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Abstract

BACKGROUND:

Physical activity as one of the major lifestyle-related health determinants is partially addressed by the Montreal Walking Exoskeleton Satisfaction and Perspectives-Questionnaire (MWESP-Q).

OBJECTIVE:

To document satisfaction of people with chronic spinal cord injury after the completion of a 10 to 16 weeks of the wearable robotic exoskeleton-assisted walking program, with the MWESP-Q updated to a context of health promotion.

METHODS:

Following a walking program (10–16 weeks), wheelchair users with chronic SCI completed the MWESP-Q online. Modification of the original questionnaire was conducted with 4 experts to ensure its content validity with a human framework to promote physical activity for health.

RESULTS:

Ten wheelchair users completed the questionnaire (men $=$ 6; 45.8 $\pm$ 13.4 years, SCI duration: 10.1 $\pm$ 5.8 years). Participants strongly agreed to be satisfied with the overall program; agreed to be satisfied towards exoskeleton, motivation to engage in physical activity, learnability and program attributes; rated “medium effort” for physical and cognitive exertion during training; reported light improvements for health benefit domain, but light to moderate improvements for general endurance (mean 5.5 /7, SD 1.4) and psychological well-being (mean 5.7 /7, SD 1.3).

CONCLUSIONS:

The updated MWESP-Q is now better equipped to measure physical and cognitive efforts in physical activity and changes in body and organic systems and in capabilities (health promotion). The updated MWESP-Q has 54 statements (14 additional statements and 1 deleted) organized around seven domains. The original measure was replaced by three 7-point Likert scales, one regarding agreement level (40 statements), level of effort (12 statements), and level of change (2 statements).

Keywords

Assistive technology mobility device robotic exoskeleton paraplegia physical activity rehabilitation spinal cord injury

1. Introduction

There is a growing body of research on the use of wearable walking exoskeletons in rehabilitation (e.g. spinal cord injury), with most focusing on walking performance [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15]. The current technology (wearable robotic exoskeleton (WRE)) is not widely available in the community or in gyms, and current exoskeletons generally require the assistance or supervision of a specially trained therapist (and a walking aid) for sit-stand transfers and safe ambulation. A satisfaction questionnaire was developed to assess user-perceived outcomes in a pilot research project in 2018 [8]. The Montreal Walking Exoskeleton Satisfaction and Perspectives – Questionnaire (MWESP-Q) comprised a total of 41 statements that were organized around seven key domains [8]. Gagnon and colleagues had used the MWESP-Q with 14 wheelchair users with SCI who finished a 6 to 8-week exoskeleton-assisted walking program. All statements were phrased in a positive manner using an electronic cursor on a horizontal and continuous 100-mm long visual analogue scale. At one extreme, 0% would indicate Totally disagree and at the other extreme, 100% would indicate Totally-completely agree. Results were presented for all statements in % with standard deviation: overall satisfaction related to the training program (2 statements, mean $=$ 95.7 $\pm$ 0.7%), satisfaction related to the overground robotic exoskeleton (6 statements, mean $=$ 82.3 $\pm$ 6.9%), perceived learnability (9 statements, mean $=$ 79.6 $\pm$ 17%), satisfaction related to the program attributes (7 statements, mean $=$ 84.5 $\pm$ 6.9%), perceived health benefits (8 statements, mean $=$ 67.9 $\pm$ 16.7%), perceived risks and fears (7 statements, mean $=$ 16.7 $\pm$ 8.2%) and perceived motivation to engage in regular physical activity (2 statements, mean $=$ 91.3 $\pm$ 0.1%).

Figure 1.

Project-specific logic model highlighting the relationships between the different domains of interest and related outcome measures. L/E: lower extremity; SCI: spinal cord injury; U/E: upper extremity; WRE: wearable robotic exoskeleton. Reproduced with the permission of JMIR Res Protoc 2020, 9(9), p. 7.

