Design and Evaluation of a Soft Assistive Lower Limb Exoskeleton

Exoskeletons vs. exosuits: A comparative analysis using biological-based computer simulation

BACKGROUND

Interest in the design of gait assistance devices has experienced significant growth in recent years. Among various uses of assistive devices, those aimed at supporting the elderly have gained importance due to the rising population of this age group.

METHODS

This study aims to compare the efficacy of two types of assistive devices through musculoskeletal simulations. One case is an ideal device, simulating the motor actuation as it would be in a rigid exoskeleton, and, cable-assisted devices, simulating the assistance of an exosuit. The simulations were based on data obtained from 9 subjects. OpenSim, an open-source software, was employed to conduct the simulations.

RESULTS

Our findings indicate that the cable-assisted device outperforms the traditional exoskeleton by achieving a more significant reduction in the metabolic cost with relatively lower assistance power.

CONCLUSION

Cable-assisted gait assistance devices have shown comparable results to traditional exoskeletons, with the added advantage of improved performance through reduced power requirements.

Exercising with a robotic exoskeleton can improve memory and gait in people with Parkinson's disease by facilitating progressive exercise intensity

People with Parkinson's disease (PwPD) can benefit from progressive high-intensity exercise facilitated with a lower-extremity exoskeleton, but the mechanisms explaining these benefits are unknown. We explored the relationship between exercise intensity progression and memory and gait outcomes in PwPD who performed 8 weeks (2 × per week) of progressive exercise with and without a lower-extremity powered exoskeleton, as the planned exploratory endpoint analysis of an open-label, parallel, pilot randomized controlled trial. Adults 50-85 years old with a confirmed diagnosis of PD participated. Twenty-seven participants randomized to exercise with (Exo = 13) or without (Nxo = 14) the exoskeleton were included in this exploratory endpoint analysis. Detailed exercise logs were kept and actigraphy was used to measure activity count*min-1 (ACPM) during all exercise sessions. Only the Exo group were able to progressively increase their ACPM over the entire 8-week intervention, whereas the Nxo group plateaued after 4 weeks. Exercise intensity progression correlated with change in the memory sub-scale of the SCOPA-COG and change in gait endurance from the 6MWT, consistent with the prevailing hypotheses linking high-intensity interval exercise to improved muscle and brain function via angiogenic and neurotrophic mechanisms. Facilitating high-intensity exercise with advanced rehabilitation technology is warranted for improving memory and gait endurance in PwPD.Registration: ClinicalTrials.gov, NCT03583879 (7/10/2018).

Quasi-passive lower limbs exosuit: an in-depth assessment of fatigue, kinematic and muscular patterns while comparing assistive strategies on an expert subject's gait analysis

Wearable robots are becoming a valuable solution that helps injured, and elderly people regain mobility and improve clinical outcomes by speeding up the rehabilitation process. The XoSoft exosuit identified several benefits, including improvement of assistance, usability, and acceptance with a soft, modular, bio-mimetic, and quasi-passive exoskeleton. This study compares two assistive configurations: (i) a bilateral hip flexion (HA, hips-assistance) and (ii) a bilateral hip flexion combined with ankle plantarflexion (HAA, hips-ankles-assistance) with the main goal of evaluating compensatory actions and synergetic effects generated by the human- exoskeleton interaction. A complete description of this complex interaction scenario with this actuated exosuit is evaluated during a treadmill walking task, using several indices to quantify the human-robot interaction in terms of muscular activation and fatigue, metabolic expenditure, and kinematic motion patterns. Evidence shows that the HAA biomimetic controller is synergetic with the musculature and performs better concerning the other control strategy. The experimentation demonstrated a metabolic expenditure reduction of 8% of Metabolic Equivalent of Task (MET), effective assistance of the muscular activation of 12.5%, a decrease of the muscular fatigue of 0.6% of the mean frequency, and a significant reduction of the compensatory actions, as discussed in this work. Compensatory effects are present in both assistive configurations, but the HAA modality provides a 47% reduction of compensatory effects when considering muscle activation.

The effect of hip exoskeleton weight on kinematics, kinetics, and electromyography during human walking

In exoskeleton research, transparency is the degree to which a device hinders the movement of the user, a critical component of performance and usability. Transparency is most often evaluated individually, thus lacking generalization. Our goal was to systematically evaluate transparency due to inertial effects on gait of a hypothetical hip exoskeleton. We predicted that the weight distribution around the pelvis and the amount of weight applied would change gait characteristics. We instructed 21 healthy individuals to walk on a treadmill while bearing weights on the pelvis between 4 and 8 kg in three different configurations, bilaterally, unilaterally (left side) and on the lumbar portion of the back (L4). We measured kinematics, kinetics, and muscle activity during randomly ordered trials of 1.5 min at typical walking speed. We also calculated the margin of stability to measure medial-lateral stability. We observed that loading the hips bilaterally with 4 kg had no changes in kinematics, kinetics, dynamic stability, or muscle activity, but above 6 kg, sagittal joint power was increased. Loading the lumbar area increased posterior pelvic tilt at 6 kg and decreased dynamic stability at 4 kg, with many individuals reporting some discomfort. For the unilateral placement, above 4 kg dynamic stability was decreased and hip joint power was increased, and above 6 kg the pelvis begins to dip towards the loaded side. These results show the different effects of weight distribution around the pelvis. This study represents a novel, systematic approach to characterizing transparency in exoskeleton design (clinicaltrials.gov: NCT05120115).

