think is around… I told you the Ekso. The Indigo is around 125. And the ReWalk I think is around $75,000 or $80,000. So the Phoenix SuitX, they’d be shooting to have like a $30,000 price point with their device, and want to make it more affordable, essentially.


Do you have a price point on HAL?


Price point on the HAL, I do not have a specific price point on the HAL, because their model is a little bit different. They’ve been seeking to do a month to month leasing model, is what my understanding is. So there’s not a pricing model to just buy the device outright.


And then I’m sure many of you guys are familiar with the Lokomat. I only put it in this presentation because I wanted to differentiate between the Lokomat and some of the other devices that I’ve been talking about. So, the Lokomat, you can see it’s a larger device made by Hocoma. It is great. I think, especially as you’re just starting to retrain people and their walking mechanisms, it has a larger footprint, and it’s based with a body weight support system, and it’s over treadmill. The other devices that we’ve been hitting on are overground. You can really go anywhere with them. And that’s next generation robotics that we’re looking at in this presentation too. So if you’re familiar with the Lokomat, I’m setting that type of device aside, it does have robotic legs that have some variability to them and how they are used. But it’s a stationary product. And it’s treadmill training with the robotic device certainly has its place along the continuum.


Again, if you think about individuals with neurological types of injuries, that you can’t just put them in a box, they fall anywhere along a continuum, right? You can have people that are on the low end of that continuum and people on the high end, and then anywhere in between. And I think from a rehabilitation standpoint, we need to be meeting people’s needs and providing the opportunities to challenge motor control in whatever way we possibly can.

How Are These Devices Being Marketed?


Okay. So we’ve hit on this a little bit, but how are these devices being used and marketed. And really, I’ve just divided this into a rehabilitation model and a home use model. Because that’s how the FDA approval for many of these currently looks. There’s FDA approval for rehabilitation use and there’s FDA approval for home use.


And again, I think I’ve talked about this throughout, but I don’t want these to just be seen as just devices that people can get so they can be walking within their homes. Right now, the primary usage of these is as a clinical tool. They require a lot of skilled decision making, not just before you even get someone in, you have to think about, is this person appropriate for use? Do they fit the parameters of the device? Are they safe to use it? But then once you get them in, you got to know what you want to get out of it too, and why you’re using it. And so there has to be a specific design within the software of the robot itself, that the therapist needs to be able to incorporate in order to accomplish and move towards some of those goals.

Benefits of Exoskeletons


Some of the benefits of use that have been coming out of some of the research that have been coming out over the last couple years. I think most of us could agree that standing and moving is better than sitting, right? And so if you think about individuals that are in wheelchairs majority of their day, there are going to be things that come along from a negative aspect, or that are going to affect their health in a negative aspect just from sitting and not moving. Standing, whether that’s in a standing frame or getting electrical stimulation to stimulate muscle groups, or getting up into an exoskeleton to walk can have positive benefits. So one of those benefits has been improvements in bowel and bladder function with regular walking training, improvements in bone density, changes in balance for individuals that have use of their lower extremities.


It’s improvements in standing balance. And for individuals that have impairment or don’t have use of their lower extremities, it even changes in their sitting balance or their dynamic sitting balance as they perhaps do a slide board transfer. We’ve seen changes in gait speed, particularly with individuals that have had strokes. So individuals that have had a stroke that use the device, retraining the trajectory of their step has led to changes in gait speed, which ultimately leads to changes in safety as well. Pain management. So individuals that again are having chronic pain or neuropathic pain of their lower extremities, movement is a key ingredient to changing that pain cycle for them. And so standing up, stepping, going through that movement pattern has had a positive effect from the pain management standpoint. Not to mention the psychological benefits, the emotional impact that you see there on this slide as well. Standing, moving. Many people have reported in the research that they have improvements in their tone and spasticity for anywhere from two to three hours up to days at a time, just from standing and stepping with these devices. And then overall lifestyle impact as well.


So you can imagine that the psychological, emotional impact of doing this plus the physiological impacts can have a change in lifestyle, perhaps even leading to healthier lifestyle.

Principles of Motor Learning


I alluded to this earlier, but these are some of the fancy things that we’re considering from a therapy standpoint on a regular basis. And these are just principles of motor learning. You guys can look at this list, and I’m thinking about this when I’m developing a therapy session for an individual within our exoskeleton device. The first one there is use it or lose it. It’s pretty, pretty simple, right? If you’re not using a muscle group that you have access to, it’s going to get weaker and lose it. You could potentially lose it over time. If you use a muscle group that you have access to, you can improve it, right?


You can challenge it. And physiologically, we know that we’re going to see better recruitment of muscle fibers through the nervous system. And we’re going to ultimately see some hypertrophy or growth within those muscle fibers. Specificity. So if you want to retrain a movement, you need to do that movement, right? If you want to retrain walking, you need to be on your feet, retraining walking. And that goes into the quality of movement, the quality of the trajectory pattern as well. If you want to learn how to play the guitar, you can’t just sit there without a guitar and think about playing the guitar. You need to have a guitar on your lap doing it. Specificity matters. Repetition matters. We know that it takes a lot of repetition to actually make some of those physiological changes within the nervous system.


Intensity matters. So there’s a difference between getting up within a therapy session and taking a hundred feet worth of steps in a body weight support system, versus getting a thousand steps in within a therapy session. Yes, that’s repetition, but it’s also raising the intensity because you have someone in a standing position and they’re having to access those muscle groups for a longer period of time. Time matters. So we always know, after a neurological type of injury, the length of time after an injury matters as well, right? Recovery, you’re going to get a lot more recovery earlier on after an injury than later on. And so there’s definitely a push to get some of these devices. Even earlier within the rehabilitation process, there are some facilities that have them across their continuum of care, from the acute setting, into their inpatient rehab setting and their outpatient rehab setting as well, with the intent that they’re getting people moving earlier on. Salience matters. Importance, right?


So the importance of the activity to the individual matters when we’re trying to reteach a motor pattern. Walking is very important to a lot of people. Age matters. So, when it comes to learning younger brain learns a little bit more readily than older brain. That doesn’t mean that older brain cannot learn. It just means that process and the changes that happen to a 10 year old or a 20 year old are going to happen maybe a little bit more quickly than that 60 or 70 year old. Transference of skills and interference of skills are a couple more principles that are on there. Transference is basically, can we take the motor movement that we’re working on within a therapy session and can we move it into real life, or into a different setting?

Ambulation Progression


I’ve alluded to this continuum, right? And this is that continuum or ambulation progression that I’m talking about. You can see on here at QLI, we’ve just identified where do some of these exoskeleton devices fit in? How can they be used? What types of people would they be used with? What would our goals be with these individuals when they’re in these specific phases? So you’re a pre-walker, your early walker, your mid-range or therapeutic walker and your functional walker, what are those goals? Those goals are right underneath. And then the modes. So maybe the devices that you might use to facilitate some of those goals within that specific phase are underneath there. And you can see our exoskeleton or any exoskeleton really fits along that continuum throughout at least 75% of it before maybe you need someone or someone would not qualify for it because they’re high enough level.

Home Model


Again, I’ve alluded to this home model as well. And we’ve had a few questions regarding home use that have come through the Indigo. And the ReWalk are the only ones that have home approval currently. Again, standing versus sitting. We know the benefits of standing versus sitting. But I think there’s some caution to be had here too. Again, these devices are relatively expensive currently. We’re not confident in the durability of them. They have a really strong usage point within the rehabilitation setting, but I don’t know that the evidence is there quite yet to have them in the home setting, if that shift happens… And, there are some devices in the home settings, the VA is paying for those work. I think there have been some work comp cases that have gotten them. And like I mentioned, there are some commercial insurances that have paid for a few devices too. Not to mention private pay. But if you’re faced with those decisions, I think you need to be cautious.


You need to get a lot of thoughts before moving forward with something like that. And, then you want to make sure that it’s going to be put to good use. You don’t want this to be a device that ends up being a clothes hanger somewhere in the house, right? And so you want someone that’s going to be motivated to use it. That is going to be using it on a regular basis. And so this is just a small decision making algorithm that we’ve put together. One, you have to determine is the individual good candidate. Yes or no. If they are, they should go through a trial and training at a center of excellence, a place that is using that particular device on a regular basis. And at which point there’s a decision making process, that should be a group collaboration to decide. Maybe this isn’t appropriate. Maybe it should only be used within a clinical setting, or hey, would it be appropriate to ultimately purchase that device?

Who is a “Good” Candidate?


You know, some things that we’ve identified as well, who’s a good candidate. We noted that on that decision making algorithm. Maybe it’s someone that needs a kickstart that you’re working with. Would it enhance their quality of life? Would it reduce care needs in the long run, right? Is it going to make them healthier in some way, shape or form? Is it going to prevent concomitant health conditions? And ultimately they would have to meet that inclusion criteria.

An Adequate Trial


That adequate trial is going to lead to an accurate assessment of compliance reduction and medication, psychosocial changes as well as functional or physiological improvement. Again, I think before you would make that decision to pay for a device, I think there’s a lot that needs to go into that decision making process and a lot of thoughts that need to go into it.

Exoskeleton Trial


In terms of functional changes, these would be objective measures that we’d be looking for from a functional change standpoint. You can see specific measures within the gait change category. Specific measures within the balance change category. And then within the cardiopulmonary system, resting heart rate, baseline, blood pressure.

The Future of Exoskeletons


Again, future. Competition’s good. So you saw a lot of devices on here. Competition drives change, right? Competition breeds improvements in this stuff. But more research needs to be done. We need to know where these can be used, how they can best be used, what changes are happening, and they need to sell themselves in some way, right?


And ultimately we’ve hit on some of these too, along the way, but we need to see improvements in durability of the motors, of the materials that are being used, of the computers, the cost, the price point. You know, we’d love to see that come down a little bit more. We need them to be more safe, prevent falls speed, I think needs to change as well too. So the speed of these devices aren’t necessarily fit for community types of walking right now. And we need to be able to overcome environmental barriers. So we don’t live in a flat world, right? There are lots of obstacles that exist out in the community. And so if there are devices to be used within the home or within the community, there’s work that needs to be done to incorporate all of those changes.

Categories: Assistive Technology, Ekso, Uncategorized