Given a new walking program with more attributes associated to health promotion, i.e. closer to adapted physical activity programs offered in rehabilitation or other specialized centers, it has become necessary to update the MWESP-Q. The protocol for the present study has been published previously in JMIR Research Protocols [16] as ‘Effects of an Overground Walking Program With a Robotic Exoskeleton on Long-Term Manual Wheelchair Users With a Chronic Spinal Cord Injury: Protocol for a Self-Controlled Interventional Study’. The questionnaire had to be updated according to a logic model in the published protocol and is reproduced here with permission (Fig. 1) [16, p. 7].

In lower left, sedentary lifestyle is prolonged nonactive sitting time and decreasing leisure-time physical activity, following a spinal cord injury. In upper left, a WRE-assisted walking program with additional attributes will increase active standing time and will increase physical activity; this will increase demands or results in adaptations of the bodily systems (musculoskeletal, cardiorespiratory, cognitive, balance, cognitive). This will possibly result in measurable effects on organic systems (e.g., bone mineral density, maximal aerobic capacity, pain) and capabilities (e.g., balance sitting, locomotion with wheelchair and the WRE), central of Fig. 1. In turn, these adaptations may impact the society and produce psychological outcomes, right of Fig. 1. It was necessary to add statements to the MWESP-Q [8] to better emphasize health promotion regarding the attributes of the program, physical activity in society and psychological impacts as well to measure statement agreement level more accurately, the level of change and the level of effort.

1.1 Objective

Given this twofold rationale (new program and need to assess it), the research objective was to document satisfaction of people with chronic spinal cord injury after the completion of a 10 to 16 weeks of the wearable robotic exoskeleton-assisted walking program, with the MWESP-Q updated to a context of health promotion. According to our published protocol [16], the objective should answer this research question “What are the participants’ satisfaction levels with the walking program and the wearable robotic exoskeleton itself?” It was hypothesized that wheelchair users with a chronic spinal cord injury would express high levels of satisfaction with the walking program using the wearable robotic exoskeleton and with the wearable robotic exoskeleton itself.

2. Method

2.1 Research design

A cross-sectional quantitative design (online questionnaire) was conducted in the retention phase of the study [16], within three weeks of discontinuing or completing the WRE walking program. This study was initiated at the Laboratoire de pathokinésiologie in the Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR), Québec, Canada, which is part of the Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l’Ile-de-Montréal in Montreal, Canada, and at the Laboratoire du muscle et de sa fonction of the Université du Québec à Montréal.

2.2 Sample and recruitment

In this study, participants were recruited to participate in an exoskeleton-assisted walking program consisting of 34 sessions (60 min/session, 1–3 sessions/week) [16]. Questionnaires and tests were used to document the intervention and personal factors presented in the logic model [16]. As stated in the published protocol, after sample size calculation, we aimed to recruit a non-probabilistic sample of 20 participants in this study [16]. Briefly, to be included, individuals needed to use a wheelchair as their primary mode of locomotion, be able to understand French or English, and reside (or be able to arrange to reside) within 75 km of the main research site. Individuals were excluded if they had neurological impairments unrelated to the spinal cord injury (e.g., multiple sclerosis), had a concomitant or secondary musculoskeletal impairment limiting their ability to safely ambulate (e.g., hip heterotopic ossification), had a history of fragility fracture within the past year, or any other condition that may preclude safe lower extremity weight-bearing, walking or exercise tolerance (e.g., unstable cardiovascular or autonomic system, renal insufficiency, etc.). Individuals also had to meet criteria specific to the wearable robotic exoskeleton (Ekso GT, Ekso Bionics) used in this study, including anthropometric measures and lower- and upper-extremity range of motion. Inclusion and exclusion criteria are described in detail in the published protocol [16]. Recruitment and interventions began in 2019 but were very much restrained due to the pandemic over the past 2 years. Due to time constraints and funding concerns, the study was not resumed after 2021. Unfortunately, this led to many participants being unable to complete the entire 16-week walking program. We therefore asked all participants who had completed or nearly completed the wearable robotic exoskeleton (WRE) walking program (10 to 16 weeks) to answer the updated version of the MWESP-Q. Out of a possible 15 participants, 66% ( $n=$ 10) could be reached. This will be addressed in the discussion.

