Category: Exoskeletons

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/

Did you know that spinal cord and brain injuries are the most common cause of paraplegia, with spinal cord injuries affecting more than seventeen thousand people annually in America and brain injuries affecting up to 1.5 million per year? [1] A 2013 study done by Christopher & Dana Reeve Foundation revealed that about 1 in 50 people live with paralysis, nearly 5.4 million people. This is equal to the combined populations of Philadelphia, Los Angeles, and Washington, D.C. [2]

Despite the high number of people who need assistive devices like wheelchairs and walkers to move about and complete daily activities, little has been done to advance innovation in that field. That is, until the last decade when robotic legs (medical exoskeletons) were introduced in rehabilitation and recovery centers. Now, patients with paraplegia aren’t limited to a wheelchair, which may have access and mobility issues. This new innovation has led to the development of external robotic devices which can help enhance recovery through repetitive movement and improved neural plasticity. Additionally, they can serve as mobility support beyond walkers, wheelchairs, and orthoses. [3] 

According to the Exoskeleton Industry 2019 Global Market research report [4], the increased uptake of exoskeletons in the medical industry has encouraged companies to invest more in research and development. 

Are robotic legs the answer to helping people with spinal cord injuries, neurological disorders, and strokes regain independent function and their ability to walk again? In this article, we will break down what robotic legs are, the paraplegic conditions that are supported by robotic legs, the benefits of robotic legs, and where you can get them.

What Are Robotic Legs?

Robotic legs are powered medical exoskeletons that are fastened to the lower back and legs. They usually have motors and sensors attached to the hip and knee joints which coordinate and adjust with each step. Some robotic legs are customized to the wearer’s needs, allowing them to perform various tasks, including driving. To break it down further, a medical exoskeleton is any robotic system that patients with conditions like stroke, multiple sclerosis, brain injuries, and spinal cord injuries can wear to support movement. 

Exoskeletons represent the coming together of man, machine, and work by responding to the user’s movement. They provide motor support to the wearer through patient-initiated movement or based on the setting the physical therapist uses and dependent on the patient’s needs.

Operating an exoskeleton is pretty easy for both you and your patient. The wearer only needs to shift their weight in the direction they want to move. The sensors then pick up the intended movement and offer support. With a powered exoskeleton, the wearer can stand from a sitting position, walk, and may even climb stairs. However, it is essential to note that these activities require training.  

Robotic wearable technology has a wide range of applications and can be used by people with spinal cord injuries, brain injuries, multiple sclerosis, and stroke. According to Conor Walsh, a roboticist at Harvard University, “Robotic technology has recently expanded to benefit stroke patients. More than 70% of people who suffer a stroke never regain their full walking capacity.” At the same time, exoskeletons are not limited to medical uses only. They are also used by industrial workers like construction workers and warehouse workers to support the lifting of heavy loads. In fact, some companies have made it mandatory for workers to use exoskeletons as part of their personal protective equipment. They include: Ford, BMW, Hyundai, Samsung, and Mitsubishi, among others.

Paraplegic Conditions That Are Supported by Exoskeletons

One of the conditions we highlighted that is a common cause of paraplegia is spinal cord injury. When spinal cord injuries happen, they interfere with the communication between the brain and body parts below the injury, leading to paralysis. Exoskeletons can be used to support paralysis caused by spinal cord injuries, including injuries to the cervical, thoracic, and lumbar regions.[5]

To support this assertion, several studies have been conducted to investigate and verify the usefulness of exoskeletons for paraplegic conditions. In a 2018 study concerned with the development and control of a robotic lower limb exoskeleton for patients with paraplegic conditions, healthy subjects tested exoskeletons by performing normal daily activities like walking, standing, and sitting. It was concluded that the exoskeletons had natural gait cycles which support ambulation. [6] In simple terms, it demonstrated the exoskeleton’s ability to aid the rhythmic movement of a stride, which is needed in walking.

Exoskeletons have been shown to have a high impact on people with disabilities who were trying to regain muscle activity in their thighs, hips, and legs. In a clinical trial published in Frontiers in Robotics and AI, it is reported that 62% – 72% of wearers who practiced using exoskeletons in physical therapy could achieve their walking goals within 12 sessions. It also noted that after the 36th session, 80%-84% of the study groups achieved their walking goals. [7]

To demonstrate how useful and practical exoskeletons are in patients’ recovery and daily activities, here are two stories of patients who rely on exoskeletons.

At 22 years old, Julio Caro, a structural steelworker in southern California, took an 18ft fall while working, which would change his life forever. He broke his back in two different places, injured his spine, and was unable to walk after the ordeal.

“I was young, and so I didn’t understand what was happening,” Caro said. “They said, ‘You’re not going to be able to walk again,’ and I thought they were lying.”

“I just wanted to get back on my feet — I was out to prove everybody wrong,” he added. “So when I first heard [about exosuits], I was, like, Robocop. As soon as I saw the machine and I saw it walk, I thought, ‘Oh cool, it does everything for you.’”

After using the exoskeleton for only five sessions in physical therapy, Caro was able to walk again. He says it made a lot of difference having the robotic legs as they allow him to work again and enjoy what we might typically take for granted, like reaching out and touching a leaf.

 “I’m glad this technology is out there, [and] it’s only getting better,” he added.

On Tuesday, December 4th, 2018, Amelia Clark dropped off her three sons at school and went to a hair-coloring class. She had a headache but thought nothing of it. She dismissed it as low blood sugar until the unthinkable happened. She couldn’t stand up.

“I must have passed out because when I woke up, I saw a whole bunch of lights, and the doctor said, ‘Hi. What’s your name? You’ve had a stroke.’”

Clark was hospitalized for a month and a half, unable to walk without any assistance. The first time she took a step after her stroke was when she was introduced to an exoskeleton, EksoNR. In just three months, she was able to walk with a cane and, by August, started driving again.

Benefits of Robotic Legs

1. Robotic Legs Don’t Require Surgery

One great thing about robotic legs for physical therapy patients is that, unlike other treatments, they don’t require invasive surgical procedures. For instance, in epidural stimulation, a device is implanted near the spine, and in stem cell transplants, spinal cord injections are done. Conversely, robotic legs (exoskeletons) are worn on the body, making them an easy way to improve mobility without risk of complications.

2. Robotic Legs Improve Circulation

When you have a spinal cord injury, blood tends to pool in the legs due to lack of movement, reducing the amount of blood flowing to the heart. It can also lead to swelling in the legs. Using exoskeletons can allow your patients to ambulate and move paralyzed areas. This contributes to the circulation of blood which is essential in supporting cellular activity. 

3. Robotic Legs Reduce Muscle Atrophy

Movement is very critical as it helps in strengthening muscles and bones. However, patients with paraplegic conditions may not be able to move around much. This can cause their muscles to reduce in size to conserve energy, hence the need for robotic legs. Though they do not stop muscle atrophy, they help maintain bone and muscle density as they keep the wearer moving and bearing their own weight. 

4. Robotic Legs Boost Confidence

When a patient experiences an injury or condition that affects their lower limbs, the recovery outlook is painted as marginally lower, and this can impact patient confidence. One of the most invaluable benefits of robotic legs is the hope they restore to patients who’ve been told they’ll never be able to walk again. Robotic legs represent an opportunity for them to walk again, which not only helps them become more independent but also more confident. Robotic legs can be used for rehabilitative exercises and help patients with complete SCI regain more mobility than they thought possible. 

5. Robotic Legs Help Manage Spasticity

One of the most common problems that patients with paraplegia face is a painful condition known as spasticity (the contraction of muscles). Robotic legs can help manage spasticity and improve other related conditions like pain and bowel function. When one robotic leg user was asked, she said that tending to her bowels took roughly 20 minutes, which was different from the hour she usually spent without an exoskeleton. [8] 

The Best Robotic Legs for Paraplegic Conditions

There are different types of exoskeletons available in the market for paraplegic conditions that assist physical therapists, additionally, these exoskeletons have been approved for use in communities and medical institutions with supervision. One great example is Ekso Bionics’ EksoNR which is used to rehabilitate people after spinal cord injury, stroke, brain injury, and MS. 

The EksoNR is like a backpack that extends to the legs and supports the torso and lower limbs. It has sensors on the footplates which signal the movements of the wearer. The exoskeleton then creates feedback and offers support to the wearer, depending on the settings. It not only supports ambulation but also helps patients regain muscle activity.

Where Can You Get Robotic Legs?

Robotic legs like the EksoNR and EksoGT are readily available in more than four hundred rehabilitation centers globally. If you’d like to acquire exoskeletons for your facility, you can contact our sales team by clicking here.

Conclusion

Robotic legs are essential for patients with paraplegic conditions. They help support movement, reduce muscle atrophy, and address other related conditions like pain, bowel function, spasticity, and overall quality of life.

