After falling off a ladder and injuring his spinal cord in 2010, Gene Laureano, now 56, was told by his doctor that he would never walk again.

Five years later Laureano, a former Army corporal, took his first post-injury steps at the James J. Peters VA Medical Center in his native Bronx, NY, with the help of the ReWalk, a robotics-assisted exoskeleton the Department of Veterans Affairs provides to eligible veterans.

Moved to tears by those first few steps, Laureano has experienced unexpected gains ever since. "I've seen improvements in my cardiovascular health, core strength, and bowel regimen—and even lost weight," he says. "My state of mind and self-esteem are much better, and I'm enjoying quality time with my family. I've even been to a carnival wearing my ReWalk system."

Next-Generation Therapy

A new generation of robotics- and technology-assisted rehabilitation therapies is helping people with spinal cord injuries and other neurologic disorders, such as stroke, regain complete or partial use of their limbs or otherwise achieve functional independence more successfully and efficiently than before.

Neurologic rehabilitation depends largely on a process called reinnervation, in which the body, in response to physical and occupational therapies, creates new neural pathways to compensate for damaged nerves. When rehabilitation includes a new robotic limb, reinnervation is enhanced by a surgery that grafts nerves to the new limb.

The new technology is also encouraging collaboration between researchers and physical and occupational therapists in ways that maximize patient recovery, says David J. Lin, MD, clinical fellow in neurorecovery in the department of neurology at Massachusetts General Hospital at Harvard Medical School.

Exoskeleton-assisted Walking

Some patients can make great strides—literally—using an exoskeleton like the one Laureano used. This assistive device is made of metal and plastic machinery that supports the hips and legs of patients who have been paralyzed because of a stroke or spinal cord injury. Using sensors attached to the body and electrically powered hip and knee attachments, the exoskeleton allows people to walk and climb stairs.

"It's possible that exoskeletons may one day be a substitute for a wheelchair, but they are currently used primarily in hospital-based physical therapy clinics because of their size and cost," says Peter Gorman, MD, FAAN, associate professor of neurology and division chief of rehabilitation medicine at the University of Maryland School of Medicine. Dr. Gorman is currently involved in a Department of Defense-funded multicenter study of people with spinal cord injuries who use exoskeletons to walk.

The devices are challenging to use, as they require significant strength, coordination, and endurance, says Andrea Coiro, PT, DPT, a physical therapist at Spaulding Rehabilitation Hospital in Boston, who has used them with two spinal cord injury patients. But for many, being upright and mobile is worth it, she says.

Exosuits for Partial Paralysis

For stroke survivors with partial paralysis, therapists use a battery-powered exosuit featuring a waist belt and leg strap made of comfortable fabric with electrodes affixed to affected areas. The suit provides physical support, and the electrodes send electrical impulses to the paralyzed muscles.

In a study published in Science Translational Medicine in 2017, stroke survivors who used the suits showed improvements in their ability to walk comparable to those who completed a standard physical therapy session. However, researchers caution that long-term therapeutic studies are needed.

Kiafar Haghkerdar, a 54-year-old retired dentist in Massachusetts and a stroke survivor with partial leg paralysis, participated in early exosuit trials at Harvard University, where the technology was invented. "The exosuit is comfortable and made me more aware of the dynamics of my walking," he says. "I appreciate how the soft exosuit adapts to my body and the cadence of my walking."

Conor Walsh, PhD, associate professor at Harvard University's John A. Paulson School of Engineering and Applied Sciences, designed the exosuit and led early trials that used the device. "Our team at Harvard demonstrated that the exosuit can improve the walking capacity of stroke survivors," he says. "Ongoing efforts are focused on understanding how to increase the benefit by customizing the suit for each patient. The technology is now being commercialized by ReWalk Robotics, which started a clinical trial last spring."

High-tech Treadmill

When used together, a combination harness, exoskeleton, and treadmill can help physical therapists measure walking stride and speed, says Dr. Gorman. On one such outfitted treadmill, called the Lokomat, patients can stand upright—supported by the exoskeleton, which is attached to a harness—and walk, as a simulated pathway projected onto a screen in front of them recreates the feeling of walking outdoors.

Rewiring Pathways

In response to aggressive and targeted types of therapies, MRI scans have revealed formations of new neural pathways that can help paralyzed limbs move and allow people to stand.

In the field of bionic limbs, such rewiring is essential. Swiss researchers at the Center for Neuroprosthetics used MRI scans to demonstrate that following reinnervation, the brain remaps the necessary motor and sensory pathways. Their findings were published in the November 2017 issue of Brain. "Brain-controlled neuroprosthetics can help restore some functional movement to people with severe spinal cord injuries, not by curing the injuries but by circumventing them and giving brain signals a different path," explains A. Bolu Ajiboye, PhD, assistant professor of biomedical engineering at Case Western University in Cleveland, OH, and the study's lead researcher.

Data Can Dictate Therapy

"Robots have the capacity to both measure and deliver high-dose, repetitive movement practice at a hospital, in rehab, and potentially even at home," says Dr. Lin. "For example, for people with arm weakness after stroke, measuring arm strength and trajectory and the functioning of joints using robot sensors can provide new insight into how people respond to repetitive exercises, how neural pathways are retrained, and how recovery is achieved," he says. As a patient performs repetitive movements, the robotic sensors gather data that can help the physical therapist deliver the most effective dose of exercise for that particular patient.