2.3 Intervention with the exoskeleton

The overground robotic exoskeleton used in this study was the Ekso GT^TM, manufactured by Ekso Bionics^® (https://eksobionics.com/about-us/). See Bass et al. [16] for pictures of the exoskeleton. The device’s battery life varies depending on the walking mode used (i.e., the amount of assistance provided by the exoskeleton) and the user’s weight, ranging from just over 30 minutes to several hours. However, sessions were capped at 1 hour in this study. Participants transferred from their wheelchair to a bariatric chair and were assisted to put on the exoskeleton. Sit-to-stand transfers were assisted by the exoskeleton and walking aids (i.e., walker or forearms crutches). To walk in the exoskeleton, the therapist initiated the first step (always right foot) using the controls on the exoskeleton. Body weight shifts are then recognized by the exoskeleton and used to initiate subsequent steps. The therapist programs the walking pattern (i.e., step height, step length, swing speed, etc.) and adjusts as needed. The WRE emits a sound to guide the participant in the movements. At all times, walking aids (i.e., walker or forearms crutches) were used and the therapist remained behind the participant for safety and to provide assistance as needed. A second therapist was also present when required. The exoskeleton and training program used in this study are extensively discussed in the published protocol [16].

2.4 Updating the MWESP-Q to a context of health promotion

In psychometrics, modification of an original questionnaire refers to content validity. Content validity primarily relies on the expertise of individuals familiar with the construct being measured [17]. These subject-matter experts are usually provided with access to the measurement tool and are asked to provide feedback on how well each question measures the construct in question. From the three key aspects of content validity (domain definition, domain representation, and domain relevance) [17], the second one was of interest for the study. Two research team meetings were devoted to the modifications to the original questionnaire to get a consensus on the statements to be added, removed or modified. Discriminant measurement scales were adopted depending on the domains of the MWESP-Q, for a total of three different scales. From the research team, there were four experts included two physiotherapists (AB, DHG), one occupational therapist (CV) and one kinesiologist (FB, see Acknowledgments). They revised all questions of the MWESP- Q and formulated new questions according to Fig. 1 (Project-specific logic model highlighting the relationships between the different domains of interest and related outcome measures) which is consistent with the European framework for physical activity [18].

The upgraded MWESP-Q includes 13 new statements for a total of 54. Items were added for four of the seven key domains: satisfaction with the robotic exoskeleton ( $+$ 1), satisfaction with the program attributes ( $+$ 5), perceived health benefits of walking with the robotic exoskeleton ( $+$ 4) and perceived risks and fears ( $+$ 4). Learnability of the robotic exoskeleton ( $-$ 1) was decreased, while satisfaction related to the training program and perceived motivation to engage in regular physical activity remained the same. Instead of percentages, each statement is now rated using one of the three different 7-point Likert scales. For 40 statements, the scale is: 1 $=$ strongly disagree, 2 $=$ disagree, 3 $=$ somewhat disagree, 4 $=$ neither disagree nor agree, 5 $=$ somewhat agree, 6 $=$ agree, 7 $=$ strongly agree. For perceived health benefits (12 statements), the scale used is: 1 $=$ substantial deterioration, 2 $=$ moderate deterioration, 3 $=$ light deterioration. 4 $=$ neutral, 5 $=$ light improvement, 6 $=$ moderate improvement, 7 $=$ substantial improvement. Finally, for two statements (level of physical and cognitive exertion during the training), the scale used is: 1 $=$ no effort, 2 $=$ very small effort, 3 $=$ small effort, 4 $=$ medium effort, 5 $=$ high effort, 6 $=$ very high effort, 7 $=$ maximal effort. The questionnaire was set up with the LimeSurvey platform, in French and in English. The online version of the MWESP-Q was pre-tested by the experts, and then by one participant. Statements were refined.

2.5 Data analysis

Descriptive analyses were conducted on the sociodemographic and clinical variables and on all statements (7-point Likert scales) included in the MWESP-Q. All statistics were perform using Excel. The seven key components (domains) are presented as means and standard deviations to help interpret the score according to the 7-point Likert scales. Furthermore, medians were also calculated for all statements.

