# Acceptability of Overground Wearable Powered Exoskeletons for People with Spinal Cord Injury: A Multicenter Qualitative Study

Noémie Fortin-Bédard, Alice Pellichero, Stephanie Leplaideur, Marie-Caroline Delebecque, Caroline Charette, Willy Allègre, Alyson Champagne, Caroline Rahn, Andréanne K Blanchette, Laurent Bouyer, et al.

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Noémie Fortin-Bédard, Alice Pellichero, Stephanie Leplaideur, Marie-Caroline Delebecque, Caroline Charette, et al. Acceptability of Overground Wearable Powered Exoskeletons for People with Spinal Cord Injury: A Multicenter Qualitative Study. Biomimetics, 2025, 10 (1), pp.36. 10.3390/biomimetics10010036. hal-04937531

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Article

# Acceptability of Overground Wearable Powered Exoskeletons for People with Spinal Cord Injury: A Multicenter Qualitative Study

Noémie Fortin-Bédard<sup>1,2 ID</sup>, Alice Pellichero<sup>3 ID</sup>, Stéphanie Leplaideur<sup>3,4,5</sup>, Marie-Caroline Delebecque<sup>3</sup>,
Caroline Charette<sup>1,2</sup>, Willy Allègre<sup>3 ID</sup>, Alyson Champagne<sup>1,6</sup>, Caroline Rahn<sup>1</sup>, Andréanne K. Blanchette<sup>1,2</sup>,
Laurent Bouyer<sup>1,2 ID</sup>, Jacques Kerdraon<sup>3 ID</sup>, Marie-Eve Lamontagne<sup>1,2 ID</sup> and François Routhier<sup>1,2,* ID</sup>

<figure><img src="image_2.png" /></figure>

check for
updates

Academic Editors: Rafhael Milanezi
de Andrade and Dapeng Wei

Received: 17 October 2024

Revised: 16 December 2024

Accepted: 27 December 2024

Published: 8 January 2025

**Citation:** Fortin-Bédard, N.; Pellichero, A.; Leplaideur, S.; Delebecque, M.-C.; Charette, C.; Allègre, W.; Champagne, A.; Rahn, C.; Blanchette, A.K.; Bouyer, L.; et al. Acceptability of Overground Wearable Powered Exoskeletons for People with Spinal Cord Injury: A Multicenter Qualitative Study.
*Biomimetics* **2025**, *10*, 36.
https://doi.org/10.3390/biomimetics10010036

**Copyright:** © 2025 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license
(https://creativecommons.org/licenses/by/4.0/).

**Abstract:** **Background:** Exoskeletons are used in rehabilitation centers for people with spinal cord injuries (SCI) due to the potential benefits they offer for locomotor rehabilitation. The acceptability of exoskeletons is crucial to promote rehabilitation and to ensure a successful implementation of this technology. The objective was to explore the acceptability of overground wearable powered exoskeleton used in rehabilitation among people with SCI.
**Methods:** Fourteen individuals with SCI (9 men, mean [SD] age 47 years [14.8], a majority with traumatic and thoracic lesion (T6–T12)) who had utilized an exoskeleton in Canada or in France during their rehabilitation participated in a semi-structured interview. A thematic analysis using the theoretical framework of acceptability was carried out.
**Results:** Participants were motivated to use an exoskeleton during their rehabilitation. They reported several perceived benefits to its use, including better walking pattern, increased endurance, and greater muscle mass. They also experienced mild pain, notable concentration demands, and fatigue. Most participants reported that using exoskeletons in their rehabilitation process was appropriate and relevant to them.
**Conclusions:** Exoskeletons are generally well accepted by participants in this study. Adjustments in their use, such as conducting training sessions in obstacle-free environment and technological improvements to address the device's restrictive characteristics, heaviness, and massiveness are however still needed.

**Keywords:** spinal cord injury; exoskeleton; rehabilitation; acceptability; experience; locomotion

## 1. Introduction

Over the past few years, there has been a noticeable increase in the number of people living with disabilities, especially due to the aging population [1]. Nine million people worldwide were living with a spinal cord injury (SCI) in 2019 [2]. A SCI may result in changes depending on the level and severity of the injury, such as sensory and motor

<footnote n="1">¹ Center for Interdisciplinary Research in Rehabilitation and Social Integration, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale, Quebec, QC G1C 3S2, Canada; noemie.fortin-bedard.1@ulaval.ca (N.F.-B.); caroline.charette.2@ulaval.ca (C.C.); alyson.champagne.1@ulaval.ca (A.C.); caroline.rahn.ciussscn@ssss.gouv.qc.ca (C.R.); andreanne.blanchette@fmed.ulaval.ca (A.K.B.); laurent.bouyer@rea.ulaval.ca (L.B.); marie-eve.lamontagne@fmed.ulaval.ca (M.-E.L.)</footnote>

<footnote n="2">² School of Rehabilitation Sciences, Université Laval, Quebec, QC G1V 0A6, Canada</footnote>

<footnote n="3">³ Kerpape Rehabilitation Center, 56275 Ploemeur, France; alice.pellichero@coworkhit.com (A.P.); stephanie.leplaideur@vyv3.fr (S.L.); marie-caroline.delebecque@vyv3.fr (M.-C.D.); willy.allegre@vyv3.fr (W.A.); jacques.kerdraon@vyv3.fr (J.K.)</footnote>

<footnote n="4">⁴ Physical and Rehabilitation Medicine Department, University Hospital of Rennes, 35000 Rennes, France</footnote>

<footnote n="5">5 EMPENN-ERL, Inria Center, CNRS, Inserm, University of Rennes, 35065 Rennes, France</footnote>

<footnote n="6">⁶ School of Psychology, Université Laval, Quebec, QC G1V 0A6, Canada</footnote>

<footnote>* Correspondence: francois.routhier@rea.ulaval.ca</footnote>
impairments [3]. These impairments often cause important issues with mobility which re-
mains a vital concern for people living with SCI and their close relatives [4,5]. In this regard,
walking has been identified as one of the rehabilitation priorities for people with SCI [6,7].
Altogether, these findings highlight the need for innovative technologies supporting gait
rehabilitation. As a result, lower limb powered exoskeletons were greatly developed and
are now being increasingly implemented.

