Using a Health Technology Assessment Framework for Evaluating the Utilization and Efficiency of Wearable Exoskeleton for Spinal Cord Injury Rehabilitation

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Robot-assisted therapy (RT) is used increasingly as a treatment to improve walking after SCI; the field has seen sustained, rapid growth over the past decade. While RT was expected to provide enhanced benefits over more labor-intensive, less controlled motor learning strategies, so far, it has not demonstrated greater effectiveness than conventional therapy in improving function in patients with a range of neurological conditions. Where some investigators are calling for RT to “trot back to the starting gate” due to its lack of superiority over standard care with respect to functional gains, an alternative scenario that could make RT an attractive supplement to conventional therapy is one in which RT provides similar patient benefits at a lower cost. Indeed, one of the main arguments supporting the continued use and development of RT in rehabilitation has been the assumption that cost savings would be achieved by reducing labor costs.

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The goal of this collaborative module was to obtain evidence that informs consumers, clinicians, insurers, and manufacturers about the utilization and cost-effectiveness of robotic exoskeletons in inpatient, outpatient, and community settings.

Aims of the project are to:

1. Describe the physical, psychological, demographic, and socio-economic characteristics, and insurance coverage of patients who receive RT-exo therapy

2. Compare the treatment goals and outcomes of patients who receive RT-exo therapy vs. conventional therapy in terms of functional goals and targeted impairments using performance-based measures (motor strength, endurance, gait characteristics), and patient-reported outcomes stratified by injury level, completeness, and chronicity.

3. Evaluate the cost effectiveness and budget impact of RT-exo therapy vs. conventional therapy to the individual, the health care system, and society.

Findings will inform clinical practice, guide commercial development of rehabilitation robots for human mobility, and assist in planning of clinical trials. 

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This project has completed.

Some of the findings have been reported in a 2023 paper in the Journal of NeuroEngineering and Rehabilitation, "Cost-effectiveness analysis of overground robotic training versus conventional locomotor training in people with spinal cord injury." 

Conventional locomotor training includes treadmill-based training using assistive devices or track-based systems with harnesses and integrated safety systems where therapists manually facilitate stepping. Multiple therapists are often required ensure patient safety and provide support, making this kind of therapy labor intensive for clinicians. Robotically-assisted locomotor therapy includes both treadmill-mounted powered assistive technology as well as stand-alone exoskeletons that can be attached to the patient’s body to facilitate motion. These devices allow the patient to take more steps per session than conventional therapy and lessen the labor needed by therapists.

The researchers estimated cost of locomotor therapy and examined data on improvement in quality adjusted life years for 99 patients with SCI undergoing locomotor training at four SCI Model Systems locations: Shirley Ryan AbilityLab, Craig Hospital in Englewood, Colorado, Shepherd Center in Atlanta and TIRR Memorial Hermann in Houston. Participants were on average 39 years old, 4.8 years post-injury during the study period and 20 percent had a complete SCI.

Complete spinal cord injuries result in paralysis below the level of injury. Incomplete spinal cord injuries result in partial damage to the spinal cord and movement depends on the location and severity of the injury. 

Costs were lower for conventional training ($1758) versus robotic training ($3952), and were lower for patients with incomplete versus complete SCI. Overall, the researchers found that the most cost-effective locomotor training strategy for people with SCI differed based on the completeness of their injury. Robotic training was more cost-effective than conventional training for people with complete SCI while traditional training was more cost-effective for people with incomplete SCI.

“Based on current knowledge, it makes sense that full, lower-body robotic exoskeleton-supported physical therapy is more cost effective for patients with complete spinal cord injuries,” said Arun Jayaraman, PhD, Director of the Max Näder Center for Rehabilitation Technologies and Outcomes Research at Shirley Ryan AbilityLab and a co-author on the paper. “Realizing that these devices are impactful in this more severely impaired population, researchers should focus on modular and soft wearable robots to enhance therapy outcomes in the future.”