Ekso Bionics has been at the forefront of creating the best quality medical exoskeletons for over a decade. Our EksoNR was one of the first FDA-approved medical exoskeletons for rehabilitation, and it continues to be the exoskeleton of choice for rehabilitation clinics. Please review our indications for use to determine eligibility. [9]

References:

1. https://www.cdc.gov/traumaticbraininjury/pubs/tbi_report_to_congress.html#:~:text=Traumatic%20brain%20injury%20(TBI)%20is,people%20are%20hospitalized%20and%20survive. 
2. Paralysis statistics – Reeve Foundation https://www.christopherreeve.org/living-with-paralysis/stats-about-paralysis
3. Robotic Rehabilitation and Spinal Cord Injury: a Narrative Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095795/
4. Exoskeleton Market Size & Share Report, 2022-2030 https://www.grandviewresearch.com/industry-analysis/exoskeleton-market
5. Robotic Rehabilitation and Spinal Cord Injury: a Narrative Review  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095795/
6. Development and control of a robotic lower limb exoskeleton for paraplegic patients https://journals.sagepub.com/doi/abs/10.1177/0954406218761484?journalCode=picb
7. How Exoskeletons Can Help People With Paraplegia Walk Again https://backend.eksobionics.com/how-exoskeletons-can-help-people-with-paraplegia-walk-again/
8. Robotics are helping paralyzed people walk again, but the price tag is huge – The Washington Post https://www.washingtonpost.com/news/morning-mix/wp/2017/06/10/robotics-are-helping-paralyzed-people-walk-again-but-the-price-tag-is-huge/
9. Indications for Use – Ekso Bionics https://backend.eksobionics.com/indications-for-use/

Physical therapy can be intimidating for patients, especially if they don’t have enough information, are afraid, or don’t have any prior experience with therapy. Misinformation and fear can lead to concerns and notions, which, if not addressed, can keep patients from seeking the help they need in order to recover well. It is important for therapists to understand their patients’ concerns to address them and increase patient safety. In this article, we will address the most common concerns patients have about physical therapy and how you, as a physical therapist, can address them to ensure patient safety and comfort.

Common Concerns Patients Have About Physical Therapy

1. Some Patients Are Afraid of Pain

One of the most common misconceptions people may have about physical therapy is that it is painful. However, contrary to popular belief, physical therapy is actually designed to help relieve and manage pain, as you already know. Sometimes it takes explaining to patients the benefits of therapy in pain management and alleviation for them to understand how it works and what they should expect from it. Many people fail to realize that though therapy can be uncomfortable, it is never meant to be painful.

2. Patients May Think Physical Therapy Is Time-Consuming

Time is generally a primary concern for most people. Most patients usually have school, careers, family, and other demands on their time. Therefore, when it comes to scheduling time for physical therapy, it can seem impossible to add one more thing to their already packed schedule. On the other hand, some patients may be concerned that physical therapy will take too long. They do not want to commit weeks and months of their time to attend therapy. When you consider the busy lives we lead and how we try to fit everything into our limited schedule, you can begin to empathize with your patients and understand where they are coming from. A great solution would be creating a rehabilitation schedule that is tailored to your patient’s schedule. It can include at-home exercises and in-office rehabilitation sessions.

3. Patients May Believe Physical Therapy Is Too Expensive

Physical therapy is not familiar to most people. It’s not a program your patient may have undergone before, and people tend to be afraid of the unknown. This can be a barrier for many patients. Additionally, if your patient does not have insurance to cover their costs, paying out of pocket can be too expensive. However, you can work with patients to discuss cost-cutting strategies they can leverage to get the treatment they need. 

4. Some Patients Are Afraid That Physical Therapy Won’t Work

How do you know something is going to work, especially if you have never experienced it before? This is the same thought that may plague patients, as they may not ascertain the effectiveness of attending therapy sessions. This might be less of a concern for patients who have undergone rehabilitation before, but it can be a very real concern for patients who haven’t undergone physical therapy. To curb this, you can share success stories with your patients that qualify the importance of therapy during consultations.

When someone is suffering from mobility issues, it might be easier to convince themselves that rehabilitation won’t work rather than have hope and then get discouraged. Getting over this mental barrier may help some patients open up to physical therapy.

5. Some Patients May Be Afraid of Working With a Physical Therapist

Even though therapists normally try to be friendly and welcoming to everyone, sometimes some patients may feel uncomfortable and even afraid to do physical therapy. This may be due to personal issues like haphephobia (the fear of being touched by strangers) and uncommunicated expectations like the outcome they desire out of physiotherapy. 

6. Patients May Be Afraid of Commitment

Just like going to the gym or starting a new diet, physical therapy comes with a demand for commitment; not many patients feel they can stick it out till the end. This may keep many patients from trying because they already believe they will fail. However, working out therapy plans that work for your patients can help them conceptualize how much will be asked of them within the program. This can help them evaluate their commitment using a tangible measure compared to going at it blindly.

7. Some Patients Are Afraid of Falling

Some patients are concerned about attending therapy because of the fear of falling, clinically referred to as “ptophobia”. According to Tinetti of the Department of Medicine and Public Health at Yale University and Powell of the Department of Epidemiology and Public Health, the fear of falling (FOF) is an ongoing concern about falling that ultimately limits the performance of daily activities.[1] Reduced mobility makes patients insecure about avoiding falls, effectively keeping them out of therapy. 

8. Patients May Be Afraid of Getting Injured

Sometimes patients incur injuries during physical therapy sessions due to falls, among other reasons. This can keep prospective patients from going to therapy as they are afraid that they’ll meet the same fate. Reassuring your patients can go a long way in overcoming this fear. Addressing patient safety is a key concern in ensuring that patients are safe within rehabilitation facilities. This might go a long way in relieving patients’ fears.

In the next section, we’ll discuss patient safety and how physical therapists can ensure they observe patient safety guidelines to ensure their patients get the best care and treatment.

How to Address Patient Concerns as a Therapist

There are a few things you can do to deal with your patient’s concerns, including:

1. Understand Your Patient’s Needs

The most significant step you can take in addressing your patient’s concerns is understanding their needs. A lot of patients have different needs and concerns that can only be met if you are empathetic and understanding enough. Addressing these needs can be the start to relieving any anxiety and worry that a patient has. It can also be the foundation of trust that you need to form with a patient in order to help them through their therapy sessions. 

2. Create a Rapport With Your Patient

This will help them to open up and be more active in therapy sessions. Building a relationship with patients is the fastest way of getting them out of bed. A 2010 study studying the influence of the therapist-patient relationship on treatment outcome in physical rehabilitation said that the connection between a therapist and patient determines the treatment outcome. [1]

3. Communicate and Address Expectations Clearly

Effective communication is a primary facet of successful rehabilitation. Communication is needed to understand your patient’s needs and expected outcome. While communicating with your patients, it’s also important to tailor your communication to your patient’s literacy level when discussing ailments and treatment. Patients value clear and simple explanations about their problems.

Addressing Patient Safety

Patient safety has become an evolving area in the healthcare industry with the increase of adverse events in hospitals. Adverse events are any unintended occurrences within the healthcare system that may lead to a longer hospitalization period, disability, or death. 

According to the Canadian Patient Safety Dictionary, patient safety is “the reduction and mitigation of unsafe acts within the healthcare system, as well as through the use of best practices shown to lead to optimal patient outcomes.” [2] Physical therapists play an important role in mitigating unsafe acts within the system, directly and indirectly. Physical therapists can contribute to a culture of safety by evaluating and implementing safety measures like improving facility layouts, training staff, and being more sensitive to patients’ needs, among others, as discussed below.

Safety issues within physical therapy are not typically big and harmful events. They are normally no-harm events classified as close calls or near misses. In other words, they are events that happen to the patient but do not produce harm. For example, a patient almost falls when they are being moved from a chair. These kinds of events happen as mistakes, and it is important to identify the source of these mishaps and learn from them so as to improve patient safety. [3]

According to a 2004 study by the Canadian Medical Association Journal, some of the adverse events that normally happen in the health care system can be prevented altogether. [4] So, let’s explore some strategies you can implement to mitigate against accidents in your practice and improve patient safety.

How to Increase Patient Safety as a Therapist

You can implement several strategies to alleviate your patient’s concerns. They include: 

1. Identifying Potential Slip and Fall Risks

This is one of the easiest things you can do to increase safety in your facility. Injured patients are vulnerable to falls and slips, so it is extremely important that you ensure slippery areas are shown well. Additionally, you can station staff in risky areas to watch patients during their visit to your practice. Also, never forget to notify patients in case you identify potentially risky areas where they may fall and injure themselves. It is also important to wipe and clean any spills immediately to avoid the risk of a fall. And if your facility has bathing areas, make sure they are always kept dry to avoid injuries. Additionally, you can add non-slip rugs in the bathrooms and grab bars for support. 

2. Improving the Facility Layout

Evaluate your facility to see if patients can easily move from one area to another without straining and injuring themselves. Remember that a good number of patients attending therapy have mobility issues. A great solution to ease patient movement would be having ramps around the facility instead of stairs. You could also place all equipment and furniture out of the way of patients to avoid any falls.

3. Making Signage and Posters Visible 

Having signage and posters all over your facility is great, but they need to be visible and legible. What good is a warning poster if a patient can’t see it or be able to read it? The United States Occupational Safety and Health Administration dictates that all labels, posters, signs, and color codes must be visible enough to warn patients of possible risks. 

4. Labeling Equipment and Providing Instructions of Use

As great as equipment exercise is, it can pose a potential hazard to patients if it does not have any clear instructions for use. Instructions are normally included in any equipment you buy, but in case it is not, make your own and make sure it is visible enough to be seen by the patients using it. 

5. Training Staff 

The best way to increase patient safety and improve healthcare quality is to train staff on the latest and best ways to take care of patients. Additionally, creating a work culture that puts patient safety first can also help address patient concerns like safety. 

Conclusion

Patient concerns are ever-changing and differ from one patient to another. If left unchecked, they can keep potential patients from attending therapy and getting the help they need. When addressed, they can help patients overcome their personal barriers and attend physiotherapy sessions.

When dealing with patients, it is important to remember that you are human, and humans make mistakes. Whenever a mistake is made, the best course of action is to learn from it and make the required changes. It is also important to create a culture and environment that facilitates the identification and reporting of mistakes so that you can improve patient safety. 

References:

1. Fear of Falling | Physical Therapy | Oxford Academic https://academic.oup.com/ptj/article/82/3/264/2837020
2. The Canadian Patient Safety Dictionary https://policycommons.net/artifacts/1212508/the-canadian-patient-safety-dictionary/1765612/
3. Patient Safety and Physiotherapy: What Does it Mean for Your Clinical Practice? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909853/
4. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada https://pubmed.ncbi.nlm.nih.gov/15159366/

Postoperative therapy is a big part of the recovery process and is necessary to restore joint movement, strength, and flexibility. It might be required after surgical procedures like orthopedic, cardiac, thoracic, neurological, and abdominal surgery. Many patients may prefer skipping this step of their recovery, but this can result in improper or incomplete healing. 

