I have two news bits about paraplegics and the possibility of walking. The first is from Alberta, Canada and the second is from Brazil.
The fellow in the video is wearing a robotic exoskeleton. As you can see, it’s not perfect but it represents an extraordinary breakthrough (from an April 16, 2019 article by Sarah Lawrynuik for the Canadian Broadcasting Corporation [CBC] Radio),
On his fifteenth birthday in December 2015, Calgary’s Alex McEwan was injured in a tobogganing accident with friends and lost the ability to walk. It’s the kind of change that could destroy a person, but Alex has thrived and is learning new skills. Watch him walk onstage, with some help from a powered exoskeleton, to receive his diploma. 1:21
Sometimes events conspire to move us in a completely unexpected ways. After his accident, Alex McEwan participated in a very special study (from an August 3, 2019 article by Colin Zak for Alberta Health Services),
Researchers at Foothills Medical Centre (FMC) are the first in Canada to examine the benefits of using an exoskeleton robotic device to rehabilitate patients with spinal cord injuries (SCI) in the days and weeks following their injury.
The device, known as the Ekso Bionic Exoskeleton, consists of a metal frame that supports and stabilizes a patient’s torso, core, legs and feet. It is moved robotically by a therapist, enabling patients with a spinal cord injury to get up and walk around. Although it is controlled by remote control, the device offers varying levels of physical control by the patient, depending on the nature and extent of their injury.
Dr. Ho [ Dr. Chester Ho, Head of Physical Medicine and Rehabilitation at FMC ] says exoskeletons may potentially promote recovery and reduce complications in SCI patients by reducing loss of bone and muscle mass caused by spending so much time lying down, and also improve breathing and bowel function.
The year-long study, which begins this summer, will include between five and 10 patients selected from across Calgary [Alberta]. It aims to examine whether treatment is safe and feasible in the days and weeks after an SCI. This study will be followed by larger studies involving more patients.
Participants in the study will receive 60-minute therapy sessions with the exoskeleton device two to three times a week, for a total of 25 training hours over an eight- to 10-week period. Safety and feasibility outcomes will be monitored and tracked by the research team throughout all sessions.
Before the advent of exoskeletons, rehabilitation for patients with an SCI required them to be hoisted with a physical therapist moving their legs.
“Every step is different with this device, so patients learn from their mistakes in real time. Patients really like to use the device; it gives them hope.”
Alex, [emphasis mine] 15, sustained a spinal cord injury while tobogganing last December.
He says rehabilitation sessions with the exoskeleton have made a difference in how he feels and gives him hope for the future.
Over 2 1/2 years later, the CBC has made a radio documentary about this study and the people who took part. Lawrynuik’s April 16, 2019 article describes some highlights from the radio documentary,
Imagine waking up in a hospital bed surrounded by the beeps and whirring sounds of the machines keeping you alive. The doctor tells you that you will likely never walk again.
But then, just as you begin to process that news, a physiotherapist shows up at your bedside and says, “Hold up. I might have a special opportunity for you.”
That’s the journey taken by a number of Albertans who landed in Calgary’s Foothills Medical Centre after accidents or trauma to their spine in the last three years. Three of those people are Alex McEwan, a university student in Lethbridge; Jean Ogilvie, a 77-year-old woman living in Calgary; and Josh Pelland, a former climber turned motivational speaker in Three Hills, Alta.
All three are united by a technology called an exoskeleton, created by a company called Ekso Bionics, that allowed them to walk despite no longer being able to use their legs.
“The first time was a bit scary actually,” Ogilvie said. “It’s like a great big skeleton that sort of clasps you in its body. [It’s] black and all sorts of straps and sensors tell you how I’m doing.”
Pelland agrees about how daunting the experience is to start.
“They just said, ‘OK, the machine is going to assist you and lift you up.’ And I was a bit like, ‘OK, this is the strangest thing ever.'”
Once the frame of the exoskeleton is strapped along the outside of the patient’s legs and up their back, starting from the seated position, it does lift them completely without the help of their own muscles.
From there they shift their upper-body weight within the machine to hit certain targets — once your body weight is shifted forward and laterally enough, a beep sounds and the exoskeleton pulls each leg forward, one at a time.
