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 Table of Contents  
Year : 2018  |  Volume : 4  |  Issue : 4  |  Page : 180-183

Exoskeleton in the neurorehabilitation process: Neuropsychological effects in patients affected by spinal cord injury and stroke

Prosperius Institute, Neurorehabilitation and Robotic Area, University of Perugia, Umbertide, Prosperius Group, Florence, Italy

Date of Web Publication28-Dec-2018

Correspondence Address:
Paolo Milia
Neurorehabilitation and Robotic Area, Prosperius Institute, University of Perugia, Umbertide
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/digm.digm_14_18

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Background and Objectives: In neurorehabilitation, exoskeleton plays a key role among the numerous innovative and advanced frontiers in technology. The exoskeleton is intended for rehabilitation and mobility in patients with neurological motor diseases. The aim of this study is to evaluate the impact of robotic training in body perception and mood. Methods: Two patients, one affected by stroke and another affected by spinal cord injury admitted to our rehabilitation unit, have been studied. We used two exoskeletons (Ekso and Indego). Training occurred 3 days a week for a total of forty sessions, with a duration of 50–60 min each session. Psychological tests focused on depression (Beck Depression Inventory), self-perception (body uneasiness test A), and the workload (NASA-Task Load Index) were used. Results: After the treatment, we found a great improvement in mood disorders and body perception in the patients. Conclusions: Patients with neurological motor diseases can increase motor and psychological skills using an active powered exoskeleton.

Keywords: Body perception, exoskeleton, mood, neurorehabilitation

How to cite this article:
Milia P, De Salvo F, Peccini MC, Sfaldaroli A, Cadri S, Caserio M, Bigazzi B, Bigazzi M. Exoskeleton in the neurorehabilitation process: Neuropsychological effects in patients affected by spinal cord injury and stroke. Digit Med 2018;4:180-3

How to cite this URL:
Milia P, De Salvo F, Peccini MC, Sfaldaroli A, Cadri S, Caserio M, Bigazzi B, Bigazzi M. Exoskeleton in the neurorehabilitation process: Neuropsychological effects in patients affected by spinal cord injury and stroke. Digit Med [serial online] 2018 [cited 2023 Jun 8];4:180-3. Available from: http://www.digitmedicine.com/text.asp?2018/4/4/180/248976

  Introduction Top

Neurorehabilitation process is an active, multidisciplinary, dynamic, and patient-specific path oriented toward a patient's global output and the recovery of the maximum level of autonomy compatible with the patient's residual skills. Technology and robotics play a major role in neurorehabilitation since not only have they allowed its expansion and development,[1] but they also offer numerous innovative and advanced rehabilitation frontiers. Exoskeleton is an outer wearable skeleton that allows people with weakness or paralysis of the lower limbs to walk. Training with the exoskeleton is aimed at patients with traumatic brain injury, stroke, spinal cord injury (SCI), multiple sclerosis, and Guillain–Barré syndrome.[2],[3] These pathologies cause serious consequences both at the physiological and motor levels and in the patient's cognitive and psychological domains with an important impact on the quality of patient and his/her family's lives.[4]


The aim of this study is to assess the impact of robotic training on two patients with different pathologies using a different exoskeleton: the Ekso Bionics and the Parker Indego. The study focuses on the changes related to body perception and mood of patients after performing gait training with the exoskeletons.

  Methods Top

We have investigated two patients: one affected by stroke and another affected by SCI.

Patient 1 is a male affected by left intraparenchymal thalamic-capsule hemorrhagic stroke. At the beginning of admission, the patient presented with cognitive deficit and depressive symptoms noted after the neuropsychological assessment. After a cognitive rehabilitation training of the executive functions, the patient was included in gait training with the exoskeleton Ekso to improve motor skills and cognitive ability.

Patient 2 is a female affected by lower-limb paraparesis who underwent surgery due to cervical hernias at level C5, C6, and C7. During the hospitalization, the patient showed a deflection of her mood and a distorted perception of her body image. She used the exoskeleton Indego to improve walking and body perception.

In this study, the psychological approach was focused on depression using the Beck Depression Inventory (BDI) scale and on self-perception after the neurological illness using the Body Uneasiness Test A (BUT-A); the NASA-Task Load Index (TLX) scale was used to assess the workload perceived by the patient during the execution of a task. A neuropsychologist administered these tests before and after the treatment.

Ekso and Indego

Two exoskeletons are available at the Prosperius Tiberino Institute – Ekso and Indego. Both are intended for rehabilitation and mobility of individuals with neurological motor diseases.

