Category: Exoskeletons

As one of the top trends in the health and tech industries today, human robotic exoskeletons are reshaping our approach to both medical treatment and industrial labor. On one hand, robotic exoskeletons are bringing hope to people across the world who are dealing with the loss of mobility and independence or suffering from paralysis after a stroke, brain injury, or spinal cord injury. On the other hand, they are enhancing worker capabilities beyond what was previously thought possible. Considering the nature of their advantages, it shouldn’t come as a surprise that they are also being used in military research and development.

What are Human Robotic Exoskeletons?

Human robotic exoskeletons are mechanically made, taking a user’s anatomy into consideration, to improve mobility and endurance. They involve the application of robotics and bio-mechatronics — a study of science that merges biology with “mechatronics”, a discipline at the crossroads of electronics, mechanics, and computing. The focus of this groundbreaking technology is to increase bodily independence and effectiveness. It is designed to assist humans by enhancing, reinforcing, or restoring, depending on the circumstances, an individual’s physical performance. Human robotic exoskeletons can also work to reduce the energy it takes to move joints, making repetitive tasks easier, and also work to improve human movement in cases of mobility loss.

The earliest work related to human robotic exoskeletons was much earlier than you might think. A Russian inventor named Nicholas Yagn had the first approved patent for a powered exoskeleton in 1890. It was a spring-operated device designed for the military with the intention of enhancing a user’s ability to run and jump, but it never made it past the drawing board.

It wasn’t until the 20th century that robotic exoskeletons were actually assembled. In 1960, General Electric created the Hardiman, or “Human Augmentation Research and Development Investigation” and “MANipulator”, a 1,500-pound machine produced with military funding. Unfortunately, the machine was too large and too heavy to operate properly and the project was discarded altogether.

Finally, around the year 2000 came BLEEX (Berkeley Lower Extremity Exoskeleton), a pair of robotic legs designed by engineers at UC Berkeley and funded by DARPA (Defense Advanced Research Project Agency) aimed at lessening the effort it takes to carry heavy loads over long stretches.

Today, robotic exoskeletons have become more prevalent and complex, with an array of functions and uses. Companies like Ekso Bionics have designed exoskeletons for the purpose of military research, assisting industrial labor, and aiding neurorehabilitation.

Components of Human Robotic Exoskeletons

Robotic exoskeletons made for humans may look different depending on the functions they serve. Exoskeletons can be made from materials such as carbon fiber, metal, and elastic. Their coverage also varies from the entire body, to lower or upper extremities, or to a specific body part like the shoulder, hip, or ankle. Some exoskeletons have adjustable hardware so they can be tailored to the individual that is using them. Overall, the technology behind the exoskeleton depends largely on its type and function.

There are two types of exoskeletons: powered and passive.

Powered exoskeletons are equipped with electronics that register how much force is being applied to any given action, allowing the exoskeleton to share some of that burden with the user. In order for the exoskeleton to work properly, there must be technologies to support the three modules: sense, decision, and execution. These technologies include sensors, actuators, mechanical structures, algorithms, and control strategies that gather necessary information for carrying out each action. It may sound complicated, but it’s actually fairly straightforward. There are three basic steps that accompany the three modules.

• The sense module is where the information gathering takes place. The exoskeleton records data from the user via the device sensors.
• Next, the decision module interprets that data and sorts it into the intended activities.
• Finally, the execution module provides the mechanical power to complete the task.

Examples of the lower-extremity powered exoskeleton at Ekso Bionics:

• Data capture

This feature allows the user to view session-specific walking time, distance, and speed. It also securely saves this information into a cloud-based dashboard for easier analytics.

• Clinician control:

This feature allows the clinician to set certain parameters they can use to help better assist their patient, ushc as training targets and step parameters.

• Smartassist software:

This feature allows the clinician to customize motor support  independently on each leg for various impairment levels, from full assistance to patient-initiated movement, in both swing and stance phases of walking.

• Adaptive gait training:

This feature consists of sensors and software continuously monitoring and regulating leg movement to minimize compensatory gait patterns.

• Pre-ambulatory tools:

The feature possesses a program suite called preGait that consists of programs that help patients balance, weight shift, squat, and step in place before walking.

To contrast with the lower-extremity exoskeleton, here are the features of the upper-extremity exoskeleton vest for construction at Ekso Bionics:

• Mobility Structure

The exoskeleton vest was built with a patented stacked-link structure that seamlessly follows the user’s arm and elbow through the full range of motion while providing proper joint alignment through repetitive movement.

• Extreme logistics positions

These positions include reaching directly overhead, across the body, or even into a back pocket for a phone — are unrestricted with this wearable exoskeleton.

• Adjustable, high-force actuators

These actuators are proven to be extremely durable with over a million cycles before requiring replacement.

• Customized Assistance Levels

The level of each device can be adjusted for the user and task by easily swapping out the set of compact gas springs. Different levels can even be selected for each arm independently depending on the task.

Passive exoskeletons are purely mechanical, providing support using pulleys, a spring balancer, and weights to counterbalance the workload. Passive systems generally take the weight off the user’s shoulders and arms and transfer it to their center of gravity so that the user obtains increased endurance during overhead tasks and other demanding work.

Exoskeleton technology not only helps the individual perform tasks that directly aid in increasing mobility, but also provides medical professionals with the information needed to offer treatment with a higher chance of success. For patients with a low likelihood of regaining their mobility, these machines can be a saving grace, in many cases enabling full rehabilitation.

Exoskeletons for Rehabilitation

Diseases or injuries that can be treated with physical therapy and a wearable exoskeleton include but are not limited to: stroke, spinal cord injury, traumatic brain injury, aneurysm, hypoxia/anoxia, ischemia, brain tumor, or any other acquired brain injury. For individuals recovering from these injuries, exoskeletons are great for rehabilitation and mobility restoration. Exoskeletons have the potential to bring these patients from lower limb disability and complete loss of movement all the way to the point of getting out of their wheelchairs, and learning to walk again. One study from 2015 found that, “The ability to restore gait for individuals with paraplegia has improved with progress in various powered exoskeletons and neuromuscular stimulation technologies. The powered exoskeletons are able to restore the stand up, sit down, and walking motions.” These human-augmenting devices are truly a rehab tool for physical therapists to challenge their patients, requiring active participation known to drive brain plasticity.

