The evolving field of exoskeleton robotics offers opportunities and rehabilitation options for physiotherapists. It is proposed that robotic technology has great prospects for cosmetic applications and the professional requirements in this field are high . The global exoskeleton market anticipates reaching a significant ten size of USD 3.340 trillion expanding at a growth rate of 46.2% by 2026 .
A significant area of robotic engineering research involves lower extremity rehabilitation. The prevalence of plantar fasciitis causing problems with walking is increasing rapidly in today’s elderly societies but the availability of personnel and specialist equipment for rehabilitation is not currently conforms to these requirements . Gait improvement is a desirable and important outcome for return to life and work  .
Cosmetic robotics can help a wide range of patient populations including:
- Spinal Cord Injury 
- Stroke 
- Cerebral Palsy 
- Parkinsons 
- Multiple Sclerosis (MS) 
- Traumatic Brain Injury 
- Elderly care 
- Post-surgery 
- Orthopaedics 
Rehabilitation of the lower extremities specifically for gait recovery can require considerable time and physical effort on the part of physical therapists. Not only is this an expensive and subsequently unrealistic approach to rehab but it takes a lot of hard work for the therapists to deliver this care. But walking is one of the most important aspects of lower limb robotic rehabilitation. With current methods of improving gait, it is important for many therapists to help the patient move each joint and leg appropriately to maximize benefit.
Robotic devices designed for lower limb rehabilitation strength orthoses with computer-controlled motors assisting joint movements can increase the therapeutic rate of movement training while potentially eliminating medical burden. When using robots, therapists are less concerned requiring the same treatment devices. While the patient is strapped into the robotic device, the therapist only needs to provide care and device settings.  This can help teach the patient the proper way to walk from the very beginning thus avoiding inappropriate ones walking paths.
In addition to extensive repetition of specific movements (e.g. walking cycles), some other ways in which robots can be useful in therapy are:
- monitoring and monitoring movement parameters (i.e. velocity direction amplitude sequencing) in real time;
- sensory feedback during flight;
- creating a safe environment for controlled violence;
- with minimal effort weight support;
- and provide objective measurement capabilities for more reliable standardized tests and goniometry measures for informing patient outcomes and treatment planning .
Another way that robots can help patients is in improving range of motion (ROM) by reducing joint immobility. Mechanisms of joint restriction such as passive and reflexive resistance may reflect the progression of joint restriction. Robots can then use a certain amount speed and amplitude to be applied to the patient based on their individual needs. This can help improve ROM by using specific forces at specific times. Continuous static devices are common in rehab to improve joint ROM. But with many newer devices ROM in theory they can improve rapidly while ensuring patient comfort and safety.
Robots can also be used to improve and actualize how a patient feels their lower limbs. Once the patient’s eyes are closed, the device can be positioned so as to move the patient’s limbs. The patient is then asked to assess the position of the limb and compare with that of the machine. This helps the patient focus on where the limb will be positioned and position the opposite limb in a similar position. Robots can also be used to test the detection of small, dysfunctional limb movements. Also when the patient is blindfolded, the bandaged limb is moved the robots slowly. The patient speaks when he feels the limb begin to move. This will determine how much movement the patient needs to feel. This can be used not only as a clinical indicator but also as an accurate diagnostic tool.
While these are just some of the benefits of robotic therapy for the lower extremities, the field of robotics is a growing field with many opportunities to improve patient care. As time goes on and research comes to the robotic field in the field of lower limb rehabilitation it will continue to do so organize.
For information on the use of robots for the upper extremity visit the Upper Extremity Rehabilitation using Robotics Physiopedia page.
Other Health Outcomes
Prolonged use of robots can lead to :
- Increased strength in lower-extremity
- Improved posture
- Increase in bone density
- Improved bowel movements
- Improved sleep
- Decreased pain
- Decreased cholesterol
- Decreased spasticity
- Decreased rate of cardiovascular disease
- Decreased rate of diabetes
Motivation and engagement are critical to a patient’s success and positive outcomes when it comes to integrating technology into treatment. A positive introduction to the robotic device will lead to longer use while a negative experience may decrease motivation and a reduction in the impact of the device’s use on clinical outcomes . The physiotherapist plays a major role in this by providing appropriate guidance and feedback as the patient learns to use the device.
To date, few studies have investigated the effects of robotic devices for lower limb rehabilitation on patient cognition or motivation. One study has shown that patients have a positive attitude towards the incorporation of robotic orthopedic prostheses in rehabilitation  . It’s also the same it is important to assess therapists’ acceptance and willingness to use robotic technology in their practice based on the learning process and to identify the use of the devices and the budding scientific evidence supporting acupuncture -correct the results
Limitations and Challenges
As the potential benefits of robotics for lower extremity rehabilitation become apparent, many challenges remain to be overcome and require further research. As of now the major limitations are the high cost of acquiring and implementing robotic systems without high-quality clinical evidence of patient outcomes and the need for standardized interventions for treatment planning and assessment. Other limitations include their bulky size and long inaccurate delivery times for mobile units. Patients with spasticity may be driven by robotic movements and greater gait long term can cause some side effects such as increased risk of fractures abrasions pressure sores and falls.  Especially regarding patients with cardiac arrest wrapping these devices can also be dangerous because cardiac resuscitation is required or at a later time emergency situations where the patient is inaccessible.
