Perspectives of people with spinal cord injury learning to walk using a powered exoskeleton

Patricia J Manns, Caitlin Hurd, Jaynie F Yang, Patricia J Manns, Caitlin Hurd, Jaynie F Yang

Abstract

Background: Powered exoskeletons for over ground walking were designed to help people with neurological impairments to walk again. Extended training in powered exoskeletons has led to changes in walking and physiological functions. Few studies have considered the perspective of the participants. The users' perspective is vital for adoption of assistive devices. We explored the expectations and experiences of persons with spinal cord injury, training with the ReWalk exoskeleton.

Methods: A qualitative research design with individual interviews was used. Eleven participants with spinal cord injury, taking part in 12 weeks of 4 times weekly training using the ReWalk, were interviewed before, immediately after, and 2 months after training. Interviews were audio recorded and transcribed verbatim. A six stage approach to thematic analysis was used.

Results: The theme consistently expressed was the exoskeleton allowed participants to do everyday activities, like everyone else, such as looking people in the eye or walking outside. Their experiences were captured in three categories: 1) learning, a description of both expectations for learning and perspectives on how learning occurred; 2) changing, perspectives on perceived changes with training; and 3) contributing, which captured participant perspectives on contributing to research, including the giving of direct feedback regarding the exoskeleton (i.e., what worked and what could be changed).

Conclusions: Incorporating the view of the user in the design and refinement of exoskeletons will help ensure that the devices are appropriate for future users. Availability and support for the use of exoskeleton devices in community settings is an interim step to home use as the devices continue to improve.

Trial registration: www.clinicaltrials.gov ( NCT02322125 ). Registered Dec 22, 2014 - Retrospectively registered after the first 4 participants had enrolled in the study.

Keywords: Qualitative; ReWalk.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Data analysis phases and activities. Work on Phases 1–3 proceeded linearly. The processes related to phases 4, 5, and 6 were highly iterative as indicated with arrows. Phases are those recommended by Braun and Clarke (Reference [33]).
Fig. 2
Fig. 2
Theme and Categories