Ekso weighs around 20 kg and is designed to adjust easily to users ranging in height between 157 and 195 cm. The device attaches to the user's torso with backpack-style shoulder harnessing and a torso brace. These characteristics allow greater stability and safety to the patient even in the case of higher injuries and therefore with greater deficits. A physiotherapist follows the patient during the entire training and controls the device by a manual controller located on the torso brace.

Indego is much lighter than Ekso (weighs around 11.8 kg) and is more practical during assembly and disassembly. Indego is as rehabilitative as Ekso with differences in the structure: it has no torso brace and can be controlled by the Indego IPod. Because of these features, this exoskeleton is meant for use at home.

Body Uneasiness Test

The BUT[5] is a self-report test consisting of a first part composed of 34 clinical items (BUT-A) and the second one consisting of a list of 37 parts or bodily functions (BUT-B). The participants are asked to assign to each item a score on a Likert scale from 0 to 5 (from “never” to “always”). The BUT takes into analysis the elements linked to the fear of being or becoming fat, the compulsive control behaviors linked to body image, and the sense of depersonalization from one's body.

Beck Depression Inventory

The BDI[6] is a self-report questionnaire used to measure the severity of depression. The BDI is a tool composed of 21 multiple-choice items that assess the severity of symptoms of depressive disorder according to the nomenclature of the fourth edition of the Statistical Diagnostic Manual of Mental Disorders[7] (1994).

NASA-Task Load Index

The NASA-TLX scale is a multidimensional procedure that provides an assessment of the workload perceived by the individual during the execution of a task.[8] It has six subscales, three of which related to the participants and their personal perception of the task and three related to the interaction of the participants with the task. Each scale is presented as a line divided into twenty equal parts whose extremes range from “very low” to “very high.”


Patients admitted to our Neurorehabilitation Hospital underwent a clinical, cognitive, and physiotherapy assessment for gait training with exoskeleton. The rehabilitation training with the exoskeleton is intensive, tailored, and organized in a hierarchical way. The gait training occurred 3 days/week for a total of forty sessions. Each session had a duration of 50–60 min. Before, during, and after the gait training with the exoskeleton, both patients underwent an evaluation of their mood, body perception, and perceived workload during the performance of the task.

  Results Top

Both patients completed the overground gait training without collateral effects and benefitted physically and psychologically.

Before the gait training, patient 1 showed great discomfort in reference to his body image and the idea of looking at himself in the mirror. After the training with Ekso, patient 1 showed an improvement in mood as tested by the BDI. The patient also showed an improvement of self-perception, specifically in the items related to body perception and avoidance behaviors as tested by BUT-A [Table 1].
Table 1: Psychological and body perception

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Before the gait training, patient 2 obtained high scores in BDI, specifically in the items concerning negative representations of the future and of oneself. The qualitative analysis of the BUT-A confirms such representations, specifically regarding the dissatisfaction of one's own body image and the behaviors referable to the sense of extraneousness with respect to one's own body. After training with Indego, patient 2 showed strong improvement on her emotional and behavioral scores.

At discharge, the patient 2 showed improvements in self-perception in daily environment and a decrease in depressive symptoms [Table 1]. From the qualitative analysis of the results of the NASA-TLX, useful data emerge for the use of these devices in rehabilitation programs. At the beginning of the gait training, the workload was perceived as very high by both patients; at the end of the training, the subjective perception of the workload decreased considerably [Figure 1] and [Figure 2].
Figure 1: Patient 1- NASA (Task Load Index): Perceived workload pre- and post-treatment with exoskeleton

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Figure 2: Patient 2- NASA (Task Load Index): Perceived workload pre- and post-treatment with exoskeleton

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The clinical analysis and the observation of the findings that emerged during the rehabilitation process of these two patients confirm that the use of robotic devices improves motor and cognitive recovery in patients with neurological damage.[9],[10],[11]

  Discussion Top

In our clinical case study, we sought to underline the positive effects of technology on cognitive and mood aspects during rehabilitation settings. We demonstrated that a better perception of the body using an exoskeleton can be an essential aspect of general recovery. In fact, active physical engagement, cognition, and motivation during therapy are important contributors to achieve optimal outcome in mobility and independence during activities of daily living (ADL).[12] Training with exoskeleton allows an increasing ability to move and performe ADLs also in terms of improved function of internal organs and general health status.[13] Different studies indicated anxiety to be a negative prognostic factor for robotic therapy with regard to the psychological status, whereas internal recovery of a locus of control was considered a positive prognostic factor of better outcomes.[14] On the other hand, a great number of studies suggest that physical activity and exercise training may reduce depressive symptoms and have positive effects on anxiety and general well-being in nonclinical and clinical populations. Nevertheless, these evidences, international scientific literature on rehabilitation, pay very little attention to personal factors and particularly they neglect the psychological variables involved in matching people with assistive technology.[8] In addition, there are many psychological and social benefits to standing, including improved self-image, eye-to-eye interpersonal contact, and increased vocational, recreational, and daily living independence.[10] The available scientific literature shows positive effect about psychological status of the patients involved in the neurorehabilitation program with exoskeleton. In institutionalized elderly patients, positive effects were found on depression and cognitive status after a physical training with the use of a human body posturizer compared to a traditional training as revealed in the score of Mini–Mental State Examination and the Geriatric Handicap Scale.[15] Finally, a positive impact on mood disorders as assessed by BDI and a self-perception of the own body after the neurological illness, using the BUT-A, was found after an intensive training with Ekso in patients with SCI. The quality of life improvements that patients felt occurred immediately after they started to walk again on the ground using the exoskeleton.[9]