A Critical Review on Factors Affecting the User Adoption of Wearable and Soft Robotics

In recent years, the advent of soft robotics has changed the landscape of wearable technologies. Soft robots are highly compliant and malleable, thus ensuring safe human-machine interactions. To date, a wide variety of actuation mechanisms have been studied and adopted into a multitude of soft wearables for use in clinical practice, such as assistive devices and rehabilitation modalities. Much research effort has been put into improving their technical performance and establishing the ideal indications for which rigid exoskeletons would play a limited role. However, despite having achieved many feats over the past decade, soft wearable technologies have not been extensively investigated from the perspective of user adoption. Most scholarly reviews of soft wearables have focused on the perspective of service providers such as developers, manufacturers, or clinicians, but few have scrutinized the factors affecting adoption and user experience. Hence, this would pose a good opportunity to gain insight into the current practice of soft robotics from a user's perspective. This review aims to provide a broad overview of the different types of soft wearables and identify the factors that hinder the adoption of soft robotics. In this paper, a systematic literature search using terms such as "soft", "robot", "wearable", and "exoskeleton" was conducted according to PRISMA guidelines to include peer-reviewed publications between 2012 and 2022. The soft robotics were classified according to their actuation mechanisms into motor-driven tendon cables, pneumatics, hydraulics, shape memory alloys, and polyvinyl chloride muscles, and their pros and cons were discussed. The identified factors affecting user adoption include design, availability of materials, durability, modeling and control, artificial intelligence augmentation, standardized evaluation criteria, public perception related to perceived utility, ease of use, and aesthetics. The critical areas for improvement and future research directions to increase adoption of soft wearables have also been highlighted.

The-state-of-the-art of soft robotics to assist mobility: a review of physiotherapist and patient identified limitations of current lower-limb exoskeletons and the potential soft-robotic solutions

BACKGROUND

Soft, wearable, powered exoskeletons are novel devices that may assist rehabilitation, allowing users to walk further or carry out activities of daily living. However, soft robotic exoskeletons, and the more commonly used rigid exoskeletons, are not widely adopted clinically. The available evidence highlights a disconnect between the needs of exoskeleton users and the engineers designing devices. This review aimed to explore the literature on physiotherapist and patient perspectives of the longer-standing, and therefore greater evidenced, rigid exoskeleton limitations. It then offered potential solutions to these limitations, including soft robotics, from an engineering standpoint.

METHODS

A state-of-the-art review was carried out which included both qualitative and quantitative research papers regarding patient and/or physiotherapist perspectives of rigid exoskeletons. Papers were themed and themes formed the review's framework.

RESULTS

Six main themes regarding the limitations of soft exoskeletons were important to physiotherapists and patients: safety; a one-size-fits approach; ease of device use; weight and placement of device; cost of device; and, specific to patients only, appearance of the device. Potential soft-robotics solutions to address these limitations were offered, including compliant actuators, sensors, suit attachments fitting to user's body, and the use of control algorithms.

CONCLUSIONS

It is evident that current exoskeletons are not meeting the needs of their users. Solutions to the limitations offered may inform device development. However, the solutions are not infallible and thus further research and development is required.

Opportunities and challenges in the development of exoskeletons for locomotor assistance

Exoskeletons can augment the performance of unimpaired users and restore movement in individuals with gait impairments. Knowledge of how users interact with wearable devices and of the physiology of locomotion have informed the design of rigid and soft exoskeletons that can specifically target a single joint or a single activity. In this Review, we highlight the main advances of the past two decades in exoskeleton technology and in the development of lower-extremity exoskeletons for locomotor assistance, discuss research needs for such wearable robots and the clinical requirements for exoskeleton-assisted gait rehabilitation, and outline the main clinical challenges and opportunities for exoskeleton technology.

Assessment methodology for human-exoskeleton interactions: Kinetic analysis based on muscle activation

During the development and assessment of an exoskeleton, many different analyzes need to be performed. The most frequently used evaluate the changes in muscle activations, metabolic consumption, kinematics, and kinetics. Since human-exoskeleton interactions are based on the exchange of forces and torques, the latter of these, kinetic analyzes, are essential and provide indispensable evaluation indices. Kinetic analyzes, however, require access to, and use of, complex experimental apparatus, involving many instruments and implicating lengthy data analysis processes. The proposed methodology in this paper, which is based on data collected via EMG and motion capture systems, considerably reduces this burden by calculating kinetic parameters, such as torque and power, without needing ground reaction force measurements. This considerably reduces the number of instruments used, allows the calculation of kinetic parameters even when the use of force sensors is problematic, does not need any dedicated software, and will be shown to have high statistical validity. The method, in fact, combines data found in the literature with those collected in the laboratory, allowing the analysis to be carried out over a much greater number of cycles than would normally be collected with force plates, thus enabling easy access to statistical analysis. This new approach evaluates the kinetic effects of the exoskeleton with respect to changes induced in the user's kinematics and muscular activation patterns and provides indices that quantify the assistance in terms of torque (AMI) and power (API). Following the User-Center Design approach, which requires driving the development process as feedback from the assessment process, this aspect is critical. Therefore, by enabling easy access to the assessment process, the development of exoskeletons could be positively affected.

Soft Wearable Robots: Development Status and Technical Challenges

In recent years, more and more research has begun to focus on the flexible and lightweight design of wearable robots. During this process, many novel concepts and achievements have been continuously made and shown to the public, while new problems have emerged at the same time, which need to be solved. In this paper, we give an overview of the development status of soft wearable robots for human movement assistance. On the basis of a clear definition, we perform a system classification according to the target assisted joint and attempt to describe the overall prototype design level in related fields. Additionally, it is necessary to sort out the latest research progress of key technologies such as structure, actuation, control and evaluation, thereby analyzing the design ideas and basic characteristics of them. Finally, we discuss the possible application fields, and propose the main challenges of this valuable research direction.