Exoskeletons have been recently used in facilities offering rehabilitation services for people with physical disabilities, including those with SCI. Although evidence varies on the nature and extent of results, and among studies, recent studies support the safety of exoskeleton use and suggests that this technology may offer potential benefits in the rehabilitation of people with SCIs [8–10]. Systematic reviews of preliminary studies found that exoskeletons allowed people with SCI to walk at a modest speed [11] and engage in movements that could potentially yield health benefits [10]. More recently, a randomized trial reported an improvement in walking independence scores after participants with incomplete SCIs completed 15 one-hour training sessions [9]. However, evidence of effectiveness in improving independent gait speed has not been found among SCI participants with residual walking ability [12]. In the acute phase of post-injury recovery, people with SCIs reported many psychological benefits of using an exoskeleton [13].

Despite the promising effects of innovative approaches, high rates of abandonment by users in rehabilitation technology are reported notably due to failure in the implementation process [14,15]. Like other rehabilitation technologies, careful considerations should be given to the acceptability of exoskeletons by users with SCIs to promote their successful implementation and sustained use in clinical settings. In that regard, Sekhon et al., 2017 have defined the acceptability of a health intervention as “a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention” [16]. Low acceptability can be a major barrier to the use of a technology and limits its widespread use [17]. Users might simply refuse or restrain activities that require the use of the technology, opting instead for more familiar activities (e.g., stretching or exercise) that align better with their usual understanding of rehabilitation.

Previous studies have investigated, sometimes as a secondary objective, the user expe-
rience of exoskeletons from the point of view of people with SCIs. Various components of
acceptability, such as high expectations toward this technology [18,19], considerable physi-
cal effort [13], and limited community use [20] after rehabilitation [20] have been reported.
The presence or absence of these components may influence the overall acceptability of
this technology. Despite its relevance for scaling up, no study has focused primarily on
qualitatively exploring acceptability from the perspective of individuals with SCIs [21],
nor using a theoretical framework of acceptability to analyze the results. The satisfaction
and perceived acceptability of patients with SCIs are critical factors in fostering their active
engagement in the rehabilitation process and ensuring the successful implementation of
this technology in settings that offer rehabilitation care [16,22]. This knowledge could lead
to better-targeted implementation strategies. Thus, the objective of this study was to ex-
plore the acceptability of overground wearable powered exoskeletons used in rehabilitation
among people with SCIs.

**2. Materials and Methods**

2.1. *Design and Participants*

A qualitative study with a descriptive interpretative approach [23] using semi-
structured interviews was conducted [24]. A qualitative design was used to provide
an in-depth exploration of the acceptability of the SCI users [25]. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used [26].

A multicenter study was conducted since participants were recruited from two rehabilitation facilities, namely the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSS-CN) in Quebec, Canada, and the Centre Mutualiste de Rééducation et de Réadaptation Fonctionnelles de Kerpape (CMRRFK) in Ploemeur, France. These two rehabilitation facilities offer rehabilitation care for people with SCIs, which encompasses rehabilitation exoskeleton treatment among other modalities. To be eligible to participate in the interview, people with SCIs had to have used an exoskeleton during their rehabilitation at the CMRRFK or the CIUSSS-CN. People who were unable to consent or complete interviews were not included. In addition, each patient was screened by a referring physician before inclusion in the study to ensure safety and relevance of the use of an exoskeleton. This study was approved by local Research Ethics Boards from the Université de Lille (2023-701-S117) and from the CIUSSS-CN (MP-13-2020-2002). Procedures were conducted in accordance with relevant laws and institutional guidelines. Participants provided their informed consent.

## 2.2. *Description of Exoskeletons and Context of Use*

The CIUSSS-CN uses the Indego® powered lower limb exoskeleton with functional electrical stimulation developed by Parker Hannifin Corporation® (Cleveland, United States) and currently supported by Ekso Bionics® (San Rafael, United States). The Indego® is an exoskeleton used for people with SCIs (levels C7 to L5) and for people with hemiplegia [27]. However, at the time of this study, the use of this technology was restricted to a research project at the CIUSSS-CN for future clinical implementation. Hence, participants were required to adhere to a predetermined protocol outlined within the ongoing research project for the conduct of the rehabilitation sessions [28]. Table 1 illustrates the overall step-by-step process of using the exoskeleton at the CIUSSS-CN according to Charette et al., 2024 [28]. To have access to the locomotor training program with the exoskeleton at the CIUSSS-CN, participants had to: (1) be aged between 18 and 70 years old; (2) have an incomplete SCI; (3) be in the subacute stage of recovery (<1 year post-injury); (4) be able to stand and/or walk therapeutically; (5) have a minimum/sufficient upper limb strength to use a rolling walker; (6) have a height between 5'1" and 6'1"; (7) have a weight <200 lbs (90 kg); (8) have a length of femurs between 37 and 49 cm; (9) have a seated hip width <42 cm; (10) have a medical approval to participate in the project following consultation with the multidisciplinary team; and (11) have a standing tolerance >15 min.

The CMRRFK uses the hand-free and self-balancing Atalante® exoskeleton developed by Wandercraft (Paris, France). The use of the exoskeleton is implemented into conventional clinical therapy sessions offered to people with SCIs by physiotherapists. Locomotor training with the exoskeleton is performed under medical prescription. To have access to the locomotor training program with the exoskeleton at the CMRRFK, participants had to (1) be at least 18 years old; (2) have a paraplegia; (3) tolerate daily verticalization; (4) have a height between 160 cm and 190 cm; (5) weight <90 kg; (6) have a hip width less than or equal to 460 mm in a sitting position; and (7) have thigh length between 380 and 460 mm. Additionally, leg length is also a criterion for inclusion, but this criteria varies according to user's range of motion in foot dorsiflexion.

