Month: October 2022

Stroke, as defined by the World Health Organization, is an accident to the brain that has “rapidly developing clinical signs of focal or global disturbance to cerebral function, with symptoms lasting 24 hours or longer, or leading to death, with no apparent cause other than of vascular origin and includes cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage”. [1]

Stroke is ranked as the 5th leading cause of death worldwide and the leading cause of disability, with a new stroke happening every 40 seconds. [2] In the United States alone, approximately 800,000 people experience a stroke each year, and about two-thirds of this population require rehabilitation to get back to their lives. With the growing need for stroke rehabilitation each year, we aim to break down what stroke rehabilitation entails and highlight some of the modern physical therapy treatment techniques you can incorporate into your stroke rehabilitation program as a physical therapist. 

The Effectiveness of Stroke Rehabilitation

Stroke rehabilitation is a program of different therapy techniques put together with the aim of helping a patient relearn lost skills, optimizing how a patient functions, and increasing their level of independence in order to achieve the best quality of life. 

Effective stroke rehabilitation requires you to work closely with your patients, altering the different types of therapy depending on their needs and changing the intensity and time of their program based on their progress. Successful stroke rehabilitation depends on: 

• Physical factors like the severity of the stroke.
• Emotional status of the patient, for example, motivation, resilience, persistence, grit, consistency, etc. 
• Social support, for example, from family and friends. 
• Curative elements like early rehabilitation and the skills of the stroke rehabilitation team. 

These factors have been practically proven to impact the success of rehabilitation in real-world scenarios. In a 2017 randomized control trial, researchers concluded that rehabilitation combined with early supported discharge (ESD) “seems to reduce death and institutional care and to improve patients’ chances of living at home 5 years after stroke compared to traditional stroke care. There is a trend toward an improved functional outcome in the ESD group.” [3] 

One of the important elements of successful rehabilitation that has been proven in neurorehabilitation is focused repetitive practice. It’s the same element we use when learning new skills like writing, playing a musical instrument, or sports. Research shows that functions located in areas of damage are normally moved to other regions of the brain, and carefully directed practice can help in the rewiring of brain circuits in the new areas. [4]

According to research, early rehabilitation is associated with better outcomes, irrespective of the severity of the stroke. Thus, physical therapy should be offered early in the recovery process. In addition, if rehabilitation happens in a different location from acute care, the transition should be seamless. A review by Harutoshi Sakakima et al. alludes to physical exercise being a prototypical precondition stimulus that provides brain protection effects. [5]

There are many treatment methods that can be incorporated into a stroke rehabilitation program, but for this article, we will specifically focus on physical therapy techniques that aid in upper and lower extremity function recovery. 

Physical Therapy Treatment Techniques

There are many treatment techniques that can be used in upper limb and lower limb rehabilitation. Therefore, these ideas are not an exhaustive list of what’s available.

Lower Limb Rehabilitation: Gait and Mobility

Gait recovery is a primary goal in any rehabilitation program for patients recovering from stroke and can be achieved using the following interventions:

• Body Weight Supported Gait Training: This training method helps a patient control their weight, balance, and posture by using a harness that is mounted from a metal frame or ceiling. It can take place over a treadmill or over the ground. When using a treadmill, the patient is secured using a harness for fall prevention and then set up over a treadmill. Body weight-supported treadmill training provides more control over the ambulation speed, environment, and allows therapists to offer cues for proper gait dynamics. 

Therapists can control the effort required by patients during training by weighting or unweighting the patient using the suspension system. Unweighted training reduces the amount of weight borne by the patient and makes the patient feel lighter. This, in effect, makes the patient expend less effort during the training sessions.

