An Exoskeleton in the Rehabilitation of Institutionalized Elderly Patients at High Risk of Falls: A Pilot Study

Age-related changes in balance control combined with inactivity can lead to decreased physical performance resulting in increased risk of falling for many elderly people. Physical training exerts several beneficial effects in the elderly people including improvement in muscle strength and body coordination, thus, reducing the risk of falls. ^,  However, poor adherence to exercise, especially in the long term, represents a problematic issue in the elderly people. New strategies to quickly improve gait and balance control in the elderly people are needed. Recent evidence support the use of robotic technologies to improve age-related health problems (eg, assistance with walking or fall prevention). ^,  The human body posturizer (HBP) is a fully articulated orthosis, consisting of 4 elements (Figure 1). The first element rests on the back. The second element is characterized by a helmet placed on the user's head and on the top of which is inserted a cervical spring mechanism that connects the helmet to the dorsal element, thus, enabling complex head and neck movements. The third element is positioned at the center of the sacrum. This element is characterized by the presence of a mobile and adjustable support that allows users to apply thrust, of greater or lesser intensity, to the lumbar region. The fourth element involves the lower limbs. As a result, users enjoy great freedom of movement and continuous central reprogramming of the users' postural attitude. The aim of this study was to evaluate the effects of a physical training with the HBP on gait and balance in the institutionalized elderly at severe risk of falls (Tinetti score <19), evaluated by (1) Tinetti balance and gait evaluation scale (28-point scale: <19 indicates a high risk of falls; 19–24 indicates a moderate risk of falls ; (2) short physical performance battery (SPPB), a tool for evaluating lower extremity functioning in the elderly by measuring balance (SPPB balance score), gait speed (SPPB gait score), lower limb strength and endurance (SPPB chair score) [each component was scored from 0 (not possible) to 4 (best performance); total score ranging from 0 to 12]. The study included elderly participants (n = 16; mean age: 87 years, standard deviation ±6.8, male 5) living in nursing homes. Patients for whom physical exercise was not recommended were excluded. All procedures performed in this study were in accordance with our institutional committee and with the 1964 Helsinki declaration. Informed consent was obtained from all participants. Participants were randomly assigned to HBP group, where individuals received physical training using the HBP; or the exercise group, where individuals received physical training without the HBP. Each patient was engaged in 3 sessions per week (each session lasting approximately 45 minutes) of training (walking, balance test, and posture strengthening exercises) under the instruction of a therapist. The physical activity was moderately intense so as not to exceed the target pulse rate, meaning 75% of the maximum pulse rate for the patient being treated. The number of falls was monitored with daily fall diaries collected monthly. The groups were homogeneous for sex (χ² = .291; P = .50), age (F = .001; P = .97), and baseline evaluations: Tinetti score (F = .002; P = .96); SPPB total score (F = .021; P = .88), SPPB balance score (F = .377; P = .55), SPPB gait score (F = .368; P = .55), and SPPB chair score (F = .104; P = .75). After 12 weeks of exercise training, the HBP group showed significant improvement in Tinetti score (P = .001), SPPB total score (P = .004), SPPB balance score (P = .005), SPPB gait score (P = .008), and SPPB chair score (P = .011). In the exercise group, significant improvements were found in Tinetti score (P = .03), SPPB total score (P = .011), and SPPB gait score (P = .02) (Table 1). Regarding differences between groups in post-training scores, the HBP group scored significantly higher in SPPB total score (F = 6.094; P = .027), SPPB balance score (F = 9.308; P = .009,) and SPPB chair score (F = 6.094; P = .027) compared with the exercise group. During training, no falls were reported in both groups. Exercise with the HBP seems to be more efficacious in quickly improving balance and gait in the elderly compared with the effectiveness of exercise without the HBP, with a significant reduction of the risk of falls. Traditional training could require more time to achieve the same results. In the elderly, compensatory response to neuronal deficits produces hyperactivation of specific brain areas, particularly in the prefrontal cortex to improve task accuracy, posture, and gait. Age-related decline in brain activity can reduce this compensatory response, especially in the oldest old. A recent study showed that the HBP rehabilitation device may improve motor control by stimulating the prefrontal cortex. We can hypothesize, therefore, a similar response to exercise using the HBP to justify our results. Further trials will be needed to verify the impact of the use of the HBP on long-term gait and balance control.