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At a rehabilitation center in Germany, which specializes in neurological rehabilitation after a stroke or head injury, a patient uses the bionic Ekso exoskeleton. BSIP/Getty Images
  • Exercise rehabilitation can help people with multiple sclerosis (MS) manage their symptoms, but it is not as useful for those whose condition is at an advanced stage.
  • Experts have evaluated a new form of rehabilitation in which an individual exercises within a supporting robotic exoskeleton.
  • A small trial of exoskeleton-based exercise produced significant benefits.
  • If a larger trial confirms the results, exoskeleton-based rehabilitation may, one day, become the new standard of care for MS.

MS is a disease in which the body’s immune system attacks the central nervous system, often leading to a loss of mobility and cognitive function.

Research indicates that exercise rehabilitation, particularly that involving walking, is the most effective means of improving mobility and cognition in people with MS. Even a short course of walking-based exercise rehabilitation (ER) can provide benefits.

Advanced disability can, however, preclude participation in ER. Several studies have shown that adaptive ER, such as body-weight-supported treadmill training and robot-assisted gait training, has not been very effective in people with substantial MS disability or produced additional benefits compared with gait training.

Recently, researchers from the Kessler Institute for Rehabilitation in New Jersey published the results of a randomized controlled trial of robotic-exoskeleton assisted ER (REAER).

A 4-week trial of exoskeleton-assisted therapy produced significant improvements in functional mobility, cognitive processing speed, and brain connectivity.

Says lead author Dr. Ghaith J. Androwis, Ph.D., from the Kessler Foundation’s Center for Mobility and Rehabilitation Engineering Research:

“This is particularly exciting because therapy using robotic exoskeletons shows such promise for improving the lives of people with co-occurring mobility and cognitive disability — a cohort that likely has the greatest potential to benefit from this new technology.”

The results appear in the journal Multiple Sclerosis and Related Disorders.

With REAER, individuals wearing a supporting robotic exoskeleton walk on the ground — not on a treadmill — with a physical therapist who closely guides them through a progressive regimen. The exoskeleton that the team used in the study was the EksoNR.

The researchers recruited 10 Kessler clients, all of whom were aged 18–75 years. All of these individuals had received a definitive MS diagnosis and had been relapse-free for 30 days and seizure-free for 90 days.

They participated in a randomized controlled trial comparing the effects of 4 weeks of REAER training with conventional gait training.

The study used four parameters to determine the effectiveness of the training:

  1. Functional mobility: The researchers used a “timed up-and-go” measurement of the time it takes to go from sitting in a chair to walking to a target and to returning to a seated position.
  2. Walking endurance: This parameter was based on the results of a 6-minute walk test on solid ground.
  3. Cognitive processing speed: The participants underwent a Symbol Digit Modalities Test.
  4. Resting-state functional brain connectivity: For this parameter, the team focused specifically on the connectivity between the thalamus and ventromedial prefrontal cortex, which functional MRI (fMRI) scans revealed.

The results of REAER were significant compared with conventional training. The researchers saw “large improvements” in functional mobility, cognitive processing speed, and brain connectivity. The only factor that REAER did not affect was walking endurance.

Dr. Brian M. Sandroff, director of the Kessler Foundation’s Exercise Neurorehabilitation Research Laboratory, explains:

“Four weeks is relatively short for an exercise training study. Seeing improvements within this time frame shows the potential for exercise to change how we treat MS. Exercise is [a] really powerful behavior that involves many brain regions and networks that can improve over time and result in improved function.”

Medical News Today asked Dr. Kathy M. Zackowski, the senior director of patient management, care, and rehabilitation research for the National MS Society, why REAER may produce such striking results. She explained:

“REAER has some novel features that may offer important benefits compared with body-weight supported treadmill training and robot-assisted walking training. There is evidence to support the idea that walking over ground is an important element and that walking on a treadmill does not generalize to improved over ground walking, resulting in fewer functional benefits.”

Dr. Zackowski added that REAER also offers something else that robot-assisted gait training does not:

“Use of robot-assisted devices removes the interactions between a patient and therapist when learning. It seems that learning new skills requires inclusion of essential elements, and when those elements are not included, improvements are diminished. Research is working hard to determine what those ‘essential elements’ are, and the use of REAER offers new opportunities to patients with MS.”

Other technology-based therapies may also be helpful for people with MS. “Functional electrical stimulation offers great opportunities to people with MS because their peripheral nervous system typically remains healthy,” said Dr. Zackowski, who explained that “these devices rely on stimulation of the peripheral nervous system to gain function.”

Mindful of its small sample size, the authors of the study stop short of recommending exoskeleton use as the new standard of ER care for people with MS. Dr. Androwis concludes:

“We’re eager to design a larger trial to further study these effects. Based on our initial results, we’re optimistic that this approach may be superior to the current standard of care.”