Postsurgical therapy is helpful if you are experiencing stiffness, pain, muscle weakness, reduced mobility, reduced balance, and reduced coordination. It also helps with any physical and psychological effects you may have endured due to surgery. 

According to a National Institutes of Health (NIH) study, patients who stay in bed after surgery tend to lose muscle strength, heart capacity, and lung capacity due to a lack of physical activity. [1] But with the incorporation of physical therapy in recovery, you can prevent functional atrophy. This article will explore the phases of postoperative rehabilitation, types of physical therapy, and the benefits of postoperative rehabilitation. 

The 3 Phases of Postoperative Rehabilitation

There are three main phases in postsurgical rehabilitation, and they differ from patient to patient depending on the type of surgery. They are broken down into:

1. Stage 1: In this stage, you’ll be immobilized as you’ll be fresh from the surgery room. Typically, you’ll be in pain, and the surgical area will be swollen. At this point, rest is recommended for a few hours or days, depending on the type of surgery. 
2. Stage 2: In this stage, the pain and swelling will reduce. You’ll be able to move a little and will be ready to start physical therapy. The goal, at this point, is to strengthen the body, improve stability, and restore range of motion. 
3. Stage 3: In this stage, you’ll be continuing to heal and are ready to rehabilitate and learn to complete your activities of daily living. The ultimate goal of physical therapy will be achieved in this stage.

Surgery Operations That Require Postoperative Physical Therapy

These are five surgical procedures that necessitate physical therapy as part of the recovery process. They include: 

• Brain tumor surgery: A 2019 pilot study on the effectiveness of rehabilitation therapy after brain tumor surgery reported that intensive rehabilitation resulted in improved motor function, cognition function, and Activities of Daily Living (ADL). [2] In this case, physical therapists focus on range-of-motion exercises, balance, gait, and endurance training. 
• ACL and Meniscus Repair: ACL knee ligament and meniscus cartilage repair is a problem often associated with athletes. According to a 2019 study conducted by the International Journal of Sports Physical Therapy, physical therapy is vital in hastening the healing process and avoiding re-injury. Physical therapists usually focus on building quadriceps and hamstring strength in the recovery process. [3]
• Back and Spine Surgery: Physical therapy is vital, especially because of the delicate nature of spinal surgeries. Your physical therapist will show you exercises and movements for your back that don’t put pressure on your spine. Therapy strategies normally include stretches and exercises that get the blood flowing. In the case of more invasive surgeries, for example, spinal fusion, your therapist can monitor your back health and update your doctor on the healing progress.
• Heart Attack/Bypass Surgery: According to a 2018 study by the Journal of Physical Therapy Science, preoperative physical therapy can help prevent cardiopulmonary complications by offering patients a safe space to move. Low-impact exercises tend to improve health and reduce your stay in the hospital. Coupled with postoperative therapy, you can recover faster while avoiding all postsurgical complications. [4] 
• Achilles Tendon Release (Tenotomy): This is a type of surgery that is done to fix a damaged or contracted Achilles tendon. This procedure can be performed to relieve shortened and stiff muscles to allow for better range of movement. This is a common problem for patients with spinal cord injuries because, after a spinal cord injury, the normal flow of nerve signals is disrupted and feet tend to relax into a toe-pointed position. This could limit a person’s ability to stand if not corrected. 

Major Types of Physical Therapy For Postoperative Patients

Physical therapy strategies are not one-size-fits-all. The type of therapy recommended always depends on your physical condition and biomechanical needs. In this section, we will explore rehabilitation methods that are applicable to patients who have undergone any kind of surgery. 

1. Stretching

After surgery, the soft tissue normally contracts, and scar tissue forms. This can decrease flexibility and make it difficult for you to move. However, regular stretching can help prevent immobility caused by scar tissue. It also helps increase joint flexibility and a full range of motion in case of joint surgeries. Overall, stretching makes life much easier and allows you to do simple tasks like reaching over your head, walking, and even climbing stairs. 

Stretching has also been shown to help improve balance and reduce pain by relaxing tense or spasming muscles. Lower back, abdominal, hip, and leg muscle stretches are recommended if you’ve undergone back surgeries.

Common hamstring exercises targeting the outer hip and lower back include Knee to Chest Stretch, Figure 4 Stretch, Pigeon Stretch, and Doorway Hamstring Stretch. These stretches are particularly great for tight and restricted muscles. The Pigeon Stretch and Doorway Hamstring Stretch are more advanced and should only be performed in a pain-free range. Other types of stretches used in postoperative therapy include:

2. Range of Motion Therapy

Range of motion (ROM) is concerned with how far you can move an affected joint or limb in all directions and positions naturally without strain and pain. There isn’t one standard definition of ROM. According to Dr. Aldalbert Kapandji, who specializes in physical therapy, range of motion is “the extent of osteokinematic motion available for movement activities, functional or otherwise, with or without assistance.” [5] 

Range of motion exercises increase movement, reduce pain, and improve joint integrity and function. Range of motion exercise and stretching are generally performed in the first phase of rehabilitation to help regain joint functionality before moving to more advanced practices.

Range of motion therapy normally includes: 

• Passive routines where the therapist guides your movements. 
• Interactive routines where both you and the therapist do the work.
• Active routines where you do the exercises on your own. 

Range of motion exercises involving circling joints and knee extensions are beneficial in different situations, including:

• Soft tissue and joint recovery
• Joint and soft tissue mobility
• Neuromuscular reeducation
• Synovial movement enhancement 

3. Strengthening

Strengthening exercises are a crucial part of physical therapy and help improve muscle function around the surgical area. Strengthening exercises are customarily performed alongside or after the range of motion exercises because increased joint movement without an equal increase in strength might cause injury.

Strengthening exercises are also vital in improving your core strength. The core is a major focus area because it is the source of stability. Rebuilding core strength improves stability and mobility and helps prevent additional injuries. It allows you to increase the load you can handle without overexerting and injuring yourself. In addition, strengthening can also be used for the back and pelvis areas. Strengthening exercises typically include leg raises, hamstring and quadriceps contractions, and squats using a chair.

Strengthening exercises can also include bridge exercises and ball bridge exercises. These exercises are great for strengthening the hamstring, lumbar extensor, pelvic, back, and buttocks. These exercises should be done in a pain-free range; once you’ve mastered them, you can move on to more advanced strengthening exercises. 

4. Ultrasound and Electrical Therapy

Ultrasound and electrical therapy help improve blood flow and retrain nerves. Ultrasound therapy involves the use of high-frequency sound waves on deep tissue. The high-frequency sound waves used to stimulate deep tissue are so low that even the human ear cannot pick them up. This type of therapy utilizes a probe for administration and is known to reduce pain, accelerate healing, and reduce inflammation in the soft tissues. A 2014 study conducted by the Journal of Physical Therapy Science reported that therapeutic ultrasound increases range of motion and pain threshold for at least 20 minutes. [6]

Electrical therapy involves the use of low electrical current on the deep tissues. Electrical stimulation works by sending small electrical currents to the targeted area and the nerves surrounding it. It is extremely helpful in increasing blood flow, pain management, and improving muscle flexibility. A 2021 study conducted by Frontiers in Medicine reported, “As a supplementary treatment after total knee arthroplasty, postoperative neuromuscular electrical stimulation could improve the short-term to long-term quadriceps muscle strength, mid-term pain, and mid-term function.” [7]

5. Gait Training

Walking is a great physiotherapy technique that’s primarily used for neurosurgery patients. It normally involves rewiring and training the brain to control walking muscles. This is achieved because of the brain’s neuroplasticity – the ability of the brain to form and reorganize synaptic connections. When walking is practiced regularly after surgery, it allows the brain to strengthen and create neural pathways that support movements involved in walking. Some high repetition walking exercises include leg and balance exercises.

Benefits of Postoperative Therapy

General Surgery 

A postoperative therapy program after general surgery is a crucial part of recovery and offers a host of benefits like: 

1. Proper Healing and Faster Recovery Time

Many complications can arise after surgery, including infection and muscle atrophy, which might lead to poor healing. That’s why postoperative therapy is important. Postoperative therapy can help wounds heal properly by minimizing scar tissue, retraining muscles, and recovering joint function. It also allows you to enjoy a faster recovery time. According to a 2017 study conducted by Acta Medica, beginning physical therapy following a joint replacement surgery can reduce your hospital stay and help you recover faster. [8]

2. Patient Participation

Patients who actively participate in their own recovery process have been shown to have better results and recovery experiences than those who don’t in a 2013 review conducted by researchers from the Health Policy Research Group at the University of Oregon. [9]

3. Improves Mobility

Joint replacement surgeries normally result in reduced mobility, making activities that may seem ordinary, like walking, difficult. This happens because of the body’s natural response, which is to protect the area of surgery by swelling, reducing the range of motion, and tightening the muscles. This makes physical therapy extremely important, especially after knee and hip replacement surgeries, as it may help you recover your mobility through targeted postoperative therapy practices. 

4. Eases Pain and Swelling

Swelling and pain after surgery normally vary from one person to another. The pain usually arises when chemicals that stimulate nerve endings are released, and the excess inflammation compresses the nerves. Exercises are a great tool for reducing swelling, which results in improved mobility, faster healing, and reduced pain. Postoperative physical therapy administration can also help in preventing chronic pain.

