Systematic review
Systematic Reviews of Clinical Benefits of Exoskeleton Use for Gait and Mobility in Neurologic Disorders: A Tertiary Study

https://doi.org/10.1016/j.apmr.2019.01.025Get rights and content

Abstract

Objective

To describe systematic reviews (SRs) of the use of exoskeletons for gait and mobility by persons with neurologic disorders and to evaluate their quality as guidance for research and clinical practice.

Data Sources

PubMed, EMBASE, Web of Science, CINAHL Complete, PsycINFO, Cochrane Database of Systematic Reviews, PEDro, and Google Scholar were searched from database inception to January 23, 2018.

Study Selection

A total of 331 deduplicated abstracts from bibliographic database and ancestor searching were independently screened by 2 reviewers, resulting in 109 articles for which full text was obtained. Independent screening of those 109 articles by 2 reviewers resulted in a final selection of 17 SRs.

Data Extraction

Data were extracted by 1 reviewer using a pretested Excel form with 158 fields and checked by a second reviewer. Key data included the purpose of the SR, methods used, outcome measures presented, and conclusions. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses and A MeaSurement Tool to Assess Systematic Reviews version 2 were used to evaluate reporting and methodological quality, respectively, of the SRs.

Data Synthesis

The SRs generally were of poor methodological and reporting quality. They failed to report some information on patients (eg, height, weight, baseline ambulatory status) and interventions (eg, treatment hours or sessions planned and delivered) that clinicians and other stakeholders might want to have, and often failed to notice that the primary studies duplicated subjects.

Conclusions

Published SRs on exoskeletons have many weaknesses in design and execution; clinicians, researchers, and other stakeholders should be cautious in relying on them to make decisions on the use of this technology. Future primary and secondary studies need to address the multiple methodological limitations.

Section snippets

Review identification

The following bibliographic databases were searched for relevant literature from database inception to January 23, 2018: PubMed, Embase, Web of Science, CINAHL Complete, PsycINFO, Cochrane Database of Systematic Reviews, PEDro, and Google Scholar. Keywords and medical subject headings or Emtree terms were used as appropriate. Search algorithms generally had the format: exoskeleton AND gait AND neurological disorder AND review. The complete search algorithm for PubMed is given in appendix 1.

Results

Database searches resulted in 328 deduplicated abstracts; 3 additional reviews were identified through ancestor searching. Independent screening by 2 reviewers resulted in 109 articles for which full text was obtained (33%). Independent screening of those 109 resulted in the selection of 17 SRs satisfying all criteria (16%). The PRISMA flow diagram is provided in figure 1. Supplemental table S1 provides the reasons for excluding 92 articles.

Discussion

The use of exoskeletons to improve gait and mobility of patients with SCI, stroke, or other disorders that may affect independent standing and walking is an area of great clinical and research interest with a quickly expanding literature. A review of PubMed abstracts suggests over 100 articles will be published per year from 2018 onward. As neither clinicians nor researchers may have the time to keep up with this rate of publication, SRs can provide a time-saving synthesis of research evidence.

Conclusions

Nearly 20 SRs have been published to summarize the findings of a quickly expanding literature on the use of exoskeletons to improve gait and mobility of individuals with neurologic disorders such as SCI and stroke. Our review of these SRs found that they have many weaknesses in design and execution; clinicians, researchers, and other stakeholders should be cautious in relying on them to make decisions on the use of exoskeleton technology. Future studies will certainly need to address these

Suppliers

  • a.

    Abstrackr; Brown University, Providence, RI.

  • b.

    Excel; Microsoft Corporation, Redmond, WA.

Acknowledgments

We thank Diane Patzer, MPT, NCS, and Phuong Vu, MPT, Rehabilitation Institute of Michigan, who participated in the early phases of this research, screening abstracts and full texts. We thank Ron Seel, PhD, who provided insights into the proper application of the AMSTAR 2 tool to systematic reviews of exoskeletons.

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    • Cited by (0)

    Current affiliation for Galen, Department of Physical Therapy, Georgia State University, Atlanta, Georgia.

    PROSPERO Systematic Review Registration No.: CRD42017058397.

    Disclosures: none.

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