Evaluation of Safety and Performance of the Atalante System With Patients With Lower Limb Paralysis

The 10mWT is used to assess walking speed in meters/second (m/s) over a short distance.

A clear pathway of at least 10-meter length is drawn. The start and the end point of a 10-m walkway is marked by lines.

The patient starts a few steps prior the starting line; during the few steps needed to reach the starting line, the physiotherapist should stabilize the exoskeleton in the frontal plane. When the patient's first foot crosses the starting line, the test begins, and the stopwatch is started. The stopwatch is stopped at the end of the 10 meters in case of success, that is to say when the patient crosses the end line.

The total time taken to ambulate is recorded. The distance covered is then divided by the total time (in seconds) taken to ambulate and recorded in meters per seconds.

In case of failure, the distance walked by the patient is measured and recorded, and the speed to walk this distance is calculated as described above.

Rating of perceived exertion (RPE) is a widely used and reliable indicator to monitor and guide exercise intensity.

The scale allows individuals to subjectively rate their level of exertion during exercise or exercise testing.

Developed by Gunnar Borg, it is often also referred to as the Borg Scale. Despite being a subjective measure of exercise intensity, RPE scales provide valuable information when used correctly.

The revised category-ratio scale (0 to 10 scale) is used:

• 0 Null
• 1 Very easy
• 2 Somewhat easy
• 3 Moderate
• 4 Somewhat hard
• 5 Hard
• 6
• 7 Very hard
• 8
• 9
• 10 Very, very hard

A Likert scale is a psychometric scale commonly involved in research based on survey questionnaires. Here, the respondents specify their level of agreement or disagreement using a symmetric agree-disagree scale for a series of statements while responding to a particular Likert questionnaire item. The range of Likert scale captures the intensity of their feelings for a given item.

The Likert scale ratings are:

• Strongly disagree
• Disagree
• Disagree somewhat
• Neither agree nor disagree
• Agree somewhat
• Agree
• Strongly agree

The perceived safety is evaluated with the 7-point Likert scale on the following statement:

"I felt safe during the test"

The neurogenic bowel dysfunction score is a questionnaire including questions about background parameters, faecal incontinence, constipation, obstructed defecation, and impact on quality of life. The NBD score is constructed from items with acceptable reproducibility and validity that were significantly associated with impact on quality of life. The type of the stool depends on the time it spends in the colon.

The Bristol Stool Chart is:

• Type 1: Separate hard lumps, like nuts (hard to pass);
• Type 2: Sausage-shaped but lumpy;
• Type 3: Like a sausage but with cracks on its surface;
• Type 4: Like a sausage or snake, smooth and soft;
• Type 5: Soft blobs with clear-cut edges (passed easily);
• Type 6: Fluffy pieces with ragged edges, a mushy stool;
• Type 7: Watery, no solid pieces. Entirety liquid.

Type 1, 2 and 3 indicate constipation. Type 4 and 5 are ideal stools. Type 6 and 7 indicate diarrhea and urgency.

The management of neurogenic bladder dysfunction is crucial in the management of paraplegic patients as it affects the morbidity of these patients. The voiding mode is described. The self-survey is the standard treatment when the subject has an overactive bladder. The mictionnel mode will be informed before the first session, and at the end of the last session with the exoskeleton using an ISCOS questionnaire (International Spinal Cord Society questionnaire).

The Qualiveen score is developed as a condition-specific quality of life measurement for individuals with SCI who have urinary disorders. It contains 4 domains:

• Limitation/ Inconvenience;
• Constrains/ Restrictions;
• Fears;
• Feelings/ Impact on Daily Life.

The test-retest reliability is high6.

The Modified Ashworth Scale measures spasticity in patients with lesion of the Central Nervous System. The relationship between the raters' judgments was significant and the reliability was good. (PMID: 3809245)

The scoring is:

• 0: No increase in muscle tone
• 1: Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension
• 1+: Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
• 2: More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved
• 3: Considerable increase in muscle tone, passive movement difficult
• 4: Affected part(s) rigid in flexion or extension

Muscles evaluated are adductor, hamstring, triceps sural and quadriceps.

The Numeric Pain Rating Scale measures the subjective intensity of pain. The NPRS is an 11-points scale from 0 to 10: "0" = no pain; "10" = the most intense pain imaginable.

The subject is asked to make pain rating corresponding to the current pain experienced.

NPSI (Neuropathic Pain Sumptom Inventory) renders it suitable for the evaluation of the different dimensions of neuropathic pain syndromes. The reliability of the different descriptors appears to be sufficient.

It allows to quantify the various pain symptoms that can be grouped into five dimensions (burn, deep pain, paroxysmal pain, pain caused, paresthesia / dysesthesia)

The Patient Global Impression of Improvement (PGI-I) is a global index that may be used to rate the response of the use of Atalante on the bowel function.

The subject should check the number that best describes how the twelfth session condition is, compared with how it has been at the first session for the bowel function:

• Very much better
• Much better
• A little better
• No change
• A little worse
• Much worse
• Very much worse

At the end of the twelfth session, the patient evaluates the interfaces and the ergonomics of Atalante (shape of the remote, mode, symbol) and the perceived safety and the level of assistance during transfer from the wheelchair to Atalante with a Likert scale.

The Likert scale is a questionnaire where the subject chooses among seven-point scales:

• Strongly disagree
• Disagree
• Disagree somewhat
• Neither agree nor disagree
• Agree somewhat
• Agree
• Strongly agree

The level of assistance is specified for each attachment (thigh, knee and foot straps). The levels of assistance are:

• Without assistance;
• With the assistance of one health professional;
• With the assistance of two health professional.

At the end of the twelfth session, the strapping system is evaluated using a 7-point Likert scale:

• Strongly disagree
• Disagree
• Disagree somewhat
• Neither agree nor disagree
• Agree somewhat
• Agree
• Strongly agree

This test evaluates the ability of the subject to balance in sitting position during disturbances induced by movements of the upper limbs. The subject is sitting without back's support and with both feet on the ground. The subject is asked to do six tasks from the easiest to the hardest. The subject must pass the task to test the next task. The score is defined by the last passed task. The sitting balance is evaluated at the first and at the last session.