Exoskeletons for Upper Extremity Therapy

Upper-extremity rehabilitation exoskeletons assist physical therapists, occupational therapists, physiatrists, and doctors in clinically rehabilitating patients with upper-body weakness or paralysis. This new technology also greatly benefits industrial applications and other workplace settings or job sites. Wearable exoskeletons help workers complete tasks with full range of motion rather than giving in to fatigue, overuse, or repetitive movements.

An injury resulting in decrease of upper-body strength can come from any number of areas whether that be occupation risks, sport injury, or illness. An upper-body exoskeleton is a wearable vest that helps you perform everyday tasks and use your arms and shoulders without limitations. There are a few different reasons why someone may benefit from upper-extremity therapy and bionics. Some conditions EksoUE is beneficial for include: stroke, spinal cord injury, traumatic brain injury, muscular dystrophy, ataxia, orthopedic injury, Guillain barre, brain tumor, brachial plexus injuries, and other upper-extremity weakness or paralysis. Rehabilitative treatments may begin immediately post-injury or after any chance of reversing the damage through medical means has passed. These treatments are designed to strengthen weakened muscles, reteach parts of the brain to take over for the damaged areas, and help the patient adapt to a new way of doing things.

Exoskeletons for Lower Extremity Therapy

Exoskeletons for lower extremity therapy are appropriate for many people recovering from spinal cord injury, stroke, and brain injury at any stage of in-patient or outpatient rehabilitation, preferably as soon as possible after diagnosis. It can be helpful for patients to stand and take their first steps post-injury and retrain brain and muscle function as they learn to walk again. It can also help fine-tune walking skills and help improve patients’ gait as they learn to regulate their movements.

With this tool, patients have the opportunity to gain as many lost abilities as possible. The exoskeleton provides progressive levels of support so the clinician can reduce the assistance the system offers patients as they improve, and can even add resistance to one or both legs. Patients who use a wheelchair can use the exoskeleton to regain the ability to stand, retraining muscles to support body weight without strain. Therapists toggle between patient-initiated and therapist-initiated movement, tailoring rehabilitation to the patient.

Human Robotics for Industrial Labor

Industrial workers in construction or manufacturing benefit from a significantly lower likelihood of injury and increased quality of work by using exoskeletons to enhance their physical capabilities. Mechanical arms and vests help them lift heavy loads and perform repetitive tasks through an active range of motion so they can avoid giving in to fatigue and/or injury.

Why Choose Ekso Bionics for Human Robotic Exoskeletons?

Ekso Bionics is the leader in exoskeleton technology with the first FDA-cleared exoskeleton for both stroke and SCI in addition to acquired brain injury. With more than 175 conference presentations, chapters, and published articles, Ekso is the most widely-studied exoskeleton for rehabilitation, progressing patients far beyond what they would otherwise be able to accomplish. Our exoskeletons are backed by data from over 40 industry-leading research partners and help those with paralysis to stand up and walk, enhance worker capabilities globally, and provide research for the advancement of R&D projects intended to benefit U.S. defense capabilities.

Industries Ekso Bionics Specializes In

EksoHealth is the arm of Ekso Bionics that specializes in neurorehabilitation. We have helped thousands of patients with lower extremity disabilities take over 180 million Ekso-aided steps and have inspired an entirely new medical device industry. Similarly, we have helped many patients with upper extremity disabilities, allowing them to achieve rehab sessions with a higher dosage, more intense therapy, and a wider active range of motion.

EksoWorks is the arm of Ekso Bionics that specializes in our exoskeleton technology for industrial applications. Our EksoWorks upper-body lifting exoskeletons were designed to increase productivity and reduce fatigue, with the goal of eliminating work-related injuries to the neck, shoulder, and back.

Conclusion

Whether you’re looking to regain mobility, increase your capabilities on the job, or prevent injuries, human robotic exoskeletons are a reliable and technologically safe choice. We hope our exoskeletons provide you support and progress in rehabilitation and lower the number of worker-related injuries for years to come.

Strokes are the fifth leading cause of death in the United States and a major cause of long-term disability. Thankfully, great strides have been made in treating patients who have had strokes and been left with a disability. Ekso Bionics is leading the way with robotic exoskeletons to help those who have lost mobility due to stroke, spinal cord injury, or brain injury regain what they have lost.

What Is a Stroke?

A stroke occurs when part of the brain is deprived of oxygen. This can be caused by a blood clot blocking blood flow or by a rupture in the artery feeding blood to that part of the brain. Either way, if blood flow is not returned to the affected part of the brain quickly, the damage to the brain can become permanent. This can result in varying degrees of disability or death. 

There is also a type of stroke that is temporary. Known as a transient ischemic attack (TIA), these happen when the blood supply to the brain is cut off for only a short time. After experiencing a TIA, a patient may become clumsy or confused, but the effects are only temporary. Once blood flow returns to the brain, the effects of the TIA dissipate. It is still vital to see a doctor after having a TIA. People who frequently have these attacks may have a full-blown stroke later on. 

Immediate treatment can sometimes reverse the effects of a stroke. In the case of permanent stroke damage, rehabilitation with EksoNR exoskeleton can successfully return patients to a lifestyle similar to the one they enjoyed previously.  You can read more about the research on EksoNR and stroke in our Clinical Summary. This transformative device has been helping adults of all ages regain their mobility and their quality of life.

Health Effects of a Stroke

Because the brain controls almost all of our bodily functions, the range of effects from a stroke is very broad. Frequently, patients who have had a stroke have complete or partial paralysis to one side of their body, including the facial muscles. This can manifest as drooping eyelids, an inability to speak or chew food properly, and reduced mobility. 

Sometimes strokes do not affect a person’s limbs and muscles but rather the parts of the brain that control thinking, speech, hearing, or eyesight. In these cases, a patient may have a diminished ability to think clearly or logically. They may show personality changes or lose their memory. If the areas of the brain that control the senses are damaged, the result may be loss of taste, smell, hearing, or sight. 