Table 1
Baseline characteristics of the study participants ( $n=$ 10)

Personal characteristics	$n$
Sex
Men	6	60%
Women	4	40%
Spinal cord injury (SCI)
Traumatic	9	90%
Non-traumatic	1	10%
Lesion
Complete	7	70%
Incomplete	3	30%
Schooling
Pre-University programs	5	50%
University	5	50%
Level of SCI
Cervical	3	30%
Thoracic	6	60%
Dorsal	1	10%
Housing condition
Alone	4	40%
With partner	6	60%
Urban area
Urban	9	90%
Suburban	1	10%
Main occupation
Working	2	20%
Unable to work	3	30%
Retired	3	30%
Study	1	10%
Volunteering	1	10%
Wheelchair user
Manual	8	80%
Powered	2	20%
Appreciation of their wheelchair (0-10)
Mean (SD)	10	8.4 (1.4)
Age
Mean (SD)	10	45.8 (13.4)
Years since injury
Mean (SD)	10	10.1 (5.8)

3. Results

3.1 Participants

Table 1 presents the baseline characteristics of the participants ( $n=$ 10). There were 6 men and 4 women with a mean age of 45.8 years old and 10.1 years since their injury. Most had a traumatic and complete SCI from the thoracic region. Seven had fully completed the WRE walking program.

Table 2
User’s satisfaction (scale 1 to 7) regarding the exoskeleton and exercise training program ( $n=$ 10)

Scale 1–7^*	Mean	SD	Median
Overall program satisfaction	6.7	0.2
1.1 satisfied with training program	6.5	1.0	7.0
1.2 would recommend to other spinal cord injured to participate in the program	6.8	0.4	7.0
Satisfaction with the robotic exoskeleton	5.8	0.8
2.1 general appearance of the exoskeleton is attractive	4.7	1.3	4.5
2.2 transfers between my wheelchair and the exoskeleton are easy	6.2	1.0	6.5
2.3 exoskeleton is easy to put on and to take off with the help of a therapist	6.5	0.5	6.5
2.4 wearing the exoskeleton is comfortable	5.9	0.9	6.0
2.5 can breathe easily when wearing the exoskeleton	6.8	0.4	7.0
2.6 leg movements generated by the exoskeleton during walking are similar to normal walking	5.1	1.4	6.0
2.7 weight of the exoskeleton when walking is not restraining	5.6	1.2	6.0
Perceived motivation to engage in regular physical activity	5.9	0.4
7.1 after, felt motivated to take part in a physical activity program	5.6	1.6	6.0
7.2 after, plan to follow the Canadian recommendations for physical activity	6.2	0.9	6.0

^*1 $=$ Strongly disagree. 2 $=$ Disagree. 3 $=$ Somewhat disagree. 4 $=$ Neither disagree nor agree. 5 $=$ Somewhat agree. 6 $=$ Agree. 7 $=$ Strongly agree.

3.2 Satisfaction towards the WRE walking program

Since the MWESP-Q is organized around seven key domains, results are presented for each domain with more details in three tables. Please note that there are three possible response scales, and they are always specified at the bottom of the tables. In Table 2, three domains are presented. Overall, participants strongly agreed with satisfaction domain statements, meaning they were satisfied with the training program and that they would recommend it to others (mean 6.7 SD 0.2). They agreed with exoskeleton domain statements, meaning that they were satisfied with the robotic exoskeleton, especially with regards to how easy it was to transfer from the wheelchair, to don and doff the exoskeleton with the help of a therapist, to breath comfortably while wearing the exoskeleton and relating to its weight (mean 5.8 SD 0.8). Participants also agreed with motivation to engage in physical activity domain statements, meaning that they felt motivated to engage in regular physical activity, as they planned to follow the Canadian recommendations for physical activity (mean 5.9 SD 0.4).