References

    1. Esquenazi A, Talaty M, Jayaraman A. Powered exoskeletons for walking assistance in persons with central nervous system injuries: a narrative review. Pm R. 2017;9(1):46–62. doi: 10.1016/j.pmrj.2016.07.534.
    1. Zeilig G, Weingarden H, Zwecker M, Dudkiewicz I, Bloch A, Esquenazi A. Safety and tolerance of the ReWalk exoskeleton suit for ambulation by people with complete spinal cord injury: a pilot study. J Spinal Cord Med. 2012;35(2):96–101. doi: 10.1179/2045772312Y.0000000003.
    1. Benson I, Hart K, Tussler D, van Middendorp JJ. Lower-limb exoskeletons for individuals with chronic spinal cord injury: findings from a feasibility study. Clin Rehabil. 2016;30(1):73–84. doi: 10.1177/0269215515575166.
    1. Esquenazi A, Talaty M, Packel A, Saulino M. The ReWalk powered exoskeleton to restore ambulatory function to individuals with thoracic-level motor-complete spinal cord injury. Am J Phys Med Rehabil. 2012;91(11):911–921. doi: 10.1097/PHM.0b013e318269d9a3.
    1. Asselin P, Knezevic S, Kornfeld S, Cirnigliaro C, Agranova-Breyter I, Bauman WA, et al. Heart rate and oxygen demand of powered exoskeleton-assisted walking in persons with paraplegia. J Rehabil Res Dev. 2015;52(2):147–158. doi: 10.1682/JRRD.2014.02.0060.
    1. Yang A, Asselin P, Knezevic S, Kornfeld S, Spungen AM. Assessment of in-hospital walking velocity and level of assistance in a powered exoskeleton in persons with spinal cord injury. Top Spinal Cord Inj Rehabil. 2015;21(2):100–109. doi: 10.1310/sci2102-100.
    1. Bach Baunsgaard C, Vig Nissen U, Katrin Brust A, Frotzler A, Ribeill C, Kalke YB, et al. Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso bionics. Spinal Cord. 2018;56(2):106–116. doi: 10.1038/s41393-017-0013-7.
    1. Kozlowski AJ, Bryce TN, Dijkers MP. Time and effort required by persons with spinal cord injury to learn to use a powered exoskeleton for assisted walking. Top Spinal Cord Inj Rehabil. 2015;21(2):110–121. doi: 10.1310/sci2102-110.
    1. Kressler J, Thomas CK, Field-Fote EC, Sanchez J, Widerstrom-Noga E, Cilien DC, et al. Understanding therapeutic benefits of overground bionic ambulation: exploratory case series in persons with chronic, complete spinal cord injury. Arch Phys Med Rehabil. 2014;95(10):1878–1887. doi: 10.1016/j.apmr.2014.04.026.
    1. Sale P, Russo EF, Russo M, Masiero S, Piccione F, Calabro RS, et al. Effects on mobility training and de-adaptations in subjects with spinal cord injury due to a wearable robot: a preliminary report. BMC Neurol. 2016;16:12. doi: 10.1186/s12883-016-0536-0.
    1. Baunsgaard CB, Nissen UV, Brust AK, Frotzler A, Ribeill C, Kalke YB, et al. Exoskeleton gait training after spinal cord injury: an exploratory study on secondary health conditions. J Rehabil Med. 2018;50(9):806–813. doi: 10.2340/16501977-2372.
    1. Farris RJ, Quintero HA, Goldfarb M. Preliminary evaluation of a powered lower limb orthosis to aid walking in paraplegic individuals. IEEE Trans Neural Syst Rehabil Eng. 2011;19(6):652–659. doi: 10.1109/TNSRE.2011.2163083.
    1. Tefertiller C, Hays K, Jones J, Jayaraman A, Hartigan C, Bushnik T, et al. Initial outcomes from a multicenter study utilizing the Indego powered exoskeleton in spinal cord injury. Top Spinal Cord Inj Rehabil. 2018;24(1):78–85. doi: 10.1310/sci17-00014.
    1. Louie DR, Eng JJ, Lam T, Spinal cord injury research evidence research T Gait speed using powered robotic exoskeletons after spinal cord injury: a systematic review and correlational study. J Neuroeng Rehabil. 2015;12:82. doi: 10.1186/s12984-015-0074-9.
    1. Miller LE, Zimmermann AK, Herbert WG. Clinical effectiveness and safety of powered exoskeleton-assisted walking in patients with spinal cord injury: systematic review with meta-analysis. Med Devices (Auckl) 2016;9:455–466.
    1. Lajeunesse V, Vincent C, Routhier F, Careau E, Michaud F. Exoskeletons' design and usefulness evidence according to a systematic review of lower limb exoskeletons used for functional mobility by people with spinal cord injury. Disabil Rehabil Assist Technol. 2016;11(7):535–547. doi: 10.3109/17483107.2015.1080766.
    1. Karelis AD, Carvalho LP, Castillo MJ, Gagnon DH, Aubertin-Leheudre M. Effect on body composition and bone mineral density of walking with a robotic exoskeleton in adults with chronic spinal cord injury. J Rehabil Med. 2017;49(1):84–87. doi: 10.2340/16501977-2173.