Even with advances in understanding strokes, it is still somewhat unpredictable how a stroke will affect someone. If the patient’s symptoms include decreased mobility, even if it is severe, EksoNR robotic exoskeleton can be a powerful tool for reversing this potentially life altering side effect.

Stroke Treatments 

Stroke treatments fit into two categories: preventative treatments and rehabilitative treatments to regain what was lost. 

Preventative Stroke Treatments 

Immediate stroke treatments vary depending on how the stroke occurred. If a blood clot caused the stroke, then medications will be given to thin the blood and reduce the size of the clot. If a rupture or other brain bleed caused the stroke, steps would be taken to stop the bleeding and return blood flow to that part of the brain. 

In both instances, medication is often given to reduce the patient’s blood pressure. High blood pressure can be both a cause and a result of a stroke. 

Rehabilitative Stroke Treatments 

Rehabilitative stroke treatments begin after any chance of reversing the damage through medical means has passed. These treatments are designed to strengthen weakened muscles, reteach parts of the brain to take over for the damaged areas, and help the patient adapt to a new way of doing things. While physical, speech, and occupational therapy is a part of these treatments, new technology, like EksoNR, gives patients who have had a stroke that resulted in paralysis or loss of mobility more options, and hope. 
 

EksoNR is a robotic exoskeleton that the Food and Drug Administration has cleared for rehabilitation after stroke. It provides therapists the opportunity to work with patients’ brain plasticity and retrain their muscles and brains to regain lost mobility.  It has shown great success at helping thousands of patients leave their wheelchairs or walkers behind. 

EksoNR can be utilized both in walking and preGait modes. Pre-gait activities include those that work on balance, midline orientation, and prepare a patient for walking. 

The various gait-training modes offer support to the torso, hips, knees, and ankles while keeping the patient in a fully upright posture and providing varying amounts of power to one or both legs. EksoNR uses a gyroscope, sensors, and software that monitors the position of the EksoNR to ensure that training is done effectively and safely. As a patient progresses and regains midline orientation, coordination, and strength, EksoNR will reduce the output of power allowing the patient to progress so they can walk out of the device. 

The patients who use EksoNR exoskeletons post-stroke are kept apprised of their progress and must actively participate in the process to succeed. This might look like assisting with weight shifts, and may progress to the patient controlling all aspects of the steps they are taking. This involvement and positive progress reports can have a profound psychological effect on the patients, increasing their odds of improving outcomes.  

A stroke is a medical emergency, capable of damaging the brain through interruption of its blood supply. There are many symptoms of stroke including difficulties walking, speaking, and understanding, as well as numbness of the face, arm, or leg. When it comes to treating subacute stroke in an inpatient rehabilitation setting, Dr. Crissy Voigtmann (Doctor of Physical Therapy and board-certified Neurological Clinical Specialist), Dr. CJ Curran (Doctor of Physical Therapy, certified brain injury specialist and board-certified Neurological Clinical Specialist), and Jose Dominguez (Director of Rehabilitation, Orlando Health) give professional insight on EksoNR, the first FDA-cleared exoskeleton for stroke and spinal cord injury, and the only FDA-cleared exoskeleton for acquired brain injury.

Orlando Health ORMC Institute for Advanced Rehabilitation (IAR) is a CARF accredited inpatient and outpatient rehab unit partnered with Ekso Bionics since 2019. Currently, they have four Level-Two trained therapists at the inpatient rehabilitation, and two Level-Two trained therapists at their outpatient rehabilitation.

What is EksoNR?

Currently, EksoNR is the only exoskeleton that is FDA-cleared for acquired brain injury. It is the first FDA-cleared exoskeleton and extremely adaptive with short-term implications as well as long-term ones. The device is capable of progressing through programming as a stroke patient progresses in recovery. This gives the long-term capability to adapt from session to session, not only for patients with strokes but spinal cord injuries or TBI.

Who can benefit from EksoNR?

In 2020, IFR had 310 stroke patients arrive at the unit. On average, they had a 1.58 acuity level, based on a case-mix index equation that determines the acuity level for inpatient rehab. Typically a stroke patient stayed at the unit for 15.7 days. In order to determine mobility scores upon admission, Crissy and CJ used Care (formerly known as FIM), which is a standardized test that all inpatient rehabilitation facilities have to use for all diagnoses. 

Additional Care scores from the facility include:

• Average Care Score: 2.9 (Max Assist)
• Average Walking Score (per 50ft): 2.2 (Max Assist)
• Average Walking Score (per 150ft): 1.7 (Total Assist)
• Average Stair Score: 1.2 (Total Assist)

At IAR, these scores were what the average numbers looked like for all stroke patients and are important to know to where those who used Ekso started from at baseline. 

[The following is condensed from the full webinar of Dr. Crissy Voigtmann and Dr. CJ Curran.]

What were the deciding factors in having Ekso a part of the program at Orlando Health?

As Dr. Crissy Voigtmann and Dr. CJ Curran were in the decision-making process of having Ekso become a part of their program, they were asking themselves: “Are we doing enough? Are we providing these patients with enough repetitions at a high enough intensity level to elicit the neural change that needs to happen during this short length of stay that we have?”

In general, the answer to the questions they asked was no. They ultimately decided there was not an exact dosage that has been established for intensity or for repetition, but there was a growing body of evidence that demonstrates for gait in particular; that stepping practice needs to be in the thousands a day for optimal improvement.

Observational studies have shown that in inpatient rehab facilities (places that have stroke programs), stroke patients are taking an average of 250 steps a day. To further reinforce that point, these same studies have shown that stroke patients on average spend greater than 50% of the day in bed and greater than 60% of their time alone. 

Not only were they not utilizing the active time with these folks to provide high-intensity therapy that is necessary for neural training, but even during the passive time, they realized they were not providing the necessary environment, whether it be with engagement or stimulation that is necessary for improvement as well. 

They determined the best solution was integrating Ekso into their program. This was the bridge. This bridged the gap between that dilemma and that solution. For them, Ekso allowed them to accomplish those goals on day one and early, especially for their folks who are significantly impaired, the ones with a lot of deficits. These were folks, in their experience, that are really difficult to gait train. These are the people that unfortunately tend to fall through the cracks and would get low level therapy or low intensity therapy otherwise.