The exclusion criteria for the use of the Indego® and Atalante® exoskeletons are provided in Supplementary Materials; Table S1 and Table S2, respectively.
<table><caption>**Table 1.** Step-by-step process of using the exoskeleton at the CIUSSS-CN.</caption><thead><tr><td>Sessions</td><td>Duration</td><td>Procedures</td></tr></thead><tbody><tr><td>(1) Initial session (Exoskeleton adjustment)</td><td>60 min for fitting the exoskeleton depending on the user</td><td>(1.1) Adjustment of the exoskeleton for the user (sitting position).<br>(1.2) Teaching and practicing sit-to-stand and stand-to-sit transfers (2–3 repetitions).<br>(1.3) Re-adjustment of the exoskeleton in standing or sitting position, if necessary.<br>(1.4) For some patients, walking between parallel bars was initiated.</td></tr><tr><td>(2) Familiarization period</td><td>2–4 sessions, 60 min each, depending on the user's capacity</td><td>(2.1) Practice of sit-to-stand and stand-to sit transfers.<br>(2.2) Walking between parallel bars, including learning to initiate gait, continue walking, and stop using the exoskeleton.<br>(2.3) Once the user was deemed safe using the exoskeleton between parallel bars, walking with a walker in a corridor of the rehabilitation center was attempted for approximately 20 m.<br>(2.4) For patient eligible for functional electrical stimulation (FES), the final session of the familiarization period was dedicated to adjusting FES parameters (amplitude, pulse width and frequency) for each stimulated muscle group.</td></tr><tr><td>(3) Locomotor training program</td><td>12 sessions, 60–90 min depending on the user</td><td>(3.1) At the beginning of each session, electrodes for FES were applied, and the exoskeleton was adjusted for the user (12–20 min)<br>(3.2) Adjustment of the exoskeleton's walking parameters (e.g., step length and height, walking speed, motorized assistance for both hip and knee joints) based on the user's capacity.<br>(3.3) The session duration and walking time were individualized based on the user's capacity, with the primary goal of optimizing the number of steps taken during each session.<br>(3.4) After four sessions, the training program was progressed by either reducing motorized assistance, transitioning from a walker to forearm crutches, or further increasing the number of steps taken during each session. FES parameters were also adjusted after four sessions, if necessary.</td></tr></tbody></table>

## 2.3. Data Collection

The recruitment of participants differed between the two rehabilitation centers, but the data collection process was similar. The recruitment began on 20 August 2022 at the CIUSSS-CN and on 1 June 2023 at the CMRRFK. At the CIUSSS-CN, the study was intro-
duced to individuals with SCIs who had used a rehabilitation exoskeleton by a member of the research team (C.C). If they were interested in taking part in the project, a Master’s student, having previous experience and knowledge in conducting interviews (N.F.-B.), contacted participants by telephone or by email. The sociodemographic data of participants at the CIUSSS-CN were collected as part of the ongoing research project. At the CMRRFK, the study was presented to clinicians by a member of the research team (N.F.-B.). People with SCIs were then offered to participate in the present project by the clinicians. Sociodemographic data were collected during the interview session for participants at the CMRRFK (e.g., gender, age, exoskeleton used, time using an exoskeleton).

Semi-structured interviews were conducted in person for participants still residing in the rehabilitation center and via telephone or videoconference using Zoom [29] for participants who had transitioned home or to other facilities offering rehabilitation services. Interviews were conducted by two authors (N.F.-B. and A.C) who had no prior relationship with the participants. Interviews were conducted in French or in English between 7 July 2021 and 26 July 2023 at the CIUSSS-CN and between 5 June 2023 and 22 June 2023 at the CMRRFK. All interviews were audio recorded for transcription.

An interview guide was developed by the research team members who all together have knowledge of exoskeletons and the context in which the technology is used. The interview guide (in Supplementary Material) was developed with consideration to different determinants of behavioral change according to the theoretical domains framework (TDF) (e.g., knowledge, abilities, motivations, and emotions toward the technology) [30] and inspired by various contextual elements that were deemed as potentially influencing the adoption and use of the exoskeleton in a larger implementation study [28]. An additional question was added to explore the satisfaction with the exoskeleton. The interview guide included a total of 30 questions and 7 prompts.

The interview guide was not pretested considering the limited number of individuals with SCIs who had used the exoskeleton, but it was validated by an expert at the CIUSSS-CN (C.R.) Additionally, the interview guide underwent validation with a physiatrist (S.L.) working with individuals with SCIs at the CMRRFK, ensuring the questions were culturally relevant and appropriately adapted to the context.

## 2.4. Data Analysis

Interviews were analyzed through thematic analysis [31] with a mixed approach (deductive and inductive) [32] using the conceptual theoretical framework of acceptability (TFA) developed by Sekhon et al. [16] to explore the acceptability of the exoskeleton [16] (see Figure 1). An initial coding tree covering all the seven domains of the TFA (i.e., affective attitude, burden, perceived effectiveness, ethicality, intervention coherence, opportunity costs, and self-efficacy) [16] was used to analyze the interviews [16]. After becoming familiar with the interviews, two co-authors (N.F-B and A.P) with complementary experience (social worker and occupational therapist) independently analyzed two interviews as part of a standardization process. Then, they met to compare their interpretation of the coding tree. The first author (N.F-B) proceeded to code the remaining interviews, and meetings were scheduled to discuss the interpretation of the content. A third person, a professor-researcher (M-E.L.), was involved to provide guidance on the analysis of the interviews. The quotes included in this article have been translated from French to English using a translation software (i.e., DeepL software; version 24.10.11297902).
<figure><img src="image_3.png" /><figcaption>**Figure 1.** Domains of the theoretical framework of acceptability (TFA) [16].</figcaption></figure>

### 3. Results

Nine participants who completed the exoskeleton training program at the CIUSSS-CN, and five participants at the CMRRFK agreed to take part in the interview, for a total of 14 participants. The mean (SD) age was 46.9 (14.8) years old; most participants were men (64%) and had a traumatic SCI (79%) (Table 2). Interview duration ranged from 19 to 63 min.

