Exoskeleton use in post-stroke gait rehabilitation: a qualitative study of the perspectives of persons post-stroke and physiotherapists

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Exoskeleton use in post-stroke gait rehabilitation: a qualitative study of the perspectives of persons post-stroke and physiotherapists

• Julie Vaughan-Graham,
• Dina Brooks,
• Lowell Rose,
• Goldie Nejat,
• Jose Pons &
• Kara Patterson 

Journal of NeuroEngineering and Rehabilitation volume 17, Article number: 123 (2020) Cite this article

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Abstract

Background

Wearable powered exoskeletons are a new and emerging technology developed to provide sensory-guided motorized lower limb assistance enabling intensive task specific locomotor training utilizing typical lower limb movement patterns for persons with gait impairments. To ensure that devices meet end-user needs it is important to understand and incorporate end-users perspectives, however research in this area is extremely limited in the post-stroke population. The purpose of this study was to explore in-depth, end-users perspectives, persons with stroke and physiotherapists, following a single-use session with a H2 exoskeleton.

Methods

We used a qualitative interpretive description approach utilizing semi-structured face to face interviews, with persons post-stroke and physiotherapists, following a 1.5 h session with a H2 exoskeleton.

Results

Five persons post-stroke and 6 physiotherapists volunteered to participate in the study. Both participant groups provided insightful comments on their experience with the exoskeleton. Four themes were developed from the persons with stroke participant data: (1) Adopting technology; (2) Device concerns; (3) Developing walking ability; and, (4) Integrating exoskeleton use. Five themes were developed from the physiotherapist participant data: (1) Developer-user collaboration; (2) Device specific concerns; (3) Device programming; (4) Patient characteristics requiring consideration; and, (5) Indications for use.

Conclusions

This study provides an interpretive understanding of end-users perspectives, persons with stroke and neurological physiotherapists, following a single-use experience with a H2 exoskeleton. The findings from both stakeholder groups overlap such that four over-arching concepts were identified including: (i) Stakeholder participation; (ii) Augmentation vs. autonomous robot; (iii) Exoskeleton usability; and (iv) Device specific concerns. The end users provided valuable perspectives on the use and design of the H2 exoskeleton, identifying needs specific to post-stroke gait rehabilitation, the need for a robust evidence base, whilst also highlighting that there is significant interest in this technology throughout the continuum of stroke rehabilitation.

Introduction

Over the period 1990–2017 there has been a 3% increase in age-standardized rates of global stroke prevalence [1] and a 33% decrease in mortality due to improved risk factor control and treatments [2]. Therefore, stroke survivors are living longer with mild to severe lifelong disabilities requiring long term assistance [1]. As a result, stroke presents a significant socioeconomic burden accounting for the largest proportion of total disability adjusted life years (47.3%) of neurological disorders [3]. Walking impairments, one aspect of stroke disabilities, negatively impact independence and quality of life [4], and recovery of walking is a primary goal post-stroke [5].

Wearable powered exoskeletons are a new and emerging technology originally developed as robots to enable persons who were completely paralyzed due to spinal cord injury to stand and walk [6, 7], but more recently developed to provide sensory-guided motorized lower limb assistance to persons with gait impairments [8]. They require the active participation of the user from the perspective of integrating postural control/balance and the locomotion pattern in real life environments whilst simultaneously providing assistance to achieve typical lower limb movement patterns in a task specific manner [8]. The Exo-H2 is a novel powered exoskeleton in that it has six actuated joints, the hip, knee and ankle bilaterally, and uses an assistive gait control algorithm to provide lower limb assistance when the gait pattern deviates from a prescribed pattern [9]. As stroke impairments typically influence hip, knee and ankle movements the H2 was considered an appropriate exoskeleton for our study [8, 10].

Significant limitations persist in current exoskeleton designs such as weight, cost, size, speed and efficiency [11]. Although end-users’ perspectives are essential in the design and development of assistive technology [12, 13], there is a paucity of literature from both persons with disabilities and physiotherapists (PTs) perspectives [14, 15]. Over the last decade end-user perspectives have primarily been studied in spinal cord injury (SCI) in which four studies used semi-structured interviews [16,17,18,19], and 3 studies used survey methods [20,21,22] with sample size ranging from 3 to 20 persons. However, these studies included both complete and incomplete SCI with most participants being non-ambulatory representing a very different end-user population compared to persons post-stroke. A further two studies reported end-user perspectives using survey methods with persons with multiple sclerosis (MS) [23], and persons with MS, SCI or acquired brain injury (ABI) [24]. Wolff et al.,(2014) utilized an online survey to evaluate perspectives on potential use of exoskeletons with wheelchair users, primarily persons with SCI, and healthcare professionals, but no PTs were included [25]. To date only one study by Read et al.,(2020) specifically investigated perspectives of 3 PTs on exoskeleton use using semi-structured interviews with persons with SCI or stroke. Currently, a mixed-methods study is underway to investigate perspectives of PTs and persons with stroke [26]. Thus, further research is needed to explore in-depth, utilizing a qualitative research approach, end-users’ perspectives on lower limb exoskeleton use in post-stroke gait rehabilitation.

It is important to understand and incorporate end-user perspectives [27], persons post-stroke and physiotherapists, with respect to the design of exoskeletons and their implementation to effectively facilitate uptake both in clinical practice and community settings. Therefore, the purpose of our study is to explore the perspectives of persons post-stroke and physiotherapists following a 1.5 h single-use session with a H2 exoskeleton.