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The world of rehabilitation for spinal cord injuries has taken some dramatic strides in the last decade, which is good news for the almost 18,000 Americans who experience one every year. Instead of extended bed rest, which was once conventional care, many people are now soon up and learning to walk with the assistance of their physical therapist. In a growing number of cases, they are also being assisted by wearable robotic exoskeletons. Some patients who have been in wheelchairs for decades can stand and walk over ground again in a robotic exoskeleton, putting them on eye-level with their family and friends for the first time in years.

Robotic exoskeletons were first invented in the 1960s for the U.S. military as a way to allow soldiers to carry heavy loads. Since then, manufacturers have marketed them to the rehabilitation field and the price has come down considerably, making them more widely available. But are the devices ready to move out of rehabilitation and wellness facilities and into the homes and communities of people with disabilities? A team of researchers at the Center for Rehabilitation Outcomes Research (CROR) at the Shirley Ryan ÌÀÍ·Ìõapp in Chicago wanted to find out. After the U.S. Department of Defense approved their proposal for a three-year study in 2017, the team began investigating how wearable exoskeletons were being used in various settings and how well they were functioning from the perspective of people with spinal cord injury and physical therapists.

As a first step, the researchers led by CROR Director Allen Heinemann, PhD, and Arun Jayaraman, PhD, Director of the Max Nader Center for Rehabilitation Technologies and Outcomes Research at the Shirley Ryan ÌÀÍ·Ìõapp, surveyed 130 participants in Chicago, Atlanta and West Orange, N.J. They included people who had used exoskeletons after a spinal cord injury and those who had not. The survey recipients also included 40 clinicians who had experience working with people who have spinal cord injury. Then the researchers held four focus groups at the various study sites to get face-to-face feedback.

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While most people might expect someone with a spinal cord injury to be very excited about the prospect of walking again, the researchers found the reality to be far more nuanced. Users of exoskeletons described them as heavy, bulky and unbalanced. The units also were relatively inflexible, which meant the users couldn¡¯t bend much at the knees or hips. Most of the devices also weren¡¯t good on steps or ramps. ¡°You can¡¯t just put the device on in the morning and wear it throughout the day,¡± says Edelle Field-Fote, PT, PhD, Director of Spinal Cord Injury Research at the Shepherd Center in Atlanta, who collaborated on the study. ¡°You can¡¯t drive a car or even get in and out of a car as a passenger while wearing one.¡±

One of the focus group participants put it this way: ¡°That exoskeleton is not going to let me care for my daughter or go to work or get in my car or do all of the things that I need to do during the day. And so, in some part I was a little frustrated that people focus so much on ¡®Oh, yeah, you got to stand,¡¯ when of all of the things in my life, that is not the most frustrating or even pressing issue.¡±

Another drawback was cost. Even though the price tag has come down significantly, the devices can cost between $40,000 and $80,000. ¡°It costs as much as an investment property,¡± noted one participant.

But the biggest drawback was that most of the exoskeletons currently available move very slowly, which means someone couldn¡¯t use them to cross a street or make a quick trip to a store. They also require users to keep both hands on crutches to maintain their equilibrium. That meant they couldn¡¯t pick up or carry anything. In fact, all manufacturers of the devices require that users have someone following them at all times in case they fall. That¡¯s fine in a rehabilitation setting but in real life, it requires a full-time assistant or caregiver. That was a tradeoff in independence that some weren¡¯t willing or able to make. ¡°An exoskeleton is not a panacea,¡± says Heinemann. ¡°It¡¯s a nice addition to their life and a way to be more physically fit but it won¡¯t allow them to catch a bus or go to work.¡±

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Yet the use of exoskeletons definitely created some perceived benefits. It provided a psychological boost to people who hadn¡¯t been able to stand or walk on their own and improved their mood. Some users reported that being upright improved their bowel and bladder function, and others noted that the exoskeletons helped reduce muscle spasms because muscles were being stretched and used. Being upright for various time periods also decreases the risk of serious pressure injuries.

In addition, the researchers held focus groups with physical therapists who specialized in spinal cord injury to learn their perceptions. They discovered that the therapists liked having patients use  the devices because they provided a new option for locomotor training and were less physically demanding than the conventional way of having therapists assist individuals with moving their legs. They also liked being able to offer the exoskeleton to their patients. But there were downsides. The exoskeletons don¡¯t fit everybody, so small or large people couldn¡¯t use them. In addition, people with cervical spinal cord injuries who have very limited arm and hand function couldn¡¯t operate them. That was difficult news for therapists to deliver.

For now, robotic exoskeletons are valuable additions to rehabilitation therapy, but they aren¡¯t ready yet to be mobility devices, the researchers concluded. For that to happen, they need to be more bendable and self-balancing, lighter and easier to put on and off, and faster. ¡°The technology needs to continue to evolve,¡± Field-Fote says, adding she is confident it will. ¡°The speed has been improving in recent years. Some of them can now go up and down ramps and stairs¡ªthat¡¯s a big plus. We¡¯re definitely making progress toward the day when robotic exoskeletons will be a viable alternative to wheelchairs.¡±