Comparing walking with knee-ankle-foot orthoses and a knee-powered exoskeleton after spinal cord injury: a randomized, crossover clinical trial

Recovering the ability to stand and walk independently can have numerous health benefits for people with spinal cord injury (SCI). Wearable exoskeletons are being considered as a promising alternative to conventional knee-ankle-foot orthoses (KAFOs) for gait training and assisting functional mobility. However, comparisons between these two types of devices in terms of gait biomechanics and energetics have been limited. Through a randomized, crossover clinical trial, this study compared the use of a knee-powered lower limb exoskeleton (the ABLE Exoskeleton) against passive orthoses, which are the current standard of care for verticalization and gait ambulation outside the clinical setting in people with SCI. Ten patients with SCI completed a 10-session gait training program with each device followed by user satisfaction questionnaires. Walking with the ABLE Exoskeleton improved gait kinematics compared to the KAFOs, providing a more physiological gait pattern with less compensatory movements (38% reduction of circumduction, 25% increase of step length, 29% improvement in weight shifting). However, participants did not exhibit significantly better results in walking performance for the standard clinical tests (Timed Up and Go, 10-m Walk Test, and 6-min Walk Test), nor significant reductions in energy consumption. These results suggest that providing powered assistance only on the knee joints is not enough to significantly reduce the energy consumption required by people with SCI to walk compared to passive orthoses. Active assistance on the hip or ankle joints seems necessary to achieve this outcome.Peer ReviewedPostprint (published version

HyExo:A Novel Quasi-Passive Hydraulic Exoskeleton for Load-Carrying Augmentation

The development of assistive lower-limb exoskeletons gains prominence for human load-carrying augmentation. Hydraulic transmission has attractive hydrostatic features and lower inertia at the end of human limbs. However, few hydraulic lower-limb exoskeletons were developed with low energy consumption and light weight. In this article, we introduce HyExo, a quasi-passive hydraulic exoskeleton that is built on a lightweight rotary cage valve (RCV) block with a fast response and low energy consumption of 1.55&amp;#x00A0;W. Based on the RCV block, we propose an optimization-based regulator for joint energy distribution to harvest and release the hydraulic energy among joints during the stance phase. The interaction force model and control of the novel nonanthropomorphic structure are presented and evaluated. The load-supporting effect was investigated and validated through human subject experiments. The results show that with an assisting fluid pressure of 2.5&amp;#x00A0;MPa, HyExo can transfer a mean force of 237&amp;#x00A0;N to the ground. Meanwhile, the impact of wearing HyExo on gait is analyzed. The metabolic expenditure test shows that HyExo can slow the increasing rate in metabolic cost as load increases. Compared with a regular backpack, walking with HyExo to carry 30&amp;#x00A0;kg of weight reduces wearers&amp;#x0027; metabolic energy expenditure by 7.8&amp;#x0025;.</p

Biomechanical Knee Joint for Exoskeleton

Our senior design project consisted of designing and manufacturing a biomechanically accurate, actuated knee joint to be integrated into an exoskeleton being developed by the Lower Limb Exoskeleton Assist Project (LLEAP), a part of the EMPOWER student association at Cal Poly, San Luis Obispo. As the human knee flexes and extends throughout gait motion, the center of rotation changes. Currently marketed exoskeletons have one point of rotation, which over constrains the knee and causes misalignment between the user and the suit [1]. Our goal was to mimic natural knee joint motion by changing the center or rotation, thus reducing misalignment and limiting power loss. We designed this knee joint for our prospective exoskeleton user: Carlo Ruggiero, a 21-year-old Cal Poly student with a complete C8 injury to his spine which resulted in loss of function and sensation from his chest and below. Our design consists of a linear actuator mounted along the outside of the user’s thigh, which drives a four-bar linkage in line with the user’s knee. After manufacturing and testing our design, it was found that the joint met the necessary power requirements and reached the required angles for human gait. However, the linear actuator that was purchased was too long to fit properly on the user’s leg and is unable to vary its speed. This verification prototype proves that mimicking knee joint motion for exoskeleton applications is feasible but requires integration of a linear actuator with greater power density and the ability for speed control. We also recommend using biomedical imaging to accurately determine the center of rotation throughout actuation. This would allow for tuning of the lengths of the links in the four-bar linkage to match the user’s knee biomechanics more precisely