Robotic systems are able to precisely measure kinematic and dynamic values that are much more reliable than those obtained by human error and have the potential to be very useful for evaluation purposes. This means that standardization still needs to be developed procedures and protocols in order to make this data useful. Currently, some examples of data that robotic systems use during evaluation are ROM walk distance gait speed and various other dynamic measures, but we don’t yet have standardized evaluation measures like those seen In other gait-related assessments (Barthel Index Dynamic Gait Index, etc.). Additionally, robotics have not been shown to be significantly more effective than typical manually assisted treatments delivered by a therapist, which is the driving reason why it has not yet been implemented into routine practice .
Current Examples of Rehabilitation Robotics
There are already several lower-limb robotic devices commercialized, and many others are in development. Several examples of robotic devices for gait rehabilitation are shown below, which can be classified into different categories :
- Powering above-ground exoskeleton devices: Above-ground exoskeleton devices allow patients to ambulate without overhead support systems, but typically require patients to have some upper body strength to use assistive devices (such as forearm crutches) with the device.
- Body Weight Supporting Treadmill (BWST) Exoskeleton Device or Driven Gait Orthotic (DGO): A BWST exoskeleton involves a harness that supports the adjusted percentage of the patient’s weight, while a robotic orthosis controls the hip, knee and/or ankle motion patterns during gait . The initial phase Recovery may require manual assistance from two therapists.
- End-effector devices: End-effector devices also provide some body weight support through the use of harnesses, but they typically strap the patient’s foot and ankle to a footplate that mimics the gait trajectory, rather than an orthosis .
Phoenix is a 23-pound exoskeleton with motors that control the movement of the hips and knees. It has an average walking speed of 1.1 mph, and its battery life allows for about 4 hours of continuous walking. It is suitable for clinics and communities .
It is intended for clinical use under the supervision and guidance of a physiotherapist for SCI (C7 and below) or stroke .
Rewalk comes in 2 models: a rehabilitation model for clinics and a personal model for community walks.
It is primarily used in SCI patients with T7 to L5 SCI requiring upper body strength. It’s available in the US and Europe. European models include ascending and descending stair features. 
Rex is designed for clinical use and can assist patients weighing up to 100 kg. It supports/stabilizes the torso with the abdominal belt and padding so the patient needs less core activation http://www.rexbionics.com/product-information/. 
Keeogo is another exoskeleton that can walk on flat ground and help you climb up and down stairs. It is available for purchase and rental in Canada and is designed for patients who are able to ambulate independently with at least an assistive device .
Hybrid Assistive Limb (HAL)
The HAL is a lightweight powered assist device that uses a technology to sense electrical signals sent from the brain to the muscles (via surface electromyography and ground reaction force sensors) and initiate the patient’s desired movement. [twenty one]
HAL is especially useful in early gait rehabilitation to create stronger brain-muscle connections. If no signal is detected (such as paraplegia), the robot adopts an automatic gait pattern to let the person pass. There are different versions of HAL according to the application (whole body low body with one leg)
Indego is a 26-pound exoskeleton that delivers functional electrical stimulation (FES) to lower body muscles. It is designed for clinic and community mobility .
Lokomat is the most popular BWSTT exoskeleton and has been used in more than 280 gait rehabilitation studies in different patient populations .
The Gait-Trainer GT 1
The Gait Trainer GT 1 provides FES for up to 8 muscle groups. In place of an orthosis, the patient’s foot is strapped to a treadmill whose trajectory mimics walking on the ground. This increases the freedom of movement of the knee and hip .
The G-EO system does not provide FES, but it does provide additional pedal trajectories to simulate stair climbing .
Lokohelp is similar to the G-EO system, but does not offer an option for climbing stairs .
Future of Robotics
As rehabilitation robotics advances, it has the potential to revolutionize the way physical therapists deliver therapy to patients. The ultimate goal is to enable physical therapists to use robotics to benefit their practice by improving the effectiveness of assessment and treatment. As the demand for physiotherapists and long-term rehabilitation is on the rise, one of the main goals of current robot development is to combine information technology with rehabilitation robotics to provide assessment and treatment via the internet so that physiotherapists can supervise the treatment in the comfort of the patient’s own home and allow a single physical therapist to see a large number of patients simultaneously .