How has Ekso changed training for the patients?

Because of Ekso, they were able to get individuals up early and on their feet for extended periods of time, participating in high-intensity therapy from the very beginning. There are certain positions that would take two or three therapists, or three pairs of hands, to get a patient to accomplish. But one therapist is able to do it whilst focusing on other deficits as well, thanks to Ekso.

Who are the candidates for Ekso?

The stroke patients primarily receiving early Ekso intervention:

• Dense Hemiparesis: 0-⅖ MMT throughout affected lower extremity
• Pusher Syndrome
• Significant Postural Control and Awareness deficits
• Motor planning and Sequencing deficits

Other patient specific factors leading to early Ekso utilization:

• Obesity/Height (under 220lbs, under 6’5” approximately) 
• Impulsivity
• Cognitive deficits 

The overall message is these patients are individuals who are very difficult to manually facilitate. They are very difficult to provide the manual techniques that are necessary to hit high repetitions or to hit high intensity levels. As a result, they are going into the exoskeleton. 

Stay Tuned For More Blogs About EksoNR or  Click Here to View The Webinar in Full 

[The following is condensed from the full webinar of Dr. Crissy Voigtmann and Dr. CJ Curran.]

The Institute For Advanced Rehabilitation (IFR, Orlando Health) is a CARF accredited inpatient and outpatient rehab unit partnered with Ekso Bionics in 2019. With the utilization of EksoNR (the first FDA cleared exoskeleton) in the rehabilitation of patients, they were able to narrow down the typical patient profile and measure their progression via outcomes from using EksoNR.

Average Stroke Patient Statistics 

The following data represents the “average” scoring of all of their 310 stroke patients. It is provided so that anyone may look over and compare this data with those they tended to put into the exoskeleton. When patients are referred to as going into the exoskeleton, please note that it means at the exoskeleton’s maximum assistance level.

Now, their outcome measures. The postural assessment scale for stroke (PASS) is a stroke specific outcome measure that is determined by movement of the patient: they’re sitting, they’re rolling in bed, they’re standing, and then picking up something off the floor, as well as single limb stance. Typically that score is out of 36. Their average PASS score on admission for all patients with stroke was a 20.7, which indicates significant deficit. 12.4 is the average PASS score for their stroke patients going into Ekso, so they are even more impaired than the average patient they saw on the floor. 

The Berg is out of 56 with the benchmark being 45; you can see the patients come in a lot lower level than that at 16.6. The Berg for the exoskeleton candidates is 4.9, meaning they can sit and maybe be transferred by one person – that’s generally a five out of 56 on the Berg. Some patients who get into the exoskeleton can sit independently and some cannot; again, as you can see reflected in the data, their gait is almost not a gait. It is very, very slow, 0.04 meters per second, if they are even ambulatory.

Average Care Score for Mobility on Admission for all CVA:

Transfers: 2.9

Gait: 2.2 for 50 feet and 1.7 for 150 feet

Stairs: 1.2

Average Outcome Measure Performance on day of evaluation for all CVA

PASS: 20.7

BBS: 16.6

10 MWT: 0.24 m/s Self Selected Speed and .33 m/s Fast Speed

Average Care Score for mobility on admission for patients using ekso:

Transfers: Total (1)

Gait: Total (1) for all ambulation

Stairs: Total (1)

Average Outcome Measure Performance on day of evaluation for patients using Ekso

PASS: 12.4

BBS: 4.9

10 MWT: 0.04 m/s Self Selected Speed and 0.04 m/s Fast Speed

How often is the exoskeleton used on the floor?

Generally, given that their length of stay is about 15 days, they were (on average) getting people into the exoskeleton four times during their stay.  However, that really depends on the type of patient and their situation. They have had people in as many as 12 times during their stay.

The average number of total steps taken per patient during their stay is 1,354 with an up and walking total of at least 11 minutes per session, but the average uptime is more than half the session. That means more than half of the session is where the patient is actually standing and in a weight bearing position. They may be working on pre-gait activities. They may be working on just standing tolerance and co-treating with OT or speech. So they do utilize it longer than that 11 minutes, but that’s active walking time.

What were the deciding factors in having Ekso a part of the program at Orlando Health?

As Dr. Crissy Voigtmann and Dr. CJ Curran were in the decision-making process of having Ekso become a part of their program, they were asking themselves: “Are we doing enough? Are we providing these patients with enough repetitions at a high enough intensity level to elicit the neural change that needs to happen during this short length of stay that we have?”

In general, the answer to the questions they asked was no. They ultimately decided there was not an exact dosage that has been established for intensity or for repetition, but there was a growing body of evidence that demonstrates for gait in particular; that stepping practice needs to be in the thousands a day for optimal improvement.

Observational studies have shown that in inpatient rehab facilities (places that have stroke programs), stroke patients are taking an average of 250 steps a day. To further reinforce that point, these same studies have shown that stroke patients on average spend greater than 50% of the day in bed and greater than 60% of their time alone. 

Not only were they not utilizing the active time with these folks to provide high-intensity therapy that is necessary for neural training, but even during the passive time, they realized they were not providing the necessary environment, whether it be with engagement or stimulation that is necessary for improvement as well. 

They determined the best solution was integrating Ekso into their program. This was the bridge. This bridged the gap between that dilemma and that solution. For them, Ekso allowed them to accomplish those goals on day one and early, especially for their folks who are significantly impaired, the ones with a lot of deficits. These were folks, in their experience, that are really difficult to gait train. These are the people that unfortunately tend to fall through the cracks and would get low level therapy or low intensity therapy otherwise.

A Case Study with EksoNR

Almost 60% of the patients are stroke patients. They found that the EksoNR does such a good job, that typically they’re ambulatory at the end of their rehabilitation, and they move on to their outpatient clinic. An incomplete spinal cord would be their second highest diagnosis in terms of volume. 