Table 3
User’s satisfaction regarding the exoskeleton and exercise training program ( $n=$ 10)

Scale 1–7	Mean	SD	Median
Learnability of the robotic exoskeleton^*	5.8	0.9
3.1 learning to walk with the exoskeleton is easy	5.0	1.4	5.5
3.2 satisfied with the progression over time of my level of walking skill with exoskeleton during training sessions	6.4	1.1	7.0
3.3 sounds emitted by the exoskeleton help to stand up and to sit down	5.0	1.8	5.0
3.4 sounds emitted by the exoskeleton help me while walking	5.6	1.2	5.5
3.5 instructions help to stand up and to sit down	6.8	0.4	7.0
3.6 instructions help while walking	6.7	0.5	7.0
3.7 the therapist’s tactile feedbacks help while walking	4.4	1.3	4.0
3.8 watching videos of me walking helped learn to walk in the exoskeleton	6.1	1.5	6.0
Satisfaction with the program attributes^*	5.2	0.9
4.1 satisfied with the skill level achieved during sit-stand transitions with the exoskeleton by the end of the training program	6.2	1.0	6.5
4.2 satisfied with the skill level achieved when walking with the exoskeleton by the end of the training program	6.3	1.1	7.0
4.3 at the end of the training program. able to stand up and sit down without the help of a therapist	4.7	2.2	5.5
4.4 at the end of the training program. able to walk without the help of a therapist	3.9	2.7	4.0
4.5 total duration of the training program is adequate considering availability	5.4	1.2	6.0
4.6 number of training sessions is adequate considering availability	5.8	1.2	6.0
4.7 duration of each training session is adequate considering availability	6.3	0.5	6.0
4.8 duration of each training session is adequate considering physical ability	5.6	1.6	6.0
^**4.9 general perceptions of level of physical exertion during training	3.8	1.5	4.0
^**4.10 general perceptions of level of cognitive exertion during training	4.4	1.3	4.5
4.11 physical environment in which the training sessions took place was suitable	4.7	1.7	4.5
4.12 opportunity for family or friends to observe me during the training sessions is motivating	5.6	1.4	6.0

^*1 $=$ Strongly disagree. 2 $=$ Disagree. 3 $=$ Somewhat disagree. 4 $=$ Neither disagree nor agree. 5 $=$ Somewhat agree. 6 $=$ Agree. 7 $=$ Strongly agree. ^**1 $=$ No effort. 2 $=$ Very small effort 3 $=$ small effort. 4 $=$ Medium effort 5 $=$ High effort. 6 $=$ Very high effort. 7 $=$ Maximal effort.

In Table 3 two domains are captured with two different Likert scales. Participants agreed that the instructions provided helped them in different aspects in learnability domain (mean 5.8 SD 0.9). However, they somewhat agreed that learning to walk with the exoskeleton was easy, that the sounds emitted by the exoskeleton helped during sit-to-stand and stand-to-sit transfers, and that the physical environment was suitable (research laboratory and the corridors of the rehab center). Participants agreed that the sounds emitted by the exoskeleton helped while walking. They neither agreed nor disagreed that the therapist’s tactile feedback help them walking. Participants agreed with the program domain statements, meaning that that they were satisfied with the attributes of the program (mean 5.2 SD 0.9), such as the skill level achieved during sit-to-stand transfers, skill level when walking by the end of the training program, number of training sessions and the duration of each training session. They somewhat agreed to being able to stand and sit in the exoskeleton without the help of the therapist, and they neither disagreed nor agreed to being able to walk without the help of the therapist. A medium effort was reported for the general perceptions of physical (3.8 SD 1.5, median 4) and cognitive exertion (4.4 SD 1.3 median 4.5) during the training sessions.