Towards a human-in-the-loop control for a smart orthotic system

Dissertação de mestrado integrado em Engenharia Biomédica (área de especialização em Eletrónica Médica)Stroke is the main cause of paralysis. This pathology has provoked a considerable increase of persons with motor impairments. With a therapy focused on each clinical case, the total or partial recovery can be achieved. Powered orthoses have been developed to promote an effective recover, based on repetitive gait training and user’s active participation. Many control approaches have been developed to control these devices, but none of them promotes an user-oriented strategy focused to the user’s needs. In an attempt of solving this issue, a new approach named Human-in-the-loop is emerging. This strategy allows the adaptation of some assistive parameters based on the user’s energetic cost, promoting a therapy tailored to each end-user needs. However, to estimate the energy expenditure, the use of non-ergonomic sensors, not suitable for clinical context, is required. Thus, it is necessary to find new ways of estimating energy expenditure using wearable and comfortable sensors. In this dissertation, the first steps to introduce the Human-in-the-loop strategy into a powered orthosis are presented. For this purpose, two strategies were developed: a strategy that allows the angular trajectory adaptation in real-time and other that promotes a stiffness adaptation all over the gait cycle. Both strategies were validated with healthy subjects. In the first strategy, the orthosis was able to modify its assistance in a fraction of microseconds, and the end-users were able to follow her with a median error below 10%. Regarding the second strategy, the results show that the orthosis allowed an effective change in the systems’ interaction stiffness, promoting an active participation of each user during its assistance. The energetic impact of using the robotic assistive device is also presented. As it promotes an energy expenditure augmentation in more than 30% in comparison to walk without the device, the necessity of implementing the Human-in-the-loop strategy was highlighted. In an attempt of finding an ergonomic technique to estimate the energetic cost, the use of machine learning algorithms was tested. The results, obtained with a MLP and a LSTM, prove that it is possible to estimate the energy expenditure with a mean error close to 11%. Future work consists in the implementation of the model in real-time and the collection of more data with the aforementioned control approaches, in a way of constructing a more robust model.O AVC é uma das maiores causas de paralisia. Esta patologia, cada vez mais com maior incidência nos jovens, tem provocado um aumento considerável de pessoas com problemas de mobilidade. Com uma terapia focada a cada caso clínico, a recuperação total ou parcial pode ser conseguida. As ortóteses ativas têm vindo a ser desenvolvidas com o propósito de promover uma recuperação eficaz, baseada em treinos repetitivos e numa participação ativa dos utilizadores. Várias abordagens de controlo têm vindo a ser desenvolvidas para controlar estes dispositivos, mas nenhuma delas promove uma estratégia orientada às necessidades do utilizador. Na tentativa de solucionar este problema, uma nova abordagem, designada por Human-in-the-loop está a emergir. Baseada no custo energético, esta estratégia permite adaptar parâmetros da assistência, promovendo uma terapia focada e direcionada a cada utilizador. No entanto, para estimar o custo energético, recorre-se ao uso de sensores que não são adequados para contexto clínico. Assim, torna-se necessário estudar novas formas de estimar o custo energético. Nesta dissertação são apresentados os primeiros passos para introduzir o controlo Human-in-the-loop numa ortótese ativa. Para isso, duas estratégias foram apresentadas: uma estratégia que permite adaptar a trajetória angular da ortótese, em tempo real, e outra que promove a adaptação da complacência do sistema ao longo do ciclo da marcha. Ambas foram validadas com sujeitos saudáveis. Relativamente à primeira abordagem, a ortótese foi capaz de modificar a sua assistência em microssegundos, e os utilizadores foram capazes de a seguir com um erro mediano inferior a 10%. No que diz respeito à segunda abordagem, os resultados mostram que a ortótese promoveu uma alteração eficaz da complacência de interação, promovendo uma participação ativa do utilizador durante a sua assistência. O impacto energético do uso do sistema robótico é, também, apresentado. Promovendo um aumento do custo energético em mais de 30%, a necessidade da estratégia Human-in-the-loop foi realçada. Na tentativa de encontrar uma técnica para estimar o custo energético, recorreu-se ao uso de machine learning. Os resultados, obtidos com uma MLP e uma LSTM, provam que é possível estimar o custo energético com um erro médio próximo dos 11%. Trabalho futuro passa pela implementação do modelo em tempo real e a recolha de mais dados com as abordagens de controlo apresentadas, de forma a construir um modelo mais robusto