Design, Analysis, and Control of A User-Adaptive

This paper presents the design and preliminary evaluation of a user-adaptive ankle foot orthosis (AFO). To begin with, according to the foot dimensions of an able-bodied subject, the structures of the ankle orthotic device are conceived. Then, based on a common two-degree-of-freedom (DOF) foot model, the AFO-human system is set up; its kinematic model and the device's mechanism of user adaptation are analyzed. After that, the layout of a portable orthotic system, as well as a smart insole that detects gait phases, is illustrated. Finally, the orthotic system is tested on the aforementioned subject. Results show that, when assistive torque of the AFO is applied, the foot's plantarflexion magnitude before the swing stage and dorsiflexion magnitude during the swing stage approximately increase by 3 and 4 degrees, respectively. Therefore, the orthosis has the potential to aid propulsion motions and control toe clearance.

Force Transmission Analysis and Optimization of Bowden Cable on Body in a Flexible Exoskeleton

The Bowden cable is a significant force transmission equipment for a flexible exoskeleton. However, the previous researches of Bowden cable had emphasized on the data from experimenting test board, instead of on human body, which produced the inaccurate assisting analysis of the flexible exoskeleton. In this paper, a flexible exoskeleton for assisting knee extension was proposed, which provided an on-body condition. Then, the friction force and its influencing factors between the wire rope and sheath of the Bowden cable from the motor to the anchor of knee have been analyzed. The segment models of force transmission with the concern of three kinds of friction modes were established, and the relationship between various lengths and bending angles of Bowden cable was fitted to the equations of curve. Furthermore, the association rule between the force transmission and the lengths of Bowden cable was obtained, based on which, the optimal force transmission efficiency was 78.68% when the length value of the Bowden cable was 475 mm. A flexible exoskeleton prototype was assembled; then, the experiments with force transmission and metabolic cost have been developed. The results showed that the force transmission efficiency had strong association with the lengths of Bowden cable, instead of the transmission velocities. Furthermore, this knee assistance exoskeleton reduced the net metabolic cost of the testees during walking. These experiments results corroborated the force transmission modeling and simulation of the Bowden cable on body we proposed in this paper.

Ergonomics Design and Assistance Strategy of A-Suit

Concerning the biomechanics and energy consumption of the lower limbs, a soft exoskeleton for the powered plantar flexion of the ankle, named A-Suit, was developed to improve walking endurance in the lower limbs and reduce metabolic consumption. The method of ergonomics design was used based on the biological structures of the lower limbs. A profile of auxiliary forces was constructed according to the biological force of the Achilles tendon, and an iterative learning control was applied to shadow this auxiliary profile by iteratively modifying the traction displacements of drive units. During the evaluation of the performance experiments, four subjects wore the A-Suit and walked on a treadmill at different speeds and over different inclines. Average heart rate was taken as the evaluation index of metabolic consumption. When subjects walked at a moderate speed of 1.25 m/s, the average heart rate H_av under the Power-ON condition was 7.25 ± 1.32% (mean ± SEM) and 14.40 ± 2.63% less than the condition of No-suit and Power-OFF. Meanwhile, the additional mass of A-Suit led to a maximum H_av increase of 7.83 ± 1.44%. The overall reduction in H_av with Power-ON over the different inclines was 6.93 ± 1.84% and 13.4 ± 1.93% compared with that of the No-Suit and Power-OFF condition. This analysis offers interesting insights into the viability of using this technology for human augmentation and assistance for medical and other purposes.

A dual-drive four joint time-sharing control walking power-assisted flexible exoskeleton robot system

Exoskeleton robot can assist people and reduce energy consumption when they walk with heavy weight, so as to protect their health and travel longer distances. This work analyzes the cross gait during walking and designs a dual-drive four joint time-sharing assistance exoskeleton system, which controls the four joints through two motors to realize the assistance to the wearer’s movement process. The control curve and adaptive control algorithm are designed to help different people with various walking gaits and speeds, the effectiveness of exoskeleton system is proved by testing metabolism. When the exoskeleton wearer carries 25 kg weight (load equal to 36% of body mass) and travels at the average speed of 5 km/h, the metabolic rate of the exoskeleton wearers decreases by an average of 7.79%, the reduction magnitude is comparable to the effect of taking off 7.33 kg during walking.

A Wearable Lower Limb Exoskeleton: Reducing the Energy Cost of Human Movement

Human body enhancement is an interesting branch of robotics. It focuses on wearable robots in order to improve the performance of human body, reduce energy consumption and delay fatigue, as well as increase body speed. Robot-assisted equipment, such as wearable exoskeletons, are wearable robot systems that integrate human intelligence and robot power. After careful design and adaptation, the human body has energy-saving sports, but it is an arduous task for the exoskeleton to achieve considerable reduction in metabolic rate. Therefore, it is necessary to understand the biomechanics of human sports, the body, and its weaknesses. In this study, a lower limb exoskeleton was classified according to the power source, and the working principle, design idea, wearing mode, material and performance of different types of lower limb exoskeletons were compared and analyzed. The study shows that the unpowered exoskeleton robot has inherent advantages in endurance, mass, volume, and cost, which is a new development direction of robot exoskeletons. This paper not only summarizes the existing research but also points out its shortcomings through the comparative analysis of different lower limb wearable exoskeletons. Furthermore, improvement measures suitable for practical application have been provided.