Take into consideration the progress of one of their patients, Sarah. She is a 62 year old female. She had multiple ischemic strokes in her right hemisphere. She also presented with pusher syndrome. With pusher syndrome, the difficulties that arise in therapy are because of misunderstanding of midline orientation: they are persistently laterally leaning, and/or they’re pushing themselves over onto their weak side. This is very challenging to treat because they are going towards a limb that is hemiperetic and does not support their body. Just getting that patient to take a step is difficult because their weight shifting is so impaired.

Sarah is also a tall and large woman, which makes it even harder for a therapist to facilitate gait. She had left neglect. Her admission was very early after her stroke, just five days post-stroke, so all of the therapy was new for her. In addition to her challenges, she was also a braille user.

Her admitting outcome measure scores PASSwas a 12 out of 36, and she was non-ambulatory, requiring maximal assistance for her bed mobility and her transfers, while being dependent for gait. They were able to get her in the Ekso three times. She didn’t take a ton of steps. They were a little bit limited in her length of stay and her time, but these steps were very effective and these sessions were very effective. They allowed the exoskeleton to facilitate those steps. When they put on the Ekso, it was just one therapist and the tech or an aide. They were able to spend more time standing doing pre-gait. The clinicians were treating that pusher syndrome by having her shift her weight onto her limb more. They recall that was a significant moment for this patient.

The data for her outcome scores are below so that you can compare her admission to her discharge:

Admission:

BBS: 5/56

PASS: 12/36

10 MTW: 0m/s

Max A bed mobility and transfers; dependent for gait

Discharge:

BBS: 17/56

PASS: 29/36

10 MTW: SS 0.15m/s; FP 0.15m/s

SBA Bed Mobility, SBA for 10 feet of gait and transfers, Min A gait >150 feet and 4 stairs

Crissy Voigtmann received her Doctor of Physical Therapy from the University of St. Augustine in 2014. She’s a board certified neurologic clinical specialist. She works as a full-time clinician serving patients with brain injury, stroke, neuro oncology, and incomplete spinal cord injury, and spearheads program development for locomotor training for all neurologic patients in the inpatient rehab setting at Orlando Health’s Institute for Advanced Rehabilitation.

What were the first steps toward introducing EksoNR in a rehab program?

When the doctors at Orlando Health first got the exoskeleton, they were collaborating and came up with this idea of having a lead locomotor person.  Dr. Voigtmann became the lead person just to help bridge the gap between their non-Ekso therapists on the floor, with either pairing them with an Ekso therapist or with Dr. Voigtmann herself. They were afforded that ability just by creating the role of lead locomotor therapist at the clinic.

The other first step was a designated area off to the side of the gym, so that the exoskeleton has everything there that it needs.  There you will find all evaluation forms and data collection sheets and the measuring tools. Everything is in one spot, so that if someone thinks, “This is a great patient for Ekso. I want to do quick measurements,” the opportunity is available to them. They get that patient on the mat, take the measurements, and that allows them the opportunity to get the patient into the Ekso the next session if the current session is unavailable. They have found that it is a nice way to keep everything in one place.

How do you refer patients to EksoNR?

They tried to come up with a referral system. For example, their unit has nine teams, so nine teams of PT/OT and they only have four Ekso-trained therapists. What do they do with the other teams? They paired up with an Ekso clinician in order to have the opportunity to propose, “Can we switch this patient off? You see one of mine and I’ll see one of yours.” With this method, they could optimize the number of patients getting into the exoskeleton and get the benefits of early gait training.

What else has helped EksoNR be successful in inpatient rehab?

At IFR, they have been very fortunate to have really engaged rehab aides in their unit. They went through training sessions with them on how to do wrenching techniques, how to size the Ekso, how to clean it, and even sometimes how to write down some of the data on a data collection sheet for them if time is critical.

They have been essential in the setup, the breakdown, and taking all of the information. They’re also really skilled at using the Ekso controller so that they don’t have to pull in too many more people. Essentially, there would be a physical therapist who is Ekso-certified and then a tech for each session. That really helps to make it effective; cost efficient for the company, and also time efficient.

Stay Tuned For More Blogs About EksoNR or  Click Here to View The Webinar in Full 

Who are the candidates for Ekso?

The stroke patients primarily receiving early Ekso intervention:

• Dense Hemiparesis: 0-⅖ MMT throughout affected lower extremity
• Pusher Syndrome
• Significant Postural Control and Awareness deficits
• Motor planning and Sequencing deficits

Other patient specific factors leading to early Ekso utilization:

• Obesity/Height (under 220lbs, under 6’5” approximately) 
• Impulsivity
• Cognitive deficits 

The overall message is these patients are individuals who are very difficult to manually facilitate. They are very difficult to provide the manual techniques that are necessary to hit high repetitions or to hit high intensity levels. As a result, they are going into the exoskeleton. 

Stay Tuned For More Blogs About EksoNR or  Click Here to View The Webinar in Full 

[The following is condensed from the full webinar of Dr. Crissy Voigtmann and Dr. CJ Curran.]

While EksoNR (the first FDA-cleared exoskeleton for ABI, stroke and spinal cord injury) is a technological advancement that has changed the way patients with stroke experience rehabilitation, it is not without its own difficulties. The Institute For Advanced Rehabilitation (IFR, Orlando Health), has been partnered with Ekso Bionics since 2019. Dr. Crissy Voigtmann and Dr. CJ Curran utilized EksoNR with certain patients and found some difficulties that they were not at first prepared for.

The Generation Gap

With stroke comes increased age. Typically speaking, some of the older individuals are not as comfortable with technology. It becomes very apparent once they get into EksoNR and they’re fearful. Their anxiety can become a pretty significant barrier to try to get them acclimated to this level of technology. Not only that, but also from a deficit standpoint, individuals that have attention deficits or engagement deficits just want to go along for the ride once they are in the suit, and it can be really tough to get them to actively engage in the process of their rehabilitation.

The patients are motivated, they want to do it, but as they tried to convey what the suit is capable of or what the progression looks like, some of the patients really struggle to grasp what that next step is or what that progression will be.

Another element that caught them off guard initially was incontinence. A lot of patients have not been up against gravity for an extended period of time in a while. That has been something that they have prepared for now, and especially in advance, before they even start the session(s).