As patients learn to use the machine, they walk with the assistance of a walker. Then, as they progress, they upgrade to forearm crutches. The entire time, they’re accompanied by the man behind the machine, Kyle McIntosh.
McIntosh is a physiotherapist and he worked with the exoskeleton both to help patients and to conduct research into the machine’s impact on rehabilitation.
After being discharged and living once again without the exoskeleton, and therefore without the ability to walk — McEwan got an idea: maybe he’d be allowed to use the robot, just one last time.
“High school wasn’t high school for me. I only really got one semester of grade 10 before I broke my spine. So that first semester was great. I enjoyed it. I played sports. I was a good student. But then it was no longer about high school anymore. It was more about adjusting to my new life.”
McIntosh and McEwan hatched the plan together and kept it a closely guarded secret. Then, on the day McEwan was set to graduate from Grade 12, he asked to be placed last on the list of students to cross the stage.
“I remember taking a first few steps and not hearing very much. Hearing people cheer because I was the kid in the wheelchair at the high school, so it makes sense. But the second they saw the canes and my first few steps, just one kid erupted: ‘Yeah!’ And then everyone went crazy.”
“I think walking across the stage — just like I got to walk into my high school on the first day of Grade 10 — was a really good closing story. The chapter of me learning to live in a wheelchair was done. And it was now my turn to go live my life. So that’s why I think it was such an important day because it gave me a lot of closure. I got to walk into the high school, I got to walk out.”
If you have the time, you might want to read Lawrynuik’s April 16, 2019 article in its entirety. It turns out that the study did much more than give a people a chance to walk again, even if just for a short time.
Anyone interested in the robotic, wearable exoskeleton used in the study can go here to EksoHealth, the company that produces the EksoGT, a bionic exoskeleton. (Lawrynuik’s article has another name for the product, i.e., Ekso Bionic Exoskeleton but all I could find was the EksoGT.)
Brazil and Walk Again
The most recent post featuring the Walk Again project is my May 20, 2014 edition which was part of a larger series on ‘Brain research, ethics, and nanotechnology’. The May 20, 2014 posting covered Walk Again’s debut at the 2014 World Cup (soccer/football) in Brazil. Unfortunately,, the lead researcher Miguel Nicolelis oversold the technology. I think people were expecting someone with paraplegia to come bounding out onto the field and give a flashy opening kick for the tournament what they saw was something a great deal more restrained.
The person was wheeled out onto the field, stood up, shuffled a bit, and nudged the ball with his foot. It represented a huge breakthrough but it wasn’t flashy.
The latest from Walk Again is in a May 14, 2019 Associação Alberto Santos Dumont para Apoio à Pesquisa press release on EurekAlert,
In another major clinical breakthrough of the Walk Again Project, a non-profit international consortium aimed at developing new neuro-rehabilitation protocols, technologies and therapies for spinal cord injury, two patients with paraplegia regained the ability to walk with minimal assistance, through the employment of a fully non-invasive brain-machine interface that does not require the use of any invasive spinal cord surgical procedure. The results of this study appeared on the May 1  issue of the journal Scientific Reports.
The two patients with paraplegia (AIS C) used their own brain activity to control the non-invasive delivery of electrical pulses to a total of 16 muscles (eight in each leg), allowing them to produce a more physiological walk than previously reported, requiring only a conventional walker and a body weight support system as assistive devices. Overall, the two patients were able to produce more than 4,500 steps using this new technology, which combines a non-invasive brain-machine interface, based on a 16-channel EEG, to control a multi-channel functional electrical stimulation system (FES), tailored to produce a much smoother gait pattern than the state of the art of this technique.
“What surprised us was that, in addition to allowing these patients to walk with little help, one of them displayed a clear motor improvement by practicing with this new approach. Patients required approximatively [sic] 25 sessions to master the training before they were able to walk using this apparatus,” said Solaiman Shokur one of the authors of the study.
