What are the recommendations for using personal exoskeletons for mobility enhancement?

Recommendations for Personal Exoskeletons for Mobility Enhancement

Motorized wheelchairs and scooters remain the primary recommended mobility assistance devices for individuals with severe mobility limitations, while personal exoskeletons are promising but not yet recommended to replace wheelchairs for daily use due to limited evidence on long-term safety and effectiveness. 1

Assessment and Selection of Mobility Assistance Devices

Recommended Mobility Devices Based on Patient Needs:

• For severe mobility limitations:

  • Motorized wheelchairs are recommended for individuals with severe mobility limitations who cannot operate manual wheelchairs, providing greater postural support and positioning options 1
  • Candidates include those with stroke, spinal cord injuries, neurological conditions, hemiplegia, paraplegia, quadriplegia, multiple sclerosis, Parkinson's disease, arthritis, muscle weakness, and cardiopulmonary conditions 1

• For rehabilitation purposes:

  • Intensive, repetitive, mobility-task training is recommended for all individuals with gait limitations after stroke (Level I, Evidence A) 2
  • Robot-assisted movement training to improve motor function and mobility after stroke in combination with conventional therapy may be considered (Level IIb, Evidence A) 2
  • Mechanically assisted walking with body weight support may be considered for patients who are nonambulatory or have low ambulatory ability early after stroke (Level IIb, Evidence A) 2

Current Status of Personal Exoskeletons:

• Personal exoskeletons show promise but are still in early development stages and not yet ready to replace wheelchairs for daily mobility 3
• While effective for walking in laboratory settings for individuals with complete lower-level SCI, their applicability and effectiveness as assistive devices in the community have not been fully demonstrated 4
• The FDA has approved several exoskeleton technologies for clinical use, but there is limited evidence to guide optimal utilization in everyday clinical practice 5

Implementation Guidelines for Mobility Devices

For Motorized Wheelchairs:

1. Required documentation:

   • Severe mobility limitation impacting activities of daily living
   • Proof that manual mobility aids are inadequate
   • Physical and cognitive capability to operate controls safely 1

2. Assessment components:

   • Thorough evaluation of mobility limitations and physical capabilities
   • Assessment of the environment of use
   • Evaluation of ability to transfer safely and sit upright for extended periods 1

3. Safety considerations:

   • Proper assessment of cognitive capacity is essential, as approximately 21% of power mobility device users report accidents resulting in personal injury 1

For Rehabilitation Exoskeletons:

1. Clinical decision framework:

   • Assess when exoskeleton use is clinically indicated
   • Identify which device is most appropriate based on patient deficits and device characteristics
   • Determine appropriate dosage parameters within a plan of care 5

2. For stroke rehabilitation:

   • Consider as part of comprehensive rehabilitation program
   • May be used in combination with conventional therapy 2

3. For spinal cord injury:

   • Can allow individuals with varying levels of injury to safely walk for personal mobility or exercise
   • Users should set realistic expectations regarding capabilities 6

Potential Benefits and Limitations

Benefits:

• Exoskeletons can provide mobility options beyond wheelchairs for specific populations 6
• Optimized exoskeleton assistance can reduce metabolic energy consumption during walking by up to 24.2% 7
• May offer psychological benefits through upright positioning and walking

Limitations:

• Current personal exoskeletons have limited applicability in community settings 4
• Maximum walking speed with ReWalk™ (one of the most advanced exoskeletons) is only 0.51 m/s after extensive training 4
• Significant cost barriers exist for personal use
• Limited evidence on long-term safety and effectiveness 4

Special Considerations

• For patients with active Charcot neuro-osteoarthropathy in diabetes, knee-high devices are preferred over ankle devices for immobilization and offloading 2
• When using assistive devices for mobility, consider the need for partial weight-bearing with crutches, walkers, or other devices to reduce pressure on affected limbs 2
• For critically ill patients, neuromuscular electrical stimulation may be considered for early mobilization (Level 1 evidence) 2

Conclusion

While personal exoskeletons show promise for mobility enhancement, current evidence supports motorized wheelchairs as the primary mobility assistance device for individuals with severe mobility limitations. Exoskeletons may be beneficial in rehabilitation settings but require further development and research before they can be widely recommended for personal mobility in community settings.