By Andrea Sweet, PT, DPT, CBIS
Rainbow Rehabilitation Centers
In our Fall 2017 issue of Rainbow Visions, readers were introduced to the ReWalk exoskeleton. The ReWalkTM is a robotic device that integrates the user’s movements with a system of motors at key joints to externally control gait.1 The ReWalk device has helped many individuals with spinal cord injury around the world to stand and walk again. In this article we will explore therapist and client experiences with training on the ReWalk for the first time.
When a therapist meets a client who is going to trial a ReWalk device for the first time, there is a lot of learning that must occur for both the therapist and the client. Clinicians who use the ReWalk undergo specialized training which includes identification and understanding of all parts and components of the device, how to identify appropriate candidates for ReWalk use, how to assess and fit a client for the device, understanding and using the software, how to operate and adjust the device, and understanding the skills inventories. Therapists who are being educated on using the ReWalk must also complete hands-on training with the device and the client.
Learning the rhythm of the device and gauging how much assistance to provide were the main challenges I experienced as a therapist working with the ReWalk for the first time. When a client first starts out on the ReWalk, the therapist must provide hands-on assistance as the client is operating the device. It is essential that the therapist move in sync with the device and the user in order to maximize the effectiveness of the training.
As always, safety is at the forefront of the therapist’s mind when guarding or assisting the client. While safety is critical, the therapist must be cautious to not assist too much, especially as the client progresses. Assisting too much, whether intentional or not, can inhibit progress. If the therapist is making all the error corrections, the client will never be able to truly feel the errors (such as loss of balance or inadequate or too much weight shift in a particular direction) and learn how to correct them. As with most skills, this improves with experience, both with the device and when working with that specific client.
The overall experience of learning the ReWalk and working with a client to use the device has been wonderful. It is always helpful to learn different treatment approaches and expand my treatment toolbox as a clinician, and it is exciting to have the opportunity to use sophisticated technology. It has also been rewarding to watch my client progress and be on this journey with him as he gets closer to reaching the goal of using the ReWalk device in the community and interacting with his family and peers in ways he thought would never again be possible.
Tommie McMullen began ReWalk training in June of 2017 at Rainbow Rehabilitation Centers. Since then, Tommie has worked hard to train and improve his skills. He has noticed several physical improvements and has been able to experience some of the emotional and social benefits of the ReWalk. As he continues to train, he is looking forward to the ongoing physical benefits and the potential for more social and emotional opportunities.
There are many physical changes that a ReWalk user may undergo with training. Research has demonstrated improvements in strength, (based on ASIA motor scores. Developed by the American Spinal Injury Association [ASIA], the scores are a way to measure and classify muscle function in individuals with spinal cord injury) resting and training heart rate, and improvement in bowel and bladder regulation.2 Tommie’s experience has aligned with the research. Specifically, he has noticed changes in muscle definition and strength in his legs, and his core strength and posture has also improved. Outside of the ReWalk, not only does he have better posture when seated in his wheelchair, he also is able to maintain that posture longer. Tommie’s physical endurance and tolerance has also improved significantly with training.
Using the ReWalk has many social implications and can improve one’s quality of life.2 The ReWalk allows him to stand without overexertion and feel safe while doing so. Others who have trialed the ReWalk have also reported significantly reduced fatigue and feeling safe in the device.1 This provides an opportunity for social interaction by standing and is one aspect to which Tommie is most looking forward. He has spent several years unable to interact with family and peers at eye level, and he feels that being able to look someone in the eye gives him more confidence in his interactions.
Additionally, the ReWalk gives Tommie an opportunity for functional walking, whereas other methods he attempted only offered walking for therapeutic purposes.1 The energy and effort required to ambulate with the ReWalk has been found to be acceptable and practical for everyday use.3 This will allow him to go for walks with his family and friends while still having enough energy and focus left to converse and better attend to the environment while in motion. Recently, Tommie was able to experience taking a walk alongside his grandson for the very first time.
Realizing the benefits of using the ReWalk does require some learning, hard work and commitment. Tommie reported that learning the rhythm of the machine was one of the most difficult parts for him at first, but with practice and repetition he quickly caught on. Once he had the rhythm down, Tommie had to work to improve his endurance to allow him to tolerate increased distances and to progress to more challenging skills. He has also had to further improve his core strength and posture to optimize his balance in the device and has been working on this in conjunction with occupational therapy.
Despite how tiring some of the training sessions with the ReWalk have been for him, Tommie feels that out of all the walking methods he has tried, the ReWalk is easiest to use, the most functional, and is still less tiring than other methods. This is because other methods tend to require high energy cost or result in rapid muscle fatigue in those with spinal cord injury or lower-limb paralysis.3
Although the ReWalk is not for everyone, Tommie recommends that anyone who is a good candidate give it a try. It may seem intimidating and challenging initially, but it gets easier with practice. A list of indications and contraindications for ReWalk use can be found on the ReWalk website (rewalk.com), and any interested individual would need to be assessed for appropriateness.
To those just starting out using the ReWalk, Tommie offers encouragement to keep going and not give up. The experience of being able to walk again is definitely worth the time and effort!
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
2. Raab K, Krakow K, Tripp F, Jung M. Effects of training with the ReWalk exoskeleton on quality of life in incomplete spinal cord injury: a single case study. Spinal Cord Series and Cases. 2016;3,15025. doi:10.1038/ scsandc.2015.25
3. Asselin P, Knezevic S, Kornfeld S, Cirnigliaro C, Agranova-Breyter I, Bauman W, M Spungen A. Heart rate and oxygen demand of powered exoskeleton-assisted walking in persons with paraplegia. The Journal of Rehabilitation Research and Development. 2015;52(2):147-158. doi: 10.1682/JRRD.2014.02.0060