How do you fix the challenges that patients face with EksoNR?

Luckily most of the issues faced are solved through individualized education, demonstration of the device, or even allowing the patients to observe other stroke patients get into the device and complete a gait training session. 

They have also implemented slow gradual exposure. Sometimes that looks like doing the evaluation, they get them up, and all they do for that session is weight shifting. It might not have been what the clinicians had planned that day, but it got then the buy-in they needed so that they could do a full gait training session the next day.

 As an inpatient rehab unit, they are very fortunate to work as an interdisciplinary team. Sometimes the solution has been doing co-treats with occupational therapy or with speech therapy, or even neuro-psychology depending on what the root causes for the difficulty of the patient to engage with the device and complete the session that they needed them to.

What are the most difficult barriers to overcome?

The patient specific barriers are the most obvious, but they have found that it’s sometimes the environmental or the clinical barriers that are the most difficult to overcome. Some environmental and clinical barriers can be as concrete or as tangible as spatial limitation, but they can also be as difficult to solve for a variety of different reasons such as scheduling issues or time constraints.

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Many people with an acquired brain injury (ABI) are told they will never walk again. Fortunately, our newly developed, cutting-edge wearable robot EksoNR© has allowed many patients with ABI to regain their mobility.

‌EksoNR is a mechanized exoskeleton that aligns with the wearer’s anatomy to provide the support and assistance they need during rehabilitation. EksoNR is the first and only exoskeleton for ABI rehabilitation to be cleared by the FDA. It fits snugly over the patient’s legs, feet, hips, and waist to support their weight and joints.

‌Designed by clinicians for clinicians, EksoNR is the most widely studied rehabilitation exoskeleton available. As of July 2020, there are 74 completed clinical research studies and countless publications and white papers involving EksoNR. These studies contain the personal experiences of more than 1,800 participants around the world.

‌Read how EksoNR has helped one of our users regain her mobility and walk again.

Kylie’s Rehabilitation

After Kylie was injured in 2019, she went into a coma. According to Dr. Kenneth Shapiro, who specializes in Physical Medicine and Rehab, her condition was serious. She had an ABI in addition to multiple internal injuries. She recovered consciousness and soon began physical therapy. Kylie was able to regain amazing levels of self-initiated movement with the help of the EksoNR bionic exoskeleton.

‌Her physical therapist, Erin, related that Kylie regained much of her mobility using the EksoNR exoskeleton. “In the first session, we took maybe ten steps,” Erin shared. “And now she’s walking over 1,200 steps.” This sort of progress is spectacular in patients with ABI injuries. Considering the extent of Kylie’s injuries, this may not have been possible without EksoNR.

‌EksoNR has helped Kylie maintain her muscle condition and start walking again using the power of brain plasticity. With Erin’s guidance, Kylie worked on vital skills including shifting her weight, balancing, and improving her lower extremity muscle strength while wearing the device. As her gait became stronger and more confident, Kylie shifted from relying on EksoNR to using her own muscles to walk. Eventually, she only relied on EksoNR to correct any errors she madewhile walking.

How Does EksoNR Help ABI Patients Regain Their Ability to Walk?

Kylie’s story is a great illustration of how EksoNR can help people with ABI to stand and walk again.

Unlike many other exoskeletons, which provide all or nearly all of the power needed to walk, EksoNR is designed to challenge patients. With its high, stiff back and various progressive modes, EksoNR requires active participation in the rehabilitation process, so the patient can:

• Learn the most efficient and highest quality gait pattern
• Develop a natural gait with secure practice
• Improve their functional balance
• Improve gait speed 
• Improve walking distance

The following features also make EksoNR for ABI the ideal choice for patients to learn to walk again:

• Unique design helps the patient focus on movement and balance
• Data capture allows the physical therapist and patient to view session-specific speed, walking time, and distance. This information is saved securely in cloud storage for reference and analytics. It can be used by the physical therapist to provide personalized care.
• Clinician control lets the physical therapist set training goals and modify EksoNR’s support and assistance levels for each leg
• Adaptive gait training uses software and sensors to regulate and observe leg movement to promote gait development and strengthening
• Pre-ambulatory tools such as PreGait help patients balance, squat, weightshift, and step in place before walking
• SmartAssist software helps the physical therapist customize motor support depending on the patient’s impairment level.
  • This featured function allowed Kylie to move from full assistance to patient-initiated movement as she regained strength and coordination
• Posture support allows for easier and faster recovery by helping patients get started on their gait training sooner 

Physical therapists can also use EksoNR at any stage of outpatient or inpatient rehabilitation.

Edward Cruz, a physical therapist at the University of Texas Southwestern Medical Center, recounted Kylie’s case. He believes EksoNR is “a good intervention for early mobilization [that taps] into neuroplasticity expediently and more successfully,” compared to the body-weight support treadmills physical therapists often use for patients with ABI.

Learn More about EksoNR

To learn more about how EksoNR can help patients with ABI improve their gait and regain their mobility, request a demo for your practice.

‌EksoNR is only one of the many wearable exoskeletons that Ekso Bionics has developed for rehabilitation. Contact us today to learn more about how we can help your practice.

Many people with spinal cord injury (SCI) experience some kind of paralysis or weakness. They are often told that they will never regain their mobility.

‌However, our wearable robots have proven many of these assumptions wrong. By providing physical support to patients’ limbs and joints when they are relearning how to walk during the rehabilitation process, our wearable robots can give people who have experienced an SCI a sense of freedom as they regain mobility.

‌Our wearable robots train patients to walk as naturally as possible, rather than having them follow a more robotic gait pattern as with some exoskeleton suits. They also aim to improve and develop walking endurance and posture without harming or stressing other joints and muscles.

‌Ekso is available in more than 30 countries around the world and has helped thousands of patients take more than 130 million steps.

‌If you are interested in learning more about Ekso as one of the rehab options for spinal cord injury, contact a center near you to get started. Note, however, that our wearable robots are not for personal or home use and are available only in certified rehabilitation centers. This is to ensure that Ekso’s wearable robots are used safely and properly.

‌Find out more about how to rehabilitate SCI with our wearable robots below.