Table 4

User’s satisfaction regarding the exoskeleton and exercise training program ( $n=$ 10)

Scale 1–7^*	Mean	SD	Median
Perceived health benefits of walking with the robotic exoskeleton^*	5.0	0.4
5.1 at the end of program, noticed a change in the strength of arms	5.4	1.2	5.5
5.2 at the end of program, noticed a change in the control of sitting balance	4.9	1.3	4.0
5.3 at the end of program, noticed a change in general endurance	5.5	1.4	5.0
5.4 at the end of program, noticed a change in the spasticity in legs	4.9	1.3	4.0
5.5 at the end of program, noticed a change in the time required for intestinal elimination	4.7	1.2	4.5
5.6 at the end of the program, noticed a change in sleep	4.7	1.2	4.0
5.7 at the end of program, noticed a change in psychological well-being	5.7	1.3	6.0
5.8 at the end of program, noticed a change in the intensity of everyday pain	4.4	1.5	4.0
5.9 at the end of program, noticed a change in ability to propel wheelchair	5,0	1.2	5.0
5.10 at the end of program, noticed a change in ability to transfer	5,0	1.1	5.0
5.11 at the end of program, noticed a change in general health	5.1	1.0	5.0
5.12 at the end of program, someone around me told me or perceived a change in general health	4.4	1.0	4.0
Perceived risks and fears^**	2.8	0.7
6.1 was afraid that exoskeleton would have a mechanical breakdown	2.5	1.4	2.0
6.2 was fearful of losing balance when walking with exoskeleton	3,0	1.6	2.5
6.3 was fearful of falling when walking with exoskeleton	3.4	1.8	3.5
6.4 was fearful of causing or exacerbating musculoskeletal pain in arms when walking with exoskeleton	4.4	1.8	5.0
6.5 was fearful of causing or exacerbating back pain around the level of spinal cord injury and/or spinal surgery when walking with exoskeleton	2.6	1.5	2.0
6.6 was fearful of causing or exacerbating neuropathic/neurogenic pain in trunk or in legs when walking with exoskeleton	2.3	1.5	2.0
6.7 was fearful of developing skin lesions when walking with exoskeleton	2.4	1.4	2.0
6.8 was fearful that blood pressure would drop when walking with exoskeleton	2.8	2.1	2.0
6.9 was fearful of being out of breath when walking with exoskeleton	2.3	1.6	1.5
6.10 was fearful of developing excessive fatigue when walking with exoskeleton	2.8	1.9	2.0
6.11 was fearful of developing a leg fracture when walking with exoskeleton	2.1	1.4	1.5

^*1 $=$ Substantial deterioration 2 $=$ Moderate deterioration 3 $=$ Light deterioration. 4 $=$ Neutral. 5 $=$ Light improvement. 6 $=$ Moderate improvement. 7 $=$ Substantial improvement. ^**1 $=$ Strongly disagree. 2 $=$ Disagree. 3 $=$ Somewhat disagree. 4 $=$ Neither disagree nor agree. 5= Somewhat agree. 6 $=$ Agree. 7 $=$ Strongly agree.

The last two domains are presented in Table 4 with two different Likert scales. In general, participants reported a light improvement or change in the different outcomes at the end of the WRE walking program in the health benefit domain (mean 5.0 SD 0.4). Light to moderate improvement was reported for general endurance (5.5 SD 1.4) and psychological well-being (5.7 SD 1.3). Neutral improvements were reported for arm strength, sitting balance, spasticity in legs, intestinal elimination, sleep, ability to propel wheelchair and to transfer. It remained neutral for the intensity of everyday pain and changes in general health. Participants reported that they somewhat disagreed in the fear and risk domain (mean 2.8 SD 0.7) such as that they were fearful for themselves when using the WRE or the possibility of potential risks like mechanical breakdown, losing balance, falling, pain around the level of spinal cord injury, drop in blood pressure, and excessive fatigue. Participants disagreed that they were fearful that walking in the exoskeleton would cause neuropathic pain in their trunk or legs, skin lesions, loss of breath or leg fracture. Finally, they neither disagreed nor agreed regarding the fear of causing or exacerbating musculoskeletal pain in their arms when walking in the exoskeleton.

