Assistive Device Interventions
Assistive technologies (ATs) and supports enable people with disabilities to live healthy, productive, independent, and dignified lives, and to participate in education, the labour market, and civic life (GOV.UK: Assistive technology: definition and safe use). They are commonly implemented providing a great opportunity to support people with different typologies of disabilities (Morone et al. 2023; Lenker et al. 2013; Ripat & Woodgate 2012).
The provision of assistance dogs is an example of an emerging support intervention that aims to address the unique participation needs of people with disability (Futeran et al. 2022). A recent scoping review by Futeran et al. (2022) including 38 studies (11 of them being performed on patients with SCI) showed how assistance dog partnerships can positively impact participation, a key factor in promoting quality of life. Another recent systematic literature review has shown that despite the purpose of these assistance dogs specifically for physical tasks, positive outcomes were noted in psychological, social, quality of life, and vitality domains; but none on psychosocial health and wellbeing (Rodriguez et al. 2020).
The Segway Personal Transporter is a self-balancing, electric-powered personal transporter and a popular mobility device among non-SCI controls (Boutilier et al. 2012; Sadeghi et al. 2016). It could be used by an individual with SCI, with or without long leg braces depending upon their level of injury (Sadeghi et al. 2016). Previous research investigating whether the Segway could be used as a mobility device for people with disabilities and limited mobility has shown that very little strength, flexibility and coordination was needed to operate the Segway, making it a good alternative to existing equipment (Sawatzky et al. 2007; Sawatzky et al. 2009).
Over the last years, overground-powered lower limb exoskeletons have emerged as practical devices for rehabilitative or substitutional interventions (Tamburella et al. 2022). The clinical feasibility of these devices has been demonstrated and research into clinical benefits suggests possible improvements in bladder and bowel function, pain, spasticity, bone density, lean body mass, muscle tone, and improved walking speed (Postol et al. 2021).
Discussion
Mobility Service Dogs
The pre-post study by Vincent et al. (2019) was the only study included in the present systematic review that assessed fatigue in manual wheelchair users with SCI during nine months of partnering each participant with a mobility service dog. They found significantly decreased end-of-day fatigue, with moderate to strong effect sizes, along with positive results in shoulder and wrist pain, wheelchair-related functional tasks, participation, and satisfaction with the psychosocial aspects and technical dimensions of their animal technical assistance over time (Vincent et al. 2019).
These results are in line with those obtained by Hubert et al. (2013) which showed reduced perceived exertion and shoulder pain, and increased endurance in 11 manual wheelchair users with SCI after seven months of training with a service dog. However, these positive effects need to be considered with caution as different systematic reviews with guide, hearing, medical, or mobility service dogs for people with disabilities have described some positive outcomes in terms of social, psychological, and functional benefits for their handlers, but with several methodological weaknesses in the original studies assessed (Winkle et al. 2012; Rodriguez et al. 2020).
Segway Personal Transporter
The pre-post study by Boutiller et al. (2012) found that a 4-week dynamic standing program using the Segway Personal Transporter improved fatigue scores, though not to a level of significance (n = 8, P > 0.05) in eight participants with SCI, pain, and spasticity. On the other hand, spasticity improved considerably immediately after the first session with the Segway, but the improvements were not significant after the 4-week program, contrary to pain which dropped significantly over time (Boutilier et al. 2012). These results raised the question as to whether the use of a Segway has additional benefits for managing spasticity over purely static standing (Sadeghi et al. 2016). The same research group performed a cross-over trial with ten participants with chronic SCI and spasticity who performed one 20-minute static standing session and one 20-minute dynamic standing session (one week apart) with the Segway (Sadeghi et al. 2016). Although in this project, fatigue was not assessed; spasticity non-significantly decreased after both conditions, but without a difference between sessions (Sadeghi et al. 2016). To the author’s knowledge, no new studies have been carried out with respect to this assistive technology in populations with disabilities such as SCI, stroke, or multiple sclerosis.
Figure 1. Segway use in the study of (Boutilier et al. 2012). Image downloaded from Youtube (https://www.youtube.com/watch?v=9W6XB8Nzmec&t=188s)
Free-standing Exoskeleton
A small (but recent) feasibility study by Postol et al. (2021) evaluated the efficacy of a 12-week intervention program using a free-standing exoskeleton for weightbearing exercises in three participants with severe mobility impairment. There were different health outcome measures assessed; however, in terms of fatigue, findings were inconsistent between the three study participants.
Exoskeleton technology is a rapidly developing field that with long-term rehabilitation therapy, could improve cardiovascular fitness, increase bone mineral density and lean body mass, lower spasticity, optimize bowel function, enhance neuromuscular and musculoskeletal function, improve gait function, promote neuroplasticity, improve the quality of life and physical discomfort, enable active participation in social and community activities, engage in employment opportunities, and pursue recreational pursuits (Pinelli et al. 2023). Fatigue represents an interesting topic to study as people with SCI who use robotic locomotor exoskeletons have cited that increased fatigue, spasticity, and spasms (among other factors) are a barrier to using exoskeletons; however, no larger studies assessing fatigue as an outcome have been conducted in this area (Kinnet-Hopkins et al. 2020).
Conclusions
There is level 4 evidence (from one pre-post: Postol et al. 2021) that 12 weeks of exercise therapy sessions in a free-standing lower limb robotic exoskeleton, performed twice a week for 30 minute each session, does not provide consistent changes in fatigue (FAS) in the three participants with SCI of this study.
There is level 4 (from one pre-post: Vincent et al. 2019) that a 9-month partnered with a mobility service dog provides significant improvements in fatigue (RPE) and vitality (vitality subscale of the SF-36) with moderate to strong effect sizes in manual wheelchair uses (82% of participants had SCI).
There is level 4 evidence (from one pre-post: Boutilier et al. 2012) that a 4-week dynamic standing program using a Segway, performed three times per week for 30 minute each session, provides a non-significant improvement in fatigue severity (FSS) in people with SCI and a history of pain and spasticity.