According to a 2013 review conducted by London-based medical researchers, postoperative therapy is quite effective in improving short-term lower back pain and long-term lower back and leg pain if you’ve undergone lumbar spinal stenosis surgery. [10]

5. Reduces Scar Tissue Formation

During the healing process, scar tissue forms, and tissues contract. This normally leads to scarring and reduced mobility. However, mobilization techniques can help prevent this using ultrasound therapy, which effectively increases flexibility and softens the scar tissue. According to a 2016 study conducted by researchers for the Internal Medicine Review journal of Washington D.C., low-intensity therapeutic ultrasound can help treat soft tissue injuries and improve musculoskeletal and post-operative recovery outcomes. [11]

6. Reduces the Development of Secondary Issues

Physical therapy can help reduce surgical complications like blood clots, and infection, among others. Specific exercises and movements may help in reducing the risk of contractures and other complications.

7. Improves Flexibility

Staying in bed after surgery is detrimental for you, and it may lead to weak muscles, which will make you susceptible to injury. When your joints become stiff, activities like walking, climbing stairs, and reaching overhead can be compromised. However, stretching exercises can help you keep your joints flexible and muscles limber. 

Neurosurgery

Neurosurgery is involved with the treatment of conditions affecting the nervous system, including the spinal cord, brain, and peripheral nervous system. This makes postoperative rehabilitation very important as part of helping a patient regain their pre-surgery functionalities. Benefits attributed to physical therapy include:

• Increased Range of Movement – Patients are able to increase their limb and joint movement in any direction without any pain.
• Improved Gait – Physical therapy can help you improve your balance, coordination, and walking movement control.
• Increased Muscle Strength – Physical therapy is great for training leg and back muscles to support the weight of the body. 
• Reduced Spasticity and Contractures (Shortened Muscles) – Surgery may lead to muscle tightness, otherwise referred to as spasticity, which can limit movement and cause pain. But physical therapy can help you avoid these complications.

Conclusion

Postoperative therapy is vital when you are recovering from surgery, and its efficacy has been shown in different studies. It will help you heal faster, regain mobility, reduce pain, and prevent postoperative complications. In case you’ve undergone surgery, physical therapy will offer you the recovery support you need on your healing journey.

References:

1. Assessing the effectiveness of routine use of post-operative in-patient physical therapy services https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5506300/
2. Intensive Rehabilitation Therapy Following Brain Tumor Surgery: A Pilot Study of Effectiveness and Long-Term Satisfaction https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6509576/
3. Restoring knee extensor strength after anterior cruciate ligament reconstruction: a clinical commentary https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6350662/
4. Prevention of postoperative pulmonary complications through preoperative physiotherapy interventions in patients undergoing coronary artery bypass graft: literature review  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110234/
5. The clinical evaluation of the upper limb joints’ function: back to Hippocrates https://www.sciencedirect.com/science/article/abs/pii/S0749071203000295?via%3Dihub
6. Effects of Therapeutic Ultrasound on Range of Motion and Stretch Pain  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4047237/
7. Effect of Neuromuscular Electrical Stimulation After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8677678/
8. Early rehabilitation after elective total knee arthroplasty  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6357664/
9. What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs https://www.ncbi.nlm.nih.gov/pubmed/23381511
10. Rehabilitation following surgery for lumbar spinal stenosis – McGregor, AH – 2013 | Cochrane Library https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009644.pub2/abstract
11. Low-Intensity Ultrasound for Promoting Soft Tissue Healing: A Systematic Review of the Literature and Medical Technology  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128661/

According to the World Health Organization (WHO), between 250,000 and 500,000 people suffer from spinal cord injuries (SCIs) every year due to blunt force trauma, road crashes, falls, and other mechanisms of injury. [1] A few years ago, this would have meant the end of autonomy and mobility for many people, but thanks to advances in technology, there are more rehabilitation therapies available, including exoskeletons. The FDA designates medical exoskeletons as a class II (intermediate risk) medical device, and they are cleared for use with patients who have an SCI. [2]

Exoskeletons give people with spinal cord injuries a chance to ambulate, exercise, and engage in mobility and autonomous activities. In this article, you’ll learn what exoskeletons are, how they operate, and how they can be beneficial in physical therapy for patients with spinal cord injuries.

What is a Spinal Cord Injury (SCI)?

According to the National Institute of Neurological Disorders and Stroke (NINDS), a spinal cord injury is “damage to the tight bundle of cells and nerves that sends and receives signals from the brain to and from the rest of the body.” [3] SCIs could be a direct result of damage to the spinal cord itself, such as from a gun shot wound, but could also result from damage to surrounding tissues and bones that then compress the spinal cord. These injuries can permanently or temporarily affect mobility, sensation, and other body processes. Depending on the extent and location of the damage to the spinal cord, patients may experience some form of paralysis and/or sensory deficits that could be improved through rehabilitation, potentially leading to full recovery.

The most common causes of SCI are grouped into traumatic and non-traumatic causes. Traumatic SCI causes may include car accidents, falls, and sports-related accidents. Non-traumatic causes include tumors, neurodegenerative diseases, infections, and genetic causes. 

Rehabilitation Methods Available for Patients with Spinal Cord Injury

Rehabilitation therapies for patients with a spinal cord injury depend on the extent of damage and the type of injury. Patients usually start in the intensive care unit, followed by acute care, inpatient, and outpatient rehabilitation. Some hospitals even have a spinal cord injury department that specializes in this type of rehabilitation. This can last anywhere from three to twelve months or more, depending on the severity of the injury. Popular rehabilitative techniques include: 

1. Range of Movement, Strength, and Stretching Exercises

Spinal cord injuries limit the range of movement by causing joint immobility and flexibility issues. However, this can be remedied using stretching and strength exercises. According to a 2020 study, range of movement exercises help “prevent contractures, protect tenodesis effect, strengthen paralyzed muscles, promote nerve and cerebral remodeling, and improve spinal microenvironment and functional prognosis.” [3]

2. Functional Electrical Stimulation

Functional electrical stimulation works by artificially stimulating the sensory-motor systems using electrical pulses. It activates neural pathways, which stimulate the muscles and cause movement. This therapy is used alongside other rehabilitation methods in order to restore mobility. According to a study, this procedure also “provides cardiorespiratory fitness; improves posture and trunk stability; prevents contractures, pressure ulcers, and orthostatic hypotension; promotes nerve restoration; and prevents peripheral nerve deterioration.” [4]

3. Epidural Electrical Stimulation (EES) of the Spinal Cord

In this procedure, a device is implanted over the spinal cord’s dura mater through a laminectomy. It then produces a rhythmic electric pulse to the posterior nerve roots, which activate the central circuits which are responsible for regulating pain, movement, and the cardiorespiratory system. EES is beneficial for reducing fatigue, improving cardiovascular fitness, increasing body mass, and improving urination in patients. [4] However, this is not a simple procedure, as patients must undergo surgery for the device to be implanted and is not yet widely available. 

4. Transcutaneous Electrical Nerve Stimulation (TENS)

TENS utilizes a high and low electrical stimulation to the nerve to manage pain. It may also help with proprioception, balance, and spasticity. This method is very affordable, and patients can do it by themselves without much assistance.  

5. Occupational Therapy

Occupational therapy focuses on improving the physical, sensory, and cognitive functions of the patients. It helps patients suffering from SCI regain their autonomy and independence. It focuses on the execution of daily activities like grooming, bathing, cooking, and dressing, among others. Occupation is the gateway that helps patients attain inclusion and total adaptation to their environment.

6. Robotic Exoskeletons

Wearable robotics, also known as robotic exoskeletons or exosuits, are a recent development in the healthcare industry that present unlimited potential for patients with spinal cord injuries and are used in conjunction with physical therapists. Robotic exoskeletons are used in rehabilitation to help in mobility recovery through repeated movements that lead to increased neural plasticity. [5] Exosuits offer benefits like improved gait, better life quality, improved moods, and better bladder control, among others, as discussed below.

According to Dr. Chester Ho, Associate Professor at the University of Calgary’s Department of Clinical Neurosciences and member of the Hotchkiss Brain Institute, introducing robotic exosuits early in a patient’s rehabilitation process offers better chances of recovery. He says, “The first nine months after a spinal cord injury are pivotal to recovery, so we want to attempt to introduce rehabilitation and mobilization early on and see if it makes a difference.” [6]

What Is An Exoskeleton?

Exoskeletons, first developed in 1890, are wearable electromechanical devices that support joint movement while enhancing the wearer’s strength and ambulatory capabilities. An exoskeleton frame is made to surround the waist and other joints like the shoulders and knees. Exoskeletons can be classified into two types: active, powered by an external power source; or passive, powered by mechanical springs and counterbalance forces. 

Exoskeletons are used in physical rehabilitation clinics to promote a patient’s mobility and increase their muscle strength. They do this by allowing for repeated movements that increase neural plasticity and help develop mobility. [4] The use of exoskeletons in physical therapy is reported to increase “quality of life, body composition, bone density, neuropathic pain, spasticity, gait speed, number of steps, and distance before and after 90 days of training.” [4]

How Are Exoskeletons Controlled?

Exoskeleton control is vital in a physical therapy environment. Exoskeletons offer multiple control modes, and operators can choose the amount of resistance that is applied at the joints. Exoskeletons can be controlled by the patient or physical therapist depending on the degree of patient recovery. Control methods include: [7]

• Sensors: Sensor-controlled exosuits have numerous sensors fitted into the build that capture nerve signals and control torque, pressure, tilt, and rotation. 
• Buttons/control panels: Some exosuits contain pre-programmed modes, which are normally controlled by the user or by the physical therapist. Most control panels are located on the walking aids.
• Joystick: This is commonly found in active exosuits that provide all the energy required by the wearer.
• Mind-Controlled: These use an electrode skull cap as the main method of control.

No-control: Most passive exosuits do not have control buttons and respond to the mechanical movements of the wearer.

