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Objective: To examine changes in quality of life (QoL) after an eight-week period of robotic exoskeleton training in a homogeneous group of patients with chronic complete spinal cord injury (SCI)., Design: Prospective single-group pre-post study., Setting: Rehabilitation center., Participants: Patients with a chronic (>6 months) motor complete SCI (T1-L1)., Intervention: Twenty-four training sessions with the ReWalk exoskeleton over an eight-week period., Main Outcome Measure: QoL, assessed with the sum score of the Short Form-36 with Walk Wheel modification (SF-36ww). Secondary outcome measures were the eight SF-36ww subdomains, satisfaction with bladder and bowel management, lower extremity joint passive range of motion (pROM), and lower extremity spasticity., Results: Twenty-one participants completed the training. QoL significantly improved after the training period (average SF-36 sum score 621 ± 90) compared to baseline (571 ± 133) ( t (20)=-2.5, P =.02). Improvements were seen on the SF-36ww subdomains for pain ( P =.003), social functioning ( P =.03), mental health ( P =.02), and general health perception ( P =.01). Satisfaction with bladder management (range 1-5) improved from median 3 at baseline to 4 after exoskeleton training ( P =0.01). No changes in satisfaction with bowel management ( P =.11), pROM (hip-extension ( P =.49), knee-extension ( P =.36), ankle dorsiflexion ( P =.69)), or spasticity ( P =.94) were found., Conclusion: Even in patients with chronic motor complete SCI and a relatively high level of QoL at baseline, a short-term exoskeleton training improved their QoL, pain and satisfaction with bladder management; findings that warrant further controlled studies in this specific SCI population.

Purpose: The System Usability Scale (SUS) is the most commonly used questionnaire to assess usability of healthcare innovations but is not available in Dutch (D-SUS). This study aims to translate the SUS to Dutch and to determine its internal consistency, test-retest reliability, and construct validity in healthcare innovations focused on rehabilitation technologies., Methods: Translation of the SUS was performed according to the WHO recommendations. Fifty-four participants filled out the D-SUS and Dutch Quebec User Evaluation of Satisfaction with assistive Technology (D-QUEST) twice. Internal consistency was assessed by Cronbach's alpha. Test-retest reliability was evaluated by Gwet's agreement coefficient (Gwet's AC2) on item scale, and Pearson correlation coefficient (PCC) for the overall D-SUS scores. Construct validity was assessed with the PCC between the D-SUS and D-QUEST overall scores (Netherlands Trial Register, ID: NL9169)., Results: After translation, Cronbach's alpha was 0.74. Gwet's AC2 was 0.68 and the PCC between the first and second overall D-SUS scores was 0.75. No significant difference in D-SUS score between the two measurements was found. Repeatability coefficient was 18.4. The PCC between the D-SUS and D-QUEST overall scores was 0.49., Conclusions: The D-SUS is a valid and reliable tool for usability assessment of healthcare innovations, specifically rehabilitation technologies.

Purpose: Exoskeleton use by people with complete spinal cord injury (SCI) in daily life is challenging. To optimize daily exoskeleton use, a better understanding of the purpose of use and the accompanying improvements are needed. The perspective of experienced exoskeleton users could guide design improvements., Methods: Face-to-face semi-structured interviews were held with 13 people with SCI with exoskeleton experience. Interviews were audio-taped, transcribed, and analysed thematically., Results: Participants expressed three future purposes of exoskeleton use: for daily activities (e.g., stair climbing), exercise (e.g., staying healthy), and social interaction (e.g., standing at parties). Exoskeleton use during daily activities was the ultimate goal. Therefore, the future exoskeleton should be: easy to use, small and lightweight, tailor made, safe, comfortable, less distinctive, durable, and affordable . Improving the ease of use was relevant for all purposes, for all participants. The other suggestions for improvement varied depending on the purpose of use and the participant., Conclusion: Increasingly more advanced improvements are needed to transition from an exercise purpose to social interaction, and ultimately use during daily activities. In the current study, detailed suggestions for improvements have been made. Only when multiple of these suggestions are adjusted, can the exoskeleton be used to its full potential.IMPLICATIONS FOR REHABILITATIONThe use of an exoskeleton by people with a complete spinal cord injury in daily life is still in its infancy.To optimize daily exoskeleton use, a better understanding of the purpose of use and exoskeleton improvements is needed.More advanced improvements to future exoskeletons are needed to make a transition from use as an exercise device to use during social interaction and daily activities.Improving the ease of use of future exoskeletons is considered a priority by experienced users, followed by making the exoskeleton small, lightweight, and tailor made .

