Specialist commentator comments

Comments on this technology were invited from clinical experts working in the field and relevant patient organisations. The comments received are individual opinions and do not represent NICE's view.

One of the 3 specialist commentators who provided comments has used this technology in their department for 2 years.

Level of innovation

One commentator stated that Ekso is a new innovation that incorporates existing technologies. Another commentator added that it is difficult to compare the different commercially available exoskeletons and stated that although Ekso is emerging as a useful rehabilitation tool, its use is limited to a rehabilitation setting. A third expert added that Ekso's main claim to innovation is the software that allows different power to be applied to each leg and that this might be useful for people with stroke and cerebral palsy. However, they also noted this is likely to be a relatively minor addition to current options.

Potential patient impact

Commentators noted that Ekso helps patients with incomplete spinal cord injuries improve mobility more quickly by providing a means for repetitive controlled practice. For people with complete spinal cord injuries (where the whole width of the spinal cord is damaged causing a full loss of muscle control and sensation below the injury), it provides a tool for exercise and health benefits associated with ongoing upright exercise if regular access is available. One commentator also added that there is a clear training effect, with patients able to walk faster and for longer after a few sessions. Another commentator noted that the device has the potential to improve outcomes by allowing people to relearn how to walk but there are currently no controlled, longer-term trials to confirm this.

Two commentators agreed that there were psychological benefits associated with users being able to stand and walk, and that this could have a positive effect on their overall health. One of these stated that it was often difficult to separate the psychological benefits from physical benefits of rehabilitation and this made it difficult to assess the total patient benefit.

Two commentators advised that Ekso would be limited to a rehabilitation setting and to patients with enough arm strength to use the device, which may mean that some stroke patients may not be able to use Ekso if their arm function is not sufficient. They added that for patients with complete spinal cord injuries there is no clear point at which to stop using the device, but for patients with incomplete spinal cord injuries (where a portion of the spinal cord is still intact and so they have some function below the injury), Ekso may increase their recovery speed.

One commentator noted that the physical benefits are still unclear, and all commentators felt that further research and evidence is needed. The first commentator also advised that a study assessing the effect of Ekso on bone mineral loss in patients with spinal cord injuries has just been approved.

No commentators reported any safety concerns with Ekso.

Potential system impact

One commentator noted that sites adopting Ekso would need extra physiotherapy services, outpatient clinics and exercise space, so its adoption may mean changes to infrastructure. A second commentator suggested that no changes in infrastructure would be needed.

One commentator noted that it does not appear that cost savings to the NHS would be generated immediately, but that they may be realised in future as the technology is refined and costs are lowered. Nevertheless, both noted that more research is needed to assess the resource and cost impact for the NHS.

A third commentator noted that the number of physiotherapy appointments could be reduced if Ekso allows people to walk sooner, but the evidence for this is not yet clear. Similarly, it is not clear how many people would be suitable for the device. They added that Ekso is expensive and the overall costs may be high.

General comments

Commentators remarked that Ekso can be used in both inpatient and outpatient settings, as part of initial rehabilitation, and as an ongoing exercise tool.

All 3 commentators agreed that further evidence is needed to show patient benefit from Ekso.

One commentator clarified that standard care for patients with complete spinal cord injuries consists of exercise and physical activity, with the ultimate aim of independent wheelchair use. Standing frames, assisted technologies and ongoing physiotherapy may all be used. For patients with incomplete spinal cord injuries, functional electrical stimulation, partial body support treadmill training and other interventions are used to speed recovery and encourage exercise in partially paralysed muscles.

Commentators agreed that although hip-knee-foot orthosis and rigid gait orthosis devices have been used in patients with spinal cord injuries, they are rarely used consistently and long‑term use is not sustained.