Switched Kinematic and Force Control for Lower-Limb Motorized Exoskeletons and Functional Electrical Stimulation

Millions of people experience movement deficits from neurological conditions (NCs) that impair their walking ability and leg function. Exercise-based rehabilitation procedures have shown the potential to facilitate neurological reorganization and functional recovery. Lower-limb powered exoskeletons and motorized ergometers have been combined with functional electrical stimulation (FES) to provide repetitive movement, partially reduce the burden of therapists, improve range of motion, and induce therapeutic benefits. FES evokes artificial muscles contractions and can improve muscle mass and strength, and bone density in people with NCs. Stationary cycling is recommended for individuals who cannot perform load-bearing activities or have increased risks of falling. Cycling has been demonstrated to impart physiological and cardiovascular benefits. Motorized FES-cycling combines an electric motor and electrical stimulation of lower-limb muscles to facilitate coordinated, long-duration exercise, while mitigating the inherent muscle fatigue due to FES. Lower-limb exoskeletons coupled with FES, also called neuroprostheses or hybrid exoskeletons, can facilitate continuous, repetitive motion to improve gait function and build muscle capacity. The human-robot interaction during rehabilitative cycling and walking yield a mix of discrete effects (i.e., foot impact, input switching to engage lower-limb muscles and electric motors, etc.) and continuous nonlinear, uncertain, time-varying dynamics. Switching control is necessary to allocate the control inputs to lower-limb muscle groups and electric motors involved during assisted cycling and walking. Kinematic tracking has been the primary control objective for devices that combine FES and electric motors. However, there are force interactions between the machine and the human during cycling and walking that motivate the design of torque-based controllers (i.e., exploit torque or force feedback) to shape the leg dynamics through controlling joint kinematics and kinetics. Technical challenges exist to develop closed-loop feedback control strategies that integrate kinematic and force feedback in the presence of switching and discontinuous effects. The motivation in this dissertation is to design, analyze and implement switching controllers for assisted cycling and walking leveraging kinematic and force feedback while guaranteeing the stability of the human-robot closed-loop system. In Chapter 1, the motivation to design closed-loop controllers for motorized FES-cycling and powered exoskeletons is described. A survey of closed-loop kinematic and force feedback control methods is also introduced related to the tracking objectives presented in the subsequent chapters of the dissertation. In Chapter 2, the dynamics models for walking and assisted cycling are described. First, a bipedal walking system model with switched dynamics is introduced to control a powered lower-limb exoskeleton. Then, a stationary FES-cycling model with nonlinear dynamics and switched control inputs is introduced based on published literature. The muscle stimulation pattern is defined based on the kinematic effectiveness of the rider, which depends on the crank angle. The experimental setup for lower-limb exoskeleton and FES-cycling are described. In Chapter 3, a hierarchical control strategy is developed to interface a cable-driven lower-limb exoskeleton. A two-layer control system is developed to adjust cable tensions and apply torque about the knee joint using a pair of electric motors that provide knee flexion and extension. The control design is segregated into a joint-level control loop and a low-level loop using feedback of the angular positions of the electric motors to mitigate cable slacking. A Lyapunov-based stability analysis is developed to ensure exponential tracking for both control objectives. Moreover, an average dwell time analysis computes an upper bound on the number of motor switches to preserve exponential tracking. Preliminary experimental results in an able-bodied individual are depicted. The developed control strategy is extended and applied to the control of both knee and hip joints in Chapter 4 for treadmill walking. In Chapter 4, a cable-driven lower-limb exoskeleton is integrated with FES for treadmill walking at a constant speed. A nonlinear robust controller is used to activate the quadriceps and hamstrings muscle groups via FES to achieve kinematic tracking about the knee joint. Moreover, electric motors adjust the knee joint stiffness throughout the gait cycle using an integral torque feedback controller. A Lyapunov-based stability analysis is developed to ensure exponential tracking of the kinematic and torque closed-loop error systems, while guaranteeing that the control input signals remain bounded. The developed controllers were tested in real-time walking experiments on a treadmill in three able-bodied individuals at two gait speeds. The experimental results demonstrate the feasibility of coupling a cable-driven exoskeleton with FES for treadmill walking using a switching-based control strategy and exploiting both kinematic and force feedback. In Chapter 5, input-output data is exploited using a finite-time algorithm to estimate the target desired torque leveraging an estimate of the active torque produced by muscles via FES. The convergence rate of the finite-time algorithm can be adjusted by tuning selectable parameters. To achieve cadence and torque tracking for FES-cycling, nonlinear robust tracking controllers are designed for muscles and motor. A Lyapunov-based stability analysis is developed to ensure exponential tracking of the closed-loop cadence error system and global uniformly ultimate bounded (GUUB) torque tracking. A discrete-time Lyapunov-based stability analysis leveraging a recent tool for finite-time systems is developed to ensure convergence and guarantee that the finite-time algorithm is Holder continuous. The developed tracking controllers for the muscles and electric motor and finite-time algorithm to compute the desired torque are implemented in real-time during cycling experiments in seven able-bodied individuals. Multiple cycling trials are implemented with different gain parameters of the finite-time torque algorithm to compare tracking performance for all participants. Chapter 6 highlights the contributions of the developed control methods and provides recommendations for future research extensions