4. Discussion

The study objective has been achieved. The research question has been answered, since participants’ satisfaction levels with the walking program and the wearable robotic exoskeleton itself have been documented in 54 statements (with the updated MWESP-Q). Our hypothesis was partially confirmed: 10 wheelchair users with chronic SCI expressed high levels of satisfaction with the walking program using the wearable robotic exoskeleton and with the wearable robotic exoskeleton itself, but only in four key components of the updated MWESP-Q. Participants expressed their satisfaction as that they “strongly agree” in satisfaction domain (over 6.5/7) and “agree” in domains of exoskeleton, learnability, and motivation to engage in physical activity (from 5.5 to 6.5/7). Regarding risks and fears domain of risks and fears, it appears that participants expressed they somewhat disagreed or disagreed with 8 of the 11 statements, which seems to be a good feeling when the fear is moderate, compared with none at all or being extremely afraid. Finally, in the domains of program and of perceived health benefits of WRE, wheelchair users had reported “medium effort” for the general perceptions of physical and cognitive exertion during the training sessions, as well as “neutral and light improvements” in the 12 outcomes at the end of the WRE walking program (from 4.4 to 5.7). The relatively small sample size ( $n=$ 10) and completion of only 10 of the 16 weeks of the program ( $n=$ 7) resulted in mixed satisfaction in the domain of perceived health benefits of WRE. Probably another 6 weeks of training 2–3 times a week would have been necessary to improve changes in body and organic systems and in capabilities, according to evidence-based date of effectiveness of a 16-week high-intensity cardio resistance training program in adults [19]. To corroborate these survey results, Bass et al. [20] had just published that the outcomes related to the wheelchair remained stable, except for natural velocity during the 20-meter wheelchair propulsion test that increased significantly ( $p=$ 0.01) and meaningfully (effect size $=$ 0.82, relative variation $=$ $+$ 14.5%) after training on 10 weeks instead of the scheduled 16.

Compared to Gagnon et al’s study where wheelchair users finished a 6 to 8-week locomotor exercise program, their results in percentage from a 100-mm long visual analogue scale were more difficult to interpret clinically, such as 67.9% $+/-$ 16.7% for the health benefits domain [8]. In our study, since the updated MWESP-Q had a 7 points Likert scale measuring level of improvement, it is easier to interpret light improvements (5/7 $+/-$ 0.5) or moderate improvements (6/7 $+/-$ 0.5), since the Likert scale is 1 $=$ Substantial deterioration 2 $=$ Moderate deterioration 3 $=$ Light deterioration. 4 $=$ Neutral. 5 $=$ Light improvement. 6 $=$ Moderate improvement. 7 $=$ Substantial improvement. It is the same rationale for the program attributes, with a Likert scale that address exertion during training (1 $=$ No effort. 2 $=$ Very small effort 3 $=$ Small effort. 4 $=$ Medium effort 5 $=$ High effort. 6 $=$ Very high effort. 7 $=$ Maximal effort).

4.1 Strengths and limitations of the study and future research

The strength of this cross-sectional quantitative design lies in its internal validity. In this respect, the survey questionnaire (MWESP-Q) was improved according to the rules of the art of content validity [17], i.e. with experts on the study and dedicated to health promotion, with the theoretical model already published [16, 18]. Also, to address a possible expectancy bias, participants were notified that the questionnaires were administered and analysed by an offsite (based in another city) research professional (FSD) that they had never met. All participants were specifically informed, and reminded on several occasions, that their therapists would not have access to their answered questionnaires. The recruitment of 15 persons was done in one city and had to stop due to the COVID-19 pandemic (3 persons could not answer the questionnaire because they did not complete at least 10 weeks of training, two did not fill the questionnaire). The external validity of the results of this study is therefore limited, given the small sample size (10 instead of 15) in a single location and the fact that only 7 out of 10 people completed 16 weeks of intense training with the walking exoskeleton. Future research is needed to assess satisfaction, health benefits and level of effort in adapted physical activity using next generation exoskeletons in a community context. Since the Ekso GT is now discontinued and replaced by Ekso NR (https://eksobionics.com/eksonr/), new research should be done with this new model. The new model includes voice control of exoskeleton functions (in addition to the controller on the side and the control buttons on the back. It also features a longer-lasting battery.

