Archive for category Gait Rehabilitation – Foot Drop

[Abstract] Lessons learned from robotic gait training during rehabilitation: Therapeutic and medical severity considerations over 3 years


BACKGROUND: Robotic exoskeletons are increasingly available to inpatient rehabilitation facilities though programmatic implementation evidence is limited.

OBJECTIVE: To describe therapists’ clinical practice experiences with robotic gait training (RGT) over 3 years during inpatient rehabilitation. 

METHODS: Therapists participated in a survey and semi-structured focus group to discuss their RGT experiences. Interviews were recorded, transcribed, and analyzed using a theoretical analysis-driven thematic approach.

RESULTS: Therapists averaged 7.6 years of neurologic rehabilitation experience and 1.85 years with RGT. Eight of 10 therapists had completed ⩾ 50 RGT sessions, with frequency of 1–5 sessions/week, including on-label (spinal cord injury, stroke) and off-label (e.g., traumatic brain injury) experiences. Three adverse events occurred over 716 RGT sessions with 186 patients. Qualitative analysis identified three major themes and corresponding subthemes: 1-Comparison with traditional gait training approaches (6 sub-themes), 2-Clinical decision-making considerations (3), and 3-On-label and off-label utilization (4). Stated RGT benefits included decreased therapists’ physical burden and increased patient motivation. Clinical concerns with RGT included tonicity, continence, and patient communication (e.g., aphasia). Off-label RGT was used to overcome barriers in traditional gait therapy and achieve early mobility.

CONCLUSIONS: Therapists’ level of training and clinical knowledge furthered RGT implementation and allowed for safe utilization with on-label and off-label patients.


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[Abstract] Gait Performance in People with Symptomatic, Chronic Mild Traumatic Brain Injury


There is a dearth of knowledge about how symptom severity affects gait in the chronic (>3 months) mild traumatic brain injury (mTBI) population despite up to 53% of people reporting persisting symptoms after mTBI. The aim of this investigation was to determine whether gait is affected in a symptomatic, chronic mTBI group and to assess the relationship between gait performance and symptom severity on the Neurobehavioral Symptom Inventory (NSI). Gait was assessed under single- and dual-task conditions using five inertial sensors in 57 control subjects and 65 persons with chronic mTBI (1.0 year from mTBI). The single- and dual-task gait domains of Pace, Rhythm, Variability, and Turning were calculated from individual gait characteristics. Dual-task cost (DTC) was calculated for each domain. The mTBI group walked (domain z-score mean difference, single-task = 0.70; dual-task = 0.71) and turned (z-score mean difference, single-task = 0.69; dual-task = 0.70) slower (p < 0.001) under both gait conditions, with less rhythm under dual-task gait (z-score difference = 0.21; p = 0.001). DTC was not different between groups. Higher NSI somatic subscore was related to higher single- and dual-task gait variability as well as slower dual-task pace and turning (p < 0.01). Persons with chronic mTBI and persistent symptoms exhibited altered gait, particularly under dual-task, and worse gait performance related to greater symptom severity. Future gait research in chronic mTBI should assess the possible underlying physiological mechanisms for persistent symptoms and gait deficits.


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[NEWS] Kessler Foundation tests digital therapeutic approach to improve walking after stroke

Karen Nolan, PhD, of Kessler Foundation, is site investigator for a multi-site trial of a music-based digital therapeutic device with the potential to improve mobility after stroke


East Hanover, NJ. September 16, 2020. Karen Nolan, PhD, of Kessler Foundation, received a grant from MedRhythms to test the company’s investigational digital therapeutic device, the Stride Plus, in individuals striving to recover mobility after stroke. Dr. Nolan, a senior research scientist in the Center for Mobility and Rehabilitation Engineering Research, specializes in the study of new technologies with potential applications in rehabilitation research for deficits in gait and balance that impair mobility.

Kessler Foundation is one of six sites participating in the randomized controlled study, “Post-stroke walking speed and community ambulation conversion: A pivotal study.” The other sites are the Shirley Ryan AbilityLab in Chicago, The Mount Sinai Hospital in New York, Spaulding Rehabilitation Hospital in Boston, Boston University Neuromotor Recovery Laboratory, and Atrium Health in Charlotte, North Carolina.