Currently, today’s gait robots are unable to generate the strength and power needed for running and jumping rehabilitation. Future developments in this field will benefit the rehabilitation of athletes with spinal cord injuries . Batteries are also being further developed to maximize their Life-size weight and easy recharging . Other areas of current focus in robotics include the development of lighter-weight technologies that allow devices to be used off-the-counter, and the incorporation of virtual reality and video games to maximize patient motivation .
- ↑ Jump up to:1.0 1.1 Shi D., Zhang W., Zhang W., Ding X. A review on lower limb rehabilitation exoskeleton robots. Chinese J Mechanical Engineering 2019; 32; 74.
- ↑ MarketsandMarkets.Exoskeleton Market by Type (Powered, Passive), Component (Hardware, Software), Mobility, Body Part (Lower Extremities, Upper Extremities, Full Body), Vertical (Healthcare, Defense, Industrial) and Region (2021-2026).Available online: https://www.marketsandmarkets.com/Market-Reports/exoskeleton-market-40697797.html?gclid=EAIaIQobChMI0sb4vu_6-AIVuY1oCR0KRguCEAAYASAAEgJQu_D_BwE [accessed 15/07/2022]
- ↑ Esquenazi A., Talaty M. Robotics for Lower Limb Rehabilitation. Phys Med Rehabil Clin N Am. 2019 May;30(2):385-397.
- ↑ Edwards, D., Forrest, G., Cortes, M. Weightman M., Sadowsky C., Chang S-H., et al. Walking improvement in chronic incomplete spinal cord injury with exoskeleton robotic training (WISE): a randomized controlled trial. Spinal Cord 2022; 60: 522–532.
- ↑ Hobbs B., Artemiadis P. A Review of Robot-Assisted Lower-Limb Stroke Therapy: Unexplored Paths and Future Directions in Gait Rehabilitation. Frontiers in Neurorobotics 2020; 14:19.
- ↑ Sandro Gatillo. Robotics Technology for Stroke and Brain Injury Rehabilitation [Internet]. 2017 [cited 8 May 2017]. Available from: https://www.youtube.com/watch?v=-EdfmoVBR5k
- ↑ Bayon C., Raya R., Lerma Lara S., Ramirez O., Serrano I., Rocon E. Robotic therapies for children with cerebral palsy:a systematic review. Translational Biomedicine 2016; 7(1):44.
- ↑ Capecci, m., Pournajaf S., Galafate D., Sale P., Le Pera D., Goffredo M., De Pandis MF., Andrenelli E., Pennacchioni M., Ceravolo MG., Franceschini M. Clinical effects of robot-assisted gait training and treadmill training for Parkinson’s disease. A randomized controlled trial. Annals Phys and Rehabil Med, 2019; 62(5):303-312.
- ↑ Sconza C., Negrini F., Di Matteo B., Borboni A., Boccia G., Petrikonis I., Stankevičius E., Casale R. Robot-Assisted Gait Training in Patients with Multiple Sclerosis: A Randomized Controlled Crossover Trial. Medicina (Kaunas) 2021; 57(7):713.
- ↑ Karunakaran K., Nisenson D., Nolan K. Alterations in Cortical Activity due to Robotic Gait Training in Traumatic Brain Injury. Annu Int Conf IEEE Eng Med Biol Soc. 2020 Jul;2020:3224-3227.
- ↑ Pearce A., Adair B., Miller K., Ozanne E., Said C., Santamaria N., Morris M. Robotics to Enable Older Adults to Remain Living at Home. J Aging Res 2012; 2012: 538169.
- ↑ Jump up to:12.0 12.1 Payedimarri A., Ratti M., Rescinito R., Vanhaecht K., Panella M. Effectiveness of Platform-Based Robot-Assisted Rehabilitation for Musculoskeletal or Neurologic Injuries: A Systematic Review. Bioengineering 2022, 9(4), 129.
- ↑ Jump up to:13.0 13.1 13.2 13.3 13.4 13.5 13.6 13.7 Bryce T, Dijkers M, Kozlowski A. Framework for Assessment of the Usability of Lower-Extremity Robotic Exoskeletal Orthoses. Am J Phys Med Rehabil. 2015;94(11):1000-1014. DOI:10.1097/PHM.0000000000000321
- ↑ Jump up to:14.0 14.1 14.2 Díaz I, Gil J, Sánchez E. Lower-Limb Robotic Rehabilitation: Literature Review and Challenges. J Robotics. 2011;2011:1-11.
- ↑ Molteni F, Gasperini G, Cannaviello G, Guanziroli E. Exoskeleton and end-effector robots for upper and lower limbs rehabilitation: narrative review. PM R. 2018;10:S174-S188.
- ↑ Jump up to:16.0 16.1 Maggioni S, Melendez-Calderon A, van Asseldonk E, Klamroth-Marganska V, Lünenburger L, Riener R et al. Robot-aided assessment of lower extremity functions: a review. J Neuroeng Rehab. 2016;13(1).