Force and Torque Characterization in the Actuation of a Walking-Assistance, Cable-Driven Exosuit

Soft exosuits stand out when it comes to the development of walking-assistance devices thanks to both their higher degree of wearability, lower weight, and price compared to the bulkier equivalent rigid exoskeletons. In cable-driven exosuits, the acting force is driven by cables from the actuation system to the anchor points; thus, the user’s movement is not restricted by a rigid structure. In this paper, a 3D inverse dynamics model is proposed and integrated with a model for a cable-driven actuation to predict the required motor torque and traction force in cables for a walking-assistance exosuit during gait. Joint torques are to be shared between the user and the exosuit for different design configurations, focusing on both hip and ankle assistance. The model is expected to guide the design of the exosuit regarding aspects such as the location of the anchor points, the cable system design, and the actuation units. An inverse dynamics analysis is performed using gait kinematic data from a public dataset to predict the cable forces and position of the exosuit during gait. The obtained joint reactions and cable forces are compared with those in the literature, and prove the model to be accurate and ready to be implemented in an exosuit control scheme. The results obtained in this study are similar to those found in the literature regarding the walking study itself as well as the forces under which cables operate during gait and the cable position cycle.

Coordination Between Partial Robotic Exoskeletons and Human Gait: A Comprehensive Review on Control Strategies

Lower-limb robotic exoskeletons have become powerful tools to assist or rehabilitate the gait of subjects with impaired walking, even when they are designed to act only partially over the locomotor system, as in the case of unilateral or single-joint exoskeletons. These partial exoskeletons require a proper method to synchronize their assistive actions and ensure correct inter-joint coordination with the user’s gait. This review analyzes the state of the art of control strategies to coordinate the assistance provided by these partial devices with the actual gait of the wearers. We have analyzed and classified the different approaches independently of the hardware implementation, describing their basis and principles. We have also reviewed the experimental validations of these devices for impaired and unimpaired walking subjects to provide the reader with a clear view of their technology readiness level. Eventually, the current state of the art and necessary future steps in the field are summarized and discussed.

Flexible lower limb exoskeleton systems: A review

BACKGROUND

As an emerging exoskeleton robot technology, flexible lower limb exoskeleton (FLLE) integrates flexible drive and wearable mechanism, effectively solving many problems of traditional rigid lower limb exoskeleton (RLLE) such as higher quality, poorer compliance and relatively poor portability, and has become one of the important development directions in the field of active rehabilitation.

OBJECTIVE

This review focused on the development and innovation process in the field of FLLE in the past decade.

METHOD

Related literature published from 2010 to 2021 were searched in EI, IEEE Xplore, PubMed and Web of Science databases. Seventy target research articles were further screened and sorted through inclusion and exclusion criteria.

RESULTS

FLLE is classified according to different driving modes, and the advantages and disadvantages of passive flexible lower limb exoskeletons and active flexible lower limb exoskeletons are comprehensively summarized.

CONCLUSION

At present, FLLE's research is mainly based on cable drive, bionic pneumatic muscles followed and matured, and new exoskeleton designs based on smart material innovations also trend to diversify. In the future, the development direction of FLLE will be lightweight and drive compliance, and the multi-mode sensory feedback control theory, motion intention recognition theory and human-machine interaction theory will be combined to reduce the metabolic energy consumption of walking.

Evaluation of Optimal Control Approaches for Predicting Active Knee-Ankle-Foot-Orthosis Motion for Individuals With Spinal Cord Injury

Gait restoration of individuals with spinal cord injury can be partially achieved using active orthoses or exoskeletons. To improve the walking ability of each patient as much as possible, it is important to personalize the parameters that define the device actuation. This study investigates whether using an optimal control-based predictive simulation approach to personalize pre-defined knee trajectory parameters for an active knee-ankle-foot orthosis (KAFO) used by spinal cord injured (SCI) subjects could potentially be an alternative to the current trial-and-error approach. We aimed to find the knee angle trajectory that produced an improved orthosis-assisted gait pattern compared to the one with passive support (locked knee). We collected experimental data from a healthy subject assisted by crutches and KAFOs (with locked knee and with knee flexion assistance) and from an SCI subject assisted by crutches and KAFOs (with locked knee). First, we compared different cost functions and chose the one that produced results closest to experimental locked knee walking for the healthy subject (angular coordinates mean RMSE was 5.74°). For this subject, we predicted crutch-orthosis-assisted walking imposing a pre-defined knee angle trajectory for different maximum knee flexion parameter values, and results were evaluated against experimental data using that same pre-defined knee flexion trajectories in the real device. Finally, using the selected cost function, gait cycles for different knee flexion assistance were predicted for an SCI subject. We evaluated changes in four clinically relevant parameters: foot clearance, stride length, cadence, and hip flexion ROM. Simulations for different values of maximum knee flexion showed variations of these parameters that were consistent with experimental data for the healthy subject (e.g., foot clearance increased/decreased similarly in experimental and predicted motions) and were reasonable for the SCI subject (e.g., maximum parameter values were found for moderate knee flexion). Although more research is needed before this method can be applied to choose optimal active orthosis controller parameters for specific subjects, these findings suggest that optimal control prediction of crutch-orthosis-assisted walking using biomechanical models might be used in place of the trial-and-error method to select the best maximum knee flexion angle during gait for a specific SCI subject.