Body weight can, however, be added back during training depending on the patient’s progress and abilities. Therapists can also help with stance with swing phases of gait, posture, knee control, heel strike, and limb advancement. Research reports that body weight-supported treadmill training can help improve motor function and balance. Additionally, it helps enhance gait quality compared to traditional gait training methods.  [6]

• Electromechanical Assisted: Electromechanical-assisted gait training is commonly used as a supplementary training technique for overground training. It’s great for completely immobilized patients as it helps them intensely practice complex gait cycles without overexertion on the therapists part. Robotic exoskeletons are popular in this category as they help increase movement during training while reducing therapists’ burden. They require less manpower for the same mechanical therapy that traditional rehabilitation methods use. Since the exoskeleton does most of the work, the therapist only needs to set the patient up in the device and supervise them. [7] 

Apart from increased repetition, exoskeletons can help patients relearn the proper walking technique from the start of the rehabilitation. They also offer other benefits like sensory feedback, weight support, and real-time control and monitoring features. Robotic exoskeletons are also advantageous in helping patients increase their range of motion. [8]

EskoNR is a leading robotic exoskeleton in use in rehabilitation clinics around the world. It is cleared by the Food and Drug Administration for rehabilitation and offers unique features to help patients learn to walk again. It provides different gait training modes that support the knees, ankles, hips, and torso and helps the patient maintain an upright posture. You can use it in the preGait mode or walking mode depending on the recovery level of your patient. The preGait mode contains activities that help prepare patients to take their first steps, like balancing and midline orientation. As a patient progresses in their recovery, the EksoNR reduces the support offered, allowing for more control and stability, eventually leading them to walk without the device. 

• Rhythm Cueing: Rhythm cueing involves the synchronization of movement to a uniform sound. Rhythmic cues are used to guide movement and influence motor execution, but they don’t have to be strictly rhythmic. According to research, rhythmic cueing can help improve timing in motor tasks that have complex timing and in conditions that affect how an individual perceives time with regard to movement. Having external rhythm can also help by supporting the mechanisms of the brain that are associated with keeping time. [9]

Successful gait training with rhythmic cues requires auditory inputs from different parts of the motor control system like the cerebellum, cerebral cortex, nervous system, and brainstem. Additionally, to achieve success, the gait must be well linked with the acoustic rhythm, and the speed of the metronome must be right. [10]

• Overground walking: Overground walking, also known as overground gait training, involves observing a patient’s walking pattern on a solid surface while cueing them to perform different activities that can help improve their gait. This is a simple and easy technique to incorporate into your rehabilitation program as it doesn’t require complex technology and can be done in a variety of locations. 
• Orthotics: Orthotics deals with the design of custom artificial braces and splinters that can be used to correct, support, or stabilize a body structure. One common type of orthosis used in lower extremity rehabilitation is an ankle foot orthosis. KNGF Clinical Guidelines recommend it for individuals whose mobility is affected by drop foot during the swing phase of walking. [11]
• Functional Electrical Stimulation (FES): This is a rehabilitation technique that uses low-energy pulses to activate weak muscles and nerves. Functional electrical stimulation has been in use since 1960. It relies on electrodes to stimulate the relaxation and contraction of muscle groups. One important and interesting thing to note is that it’s the nerves and not the muscles that are stimulated, as they have lower current requirements compared to muscles. Some of the factors that affect how electrical stimulation works include the size of the surrounding tissue and the distance between the nerve fiber and electrode.

FES application in rehabilitation settings is important because it helps promote motor recovery by providing visual and sensory feedback. It also helps avoid disuse atrophy, a common stroke complication resulting in muscle fiber changes. FES can help by correcting the muscle fiber changes by changing the type II glycolytic fibers back to type I oxidative skeletal muscle fibers.

• Balance Training: A stroke can cause weakness in one side of the body, leading to balance impairment. Hence the need for balance training and weight-shifting exercises. Researchers reviewed literature published between January 2006 and February 2010 and concluded that balance training is an effective technique for rehabilitating patients with stroke. [12]
• Stair Training: Stair training is a great training method for mobility rehabilitation as it helps patients recover their range of motion in slopped environments. In a 2017 study investigating the effects of stair task training on walking ability in stroke patients, thirty-six patients with stroke were selected randomly and divided into two groups: the experimental group and the control group. The study reported that the gait training group that used the 10-cm high stairs showed the biggest improvement in balance and muscle activities compared to the other group. These results conclusively showed that stair training is a viable rehabilitation technique in clinical environments and can be used to improve patients’ walking ability. [13]