EksoNR©: Our Lower Extremity Exoskeleton

EksoNR© is our lower extremity medical exoskeleton and one of our rehab tools for spinal cord injury. The only exoskeleton to be cleared by the FDA for use on patients with SCI, stroke, and acquired brain injury, EksoNR is an effective way of retraining the muscles and reteaching the brain to walk.

‌With the help of EksoNR, patients will learn how to balance and walk again during rehabilitation after SCI. EksoNR also comes with powerful technology that calculates gait inefficiencies, which will help clinicians and physical therapists set goals and record patient progress.

‌Unlike some other exoskeletons, EksoNR promotes brain plasticity by challenging patients through active participation. Attaching comfortably to the thighs, hips, and waist, EksoNR is designed to be used with many different body shapes and sizes and fits patients under 220 pounds who are between 5 feet and 6 feet, 4 inches.)

EksoNR has the following features:

• Data capture. Allows viewing of session-specific walking time, speed, and distance. All data is saved onto a cloud-based dashboard.
• Long-lasting. Comes with two sets of rechargeable lithium-ion batteries, allowing for continuous use.
• Clinician control. Provides real-time modification of assistance levels for each leg based on session feedback and patient goals. It also sets training targets.
• SmartAssist software. Allows customization of motor support during swing and stance phases of walking for different levels of impairment, from full assistance to patient-initiated movement.
• Adaptive gait training. To minimize compensatory gait patterns, software and sensors constantly regulate and monitor leg movement.
• Posture support. EksoNR offers posture support with a high, rigid back and helps patients bear only their own weight with proper postural alignment. 
• Pre-ambulatory tools. EksoNR comes with preGait, a set of programs that help patients balance, step in place, squat, and weight shift before walking.

EksoUE©: Our Upper Extremity Exoskeleton

EksoUE© is an upper extremity wearable exoskeleton that fits snugly over the arm and shoulder. It gives patients a wider active range of motion with assistance in all planes.

‌Designed for patients with extremity weakness or paralysis due to SCI and other injuries, EksoUE helps patients recover and build strength, range of motion, and endurance. Lightweight and mobile, EksoUE can be used while sitting, moving, or standing.

EksoUE has the following features:

• Manual therapy access. Helps therapists facilitate movement by providing access to the scapula and shoulder joint.
• 180 degrees of assisted motion. Allows the patient to have a wider, more varied active range of motion and assists in all planes.
• Natural movement pattern. Allows for more natural movements than traditional therapy or other devices by supporting the patient’s arm with minimal interference.
• Multifaceted use cases. Can be used while moving around, standing, or sitting. EksoUE is not connected to static equipment, so it can be worn while doing daily activities, with other technologies, or gaming.
• Fully mechanical operation. Instead of being powered by batteries, EksoUE is spring-powered, allowing for continuous use without recharging.
• Increased workload. With EksoUE, patients can tolerate higher therapy dosages for longer periods.
• Adaptable ergonomics and assistance. Adaptable and easily reconfigured for different patient sizes and ability levels.
• Easy to set up and use. Includes a self-guided online course for therapists consisting of modules on both able-bodied individuals and patients.

Rehabilitation for brain injury depends on a thorough understanding of the neural damage involved. All traumatic brain injuries are ABIs, but not all ABIs are traumatic. Read on to find out what that means, and learn how our FDA-cleared EksoNR© robotic exoskeleton can help with recovery.

What Is an Acquired Brain Injury?

The Brain Injury Association of America defines an acquired brain injury as one that is “not hereditary, congenital, degenerative, or induced by birth trauma.” The injury changes the way neurons in the brain activate, ultimately altering the structure and function of brain cells.

‌ABIs can be traumatic or non-traumatic. The distinction is the cause of damage and whether it comes from inside or outside the body.

Traumatic Brain Injuries

A traumatic brain injury is a change in brain function due to an external force. An estimated 5.3 million people in the U.S. live with TBI-induced long-term disability, and up to 90,000 people join that cohort every year. The leading causes of TBI are:

• ‌Motor vehicle accidents
• ‌Suicidal attempts
• ‌Gun assaults
• ‌Falls

‌A TBI may develop from either a closed or open head injury or brain movement inside the skull.

‌An open injury penetrates the dura mater, the outermost membrane surrounding the brain and spinal cord. The penetrating object may be an external projectile or a broken piece of skull that enters the brain due to impact.

‌Closed (non-penetrating) injuries damage the brain without penetration of the skull or dura mater. These injuries can lead to dangerous intracranial pressure as the brain swells without room to expand. This swelling can cause further brain damage and increase the TBI’s severity.

‌A TBI may also develop if an incident jostles the brain within the skull. This is called traumatic inertial or non-contact injury. Falls, car accidents, and sports injuries are common causes of traumatic inertial injury.  

Non-Traumatic Brain Injuries

Non-traumatic brain injuries develop due to internal processes. Some arise suddenly, as in the case of oxygen deprivation. Others develop gradually due to illness or prolonged toxin exposure. Causes of non-traumatic brain injuries include:

• ‌Stroke
• ‌Aneurysm
• ‌Brain tumor
• ‌Infectious disease (encephalitis, meningitis, and others)
• ‌Near-drowning
• ‌Ongoing substance abuse

Effects of Acquired Brain Injuries

The effects of an ABI, whether traumatic or non-traumatic, depend on the brain damage’s location and severity. Many ABIs affect multiple body systems, including:

• ‌Thinking and behavior
• ‌Speech
• ‌Sensory abilities
• ‌Perception

‌‌ABIs, including TBIs, often result in impairments to a person’s mobility and activities of daily living. Recovery can be a long journey for patients and their family members, but our EksoNR exoskeleton for patients who have lost mobility or function can help many patients recover more completely.

Rehabilitation for Brain Injury

Treatment for an acquired brain injury can begin as soon as a medical professional has diagnosed the extent and effects of the illness or injury. Diagnosis typically involves scanning technology like computed tomography (CT) and magnetic resonance imaging (MRI).