Challenges and solutions for application and wider adoption of wearable robots

The science and technology of wearable robots are steadily advancing, and the use of such robots in our everyday life appears to be within reach. Nevertheless, widespread adoption of wearable robots should not be taken for granted, especially since many recent attempts to bring them to real-life applications resulted in mixed outcomes. The aim of this article is to address the current challenges that are limiting the application and wider adoption of wearable robots that are typically worn over the human body. We categorized the challenges into mechanical layout, actuation, sensing, body interface, control, human-robot interfacing and coadaptation, and benchmarking. For each category, we discuss specific challenges and the rationale for why solving them is important, followed by an overview of relevant recent works. We conclude with an opinion that summarizes possible solutions that could contribute to the wider adoption of wearable robots.

Emergence of flexible technology in developing advanced systems for post-stroke rehabilitation: a comprehensive review

OBJECTIVE

Stroke is one of the most common neural disorders, which causes physical disabilities and motor impairments among its survivors. Several technologies have been developed for providing stroke rehabilitation and to assist the survivors in performing their daily life activities. Currently, the use of flexible technology (FT) for stroke rehabilitation systems is on a rise that allows the development of more compact and lightweight wearable systems, which stroke survivors can easily use for long-term activities.

APPROACH

For stroke applications, FT mainly includes the "flexible/stretchable electronics", "e-textile (electronic textile)" and "soft robotics". Thus, a thorough literature review has been performed to report the practical implementation of FT for post-stroke application.

MAIN RESULTS

In this review, the highlights of the advancement of FT in stroke rehabilitation systems are dealt with. Such systems mainly involve the "biosignal acquisition unit", "rehabilitation devices" and "assistive systems". In terms of biosignals acquisition, electroencephalography (EEG) and electromyography (EMG) are comprehensively described. For rehabilitation/assistive systems, the application of functional electrical stimulation (FES) and robotics units (exoskeleton, orthosis, etc.) have been explained.

SIGNIFICANCE

This is the first review article that compiles the different studies regarding flexible technology based post-stroke systems. Furthermore, the technological advantages, limitations, and possible future implications are also discussed to help improve and advance the flexible systems for the betterment of the stroke community.

Preliminary evaluation of an objective assessment approach from session data in exoskeleton-assisted gait rehabilitation after SCI

Exoskeleton-assisted gait rehabilitation is a promising complement to traditional motion rehabilitation programs for afflictions such as stroke or spinal cord injury. However, some challenges persist that hinder the translation of this approach to the clinical practice. One of these aspects is the objective assessment of patients' progress from information collected during exoskeleton-assisted therapy sessions with minimal hardware setup. In order to carry out an objective assessment with the data collected during the sessions, in this work: (1) we implement and compute a set of metrics (Harmonic Ratio, Joint Trajectory Correlation, and Intralimb Coordination) from data provided by the exoskeleton and two inertial motion units (IMUs) while subjects walked during their rehabilitation sessions, (2) we evaluate the capacity of the metrics to discriminate between the different patients' physical conditions, and (3) assess the correspondence of the patient evaluations using the mentioned metrics and traditional clinical scores. Our results show that Intralimb Coordination has the greatest capacity to discriminate between different physical states of the patients and presents the best correlation with their clinical assessment.Clinical relevance- This work could guide clinicians and researchers to formulate a more objective assessment of progress of patients who have experienced a spinal cord in- jury using data collected during exoskeleton-assisted therapy sessions.

Knee Exoskeletons Design Approaches to Boost Strength Capability: A Review

There are different devices to increase the strength capacity of people with walking problems. These devices can be classified into exoskeletons, orthotics, and braces. This review aims to identify the state of the art in the design of these medical devices, based on an analysis of patents and literature. However, there are some difficulties in processing the records due to the lack of filters and standardization in the names, generating discrepancies between the search engines, among others. Concerning the patents, 74 patents were analyzed using search engines such as Google Patents, Derwent, The Lens, Patentscope, and Espacenet over the past ten years. A bibliometric analysis was performed using 63 scientific reports from Web of Science and The Lens in the same period for scientific communications. The results show a trend to use the mechanical design of exoskeletons based on articulated rigid structures and elements that provide force to move the structure. These are generally two types: (a) elastic elements and (b) electromechanical elements. The United States accounts for 32% of the technological patents reviewed. The results suggest that the use of exoskeletons or orthoses customized to the users’ needs will continue to increase over the years due to the worldwide growth in disability, particularly related to mobility difficulties and technologies related to the combined use of springs and actuators.

MotorSkins-a bio-inspired design approach towards an interactive soft-robotic exosuit

The work presents a bio-inspired design approach to a soft-robotic solution for assisting the knee-bending in users with reduced mobility in lower limbs. Exosuits and fluid-driven actuators are fabric-based devices that are gaining increasing relevance as alternatives assistive technologies that can provide simpler, more flexible solutions in comparison with the rigid exoskeletons. These devices, however, commonly require an external energy supply or a pressurized-fluid reservoir, which considerably constrain the autonomy of such solutions. In this work, we introduce an event-based energy cycle (EBEC) design concept, that can harvest, store, and release the required energy for assisting the knee-bending, in a synchronised interaction with the user and the environment, thus eliminating any need for external energy or control input. Ice-plant hydro-actuation system served as the source of inspiration to address the specific requirements of such interactive exosuit through a fluid-driven material system. Based on the EBEC design concepts and the abstracted bio-inspired principles, a series of (material and process driven) design experimentations helped to address the challenges of realising various functionalities of the harvest, storage, actuation and control instances within a closed hydraulic circuit. Sealing and defining various areas of water-tight seam made out of thermoplastic elastomers provided the base material system to program various chambers, channels, flow-check valves etc of such EBEC system. The resulting fluid-driven EBEC-skin served as a proof of concept for such active exosuit, that brings these functionalities into an integrated 'sense-acting' material system, realising an auto-synchronised energy and information cycles. The proposed design concept can serve as a model for development of similar fluid-driven EBEC soft-machines for further applications. On the more general scheme, the work presents an interdisciplinary design-science approach to bio-inspiration and showcases how biological material solutions can be looked at from a design/designer perspective to bridge the bottom-up and top-down approach to bio-inspiration.