The study’s objective is to help individuals whose walking ability is affected by stroke to improve their walking speed and advance from limited community ambulation to community ambulation. The data collected from the six sites will support MedRhythm’s application for FDA approval of the device, which received Breakthrough Device Designation from the FDA in June 2020.

The Stride Plus device, which relies on internet connectivity, includes: 1) mobile device that provides rhythmic auditory stimulation in the form of music and rhythmic cues to facilitate the speed and quality of walking; 2) sensors that attach to each shoe to measure biomechanics; and 3) headphones that deliver the auditory cues. Feedback from the sensors is used to augment the music to encourage stable gait patterns and faster walking speed. The sensors also allow for monitoring and recording of the individual’s progress.

A total of 78 participants, including stroke survivors and controls, will be randomized to treatment and control groups. The treatment group will train in the Stride Plus three times a week for five weeks.

“Loss of mobility after stroke exerts a huge toll on individuals, their caregivers, our healthcare system, and society,” said Dr. Nolan, site investigator for the Kessler site. “Stroke rehabilitation is an area where we need to test new technologies to change the outlook for recovery. Applying digital therapeutics is a promising approach for restoring lost mobility,” she noted, “which may foster greater independence and better quality of life in this population.”

As stroke survival rates increase and the population ages, the population of stroke survivors in the U.S. is growing, according to Brian Harris, founder and CEO of MedRhythms. “Progress in stroke rehabilitation has lagged the needs of this growing population. Randomized controlled trials like this pivotal study will help us determine the potential for digital therapeutics in filling these unmet needs for rehabilitation that improves outcomes,” Harris added. “We are encouraged by the FDA’s Breakthrough Device Designation for Stride Plus, which supports our efforts to raise the standard of care for chronic stroke.”


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[NEWS] B-Temia gains traction with 510(k) clearance for mobility device

Man wearing Keeogo about to climb stairs
Keeogo provides stability and strength to stroke patients with limited mobility. Credit: B-Temia Inc.

September 14, 2020 By Annette Boyle

B-Temia Inc.’s Keeogo mobility device is on the move in the U.S. now that it has received 510(k) clearance from the U.S. FDA. Unlike currently available exoskeletons that move for patients, the Keeogo (keep on going) Dermoskeleton system amplifies signals from patients who can initiate movement but need additional assistance.

“This U.S. market clearance is the biggest milestone of our global regulatory expansion, as the USA is the largest medical device market. It also gives us great confidence for the other regulatory approvals we are currently completing for additional territories,” said B-Temia’s president and CEO Stéphane Bédard.

The U.S. action specifically covers use of the device for stroke patients in rehabilitation settings. “Stroke is just the entry door,” Bédard told BioWorld. “We want to extend U.S. authorization for other indications in the future. We’ve done very well for stroke patients and want to do the same for those with multiple sclerosis, osteoarthritis of the knee, Parkinson’s disease, and partial spinal cord injuries.”

The company also hopes to gain clearance for patients to use the device on a day-to-day basis, not just during rehab sessions. “Keeogo has as its main purpose providing the person the ability to regain their activity on a daily basis walking, shopping, out in the yard. That’s why we invented it,” Bédard added. “We will reach that level in the U.S., but with the FDA, you have to go step-by-step for each indication.”

Keeogo already has much broader authorization in Europe where it received CE mark authorization in December 2019. In the 28 European countries covered by the CE mark, Quebec-based B-Temia can market the system to provide additional strength and stability to users with musculoskeletal weakness or lower limb instability both at home and in clinics. The system has been approved by Health Canada since 2015 for a range of indications as well.

The technology

Keeogo is a lightweight motorized walking assistive device that boosts leg power. Its dermoskeleton technology employs artificial intelligence (AI) to help individuals with impaired mobility walk, run, sit, and climb. Underpinned by a model of human biomechanics and the basics elements of gait, the AI uses additional mathematical equations to intervene properly in the movement.

The AI, housed on a belt worn at the waist, interprets information transmitted by sensors strapped to the leg to understand the user’s intent and then provides the compensation needed so they can achieve their goal. It is unique in that it does not replace an individual’s motion, only augments it. “If you don’t walk, it won’t move,” said Bédard. “It will add its response to your own characteristic speed and cadence and is fully customizable to the specifics of a disease and person. We’re only able to achieve this level of sophistication with AI.”