<table><caption>**Table 2.** Characteristics of the participants.</caption><thead><tr><th>Characteristics</th><th>n (%)</th></tr></thead><tbody><tr><td>Age, years (mean [SD])</td><td>46.9 [14.8]</td></tr><tr><td>Gender</td><td></td></tr><tr><td>Women</td><td>5 (36)</td></tr><tr><td>Men</td><td>9 (64)</td></tr><tr><td>Country</td><td></td></tr><tr><td>France</td><td>5 (36)</td></tr><tr><td>Canada</td><td>9 (64)</td></tr><tr><td>Time since the injury of all participants, months (mean [SD])<sup>1</sup></td><td>9.9 [7.6]</td></tr><tr><td>Time since the injury of Canada's participants, months (mean [SD])<sup>2</sup></td><td>6.5 [3.54]</td></tr><tr><td>Time since the injury of France's participants, months (mean [SD])<sup>3</sup></td><td>43.8 [9.45]</td></tr><tr><td>Mechanism of injury</td><td></td></tr><tr><td>Non-traumatic</td><td>3 (21)</td></tr><tr><td>Traumatic</td><td>11 (79)</td></tr><tr><td>Self-reported level of injury</td><td></td></tr><tr><td>High-Cervical Nerves (C1-C4)</td><td>1 (7.1)</td></tr><tr><td>Low-Cervical Nerves (C5-C8)</td><td>2 (14.3)</td></tr><tr><td>Thoracic Nerves (T1-T5)</td><td>1 (7.1)</td></tr><tr><td>Thoracic Nerves (T6-T12)</td><td>8 (57.1)</td></tr><tr><td>Lumbar Nerves (L1-L5)</td><td>2 (14.3)</td></tr><tr><td>Sacral Nerves (S1-S5)</td><td>0</td></tr></tbody></table>

Results relevant to the acceptability of exoskeletons are presented according to overall main themes including all seven domains. Figure 2 presents the summary of the main findings.

<footnote n="1">¹ Missing information for three participants. ² Missing information for two participants. ³ Missing information for one participant.</footnote>
<figure><img src="image_4.png" /><figcaption>**Figure 2.** Summary of the main findings.</figcaption></figure>

### 3.1. *General Positive Affective Attitude*

Most participants had no initial apprehension about using the exoskeleton in their rehabilitation. The exoskeleton was considered an additional tool for achieving their rehabilitation goal. In this regard, half of the participants hoped to walk again after using the exoskeleton:

> "That's what I was hoping for and still hope for that it would help me walk again.
> [...] I was ready to take part in anything. That was my hope, to shock my body and then stand up most of the time. Then, the exoskeleton was part of it. We did big sessions. I wanted to take a lot of steps too, to give myself every chance."

*(Participant in Quebec City, Canada)*

Some participants mentioned having no expectations regarding experience or outcomes to avoid disappointment. A few participants were primarily interested in better understanding the device. Three participants reported that their expectations had been met:

> "Because it put me back on my feet, because it gave me a little hope because it gave me hope. And it [the exoskeleton] really exceeded my expectations, I was able to have fun with it."

*(Participant in Ploemeur, France)*
Almost all participants indicated that they were extremely motivated to use an exoskeleton. While walking again was identified as their main goal and motivation, others had an objective to achieve a more natural walking pattern. Their motivation stemmed from a willingness to explore every available tool that could assist in their rehabilitation, as well as to contribute to the advancement of knowledge about the exoskeleton for the benefit of others. In this regard, three participants expressed feeling privileged to use an exoskeleton during their rehabilitation:

> "I was very motivated. I was told that I was lucky to be able to participate in this [to use the device], and that it wasn't for everyone. So, well, I saw it as another chance, another tool, to help me achieve walking as normally as possible."

(Participant in Quebec City, Canada)

One participant, who felt that the exoskeleton had not been used sufficiently to observe significant improvement, expressed moderate satisfaction. However, almost all participants reported being satisfied or very satisfied with the exoskeleton, even if they did not all achieve their desired outcomes:

> "[I] am very grateful, but [I] don't have the end result we'd like. We'd all like the miracle."

(Participant in Quebec City, Canada)

A few participants reported that their relatives were excited, happy, and impressed to see the potential benefits of exoskeleton use on their loved ones with an SCI. However, participants had to explain the actual effects to their relatives:

> "For them [relative], it's magical to be able to see us again through videos of us walking vertically, especially since they mostly see us in a wheelchair. However, from their perspective, they see it more as an indication that, since we're in it, we must be going to walk again. It's always a bit more complicated to explain to them that it's not necessarily the case, but it's a good tool for rehabilitation."

(Participant in Ploemeur, France)

In summary, participants were generally motivated and satisfied with using an exoskeleton during their rehabilitation, and the majority had no apprehensions or expectations.

## 3.2. Requirements for Physical and Cognitive Engagement

Almost all participants reported that using an exoskeleton was physically and cognitively demanding. On the one hand, it required a high level of attention to follow instructions given by the therapist during sessions:

> "You have to be 100% focused on every step, on every breath, leaning forward, which is unnatural. You must be 100% focused. And especially at the beginning; I couldn't talk and walk at the same time."

(Participant in Quebec City, Canada)

On the other hand, the use of the exoskeleton was physically demanding, especially at the beginning of use, even if the participants were in good physical shape:

> "It's a lot of energy, a lot of energy for a little progress."

(Participant in Quebec City, Canada)

In this regard, a few individuals reported that the device was massive and heavy. A participant also expressed that the device looked like a robot. Additionally, four participants reported experiencing minor soreness during or after sessions, including back pain,
discomfort around the lesion, tendon rubbing, spasms, and minor grazes. Nevertheless, participants said that the therapists had been alerted and that the pain was minor:

> "I was more satisfied to have done it than the pain it would bring. The pain was small. [...] All the happiness of having done it made up for the pain it brought."

(Participant in Quebec City, Canada)

Finally, one participant living outside the area where the exoskeleton sessions took place reported significant costs, particularly for travel and accommodation. Certain expenses should have been covered to enable more participants to use the exoskeleton to advance knowledge of this device:

> "Candidates from outside [...] they should absolutely have an allowance for the hotel, an allowance for meals, then a travel allowance. Because if not, it [knowledge about exoskeletons] won't advance as much."

(Participant in Quebec City, Canada)

All these results highlighted, in sum, the physical and cognitive demands of using an exoskeleton, as well as the massiveness and heaviness of the device.

### 3.3. *Emerging Ethical Considerations*

Few participants discussed ethical issues regarding the use of exoskeletons. One participant reported disappointment due to the temporary effects of the use of the device:

> "On the downside, there's the disappointment, of course. When you finish, you go back into a wheelchair. That's how it is, it's part of the game; you must accept it. Accepting it is already a chance to be able to try it. I was aware of that."

(Participant in Ploemeur, France)

Another participant expressed the possibility of false hope regarding the outcomes of the use of the exoskeleton, highlighting the importance of carefully selecting participants:

> "These are the tests that are conducted [before use] which will determine whether you can go in or not. I think putting someone in it, especially someone on whom we are almost certain will not walk again, and giving them false hope, may not necessarily be a good idea; hence the tests conducted at the beginning."