5. Conclusions

This study has documented satisfaction of 10 people with chronic spinal cord injury after the completion of a 10 to 16 weeks of the wearable robotic exoskeleton-assisted walking program, in a context of health promotion. The participants agreed and strongly agreed with satisfaction domain statements as well as ‘exoskeleton, learnability, and motivation to engage in physical activity” domain statements, meaning that they were satisfied with the training program and that they would recommend it to others. After only 10 to 16 weeks of sit-stand transfer training and intensive walking with the assistance of a therapist, users reported light improvements, e.g., arm strength, sitting balance, spasticity in the legs, intestinal elimination, sleep, ability to propel wheelchair and to transfer. They also declared moderate improvements in general endurance and psychological well-being. This study also recommends using the updated MWESP-Q in future research where a walking robotic exoskeleton is used in a health promotion context, i.e., in a context of adapted physical activity to stay fit or to prevent secondary health complications. The original questionnaire of satisfaction (MWESP-Q) was updated to include physical and cognitive efforts in physical activity and changes in body and organic systems and in capabilities, that is part of health promotion, that is fully supported by WHO Europe, since physical activity is one of the major lifestyle-related health determinants [18]. The updated MWESP-Q proposes 13 additional statements for heath promotion in the WRE walking program attributes, in perceived health benefits of walking with the robotic exoskeleton and in perceived fears. The MWESP-Q also now measures level of agreement in seven key components, The level of perceived change and level of effort. original measure (in percentage) was replaced by three 7-point Likert scales, one regarding agreement level (40 statements), level of effort (12 statements), and level of change (2 statements).

Author contributions

CONCEPTION: Dany H Gagnon, Mylène Aubertin-Leheudre PhD, Antony D Karelis, Suzanne N Morin, Michelle McKerral, Cyril Duclos, Claude Vincent.

PERFORMANCE OF WORK: Alec Bass and Frédéric S Dumont for data collection.

INTERPRETATION OR ANALYSIS OF DATA: Frédéric S Dumont.

PREPARATION OF THE MANUSCRIPT: Claude Vincent.

REVISION FOR IMPORTANT INTELLECTUAL CONTENT: All.

SUPERVISION: Dany H Gagnon and Mylène Aubertin-Leheudre supervised Alec Bass.

Ethical considerations

This project received ethical approval on March 14, 2019, from the CRIR ethics committee and was registered on June 7, 2019, with the US National Library of Medicine at ClinicalTrials.gov (NCT03989752).

Footnotes

Acknowledgments

Special thanks are extended to Florian Bobeuf for his substantial contribution in the coordination of this project and during the training sessions, as well as Martin Vermette and Manual Escalona for their expertise and assistance with the exoskeleton. Thank you to Manon Rogers and Tiffany Hu, both students supported by the Cirris who have first computed part of the results of the MWESP-Q during the first year of the COVID in 2020. Dany Gagnon and Sara Ahmed co-chair the Initiative for the Development of New Technologies and Practices in Rehabilitation (INSPIRE) funded by the LRH Foundation and co-leads the Rehabilitation Interventions for Individuals with a SCI in the Community (RIISC) research team funded by the Ontario Neurotrauma Foundation and the Quebec Rehabilitation Research Network.

Conflict of interest

The authors have no conflicts of interest to report.

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Updating the Montreal walking exoskeleton satisfaction and perspectives questionnaire (MWESP-Q) following a 16-week walking program with the use of a wearable robotic exoskeleton

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Method

2.1 Research design

2.2 Sample and recruitment

2.3 Intervention with the exoskeleton

2.4 Updating the MWESP-Q to a context of health promotion

2.5 Data analysis

Table 1 Baseline characteristics of the study participants ( n = 10)

3.1 Participants

Table 2 User’s satisfaction (scale 1 to 7) regarding the exoskeleton and exercise training program ( n = 10)

Table 3 User’s satisfaction regarding the exoskeleton and exercise training program ( n = 10)

4.1 Strengths and limitations of the study and future research

5. Conclusions

Author contributions

Ethical considerations

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Baseline characteristics of the study participants ( $n=$ 10)

Table 2
User’s satisfaction (scale 1 to 7) regarding the exoskeleton and exercise training program ( $n=$ 10)

Table 3
User’s satisfaction regarding the exoskeleton and exercise training program ( $n=$ 10)