By augmenting the user’s motions, Keeogo works to help them regain or retain their autonomy and mobility. “When you go in the lab with Keeogo, you extend your range of motion, augment stride length, and increase the biomechanical ability to walk,” explained Bédard. “When you repeat recursive exercises, you build your capacity. You extend what you’ve done in the past– the body has a memory of that – and Keeogo synchronizes the motions, extends the gait, so that day after day you regain capacity.” In Parkinson’s and other degenerative diseases, the system helps patients hold onto their independence and not fall into a pattern of doing less and less as the disease progresses and movement becomes more challenging.

Notably, the system is not tied to an idealized motion. “We’re not trying to perfect the individual’s gait, just to improve it. We want to keep the individual’s natural gait. They will improve themselves as they use the system,” Bédard said.

Aside from its clinical applications, B-Temia also continues to develop its military version of Keeogo, the Onyx exoskeleton, for the U.S. Army. It has worked with Lockheed Martin since 2017 to support soldiers tasked with carrying loads of more than 100 pounds. Under that weight, people naturally change their gait. In addition, the weight puts such pressure on the joints that it often leads to both acute and chronic musculoskeletal injuries.

Future plans

“The approval also confers additional credibility for the corporation that will open a lot of doors in terms of investors, financing, and partnerships,” Bédard said.

He plans to spend the next several weeks determining how to execute properly on commercialization in the U.S. and elsewhere so that the device can be easily acquired by individuals who could benefit. “Our next challenge is to establish a good strategy. There are many options on the table and we want to make sure we choose the right structure, partners and channels.


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[Abstract + References] Toward Human-Powered Lower Limb Exoskeletons: A Review – Conference paper


Most of the commercially available exoskeletons use rechargeable Li-ion batteries, which require frequent charging. The battery charging becomes a big bottleneck, when the person, wearing the exoskeleton, needs to go for a week trip on trekking or mountaineering. In order to make batteries more reliable and portable, an alternative energy source can be a good option. Human-powered devices are useful as an emergency electric power source, during natural disaster, war, or civil disturbance make regular power supplies unavailable. These devices have also been treated as an economical and environment-friendly option for use in underdeveloped countries, where batteries may be expensive and main power supply is unreliable or sometimes unavailable. Some of the environmental-energy-producing sources are piezoelectric devices, vibrational sources, RF transmitters, etc., where each method produces different amount of electricity. Some of these sources do not produce enough energy to charge an exoskeleton’s battery. Therefore, in this article, an effort has been made to review the human-powered products in order to develop a mechanism that can be used for charging the battery of exoskeletons. Human power is defined as the use of human work for energy generation. The energy is harvested from the user’s daily actions (walking, breathing, body heat, blood pressure, finger motion, etc.). This paper compares the various conventional and alternative methods to charge lower limb exoskeletons to be used for elderly people.


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[ARTICLE] Exoskeleton use in post-stroke gait rehabilitation: a qualitative study of the perspectives of persons post-stroke and physiotherapists – Full Text



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.


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.


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.


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.


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 [67], 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 [810].

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 [1213], there is a paucity of literature from both persons with disabilities and physiotherapists (PTs) perspectives [1415]. 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.[…]

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[Abstract + References] Adaptive Gait Planning for Walking Assistance Lower Limb Exoskeletons in Slope Scenarios


Lower-limb exoskeleton has gained considerable interests in walking assistance applications for paraplegic patients. In walking assistance of paraplegic patients, the exoskeleton should have the ability to help patients to walk over different terrains in the daily life, such as slope terrains. One critical issue is how to plan the stepping locations on slopes with different gradients, and generate stable and human-like gaits for patients. This paper proposed an adaptive gait planning approach which can generate gait trajectories adapt to slopes with different gradients for lower-limb walking assistance exoskeletons. We modeled the human-exoskeleton system as a 2D Linear Inverted Pendulum Model (2D-LIPM) with an external force in the two-dimensional sagittal plane, and proposed a Dynamic Gait Generator (DGG) based on an extension of the conventional Capture Point (CP) theory and Dynamic Movement Primitives (DMPs). The proposed approach can dynamically generate reference foot locations for each step on slopes, and human-like adaptive gait trajectories can be reproduced after the learning from demonstrated trajectories that sampled from level ground walking of normal healthy human. We demonstrated the efficiency of the proposed approach on both the Gazebo simulation platform and an exoskeleton named AIDER. Experimental results indicate that the proposed approach is able to provide the ability for exoskeletons to generate appropriate gaits adapt to slopes with different gradients.