Purpose of the Article: Learning to use an exoskeleton is time consuming and diverse between users. Knowledge about trainability of exoskeleton skills is relevant for planning and expectation management. The objective was to assess predictors of exoskeleton skill performance during and after exoskeleton training., Materials and Methods: Twenty-four participants with a motor complete spinal cord injury were given 24 training sessions in 8 weeks. Nine potential predictors were identified: lesion level, age, gender, age at injury, time since injury, BMI, sport, active lifestyle, and anxiety. Univariate and multivariate linear regression analyses were performed to examine predictors of skill performance after 2, 4, 6, and 8 weeks., Results and Conclusions: Twenty participants completed the training. Univariate analysis revealed that positive predictors were: low lesion level and more active lifestyle after 2 weeks, whereas low age at injury, low BMI, and more active lifestyle were positive predictors after 6 weeks. Multivariate regression model explained 65% of the performance after 2 weeks (predictors: lesion level, anxiety, active lifestyle) and 66% after 6 weeks (predictors: BMI, active lifestyle, age). Lesion level was a predictor during the first 4 weeks, but did not influence participants' final skill level. BMI, age, and active lifestyle were predictors toward the end of the training period.Implications for rehabilitationWith the help of wearable exoskeletons people with a complete spinal cord injury can regain their standing and walking mobility.Learning to use an exoskeleton is time consuming and the number of training sessions required to walk independently differs greatly between users.This study shows that lesion level was an important predictor of exoskeleton motor learning in the first 4 weeks of training.BMI, age, and active lifestyle were predictors of exoskeleton skill performance toward the end of the 8 week training period.

Background : In infants with indications of upper cervical dysfunction, the Flexion-Rotation-Test and Lateral-Flexion-Test are used to indicate reduced upper cervical range-of-motion (ROM). In infants, the inter-rater reliability of these tests is unknown. Objective : To assess the inter-rater reliability of subjectively and objectively measured ROM by using the Flexion-Rotation-Test and Lateral-Flexion-Test. Methods : 36 infants (<6 months) and three manual therapists participated in this cross-sectional observational study. Pairs of two manual therapists independently assessed infants' upper cervical ROM using the Flexion-Rotation-Test and Lateral-Flexion-Test, blinded for each other's outcomes. Two inertial motion sensors objectively measured cervical ROM. Inter-rater reliability was determined between each pair of manual therapists. For subjective outcomes, Cohen's kappa (ĸ) and the proportion of agreement (Pr a) were calculated. For objectively measured ROM, Bland Altman plots were conducted and Limits of Agreement and Intraclass Correlation Coefficients (ICC) were calculated. Results : The inter-rater reliability of the Flexion-Rotation-Test and Lateral-Flexion-Test for subjective (ĸ: 0.077-0.727; Pr a : 0.46-0.86) and objective outcomes (ICC: 0.019-0.496) varied between pairs of manual therapists. Conclusion : Assessed ROM largely depends on the performance of the assessment and its interpretation by manual therapists, leading to high variation in outcomes. Therefore, the Flexion-Rotation-Test and Lateral-Flexion-Test cannot be used solely as a reliable outcome measure in clinical practice and research context.