- ↑ Manns P.J., Hurd C., Yang JF. Perspectives of people with spinal cord injury learning to walk using a powered exoskeleton. J Neuroeng Rehabil. 2019;16:94.
- ↑ Postol N., Grissell j., McHugh C., Bivard A., Spratt N. , Marquez J. Effects of therapy with a free-standing robotic exoskeleton on motor function and other health indicators in people with severe mobility impairment due to chronic stroke: A quasi-controlled study. J Rehabil Assist Technol Eng. 2021 Jan-Dec; 8: 20556683211045837.
- ↑ Mortenson WB, Pysklywec A, Chau L, Prescott M, Townson A. Therapists’ experience of training and implementing an exoskeleton in a rehabilitation centre. Disabil Rehabil. 2020. https://doi.org/10.1080/09638288.2020.1789765
- ↑ Harwin W, Patton J, Edgerton V. Challenges and Opportunities for Robot-Mediated Neurorehabilitation. Proc IEEE. 2006;94(9):1717-1726.
- ↑ Jump up to:21.0 21.1 21.2 Ramesh N., Iwaniec M., Arawade S. Past, present and future of assistive robotic lower limb exoskeletons. MATEC Web of Conferences 2022; 357:03005.
- ↑ Mehrholz J, Pohl M. Electromechanical-assisted gait training after stroke: A systematic review comparing end-effector and exoskeleton devices. Journal of Rehabil Med. 2012;44(3):193-199.
- ↑ Phoenix | suitX [Internet]. Suitx.com. 2017 [cited 9 May 2017]. Available from: http://www.suitx.com/phoenix
- ↑ suitX. Phoenix [Internet]. 2017 [cited 8 May 2017]. Available from: http://www.suitx.com/phoenix
- ↑ Products | Ekso Bionics [Internet]. Ekso Bionics. 2017 [cited 9 May 2017]. Available from: http://eksobionics.com/eksohealth/products/
- ↑ Business Street. Community Regional Medical Center Demonstrates Esko Bionic Exoskeleton [Internet]. 2014 [cited 8 May 2017]. Available from: https://www.youtube.com/watch?v=fav-sgk7_yA
- ↑ Madonna Rehabilitation Hospitals. Ekso GT Robotic Exoskeleton [Internet]. 2017 [cited 8 May 2017]. Available from:https://www.madonna.org/images/uploads-users/content/gallery/Ekso_1200x630_2 .jpg
- ↑ Comparing Indego vs Ekso GT vs ReWalk, Researched by VAPAHCS [Internet]. Exoskeleton Report. 2017 [cited 9 May 2017]. Available from: http://exoskeletonreport.com/2016/09/comparing-indego-vs-ekso-gt-vs-rewalk-researched-vapahcs/
- ↑ Product Information – Rex Bionics [Internet]. Rex Bionics. 2017 [cited 9 May 2017]. Available from: http://www.rexbionics.com/product-information/
- ↑ Who is Keeogo™ for? [Internet]. Keeogo restores and enhances autonomy in mobility. [cited 2017May9]. Available from: http://www.keeogo.com/who-is-keeogo-for
- ↑ Spinal Cord Research and Advocacy. Lower Limb HAL [Internet]. 2015 [cited 8 May 2017]. Available from: https://spinalcordresearchandadvocacy.files.wordpress.com/2015/09/lower-limb-hal .jpg
- ↑ Indego – Powering People Forward | Parker Indego [Internet]. Indego.com. 2017 [cited 9 May 2017]. Available from: http://www.indego.com/indego/en/home
- ↑ Lokomat® – Hocoma [Internet]. Hocoma. 2017 [cited 9 May 2017]. Available from: https://www.hocoma.com/solutions/lokomat/
- ↑ Center For Neuro Recovery. Lokomat Pro Gait Training [Internet]. 2015 [cited 8 May 2017]. Available from: http://www.centerforneurorecovery.com/wp-content/uploads/2015/06/Lokomat-Pro-Robotic-Gait-Training .jpg
- ↑ Reha Stim | Gait Trainer GT I [Internet]. Reha-stim.de. 2017 [cited 9 May 2017]. Available from: http://www.reha-stim.de/cms/index.php?id=76
- ↑ G-EO System – Reha Technology [Internet]. Rehatechnology.com. 2017 [cited 9 May 2017]. Available from: https://www.rehatechnology.com/en/products/g-eo-system
- ↑ LokoHelp | Woodway [Internet]. Woodway.com. 2017 [cited 9 May 2017]. Available from: https://www.woodway.com/products/lokohelp
- ↑ Laut J , Porfiri M & Raghavan P. The present and future of robotic technology in rehabilitation. Curr Phys Med Rehabil Rep. 2016;4: 312.