Development of a Control System and Functional Validation of a Parallel Robot for Lower Limb Rehabilitation

This paper is focused on the development of a control system, implemented on a parallel robot designed for the lower limb rehabilitation of bedridden stroke survivors. The paper presents the RECOVER robotic system kinematics, further implemented into the control system, which is described in terms of architecture and functionality. Through a battery of experimental tests, achieved in laboratory conditions using eight healthy subjects, the feasibility and functionality of the proposed robotic system have been validated, and the overall performance of the control system has been studied. The range of motion of each targeted joint has been recorded using a commercially available external sensor system. The kinematic parameters, namely the patient’s joints velocities and accelerations have been recorded and compared to the ones obtained using the virtual model, yielding a very small difference between them, which provides a validation of the RECOVER initial design, both in terms of mechanical construction and control system.

Review of control strategies for lower-limb exoskeletons to assist gait

Background

Many lower-limb exoskeletons have been developed to assist gait, exhibiting a large range of control methods. The goal of this paper is to review and classify these control strategies, that determine how these devices interact with the user.

Methods

In addition to covering the recent publications on the control of lower-limb exoskeletons for gait assistance, an effort has been made to review the controllers independently of the hardware and implementation aspects. The common 3-level structure (high, middle, and low levels) is first used to separate the continuous behavior (mid-level) from the implementation of position/torque control (low-level) and the detection of the terrain or user’s intention (high-level). Within these levels, different approaches (functional units) have been identified and combined to describe each considered controller.

Results

291 references have been considered and sorted by the proposed classification. The methods identified in the high-level are manual user input, brain interfaces, or automatic mode detection based on the terrain or user’s movements. In the mid-level, the synchronization is most often based on manual triggers by the user, discrete events (followed by state machines or time-based progression), or continuous estimations using state variables. The desired action is determined based on position/torque profiles, model-based calculations, or other custom functions of the sensory signals. In the low-level, position or torque controllers are used to carry out the desired actions. In addition to a more detailed description of these methods, the variants of implementation within each one are also compared and discussed in the paper.

Conclusions

By listing and comparing the features of the reviewed controllers, this work can help in understanding the numerous techniques found in the literature. The main identified trends are the use of pre-defined trajectories for full-mobilization and event-triggered (or adaptive-frequency-oscillator-synchronized) torque profiles for partial assistance. More recently, advanced methods to adapt the position/torque profiles online and automatically detect terrains or locomotion modes have become more common, but these are largely still limited to laboratory settings. An analysis of the possible underlying reasons of the identified trends is also carried out and opportunities for further studies are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-021-00906-3.

Soft Exoskeletons: Development, Requirements, and Challenges of the Last Decade

In this article, various investigations on soft exoskeletons are presented and their functional and structural characteristics are analyzed. The present work is oriented to the studies of the last decade and covers the upper and lower joints, specifically the shoulder, elbow, wrist, hand, hip, knee, and ankle. Its functionality, applicability, and main characteristics are exposed, such as degrees of freedom, force, actuators, power transmission methods, control systems, and sensors. The purpose of this work is to show the current trend in the development of soft exoskeletons, in addition to specifying the essential characteristics that must be considered in its design and the challenges that its construction implies.

Evaluation of a lower-extremity robotic exoskeleton for people with knee osteoarthritis

A multi-site study was conducted to evaluate the efficacy of the Keeogo™ exoskeleton as a mobility assist device for use in the clinic and at home in people with knee osteoarthritis (KOA). Twenty-four participants were randomized in a two-stage cross-over design that evaluated the immediate effects of using the exoskeleton in the clinic and the cumulative effects of training and home use. Immediate effects were quantified by comparing 1) physical performance with|without (W|WO) the device during a battery of mobility tests, and 2) physical activity levels at home (actigraphy) for one month, two weeks W|WO the device. Cumulative effects were quantified as change in physical performance W and WO over time. WOMAC and other self-report scales were measured and usability assessed. There were no immediate effects on physical performance or physical activity at home; however, there were cumulative effects as indicated by improved stair time (p = .001) as well as improved WOMAC pain (p = .004) and function (p = .003). There was a direct relationship between improved physical function and improved WOMAC pain (r = -.677, p < .001) and stiffness (r = .537, p = .007). Weight and battery life were identified as important to usability. A full-scale RCT with more participants, longer study period, and better usage monitoring is warranted.

