Veterans and civilians with spinal cord injuries (SCI) need therapists, clinical staff, and support equipment for a large portion of therapy when using body-weight supported treadmill training and other over-ground strategies. Even with all these resources, patients take very few steps, limiting their benefit. Wearable robots, including exoskeletons, provide therapeutic and mobility benefits. Therapy using robotic exoskeletons is promising for rehabilitation of individuals with SCI. Exoskeletons provide high intensity training for longer periods to promote gains in strength, coordination, and range of motion. Like robot-based treadmill treatment, exoskeletons could lower the physical burden on therapists and lower labor costs to the health system compared to usual therapy, while providing the same functional and health outcomes. Exoskeletons allow mobility in home and community settings for individuals who may not reach this level of function in regular therapy alone. Even though there is no evidence that these devices are better than usual therapy, a recent report projects growth in rehabilitation robotics, active prostheses, and exoskeletons from $43.3 million in 2014 to $1.8 billion in 2020. While about 500 to 550 exoskeletons have been sold worldwide, there has been little clinical research on their benefit.

Little or no information is available on patients’ preferences or therapists’ experiences with robotic exoskeletons. More information is needed to rate and make clinical decisions about the safety and usefulness of these devices to improve mobility. The goal of this application is to obtain information that will guide patient evaluation strategies, training strategies, and clinical decision plans to promote the safe and effective use of robotic exoskeletons to improve mobility in Veterans and civilians with SCI.

This proposal will add to the understanding of patients’ preferences for robotic therapies, which will allow a focus on the individual with SCI for research and therapy guidelines. The results of this research will lead to treatments designed to focus on side effects of SCI, including obesity, pressure ulcer risk, and heart conditions; it will help identify barriers, helpers, and preferences to develop treatment guidelines.

The aims of the project are to: (1) Describe interest in, perceived need for, and expected outcomes of robotic exoskeleton therapy of persons who have not received robotic exoskeleton therapy. (2) Describe the perceived benefits, limitations, and costs of robotic exoskeleton therapy among persons with SCI who have received robotic exoskeleton therapy during SCI rehabilitation or in the community. (3) Describe physical therapists’ experiences, clinical evaluation and training strategies using robotic exoskeleton therapy in rehabilitation and community settings.

This 2-year project will achieve its aims through interviews and focus groups. We will conduct focus groups at four sites: Jesse Brown VA Medical Center (Chicago), Shepherd Center (Atlanta), Kessler Foundation (West Orange, NJ), and the Rehabilitation Institute of Chicago. At each site, three focus groups will discuss the perceived benefits and limitations of robotic exoskeleton therapy with: (1) persons with SCI who could receive robotic exoskeleton therapy but who have not received exoskeleton therapy, (2) persons with SCI who have received robotic exoskeleton therapy, and (3) physical therapists who treat individuals with SCI and have provided robotic exoskeleton therapy. An Advisory Committee made up of key representatives including patients and caregivers, consumer organizations, robot manufacturers, professional organizations, rehabilitation providers, insurers, and policymakers will provide guidance to the project. They will meet quarterly via conference call; members will make sure study findings are relevant and will help put these findings into practice.

Findings for this proposed research project will improve our understanding of the needs, perceived benefits, and limitations of robotic exoskeletons in rehabilitation of persons with SCI. The project will identify appropriate use of robotic exoskeletons during inpatient and outpatient rehabilitation, which could improve function, decrease other illnesses, and improve overall quality of life after SCI. The project will benefit to about 240,000 to 337,000 persons living with SCI in the United States.