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[WEB PAGE] DorsiFLEX: Physical Therapy Device for the Treatment and Prevention of Plantar Fasciitis, and More

Jim Cooper, a world-class runner during the 1980s and early 1990s, developed bilateral plantar fasciitis late in his running career. He sought help from a physical therapist, he says, and was given stretching exercises to do—wall leans, heel drops, and pulling on his toes with a towel—none of which seemed to help.

“I started looking at the position of my foot when it hurt the worst,” he says. “And I noticed that my toes were inclined upwards and on a different plane than the arch of my foot.” Armed with this observation, he started stretching his feet with his toes turned upward, and his plantar fasciitis started clearing up almost immediately, he says. After not finding a suitable product on the market that could help with this stretching exercise, Cooper applied his mechanical engineering degree to develop a device to incline the toes upward; he received a patent for that device, which he called the Footflex, in 1992.

The original Footflex was made of wood. It had 3 angles in the strict sagittal plane. While that original device is no longer commercially available, it led to a lasting friendship and, 20 years later, to a collaboration on subsequent versions of that first device with customer Steve Sims. Sims was also a distance runner as well as the former massage therapist for the University of North Carolina women’s soccer team and Duke University’s track and cross-country teams. The two bonded over their love of running and mutual loathing of plantar fasciitis, Cooper says.

In August of 2012, the two men got together to discuss design improvements to the Footflex and developed a new prototype. They were joined by Cameron Bell, a Duke engineering graduate and former distance runner for Duke. “I was told by a number of medical professionals that while the original product was good, it would be much better if it could function in the manner in which the foot functions…,” Cooper says. With this guidance, their “goal was to develop an innovative product to employ the Windlass Mechanism of Biomechanics that can variably and selectively position the foot in a neutral position, everted position, or inverted position while performing traditional foot, ankle, and lower-leg stretching and strengthening exercises.” They received a patent, for what is now known as the DorsiFLEX, on June 14, 2016, and the trademark “dorsiflex” on May 16, 2017.

The current model is made of a cast aluminum base with machined aluminum outside “fingers” which are anodized black in color. The “inner fingers” are 3D molded glass-filled nylon. There is a rubber non-slip surface for the foot on the base. The positioning of the vertical and/or lateral angle is adjustable via indexed holes. The patented design of the fingers allows placement of the forefoot both vertically and laterally, simultaneously.  As stated in the patent, “The fingers are adjustable relative to the base about a first axis to a variety of different angular orientations in the first plane. The fingers are also able to be adjusted at different angular positions relative to one another to provide for additional stretching of the foot in one or more additional planes.” The stretch is controlled using bodyweight. Multiple ranges of motion make the DorsiFLEX adaptable for most any foot condition and rehabilitation starting point and allows for personalized approaches to injury recovery. “The DorsiFLEX works very well for plantar fasciitis rehabilitation and prevention when the primary cause is lost ankle range of motion due to muscle tightness or muscle weakness,” Cooper says. “We have also learned the DorsiFLEX has an application for helping people with Achilles tendon problems, turf toe, and hallux rigidus problems.”

While no clinical studies have been conducted on the device, “in an effort to ensure we develop a viable product and not a gimmick, we have constantly sought healthcare and clinical input in the development, design, and manufacture of the DorsiFLEX,” Cooper says. And so far, no one has told them they are wasting their time. Additionally, feedback from consumers and healthcare professionals has been positive, he says, with most people experiencing pain reduction in 4 weeks or less and significant to total pain reduction in 8 weeks or less. “Reports back from users are that the DorsiFLEX does what is promised, provides a targeted and amplified stretch of all the muscles in the lower leg and foot causing the problem,” something that cannot be done with a slant board or heel drops on stairs, Cooper says. “It is multifunctional when compared to other products due to variability and adjustments…and can be used to perform eccentric exercises while also doing static work.”