    1. Spungen AM, Asselin P, Fineberg D, Harel NY, Kornfeld S. WA. B. Beneficial changes in body composition after exoskeletal-assisted walking; implications for improved metabolic function. Top Spinal Cord Inj Rehabil. 2013;19(5):8–9.
    1. Biddiss E, Chau T. Upper-limb prosthetics: critical factors in device abandonment. Am J Phys Med Rehabil. 2007;86(12):977–987. doi: 10.1097/PHM.0b013e3181587f6c.
    1. Phillips B, Zhao H. Predictors of assistive technology abandonment. Assist Technol. 1993;5(1):36–45. doi: 10.1080/10400435.1993.10132205.
    1. Hill D, Holloway CS, Morgado Ramirez DZ, Smitham P, Pappas Y. What are user perspectives of exoskeleton technology? A literature review. Int J Technol Assess Health Care. 2017;33(2):160–167. doi: 10.1017/S0266462317000460.
    1. Bortole M, Venkatakrishnan A, Zhu F, Moreno JC, Francisco GE, Pons JL, et al. The H2 robotic exoskeleton for gait rehabilitation after stroke: early findings from a clinical study. J Neuroeng Rehabil. 2015;12:54. doi: 10.1186/s12984-015-0048-y.
    1. Wolff J, Parker C, Borisoff J, Mortenson WB, Mattie J. A survey of stakeholder perspectives on exoskeleton technology. J neuroeng Rehabil. 2014;11:169. doi: 10.1186/1743-0003-11-169.
    1. Stampacchia G, Rustici A, Bigazzi S, Gerini A, Tombini T, Mazzoleni S. Walking with a powered robotic exoskeleton: subjective experience, spasticity and pain in spinal cord injured persons. NeuroRehabilitation. 2016;39(2):277–283. doi: 10.3233/NRE-161358.
    1. Moser I. Disability and the promises of technology: technology, subjectivity and the embodiment within an order of normal. Inf Commun Soc. 2006;9(3):373–395. doi: 10.1080/13691180600751348.
    1. Phelan SK, Wright V, Gibson BE. Representations of disability and normality in rehabilitation technology promotional materials. Disabil Rehabil. 2014;36(24):2072–2079. doi: 10.3109/09638288.2014.891055.
    1. Morse JM, Richards L. Readme first for a User's guide to qualitative methods. Thousand Oaks, CA: Sage Publications; 2002.
    1. Cahill A, Ginley OM, Bertrand C, Lennon O. Gym-based exoskeleton walking: a preliminary exploration of non-ambulatory end-user perspectives. Disabil Health J. 2018;11(3):478–485. doi: 10.1016/j.dhjo.2018.01.004.
    1. Heinemann AW, Jayaraman A, Mummidisetty CK, Spraggins J, Pinto D, Charlifue S, et al. Experience of robotic exoskeleton use at four spinal cord injury model systems centers. J Neurol Phys Ther. 2018;42(4):256–267. doi: 10.1097/NPT.0000000000000235.
    1. Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334–340. doi: 10.1002/1098-240X(200008)23:4<334::AID-NUR9>;2-G.
    1. Sandelowski M. What's in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77–84.
    1. Bradshaw C, Atkinson S, Doody O. Employing a qualitative description approach in health care research. Glob Qual Nurs Res. 2017;4:2333393617742282.
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa.
    1. Morse JM. Confusing categories and themes. Qual Health Res. 2008;18(6):727–728. doi: 10.1177/1049732308314930.
    1. Musselman KE, Shah M, Zariffa J. Rehabilitation technologies and interventions for individuals with spinal cord injury: translational potential of current trends. J neuroeng Rehabil. 2018;15(1):40. doi: 10.1186/s12984-018-0386-7.
    1. Straus EW. The upright posture. Psychiatr Q. 1952;26(4):529–561. doi: 10.1007/BF01568490.
    1. Abrams T. Is everyone upright? Erwin Straus" the upright posture" and disabled phenomenology. Hum Aff. 2014;24(4):564–573.
    1. Gibson BE, Teachman G. Critical approaches in physical therapy research: investigating the symbolic value of walking. Physiother Theory Pract. 2012;28(6):474–484. doi: 10.3109/09593985.2012.676936.
    1. Jordan MM, Berkowitz D, Hannold E, Velozo CA, Behrman AL. Thinking through every step: how people with spinal cord injuries relearn to walk. Qual Health Res. 2013;23(8):1027–1041. doi: 10.1177/1049732313494119.
    1. Phelan SK, Gibson BE, Wright FV. What is it like to walk with the help of a robot? Children's perspectives on robotic gait training technology. Disabil Rehabil. 2015;37(24):2272–2281. doi: 10.3109/09638288.2015.1019648.
    1. Goering S. Rethinking disability: the social model of disability and chronic disease. Curr Rev Musculoskelet Med. 2015;8(2):134–138. doi: 10.1007/s12178-015-9273-z.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться