NeuroVoices: Francois Bethoux, MD, on Realistic Expectations for Exoskeletons to Improve Fatigue in Multiple Sclerosis


The chair of Cleveland Clinic’s Department of Physical Medicine provided commentary on the goals for the newly approved EksoNR robotic exoskeleton in rehabilitative efforts for patients with multiple sclerosis.

Francois Bethoux, MD

Francois Bethoux, MD

This is a 2-part interview. Click here for part 1.

Typically, the goal of rehabilitation is to improve and maintain function, and this is no different for patients with multiple sclerosis (MS). Over the years, the knowledge of rehabilitating these patients has grown, as have the field’s technological capabilities. Most recently, in June 2022, the FDA cleared the EksoNR robotic exoskeleton for use in patients with MS, making it the first such device to be approved for rehabilitative efforts for the disease.

A retrospective study, led by Cleveland Clinic’s Francois Bethoux, MD, analyzed patients with MS who participated in at least 3 sessions of gait training with the exoskeleton. Between the initial and final gait training session, patients demonstrated statistically significant increases in walk time (P = .008), number of steps (P = .011), and programmed step length (P <.001). Within-group analysis showed no significant change on the Timed 25 Foot Walk, though 20% (3 of 15) of patients exhibiting a greater than 20% increase in walking speed.

The real-world findings suggested that gait training with the modality is safe and feasible in individuals with MS and severe walking limitations, with further studies needed to determine optimal training paradigms and predictors of response to treatment. To better understand the overall potential of the exoskeleton, NeurologyLive® sat down with Bethoux, who is the chair of Cleveland Clinic’s Department of Physical Medicine. As part of a new iteration of NeuroVoices, he discussed the capabilities and limitations of this new approach, and how it may be used in conjunction with other treatments or rehabilitative efforts.

NeurologyLive®: What are the realistic goals of improvement for patients on the exoskeleton?

Francois Bethoux, MD: Realistic goals is a key phrase here. We certainly want to bring as much hope as possible to our patients. Technology brings great hope, and not only in the world of MS rehabilitation. When we get the newest smartphone, we always think it’s going to change our life and make things much easier. And so, at the same time we want to have this reality check.Yes, it’s an awesome piece of technology that has capabilities that allow someone to do more repetitions in a more optimal condition, which we think can trigger some plasticity in the brain and have some benefits that carry over once you’re off the device. But, in terms of the efficacy we’re hoping to get, we’re hoping to see improved ease and ability of walking without using this device because right now, this is not a device that people would take home and use in their daily life. Hopefully, we see an improvement in the overall level of energy, which is often seen with exercise.

In being able to push exercise further with the use of a device like the exoskeleton, we hope to have a more sustained improvement of energy level. Of course, this must transition to a home exercise program. Again, there’s a continuity of treatment there. We hope to improve quality of life altogether, through improved ease of performing daily activities. Those are the outcomes we’re looking into. We always want to impress upon everyone that, even at the level of technology we’re at, it’s not expected that one device, no matter how sophisticated it is, would resolve all the issues. Similarly, this would not allow a patient to go from walking a few steps to running, because we still have to take into account the disease itself.

MS is a disease that causes damage to the brain and spinal cord. We would never want to imply that using rehab technology would allow us to erase the consequences of their damage, but we’re also looking forward to the next steps in treatment for MS. The world of MS is abuzz with treatments for neurorestoration and preventing neurodegeneration. It is very much thought that if we have some medications or a treatment that can be seen to protect the central nervous system, using rehab and devices like the exoskeleton could help us with that neuroplasticity and help restore some function. If we saw a synergistic effect, it would become part of managing the disease overall. It’s not like there’s one piece that’s giving medication for the disease and one piece for walking. Altogether, it would manage the disease and its consequences. That’s the bigger view I want to gain, and within that, be realistic about what it is that we can achieve.

What is the feasibility of this type of exoskeleton? What types of limitations do we have right now to it?

Right now, the exoskeletons are used in the clinic, hospital, or in the outpatient clinic for rehabilitation, and people don’t take them home. We have a model in another condition, spinal cord injury, which is probably the group of patients where the exoskeleton has been used first and for the longest time, and where home use is possible. If it’s proven to be safe and effective, as well as cost effective, one could imagine using it in clinic, where they are under the supervision of a skilled therapist. Then, once they complete the training, it begs the question, could it transition to home use? A person at home and could use it in their daily life to either get from point A to point B or to exercise daily at home so that they can get from point A to point B without the device and with greater ease. Or there’s a possibility to have these devices available at gyms and fitness centers with trained staff, which has been seen with spinal cord injury. Again, after making sure that safety is preserved, people could go there and use the devices as their exercise device, the same way they would use a specialized treadmill or any other exercise device. That’s a very interesting concept because it would make these devices available in the community close to where people live without raising the cost issue of owning such a device because they are expensive. This would also allow access to these outside of a medical setting and closer to where they live. That’s a possibility for the future that we’re contemplating.

Transcript edited for clarity. Click here for more NeuroVoices.

1. Bethoux F, Stallkamp S, Thompson N, Linder SM. Feasibility and outcomes of gait training with a powered exoskeleton in individuals with multiple sclerosis. Presented at: CMSC Annual Meeting, 2022; June 1-4; National Harbor, MD. REH03
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