The two patients that used this new rehabilitation approach had previously participated in the long-term neurorehabilitation study carried out using the Walk Again Project Neurorehabilitation (WANR) protocol. As reported in a recent publication from the same team (Shokur et al., PLoS One, Nov. 2018), all seven patients who participated in that protocol for a period of 28 months improved their clinical status, from complete paraplegia (AIS A or B, meaning no motor functions below the level of the injury, according to the ASIA classification) to partial paraplegia (AIS C, meaning partial recovery of sensory and motor function below the injury level). This significant neurological recovery included major clinical improvements in sensory discrimination (tactile, nociception, vibration, and pressure), voluntary motor control of abdomen and leg muscles, and important gains in autonomic control, such as bladder, bowel, and sexual functions.
“The last two studies published by the Walk Again Project clearly indicate that partial neurological and functional recovery can be induced in chronic spinal cord injury patients by combining multiple non-invasive technologies that are based around the concept of using a brain-machine interface to control different types of actuators, like virtual avatars, robotic walkers, or muscle stimulating devices, to allow the total involvement of patients in their own rehabilitation routine,” said Miguel Nicolelis, scientific director of the Walk Again Project and one of the authors of the study.
In a recent report by another group, one AIS C and two AIS D patients were able to walk thanks to the employment of an invasive method for spinal cord electrical stimulation, which required a spinal surgical procedure. In contrast, in the present study two AIS C patients – which originally were AIS A (see Supplemental Material below)- and a third AIS B subject, who recently achieved similar results, were able to regain a significant degree of autonomous walking without the need for such invasive treatments. Instead, these patients only received electrical stimulation patterns delivered to the skin surface of their legs, so that a total of eight muscles in each limb could be electrically stimulated in a physiologically accurate sequence. This was done in order to produce a smoother and more natural pattern of locomotion.
“Crucial for this implementation was the development of a closed-loop controller that allowed real-time correction of the patients’ walking pattern, taking into account muscle fatigue and external perturbations, in order to produce a predefined gait trajectory. Another major component of our approach was the use of a wearable haptic display to deliver tactile feedback to the patients´ forearms in order to provide them with a continuous source of proprioceptive feedback related to their walking,” said Solaiman Shokur.
To control the pattern of electrical muscle stimulation in each leg, these patients utilized an EEG-based brain-machine interface. In this setup, patients learned to alternate the generation of “stepping motor imagery” activity in their right and left motor cortices, in order to create alternated movements of their left and right legs.
According to the authors, the patients exhibited not only “less dependency on walking assistance, but also partial neurological recovery, with substantial rates of motor improvement in one of them.” The improvement in motor control in this last AIS C patient was 9 points in the lower extremity motor score (LEMS), which was comparable with that observed using invasive spinal cord stimulation.
Based on the results obtained over the past 5 years, the WAP now intends to combine all its neurorehabilitation tools into a single integrated, non-invasive platform to treat spinal cord injury patients. This platform will allow patients to begin training soon after the injury occurs. It will also allow the employment of a multi-dimensional integrated brain-machine interface capable of simultaneously controlling virtual and robotic actuators (like a lowerlimb exoskeleton), a multi-channel non-invasive electrical muscle stimulation system (like the FES used in the present study), and a novel non-invasive spinal cord stimulation approach. In this final configuration, this WAP platform will incorporate all these technologies together in order to maximize neurological and functional recovery in the shortest possible time, without the need of any invasive procedure.
According to Dr. Nicolelis, “there is no silver bullet to treat spinal cord injuries. More and more, it looks like we need to implement multiple techniques simultaneously to achieve the best neurorehabilitation results. In this context, it is also imperative to consider the occurrence of cortical plasticity as a major component in the planning of our rehabilitation approach.”
Here’s a link to and a citation for the paper,
Non-invasive, Brain-controlled Functional Electrical Stimulation for Locomotion Rehabilitation in Individuals with Paraplegia by Aurelie Selfslagh, Solaiman Shokur, Debora S. F. Campos, Ana R. C. Donati, Sabrina Almeida, Seidi Y. Yamauti, Daniel B. Coelho, Mohamed Bouri & Miguel A. L. Nicolelis. Scientific Reports volume 9, Article number: 6782 (2019) DOI: https://doi.org/10.1038/s41598-019-43041-9 Published 01 May 2019
This paper is open access.
There’s also a video for Walk Again,