Exoskeleton control is vital in a physical therapy environment. Exoskeletons offer multiple control modes, and operators can choose the amount of resistance that is applied at the joints. Exoskeletons can be controlled by the patient or physical therapist depending on the degree of patient recovery. Control methods include: [7]

• Sensors: Sensor-controlled exosuits have numerous sensors fitted into the build that capture nerve signals and control torque, pressure, tilt, and rotation. 
• Buttons/control panels: Some exosuits contain pre-programmed modes, which are normally controlled by the user or by the physical therapist. Most control panels are located on the walking aids.
• Joystick: This is commonly found in active exosuits that provide all the energy required by the wearer.
• Mind-Controlled: These use an electrode skull cap as the main method of control.

No-control: Most passive exosuits do not have control buttons and respond to the mechanical movements of the wearer.

Types of Medical Exoskeletons

All exoskeletons are not built equally. They have different features and capabilities. In addition, the use of medical exoskeletons may differ between individuals based on the extent of injury and their recovery capacity. Exoskeletons are normally divided into:

• Upper Body Exoskeletons

Upper body exoskeletons are built to support the upper extremities, including the arms and torso. They are specifically designed to help patients with upper-body motor rehabilitation by positioning the shoulder, arm, and elbow through specific motions and orientations. They are extremely important to therapists because they can be used for intense motor exercises and task-specific movements.

• Lower Body Exoskeletons

Rehabilitative lower body exoskeletons are made for patients with lower limb motor dysfunctions to enable the recovery of lower extremity mobility. They normally use impedance control to generate resistance forces which are essential for rehabilitation training. Lower body exoskeletons have the ability to control joint movement in the hip, knee, and ankle.

Benefits of Using Exoskeletons After Spinal Cord Injuries

Exoskeletons are advantageous for patients and therapists alike. They have the ability to reduce the burden on therapists and help with quantitative data collection and patient evaluation.

1. Gait Training:

Gait training consists of walking practice with the aim of helping the patient regain their normal walking gait. Using exoskeletons has the potential to make gait training easier and more convenient for therapists, given the numerous support features they offer. For instance, free-standing exoskeletons help patients to exercise in upright positions, which would be almost impossible and cumbersome without the use of exoskeletons. [8]

A 2008 gait training study carried out on two stroke survivors reports that “by the end of the training the gait pattern of the patients improved and became closer to a healthy subject’s gait pattern.” Improvement in this study was defined as “the increase in the size of the patients’ gait pattern, increased knee and ankle joint excursions and increase in their walking speeds on the treadmill.” [9] Exoskeletons also have unique features that help with rehabilitation. For example, the EksoNR has sensors that are made to monitor your patient’s leg movements and regulate their gait patterns. [10] 

2. Bladder and Bowel Function:

The use of exoskeletons may improve your patient’s bladder and bowel function. This is according to feedback that was received by researchers at the Spinal Cord Injury Model System Centers (SCIMS) from focus groups held with 30 therapists. They record that, “patients who gained the ability to stand and walk with an exoskeleton often developed better endurance, improved their bowel and bladder control, and were less likely to develop urinary tract infections.” [11]

Scientists believe that engaging patients in physical activities and maintaining upright postures may play a role in improving bowel motility. A 2019 study tested bowel management after exoskeleton training and reported an improvement of up to 80%. [12]

3. Improved Muscle Strength and Spasticity:

Incorporating exoskeletons in your physiotherapy treatment may help patients improve their muscle strength. A 2021 study examining the effects of exoskeletons in physiotherapy observed that the use of exoskeletons improved grip strength, quadriceps strength, and lower limb motor function. [8] This was also observed in a 2019 study that reported exoskeletons improved muscle strength after a Manual Muscle Strength Test, “total score from both sides were: P3 UEMS increased from 30 to 37, and LEMS from 23 to 25; P11 UEMS increased from 33 to 37, and LEMS from 27 to 30, where the maximum score for UEMS and LEMS is 50.” [13]

Another study conducted on patients who had a stroke concluded that the use of exoskeletons in therapy improved the tibialis anterior muscle strength and lower limb motor function of the patients. [14]

4. Improved Patient Moods:

Though not a significant benefit, the use of exoskeletons in therapy can help improve your patient’s moods. A 2021 study examining the effects of exoskeletons on patients with spinal cord injuries shows improved moods in one of the patients during the rehabilitation phase. It also reports a decrease in fatigue and an improved quality of life. [8] Since robotic exoskeletons are a “new” technology in rehabilitation, they can be exciting for patients and may motivate them to exercise more. Some therapists also report that exoskeletons offer extra psychological benefits to patients. For instance, patients reported psychological effects of having eye-to-eye conversations with others and also increased engagement in daily activities. [11]

5. Patient Independence:

Exoskeletons can help patients gain some independence in their day-to-day activities like moving and walking around. Before the invention of medical exoskeletons, patients had to rely on their therapists to move around and exercise. However, that is no longer the case. They can now exercise and ambulate on their own, which gives them a sense of independence. Physical therapist Kyle McIntosh says, “The exoskeleton lets patients take actual steps, which is not only more realistic but much less cumbersome,” McIntosh also says, “Every step is different with this device, so patients learn from their mistakes in real time. Patients really like to use the device; it gives them hope.” [6]

Conclusion

Rehabilitative technology has come a long way, from crutches to walkers to wheelchairs and now, robotic exoskeletons. Robotic-assisted rehabilitation holds a lot of promise for both patients and physical therapists alike. Several studies have shown the potential benefits of exercising in a free-standing exoskeleton for patients with spinal cord injuries. If you are a physical therapist, this is the next medical technology shift that will help you offer next-level therapy solutions for your patients.

Ekso Bionics has been at the forefront of creating the best quality medical exoskeletons for more than a decade now. Our EksoNR was one of the first FDA-approved medical exoskeletons for rehabilitation, and it continues to be the exoskeleton of choice for many mobility rehabilitation clinics. Please review our indications for use to determine eligibility. [15]

References: 

1. Spinal cord injury https://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury#:~:text=Key%20facts,traffic%20crashes%2C%20falls%20or%20violence. }
2. Exoskeletal Assisted Rehabilitation After Spinal Cord Injury https://www.sciencedirect.com/topics/nursing-and-health-professions/exoskeleton-rehabilitation
3. Spinal Cord Injury https://www.ninds.nih.gov/health-information/disorders/spinal-cord-injury
4. Rehabilitation Therapies in Spinal Cord Injury Patients https://www.intechopen.com/chapters/72439
5. Robotic Rehabilitation and Spinal Cord Injury: a Narrative Review https://pubmed.ncbi.nlm.nih.gov/29987763/ 
6. Spinal cord injury patients may benefit from using exoskeleton earlier in treatment https://ucalgary.ca/news/spinal-cord-injury-patients-may-benefit-using-exoskeleton-earlier-treatment
7. Types And Classifications of Exoskeletons https://exoskeletonreport.com/2015/08/types-and-classifications-of-exoskeletons/
8. Physiotherapy using a free-standing robotic exoskeleton for patients with spinal cord injury: a feasibility study https://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-021-00967-4
9. Robot Assisted Gait Training With Active Leg Exoskeleton (ALEX) https://ieeexplore.ieee.org/document/4663875
10. https://backend.eksobionics.com/eksonr/ 
11. Robotic Exoskeletons May Provide Health Benefits for People with Spinal Cord Injuriesnhttps://naric.com/?q=en/content/robotic-exoskeletons-may-provide-health-benefits-people-spinal-cord-injuries
12. Changes in Bowel Function Following Exoskeletal-Assisted Walking in Persons with Spinal Cord Injury: An Observational Pilot Study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7145720/
13. Retraining walking over ground in a powered exoskeleton after spinal cord injury: a prospective cohort study to examine functional gains and neuroplasticity https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868817/
14. Impacts of a lower limb exoskeleton robot on the muscle strength of tibialis anterior muscle in stroke patients https://www.researchgate.net/publication/344023059_Impacts_of_a_lower_limb_exoskeleton_robot_on_the_muscle_strength_of_tibialis_anterior_muscle_in_stroke_patients/fulltext/5f519787a6fdcc9879c9cc2f/Impacts-of-a-lower-limb-exoskeleton-robot-on-the-muscle-strength-of-tibialis-anterior-muscle-in-stroke-patients.pdf 

Work injuries are any injuries that arise during the course of employment. They may be categorized as traumatic, chronic exposure, psychological or emotional injuries. Among industrial workers, traumatic injuries are the highest due to the physically demanding nature of their jobs. This leads to Workplace Musculoskeletal Disorders (WMSDs) such as strains, sprains, bone fractures, back pain, carpal tunnel syndrome, tendonitis, osteoarthritis, hernia, among others.

Construction and industrial workers are at a higher risk of WMSDs, given the physical demands of their jobs. WMSDs are any conditions that involve soft tissues like muscles, nerves, cartilage, etc. According to the Centers for Disease Control and Prevention (CDC), construction workers have increased workplace musculoskeletal injuries associated with exposure to vibrations, awkward postures, and repetitive tasks during work. [1]

However, all is not lost. Ergonomic innovations and technologies like exoskeletons may hold the answer to reducing workplace-related injuries. They are task-specific robotic tools that help with reducing the load of repetitive work, reducing discomfort in awkward postures, and bearing extra weight on the body. Exoskeletons have wide applications and may be useful in a variety of industries such as, automotive, manufacturing, logistics, construction, and shipping industries.

Common Causes of Workplace Musculoskeletal Injuries

Construction environments are typically overflowing with activity and demand high amounts of physical exertion. This typically leads to overexertion as a result of lifting, carrying, pulling, holding, and pushing tasks – all inevitably leading to injury. In construction, workplace musculoskeletal injuries are commonly caused by repetitive work, strenuous work positions, continuous exertion and vibration. 

