Christina Patterson
Osteoarthritis, the leading cause of impaired mobility in the elderly, affects all structures within a joint (3). Approximately twelve percent of the adult population is affected by osteoarthritis and approximately one fourth of adults over the age of 55 experience knee pain (2). In the case of osteoarthritis, hyaline articular cartilage is lost, and bony remodeling occurs. As cartilage continues to be lost, a variety of problems arise. Among them are malalignment and tilting. Some individuals with osteoarthritis often experience loss of mobility or function in the affected area. In almost all circumstances, though, patients quote the intense pain that they endure. Although cartilage does not contain pain receptors, the receptors in surrounding tissues are stimulated as a result of osteoarthritis (4).
One parameter that may be of importance to a study in persons with knee osteoarthritis (KOA) is the use of the Kellgren-Lawrence (KL) scale scoring systems. As KO can range in multiple levels of severity, it is important to differentiate between modern and severe levels of osteoarthritis. In doing so, it may be determined what type of users the Keeogo best serves. Furthermore, in a study analyzing what may determine pain severity in knee osteoarthritis, it was found that BMI and helplessness were both found to be positively correlated with pain (6).
The Keeogo is an assistive device that can be used by a variety of people with disabilities, especially those with osteoarthritis. Here is a short statement included on Keeogo’s website
“Using high-end sensors and advanced artificial intelligence proprietary software, the Dermoskeleton senses the user’s mobility intentions and generates synchronized movements at the motorized knees. The robotic system does not move for the user – instead, it senses the intended movement and provides the right level of assistance in perfect symbiosis with the body motion. Acting as a secondary artificial musculo-skeletal structure surrounding the body, the Dermoskeleton can protect the wearer against extreme activities, and prevent acute or chronic musculoskeletal injuries while increasing strength, endurance and stability.”
-Keeogo (http://keeogo.com/about-keeogo/the-science)
As discussed in the paragraph, Keeogo is primarily intended to aid the user in their movements. It does not do the moving entirely for them. Because the Keeogo sensese the intended movement, it is likely that there are some participants with extremely limited mobility that would not be able to use the Keeogo. However, the Keeogo does have a wide audience and could be used by millions of people in the US alone.
Participants that fall in the so-called treatment gap, with moderate osteoarthritis for who a total knee arthroplasty may be extreme, would likely be even more inclined to favor an exoskeleton product, especially if they experienced increased mobility(1). It seems that for patients with moderate KOA, total knee arthroplasty results are not as significant. Particularly for the large population of people with osteoarthritis under the age of 55, it can be difficult to justify such a procedure with the possibility of minimal improvement in quality of life.
Additionally, in 2005 roughly $11 billion dollars was spent on knee arthroplasties alone (5). In 2009, approximately $42.3 billion dollars were spent on knee and hip arthroplasties. Also in 2009, it was found that approximately 21 million people had arthritis related limitations. As found by the AARP, the average cost for a total knee arthroplasty is typically about $50,000. This number does not include the follow ups and repeated surgeries as many TKAs only last 10 to 15 years. The market price for the Keeogo is now approximately $39,000 dollars. This number is expected to decrease as the Keeogo is approved for use in more countries, and its industry is expanded. A number of Keeogo users will likely be able to use their insurance. There is also a tax credit that can help with covering the cost of the Keeogo. In comparison with the cost of surgery, the Keeogo is a feasible option that evades many of the risks of a total knee arthroplasty. As the number of people with arthritis is expected to rise from 50 million to 67 million by 2030, it is imperative that quality of life and inclusivity are stressed for the still-growing population of people with arthritis, especially osteoarthritis (7). As the market grows for devices like Keeogo, the cost will further decrease, so that more people with arthritis can afford to improve their quality of life.
In a study on older adults with KOA, researchers tested the effects of exercise on the participants. They concluded that exercise improved mobility and some function in the participants with KOA. However, they noted the study was limited and that more time may have produced more pronounced results (8). A product such as Keeogo may encourage both the young and older adults to exercise more. Furthermore, if Keeogo reduces their pain, users may be able to walk longer distances or lose weight as a result of the increased exercise.
For those people with previously high BMIs, Keeogo may help them to lose weight more easily and make that process much less painful. Rates of total joint arthroplasty infection rates are typically increased for obese persons (9). Once infection occurs, it often causes a significant loss of time, many financial issues, and increased pain. Therefore, obese individuals with arthritis might benefit from the use of an exoskeleton. An additional benefit of Keeogo for obese persons is their increased ability to exercise, and therefore lose weight, will likely relieve a large portion of the stress the is placed on their joints. While it may not remove the need for a device such as the Keeogo, it may preserve those areas of the body and decrease the limitations that those people experience in their daily routines.
As for measuring mobility, it may be beneficial to examine the difference in pain levels with an without the Keeogo in performing specific exercises testing mobility. As stated by Keeogo, approximately half of the patients immediately saw an increase in their 6MWT (10). The original study did examine mobility, however, it was only tested at a maximum of 6 weeks. In future studies, allowing a number of participants to use the Keeogo over a more significant period of time will likely give more insight as to some of the long-term improvements and issues that may arise after daily usage over an extended period. Furthermore, the habits of each participant are not likely to drastically change in a short period of time. Rather, the small changes form a large change compositely.