Effectiveness of intensive physiotherapy for gait improvement in stroke: systematic review

Introduction: Stroke is one of the leading causes of functional disability worldwide. Approximately 80% of post-stroke subjects have motor changes. Improvement of gait pattern is one of the main objectives of physiotherapists intervention in these cases. The real challenge in the recovery of gait after stroke is to understand how the remaining neural networks can be modified, to be able to provide response strategies that compensate for the function of the affected structures. There is evidence that intensive training, including physiotherapy, positively influences neuroplasticity, improving mobility, pattern and gait velocity in post-stroke recovery. Objectives: Review and analyze in a systematic way the experimental studies (RCT) that evaluate the effects of Intensive Physiotherapy on gait improvement in poststroke subjects. Methodology: Were only included all RCT performed in humans, without any specific age, that had a clinical diagnosis of stroke at any stage of evolution, with sensorimotor deficits and functional gait changes. The databases used were: Pubmed, PEDro (Physiotherapy Evidence Database) and CENTRAL (Cochrane Center Register of Controlled Trials). Results: After the application of the criteria, there were 4 final studies that were included in the systematic review. 3 of the studies obtained a score of 8 on the PEDro scale and 1 obtained a score of 4. The fact that there is clinical and methodological heterogeneity in the studies evaluated, supports the realization of the current systematic narrative review, without meta-analysis. Discussion: Although the results obtained in the 4 studies are promising, it is important to note that the significant improvements that have been found, should be carefully considered since pilot studies with small samples, such as these, are not designed to test differences between groups, in terms of the effectiveness of the intervention applied. Conclusion: Intensive Physiotherapy seems to be safe and applicable in post-stroke subjects and there are indications that it is effective in improving gait, namely speed, travelled distance and spatiotemporal parameters. However, there is a need to develop more RCTs with larger samples and that evaluate the longterm resultsN/

Hybrid walking therapy with fatigue management for spinal cord injured individuals

