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ExoRehabNHS

Stakeholder elicitation to develop a value proposition for exoskeleton rehabilitation technology in the NHS

Principal Investigator: Michael Craven

The project was awarded £9.5K from the University of Nottingham National Rehabilitation Centre and Faculty of Medicine and Health Sciences strategic funds via an open call held in March 2022.

The project was successfully completed in the period April to July 2022. The project team included the initial applicants:

  • Dr. Michael Craven (MC) who is part of the NIHR MindTech MedTech Co-operative based in the Institute of Mental Health at the University of Nottingham
  • Dr. Kyle Harrington (KH), early career researcher who is also part of the NIHR MindTech MedTech Co-operative based in the Institute of Mental Health at the University of Nottingham
  • Dr. Sarah Bolton (SB), Business Manager of the Centre for Healthcare Equipment And Technology Assessment (CHEATA) based at Clinical Engineering at Nottingham University Hospitals (NUH) NHS Trust and a public contributor from the MindTech Involvement Team
  • Louisa Gerrard (LG) who was recruited at the start of the project.

The budget included incurred staff costs for KH, involvement fees for LG, travel for site visits and reward shopping vouchers for respondents.

The work comprised of an initial literature review by SB and communication with the UoN Faculty of Medicine and Health Sciences ethics committee chair (exception provided on full ethical approval for this stakeholder project), and co-design of study instruments in April 2022.

This was followed by 6 stakeholder meetings conducted in May to July 2022. Meetings were attended by members of the project team with two visits in-person and the remainder conducted online. The team met with 4 physiotherapists having expertise with using exoskeletons with patients, at three independent physiotherapy services and DMRC-Stanford Hall, and with 4 people living with complete or incomplete spinal cord injury (SCI), which included one current user of the ReWalk exoskeleton.

At present, lower-limb exoskeletons are predominantly used in independent physiotherapy centres as part of a rehabilitation programme and/or as a purchase by individuals through medico-legal, charity or crowd-funding routes. The market is emerging in the UK, with five products found to be available with some level of manufacturer support, and several others that are known by physiotherapists. Products are available from various international manufacturers but are not manufactured in the UK, however training, maintenance and servicing are provided directly by UK suppliers.

Views on the usefulness of exoskeletons from physiotherapists and people living with SCI were mixed but generally positive, with advocates emphasising both the rehabilitative aspects and documented health benefits (primarily musculoskeletal, but also benefitting other functions including bowel and vascular health), as well as the motivational aspect of being able to walk upright. Assessment of individual users is critical to ensure physical suitability (such as body dimensions, weight and adequate bone density) and to ensure that expectations are met. Transfer in/out of an exoskeleton typically requires support of at least one other person, ideally from an experienced physiotherapist assisted by ‘spotters’ during the session. Multiple training sessions are needed prior to use which need to be included in the cost of deployment. Additionally, crutches are almost always needed during use, which limits the tasks a wearer can perform whilst wearing an exoskeleton and requires sufficient upper limb capability.

From our discussions with users, suppliers in the UK appear to be responsive to help them get the best from the devices, and, as mentioned above, directly supply training and servicing (software support, replacement straps, battery health). The development of exoskeleton technology is ongoing, and there are likely to be considerable improvements over the coming years, which should help address some of the present limitations. Cost lies between some of the cheaper lower-limb rehabilitation devices (such as motorised standing frames and Functional Electrical Stimulation bikes), and the more expensive supported treadmills that are purchased by independent physiotherapists. Some of the cheaper devices are within the buying capacity of individuals, for home use.

We produced a 37-page report which made several recommendations and these will be presented to NHS Supply Chain by SB. MC is in communication with MSK leads at NHS England to discuss the findings. We aim to write a journal publication to disseminate the findings later in the year. A particular gain from the project is the new contact made with the Matt Hampson Foundation charity ‘Get Busy Living Centre’ near Melton Mowbray who were very accommodating for two site visits and we were delighted to have the opportunity to speak with beneficiaries of the centre as well as the physiotherapy staff and user of ReWalk. MHF was added as a supplier of services on the UoN procurement system. It will be fruitful for NRC to continue to develop the relationship with MHF. We were also very pleased with the support of the MindTech Involvement team from the beginning of the project.

The project was a good learning experience for the project team that will help inform future robotic technology grant bids.