1. Repetitive Tasks

Repetition plays a big role in workplace injuries. Did you know workers lift their arms up to 4,600 times a day on average — consider how much toll this takes on their upper extremities. Repetitive tasks are very hazardous because they lead to repeated strain in the same muscle groups and joints. This can lead to injury and disability, which eventually impacts productivity and work efficiency. If the cycle time of your job is 30 seconds or less, it is classified as a repetitive job and may expose you to a higher risk of work injury.

2. Awkward Work Positions

Awkward positions include any position that differs from the natural body positions we should inhabit while working. Even maintaining the same position in normal postures for long periods of time usually leads to fatigue. Now consider unnatural work positions; they lead to muscle inefficiency and exertion, which inadvertently leads to musculoskeletal injuries. Examples of common awkward postures include prolonged standing, which may cause fatigue and lower back pain, bending forward, which can cause lower back injuries, and reaching overhead which may cause damage to your shoulders and arms. Sometimes, maintaining fixed positions may also lead to stiffness and injury.

3. Continuous Exertion

The human body is not designed to take on continuous force and exertion. It needs recovery time in order to regain strength and vitality. Unfortunately, long work hours subject our bodies to constant exertion with limited recovery time. This leads to accumulated fatigue in certain body parts like the lower back, which makes them prone to injury. Continuous exertion exposes the same muscle groups and body parts to wear and tear, which may lead to injury if not attended to.

According to the Center for Construction Research and Training, overexertion is the leading cause of WMSDs, causing up to 67% of musculoskeletal disorders among construction workers in 2015. [2] Apart from causing WMSDs, overexertion  also results in lost productivity, disability, and costly medical expenses. The effects of overexertion are also experienced on a more significant economic scale. According to the CDC, “the economic burden of construction industry worker’s compensation costs brought on by WMSDs in the United States has been estimated to be more than $2 billion annually (Liberty Mutual 2021).” [1] 

4. Vibration

Vibration may affect the whole body or a specific body part. It usually affects workers who operate power tools, machines, and even trucks. Vibration can affect the nerves, muscles, tendons, and joints, and it usually results in fatigue, pain, loss of touch, and numbness. Continuous exposure to vibration is very detrimental to workers.

What Are Exoskeletons?

Exoskeletons, also known as exosuits, were first developed in 1890. They are wearable frames that provide support and enhance the wearer’s capabilities. Exoskeletons amplify the strength of the wearer and augment their physical performance. While they do not give superhuman strength to the individual, exoskeletons are instrumental in increasing productivity, supporting heavy lifting, and reducing physical workload. This has an overall positive effect on reducing musculoskeletal injuries.

Exoskeletons can be classified into two: passive or active. Passive exoskeletons are mechanical, use springs, and counterbalance forces to operate, whereas active exoskeletons use powered mechanisms like hydraulics and electric motors. Despite their differences, passive and active exoskeletons are equally used in providing support to the waist, shoulder, and thigh. However, research shows passive exoskeletons are preferred in industrial workplaces. [3]

Types of Industrial Exoskeletons

There are two main types of industrial exoskeletons: upper-body exoskeletons and lower-limb exoskeletons. Although both reduce the risk of WMSDs, they operate differently and provide support to different parts of the body.

1. Upper-Body Exoskeletons

Upper-body exoskeletons are designed similarly to a backpack. They support the upper extremities and play a significant role in reducing shoulder injuries, particularly among workers who engage in repetitive overhead work. The exoskeleton engages every time you raise your arms or lift something and creates a counterbalancing force that reduces the total load and provides support. This makes completing the task at hand easier and safer.

Upper-body exoskeleton technology is continuously improving and evolving. For instance, Ekso Bionics changed the Ekso EVO from a “backpack” design to a “strap” design that makes the exoskeleton extremely lightweight and comfortable to wear. [4] EVO provides 5 – 15 lb. (2.2 – 6.8 kg) of list assistance per arm to give your natural strength a boost throughout your work day. This is not intended to give you super strength but instead give you super endurance and reduce fatigue so that you have more energy and less soreness at the end of your shift. Whatever payload you normally lift (a 4 lb. torque wrench, a 10 lb. component, or even just the weight of your arm) will feel lighter with the boost you get from your EVO.

2. Lower-Limb Exoskeletons

Lower-limb exoskeletons are generally designed to support the lower body and augment strength when moving or performing heavy tasks. They are made to support joints like your hips, knees, and ankles. Lower-limb exosuits offer support any time you bend or lift a heavy load by passing on the weight to your legs, thus relieving the lower back from heavy weight. [5] Lower-body exoskeletons normally follow the wearer’s motions and respond to the different actions they take.

Benefits of Using Exoskeletons at Work

Exoskeletons present many benefits to construction workers. They provide ergonomic assistance when performing repetitive tasks, enhance worker safety when working in hazardous environments and even reduce fatigue. They remain to be an unrivaled innovation for reducing Workplace Musculoskeletal Disorders and present a practical solution to workplace safety.

1. Improved Comfort At Work

Exoskeletons are lightweight, easy to use, and are  made with comfortable materials that help reduce discomfort when wearing them. For instance, Ekso EVO is made with a compact design that is designed to minimize the exoskeleton’s weight for easy wearability. Ekso EVO also has minimal touch-points, which help you keep cool while working, improving your overall comfort. 

2. Reduced Fatigue

Exoskeletons reduce fatigue by bearing the weight of heavy loads. They do this by distributing the wearer’s weight evenly to the core and waist, thus reducing repetitive force on specific body parts. Some exoskeletons also use counterbalance forces to provide support to the wearer. According to the CDC, “Back assist exoskeletons were found to reduce back muscle activity by 10-44% during handling tasks, and hip extensor muscle activity was reduced by 24% in laboratory studies.” [1] In a 2015 study, researchers reported up to 80% muscle activity reductions due to the use of active exoskeletons. [6]

3. Increased Productivity

Exoskeletons are great at boosting productivity and efficiency. They help workers lift heavier loads for more extended periods of time, effectively increasing the amount of work one can do per day without compromising physical health. Exoskeletons also improve speed and accuracy, which results in a more efficient workflow. Apart from productivity, exoskeletons help workers end shifts with more energy and less soreness, which goes a long way in improving morale. Increased productivity also positively affects a company’s bottom line due to improved output and less sick days.

4. Reduced Injury and Sick Days

According to the U.S. Bureau of Labor Statistics, workplace injuries result in an average of 34 days of sick leave. [7] According to the 2021 AmTrust Contractor Risk Report, 34% of workplace injury claims come from plumbers and 27% from electricians who have repetitive overhead tasks, which lead to strain and musculoskeletal injuries. [8] Exoskeletons can help reduce workplace injuries which effectively reduces the number of sick days workers have to take. 

Exoskeletons reduce the load that workers bear and offer support to the shoulder and arms in case of overhead tasks. This helps minimize repetitive wear and tear on body parts, reducing the number of work-related injuries. Ford Motor Company has been at the forefront of acquiring exoskeletons for their workforce, and since 2011, they have recorded an 83% reduction in workplace injuries in departments that use exoskeletons. [9] The CDC also believes that exoskeletons are the best alternative to reducing musculoskeletal injuries and associated costs in different industries. [1]

5. Improved Work Quality

Exoskeletons may help improve the quality of work since workers are less fatigued, which contributes to alertness and accuracy. This results in a higher level of work output within shorter periods of time, boosting productivity. [10]

Conclusion

Occupational exoskeleton technology is undeniably the next-best solution to reducing workplace injuries, especially in industries that require heavy lifting and expose workers to repetitive tasks and awkward working positions. Exoskeletons are beneficial in reducing strain, fatigue, injury, and improving overall productivity. Just to show how critical exoskeletons are for work, in 2019, Toyota made upper-body exoskeletons a mandatory part of Personal Protective Equipment (PPE) for workers who engage in overhead work.

Ekso Bionics has been at the forefront of producing the best-in-class wearable technology for years, and all our exoskeletons are made with insight from industry experts and stakeholders. Our Ekso EVO exoskeleton vest is the product of choice among workers who care about their health and comfort while performing their daily activities. Ekso EVO remains to be the go-to exosuit for our partners, Boeing and Ford. [4]

References:

1. Exoskeletons: Potential for Preventing Work-related Musculoskeletal Injuries and Disorders in Construction Workplaces https://blogs.cdc.gov/niosh-science-blog/2022/02/03/exoskeletons-construction/
2. Chart Book (6th edition): Fatal and Nonfatal Injuries – Musculoskeletal Disorders in Construction and Other Industries https://www.cpwr.com/research/data-center/the-construction-chart-book/chart-book-6th-edition-fatal-and-nonfatal-injuries-musculoskeletal-disorders-in-construction-and-other-industries/
3. The Effects of Upper-Body Exoskeletons on Human Metabolic Cost and Thermal Response during Work Tasks—A Systematic Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600262/ 
4. https://backend.eksobionics.com/ekso-evo/ 
5. Exoskeletons are reducing ergonomic injuries https://www.thesafetymag.com/ca/topics/technology/exoskeletons-are-reducing-ergonomic-injuries/184498#:~:text=%E2%80%9CWe%20know%20that%20in%20a,compressive%20forces%20in%20the%20spine
6. Exoskeletons for industrial application and their potential effects on physical work load https://pubmed.ncbi.nlm.nih.gov/26444053/ 
7. Occupational Injury and Illness Classification Manual https://www.bls.gov/iif/oshoiics.htm
8. AmTrust 2021Contractor Risk Report  https://amtrustfinancial.com/contractor-report
9. How Exoskeletons Impact The Workplace https://backend.eksobionics.com/how-exoskeletons-impact-the-workplace/ 
10. https://backend.eksobionics.com/manufacturing/

Acquired brain injuries (ABI) are more common than we’d like to imagine. According to the Brain Injury Association of America (1), brain injury is a leading cause of death and disability in the U.S., with at least 2.8 million Americans sustaining a traumatic brain injury each year. In the U.K. (2), approximately 348,453 ABI patients were admitted to the hospital in 2017, which translates to one person every 90 seconds. These statistics are not limited to the U.S. and U.K.; a similar pattern is observable in other parts of the world. Despite the bleak outlook from these statistics, modern medical exoskeletons offer hope and an opportunity for recovery from brain injury patients who’ve lost their mobility.