In paraplegic individuals with upper motor neuron lesions the descending path for signals from central nervous system to the muscles are lost or diminished. Motor neuroprosthesis based on electrical stimulation can be applied to induce restoration of motor function in paraplegic patients. Furthermore, electrical stimulation of such motor neuroprosthesis can be more efficiently managed and delivered if combined with powered exoskeletons that compensate the limited force in the stimulated muscles and bring additional support to the human body. Such hybrid overground gait therapy is likely to be more efficient to retrain the spinal cord in incomplete injuries than conventional, robotic or neuroprosthetic approaches. However, the control of bilateral joints is difficult due to the complexity, non-linearity and time-variance of the system involved. Also, the effects of muscle fatigue and spasticity in the stimulated muscles complicate the control task. Furthermore, a compliant joint actuation is required to allow for a cooperative control approach that is compatible with the assist-as-needed rehabilitation paradigm. These were direct motivations for this research. The overall aim was to generate the necessary knowledge to design a novel hybrid walking therapy with fatigue management for incomplete spinal cord injured subjects. Research activities were conducted towards the establishment of the required methods and (hardware and software) systems that required to proof the concept with a pilot clinical evaluation. Speciffically, a compressive analysis of the state of the art on hybrid exoskeletons revealed several challenges which were tackled by this dissertation. Firstly, assist-as-needed was implemented over the basis of a compliant control of the robotic exoskeleton and a closed-loop control of the neuroprosthesis. Both controllers are integrated within a hybrid-cooperative strategy that is able to balance the assistance of the robotic exoskeleton regarding muscle performance. This approach is supported on the monitoring of the leg-exoskeleton physical interaction. Thus the fatigue caused by neuromuscular stimulation was also subject of speciffic research. Experimental studies were conducted with paraplegic patients towards the establishment of an objective criteria for muscle fatigue estimation and management. The results of these studies were integrated in the hybrid-cooperative controller in order to detect and manage muscle fatigue while providing walking therapy. Secondly closed-loop control of the neuroprosthesis was addressed in this dissertation. The proposed control approach allowed to tailor the stimulation pattern regarding the speciffic residual motor function of the lower limb of the patient. In order to uncouple the closed-loop control from muscle performance monitoring, the hybrid-cooperative control approach implemented a sequential switch between closed-loop and open-loop control of the neuroprosthesis. Lastly, a comprehensive clinical evaluation protocol allowed to assess the impact of the hybrid walking therapy on the gait function of a sample of paraplegic patients. Results demonstrate that: 1) the hybrid controller adapts to patient residual function during walking, 2) the therapy is tolerated by patients, and 3) the walking function of patients was improved after participating in the study. In conclusion, the hybrid walking therapy holds potential for rehabilitate walking in motor incomplete paraplegic patients, guaranteeing further research on this topic. This dissertation is framed within two research projects: REHABOT (Ministerio de Ciencia e Innovación, grant DPI2008-06772-C03-02) and HYPER (Hybrid Neuroprosthetic and Neurorobotic Devices for Functional Compensation and Rehabilitation of Motor Disorders, grant CSD2009-00067 CONSOLIDER INGENIO 2010). Within these research projects, cutting-edge research is conducted in the eld of hybrid actuation and control for rehabilitation of motor disorders. This dissertation constitutes proof-of concept of the hybrid walking therapy for paraplegic individuals for these projects. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------En individuos parapléjicos con lesiones de la motoneurona superior, la conexión descendente para la transmisión de las señales del sistema nervioso central a los músculos se ve perdida o disminuida. Las neuroprótesis motoras basadas en la estimulación eléctrica pueden ser aplicadas para inducir la restauración de la función motora en pacientes con paraplejia. Además, la estimulación eléctrica de tales neuroprótesis motoras se puede gestionar y aplicar de manera más eficiente mediante la combinación con exoesqueletos robóticos que compensen la generación limitada de fuerza de los músculos estimulados, y proporcionen soporte adicional para el cuerpo. Dicha terapia de marcha ambulatoria puede ser probablemente más eficaz para la recuperación de las funciones de la médula espinal en lesiones incompletas que las terapias convencionales, robóticas o neuroprotesicas. Sin embargo, el control bilateral de las articulaciones es difícil debido a la complejidad, no-linealidad y la variación con el tiempo de las características del sistema en cuestión. Además, la fatiga muscular y la espasticidad de los músculos estimulados complican la tarea de control. Por otra parte, se requiere una actuación robótica modulable para permitir un enfoque de control cooperativo compatible con el paradigma de rehabilitación de asistencia bajo demanda. Todo lo anterior constituyó las motivaciones directas para esta investigación. El objetivo general fue generar el conocimiento necesario para diseñar un nuevo tratamiento híbrido de rehabilitación marcha con gestión de la fatiga para lesionados medulares incompletos. Se llevaron a cabo actividades de investigación para el establecimiento de los métodos necesarios y los sistemas (hardware y software) requeridos para probar el concepto mediante una evaluación clínica piloto. Específicamente, un análisis del estado de la técnica sobre exoesqueletos híbridos reveló varios retos que fueron abordados en esta tesis. En primer lugar, el paradigma de asistencia bajo demanda se implementó sobre la base de un control adaptable del exoesqueleto robótico y un control en lazo cerrado de la neuroprótesis. Ambos controladores están integrados dentro de una estrategia híbrida cooperativa que es capaz de equilibrar la asistencia del exoesqueleto robótico en relación con el rendimiento muscular. Este enfoque se soporta sobre la monitorización de la interacción física entre la pierna y el exoesqueleto. Por tanto, la fatiga causada por la estimulación neuromuscular también fue objeto de una investigación específica. Se realizaron estudios experimentales con pacientes parapléjicos para el establecimiento de un criterio objetivo para la detección y la gestión de la fatiga muscular. Los resultados de estos estudios fueron integrados en el controlador híbrido-cooperativo con el fin de detectar y gestionar la fatiga muscular mientras se realiza la terapia híbrida de rehabilitación de la marcha. En segundo lugar, el control en lazo cerrado de la neuroprótesis fue abordado en esta tesis. El método de control propuesto permite adaptar el patrón de estimulación en relación con la funcionalidad residual específica de la extremidad inferior del paciente. Sin embargo, con el n de desacoplar el control en lazo cerrado de la monitorización del rendimiento muscular, el enfoque de control híbrido-cooperativo incorpora una conmutación secuencial entre el control en lazo cerrado y en lazo abierto de la neuropr otesis. Por último, un protocolo de evaluación clínica global permitido evaluar el impacto de la terapia híbrida de la marcha en la función de la marcha de una muestra de pacientes parapléjicos. Los resultados demuestran que: 1) el controlador híbrido se adapta a la función residual del paciente durante la marcha, 2) la terapia es tolerada por los pacientes, y 3) la funci on de marcha del paciente mejora despu es de participar en el estudio. En conclusión, la terapia de híbrida de la marcha alberga un potencial para la rehabilitación de la marcha en pacientes parapléjicos incompletos motor, garantizando realizar investigación más profunda sobre este tema. Esta tesis se enmarca dentro de los dos proyectos de investigación: REHABOT (Ministerio de Ciencia e Innovación, referencia DPI2008-06772-C03-02) y HYPER (Hybrid Neuroprosthetic and Neurorobotic Devices for Functional Compensation and Rehabilitation of Motor Disorders, referencia CSD2009-00067 CONSOLIDER INGENIO 2010). Dentro de estos proyectos se lleva a cabo investigación de vanguardia en el campo de la actuación y el control híbrido de la combinación robot-neuroprótesis para la rehabilitación de trastornos motores. Esta tesis constituye la prueba de concepto de la terapia de híbrida de la marcha para individuos parapléjicos en estos proyectos.This dissertation is framed within two research projects: REHABOT (Ministerio de Ciencia e Innovación, grant DPI2008-06772-C03-02) and HYPER (Hybrid Neuroprosthetic and Neurorobotic Devices for Functional Compensation and Rehabilitation of Motor Disorders, grant CSD2009-00067 CONSOLIDER INGENIO 2010