"The data allow physical therapists to initiate gait training safely in moderately to severely affected patients," says Kristin Parlman, PT, DPT, NCS, neurologic clinical specialist in the department of physical therapy at Massachusetts General Hospital. "For people who've had strokes or spinal cord injuries, exoskeletons, robotic treadmills, and harnesses allow them to move in ways that otherwise would be very challenging or impossible."

What Therapists Are Learning

Robotics and other technologies are also teaching physical therapists new ways to treat patients. "In stroke in particular, we have learned that there is a period of 'spontaneous biological recovery' in the first three months," says Dr. Lin. That's when the brain tries to restore neurologic function and create new neural pathways in damaged areas, he says. "We are starting to understand the neurologic mechanisms that underpin this critical period. I'm hopeful that these principles will help us target specific areas of a limb, joints, and neural pathways to optimize timing, dose, and strategy of neurorehab or neurotechnological rehabilitation."

Physical therapists still use established assessment tools, such as gait-training techniques, which are designed to strengthen muscles and joints, improve balance, and build endurance, but "technology can provide a layer of safety and allow us to accurately reproduce repetitive motion tasks," says Dr. Gorman.

Cost Obstacles

Robotics-enhanced therapies are not cheap. "Some exoskeletons being approved by the US Food and Drug Administration for use at home cost more than $70,000, and insurance has not yet covered all these devices," says Dr. Gorman. "It will require larger volumes of production and distribution before the price will decrease."

Dr. Gorman also notes that robotic treadmills such as the Lokomat and partial weight-supported devices such as harnesses and conventional treadmills will likely continue to be used primarily at major centers for neurologic rehabilitation. Insurers are unlikely to cover unsupervised personal use of a heavy exoskeleton, for example, questioning the safety, efficacy, and likelihood of falls. Small, wearable biosensors that measure patient activity at home and deliver those data to a physical therapist for use in a clinical setting may be a good example of a less risky approach to home-based technology, says Parlman.

And no matter how impressive robotics-assisted therapies are, sometimes there is no substitute for a human therapist, she says. "Robotic gait training on a treadmill allows patients to take more steps at a faster pace, but it cannot substitute for therapists helping patients walk on real ground, which teaches them how to correct for poor balance and make movement decisions as they navigate their environment."

What the Future Holds

"Brain-controlled prosthetics and brain-computer interfaces are exciting, especially for people with severe paralysis, but their scope is limited," says Dr. Gorman. "Robotics have the potential to serve a larger, broader spectrum of patients with neurologic impairments."

Another promising area of research is combining robotics-assisted movement therapy with traditional physical and occupational therapy. A stroke patient recovering from partial paralysis, for instance, could improve his or her ability to use a weak limb through a combination of robotic technology and cognitive training, says Susan Fasoli, ScD, OTR/L, associate professor in the department of occupational therapy at the School of Health and Rehabilitation Sciences at the Massachusetts General Hospital Institute of Health Professionals.

"A combined approach takes into account each patient's personal challenges and goals, resulting in a more holistic recovery process," she says.

"I am most excited about personalizing robotics and other technologies," says Dr. Lin. "This means understanding how the nervous system and movement are impaired and using robotics to address specific patient needs. We are making great advances in all of these directions."

Clinical Trials for Robotic Therapy

If you or someone you know is recovering from stroke or spinal cord injury, or is living with multiple sclerosis, amyotrophic lateral sclerosis, or cerebral palsy, talk to your primary care provider or physical or occupational therapist about the possibility of robotics-assisted therapy.

Any prescription will likely have a set number of sessions covered by insurance, but you may find yourself wanting to extend therapy or explore something new.

If so, clinicaltrials.gov is a good place to find studies that are recruiting participants. In your web browser, type in your condition and "robotics" to find a current or upcoming study that may include an exoskeleton, exosuit, "smart" treadmill, or other technologies.

Here are three examples of current neurologic robotics studies taking place in Illinois, Texas, and New Jersey.

Constraint-Induced Movement Therapy for Walking in Individuals Post-Stroke

What: This study compares conventional treadmill training with constraint-induced movement therapy, which focuses on increasing the use of the affected limb by strapping down the non-affected limb. Participants will train three times a week for six weeks.
Where: AbilityLab, Chicago
When: Currently recruiting
Who: Weena Dee, PT, wdee@sralab.org
More information: clinicaltrials.gov

Brain-Machine Interface Control of a Robotic Exoskeleton in Training Upper Extremity Functions in Stroke

What: This study is designed to demonstrate that noninvasive brain-machine interface control of a robotic exoskeleton is feasible and effective in improving upper body motor functions in stroke survivors.
Where: The Institute for Rehabilitation and Research at Memorial Hermann, Houston
When: Currently recruiting
Who: Nuray Yozbatiran, PhD, nuray.yozbatiran@uth.tomc.edu
More information: clinicaltrials.gov

Exoskeleton and Spinal Cord Stimulation for Spinal Cord Injury

What: This study will assess the combination of exoskeleton-assisted walking with electrical stimulation of the nerves of the lower back on walking recovery.
Where: Kessler Foundation, West Orange, NJ
When: Currently recruiting
Who: Gail F. Forrest, PhD, gforrest@kesslerfoundation.org
More information: clinicaltrials.gov