Patients with neurological lesions or peripheral neuromotor deficits have a great potential for recovery if they are subjected to repetitive, frequent, intense, and functional recovery programs.

This clinical case study shows the contribution that the exoskeletons offer to the neurorehabilitation process, specifically focusing on the arising concept that these devices are not only for motor skills but can also play an important role on mood and self-image or self-perception.

Future research should focus on understanding and developing exoskeleton protocols not only in rehabilitative contexts, but also in daily activities to restore the ADL lost after the lesions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Esquenazi A, Packel A. Robotic-assisted gait training and restoration. Am J Phys Med Rehabil 2012;91:S217-27.  Back to cited text no. 1
Kolakowsky-Hayner SA. Safety and feasibility of using the Ekso TM bionic exoskeleton to aid ambulation after spinal cord injury. J Spine 2013;S4:003.  Back to cited text no. 2
Federici S, Meloni F, Bracalenti M. Gait rehabilitation with exoskeletons. In: Müller B, Wolf SI, Brueggemann GP, Deng Z, McIntosh A, Miller F, et al., editors. Handbook of Human Motion. Cham: Springer International Publishing; 2016. p. 1-38.  Back to cited text no. 3
Post MW, van Leeuwen CM. Psychosocial issues in spinal cord injury: A review. Spinal Cord 2012;50:382-9.  Back to cited text no. 4
Cuzzolaro M, Vetrone G, Marano GF, Battacchi MW. BUT: Una nuova scala per la valutazione del disagio relativo all'immagine del corpo. Psichiatr Infanz Adolescenza 1999;66:417-28.  Back to cited text no. 5
Beck AT, Steer RA, Brown GK. Beck Depression Inventory-II. San Antonio, TX: San Antonio, TX: Psychological Corporation; 1996.  Back to cited text no. 6
NASA. Nasa Task Load Index (TLX) v. 1.0 Manual; 1986.  Back to cited text no. 7
Federici S, Meloni F, Bracalenti M, De Filippis ML. The effectiveness of powered, active lower limb exoskeletons in neurorehabilitation: A systematic review. NeuroRehabilitation 2015;37:321-40.  Back to cited text no. 8
Milia P, De Salvo F, Caserio M, Cope T, Weber P, Santella C, et al. Neurorehabilitation in paraplegicpatients with an activepoweredexoskeleton (Ekso). Digital Med 2016;2:163.  Back to cited text no. 9
Sale P, Russo EF, Russo M, Masiero S, Piccione F, Calabrò RS, et al. Effects on mobility training and de-adaptations in subjects with spinal cord injury due to a wearable robot: A preliminary report. BMC Neurol 2016;16:12.  Back to cited text no. 10
Kennedy P, Rogers BA. Anxiety and depression after spinal cord injury: A longitudinal analysis. Arch Phys Med Rehabil 2000;81:932-7.  Back to cited text no. 11
Gassert R, Dietz V. Rehabilitation robots for the treatment of sensorimotor deficits: A neurophysiological perspective. J Neuroeng Rehabil 2018;15:46.  Back to cited text no. 12
Frisoli A, Solazzi M, Loconsole C, Barsotti M. New generation emerging technologies for neurorehabilitation and motor assistance. Acta Myol 2016;35:141-4.  Back to cited text no. 13
Masiero S, Poli P, Rosati G, Zanotto D, Iosa M, Paolucci S, et al. The value of robotic systems in stroke rehabilitation. Expert Rev Med Devices 2014;11:187-98.  Back to cited text no. 14
Verrusio W, Renzi A, Cecchetti F, Gaj F, Coi M, Ripani M, et al. The effect of a physical training with the use of an exoskeleton on depression levels in institutionalized elderly patients: A Pilot study. J Nutr Health Aging 2018;22:934-7.  Back to cited text no. 15


  [Figure 1], [Figure 2]

  [Table 1]

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