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PAPER: Robotic locomotor training more cost-effective than conventional training for patients with complete spinal cord injuries


For patients with spinal cord injuries (SCI), locomotor training to improve or recover motor function after injury is a cornerstone of rehabilitation therapy. A new study reported in the Journal of NeuroEngineering and Rehabilitation found that the cost-effectiveness of the type of locomotor training received – traditional versus robotic – depends on the severity of the injury. Robotic-assisted locomotor training is more cost-effective for patients with complete spinal cord injury while traditional therapy is more cost-effective for patients with incomplete spinal cord injuries.

“We wanted to look at what was the most cost-effective locomotor training strategy for people with SCI,” said Dr. Allen Heinemann, Director of the Center for Rehabilitation Outcomes Research at the Shirley Ryan AbilityLab and Professor of Physical Medicine and Rehabilitation at Northwestern University’s Feinberg School of Medicine and a co-author on the paper. “Robotic and traditional locomotor training are both options for treating gait impairments following spinal cord injury but robotic exoskeletons are expensive and locomotor training is labor-intensive for both the patient and therapists. Having an idea of which is most cost effective is important.”

The report was led by Daniel Pinto, PhD, Assistant Professor of Physical Therapy at Marquette University, Milwaukee and corresponding author on the paper, and Dustin French, PhD, Professor of Medical Social Sciences and Ophthalmology at Northwestern University. Dr. French is a health economist and a co-author on the paper.

Following SCI there is often a loss of motor control of parts of the body depending on where the injury occurs and its severity. Locomotor training to improve or recover motor function after SCI can help improve quality of life. This kind of therapy, which can be delivered traditionally or with robotic assistance, can last anywhere from weeks to years and represents a significant portion of healthcare costs associated with SCI. Understanding the cost-effectiveness of these interventions is crucial for improving patient health and lessening the economic burden of spinal cord injury on patients and insurers.

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.”