In a 2021 randomized controlled study investigating the efficacy of lateral stair walking training in patients with chronic stroke, it was revealed that lateral stair walking improves hip muscle strength and gait in patients. Thus, stair walking can be added to rehabilitation programs to aid gait and balance improvement. [14]

• Strength Training: Strength training is a versatile technique that can be used to rehabilitate both the upper and lower extremities. While there isn’t a specific strength training approach for lower extremity rehabilitation, progressive exercise has been shown to help improve muscle strength and is recommended by Australian Stroke Foundation guidelines (2017) and the AHA guidelines (2010). [15] Although resistance training effectively improves strength, there is limited evidence supporting its influence on walking parameters. [15] [16] Common strength training exercises used in physical therapy target the quadriceps and hamstrings. 

Upper Limb Rehabilitation Practices

• Bilateral Arm Training: Bilateral arm training is a form of intensive training that involves performing movement patterns or activities with both hands at the same time but independently of one another. These movements or activities may also be cyclic. This method was created in response to CIMT’s (Constraint Induced Movement Therapy) known drawbacks, which include its inability to allow for the practice of bilateral skills, especially those involved in functional activities that are by their very nature bimanual. Both bilateral and unilateral training have the same positive effects. The severity of upper limb paresis and the timing of the intervention following the stroke, however, may affect the outcome of the intervention. 
• Constraint-Induced Movement Therapy: The goal of constraint-induced movement therapy (CIMT) is to encourage patients with hemiplegic stroke to practice moving their affected limb while restraining the unaffected limb. 

• Robot-Assisted Arm Training: Robot-centered training involves the use of mechanical devices to offer active, passive, and resistive limb movement. This method is great for extended treatment periods and can be customized to the needs of the patient by using their movement as feedback. Though there is limited evidence on the use of robot-assisted arm movement, it can be combined with other conventional therapy methods to provide better rehabilitation outcomes. According to a 2018 study, “People who receive electromechanical and robot-assisted arm training after stroke might improve their activities of daily living, arm function, and arm muscle strength.” [17]
• Strength Training: Strength training is designed to increase muscle strength and endurance. According to research, strength training has the ability to improve strength and function in the upper extremity without increasing pain in patients with stroke. [18] However, the intensity of strength training doesn’t affect outcomes, as shown in a recent study. Common strength training exercises that are commonly used in upper limb training include bridges, tricep dips, weight-bearing leans, tabletop lateral pushing exercises, tabletop forward pushing exercises, and bicep curls. For effective strength training, all the training exercises should be adjusted to the level of the patient’s ability.

Conclusion

All these training methods can be incorporated into a rehabilitation program in different combinations and at different times. The key to maximizing their effectiveness is tailoring them to your patient’s individual needs and abilities. When introduced early, they can help improve results and boost the success rate of your program. Above all, intensive practice is an important factor irrespective of the technique you choose. 

Ekso Bionics is a leading medical exoskeleton manufacturer on a mission to help patients learn how to walk again. EksoNR was one of the first FDA-approved medical exoskeletons for stroke rehabilitation. It is the exoskeleton of choice for many physical therapists and is available in rehabilitation clinics around the world. If you would like to procure an exoskeleton for your clinic, contact us by clicking here. 

References:

1. Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6288566/#B1
2. Acute Stroke – StatPearls – NCBI Bookshelf  https://www.ncbi.nlm.nih.gov/books/NBK535369/
3. Stroke unit care combined with early supported discharge improves 5-year outcome: a randomized controlled trial  https://pubmed.ncbi.nlm.nih.gov/21474806/
4. Post-Stroke Rehabilitation Fact Sheet | National Institute of Neurological Disorders and Stroke https://www.ninds.nih.gov/post-stroke-rehabilitation-fact-sheet
5. Endogenous neuroprotective potential due to preconditioning exercise in stroke – PMC  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6992848/#!po=18.4211
6. The Effect of Body Weight Support Treadmill Training on Gait Recovery, Proximal Lower Limb Motor Pattern, and Balance in Patients with Subacute Stroke – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4663281/
7.  Lower-Limb Robotic Rehabilitation: Literature Review and Challenges https://www.hindawi.com/journals/jr/2011/759764/
8. Robot-aided assessment of lower extremity functions: a review | Journal of NeuroEngineering and Rehabilitation | Full Text https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0180-3
9. Immediate Effects of Rhythmic Auditory Stimulation with Tempo Changes on Gait in Stroke Patients – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3996403/
10.  Walking to the beat of different drums: Practical implications for the use of acoustic rhythms in gait rehabilitation – ScienceDirect https://www.sciencedirect.com/science/article/pii/S0966636211000786
11. What Is the Evidence for Physical Therapy Poststroke? A Systematic Review and Meta-Analysis – PMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3913786/
12.  The effect of balance training on balance performance in individuals poststroke: a systematic review https://pubmed.ncbi.nlm.nih.gov/20716987/
13. Effects of stair task training on walking ability in stroke patients – PMC

Multiple Sclerosis (MS) is a leading cause of disability, affecting more than a million people in the US. There is no cure for MS, but there are treatments that can help slow the progression of the disease. [1] Exoskeletons present a more advanced and better rehabilitation solution for patients with MS to recover their mobility skills. And with the recent FDA approval, they might become an integral rehabilitation method in rehabilitation centers. This article explores multiple sclerosis, its causes, symptoms, and the application of exoskeletons in the treatment of MS. 

What is Multiple Sclerosis?

Multiple sclerosis is an inflammatory neurological condition that affects the central nervous system – optic nerves, spinal cord, and brain. It is commonly diagnosed in people who are between 20 years and 40 years. There is no known cause for MS, but research has shown that certain factors trigger the immune system to attack the central nervous system. The attack destroys myelin and damages the underlying nerve fiber. This disrupts communication signals from and to the brain, producing symptoms like memory problems, fatigue, paralysis, numbness, blindness, pain, etc. MS symptoms manifest differently in each patient, and they may be temporary or long-term. While there is no cure, medication and physical therapy can be used to manage its effects.

What Causes Multiple Sclerosis?

While the cause of MS has not been identified yet, researchers believe that different factors trigger it. Some factors under research include: 

1. Immunological factors: Abnormal immune response causes damage to the central nervous system. T cells and B cells are the two most prominent cells involved in the abnormal immune response. 
2. Environmental factors: According to research, MS occurs in areas that are farther away from the equator. Evidence shows vitamin D plays a critical role, and low vitamin D levels present a risk factor in developing the condition. Some scientists use sun exposure to explain the north-south distribution of MS, saying that people closer to the equator are exposed to more sunlight, hence lower MS prevalence. [2] However, epidemiologists are studying more patterns to establish a clear relationship.

Researchers believe smoking also plays a critical role in MS. Some studies show that smoking increases the risk of developing MS and contributes to severe symptoms and faster disease progression. [3]

3. Infectious factors: MS is associated with many bacteria and viruses. Some of the bacteria and viruses under investigation in the development of MS include: canine distemper, Chlamydia pneumonia, human herpesvirus 6 (HHV-6), measles, and Epstein-Barr virus (EBV). A recent study shows that previous infection with EBV puts you at a higher risk of developing MS. [4]
4. Genetic factors: MS is not passed down from one generation to another. However, researchers are investigating the genetic risk of inheritance. The risk of developing MS in a general population sample is about one in seven hundred and fifty, but the risk increases when first-degree relatives like parents and siblings have MS.

What Are the Symptoms of Multiple Sclerosis

Multiple Sclerosis symptoms are different in each person, and they can change over time. Some people only experience one symptom, while others experience numerous symptoms. Some of the symptoms commonly observed in people with MS include: 

• MS Hug (Dysesthesia): This is the feeling of squeezing around the torso. It can be likened to a tight blood pressure cuff around the arm and is the most common first symptom.
• Fatigue: Occurs in 80% of patients and interferes with work performance and engagement at home. 
• Numbness or Tingling: People with MS typically experience numbness of the body, arms, face, and legs. 
• Vision Problems: This is a common first symptom in many people and can include eye problems like neuromyelitis optica, poor contrast, blurred vision, and pain when moving the eyes. 
• Cognitive Changes: Cognitive changes can affect the ability to learn, recall, solve problems, pay attention, focus attention, and process information. This affects more than 50% of people with MS. 
• Emotional Changes: Emotional changes result from neurologic changes, but sometimes they can be a result of the stress of living with the condition. These changes can be in the form of irritability, anxiety, mood swings, and uncontrollable laughing or crying. 
• Walking (Gait) Difficulties: These mobility impairments are due to factors like fatigue, spasticity, and muscle weakness, among others, but medication, physical therapy, or assistive devices like exoskeletons can resolve them.
• Spasticity: This is the condition where there’s increased muscle stiffness and tone, which affects movement. It may also be accompanied by discomfort and pain