(Participant in Ploemeur, France)

Finally, a participant reported that access to the use of an exoskeleton in the rehabilitation process of people with SCI should be more inclusive:

> "Like me, I was pretty standard, no health issues, height, size, it fits, everything is fine. Granted, there are those who may not be as fortunate and might possibly need it, but in a future, maybe not too distant, we can understand that it might be enjoyable for those individuals to have access to a similar experience"

(Participant in Quebec City, Canada)

In sum, few ethical considerations were discussed, but the risk of disappointment, the possibility of false hope, and accessibility issues were reported by participants.

### 3.4. *Variable Intervention Coherence*

Most participants did not have prior knowledge about exoskeletons before being approached by therapists to use the device. Even if the majority of participants received sufficient information from their therapists, others reported insufficient information about the benefits and risks. A participant suggested presenting short videos to future participants before use to increase their knowledge:
"Perhaps there could have been some small videos featuring 2-3 people without showing their faces, maybe doing the workout sequence. And, maybe showing when they put on the device. [...] It would probably be interesting to be able to see a short video before signing the consent. I don't think it scares people."

(Participant in Quebec City, Canada)

One participant discovered exoskeletons through the media:

"Like everyone else. I saw it a little in the media, but without thinking that one day I would have the opportunity to try it as a patient at the center."

(Participant in Ploemeur, France)

Participants reported that individuals with an SCI having strength, endurance, and determination and who fit the inclusion criteria should have the opportunity to use an exoskeleton during rehabilitation. Some participants would have liked to use the device earlier in their rehabilitation and to continue using it for a longer period. However, one participant said that the frequency of sessions was adequate, given the effort required to participate:

"I had two sessions a week, and then that was fine. I'm not sure I would have taken three, certainly not four, because it's very demanding."

(Participant in Quebec City, Canada)

Finally, three participants reported that they would have liked to use the exoskeleton in real-world situations but that the usage of the exoskeleton is currently mainly in the context of rehabilitation:

"What does it give me to take 2500 steps with two crutches if I can't go grocery shopping? I can't go for a walk. Because I walk on hard surfaces, so..."

(Participant in Quebec City, Canada)

Overall, these results highlighted the lack of prior knowledge about exoskeletons and that participants would have liked to use the device earlier and longer in their rehabilitation.

### 3.5. *Remaining Opportunity Costs*

The exoskeleton was deemed time-consuming to install, especially during the initial fitting sessions. One participant reported that this initial preparation takes therapy time:

"It's the implementation because we have an hour of physiotherapy, and as a result, it takes three-quarters of an hour to set up. But that's the way it is. You must accept it, so you're a guinea pig for 45 min for ten minutes of walking. You have to accept it."

(Participant in Ploemeur, France)

A participant also reported not being autonomous during the use of the exoskeleton, unlike when his wheelchair is used, resulting in a temporary loss of autonomy:

"I could never walk as fast as the exoskeleton allows me to, but with my canes, I walk more slowly but I can walk, I can climb stairs, which I can't do with an exoskeleton, it would limit me. I can go down a ramp, I can turn, I can... and then when I want to shave, and I stand up because I am able to stand, it won't take me 15 min to put on the device."

(Participant in Quebec City, Canada)

Finally, while most participants reported no technical problems and adequate equipment, four participants reported that the device freezes and jams, as well as problems with the waist belt, resulting in loss of time and inefficient use of therapeutic expertise.
In sum, these findings highlighted the additional time needed for setting up exoskeletons and the occurrence of technical and equipment-related issues.

### 3.6. *Positive Perception of Effectiveness*

The participants' perceptions of the effectiveness of the exoskeleton during their rehabilitation varied widely. A few participants reported benefits such as better walking pattern, increased endurance, increased muscle mass, greater leg strength, less spasticity, and improved ability to walk and walk faster:

> "I liked feeling like I did before my accident."

(Participant in Quebec City, Canada)

However, one participant reported not feeling enough benefit from using this technology. In addition, few participants noted the challenge to distinguish the effects of the exoskeleton from those of other conventional rehabilitation therapies to achieve a clear picture of the benefits:

> "I was still willing to do anything to try to improve my condition. So, I don't know if it improved anything, but I think it's a combination of all the little progress I've had, but it's connected to physiotherapy, the exoskeleton, and all that. That's for sure better than lying in bed."

(Participant in Quebec City, Canada)

Participants identified several barriers that could limit the exoskeleton's effectiveness in rehabilitation settings, including physical constraints in the training environment, such as narrow corridors, crowded spaces, and uneven floors. However, the support received from the therapists and their knowledge, such as giving advice, being attentive to participants' needs, and establishing a sense of trust, was reported to be an important facilitator of exoskeleton use:

> "Like being in symbiosis with the person behind you to support you. So, you need to communicate together, and it helps a lot."

(Participant in Quebec City, Canada)

Overall, most participants perceived that the use of the exoskeleton during their rehabilitation was suitable and relevant for them. When questioned, almost all participants said that the use of an exoskeleton should be offered to improve the rehabilitation of people with SCI:

> "I think it can be a good complement. [...] It's a somewhat less medical approach to things. As I was saying, through games or through activities like this, where ultimately, one can regain a certain movement without even realizing it, to strengthen muscles, even at the level of the torso, arms, and all that."

(Participant in Ploemeur, France)

In conclusion, participants recognized the overall benefits of exoskeleton use, although attributing these benefits specifically to the device remains challenging. They also identified barriers and facilitators that could influence the effectiveness of this technology.

### 3.7. *Confident Self-Efficacy*

Despite the physical and cognitive demands of using the device, most participants reported no difficulties or issues in remembering the steps involved in using it. Of note, a few participants reported higher complexity in learning how to use it at first, but that the usability improved over time:
"At first, [it's] quite challenging. [...] Because it's not just a machine, it's not just a robot. You must understand it. Its functioning is designed to be as close as possible to our natural movements, and you must understand that it's a robot that's doing it. So, you also need to... it accompanies you, and you must accompany it at the same time. We must become one. That's why I talk about a second skin, because it's a bit like that."

(Participant in Ploemeur, France)

Participants identified key qualities for using the device, including mental focus, realistic expectations, and motivation. They emphasized the importance of determination, ambition, and persistence:

"You must be ready to stand up, to be supported by a machine. [...] When you've been lying down, or at least sitting for long months and suddenly, it's a machine that allows us to [walk]—there's no need to be apprehensive about that, I think."

