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Experience of Robotic Exoskeleton Use at Four Spinal Cord Injury Model Systems Centers

Heinemann, Allen W. PhD; Jayaraman, Arun PT, PhD; Mummidisetty, Chaithanya K. MS; Spraggins, Jamal MS; Pinto, Daniel PT, PhD; Charlifue, Susan PhD, FISCoS, FASIA, FACRM; Tefertiller, Candy PT, DPT, NCS; Taylor, Heather B. PhD; Chang, Shuo-Hsiu PT, PhD; Stampas, Argyrios MD; Furbish, Catherine L. PT, DPT, CLT; Field-Fote, Edelle C. PT, PhD

Journal of Neurologic Physical Therapy: October 2018 - Volume 42 - Issue 4 - p 256–267
doi: 10.1097/NPT.0000000000000235
Research Articles

Background and Purpose: Refinement of robotic exoskeletons for overground walking is progressing rapidly. We describe clinicians' experiences, evaluations, and training strategies using robotic exoskeletons in spinal cord injury rehabilitation and wellness settings and describe clinicians' perceptions of exoskeleton benefits and risks and developments that would enhance utility.

Methods: We convened focus groups at 4 spinal cord injury model system centers. A court reporter took verbatim notes and provided a transcript. Research staff used a thematic coding approach to summarize discussions.

Results: Thirty clinicians participated in focus groups. They reported using exoskeletons primarily in outpatient and wellness settings; 1 center used exoskeletons during inpatient rehabilitation. A typical episode of outpatient exoskeleton therapy comprises 20 to 30 sessions and at least 2 staff members are involved in each session. Treatment focuses on standing, stepping, and gait training; therapists measure progress with standardized assessments. Beyond improved gait, participants attributed physiological, psychological, and social benefits to exoskeleton use. Potential risks included falls, skin irritation, and disappointed expectations. Participants identified enhancements that would be of value including greater durability and adjustability, lighter weight, 1-hand controls, ability to navigate stairs and uneven surfaces, and ability to balance without upper extremity support.

Discussion and Conclusions: Each spinal cord injury model system center had shared and distinct practices in terms of how it integrates robotic exoskeletons into physical therapy services. There is currently little evidence to guide integration of exoskeletons into rehabilitation therapy services and a pressing need to generate evidence to guide practice and to inform patients' expectations as more devices enter the market.

Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at:

Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, Illinois (A.W.H. and A.J.); Center for Rehabilitation Outcomes Research, Shirley Ryan AbilityLab, Chicago, Illinois (A.W.H.; J.S.); Max Näder Center for Rehabilitation Technologies and Outcomes Research (A.J.; C.K.M), Shirley Ryan AbilityLab, Chicago, Illinois (C.K.M. and J.S.); Marquette University, Milwaukee, Wisconsin (D.P.); Physical Therapy (C.T.), Craig Hospital, Englewood, Colorado (S.C.); Spinal Cord Injury and Disability Research (H.B.T.), TIRR Memorial Hermann, Houston, Texas (S.H.C. and A.S.); The University of Texas Health Science Center at Houston Department of PM&R (H.B.T, S.H.C., and A.S.); Crawford Research Institute, Shepherd Center, Atlanta, Georgia (C.L.F.; E.C.F-F.); Division of Physical Therapy, Emory University, Atlanta, Georgia (E.C.F.-F.); and School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia (E.C.F.-F.).

Correspondence: Allen W. Heinemann, AbilityLab, 355 E. Erie, Suite 14 South, Chicago, IL 60611 (

The National Institute on Disability, Independent Living, and Rehabilitation Research provided funding through the Midwest Regional SCI Model System (90SI5009), the Rocky Mountain Regional Spinal Injury System (90SI5015), the Southeastern Regional Spinal Cord Injury Model System at Shepherd Center (90SI5016), and the Texas Model Spinal Cord Injury System at TIRR Memorial Hermann (90SI5027).

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

© 2018 Academy of Neurologic Physical Therapy, APTA