Exoskeletons for Multiple Sclerosis

An exoskeleton is an external device a patient wears to enhance their endurance and support their mobility. It can be battery-powered or mechanical. It is used to help the wearer stand, walk, sit and move their legs. Battery-powered exoskeletons manipulate the knee and hip joints to initiate movement while the wearer gains balance support using their upper limbs. The wearer can operate the exoskeleton on their own or with the help of a physical therapist. Exoskeletons are great for rehabilitation because they can be customized to a patient’s specific needs and abilities. 

EksoNR is the first and only exoskeleton cleared for the rehabilitation of people with MS by the FDA. It can also be used by patients recovering from a stroke, spinal cord injury, or acquired brain injury. EksoNR is uniquely different from other exoskeletons because it is not just an assistive device that provides all the power a patient needs to walk. Instead, its main focus is to help patients “walk out of the device and back into their communities”- Ekso Bionics Chairman and CEO Steven Sherman.

EksoNR is preprogrammed with specific movements that patients require during rehabilitation, like marching, weight shifting, squatting, and stepping. It also has therapist-programmed settings that can help set the amount of assistance based on the patient’s needs. Additionally, it has a cloud-based dashboard that records session data (speed, walking time, and distance) in real time. EksoNR is a game changer in rehabilitation, and it can help patients develop better balance, coordination, endurance, gait quality, and quality of life. 

Benefits of Exoskeletons

Using exoskeletons in physical therapy can help improve gait quality, muscle strength, and cognitive ability. 

1. Improved Gait Quality

In a study involving ten patients with MS, conducted by Kessler Foundation, patients were rehabilitated using an Ekso Bionics exoskeleton, and their recovery progress was compared to participants who used conventional gait training methods. The outcomes studied in this case were walking endurance, functional mobility, brain connectivity, and cognitive processing speed. After four weeks, the patients who used the exoskeleton were shown to have outperformed those who used conventional gait training methods. Additionally, these results were also corroborated by MRI brain scans.  [5]

In a 2021 randomized controlled trial investigating how exoskeletons affect gait speed and functional mobility in individuals with multiple sclerosis (MS), the researchers concluded that exoskeletons could help preserve gait speed and improve functional mobility.  [6]

2. Increased Exercise Intensity

Over-exertion is a big concern for people with MS because it contributes to the progression of the disease. The question then becomes, how can patients train without overexerting themselves? Another part of this puzzle is attending to patients who might not be able to achieve the required intensity in their exercise program. According to Brian M. Sandroff, Ph.D., lead investigator and a Senior Research Scientist at the Kessler Foundation’s Exercise Neurorehabilitation Research Laboratory, “One of the big problems is that people with MS who have a severe disability status in terms of walking might not be able to exercise at a sufficient intensity to elicit benefits.” [7]

Exoskeletons offer the solution in these two instances as they can help patients train intensely without over-exertion, as evidenced in a 2021 study. [6] They can also help patients with severe mobility disabilities to attain the required intensity for their progress. An exoskeleton like EksoNR allows physical therapists to customize the steps in each session, thereby reducing the possibility of over-exertion.

3. Improved Muscle Strength

Exoskeletons are extremely helpful and can help patients with different degrees of injury increase their muscle strength. They can also help patients with leg weakness to stand, walk, squat, and perform other movements. In a 2015 study of patients with spinal cord injuries, patients were shown to achieve walk times ranging from 28 to 94 minutes, with some averaging a speed of up to 0.21m/s. [8]

4. Improved Cognitive and Emotional State

Exoskeleton benefits go beyond physical improvements. They also affect a patient’s mental abilities. The direct involvement required from patients during the rehabilitation period can produce a psychological effect. Some exoskeletons like EksoNR keep track of a patient’s progress, and showing patients positive progress reports can help improve their hope and boost their morale.

