## 3 Treatments for Spinal Cord Injury
### Exoskeletons and Robotic Systems  
Exoskeletons have been used to increase the independence of a patient with spinal cord injury [34]. This method is predominantly used in patients who have control over their hip flexion but do not have control over the knee and ankle muscles. A study performed by [PERSON] developed two robotic orthoses as part of an exoskeleton that allows for knee flexion and extension with a motor-harmonic drive actuation software [35]. Regarding the transportability of this method, the patient can carry a specifically designed backpack that contains the computer boards, various motor drives, and the battery that powers the equipment, as shown in Figure 5. Movement of the knee flexion and extension is gained through the stance-to-swing transition, which will be distinguished by the inertial recording units that are placed on top of each tibial support. The motor drivers will initiate the corresponding flexion extension that has been previously uploaded, particularly to the patient's motor functions. This equipment was tested on a female patient who was suffering from SCI at the T11 vertebrae. Overall, the results showed an increase in gait symmetry and a significant increase in walking capability. However, there are various limitations to this design. The exoskeleton itself is bulky and has various parts to its structure. Although it aids in walking, the quality of life for the patient may be diminished by the sheer volume of requirements and materials the patient must wear to be able to do so. Furthermore, the backpack that contains the electrical components of the equipment contains a battery that must be charged, creating a window of time where the patient is not able to use the equipment, therefore diminishing the longevity of usage.  
Moreover, a randomised clinical trial by [PERSON] et al. studied robotic exoskeleton gait training (RGT) post spinal cord injury as a rehabilitation approach [36]. This approach used dosing through the robotic exoskeleton to maximise neuroplastic potential in patients after spinal cord injury. There were 144 participants with motor incomplete spinal cord injury, obtained within six months of injury. Participants were randomised and categorised into three groups (high, moderate, low) and a control group who only received the usual care. Participants of each group completed 24 RGT sessions with assessments until nine months post SCI. Each participant's outcomes were measured on walking ability via walking index for spinal cord injury; health outcomes, which included gait speed, pain levels, fatigue,  
Figure 4: (**A**) A design image of the i360 device. (**B**) An image showing the implanted device wrapped around the spinal cord during surgery [32].  
physical activity, general health, and quality of life; and neuoplastic effects, assessing the motor-evoked potential amplitudes. The results show that high-frequency RGT sessions led to more significant improvements in walking ability and neuoplasticity. These patients further showed a significant gain in gait speed and independence in comparison to the control group. Finally, the neuoplastic assessment results suggested that RTG enhanced spinal cord recovery [36]. The spinal cord injury evaluated was motor-incomplete, meaning the impact on complete spinal cord injury is still unknown. Though this study showed significant effectiveness in reducing the effects of spinal cord injury, there are various limitations to this research, including duration of study and battery life concerns. This means there will be periods of time where the patients are not able to use the device, reverting to paralysis.