‌Once the care team has confirmed the person to be medically stable, their rehabilitation can begin. Rehabilitation for brain injury involves some to all of the following components:

• ‌Physical therapy
• ‌Occupational therapy
• ‌Speech-language therapy
• ‌Neuropsychology

‌The goal is to help the person regain as many lost abilities as possible. EksoNR fits into the physical therapy aspect of rehabilitation.

EksoNR Robotic Exoskeleton

EksoNR helps people with ABI retrain their muscles and start walking again, using the power of brain plasticity. It’s the first and only wearable robotic skeleton to receive FDA clearance for ABI rehabilitation.

‌To use EksoNR, the patient wears a “backpack” supporting their torso connected to a robotic leg-support structure. The structure attaches comfortably to the patient’s waist, hips, legs, and feet, supporting their weight and joints. While wearing our robotic legs and following PT guidance, patients with ABI can work on vital skills like:

• ‌Orientation to midline
• ‌Weight shit
• ‌Stepping quality
• ‌Lower extremity muscle strength

‌The system features smart data capture and clinician controls so that medical professionals can customize their sessions to patient needs in real-time.

‌Physical therapists and other clinicians can use EksoNR at any stage of inpatient or outpatient rehabilitation. It can help someone stand up for the first time and take their first steps after ABI. 

As a person learns to walk again, EksoNR retrains their brain and muscles. It can also help someone with fine-tuning their walking skills, as they learn to regulate their movements and improve gait quality. 

To date, Ekso Bionics has positively impacted the lives of thousands thanks to over a decade of experience in the world of wearable bionics. Our wearable robotic exoskeleton is revolutionizing human potential in a variety of ways, all of which have already started to have a lasting impact on a broad array of fields. While many robotics companies are focused on developing bionics to help those dealing with paralysis or other movement-based disorders in  rehabilitation, Ekso has invested our knowledge and expertise in finding multiple ways for our bionics to be utilized beyond just rehab.

Ekso Bionics is, therefore, not only focused on helping those who have lost mobility due to health events but is also focused on increasing the human potential for movement in a variety of ways for able-bodied individuals. From rehabilitation to pioneering ways for workers to operate more safely and protect their bodies in the process, Ekso Bionics is revolutionizing the field of wearable robotic technology with our focus on improving humans’ natural movement potential in safe, efficient, and dynamic new ways. Keep reading for an overview of just a few of the applications that Ekso Bionics is helping to pioneer.

Robotic exoskeletons by Ekso are a technological way to improve quality of life.

While Ekso’s exoskeleton applications aren’t limited to medical settings, many physical therapists are using wearable robotic exoskeleton technology to help patients regain movement and other abilities that have been lost. Whether patients have had a spinal cord injury or were dealing with the after-effects of a stroke, EksoNR© neurorehabilitation suit was the first exoskeleton suit of its kind to be cleared by the FDA to address these mobility related issues. Beyond spinal cord injury (SCI) use and use in patients post-stroke, EksoNR is also the only robotic exoskeleton that has been cleared by the FDA to have potential benefits for those facing acquired brain injuries.

These sorts of rehabilitative features of exoskeletons and EksoNR, in particular, are major. Being supported by the Food and Drug Administration means that these devices can be freely applied to rehabilitation programs that allow wearers to work on increasing and enhancing mobility. Rehabilitation centers have continued to help patients through the use of EksoNR to work on gait training and other skills that patients may need to re-learn after a traumatic SCI or stroke.

EksoNR builds upon the progress that Ekso made with the Ekso GT to create a much more responsive exoskeleton with sensors and feedback that offer physical therapists a much more customizable approach to using the device in conjunction with physical therapy sessions. It was Ekso’s ongoing commitment to logistics and technological advancement in the field of robotics, not to mention our years of experience, that allowed us to pioneer such an exoskeleton.

Industrial exoskeletons help to prevent fatigue and improve endurance.

While Ekso’s clinical expertise has resulted in the only exoskeleton to be cleared by the FDA for brain injuries in addition to patients with spine injuries or strokes, people and businesses are also using our exoskeleton designs to help boost human performance in other ways. There are plenty of fields and occupations where the risk of injury is quite high if the proper steps are not followed. Even then, some workplace injuries are going to happen from overworking or repetitive movements. The human body can only withstand so much, even if it is in peak physical shape, driving Ekso to build an exoskeleton designed for industrial applications.

For example, Ekso sees potential for our exoskeleton models to be used in a broad array of construction and manufacturing tasks and not just in rehabilitation clinics with physical therapists. Many manufacturing lines still require a human element, and these sorts of human-powered lines run the risk of overuse injuries due to the rigorous, physical nature of the job. The EksoVest was one solution our wearable robotics company pioneered that gained traction in major companies like Ford and Boeing. The fact that these companies recognized the value offered by the EksoVest is clear, and science backs up these findings, too. Many estimates show that the injuries that come from overhead lifting, shoulder, and neck strain can be prevented by the use of the EksoVest and now, EVO, which aids in the performance of these tasks.

Not one to rest on laurels, our company launched the next generation of wearable robotics in 2020 called EVO, which builds upon the success EksoVest has had since 2016. With five years of experience and customer feedback onthe EksoVest, EVO offers increased safety and more efficient performance to construction workers, as well as those on manufacturing lines. With improved materials and a more customized fit, EVO is much more comfortable to use for an extended period of time. EVO is also more affordable for companies to adopt it to use in a variety of industrial applications, which not only helps protect workers, but also improves a business’s bottom line.

Robotics and exoskeleton technology are changing the way the world works in a variety of ways. From offering medical breakthroughs to increasing safety in physically demanding jobs, people are able to live and work better thanks to the presence of wearable exoskeletons. Throughout all of these cases, Ekso Bionics has been a pioneer, using its skills and expertise to continue pushing the world of wearable robotics forward. By leveraging technology and humans’ existing potential, we are finding ways to help the medical profession and manufacturing and construction industries evolve in previously unthinkable ways. Thanks to partnerships with world-renowned businesses and thought leaders in these fields, our company continues to find ways to help exoskeletons evolve to meet the growing demand for such applications. Since 2005, Ekso has been making significant contributions, not only to the world of robotics, but to the lives and livelihoods of real people all across the globe.