Testimonial

Kathy Miska was diagnosed with MS more than 20 years ago. Over the past few years, Kathy’s symptoms have worsened and impacted her ability to walk. But thanks to exoskeletons, she can now practice and improve her mobility skills. She is one of the patients with MS at Cleveland Clinic’s Mellen Center for Multiple Sclerosis, participating in a study investigating the effectiveness of exoskeletons in MS rehabilitation.

Kathy reports, “My walking speed has increased, my endurance has improved, my gait is more normal, and I get intermittent periods of my leg getting signals from my brain,” After completing a total of 24 hours in the Ekso exoskeleton, over eight weeks, Kathy says, “I feel like I have really made progress. My posture looks better, and my walking has improved. Hopefully, this will get me stronger. It’s encouraging.” [9]

Conclusion

Introducing advanced technology in your rehabilitation center will help your patients achieve better treatment outcomes and improve the quality of their life. We’d like to point out that the exoskeleton is not intended to take over the work for the patient but to stimulate “nerve memory” so that the muscles can be activated. We aspire to help patients recover their walking ability and walk right back into their lives. 

Ekso Bionics is at the forefront of creating the best quality medical exoskeletons. Our mission is to create accessible mobility solutions for patients recovering from a stroke, brain injury, spinal cord injury, and MS. Would you like to outfit your rehabilitation center with one of our exoskeletons? Contact us at 510-984-1761 or request a free demo online. 

References: 

1. Landmark Study Estimates Nearly 1 Million in the U.S. Have Multiple Sclerosis https://www.nationalmssociety.org/About-the-Society/News
2. Vitamin D | National Multiple Sclerosis Society https://www.nationalmssociety.org/Research/
3. Multiple Sclerosis and Smoking https://nms2cdn.azureedge.net/cmssite/nationalmssociety/media/
4. Study Provides Strongest Evidence Yet for the Role of Epstein-Barr Virus in Triggering Multiple Sclerosis https://www.nationalmssociety.org/About-the-Society/News/
5. A pilot randomized controlled trial of robotic exoskeleton-assisted exercise rehabilitation in multiple sclerosis https://www.msard-journal.com/article/
6. Overground Robotic Program Preserves Gait in Individuals With Multiple Sclerosis and Moderate to Severe Impairments: A Randomized Controlled Trial https://pubmed.ncbi.nlm.nih.gov/33316225/
7. Robotic Exoskeleton Therapy Shown To Improve Mobility And Cognition In People With MS https://www.forbes.com/sites/gusalexiou/2021/05/30/
8. Time and Effort Required by Persons with Spinal Cord Injury to Learn to Use a Powered Exoskeleton for Assisted Walking https://pubmed.ncbi.nlm.nih.gov/26364280/
9. Robotic Device May Make Walking Easier for Multiple Sclerosis Patients https://my.clevelandclinic.org/patient-stories/

Stroke is the leading cause of disability.[1] In a report published by the CDC, about 795,000 people in the U.S have a stroke every year, with 610,000 being first strokes and nearly 185,000 being repeat strokes. [2] This results in reduced mobility, balance, and coordination. Stroke also limits social interaction and activities of daily living (ADLs) due to impaired mobility and balance.

If you are recovering from a stroke, you’ll generally be subjected to a few weeks of inpatient rehabilitation which targets the recovery of independent ambulation. After rehabilitation at the hospital, you’ll be discharged and given a cane, brace, walker or wheelchair, depending on the progress of your recovery.

Stroke Mobility Aids

Mobility devices are apparatuses that support the user’s mobility and help them move around. These include walkers, canes, wheelchairs, and even orthotics. They may help increase your independence, reduce residual disability, and slow the decline of certain functions.

1. Rolling Walker

Rolling walkers help support mobility by providing balance and supporting the leg muscles. To move forward, apply force with your arms and make a step in the direction you wish to go. There are two types of walkers: 2-wheel walkers and 4-wheel walkers. Some walkers have seats which can allow you to take a break anywhere.