Quasi-Passive Resistive Exosuit for Space Activities: Proof of Concept

The limits of space travel are continuously evolving, and this creates increasingly extreme challenges for the crew’s health that must be addressed by the scientific community. Long-term exposure to micro-gravity, during orbital flights, contributes to muscle strength degradation and increases bone density loss. In recent years, several exercise devices have been developed to counteract the negative health effects of zero-gravity on astronauts. However, the relatively large size of these devices, the need for a dedicated space and the exercise time-frame for each astronaut, does not make these devices the best choice for future long range exploration missions. This paper presents a quasi-passive exosuit to provide muscle training using a small, portable, proprioceptive device. The exosuit promotes continuous exercise, by resisting the user’s motion, during routine all-day activity. This study assesses the effectiveness of the resistive exosuit by evaluating its effects on muscular endurance during a terrestrial walking task. The experimental assessment on biceps femoris and vastus lateralis, shows a mean increase in muscular activation of about 97.8% during five repetitions of 3 min walking task at 3 km/h. The power frequency analysis shows an increase in muscular fatigue with a reduction of EMG median frequency of about 15.4% for the studied muscles.

Review: How Can Intelligent Robots and Smart Mechatronic Modules Facilitate Remote Assessment, Assistance, and Rehabilitation for Isolated Adults With Neuro-Musculoskeletal Conditions?

Worldwide, at the time this article was written, there are over 127 million cases of patients with a confirmed link to COVID-19 and about 2.78 million deaths reported. With limited access to vaccine or strong antiviral treatment for the novel coronavirus, actions in terms of prevention and containment of the virus transmission rely mostly on social distancing among susceptible and high-risk populations. Aside from the direct challenges posed by the novel coronavirus pandemic, there are serious and growing secondary consequences caused by the physical distancing and isolation guidelines, among vulnerable populations. Moreover, the healthcare system's resources and capacity have been focused on addressing the COVID-19 pandemic, causing less urgent care, such as physical neurorehabilitation and assessment, to be paused, canceled, or delayed. Overall, this has left elderly adults, in particular those with neuromusculoskeletal (NMSK) conditions, without the required service support. However, in many cases, such as stroke, the available time window of recovery through rehabilitation is limited since neural plasticity decays quickly with time. Given that future waves of the outbreak are expected in the coming months worldwide, it is important to discuss the possibility of using available technologies to address this issue, as societies have a duty to protect the most vulnerable populations. In this perspective review article, we argue that intelligent robotics and wearable technologies can help with remote delivery of assessment, assistance, and rehabilitation services while physical distancing and isolation measures are in place to curtail the spread of the virus. By supporting patients and medical professionals during this pandemic, robots, and smart digital mechatronic systems can reduce the non-COVID-19 burden on healthcare systems. Digital health and cloud telehealth solutions that can complement remote delivery of assessment and physical rehabilitation services will be the subject of discussion in this article due to their potential in enabling more effective and safer NMSDK rehabilitation, assistance, and assessment service delivery. This article will hopefully lead to an interdisciplinary dialogue between the medical and engineering sectors, stake holders, and policy makers for a better delivery of care for those with NMSK conditions during a global health crisis including future pandemics.

An Identification-Based Method Improving the Transparency of a Robotic Upper Limb Exoskeleton

Over the past decade, research on human–robot collaboration has grown exponentially, motivated by appealing applications to improve the daily life of patients/operators. A primary requirement in many applications is to implement highly “transparent” control laws to reduce the robot impact on human movement. This impact may be quantified through relevant motor control indices. In this paper, we show that control laws based on careful identification procedures improve transparency compared to classical closed-loop position control laws. A new performance index based on the ratio between electromyographic activity and limb acceleration is also introduced to assess the quality of human exoskeleton interaction.

A Fully Soft and Passive Assistive Device to Lower the Metabolic Cost of Sit-to-Stand

Various assistive devices like exoskeletons have been developed to aid the growing number of disabled people. Recent studies have started to explore using soft rather than rigid components to create lightweight and unobtrusive systems that can be more easily adopted by the general population. However, there is a tradeoff between compliance and power in these systems. We investigated the physiological benefits of using an inconspicuous, soft and passive assistive device which would avoid bulkiness, heaviness and user discomfort. We chose to assist the sit-to-stand (STS) maneuver because it is a common activity of daily living (ADL). STS is also recognized as one of the most challenging ADLs due to the high knee torque required, and the primary limiting factor is known to be knee extensor strength. Thus, the objective of this research was to develop and evaluate an unobtrusive knee assist wear called X-tights that could aid knee extension during STS using only soft and passive components. This was accomplished by routing elastic bands across the lower extremity. Thirty-one healthy participants performed STS tests with and without the X-tights, while metabolic cost and muscle activity were recorded. Metabolic power significantly decreased, by 3.2 ± 1.5% (P = 0.04), when utilizing the X-tights during the STS, while there was no statistically significant differences in muscle activity. The present work introduces a new soft and passive assist wear that can be worn inconspicuously under normal clothing, and we demonstrate promising results for the future development and integration of soft assistive technology for daily life.

Iterative Learning Control for a Soft Exoskeleton with Hip and Knee Joint Assistance

Walking on different terrains leads to different biomechanics, which motivates the development of exoskeletons for assisting on walking according to the type of a terrain. The design of a lightweight soft exoskeleton that simultaneously assists multiple joints in the lower limb is presented in this paper. It is used to assist both hip and knee joints in a single system, the assistance force is directly applied to the hip joint flexion and the knee joint extension, while indirectly to the hip extension also. Based on the biological torque of human walking at three different slopes, a novel strategy is developed to improve the performance of assistance. A parameter optimal iterative learning control (POILC) method is introduced to reduce the error generated due to the difference between the wearing position and the biological features of the different wearers. In order to obtain the metabolic rate, three subjects walked on a treadmill, for 10 min on each terrain, at a speed of 4 km/h under both conditions of wearing and not wearing the soft exoskeleton. Results showed that the metabolic rate was decreased with the increasing slope of the terrain. The reductions in the net metabolic rate in the experiments on the downhill, flat ground, and uphill were, respectively, 9.86%, 12.48%, and 22.08% compared to the condition of not wearing the soft exoskeleton, where their corresponding absolute values were 0.28 W/kg, 0.72 W/kg, and 1.60 W/kg.