Other differentiating features from products available on the market (to the best of the team’s knowledge) includes the ability to isolate the medial longitudinal arch leading to the big toe and isolate the bands of the plantar fascia and muscles of the foot leading to the smaller toes. Further, because the angles are indexed and measurable, the foot position is reproducible. Users can repeat the stretch and measure improvement at a known quantifiable angle—a feat, Cooper points out, that cannot be done with a rolled-up towel or while stretching against the wall. Moreover, he says that because the device is stable and easy to use, compliance is high. He recommends that users keep it in front of the bathroom vanity to incorporate stretching every day while brushing their teeth.

Out of 300 devices sold to date, of which about 10% have been sold to healthcare professionals, only 2 have been returned–DorsiFLEX has a 100% satisfaction guaranteed return policy. The only negative feedback received on the DorsiFLEX, according to Cooper, is the price ($165) and weight (5 pounds). Toward this end, the team is moving from the metal model to 3D injection molded manufacturing using a composite material, which will result in a lighter weight. The device will have a sleeker look, legs will be added so users can incline the base while also inclining the toes, and the gap between the base and fingers will be closed in response to user input, Cooper explains. The new model is in the prototyping and testing stage. If all goes as planned, a market launch date is anticipated during the first quarter of 2021.


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[WEB SITE] Gait Training & Ceiling Mounted Physical Therapy System – Gorbel Rehabilitation


Gorbel Rehabilitation

“We Improve People’s Lives” is the cornerstone in Gorbel’s Mission. Improving the safety, efficiency and quality of gait training and balance therapy is our fundamental purpose with each device we design, develop and manufacture. Our best opportunity to meet this objective has always been by working directly with the people we aim to serve; rehabilitation therapists. Whether it is a body weight support system, a rehabilitation harness, or a fall protection mobility trainer, the contributions of therapists are evident in every product in the SafeGait Solutions for rehabilitation.

Dynamic Gait and Mobility Products









For more visit site —–>

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[Abstract] Implementing the exoskeleton Ekso GTTM for gait rehabilitation in a stroke unit – feasibility, functional benefits and patient experiences



Reports on the implementation of exoskeletons for gait rehabilitation in clinical settings are limited.


How feasible is the introduction of exoskeleton gait training for patients with subacute stroke in a specialized rehabilitation hospital?

What are the functional benefits and the patient experiences with training in the Ekso GTTM exoskeleton?


Explorative study.


During an 18 months inclusion period, 255 in-patients were screened for eligibility. Inclusion criteria were; walking difficulties, able to stand 10 min in a standing frame, fitting into the robot and able to cooperate. One-hour training sessions 2–3 times per week for approximately 3 weeks were applied as a part of the patients’ ordinary rehabilitation programme. Assessments: Functional Independence Measure, Motor Assessment Scale (MAS), Ekso GTTM walking data, patient satisfaction and perceived exertion of the training sessions (Borg scale).


Two physiotherapists were certified at the highest level of Ekso GTTM. Twenty-six patients, median age 54 years, were included. 177 training sessions were performed. Statistical significant changes were found in MAS total score (p < 0.003) and in the gait variables walking time, up-time, and a number of steps (p < 0.001). Patients reported fairly light perceived exertion and a high level of satisfaction and usefulness with the training sessions. Few disadvantages were reported. Most patients would like to repeat this training if offered.


Ekso GTTM can safely be implemented as a training tool in ordinary rehabilitation under the prerequisite of a structured organization and certified personnel. The patients progressed in all outcome measures and reported a high level of satisfaction.

  • Implications for rehabilitation
  • The powered exoskeleton Ekso GTTM was found feasible as a training option for in-patients with severe gait disorders after stroke within an ordinary rehabilitation setting.
  • The Ekso GTTM must be operated by a certified physiotherapist, and sufficient assistive personnel must be available for safe implementation.
  • Patients’ perceived exertion when training in the Ekso GTTM was relatively low.
  • The patients expressed satisfaction with this training option.


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