Walkers are a great mobility device for people who are not entirely immobile. However, when using a walker, the body uses the hips for balance instead of the ankles. This inadvertently leads to reduced ankle sway, which results in decreased ankle strength and flexibility, prompting a decline in mobility.

2. Cane or Quad Cane

Canes are normally used to steady the body while in motion, contributing to improved balance and lower risk of falling. The quad cane is the best option for people who need a little support —using a cane when walking increases your base of support, providing you increased balance. When in motion, it causes your center of gravity to shift in the cane’s direction. This reduces postural sway which aids in mobility and balance.

3. Wheelchair

Wheelchairs are great mobility devices if you are completely immobilized or get fatigued easily. There are different chair designs and options available in the market, but the most important thing is to ensure that a wheelchair is specifically designed for your needs and environment. The comfort of the person using the wheelchair is vital because poor fit can lead to discomfort. It can also cause back injuries, reduced mobility, skin breakdown, and affect how well they can propel the chair. Therefore, always consult with a healthcare professional in order to get the type of wheelchair that addresses your specific needs.

4. Orthotics

An orthosis is an artificial external device that is created to support a joint or body part. It is normally used to offer the wearer stability, protection, and support. An orthosis varies depending on the area of the body they are being worn and can be fabricated or custom-made. Ankle-foot orthoses are commonly prescribed to individuals recovering from a stroke. They are used to improve gait by providing support to the knee and ankle, helping to keep your toes from dragging on the ground when swinging that leg, and keeping you steady over that foot when you are putting weight on it. The main function is to help you become more independent with your activities of daily living (ADLs) and mobility. Just like a wheelchair, selecting the right device is essential to get the best support and results.

There are also orthoses that can be used if your muscles have become tight. Two types may help assist you in stretching and recovering the lost range of motion:

• Static orthosis: It cannot move and is normally used to apply force to a joint and hold it in a position to increase the passive range of motion.
• Dynamic orthosis: It is mobile and is worn to support the proper movement of a joint.

When prescribed, orthoses are used to maintain range of motion, manage pain, prevent contractures, protect tissues, support weaker muscles, prevent unwanted movement, and increase function.

Exoskeletons for Stroke Recovery

Walkers, canes, wheelchairs, and orthotics are great devices for mobility. However, not all individuals recovering from a stroke will be able to practice walking or use them in their daily life, especially if they need more assistance from their therapist. This is where the exoskeleton comes in. An exoskeleton is a powered robotic gait training device that is used to support the movement of lower limbs through repetitive overground walking practice.

One such exoskeleton that the FDA approves for the rehabilitation of individuals recovering from a stroke, brain injury, spinal cord injury, and MS is EksoNR. It re-trains the user’s brain and the muscles on how to walk again by ensuring the most natural gait pattern is achieved during rehabilitation. EksoNR is currently available for use in more than 400 rehabilitation centers around the world.

EksoNR’s Features and Benefits

EksoNR contains special features designed to help you regain mobility quickly and effectively. They include:

1. Pre-ambulatory tools – This is a set of programs designed to help you make a step, squat, balance, and shift your weight before walking. It helps form the foundation of necessary movements.
2. Adaptive gait training – EksoNR contains sensors and software that monitor and correct leg movements to reduce compensatory gait patterns.
3. Smartassist software – Your physical therapist can customize the amount of support EksoNR offers in the swing and stance phases of walking, depending on your impairment level.
4. Clinician control – With EksoNR, it is possible to set training goals and change the assistance levels for each leg based on the goals you have set and the feedback after the session.
5. Posture support – To help maximize rehabilitation sessions, EksoNR provides support by ensuring proper postural alignment as you move.
6. Data capture – Your physical therapist can access all session data and analytics on the cloud-based dashboard that saves progress and data in real-time.

Ekso Bionics has had massive success in mobility rehabilitation. According to a health professional, Dr. Jennifer Cohen, MD, “Ekso helps us get patients up, out of bed, and ambulatory as soon as possible.” Duncan Monger, PT, DPT, CBIS, also says, “We were able to see an immediate impact on the patient’s ability to perform bed mobility, transfers, and independence with all functional activities after one session with the device. This device has greatly improved our patient’s outcomes while decreasing physical assistance required by staff members.”

