5 Stakeholders Every Rehabilitation Center Should Consider When Buying Exoskeletons


There’s been an explosion in the creation of rehabilitation technology over the last 10 years. As rehabilitation professionals, we’re fortunate to provide our patients with more opportunities for recovery than we ever have. However, these technologies are often costly capital purchases which can be challenging to justify in an environment where reimbursement rates and lengths of stay continue to decline. Therefore, it’s essential to critically evaluate each piece of technology for potential purchase to ensure maximum return on investment for our specific patient populations.

Interdisciplinary Team Evaluation

When evaluating a piece of rehabilitation technology, it’s vital to take an interdisciplinary approach to ensure stakeholders’ needs are met. Some of the groups you should involve in the evaluation process include:

  • Therapists who will be using the technologies daily.
  • Senior administrators who understand the financial impact of the technology.
  • Researchers to evaluate the research potential of the technology.
  • Engineering to assess maintenance and warranty issues.
  • Most importantly, patients and caregivers in order to understand their true goals and priorities.

​​5 People Who Should Be Involved in Exoskeleton Purchase Decisions

1.     Therapists: Acceptance and Responsibility

Therapists are extremely motivated to help patients recover. They commonly go above and beyond to ensure their patients reach their maximum potential. In order to embrace technological advances, they need to be included in the decision-making regarding the initial purchase of a piece of advanced technology as well as how to implement the device in their continuum of care.

When making these purchasing decisions, therapists must be responsible for evaluating the clinical utility of these technologies, such as how many therapists/aides are required for the initial setup of the device and how long the setup process takes. They need to complete a literature search to understand the known efficacy of the interventions provided by these technologies for the specific patient populations they treat. They must also put time and thought into how these devices will be implemented into their continuum of care, from inpatient rehabilitation through outpatient and community programs. This information will be a large part of their contribution to the interdisciplinary team evaluation of advanced technologies for purchase in their organization.

2.     Senior administration: Cost Approval

A member of the senior administrative team must be included in the evaluation of exoskeleton purchases. This team member is responsible for understanding the financial picture of purchasing this device, including, but not limited to, the following: initial capital purchase price; ongoing maintenance, and warranty packages; and must share with the team the fiscal priorities for the organization over the next 3-5 years. It is crucial to understand not only the immediate impact of a piece of advanced technology but also to consider how this investment may or may not support the organization’s five-year strategic plan.

3.     Researchers: Viability Reports

Members of the organization’s research department should provide the interdisciplinary team with a perspective of potential research gaps that exist with the advanced technology being evaluated. They, too, should complete a thorough literature review before meeting with the interdisciplinary team and reviewing potential grant opportunities. They must share their knowledge regarding the opportunity to conduct research with this specific technology and potential upcoming funding opportunities.

4.     Engineers: Maintenance Expertise

Advanced rehabilitation technologies often include a complex interaction of hardware and software. When technologies are first on the market, they can often exhibit software and hardware challenges even during the first year they are acquired. They also often come with yearly warranty packages with a very hefty price tag. It’s essential for the engineering department to critically evaluate the in-house expertise they have to manage both the hardware and software of each specific piece of technology.

Many hospitals now employ mechanical and electrical engineers who may be able to troubleshoot and fix small problems that occur with these advanced technologies. Along with evaluating in-house expertise, a thorough understanding of the cost of the warranty package and its coverage is fundamental to the decision-making process.

5.     End-Users: Patients and Caregivers Opinions

Patients’ and families’ perspectives are critical in making successful decisions about which types of exoskeletons the clinic should purchase. It’s important to include patients and families on this team and/or to survey patients from the various diagnostic groups in order to truly understand what type of recovery and opportunity for recovery is most important to them. Patients and families are very savvy regarding what types of advanced technologies are now available, and many anecdotally report that technology availability is included in their decision-making process when determining which rehabilitation hospital they choose for themselves or their loved ones. This information should be gathered and provided to the interdisciplinary team to be included in the decision-making process for an exoskeleton purchase.

Why We Purchased Indego Exoskeleton in Our Clinic

Our organization utilized the perspectives of the various team members reported above when purchasing the Indego exoskeleton in 2016. Craig Hospital was involved in a multi-center research study utilizing the Indego in 2015. This research opportunity provided therapists with first-hand knowledge of the system in terms of clinical utility (patient appropriateness; setup time; the number of staff required for safety), allowing them to bring a unique hands-on clinical perspective to decision-making. The therapists involved in the trial reported a very positive experience with the system and advocated for its purchase.

As an administrator, I evaluated the opportunity for integration throughout our continuum of care and assessed the financial impact regarding patient lengths of stay, outpatient benefit limits, and involvement in our community wellness program. In addition, wanting to maintain Craig’s position as a leader in spinal cord injury and traumatic brain injury rehabilitation and research (one of the foundational aspects of our five-year strategic plan) led me to support the purchase of the Indego exoskeleton.

Our research team evaluated the many gaps (bone density, recovery of walking, balance reaction training, and much more) in the literature surrounding exoskeletons and agreed there was great potential to make meaningful contributions to this field and also supported the purchase of this device. Our engineering team had experience with the system during the research study and felt comfortable with the response time and follow-through from the Parker Hannifin technical support team.

Most importantly, the subjects and families who participated in the trial really enjoyed using the device and reported that they believed this technology was among the “next steps” in neurorehabilitation and should be a part of the care we provide at Craig Hospital. Therefore, the decision from the interdisciplinary team was to purchase this device as soon as the FDA approved it for personal use.

With the increasing opportunities to provide our patients with the latest rehabilitation technologies also comes the responsibility to vet each technology carefully to ensure we’re providing our patients with an optimal opportunity for recovery while focusing on technologies that improve their quality of life.

Candy, PT, DPT, ATP, NCS is the Director of Physical Therapy at Craig Hospital. Candy received a B.S in Biology from Mount Olive College in 1997 and a Master’s in Physical Therapy from East Carolina University in 2000. She then completed a Doctorate of Physical Therapy degree from Rocky Mountain Health Care University in 2008. Candy has been working in the field of neurological rehabilitation since 2000 and received an assistive technology practitioner (ATP) certification in 2005 and became a certified neurological clinical specialist (NCS) in 2007. She has been involved in numerous research projects and has focused much of her career on interventions and program development promoting recovery after neurologic injury or disease. Candy is a member of the American Physical Therapy Association and the Neurologic Section.

Craig Hospital is a world-renowned, 93-bed, private, not-for-profit rehabilitation hospital and research center that specializes in the care of people who have sustained a spinal cord and/or a brain injury. Craig provides a comprehensive system of inpatient and outpatient medical care, rehabilitation, neurosurgical rehabilitative care, and long-term follow-up services. Half of Craig’s patients come from outside of Colorado. Craig has been ranked as a top 10 rehabilitation center by U.S. News and World Report for 27 consecutive years. Craig has received the NDNQI® award in 2009, 2012, 2013, 2014 and 2015 for the highest quality outcomes in nursing care in a rehabilitation facility. Craig was voted by employees as a “Top Work Place” by the Denver Post for the past three years and was ranked in the top 150 places to work in healthcare by Becker’s Healthcare in 2014.