(Participant in Ploemeur, France)

In summary, participants identified necessary skills for using exoskeletons and reported no difficulties in remembering the steps for using the device.

## 4. Discussion

The objective of this study was to explore, among individuals with SCIs, the acceptability of locomotor exoskeletons as used in two rehabilitation centers located in France and Canada. Participants generally expressed positive acceptability regarding the exoskeleton used. Almost all participants reported a high level of satisfaction with the use of the exoskeleton in their rehabilitation. This satisfaction remained high despite the exoskeleton not meeting all of the participants' expectations and a few experiencing discomforts. Most participants perceived the use of the exoskeleton as effective, experiencing little to no difficulty in its use, despite its physical and cognitive demands. While few participants reported ethical issues, some highlighted considerations regarding access to exoskeletons and possibilities of unrealistic expectations toward the use of the technology. To favorize the successful implementation of exoskeletons in facilities offering rehabilitation services for people with SCI, it is crucial to have before considering other features sufficient information on the acceptability of this technology by users [33]. The results of this multicenter study, based on TFA, provide in-depth insights into the diverse experiences of individuals with SCI regarding the perceived acceptability of this technology. These results add additional knowledge to the previous studies conducted about the feasibility and effectiveness of exoskeletons used in rehabilitation. Overall, these results are consistent with a systematic literature review reporting a favorable acceptability of the use of exoskeletons among people with SCIs [21]. This literature review identified the need to assess the acceptability of this technology more systematically. The use of TFA thus enables this study to respond to this knowledge limitation.

The personal characteristics of participants, including individual culture and previous knowledge, might be an important factor that influences the acceptability and use of technologies. In the present study, most participants were unfamiliar with the exoskeleton before its use, although they had been informed about the risks and benefits and their few questions have been answered. A previous study found that most people with SCI learned about exoskeletons through traditional media channels (e.g., documentaries or news on television) [19]. The extent to which suboptimal knowledge about the effects of exoskeletons influences expectations should be examined in future studies. In this regard, clinicians involved in the study of Heinemann et al., 2018 reported that high expectations in terms of perceived benefits may be a risk for users [34]. Considering that potential benefits
of exoskeleton use extend beyond physiological effects and can have a great psychological influence, these high expectations may be particularly common [35]. Consequently, future studies should focus on the development of an intervention to facilitate the adoption of realistic expectations by people using a rehabilitation exoskeleton to avoid disappointment toward technology, and, in turn, a low acceptability. This intervention could take the form of an educational activity aimed at enhancing the knowledge of both current and potential users.

Moreover, users with an SCI may feel privileged to be selected to use the exoskeleton. This feeling of privilege may bias the reported acceptability toward the exoskeleton in a favorable direction and thus potentially influence the findings. Indeed, the limited number of exoskeletons currently available in rehabilitation centers as well as the stringent eligibility criteria (e.g., morphology, level of injury) due to the characteristics of the device are major accessibility issues [36]. This context of limited technology availability highlights the relevance of the global principles of diversity, equity, and inclusion in the use and development of innovative technologies such as exoskeletons. Consequently, as proposed in the present study, developers, managers, decision makers, and others should initiate a collective reflection to ensure that exoskeletons can be used by a greater number of people with SCI or any other conditions leading to limitations in walking in the future.

The context of use of the exoskeleton [37], whether for clinical or research purpose, can also influence user acceptability. For example, in a research context, participants and clinicians must follow predetermined protocols. These protocols restrict the adaptability of exoskeletons and, to some extent, fail to consider users' expectations, goals, and capacities. This lack of adaptability can greatly influence the acceptance of the technology, as the personalization of interventions provided is an important factor of acceptability [38]. In addition, the intrinsic features of a specific exoskeleton model that influence perceived effectiveness may also impact user acceptability [16]. For example, the Atalante exoskeleton allows users to have their arms free during its use which, in turn, allows the combination of upper-body activities with walking rehabilitation. Therefore, it is essential to analyze the goals of users when implementing a rehabilitation exoskeleton.

Limitations of our study must be considered. First, the context of use in two different rehabilitation centers with potential cultural and organizational differences, may influence the results obtained. Future studies should comprehensively assess how the context of use influences the acceptability of exoskeletons among people with SCI. Second, the time since the occurrence of the SCI was much shorter for people with SCI using an exoskeleton at the CIUSSS-CN center than at the CMRRFK center. This may influence the perceived acceptability regardless of the exoskeleton per se. The different walking prognosis among the participants could also influence the acceptability of the technology. However, we did not discern any major differences in the participants' opinions. In addition, people with SCI at the CIUSSS-CN had to follow a research protocol for the use of the exoskeleton. The research protocol restricted the use of the exoskeleton to predefined sessions compared with more flexible sessions at the CMRRFK, where users had the possibility of performing different programs and even sporting activities. The number of usage sessions by participants could also influence their perspective. Indeed, Sekhon et al. describe well the influence of time on the acceptability of technology [16]. In addition, the interview guide was based on the TDF, and, consequently, users were not specifically asked about certain areas of the TFA (e.g., ethics). Finally, CIUSSS-CN participants were invited to take part in interviews only if they completed the twelve-session training program of the research protocol. Thus, the few participants who dropped out of the program were not invited to participate in the interviews and their perceived acceptability of the exoskeleton
may differ from those included in the study. Hypothetically, these individuals could report different experiences influencing their acceptability of the technology.

**5. Conclusions**

The exoskeleton is a promising rehabilitation technology that was generally accepted by the participants in this study. Indeed, the present study highlighted that users with SCI were satisfied with using an exoskeleton during their rehabilitation, even if the use was physically and cognitively demanding. Several perceived benefits to its use, such as better walking pattern, increased endurance and greater muscle mass, and mild pain were reported. The use of an exoskeleton during rehabilitation process was appropriate and relevant to them for most of the participants. However, adjustments in its use, such as conducting training sessions in obstacle-free environment and technological improvements to address the device's restrictive characteristics, heaviness, and massiveness are, however, still needed. In future studies, a deeper exploration of the ethical considerations will be important, along with efforts to increase the inclusivity of exoskeleton characteristics and accessibility for a broader spectrum of individuals with walking limitations.

**Supplementary Materials:** The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/biomimetics10010036/s1, Table S1: Exclusion criteria for the use of the Indego® exoskeleton; Table S2: Exclusion criteria for the use of the Atalante® exoskeleton; Interview questions.