Benefits of Exoskeletons

The impact of exoskeletons on stroke recovery is undisputed. They can help in gait training, ambulation, and improve motivation, among other related benefits.

1. Ambulation

If you are recovering from a stroke, you may experience gait deficits like reduced mobility, speed, and asymmetrical walking patterns, which affect your ability to ambulate. Robotic exoskeletons help with correcting gait deficits which help with ambulation. They are used for gait training, guiding weight shifts, and improving step patterns and cadence.

In a study investigating the effects of robotic exoskeletons on functional ambulation in adults with stroke, it was reported that exoskeletons help increase functional ambulation. Additionally, it’s an effective way of providing high-dose therapy without increasing the duration of training. [3]

2. Gait Rehabilitation

Traditionally, gait training involves exercising on a treadmill with the assistance of physical therapists. On the other hand, exoskeletons help you improve your gait by practicing your walking movements repetitively and correctly with anatomically aligned motors. This also aids in the strengthening and recovery of leg muscles and improves coordination. Exoskeletons also track progress and document improvement, which can be used to analyze your rehabilitation progress. According to a recent study, combining exoskeletons and conventional gait training therapy may lead to better results and a more efficient gait.  [4]

3. Improved Motivation

Rehabilitation sessions with exoskeletons include walking time which is a huge morale and motivation booster, especially if you cannot move. Moving and holding conversations at eye level in an exoskeleton is empowering and may help improve your enthusiasm. This can lead to more steps per session and increased functional independence. [5]

4. Reduces Burden on Physical Therapists

Rehabilitation can sometimes be taxing and very exhausting for therapists. Fangshi Zhu, Senior Biomedical Research Scientist at the University of Texas Health, says, “Traditional therapy usually involves two or three physical therapists manually guiding a patient’s impaired limb to follow and reinforce the desired trajectories, which can be very labor-intensive and even unsafe.” [6] This limits results as physical therapists cannot provide enough high-dose, task-specific repetitive gait training during the acute stages of recovery.

With exoskeletons, you only need one physical therapist to guide you through an exercise. This frees up physical therapists to attend to more people. Additionally, exoskeletons can deliver so many gait repetitions during the acute recovery phase, which helps in positive rehabilitation outcomes.

Conclusion

There are many mobility devices available for people who are recovering from a stroke. However, they are not the foolproof solution in mobility rehabilitation. For example, wheelchairs cannot help you practice your walking skills. In fact, sitting all day may negatively impact mobility skills. Exoskeletons are purposely built for rehabilitation and can assist you in developing your mobility, strength, and balance.

Ekso Bionics is a leading exoskeleton manufacturer which has been making the best-in-class medical exoskeletons for over a decade. Our mission is to create mobility solutions that help individuals recovering from a stroke, brain injury, spinal cord injury, and MS walk again. To learn more about the exoskeletons we create to benefit a variety of conditions, contact us at 510-984-1761 or request a free demo online.

Appendix:

1. The global burden of stroke: persistent and disabling https://pubmed.ncbi.nlm.nih.gov/30871943/
2. Stroke Facts | cdc.gov https://www.cdc.gov/stroke/facts.htm
3. (PDF) Effect of robotic exoskeleton gait training during acute stroke on functional ambulation https://www.researchgate.net/publication/350507385_Effect_of_robotic_exoskeleton_gait_training_during_acute_stroke_on_functional_ambulation
4. Robotic Exoskeleton Gait Training in Stroke: An Electromyography-Based Evaluation https://www.frontiersin.org/articles/10.3389/fnbot.2021.733738/full
5. Robotic Exoskeletons May Provide Health Benefits for People with Spinal Cord Injuries | National Rehabilitation Information Center https://naric.com/?q=en/content/robotic-exoskeletons-may-provide-health-benefits-people-spinal-cord-injuries
6. How can powered exoskeletons restore walking ability after stroke? – Physics World https://physicsworld.com/a/how-can-powered-exoskeletons-restore-walking-ability-after-stroke/