This article investigates the causes, types, and effects of brain injuries. It also looks into the various treatments available with a special focus on medical exoskeletons and how they are improving mobility rehabilitation in ABI patients.

What Is An Acquired Brain Injury?

The Brain Injury Association of America describes an acquired brain injury (ABI) (3) as any injury to the brain that occurs after birth and affects the brain’s physical integrity, functionality, and metabolic activity. In other words, the term ABI is used as an umbrella term for all brain injuries. An acquired brain injury can occur in many different ways. It can be sudden, resulting from a blow to the head, stroke, infection, trauma, or lack of oxygen. It can also result from a long-term process such as degenerative disease, prolonged drug abuse, or a growing tumor. An ABI may lead to cognitive, sensory, physical, and behavioral changes like physical weakness, impaired vision, forgetfulness, mood swings, slurred speech, and impaired mobility.

Major causes of ABI include:

• Substance abuse – Psychoactive drugs (stimulants, depressants, and hallucinogens) can poison the brain, leading to impairment. 
• Age-related and degenerative conditions – As we get older, we become more susceptible to degenerative brain conditions like Dementia and Parkinson’s disease, which increase the risk of developing a brain injury.
• Diseases – Such as meningitis, Alzheimer’s disease, brain abscess, multiple sclerosis, and cancer.
• Anoxia and Hypoxia – This is the lack of sufficient oxygen supply to the brain. It can result from strangulation, heart attack, or near-drowning.
• Concussion – This is caused by a blow to the head. It can occur in vehicle or sporting accidents, fights, or falls. It is the most common type of brain injury.
• Stroke – which happens when there is an interruption of blood supply to the brain. It can be caused by blocked or broken arteries, which in turn leads to damaged brain tissue.

Types and Effects of Acquired Brain Injuries

There are two types of acquired brain injuries: traumatic brain injury (TBI) and non-traumatic brain injury. A traumatic brain injury is any type of brain injury that is caused by an external force—for example, a blow to the head, car accident, or a fall. However, not all head injuries cause a TBI because you can sustain an external impact to the head that doesn’t alter the brain in any way. On the other hand, a non-traumatic brain injury is caused by internal factors like oxygen deprivation, tumors, substance abuse, and strokes. Non-traumatic brain injuries can be sudden, as in the case of a stroke, or can progress over time, as in the case of a degenerative brain disease.

Acquired brain injuries affect people differently based on the extent of damage sustained to the brain and the areas affected. For instance, one type of injury may affect a person’s mobility, while another may affect their speech or cognitive functions.

Here’s a detailed list of the effects of acquired brain damage (4):

Acquired Brain Injury Therapy

A wide range of treatments are available for people with an acquired brain injury ranging from surgery to speech therapy to cognitive therapy and physical therapy. Each treatment is dependent on the effects the patient is experiencing. Generally, all types of treatment are designed to help improve and recover affected functionalities, but recovery differs from person to person. It usually depends on the extent of brain damage, the general health of an individual, and the quality of treatment.

• Physical therapy: The main function of physical therapy is rebuilding mobility after sustaining an ABI. It focuses on areas like muscular strength, balance, coordination, and flexibility. It is normally conducted by a physiotherapist who is trained in physical mobility restoration. Physical therapy can also be aided by the use of a medical exoskeleton.
• Occupational therapy: Occupational therapy typically goes hand in hand with physical therapy. Occupational therapy is aimed at helping you relearn daily living activities like bathing, making your bed, dressing, etc. It is conducted by occupational therapists who are experts in training people how to regain independent functioning in daily activities.
• Cognitive-behavioral therapy (CBT): This addresses the cognitive and behavioral functions that might have been affected after sustaining an ABI. It is common for patients to experience stress, anxiety, depression, and panic attacks during recovery. CBT therapy helps them learn how to manage their emotions by teaching how to identify unhealthy thinking patterns and healthy emotion management techniques.
• Speech therapy: Speech therapy is a recommended treatment option for people with speech impediments like communication disorders and apraxia. Speech pathologists help patients regain their communication and language skills by taking them through speech recovery exercises.

Exoskeleton Benefits for Acquired Brain Injuries

Medical exoskeletons have gained a lot of popularity in the medical field and are a great physical therapy treatment option. Instances of health-related applications (5) for exoskeletons include stroke, spinal cord injury, acquired and traumatic brain injury. They offer benefits like improved step quality, muscle strength, and postural balance, as discussed below.

• Improves Patients’ Orientation to Midline

The midline is an imaginary line that runs from the top of your head to the point between your feet. Proper midline orientation (6) means that your brain’s left and right hemispheres are working together and not in isolation. This helps with balance perception when walking and conducting other activities. However, some patients, who have sustained an ABI, may lack proper orientation due to their injury, which leads to reduced limb and motor control, and postural misalignment. Exoskeletons help match both sides of the body through kinesthetic and proprioceptive systems, leading to an improved orientation to the midline.

• Allows For Easier Weight Shifting

Proper weight shifting allows body weight to be evenly distributed on all limbs. However, this may be impossible for people diagnosed with an ABI.  (7) This is where exoskeletons come in handy. Medical Exoskeletons offer posture and limb support (8) which helps patients bear their own weight properly for proper postural alignment and blood circulation within the limbs.

• Improves Stepping Quality

According to a 2020 study, (9) conducted on adolescents and young adults with acquired brain injury, gait training with exoskeletons is an effective physiotherapy treatment option that leads to improved motor function in patients. Many patients struggle with ambulation (movement), but with the help of medical exoskeletons, they can increase their neurological recovery through movement. Dr. Karunakaran reported, “At the end of the 4-week training, participants had progressed to a more normal gait pattern, including improved loading, a longer step length, and faster walking speed.” (9)

• Increases Lower Extremity Muscle Strength

Exoskeletons amplify human strength and endurance during movement, improving muscle strength. One 2020 study (10) on the impact of a lower limb exoskeleton robot on muscle strength showed that patients with stroke hemiplegia, who trained using lower limb exoskeletons, experienced an increase in the tibialis’ anterior muscle strength compared to those who relied on conventional rehabilitation.

• Great for Repetitive Motions

Repetition in motor rehabilitation is a crucial element of recovery, and exoskeletons provide patients with high repetitions of complex gait cycles. Additionally, where a patient used to only take few steps a day with the help of a physical therapist, they can take more steps with the help of a medical exoskeleton. (8)

• Provides Support to Physical Therapists 

Physical therapists can only do so much. They are human and prone to fatigue and exhaustion. A 2020 study (11) revealed that stroke patients get an average of 14 minutes of physiotherapy per day, which is less than the recommended threshold. However, exoskeletons have unlimited capacity, and using them reduces the workload for physical therapists and increases the quality of rehabilitation for patients. Exoskeletons allow for increased intensity, longer duration of practice, and increased patient engagement. (12) They also provide a chance for physical therapists to challenge their patients since they require active participation, which is known to improve brain plasticity. (13)

Diane Patzer, a physical therapist from the Rehabilitation Institute of Michigan (8), says, “We went from taking 20 steps with three physical therapists to taking hundreds of steps in a session with one.”

Conclusion

Medical exoskeletons are a great mobility recovery tool to use in physical therapy. They enhance motor rehabilitation by giving patients the confidence to get up and begin walking. They eliminate a patient’s fear of falling, which helps them start their mobility recovery faster. And above all, exoskeletons are very engaging compared to other tools. This makes them a great tool for patients who want to increase their chance of mobility recovery.

Ekso Bionics has been at the center of developing medical exoskeletons for more than a decade. Our products are created by clinical and engineering experts in conjunction with feedback from industry leaders. EksoNR, a product of Ekso Bionics, is the first and only FDA-cleared medical exoskeleton for rehabilitation use with ABI. EksoNR is versatile and can be used by ABI patients at any stage in their recovery journey.

References:

(1) https://www.biausa.org/public-affairs/public-awareness/brain-injury-awareness 

(2) https://www.headway.org.uk/about-brain-injury/further-information/statistics/ 

(3) https://www.biausa.org/brain-injury/about-brain-injury/basics/overview 

(4) https://www.headway.org.uk/about-brain-injury/individuals/effects-of-brain-injury/ 

(5) https://backend.eksobionics.com/indications-for-use/ 

(6) https://backend.eksobionics.com/acquired-brain-injury/ 

(7) The scaling of postural adjustments during bimanual load-lifting in traumatic brain-injured adults

https://pubmed.ncbi.nlm.nih.gov/15063052/

(8) https://backend.eksobionics.com/eksonr/ 

(9) Kinetic Gait Changes after Robotic Exoskeleton Training in Adolescents and Young Adults with Acquired Brain Injury 

https://www.hindawi.com/journals/abb/2020/8845772/

(10) Impacts of a lower limb exoskeleton robot on the muscle strength of tibialis anterior muscle in stroke patients

https://www.e3s-conferences.org/articles/e3sconf/abs/2020/45/e3sconf_iceeb2020_03036/e3sconf_iceeb2020_03036.html

(11) Factors influencing the amount of therapy received during inpatient stroke care: an analysis of data from the UK Sentinel Stroke National Audit Programme

https://journals.sagepub.com/doi/10.1177/0269215520927454

(12) Exoskeleton Training May Improve Level of Physical Activity After Spinal Cord Injury: A Case Series

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5562032/

(13) Effects of Physical Exercise on Neuroplasticity and Brain Function: A Systematic Review in Human and Animal Studies

https://www.hindawi.com/journals/np/2020/8856621/

Whether you are lifting heavy objects or completing light and repetitive tasks, construction exoskeletons are your best chance of injury prevention and productivity enhancement. In 2017 alone, there were at least 12,000 injuries per month in the construction industry (1), many of which could have been prevented with the use of exoskeletons. According to research (2), exoskeletons reduce human metabolic cost and thermophysiological response during upper-body work tasks, which translates to less fatigue and strain for workers., resulting in increased productivity. For construction and warehouse workers, exoskeletons are the next industrial shift that will lead to increased efficiency and productivity. 