Motor Compensation During Lower Limb Pedaling After Stroke

Long-term motor dysfunction in the lower limb is common after stroke. One potential contributor is motor compensation, a behavior in which functions originally performed by the paretic limb are performed by the non-paretic limb. Compensation in chronic stroke may contribute to long-term motor dysfunction by limiting functional ability, impairing future recovery, and eliciting maladaptive neuroplasticity. The purpose of this dissertation was to describe the impact of compensation on motor function and brain activation during lower limb pedaling and identify elements that produce this behavior. To achieve this purpose, we evaluated muscle activation and motor performance when compensation was prevented. During unilateral pedaling, paretic muscle activation increased but motor performance deteriorated. During bilateral uncoupled pedaling, paretic muscle activation further increased. However, subjects were unable to coordinate movements of the legs, and motor performance further deteriorated. These results suggest that compensation improves motor performance but limits paretic motor output. Because motor performance was worse during bilateral uncoupled than unilateral pedaling, impaired interlimb coordination may be a primary factor leading to compensation. As a follow-up, we determined whether altered interlimb spinal reflex pathways contribute to impaired interlimb coordination after stroke. Interlimb cutaneous reflexes were elicited during pedaling, and we assessed whether the amplitude was altered. Interlimb reflex was altered, particularly in bifunctional muscles and at pedaling transitions. Reflex alterations were correlated with impairments in interlimb coordination and compensation. These data suggest that stroke-related changes in interlimb reflex pathways undermine interlimb coordination. Finally, we assessed whether altered motor commands and performance, such as seen with compensation, are related to decreased pedaling-related brain activation after stroke. Brain activation was measured during volitional pedaling and during passive pedaling, when between-group differences were minimized. Between-group differences in brain activation persisted during passive pedaling, suggesting that altered motor commands and pedaling performance do not account for reduced brain activation after stroke. Overall, these studies provide insight into rehabilitative interventions that may decrease long-term motor dysfunction in the lower limb after stroke. One potential strategy is to enhance paretic muscle activity by preventing compensation while simultaneously employing efforts to improve interlimb coordination, possibly by manipulating interlimb reflex pathways

The effect of functional electrical stimulation on abdominal muscle strength and gross motor function in children with cerebral palsy a randomised control trial

Includes abstract. Includes bibliographical references