The Effects of Powered Exoskeleton Gait Training on Cardiovascular Function and Gait Performance: A Systematic Review

Patients with neurological impairments often experience physical deconditioning, resulting in reduced fitness and health. Powered exoskeleton training may be a successful method to combat physical deconditioning and its comorbidities, providing patients with a valuable and novel experience. This systematic review aimed to conduct a search of relevant literature, to examine the effects of powered exoskeleton training on cardiovascular function and gait performance. Two electronic database searches were performed (2 April 2020 to 12 February 2021) and manual reference list searches of relevant manuscripts were completed. Studies meeting the inclusion criteria were systematically reviewed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. n = 63 relevant titles were highlighed; two further titles were identified through manual reference list searches. Following analysis n = 23 studies were included. Data extraction details included; sample size, age, gender, injury, the exoskeleton used, intervention duration, weekly sessions, total sessions, session duration and outcome measures. Results indicated that exoskeleton gait training elevated energy expenditure greater than wheelchair propulsion and improved gait function. Patients exercised at a moderate-intensity. Powered exoskeletons may increase energy expenditure to a similar level as non-exoskeleton walking, which may improve cardiovascular function more effectively than wheelchair propulsion alone

Design and control of a single-leg exoskeleton with gravity compensation for children with unilateral cerebral palsy

Children with cerebral palsy (CP) experience reduced quality of life due to limited mobility and independence. Recent studies have shown that lower-limb exoskeletons (LLEs) have significant potential to improve the walking ability of children with CP. However, the number of prototyped LLEs for children with CP is very limited, while no single-leg exoskeleton (SLE) has been developed specifically for children with CP. This study aims to fill this gap by designing the first size-adjustable SLE for children with CP aged 8 to 12, covering Gross Motor Function Classification System (GMFCS) levels I to IV. The exoskeleton incorporates three active joints at the hip, knee, and ankle, actuated by brushless DC motors and harmonic drive gears. Individuals with CP have higher metabolic consumption than their typically developed (TD) peers, with gravity being a significant contributing factor. To address this, the study designed a model-based gravity-compensator impedance controller for the SLE. A dynamic model of user and exoskeleton interaction based on the Euler–Lagrange formulation and following Denavit–Hartenberg rules was derived and validated in Simscape™ and Simulink® with remarkable precision. Additionally, a novel systematic simplification method was developed to facilitate dynamic modelling. The simulation results demonstrate that the controlled SLE can improve the walking functionality of children with CP, enabling them to follow predefined target trajectories with high accuracy

Enhancing performance during inclined loaded walking with a powered ankle-foot exoskeleton

A simple ankle-foot exoskeleton that assists plantarflexion during push-off can reduce the metabolic power during walking. This suggests that walking performance during a maximal incremental exercise could be improved with an exoskeleton if the exoskeleton is still efficient during maximal exercise intensities. Therefore, we quantified the walking performance during a maximal incremental exercise test with a powered and unpowered exoskeleton: uphill walking with progressively higher weights. Nine female subjects performed two incremental exercise tests with an exoskeleton: 1 day with (powered condition) and another day without (unpowered condition) plantarflexion assistance. Subjects walked on an inclined treadmill (15 %) at 5 km h(-1) and 5 % of body weight was added every 3 min until exhaustion. At volitional termination no significant differences were found between the powered and unpowered condition for blood lactate concentration (respectively, 7.93 +/- A 2.49; 8.14 +/- A 2.24 mmol L-1), heart rate (respectively, 190.00 +/- A 6.50; 191.78 +/- A 6.50 bpm), Borg score (respectively, 18.57 +/- A 0.79; 18.93 +/- A 0.73) and peak (respectively, 40.55 +/- A 2.78; 40.55 +/- A 3.05 ml min(-1) kg(-1)). Thus, subjects were able to reach the same (near) maximal effort in both conditions. However, subjects continued the exercise test longer in the powered condition and carried 7.07 +/- A 3.34 kg more weight because of the assistance of the exoskeleton. Our results show that plantarflexion assistance during push-off can increase walking performance during a maximal exercise test as subjects were able to carry more weight. This emphasizes the importance of acting on the ankle joint in assistive devices and the potential of simple ankle-foot exoskeletons for reducing metabolic power and increasing weight carrying capability, even during maximal intensities