A Mobile Future

Why Providing Mobility is a Vital Component to Rehabilitation Technology

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An exoskeleton is tested by staff at the Max Näder Lab for Rehabilitation Technologies and Outcomes Research. Photos Courtesy of the Shirley Ryan AbilityLab

On stage at the Steppenwolf’s Garage Theatre in 2016, actor and director Michael Patrick Thornton stood ready to play the part of Richard III, the crowned King of England often referred to as the “hunchback king” due to his curved spine. While the costumes and scenes evoked the darkness of the historical tale, Thornton’s means of walking was something from the future: a powered exoskeleton. Thornton, an acclaimed actor who suffered two spinal strokes more than a decade ago that left him paralyzed from the waist down, regarded use of the exoskeleton on stage as a way to represent Richard III’s shifting identity and self-perception; the character is at once vulnerable, fixated on his disability as the source of his pain, as he is conniving in a blood-thirsty quest for power.

“Disability gets consigned to the inspirational triumph story where a saint-like patient quietly bears the load and teaches us all how to appreciate what we have,” he told The Daily Herald. “That is not Richard III.”

Two years later, within the research laboratory where Thornton first learned to use the exoskeleton, the rhythmic hum of exoskeletons moving in sync with their users often reverberates through the rooms of the Max Näder Lab for Rehabilitation Technologies and Outcomes Research at the Shirley Ryan AbilityLab. Guided by a physical therapist, research participants will walk with the frame of the exoskeleton secured around their body. As they step and shift their weight in a specific manner, the motors of the device power users forward.

For the moment, the interaction between exoskeleton and human is not as intuitive and graceful as the scenes depicted in movies like the Iron Man franchise; participants often tire quickly and must practice maintaining their balance before taking their first steps.

While research on these machines is still in its infancy, exoskeletons — once something limited to science fiction or bulky, impractical designs — are part of a movement in the field of rehabilitation to design wearable devices and technologies that can help people who have disabilities that limit mobility, such as stroke or spinal cord injury, practice standing and walking in conditions that mimic everyday life: walking through hallways or outdoors, climbing stairs, or as Thornton did, using the robot on stage. Designs vary, but most exoskeletons work by supporting the joints of the user and providing power to assist with movements. Some may be full-body rigid machines, while others may use compliant, clothing-like material that conforms to the body (“soft exoskeletons”) or be designed to only to support an arm or leg.

Longer-term studies are needed to determine how these machines should be integrated into current therapy practices and if they provide benefits beyond current standards. They are, however, unique in their ability to provide high-intensity therapy without a treadmill or harness — therapy that may prevent muscle loss and pressure ulcers, or help patients walk with proper biomechanical patterns.

The rise of exoskeletons comes at a time when a growing body of research is warning of the detrimental effects of prolonged sitting and a sedentary lifestyle – increased risk of heart disease or diabetes for people who are physically inactive, for instance; these issues are magnified in people with physical disabilities who may be confined to a wheelchair or use braces for walking support.

Arun Jayaraman, director of the Max Nader Lab and an associate professor of medical social sciences at Northwestern, describes the future of exoskeletons and other technologies in rehabilitation as promising, though they must evolve. His group studies how exoskeletons may be used for therapy and how they may impact the overall recovery of patients. Recently, his group launched project with researchers at the Wyss Institute at Harvard that will evaluate how a soft exoskeleton may help individuals who have recently had a stroke. That project is part of a five-year engineering center grant funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR).

“You have to be patient with technology, rehab technology specifically,” says Jayaraman, likening first generation exoskeletons to cell phones from 10 or 20 years ago. “Standard deviations of patients’ impairments are very high. Trials are very hard to run. You can’t find the same type of patient so you can say this type of technology works perfectly on this type of patient and not on this type of patient…But in time some of these technologies will get to the stage where they may significantly change the quality of life of patients and help them recover.”

Manual Standing Wheelchair

Although exoskeletons continue to be rapidly developed, they are not yet poised to replace the wheelchair, an important mobility tool used by an estimated 1.7 million people in the United States, and more than 65 million people worldwide.

Down the hall from the Max Nader Lab, engineers within the Center for Bionic Medicine at the Shirley Ryan AbilityLab are testing and refining a recently developed manual standing wheelchair that allows the user to move in the seated or standing position, or any mode in between.

The new wheelchair, which researchers recently presented at the 40th anniversary for NIDILRR, is the first to be manual and offer this ability; other electronic wheelchairs that provide mobility in the standing mode exist but are heavy and costly.

The device provides mobility in any mode through a clever engineering design: The hand drive system of the wheelchair has a continuous track (similar to a chain on a bicycle) that the user drives to move the chair. In the current prototype, a wireless control system drives a linear actuator up and down, which lifts the seat of the chair into standing position. The user is secured through a belt around the waist and shins.

According to Todd Kuiken, director emeritus of the Center for Bionic Medicine and a professor of physical medicine and rehabilitation at Northwestern, users frequently comment on their excitement over having conversations at eye level.

“That’s probably one of the biggest things, to put people on an even keel with communication,” Kuiken said during a presentation for NIDILRR in October. “A second big advantage is of course functional. It’s really hard to reach anything above your head when you’re sitting in a wheelchair. When you can stand, your workspace gets much bigger. On top of the functional and psychological benefits, there are many health benefits. You’ve probably heard that sitting is the new smoking and there’s a push to have people stand more. That’s because standing is better for many systems from the top down.”

The wheelchair is still in the research phase, though the group hopes that the product will eventually be brought to market. In the next five years, through support from a grant from NIDILRR, researchers will continue testing and evaluating the wheelchair to improve its design.

“Standing is healthy for us all,” Kuiken said. “We want to give at least some of that back to people with disabilities.”

Sheila Burt is a science writer at the Center for Bionic Medicine within the Shirley Ryan AbilityLab. She will be writing on some of the group’s research activities for Helix this year.

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