Keeogo’s applications extend to a variety of populations. Its target audience is open to anyone who has limited mobility or walking endurance. Therefore, there is a vast market for the Keeogo, especially for people over the age of 55, both with and without arthritis(11). There have been previous exoskeletons that have been found to reduce metabolic cost. In one study by the Public Library of Science (PLOS), using a performance index they reduced the metabolic cost with a pneumatic exoskeleton. To properly examine Keeogo, it may be of interest to measure the increase or reduction in energy expended by each participant. In the study by PLOS, they mentioned their use of a computerized O2-CO2 analyzer flow meter by Oxycon Pro (16). While this method may not be feasible in a residential setting, it may be worthwhile to have future study participants self-measure the amount of energy they are using each day with and without the Keeogo’s aid.
Because one of Keeogo’s features is its ability to increase walking endurance, it may be of interest to find the exoskeletons effects on each individual’s walking ability and distance. There are multiple methods that could be enacted to test this. It is possible to purchase low-cost tracking devices with pedometer capabilities. However, it may be difficult to receive consent from many participants. Since that option may be difficult to carry out, it may be beneficial to use a device that solely tracks the distance each person walks in the span of their day without the use of any GPS. Using this method, the participant’s previous distances should be either estimated or measured over a small period of time so as to have a comparison and idea of the improvements aided by the Keeogo.
To further understand the effects of the Keeogo, gait speed and symmetry would both be potentially helpful variables to measure. The reduced motion of the knee joint in knee osteoarthritis can cause increased pelvic motion(13). This can in turn affect the lumbar region of the spine and cause pain in all areas involved(14). If the motion of the knee joint were to be increased, it is likely many of the individuals’ gaits would normalize. As gait speed and symmetry are positively correlated in most cases, the normalized gait would lead to a more efficient and enjoyable walking experience (15). Furthermore, as gait speed is typically expected to decline in individuals with knee osteoarthritis, measuring the speed could find if the Keeogo helps prevent that decline.
In all of these parameters, it is suggested that the success rates are fairly sensitive particularly with participants who have severe KOA. Even small changes change make large impacts on their everyday lives. Conversely, in people with more mobility, it may be worthwhile set or expect a greater difference in the various aspects that will be tested. The Keeogo website has not published in depth about the lifespan and maintenance of such a device, but that is definitely an important factor for a high technology item like Keeogo. As well as the Keeogo’s great capabilities, it may be a more inclusive device because of the large percentage of the entire adult and older adult population that would use Keeogo.
McGibbon CA, et al, Effects of an over-ground exoskeleton on external knee moments during stance phase of gait in healthy adults, Knee (2017),
Felson, David T. "Osteoarthritis of the knee." New England Journal of Medicine 354.8 (2006): 841-848.
Roman‐Blas, Jorge A., et al. "Combined Treatment With Chondroitin Sulfate and Glucosamine Sulfate Shows No Superiority Over Placebo for Reduction of Joint Pain and Functional Impairment in Patients With Knee Osteoarthritis: A Six‐Month Multicenter, Randomized, Double‐Blind, Placebo‐Controlled Clinical Trial." Arthritis & rheumatology 69.1 (2017): 77-85.
Mochizuki, ROBERT M., and D. J. Schurman. "Patellar complications following total knee arthroplasty." JBJS 61.6 (1979): 879-883
Losina, Elena, et al. "Cost-effectiveness of total knee arthroplasty in the United States: patient risk and hospital volume." Archives of internal medicine 169.12 (2009): 1113.
Creamer, P., M. Lethbridge-Cejku, and M. C. Hochberg. "Determinants of pain severity in knee osteoarthritis: effect of demographic and psychosocial variables using 3 pain measures." The Journal of Rheumatology 26.8 (1999): 1785-1792.
Murphy, Louise, and Charles G. Helmick. "The impact of osteoarthritis in the United States: a population-health perspective." AJN The American Journal of Nursing 112.3 (2012): S13-S19.
Ettinger, Walter H., et al. "A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis: the Fitness Arthritis and Seniors Trial (FAST)." Jama 277.1 (1997): 25-31.
Malinzak, Robert A., et al. "Morbidly obese, diabetic, younger, and unilateral joint arthroplasty patients have elevated total joint arthroplasty infection rates." The Journal of arthroplasty24.6 (2009): 84-88.
Paper by Keeogo
https://exoskeletonreport.com/product/keeogo/ (Keeogo website description)
https://www.aarp.org/health/conditions-treatments/info-12-2013/knee-replacement-surgery-nancy-snyderman.html
Wilson, Janie L. Astephen. "Challenges in dealing with walking speed in knee osteoarthritis gait analyses." Clinical biomechanics 27.3 (2012): 210-212.
Bejek, Zoltán, et al. "The influence of walking speed on gait parameters in healthy people and in patients with osteoarthritis." Knee Surgery, Sports Traumatology, Arthroscopy 14.7 (2006): 612-622.
Roth, Elliot J., et al. "Hemiplegic gait: Relationships between walking speed and other temporal parameters1." American journal of physical medicine & rehabilitation 76.2 (1997): 128-133.
Malcolm, Philippe, et al. "A simple exoskeleton that assists plantarflexion can reduce the metabolic cost of human walking." PloS one 8.2 (2013): e56137.