**Author Contributions:** Conceptualization, N.F.-B., F.R., and M.-E.L.; methodology, N.F.-B., S.L., F.R., and M.-E.L.; formal analysis, N.F.-B., A.P., and M.-E.L.; investigation, N.F.-B. and A.C.; writing—original draft preparation, N.F.-B.; writing—review and editing, N.F.-B., A.P., S.L., M.-C.D., C.C., W.A., A.C., C.R., A.K.B., L.B., J.K., F.R., and M.-E.L.; supervision, S.L., M.-E.L., and F.R. All authors have read and agreed to the published version of the manuscript.

**Funding:** This work was partially carried out within the Handicap Innovation Territoire project, supported by the French Government as part of France 2030—Territoires d'innovation program for innovative territories and received funding from the Praxis Spinal Cord Institute (Research Grant No: G2020-33) and the Social Sciences and Humanities Research Council (Research Grant No: 892-2021-2033). Noémie Fortin-Bédard was supported through a scholarship from the Réseau provincial de recherche en adaptation-réadaptation (REPAR) and holds a master training award from the CIHR and from the Quebec Health Research Funds (FRQS) (#311138) in partnership with the Unité de soutien au système de santé apprenant (SSA) Québec. Salary support for François Routhier were provided by FRQS Senior Research Scholar program (#296761).

**Institutional Review Board Statement:** The study was conducted in accordance with the Declaration of Helsinki and approved by local Research Ethics Boards from the Université de Lille (2023-701-S117) and from the CIUSSS-CN (MP-13-2020-2002).

**Data Availability Statement:** Due to ethical reasons (i.e., the potential risk of identifying participants), the qualitative data are not available.

**Acknowledgments:** The authors thank the clinical teams of the myelopathy program of CIUSSS-CN center and from the spinal cord injury programs of CMRRFK for their contribution to the completion of this study. Conducting interviews in France by Noémie Fortin-Bédard was made possible with travel grants received from the Canadian Institutes of Health Research (CIHR), Mitacs Globalink program, and the Bureau International of Université Laval.

**Conflicts of Interest:** The authors declare no conflicts of interest.
## References

1. Statistiques Canada. Canadian Survey on Disability, 2017 to 2022. Available online: https://www150.statcan.gc.ca/n1/daily-quotidien/231201/dq231201b-eng.htm (accessed on 7 June 2023).

2. Liu, Y.; Yang, X.; He, Z.; Li, J.; Li, Y.; Wu, Y.; Manyande, A.; Feng, M.; Xiang, H. Spinal cord injury: Global burden from 1990 to 2019 and projections up to 2030 using Bayesian age-period-cohort analysis. *Front. Neurol.* **2023**, *14*, 1304153. [CrossRef] [PubMed]

3. World Health Organization. Spinal Cord Injury 2013. Available online: https://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury (accessed on 7 June 2023).

4. Juguera Rodriguez, L.; Pardo Rios, M.; Leal Costa, C.; Castillo Hermoso, M.; Perez Alonso, N.; Diaz Agea, J.L. Relatives of people with spinal cord injury: A qualitative study of caregivers' metamorphosis. *Spinal Cord* **2018**, *56*, 548–559. [CrossRef] [PubMed]

5. Estores, I.M. The consumer's perspective and the professional literature: What do persons with spinal cord injury want? *J. Rehabil. Res. Dev.* **2003**, *40* (Suppl. S1), 93–98. [CrossRef]

6. Ditunno, P.L.; Patrick, M.; Stineman, M.; Ditunno, J.F. Who wants to walk? Preferences for recovery after SCI: A longitudinal and cross-sectional study. *Spinal Cord* **2008**, *46*, 500–506. [CrossRef]

7. Anderson, K.D. Targeting recovery: Priorities of the spinal cord-injured population. *J. Neurotrauma* **2004**, *21*, 1371–1383. [CrossRef]

8. Stampacchia, G.; Olivieri, M.; Rustici, A.; D'avino, C.; Gerini, A.; Mazzoleni, S. Gait rehabilitation in persons with spinal cord injury using innovative technologies: An observational study. *Spinal Cord* **2020**, *58*, 988–997. [CrossRef] [PubMed]

9. Gil-Agudo, Á.; Megía-García, Á.; Pons, J.L.; Sinovas-Alonso, I.; Comino-Suárez, N.; Lozano-Berrio, V.; Del-Ama, A.J. Exoskeleton-based training improves walking independence in incomplete spinal cord injury patients: Results from a randomized controlled trial. *J. NeuroEng. Rehabil.* **2023**, *20*, 36. [CrossRef]

10. Miller, L.; Zimmermann, A.K.; Herbert, W.G. Clinical effectiveness and safety of powered exoskeleton-assisted walking in patients with spinal cord injury: Systematic review with meta-analysis. *Med. Devices Evid. Res.* **2016**, *9*, 455–466. [CrossRef] [PubMed]

11. Louie, D.R.; Eng, J.J.; Lam, T. Gait speed using powered robotic exoskeletons after spinal cord injury: A systematic review and correlational study. *J. NeuroEng. Rehabil.* **2015**, *12*, 82. [CrossRef] [PubMed]

12. Edwards, D.J.; Forrest, G.; Cortes, M.; Weightman, M.M.; Sadowsky, C.; Chang, S.-H.; Furman, K.; Bialek, A.; Prokup, S.; Carlow, J.; et al. Walking improvement in chronic incomplete spinal cord injury with exoskeleton robotic training (WISE): A randomized controlled trial. *Spinal Cord* **2022**, *60*, 522–532. [CrossRef]

13. Charbonneau, R.; Loyola-Sanchez, A.; McIntosh, K.; MacKean, G.; Ho, C. Exoskeleton use in acute rehabilitation post spinal cord injury: A qualitative study exploring patients' experiences. *J. Spinal Cord Med.* **2022**, *45*, 848–856. [CrossRef] [PubMed]

14. Chau, T.; Moghimi, S.; Popovic, M.R. Knowledge translation in rehabilitation engineering research and development: A knowledge ecosystem framework. *Arch. Phys. Med. Rehabil.* **2013**, *94*, S9–S19. [CrossRef]