Pneumatic Quasi-Passive Actuation for Soft Assistive Lower Limbs Exoskeleton

There is a growing international interest in developing soft wearable robotic devices to improve mobility and daily life autonomy as well as for rehabilitation purposes. Usability, comfort and acceptance of such devices will affect their uptakes in mainstream daily life. The XoSoft EU project developed a modular soft lower-limb exoskeleton to assist people with low mobility impairments. This paper presents the bio-inspired design of a soft, modular exoskeleton for lower limb assistance based on pneumatic quasi-passive actuation. The design of a modular reconfigurable prototype and its performance are presented. This actuation centers on an active mechanical element to modulate the assistance generated by a traditional passive component, in this case an elastic belt. This study assesses the feasibility of this type of assistive device by evaluating the energetic outcomes on a healthy subject during a walking task. Human-exoskeleton interaction in relation to task-based biological power assistance and kinematics variations of the gait are evaluated. The resultant assistance, in terms of overall power ratio (Λ) between the exoskeleton and the assisted joint, was 26.6% for hip actuation, 9.3% for the knee and 12.6% for the ankle. The released maximum power supplied on each articulation, was 113.6% for the hip, 93.2% for the knee, and 150.8% for the ankle.

A Review of Robot-Assisted Lower-Limb Stroke Therapy: Unexplored Paths and Future Directions in Gait Rehabilitation

Stroke affects one out of every six people on Earth. Approximately 90% of stroke survivors have some functional disability with mobility being a major impairment, which not only affects important daily activities but also increases the likelihood of falling. Originally intended to supplement traditional post-stroke gait rehabilitation, robotic systems have gained remarkable attention in recent years as a tool to decrease the strain on physical therapists while increasing the precision and repeatability of the therapy. While some of the current methods for robot-assisted rehabilitation have had many positive and promising outcomes, there is moderate evidence of improvement in walking and motor recovery using robotic devices compared to traditional practice. In order to better understand how and where robot-assisted rehabilitation has been effective, it is imperative to identify the main schools of thought that have prevailed. This review intends to observe those perspectives through three different lenses: the goal and type of interaction, the physical implementation, and the sensorimotor pathways targeted by robotic devices. The ways that researchers approach the problem of restoring gait function are grouped together in an intuitive way. Seeing robot-assisted rehabilitation in this unique light can naturally provoke the development of new directions to potentially fill the current research gaps and eventually discover more effective ways to provide therapy. In particular, the idea of utilizing the human inter-limb coordination mechanisms is brought up as an especially promising area for rehabilitation and is extensively discussed.

Mechanical Sensing for Lower Limb Soft Exoskeletons: Recent Progress and Challenges

Soft exoskeletons hold promise for facilitating monitoring and assistance in case of light impairment and for prolonging independent living. In contrast to rigid material-based exoskeletons, they strongly demand for new approaches of soft sensing and actuation solutions. This chapter overviews soft exoskeletons in contrast to rigid exoskeletons and focuses on the recent advancements on the movement monitoring in lower limb soft exoskeletons. Compliant materials and soft tactile sensing approaches can be utilized to build smart sensorized garments for joint angle measurements (needed for both control and monitoring). However, currently there are still several open challenges derived from the needed close interaction between the human body and the soft exoskeleton itself, especially related to how sensing function and robustness are strongly affected by wearability, which will need to be overcome in the near future.

Electrically-Driven Soft Fluidic Actuators Combining Stretchable Pumps With Thin McKibben Muscles

Soft wearable robots could provide support for lower and upper limbs, increase weight lifting ability, decrease energy required for walking and running, and even provide haptic feedback. However, to date most of wearable robots are based on electromagnetic motors or fluidic actuators, the former being rigid and bulky, the latter requiring external pumps or compressors, greatly limiting integration and portability. Here we describe a new class of electrically-driven soft fluidic muscles combining thin, fiber-like McKibben actuators with fully Stretchable Pumps. These pumps rely on ElectroHydroDynamics, a solid-state pumping mechanism that directly accelerates liquid molecules by means of an electric field. Requiring no moving parts, these pumps are silent and can be bent and stretched while operating. Each electrically-driven fluidic muscle consists of one Stretchable Pump and one thin McKibben actuator, resulting in a slender soft device weighing 2 g. We characterized the response of these devices, obtaining a blocked force of 0.84 N and a maximum stroke of 4 mm. Future work will focus on decreasing the response time and increasing the energy efficiency. Modular and straightforward to integrate in textiles, these electrically-driven fluidic muscles will enable soft smart clothing with multi-functional capabilities for human assistance and augmentation.

Special Issue on Wearable Robotics: Dynamics, Control and Applications

While initially conceived for human motion augmentation, wearable robots have gradually evolved as technological aids in motion assistance and rehabilitation. There are increasing real-world applications in industrial and medical scenarios. Though efforts have been made on wearable robotic systems, e.g. robotic prostheses and exoskeletons, there are still several challenges in kinematics and actuation solutions, dynamic analysis and control of human-robot systems, neuro-control and human-robot interfaces; ergonomics and human-in-the-loop optimization. Meanwhile, real-world applications in industrial or medical scenarios are facing difficulties considering effectiveness.