In this article, you will learn what exoskeletons are, how they are applied in construction, and their benefits. Let’s dive in.

What Are Exoskeletons? 

Exoskeletons, also referred to as exosuits, powered-armor, or exo frames, are wearable external frames that offer extra support and enhance a person’s biomechanical capabilities. Think Iron Man from the Avengers, but in real life. The exoskeleton acts as a strength amplifier that augments physical performance or a corrective device for restoring mobility. 

Some people believe that exoskeletons are a new “thing”. However, this technology has been in existence since 1890 but has only gained more traction in recent years due to accelerated technology developments. The early model, designed and patented by Nicholas Yagn (3), was a spring-operated device that enhanced the user’s ability to run and jump. 

Today, exoskeletons have wide applications and are used in the military, medical, and construction fields. In the medical industry, physical therapists use them as locomotive assistance and gait training devices for patients who have a condition or injury that affects mobility. While in the construction industry, they are primarily used to help workers with their upper extremity mobility by reducing strain and increasing productivity. 

There are two types of exoskeletons, powered and passive. A powered exoskeleton contains electric motors, levers, hydraulics, and other technologies that enable limb mobility with increased endurance and strength. It works by sensing the wearer’s motions, sending signals to the motors, and offering the necessary support. A passive exoskeleton differs from a powered exoskeleton because it is purely mechanical. However, they both offer benefits such as shoulder, waist, or thigh support.  Additionally, it offers movement assistance when lifting heavy items. Powered exoskeletons are mostly used in military and physical therapy, while passive exoskeletons are more commonly used in construction and other industrial industries.

Exoskeletons and Injury in the Construction Industry 

Did you know that the rate of work-related musculoskeletal disorders in construction is 16% higher than in all industries combined?(4) This statistic alone should be enough to point you to the most significant challenge that construction workers face: workplace injury. According to the Construction Chartbook (5), the most common injuries in construction are located in the back, shoulders, and other joints. This can be attributed to the long and repetitive tasks that eventually lead to overexertion and strain to workers’ bodies. 

“The most common cause of workplace injuries was overexertion and fatigue. With 20% of construction workers reporting severe pain, construction workers are five times more likely to report poor health. US companies pay nearly $62 billion per year for workplace injuries.” (6)

Workplace injury results in lower productivity, which accumulates to more than 104 million lost production days.(1) In addition, it impacts construction workers’ morale as the uninjured employees have to take up bigger workloads to make up for the injured and recuperating workers. It also affects the injured person’s ability to complete future tasks and lowers their working lifespan.. However, organizations can avoid this by investing in construction exoskeletons. 

In a study conducted in 2015 on the application of exoskeletons in industrial applications and their potential effects on physical workload, researchers discovered that exoskeletons greatly reduce fatigue while improving endurance (7). Additionally, exoskeletons reduce shoulder discomfort, thereby improving work quality and productivity among workers. Apart from decreasing the risk of workplace injury, exoskeletons also assist aging workers, and give them an opportunity to work beyond their age and physical limit.

Construction exoskeletons are the future of the construction industry due to the efficiency and productivity opportunities they present. Their primary purpose being: to improve the quality of life for construction workers and prevent injury. 

You can use exoskeletons on the manufacturing floor to engage in long-intensive overhead work like installing sensors and filters without straining or injuring yourself. Benefits include joint support that’ll boost your endurance, productivity and prevent injury.

The Construction Exoskeleton Vest 

Construction exoskeletons come in different shapes and variations suited to a specific task. Depending on the workload, it can be a full suit, a simple vest to support upper limb mobility or just a glove. Let’s take a look into an exoskeleton vest.

The construction exoskeleton vest is an upper-body exosuit specifically designed to support upper extremity mobility. Its main goal is to reduce workplace injury and worker fatigue by supporting muscle activity and joint movement. It also reduces discomfort when performing repetitive overhead tasks. Let’s establish one important fact; a construction exoskeleton won’t give you ‘Iron Man-level’ superhuman strength. In essence, the vest serves to reduce musculoskeletal loads. You’ll still lift an equal amount of load as you could before. The only difference will be that the load will be lighter and easier to carry since you’ll have additional muscle support. 

The construction exoskeleton vest contains features like:

• Lightweight frame: This makes it easy and comfortable to wear. 
• Durable materials: The vest is built for the construction environment where they can be exposed to the harshest element and function fully without breakage.
• Assistive: The Exo suit has an adjustable force assistance level that allows you to determine the amount of arm support you want from the suit. 
• Natural-tracking: You can wear the suit and move naturally using your intuition, instincts, and reflexes to control it.
• Minimal contact points: This allows workers to work unhindered with a full range of motion and great airflow for comfort.

How Does The Construction Exoskeleton Vest Work?

Exosuits work in different ways depending on how they are powered. Mechanical exoskeletons, which do not use electricity, take weight from certain parts of the body and redistribute it to other areas. For instance, it can take weight from the arms or back when doing tedious overhead work and transfer it to your core to reduce fatigue and strain on muscles and joints. Mechanical exoskeletons are more advantageous since they don’t need to be recharged to use them. So, there’s no downtime. Additionally, they offer more longevity. 

On the other hand, electric exoskeletons are more powerful and can handle more weight. They work by increasing pressure and strength in targeted areas as required. The frame responds to the wearer’s motion and provides support when needed. Due to their reliance on power, they can stop work if they run out of charge. In addition, you have to recharge them between uses. 

The construction exoskeleton vest is one of the must-have technologies for construction, logistics, and warehouse workers, and for manufacturers who are interested in increasing occupational safety. It is the best solution to reducing muscle pulls, elbow and spinal injuries, and back sprains. It represents the coming together of man and machine to make work easier and more efficient. Let’s dive into the benefits more extensively below. 

Fun Fact: The Master Mystery, released in 1919, is the first movie to feature a powered exoskeleton

5 Benefits Of Construction Exoskeletons 

You can enjoy many benefits from using industrial exoskeletons, like lifting heavy loads, performing repetitive tasks, reducing the risk of injuries, supporting joints, and increasing work efficiency. 

1. Injury and Strain Prevention

Exoskeletons cut down on overexertion by supporting workers’ upper limbs when performing monotonous activities. They distribute the user’s weight evenly to the core and waist by reducing strain on the arms and shoulders. This leads to decreased workplace injuries like back sprains and shoulder injuries. 

2. Withstanding Repetitive Tasks

Picture a construction worker who has to raise their arms over their heads for hours on end plastering a wall or installing drywall. That’s a daunting task, but with a construction exoskeleton, their workload is made more bearable because they have extra support for their arms. They no longer have to go home with joint and back pains, and they can work for more hours without overexerting themselves and thereby increasing their productivity. 

3. Increased Productivity

Exoskeletons have been proven to increase workers’ endurance by reducing the amount of energy exerted on repetitive tasks. Additionally, since the frame takes on a portion of the musculoskeletal load, it reduces strain on the worker’s muscles and lowers fatigue. Coupled with less injury and strain, this becomes a great productivity enhancer for workers since they can work longer and more efficiently. 

4. More Work Accuracy

After endless hours of overhead work, accuracy is lowered due to muscle fatigue and exhaustion. However, with an exosuit, you can practically maintain most of your attention and focus on the task at hand without the distraction of strain and fatigue. 

5. More Opportunities For Aged Contractors

Due to the labor-intensive nature of construction work, older contractors are more likely to be limited by their physical abilities. But with a construction exoskeleton, these workers are able to handle more strenuous work effectively.

Conclusion

In recent years, the construction industry has experienced a lot of automation. However, not every task can be automated and replaced with a robot. There are specific, heavy and repetitive tasks that only humans can do. And the best option for attaining more efficiency and productivity in these non-autonomous tasks is to invest in well-produced exoskeletons. They are an innovative injury prevention solution and present great productivity potential in the construction industry. 

If you are considering getting a construction exoskeleton, Ekso Bionics is your best choice. We are the leading company in exoskeleton technologies and have produced some of the best products in the world for the last 17 years. We’ve worked with the United States military, DARPA, Johns Hopkins, Shirley Ryan AbilityLab, Kessler Institute, the Department for Veterans Affairs, and UCLA, among others. Our products are FDA-Approved and are based on clinical experts and feedback from industry leaders.

References:

1. https://backend.eksobionics.com/eksoworks/
2. The Effects of Upper-Body Exoskeletons on Human Metabolic Cost and Thermal Response during Work Tasks—A Systematic Review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600262/ 
3. APPARATUS FOR FACILITATING WALKING, RUNNING, AND JUMPING. No. 420,179 https://patents.google.com/patent/US420179A/en 
4. Exoskeletons in Construction: Will they reduce or create hazards? https://blogs.cdc.gov/niosh-science-blog/2017/06/15/exoskeletons-in-construction/ 
5. CPWR. The Construction Chartbook. Fifth Ed. CPWR- the Center for Construction Research and Training.  Silver Spring, MD.  April 2013. http://www.cpwr.com/publications/construction-chart-book 
6. https://backend.eksobionics.com/construction/
7.  Exoskeletons for industrial application and their potential effects on physical work load https://pubmed.ncbi.nlm.nih.gov/26444053/