15. Waldron, D.; Layton, N. Hard and soft assistive technologies: Defining roles for clinicians. *Aust. Occup. Ther. J.* **2008**, *55*, 61–64. [CrossRef] [PubMed]

16. Sekhon, M.; Cartwright, M.; Francis, J.J. Acceptability of healthcare interventions: An overview of reviews and development of a theoretical framework. *BMC Health Serv. Res.* **2017**, *17*, 88. [CrossRef]

17. Ramsey, A.; Lord, S.; Torrey, J.; Marsch, L.; Lardiere, M. Paving the Way to Successful Implementation: Identifying Key Barriers to Use of Technology-Based Therapeutic Tools for Behavioral Health Care. *J. Behav. Health Serv. Res.* **2016**, *43*, 54–70. [CrossRef] [PubMed]

18. Ben Mortenson, W.; Pysklywec, A.; Chau, L.; Prescott, M.; Townson, A. Therapists' experience of training and implementing an exoskeleton in a rehabilitation centre. *Disabil. Rehabil. 2022*, *44*, 1060–1066. [CrossRef]

19. van Silfhout, L.; Hosman, A.J.F.; van de Meent, H.; Bartels, R.H.M.A.; Edwards, M.J.R. Design recommendations for exoskeletons: Perspectives of individuals with spinal cord injury. *J. Spinal Cord Med.* **2023**, *46*, 256–261. [CrossRef]

20. van Dijsseldonk, R.B.; van Nes, I.J.; Geurts, A.C.; Keijsers, N.L. Exoskeleton home and community use in people with complete spinal cord injury. *Sci. Rep.* **2020**, *10*, 15600. [CrossRef]

21. Fortin-Bedard, N.; Dery, J.; Simon, M.; Blanchette, A.K.; Bouyer, L.; Gagnon, M.; Routhier, F.; Lamontagne, M.E. Acceptability of Rehabilitation Exoskeleton from the Perspective of Users with Spinal Cord Injury and Healthcare Professionals: A Mixed Methods Systematic Review. *medRxiv* **2024.09.18.24313846**.

22. Keith, R.A. Patient satisfaction and rehabilitation services. *Arch. Phys. Med. Rehabil.* **1998**, *79*, 1122–1128. [CrossRef] [PubMed]

23. Elliott, R.; Timulak, L. Descriptive and interpretive approaches to qualitative research. In *A Handbook of Research Methods for Clinical and Health Psychology*; Oxford University Press: New York, NY, USA, 2005; pp. 147–159.

24. Greenfield, B.; Jensen, G.M. Phenomenology: A powerful tool for patient-centered rehabilitation. *Phys. Ther. Rev.* **2012**, *17*, 417–424. [CrossRef]

25. Curry, L.A.; Nembhard, I.M.; Bradley, E.H. Qualitative and mixed methods provide unique contributions to outcomes research. *Circulation* **2009**, *119*, 1442–1452. [CrossRef]

26. Tong, A.; Sainsbury, P.; Craig, J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. *Int. J. Qual. Health Care* **2007**, *19*, 349–357. [CrossRef] [PubMed]
27. Ekso Bionics. Introduction to Ekso Indego® Therapy 2023. Available online: https://eksobionics.com/static/4d9b53aafcee35933e3df49873c26b3a/Ekso-Indego-Therapy-Exoskeleton-Website.pdf (accessed on 12 February 2024).

28. Charrette, C.; Faure, C.; Mailloux, O.; Simon, M.; Routhier, F.; Bouyer, L.; Blanchette, A.K. Feasibility and preliminary effects of a locomotor training program using an overground powered exoskeleton combined with functional electrical stimulation in clinical practice for individuals with a subacute spinal cord injury. Center for Interdisciplinary Research in Rehabilitation and Social Integration, Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale, Quebec, QC, Canada. 2024; In preparation.

29. Zoom Video Communications Inc. Zoom 2024. Available online: https://zoom.us/fr. (accessed on 7 March 2024).

30. Michie, S.; Johnston, M.; Abraham, C.; Lawton, R.; Parker, D.; Walker, A. Making psychological theory useful for implementing evidence based practice: A consensus approach. *Qual. Saf. Heal. Care* **2005**, *14*, 26–33. [CrossRef]

31. Braun, V.; Clarke, V. Thematic analysis. In *APA Handbook of Research Methods in Psychology, Vol 2: Research designs: Quantitative, Qualitative, Neuropsychological, and Biological*. APA Handbooks in Psychology®; Psychological Association: Washington, DC, USA, 2012; pp. 57–71.

32. Fereday, J.; Muir-Cochrane, E. Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development. *Int. J. Qual. Methods* **2006**, *5*, 80–92. [CrossRef]

33. Taherdoost, H. A review of technology acceptance and adoption models and theories. *Procedia Manuf.* **2018**, *22*, 960–967. [CrossRef]

34. Heinemann, A.W.; Jayaraman, A.; Mummidisetty, C.K.; Spraggins, J.; Pinto, D.; Charlifue, S.P.; Tefertiller, C.P.; Taylor, H.B.; Chang, S.-H.; Stampas, A.; et al. Experience of Robotic Exoskeleton Use at Four Spinal Cord Injury Model Systems Centers. *J. Neurol. Phys. Ther.* **2018**, *42*, 256–267. [CrossRef]

35. Maribo, T.; Jensen, C.M.; Madsen, L.S.; Handberg, C. Experiences with and perspectives on goal setting in spinal cord injury rehabilitation: A systematic review of qualitative studies. *Spinal Cord* **2020**, *58*, 949–958. [CrossRef]

36. Søraa, R.A.; Fosch-Villaronga, E. Exoskeletons for all: The interplay between exoskeletons, inclusion, gender, and intersectionality. *Paladyn J. Behav. Robot.* **2020**, *11*, 217–227. [CrossRef]

37. Charette, C.; Déry, J.; Blanchette, A.K.; Faure, C.; Routhier, F.; Bouyer, L.J.; Lamontagne, M.-E. A systematic review of the determinants of implementation of a locomotor training program using a powered exoskeleton for individuals with a spinal cord injury. *Clin. Rehabil.* **2023**, *37*, 1119–1138. [CrossRef] [PubMed]

38. Bennett, S.D.; Shafran, R. Adaptation, personalization and capacity in mental health treatments: A balancing act? *Curr. Opin. Psychiatry* **2023**, *36*, 28–33. [CrossRef]

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