Currently submitted to: JMIR Rehabilitation and Assistive Technologies
Date Submitted: Mar 25, 2026
Open Peer Review Period: Apr 17, 2026 - Jun 12, 2026
(currently open for review)
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Establishing consensus on the optimal applications of robotic exoskeleton walking in clinical practice: A Delphi Study
ABSTRACT
Background:
Despite the increasing global availability of robotic exoskeleton walking (REW), its clinical application remains highly inconsistent. This variability can be attributed to a lack of clinical guidelines and the significant time burden required for clinicians to synthesize emerging evidence. Consequently, there is a need for expert-driven consensus on how to optimize the integration of REW into neurological rehabilitation.
Objective:
To generate an international, expert-led consensus on the optimal clinical use of robotic exoskeletons in practice using a Delphi methodology.
Methods:
A three-round classic Delphi process was conducted. An international panel of twenty-six expert physiotherapists with significant clinical experience in REW was recruited. Panelists evaluated the use of robotic exoskeletons in terms of patient selection, treatment effects, dosage (frequency, duration, weeks of treatment), and integration with conventional physiotherapy. Consensus was predefined as 70% agreement, while median and interquartile range measured the central tendency of the results.
Results:
The panel reached a high level of consensus on several key areas necessary to support the use of REW in practice. Experts provided very strong consensus for specific conditions, notably incomplete spinal cord injury and stroke. Recommendations such as 2 -3 sessions per week for 30-45 minutes in sub-acute incomplete spinal cord injury, were established. Furthermore, the panel reached consensus on the necessity of "combination therapy," viewing REW as superior or complementary to conventional therapy in a variety of clinical circumstances.
Conclusions:
This study provides robust, expert-validated recommendations on the implementation of REW. REW should be prioritized in the rehabilitation of gait and motor control for incomplete SCI and stroke due to its high levels of consensus for benefit in these conditions. This contrasts with its role in non-ambulant neurological conditions (e.g., complete SCI where health benefits and symptom management are the expected therapeutic effects of REW). These consensus-based recommendations may help to reduce clinical uncertainty, bridging the evidence-practice gap in robotic-assisted rehabilitation, but should not act as a replacement for clinical reasoning and patient-centered decision making.
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